A number of the key provisions of the Affordable Care Act went into effect last week. We discuss what they mean for consumers and the role of health care reform in the midterm elections.

Guests

  • Dave Camp congressman representing the 4th Congressional District of Michigan and the top Republican on the House Ways and Means Committee.
  • Matthew DoBias health care correspondent for National Journal.
  • Stephanie Cutter Assistant to the President for Special Projects
  • Susan Dentzer editor-in-chief of Health Affairs, and an on-air analyst on health issues for The PBS NewsHour

Transcript

  • 10:06:55

    MS. SUSAN PAGEThanks for joining us. I'm Susan Page of USA Today, sitting in for Diane Rehm. Last week, President Obama and his administration touted the benefits of the health care bill as some key provisions went into effect. But the only candidates talking about the landmark legislation on the campaign trail seem to be Republicans who promise to repeal and replace the law. Joining me in the studio for a six month checkup on the law and its political impact are Susan Dentzer, editor in chief of Health Affairs and an analyst for "PBS NewsHour," and Matthew DoBias, senior health care correspondent for National Journal. Thank you for joining us.

  • 10:07:36

    MR. MATTHEW DOBIASGood morning.

  • 10:07:37

    MS. SUSAN DENTZERGood morning.

  • 10:07:37

    PAGEWe invite our listeners to join our conversation later in this hour. You can call our toll-free number, 1-800-433-8850. Or send us an e-mail to drshow@wamu.org. Or you can find us on Twitter or Facebook. First, we're joined from the White House by Stephanie Cutter, Assistant to the President for Special Projects. Welcome to the show, Stephanie.

  • 10:08:01

    MS. STEPHANIE CUTTERGood morning.

  • 10:08:02

    PAGENow, last week, the president and others in the administration were talking about some of the provisions of the health care law that went into effect just last week. Just briefly, what are the things that went into effect last week?

  • 10:08:14

    CUTTERWell, it's what we call the Patients' Bill of Rights. On Sept. 23, there were a number of consumer protections that went into effect. For instance, insurance companies can no longer discriminate against kids with pre-existing conditions. They can't drop individuals when they're sick. They can't limit your coverage in terms of lifetime limits or restricted annual limits. And it gives you a choice of doctor among a number of other things, including a focus on preventive care without any cost-sharing. So folks across the country have better access to the things they need to keep them healthy. So it's a whole array of provisions that were put into law by the Affordable Care Act. And on Sept. 23, they went into effect.

  • 10:08:58

    PAGENow, we had a long debate about this health care bill followed by six months since its passage. And yet we see a Kaiser Poll this morning that shows that number of Americans who say they are confused about the law is actually going up now to 53 percent. Why do you think Americans continue to be, you know, flummoxed by this law?

  • 10:09:21

    CUTTERWell, you know, I always think about this in two tracks. You know, we are busy implementing the law as responsibly and expeditiously as possible. Sept. 23 was the key date in which all of these consumer protections go into effect. The second track is, actually, what is the continuation of the debate on health care that's happening across the country. In some states, spending on up -- opposing the new law is up to 7-to-1 of people running out in support of the new law. So the opposition and the, you know, the politics of fear, I shall say, is still happening across the country, which is causing confusion. And it will continue to cause confusion until we effectively implement the law, and people are living the benefits of it.

  • 10:10:13

    PAGEWell, we know that when the law was passed, and as the administration was pushing so hard to get it through, that some administration officials were assuring Democratic members of Congress that once a law was passed -- once you saw this kind of provisions go into effect that public opinion on the law would turn around. But we haven't really seen that happen yet. What's the time frame, do you think? Do you think this law will eventually be popular? What's the time frame for that to happen?

  • 10:10:39

    CUTTERWell, I think that you can't really put a time frame on it. You know, we always considered this to be a slow process in educating the American people about what's in the new law that will benefit them, whether it's small business tax credits or resources from employers to cover early retirees who are too young for Medicare, or resources to states to help them strengthen their premium review. You know, we are starting to see the results of the new law in keeping premiums down and affecting the quality of care that people are getting. As more and more of this law is implemented, I think that consumer behavior on it will change. I will say though, you know, there's polls all the time, as you know, on health care.

  • 10:11:21

    CUTTERIf you look at the polls, the really important number is that the country is split on it, no doubt, and it largely falls along political lines. But if you look at the people who have an unfavorable position on the law and ask them the question, well, you may not like it, you may not favor it, but do you want to do a way with it? That number drops dramatically to low percentages of people that want to do away with it. People want to give it a chance. People want to implement it. And as these benefits come on line, like we saw last week, I think that number of people who want to give it a chance and the favorability number is going to grow. You know, I did notice in the poll that's out today -- the Kaiser Poll -- Democrats remained the more trusted party on health care and Medicare by a 3-2 ratio.

  • 10:12:02

    CUTTERAnd the overall approval number is up, and the motivators are down. So, you know, slowly but surely, we are going to continue implementing the law. And as we implement it, and as it takes effects, and as it changes the quality of care and costs, more and more people are going to grow comfortable with it. You know, passing the law, as everybody knows, was not easy. And there was a massive opposition campaign launched throughout the course of the debate. That opposition campaign hasn't stopped. As I said, we're being outspent 7-to-1 in opposition to the new law. Despite being outspent 7-to-1, we're still doing well in the polls. We are, you know, holding the line. So I think that, you know, we're looking ahead. We're continuing to implement, and there's a lot of good things to come.

