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.

Sen. Tammy Baldwin attends a press conference on the positive affects of the Affordable Care Act in July 2015.
AP Photo/Andrew Harnik
April 21, 2016, 8:01 p.m.

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.

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