The Affordable Care Act survived Year One. Fifteen health-care thinkers tell us how to fix—or reimagine—it for the long haul.

ce President Obama signed the Affordable Care Act in 2010, the law has weathered a government shutdown, a Supreme Court challenge and scores of political attack ads. But while an estimated 20 million people have gained insurance under the law, it still has no shortage of opponents, from lawmakers trying to repeal it, governors blocking portions of it and lawyers challenging its constitutionality. More Americans, after all, still oppose the law than support it. So where does that leave us

One year after the ACA opened its new health insurance markets to the public, we asked some of the country’s smartest health-care thinkers, from in and outside government and both sides of the aisle, to tell us what Obamacare hasn’t fixed in the American health-care system—and what we can do now. If there was one thing they agreed on, it was that health-care costs in the United States are too high. But their prescriptions were all over the map—from doing away with employer-based insurance to moving to a single-payer system to giving states more power to set their own terms under the ACA—showing just how hard it will be to forge a consensus on a way forward.

Whether Obamacare gets tweaked, overhauled or repealed in the years to come of course depends on the outcome of the midterm elections this fall and the 2016 presidential election. But for now, consider this—the first installment of The Agenda, Politico Magazine’s series on the country’s most pressing policy issues—a preview of the debates soon to come.

6. A conservative alternative.
By Sen. Lamar Alexander

Obamacare has failed Americans in many predictable ways: It has increased premiums and out-of-pocket expenses for many; it has added to the deficit that our children and grandchildren will have to repay; it has decreased choices for many Americans, with smaller networks of doctors and fewer drugs covered on the plans sold in the exchanges; it has expanded access to Medicaid without fixing what is already a broken program; it has kept many Americans from earning a living because their work hours have been cut; it has driven up the cost of medical devices; and it cuts billions from Medicare.

Obamacare is so flawed that it cannot be fixed. Instead of tinkering at the edges of this historic mistake, we need to move as rapidly and responsibly as we can in an entirely different direction. We need to transform our health-care delivery system into one that emphasizes freedom and choice and lower costs.

Republicans have legislation to start taking those steps immediately. One step is to enable families who liked their health-care plans before Obamacare took them away to buy them again. A second step is to allow all individuals, not just those under 30, to buy major medical plans to avoid a catastrophe that wipes you out if you have a large-scale health-care problem. A third step is to expand health savings accounts so that more Americans can save for future health-care costs. A fourth step is to allow small businesses to pool their resources and buy health insurance for their employees at a lower price. A fifth step is to allow individuals to buy their health insurance in another state if that plan better suits their needs.

Obamacare has failed Americans on cost. A recent study by PricewaterhouseCoopers shows Tennesseans’ premiums are going up another 14 percent on average next year. Higher premiums means reduced access because fewer people can afford to buy insurance. Take a 39-year-old woman in Lawrenceburg, Tennessee, who had a $50 a month policy before Obamacare and lost it because of Obamacare, and therefore had to go into the exchange for a plan that costs $400 a month. We would allow her instead to buy a catastrophic plan that meets her needs, or buy a policy outside of Tennessee that suits her needs and her budget, or get coverage through a small business health-care plan—three options that give her access to care at a lower cost.

That’s what health reform should have done before Democrats passed this historic mistake. Republicans are ready to repair the damage of Obamacare, prevent future damage and transform our health-care delivery system step by step.

Sen. Lamar Alexander (R-Tenn.) is the ranking member on the Committee on Health, Education, Labor and Pensions.