Consensus Is Health Law Can Be Fixed. Now the Hard Part.

Among the hardest hit are those who do not qualify for subsidies to help with premiums or out-of-pocket costs, which rise along with rate increases. Michael Lawson, an independent consultant for local governments in Washington, D.C., said the monthly premiums for his basic plan from CareFirst jumped to $527 this year from $290 last year. He is 60 and earns too much to get a subsidy, but because of various health problems he has already reached his $5,000 deductible for the year. He likes his plan but thinks that to keep rates more stable, Congress and the Trump administration need to do a better job of enforcing the law, particularly its requirement that most people have health insurance.


Demonstrators in front of the Supreme Court in Washington in 2015 cheered after its decision to allow nationwide health care subsidies, which affirmed a key element of the health care law.

Zach Gibson/The New York Times

“They need to enforce the A.C.A. as it’s written,” he said. “Don’t kill it by benign or even malicious neglect.”

The politics are exceedingly tricky in a divided and dysfunctional Washington, but economists, insurers, doctors and health policy experts across the political spectrum agree that immediately addressing three or four basic shortcomings in the existing system would go a long way toward making the law more effective and financially stable.

Stabilize the Markets

There is widespread agreement that the first order of business is to calm very jittery insurance markets. “You need to stabilize things before we change them,” said Michael Neidorff, the chief executive of Centene, one of the few insurers that are aggressively expanding in the market.

Time is of the essence: Next month, insurers must decide what they charge for 2018 or whether they want to stay in the marketplaces at all.

The most significant step would be to guarantee continued funding to reimburse insurers for waiving deductibles and co-payments for low-income customers, as the health law requires companies to do. The Trump administration has threatened to stop making the payments; insurers are now getting them on a month-to-month basis.

If these so-called cost-sharing reductions are not paid for the remainder of the year or in future years, people will see premiums go up by nearly 20 percent to cover them, according to the Kaiser Family Foundation.

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