Since presidential candidate Hillary Clinton quietly updated the healthcare policy page on her campaign website over the last few days, most commentators have focused on the especially notable paragraphs stating that she will "continue to support a 'public option' — and work to build on the Affordable Care Act to make it possible."
The policy page includes several other elements aimed at improving the Affordable Care Act, including broadening the accessibility of heath coverage to otherwise excluded populations and reducing its cost. More on those in a moment.
Clinton's support of the public option has drawn the most attention because it revives a provision of healthcare reform that was dropped from the ACA during the drafting and debate era of 2009-2010 — to the disadvantage of the package as a whole, in the view of many reformers.
It's also Clinton's strongest counterpunch to the single-payer plan proposed by her Democratic opponent, Sen. Bernie Sanders of Vermont, an excessively expensive program that would start reform from square one and eliminate many of the cost controls written into the ACA. Along with her other proposals, it's a reproach to Republican presidential candidates whose only idea is to scrap Obamacare in its entirety, without seriously contemplating how to cover Americans in its stead. However you feel about Obamacare, the difference in their approaches is unmistakable.
As Charles Gaba notes, Clinton isn't kidding when she says she supported the public option in the past — the evidence can be found among those accursed emails of hers, which document her efforts to keep the provision in the bill. (She was acting as an outsider, as she had left the Senate to become secretary of State in January 2009.)
The public option, it will be remembered, was a way to provide competition to the commercial insurance industry via a government-run alternative, perhaps using Medicaid-level reimbursement rates for doctors and hospitals. The idea was dropped under pressure from the insurance industry and replaced with a hybrid system of nonprofit co-ops, which haven't worked very well.
Clinton's idea is to establish the public option beginning at the state level using existing provisions of the ACA — to "work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice."
She's referring implicitly to the ACA's section 1332 "innovation waivers." As Andrew Sprung of xpostfactoid observes, these aim to encourage states to develop alternative mechanisms for health coverage, as long as they hew to Obamacare's coverage and affordability standards. The beauty of the proposal, Sprung notes, is that it doesn't require additional legislation.
"It would, however, need funding," Sprung notes. That's where cooperation between governors and a President Clinton might come in. And that's where the waiver might come in. If the state could find other means of savings, those measures might be integrated in a waiver proposal with a public option. In time, state-level public options could be brought upstream to the federal level and — presto! — you've re-created the original ACA public option.
Clinton's other proposals reflect a determination to fix the known shortcomings of the Affordable Care Act without eroding its consumer protections. She would address the sticker shock of deductibles and co-pays of low-premium individual health plans by providing a tax credit of up to $5,000 per family to cover those out-of-pocket expenses.
Clinton also would increase tax subsidies for families by lowering the maximum percentage of income that makes families eligible for premium subsidies to 8.5%, from the current 9.5%. And she would eliminate the "family glitch," a notorious flaw in the ACA that makes whole families ineligible for premium subsidies if even one member of the family is eligible for employer-paid insurance, even if the workplace plan is too expensive to cover them all.
Another proposal is to make Medicaid expansion an offer that the last 16 holdout states — all under the control of anti-Obamacare Republican governors or legislators — can't refuse. Clinton's idea is for the federal government to provide 100% of the expansion's cost for the first three years of implementation. Under current law, the government pays 100% for three years ending this year, after which its share declines toward 90% by 2020 and stays there for good.
Her hope is that the prospect of more free money will goad these states to climb down from their ideological resistance, even if the prospect of providing decent health coverage to hundreds of thousands of their lowest-income residents hasn't done the trick.
Finally, Clinton is proposing to extend access to Obamacare exchange plans to all families, including those of undocumented immigrants. Their exclusion from the right to purchase health plans on ACA exchanges serves no purpose except a punitive one, but those most severely punished are children.