Politicians have debated bold proposals to reform the health system in the wake of last year’s failed effort to repeal and replace the Affordable Care Act (ACA). Conservatives have closed in on the idea of a massive state block grant as a substitute for the ACA’s Medicaid expansion and Health Insurance Marketplace subsidies. Progressives have introduced versions of expanded public health insurance plans such as Medicare for More or Medicare for All. Candidates will likely debate these types of proposals in the 2020 run for the White House.

Yet the benefits of any future health reforms signed into law by a new president would be, even optimistically, still half a decade from realization. This helps explain why lawmakers have introduced numerous less radical, but more actionable, proposals to improve current insurance’s quality, affordability, and enrollment. Some of these bills would restore funding or consumer protections that were rolled back by the Trump administration (for example, reimposing ACA protections for people with pre-existing conditions on short-term health plans). Others seek to inject public policies into the private markets to improve their performance (for example, “reinsurance” or federal payments to insurers for their most expensive enrollees’ costs). A subset has gained bipartisan support. Beneath the cloud of partisanship over health policy, it is still possible that Congress will pass policies that help Americans afford quality coverage.

This table summarizes legislative proposals introduced in the 115th Congress that exclusively aim to lower costs and increase enrollment in individual and small group health insurance. The table includes columns for policies that experts largely agree would make health coverage more affordable and accessible; it excludes policies that may not achieve these outcomes, such as expanding health savings accounts.

As the table shows, recent bills tend to focus on restoring rather than expanding the ACA’s health insurance regulations. Expansions tends to focus on holding insurers accountable for high rate increases, high overhead and profits, and “surprise” medical bills (typically, an unexpected bill from an out-of-network provider at an in-network hospital). Reinsurance is common, with lawmakers proposing different roles for states in administering it. Similarly, several bills would restore the payments to health plans for cost sharing subsidies halted by President Trump, although recent evidence suggests that this attempt to undermine the ACA backfired—instead, lowing costs for enrollees with income from 200 to 400 percent of poverty. A number of Democrats’ bills would increase premium tax credits: across the board, for middle-income enrollees, or for young adults. Doing so would likely increase enrollment as well as help current enrollees afford coverage. Legislation also would increase funding for education and enrollment activities—which will increase in importance starting in 2019, when there is no longer a tax penalty associated with being uninsured when coverage is affordable.

Table 1

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LEGISLATION Restores or Expands ACA Health Insurance Rules Restores or Expands ACA Financial Assistance Increases Consumer Engagement
Premiums Benefits and Cost Sharing Profits (Medical Loss Ratio) Reinsurance Premium Tax Credits Cost Sharing Subsidies Education, Outreach Funding Other Consumer Policies
Bipartisan Bills
Bipartisan Health Care Stabilization Act (Alexander, Murray: October 29, 2017)

Restores funding

Restores funding

Broadens access to catastrophic health plans

Bipartisan Market Stabilization and Innovation Act (Schrader, Reed: H.R. 4695)

Primarily through state grants

Restores funding

Lower Premiums Through Reinsurance Act (Collins, Nelson: S. 1835)

Solely through state grants

Increasing Access to Care Act (Scott, Carper: S. 1976)

Broadens access to catastrophic health plans

Protecting Patients from Surprise Medical Bills Act (Cassidy, Bennet)

Limits copays for certain out-of -network care

Republicans’ Bills
Premium Relief Act (Costello: H.R. 4666)

Primarily through state grants; adds abortion restriction

Restores funding; adds abortion restriction

Increasing Access to Lower Premium Plans and Expanding Health Savings Accounts Act (Roskam: H.R. 6311)

Broadens access to catastrophic health plans; expands health savings accounts; suspends health insurance tax

Democrats’ Bills
Undo Sabotage and Expand Affordability of Health Insurance Act (Pallone: H.R. 5155)

Restores for short-term plans, association health plans

Restores for short-term plans, association health plans; codifies and standardizes essential health benefits

Restores for short-term plans, association health plans

Increases amounts,  removes upper income limit, and expands eligibility

Restores funding and increases amounts

Funds state demonstrations; supports state-based Marketplaces; requires transparency for federal outreach

Consumer Health Insurance Protection Act (Warren: S. 2582)

Restores for short-term plans, association health plans, expands rate review

Restores for short-term plans, association health plans; codifies and standardizes essential health benefits; adds cost sharing limits

Restores for short-term plans, association health plans; increases limit on profits and overhead costs

Links credit to more generous (gold) plan, increases amounts,  removes upper income limit, and expands eligibility

Restores funding and increases amounts

Requires Medicare or Medicaid plans to offer Marketplace plans in low-competition areas; lengthens open enrollment period

Fair Care Act (Baldwin: S. 2494); Stop Junk Health Plans Act of 2018 (H.R. 6479)

Restores for short-term plans

Restores for short-term plans

Restores for short-term plans

Individual Health Insurance Marketplace Improvement Act (Carper: S. 1354, Langevin: H.R. 3311)
Marketplace Certainty Act (Shaheen: S. 1462, Ruiz H.R. 3258)

Restores funding and increases amounts

Affordable Health Insurance for the Middle Class Act (Feinstein: S. 1307, DeSaulnier: H.R. 5258)

Removes upper income limit

Addressing Affordability for More Americans Act (Heitkamp: S. 1529, Ruiz: H.R. 3620)

Extends to enrollees with income below 600 to 800% of poverty

Advancing Youth Enrollment Act (Baldwin: S. 2529, McEachin: H.R. 6432)

Increases amounts for enrollees ages 18–34

Health Care for Small Business Act (Stabenow: S. 1254)

Increases amounts and extends eligibility for small businesses

ACA OUTREACH Act (Waters H.R. 4784)