华盛顿——华盛顿似乎没有人喜欢平价医疗法案。共和党人在2009年和2010年通过该法案时一致反对，他们希望完全废除该法案，声称该法案赋予联邦政府太多的权力。民主党人认为这项法律还不够深入:参议员伯尼桑德斯。，希望用全民医疗保险取代aca，这将彻底摆脱私人保险。

事实是，除了华盛顿，没有人希望对一项健康法律进行戏剧性的修改，该法律为2000万以前没有健康保险的美国人提供保险，同时也在降低医疗保健成本方面做了初步尝试。

借用温斯顿·丘吉尔的一句话，选民可能会相信，巴拉克·奥巴马总统的标志性健康法，就像民主本身一样，是除了所有其他已经尝试过的政策之外最糟糕的健康保健政策。近代史也显示了同样的情况。当共和党在2017年春天和夏天试图废除和取代aca时，它的各种计划被证明不受欢迎。

与此同时，桑德斯提出并得到他的许多同事支持的渐进式替代方案——完全由联邦政府管理的医疗保健系统——也没有得到广泛支持，至少在人们发现这意味着他们必须放弃私人计划并可能支付更高的税收时是这样。

民主党总统候选人伯尼·桑德斯。(照片:史蒂夫·马库斯/拉斯维加斯太阳报通过美联社报道)

 

华盛顿邮报最近报道说，“问题是许多选民不关注全民医保这样的崇高目标”。“他们想要更简单的东西——支付更少的医疗费用。”这正是凯泽家族基金会4月份进行的一项民意调查所发现的，近四分之三的受访者表示，他们希望国会修正aca，而不是废除它，转而支持一个由政治意识形态塑造的体系。

来自芝加哥郊区的32岁民主党众议员劳伦安德伍德(lauren underwood)说，她在共和党占多数的选区获胜，承诺利用她作为护士和健康政策专家的经验来修正奥巴马备受诟病的健康法。

现在，对于一个被意识形态分裂的国会来说，这是一个罕见的老式发展，她正试图通过引入一项计划来兑现她的承诺，该计划将允许更多的人通过联邦政府购买医疗保险，并使该保险变得更加负担得起。

劳伦·安德伍德议员。，在新闻发布会上发表讲话，公布医疗保健立法。(照片:安德鲁·哈勒/彭博社通过盖蒂图片社报道)

 

安德伍德的计划于3月份推出，被称为《医疗保健可负担性法案》，该计划将通过打破可怕的“补贴悬崖”为aca的注册提供一个潜在的至关重要的推动力，该悬崖要求年收入超过100，400美元的四口之家没有资格获得任何税收抵免来帮助支付保险费用。

该计划还将把人们支付的健康保险保费限制在收入的8.5%。一些人现在可能要支付三倍的费用，使得保险在技术上可行，但实际上负担不起。她的工作人员表示，她的计划将减少2000万人的保费，其中包括900万目前有资格享受税收抵免但选择不购买保险的人。

 

众议员劳伦安德伍德(照片:汤姆威廉姆斯/cq点名/盖蒂图像)

 

医疗保健专家称赞安德伍德的远见卓识，尽管他们承认要将这一远见卓识卖给一个由共和党控制的充满敌意的参议院，需要的不仅仅是健全的政策。“就是这样，”查尔斯·加巴说，他是一名在acasignups.net博客的医疗保健政策分析师。"就我而言，这是改善平价医疗法案最重要的部分之一，

"他谈到安德伍德的法案时说。gaba解释说,“aca最大的一个缺点”是对那些希望通过市场购买医疗保健的人的补贴“太低了”,而对那些确实做到了这一点的人来说,“不够慷慨”。

安迪·斯拉维特(andy slavitt)是奥巴马政府的高级卫生保健官员，他对此表示赞同。“声音很大。最重要的法案，”他说，提到了面对特朗普政府似乎无情的攻击，民主党为支持aca而推出的几项措施。安德伍德唯一关注的是可负担性，这是民主党和共和党的主要抱怨。

她的法案——与aca的974页相比，只有一页长——将允许收入约为联邦贫困水平400%的个人和家庭在通过政府市场购买医疗保健时有资格获得补贴。与此同时，保费支付的浮动比例将遭遇8.5%的硬性上限，这将产生使保险农场比目前更加负担得起的效果。

众议院议长南希·佩洛西(nancy pelosi)和能源和商业委员会主席弗兰克·帕隆(frank pallone，d-n.j .(照片:j. scott applewhite/ap)

 

