Something strange is happening in Washington.
Democrats and Republicans in Congress are talking about working together.
On a healthcare bill, no less.
The discussions began after the Republicans’ “skinny” repeal plan for the Affordable Care Act (ACA) suffered a narrow defeat a week and a half ago.
Since then, Republican Senator Lamar Alexander of Tennessee announced his health committee would hold bipartisan hearings in September on ways to stabilize the insurance marketplaces.
These bipartisan efforts are not a sure thing.
Conservatives in Congress still say they won’t vote for anything that falls short of repealing the ACA.
And there is some urgency.
Insurance companies need to sign contracts with the federal government by Sept. 27, detailing what insurance plans they will sell on the marketplaces in 2018.
Without a solid plan, some insurance firms could decide to leave the system.
With all this going on, experts interviewed by Healthline said there are a number of things that most people agree need to fixed in the ACA, as well as a number of things most people think should stay.
“Why repeal something that has a lot of good in it,” said Kurt Mosley, vice president of strategic alliances at Merritt Hawkins healthcare consultants. “Let’s reform it.”
What needs to be fixed
One of the top things Mosley and others agreed needs to be repaired is the state insurance marketplaces.
That’s where people without employer-sponsored or government-sponsored healthcare can purchase insurance plans. Almost 11 million people are enrolled in those policies this year.
The best way to shore up those marketplaces, the experts said, is to continue the federal cost-sharing subsidies to insurance companies to help with low-income policyholders.
President Trump has threatened to cut off these “bailouts.”
The experts, however, said that would be a mistake. In fact, they recommended the subsidies not only continue, but also be guaranteed. That is also one of the provisions in the Problem Solvers Caucus’ five-point plan.
“The subsidies have to be in place or the insurance companies will drop out,” Mosley told Healthline.
“If insurers know their coverage of expensive patients is backed up, then they can keep rates lower for all,” added Jeananne Sciabarra, executive director of Consumer Health First.
Sciabarra suggested the maximum income to qualify for subsidies be raised so more consumers could participate.
“Middle income people are really getting squeezed out,” she said.
Dr. Meghana Rao, an OB-GYN who is on the board of directors of Doctors for America, suggested a public option be added to the state marketplaces.
That, she told Healthline, would increase competition and give consumers a low-price alternative.
Another key, the experts said, is to continue the expansion of Medicaid.
Currently, 31 states and the District of Columbia have expanded the Medicaid program under Obamacare to cover more people with lower incomes.
Officials in some of the 19 states that don’t have Medicaid expansion have talked about joining the program if the ACA isn’t repealed.
The experts said the Medicaid expansion provides more people with insurance, which stabilizes the overall marketplace.
Sciabarra also recommended legislators fix the “family glitch” issue. That’s where members of some households cannot buy ACA marketplace insurance if the breadwinner in the family has coverage through their employer.
“It definitely is a problem,” she told Healthline.
Sciabarra also said the new plans should have some mechanisms to lower the higher deductibles required in some plans.
“It really does discourage people from using their insurance,” she said.
Mosley agreed. He noted that some of the “bronze plans” in the ACA have annual deductibles of $6,100 for individuals and $12,000 for families.
“That’s not really being insured,” he said.
Mosley would also like to see more health saving accounts (HSA) offered. That, he said, would attract more young adults.
The key to shoring up the ACA, the experts agreed, is simply getting more insurers into the marketplaces and more people signing up for coverage.
What should be kept
The experts agreed that the most important thing to keep in place in the ACA is the individual mandate.
That’s the requirement that everyone purchase insurance. Consumers who don’t purchase insurance pay a penalty on their income taxes.
The experts said without the individual mandate, the ACA marketplace would collapse because insurance companies wouldn’t have enough less-expensive healthy people on their rolls to help pay for more expensive clients.
“It won’t work,” said Mosley. “Unless you have the mandate, younger people won’t sign up.”
“There’s no way it works unless everybody buys into the system,” added Rao.
The experts agreed that the penalty for not signing up should be higher. Right now, it’s cheaper than paying insurance premiums for most people.
The experts also said the basic coverage requirements for employers should also stay. That provision spells out the minimum coverage companies with at least 50 employees must provide for their workers.
The Problem Solvers Caucus agreed, except they want to change the provision so it only applies to companies with at least 500 employees.
The experts also agreed that the provision requiring insurance firms to provide coverage for people with preexisting conditions should stay.
They also said the provision that allows adults under 26 years of age to remain on their parents’ health insurance is a vital component.
Will they do it?
So, will Democrats and Republicans be able to pull this off?
Will they be able to resist the pressure from the left side and right side of the political spectrum and compromise on a healthcare plan?
That’s anybody’s guess, but there is hope.
“Instead of just focusing on killing the ACA, we’re focused on fixing it in a smart way,” Rep. Josh Gottheimer, D-N.J., of the Problem Solvers Caucus told CNN last week.
The experts also show some glimmers of optimism.
“I think the momentum is in the right direction,” said Sciabarra.
“I hope so,” added Rao. “I think they will. But maybe I’m just young and naive.”
Mosley noted the track record so far isn’t encouraging.
“They haven’t been able to do it yet,” he said, “but they really need to. There’s no other choice.”