Four things that would improve the Affordable Care Act

After reflection on the first year of health care reform, and the conclusion of the first enrollment period, 4 aspects could make the program work even better.

The fate of the Affordable Care Act (ACA) will be the big issue in the upcoming mid-term congressional elections, with Republicans and their allies continuing to press for repeal, believing that it is a winning issue with voters (or at least the base voters who lean Republican). Opinion polls are not as clear-cut, though. Although more Americans continue to have a less favorable than more favorable view of the law, most oppose outright repeal.

But no matter what the politicians say in the election, the ACA is here to stay, at least as long as President Obama is in the White House and probably much longer than that. Although we don't have the final enrollment numbers from October 2013 through the first 3 months of 2014, when the first open-enrollment period for the marketplace plans created by the ACA ended, it is likely that total enrollment as of April 15 will fall between 15 and 18 million people, nearly 8 million in the marketplace plans, another 5 to 7 million in Medicaid, and between 1.6 and 3 million young adults on their parents' plans.

Because of the ACA, tens of millions more Americans have no lifetime or annual limits on coverage, and seniors enrolled in Medicare have better coverage of prescription drugs and preventive services. No one, regardless of health status, can be turned down or charged more by insurers. These enrollment numbers will likely increase over the next several months and years as more states decide to expand their Medicaid programs and as the next wave of marketplace enrollment occurs in fall 2014.

Politicians, regardless of their political leanings, can count. As more voters benefit from the ACA, I see no scenario where Congress will reverse course, even if the Republicans take control of the Senate next year. (And, of course, President Obama would veto any major changes to the ACA.) At some point in the future, but unfortunately not for another election cycle or two, I believe that our politics will shift to a new normal, where the ACA is accepted by both political parties (like Medicare, which itself was initially very controversial, is today), and the debate will shift to how to revise it, not repeal and replace it. I doubt that will happen until the next presidential election in 2016, though.

In the meantime, 4 things could be done to make the ACA better, learning from the experiences, good and bad, in this first year of enrollment.

First, make the enrollment portals work better. The federal enrollment portal,, is obviously working much better than it did a few months ago, but it is still a work in progress. And several states running their own marketplaces, including Maryland, Oregon, and Massachusetts, continue to struggle with enrollment software that is minimally working (or in the case of Oregon, not working at all). These all need to be improved by Nov. 1 of this year, when the next enrollment period begins.

Second, make the consumer shopping experience better. It may be years before the enrollment process makes it as easy to select a plan as makes it to shop for products, but there are several things that would make the experience so much better than it was this time around. Provide consumers with real-time access to up-to-date directories of participating physicians and hospitals, so they know which are in or out of the plans they are considering. Make it possible for them and their physicians to review whether a particular prescription drug is in a plan's formulary. Make it easier to compare the plans based on premiums, deductibles, and co-payments; the benefits offered; and the enrollee's total premium cost after income-based subsidies are applied.

Third, improve network adequacy standards, ensure greater health plan transparency, and strengthen rights of appeal. The federal government and state regulators should develop clearer standards to set a higher bar on network adequacy, so that patients have greater access to the physicians and hospitals of their choice, are not forced to go long distances to get care, and experience fewer disruptions in continuity of care. Potential enrollees and their physicians should be able to know, and challenge, the criteria used by qualified health plans in determining who is in or out of their networks. Physicians should be able to challenge and appeal de-selection decisions. Patients should have expedited appeals if the medication their physician prescribes for them is not on a plan's formula, especially in medically urgent situations.

Fourth, improve the Medicaid program. The fact that tens of millions of poor people will have access to Medicaid is a good thing. The most important improvement for this population would be for all of the states that have declined to expand the program to get on board. At the same time, Medicaid is by no means a state-of-the art program. Except for a few pioneering states, Medicaid is not considered to be a hotbed of innovation in payment and delivery. The program's rules are cumbersome, and its payments to physicians and hospitals are too low. Yet Medicaid already is the single largest coverage program in the United States, and as more join the program, state governors, legislators, Congress, and the Obama administration should find bipartisan approaches to making it less expensive, more efficient, and more accessible to both patients and physicians.

Such improvements are not conducive to the red-hot politics over the ACA's fate, where everything is shouted in apocalyptic terms designed to scare and motivate voters. But isn't the purpose of politics to elect people who will do what is best for their constituents? Wouldn't constituents benefit by making the ACA work better for them?

Many of the improvements discussed here can be made without Congress' consent, through administrative rule-making, oversight, and state regulation. Congress and the states, though, can make things worse by denying the funds needed to, say, build a better federal enrollment site or by declining to expand Medicaid, not because this would be in the best interests of constituents, but for partisan, ideological, and political reasons.

We have an opportunity to improve the ACA, and the least we can hope is that politicians don't get in the way.