I am far from an expert in health-care policy, but having been accountable to residents, employees and family members who pay for and rely on the City of Missoula’s health-insurance program, I do know that the system could be better in terms of being less expensive while delivering better outcomes.

And, despite my lack of expertise in health-care policy, nearly 14 years serving as Missoula’s full-time mayor has provided me with considerable experience in policy development, implementation and plain, old governing. So, while a Medicare-for-all system sounds mighty attractive to me on many fronts, as a practical matter, making the Affordable Care Act better seems like the best step.

At the local level, we’re in the business of incremental change and refinement. And while my example isn’t particularly sexy, it is illustrative.

During my first term as mayor, my team took a decades-old zoning code, our road map for community growth and development, and started over. The process took a couple of years, was contentious and subject to a failed effort to stop its adoption in the courts. Countless hours of public process and compromise produced what we call Title 20, a zoning code that reflects the state of our community today, its history and its future. On its first effective date, it was flawed. So we addressed the flaws.

And, each year, we update the code with the understanding that we have a modern foundation for moving our community forward but time doesn’t stand still. We change parts and pieces of the regulations to reflect our current reality. Sweeping change followed by fine-tuning.

Despite the noise we all heard about “Obamacare,” the ACA became hugely popular very quickly because of the vacuum that was created by waiting for the perfect policy. More Americans are better off than they were without the Affordable Care Act, but it clearly isn’t perfect.

But if the question put before me is start over or make smart incremental changes to a reasonably functional foundation, the answer is easy. Let’s make the ACA better.

Barring a wholesale change in Congress and the White House, a complete disruption of the health-care industry and a revolution in the way money influences national policy, incremental change is our best bet today.

The heavy lifting that a much-different Congress and a much-different president applied to crafting and passing the ACA wasn’t in vain. Today, smart, passionate members of Congress can continue to advocate for their ideas, but they have real opportunity to make important, concrete change more quickly by improving the state of the ACA.

What works in Missoula, Montana, may well work in Washington, D.C.

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John Engen is mayor of Missoula. 

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