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Health care is a top issue for voters in this fall's presidential election, with Americans still divided over the Affordable Care Act. Yamiche Alcindor and Lisa Desjardins explain the policies of President Trump and Democratic presidential nominee Joe Biden, and William Brangham talks to Dr. Ezekiel Emanuel of the University of Pennsylvania and the Hoover Institution’s Lanhee Chen for analysis.
Meantime, throughout the past week, William Brangham has been looking at how other countries built toward universal health care coverage and the trade-offs they have made. Those questions have been a part of our presidential campaign season, too.
That includes sharply divided views about the Affordable Care Act, which expanded coverage for 20 million Americans, but is still not affordable enough for some citizens.
William is going to have a conversation about all of this in a moment.
But, first, let's hear about where the presidential candidates stand with our correspondents Lisa Desjardins and Yamiche Alcindor.
It was the signature legislation of the Obama administration, the Affordable Care Act, better known as Obamacare.
When it was signed into law 10 years ago, then Vice President Biden celebrated passage, memorably putting it like this:
Former Vice President Joe Biden:
This is a big (EXPLETIVE DELETED) deal.
(CHEERING AND APPLAUSE)
The law has been both incredibly popular with some and controversial with others. Among core aspects, it protects Americans with preexisting conditions, allows parents to keep kids on their plan until age 26, and eliminates out-of-pocket expenses for many preventative services.
Since passage of Obamacare, the Democratic Party at large has shifted left on health care, led in large part by Senator Bernie Sanders and his signature Medicare for All proposal.
Despite that pressure, Biden largely held center during his primary campaign. His health care plan focuses on a public option, where anyone could buy into a Medicare-like plan. He would automatically enroll some people in states that didn't expand Medicaid.
He'd also increase tax credits to help lower costs for low-income people. Biden's focus remains building onto the ACA.
Meanwhile, one of the core tenets of President Trump's 2016 campaign and his first term was to repeal Obamacare.
In 2017, Trump came one vote short of passing an Obamacare repeal through the U.S. Senate. The question has often been: What exactly is the GOP plan in their repeal-and-replace pledge? In the past, his administration has taken steps to roll back the ACA. He ended the penalty for the individual mandate, one of the law's more unpopular requirements.
That change once again puts the fate of the entire law before the Supreme Court. In recent months, Trump has repeatedly said he would unveil a health care proposal in weeks. But those self-imposed timelines have come and gone.
The president is also taking some smaller actions. Recently, he signed an executive order to expand telehealth for Medicare recipients. President Trump has also criticized Biden's plan as moving too far toward Medicare for All, which President Trump sees as radical and too great of a government role in health care.
Biden responds that Trump's attempts to repeal Obamacare would leave millions of Americans without insurance, and his limits on it have already cut access to care, something he says is especially dangerous in the pandemic.
So, there are two very different visions meant to address in part the fact that roughly 30 million Americans still have no health insurance today, and the pandemic's economic toll is only making those numbers worse.
So, let's hear from two people who are intimately involved in the political dynamics around health care reform.
Dr. Ezekiel Emanuel is the chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. He's the author of a book looking at health care systems around the world. And he was special adviser to President Obama and now advises Joe Biden's coronavirus task force. And Lanhee Chen is a fellow at the Hoover Institution and teaches public policy at Stanford University. He's an informal health policy adviser to congressional Republicans and to the Trump administration.
Gentlemen, welcome to you both.
Can I just lay out the ground terms here? Just for the sake of this conversation, I know you both share these two main goals, which is expanding coverage, so that more Americans have access to good care, and lowering costs, so that it's — the health care is not so expensive for individuals and not so expensive as a system overall.
So, starting with that premise, Lanhee Chen, let's start with this issue of cost.
You have consulted with the GOP and with the Trump administration. Let's say President Trump wins a second term. How do you foresee him trying to bring down the cost of health care in this country?
Well, in a few ways.
First of all, I do think you're going to see him continue to push forward in creating more choices on the health care marketplace. That's something that's been a focus of his first term in office, trying, for example, to expand access to plans that may suit people better where their needs are.
I think you're also going to see him push forward on price and quality transparency, which, in my mind, is a significant goal that we, as Americans, should all share. Can we get a health care system where we understand more about what we're paying and what we're getting with our dollars?
And then, finally, I think he's going to address some specifics around issues like prescription drug pricing, surprise billing. These are issues that continue to plague many Americans. The high cost of prescription drugs continues to be an issue.
And I actually think there can be bipartisan agreement on addressing, for example, the price of prescription drugs or in getting rid of some of these challenges created by surprise billing practices.
So, Zeke Emanuel, you heard that menu of things that's hopeful in a Trump administration.
Do you think that those would be enough to manage costs in a meaningful way? Or are there other things you would add to that or tweak that in some way?
First of all, Lanhee is talking as if the president hasn't been the president.
He's had four years to lower drug prices, and hasn't succeeded in lowering drug prices at all. He's had four years to have more price transparency, and hasn't done very much on it. And, certainly, the Obama administration did more on price transparency than he did.
So, it's an important question as to what he's actually going to do, since he's had four years and done almost nothing, on that.
