The fixes Obamacare really does need

Still looking for a solution: HHS Secretary Kathleen Sebelius (standing, left) at an Obamacare enrollment event in Florida.
(Lynne Sladky/AP)

You may have heard, unless you’ve been living under a rock, that the Affordable Care Act isn’t perfect. Programs that aim to restructure one-sixth of the U.S. economy rarely are at the outset, and that’s even more true when their introduction is accompanied by determined efforts by some politicians in some states to make them fail.

Some changes aimed at perfecting Obamacare will require months, even years, to work out, for the simple reason that they address provisions of the law that will take months or years to have an effect. Cost-reduction provisions for Medicare, for instance.

But there are some improvements that can be managed right now. For the most part, all they require are political will -- and money. None of them relate to the “fixes” being offered by members of both parties in Congress, some of which are fatuously cynical proposals that aim to “fix” the Affordable Care Act in the same sense that the Mafia “fixes” an informer (I’m looking at you, Marco Rubio, R-Fla.) and others of which are basically ineffective (the proposals to let insurers continue to sell their old plans fall into that category).

Here’s what can be done now:


1. Fix the website. There’s nearly universal agreement on the shortcomings of the federal government’s There are also signs that things are improving as the technical surge takes hold and the system moves toward a self-imposed deadline of Dec. 1 to be broadly functional for the vast majority of users. The site’s problems are responsible both for the low rate of insurance enrollments in the 36 states whose residents rely on the federal site for purchases, and for the widespread perception that millions of people will be left without coverage Jan. 1, when individuals must have new Obamacare-compliant policies and their old coverage expires.

The importance of the website can be seen from the much greater success the ACA is showing in 14 states and the District of Columbia, which are running their own websites for information and enrollment. As my colleague Noam Levey reported this week, some of those states are seeing an enrollment surge as the deadline nears.

For example, California, which enrolled about 31,000 people in October through its Covered California site, nearly doubled that figure in the first two weeks of November. Kentucky, which has been an enthusiastic promoter of the ACA and has its own website, has enrolled more residents than Texas, which is six times larger but where Gov. Rick Perry and a Republican majority have fought the ACA every inch of the way.

2. Expand Medicaid. Many of the same states that fobbed off the opportunity to run their own insurance exchanges and enrollment programs on the federal government -- and are now griping that the feds aren’t doing their jobs -- also punked out on what may be the most important facet of the ACA: a federally -financed expansion of Medicaid.


The Kaiser Family Foundation estimates that this dereliction in 25 states (including four that are still thinking about it) has left roughly 5 million Americans without affordable coverage. That’s a figure, by the way, that probably dwarfs the number of people nationwide whose individual policies have been canceled and can’t find replacement coverage except at higher cost. 

In some states that opted to accept the federally funded expansion of Medicaid (to families and individuals with incomes up to 138% of the federal poverty level) Medicaid enrollment accounts for nearly half of all new insurance enrollments under the ACA.  

The Robert Wood Johnson Foundation reported Wednesday that as many as 2.4 million Americans ages 19 to 24 will become newly eligible for Medicaid in expansion states, among 5.4 million currently uninsured young adults eligible for the program. That’s the age range known as the “young invincibles” -- the young people who are basically healthy, traditionally disinclined to pay for individual coverage themselves, and needed for the national insurance pool to keep overall premiums down. Importantly, they’re not immune to injury or illness -- they’re just less likely to buy insurance coverage on their own. 

3. A radical solution: Expand the premium subsidies. Many people complaining that they’re facing higher premium costs in the next year because their cheaper individual plans have been canceled seem to live right on the edge of eligibility for the ACA’s premium subsidies. It’s not unreasonable for some of them to consider the new insurance mandate to be a financial burden.

Under the law, individuals and families are eligible for premium subsidies on a sliding scale. At 150% of the poverty line -- $17,200 for an individual and $35,325 for a family of four, based on 2013 poverty standards -- the law limits premiums for a mid-level “silver” health plan to 4% of income, or $690 a year for an individual and about $1,400 for a family.  

For those with income up to 400% of the federal poverty level -- that’s $45,960 for an individual and $94,200 for a family of four -- the law limits silver premiums to 9.5% of income, or $4,366 for an individual and $8,949 for a family of four.  

If you earn more than 400% of the poverty level, however, you get no subsidy. Arguably, that’s a steep cutoff. And plainly, the problem could be reduced by extending the subsidies, perhaps at a lower level. That would require congressional action and appropriations, of course, and with today’s do-nothing-useful Congress, that could be a tall order.

But it’s vastly preferable to the snake-oil remedies being offered for the highly publicized and politicized crisis of canceled individual plans. The proposals at hand involve allowing insurers to continue to market non-compliant plans for as much as another year. One proposal would require insurers to keep offering the plans, and even to sign up new customers for them.


It’s not surprising that the insurers themselves don’t care for these nostrums, and that many state regulators don’t either. That’s because the whole point of the ACA was to eradicate health plans that cater to limited numbers of customers, often by offering minimal benefits. The insurance industry knows it’s best to bring the largest number of people into the largest possible insurance pools, and the congressional solutions undermine that goal. 

So let’s see the fix-Obamacare brigade take some sensible steps for once: pressure hold-out states to accept expanded Medicaid and consider loosening the reins on insurance subsidies. If they don’t do that, we’ll know they’re not serious about making things better.

Have a fix for the ACA? Tell me about it.