“这是一个我们现在可以通过的重要修正，”安德伍德在最近与雅虎新闻的对话中说。她的工作人员表示，他们还不知道该法案将花费多少，因为国会预算办公室尚未对其进行“评分”。卫生保健分析师gaba表示，每年的成本可能为150亿美元，仅占4万亿美元预算的1%。如果扩大福利的2000万受益人的估计是正确的，这相当于每人每年750美元的支出。斯拉维特认为，提高2%或3%的公司税率将完全支付更慷慨的补贴。

聪明的政治家安德伍德知道，政策的好坏取决于能够贯彻到底的政治。安德伍德的法案连同其他几个aca修正方案一起，已经提交给众议院，众议院是由民主党众议员理查德尼尔领导的有影响力的委员会。如果该法案在委员会通过，以及通过的速度有多快，将是该法案前景的第一个迹象。委员会的一名民主党工作人员告诉雅虎新闻，“委员会还没有决定将接受哪些与aca相关的法案，但是尼尔主席已经和安德伍德议员谈了她的立法。”

"目前，我们仍在评估账单，并决定如何前进."安德伍德的法案确实得到了众议院议长南希·佩洛西(nancy pelosi，d-calif)的支持，尽管佩洛西对其他第一任期议员提出的提案很冷淡——最显著的是纽约州众议员亚历山大·奥卡西奥-科尔特斯(alexandria ocasio-cortez)提出的全面绿色新政环境计划——佩洛西一直在吹捧安德伍德的解决方案。众议院民主党领袖的助手要求不要将安德伍德的法案命名为“重大影响”。(他还称赞民主党众议员安迪·金(andy kim)提议帮助各州建立自己的健康保险市场，而不是依赖联邦市场。

hoyer办公室发言人mariel saez说，众议院多数党领袖d-MD steny hoyer是该法案的另一个支持者，他“支持扩大税收抵免的努力，使医疗保险更加负担得起，并赞扬安德伍德众议员对这个问题的关注”。

众议院多数党领袖steny hoyer(照片:bill clark/cq点名/getty images)

 

得到了众议院两个最有权力的民主党人的支持，尼尔很难忽视该法案。当然，挑战不会出现在众议院，也不会出现在其他民主党人身上。这将在参议院进行，共和党人只差一票就要废除aca，不太可能签署民主党的解决方案。

安德伍德承认，说服共和党成员“不是我的重点”。但是她也希望到时候，他们至少能听到她的声音。安德伍德是一名受过训练的护士，拥有密歇根大学和约翰霍普金斯大学的学位，他于2014年加入奥巴马政府，在aca工作。三年后，她决定自己去找工作。她竞选的席位当时由共和党人randy hultgren占据，他投票废除并取代aca。在此之前，2007年因丑闻辞职的共和党众议院议长丹尼斯·哈斯泰特(dennis hastert)已经有20年了。

非裔美国人安德伍德明确承诺维护健康法，并在芝加哥论坛报称之为“可靠的共和党堡垒”的白人占压倒多数的地区赢得了15000票。换句话说，安德伍德已经说服了共和党选民。她还能说服共和党议员吗？她最好的武器是一种基于政策分析的不靠谱的、几乎不涉及政治的方法——一种摆脱了一些同事所信奉的对抗性进步言论的方法。这种言论可能会导致转发，但正如最近关于边境紧急事件资金的斗争所显示的那样，它也可能通过排斥温和的民主党人来阻碍立法成果，更不用说几乎所有的共和党人了。

安德伍德还没有加入华盛顿众议员普拉米拉·贾亚帕尔提出的全民医保计划。并且，总的来说，刻意避免谈论这种有争议的方法。但是安德伍德的法案可以为这个目标铺平道路。左倾进步新闻网站wonkette的标题写道:“劳伦安德伍德为所有人的医疗保健搭建了一座糟糕的桥梁。”

pramila jayapal议员，华盛顿(照片:andrew harnik/ap)

 

共和党人对改进aca没有兴趣，他们普遍认为这是迈向社会化医疗的一步。

“在参议院，它哪儿也去不了，”卫生保健分析师gaba认为。他说，参议院多数派“不会允许任何改善平价医疗法案的措施通过这个周期”。该法案将由r-tenn参议员拉马尔亚历山大负责，他是卫生、教育、劳工和养老金委员会的负责人。

虽然亚历山大是aca的批评者，但他也起草了修复它的计划。能说服他接受安德伍德的计划吗？不太可能，但也不是不可能，不是在这个时代。更不可能的是参议院多数党领袖米奇·麦康奈尔的支持。他对奥巴马标志性成就的仇恨有着深刻的宗教信仰。

“这仍然是个好政策，”gaba说。“他们应该继续努力。”

 

 

How one freshman congresswoman plans to save the Affordable Care Act

 

WASHINGTON — Nobody in Washington seems to like the Affordable Care Act. Republicans, who opposed it unanimously when it passed in 2009 and 2010, want to repeal it altogether, claiming it gives too much power to the federal government. Democrats argue the law doesn’t go far enough: Sen. Bernie Sanders, I-Vt., wants to replace the ACA with Medicare for All, which would get rid of private insurance entirely.

