Obamacare survives as the law of the land. Here’s how Congress can fix it.

July 29--The effort to repeal the Affordable Care Act has failed again. What can Congress do now?

Republicans gave birth to ACA repeal and raised it into a healthy 7-year-old campaign promise. But a few of them decided to kill the repeal before it could go out into the world and do what they worried would be serious damage -- like causing millions of people to lose health insurance.

There are problems the ACA has not fixed. Here are a few: Five-digit deductibles, high-priced medications and insurers pulling out of ACA marketplaces.

"Most of the potential fixes share one common goal: They would help insurance companies," Michael Grunwald wrote in Politico earlier this year.

That's because almost every spoke of the Affordable Care Act wheel emanates from the hub of insurance coverage. If those spokes are too loose, the wheel falls apart.

Here are some ideas that could keep that from happening:

-- Don't hold subsidies hostage.

The ACA includes special subsidies for low-income Americans, reducing their out-of-pocket costs. About 7 million people -- or 58 percent of all ACA signups -- qualify for those "cost share reduction" payments, which are basically passed through to a patient's insurance company by the federal government.

The House of Representatives sued over them in 2014, arguing that it was unconstitutional to promise money that wasn't authorized by Congress. The lawsuit is on hold, and the Trump administration is keeping up the payments for now. But health insurers are freaked out because cuts are still looming.

-- Give the insurance companies a buffer.

The people who drafted the Affordable Care Act knew that many people who hadn't seen a doctor for years would suddenly flood the insurance market. Many of the had undiagnosed and untreated medical problems. And the law required insurers to cover more illnesses and services than ever before. It was hard to predict what the cost to insurers would be.

The ACA had a few built-in programs to help insurers get through that transition. One of them was only temporary. It expired in 2016, and insurers have blamed part of their premium increases on its sunset.

Grunwald noted that Alaska created its own $64 million fund to help insurers pay for high-cost customers.

"For all its faults -- and there were many -- the GOP's American Health Care Act did include a $10 billion-a-year 'stability fund' designed for states to use on things like reinsurance and other approaches for the highest-cost, highest-risk consumers," Grunwald wrote.

How much do insurers need this help? Hard to say. Lately, insurers have been making a profit on the previously much shakier ACA market. But there are parts of the country where that's not true, and where exchanges now are at risk of having no insurers willing to cover ACA customers.

-- Get a bigger stick. Get a bigger carrot.

The federal government could increase the fine that people must pay if they go uninsured, until it's clearly a better deal to get insurance than to go without. At this point, the penalty is low enough that millions of people have decided to pay it instead of buying insurance.

Alternately, the government could raise the premium subsidy to make insurance more affordable. That could attract healthier and younger customers to the pool, diluting the cancer and back-surgery costs that drive up premiums every year.

-- Give states a guarantee on Medicaid expansion.

Many Republican-controlled states, including Idaho, have refused to add working-poor adults to their Medicaid rolls. One big argument: The chance of the federal government going back on its promise to cover almost the entire cost of that expansion.

What would happen if there were no chance of the federal government breaking its promise, or if the federal government raised its share from 90 percent to 100 percent? A nationwide Medicaid expansion could slow the cost-shifting that plays a role in driving up insurance premiums.

When poor adults don't have health insurance, they end up in the hospital with advanced medical problems and no ability to pay. Doctors and nurses don't work for free. Those unpaid medical costs have to be made up elsewhere -- generally from higher charges for patients who do have health insurance, and from local taxpayers.

-- Bring in a single-payer option.

This would turn American's health care system inside out. But Medicare is popular. And the ACA has the ability to use Medicare's giant pockets for better patient safety and for managing spending.

Rep. Mike Simpson, R-Idaho, said in May that he saw "no tweaks" that could make the Affordable Care Act work. He predicted instead that it would be replaced either by a more decentralized system or a single-payer system like Medicare.

"It's been surprising to me how many people I've heard who, five years ago, wouldn't have said something like that," he said, referring to single-payer. "Business people. Who said, 'Just go to a one-payer system. It's the simplest thing to do.'"

Simpson, who represents the eastern part of Idaho including most of Boise, followed that up by questioning whether single-payer was the "best thing to do."

Democrats have proposed a "public option" that John Cassidy of The New Yorker pointed out is the "way most countries have dealt with" health care.

"So far, the American political system, which is highly vulnerable to capture by powerful interest groups, such as doctors, hospitals, and pharmaceutical companies, has resisted going down this route," Cassidy wrote. "But this may be changing."

-- Fix the glitches.

There are many quirks in the ACA that undermine the law, according to experts.

There's the 30-hour-a-week minimum that workers must put in before employers must offer insurance to them.

There's the "family glitch," which keeps up to 4.7 million people from signing up for health insurance through the ACA.

Audrey Dutton: 208-377-6448, @audreydutton

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