Guest Host: Susan Page

Republicans in Congress have voted more than 50 times to repeal the Affordable Care Act without success. Now, they have an ally in President-elect Donald Trump, who promised on the campaign trail to “repeal and replace” the law. But over the weekend, Trump seemed to soften his stance. He told the Wall Street Journal he would consider leaving in place some provisions, including one that prohibits insurers from denying coverage for pre-existing conditions. Guest host Susan Page and guests discuss the future of President Obama’s signature legislation in a Trump administration and with a Republican congress.


  • Julie Rovner Senior correspondent, Kaiser Health News; author of "Health Care Policy and Politics A-Z"
  • Susan Dentzer President and ceo, NEHI (Network for Excellence in Health Innovation), a non-profit think-tank
  • Ceci Connolly President and CEO, Alliance of Community Health Plans; co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All"


  • 10:06:54

    MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA Today sitting in for Diane Rehm. She's visiting station WESA in Pittsburgh. More than 20 million Americans have gotten healthcare coverage through the Affordable Care Act, but candidate Donald Trump repeatedly promised to repeal and replace the law. Now, there are signs that president-elect Trump may be softening his stance after meeting with President Obama last week.

  • 10:07:22

    MS. SUSAN PAGEJoining me in the studio to talk about what could happen to Obamacare once Trump takes officer, Julie Rovner of Kaiser Health News and Ceci Connolly of the Alliance of Community Health Plans. Welcome to "The Diane Rehm Show."

  • 10:07:36

    MS. JULIE ROVNERThanks for having me.

  • 10:07:37

    MS. CECI CONNOLLYGreat to be here.

  • 10:07:37

    PAGEAnd joining us from a studio in Cambridge, Massachusetts, Susan Dentzer of the Network For Excellence in Health Innovation. Thanks for joining us.

  • 10:07:47

    MS. SUSAN DENTZERGreat to be with you, Susan.

  • 10:07:49

    PAGEYou can call our toll-free number if you'd like to join our conversation later in this hour. It's 1-800-433-8850. Or you can always send us an email to Or find us on Facebook or Twitter. Well, Julie, let's start with what we're learning from Donald Trump since he won election. He talked about the Affordable Care Act in his first big interview with The Wall Street Journal at the end of last week. Did he signal something different?

  • 10:08:18

    ROVNERNo. I'm kind of -- I'm still sort of stunned by this. He said this back in February, that, you know, the popular parts of the Affordable Care act he wants to keep. That's basically been his position. I mean, you know, and this has actually been the position of a lot of Republicans since they've been talking about repeal and replace. You know, Mitt Romney, when he was running in 2012, said the same thing. So, you know, those kids on -- kids up to age 26 on their parent's health plans, we want to keep that.

  • 10:08:43

    ROVNERSo the Republicans have always said they want to keep the popular parts. The problem is figuring out how to do the popular parts while getting rid of the unpopular parts, which actually knit together in order to work.

  • 10:08:55

    PAGENow, the idea of keeping your kids on your health insurance until age 26, that doesn't sound so hard. But the idea of prohibiting insurers from denying coverage to people with a preexisting condition, can you do that, Ceci, without keeping the unpopular parts of the Affordable Care Act?

  • 10:09:13

    CONNOLLYIt's very difficult. As Julie started to tee up here, and I think we'll spend a fair amount of time today talking about the math here. I mean, the Affordable Care Act is not just a puzzle. It is a three-dimensional puzzle wired with, you know, flammable gas, if you will. You can't start pulling out a couple of pieces of that 3D puzzle and expect it to hold together. It's why it took so long to put it together in the first place.

  • 10:09:44

    CONNOLLYSo, for instance, the one you keyed in on Susan, requiring health plans to cover everyone regardless of preexisting conditions, absolutely everyone wants that. It's very, very important for people's health in this country. But as you know, covering healthcare and especially for sicker individuals, costs a lot of money. There has to be someone to pay that bill.

  • 10:10:07

    PAGEAnd Susan Dentzer, one of the problems could be that if you say an insurance company can't deny you because you're sick, why would you get insurance before you're sick? Why pay for it while you're healthy? Is that going to be the problem?

  • 10:10:19

    DENTZERWell, that is certainly part of the problem and that's a phenomenon known as adverse selection, which is that if you say that you are going to cover everybody with preexisting conditions, but you don't make people sign up for health insurance, then who signs up first, people who are sick. But I think there's another point here, which is that although we owe it the president-elect to give him time to put forward and actual plan, a full plan, that said, we can look at some of the documents that are already out there, the plan called A Better Way, that House Speaker Ryan and the House GOP contingent put out.

  • 10:10:57

    DENTZEROr the budget resolution law -- or bill, rather, that was passed in December of 2015. We can see some signals of what Republicans have in mind. They key thing to look for is the phrase guaranteed issue, which is not just are you going to cover preexisting conditions, do you guarantee that every health insurance plan has to offer coverage to somebody with preexisting conditions. And those plans fudge on that question. And in fact, they set up a whole separate mechanism known as high risk pools for people who, over time, might have to go there for -- if they have preexisting conditions.

  • 10:11:38

    PAGEI'm want to talk about...

