Good morning and welcome to The Blair House.
I’m Ezra Klein, founder and editor-in-chief of Vox, here alongside my colleague Sarah Kliff.
We are honored to be here today to speak with
President Obama about the Affordable Care Act.
Its performance, its passage and its now uncertain
future.
I think we would all prefer to hear from him
than from me
so I won’t waste any more of your time with introduction,
please join me in welcoming
President Barack Obama.
Hello, hello, hello.
Thank you!
Thank you.
Good morning.
Good morning!
Thank you for being here.
It is great to be here.
Thank you so much for all the good reporting
you guys have been doing on this important issue.
Well, thank you.
So we will get started.
There was an expectation that was shared among many
of your staff
— many congressional Democrats —
that as the Affordable Care
Act rolled out,
as it delivered benefits to millions of people,
that it would become more popular.
It would be safe from repeal or even substantial reform.
It appears at this point that doesn't seem to be quite true.
What do you think that theory got wrong?
Why didn’t the health care law become more popular?
Well...
Let’s back up and say from the start, 
there’s a reason why, for 100 years,
no president could get expansion of health
care coverage
beyond the work that had been done for Medicare and Medicaid, targeting primarily seniors.
And the reason was that this is hard.
The health care system is big; it is very
personal;
families, I think, recognize the need
for health insurance, but it’s not something
that they think about except when things
go wrong — when you have an accident, or
you’re sick.
And so, any costs, particularly at a time when families
are feeling stressed economically
— any added costs, higher premiums, higher copays —
all that ends up having real impacts on families.
So the challenge of getting it passed was
always the fact that,
unlike other advanced countries, we didn’t start with a system in which everybody was covered.
And we have a very complicated marketplace
and we have third-party insurers.
And what that meant was that even after we got the law passed, anything that dissatisfied
people about the health care system could
be attributed to, quote unquote, “Obamacare”
— even if it had nothing to do with Obamacare.
And that was something that we recognized even when we were trying to get the law passed.
The other thing is the fact that the unwillingness of
Republicans in Congress and around the country, including some governors,
to, after the fight was over, to say,
'Alright, let’s try to make this work,'
the way Democrats did during the time when
President Bush tried to expand the prescription drug program, part D.
Meant that the public never heard from
those who had originally been opposed,
any concession that, you know what, this is actually doing some good.
And that ends up affecting public opinion.
And the third thing is that, whenever you look at polls that say 40 something percent are
supportive of the law, 40 something percent
are dissatisfied, in the dissatisfied column
are a whole bunch of Bernie Sanders supporters
who want a single-payer plan.
And so the problem is not that they think
Obamacare is a failure.
The problem is that they don’t think it
went far enough.
That it left too many people still uncovered,
that the subsidies that people were getting weren’t
as rich as they should have been, that there
is a way of dealing with prescription drug
makers in a way that would drive down those costs, and so...
All of those things meant that even after
the law was passed, there was gonna still
be a lot of tough politics.
Having said all that, the thing that I’ve
been most proud of is the fact that not only
have we gotten 20 million people covered;
not only have we been able to reduce the pace
at which health care costs have been going
up — ever since the law was passed, basically,
health care inflation has been as low as it’s
been in 50 years, which has saved the federal
government hundreds of billions of dollars, extended the Medicare trust fund by eleven years.
But, most importantly for the people who have gotten insurance through the exchanges,
there has been pretty high satisfaction rates, as
surveys have shown.
So, rather than look at public opinion as a
whole, the thing I have been most interested
in is, how is this affecting families who
have gotten benefits?
These are real families who have gotten real coverage.
And...
I get letters every single day from people who say,
“This has saved my life,” or, “This has saved my bank account,”
or, “This has made sure that my son, who got hooked on some sort of opioid, was been able to get
treatment,”
or, “I was able to get a mammogram that caught a cancer in time.”
That, ultimately, is the measure of the success of the law.
Do you think this dynamic where when you reform
the health care system, you own it,
goes the other way?
Republicans are beginning with the repeal-and-delay
strategy.
President-elect Trump has said that he does
want to repeal Obamacare, but he also wants
to replace it with something that covers as
many people —
or he’s said that, at least at certain points.
Do you think that the dynamic in which you
became responsible for what people didn’t
like is going to hamper Republican movement in their
efforts to change a system that maybe they
don’t like, but does have a lot of people
relying on it?
Well, let me start from a very simple premise:
If it works, I’m for it.
If something can cover all Americans,  make sure that, if they have a preexisting condition,
they can still get coverage.
Make sure that prescription drugs are affordable.
Encourage preventive measures to keep people healthy.
Make sure that, in rural communities, people
have access to substance abuse care,
or mental health care.
That Medicare and Medicaid continue to function effectively.
If you can do all of that cheaper than we
talked about, cheaper than Obamacare achieves,
and with better quality and it’s just terrific
— I’m for it.
I think that part of the challenge in this whole debate
— and this is true dating back to 2009,
back to 2010 — is this idea that somehow
we had a fixed way of trying to fix the health
care system, that we were rigid and stubborn
and wouldn’t welcome Republican ideas, and
if we only had, they had all these great solutions.