So, on prices, one of the things that we have argued, and I think is very important, is, we need to change how we actually pay for health care to doctors and hospitals. We need to move off the fee-for-service system, and we need to get to more value-based payment, so doctors don't get paid for everything they do. They get paid for managing your health problems and keeping you healthy.
That's called value-based payment. We also need to change physician behavior, so they refer you to places that are lower cost, hospitals that charge less, lab facilities that charge less. Those are going to be really important.
We also, I do think, need to have serious drug price control. Right now, we let drug prices — drug companies set prices, instead of linking prices to how much of a health impact those drugs actually make.
In many other countries, you release a new drug that has a comparable existing drug on the market, you can't increase that price. But, in the United States, we have a lot of cases where drugs just the same as some other drug on the market, and that price actually goes up to $200, $300, $400, for no health benefit, no health advantage, compared to what's already there.
So, we definitely need to change how we're paying for drug prices. And I think the Democrats have been serious about this. But the Republicans haven't wanted to come to the table.
Lanhee Chen, what about that point?
I mean, as Zeke Emanuel points out, the president has been the president for a long time and has had substantial support in the Congress and in the Senate. Why haven't those things that you hope he would do in a second term been done in the first term?
Well, I think he's made progress on a few things via executive action, which is what he has sort of had to resort to in some ways, because negotiations have broken down with Democrats over issues like drug pricing, surprise billing, et cetera.
So, on the first order, I would say I think using executive action can be a Band-Aid approach. It's not something I would recommend in the longer run. I think, in the longer run, Democrats and Republicans are going to have to come together, for example, to address the prescription drug pricing issue.
And I do think that there have been situations where the president and the administration have come forward with reasonable proposals that previously, at least, Democrats have supported, like, for example, tying drug pricing more to what drug prices are in other countries that might be comparable.
That proposal, it seems to me, has traction with some Republicans and a heck of a lot of Democrats. But, unfortunately, because of the politics of this, Democrats haven't always wanted to work together with the Trump administration to — quote — "give President Trump a win."
So, I do think that the politics here is not as simple as Zeke suggests. It actually cuts both ways.
Zeke Emanuel, let's turn to this issue of expanding coverage.
You were there at the conception of the Affordable Care Act. You know and have seen how it's been chipped away at and it's been taken to court by the Trump administration.
If Biden were to win and become the president, he's talked a lot about strengthening the ACA and expanding its protections for people. How do you see a Biden administration trying to deal with getting more people more health care?
Well, I think the first thing you would do is to try to expand what we have, increase the subsidies on the exchanges, increase choice with a public option, so that more people could afford insurance through the exchanges.
We're going to have to do something on Medicaid, because we have these 12 intransigent states — Texas, Florida, Georgia, North Carolina — that aren't expanding Medicaid. And we cannot get to universal coverage without that expansion of Medicaid.
And I think that's going to require some serious action. No incentives seem to be willing to make those states move. And the people who are being excluded typically are people who are working, but their salaries are too low to actually get private insurance or even get good insurance on the exchanges. And yet those states don't seem to want to give them health coverage.
I think, if COVID has made anything clear to all Americans, it's, we all need health coverage, so we can actually get the care we need.
Lanhee Chen, what about this issue of the Affordable Care Act?
The president has been vehemently opposed to it, keeps telling us that there will be a new proposed plan to replace it. But he's currently in court and trying to chip away at it very aggressively.
Do you think that there will be a substantive plan eventually, if the president wins a second term?
Well, I think there should be.
Republicans need to be absolutely clear — this includes the president, as well as congressional Republicans — about what they intend to do on health policy. I think the ACA, the Affordable Care Act, is an important part of that.
I think the fact that it's been around for 11 years now suggests that, at this point, the changes that are going to be made are changes that are more incremental in nature.
Now, as much as I would like to agree with Zeke, I simply cannot on this, because there are actually areas where the ACA could be improved by focusing on people who need assistance. Zeke is talking about expanding subsidies to people making $200,000, $300,000 a year.
Instead of that, why not focus assistance on people who really need it? Why not try and determine who actually really needs help, and then empowering states, for example, to assist those people?
Now, beyond that, I would say that Biden's plan to put in place a public option raises serious concerns with me about the way in which it would erode access to physicians, erode access to hospitals and care that people need, and also create a costly new government entitlement.
So there are all sorts of reasons why, even though Vice President Biden's plans have been framed as being more moderate in the health care space, there's a lot of reason to believe that they're actually quite progressive in nature and would fundamentally alter the U.S. health care system.
The Republicans, as he points out, have had 11 years to come up with a replacement to the Affordable Care Act, and you have never seen them produce a replacement to the Affordable Care Act that will get to expanded coverage.
And they simply don't have a plan, and they have never had a plan.
The second point I would note is that, every year under President Trump, including this COVID year, the uninsured rate has gone up and up and up. He has not introduced one policy that has enhanced coverage. Every single policy has ended up cutting back on coverage.
You get rid of the mandate, you cut back on coverage. You create these pseudo-programs that really aren't health insurance and you call them choice — cuts back on the number of people who have insurance.
This is — they haven't expanded coverage one iota, and they don't have a plan to expand coverage. And I noticed he began his statement, they should have a plan.
Well, they have had 11 years to develop it. Where is the plan?
All right, Zeke Emanuel, Lanhee Chen, thank you both very much for being here.
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