How to improve the Affordable Care Act

Here’s some news from 2020 that seems almost good: Despite heavy job losses during the pandemic, the proportion of Americans without health insurance didn’t spike, as you might have expected. Some employers maintained their coverage. Many of those who lost their employer-provided policies picked up Medicaid coverage instead. And others bought individual policies on the state and federal Obamacare marketplaces.

This illustrates how the 2010 Affordable Care Act broadly improved Americans’ health security — by making it possible to buy good-quality, often subsidized insurance, and by expanding eligibility for Medicaid.

Even so, the uninsured population in the U.S. remains unacceptably large — nearly 30 million people, according to the Census Bureau’s 2019 count, and probably more now, as the number rose steadily while Donald Trump was in the White House. His team worked what mischief it could — shortening to six weeks the fall window for buying insurance on the federal marketplace, for example, and taking various steps to squeeze Medicaid enrollment. President

Joe Biden is right to move quickly to reverse the damage.

Biden’s first step has been to reopen the federal Obamacare marketplace for three months beginning Feb. 15, and to boost outreach and marketing efforts to help people figure out which policies are most economical for them. Several states that run their own insurance marketplaces have likewise provided special enrollment windows for people who have lost employer coverage during the pandemic.

Some 4 million uninsured, low-income Americans could take this new opportunity to obtain health insurance at no cost because they are entitled to federal subsidies large enough to cover their entire premiums, according to the Kaiser Family Foundation. Another 4.9 million qualify for subsidies to cover a large part of their premiums.

Biden has also told federal health agencies to review many administrative changes that the Trump administration made to weaken the ACA — including an 84% cut in the budget for helping people navigate insurance exchanges, and a decision to allow substandard “short-term” insurance policies to last as long as three years.

Also under review will be two kinds of state Medicaid waivers floated by the Trump administration. One kind would allow states to impose work rules for Medicaid beneficiaries, potentially knocking hundreds of thousands of people off the program. The other would allow states to restrict Medicaid coverage in return for limited federal funding (block grants). Such waivers were obviously not designed to advance Medicaid’s mission to provide health coverage for the poor, and are properly being challenged in court. Biden’s new secretary of Health and Human Services (California Attorney General Xavier Becerra has been nominated) should rescind them.

Biden can further buttress the ACA by working with Congress to enlarge subsidies for low-income families buying individual policies. One good strategy is included in the COVID-19 relief package now under consideration: replacing the existing income ceiling for subsidies — set at 400% of the federal poverty line — with a commitment to ensure that no one spends more than 8.5% of their income on premiums.

A bare majority could also nullify a prominent lawsuit seeking to invalidate the ACA that was filed by Republican-led states, supported by the Trump administration, and heard but not yet decided by the Supreme Court. All that’s needed is to restore the individual mandate’s tax penalty, even if it were set as low as a dollar. Democrats might also be able to create, through budget reconciliation, new incentives for the 12 states that have not yet expanded Medicaid under the ACA to do so.

Probably off the table this year, given the Democrats’ slim advantage in Congress, are two of Biden’s signature campaign proposals: a public insurance option, and a reduction in the Medicare age from 65 to 60. Even if those efforts have to wait, progress through smaller steps is feasible. The administration should do everything it can to repair and fortify the ACA. This editorial comes from the Bloomberg Opinion editorial board.