  • 10:12:53

    PAGEStephanie Cutter, do you think the administration has done a good job in explaining and selling this health care law to Americans?

  • 10:13:02

    CUTTERI think that -- yes, I do. I think if you look at what we've done just over the course of the last several months to actually implement the law and make sure people know about it. There is a new consumer website, first of its kind, for the federal government called HealthCare.gov, where at the end of this week consumers can go and look at plans that are available to them where they live. But for the first time ever, they will be able to compare apples to apples in terms of insurance plans and have cost information -- premium information in front of them -- so that they can make the best informed choice on what coverage is best for them and their families. People never had access to that information before. They always, you know -- purchasing insurance was always a difficult, confusing thing for individuals because insurance companies operate -- and under a cloud of darkness -- and they benefited from that confusion and cloud of darkness.

  • 10:13:53

    CUTTERWe have effectively removed it with HealthCare.gov, so I think that, you know, implementing a law of this size, moving forward on a fundamental market reform that takes control away from insurance companies and gives it to consumers is a difficult thing to do, and it takes time. And I'm incredibly proud of what this administration has done, and they're even working with Congress to get it done in an expedited fashion.

  • 10:14:19

    PAGEOne last question, you are an experienced figure in politics and the Obama campaign and the John Kerry campaign, and I wonder if it's disappointing after passage of this law. You know, Democratic presidents back to Truman had talked about passing big health care reform -- it finally was passed six months ago. Is it disappointing that when you go across the country, Democratic candidates for Congress, almost none of them that I've seen are campaigning -- touting the bill, saying I voted for it, I'm proud of that? Is that -- how do you feel about that?

  • 10:14:52

    CUTTERWell, you know, I think that the number one issue in this election -- and the Kaiser poll says it today -- is the economy. That's what candidates are talking about, how they're going to get Americans back to work. What we've done to break the back of this recession -- create jobs, strengthen the middle class -- that's what Democratic candidates are talking about. And if I were advising them, that's what I tell them to talk about. But, you know, whether or not it's disappointing that they're not talking about health care -- no. What is incredibly great is the accomplishment of health care that it actually -- you know, you're right. People have been talking about passing health care reform since Truman.

  • 10:15:33

    CUTTERYou know, I'm a former Kennedy staffer, and I know how important it was to Senator Kennedy to get national health reform done. And it's -- I'm incredibly proud that this president got it done with the help of a Democratic Congress. So I think that, you know, implementation is going to continue to happen over the next several years. More and more benefits are going to come online, and costs savings and individuals are going to realize that, you know, the power has shifted from insurance companies to individuals and families. And I think that will be, you know -- that will be a good thing.

  • 10:16:04

    PAGEStephanie Cutter, she's assistant to the president for Special Projects. Thanks so much for being with us on "The Diane Rehm Show."

  • 10:16:08

    CUTTERThank you.

  • 10:16:10

    PAGEWe're joined now by Congressman Dave Camp. He is the top Republican on the House Ways and Means Committee. He's joining us from his district office in Midland, Mich. Congressman, thanks for being with us.

  • 10:16:22

    REP. DAVE CAMPWell, good morning, Susan. Thank you for having me.

  • 10:16:24

    PAGENow, we've just heard Stephanie Cutter of the White House talk about all the benefits of the law, and yet -- of this healthcare law. And yet Republicans have made a promise to try to repeal it if you manage to win control in November's election. What is yours -- what's your plan going ahead?

  • 10:16:42

    CAMPWell, actually we would -- we do pledge to repeal and replace this legislation. I think part of the problems that come with this bill are that it was written in secret. It didn't go through the normal committee process. There was no transparency. The American people did not have a chance to be heard on this bill. They weren't listened to. The opposition of this legislation was bipartisan. There was only partisan support for it. There was bipartisan opposition as many Democrats opposed the bill. And, obviously now, we're seeing in the campaign election, they're running as far from it as they can. What we replace it with is legislation that would allow people to be covered if they have a pre-existing condition that would eliminate the annual lifetime insurance caps and would say that you can't be dropped if you -- from your coverage if you get sick.

  • 10:17:25

    CAMPI think what's important is this particular health care law that's enacted is actually going to make health insurance more expensive for Americans. That's according to Congressional Budget Office -- that's not according to me -- that millions of families will pay up to $2,100 on average more by 2016. This bill also discourages employers from hiring new workers and increasing wages or retaining their employees because of the costs. And that's why you're seeing leading employer groups -- like, the National Federation of Independent Business, the U.S. Chamber, the Business Roundtable -- are all calling this a destructive and dangerous law because it's created this massive economic uncertainty. The other problem is this law actually jeopardizes seniors' health care. The Center for Medicare and Medicaid Services -- not me, but a government agency -- says, nonpartisan -- that this health law could threaten seniors' access to care. And even the administration predicts that nine out of 10 seniors will lose their employer-sponsored, retiree drug coverage.

  • 10:18:23

    PAGEMm hmm.