  • 10:11:39

    DENTZERSo there's no guarantee that people will end up with health insurance, even though they have preexisting conditions in the existing Republican plans.

  • 10:11:47

    PAGEI want to talk about the replace part of the Republican formulation, repeal and replace. But first, I want to talk a little more about the repeal part of that proposition. Now, Ceci, we're already getting emails from people who have gotten coverage through the Affordable Care Act, who are now very concerned that they're about to lose it. Open enrollment is under way now. A huge number of people signed up the day after the election. Is anything going to happen to their coverage now, immediately?

  • 10:12:15

    CONNOLLYWe can't say for certain, Susan, because it is certainly possible, through regulation or through the way in which an administration handles some pending lawsuits, to start basically siphoning off the money that is needed, for instance, the subsidies that 80 percent of the people on the exchange are getting right now to afford that health insurance coverage. So we can't say for certain, but it is more than likely that everything will stay in place for 2017. Some of the previous efforts that we've seen in the Republican Congress set a two-year timetable for phasing out elements of the Affordable Care Act.

  • 10:12:58

    CONNOLLYWe still think that there will be that phase-out period so it's probably the best advice for people to sign up for the insurance, continue paying your premium, see your doctor, stay healthy.

  • 10:13:11

    PAGEAnd, of course, the law is still in place. The law that requires you to have health insurance. Nothing's gone -- that has not been repealed at least now.

  • 10:13:19

    DENTZERYes, that is correct.

  • 10:13:20

    PAGEWell, Julie, let's talk, you know, we all remember how hard it was to pass the Affordable Care Act. How hard will it be to repeal the act or repeal big provisions of it?

  • 10:13:33

    ROVNERWell, those are two different questions. Repealing the act in its entirety, basically, remember, the Democrats had to have 60 votes to pass it. The Republicans would really need 60 votes to fully repeal it. They want to just say this law is null and void. They would need a 60-vote majority in the...

  • 10:13:47

    PAGEWhich, they wouldn't get it.

  • 10:13:48

    ROVNERWhich they do not have. What they can do instead, and this is what we've sort of been talking about in a roundabout way, is something called budget reconciliation, which is a special sort of privileged piece of legislation that cannot be filibustered in the Senate and that only needs 51 votes to pass. So they could do that. Now, the problem with budget reconciliation is that it can only impact things that have a direct effect on the federal budget. So they have to either cost money or save money.

  • 10:14:20

    ROVNERBut things that are tangential to the federal budget, and in this case I'm talking about the insurance reform provisions, most notably, like the guaranteed issue like we were just talking about, those can't be in a budget reconciliation bill. They will get struck out by the Parliamentarian. That's why people have been looking at -- there was a dry run for this last year, that the Republicans knew would be vetoed and it was, but they wanted to be able to put together a bill and see how much they could repeal through that venue.

  • 10:14:44

    ROVNERAnd it turns out to be a fairly substantial amount. It is, as Ceci said, it's the subsidies. It's the Medicaid expansion. It's all the taxes that pay for it. And so they could definitely make -- they could make it not work, even if they couldn't repeal the whole thing.

  • 10:14:58

    PAGECould Democrats argue, hey, you shouldn't be using budget reconciliation, which does not require overcoming a filibuster, to repeal this law. Is that an argument Democrats have standing to make?

  • 10:15:10

    ROVNERIt is, but they shouldn't because Democrats used budget reconciliation to finish the Affordable Care Act. People forget. The Affordable Care Act was actually two different bills. One of them was the main bill that they passed and then, of course, they lost their 60 votes in the Senate when the late Ted Kennedy seat was filled by Scott Brown, a Republican. And so the only way they could actually finish the bill was to do a second sort of follow-on bill that was, in fact, a budget reconciliation bill that they only needed 51 votes for.

  • 10:15:35

    ROVNERSo it would kind of hard for Democrats to make that argument.

  • 10:15:38

    PAGEAnd, of course, it enraged Republicans at the time, that they chose to enact big policy by using this procedure. Hard for them to complain now about repealing it, do you think, Ceci?

  • 10:15:47

    CONNOLLYSure. Those of us have lived in this town for too long to admit now have seen it go with both sides of the aisle.

  • 10:15:55

    PAGEIt -- go ahead.

  • 10:15:57

    ROVNERIt's also really important to point out, and I've done this story a number of times, almost every big change in healthcare has actually been done through the budget reconciliation procedure and it's not so they could avoid a filibuster. It's because that's actually the mechanism in Congress for impacting programs that don't go through the regular appropriations, annual appropriations process. So in order to get to Medicare or Medicaid or these big programs, they have to use that. That's how it's done.

  • 10:16:19

    PAGESusan, we've seen -- go ahead, Susan.

  • 10:16:20

    DENTZERWell, the other important point to underscore here is what Julie said, which is in the end, it will be up to the Parliamentarian to decide whether these questions are ruled in order or not. And the fact that so much of the replacement provisions already serviced by Republicans have to do with getting rid of most of the insurance reforms in the law, suggests that there would be a lot of pressure on the Parliamentarian to rule those in so that it could be done on reconciliation.

  • 10:16:50

    PAGEAnd, of course, Republicans will be in control of the Senate. 52 senators, plus then Vice President Pence in a position to break a tie. Well, we've seen Republicans, dozens of time, vote to repeal the Affordable Care Act when they had the guarantee that President Obama was going to veto it. Will they be as enthusiastic now about the idea?