In fact, if you look at how this law evolved
— and I’ve said this publicly before,
if I was starting from scratch, I probably
would have supported a single-payer system
because it’s just easier to...for people to understand and manage
and that’s essentially what Medicare is:
a single-payer system for people of a certain age
and people are very satisfied
with it, and it’s not that complicated to
understand or to access services.
But that wasn’t available.
We weren’t starting from scratch.
So what did I then do?
I said, 'Well, where's a system out there
that seems to be providing coverage for everybody
that politically we could actually get through
a Congress and where we could get Republican support?”
And, lo and behold, in Massachusetts, there was a plan that had been designed on a bipartisan basis,
including by a Republican governor who ultimately
became the nominee for the Republican Party,
that, came close to providing universal coverage.
And, I would have thought — since this was
an idea that had previously gotten a lot of
Republican support — it would continue to
get a lot of Republican support.
And yet, somehow magically, the minute we said,
“This is a great idea and it’s working,”
the Republicans said, “This is terrible,
and we don’t want to do this.”
So I say all this, Ezra, simply to make something
very clear.
From the very start,
in the earliest negotiations in 2009 and 2010,
I made clear to Republicans
that if they had ideas that they could show would work
better than the ideas that we had thought of,
I would be happy to incorporate them into
the law.
And rather than offer ideas, what we got was
a big “no, we just don’t want to do this.”
After the law passed, for the last six,
seven years, there was an argument that
“we can provide a great replacement that will be much better for everybody
than what the Affordable Care Act is providing.”
And yet, over the last six, seven years,
there’s been no actual replacement law that
any credible health care policy experts have said would work better.
In fact, many of them would result in millions
of people losing coverage
and the coverage being worse for those who kept it.
And so now is the time when Republicans have
to go ahead and show their cards.
If, in fact, they have a program that would
genuinely work better,
— and they want to call it whatever they want,
they can call it Trumpcare,
they can call it McConnellcare or Ryancare —
if it actually works, I will
be the first one to say,
'Great! You should have told me that back in 2009. I asked.'
I suspect that will not happen
and the reason it will not happen is because,
if you want to provide coverage to people,
then there are certain baseline things that you’ve got to do.
Number one: Health care is not cheap.
And for those who can’t afford health care or don't
get it through their job,
that means the government has got to pay some money.
Number two: All those provisions that the
Republicans say they want to keep and that they like —
for example, making sure that people
can get health insurance
even if they have a preexisting condition —
well, it turns out that the only way to meet that guarantee
is to either make sure that everybody has
some modest obligation to get health care,
so that they’re not gaming the system, or
you’ve got to be willing to provide huge
subsidies to the insurance companies so that they’re
taking in people who are already sick.
And I think what you’re going to see now,
now that you have a Republican president-elect,
you have Republicans control both chambers
in Congress, is that all of the promises
they made about how they can do it better,
cheaper...everybody's gonna be satisfied,
are going to be really hard to meet.
This is why this strategy of 'repeal first
and replace later' is just a huge disservice
to the American people and is something that
I think,
whether you're a Republican or a Democrat, you should be opposed to.
These are real lives at stake.
I’m getting letters right now from people
who say, “I am terrified, because my son’s
or daughter’s insurance, their ability to
get life-saving drugs, their ability to get
drug treatment, their ability to get mental
health services are entirely dependent on
us being able to afford and keep our insurance.”
And if, in fact, there's going to be a massive
undoing of what's one-sixth of our economy,
then the Republicans need to put forward very
specific ideas of how they’re going to do it.
People need to be able to debate it, they
need to be able to study it, the same way
they did when we passed the Affordable Care Act.
And let the American people gauge:
Is this going to result in something better than what Obamacare has produced?
And if they’re so convinced that they can
do it better,
they shouldn’t be afraid to make that presentation.
It is really interesting to try to figure out, 'Why is that they are trying to rush the repeal so quick?'
What is it that they’re afraid of?
Why wouldn’t they want to say, 'Here’s
our plan,' and show, side by side,
'Here's why our plan is better than what Obamacare
has produced.
Because they have said absolutely, adamantly,
that they can do it better.
I am saying to every Republican right now:
“If you, in fact, can put a plan together
that is demonstrably better than what Obamacare
is doing, I will publicly support repealing
Obamacare and replacing it with your plan.”
But I want to see it first.
I want to see it first.
And I want third-party, objective people — whether
it’s the Congressional Budget Office, or
health care experts across the ideological
spectrum, or Vox, or —
We’d be happy to, yes.
— to just evaluate it.
And the public will not have to take my word
for it.
We can designate some referees.
And if they show that they can do it better, cheaper,
more effective, provide better coverage,
why wouldn’t I be for it?
Why wouldn’t I be for it?
This idea that somehow, 'Oh, this about Obama preserving his legacy' — keep in mind,
I’m not the one who named it Obamacare.
They were the ones who named it Obamacare,
because what they wanted to do was personalize
this and feed on antipathy toward me in their
party as an organizing tool, as politics.
But I don’t have a pride of authorship on
this thing.
If they can come up with something better,
I’m for it.
