Conservative adjustments to the Affordable Care Act, in order of feasibility

I’d love reader feedback on this, in the comments, on Twitter, by email, whatever. Below is a list of potential changes to the ACA that might be appealing to conservatives, and maybe even some near-center liberals. I’ve listed them in approximate order of technical — not necessarily political — feasibility (lower number = more feasible; ties are possible). But I could be wrong in ordering. (These are rough guesses.) So, correct me! I am almost certainly wrong in completeness. What did I leave out? And, which ideas aren’t as appealing to conservatives as I might be implying?

Even though I’m not considering politics here, you can. How would you reorder the list in terms of political feasibility?

The possible “conservative-appealing (?)” adjustments are:

  1. Some type of malpractice reform
  2. Support for more competition among providers (including reform of scope-of-practice laws)
  3. Paring back essential health benefits
  4. Permitting more catastrophic plans on exchanges
  5. Eliminating the employer mandate
  6. Replacing the individual mandate with some other inducement (late enrollment penalty?)
  7. More support (in some fashion) for coverage for medical tourism
  8. Allowing inter-state competition among health plans
  9. Permitting all Medicaid eligibles to shop on exchanges (akin to Arkansas’s private option)
  10. Capping and/or more quickly phasing out of the employer-sponsored health insurance tax subsidy
  11. Equalizing tax treatment of all plans and medical savings vehicles, regardless of source or type
  12. Creating high risk pools for sicker individuals without continuous coverage, if only as a transitional measure
  13. Universal, zero- or low-premium catastrophic (akin to Singapore)
  14. Risk rating (or a lot more of it). Note, if only tweaking the age-based constraints on premiums, this is a lot more feasible — move it up to near the top of the list.

To be clear, my notion of technical feasibility here is the extent of interference/disruption of the existing ACA structure and/or other insurance arrangements (like Medicaid or employer-sponsored coverage). I’ve deliberately ignored Medicare, but one could draw up a list for that program. My read of recent right-of-center thinkers is that structural reform of Medicare has fallen away or taken a back seat. The focus seems to be on how the ACA impacts group and non-group markets for the non-elderly, as well as Medicaid.

Have at it!

LATE ADDITIONS: I don’t want to further mess up the numbering, so here are some other ideas from comments: Price transparency (not sure what the specific policy is, but I’d give this a low number on the list because it’s not disruptive to the structure of the ACA at all.)


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