President Obama Sits Down with Vox’s Ezra Klein on the Affordable Care Act


Mr. Klien: Goodmorning and welcome to the blair house. Im Mr. Klien founder and editor in chief at Vox along side 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 wed all prefer to hear from him then me so I wont waste any more of your time with introduction. Please join me in welcoming President Barack Obama. (applause) The President: Thank you. (Applause.) Good morning. Ms. Kliff: Good morning. Mr. Klein: Thank
you for being here. The President: It
is great to be here. And thank you so much for
all the good reporting you guys have been doing on
this important issue. Mr. Klein: Thank you. Ms. Kliff: So we
will get started. So 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. And 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? The President: Well, let’s
back up and say from the start there’s a reason why
for a hundred 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 co-pays, all that ends up having
real impacts on families. And 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, say, all right, 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 and
40-something percent are dissatisfied — in the
dissatisfied column are a whole bunch of Bernie
Sanders supporters who wanted a
single-payer plan. (Laughter.) 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 and 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’s a way of dealing with prescription
drug makers in a way that drives down those costs. And so all those things
meant that even after the law was passed there was
going to still be a lot 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 11 years — but most
importantly, for the people who have gotten
insurance through the exchanges, there’s been
pretty high satisfaction rates, as surveys
have shown. So rather than look at
public opinion as a whole, the thing I’ve been most
interested in is, how is this affecting the people
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 able to get treatment, or I was able
to get a mammogram that caught a cancer in time. And that ultimately is the measure of the success of the law. Mr. Klein: So 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 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? The President: 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, that
makes 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 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 for people to
understand and manage. And that’s essentially
what Medicare is, 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 is
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 that 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, 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, 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 has been the
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 has 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, I think, 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. (Laughter.) 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 got to do. Number one, health
care is not cheap. And for people who can’t
afford health care or don’t get it through
the 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 care 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 that you have a Republican
President-elect, you have Republicans who control
both chambers in Congress — is that all the
promises they made about how they can do it better,
cheaper, everybody is going to be satisfied, are going to be really hard to meet. And this is why the
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 lifesaving 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 about 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 it that they’re 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. (Applause.) 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 whoever — Mr. Klein: We’d be happy to, yes. (Laughter.) The President: — to just evaluate it. And the public will not
have to take my word for it. They can — we can
designate some referees. And if they can 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 is about Obama preserving his legacy —
keep in mind, I’m not the one who named
it Obamacare. (Laughter.) They were the ones who named it Obamacare, because what
they wanted to do was personalize this and feed
on antipathy towards 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 is going to replace? Because the majority of
Americans have been very clear that they think
that’s a bad idea. You now have Republican
governors, some Republican senators, who have said,
we don’t think that’s a good idea. And there’s been no real
explanation to why you would actually try to
do this before the new President is even
inaugurated. (Laughter.) 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, but then were
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 — (laughter) — 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 that
they’re 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. Ms. Kliff: Let me follow
up a little bit on the congressional fight. So we saw yesterday
President-elect Donald Trump, he said yesterday
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 —
I remember you saying similar things in 2009,
2010, when I was covering this debate. Knowing what you know now
about partisanship, 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 someone trying to attempt to pass
a bipartisan health care law? The President: 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 that 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 that 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’ve got 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. All right, 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 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 we 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
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 — (laughter) — to do. Ms. Kliff: I don’t
think so, no. The President: But I guess
my point is this, that it is possible for people of
goodwill to try to 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 right
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. Mr. Klein: 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 part of the ways it’s
done that are higher deductibles than people
expected, higher co-pays now in 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 —
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? The President: Well,
let me make a couple distinctions. First of all, part of what
happened at the beginning of the marketplaces — and
for those who aren’t wonks — (laughter) — I was
teasing Ezra and Sarah, I said this is like
a Wonkapalooza. (Laughter.) This is some
serious policy detail, here. But so the marketplaces
are basically just those places where insurers put
up, 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 that will give you a sense of what your
out-of-pocket costs are. And what we discovered was
that a lot of insurers underpriced early on,
because they had done surveys and — look,
people who are purchasing health insurance are like
people who are purchasing everything else, they 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, heaven forbid, you
get sick and it turns out, gosh, I can’t see the
doctor I want or the specialist I want, or this
is more inconvenient than I expected. So what ended up happening
was people bought, 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 and 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 — 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 co-pays. 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 is not
returned 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’re going to
access the system more. And I think the proof of
that is, 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 that they’re getting regular
checkups and mammograms, those are the things that
are ultimately going to save us as much
money as we can. Ms. Kliff: I have a wonky
follow-up question. The President: There you go. (Laughter.) Ms. Kliff: 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 an MRI, for an emergency room visit,
for 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 to hear
you reflect on that and what you would think about
the role of price controls in American medicine. The President: Well, look,
this is the irony of this whole debate, is the
things that people are most dissatisfied with
about Obamacare, about the Affordable Care Act, are
things that essentially in other countries are
solved by more government control, not less. (Laughter.) And so Republicans are pointing at these things to stir up