But you have to show — and I would advise
every Democrat to be for it —
but you have to show that it’s better.
And that’s not too much to ask.
And that’s the challenge.
And the question right now for Paul Ryan and
Mitch McConnell is:
Why is it that you feel obliged to repeal it before you show what it is that’s going to replace it?
Because the majority of Americans have been very clear that they think that’s a bad idea.
You now have Republican governors, and some Republican senators, who have said,
'We don’t think that’s a good idea.'
And there’s been no real explanation why
you would actually try do this
before the new president is even inaugurated.
What exactly is this rush?
Particularly if you’re going to delay the
actual repeal.
If they were making the argument that this
is so disastrous that we actually think we have
to repeal it completely today because it’s
just terrible,
well I would disagree, but at least I could understand it.
But here, you’re saying, 'We’re going
to vote to repeal it, but we’re going to
delay its effects for a couple of years.'
Well why, if it’s so bad?
And if the answer is, 'Well, it would be disruptive and we don’t want to take people’s insurance away right away,'
well then that means you have time
to show us — and, more importantly, show
the American people who need health insurance — what exactly you’re replacing it with.
In that sense, Ezra — I know
that was a long answer here —
but in that sense, the answer is: The Republicans, yes,
will own the problems with the health care system,
if they choose to repeal something
that is providing health insurance to a lot
of people and providing benefits to every
American who has health insurance,
even if they’re getting it through the job,
and they haven’t shown us what it is they
are going to do.
Then they do own it because that is irresponsible,
and even members of their own party,
even those who are opposed to me,
have said that that is an irresponsible thing to do.
Let me follow up a little bit on the congressional
fight.
So we saw yesterday, President-elect Donald
Trump, he said on Twitter,
“It’s time for Republicans and Democrats
to get together
and come up with a health care plan that really works.”
Which is something, you know, I remember you
saying similar things in 2009, 2010
when I was covering this debate.
Knowing what you know now: about partisanship,
being a president who has tried to do this
— was, like you said, unable to get Republican
votes,
what three pieces of advice would you give
to someone trying
to attempt to pass a bipartisan health care law?
Well.
Look, I think I sort of gave the advice just
now, which is:
if, in fact, this is not about politics but
this is about providing the best possible
health care system for the American people,
then my advice would be to say,
'What precisely is it about Obamacare that
you think doesn’t work?'
Because you’ve already said there are some
things you think do work.
The Republicans keep on saying, 'Well, we
want to keep the things that people like
and that are working well.”
So, they think it’s a good idea that Obamacare
says your kids can stay on your health insurance
plan until they’re 26.
They think that’s a good idea.
They think it’s a good idea that, if you
have a preexisting condition,
you can still get health insurance.
I assume they think it’s a good idea that seniors have gotten discounts on their prescription drugs —
we closed the doughnut hole during the course of Obamacare.
They approve of some of the changes we’ve
made to encourage
a health care system that rewards quality
rather than just the number of procedures
involved, and how we pay providers.
So we could make a list of all the things that, as terrible as Obamacare is,
actually, they think works — according to them.
Alright, well, let’s make, then, a list
of the things they don't like
or the American people are concerned about.
Well, what we know is that people would always
like lower costs on their premiums
and their out-of-pocket expenses.
And although the Affordable Care Act provides
a lot of subsidies to a lot of people so they
can afford health insurance,
what is absolutely true is that we would love
to see even higher subsidies to relieve the
costs even more,
but that costs money.
What we also know is that where we’ve seen
problems
in the implementation of the Affordable Care
Act, it has been in certain areas
— particularly more rural areas, less densely
populated areas —
where we’re not seeing as many insurers,
so there’s not as much competition.
Well, one way that we’ve suggested you could
solve that problem is
to say that, 'If, in fact, there aren’t enough
insurers to drive competition and reduce costs
and give people enough choices,
then we should have a public option that’s available.'
So, if you look at the things that people
are frustrated about with Obamacare,
the Affordable Care Act,
the big things are:
the subsidies aren’t as high as they’d like and they don’t have as many options as they’d like.
And I’m happy to provide those...both those
things.
I’d sign on to a Republican plan that said,
“We’re going to give more subsidies to
people to make it even cheaper,
and we’re going to have a public option
where there isn’t an option.”
Here’s the problem: I don’t think that’s
the thing that they want to...
I don’t think so, no.
...to do.
So, but, I guess my point is this: that,
it is possible for people of goodwill to try
and come up with significant improvements
to the law that we already have,
but it does require to be specific about what
it is that you think needs to be changed.
And that, so far, has not happened.
And my advice to the president-elect
— in fact, we talked about this when I met
with him for an hour and a half after he got
elected —
I said, “Make your team and make the Republican
members of Congress
come up with things that they can show will
actually make this work better for people.”
And if they’re convincing, I think you would
find
that there are a lot of Democrats out there
— including me — that would be prepared to support it.
But, so far at least, that’s not what’s
happened.
So I think Obamacare has exposed an interesting
tension
between controlling costs in the system and
controlling economic pain for individuals.
So the law has, until now, come in under budget.
