The American College of Physicians (ACP) published a position paper April 16 in the Annals of Internal Medicine, voicing their discontent with recent federal actions to weaken the Affordable Care Act and offering seven recommendations on how to improve it.
The ACA has had its fair share of ups and downs since it was signed into law in 2010, wrote Ryan A. Crowley, BSJ, and Sue S. Bornstein, MD, who penned the paper on behalf of the ACP’s Health and Public Policy Committee. While the law has regulated protections for patients with preexisting conditions, made non-group coverage more affordable for Americans and expanded access to health insurance across the country, it also struggled in its early years, grappling with technical issues and underfunding.
“Despite impressive improvements in insurance status, access to care and economic security measures, the ACA is imperfect and several repeal efforts and poor stewardship threaten to exacerbate the law’s problems,” Crowley and Bornstein wrote.
The authors said ACA sign-ups were better this year than last—2018 open enrollment reached 10.6 million individuals—but recent actions like killing the individual mandate penalty and expanding the availability of unregulated insurance products could have a detrimental effect on that trend.
“Other problems are a product of the law’s design, including limits on premium tax credit and cost-sharing reduction (CSR) eligibility,” Crowley and Bornstein said. “Although a recent report indicates that the number of uninsured persons remained steady in the first three months of 2018, the Congressional Budget Office projects that the number of uninsured will rise from 32 million to 35 million during 2019 to 2028.”
The ACP committee reviewed studies, reports and surveys on the ACA from PubMed, Google Scholar, news articles, policy documents and medical journals and agreed on seven recommendations that could strengthen Obamacare. In brief, these were their points:
- Act fast: Immediate efforts are needed to strengthen the ACA and prepare for an overhaul of the healthcare system, especially if we’re looking to achieve universal coverage.
- Redesign tax credits: Eligibility requirements for premium tax credits and cost sharing should be reworked to enhance individual market insurance affordability, and the 400% federal poverty level premium tax credit eligibility cap should be eliminated.
- Establish a reinsurance program: Federal and state regulators should stabilize the marketplace by establishing a permanent reinsurance program and limit the sale of individual market plans that don’t comply with ACA regulations.
- Ensure funding: The government will need sustained funding for outreach, consumer assistance and education to promote open enrollment.
- Mandate insurance: Federal and state governments should ensure all residents (with some exemptions) enroll in coverage, either by establishing an auto-enrollment program, an individual mandate or enacting a penalty for failing to enroll.
- Expand Medicaid further: The ACP supports full Medicaid expansion in all states. Expansion began in 2014 and has allowed millions of low-income adults to enroll in health coverage.
- Authorize a public plan: Congress should enact legislation to authorize the development of a public insurance plan, ensuring enrollees have access to a multitude of coverage options and encouraging market competition.
Crowley and Bornstein said that to accomplish universal coverage—the source of an ongoing debate in Congress—lawmakers will need to transform the U.S. healthcare system into one that’s less complex and less costly.
“For policymakers, the pragmatic proposals offered here will require substantial political will and funding,” they wrote. “If these proposals are fully implemented, coverage and market stability problems will probably remain. However, adopting these policies will be a step toward realizing what has been an unachievable goal: affordable, comprehensive insurance for all.”