  • 10:18:23

    CAMPAnd also then this bill had massive tax increases and an individual mandate that's being challenged in court right now as well.

  • 10:18:29

    PAGENow Congressman Camp, we have to take a very short break. That's what that music signals. We hope you'll hold on to the lines, so we can ask you couple more questions when we come back from the break. And we hope that our listeners will stay with us.

  • 10:20:03

    PAGEWelcome back. I'm Susan Page of USA Today, sitting in for Diane Rehm. And we're talking this hour about where the health care debate stands six months after the health care law was passed and signed into law by President Obama. We have on the phone Congressman Dave Camp. If Republicans manage to win control of the House in November, he will be the chairman of the Ways and Means Committee with a lot to say about the issue of health care. Congressman Camp, you've talked about Republican intentions to repeal this law but to protect or to enact some of the provisions that are most popular, like, for instance, guaranteeing access for people who have pre-existing medical conditions. But some analysts in this debate say that's just not possible to do unless you guarantee universal coverage, that it doesn't work for insurance companies unless there's universal coverage. Is that something that Republicans plan to do?

  • 10:20:56

    CAMPWell, one of the things that we do in our bill, and, I think, one of the unfortunate things about the existing law is that they're really squelching innovation. And what we do in our legislation is have state innovation grants that really give an opportunity for states to find creative solutions to expand coverage. We also have medical liability reform, which this bill doesn't have. And only -- on the government side alone, that could save up to $50 billion. And if you include the private sector side on medics, it would be two or three times that. Yet in the so-called reform bill, there is no reform with the ability of trying to find a way to reduce cost on families and patients by having some sort of liability reform.

  • 10:21:38

    CAMPI think one of the exciting things about medicine in America is it has been innovative, and these innovation grants that are part of our bill -- which are not part of this so-called health reform bill -- will actually help in many ways. And that's what we need to continue, unleash creativity on the medical side to both reduce cost and coverage. And let me just say this. Our legislation was the only legislation scored by the Congressional Budget Office that actually reduced health care premiums for families, and that's what we would need to try to do first. And this is not meant to be the final answer on health care. I think one of the big problems is they tried to take an apple and swallow it all at once. And what we were saying is we need to start with some reforms and innovations and continue down a path to do that and not try to swallow the whole apple in one piece but to go through it bite by bite, and our legislation will begin to do that. Once we bring costs down, then we can move ahead with other reforms.

  • 10:22:34

    PAGECongressman Camp, if Republicans do manage to vote a repeal of the health care bill, that'd be a big step. Wouldn't President Obama just veto it?

  • 10:22:44

    CAMPWell, obviously we have to see what the election will bring. None of this will happen before the election. I think we need, though, to let the American people know what we're about and what our pledge is. And our pledge is to repeal and replace, and we would replace this legislation with legislation that actually would begin to reduce costs. And as I mentioned, the Congressional Budget Office has scored this, the current bill, is actually making health insurance more expensive. There's nothing to so -- to quote/unquote, "bend the cost curve" and reduce overall health care spending either.

  • 10:23:16

    PAGEAll right. Congressman Dave Camp from Michigan, the top Republican on the House Ways and Means Committee, thank you so much for joining us.

  • 10:23:22

    CAMPWell, thanks, Susan. Thanks for having me.

  • 10:23:24

    PAGEI'm joined in the studio now by Susan Dentzer from the "PBS NewsHour" and Matthew DoBias from National Journal. You're both experts on health care, cover it all the time. Did you hear anything from Stephanie Cutter or Congressman Camp that's new or that surprised you?

  • 10:23:39

    DENTZERSusan, I think we heard a restatement of some of the perspectives that we've been hearing from both sides for quite some time. For example, hearing very much from Stephanie that they're trying desperately to explain to many Americans that they will come out better if they have health insurance, that their health insurance will be safer, more secure, sounder. The problem I think they're running into is, first of all, most people don't know what's in the health insurance that they have now, so persuading them that there are some new nifty things is a tough sell.

  • 10:24:09

    DENTZERThe other, really, problem that the administration has is, frankly, one thing that Stephanie didn't mention, was that our latest numbers on the uninsured in America showed that the number of uninsured jumped from 2008 to 2009 by 4.4 million people. So we're now at a record all-time high of Americans without health insurance, and unfortunately, the provisions that would deal with that don't go into effect 'till 2014. So right now, the administration is stuck selling some things that are hard to sell and explain and doesn't have the big package to sell at the moment and can only talk about 2014 being around the corner.

  • 10:24:45

    PAGESusan Dentzer, why has the number of uninsured gone up?

  • 10:24:49

    DENTZERThe biggest explanation is the weak economy. In fact, most of the uninsured who became uninsured from '08 to '09 did so because they went from full-time employment to part-time employment. So, unfortunately for the administration, this whole discussion would -- comes right back to the weakness of the economy. And as Stephanie said, that is the number one issue this year. So it's -- they're in a particularly tough position at this point.

  • 10:25:14

    PAGEMatthew, as an independent analyst, how much effect has the health care bill had, to date, on the lives of Americans? Has it had much of an effect?

