The Ground Has Shifted on U.S. Health Care

Congress’s failed effort to undo Obamacare this year revealed an important political shift in the U.S.: Americans are no longer content to let people go without health insurance. As the Affordable Care Act has taken root, most have come to believe the federal government has a responsibility to make sure everyone is covered.

Republicans should take note: Another stab at destroying Obamacare is not what voters want. Instead, both parties should dedicate themselves to building on it — and, to that end, work is needed by the end of this month, when insurers are due to sign contracts to sell policies on the state exchanges next year.

To be sure, merely shoring up Obamacare won’t bring universal coverage. The law has cut the number of uninsured by half, but 26 million people remain without coverage, and that number is expected to rise. To eliminate this gap, big new initiatives are needed: automatic enrollment of the uninsured into subsidized, no-frills plans, for example, or state programs that let people buy Medicaid policies.

For the moment, however, it’s essential to keep the ACA functioning. President Donald Trump and Republicans in Congress have argued for dumping Obamacare and starting over, but the most sensible path toward universal coverage is to build on the progress already made toward that goal.

The immediate danger is that individual policies sold through state exchanges may be priced out of the market. This threat stems directly from the Trump administration’s efforts to destabilize that market. Each month, the president holds out the possibility that he might refuse to reimburse insurers for lowering some policy holders’ out-of-pocket costs, as the ACA provides. And this is driving insurers to either push up premiums or leave the market altogether.

Congress could counteract the sabotage by expressly appropriating the subsidies, at least through 2018. It could also create a permanent federal reinsurance program to help insurers pay the biggest claims. Alaska and Minnesota have demonstrated how this strategy keeps premiums to a minimum.

Such steps will appeal more to Democrats than to Republicans — so in return Democrats should agree to allow states greater authority to determine the minimum requirements for insurance policies sold on the Obamacare exchanges. Some states, for example, would like to allow relatively cheap catastrophic-care policies combined with health savings accounts to be sold on their exchanges.

Republican Senator Lamar Alexander of Tennessee and Democratic Senator Patty Murray of Washington are having a conversation of this kind. Their push for legislation is made more urgent by the White House’s continuing efforts to sow division. Most recently, the Trump administration slashed the ACA’s advertising budget by 90 percent. If that results in fewer healthy customers being attracted to open enrollment this fall, premiums could rise higher.  

Recognizing that the country’s attitude to health care has shifted should make bipartisan compromise on the issue — hitherto hard to imagine — possible for the first time. Congress needs to stop fighting over Obamacare, and begin discussing how best to get from here to granting all Americans access to health insurance.

–Editors: Mary Duenwald, Clive Crook

To contact the senior editor responsible for Bloomberg View’s editorials: David Shipley at


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