FILE – Pages from the U.S. Affordable Care Act health insurance website healthcare.gov are seen on a computer screen in New York, Aug. 19, 2025. (AP Photo/Patrick Sison, File)

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Congress is deeply divided over what to do about the Affordable Care Act’s health insurance exchanges. Democrats are understandably concerned about potential premium increases, especially for older workers. Republicans want to empower people and give them more choices.

We think the goals of both parties can be met if Congress takes a bolder approach to reform. Before you can fix a problem, however, you must acknowledge a problem exists.

Most Americans are fully aware — one in four, according to Gallup — that the health care system is in crisis. And nowhere is the crisis more evident than in the Affordable Care Act insurance exchange.

Since 2014, premiums in Affordable Care Act plans have increased twice as fast as employer plan premiums and three times as fast as overall inflation. Last year, the average deductible in the most commonly selected plan was $4,572, more than twice as high as in an average employer plan ($1,787). The maximum out-of-pocket expense in the average exchange plan also was more than twice as high ($9,450) as in the average employer plan ($4,750).

For most people enrolled in an exchange plan, the insurance is free, or almost free. Four out of five enrollees (19 million) are paying $10 or less per month, and more than half of those are paying no premium at all. If you are healthy, the only care you need is preventive care, which is also free.

Unfortunately, exchange plans are not accepted by many of the best doctors and medical centers. Without changes, this year the out-of-pocket exposure in all Affordable Care Act exchange plans will be $10,600 for an individual and twice that for a family. So in other words, ObamaCare is a bargain for those who don’t really need insurance. But for patients who are chronically ill or require expensive medical care, it can be a financial disaster.

So, what should be done? Congress has until Jan. 31 to solve these problems. It is struggling to find a much-needed alternative. Democrats understandably want to preserve the system they created. Republicans have proposed a few helpful reforms. Neither party has been bold enough, however.

MIT economist Jonathan Gruber is often called the “father of ObamaCare.” In a recent interview in The Atlantic, he said, “if the market works, government should stay out. But when the market doesn’t work, government needs to be in.”

Working together with business groups and physicians across the country, we have identified a number of reforms that can produce lower cost, higher quality health coverage. Incorporated in the Healthcare Fairness for All Act, the basic elements include:

A real market for health insurance. Let insurers do what they are not allowed to do: offer a wide variety of products so people can purchase the insurance that best suits their needs with their own money.

Experience tells us what the results will be. Many people will choose a less comprehensive benefit package, with less out-of-pocket financial exposure. According to the Kaiser Family Foundation, people who purchase alternatives to Affordable Care Act insurance are paying less than half of the premiums charged in today’s exchange.

So, what if people choose a plan that doesn’t cover a problem like substance abuse because they mistakenly think no one in their household has that problem? This is where the second part of Gruber’s guidance becomes relevant. Let a family that discovers a medical condition not covered by their chosen insurance plan, but covered under ObamaCare, enroll immediately in a benchmark exchange silver plan.

Tax credits. People who purchase insurance outside the exchanges should receive a refundable tax credit, which in most cases would cover more than half the cost of the insurance. As an alternative, people could have a tax credit equal to the subsidy they would have received if they had entered the ObamaCare exchange. Tax credits also could be used to pay premiums and make deposits to Roth Health Savings Accounts, discussed below.

Special needs plans for the chronically ill. State governments should offer safety net health plans designed for residents with costly chronic conditions, including diabetes, heart disease, respiratory disease, etc. This should be similar to what happens in the Medicare Advantage program.

Roth Health Savings Accounts. These accounts should be flexible enough to meet the needs of the chronically ill. After a period of time, withdrawals for non-medical purposes should be without taxes or penalties — allowing patients to reap the economic rewards from being smart shoppers in the medical marketplace.