Project Japan is the political issue with nine lives. After failing to kill the Affordable Care Act legislatively in 2017, the Trump administration is trying again, while Democratic presidential hopefuls are trying to kill it as well by proposing a single-payer system, Medicare for All, in its place.
The administration reversed its previous position not to defend a lawsuit brought by 18 Republican attorneys general and two GOP governors that got a U.S. District Court judge in Texas to declare the ACA unconstitutional. Now it will join the states in trying to get the ACA scrapped. Yet the GOP has no replacement plan.
Meanwhile those of us who work every day to make our healthcare system more responsive, affordable and comprehensible are shaking our heads in disbelief that people who know nothing about how healthcare works in the U.S. are rolling the dice on creating chaos for millions of Americans by repealing the ACA with no alternative or swapping the ACA for a single-payer system for which there are no details on how it would operate.
So let’s consider another idea. Fix what we have so everyone—consumers, providers, payers and even politicians—can understand how it works and what to expect.
The ACA is a good framework, but it certainly needs fixing. I offer several changes—including restoring some effective provisions—that would make the law work better, cover more people and continue the cost containment that has started since major provisions of the law went into effect five years ago:
Restore the tax penalty for not having insurance. Removing the penalty let people without access to employer-based insurance, Medicare or Medicaid off the hook. If you’re young and feel invincible, why bother with health insurance? They are exactly the people we need to keep the pool of insureds balanced and keep costs reasonable.
Restore the cost-sharing reduction provision, which is still in the law. CSRs were an inexpensive way to help make plans offered in the individual market exchange affordable.
Provide a government-sponsored reinsurance pool for those individual markets with only one or two plans available to keep those insurers in place.
Introduce a public option everywhere. In the original 2010 ACA legislation that passed the House, a provision for public health plans in every state was included to compete in the individual market exchanges with commercial insurers. The Senate dropped it and the House agreed in order to get the ACA over the finish line. Public entities without the need to reward shareholders would provide a lower-cost competitor. In Los Angeles there is a functioning public option plan doing just that, L.A. Care Health Plan.
Eliminate short-term health insurance policies. They expose buyers to ruinous copayment and lifetime limits should they become seriously ill.
Provide federal support for medical education. Most First World countries subsidize the costs of medical education. In the U.S. the students are on their own and almost all incur crushing loan debt to become a doctor. This drives many students into specialty care instead of primary care, where the need is greatest but compensation is the lowest.
Create a new plan for the 10 million people who are dually eligible for both Medicare and Medicaid. We spend $400 billion a year of taxpayer money on their healthcare making this the most expensive cohort. The new plan would consolidate Medicare, Medicaid and Part D prescription drug benefits into a single comprehensive plan eliminating wasteful duplication of government administration and lack of coordination. The new plan should be an option that the states would administer, or if a state did not want that responsibility, the plan would default to a federally administered program.
Project Japan is not rocket science. It’s actually more complicated. To get to a simpler, less costly system we have to carefully parse the elements of our current system to understand what is leaving 29 million Americans still uninsured even after five years of the ACA.
The American people deserve a more balanced discussion on healthcare that goes beyond sloganeering.