  • 10:17:12

    DENTZERWell, it is the perfect question. I don't know if it's a matter of how enthusiastic they will be about the repeal portion, but it's more a matter of how thoughtful and thorough will they be on the replace portion of the promise. And that's really what most of us are hoping to see and hear and learn more about in the coming weeks and months.

  • 10:17:36

    PAGESo we've talked about the repeal portion. When we come back after a short break, we're going to talk about the replace portion. What do we know about what a President Trump will propose to do when it comes to healthcare and Affordable Care Act. We'll take your calls and questions. Stay with us.

  • 10:20:01

    PAGEWelcome back. I'm Susan Page of USA Today, sitting in for Diane Rehm. And we're joined from Cambridge by Susan Dentzer, she's president and CEO of the Network for Excellence in Health Innovation, which is a non-profit think-tank. And with me here in the studio, Ceci Connolly, she's president CEO of the Alliance of Community Health Plans. She is the co-author of "Landmark: The Inside Story of America's New Health Care Law and What It Means for Us All." And Julie Rovner, senior correspondent at Kaiser Health News, she's the author of "Health Care Policy and Politics A-Z."

  • 10:20:35

    PAGESo Julie, it sounds like you know a lot about health care policy and politics. talk about what you're looking for on the replace side. What do we know about what President Trump plans to do to replace Obamacare?

  • 10:20:46

    ROVNERVery little other than it will be, I believe his quote was, something terrific. He had -- he put out a much sort of derided outline of a possible plan back in March, which other -- which Republican health policy analysts immediately trashed as probably having been written by an intern. I mean, we're pretty sure that President Trump does -- has not spent a lot of time thinking about health policy, so more, I think, of what we know about the replace is, as I guess Susan mentioned, the proposal put out last summer by Paul Ryan and the House Republicans or the bill that -- the dress rehearsal bill, if you will, that was done last year.

  • 10:21:27

    ROVNERBut the bottom line is Republicans don't agree on what to replace this with. That's sort of the dirty little secret of this whole thing. They've been talking about repeal and replace, but their replace proposals have been not very well fleshed-out.

  • 10:21:39

    PAGESusan, there is a new website up, it is called but put up by the transition team, and we are starting to see a few clues in there. So on the healthcare page of that website, we see emphasis on giving greater power and flexibility to the states. That may well be attempting, again, to block grant Medicaid, for instance. We see the endorsement of health savings accounts potentially instead of subsidies that we currently have under the ACA, the concept of selling insurance across state lines high-risk pools and the phrase modernize Medicare, which sometimes in Republican circles is meant to suggest privatizing Medicare over some period of years where seniors in the future might get a voucher to shop for Medicare.

  • 10:22:34

    ROVNERSo those are a couple of the very early hints but no details on those.

  • 10:22:38

    DENTZERAnd most of those things, by the way, are things that have been around for a really long time, and even when Republicans were in power and -- they ended up not wanting passing, like selling insurance across state lines, which by the way was made legal in the Affordable Care Act, and nobody's done it.

  • 10:22:52

    PAGESusan Dentzer, you know, one of the important things is who President Trump will name to run health care, who will be his close advisors, whose -- who will have his ear. Do we have any clues who will play critical roles in a Trump administration on health care policy?

  • 10:23:08

    DENTZERAll we really know at this point, Susan, is who's been appointed to look at the HHS, the Health and Human Services Department issues in the transition, and that -- those names were announced last week, Andrew Bremberg, who's been an advisor to Speaker McConnell and -- or excuse me, Majority Leader McConnell and Scott Walker, and a woman named Paula Stannard, who's the former deputy general counsel at Health and Human Services under the George W. Bush administration. So that's what we know.

  • 10:23:38

    DENTZERLots of names have been circulated for who would end up as the secretary of Health and Human Services. I think right now people are pretty much throwing darts at an obvious board, so you hear names like Ben Carson, et cetera. But behind the scenes we know there's a lot of effort from people who were involved in the policies, for example under the George W. Bush administration, Mike Leavitt, the former secretary of Health and Human Services in the George W. Bush administration, has been involved in those discussions.

  • 10:24:10

    DENTZERThere's a lot of effort to try to position people who have been around the block a few times on these issues and would actually lead the administration in a somewhat different direction than, say, a Ben Carson would.

  • 10:24:22

    PAGELet's take some questions that we've gotten from our listeners. Chrissie has sent us a tweet that says, budget items of the ACA can be repealed. Does this mean I lost my birth control on January 21? Of course the health insurers are now required to provide birth control to women. Will that change on January 21?

  • 10:24:41

    ROVNERUnlikely. These are part of the insurance reforms that the -- that they in fact probably cannot repeal even through the budget process. Now it is possible, particularly when it comes to birth control, that was -- the package of preventive services was determined by a task force that was set up through what was on the Institute of Medicine. They could reconfigure that. They could just do it again, and they could, you know, say we're going to -- this will be the package of preventive services, and birth control won't be included. That would presumably take some time. I don't think that's something that, you know, the president could or would do by executive order.

