WASHINGTON, D.C. — Vermont’s sole Congressman, Democrat Peter Welch, is hopeful Congress will be able to address some of the weaknesses in the Affordable Care Act (ACA), more commonly called Obamacare, following Republican efforts to repeal the popular law.
Welch is part of a bi-partisan group in the House of 20 Republican representatives and 20 Democrats calling themselves the Problem Solvers. They have proposed four actions Congress can take to reduce premiums in the individual insurance market and provide stability for insurance companies.
It is the first time since the passage of the ACA seven years ago that members of both parties have proposed a “concrete fix to a concrete problem,” Welch said.
The ACA sought to expand health care coverage in two ways. The first was expanding Medicaid to cover more people. Following a lawsuit by Republicans, the Supreme Court ruled the federal government could not require states to expand Medicaid coverage and 19 refused to do so.
The second was by creating an exchange to make it possible for those without insurance through their employer to more easily compare policies and purchase insurance. Everyone was required to purchase insurance or be fined. To help those with lower incomes afford insurance, the government provided subsidies to cover part of the cost of the premiums.
The law also required insurance companies to cover pre-existing conditions and provide preventive care without co-pays or deductibles.
Six to seven percent of Americans receive their insurance coverage through the individual market.
The law also provides cost-sharing reduction (CSR) payments to insurance companies which make it possible for insurance companies to write policies with lower deductibles and co-pays, explained Welch.
Those payments don’t just benefit insurance companies, according to Welch. They also benefit individuals by making it possible for them to afford meaningful insurance coverage and hospital care by reducing their losses from unpaid bills.
President Donald Trump has threatened to not make the payments.
“That would wreak havoc in the private insurance market,” said Welch.
The uncertainty over the CSR payments and the ACA in general is creating instability, which, in turn, is causing insurance companies to either raise premiums sharply, particularly in areas with low populations, or withdraw from those small markets entirely, according to Welch.
“Insurance companies cannot operate in an environment of instability,” said Welch. 
Insurance companies depend on the ability to predict costs, which then allow them to price their policies at a level sufficient to cover those costs. When costs are unpredictable, the companies lose their ability to create and price policies accurately.
In a letter to House Speaker Paul Ryan drafted by Welch, the Problem Solvers group cites a Kaiser Family Foundation study, which found that eliminating the CSR payments would increase government spending by $2.3 billion next year.
Welch and the Problem Solvers also advocate providing $15 billion to the states for a reinsurance program. Reinsurance allows states to assist insurance companies with paying for the care of high-cost patients whose care may cost hundreds of thousands or millions of dollars.
Reinsurance would lower premiums by an estimated 14 percent, because companies wouldn’t have to cover those extraordinary costs through premiums. The lowered premiums would, in turn, save the government $11 billion in tax credits used to help Americans purchase insurance, according to Welch’s letter.
The combination of reinsurance and CSR payments would make it possible for insurance companies to continue to offer policies in small, rural markets, some of which have as few as 3,000 people, explained Welch.
The Problem Solvers also advocate advertising campaigns to encourage enrollment in health insurance plans, citing the success of California’s marketing efforts, and potentially targeting subsidies more tightly by possibly incorporating such factors as age and location.
There are also bills being offered in Congress to allow those aged 50 to 64 to buy into Medicare. Welch supports those proposals.
“Medicare works,” he said. “People understand it and it works.”
The program, he said, would not cost taxpayers any additional money. The costs of covering those aged 50-64 would be covered by the premiums they would pay, just as with a private insurance company. The government would also likely save through a reduction in tax credits to individuals purchasing insurance.
Welch also spoke of the challenge now faced by his Republican colleagues. “They failed to repeal it,” he said. “Do they want to wreck it or do they want to improve it?”
Various proposals ultimately rejected by the Senate would have ended health care coverage for an estimated 16 million to 23 million people depending on the proposal.
The repeal effort was deeply unpopular, with some polls showing support for repeal at just 17 percent. That unpopularity “really made a difference for some of the senators,” said Welch.
The repeal effort ended in the Senate when three Republicans, Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona, voted against it.
“They decided to stand up for the people they represent,” said Welch, praising their willingness to go against their party.
Asked about Trump’s impact on the debate over health care, Welch said, “He’s not familiar with the details of the health care legislation.”
Indeed, in one recent interview with the New York Times, Trump appeared to confuse health insurance with life insurance. “Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan,” he stated.
His unfamiliarity with health care policy means “he foregoes the ability to use that bully pulpit to bring the public around,” said Welch.
Nevertheless, Trump has continued to press for repeal.
“The unpopularity of the bill… that’s making it very tough for a lot of Republicans to support the President’s proposal when the President can’t explain it,” Welch added.