MICHEL MARTIN, HOST:
Democrats argue that without these subsidies, the cost to buy these policies is going to skyrocket. Republicans say the Affordable Care Act isn't doing anything about runaway health costs, but they insist they will talk about this once Democrats agree to support the Republican spending bill. But that invites the question of why so many people need a subsidy from the government to afford health insurance to begin with, and is this really the best way to get health care to people who didn't already have access to it? So we're calling somebody who was there at the creation. That's Dr. Ezekiel Emanuel. He is an oncologist, an authority on bioethics and the vice provost for global initiatives at the University of Pennsylvania Perelman School of Medicine. And he is considered one of the architects of the ACA, and he's with us now. Good morning, Dr. Thanks so much for joining us.
EZEKIEL EMANUEL: It's my great pleasure to be with you.
MARTIN: So a lot of people get health insurance through their employers. We've had Medicare, which helps pay for health care for seniors. We have Medicaid, which helps pay for health care for people with very low incomes. What was the problem the ACA was intended to solve?
EMANUEL: Well, the problem was about 45 million uninsured Americans, many of them working at relatively low-paying jobs where the employer could not afford to offer health insurance. Some of them disabled. Some of them just out of the system or not understanding how to get health insurance 'cause it was complicated. That constituted, when we passed the ACA, 18% of the population. The other aspect is that health care costs have been going up nearly 7% per year under the Bush administration from 2000 to 2009. And that rise in health care cost was putting a lot of pressure on families.
MARTIN: So tell - let's talk about the first one. As you just mentioned, it was designed to increase access to health insurance, health insurance coverage. It's largely done that. The uninsured rate has gone from what? - about 15% in 2010 to about 8% in 2024. That's according to the most recent estimate that we have by the Centers for Disease Control. How did it accomplish that?
EMANUEL: Well, one, many of your listeners will remember, we allowed young people to stay on their parents' insurance all the way up to age 26 while they were getting their first job. The second was we expanded Medicaid in conjunction with the states. We changed it from a program that only covered pregnant women or the disabled or the elderly who were poor to cover all poor people under 138% of the federal poverty line. And the third way is we established these exchanges for people who were working in middle-class jobs often, who just couldn't get insurance for a variety of reasons. And we had an exchange where private insurers would offer policies that people could get. I would say there was a fourth thing, which is, we got rid of the preexisting disease exclusions.
MARTIN: Are there issues that you see now that you didn't see when you were first helping to craft the ACA? And is there anything that has emerged since then that you didn't anticipate?
EMANUEL: Yes. I would say two major changes I would like to make in hindsight. One is, the system's incredibly complicated. You can get insurance through Medicare. You can get insurance through Medicaid. You can get insurance through your employer. You can get insurance in the exchanges, in the VA, if you're a Native American - Indian Health Service, and on and on and on. That complication - frankly, the affordable care added to that complication by putting in the exchanges.
The second, I think, big change that I would like to make is more standardization of the insurance products. We allowed these high-deductible plans so that even people who have insurance are dissuaded from going to the doctor 'cause they're worried about the cost. We have high co-pay so that, again, even if you're insured, you can actually be spending out-of-pocket expenses of thousands and thousands of dollars and go bankrupt. And by the way, there are some states that have really done that like California in its exchange has really standardized the products that are offered. So it's a lot easier for people to compare products, and with more competition over the same kind of product, you should lower the costs.
MARTIN: Well, to that end, let's talk about the cost. The Congressional Budget Office estimates that these subsidies that we've been talking about - these tax credits - will cost about $350 billion over 10 years. And there are people like, I mean, for example, I'm saying Wisconsin Senator Ron Johnson who was on this program a couple of weeks ago said we just can't afford it. It's just too expensive. What do you say to that?
EMANUEL: We are spending 17.5% of our GDP. We have a completely inefficient health care system. We can afford it. We spend more by $1.5 trillion than any other country on health care. We could afford it. We have way too much administrative costs - $1 trillion. So I think there's a lot we could do to actually streamline the system, save money and use it to cover people. But the idea that some people should risk dying because we don't have $350 billion over 10 years, and Ron Johnson is voting for tax cuts for billionaires, that just doesn't compute. That's not a consistent policy.
MARTIN: Why is this such an intractable problem?
EMANUEL: That has to do with how we've structured the system. The fact that the system is this complicated, as I mentioned, increases administrative costs to $1 trillion. Another problem is the way we pay doctors and hospitals and other people providing care mainly by fee for service. That obviously creates an incentive to do more even when that more is not the most efficient way to do it or totally necessary. We have variable costs. You know, there's not a single price for a stay in the hospital. There's a Medicare price. There's a Medicaid price. And every insurance company has multiple prices with that exact same hospital for that exact same procedure or overnight stay, whatever. Talk about creating all sorts of gaming opportunities for people to make money even though they're not providing better care.
MARTIN: You once told my colleague, Scott Simon - I think this was back in 2014 - that while the Affordable Care Act isn't perfect, it's a, quote, "pretty good structure to go forward," unquote. You still think so?
EMANUEL: Yeah. It certainly accomplished a lot. It reduced the uninsured rate. It controlled costs. Now we need even more extensive reform to reform the health insurance system, to reform the delivery system and how we pay. Those things we couldn't get to without the Affordable Care Act being a step in the right direction, but it wasn't a finished product.
MARTIN: That is Dr. Ezekiel Emanuel. He's considered one of the architects of the Affordable Care Act. Dr. Emanuel, thanks so much for sharing these insights and recollections with us.
EMANUEL: Well, this has been a wonderful interview, and I hope your audience has learned something about the benefits of the Affordable Care Act.
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