But, in part, the way it’s done that is
higher deductibles than people expected,
higher copays, narrower networks;
in a couple of years, if it doesn’t change,
the excise tax on high-value insurance will
come into play, the individual mandate,
and these things to individual people, while
they keep the usage of health care down and
they keep the cost of health care down, they
make health care feel more expensive,
they make health care feel unusable.
Do you think the Affordable Care Act got the
balance right on controlling system-wide costs
versus insulating individuals from their health expenses?
Well, let me make a couple of distinctions.
First of all, part of what happened at the beginning of
the marketplaces…
and for those who aren’t wonks,
I was teasing Ezra and Sarah, I said this
is like a “wonkapalooza.”
This is some serious policy detail here.
So the marketplaces are basically just those
places where insurers put up,
‘Here’s…you know, here’s the insurance
package we’re offering
and you can choose from a variety of different
packages;
and then once you’ve chosen, you can figure
out the subsidies that you’re qualified
for and it will give you a sense of what your out-of-pocket costs are.
And what we’ve discovered was that a lot
of insurers underpriced, early on, because
they had done surveys and, look,
people were purchasing health insurance like
people are purchasing everything else — they'd
like to get the best deal for the lowest price.
What makes health care tricky
is, when you buy a TV, you can kind of
see what the picture looks like;
when you’re buying health insurance, it’s
tempting to initially buy the cheapest
thing until if,
heaven forbid, you get sick and it turns out,
gosh, I can’t see the doctor I want, or
the specialist I want,
or, you know,
this is more inconvenient than I expected.
So what ended up happening was, people bought
the, oftentimes, the cheapest insurance that they could.
Insurance companies wanting to get as much
market share as possible
ended up creating very low-cost plans.
But those are going to have restrictions on
them —
and that’s not just if you’re buying health
insurance in Obamacare;
that’s generally how it is even when employers
buy health insurance for their employees.
Now, I think that what we’re seeing is insurers
now making adjustments, saying,
‘Okay, we need to charge more.’
And that is something that, the good news
is, appears to
— may have stabilized, that might be kind
of a one-time thing  —
and now we're in a position to be able to
do an evaluation of
have we gotten this balance right, as you say.
We can’t get health care for free.
You’re going to have to pay for it one way
or another.
Either the government is going to pay more,
so that people don’t have as many out-of-pocket costs
or...
— and that means, in some fashion, higher taxes for somebody —
or individuals are going to have to pay more out of pocket, in one way or another.
The same is true for employers.
Either employers pay more for a really good
health care package,
but that takes something out of the employer’s
bottom line,
or they’re putting more costs onto workers
in the form of higher deductibles and higher copays.
And I think that a lot of the good work that
can be done in lowering costs
had to do not with cost shifting but with
actually making the system work better.
And we’ve done a lot of work on that.
What I referred to earlier: incentivizing
a system that,
instead of ordering five tests because doctors
and providers are getting paid for the test,
you now have a system where you’re going
to get reimbursed if the person gets healthy
quicker and does not return to the hospital.
Well, it turns out that that can, over time,
be a real cost reduction.
Those are the kinds of things that we’re
implementing in the system
as a consequence of Obamacare.
The more we do that kind of stuff, the less
we’re going to see this cost shifting.
But the intention has never been to say, 'Let’s make it more expensive for people to get health
care so they are going to access the system more.'
And I think the proof of that is that, even
though per-person costs have not gone up a lot,
the overall spending on health care has gone up
because more people have come into the system.
We want people to use the health care system.
We just don’t want them to use it in the
emergency room.
We want them to use it to stay healthy, and
smoking cessation plans, and making sure they’re
getting regular check-ups, and mammograms
— those are the things that will save us as much money as we can.
I have a wonky follow-up question...
There you go.
...since this is a wonkfest.
What about controlling prices?
We have some of the highest health care prices
in the world in the United States.
Most other developed countries, they regulate
how much you can charge for a MRI,
for an emergency room visit, an appendectomy.
That seems like it’s really at the core
of this tension:
the fact that we have these very high prices.
Americans don’t go to the doctor more, we
just pay a lot more when we go to the doctor.
That is something the health care law did
not tackle
and I’m curious as to hear you reflect on that
and what you would think about the role of price controls in American medicine.
Well, look, this is the irony of this whole
debate: is …
The things that people are most satisfied
with about Obamacare, about the Affordable Care Act,
are things that, essentially, in other countries
are solved by more government control, not
less.
And so Republicans are pointing at these things
to stir up dissatisfaction,
but when it comes to, ‘Alright what’s
the solution for it?’
Their answer is less government regulation
and letting folks charge even more and doing
whatever they want and letting the marketplace
work its will.
I think that there are strengths to our system
because we have a more market-based system.
Our health care system is more innovative.
Prescription drugs is probably the best example of this.
It is true that we essentially come up with
the new drugs in this country,
because our drug companies are fat and wealthy enough
that they can invest in the research and development.
They make bigger profits, which they can then
plow back into drug development.
And, essentially, we have a lot of other countries
that are free riders on that system.
So they can negotiate with the drug companies
and force much lower prices,
but they generally don’t have a drug industry
that develops new drugs.
