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Building on Obamacare

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The Affordable Care Act is arguably the biggest progressive legislative victory since the Johnson administration. It’s also deeply flawed and in need of update in many areas. These two statements are not contradictory. The question, as Jim Newell asks, is whether Democrats are ready to build upon that great victory and improve the law.

First, some of the issues, which have been more in the news lately because of Aetna deciding to play the villain.

But it’s becoming clearer that the Affordable Care Act, for all its advances, is due for the sort of legislative maintenance that most major laws require after implementation. Two temporary federal programs, reinsurance and risk corridors, designed to cushion losses for insurers as they determined sustainable premium price points in new markets, expire in 2017 as the exchanges enter their fourth year of operation. Carriers serving sicker-than-expected pools or rural areas find that their options are either to sharply increase premiums or to leave the exchanges altogether. Average premium increase requests from insurers on the individual exchanges are well into the double digits across much of the country. And a Kaiser estimate in May projected the number of counties that could have a single exchange insurer in 2017 to be 664—70 percent of which are mostly rural—up from 225 in 2016. That number will increase following Aetna’s withdrawal and could reach roughly a quarter of all counties in the country. Alabama, Alaska, South Carolina, and Wyoming are set to have just one insurer offering coverage on their exchanges in 2017. Most of North Carolina, except for the Raleigh metropolitan region, will be down to one insurer as well.

One problem with legislative redress for Obamacare is that the legislators who are supposed to do the redressing seem less than eager to return to the front where not long ago they’d declared victory. The second problem is that, once again, the fight will almost certainly involve the public option.

So what about the public option and what, if anything, are Democrats ready to do if they have a big win in November? Newell correctly notes that most Democratic politicians see the fight as protecting the ACA from Republicans and therefore really not articulating any changes. He does have a slight bit of hope that Hillary Clinton will push toward something like the public option.

There is one Democratic figure who might be in office in 2017 who has treated the law’s shortcomings seriously and put together a bevy of health care proposals—and she happens to be the party’s presidential nominee.

In the beginning of the campaign, Hillary Clinton, too, suffered from the “everything is fine!” bug, going so far as to red-bait Sen. Bernie Sanders over his Medicare-for-all plan. Sanders’ specific proposal suffered from some fuzzy math. But he understood that though the ACA was a vast improvement on an untenable status quo, its flaws really were flaws, and it made little sense to avoid confronting them just because doing so would be a pain. One staple of Sanders’ events during the campaign was to ask members of his crowds to raise their hands if they were facing sharp premium increases, and then to say how large the increase was. There was never a shortage of volunteers.

Eventually Clinton put together a series of health care proposals. It wasn’t the overhaul Sanders wanted, but he gave his enthusiastic endorsement anyway. Clinton would add a Medicare “buy-in” option for those 55 and older, and she also committed to doubling the money for community health centers from the funding mark set in the original ACA, an important provision won by Sanders in 2009. She offered further inducement for states that haven’t already accepted the Medicaid expansion to do so and would grant the HHS secretary additional “authority to block or modify unreasonable health insurance premium rate increases,” increase resources for enrollment outreach, and expand existing exchange subsidies.

And yes, she’s also pledged to “pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan.”

It’s unclear how high a public option, and the political fight that will come with it, ranks atop Clinton’s list of priorities. But if 2017 open enrollment goes poorly and more insurers flee the exchanges, the public option—which has always polled well—would be an obvious go-to solution for restoring competition. The idea doesn’t rely on hand-holding private insurers until they feel properly incentivized to perform their societal function. It is a direct delivery of health insurance plans to health insurances exchanges. “Health care markets will inevitably differ from region to region,” Jacob Hacker, the Yale professor and so-called “father of the public option,” wrote in Vox on Thursday, “but there’s no reason every one of the existing marketplaces couldn’t offer a Medicare-like plan—a plan that’s stable; a plan with predictable costs; a plan that gives patients a broad choice of providers just as Medicare does.” It would also save money—$158 billion over 10 years, according to a 2013 Congressional Budget Office estimate.

There’s another problem that Newell does not discuss, but that I feel. The ACA was a big win but the Tea Party’s rise and McConnell destroying the historical norms of the Senate has meant that it’s now been 7 years since we have seen a major progressive bill become law. The victories of the last 7 years have been in the courts (especially in the last few months) and through the executive branch. There are a lot of other priorities that have been ignored or put aside. If Clinton wins and has the ability to pass any legislation (just play along here), I think her top two priorities should be an immigration bill with a path to citizenship for undocumented Americans and a sizable minimum wage increase. Both of these have significant political support and are fairly simply to articulate. After that, maybe health care comes back on the table, but so does a climate bill, college tuition and debt issues, a revived Employee Free Choice Act, and a whole lot of other things. Given all of this, to what extent should Democrats fight to improve Obamacare?

Which, in other words, means that this could serve as a thread on what you think Clinton’s top legislative priorities should be, in particular keeping in mind what is actually possible, even if she does have 55 senators and a narrow House majority for the precisely 2 years that will probably last.

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