It’s unlikely that as president, Hillary Clinton would get help from Congress in fixing problems with the Affordable Care Act, but she could make some smaller-scale tweaks on her own.
Clinton would enter the White House just as Obamacare’s open enrollment season winds down and insurers consider their prices and participation for the following year. She would be sure to face pressure to improve the marketplaces, which are suffering from spiking premiums and diminished plan options for consumers.
She has said she wants to improve the healthcare law and has proposed a laundry list of things she would do as president to make its coverage more affordable for Americans.
“I want very much to save what works and is good about the Affordable Care Act,” Clinton said at the second presidential debate on Oct. 9. “But we’ve got to get costs down.”
But the biggest things Clinton wants to change, such as increasing the law’s subsidies for low and middle-income Americans and paying states more for expanding Medicaid, would require approval from a Republican-led House, which has been highly reluctant to dramatically change the law apart from repealing it altogether.
Yet Clinton could enact some other changes through executive rules to try to make the marketplaces a more hospitable place for insurers, which need to be persuaded to keep selling there for years to come.
“There’s not a regulatory silver bullet here … if there was anything obvious, I think the Obama administration would have found it,” said Larry Levitt, a senor vice president at the Kaiser Family Foundation. “But there are a bunch of small things.”
The first route most health policy analysts point to is tightening the ways people can enroll in marketplace coverage outside the normal enrollment season. There is a list of reasons people can sign up throughout the year, including if they lose their job, divorce or have a baby.
But insurers have complained that people are abusing the system by procuring coverage when they have a serious medical problem and then dropping it later. A recent analysis by Avalere Health found that consumers enrolling outside the official signup season have 5 percent higher costs than those who bought a marketplace plan during enrollment time.
And significant numbers of people are availing themselves of the special signup periods. In the first half of 2015, about 940,000 people signed up outside open enrollment, about 15 percent of the year-end total enrollment.
In August, the administration proposed codifying several special enrollment periods to cut down on consumer abuse. Insurers also have pushed for requiring people to have their eligibility verified before they can enroll off-season. Clinton could direct the Centers for Medicare and Medicaid Services to continue efforts on both fronts, experts say.
“They control completely the special enrollment periods, the things insurers have complained so much about,” said Douglas Holtz-Eakin, former Congressional Budget Office director and president of the right-of-center American Action Forum. “They can clean that stuff up, there’s no question about that.”
Another possible venue for Clinton is to improve an ongoing program called risk adjustment, which redistributes dollars from insurers with lower-risk enrollees to insurers with higher-risk enrollees, as a way of evening out losses in the marketplaces.
The Obama administration has taken some steps toward that end, proposing changes it says will make the risk adjustment program more effective at pooling risk by considering enrollees who drop out mid-year and using prescription drug use data.
“There’s a lot of talk about how we could modify [risk adjustment] to make it more attractive for insurers,” said Tim Jost, a health law professor at Washington and Lee University. “The insurers that have left … they can come back in if they feel it’s a comfortable place to be.”
There’s another lever a Clinton administration could pull, too, by giving states wide latitude in how they run their insurance marketplaces through the use of innovation waivers provided in the healthcare law.
Three major health insurers — UnitedHealthcare, Aetna and Humana — have left the state-based insurance marketplaces mostly or completely, saying the new enrollees were sicker than expected and cost them too much money. So whatever approach Clinton would take to improve the healthcare law would likely include making it more inviting to insurers.
But to improve the marketplaces, consumers must be persuaded to buy plans. After an initially disastrous launch of the federal marketplace, healthcare.gov, the administration has majorly improved the website, making it more user-friendly and creating a mobile site.
The Department of Health and Human Services also has announced a more targeted outreach during the fourth enrollment season by partnering with popular companies and websites such as Instagram, Facebook, Uber and Lyft to reach healthy young people.
A Clinton White House could continue and expand upon those efforts, potentially drawing in less-risky consumers to improve the risk pools.
“That could have a huge impact because the biggest problem right now is you’ve got a population that is too old and too sick,” Jost said. “That in itself will make the marketplace a more comfortable place for insurers.”