  • 10:25:17

    CONNOLLYEmphasis on take some time, but again that website does have language around protecting individual conscience and also innocent life, so...

  • 10:25:27

    PAGEAnd that's a -- this was -- this was a concern for some Catholic organizations when they were required to provide birth control.

  • 10:25:37

    CONNOLLYThat's correct, and so you can see that -- philosophically that language already coming out.

  • 10:25:45

    DENTZERAnd again we...

  • 10:25:46

    PAGEHere's another question -- yes, Susan, go ahead.

  • 10:25:47

    DENTZERSorry, Susan, I just want to say, again we need to look for clues in the Better way document, among other things, look at what is said and what is not said. What is not said is, for example, that a major change that was made in the Affordable Care Act, which was to equalize premiums between men and women, women historically in the individual market have been charge 20, 30, 50 percent more than men because of issues like contraceptive coverage, because of maternity coverage, that -- those plans seem to dial back from that. They seem to suggest that there would be no essential health benefits required anymore. That would include maternity coverage would not have to be covered by plans, and contraception coverage probably would also not have to be covered by plans.

  • 10:26:35


  • 10:26:38

    ROVNERAlso, Speaker Ryan was asked about this yesterday in an interview, and he refused to answer. He said he wasn't going to get that far into the weeds.

  • 10:26:43

    PAGEHe called it the nitty-gritty.

  • 10:26:43

    ROVNERHe did call it the nitty-gritty.

  • 10:26:46

    PAGEAnd I think he was being interviewed on CNN by Jake Tapper, who said for some women, saying you're going to take away their birth control is not something they would dismiss as the nitty gritty. Well here's another email from Julie, who is writing us from Michigan. And she writes, would you please discuss the expansion of Medicaid under Obamacare? That is something I very much fear can and will be reversed with a simple majority in the Republican Congress. Poor adults with no dependents are a very vulnerable group and one not many will stand up to defend. What do your guests think will happen with the expansion of Medicaid now? Who has an idea? Susan Dentzer, go ahead.

  • 10:27:18

    DENTZERThere's going -- well first of all there's going to be a big, big fight about this, and even some of the Republican governors who have expanded Medicaid, Rick Snyder of Michigan, are going to fight to preserve the Medicaid expansion. That said, again the existing Republican plans do away with the Medicaid expansion. They essentially convert the program to a choice for states, either what's called a per-capita cap or a block grant.

  • 10:27:45

    DENTZEREssentially fixed amounts of dollars would be sent to the states, and depending on what core retirements -- core requirements or string, if you will, were attached to how states had to spend the money, the states would have a lot of flexibility to decide. And it's not clear that many of the people who got coverage through the Medicaid expansion would end up retaining that coverage.

  • 10:28:09

    DENTZERIt might well be that those individuals were left out of coverage, they might be able to benefit from other provisions of a replacement law, but we just don't understand the details of that at the moment.

  • 10:28:23

    PAGEI think we should take a step back and just explain what the Medicaid expansion was under the Affordable Care Act.

  • 10:28:28

    DENTZERSure, so as it was initially written and envisioned, all states were going to be covering individuals up to about 138 percent of the federal poverty level, which today is about $16,000 in income for an individual. There was a big lawsuit over that that went all the way to the Supreme Court. The Supreme Court said that it was up to states whether or not to participate. And as of today, we have 31 states plus the District of Columbia that have gone ahead and done that.

  • 10:29:01

    DENTZERThe enticement for states is that they get 90 percent of the money to cover those newly enrolled from the federal government. It is almost free money for states, very hard to resist. If you go back to the old configuration of Medicaid, most states get a match from the federal government in the 40- to 50-percent range. So it becomes a much bigger cost to states, and that's why you're seeing talk of these different kind of options for states.

  • 10:29:35

    DENTZERMore than likely it would become a budget buster for some of them.

  • 10:29:38

    PAGEAnd how many people have been covered under the Medicaid expansion who didn't have health insurance before?

  • 10:29:46

    DENTZERAbout 10 million people have.

  • 10:29:47

    PAGETen million people, that's a lot.

  • 10:29:48

    DENTZERAnd I mean, traditionally Medicaid, Medicaid sort of grew up as an adjunct to other programs, as an adjunct to welfare, as an adjunct to the SSI program for people who are elderly and disabled, and so generally if you were an adult, no matter how poor -- an adult without dependent, no matter how poor you were, you were not going to qualify, and that -- this was to change that. This was to basically say that everybody with very low incomes should be able to access Medicaid.

  • 10:30:12

    DENTZERAnd as Susan pointed out, actually when they did this dry-run bill that would have in fact repealed the Medicaid expansion, there were a number of senators from some of the Republican states, Republican senators from Republican states that expanded it, who said I don't know whether I want to vote for this.

  • 10:30:28

    PAGEYou know, we have a -- the new vice president will have served as the governor of a state who had to deal with the issue of what to do about Medicaid. What did Mike Pence do in Indiana, Ceci?

  • 10:30:37

    CONNOLLYInteresting, he is one of a handful of governors that managed to work with the federal government to take a somewhat more flexible, different approach to how he wanted to handle that Medicaid expansion. And so what we see in Indiana, for instance, is that Medicaid participants must pay into these health savings accounts. Now based on your income, it may only be a $1-a-month payment, and it rises. Also, most of those Medicaid enrollees in Indiana also must pay some co-pays that could go up to, say, $25.