dissatisfaction, but when it comes to, all right,
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, is that when we tried 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 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 costs later. And that’s the mentality
that most people have when it comes to 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 areas 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 expensive regulation in certain areas than we currently have. Ms. Kliff: So I recently
took a trip to an area of Kentucky — on a slightly
different topic — I 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’s here with us today. She is an Obamacare
enrollment worker who has signed up more than a thousand 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. The President:
Go ahead, Kathy. Female Speaker: Hello, President Obama. I’m so excited
to meet you. The President: It’s
good to see you. Female Speaker: 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’ve signed up some the first time — so it
was working — in 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 of them. And 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? The President: Well, first
of all, Kathy, I want to thank you for being out
there enrolling people. Female Speaker: Thank you. The President: 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 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 those 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 Connect — Kentucky Connect, right? (Laughter.) And so there
were a whole lot of people who said, well, we
don’t like Obamacare — (laughter) — but I like
this program and we’ll signed you up, right? You signed people up, you
didn’t tell them it was Obamacare all the time. (Laughter.) 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 onto
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
that’s 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 at 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 who you’ve been
signing up, better health care, except there’s not
going to be any money to pay for it. And nobody has 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, 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, they may not be as happy as they’d like,
but — tell me if I’m wrong — they like it
better than not having any insurance at all. Ms. Kliff: And some didn’t
even have insurance. The President: 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 back to a
system where they’ve got to buy it on their own,
they’re not going to buy it because they’ll have
even less subsidy. How much time do we got? Mr. Klein: I think
we’re quite low. The President:
We got low time? Because I got all
kinds of more stuff. (Laughter.) Mr. Klein:
Well, it’s your schedule. We’re happy to keep you
as long as you’d like. The President: Well, there
are a couple points I want to make in closing —
Mr. Klein: Excellent. The President: — but
why don’t you ask some questions. Mr. Klein: So one thing we
haven’t touched on yet in much detail is the
delivery system of follow-ups, which are
a big part of the law. So what is a policy or
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? The President: 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
that help reduce people being readmitted. First of all, making sure
that the first procedure goes well, but, secondly,
making sure that there’s 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’s
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 — 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, and nobody — and the doctors
still have to input stuff, and the nurses are
spending all their time on all this administrative
work — we put a big slug of money into trying to
encourage everybody to digitalize, 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 are some folks who
could lose business. And that has turned
out to be a little more complicated
than I expected. Ms. Kliff: 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. The President: 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 — quote,
unquote — “repeal Obamacare.” But really
all that is, is it’s 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. Then, 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.” (Laughter.) 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 can
come up with something better for seven years
and I’ve never seen it. (Laughter.) But we’ll
restart the clock. It’s interesting that
we’re here in the 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 hours — how long was it? SECRETARY SEBELIUS: Eight. The President:
Eight hours. (Laughter.) Kathleen
Sebelius, who is 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’re
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’re satisfied with their care and that
they’re 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
benefitted, 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 those things, I
would think that 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’m 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 research in that, and the bill also contained
a big investment in the opioid challenge. As many of you know,
you’re seeing more and more communities that
are being ravaged by, initially, 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 deaths. And this is not an
inner-city problem, per se, but this is reaching
every community. In some ways, it’s
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 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 I think part of the
problem with this whole law has been that the
people who benefit aren’t out there making noise,
and the people who ideologically have opposed
it have been really loud. Well, now is the time for
people who have benefitted 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 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, 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’s winning here in Washington. It becomes about how are
we 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’re not always going to get a lot of attention
here in Washington because they want to know 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 the American people want
to do the right thing. They just — it’s hard to
get good information, and unless you’re reading Vox every day, which is hard to do — Mr. Klein: It’s
not that hard to do. (Laughter.) The President: — getting the details of all this
policy is hard. It’s 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. And what you don’t want
is a situation where they make a promise that
they can’t keep. And I’ve worked on
this a long time. If we had had a better way
to do this, we would have 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 had 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 they’re doing. So, anyway, I appreciate
you guys taking the time to tell the story. Mr. Klein: Real quick,
Sarah had asked about your role going forward. The President: Oh, my
role going forward? Well, look, I mean, I do
deserve a little sleep. (Laughter.) And I’ve got
to take Michelle on a vacation. 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 health
care system enough to have early detection that might
have prevented her from passing away. You know, 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 and so just kind
of suffered for years. I mean, 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 got health care. If you’re in Australia,
you got health care. If you’re in New Zealand,
you 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, boy, if I
proposed that we took away people’s health care, that
we repealed it, I’d be run out of office
by my own party. (Laughter.) Because it was
just assumed that, in a country this wealthy that
this is 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 going to
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 an ideological
concern about expansion on 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 got
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 a time where people can be a
little — this doesn’t apply to Vox, by the way. (Laughter.) 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 applied to people who were
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 increase 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, I
mean because it’s not controversial enough, or
it’s a little bit too complicated to get
in a soundbite. So that’s why the
individual voice is so important. And that’s why I’m
so appreciative of journalists who actually
know what they’re talking about. (Applause.) Mr. Klein: Thank you, Mr. President. (Applause.) The President: Thanks. Appreciate it. (Applause.) Ms. Kliff: Thank you

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