Looking Beyond the Obamacare Debate to Improve Health Care
Now that Republicans in Congress appear to have at least temporarily abandoned their crusade against the Affordable Care Act, it seems like a good time for lawmakers to come up with plans to fulfill their promises to increase access to health care and to lower costs.

Obamacare has helped 20 million people gain access to insurance, and it appears to have helped slow the growth in health care costs. But even former President Barack Obama has said that there is still work to be done. The United States spends much more on medical care than other rich countries, like Britain, Australia and the Netherlands, according to a recent Commonwealth Fund report, yet its citizens live shorter lives and suffer from more illnesses and injuries than people in other industrialized nations.

One option that appears to have gained support among the public is a single-payer system, which proponents like Senators Bernie Sanders and Elizabeth Warren call “Medicare for All.” A Kaiser Family Foundation poll found in June that 53 percent of Americans favor such a system. This was up from 46 percent, according to an average of seven polls conducted in 2008 and 2009. But moving to a single-payer system from one dominated by employer-paid health coverage would be a big leap, and in any case the political climate is clearly not ready for it. Many Democratic voters as well as party leaders like Representative Nancy Pelosi and Senator Chuck Schumer have been reluctant to embrace the idea, and, no surprise, most Republican voters and lawmakers oppose it.

Single-payer advocates point out that the United States is the only advanced nation without universal health care, which is true. Germany, the Netherlands and Switzerland have achieved universal coverage and affordable health care with, essentially, more comprehensive and generous forms of Obamacare that require people to buy insurance, tightly regulate insurers and provide subsidies to the poor and middle class.

State and federal lawmakers are exploring ways to increase coverage and lower costs. For example, the Nevada Legislature passed a bill in June that would have allowed people who make too much money to qualify for Medicaid to buy into that program. The bill, which would have required a federal waiver, did not become law because Gov. Brian Sandoval, a Republican, vetoed it. But the idea has other backers. Senator Brian Schatz of Hawaii said on Tuesday that he would introduce a bill that would explicitly allow states to let people buy into Medicaid.

Another approach would be to let people buy into Medicare at some point before they become eligible for the program at age 65. Hillary Clinton proposed this during her presidential campaign. Congress could also provide more generous subsidies to help middle-class people buy insurance on Obamacare exchanges. At the state level, four million people would gain coverage if Florida, Georgia, Texas and the 16 other states that have not expanded Medicaid under Obamacare changed their minds and opted in.