This Senate bill is bad and there are many ways to improve it. Right now, it is not real reform–it is only a corporate giveaway that might trickle down to help a few Americans. The ideas listed here are a guide to transform this legislation into real reform.

  1. Add a robust public option open to all Americans.
  2. Remove the rollback of a woman’s right to choose.
  3. Repeal the anti-trust exemption for private insurance companies.
  4. Add early Medicare buy-in.
  5. Add a real employer mandate.
  6. Fix the excise tax that would reduce the quality of many Americans’ insurance. This can be done by properly indexing it so that it forever remains only a tax on “Cadillac” plans.
  7. Move up the start date of reform to as soon as possible. Three years is too long!
  8. Increase the affordability tax credits to individuals.
  9. Expand Medicaid to 150% of FPL.
  10. Reduce the maximum annual out-of-pocket limit to 5% of income.
  11. Move up state waiver for innovation to 2014 and add ERISA waiver. The state waiver for innovation is a good idea, but having it start in 2017 creates a bureaucratic nightmare of putting in place one reform only to replace it a few years later. We need to fix our system now, not have states start working toward a real solution a decade from now.
  12. Give states that set up “basic health programs” 100% of the money, and allow them to use the program for people above 200% of FPL.
  13. Allow for drug re-importation so Americans can get cheaper drugs from Canada or Europe.
  14. Give Medicare the power to directly negotiate for lower drug prices.
  15. Give the government the power to negotiate for lower drug prices on behalf of all Americans (like every other industrialized country does to bring down pharmaceutical prices).
  16. Create a national exchange with a strong regulation enforcer instead of state-based exchanges with weak local insurance commissioners.
  17. Force all non-HMO insurance plans on the exchange (or at least on the new OPM exchange) to work with the exchange commissioners to collectively negotiate a single provider reimbursement rate for all insurance plans (as it is in Switzerland, Belgium, and The Netherlands.)
  18. Add truly strong risk adjustment mechanisms to force competition based on quality instead of trying to dump sick customers (as is done in The Netherlands).
  19. Increase the actuarial value of the minimum qualified plans offered on the exchange and base subsidies on the gold level (80% actuarial value) instead of silver level plan (70% actuarial value).
  20. Force all insurance companies on the exchange to offer at least one precisely designed high quality insurance plan. This will allow true apple-to-apple comparisons, and make it harder for insurance companies to game the system.
  21. Greatly reduce the amount of plan design leeway given to insurance companies to reduce their ability to game the system.
  22. Make it illegal to sell basic health insurance for profit, like in almost every first-world country on Earth.
  23. At the least, allow only non-profit insurance plans to take part in the new exchanges (or OPM exchange).
  24. Reduce the community rating based on age to at most a 1:2 ratio with age rating bands. (one price for all 18-30 year olds, one price for 30-45 year olds, and one price for all 45-64 year olds).
  25. Make minimum medical loss ratio 92%. (Try to do this in way to get around the CBO.)
  26. At the very least, remove the MLR loophole for the individual market.
  27. Allow state and local governments to apply for grants from the CO-OP program.
  28. Allow the co-ops to sell insurance to anyone, not just the small group and individual markets.
  29. Allow undocumented immigrants to buy health insurance with their own money on the new exchange.
  30. Make all legal immigrants eligible for all public health care programs right away, instead of creating a five year wait.
  31. Eliminate direct-to-consumer advertising for prescription medication.
  32. Provide enough money to give every American access to a community health care center.
  33. Follow the FTC recommendations and create a real pathway for biosimilars to create generic forms of the most expensive medications in this country.
  34. Create a Government-run HMO option modeled on the VA system.
  35. Scrap the whole bill and replace it with a single payer “Medicare-for-all” system.

If they implement a vast majority of these reforms, progressives should only then embrace the individual mandate. Until the government takes real steps to ensure that people actually have access to high-quality, affordable health insurance it is immoral to force people to buy expensive, junk insurance from private corporations.

Right now, the bill is only a big corporate giveaway masquerading as reform–reform that will only enrich, empower, and entrench the enemies of real reform. Only if they add the bulk of these ideas could you ever honestly call the bill reform, and, so, make it worth passing.