‘Repeal and replace’? More like repeal and collapse, warns HHS Secretary Burwell

During the presidential campaign, President-elect Donald Trump promised to repeal and replace the Affordable Care Act, also known as “Obamacare.” But undoing the law and creating a new one may be more difficult than his campaign rhetoric suggested. Judy Woodruff speaks with President Obama’s Secretary of Health and Human Services Sylvia Burwell about the future of the health care law.

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    Now: the future of Obamacare and the many questions about what will happen to those covered by it now.

    With less than six weeks left until Donald Trump is sworn in as the 45th president of the United States, one of his most common campaign pledges remains constant: ending it.

    DONALD TRUMP (R), President-Elect: First, we're going to repeal and replace the disaster known as Obamacare.


    We will and must repeal and replace Obamacare.


    We are going to repeal and replace Obamacare so quickly.


    The president-elect says the Affordable Care Act, more commonly known as Obamacare, will be replaced with more market-driven alternatives.

  • REP. TOM PRICE (R-Ga.):

    This law violates the principles that every American holds dear when it comes to health care.


    He's tapped one of the law's fiercest critics, Congressman Tom Price of Georgia, to oversee those efforts as chief of the Department of Health and Human Services.

    The law, signed in 2010, has experienced big turbulence in recent months, including double-digit rate increases in many states, and some insurers abandoning marketplaces.

    But unwinding the law may be far more difficult than the campaign rhetoric suggests. It's why more than 20 million Americans now have insurance, including 11 million covered through an expansion of Medicaid.

    While some parts of the law are unpopular — such as the individual mandate and increased costs for better benefits — one piece that Mr. Trump has promised to keep is very popular. Insurers are barred from discriminating against people with pre-existing conditions.

    Yet, how to guarantee that while repealing the law is an open question. Republicans are divided over a time frame for replacing it.

    Senate Majority Leader Mitch McConnell spoke to that today.

  • SEN. MITCH MCCONNELL, Majority Leader:

    We will move right after the 1st of the year on an Obamacare replacement resolution. And then will work expeditiously to come up with a better proposal than current law. Doing nothing is not an option, because you have seen the headlines all across America all last year about the status quo.


    Health care providers and insurers have warned of potential chaos. Last week, two major hospital groups warned, repealing the law without a suitable replacement would lead to — quote — "an unprecedented public health crisis."


    Protect the great moments in your life with an affordable health plan through Healthcare.gov.


    Meanwhile, open enrollment season for the new year continues.

    Health and Human Services Secretary Sylvia Burwell has been traveling the country encouraging people to sign up before enrollment is finished January 31.

    I sat down with her at HHS headquarters in Washington earlier today.

    Secretary Sylvia Burwell, thank you for talking with us.

    SYLVIA MATHEWS BURWELL, Secretary of Health & Human Services: Thank you so much for having me today.


    So, President-elect Trump, congressional Republicans are making it very clear that they plan to repeal and replace the Affordable Care Act. They don't make any bones about it.

    What do you think the consequences will be?


    The consequences are great, and they're great for all Americans, not just those that are the 20 million who have received insurance. Certainly, that could all go away, those who were uninsured and now insured. That's 20 million people.

    We have the lowest rate of uninsured in our nation in history. Those folks would lose their coverage. But I think most people don't realize that there are many other benefits for those who get insurance through their employer, things like children under your plan until 26, things like pre-existing conditions, things like preventative coverage without any additional co-pays.

    And those are some, just a few of the many things that would go away in a repeal.


    Well, Mr. Trump has said, among other things, that he would like to keep the provision that allows children, adult children up to age 26, to be covered under their parents' plan. He has also said he doesn't want anything to change with regard to pre-existing conditions.

    Is it possible to do that and dismantle the rest of it and still take care of people?


    You know, that's the thing, is, it's like a game of Jenga, where you have the puzzle pieces, and, if you pull one out, the thing will topple.

    And it's important to understand, when one has people with pre-existing conditions in the insurance pool, there are other things that you have to do. You have to make sure everybody is in the pool, so you spread that risk. That is what insurance is. It is about spreading risk. And that's why there is a mandate to have everyone in.

    And the other thing is, is, it does increase costs to have people who are more expensive in. But what you want to do is make sure that you subsidize or help those. And that is where the Affordable Care Act's subsidies or tax credits are very, very important.

    So, it is a situation where you can't just pick and choose the things you like. Everything has to work together in order to pay and have those with pre-existing conditions be in and covered by insurance.


