Here’s our Pick Six winner for Trump on health care

You win some, you lose some. Americans have made it clear to President Donald Trump and Republicans in Congress that they don’t want a repeal of Barack Obama’s signature health care achievement, and that they really don’t want the replacement Republicans had in mind.

That should have been enough. Contrary to the president’s Twitter feed, the Affordable Care Act isn’t about to “explode.” More than 20 million previously uninsured Americans now have health insurance, including more than 5 million in California. That coverage has changed and even saved lives.

The optional Medicaid expansion responsible for much of that change has been adopted by 32 states, and is working well enough that holdouts such as Kansas are starting to rethink their resistance. Private insurance exchanges are stable in most states, particularly California.

And while premiums have risen, tax credits have covered most of the increase for most exchange policy holders.

No matter. “The Democrats will make a deal with me on healthcare as soon as Obamacare folds – not long,” Trump tweeted Tuesday, a la Snidely Whiplash.

“I think we’re closer today to repealing Obamacare than we ever were before,” House Majority Whip Steve Scalise, R-LA, optimistically said.

Clearly, they haven’t gotten the memo from voters. Most Americans get coverage through their employers, but no one wants a return to the pre-Obamacare days.

The far smarter route for Trump and Congress would be to listen to 65 percent of American voters and maintain or strengthen the existing system. Just removing some obstacles Republicans have used to hobble the system would lower costs and make them look like heroes. Here’s what would help:

Don’t subvert the individual mandate

The Affordable Care Act hinges on a law requiring everyone to buy health insurance, so that premiums from healthy people mitigate the costs of payouts for the sick.

After the failed repeal effort, Health & Human Services Secretary Tom Price told a congressional subcommittee that as long as existing law stood, he was “obliged” to enforce the mandate, but one of Trump’s first executive orders instructed the IRS, among other executive branch offices, not to. Starting this year, for example, tax returns were to have been kicked back if the filer failed to disclose coverage status; now they won’t be.

Without enforcement, more healthy people will drop out of the private market and premiums will skyrocket. Why create such hardship?

Ante up for “cost sharing” subsidies

People who don’t qualify for Medicaid and can’t afford private insurance get two kinds of help under the Affordable Care Act: tax credits to help cover premiums, and subsidies, paid to health plans, to help cover deductibles and co-pays.

In 2014, House Republicans sued the Obama administration, challenging that latter “cost-sharing” assistance, which this year added up to about $7 billion nationally, including about $800 million in California. A judge sided with the GOP, but an appeal is pending.

Without that assistance, premiums will soar; with it, private exchanges may finally work as intended. A status update on the lawsuit is due in late May.

Stop trying to constrict open enrollment

Among the various Trump initiatives to cripple the Affordable Care Act is the administration’s effort to shorten open enrollment on the exchanges. We get it; conservatives aren’t supposed to encourage participation in government programs.

But the Affordable Care Act exchanges are market-based; Democrats cribbed their blueprint from the Heritage Foundation. Shorter sign-ups cost money. Sick people, who need the coverage, tend to sign up earlier than healthy people, so moving up the deadline just sickens the risk pool and drives up premiums.

Stop destabilizing the insurance market

In a letter to Trump last week, California Insurance Commissioner Dave Jones noted that Congress has short-changed re-insurance and other key programs set up to help health plans adjust when risk pools turn out to be more costly than expected.

Republicans know that backstop is needed. A $100 billion, 10-year stability fund was in their proposed Obamacare replacement.

One way or the other, Congress needs to fund this cushion for health plans and stop undermining coverage.

Learn from the states

A state-based reinsurance program in Alaska dramatically cut premiums in that high-cost part of the country. Arkansas and Tennessee are experimenting with “bundling” a set of services for a given condition into a fixed payment for providers, the better to drive down health-care costs.

In California, where enrollment on the exchanges has been especially successful, heavy advertisement has made all the difference. Such initiatives should be national best practices; Trump could build on them and win.

Free the Medicaid resisters

Kansas isn’t the only red state weary of leaving big federal subsidies on the table. If the 18 states that have refused to opt into the Medicaid expansion dropped their resistance, more than 4 million Americans would be eligible.

Yes, the expansion spends tax money. But it also lowers premiums and medical bills, which also come out of American pockets. Republican leaders should let state lawmakers get past the dogma and remember another old sports adage: If you can’t beat ‘em, join ‘em.

This story was originally published April 1, 2017 at 5:00 AM with the headline "Here’s our Pick Six winner for Trump on health care."