How Democrats Would Change Obamacare

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.