Congress Can Fix the ACA With These Three Principles

The ACA contains myriad problems; these and other provisions will come under increased scrutiny going forward. As lawmakers approach repairs, they will need to bear in mind what is politically achievable as well as what is fiscally responsible.

The Affordable Care Act presents the incoming Congress with substantive and political challenges. On the one hand its widely-acknowledged problems warrant repair, and the electorate has made its displeasure with it loud and clear. On the other hand, the whole ACA will not be repealed while there is power-sharing between a Republican Congress and a Democratic administration. Consequently this Congress will need to be very clear-sighted about what it can fix and what it cannot. 

I do not pretend to have all the answers to questions that are as much tactical as they are substantive. However, I suggest that three foundational principles guide the new Congress’s approach to the ACA.

Principle #1: Fixes should address clear substantive problems. There is no shortage of these, evidenced by the fact that the law’s sponsors have repeatedly concluded that the law cannot be safely implemented as originally written. With so many substantive problems in need of repair, Congress need not waste energy debating symbolic or ineffectual measures. 

Principle #2: Fixes should improve the law’s finances or at least not worsen them. This is important. The ACA encompasses a vast expansion of federal health spending obligations, financed by a number of controversial savings measures and new taxes. It would be tempting but irresponsible to worsen fiscal problems by selectively attacking its controversial financing measures while leaving its spending provisions intact. This does not mean that various savings and tax provisions should not be repealed, but such actions are best accompanied by cost reductions.

Principle #3: Reformers should begin with fixes that can attract bipartisan support. Again, there is no shortage of these; many ACA provisions are opposed on both sides of the aisle. This is simple realism given that the president supports the ACA and will not sign its repeal. The ACA’s supporters committed a huge tactical blunder in 2010 by pushing the law through in a manner guaranteed to unite the opposition party against it. Those who want to fix problems with the ACA should avoid repeating this mistake in reverse when bipartisan options are available.

Below is an incomplete list of the law’s major provisions, as well as some subjective guesses on how they fit into these various categories. Other experts may disagree with my reads on them.

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