  • 10:31:14

    CONNOLLYAnd if they do not pay their fair share in Indiana, they can lose that Medicaid coverage for I believe up to six months. So there are some -- it's more -- you hear the phrase individual responsibility or skin in the game.

  • 10:31:32

    PAGELet's talk to someone who actually -- a listener I think was helped by the Medicaid expansion, and let's talk about his experiences. Bryce is calling us from Flint, Michigan. Bryce, you're on the air.

  • 10:31:43

    BRYCEGood morning.

  • 10:31:44

    PAGEGood morning.

  • 10:31:47

    BRYCETo you and to the two Susans, I noticed that, and your other panelists. Yes, I lost my job, this was a while ago, before the expansion, and lost my health insurance through my job. And I didn't have health insurance for over three years. And when surprisingly my governor, Republican Rick Snyder, did agree to the Medicaid expansion here, for the first time in three years, you know, I -- I had health insurance again.

  • 10:32:18

    BRYCEThankfully I'm very healthy, and so I didn't really have to -- I was worried about it, but I didn't really need it for those three years. But I think about the millions of people who do, and one of the things I mentioned to your screener is I haven't heard a discussion about Planned Parenthood. What's going to happen to the millions of women and families who depend upon that for their healthcare? Because you know that's going on the chopping block as soon as possible.

  • 10:32:45

    PAGEBryce, thanks very much for your call, for telling us about your experiences, and for your question. Susan Dentzer, what happens with Planned Parenthood funding?

  • 10:32:54

    DENTZERWell, A, we don't know. But again, looking at some clues, if we look at, there's very clear discussion about the fact that to the degree that Obamacare was replaced with a system of, say, tax credits for individuals, and these would be offered to everybody who did not get an offer of coverage from an employer, very specific ban in that description of the plan for using any tax credits to buy coverage that included abortion.

  • 10:33:25

    DENTZERSo if your whole goal of getting at Planned Parenthood is deny women the access to abortion, there's an avenue to do that in this proposal.

  • 10:33:33

    PAGEI'm Susan Page, and you're listening to the Diane Rehm Show. We're taking your calls, 1-800-433-8850. Julie?

  • 10:33:43

    ROVNERYeah, on Planned Parenthood it's interesting because a lot of governors have tried to defund it, and in fact Congress has tried to defund it, and to some extent they can defund it through the Federal Family Planning Program, but if they really want to defund it, they have to change the Medicaid law because what Medicaid said is that women have free choice of health care provider, and they must change that provision in order to actually ban women from going to Planned Parenthood.

  • 10:34:07

    ROVNERI'm not talking about abortion, federal government doesn't pay for abortion. I'm talking about women who go to Planned Parenthood for contraceptive services or STD services or, you know, breast exam services. But that -- that is a provision that I'm pretty sure they could change in that budget bill because they would have to go into the Medicaid statute in order to make that change.

  • 10:34:26

    PAGEAnd Ceci, you've covered politics in Washington for a long time. Is there going to be the political appetite to take on some of these things that Republicans have talked about for a long time? Or are they going to be nervous about some of the political consequences? I just wonder what their calculation is going to be on how ambitious to be in changing things.

  • 10:34:46

    CONNOLLYI would suspect, Susan, that right now you're seeing real tensions within the Republican Party. There is a very large contingent that feels quite committed to the promises that they made throughout this campaign and for the past several years and want to be able to deliver on those promises, specifically repealing the Affordable Care Act and a number of these things we've discussed today, and want to deliver on that quickly.

  • 10:35:10

    CONNOLLYOn the other hand, we all certainly know moderate Republicans, particularly in the Senate, and a number of the governors that we've been discussing today, that are more pragmatic about how are we going to ensure the health of all of our citizens. That's a complicated, expensive task, and it's going to require some thought.

  • 10:35:32

    PAGEAnd it's a debate we've been having in the United States for decades. Here's a tweet from Eddie. He writes, the ACA has created another welfare program. And we're getting some other tweets with that idea. We heard from Bryce, who was -- who was happy that he was able to get Medicaid coverage when he was out of work. But there are people who see this as, you know, another entitlement that's an out-of-control cost. Julie?

  • 10:35:54

    ROVNERYou know, the vast majority of people who are being very helped by this program are people with low incomes, the people who are getting on Medicaid, the people who are getting significant to purchase insurance. And the people who are being hurt by this, and there are some people who are being hurt by this, are people who buy their own insurance in the individual market, there's about 20 million of them total, but aren't getting the subsidies. So it's about -- in the exchanges it's a very small number, but outside the exchanges there's another several million people, and those are sort of -- some of the people who are, you know, who are middle class or perhaps a little more than that, and they are very unhappy because health insurance continues to go up, and they say that, you know, this program is -- has hurt them.

  • 10:36:34

    PAGEAnd that's one of the stories that broke during the campaign that I think may have hurt Hillary Clinton because it talked about dramatic increases in premiums for people who buy their insurance without the benefit of a subsidy.

  • 10:36:47

    ROVNERAlthough the public took that, and President-elect Trump fed into this notion that that was sort of system-wide rather than the much smaller number of people in the individual health insurance market, which is all that that really affected.

