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The Toughest Questions Democrats Should Have To Answer On Obamacare

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AP Photo / Evan Vucci

1. What improvements to the law would you be willing to vote for right now that could win support from House Republicans?

Nobody is giving Democrats much -- or any -- shot of retaking the House. So any refinements to Obamacare are going to have to pass through a Republican House for the foreseeable future.

Senate Democrats have already proposed a laundry list of fixes -- raising the threshold for the employer mandate, introducing a cheaper level of coverage, etc. -- but if Democrats hold the Senate, they might have a real shot to act on them. So what would they be willing to put to a vote and see implemented?

2. The law is going to leave some people uninsured for a variety of reasons. What would you propose to either entice this population to obtain coverage or help prevent the medical bankruptcies that the law is designed to prevent?

The Congressional Budget Office estimated in April that 31 million people would still be uninsured in 2024. That includes people with options -- those who decline to purchase insurance -- and people without them like undocumented immigrants. But if the United States is really going to eliminate the risk of medical bankruptcy, as is the presumed goal of Obamacare, this population needs to be addressed.

It's not a question that has gotten a lot of attention. But any discussion of, say, immigration reform isn't complete without addressing how it would interact with the Affordable Care Act.

3. What about those left uncovered by the Medicaid expansion gap? If Republican state leaders remain opposed to expansion, how would you propose covering that population? Or alternatively, what GOP proposals are you willing to accept to achieve expansion?

About 5 million people aren't covered under Obamacare because their states refused to expand Medicaid. The thinking has been Republican state leaders won't be able to resist the expansion deal -- never less than 90 percent federal funding -- and the pressure from the business community that has accompanied it.

But GOP intransigence on Obamacare has proven stubborn over the last few years. Barring an unexpected change of heart by Republicans, Democrats need to grapple with a reality that millions of most vulnerable are still uninsured under the law.

So they either need to figure out an alternative or consider whether they can stomach conservative alternatives -- like those in states like Arkansas and Indiana, which use Medicaid dollars to buy private coverage or require recipients to pay some premiums. The Obama administration has been facing this question when Republican governors have submitted these alternative plans.

4. If the law doesn't achieve its goals in cost control, what else would you propose to bend the cost curve? How would you strike the balance between cost control and choice?

The evidence for Obamacare's effect on U.S. health care costs is mixed for the moment. In part, that's because the economic downturn helped drive down costs for reasons unrelated to the law. More recent data has erased the apparent gains made in the last few years in bending the cost curve. At some point, it could turn out that while Obamacare helped expand coverage, it didn't achieve its goals on the cost side.

So what are Democrats willing to do about it? The trick is that many efforts to control costs come with some trade-offs. The narrow provider networks in the Obamacare plans offered in 2014 are the result of insurance companies trying to keep premiums down. Other proposals, like reference pricing, lead to some kind of elimination or narrowing of consumer choice.

When the tradeoffs are worth the savings is a key question for Democrats to address.