That’s true.
This is an example where you probably do want
some balance to maintain innovation,
but to have some tougher negotiations around
the system as a whole.
And we are trying to use Medicare as the place where,
since there’s no health care provider or
stakeholder in the health care industry that
doesn’t in some ways want to get Medicare
business,
we’re trying to use Medicare as a lever
to get better deals for consumers
and better prices for consumers.
Not just those in Medicare, but also people throughout the system.
But as I said, the irony is that when we try
to do that,
the people who are most resistant are the
very Republican members of Congress who are
criticizing us or at least telling the American people that
you should want lower prices on various procedures.
If we want to control prices for consumers
more, then the marketplace by itself will not do that.
And the reason is because health care is not
exactly like other products.
It’s not like buying a flat screen TV.
If you’re sick, or if your kid is sick,
most of the time you’re not in a position
to negotiate right there and then.
You can’t walk out of the store and just
say, 'Well I’m going to see if I can get a better deal.'
You’re trying to figure out, like when Sasha
got meningitis when she was four-months-old,
make my child better and that’s all and
I’ll worry about the cost later.
And that’s the mentality that most people have when it goes into health care.
So the traditional models of the marketplace
don’t work perfectly in the health care system.
There are areas where we can increase marketplace competition.
There are ways in which we can make it work better.
But ultimately, if we want to really get at some of these costs, there has to be some
more extensive regulation in certain areas than we currently have.
So, I recently took a trip to an area of Kentucky
— on a slightly different topic —
that saw some huge coverage gains under the
health care law, but also voted overwhelmingly
for President-elect Trump.
And one of the people I met there was Kathy
Oller, who is here with us today.
She is an Obamacare enrollment worker who
has signed up more than 1,000 people for coverage.
She supported you in 2008 and 2012 but voted
for President-elect Trump in 2016 and expects
him to improve on the Affordable Care Act
and she would like to ask you a question about that.
Go ahead, Kathy.
Is it working?
Let’s see if it’s on.
Yeah, it’s on.
Yeah, it looks on.
Oh. Ok, I'm supposed to karaoke now.
Hello, President Obama, I’m so excited to
meet you.
President Obama: It's good to see you.
Thanks.
I'm a little bit nervous, as you can see.
But, over the years, I’ve enrolled and talked
to numerous Kentuckians
and I have signed up some for even the first time,
so it was working — the Affordable Care Act —
and also we’ve been going over the years
and I’ve talked to people,
but recently we found out that there was fewer
choices in our area and the increase in the
premiums and deductibles and our facilities aren’t even taking some them.
Many Kentuckians now are looking at the "Affordable
Care" as unaffordable and unusable.
And I have the opportunity to ask you a few
questions that you have probably went over,
but how do you think this happened?
How can we fix it?
Do we start all over again?
What do you think we should do?
Well, first of all, Kathy, I want to thank
you for being out there enrolling people
— that’s been hugely important.
[applause]
The second point I would make is that Kentucky
is a place where this has really worked.
And it’s worked for two reasons:
one is Kentucky expanded Medicaid.
And we haven’t talked a lot about that,
but a big chunk of Obamacare was just making
Medicaid accessible to more people.
And those states that expanded Medicaid have
seen a much bigger drop in the uninsured
than those states who didn't.
And, by the way, those states that didn’t?
They didn’t do so just out of politics.
I’ll just be very blunt.
Because the federal government was going to
pay for this Medicaid expansion.
And states...there are some states, because they had all this uncompensated care,
ended up making money by providing more health insurance to your people.
It was a hard bargain, a hard deal to turn down,
and yet, you got a number of states that turned it down mainly because Republican governors
and Republican state legislatures didn’t
want to make it work.
Kentucky, under Steve Beshear, was one of
the people that did expand Medicaid,
had a really active program.
Because I don’t poll that well in Kentucky,
they didn’t call it Obamacare;
they called it “Kentucky Connect”, right?
Right.
And so there were a whole lot of people who said,
“Well we don’t like Obamacare, but I like this program” and we'll sign you up, right?
You signed people up. You didn't tell them it was Obamacare all the time.
And it's actually worked, right?
Now, what is true in Kentucky though, is true
in some other states.
You had a governor who ran explicitly on the
idea of rolling back Obamacare,
even though it was working.
And so the state marketplace — the state
exchange — he dismantled,
which means we had to shift everything on to the federal exchange.
Most people got shifted, but it indicated
a lack of interest and effort on his part
in making the thing work.
He promised to roll back Medicaid, but he
started realizing that wasn’t as good politics
as he thought it was when he was running.
So he hasn’t done that.
But what is also true is — and this is my
main criticism of Obamacare, of the Affordable
Care Act — is that the subsidies aren’t
as high as they probably should be for a lot
of working people.
If you don’t qualify for Medicaid, where
you don’t have to pay, for the most part,
for your coverage, and instead you’re buying
health insurance on the marketplace
— so you’re a working person but you don’t
have a lot of money,
and particularly if you are older, where you use the health care system more
and you need a better benefit package than somebody 18 or 20 might —
then there are families where the premiums are still too high.
