(Abstracted from N Engl J Med 2019;380(18):1685–1688) Before the Affordable Care Act (ACA), the United States did not significantly reduce the percentage of Americans without health insurance coverage over the past several decades. After the ACA was enacted, US residents without coverage went from 16% to 9%.

The United States could extend insurance coverage by replacing the current system with a national, tax-financed system or by extending components of our public–private system to fill in coverage gaps. The latter approach would allow us to simultaneously tackle other needs.

The Graham–Cassidy proposal excludes most of the tax cuts that were central to previous “repeal and replace” efforts. But in many ways, it would go further than earlier bills in reducing health insurance coverage and affordability.

Claims that the Affordable Care Act’s individual insurance market is in a death spiral reflecting design flaws are misdiagnoses. The market structure is sound and has greatly expanded coverage; the President and Congress have created needless turmoil.

Interview with Dr. Matthew Fiedler on the American Health Care Act and its likely effects on insurance coverage. (07:42)Download The American Health Care Act would change the U.S. health care system in several major ways, dramatically and immediately reducing insurance coverage. In many states, the seriously ill would be at particular risk of losing coverage.

Interview with Dr. Henry Aaron on new legislation that reforms physician reimbursement under Medicare. (13:00)Download Thanks to old-fashioned vote trading, Congress has finally scrapped the sustainable growth rate formula for calculating Medicare's physician fees, replacing it with new but promising incentives that could catalyze increased efficiency and greater cost control.

Medicare today is a better program on almost every dimension than it was just after July 30, 1965 when Lyndon Johnson signed public law 89-97. Nonetheless, short-comings, limitations, and inadequacies remain. What should be done to make Medicare a better program? What should Medicare look like in 2030? In this paper we try to answer these questions. Three perspectives are relevant: that of beneficiaries, current and future; that of policymakers and administrators, the program's stewards; and that of society at large. We posit certain objectives and goals that we believe - and that we think a broad swath of Americans would agree - should be pursued to improve the Medicare program. Those goals include (a) affordability for Medicare beneficiaries, (b) affordability for the working population that is paying and should continue to pay for much of the current cost of the program, (c) reduction in what we regard as needless complexity, and (d) stability and continuity in several different senses. We restrict ourselves to changes that we judge to be affordable and feasible - politically, technically, and administratively - if not today, then over the next decade or two. We believe that changes in Medicare will remain incremental, as they have been for the last 50 years. We shall assume that the ACA takes root and that the exchanges, whether managed by states or by the federal government on behalf of the states, continue to operate. We shall assume that federal and state officials eventually surmount the administrative challenges they still confront. In particular, we assume that the exchanges come to serve a growing share of the American population and that they increasingly exercise the rather considerable regulatory powers over insurance offerings that the ACA grants to them. We divide Medicare reforms into four categories: payment reform, benefit reform, quality reform and management, and the role of private insurance plans (Medicare Advantage [MA]).

Social Security is often described as a "foundational" element of the nation's social safety net. Almost all Americans are directly affected by the program and many millions primarily depend on its benefits for supporting themselves during retirement. But the program's financial condition has worsened considerably since the last recession, which began in 2007. In that year, the Social Security trustees estimated that the program's trust fund would be exhausted by 2042. The trustees' annual report for 2011 brings the trust fund exhaustion date forward to 2038. Indeed, the programs revenues fell short of its benefit expenditures in 2010 and it appears unlikely that significant surpluses will emerge again under the program's current rules. If the program's finances continue to worsen at this rate, it won’t be long before the debate on reforming the program assumes an urgency and intensity similar to that during 1982-83, when imminent insolvency forced lawmakers to implement payroll tax increases and scale back its benefits.

With time and administrative care, the ACA can be implemented successfully. For the next several years, political battles will determine the law's fate, but over the longer term, its success will depend on elected officials' responses to emerging challenges.

As the average age of the population continues to rise in industrialized nations, the fiscal impacts of aging demand ever-closer attention. Closing the Deficit examines one oft-discussed approach to the issue - encouraging people to work longer than they now do. Workers would spend more years paying taxes and fewer years drawing pension and health benefits. But how much difference to spending and revenues would longer working lives make? What steps could be taken to make longer working lives attractive? And what would happen to older Americans not in a position to prolong their work lives? Leading scholars examine these issues in Closing the Deficit , edited by Brookings economists Gary Burtless and Henry Aaron.

Previous article No AccessBook ReviewTHE ELGAR GUIDE TO TAX SYSTEMS. By EMILIO ALBI and JORGE MARTINEZ-VAZQUEZ.Henry J. AaronHenry J. Aaron Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by National Tax Journal Volume 66, Number 2June 2013 Published for: The National Tax Association Article DOIhttps://doi.org/10.1086/NTJ24370054 Views: 1Total views on this site © 2013 National Tax Association. All rights reserved.PDF download Crossref reports no articles citing this article.

After the state-based health insurance exchanges created by the Affordable Care Act are up and running, they will be in a position to make decisions that will help shape the organization, quality, and financing of all U.S. health care.

The idea of a premium-support system for Medicare dates from 1995, but current proposals do not contain appropriate safeguards, and the circumstances of the U.S. health care system have changed in ways that would make the approach unwise today.