A system that cannot change on its own becomes brittle and likely to fail.

That’s true of our health care system, which touches the lives of every single American and represents one sixth of the our economy. It’s also true of our system of government, which, when bogged down in partisan gridlock, can’t do its job.

Both systems are being tested right now in ways unseen in living memory.

There’s a battle going on now over the Affordable Care Act (or “Obamacare”), centering on whether the landmark 2010 overhaul should be wiped off the books or protected in its current form. But that’s the wrong question.

The real debate should be over how the system could be improved so more people can access health care at costs that they can manage. Right now, there is only one vehicle for that debate, and it’s the Patient Freedom Act, sponsored by Republican Sens. Bill Cassidy of Louisiana and Susan Collins of Maine.

The bill introduced last week would give states three options to manage their health care programs. A state could choose to keep the Affordable Care Act as it currently exists, swap it for a system of high-deductible insurance plans supplemented with government-funded health savings accounts, or run its own system with no federal support.

By allowing states to adapt the federal program to their own local needs, the legislation could expand coverage and control costs. In the short term, it has the advantage of moving an important debate in a more constructive direction toward finding solutions to real problems.

Republicans have been running political campaigns against Obamacare for so long, it’s easy to lose sight of the program’s successes.

Twenty million Americans have health insurance as a direct result of the law, and not just the people who were able to buy insurance on the indidual market exchanges. Those who have gained coverage also include low-income working people who live in states that expanded Medicaid, young adults who could stay on their parents’ insurance and people who had been prevented from buying insurance because they had pre-existing conditions or had exceeded lifetime caps.

The uninsured rate is at an all-time low, and overall health care costs are beating projections because more people are covered.

Which is not to say that the ACA is an unqualified success. There is a lack of competition among insurers in many states, including Maine. Subsidies reach a dead stop at 400 percent of federal poverty ($47,520 for an individual), making anyone in that bracket fully responsible for any premium increases, which have hit double digits in many places. A family of three with a combined income below $80,000 could be receiving a subsidy until their child turns 27. Then the income cutoff drops to $64,000 overnight.

There are other problems built into the system — problems kept there, in part, by Republican intransigence over the last six years — that threaten its viability. Even former President Barack Obama agrees that the act could be reformed.

If the Democrats had won the presidential election and taken control of the U.S. Senate, the debate over what to do next would be taking place on significantly different terms. But even if the election had turned out that way, changes would still be necessary.

Collins and a small group of Republican colleagues in the Senate deserve credit for steering the health care debate in a positive direction. In the days following the election there were predictions by Republican leaders in Congress that there would be a bill to defund Obamacare and Planned Parenthood ready for President Trump’s signature as soon as he took the oath of office. There was no such bill, and although the defunding process has begun, it’s clear that it will not be a quick fix.

The Cassidy-Collins proposal has some strong selling points. It would maintain the consumer protections in the ACA and keep coverage for preventative and mental health care. The bill has the potential to increase the number of people insured, which could better control costs. It extends assistance deeper into the middle class.

There are still, however, many unknowns. The type of insurance it promotes works best for people who are relatively healthy or who have a catastrophic event, but it’s less clear how well it would work for people with chronic conditions. There are details that will have to be fleshed out over how to treat low-income people who run out of money in their savings accounts before meeting their deductibles, or who can’t afford to pay their premiums.

Those are discussions that Democrats and Republicans should be willing to have. It’s not just our health care system that needs to adapt to circumstances, but our political system as well.

If either one can’t change gradually, it will become brittle and in danger of failure. No one should want to take that risk.

filed under: