“We need an alternative to the ‘just say no’ policy that has pervaded Democrats up until now,” says Rep. Kurt Schrader (D-OR), who is involved with the new proposal. “Let’s have that conversation. Let’s fix the damn thing and get real.”
The plan notably does not come from House Minority Leader Nancy Pelosi’s office, which has not put forward any similar proposal. An aide said Pelosi was aware of this effort and supportive of the discussion, although did not comment on the specific policies.
Still, it represents a shift from congressional Democrats’ Obamacare strategy thus far, which has largely focused on defending the law — alongside a mounting push for a single-payer-style health plan to replace it eventually.
“Some Democrats are fearful to talk about what is wrong with [Obamacare] for fear we’ll be seen as abandoning it,” says Rep. Peter Welch (D-VT), a relatively progressive Democrat who supports Medicare-for-all. But he says now is a moment to talk about fixing Obamacare, and not single-payer. “There is the practical reality that we’ve got a Republican president and a Republican Congress,” he says. “That’s not the opportune moment for Medicare-for-all. We’ve got to defend what we have.”
The new plan to fix Obamacare, explained
This plan focuses on the Affordable Care Act’s individual market, which is struggling to attract health plans to sell coverage in 2018. There are 38 counties that currently have zero options for next year.
Some of the representatives involved in this effort have districts with significant rural areas, which have particularly struggled to attract multiple insurers.
The marketplaces have never had the robust competition that the health law’s drafters expected. Many plans lost money during their first years and quit. The Trump administration’s uncertain management of the marketplaces and threats of repeal have exacerbated the challenge.
This new plan proposes stabilizing the individual market with the following policies:
Creating a permanent fund to offset the costs of especially expensivepatients. This reinsurance program would funnel extra money to the health insurers who get stuck with high-cost patients. The Affordable Care Act included a program like this, but it was temporary and set to phase out in 2018.
This program would be expected to reduce premiums, as insurance plans would know they’d get federal help for their highest bills. The Democrats’ proposal would make this a permanent program with $15 billion in annual funding. The idea has found at least some favor with Republicans: This week, the Trump administration gave Alaska the funding it would need to create a state-level version of the program.
Making permanent the health law’s cost-sharing reduction subsidies.The Affordable Care Act included subsidies to reduce low-income patients’ copayments and deductibles. The program is currently facing a federal court challenge, where House Republicans have argued the law didn’t appropriate its funding. The White House has floated the idea of halting the subsidies abruptly. This proposal would make them permanent and no longer subject to uncertainty.
Enforcing the individual mandate and advertising open enrollment.This isn’t as much of a fix to the Affordable Care Act as it is a directive to the Trump administration to continue enforcing the health law’s requirement that all Americans purchase health coverage — and let people know when to sign up. Fears were stoked this winter when the administration came into power and quickly canceled outreach advertising contracts the Obama administration had purchased.
One other way the Democrats could strengthen the law would be to make the individual mandate penalty more severe, charging people a higher price to remain uninsured. But the group didn’t go that way, knowing such a proposal would be unpopular — and toxic to Republicans with whom they hope to discuss their ideas. “The mandate may be too hard for the Republicans to swallow,” says Rep. Ami Bera (D-CA).
Possibly changing the open enrollment period to align with tax season.This is an idea that hasn’t gotten mentioned as much: Move the open enrollment season to the spring, to coincide with when Americans are getting their tax returns and may have some extra cash to spend on health insurance. The Trump administration currently plans to end open enrollment on December 31, which some consumer advocates worry will lead those who are cash-strapped from Christmas spending to skip coverage.
A Medicare buy-in for older Americans. This idea was tossed around during the health care law’s drafting, and it would allow the elderly — who face some of the highest premiums in the individual market — to enroll in Medicare instead. The proposal does not specify at what age the buy-in would begin.
Some of these ideas, like the reinsurance fund and the permanent cost-sharing reduction subsidies, are broadly quite similar to reforms recently proposed by the liberal Center for American Progress think tank.
The fixes face an uncertain future in the House
The group of 10 Democrats will roll out their proposal Wednesday morning and then begin outreach on both sides of the aisle, hoping to gin up some momentum for turning the three-page white paper into actual legislation.
Schrader was uncertain about whether Pelosi would endorse the bill and made the case that it might depend on rank-and-file members demanding that this Obamacare fix plan be taken seriously.
“Hopefully a number of members will petition Pelosi and will petition [House Speaker Paul] Ryan about this,” he says. “We’ve got a reasonable solution. I think our leadership is coming around. We’ve worked with them on the timing of this.”
But getting either party on board may be a tough sell. This proposal comes mostly from more centrist Democratic legislators. The more progressive wing of the party has looked at single-payer health care as the next policy objective rather than small tweaks to existing law.
And Republicans have so far been hesitant to do anything to help Democrats run the Affordable Care Act. House members would be unlikely to do so as the Senate continues to debate its repeal bill, which could stretch into early August.
Welch argues the Democrats need to at least start somewhere. That’s what the constituents who show up to his town hall meetings, frustrated with not many choices on the Obamacare marketplaces or too high premiums, expect.
“I’ve got a lot of folks in my district really struggling with some of these problems that we could correct,” he says. “That’s our job. So to not do it, and stand on opposite sides of the line, undercuts our credibility. We’re defining the problem and suggesting concrete fixes. I think that is the only way to get credibility.”