Sen. Tammy Baldwin, D-Wis., attends a press conference in July highlighting the positive aspects of the Affordable Care Act.

Sen. Tammy Baldwin, D-Wis., attends a press conference in July highlighting the positive aspects of the Affordable Care Act. Andrew Harnik/AP

How Democrats Would Change Obamacare

If they keep the White House and win the Senate—and don’t have to focus their energy on blocking repeal—Democrats have some things about the Affordable Care Act they’d like to fix.

With the GOP in con­trol of both cham­bers of Con­gress, Demo­crats have spent the lat­ter part of Pres­id­ent Obama’s time in of­fice fight­ing to pre­serve his sig­na­ture policy achieve­ment—the Af­ford­able Care Act.

But with Demo­crats now po­ten­tially in po­s­i­tion to both keep the White House and cap­ture the Sen­ate in Novem­ber, the party can try to fo­cus on ways to re­form and ex­pand Obama­care, rather than just block­ing Re­pub­lic­ans from re­peal­ing it.

Demo­crats don’t think the ACA is per­fect. On their wish list are small tweaks or ad­di­tions they hope lead to more af­ford­able and uni­ver­sal cov­er­age—and they hope the GOP, which most ex­perts still fa­vor to keep the House, can move past its “re­peal and re­place” calls.

In in­ter­views, Sen­ate Demo­crats poin­ted to items like sort­ing out the “Ca­dillac tax,” build­ing on de­liv­ery-sys­tem re­forms, mak­ing sure states are af­forded flex­ib­il­ity in the law, and more. The Demo­crat­ic pres­id­en­tial front-run­ner, Hil­lary Clin­ton, has based her own health plat­form on pro­tect­ing and build­ing on the Af­ford­able Care Act. Her pro­pos­als in­clude adding a new tax cred­it to help with ex­cess­ive out-of-pock­et med­ic­al costs, cap­ping monthly pre­scrip­tion-drug costs, and al­low­ing three free sick vis­its per year, to name a few.

The Af­ford­able Care Act was the product of much polit­ic­al wrangling, passing in 2009 without a single Re­pub­lic­an vote. At least 18 times, le­gis­la­tion has been en­acted amend­ing the ACA, in­clud­ing some tech­nic­al ad­just­ments and cla­ri­fic­a­tions in the 111th Con­gress and some sub­stant­ive bi­par­tis­an al­ter­a­tions later on, ac­cord­ing to a Feb­ru­ary Con­gres­sion­al Re­search Ser­vice re­port. But the law’s con­ten­tious polit­ics don’t make changes and health care le­gis­lat­ing easy.

The ACA “was a com­plex un­der­tak­ing,” Demo­crat­ic Sen. Tammy Bald­win told Na­tion­al Journ­al, “and there were things ob­vi­ously that need per­fect­ing, need re­vis­it­ing. Even if it were per­fect, over time we would have ad­apt­a­tions we’d need to make, and so I think we would ab­so­lutely want to strengthen it.”

To bol­ster the law, Bald­win’s of­fice poin­ted to sev­er­al pieces of Demo­crat­ic le­gis­la­tion she has co­sponsored over the years: grant­ing the same fed­er­al funds to states choos­ing to ex­pand Medi­caid after 2014 as those that made the de­cision earli­er; fix­ing the “fam­ily glitch,” which keeps fam­il­ies with un­af­ford­able em­ploy­er cov­er­age from ac­cess­ing tax cred­its; and re­peal­ing the Ca­dillac tax with a sense-of-the-Sen­ate that the rev­en­ue be off­set.

“Oh, I think there’s a list,” Sen. Claire Mc­Caskill said of changes she’d like to see to the ACA. “And this is prob­ably not a hall­way con­ver­sa­tion, but there’s a list of things we could im­prove upon.”

But the Mis­souri Demo­crat began to quickly tick off a whole host of items any­way: con­tinu­ing to re­align in­cent­ives so the fo­cus for doc­tors is help­ing people stay well, and ex­amin­ing how to lower Amer­ic­ans’ health care costs while still “giv­ing them skin in the game, so that they care how much they’re spend­ing on health care.” And she poin­ted to an is­sue im­pact­ing Mis­souri and oth­er con­ser­vat­ive-lean­ing states: “work­ing with the states to provide as much flex­ib­il­ity as pos­sible so that we can ex­pand Medi­caid in those states that have stub­bornly re­fused to.  

“That is a huge prob­lem in my state,” she told Na­tion­al Journ­al. “And I know it is in dozens of oth­ers.”

She wasn’t the only mem­ber to men­tion provid­ing more flex­ib­il­ity to the states. The top Demo­crat on the Fin­ance Com­mit­tee, Sen. Ron Wyden, poin­ted to Clin­ton’s plan to build upon the Af­ford­able Care Act, which in­cludes let­ting gov­ernors pur­sue a pub­lic op­tion through flex­ib­il­it­ies offered un­der the law it­self. This could pos­sibly be done through the state in­nov­a­tion waiver—a pro­vi­sion in the ACA au­thored by Wyden that al­lows states to re­ceive per­mis­sion to waive parts of the law start­ing in 2017 (as long as cov­er­age is still af­ford­able and com­pre­hens­ive by ACA stand­ards).

And there’s been bi­par­tis­an agree­ment on re­peal­ing the Ca­dillac tax. Last Decem­ber’s om­ni­bus bill delayed the im­ple­ment­a­tion of the tax levied on pricey em­ploy­er-sponsored health cov­er­age, and a vote for re­peal passed 90 to 10 (though it was an amend­ment tacked onto the re­con­cili­ation bill, which Pres­id­ent Obama ve­toed). Many Demo­crats are in fa­vor of get­ting rid of the tax for good, sev­er­al—such as Sens. Ben Cardin and Chris Murphy—said they would want to make sure any po­ten­tial im­pact from the lost rev­en­ue is dealt with re­spons­ibly.

But however long or short the wish list of changes or ad­di­tions may be, Wyden says, if the Demo­crat­ic Party wins the White House and the Sen­ate, there’s a “threshold ques­tion” to tackle first: “Can we get bey­ond the de­bate of re­peal­ing the Af­ford­able Care Act?”

Be­cause, as Murphy put it, there’s “more to the health care sys­tem than the Af­ford­able Care Act.” The Con­necti­c­ut Demo­crat said it’s time to move on, that there’s a “next gen­er­a­tion of health care re­form” to tackle, such as ad­dress­ing high pre­scrip­tion-drug costs and re­form­ing the coun­try’s men­tal-health sys­tem.