Ten Features of the Durable Path Forward on American Health Care
How reinsurance, portable coverage, savings reform, and a smarter role for Medicaid could provide affordable, nearly universal coverage
The book A Durable Path Forward on American Health Care lays out an economically and politically feasible path toward universal, high-quality health insurance coverage in the United States.
None of the existing partisan approaches is working. Centrist Democrats continue to patch the Affordable Care Act with temporary subsidies rather than establish durable, adequate coverage. The enhanced Premium Tax Credits were enacted temporarily and extended only through 2025, making them exceptionally easy for a later Congress to allow to expire. Whatever the political rationale, temporary benefits turn health coverage into a recurring election issue rather than a stable national commitment. Progressive Democrats answer with Medicare for All, while Republicans largely respond with eligibility restrictions and spending cuts that make existing coverage problems worse.
This instability has consequences beyond health care. Many Americans cannot accumulate sufficient retirement savings when premiums, deductibles, and medical bills repeatedly drain household finances. Without greater private savings, it will be much harder to make the adjustments eventually required to stabilize Social Security and the nation’s finances.
Here are ten features of the new approach:
1. It focuses on lowering the actual cost of insurance.
Instead of relying exclusively on ever-larger premium subsidies, federal reinsurance would pay part of exceptionally expensive claims before those costs are incorporated into premiums.
2. It could expand coverage at a relatively low net federal cost.
Reinsurance requires federal spending, but it lowers the underlying premiums used to calculate Premium Tax Credits, so part of its cost is automatically offset by smaller subsidy payments. Medicaid may also cover some low-income households more cheaply than heavily subsidized private plans that pay higher provider prices, while portable employer contributions could reduce coverage losses and recession-related Medicaid enrollment when workers lose or change jobs. The proposal is therefore less fiscally expensive than its individual spending provisions might initially appear: several reforms replace or reduce existing federal costs rather than simply adding new ones. These interactions must be incorporated into a dynamic, systemwide budget analysis that measures net costs across reinsurance, Premium Tax Credits, Medicaid, CHIP, and employer-financed coverage.
3. It protects families with seriously ill children.
A separate pediatric reinsurance program would help finance neonatal intensive care, childhood cancer, rare diseases, organ transplants, complex disabilities, and extremely expensive new treatments without loading the entire cost into family premiums.
4. It makes health coverage portable from job to job.
Workers could own their Marketplace policies while employers contribute toward the premiums. Changing jobs, starting a business, reducing hours, or retiring before Medicare would no longer automatically require changing insurance.
5. It reduces job lock and coverage interruptions.
After a layoff, the employer contribution could end and the federal subsidy could be recalculated, but the worker’s underlying insurance policy could remain in place.
6. It protects household savings as well as health coverage.
The book recognizes that insurance is inadequate when families cannot afford their deductibles. It proposes targeted assistance through Health Savings Accounts and would end the wasteful FSA use-it-or-lose-it rule, allowing workers to preserve unused medical savings or transfer excess balances into retirement accounts under carefully designed rules.
7. It reduces penalties on work, raises, and marriage.
A smoother Premium Tax Credit formula would prevent modest increases in earnings from causing abrupt losses of assistance. It would also reduce the marriage penalties that can arise when two incomes are combined and a household suddenly loses a large subsidy.
8. It uses Medicaid where Medicaid works better.
For many lower-income households, Medicaid can provide more comprehensive protection at lower public and household cost than a private policy with a large deductible. The objective is not to maximize government coverage, but to use the most efficient system for each population.
9. It combines private choice with public responsibility and better insurer incentives.
Consumers would continue choosing among privately administered health plans, but a federally sponsored reinsurance program would assume part of the cost of exceptionally expensive claims. Insurers would still negotiate prices, manage care, and bear substantial financial risk, while public rules would determine which high-cost claims qualify for reimbursement and require the resulting savings to reduce premiums. By sharing catastrophic risk, the system would reduce insurers’ incentives to avoid high-cost patients, deny legitimate claims, or impose overly aggressive utilization controls without turning every coverage decision over to the federal government.
10. It provides an implementable legislative roadmap.
The book identifies 25 specific provisions that could translate the four reforms into law. Most operate through taxes, mandatory spending, Medicaid financing, Premium Tax Credits, or employer-benefit rules and therefore appear suitable for the budget-reconciliation process.
The result is not a promise that health care can be made free. It is a serious strategy for making affordable and continuous coverage available to almost everyone while preserving private choice, encouraging work and mobility, protecting household savings, and obtaining better value from public spending.
A Durable Path Forward on American Health Care is for readers who believe the country needs something more ambitious than another temporary subsidy, but more practical, affordable, and politically durable than replacing the entire health-care system with a single federal program.
The Kindle edition costs $5.99. View the book on Amazon.
Most of the revenue from my Kindle publications and paid subscriptions supports economic research and the development of a third-party economic platform.