Fixing/Improving the Affordable Care Act (ACA)
Cover everyone with affordable and effective care
As a nation we have had a hybrid system of health coverage. Public coverage for the poor, elderly, and disabled. Private employment-based coverage for the workers and their families. There were huge gaping holes in that model that the Affordable Care Act (ACA) tried to fill and fix in 2010.
1) Many employers did not offer coverage, particularly the smaller and lower wage businesses.
2) Medicaid in most states did not cover the working poor.
3) Many insurers would not cover individuals with a range of pre-existing medical conditions.
4) The numbers of uninsured were growing, and the numbers of insured were shrinking, as was the extent of their coverage,
5) There were a growing flex workforce or gig workers without access to affordable coverage, and
6) Insurers and employers were increasing copays and deductibles beyond the ability of workers to access covered services and putting sick patients deeply into debt and medical bankruptcies.
The Supreme Court, many deep red states, and Republicans in Congress and the White House have sought to dismantle and destroy, rather build upon and improve the ACA. These are a range of ideas on how to improve the American hybrid system short of adopting a Canadian style single payer or a British style fully socialist system, which, while much better systems, would require a very expensive and thus politically challenging transition.
· Replace the individual mandate with a health coverage tax
The ACA was premised on an individual mandate that required everyone to enroll in health coverage or pay a small fee; this pay or play concept was paired with affordable and available coverage for everyone. This was an idea originally pioneered by the Heritage Foundation as an alternative to the Clinton Health Plan in the 90’s which had been structured around an employer mandate. https://www.heritage.org/social-security/report/assuring-affordable-health-care-all-americans
The Supreme Court in upholding it, said it was really a tax, not a mandate. https://supreme.justia.com/cases/federal/us/567/519/ The individual mandate was the most singularly unpopular component of the ACA, and it was repealed during the first Trump Administration. https://www.commonwealthfund.org/sites/default/files/2018-07/Eibner_individual_mandate_repeal.pdf Some states still have them. https://unifyhrcorporatesite.azurewebsites.net/state-mandates/ You unfortunately pay this particular tax/mandate, but you get nothing for it.
I think we should acknowledge it, reinstate it and make it a health coverage premium tax; “you pay your health insurance tax, and you get your health coverage”, just like Social Security works. If we are indeed collecting taxes from the uninsured to pay for health coverage of the uninsured, we would need to collect more than the nominal $695 a year prescribed by the ACA. We should consider graduated health insurance tax rates of 0% for incomes below poverty, 2% on incomes between the federal poverty line and 200% of poverty, etc. to pay towards the actual costs of coverage.
· Seamless transitions
We have multiple complex forms of coverage, but no adequate connective tissue between them. As just one example, one of the big challenges for people with federal Medicare and state Medicaid coverage (they are known as the Medi-Medis) is that the two public programs are quite different, managed and run by different levels of government and different health plans. An individual’s health care and providers may be divided between a fee for service system with significant copays and deductibles operated by the federal government and a managed care system with no out of pocket and much stronger incentives to avoid acute hospital care operated by a managed care health plan.
Each of the many national, state, county and commercial health programs was created and has evolved and operates quite differently, at times act with counter purposes that make it difficult for providers and patients alike. The ACA added several important new forms of affordable coverage, but other than the support for electronic health records and some pilot programs, it did not adequately provide for the ready connectivity and compatibility between the different forms of public and private coverage.
As people change jobs or status at work, as their incomes change, as their program eligibility changes, they should simply transition seamlessly to new coverage. What do I mean? Here are some examples. When someone is laid off, their coverage should seamlessly transition to Covered California or to MediCal depending on their income eligibility level. When they turn 65 or become disabled, their coverage should seamlessly and promptly transition to Medicare. When they get a job offering health coverage, it should seamlessly transition from MediCal or Covered California or their old job to their new employment-based coverage. This would eliminate the phenomenon of frictional uninsurance during coverage transitions. https://www.aeaweb.org/articles?id=10.1257/aer.20190823
There are solvable difficulties, such as selecting a new plan, a new level of coverage, new levels of premiums, and a new provider and provider network, that would need resolution. After we streamline transitions we should ask, how much do we really need dated features such as COBRA or CalCOBRA coverage anymore or in what form? How much if any disruption in patients’ lives and providers’ continuity of care should transitions entail and how do we mitigate?
