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Architect Of The Affordable Care Act Reacts To Supreme Court Upholding The Law


Once again, the Affordable Care Act remains in place. The U.S. Supreme Court threw out the most recent challenge to the Affordable Care Act today, saying plaintiffs in the case lacked standing. It's the third Supreme Court challenge and victory for the ACA. Joining us now is Dr. Zeke Emanuel, who was an architect of the law in the Obama administration. Welcome to the program.

ZEKE EMANUEL: Great to be with you, Audie.

CORNISH: On Twitter, Barack Obama, former president, was basically saying that the Affordable Care Act is here to stay. What's your reaction to this ruling, which was 7-2 in favor of the ACA?

EMANUEL: Well, from the health care system perspective, the Affordable Care Act has been the structure under which hospitals and doctors and insurance companies and pharmaceutical companies have been operating for the last decade. It's really only in the judiciary where there's been this debate about, is it the law of the land? And I think the Supreme Court swatted away this case and said, stop annoying us with these cases; it's the law of the land, and let's move on.

CORNISH: I want to ask you about some of the goals of the ACA going forward - of course, affordable care. During the pandemic, lawmakers have increased funding for Americans, part of the kind of COVID relief packages. Those are going to last for about two years. Do you think you can make them permanent? Politically, do you think that's possible?

EMANUEL: I think it's possible. I think it's very expensive to increase the subsidies in the exchanges, which is the main thing that's been done. But there are other...

CORNISH: So people shouldn't get used to that. That, to you, is a kind of very specific relief effort.

EMANUEL: Yes, I think there are other things we can do to expand coverage. There are 17 million Americans who are eligible for Medicaid and-or the exchanges who aren't enrolled. Raising the subsidies is one way to get some of them in, but many of them don't even know how cheap plans are available in the exchanges. Many people don't know that they are eligible for Medicaid or just don't have the wherewithal to navigate the complexities of applying. I think getting those 17 million who are eligible today but not enrolled is critical for getting us - the country above 95, 96% of the population covered by some kind of health insurance.

CORNISH: But can I follow up on that gap? There are 12 states that refuse to expand Medicaid, right? That was after some legal challenge that allowed them to do so. So that's some 4 million people - I assume it's out in the number you're talking about - who could have been covered but are not because their states have decided not to take part in the program. And I know that there's been some effort at legislation or kind of ballot initiatives. But are they - have those tools been exhausted? I mean, are these - are there are people in these 12 states who aren't going to get the advantage of this benefit?

EMANUEL: First of all, that 3 to 4 million people who could be eligible if states expanded Medicaid is in addition to the 17 million who are eligible today throughout the country and through the states that did expand Medicaid. So that would be an additional amount.

CORNISH: So the number is a little worse than we thought.

EMANUEL: (Laughter) Well, yes, the numbers are a little worse. I mean, Congress has tried a lot of things to increase the appeal here or proposed a lot of things. The initial bill, the Affordable Care Act, is very appealing from a financial standpoint. This isn't about money; this is about ideology. All the analyses show that states are better off financially if they expand Medicaid. Money comes into the states. The states actually reduce their expenditures for uncovered people. The - hospitals actually make more money.

So this, again, isn't a financial decision by states. This is purely ideological. We're opposed to the ACA. We're not going to partake. And of course, it hurts the poorest people in America and, disproportionately, minorities. So trying to increase the appeal, adding more money, doing other things, I think is not - probably not going to get these states to change. What has made these states change is putting the question of expanding Medicaid on the ballot. Every state that has had it on the ballot - deep-red states like Idaho, Nebraska, Utah, have passed this. So people want the expanded Medicaid. It's just Republican politicians who don't want it.

CORNISH: In just our last moment, there are still people who can face high out-of-pocket costs. Some of that was alleviated with the subsidies, but this is still a problem. Is there going to be a formal policy approach to this?

EMANUEL: I think affordability is going to come back as a very, very big issue, even for the insured people in America, whether it's surprise medical billing, high drug costs, high hospital costs. And I think people are very, very worried about this. When COVID is under control towards the end of this year, I think affordability is going to rear its head and become a dominant issue for the American public. And I do think we need to tackle that. There are a variety of things that have to be done from, you know, limiting drug costs to changing how we pay hospitals and doctors to lower the costs and the impact on people. So I do think it's a major unsolved issue that has to get some attention.

CORNISH: That's Dr. Zeke Emanuel, currently vice provost for the University of Pennsylvania and writer of the Affordable Care Act law. Thanks so much for your time.

EMANUEL: Thank you, Audie. Transcript provided by NPR, Copyright NPR.

Over two decades of journalism, Audie Cornish has become a recognized and trusted voice on the airwaves as co-host of NPR's flagship news program, All Things Considered.
Justine Kenin
Justine Kenin is an editor on All Things Considered. She joined NPR in 1999 as an intern. Nothing makes her happier than getting a book in the right reader's hands – most especially her own.
Jonaki Mehta
Jonaki Mehta is a producer for All Things Considered. Before ATC, she worked at Neon Hum Media where she produced a documentary series and talk show. Prior to that, Mehta was a producer at Member station KPCC and director/associate producer at Marketplace Morning Report, where she helped shape the morning's business news.