Strengthen the Affordable Care Act (ACA)
First, Improve the ACA & Protect the Basics
Reassess the tax subsidies for individuals and the tax exemptions for employer/employee contributions to employer-sponsored insurance and make sure they are set at the fairest, most effective levels.
Work to reverse the cuts to Medicaid in the One Big Beautiful Bill, then implement long-term changes to stabilize the program as part of 1787’s Operation Overhaul program.
Pressure the states that are hold-outs to expand Medicaid. Give them the same federal funding as those that previously expanded.
Under no circumstance can pre-existing conditions be excluded from health insurance coverage.
If a parent’s plan covers children, they can add or keep their children on their health insurance policy until they turn 26 years old.
Allow small businesses to form a larger risk pool to make offering insurance more feasible.
Allow companies to offer benefits to independent contractors on a federal level and encourage states to do the same. Allow independent contractors to access benefits without losing their independent status.
Encourage portable benefit plans that can travel with workers.
Support plans that can be combined with tax-preferred health-savings accounts.
Address the medical-loss ratio (MLR) that forces insurers to spend 80 percent of premiums on claims. This profit cap has encouraged insurers to merge with or acquire pharmacy benefit managers (PBMs) and healthcare providers, making spending less transparent.
Expand site-neutral payments to align Medicare payments for outpatient services across care settings.
Compensate doctors based on value-based care, not fee for service. Move to a bundled payment model that includes bonuses for high-quality, lower-cost outcomes.
Change the Medicare Advantage structure to have insurers compete against each other based on their premiums instead of being compensated based on how low their bids are compared to a Medicare benchmark.
Require insurers to offer their lowest negotiated prices to all customers.
Cap deductibles for all private plans at no more than 2 percent of the median household income.
Reject Most-Favored-Nations (MFN) price controls on drugs, which only discourages the development of generics and new breakthrough treatments, and crushes incentives for drug makers to innovate.
Do not raise the 3-to-1 rate band (premiums for those 55+ cannot be more than three times higher than those for younger people).
Protect the ban on yearly or lifetime dollar limits on essential health benefits.
Protect the cap on out-of-pocket spending. For 2025, these amounts are $9,200 for individuals and $18,400 for families.
Protect the ACA ban on gender-based premiums and the requirement that all insurers cover preventive health services without co-pays.
Listen to the private sector. For example, the global management consulting firm McKinsey & Co. built a roadmap of around 30 interventions that could deliver up to $265 billion in annual health care savings in administrative functions alone.
Next, Be Proactive About the Potential Spoilers.
Spoiler: Low Enrollment
(i.e., not enough healthy people in the exchanges)
No longer require businesses to offer insurance to their employees.
Extend the Affordable Care Act’s subsidies to all consumers and place a floor on subsidies.
Reinstate and raise the Individual Shared Responsibility Payment and strictly enforce the penalty. Garnish wages if necessary.
Give states flexibility to implement automatic enrollment programs.
Spoiler: Private Insurers Leaving the Exchanges
STABILIZATION: Make the risk corridor permanent.
STABILIZATION: Resume and protect the insurers' disbursements guaranteed under the risk adjustment program.
STABILIZATION: Encourage states to start reinsurance programs.
Protect the ability of insurance companies to “silver load.”
Do not restrict narrowed network products.
Spoiler: Lack of Competition in Many of the Online Insurance Marketplaces
Open contracts for government programs (i.e., Medicaid) only to insurers that participate in the exchanges.
Strengthen competition and market incentives to control costs.
Require insurers to participate in broad regions.