Obama Offers Ways to Improve His Health Care Law

JULY 11, 2016

WASHINGTON — After defending the Affordable Care Act in all its intricacies for six years, President Obama proposed ways to improve it on Monday, saying that Congress should provide larger subsidies for private health insurance and create a public plan like Medicare to compete with private insurers in some states.

At the same time, he accused the pharmaceutical industry of trying to protect its profits by opposing any constraints on drug prices.

Mr. Obama offered his views in a valedictory message summarizing what he sees as his legacy on health care, together with his ideas to improve the Affordable Care Act.

He said he was proud of the progress of the last six years, especially the fact that 20 million people had gained coverage because of the law. But he acknowledged that — despite the title of the law — health care and health insurance were still unaffordable for some people.

“Too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain uninsured,” Mr. Obama said in an article published online in The Journal of the American Medical Association.

The article can be read as an effort by Mr. Obama to entrench his approach to health care, which is sure to be debated fiercely by candidates for president and Congress in this election year. Without mentioning names, Mr. Obama aligns himself more closely with the presumptive Democratic nominee, Hillary Clinton, who wants to build on the Affordable Care Act, and he rebuts her Republican counterpart, Donald J. Trump, who promises to replace “this horrible, stupid Obamacare” with “something that’s great.”

The number of uninsured has dropped to 29 million, from 49 million in 2010, Mr. Obama said. Many of those who remain uninsured want coverage but say they cannot afford it, he said. Accordingly, he wrote, Congress should increase federal financial assistance to help people buy coverage through public marketplaces like HealthCare.gov.

The online exchanges will be a viable source of coverage “for decades to come,” Mr. Obama said, but “further adjustments and recalibrations will likely be needed.”

Of the 11 million people with marketplace coverage, 85 percent receive tax credits that, on average, cover nearly three-fourths of their premium costs. But for some, said Kristie Canegallo, a deputy chief of staff at the White House, the “tax credits aren’t big enough.”

Mr. Obama said the health law was costing less than originally projected, so Congress could provide more generous subsidies while still keeping federal costs below initial estimates.

White House officials said that Mr. Obama’s purpose in writing the article was to start a discussion and suggest a direction for elected officials and future policy makers, but that he would not be offering detailed new legislative proposals to carry out his ideas.

Based on his experience in the last few years, Mr. Obama said, Congress should establish “a public plan to compete alongside private insurers in areas of the country where competition is limited.”

Most of the country has benefited from competition in the marketplaces, and 88 percent of the people who have enrolled live in counties where at least three insurers offer plans, Mr. Obama said. But, he said, the remaining 12 percent are in areas with only one or two insurers.

Jason Furman, the chairman of Mr. Obama’s Council of Economic Advisers, said, “A public option would be one way to make sure that there was competition everywhere.”

In the debate on health care in 2009 and 2010, Mr. Obama said he supported the idea of a public option, but he did not always insist on it, and the administration sent mixed signals about how important it was.

Reviving the idea on Monday, Mr. Obama said a public plan — in places lacking competition — would give consumers more affordable options while also saving money for the government.

“Public programs like Medicare often deliver care more cost-effectively,” by securing better prices from health care providers, Mr. Obama said. Critics say the savings result, in large part, from price controls imposed by federal laws and regulations.

Mrs. Clinton has proposed her own approach, which would allow people to buy into Medicare.

Medical journals nowadays are full of articles on health policy, but Mr. Obama’s is strikingly different in one respect. It includes a blistering attack on Republicans, who he said had tried to sabotage the health care law “through inadequate funding, opposition to routine technical corrections, excessive oversight and relentless litigation.”

Mr. Obama accused Republicans of “hyperpartisanship” without saying what he might have done differently. The law was adopted without any Republican votes, and to this day, polls show public opinion almost evenly split between favorable and unfavorable views of it.

The president described Medicaid as “a critical piece of unfinished business.” Because of Republican opposition, he said, 19 states have not expanded Medicaid eligibility. If they did, he said, four million fewer people would be uninsured.

Mr. Obama also assailed “special interests,” suggesting that the pharmaceutical industry has been particularly bad.

Drug companies, he wrote, “oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits.”

In conclusion, Mr. Obama predicted that history would vindicate his work. “Looking back 20 years from now,” he said, “the nation will be better off because of having the courage to pass this law and persevere.”