And as I said earlier, there are some parts
of the country where there are only a handful
of hospitals and a few doctors and where you
don’t have a lot of competition.
And the insurers are looking, and they’re
saying, “We’re not going to make a lot of money there.”
So you don’t end up having a lot of insurance plans in those areas.
So the two things that we could do, that would really make it work even better for people in Kentucky,
would be, number one: provide
more subsidies to folks who are working hard
every day but still find the premiums — even
with the subsidies — hard to meet.
And, have the public option for those communities
where they’re not getting a lot of competition
and insurers aren’t coming in.
The problem is, is that is not what’s being
proposed by Mitch McConnell,
the senator from Kentucky.
Instead, what he’s proposing, I gather, is you’re going to repeal the law, then
you’re going to come up with something.
Except you will have taken away all the…
The way we pay for the subsidies for working people is we’re taxing wealthier folks a little bit higher.
So he wants to cut those taxes, and that money
would be gone right away.
And then he’s going to promise you, or those
people you’ve been signing up,
better health care.
Except there’s not going to be any money
to pay for it.
And nobody’s explained to me yet how that’s
going to work.
And so I think this takes me back to the point I made earlier:
If, in fact, the people you’ve been signing
up and the folks in your communities are not
fully satisfied with the benefits that they’re
getting now and are hopeful for something better,
then, at the very least, you should
be putting pressure on your members of Congress
to say, 'Show us exactly what the deal is
going to be for us
before you take away the deal that we got.'
Because the people you sign up for, they
may not be exactly as happy as they’d like,
but — tell me if I’m wrong — they like
it better than not having any insurance at all.
Kathy Oller: Correct, and some never even had insurance.
And some people didn’t have insurance.
Because I get letters from folks who say,
“For the first time in my life — I have
had a bad hip for 15 years, and I’ve been
pain-free for the first time
because I finally got insurance.”
So...
The answer is not for them not to have insurance.
And if we go to a system where they’ve got
to buy it on their own,
they are not going to buy it.
Because they’ll have even less subsidy.
How much time do we got?
I think we’re quite low.
We’ve got low time? Because I’ve got all kinds of more stuff.
Well, it’s your schedule.
We’re happy to keep you as long as you like.
Well, why don’t you … there are couple
points I want to make in closing,
but why don’t you ask some questions?
So, one thing we haven’t touched on yet in
much detail is the delivery system reforms,
which are a big part of the law.
So what is a policy or an experiment or change
in that space that has over performed your
expectations, and what’s one that has maybe
not panned out as you’d liked or hoped?
You know, I think a good example of something that’s
worked better than we expected, or at least
worked as well as we expected, is the issue
of hospital readmissions.
Now, it turns out that a lot of times you
go to the hospital,
let’s say you get your appendix taken out.
And then you go home and then there’s a
complication, and then you have to go back
into the hospital.
That’s obviously inconvenient for you and
it’s expensive for the system as a whole.
And it turns out that there are just a few things that
you can do to help reduce people being readmitted.
First of all, making sure that the first procedure goes well.
But, secondly, making sure that there is good follow-up.
So it might be that a hospital or a health
care system pays for, when you do go home,
you just getting some phone calls to remind
you to take the medicine that you got to take
to make sure you heal properly.
Because they may have done a study and it
turns out that people forget to do what they're
supposed to do.
They don’t follow exactly their doctor's
instructions, and they can't afford to have
a nurse in their house who's doing it for
them.
Well, maybe there are just a few things that
can be done to help make sure that they do
what they are supposed to do, and that way
they don’t have complications.
What we've seen is a significant reduction
in hospital readmissions over the course of
this law just by doing some smart incentivizing,
just saying to the hospitals, “We'll reimburse
you,” or, “We'll give you some other benefit
for doing smart follow-up.”
That's an area where I think we've made some real progress.
The other place, and this is connected, where
I think we've got some good bipartisan support
is just encouraging what's called...shifting
from what’s called "fee-for-service payments",
where you get paid by the procedure.
Which means that you may end up getting five
tests instead of getting one test that is
emailed to five providers who are treating
you.
And we’ve started to see some real movement
when we say to the system as a whole,
"We're going to pay you for outcomes.”
"Did the patient do well?"
And that has been helpful.
In terms of areas where I think we haven’t
seen as much improvement as I’d like,
it's probably...one thing that comes to mind is on the electronic medical records.
If you think about how wired and plugged in
everybody is now,
you know, I mean, you can basically do everything off your phone,
the fact that there are still just mountains of paperwork
and you don’t understand what these bills
are that still get sent to your house.
Nobody...and the doctors still have to input
stuff and the nurses are spending all their
time on all this the administrative work.
We put a big slug of money into trying to
encourage everybody to digitalize, you know,
catch up with the rest of the world here.
And it’s proven to be harder than we expected,
partly because everybody has different systems,
they don’t all talk to each other, it requires
retraining people in how to use them effectively.
And I’m optimistic that over time it’s
inevitable that it’s going to get better because
every other part of our lives, it’s become
paperless.
But it’s been a lot slower than I would have expected.