The thing is, nobody outside Washington wants a dramatic reworking of a health law that provides coverage to 20 million Americans who previously didn’t have health insurance, while also making a tentative start on lowering the costs of medical care. Voters may believe, to borrow a phrase from Winston Churchill, that President Barack Obama’s signature health law, like democracy itself, is the worst health care policy except for everything else that has been tried.

Recent history has shown as much. When the GOP tried to repeal and replace the ACA in the spring and summer of 2017, its various plans proved unpopular. Meanwhile, the progressive alternativeproposed by Sanders and championed by many of his colleagues—a health care system run entirely by the federal government — also does not enjoy broad support, at least not once people find out it means they have to give up their private plans and potentially pay higher taxes.

 

Democratic presidential candidate Sen. Bernie Sanders. (Photo: Steve Marcus/Las Vegas Sun via AP)

“The problem is that many voters are not focused on such lofty goals” as Medicare for All, theWashington Post recently reported. “They want something simpler — to pay less for their own health care.” That’s exactly what a Kaiser Family Foundation poll conducted in April found, with nearly three-quarters of respondents saying they wanted Congress to fix the ACA, not scrap it in favor of a system shaped by political ideology.

Enter Lauren Underwood, a 32-year-old Democratic congresswoman from suburban Chicago, who won in a heavily Republican district by promising to use her experience as a nurse and health policy expert to fix Obama’s much-maligned health law. Now, in an old-fashioned development rare for a Congress riven by ideology, she is trying to make good on her promise by introducing a plan that would both allow more people to buy health insurance through the federal government and make that insurance significantly more affordable.

 

​

Rep. Lauren Underwood, D-Ill.,, speaks during a news conference to unveil health care legislation. (Photo: Andrew Harrer/Bloomberg via Getty Images)

Underwood’s plan — introduced in March and known as the Health Care Affordability Act — would offer a potentially crucial boost to ACA enrollment by blasting away the dreaded “subsidy cliff,” which mandates that no family of four making more than $100,400 can qualify for any tax credits whatever to help pay for insurance. The plan would also cap the premiums people pay on their health insurance at 8.5 percent of income. Some people now could be paying three times that much, making insurance technically attainable but practically unaffordable.

Her staff says her plan would reduce premiums for 20 million people, including 9 million who currently do qualify for tax credits but have chosen not to buy insurance.

 

 

Rep. Lauren Underwood (Photo: Tom Williams/CQ Roll Call/Getty Images)

Health care experts praise Underwood’s vision, even while acknowledging that it will take more than sound policy to sell that vision to a hostile Senate controlled by Republicans. “This is it,” says Charles Gaba, a health care policy analyst who blogs at ACAsignups.net. “As far as I am concerned, it’s one of the most important parts of improving the Affordable Care Act, period,” he says of Underwood’s bill.

Gaba explains that “the single biggest shortcoming of the ACA” is that subsidies for people who wish to purchase health care through the marketplace “cut off too low” and “are simply not generous enough” for those who do make the cutoff.

Andy Slavitt, who was a top health care official in the Obama administration, agrees. “Very sound. Most important of the bills,” he says, referencing the several measures Democrats have introduced to shore up the ACA in the face of a seemingly unrelenting onslaught by the Trump administration.

Underwood’s sole focus is affordability, a major complaint of bothDemocrats and Republicans. Her bill — a single page in length, compared with the 974 pages of the ACA — would allow even individuals and families with incomes about 400 percent of the federal poverty level, where all current subsidies end, to qualify for subsidies when purchasing health care through the government marketplaces. At the same time, the sliding scale of premium payments would encounter a hard ceiling at 8.5 percent of income, which would have the effect of making insurance farmore affordable than it currently is.

