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Physicians Write 7-Part Prescription to Improve the Affordable Care Act

By Christopher Cheney  
   May 21, 2019

The American College of Physicians is calling on policymakers to strengthen and expand the Patient Protection and Affordable Care Act.

The PPACA has achieved significant gains in access to healthcare, and policy makers should focus on nurturing and expanding the healthcare law, the American College of Physicians (ACP) says.

The healthcare law enacted by the Obama administration has notched several achievements, the ACP says in a recent article published by Annals of Internal Medicine. PPACA regulations such as barring coverage restrictions on pre-existing conditions have made health insurance more accessible. Premium tax credits and cost-sharing subsidies have made individual and family coverage more affordable. The essential health benefit package and preventive service coverage has made insurance more comprehensive. And Medicaid expansion has insured millions of previously uninsured adults.

The ACP, which represents internal medicine specialists and has more than 150,000 members worldwide, is making seven recommendations to improve the healthcare law:

1. Strengthen the PPACA: Efforts to undermine the PPACA such as decreased outreach and education funding should be reversed or eased. The PPACA should be redesigned to move closer to universal coverage. The current healthcare law falls short of universal coverage, with unaffordable premiums, coverage gaps, and weak insurer participation.

2. Individual insurance market affordability: Premium subsidies should be expanded and increased such as removing the 400% Federal Poverty Level cap for premium tax credits to boost enrollment and offset premium hikes. Incentivizing more healthy people to purchase insurance on the PPACA marketplace strengthens the individual insurance market.

3. Stabilize the marketplace: The federal government should take several steps to stabilize the PPACA marketplace, including adoption of a permanent reinsurance program and rollback of proposals to sell health plans that do not comply with PPACA regulations such as limited-duration plans. The reinsurance program provides financial protection to health plans with high-cost enrollees. Noncompliant health plans segment the risk pool and drive premiums for compliant marketplace plans higher.

4. Outreach, consumer assistance, and education funding: In 2017 and 2018, the federal government slashed funding for the PPACA's Navigator program and other efforts to provide education, outreach, and enrollment assistance. Federal, state and local agencies should fund initiatives to promote the PPACA's coverage options. These efforts should target people who are eligible for Medicaid or premium tax credits but are not enrolled in PPACA coverage.

5. Enrollment mechanisms: To increase patient participation in PPACA coverage, federal and state marketplace officials should strengthen enrollment mechanisms such as developing auto-enrollment programs, levying penalties for failure to enroll upon eligibility, and adopting an individual mandate.

6. Medicaid expansion: The expansion of Medicaid coverage to more adults in 36 states has increased access to care significantly, with more than 12 million newly eligible adults covered by Medicaid in September 2017. Medicaid should not be expanded with counterproductive conditions such as onerous work requirements that prompt patients to disenroll.

7. Public option: Congress should craft a public insurance plan to increase competition in the individual marketplace. For example, Sens. Tim Kaine (D-Virginia) and Michael Bennet (D-Colorado) have proposed "Medicare X," which would give PPACA marketplace enrollees a public insurance offering based on Medicare's provider network and reimbursement policies. Medicare X would have an expanded benefit package including services such as maternity and pediatric care.

PPACA by the numbers

The ACP says the health law has posted promising numbers:

  • With Medicaid expansion states leading the advance, the country's uninsured rate hit a historic low in 2016, dipping to 8.8%.
  • In 2017 and early 2018, the uninsured rate held steady at 8.8%.
  • About 10.6 million people selected or reenrolled in a 2018 health plan through the PPACA marketplace.
  • In September 2017, more than 12 million newly eligible people received health coverage through Medicaid expansion.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


The country's uninsured rate hit a historic low in 2016—two years after the launch of the PPACA health plan marketplace for individual and family coverage.

Bolstering the PPACA is an essential step toward achieving universal health coverage, the American College of Physicians says.

Proposals to strengthen the PPACA include increasing affordability, stabilizing the PPACA health plan marketplace, and expanding Medicaid nationwide.

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