President Obama: Thank you. Good morning.
Ms. Kliff: Good morning.
Mr. Klein: Thank you for being here.
President Obama: 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?

President Obama: 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. 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?

President Obama: 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. 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. 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.
President Obama: — 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. 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. 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 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?

President Obama: 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 to do.

Ms. Kliff: I don’t think so, no.
President Obama: 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?
President Obama: 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 — I was teasing Ezra and Sarah, I said this is like a Wonkapalooza. 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.