Dr. Richard Feldman: Four steps to affordable health care for everyone in U.S.

The Affordable Care Act’s future continues in doubt.

Changes in presidential leadership and Senate majority could portend a more positive outlook for the health care law. Meanwhile, the U.S. 5th District Court of Appeals upheld a lower court’s decision that the individual mandate became unconstitutional when Congress revoked the tax penalty for failure to buy insurance. This fall, the U.S. Supreme Court will hear the case and decide if the mandate is unconstitutional and, if so, whether it invalidates the entire law. Invalidation would result in loss of insurance and coverage safeguards for millions and plunge the health care system into chaos.

Nevertheless, fixing Obamacare to create a better and more equitable law and potentially achieve universal health insurance coverage was the subject of a New England Journal of Medicine article. It’s one of the clearest attempts to address this issue I have seen. Along with some of my own perspective, let me share its ideas.

Before Obamacare, our country failed to appreciably reduce either health care costs or the percentage of the uninsured. After the ACA’s enactment, the escalating costs moderated and the portion of uninsured fell from 16% to 9%. Still, Obamacare was far from a perfect system and never achieved universal coverage.

The article outlined four basic steps to achieve these goals. This wasn’t necessarily an all-or-nothing proposal; enacting portions of it could be a “stepping stone” to universal coverage.

First, ensuring Medicaid expansion in all states could be accomplished with a combination of a penalty and an incentive. The “stick” is reducing the amount of federal matching rates for Medicaid for states that fail to expand, and the “carrot” is increasing the federal matching rate for those that do.

It wouldn’t need to be a large increase (2%) to make expansion essentially free for a typical state. Recall that the Supreme Court struck down the ACA mandatory state expansion as “unconstitutionally coercive,” which required the expansion to retain the entirety of the Medicaid federal match. This small percentage would protect this action from such a judgment. It would also preserve coverage for Medicaid patients in states that refuse to expand.

Second, increasing eligibility and amounts of marketplace cost-sharing subsidies and premium tax credits is essential to making Obamacare more equitable and more appealing to individuals to obtain coverage. This would include expanding subsidies to people at over 400% of poverty, the current limit. It appears to me that, if one receives a subsidy, Obamacare is great, but for those who are not eligible, even those of middle income, the ACA is not necessarily so affordable.

And third, higher-income people not obtaining coverage would be automatically enrolled in a “backstop” insurance plan, either public or private. Patients would be charged premiums through their income tax return.

Although controversial, the final step to ensure true universal coverage would be to grant immigrants not in the country legally, one-sixth of the population, eligibility for insurance programs by changes in immigration policies and paths to citizenship.

Financing sources to attain these changes could be similar to those already in effect for the ACA. Additionally, reducing the price of health care services through various strategies, including a public-plan option to increase private insurance competition, could be implemented to reduce costs to the entire system.

Medicare-for-all proposals are exceedingly expensive and currently politically unfeasible. Given there is no coherent Republican health care reform plan, fixing Obamacare would be an affordable and achievable way to proceed.•

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Feldman is a family physician, author, lecturer and former Indiana State Department of Health commissioner for Gov. Frank O’Bannon. Send comments to ibjedit@ibj.com.

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