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How to make Obamacare better

A laptop showed the website during an enrollment event in February in Fort Worth, Texas.AP/file 2015

Thursday's Supreme Court decision upholding the federal subsidies that are at the heart of Obamacare offered that rare political moment in which nearly everyone wins. Democrats saw the most significant expansion of the social safety net in four decades upheld. Republicans were spared the political fallout of demands to fix a gutted health care bill and can now continue to bash the law without having to offer any alternative. Above all, ordinary Americans who rely on Obamacare no longer need to worry about losing their insurance or see their premiums spike overnight.

The Obamacare dead-enders are disappointed, but considering their goal was to force millions of Americans to lose their health insurance, their unhappiness is the only positive note from the collective waste of time that was this court case.


Still, while Obamacare has made it possible for 16 million Americans to receive health insurance and helped reduce the increase in health care spending to its lowest rate since the 1960s, the law is far from perfect. I talked to a few health policy experts and here are a few ideas for making it better.

1. Back in 2012, when the Supreme Court first saved Obamacare, the court imposed one restriction that has wreaked terrible havoc: allowing states to opt out of the bill's Medicaid expansion.

So today, 19 states (all with a Republican governor or a Republican legislature) have refused federal monies — even though the government is initially picking up the entire tab for the expansion and within a few years 90 percent of it. This is basically a partisan legislative temper tantrum by Republicans who hate the president. The result is that more than four million Americans are being deprived of the chance to have health care coverage. Ideally, Thursday's decision will convince the GOP to give up this pointless fight and work with the Obama administration to make expanded Medicaid universal.


2. "Helping human beings navigate a bewildering set of health care and insurance systems remains a key challenge," says Harold Pollack, a professor of social service administration and public health at the University of Chicago. "As others have also noted, buying insurance will never completely resemble buying a book on Amazon." As someone who previously bought insurance on an Obamacare exchange, I can more than vouch for this. There are so many options and so many different provisions to consider and there's virtually nowhere to turn for help.

There needs to be more money and better training for health care navigators, exchange websites need to be made more intuitive to help consumers make the best insurance decisions, and, above all, insurance companies should be forced to maintain up-to-date provider lists so consumers know, in advance, which doctors they can see. Now that Obamacare is free from legal challenges, perhaps the private sector can fill some of this gap.

3. One of the biggest and most legitimate complaints against Obamacare is that the cheapest plans on the federal and state exchanges have huge deductibles that mean big out-of-pocket costs for consumers. It's an issue that Republicans regularly focus on, and with Obamacare out of legal jeopardy, Congress could pass legislation to make subsidies more generous and ease the financial burdens for consumers.

But don't hold your breath on that happening.

4. Finally, Congress should fix what is called the "family glitch," which makes it more difficult for people with employer-based insurance to receive tax credits for buying coverage for their family on an Obamacare exchange. Their eligibility to receive subsidies is defined by the costs of an individual plan, rather than a family plan, even if they are buying for their whole family. Fixing it would help between two and four million low-income Americans afford coverage.


Obamacare has helped more Americans get access to insurance coverage, but it's hardly fixed the endemic challenges facing the US health care system. With the Supreme Court confirming once again that Obamacare will remain the law of the land, hopefully we can put to rest all the talk about repealing it and focus instead on making it better.

Michael A. Cohen's column appears regularly in the Globe. Follow him on Twitter @speechboy71.