Everyone agrees the Affordable Care Act exchanges need some fixes. Now a senior House Democrat says Republican leaders are telling her privately that after years of all-out opposition to the law, they are open to working with Democrats after the November elections on measures to improve the functioning of the exchanges.
Rep. Diana DeGette (D-Colo.), the top Democrat on the Energy and Commerce subcommittee on oversight and investigations, said in an interview that she has had a number of private conversations with senior Republicans who have told her they realize the ACA is here to stay and that they can't yank coverage away from the millions of Americans who have benefited. They have told her that “after the election we need to seriously talk about how to improve it.”
In those discussions with Republicans, whom she declined to name, they did not offer specific proposals. She said much will depend on whether Democratic presidential nominee Hillary Clinton wins the election, and whether Democrats or Republicans control the Senate and the House.
DeGette is known as someone who can reach across the aisle and strike deals with Republicans. She is the chief Democratic sponsor of the 21st Century Cures Act, a major bill to expedite federal approvals of new prescription drugs and medical devices. It overwhelmingly passed the House last year and currently is being considered by the Senate.
She said she is in close contact with Energy and Commerce Committee chairman Fred Upton (R-Mi.), Senate HELP Committee chairman Lamar Alexander (R-Tenn.), Democratic Senate leaders, and the White House, and is optimistic that comprehensive legislation to accelerate access to new medical products will pass this year.
Upton's office did not return a call for comment by deadline.
To strengthen competition on the exchanges, candidate Clinton has proposed additional premium subsidies and tax credits for consumers, stronger risk protections for insurers, and the establishment of public plans to compete with private insurers. The Obama administration just released a proposed rule to provide additional financial protections for insurers.
But Republican president nominee Donald Trump and House Republican leaders continue to call for repealing the ACA and replacing it with some type of more market-based system, though details are sketchy.
Some Republican health policy experts have said, however, that full repeal is politically untenable. They instead have proposed that if Clinton wins the election, congressional Republicans should pursue a deal that would give GOP-led states greater flexibility to design market-based approaches to make coverage more affordable and reduce spending in exchange for covering low-income workers in non-Medicaid expansion states. A key element, conservative experts say, would be for a Clinton administration to make it easier for states to obtain Section 1332 waivers under the Affordable Care Act. Those waivers allow states to replace the law's insurance exchange structure with their own innovative models.
Conservative experts also favor changes in the ACA to make coverage more attractive and affordable for younger people, including allowing lower premiums for young people, a wider range of benefit designs and premium subsidies for plans bought outside the exchanges and easing minimum benefit requirements.
Asked what type of fixes her GOP colleagues are willing to consider, DeGette said she doesn't want to guess. “I'm not sure they have thought it out specifically,” she said.
DeGette said she expects Republicans to work with Democrats on finding ways to increase exchange enrollment and competition among health plans, including through re-establishing a risk corridor system. She does not anticipate that Republicans will support Clinton's proposal to establish public plans to compete with private insurers.
Democrats see standard GOP proposals to eliminate the ACA's individual and employer mandates as “not being really fruitful suggestions," she said. "If you eliminate the mandates, you immediately will make it wildly expensive for remaining people in exchanges to afford insurance because you'll limit the size of the pool. We see the elimination of mandates as way to repeal the fundamentals of the ACA. That's not what we mean by improvement.”
We'll probably have to wait until after the election to see what Republicans mean by improvement.