· Immigrants
Our nation is populated with immigrants coming from all over the world at different times. Some of their ancestors came on the Mayflower seeking freedom from religious persecution; others fled for their lives from Germany or Russia or Guatemala or Iran; others arrived from our neighbor Mexico which in the 19th Century governed much of the current USA west of the Mississippi, or from our once would be colonial territory, the Philippines, or from India or South Korea; some from small islands such as Ireland or Haiti or Cuba, others from the strife torn Afghanistan, Sudan or Eritrea. https://www.pewresearch.org/short-reads/2025/08/21/key-findings-about-us-immigrants/
The federal government, and some states place exclusions on immigrant eligibility for publicly funded health coverage – 5 years for new legal immigrants. https://www.commonwealthfund.org/publications/explainer/2025/oct/what-recent-policy-changes-mean-immigrant-health-coverage Some of these restrictions are time restrictions such as five years living here. Others are status linked, such as admission for legal, permanent residency (a green card). States like California and Massachusetts have sought to maximize coverage of the different categories of immigrants, while states like Texas and Florida have taken the opposite tack.
There are many levels of immigration status, and the Trump Administration and the GOP Congress have further restricted which ones qualify for a federal match, and it has expanded those from categories which do not. Think about health coverage for the Dreamers or those with Temporary Protected Status due to disasters like a devastating earthquake in their own country, or those in limbo seeking asylum or refuge from deadly Civil Wars or religiously motivated massacres. https://www.commonwealthfund.org/publications/explainer/2025/oct/what-recent-policy-changes-mean-immigrant-health-coverage
In the past, there have been no restrictions on any immigrant’s ability to have coverage through the workplace (if offered) or by purchasing unsubsidized individual coverage. The Trump Administration and Congress have recently specified that undocumented workers are not required to be covered under the ACA’s employer mandate – i.e. it’s now optional with their employer. https://www.commonwealthfund.org/publications/explainer/2025/oct/what-recent-policy-changes-mean-immigrant-health-coverage
It makes absolutely no sense at all to exclude hard working, tax paying immigrants from health coverage, such that they get sicker, and their conditions cost much more to treat. Do you really want the people who grow your food, slaughter the cows, pick the fruits and vegetables, pack it, prepare it and serve it to not have health coverage? Do you really want the people who take care of all the physical needs of your parents or grandparents to not have health coverage? How about those who helped build your house, nanny your children, landscape your yard, pick up the trash, or are simply your neighbors or fellow church members? We need immigrants to supplement our aging workforce and declining birth rates, let’s value them rather than oppress them.
On the other hand, we need to acknowledge that it can be a politically tough sell to American voters to open eligibility to a tax-funded entitlement program to individuals who have just arrived (new entrants) and have not yet contributed towards the common good through their work and their own taxes. It is important for American citizen voters to understand and fully recognize that undocumented immigrants pay quite substantial taxes to the federal, state and local governments. https://itep.org/undocumented-immigrants-taxes-2024/ The undocumented immigrants pay significantly more in taxes than they receive in benefits. https://forumtogether.org/wp-content/uploads/2018/08/Immigrants-and-Public-Benefits-FINALupdated.pdf
California under Governor Newson has made progress in covering the low income uninsured undocumented through Medi-Cal with state only funding. https://www.ppic.org/wp-content/uploads/health-coverage-and-care-for-undocumented-immigrants-in-california-june-2021.pdf A few other states have done so, with their state only dollars. https://www.healthinsurance.org/faqs/can-undocumented-immigrants-get-medicaid/ Most do not, as yet.
It makes good political and economic sense to build and finance health coverage for new immigrants through their own employment and through workforce organizing efforts such as Justice for Janitors, construction, and farm worker unions. See https://caimmigrant.org/wp-content/uploads/2023/03/legalaidatwork.org-Employment-Rights-of-Undocumented-Workers.pdf for a discussion of rights on the job for the undocumented.
· The Deep South and the working poor
The working poor were and are uninsured for two reasons: 1) their employer did not offer them coverage or did not offer coverage to particular classes of employees, and 2) they did not qualify for Medicaid. Medicaid at its inception was a welfare linked program, i.e. you had to qualify for one of the four welfare cash assistance categories and be poor – aged, blind, disabled or a parent with dependent children. In other words, intact families did not qualify, working parents did not qualify, and poor workers with no minor children living in the home did not qualify. Only welfare or welfare linked families qualified. States could set their income eligibility standards just as low as they wished, and some did so – i.e. 10-25% of the Federal Poverty Level in states like Texas and Florida.