  • 10:25:22

    DOBIASNot just yet, I would argue. Now we just saw the --what Stephanie calls the Bill of Rights to patients -- Bill of Rights go into effect Sept. 23. Now, there is a lag time with a lot of those provisions. So as we were talking in studio a little bit earlier about, say, for example, the provision to have your young adults stay on your insurance until the age of 26, you know, we know that buy-in for that for most insurance periods won't be until early next year. So, you know, they are, in terms of messaging and the provisions in the law, they are dealing with something of a lag time.

  • 10:26:00

    PAGEWe know how complicated health care is. We know that from the long debate that we had in this country about it. We heard Stephanie Cutter from the White House say that she thought the administration done a good job in explaining and defending this bill. What do you think, Susan? Have they?

  • 10:26:15

    DENTZERI think, yes. Within -- in terribly difficult circumstances, probably not as much as could have been done, obviously, to explain. Frankly, it's hard in this age of soundbite journalism to figure out how they might have gotten this across differently. I suppose the only realistic way would have been to hire a bunch of unemployed census workers and send them out across the country explaining, house by house, what goes on because it is the case when you walk people through the provisions, even the ones that just took effect or will take effect for those with employer-based coverage who will get their new coverage as of Jan. 1.

  • 10:26:53

    DENTZERLook at what we've said for years in this country, that the health care system really is a sickness care system and that we don't do enough to keep people healthy. Well, under the legislation, there will no longer be cost-sharing requirements for people to get a number of preventive services. So those blood pressure checks, diabetes checks, cholesterol checks, a lot of cancer screenings, routine vaccinations, all of that you won't have to pay a deductible or co-payment anymore. Now this doesn't sound like a big deal, but we know from a lot of studies that have been done that if you just put up minor roadblocks to people getting these things, like co-payments and deductibles, they don't get them. So this is a major, major and important shift, but explaining that again to many people, who -- as I say -- don't know what's in their health insurance to begin with, is tough.

  • 10:27:40

    PAGEMatthew DoBias, we're just five weeks out from a midterm election, a critical one, Democrats really struggling to hold on to their control of the House and Senate -- what kind of role is health care playing in the congressional campaigns?

  • 10:27:53

    DOBIASRight. It's an interesting question because I think the polling is all over the place on this, you know. And Stephanie had mentioned and -- to the Democrats that I talk to on the Hill when they go out on the campaign trail. When they were over the recess break, and they were in their hometowns, they were talking and knocking on doors to all their -- you know, to their constituents. And they said that they heard jobs and economy, one and two, jobs and economy, which gives them a little bit of cover from talking about the health reform law.

  • 10:28:22

    DOBIASNow, over the years -- and Susan can back me up on this -- it -- when we've covered polling in the past heading into elections, you know, usually economy is number one. And when the Democrats were on the cusp of taking the majority, and they were going to push their -- the reform efforts, they really wanted to do health care reform. They used to say that inherent in that concern about the economy is health care. So, you know, it depends on how you parse it. When there is concern in the economy, when there is concern about jobs, so much of that is linked to health care. So much of that is linked to coverage, and I think we saw that in the census numbers.

  • 10:29:00

    PAGEYou know, I was in Arkansas last week talking to voters before the midterm election, and health care was the number one thing people mentioned to me. And they were almost entirely against the law, confused about it, felt it was big government, worried it was going to increase their cost -- clearly a lot of concern.

  • 10:29:18

    DENTZERLots of concern and lots of lack of understanding. We note that Congressman Camp said the bill was written in secret. Well, semi-secret, but let's -- it's also been in law now since March 23, so there's been plenty of time to sort of go through the details and understand what it would do and what it would not do. So it is, I think, very much a problem of the complexity of health care and health insurance. The ability to manufacture -- I guess Stephanie was -- who used the phrase politics of fear. It is very easy to manufacture fear. The polls indicate that people believe that things are in the law that, in fact, are not in the law, and they were carryovers of the debate leading up to passage of reforms. So there are lots of Americans who believe there are death panels, et cetera, et cetera. So these are very hard perceptions to fight. And the perception now, in the weak economy, coming after the stimulus law and everything else, people do view this as a terrible failure of government and perhaps even a takeover by government.

  • 10:30:21

    PAGEThe Kaiser Poll out this morning shows that three in 10 seniors believe there are death panels in this law. Are there, Matthew?

  • 10:30:28

    DOBIASNo, there aren't. But politics is perception, and I think the perception has been out there for a long time, and Stephanie mentioned this in her call. HHS Secretary Kathleen Sebelius mentioned this last week when they were out there on the stump for this and that is, it's really hard to walk those claims back, and that's what they've been struggling against.

  • 10:30:53

    PAGEDo you think the administration is surprised by where they are at this point, six months after the law was passed? Do you think they thought they would be in a better place, Susan?

  • 10:31:04

    DENTZERI think they got very excited a couple of months ago when that same Kaiser Poll showed that support for the legislation was going up. And they thought, well, maybe we're turning the corner here. It looks like -- unfortunately for them, this is tracking the performance of the economy as we would expect. And therefore, as the economic news has continued to be pretty much in the doldrums, support for health reform has declined. And, of course, we know that the political dialogue has -- if anything -- gotten louder and resuscitated a lot of fears that people have.

