Resolving ObamaCare: the Patient Protection and Affordable Care Act remains a work in progress, but when will any real progress be shown?

• Author: Garner, John C.
• Position: Medicine & Health

AN INFLECTION POINT for the Patient Protection and Affordable Care Act may be here. There are signs that Republicans may be willing to talk about changes rather than devoting all of their efforts to repealing it. There also are signs that Democrats may be willing to agree to some changes rather than staunchly defending the bill as passed:

Amend the 30-hour cliff. Starting in 2015, if an employer with 100 or more full-time equivalent employees does not offer affordable, minimum value coverage to employees working 30 or more hours per week, the employer must pay a penalty. This will lead employers to cut the hours employees work. There is legislation pending in Congress that would raise the definition of full-time from 30 hours to 40 or more hours per week. However, no matter where Congress sets the limit, employers will schedule employees in such a manner as to avoid classifying them as full-timers. Insert a provision that requires an employer to pay the current penalty for employees working 35 hours a week or more and a pro-rated penalty for part-time employees if it does not offer minimum value coverage.

Attract younger enrollees. One of the keys to the success of health care reform will be to have large numbers of young people buying health insurance. Without that, costs will go up for everyone, perhaps causing the system to collapse and making a single-payer plan the No. 1 option. One part of health care reform that raises costs for younger people is the three-to-one ratio maximum on premiums, whereby a person age 64 cannot be charged more than three times that of a person age 21. In fact, people in their 60s use several times as much health care as those in their 20s. This ratio rule artificially lowers premiums for older people and artificially raises them for younger people, who are the very persons we most need to convince to buy health insurance. A six-to-one ratio would lead to having more young people covered.

Eliminate or adjust the medical loss ratio requirement. The MLR requirement says that plans must spend at least 80% of premiums on claims and quality improvement efforts (85% for large groups). Because of the fixed costs associated with issuing any policy, administrative expenses are a higher percentage of total costs for more affordable plans than for rich ones. This makes it more difficult for affordable plans to meet the medical loss ratio requirement, making it less likely insurers will offer these plans. Either repeal...