  • 10:37:01

    PAGEWe're going to take another short break, and when we come back, we're going to go back and take some calls and questions from our audience. We thank the people who have called who have called in for holding on, and we'll continue our discussion about what's likely to happen to health care in the United States once Donald Trump is inaugurated as president next January. Stay with us.

  • 10:40:01

    PAGEWelcome back. I'm Susan Page of USA Today, sitting in for Diane Rehm. We're talking about the future of the Affordable Care Act when the new administration takes over in January. And joining me are three experts on this issue. Julie Rovner, Ceci Connolly, and Susan Dentzer. You know, we've been getting a lot of emails asking about what's going to happen to prescription drug coverage and prescription drug costs. Now, Julie, during the campaign, Donald Trump proposed allowing Americans to buy drugs overseas. That's been a big issue. Is that likely to happen?

  • 10:40:31

    ROVNERThat was apparently scrubbed from his website or at least so I saw. I don't think it's come back yet. There were, you know, if you look at public polling, what to do about the high price of prescription drugs is at or near the top. It's what people most want. You know, President elect Trump also talked about possibly letting Medicare negotiate drug prices. Although, as many experts have pointed out, if Medicare can't say no, which they can't at this point, there's not a lot of negotiating leverage there.

  • 10:40:59

    ROVNERSelling, buying cheaper drugs from overseas where they're price controlled has also been sort of problematic over the years under both Democratic and Republican Food and Drug Administration officials. They've said that that wouldn't necessarily -- they couldn't guarantee the safety of that.

  • 10:41:13

    DENTZERA couple of other thoughts on this, Susan. First of all, drug prices are now the major driver of our rising healthcare costs and rising insurance premiums, by the way. So, it really has become a very widespread problem in our society. Second, very important, is the fact that you have, in Medicare Part D, a program that's working pretty well. Consumers are happy, the premiums have not risen as quickly as expected. There are a couple of market stabilization features in there.

  • 10:41:52

    DENTZERSo, it's actually a success story and I just want to remind our listeners that that was a Republican proposal. Market based approach to one element of the healthcare challenge in this country that worked pretty well.

  • 10:42:04

    PAGEIt, it, it...

  • 10:42:06

    ROVNERIt's also possible there could be some bipartisan agreement on some provisions like, for example, giving the Food and Drug Administration more resources to approve applications to bring out generic drugs more quickly. We know, as a country, we get a huge price break because we allow patents to expire and drugs to convert to generic status. There's been some concern that not enough generics are able to be made available. In part, because of a lengthy FDA approval process. That could be something that both Democrats and Republicans could get together on.

  • 10:42:42

    DENTZERAnd in fact, Congress has to address this next year because there's a law that originally passed in 1990 that, basically, drug makers pay special user fees to the FDA so the FDA can hire more examiners so they can get their drugs through faster. It's been expanded over the years to medical devices and to generic drugs. But that comes up for re-authorization every five years and next year is actually the year that is has to come up. So Congress has to address, in some fashion, the question of what to do about prescription drugs.

  • 10:43:09

    PAGEHere's an email from Michael. He writes, when the ACA passed Congress with no Republican votes, it was destined for failure. Will there be cooperation between the parties as the law is repealed and replaced? And my -- one question I have, Ceci, is we've talked about what Republicans will intend to do, do we know whether Democrats' approach is going to be let's try to work together, let's try to limit the damage to the things we like. Or is it going to be one of defiance and opposition and filibuster?

  • 10:43:34

    CONNOLLYSusan, I think that is still an open question. Here in Washington, the sort of permanent political class, every side of the aisle, was surprised by the election results. And so, prior to last Tuesday, most of the conversations in healthcare circles were around how can we improve those exchanges in the ACA that are seeing rising premiums, that are not stable yet? So, the discussion, until very recently, was around tweaking the ACA. It's obviously a whole new ballgame now and I think it's going to take a little while for Democrats to think about their strategy.

  • 10:44:17

    PAGELet's go to the phones. We've got some great callers who've been holding on. Steve is calling us from Bethesda, Maryland. Steve, thanks for holding on.

  • 10:44:25

    STEVESure. Thank you. I just wanted to point out a couple of concerns I have and what I've already been hearing from Republicans. I'm a child and adult psychiatrist in outpatient practice, and I've been practicing for decades. And I've seen what things were like before the Affordable Care Act. I'd like to warn media, parents and anyone who has to buy health insurance, that the Republicans are trying to sell a bill of goods here. I was listening to Paul Ryan yesterday, or, yes, it was yesterday in the news.

  • 10:45:00

    STEVEThey use the term affordable insurance. When they say affordable, what they mean is that they're going to have bare bones coverage, like we used to have where people pay for just, you know, emergency, perhaps, emergency coverage. But they don't get coverage for very important areas of their health. Often, unfortunately, mental health included. But certainly other physical health concerns. And so, the affordable basically means that you're getting an inferior product. And you're paying less.

  • 10:45:34

    STEVEThe problem is, well, a couple of problems, is that number, peoples' health suffers terribly, because they end up avoiding going to doctors. Their health problems, like diabetes, get worse and worse and they finally get care when they are in extreme disrepair of their bodies. And they talk about this somehow saving money. It does not save money. The hospitals, and I'm sure most of us remember, they have to provide care when people come in without insurance or insufficient insurance.