  • 10:31:36

    PAGEJust one more piece of information from that Kaiser Poll, it showed that a plurality of Americans support the law. But it showed that the margin got really evenly divided among the voters who are most enthused about the election, the people who are most likely to go to the polls in a midterm election. Let's talk about Republican repeal, which is something we heard Congressman Camp talk about. Matthew, are Republicans likely to, in fact, repeal the health care bill?

  • 10:32:03

    DOBIASThey're going to give it a shot, would be my guess. You know, the shorthand on Capitol Hill is bill numbers, and there is a lot of talk of H.R.1 being a bill to replace the health care reform act. It's a good bumper sticker. And again, I think it has -- it really has traction. But legislatively, on Capitol Hill, things work very differently, so I don't think that's realistic. But I do think they're going to give it a run. And who knows? You know, who knows?

  • 10:32:34

    PAGEI'm Susan Page of USA Today, and you're listening to "The Diane Rehm Show." We're taking your calls at 1-800-433-8850, or you can always send an e-mail to drshow@wamu.org. Well, Susan Dentzer, Congressman Camp said that they would not just repeal this law but replace it and protect some of the provisions that are most popular. Can they do that?

  • 10:32:55

    DENTZERWell, exactly. What we just heard was what they would not repeal, which was all of these Patients' Bill of Rights provisions that have taken effect. So that's an implicit, I think, nod to the fact that these provisions are kind of straightforward and, frankly, have been debated in Congress for a long, long time. Written in secret or not, they have been proposed since the late 1990s, a lot of these insurance reform provisions. So as to the rest of what they would repeal it with, you heard the congressman say, it essentially grants to states to be innovative. Well, that's an interesting concept. And we will point that out, that, in the Affordable Care Act, a lot of the burden is put on states to figure out how to implement various provisions of it. So how the states would do things differently under money from -- that will be put forward for them under a replacement bill versus what they're going to do under the affordable care act remains to be seen. And we don't really have a lot of explanation coming out of the Republicans to delineate that for us.

  • 10:33:56

    PAGECongressman Camp made, I thought, an effective image when he said Democrats tried to swallow the apple whole, and they want to take bites out of the apple and approach it that way. Matthew DoBias, is there a problem with that though? I mean, one of the things we heard about during this debate is that health care doesn't -- it doesn't work to do it piecemeal. You can't do the popular revisions...

  • 10:34:14

    DOBIASRight.

  • 10:34:15

    PAGE...unless you do some of the things that are quite (sounds like) far-reaching.

  • 10:34:17

    DOBIASAnd that's why you have a 2,700-page bill for the most part. Because when you do comprehensive reform, you have to -- to borrow Camp's word -- you have to swallow the apple. And that means -- I mean, it simply means that one provision that doesn't look like it ends up being related to another provision. So you take the individual mandate, for example. You know, it is a provision that got a lot of attention. There's a lot of debate over it, but it's also the spine of this bill because it's so linked to coverage. So when you link this to coverage, that means it's linked to the hospitals and the physicians who, you know, really kind of crafted their support based on the fact that they're going to get the amount of coverage expansion to help defray the cost that they pay for treating the uninsured.

  • 10:35:01

    PAGEPresident Obama surely would repeal efforts to eat away at this law that he fought so hard for. But, Susan Dentzer, could Congress pursue a kind of guerilla strategy of denying funding to make it hard for the administration to implement this law?

  • 10:35:15

    DENTZERYes, clearly it could. And the big thing would be to repeal the subsidies that will go into effect in 2014 that will help people either obtain coverage -- private insurance coverage through health insurance exchanges -- or that will go to the states to enable them to expand the Medicaid program. Now, an interesting challenge for Republicans is that overall the Congressional Budget Office said the entire package of the Affordable Care Act would reduce the deficit over time. If it gets repealed, the deficit goes up unless the Republicans have other ideas for how the problem of rising health care costs, et cetera, gets dealt with. So it's not a slam dunk that they'll be able to put something through and claim that they are pushing us toward a better fiscal position at the same time.

  • 10:36:04

    PAGEMatthew.

  • 10:36:05

    DOBIASRight. That -- I think the CBO said it reduces the deficit by 140 odd numbers, and that is something that any kind of replacement from the Republican side would have to backfill. They'd have to fill that amount that...

  • 10:36:19

    PAGEAnd thinking about family budgets and the deficits that some families see, they were at the point where people with employer-based plans are often choosing what kind of coverage to have next year. Are they going to see an impact on their premiums as a result of this health care bill?

  • 10:36:34

    DENTZERI think premiums -- the simplest thing to say is premiums are going to continue to go up because health spending is going up in this country and will. But we will also see some premiums bouncing around. And here is an example, some states have -- or excuse me, some insurance companies have, in fact, asked states to approve increases in premiums for individual insurance plans that the companies say is, in fact, due to provisions of health reform. On the other hand, Blue Cross Blue Shield of North Carolina announced that it was going to pay back to individual policyholders $156 million because certain provisions of health reform mean that they've been overcharging on premiums. So we're going to see this sort of bouncing around effect for some time, some premiums going up, some going down.

  • 10:37:21

    PAGESusan Dentzer, she is editor-in-chief-of Health Affairs and an on-air analyst on health issues for the "PBS NewsHour." And we're also joined by Matthew DoBias, health care correspondent for National Journal. Surely, no issue affects people's personal lives more than the issue of health care. We're going to hear from some of our listeners on this after we take a short break. Stay with us.