The Medicaid program has steadily evolved to cover more of the poor – many different Medicaid eligibility options were created by Congressional action which some states took enthusiastically while others did not. The ACA offered a 90/10 federal Medicaid match to cover the working poor -- i.e. poor citizens who did not qualify for or receive welfare. It simplified the program dramatically – if your income was under 138% of the Federal Poverty Level, you were eligible; all the time-consuming application processes to show your welfare linkage and your assets were eliminated. It required all states to cover them. The Supreme Court said Congress and the Obama Administration could not compel states to adopt the Medicaid expansion for the working poor; it was an option for the states, a very attractive financial option, nevertheless. NFIB v. Sebelius https://supreme.justia.com/cases/federal/us/567/519/
The heart of the old Confederacy has a high percentage of poor and very high percentages of uninsured, has high percentages of citizens with serious health issues; there is nowhere that this expansions was more sorely needed. However, it is governed by powerful Republican politicians who have resolutely opposed expanding Medicaid to the working poor, especially because it is linked to President Obama whom they politically despised. Southern and Appalachian states like Louisiana, Arkansas, Kentucky, West Virginia and North Carolina have accepted the match, covered their citizens, kept their rural hospitals open and improved health outcomes. Citizens have developed, passed and sustained ballot initiatives requiring their states to adopt the Medicaid expansion in deep red states in this region like Missouri and Oklahoma. https://www.kff.org/medicaid/status-of-state-medicaid-expansion-decisions/
Medicaid expansion legislation in states like Kansas and Mississippi was blocked by hardline, right-wing Republicans despite growing support among state Republican voters, business leaders and medical professionals for Medicaid expansion. https://www.npr.org/sections/health-shots/2024/05/16/1251691921/medicaid-expansion-mississippi-alabama-south and https://www.khi.org/articles/medicaid-expansion-in-kansas-impacts-of-federal-policy-options-under-consideration-and-updated-estimates/
There are three potential routes to expanding Medicaid to the working poor in the Deep South. 1) Use the ballot initiative process if there is a viable one in your state. But see the barriers in Texas for example. https://texasstandard.org/stories/why-texas-does-not-have-citizen-led-ballot-referendums/ or the ones put in place in Florida’s legislature. https://floridaphoenix.com/2026/04/30/federal-judge-upholds-floridas-citizen-initiative-restrictions/ 2) Replace the most vulnerable leading politicians opposing expansion with more rational and compassionate political leaders. https://pmc.ncbi.nlm.nih.gov/articles/PMC8356545/ Southern voters given a real choice at the ballot box might prefer effective, pragmatic governance for the common good, to the extreme right currently controlling their state legislatures and gubernatorial offices. 3) Change federal law to allow the uninsured working poor in the 10 hold out states to enroll in either the federal Exchanges or in Medicare (neither offers as affordable coverage as Medicaid would be for the poor). https://ccf.georgetown.edu/2024/06/12/the-unlikely-new-defenders-of-at-least-part-of-the-affordable-care-act-opponents-of-medicaid-expansion/
· Expanding and or reconfiguring the employer mandate
Most Americans are covered through employment. That coverage is subsidized by federal and state pretax purchasing advantages that effectively subsidize about 1/3 of the costs of coverage. Counterintuitively, these tax advantages are much higher for higher wage workers such as computer programmers or attorneys than they are for lower wage workers like farm workers or unskilled laborers. Likewise, the employees’ share of premiums (averaging about 20%, but highly variable among employers) is structured by carriers and employers in ways that fall most heavily on those least able to afford them, particularly for family coverage.
The ACA improved coverage for small businesses and the self-employed through the Exchanges. https://www.cbpp.org/blog/aca-drove-record-coverage-gains-for-small-business-and-self-employed-workers It ended and disrupted insurance industry practices of denying coverage to those individuals and businesses they deemed uninsurable – this was known as pre-existing condition exclusions. https://www.brookings.edu/articles/obamacare-the-business-worlds-biggest-disruptor/ And it capped the amounts of consumer exposure to out-of-pocket expenditures, albeit at still abhorrently expensive levels.
The ACA included an employer mandate that requires employers with 50 or more full-time employees to offer coverage for the ten essential health benefits to their employees and their families. That mandate could be expanded to smaller employers of 25 to 50 employees or conceivably down to 10 employees. It could be combined with expanded tax advantages for coverage of low wage workforces or for small businesses that offer family coverage. It could require employers to contribute pro rata towards Exchange coverage for their part-time workers, seasonal workers, and other flex and gig workforces. That needs to be done by Congress, and it is not easy to do so in the face of employer opposition.
The existing mandate requires that employers pay at least 60% of the cost of a bronze essential benefits plan that in turn would pay 60% of expected medical claims. In other words, the employer must pay 36% of expected medical costs and premiums, leaving employees potentially responsible for up to 64% of their health costs if they get seriously ill or injured. This needs to be changed as it leaves America’s employees with far too much financial exposure when they get sick. Congress should upgrade an employer’s responsibilities to pay 80% of a gold plan (pays 80% of expected medical costs). This would switch the employer’s share to 64% and the employees’ maximum exposure to 36% of potentially incurred medical costs. Many employer plans already meet this threshold. Hawaii’s plan is far better yet, and it’s the right model for all of us to consider; its mandate applies all the way down to one employee and limits the “employee only” share of coverage costs to 1.5% of employees’ wages; this helps lower wage workers better afford their premiums. https://labor.hawaii.gov/dcd/frequently-asked-questions/phc/ Germany (also built on private employer insurance) has had comparable requirements for low wage workforces. https://www.commonwealthfund.org/international-health-policy-center/countries/germany This needs to be thoughtfully done as we cannot impair job creation by imposing too many costs on employers. Trump is already doing that in ham-handed fashion with his everchanging tariff duties.