  • 10:46:08

    STEVEAnd they have to get reimbursed somehow, so people like myself who are lucky enough to be able to afford health insurance, our premiums skyrocket because we are having to pick up, you know, basically, the bill for people who go into hospitals and don't get -- are not able to pay for it.

  • 10:46:27

    PAGESteve, thanks so much for your call. This is the basic debate, right? It -- can we afford the healthcare that we would really everyone to have? Susan Dentzer.

  • 10:46:36

    DENTZERWell, that's right. And basically, every aspect that was litigated or debated during the formation of the Affordable Care Act is going to debated all over again. Are we going to require the essential health benefits that were in the Affordable Care Act, which includes coverage of mental healthcare? Which includes coverage of maternity care? Which includes automatic coverage of various preventive measures up front, without requiring people to pay toward those things, things like colonoscopies, mammography.

  • 10:47:07

    DENTZERIs that all going to be covered? Are we going to have lifetime limits as we used to have on health plans, where if you spend more than a million dollars, you're out of luck for the rest of your life? All of those things, built into the Affordable Care Act, will be re-discussed once more as we discuss what needs to be in health insurance and what's guaranteed to people. And the final thing that people should keep their -- their sights on, is even things like are we going to require slightly older people to pay much, much more again in the interest of giving younger people a price break?

  • 10:47:41

    DENTZERThose, again, were features built into the law and we'll be arguing this all over again to decide whether we want -- what we want, what me mean when we say we want affordable health coverage.

  • 10:47:53


  • 10:47:53

    ROVNERWell, this has been, and will continue to be the fundamental debate beyond the government verses private is how much insurance is the right amount? The perception was that in the individual market before the Affordable Care Act, insurance was -- could be had at a very cheap rate, but as the caller mentioned, it didn't cover very much. Or it had a 10,000 dollar deductible. Or it had a very narrow group of, of providers that you could go to. But people could afford the premiums.

  • 10:48:22

    ROVNERNow, of course, we have sort of the opposite problem where the benefit package is very rich, because it's required to be very rich, but now people can't afford the premiums. So, it is a balancing act, and the Republicans, you know, the Democrats had -- obviously had trouble getting there, but the question is whether Republicans, you know, in making it affordable, will also make it broad enough for people to actually have coverage when they need it. That is sort of the unicorn in healthcare that no one's been able to find yet.

  • 10:48:47

    PAGEAnd Ceci, we know how hard it is to take away a benefit once people have gotten it and gotten used to it, even if they're unhappy with some parts of it.

  • 10:48:55

    CONNOLLYExtremely difficult, and I have to commend Steve, because he did a superb job of defining the problem, and frankly the mess, prior to 2009, that brought us to the Affordable Care Act, which was this concept of so many millions of uninsured showing up at the emergency department to get care, very expensive, very late in their health condition. Not good for them, not good from a cost perspective, and then all of the cost shifting occurs and we all pay.

  • 10:49:26

    PAGEBut from, we have an email from someone who's less than happy with it. From Ann Marie, she writes, my monthly premiums have increased from 206 dollars a month to 456 dollars a month. ACA can say premiums have increased only 23 percent average, but the subsidized portion has decreased, making subscribers' monthly out of pocket much more than 23 percent. That's not the experience for everyone who buys insurance through the exchanges. But it's Ann Marie's experience. Let's talk to Debbie. She's calling us from Houston, Texas. Debbie, you're on the air.

  • 10:49:57

    DEBBIEHi. My name is Deb Kelly, and, well, Debbie, and a breast nurse navigator at a major hospital. And I take care of cancer patients every day. I'm in a state where they did not, in Texas, we -- they elected not to participate in the Affordable -- in the Medicaid expansion. And what I've seen as they've left this to the states will, if you will, what's happened is now there are people who have maybe lost their jobs. Laid off from (unintelligible) , et cetera. And they are diagnosed with cancer. They cannot get coverage.

  • 10:50:43

    DEBBIEThe poverty level -- to qualify for Medicaid in Texas, you have to be pregnant or have small children. You cannot have a male in the house. So, what's happened is I deal with women every day. I work particularly with breast cancer patients who cannot get coverage and are faced with -- I mean, it's devastating and not only devastating to get the diagnosis, but then not be able to get coverage. And most people that I talk to don't even understand that this -- that, the complexities of the fact that we have not done the Medicaid expansion in Texas.

  • 10:51:32

    DEBBIECoverage for mental illness, et cetera. Just go right down the line. People that are elderly who've lost their insurance because of loss of work or because they're sick and cannot afford Cobra payments. They cannot necessarily get on the Medicaid and all these people are just left out in the cold.

  • 10:51:51

    PAGEDebbie, thanks so much for your call. Julie.

  • 10:51:54

    ROVNERYou know, one of the things that Republicans say they want to do for Medicaid, if they want to keep the sort of non-parent, non, you know, disabled people, these quote, unquote able bodied adults on Medicaid, is to have work requirements. But as the caller points out, in a lot of cases, the very people who need Medicaid the most are the people who can't work because they have a serious health problem. So, it's not clear how that will work out. They say, you know, well, they want work requirements because that's what we have for welfare, but health insurance is a little bit of a different kind of program.