  • 10:40:02

    PAGEWelcome back. I'm Susan Page, sitting in for Diane Rehm. We're talking about the health care bill six months after enactment. With me, Susan Dentzer and Matthew DoBias, and we're going to go to the phones and take some of your calls and questions. We're going to go first to Weare, N.H. and talk to Michael. Michael, thanks so much for joining us.

  • 10:40:20

    MICHAELHi. Good morning.

  • 10:40:21

    PAGEGood morning.

  • 10:40:22

    MICHAELI just have some, well, questions, I guess, on this new reform and some comments on -- I've been on disability for the last six years. I was in a car accident. That's not the important thing so much as on the prescriptions on the new bills that they put in, is anything to do with the, I guess, raising the cap on prescription drugs? I don't know how people can afford -- it seems -- that are on -- or on Social Security or disability -- afford to pay for prescriptions. I just don't understand it. (unintelligible)

  • 10:41:04

    PAGEAll right. Michael, thanks so much for your call. Susan Dentzer.

  • 10:41:08

    DENTZERWell, if Michael is in fact on Medicare -- which I would guess he probably is because he's been disabled long enough to have applied for Medicare -- then the answer is that the alleged doughnut hole -- the so-called doughnut hole does go away under health care reform, is phased out over time. And if he is in fact on Medicare and got in to the doughnut hole, he got a $200 check from the government last summer to deal with that. So that's the situation with respect to Medicare beneficiaries. For people who are on private health insurance plans, the annual limits on overall coverage go away, and that will apply to prescription drugs as well. And the lifetime limits on coverage go away, and that also will apply to prescription drug coverage. So there will be hope for people in that category as well.

  • 10:41:55

    PAGEAll right. Well, Michael, thanks for your call. Let's go to Bruce. He's calling us from Detroit. Bruce, hi, you're on the air.

  • 10:42:03

    BRUCEHello. Thanks for giving me a chance to speak. I wanted to reply to some of the things that Sen. Camp -- I mean, Congressman Camp said.

  • 10:42:12

    PAGEYes.

  • 10:42:12

    BRUCECan you...

  • 10:42:14

    PAGEGo ahead, Bruce. We can hear you.

  • 10:42:16

    BRUCEOkay. Great. He was talking about some parts of the bill that they liked, like the -- letting the people's kids stay on 'till 26 and other aspects, and I'm wondering why they didn't do those kind of reforms during the 12 years they had total control of Congress. And also, when they start talking about the increases in cost that the Congressional Budget Office is predicting, why don't they address the -- or why doesn't someone ask him about how our gross national product that goes to health care went from 12 percent to 17 percent during the 12 years that the Republicans were in control of Congress?

  • 10:42:58

    PAGEYeah, Bruce, well, thanks for your call. You know, we have a similar e-mail from Jack who writes us, "Where were all Congressman Camp's ideas during the debate on health care legislation? Some of these ideas sound interesting, but I didn't hear or see any desire from the Republicans regarding health care." Matthew, is this a fair point? Or did Republicans talk about alternatives during the debate?

  • 10:43:17

    DOBIASYou know, I think those are interesting comments. From observing Capitol Hill at a pretty close level, I -- you know, I think there's an ebb and flow to the legislative process. And, you know, people ask me all the time, well, why did -- you know, why health care reform? Why now? And, you know, sometimes the answer is just as simple as, the timing was there. And, I think, over the past decade or so, you know, the timing just may not have been there. While you had a GOP run Congress or other priorities, other legislative issues that came up. Also, I think a lot of it is also difficult to do when it's not done comprehensively. You know, we talk about, you know, one part of the health reform law affecting another part where they -- you know, to the untrained eye, they don't look like they're related, but they genuinely are. So, I think, some of those reforms that the Congressman was talking about would have been difficult to do in a vacuum.

  • 10:44:10

    PAGEHow serious, Susan, do you think Republicans are about the replace part of their commitment? Is there, do you think, a real Republican commitment to address health care in a way that meets some of the needs this bill was designed to try to address?

  • 10:44:25

    DENTZERCertainly, if one looks at the goal of getting toward universal coverage, the answer is, no. They simply have not put forward a plan that would expand coverage substantially. And the only proposals that have come out of Republicans that would result in major reform, frankly, have some very controversial pieces to them.

  • 10:44:46

    PAGESomething like...

  • 10:44:46

    DENTZERPaul Ryan, for example, a member from Wisconsin -- Republican member of Wisconsin -- has proposed essentially eliminating the tax protection of health insurance, which -- as we saw, the Democrats tried to get pieces of that through in the recent reform legislation, and even many Democrats were opposed to that. So the notion that somehow you would essentially make health insurance benefits taxable to individuals and use that tax revenue to give back to people in the form of vouchers, politically is very, very difficult to see how that would come about and no guarantee, no explicit decision on the part of any Republicans to put more money into that approach to cover more of the people who can't afford coverage as it is. A lot of people don't have health insurance simply because they can't afford to buy it.

