Americans have much to look forward to as the Affordable Care Act goes into full effect in January. But major legislation never passes without political compromise, ensuring that fixes and revisions will be required, just as has happened to Medicare, Medicaid and Social Security. President Barack Obama borrowed heavily from former Gov. Mitt Romney's health reforms in Massachusetts and overlaid a new system atop the established private insurance market. That made the law far more complex and increased the likelihood that changes would have to be made. Now that it's just months from full implementation, the following are among the tweaks needed to ensure more people get health coverage.
Close the bare-bones health plan loophole
An important goal of the ACA was to nearly eliminate health insurance that failed as a true medical safety net, where people would get sick or injured and find out their coverage was lacking.
But a glitch in the law may allow large employers to offer employees coverage that can barely be called insurance. Beginning in 2014, employers with 50 or more full-time employees must offer affordable health coverage or pay a penalty of $2,000 per worker, minus the first 30 workers. Large employers must offer "minimum essential coverage," a term so broadly defined that it appears to be satisfied with plans that cover little more than preventive services, costing as little as $50 per month per employee. Employees who want more coverage could seek it through an exchange, and if they qualify for a federal subsidy to help cover the cost, their employer is penalized $3,000. But some employers appear willing to gamble their low-wage workers won't do so since it would mean additional cash out of their pocket as well. This needs fixing.
Adjust the "full-time employee" definition to minimize evasion
Part-time workers may soon find that the ACA is harming their ability to work a desirable number of hours. In a disturbing trend, workers at chain restaurants, retail stores and even part-time professors at college campuses are having their weekly hours shortened to under 30 per week so their employers can avoid the health insurance mandate. The ACA defines a full-time worker as on the job an average of 30 hours per week or more.
Large employers who are capping hours at 29 per week to avoid the ACA should not get away with it. There needs to be a secondary formula for determining what constitutes a large employer that includes the part-time workforce in some fashion, at least for the purposes of the health insurance mandate and assessing the penalty, if not for providing coverage.
Clarify that states may use expanded Medicaid funds for private insurance
After the U.S. Supreme Court made expanded Medicaid under the ACA optional for the states, some conservative lawmakers objected to adding participants to traditional Medicaid. To overcome this resistance the Obama administration has said it will grant waivers to states that want to use expanded Medicaid funds to buy comprehensive private insurance for low-income people, as long as the costs are the same.
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A Florida Senate-passed plan would have needed such a waiver. But the Florida House refused to go along. Florida House Speaker Will Weatherford, R-Wesley Chapel, claimed the waiver might not come through — one of many excuses he made to reject $51 billion in expanded Medicaid funds over 10 years that would have extended health coverage to nearly a million poor adults. The law needs to eliminate this excuse.
Provide federalsubsidies to adults under the federal poverty line to buy private health insurance on the exchanges
The poorest Americans in states that reject expanded Medicaid are caught in a bind. They will have to pay more for private health insurance on the online exchanges than people far wealthier. That's because the ACA provides federal subsidies only to people earning between 100 and 400 percent of the federal poverty line (for individuals 100 percent is $11,490 in 2013; 400 percent is $45,960). The law anticipated that adults with incomes under 138 percent of the federal poverty line would be covered by expanded Medicaid. But in places like Florida where Medicaid expansion has been rejected, a change is needed so these adults can also receive federal subsidies.
These recommended revisions would close problematic loopholes and coverage gaps. Republicans in Congress are resisting any efforts to better Obama's signature domestic achievement, holding out instead for a wholesale repeal of the ACA. It is a virtual obsession in the Republican-controlled House, which has voted for a full or partial repeal 37 times. But these changes would serve their constituents without costing any additional tax money. Florida Gov. Rick Scott, a fierce opponent of the ACA, was willing to accept expanded Medicaid funds for the good of Floridians. Republicans in Congress should make the same calculation and end their obstruction and help make the law better.