And some of it has to do with the fact that, as I said,
it's decentralized and everybody has different systems.
In some cases, you have sort of economic incentives
that are pushing against making the system work better.
For example, there are service providers
— people make money on keeping people’s medical records —
so making it easier for everybody to access
each other’s medical records means that
there’s some folks who could lose business.
And that has turned out to be a little more complicated than I expected.
Do you have any closing remarks?
And one thing I’m interested in is,
kind of, what you see your role, in this debate we’re gearing up for, as.
Well let me make a couple of closing remarks.
Number one, I think it is important to remember
that just because people campaigned on repealing
this law, it is a much more complicated process
to repeal this law than I think was being
presented on the campaign trail, as my Republican
friends are discovering.
The way this process is going to work — there’s
this rushed vote that’s taking place this
week, next week, to “repeal Obamacare.”
But really all that is, is it is a resolution that is then
instructing these committees in Congress to
start actually drafting a law that specifically
would say what’s being repealed and what’s not.
And after that, they’d have to make a decision
about what’s going to replace it.
And how long is that going to take?
And that stretches the process out further.
And so...
I think whether you originally supported Obamacare
or you didn’t, whether you like me or you don't,
the one thing I would just ask all
the American people to do is adopt the slogan
of the great state of Missouri: "Show me."
Show me.
Do not rush this process.
And to Republicans I would say:
"What are you scared of?"
If you are absolutely convinced — as you
have been adamant about for the last seven years —
that you can come up with something
better, go ahead and come up with it.
And I’ll even cut you some slack for the fact
that you’ve been saying you would come up
with something better for seven years, and
I’ve never seen it.
But we’ll restart the clock.
It’s interesting that we’re here in Blair House,
because this is a place where I met in front of
the American people with Republicans who had already
indicated their adamant opposition to health care.
And I sat with them for a couple of hours.
How long was it?
Eight.
Eight hours.
Kathleen Sebelius, who was my secretary of
health and human services, remembers, for
eight hours on live TV, to talk about here’s
why we’re trying to do what we’re doing
here, and challenging them to come up with better
answers than the ones we had come up with.
And we spent a year of really significant debate,
and I would think that,
given that we now have proof that 20 million people do have health insurance,
that we are at the lowest rate of uninsured in our history,
that health care costs, rather than spiking way up,
have actually gone up slower than
they have in 50 years,
given that the vast majority of people who get health insurance through Obamacare
have said they are satisfied with their care,
and that they are better off than when they didn’t have care,
given that, even though a lot of people don’t know it, even if you’re not getting health
insurance through Obamacare, you've benefited
because if you get health insurance on the job it now doesn’t have a lifetime limit.
It doesn’t have fine print that could end
up costing you a lot of money.
Given all of those things, I would think you’d
at least want to explain to the American people
what it is that you want to do.
And that, I think, is a minimum expectation out of this Congress and out of the president-elect.
I would make a second point.
And that is that we just worked on a bipartisan
basis to sign something called the CURES bill
that included two really important bipartisan priorities.
One was Joe Biden’s cancer moonshot initiative,
because we’re seeing so many medical breakthroughs
in so many areas that we have an opportunity
to make a real dent in how we deal with cancer,
which affects everybody in some fashion.
Somebody has been touched in your family with this terrible disease.
So we got a lot more money for researching that, and
the bill also contained a big investment in opioid...the opioid challenge.
As many of you know, you're seeing more and
more communities that are being ravaged by,
initially by prescription drugs, then that
ends up being a gateway into heroin.
Some of which — like synthetic heroin being
produced called fentanyl — just has terrible
rates of overdose death.
And this is not an inner-city problem, per se,
but this is reaching every community,
and in some ways it’s a lot worse in a lot of
rural communities.
So there was a bipartisan effort for us to
put some more money into that.
But here’s the thing:
if we just put more money into cancer research
and we just put money into dealing with the
opioid crisis, and now we’re taking away
money that is providing drug treatment services in
those very same communities by repealing Obamacare
and taking away the ability to access a doctor
to get new cancer treatments, then we’re
not really helping anybody.
So that’s a second point I want to make.
A third point I want to make
is that I would encourage local communities to get involved in this process.
And...
You know, I think that part of the problem with this whole law has been that
the people who benefit aren’t out there making noise.
The people who ideologically have opposed it have been really loud.
Well now is the time for people who have
benefited or seen their families benefit to
tell their stories.
Because ultimately this is not a political game.
This is really something that affects people
in the most personal ways.
My friend Natoma Canfield is here, in the
front row.
Some of you’ve heard Natoma’s story before: where a cancer survivor who, because she
had now a preexisting condition, was faced
with either keeping her health insurance at
such a high rate — the only way she could get health insurance with a preexisting condition
was to basically pay so much that she could no longer afford to pay the mortgage on her house.
And I remember her writing to me.
And I thought, you know, 'That could be my mom; that
could be yours.'
And that’s not a choice that people should have to make.
And when most people, even if they’re not
Obama supporters, hear Natoma’s story or
the stories of other people who have been
helped — they know it’s wrong to just
take away their health care.