 

 

House Speaker Nancy Pelosi, joined at left by Energy and Commerce Committee Chair Frank Pallone, D-N.J. (Photo: J. Scott Applewhite/AP)

"This is an important fix that we can pass now,” Underwood said in a recent conversation with Yahoo News. Her staff says they do not yet know how much the bill would cost because it has not yet been “scored” by the Congressional Budget Office. Gaba, the health care analyst, says the cost could be $15 billion per year, a fraction of 1 percent of a $4 trillion budget. If the estimate of 20 million beneficiaries of the expanded benefits is correct, that translates to an outlay of $750 per person per year. Slavitt believes a corporate tax rate increase of 2 or 3 percent would fully pay for the more generous subsidies.

Underwood, a smart politician, knows that policy is only as good as the politics that see it through. Along with several other ACA fixes, Underwood’s bill has been put before House Ways and Means, the influential committee helmed by Rep. Richard Neal, D-Mass. If, and how quickly, the bill moves through the committee will be the first indication of its prospects.

“The committee has not yet decided which ACA-related bills it’s going to be taking up, but Chairman Neal has talked to Rep. Underwood about her legislation,” a Democratic staffer on the committee told Yahoo News. “At this point, we’re still evaluating bills and determining how to move forward.”

Underwood’s bill does havethe support of House Speaker Nancy Pelosi, D-Calif. Though she has been cool to proposals put forth by other first-termers — most notably the sweeping Green New Deal environmental plan introduced by Rep. Alexandria Ocasio-Cortez, D-N.Y. — Pelosi has touted Underwood’s solution. An aide to Democratic leadership in the House who asked not to be namedpraised Underwood’s bill as “hugely consequential.” (He also praised Rep. Andy Kim, D-N.J., for his proposal to help states create their own health insurance marketplaces instead of relying on the federal one.)

Another booster of the bill is House Majority Leader Steny Hoyer, D-Md., who “supports efforts to expand tax credits to make health coverage more affordable and commends Rep. Underwood's focus on this issue,” according to Mariel Saez, a spokesperson for Hoyer’s office.

 

 

House Majority Leader Steny Hoyer (Photo: Bill Clark/CQ Roll Call/Getty Images)

Endorsed by two of the chamber’s most powerful Democrats, the bill will be difficult for Neal to ignore. The challenge, of course, will not be in the House, with fellow Democrats. It will be in the Senate, with Republicans who fell just a vote short of repealing the ACA and are unlikely to sign on to a Democratic fix.

Persuading GOP members “has not been my focus,” Underwood acknowledges. But she also hopes that when the time comes, they will at least hear out her pitch.

A trained nurse with degrees from the University of Michigan and Johns Hopkins, Underwood joined the Obama administration in 2014 to work on the ACA. Three years later, she decided to seek office herself. The seat she ran for was held at the time by Republican Randy Hultgren, who had voted to repeal and replace the ACA. Before that, it had been the two-decade domain of Dennis Hastert, a Republican House speaker who resigned in scandal in 2007.

Underwood, who is African-American, explicitly promised to preserve the health law, and won by 15,000 votes in an overwhelmingly white district that the Chicago Tribune called “a reliable Republican bulwark.” In other words, Underwood has already persuaded Republican voters. Can she also persuade Republican legislators?

Her best weapon is a wonkish, almost apolitical approach rooted in policy analysis — one free of the confrontationally progressive rhetoric some of her colleagues have embraced. That rhetoric can yield retweets, but as the recent fight over funding for the border emergency showed, it can also hamper legislative accomplishments by repelling moderate Democrats, not to mention just about all Republicans.

Underwood has not signed on to the Medicare for All plan introduced by Rep. Pramila Jayapal, D-Wash., and, in general, studiously avoids talking about that controversial approach. But Underwood’s bill could pave a path toward that goal. “Lauren Underwood Builds A Bad-Ass Healthcare Bridge To Medicare For All,” ran a headline in Wonkette, the left-leaning progressive news site.

 

 

Rep. Pramila Jayapal, D-Wash. (Photo: Andrew Harnik/AP)

Republicans have shown no interest in improving the ACA, which they generally consider a step toward socialized medicine.

“In the Senate, it's not gonna go anywhere,” believes health care analyst Gaba. The Senate majority “is not going to allow anything that improves the Affordable Care Act to pass this cycle,” he says. The bill would run through Sen. Lamar Alexander, R-Tenn., who heads the Health, Education, Labor and Pensions Committee.

Though a critic of the ACA, Alexander has also drafted plans to fix it. Could he be persuaded to take up Underwood’s plan? Unlikely, but not impossible, not in this day and age. Far more improbable is the support of Senate Majority Leader Mitch McConnell, R-Ky., whose hatred of Obama’s signature accomplishment has the depth of religious conviction.

“It’s still good policy,” Gaba says. “And they should still push it.”