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ACA Wish List: What Experts Say Congress Should Change About the Law This Year

The House has voted to repeal the Affordable Care Act in its entirety six times — but the measures have never advanced any further. While not everyone thinks that the law should be completely dismantled, most experts agreed that some changes are in order.

During a panel discussion earlier this month at Academy Health’s 15th Annual National Health Policy Conference, speakers discussed — and sometimes disagreed about — what parts of the law they think Congress should fix this year.

What Should Change for Businesses

Sabrina Corlette, with Georgetown University’s Center on Health Insurance Reforms, outlined several items related to employer-based health coverage under the law that she’d like to see addressed.

First, she said that Congress should “repeal the ACA provision allowing employers to charge workers up to 50% more for failure to participate in a wellness program or achieve a wellness target.” Corlette argued, “There is minimal evidence that these programs do anything to improve health problems or reduce employer costs,” adding, “What we do know is that some of these programs are simply subterfuges for existing costs.”

Instead, Corlette said legislators should make changes to the law that would give insurers “greater incentive to cover primary care and chronic disease management pre-deductible.” She said, “We know that deductibles are an effective tool for containing costs, but they are a very blunt instrument,” noting that individuals with high-deductible plans often delay or forego both unnecessary and necessary care.

Corlette also said Congress should cancel plans to expand the definition of small group coverage. The change defines small businesses as those with 100 or fewer workers — up from the current definition of 50 or fewer workers. The change is set to take effect next year.

“I’m generally of the school of thought that if something isn’t broken, we shouldn’t try to fix it,” Corlette said, adding, “By moving the definition to 100 or fewer employees, I think it will result in a lot of frustrated and angry employers.” She also noted that the change “could lead to a number of employers deciding to self-fund.”

Fixing the ‘Family Glitch’

Judith Solomon, vice president for health policy at the Center of Budget and Policy Priorities, said one of the most important ACA issues that must be fixed is the so-called “family glitch.” Under an ACA provision, some low- and moderate-income families are at risk of being locked out of receiving health subsidies. Subsidies are based on whether families have access to “affordable” work-based health coverage, but the definition of affordable is based solely on the cost of individual coverage — not the cost of a family plan.

Solomon said the provision “bars a lot of dependents from receiving affordable health coverage.”

Dealing With Subsidy Overpayments

As tax season gets underway, Solomon said another issue is becoming apparent. “The problem is that there’s no relief valve for people who just kind of did everything they were told, gave all the right information [to receive subsidies under the ACA], but it ended up wrong and now they’re facing” having to repay subsidy overpayments.

Solomon noted that the Social Security system has “a ‘waiver of overpayments’ provision.” Under the measure, “if an overpayment resulted from something that was no fault of the person — it was a glitch or error — and recovery would be a hardship (and it often was), you could get a waiver.” She added, “These were not easy to get; the hardship inquiry was fairly rigorous.”

She said, “I think we need that relief valve in the premium credit as well.”

However, Joseph Antos, with the American Enterprise Institute, said, “I don’t think the solution is to find a relief valve because a relief valve doesn’t solve the complexity of the problem.”

Solomon also suggested that lawmakers could reinstate a larger cap on overpayments so that consumers “don’t fall off that cliff and have to pay so much back.”

Ensuring Assistance Is Available

Meanwhile, Solomon suggested that Congress “establish a permanent and professional cadre of consumer assisters” to help individuals obtain coverage, subsidies and other services related to the ACA. She noted that funding for such assisters currently is on a year-to-year basis, so “a lot of the programs don’t know if it’s going to continue.”

In addition, Solomon said call centers — including those run by the IRS and HHS — need to be fully funded so that assistance is available to consumers. However, Solomon said, “This is not something that has to stay at a top level forever,” adding, “If we fix the IT … we won’t need as many people in the call center, but right now we do.”

Simplifying the Law Overall

Jon Kingsdale, director of the Wakely Consulting Group, said the ACA “took the most complex health care system on God’s green earth and made it 10 times more complex.” Kingsdale said the best way that Congress can improve the law is to “simplify, simplify, simplify.”

For instance, Kingsdale said that the system for calculating tax credits under the law is “ridiculously complicated.” He suggested that Congress should replace that system and instead offer progressively graduated tax credits based on income level and household size.

In addition, Kingsdale suggested eliminating the “platinum” level for insurance plans sold through the exchanges. Currently, the ACA exchanges offer four metallic plan levels:

  • Bronze, which covers 60% of health care costs;
  • Silver, which covers 70%;
  • Gold, which covers 80%; and
  • Platinum, which covers 90%.

Kingsdale said the ACA should instead return to the “good old Olympic standard” of bronze plans covering 60%, silver plans covering 75% and gold plans covering 90% — thereby removing the platinum option.

Any Chance Left for a Full Repeal?

Antos — another speaker on the panel — made other suggestions for fixing the ACA this year, including eliminating the law’s mandates and creating high-risk insurance pools. But he said the thing that Congress really should do is “repeal and replace” the law completely.

While some, like Antos, might think it would be easier to scrap the law in its entirety and start over, panel moderator Timothy Jost, with Washington and Lee University’s School of Law, argued, “At this point, repealing the ACA is no more possible than repealing the interstate highway system.”

Around the Nation

Data fees thwarting health reform goals. Arthur Allen writes in Politico that the exorbitant prices charged by vendors to transmit and receive health data are holding some doctors back from digitizing their records.

Roberts’ rules. Reuters reports that another Supreme Court ruling related to the ACA — this time related to the law’s premium subsidies — could once again come down to Chief Justice John Roberts’ opinion.

Red states prove ACA works. Some of the fastest drops in uninsured rates across the U.S. occurred in two predominantly red states — Arkansas and Kentucky — that opted to embrace the ACA.

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