And it becomes less about who is winning here
in Washington and it becomes about how we are
doing right by our fellow Americans.
But those stories have to be heard.
And I would just encourage people to start
telling their stories, and tell their stories...
you know...
...you’re not always going to get a lot
of attention here in Washington, because they
want to know about 'this vote' and 'this
insult' that was hurled back and forth between whoever.
But you know what?
Tell that story in your local newspapers;
talk to your local reporters; congregations
that are involved in caring for those in need.
Make sure that you’re telling stories in
church and in services so that people know.
Because the one thing that I’m convinced
about is that the American people want
to do the right thing.
It’s hard to get good information and,
unless you’re reading Vox everyday,
which is hard to do.
It’s not that hard to do.
Getting the details of all this policy is…
It is hard. It is complicated.
You don’t know what’s true, you don’t
know what’s not true.
I mean, those folks in Kentucky that you’ve signed up.
There are a lot of people who voted for not
just a president but also for a member of Congress
who said, explicitly, “we’re going to eliminate this.”
Well I understand why people might think,
'Okay, well he’s going to eliminate it
but he will give us something better.'
But this is hard.
You know, and what you don’t want is a situation
where they make a promise that they can’t keep.
And I worked on this a long time — if we had
had a better way to do this, we would’ve done it.
It would have been in my interest to do it.
Because I knew I was going to be judged on
whether or not it worked.
And those areas that don’t work have to
do with there not being enough money in the system
and not having a public option.
And I’m more than happy to put those fixes
in place, anytime, anyplace.
But that’s not, so far, what the Republicans
are proposing.
You deserve to know what it is that that they are doing.
So, anyway, I appreciate you guys taking the
time to —
Real quick sir, Sarah asked about your role
going forward.
Oh, well, my role going forward?
Well, look, I mean... I do deserve a little sleep.
So...
And I’ve got to take Michelle on a vacation.
So, but...
I’ve said consistently that the most important
office in a democracy is the office of citizen.
And I will be a citizen, who still remembers
what it was like when his mom died of cancer
younger than I am now.
And who didn’t have all the insurance and
disability insurance and support and wasn’t
using the healthcare system enough to have
early detection that might have prevented
her from passing away.
Michelle’s dad had multiple sclerosis, MS,
 but was part of that generation that just
didn’t have a lot of expectations about
health care so just kind of suffered for years.
Those are our stories, so it’s not like
I’m going to suddenly fade away on this.
I will be a part of the work of our fellow
citizens in trying to make sure that the wealthiest
country on Earth is able to do the same thing
that every other advanced country is able to do.
I mean, it’s not as if this has never been done before.
If you’re in Canada, you got health care.
No matter who you are.
If you’re in France, you got health care.
If you’re in England, you’ve got health care.
If you are in Australia, you got health care.
If you’re in New Zealand, you’ve got health care.
I remember talking to my friend John Key,
who was the prime minister of New Zealand.
He is part of the conservative party in New
Zealand, and he said to me, in the middle of this
health care debate, he said, “If I proposed that we took away people’s health care, that we
repeal it, I’d be run out of office by my own party.”
Because it was just assumed that in a country
this wealthy that this was one of the basic
rights — not privileges — of citizenship
in a well-to-do country like ours.
So I’ll be working with all of you.
But my voice is gonna be less important than
the voices of people who are directly affected.
And so I would urge everybody to
make your voice heard.
Now is the time to do it.
The people who have opposed this were opposing
it not based on facts but were opposing
it based on sort of on an ideological concern about
expansion of the state and taxes on wealthier
people that are helping people who don’t
have as much money — and I respect their
role in the democracy, they’ve been really fighting hard.
Well, folks here gotta have to fight just as hard.
My final piece of advice would be to the news media.
Which is...
Generally speaking, when Obamacare has worked well, it wasn’t attributed to Obamacare.
And when there were problems, they got front
page headlines.
And I think that hopefully now is the time where people can be a little
— this doesn’t apply to Vox by the way —
but I think it would be a good time for people to be a little more measured
and take a look at what are the facts of this thing.
Because the stakes are high.
Even on this whole premium issue, increase issue, that happened right before the election.
It is true, as I said, that insurers adjusted
and hiked premiums.
But I kept on trying to explain, number
one, if you’re getting a tax subsidy this
wasn’t going to affect your out-of-pocket costs because the tax credit would just go up,
but nobody kind of heard that.
And, number two, these increases in premiums
only apply to people who are buying health insurance
on the exchanges.
In fact, 85 percent of the people
don’t get health insurance through Obamacare.
And for you, your health care premiums, actually have
gone up a lot less since Obamacare was passed
than they did before Obamacare was passed.
The average family has probably saved about
$3,000 in lower health care premiums than
if you had seen those same health care cost trends
increased at the pace that they did before
the law was passed.
But I didn’t see a lot of headlines about
that, which I understand because it's not
controversial enough or it's a little bit too complicated to get in a soundbite.
So that’s why individual voices are so important
and that’s why I’m so appreciative of
journalists who actually know what they’re
talking about.
Thank you.
Thank you, Mr. President.
Thanks, appreciate it.
Thank you.