    So, are you saying, Secretary Burwell, it's literally impossible to do what Donald Trump says he wants to do? He said words to the effect, people will have other options. He said, we're not going to leave people — quote — "dying in the streets."

    Is there a way to do — to dismantle and still take care of people?


    So, Judy, I think it is now the point in time where this conversation about health care is going to move from the rhetoric to the reality.

    And the reality of how you need to put the pieces together, but you really have to focus on what are the real facts of how these pieces interact.


    Are there any parts of this plan that could be pulled out and still keep an important piece of what is protecting Americans and their health care?


    You know, I think that's the conversation that we should have about the question of how to go forward. Are there improvements that can be made?

    I think that's — the question I think we need to be focused on … three things. Access: How many insured or uninsured? Affordability: What does it cost people? And quality: What's covered?


    And, as you know, right now, among Republicans on the Hill — at least it's reported that they are talking about a repeal vote, and then figuring out what to do next with replacement. There's not complete agreement on replacement.

    How much difference does it make if they go ahead and repeal, and then we see how much of a delay there is before we know what succeeds?


    Well, the idea of repeal and delayed replace is really repeal and collapse. Because once they have taken those actions to repeal and say, 'Oh, we will replace it two, three years from now,' you already start to have the negative impact that will occur.

    And, by that, I mean insurance companies, because of the uncertainty, will make decisions to not go into the marketplace. They will make decisions to raise their prices because of the uncertainty. Hospitals across the country who have been benefiting from a reduction in uncompensated care, when people just go to the hospital and don't pay, because they don't have insurance, they're not going to be able to make decisions.

    States who have been getting the funds for Medicaid expansion will not know in their budgets whether they're going to get the funds. What will happen if there is a repeal and a delayed replacement is, actually, collapse will start to occur immediately because of the uncertainty.

    And when you think that it's been six years, and there hasn't been an agreed-upon replacement … And so that will fuel this uncertainty that anything will really happen.


    And what does that mean in human terms if it collapses?


    In human terms, what it means is, we know that right now 20 million folks have insurance through the Affordable Care Act.

    Last week, the Urban Institute came out with a study that said that approach could result in up to 30 million people uninsured. And why that is, is, because this approach would not only take away what we gained, but would take us back further, because it will affect negatively the individual market.


    You're speaking about what will happen in the insurance markets to hospitals, decisions that they will make.

    And yet we're already seeing in this: President-elect Donald Trump, he is somebody who is not afraid to go after individual companies, individual leaders in the private sector. He has done it again today in talking about an aerospace company.

    Who's to say he might not try to personally talk the hospital or insurance industry into doing something different?


    So, I think this is one of those situations where, as I said, moving to the substance.

    And for the insurers and providers to be able to provide the kind of care and insurance they need to, there is a certain level of certainty that they need. They need to know. One of the most important things in the marketplace is the subsidies that occur to help people afford health care.


    Even fans of the accord Affordable Care Act acknowledge there have been issues with it. And, given that, as you look back on how you, how the administration has handled it, are there things that could have been, should have been done differently?


    You know, the president actually made a very public pronouncement through the — a journal even, in publishing an article about things we think could improve the Affordable Care Act.

    And there are a number of places where we believe there could be improvements. And they mainly focus on affordability and access and competition, having competition in the marketplace.

    And some of the things we think could help and improve are changes in things like high-cost drugs and making sure that HHS has the ability to negotiate, to put downward pressure, or the idea of, in places where you don't have a lot of competition, in other words, a number of insurers offering, create a public option that would sit beside other market options.


    You have had some — a conversation with the man who the president-elect has chosen to be the next secretary, or has appointed to be the next secretary of health and human services, Congressman Tom Price from Georgia.

    Any advice you would offer him?


    You know, I think the only thing I would say — and I would say this to anyone coming into HHS — is, it is so important to really focus on those we serve.

    That is who our boss really is. It is the consumer. And whether that's the child in Head Start, the person getting health care or the person who is going to benefit from NIH research, or any of us eating that food that we trust is safe because of the FDA, keeping your eye on what this department is about for those people, and how do we achieve and serve the best for them, that's the one thing that I think helps in this job, which has lots of different parts and pieces.


    Secretary Sylvia Burwell, thank you.


    Thank you.


    And we will be discussing the future of Obamacare with leading Republicans in the coming weeks.

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