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American Health Care Act

Here's the bipartisan path forward on health care: Andy Slavitt

Trumpcare failure is an opportunity to end the divisiveness that hampered the Obamacare era.

Andy Slavitt

The failure of Trumpcare last week can be seen as a rejection of policies that Americans judged would move the country backwards. But it also presents the opportunity to end the divisiveness that hampered the Obamacare era and move forward in a bipartisan direction that focuses not on destructive rhetoric, but squarely on reducing premiums and expanding access for all Americans.

House Speaker Paul Ryan after answering questions about the failure of the Republican health bill, Washington, March 24, 2017.

The policies and the politics of Trumpcare were extreme and favored by only 17% of voters as compared with the Affordable Care Act (ACA), which enjoys support from 50%. The central plank of the bill cut care for the neediest children, elderly and disabled to pay for a large tax cut for the wealthy. The process, likewise, began with the most partisan approach possible. Republicans skirted Democratic input, avoided public hearings, and ended up rushing a bill without enough time for impartial evaluation.

The president has a chance now to turn this around. Last week, he invited Ezekiel Emanuel, a Democratic policy expert who helped craft the ACA, to the White House. Emanuel and I had dinner after his visit to the Oval Office, and he reviewed the commonsense ideas he shared with the president that were neither Democratic- nor Republican-leaning. The president had already chosen to head down a partisan path, but by inviting Emanuel, he might have signaled a potential interest in a bipartisan approach should that one fail.

Trump has an immediate opportunity to help Americans reduce their costs by choosing to enforce and properly steward what House Speaker Paul Ryan rightly called the "law of the land." The administration has the power to impact the cost of insurance by 25% to 30% with two simple decisions, according to a conversation I had with Mario Molina, CEO of Molina Health, one of the largest insurers in the exchange.

First, the administration, with support from Congress, should commit to permanently funding payments that reduce the size of deductibles for lower-income Americans (called cost-sharing reductions). Republicans need to drop a lawsuit they filed to stop these payments, or Trump needs to say they are going to continue. Second, the administration should enforce the individual insurance mandate until a different approach can be agreed upon. Those two actions will reduce costs for millions and need to be done now before insurers submit initial premiums for next year, or inaction will drive up premiums. Americans should watch this intently.

A third step would be to grant states the flexibility to increase competition and reduce costs. Non-partisan analysts such as Standard & Poor's confirm that the online exchanges that sell ACA insurance policies are stable, but in some states the cost of insurance is out of reach for those who earn too much to receive tax credits.

The administration has tools to do this, including a section of the ACA designed to allow states to pursue different approaches, including those more suited to their political philosophy, so long as they continue to meet the basic aims of covering more people with high-quality coverage. Alaska was the first to use this process last year by creating a statewide reinsurance pool. Such pools protect insurers against losses in high-cost cases, and the savings are passed along to consumers. In Alaska, the result was a dramatic reduction in premiums.

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Many red or purple states, such as Kansas and North Carolina, have expressed recent interest in expanding Medicaid to low-income adults. This will not only cover more people, it also would reduce premiums for private policies on the exchanges. Premiums are 7% lower in states that have expanded Medicaid, the result of lower-income people (who tend to have more health problems) moving off the exchanges and into the Medicaid program.

Next, while Congress might be wary of taking up another major health care bill, lawmakers could have an opportunity to make bipartisan, surgical improvements in health care by adding their changes to a bill important to Trump and both parties. One possibility is an infrastructure package that might come up this year.

Learning the lessons from both the ACA and the unsuccessful Republican bill, Americans deserve the stability of a law both sides have a stake in. There are good ideas that can garner bipartisan support. State-based reinsurance funds, such as the one Alaska established, were part of the Republican health bill and could be enacted this year.

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In recognition that bigger solutions will take time, the president and Democratic leaders should create a bipartisan commission with experts from Congress and the real world, charged with exploring smart ways to reduce health care costs that could result in bipartisan legislation. Health care is too expensive. It's the cost of a prescription or a night in the hospital that drives our premiums. Former Senate majority leaders Bill Frist and Tom Daschle are already leading a bipartisan group to find solutions.

The president has pledged to bring down drug costs and should push forward with initiatives to bundle payments (charge patients for a set of services related to a health episode rather than separately for every test, pill, bandage and procedure) and to pay for what works, so American taxpayers and families get the most for our money. Common ground can be found here and was the focus of what Emanuel reviewed with the president last week.

With the White House, the Senate and the House under the control of Republicans, the fate of the exchanges in 2018 is up to them. The ACA has provided a foundation that allows millions of Americans access to care. The focus should turn away from repealing it and toward what Americans now expect — both parties working together to improve it.

Andy Slavitt, a senior adviser to the Bipartisan Policy Center and a member of USA TODAY's Board of Contributors, is a former health care industry executive who was acting administrator for the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter: @ASlavitt 

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