EDITORIAL: First, repair and enhance the Affordable Care Act

Akron Beacon Journal (OH)

March 27-- Mar. 27--In November, Nancy Pelosi sized up the election victory that brought Democrats the majority in the U.S. House. "Health care was on the ballot," she declared, "and health care won." Recall Democratic candidates pressuring Republicans on insurance coverage for pre-existing conditions. Many of those victories went to centrists defeating Republicans in districts carried by President Trump. Which helps to frame the dilemma facing Speaker Pelosi and her party: What course to take in addressing health care?

Many Democrats call for taking a most ambitious route in the shape of Medicare for all, and polls indicate considerable public support for the concept, though it begins to erode when the factor of cost enters the equation. The centrists have something more practical in mind. They prefer to repair and enhance the Affordable Care Act, thus avoiding the disruption that would accompany dismantling the employer-based system, serving roughly 150 million Americans.

That instinct is sound, especially in view of how contentious the discussion of health care long has been. Democrats built their victory on the growing popularity of the Affordable Care Act, the promise of the campaign about making improvements, and less about a leap into areas fraught with unknowns.

So what is involved in improving the Affordable Care Act? The Center on Budget and Policy Priorities, a Washington think tank, charted the way forward in a set of reports last week. The objective is to get much closer to universal coverage, today with 30 million people still lacking health insurance.

Around one-third of the uninsured are likely eligible for Medicaid but not enrolled or ineligible because their states have not expanded Medicaid. It follows then, as the center points out, to simplify enrollment and improve retention, for instance, by implementing "continuous eligibility," correcting for the constant churn on and off the program by allowing recipients to stay enrolled for a year. This also saves on administrative costs.

How to get reluctant states to expand their Medicaid coverage? Add to the incentives by allowing those states to receive the same 100 percent federal match for the first three years (then 90 percent going forward). That is the deal John Kasich essentially said Ohio couldn't refuse.

Nearly half of the remaining uninsured are ineligible in some way for the subsidies that help make health insurance affordable. These are people buying coverage on their own, often through the online exchanges of the Affordable Care Act. Some are just above the eligibility threshold of 400 percent of the poverty level (about $100,000 a year for a family of four). Their circumstances reinforce the steep expense of insurance and the need for more generous subsidies.

Yet the larger problem with the subsidies, as the center makes clear, involves households at lower income rungs. In Ohio, the uninsured rate for those at 400 percent to 500 percent of the poverty level is 4.1 percent. For those at 138 percent to 250 percent ($35,535 to $64,375), the rate is 11.6 percent. These households are eligible for subsidies, yet even with financial assistance, they cannot afford coverage. Their situation makes even more evident the need for subsidies that reflect the reality of the cost.

Those with coverage tend to be healthier. They also improve the insurance risk pool. Both factors work to depress premium costs. There are other ways to enhance the Affordable Care Act, from improving outreach to reviving the individual mandate and reversing the actions of the Trump White House to promote substandard coverage. Yet the most important go to extending the Medicaid expansion and providing better subsidies. Achieve those objectives, and health care wins, universal coverage within reach, coverage coming to virtually all of the current uninsured.

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