Making Obamacare Work Better

It was six years ago this month, on March 23 2010, that President Obama signed the Patient Protection and Affordable Care Act into law. Some provisions became effective six months later in September 2010, such as allowing young adults to remain on their parent’s health insurance until age 26. No cost preventative care for everyone became effective on January 1 2011. But it was on January 1 2014 that the Medicaid expansion and health insurance exchanges became effective as well as the individual mandate.

Whether the ACA or Obamacare is a success may not be determined for some time. But clearly the figures are moving in the right direction. While health care costs continue to increase faster than incomes, that rate has actually slowed since 2010. With more people becoming insured and with a pent up demand for health care because of many previously uninsured Americans seeking medical care, this may skew some cost figures. But no doubt the act has made a significant difference.

However there are many serious flaws in the act that should be fixed to make it work much better for more Americans. Here are some ways that the ACA can be fixed to work better:

1. The Medicaid expansion did not include anyone who is eligible for Medicare. The expansion of Medicaid as far as income levels should apply to everyone, including those who are eligible for Medicare.
2. Regarding the Medicaid expansion, when the Supreme Court said that each state had the option whether or not to accept the Medicaid expansion, that needs to be addressed. Medicaid should be federalized completely and not left to the individual states. With the federalization of Medicaid, those on Medicaid could transfer their Medicaid coverage and benefits from one state to another. Federalizing Medicaid would save a lot of money and make Medicaid benefits uniform across the nation like Medicare.  
3. The penalty "tax" for not getting covered or enrolling in the exchanges is way too low. This year the penalty is $695 for a single adult or 5% of income whichever is greater. The penalty should be at least 150% of a basic level bronze level plan for that person's age or 10% of income whichever is greater. This would be the hammer that will get the young invincibles to enroll.  
4. Rein in abuse of special enrollment periods for enrolling in the health insurance exchanges. This is already being done as I post this since CMS (the government agency that administers Medicare as well as the health insurance exchanges) has issued new rules regarding special enrollment periods that should curb the greatest abuses.  
5. Eliminate the "cliff" as far as income eligibility for premium subsidies as well as Medicaid eligibility. If an individual or family is just $1.00 above the upper income level for either Medicaid eligibility or a premium subsidy, then they have a great financial penalty. A better solution would be to gradually limit the Medicaid benefits or a premium subsidy rather than have it as a "cliff". 
6. Premium subsidies should be available to anyone so that the silver level plan should not exceed 8% of an individual's or family's adjusted federal gross income. Currently if the premium for a silver level plan exceeds 8% of that individual's or family's federally adjusted gross income; than that individual or family is exempt from any penalty if they do not enroll through the health insurance exchange. But then that individual or family would be uninsured. It doesn't make sense. 
7. Let's wean the United States off employment based health insurance. If an employer wishes to drop employer health insurance and allow their employees the ability to go on the exchanges to get their own health insurance; either mandate that the savings to the employer be given to the employees through increased wages and salaries (to better enable them to get their own health insurance) or as a tax deductible health insurance account (similar to a flexible spending account that many employers give employees already) for the purchase of health insurance through the exchanges. 
8. Although not part of the ACA or Obamacare; repeal the outdated (from 1945) McCarran - Ferguson Act that exempted insurance from federal regulation and create a federal regulatory agency for insurance that is sold across state lines. This way insurance could be sold across state lines if the insurance company is operating in many states, but policies will be valid and benefits recognized in all states. States will still have the authority to license agents and regulate those insurance companies that sell only within the borders of that state (as many good insurance companies do). The McCarran - Ferguson Act is as outdated now as a car or household appliance made in 1945 would be today. 

Instead of constantly passing meaningless repeal bills, perhaps it is time for congress and the President to work together and make the ACA work better for all Americans. It can be done if both parties decide that working together is better than political grandstanding.