  • 10:45:35

    PAGEHere's a comment that Thomas posted on our Facebook page. He wrote, "I feel like the tasty, easy-to-swallow parts of the bill have been sprinkled on top -- changes most everyone agreed were needed -- but the yucky, painful-to-enact and pay-for parts of the bill are yet to come." And Chris also sends us an e-mail that's similar. He writes, "The Democrats designed this law so that the goodies would come into effect prior to the midterms, and the most onerous, costly parts would only come into effect in 2013 after the next general election. Why are you allowing your guests to leverage this cynical ploy by only discussing the so-called benefits?" Matthew, what do you think?

  • 10:46:12

    DOBIASYou know, I think there is something to the design and structure of this legislative package. I wouldn't doubt it. But again, it's a 10-year implementation timeline that we're looking at and very likely even longer than that. You know, we have, of course, the Bill of Right issues that came up -- Patients' Bill of Right issues that came up last week. 2014 will bring -- you know, that's going to bring the exchange. But there are also, you know, peppered throughout this bill, there are so many different aspects that, you know, again, to the untrained eye, don't seem like a big deal. You have -- you're beginning to see a movement for Medicare better-paying providers, the hospitals and physicians.

  • 10:46:55

    DOBIASYou know, this is going to be a movement toward paying them for the quality of care that they deliver rather than the quantity of care. So you're fundamentally changing a payment model from what's known as fee-for-service to now, you know, more of a, you know, pay-for-quality. So there's a lot in the bill. And really, when you take a look at the timeline, there's a lot that's going to be implemented. These may be the headline grabbers right now, but certainly at the surface, there's a lot that the administration is working towards.

  • 10:47:26

    PAGENow Chris wrote in his e-mail that the big provisions, the most far-reaching ones, don't go into effect 'till 2014, which, of course, is after -- I'm sure President Obama hopes to have won a second term after the next presidential election. Is that timing intentional, Susan?

  • 10:47:40

    DENTZERIt was intentional from the respect that there -- these reforms are going to be extremely costly. And they had to be ramped up by virtue of the fact that we're in a major deficit position at the moment, and we have a very weak economy. And so the supposition all along was that it was going to take a while for the economy to rebound, tax revenues to rebound accordingly, and us to be able to afford the major subsidies that will go into effect in 2014. I would say, to the point that the goodies are all taking effect now and that the pain is ahead, try telling that to 50.4 million uninsured Americans, that the goodies have already happened and that the pain is going to come when they get health insurance...

  • 10:48:23

    DOBIASRight.

  • 10:48:23

    DENTZER...in the year 2014 and beyond.

  • 10:48:26

    PAGELet's talk to Roger. He's calling us from Clearwater, Fla. Roger, hi. Thanks for being with us.

  • 10:48:31

    ROGERPleasure to be here, enjoy your show. I have a couple of questions or -- I've been around while and thank God, I'm on Medicare, so a lot of these problems don't exist for me. But I have children, and I have employees that were on insurance. I always found, in past years, that insurance was what's more affordable, the more competition they had. And -- 'cause I've been buying health insurance for my company for over 30 years, and as the smaller companies got consumed by the bigger companies, prices escalated. And there was no one to talk to because competition was removed. And I was very much disappointed that there wasn't an alternative, that there -- a public plan that would allow businesses, as well as individuals, to be competitive. Or there wasn't a plan to break up these major insurance companies just like these major banks that have escalated the cost of using money.

  • 10:49:28

    PAGEAll right. Roger, let me ask you, have you seen in your -- personally, any effect from this law so far in the first six months of its existence?

  • 10:49:37

    ROGERCould you repeat that? I didn't...

  • 10:49:37

    PAGEDo you think this has -- has it -- I'm just curious -- this doesn't really relate to your question, which we'll pose to the panel just briefly, but have you seen any affect in your life or in the life of the people in your family from the health care bill so far?

  • 10:49:51

    ROGERYes.

  • 10:49:52

    PAGEAnd what kind of effect have you seen?

  • 10:49:55

    ROGERWell, not only for me but for my neighbors. The 26-year-old provision has helped a tremendous amount of people that I know who have kids in college or just out of college, that they were shopping the marketplace, and then they were trying to get it done early in all of their companies -- from our conversations -- were holding off until the last minute to have to do it. But when the law went into effect -- I probably know in excess of 40 people that have kids that are under the age of 26, are still going to school or trying to get employed, which was a part -- important part of it that -- because they just needed to be -- trying to be in the workforce, that they were able to get this coverage because it's -- it was expensive for them.

  • 10:50:39

    ROGEROr they were going without it, or there were so many -- almost insurance policies out there, these discount programs that really didn't give the public anything except a bill who paid for them. And those -- they were horrible, and I noticed that in our state. I'm in Florida. In our state, several of them have been shut down, but they were taking people for a lot of money on a regular basis...

  • 10:51:04

    PAGEYeah...

  • 10:51:04

    ROGER...because they presented themselves as an alternative to insurance when they weren't even close. So...

  • 10:51:10

    PAGERight. Yeah, Roger, thanks so much for your call. Well, let me pose to the panel your original question that went to the -- to encouraging some competition.