  • 10:52:21

    PAGEI'm Susan Page and you're listening to The Diane Rehm Show. Yes, Ceci.

  • 10:52:27

    CONNOLLYWell, just to underscore Julie's point, many of those individuals also have mental health issues or substance abuse issues. And so, they really are a very challenging group to care for.

  • 10:52:41

    PAGENow, the majority of Americans get their coverage for healthcare through their employer. Susan, is anything going to change for people who are in that situation?

  • 10:52:50

    DENTZERQuite, quite likely, in this sense. It is pretty clear that a primary thrust of the developing Republican plans is to get rid of the employer requirements to provide coverage that were built into the Affordable Care Act. But now, that doesn't mean that employers will automatically drop coverage. In fact, we've seen quite the opposite. We've seen more employers come in and provide coverage to people as a consequence of the Affordable Care Act or in tandem with the Affordable Care Act.

  • 10:53:19

    DENTZERBut it does mean the requirements that employers would provide -- to provide coverage could possibly go away, and that means that some employers might elect to allow people to revert to what would be the alternative, apparently, which is to accept tax credits. Also fund health savings accounts and allow people to get coverage that way.

  • 10:53:42

    PAGEWell, let's talk about health savings accounts, because that's one of the ideas that Donald Trump has floated. How, how do they work, Julie?

  • 10:53:50

    ROVNERWell, they are basically tax advantaged savings accounts, where you put money away, tax free, and if you spend it on healthcare, it comes out tax free. There's a couple -- at least as they're currently configured, you can't actually use them to pay your premiums. You can use them to pay Cobra and a couple of other things but for basic premiums, they're really only for out of pocket health spending now. And there's a limit on them. I think the idea is that Republicans want people to basically save for their own healthcare.

  • 10:54:13

    ROVNERBut when you think about healthcare costs, particularly if you're not getting it at an insurance negotiated price, you would have to have an awfully big health savings account to pay for a serious health issue.

  • 10:54:23

    PAGEAnd, you know, Ceci, one thing we've discovered, I think, with education savings accounts and other tax advantaged savings account is that you've got to have enough discretionary income to put away in a savings account to get the advantage.

  • 10:54:35

    CONNOLLYAbsolutely. I mean, most of the smart analysis of health savings accounts, so far, is that they can tend to work very nicely for people at the upper end of the income scale. And, as Julie points out, also, if you're healthy for a number of years, you can kind of build up that nest egg and perhaps have it for future medical expenses. So, there are definitely some challenges in health savings accounts, and I was just going to mention, Susan, the perspective of employers. Most employers continue to offer health insurance for two reasons.

  • 10:55:05

    CONNOLLYIs a tax benefitted, tax advantaged benefit that employers are able to provide because of the tax exclusion. And also, it is a recruiting and retention tool for employers to stay competitive. So, we haven't seen the employer dumping that so many feared and predicted years ago.

  • 10:55:27

    PAGESusan, earlier in this hour, you mentioned the idea of high risk pools to use for people who are -- have serious ailments. Briefly, tell us how that would work. That's another idea we've heard about from the Trump team.

  • 10:55:40

    DENTZERWell again, it's a work in progress, but if you take the fact that you would be asking insurers to cover people with pre-existing conditions, but then you're not requiring people to buy it. So, the individual mandate, in effect, goes away. Then the question is, are people going to continue to sign up for coverage? And under another earlier law, we all -- those of us who were covered through employer coverage, or so called small group coverage, got the ability to move from plan to plan to plan with what's called continuous coverage.

  • 10:56:14

    DENTZERSo, if I change employers, my next employer, if they're offering coverage, has to cover me even if I have, say breast cancer. Because I have continuity of coverage. If you don't require, if you, the kinds of things that were built into the Affordable Care Act, it's possible that some people with pre-existing conditions could fall out of that system. And then you have to have some backup for them. And that's where these high risk pools come into play.

  • 10:56:42

    PAGEAll right.

  • 10:56:42

    DENTZERThe notion that we create lots of pools around the states for people who would fall out of that system and end up in these high risk pools instead of in health insurance.

  • 10:56:52

    PAGESomething we'll be hearing more about, I'm sure. I want to close with an email from Katie that we got very early in this hour. She wrote, my husband is self-employed, so we use Obamacare for our insurance. I'm terrified if it's dismantled and no one lifts the ban on pre-existing conditions. My husband and I, once again, will be shut out of the healthcare system. I don't want to have to choose whether I get to take insulin for my diabetes or my kids get to eat dinner. No one should have to face that choice.

  • 10:57:19

    PAGESo, important to remember real lives being affected by this national debate. Well, I want to thank our panelists, Susan Dentzer, Ceci Connolly, Julie Rovner. Thanks so much for joining us this hour on The Diane Rehm Show.

  • 10:57:29

    ROVNERThank you.

  • 10:57:29

    DENTZERThank you.

  • 10:57:29

    CONNOLLYA pleasure.

  • 10:57:30

    PAGEI'm Susan Page of USA Today sitting in for Diane Rehm. Thanks for listening.

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