· Whole family coverage
The whole family ought to be enrolled in the same health plan with common access to their network of physicians and other providers. Under the current system, one spouse can have coverage through their employer’s plan; the other spouse can have coverage through their employer’s plan, and their children could have coverage through Medicaid or through the Exchanges. In other words, families can have three different health plans with different provider networks and paperwork. This can be a paperwork and bureaucratic nightmare for the family when there are serious family illnesses, and it makes it difficult for the family’s doctor(s) to provide coordinated care for the entire family.
Could we simplify? Yes! The family should be able to choose a common plan for all its family members. The other plans should issue a voucher to the family’s preferred health plan. The family’s preferred plan must accept the voucher from the other plans, and the family’s chosen providers should be required to accept the plan payments, even though different.
· Paperwork barriers
The ACA vastly simplified eligibility for Medicaid expansion coverage – a family’s income must fall below 138% of the Federal Poverty Level, plus there is no asset test; it is easy to administer and to comply with; it minimizes fraud and paperwork errors. https://aspe.hhs.gov/sites/default/files/documents/b1bfa16b20ae9b89d525bc35de7c1643/detailed-guidelines-2026.pdf
The Trump Administration is needlessly complicating the Medicaid eligibility process once again, with more frequent eligibility redeterminations and requiring proof of work searches. This turns the health care program back into a paper chase that deters rather than assists program eligibility. https://hsph.harvard.edu/news/new-medicaid-work-rules-could-lead-to-greater-than-expected-coverage-losses-administrative-hurdles/
This is based on a fundamental misunderstanding and a crass political calculation; Medicaid is expensive for the federal and state governments; it was cut to pay for tax cuts to the wealthiest Americans. It is not a cash assistance program; the Medicaid recipient gets no cash from the program. The doctors, hospitals, pharmacies and nursing homes do get cash, but not the Medicaid recipients themselves; they get health care. The Medicaid program enables work; it helps sick people get better and be able to return to work. It helps women have healthy babies. It helps the disabled to function in their daily lives. It helps people with serious mental illness or substance abuse get treatment so they can function better both at home with their families and in the workplace. It helps patients with broken bones or severe illness to heal, and it restores their mobility and ability to work. It takes care of the frail elderly in nursing homes and pays for in home care for your very elderly grandparents.
Obama had the right idea. Make the program simple and easy to understand and administer, reduce administrative eligibility barriers. Monitor program compliance electronically through routine data matches so that no fraud can be committed.
Assure Affordability of care and coverage
· The Exchanges were designed to make both premiums and care affordable to subscribers. The premium subsidies (refundable tax credits) were improved dramatically under Biden, and enrollment soared to 24 million. https://abcnews.com/US/affordable-care-act-enrollments-surge-bidens-term-nears/story?id=117451514 The Trump Administration allowed these enhanced subsidies to expire, and enrollment has fallen off significantly, except in New Mexico which fully replaced the federal funding cuts, and program enrollment there grew by another 14%. https://stateline.org/2026/07/28/obamacare-enrollment-declines-in-49-states/ In states like Ohio, Oklahoma and Arizona, enrollment fell by 30% or more due to the Trump Administration’s actions. Either individual states or Congress need to act to replace the premium assistance that Trump and the GOP Congress decimated. See https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double-on-average-next-year-if-enhanced-premium-tax-credits-expire/ Insurers have been responding to Trump’s policies by proposing to increase premiums by 14% due to the loss of enrollment of the healthiest lives; this hurts everyone involved in the program.
The Exchanges give subscribers a choice of levels of coverage and of different commercial plans. Individuals can choose from among platinum, gold, silver or bronze levels of coverage which range in coverage from 90% to 60% of expected medical expenses. The levels of premium assistance are tied to the second lowest cost silver plan (70% of expected medical expenses), such that those who want and need gold or platinum levels because of their medical conditions must pay much more for their coverage. Silver and bronze plans are the most commonly picked tiers of coverage – by 85-90% of enrollees. https://www.ncbi.nlm.nih.gov/books/NBK610894/ This gives those subscribers not eligible for the cost sharing subsidies too little coverage and leaves them too much financially exposed when serious illness strikes. I would encourage policymakers and advocates to link the premium assistance to the second lowest cost gold coverage, which picks up 80% of expected medical expenses. Coverage for the unsubsidized in the Exchanges ought to be about equivalent to the levels of Medicare coverage or to the most common employer plans. See https://www.retiremed.com/library/articles/comparing-employer-coverage-medicare-whats-better-option and https://www.gao.gov/products/gao-25-106798
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