Decreases in the number of uninsured resulted from ACA subsidies in the health insurance exchanges to those with low incomes and from Medicaid expansions. It is unlikely, however, that the health insurance exchanges will be able to further reduce the 28 million uninsured. Several approaches are avail- able that can expand coverage by lowering premiums and reducing adverse selection in the exchanges. Implementing any of these approaches requires legislative changes to the ACA.
Increasing the individual mandate penalty would incentivize more unin- sured to buy insurance. However, public opinion polls show that the penalty was very unpopular, and it was repealed by the Republican-controlled Congress as part of a tax bill in 2017.
To reduce the cost of insurance for young adults and increase their enroll- ment, Congress should replace the exchange cross subsidies (requiring young adults to subsidize older adults [age rating]) with refundable tax credits, which would be based on age and income. Older adults would still receive a subsidy, but it would come from the federal government (taxpayers), not from young adults. (The same approach should be used to eliminate the gender rating.) Insurers would then base their premiums on the expected medical costs of different age groups.