Congressional House leaders plan legislation this year to tackle deficits by curbing entitlements, just weeks after digging a deeper deficit hole with a tax plan that will add an estimated $1.5 trillion to the national debt over the next 10 years.

Entitlement reform is certainly needed. Even before the tax legislation, the Congressional Budget Office (CBO) forecast a major rise in federal deficits, from 2.9% of gross domestic product (GDP) in 2017 to nearly 10% within 30 years. Over that period, says the CBO, health spending, and in particular Medicare, will be one of the largest drivers of spending.

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In this issue of JAMA, Emanuel and colleagues propose an Affordability Index to measure the ability of the average US household to pay for its medical expenses. As the authors point out, standard economic measures used to track health spending do not adequately represent the effect of rising costs on families.

Emanuel and colleagues correctly observe that aggregated measures of health spending in the United States are not helpful to most people. Their intent is to create a measure using readily accessible data that is intuitive and easy for the average person to understand. Such an index, if widely adopted, might help galvanize public support for efforts to bring more cost discipline to the provision of medical care.

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We are 2 former Administrators of the Medicare and Medicaid programs, under Presidents Barack Obama and George H. W. Bush. Although we represent different political parties, we take pride in the accomplishments of these 2 programs, which collectively help millions of US residents get the health care they need.

Medicaid has become a major focus in the debate over repealing the Affordable Care Act (ACA), because the proposed replacement bills go beyond the ACA into the underlying Medicaid program that was originally passed by Congress in 1965. As we have overseen the Medicaid program at various stages, we are familiar with its successes, its areas for improvement, its effect on state budgets, and its importance to millions of ordinary people who count on the program and will need it in the future.

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Section 1332 of the ACA permits states to submit simultaneous and combined “superwaivers” for Medicaid and for provisions of the ACA itself. These superwaivers could make it easier for states proposing plausible ways to allow states that serve Medicaid beneficiaries more efficiently to reprogram federal and state savings into health programs for non-Medicaid eligible households. For households with working, nondisabled adults, it should also be made easier for states to pool their federal and state funds for Medicaid, the Children’s Health Insurance Program (CHIP), the ACA, and other programs to deliver coverage through private plans in the ACA exchanges. It is also time to allow states more flexibility in using Medicaid and other health care funds to invest in the social determinants of health—items such as adequate housing, school-based social services, improved lifestyles, and safer household environments, which can contribute to improved health and reduced medical costs.

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Some Republican leaders in Congress are trying to pass legislation rolling back and replacing key features of the ACA without securing any Democratic support in the effort. The ACA was passed in 2010 with only Democratic votes, and that is a major reason the law remains politically and, to a degree, programmatically unstable. The Democratic Party has lost numerous seats at the federal and state levels of government since the ACA was enacted. It would be better for the United States if a broad consensus could be reached on health care. A bill that passed with support from some Republicans and some Democrats has a better chance of political survival than a bill passed by just one party.

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The most popular parts of the Affordable Care Act (ACA) are the most expensive. Universal coverage is a top priority not only for Democrats but also for President Trump. Both Republicans and Democrats want to preserve many costly coverage features of the ACA, including those that prevent insurers from precluding people with preexisting conditions and those that eliminate lifetime or annual coverage limits. The challenge is how to preserve these features and make insurance affordable.

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Since its passage in 1965, Medicaid has expanded and contracted with the political tides. With concurrent Republican executive and legislative control in 2017, conservative policy makers have already declared their desire to repeal the Affordable Care Act (ACA) and its Medicaid expansion, which has been responsible for approximately 12 million of the 20 million individuals who became newly insured as a result of the ACA. But proposals for fundamental reform of Medicaid are even more far-reaching in terms of their consequences for the other 60 million low-income children, parents, the elderly, and individuals with disabilities who rely on the program. Understanding the rationale for and likely effects of these proposals is critical for physicians and patients alike.

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Donald Trump’s pledge to “repeal and replace Obamacare” was one of his biggest crowd pleasers. Moving forward on his broad replacement themes—expanding health savings accounts (HSAs) and state flexibility—could lead to some surprising and intriguing reforms.

During the campaign, Trump supported the familiar Republican themes of tax-free HSAs and allowing families to deduct health insurance premiums in their tax-returns. He pledged that “we must also make sure that no one slips through the cracks simply because they cannot afford [health] insurance.” This opens the door to a serious and conceivably bipartisan discussion about how to replace the complex structure of ACA subsidies and tax breaks.

In addition to redesigning subsidies, another element is an expanded role for states. The familiar Republican call to take the federal money for Medicaid expansion as a block grant and turn it into subsidies for families to buy private coverage has received plenty of the attention. But the broader theme of giving states much greater flexibility could become a different pathway to the goal of affordable and adequate health coverage for all.

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The most likely scenario to achieve reform and assure coverage similar to what currently exists is to pass a reconciliation bill similar or identical to the bill passed approximately a year ago. This bill eliminated funding for the Medicaid expansion and the subsidies in the exchange and also includes a two-year implementation delay. Since the majority of newly insured individuals have come from Medicaid rather than the exchanges, this portion of the repeal, unless accompanied by other changes such as a refundable tax credit, would have the largest effect on the newly insured.

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What are the prospects for action on the Affordable Care Act (ACA) during the next Congress and presidential administration? There is no easy answer to that question in this unusual election year, although one’s first reaction might be “not much.” As Larry Leavitt, MPP, noted in the JAMA Forum recently, the presidential platforms suggest fundamentally different, maybe even irreconcilable, approaches.

At the risk of being proven wrong, it also seems reasonable to assume that there will continue to be a political standoff in practice next year, with neither party able to push through its preferred solutions for health care.
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