Thus far, all the Congressional legislative proposals to repeal and replace the Affordable Care Act (ACA) worsened healthcare insurance for rural and farm residents, including the proposal that was defeated in the U.S. Senate on July 28th. The alternatives increased premiums and deductibles for persons in the 50-65 year age group; they decreased coverage for preexisting and chronic conditions such as cancer.

There are parts of the ACA that most people like (e.g., affordable coverage for preexisting and chronic health conditions, allowing children on their parents’ insurance plans until age 26, parity for physical and behavioral healthcare, expanded Medicaid for the disabled, aged persons, and others without viable options) is an alternate approach that most Americans say deserves consideration.

It’s time to consider how to fix the ACA, instead of demolishing it. A two-tiered healthcare insurance system that includes both private insurance coverage options as well as government options for those who can’t afford anything else, is likely to succeed.

There are big income and healthcare gaps between agricultural and rural residents who can pay for healthcare insurance and those who depend on subsidized assistance. Those who need care the most may have depleted their resources, such as farmers in economic trouble, persons dependent on opioids or other addictive substances, and those who exhausted their insurance limits and will have to sell off assets to afford further care.

Prior to the ACA, paying for healthcare after insurance was used up was the main cause of farm-owner bankruptcy.

Several ideas for fixing the ACA were obtained from five Midwesterners and one Coloradoan (three farmers, two female farm owners, and a physician) with whom I spoke about alternatives to the ACA. Information from the nonpartisan Congressional Budget Office and the Pew Research Center also helped shape the following recommendations:

  • Members of Congress should have the same healthcare insurance that is available to everyone else in the U.S. Senators voted to exempt themselves from the provisions of their own legislation in June in order to keep their special privileges.
  • Allow everyone the option of purchasing private health insurance coverage with superior benefits if they are willing to pay for superior care, but require all U.S. residents to obtain health insurance of some kind, so that everyone is in an insurance pool and everybody pays something, even if a copay. A two-tier private and national healthcare insurance system works well in many countries.
  • All insurers, including those that pay for superior care and those on a national healthcare service, should utilize a single government-supervised entity to process all insurance claims. Administrative costs for insurance coverage for everyone would almost certainly decline. Private insurers currently expend 31% for administrative costs, while the federal Medicare system consumes 2.6% of its total expenditures for administration. A government-regulated, single processor would also halt tactics some private insurers undertake, such as denying claims even when they are submitted correctly. This tactic delays payments to providers and drives up healthcare costs for their resubmission, or shifts the burden to the consumers.
  • Negotiate prices with drug manufacturers for medications. Current statutes, for which drug manufacturers lobbied heavily, banned bargaining for medications in the U.S., and drove up medication costs.
  • Allow private insurers to compete in all states, thereby expanding options for private coverage, but require that they do not exclude any counties within any state in which they compete.
  • Expand rather than curtail Medicaid for residents who can’t afford insurance, but charge copays based on income. Medicaid currently pays 55% of costs for all persons in nursing homes and for most disabled persons living in residential care and home programs. Cutting back on Medicaid by eliminating the ACA, rather than modifying it, would make it difficult for a majority of the poorest, the elderly, and disabled persons to receive the services necessary for their well-being.
  • Place reasonable limits on medical malpractice awards; currently there are no limits.
  • Require states to develop programs to recycle unused and unexpired medications from pharmacies, hospitals and other healthcare providers, while making these medications available to persons in greatest need. This also would eliminate incineration costs until after their expiration date.

These are practical solutions to our healthcare insurance problems. Fixing existing problems of the ACA allows both private insurers and the federal government to offer competitive insurance policies.

This approach should appeal to those who desire higher-quality care than Medicare and Medicaid offer. It’s a common-sense approach to fixing a current system that denies coverage for many U.S. citizens.

The U.S. currently ranks 35th in the world in healthcare outcomes but pays twice as much as the average of the countries that are ranked higher. We can do better but doing better involves practical rather than political thinking.

Let your senators and representatives know how you feel about revising federal healthcare legislation.

Please also share any further useful ideas with me. Thanks to everyone who helped with this article.