  • 10:51:19

    DENTZERWell, it is true that, as he says, there was no public plan enacted in the final legislation. However, it is also true that when the new state-based exchanges are set up, we will see, likely, competition. We'll see insurers having to post their premiums, what they would charge for the exact same benefit package across the board, and when this was done in Massachusetts, it did force premiums down somewhat. The other thing I would say is that you already are seeing the beginnings of a major restructuring in the health insurance sector. If you go to today's health-insured companies, they're not rejoicing about what's in the law. They know they're going to have to reduce costs. They're going to have to shift to a whole new way of helping Americans take care of themselves. It's really a major shift for the industry, and the industry that comes out of health reform is not going to look like the one going into it.

  • 10:52:10

    PAGEHere's a question by e-mail from Martin who writes us from Ohio. He writes, "There still seems to be a question on whether abortion is funded or can be mandated. Also, questions regarding the conscientious objection rights of medical workers still exist. This confusion breeds mistrust in government." Matthew, what are the provisions on abortion in the law?

  • 10:52:31

    DOBIASThis is an interesting question as well. Obviously, during the course of the year-and-a-half long debate as this bill was getting framed, you know, abortion became a very big issue and actually threatened the bill going down to the final weeks. If -- now, correct me if I'm wrong, Susan -- but if I remember correctly, this was satisfied by President Obama signing a presidential executive order saying that the Hyde Amendment -- which is the amendment that basically puts a wall between federal dollars going towards abortion services -- would stay in place. And, you know, I believe, the -- you know, the answer of the administration said was that, you know, this is, you know, the wall to keep federal dollars away from, you know, money being funneled to the providers for performing these types of services.

  • 10:53:25

    PAGENow, Martin also asks about conscientious objection rights of medical workers. Does the law affect that, Susan?

  • 10:53:31

    DENTZERI -- boy, that one -- I'm sorry, that is beyond my ken here.

  • 10:53:36

    DOBIASYou're right. I...

  • 10:53:37

    DENTZERI believe that there were no particular changes with respect to existing law. And, of course, much of that would be...

  • 10:53:45

    DOBIASRight.

  • 10:53:45

    DENTZER...would essentially depend on what state legislation said on those issues.

  • 10:53:49

    DOBIASRight.

  • 10:53:49

    PAGEI'm Susan Page, and you're listening to "The Diane Rehm Show." Let's go back to the phones, take another call. We'll go to York County, Va. and talk to Tony. Tony, hi.

  • 10:53:59

    TONYGood morning. I enjoy your show very much. Thank you very much for taking my call.

  • 10:54:02

    PAGESure.

  • 10:54:03

    TONYI had a comment through an observation that I would like all our listeners to think about. And it's simply that this country can pay trillions of dollars of interest on a national debt, but we can't afford health care. And that's it.

  • 10:54:22

    PAGEAll right. Tony, thank you very much for your call. Let's go to Terry calling us from Kill Devil Hills, N.C. Terry, hi.

  • 10:54:30

    TERRYGood morning. Thank you for taking my call. I've had experience with health care in both -- around national health care systems in England and in Canada, and I've also traveled in Australia and Mexico, where they also have national health care systems. My question is this, what has private insurance to do with health care for individuals? I fail to see why they play such a strong part in this proposed bill. And I wonder why Americans are oblivious to the truth of how these national health care systems work all over the world and prefer to live -- listen to the dissemination and outright lies that are told about these systems. The fact is, health care systems work worldwide. Why can't we make one work in the United States?

  • 10:55:30

    PAGEAll right. Terry, thanks for call. What do you think?

  • 10:55:33

    DENTZERWell, the reason that there is so much emphasis on private health insurance in the law is because that's what we have in the United States. And this was a question really of inertia -- if you will -- inability to take on a large industry and put it out of business, et cetera. We have a very vibrant private health insurance market as we have a lot of public coverage. We have, essentially, a hybrid system in the United States with a lot on the private side, a lot on the public side -- Medicare, Medicaid. And I think anybody who's watched the health reform debates over the last two decades knows that changing that was probably next to impossible.

  • 10:56:11

    PAGEI wonder also -- I understand Terry's point about having been in a public health system that worked. But, you know, the United States isn't exactly like other countries, countries in Western Europe or elsewhere. It's a distinctive country. And I wonder if a hybrid system is really the one that Americans are going to feel more comfortable with and that might work better in our country. What do you think, Matthew?

  • 10:56:32

    DOBIASYou know, I think there's the old saying that it's the devil that you know, and I think, to a large extent, having the private insurance system is what we do know. You know, we share volume, you know, sheer numbers of people who get their insurance through this process. You know, I think it's an interesting question. Sometimes, I like to take it from not just the individual perspective but look at how the providers feel about it -- again, the physicians, the hospitals -- and I think, you know, when it comes to them, I think they almost prefer a government pair.

  • 10:57:01

    PAGEI want to thank Susan Dentzer and Matthew DoBias for being with us this hour on "The Diane Rehm Show."

  • 10:57:06

    DENTZERThanks, Susan. Great to be here with you.

  • 10:57:07

    DOBIASThanks so much.

  • 10:57:08

    PAGEI suspect this is not the last time we'll be discussing the provisions of this health care law. I'm Susan Page of USA Today, sitting in for Diane Rehm. Thanks for listening.

  • 10:57:12

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture and Monique Nazareth. The engineer is Tobey Schreiner. Dorie Anisman answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org. And we're on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.

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