Now that Republicans in Congress appear to have at least temporarily abandoned their crusade against the Affordable Care Act, it seems like a good time for lawmakers to come up with plans to fulfill their promises to increase access to health care and to lower costs.
Let’s stipulate up front that congressional leaders and President Trump are unlikely to lead that effort, given that they narrowly failed to take health insurance away from millions of people. This conversation would need to be led by senators who have committed to a bipartisan approach, and by state governments, some of which have already begun to take action.
Change might not come soon enough for the 29 million people without health insurance or the many millions who struggle to afford high premiums, deductibles and other health costs. But even the A.C.A., the 2010 health law also known as Obamacare, was the product of many years of spadework and was based on a Massachusetts health reform bill signed into law by Gov. Mitt Romney in 2006.
Obamacare has helped 20 million people gain access to insurance, and it appears to have helped slow the growth in health care costs. But even former President Barack Obama has said that there is still work to be done. The United States spends much more on medical care than other rich countries, like Britain, Australia and the Netherlands, according to a recent Commonwealth Fund report, yet its citizens live shorter lives and suffer from more illnesses and injuries than people in other industrialized nations.
One option that appears to have gained support among the public is a single-payer system, which proponents like Senators Bernie Sanders and Elizabeth Warren call “Medicare for All.” A Kaiser Family Foundation poll found in June that 53 percent of Americans favor such a system. This was up from 46 percent, according to an average of seven polls conducted in 2008 and 2009. But moving to a single-payer system from one dominated by employer-paid health coverage would be a big leap, and in any case the political climate is clearly not ready for it. Many Democratic voters as well as party leaders like Representative Nancy Pelosi and Senator Chuck Schumer have been reluctant to embrace the idea, and, no surprise, most Republican voters and lawmakers
Single-payer advocates point out that the United States is the only advanced nation without universal health care, which is true. Germany, the Netherlands and Switzerland have achieved universal coverage and affordable health care with, essentially, more comprehensive and generous forms of Obamacare that require people to buy insurance, tightly regulate insurers and provide subsidies to the poor and middle class.
State and federal lawmakers are exploring ways to increase coverage and lower costs. For example, the Nevada Legislature passed a bill in June that would have allowed people who make too much money to qualify for Medicaid to buy into that program. The bill, which would have required a federal waiver, did not become law because Gov. Brian Sandoval, a Republican, vetoed it. But the idea has other backers. Senator Brian Schatz of Hawaii said on Tuesday that he would introduce a bill that would explicitly allow states to let people buy into Medicaid.
Another approach would be to let people buy into Medicare at some point before they become eligible for the program at age 65. Hillary Clinton proposed this during her presidential campaign. Congress could also provide more generous subsidies to help middle-class people buy insurance on Obamacare exchanges. At the state level, four million people would gain coverage if Florida, Georgia, Texas and the 16 other states that
Ms. Pelosi has said that some states could go even further by approving single-payer systems of their own. California, Colorado, New York and Vermont have considered such proposals in recent years. If one or two states moved in that direction, it could help demonstrate the feasibility of such an approach in much the same way that Romneycare in Massachusetts provided plausibility for Obamacare.
The Republican campaign to repeal Obamacare, for all its waste of time and energy, has at least gotten people to talk seriously about proposals to improve the health care system.