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Transcript: President Obama talks to Vox about Obamacare's future

President Barack Obama joined Vox’s Sarah Kliff and Ezra Klein on Friday for a wide-ranging discussion about the future of Obamacare.

A transcript of their conversation is below.

Sarah Kliff

There was an expectation shared among many of your staff — among many congressional Democrats — that as the Affordable Care Act was rolled out, as it delivered benefits to millions of people, that it would become more popular. That it would be safe from repeal and even substantial reform. That doesn’t appear at this point to be quite true.

What did the theory get wrong? Why didn’t the Affordable Care Act become more popular?

President Obama

Well, let’s back up and say that there’s a reason why, for 100 years, no president could get expansion of health care coverage beyond the work that had been done through 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 recognize the need for health insurance, but it’s not something they think about except for when things go wrong — you have an accident, or you’re sick. Any costs, particularly when families are feeling stressed economically — any added costs, higher premiums, higher copays — end up having real impacts on families.

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 third-party insurers. What that meant was that even after we had gotten 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’s something we recognized even when we were trying to get the law passed.

The other thing was the unwillingness of Republicans in Congress and around the country, including even some governors, to, after the fight was over, to say, “Okay, let’s try to make this work,” the way Democrats did when President Bush tried to expand the prescription drug program part D. It meant that the public never heard from those who had originally been opposed, any concession that this is doing some good. And that affects public opinion.

And the third thing is that the polls — whenever you look at polls showing 40 percent are supportive of the law, 40 percent or so are dissatisfied, in the dissatisfied column are a whole bunch of Bernie Sanders supporters who want a single-payer plan. The problem is not that they think it’s a failure. The problem is that they don’t think it went far enough. That it left too many people uncovered, the subsidies were not as rich as they should have been, that there was a way of dealing with prescription drug makers in a way that would drive down those costs. All of those things meant that even after the law was passed, there were still going to be a lot of tough politics.

Having said all of that, the thing 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 and extended the Medicare trust fund for 11 years — but most importantly for the people who have gotten insurance through the exchanges, there have been pretty high satisfaction rates, as surveys have shown.

Rather than looking at public opinion as a whole, how is this affecting families who have gotten benefits? These are real families getting real coverage. I get letters every day from people who say, “This has saved my life,” or, “This has saved my bank account,” or, “My son, who got hooked on some sort of opioid, has been able to get treatment,” or, “I was able to get a mammogram that caught a cancer in time.” That, ultimately, is the measure of the success of the law.

President Obama: “If it works, I’m for it”

President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017.
President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017.
Kainaz Amaria/Vox

Ezra Klein

Do you think this dynamic where if 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 at least he’s said that at certain points.

Do you think the dynamic in which you became responsible for what people didn’t like will hamper Republican efforts to change a system that maybe they don’t like?

President Obama

Let me start from a very simple premise: If it works, I’m for it.

If something can cover all Americans and make sure if they have a preexisting condition, they can still get coverage. Make sure prescription drugs are affordable. Encourage preventive measures to keep people healthy. Make 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 of that cheaper than we talked about, cheaper than Obamacare achieves, and with better quality and it’s just terrific — I’m for it.

Part of the challenge in this whole debate — and this is true dating back to 2009 and back to 2010 — is this idea that somehow we had a fixed way of trying to fix the health care system, and 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 would have supported a single-payer system, because it’s easier for people to understand and manage. And that’s essentially what Medicare 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 how to access services.

But that wasn’t available. We weren’t starting from scratch. So what did I then do? We said, “What’s a system out there that seems to be providing coverage for everybody that politically we could get through a Congress which we can get Republican support?”

And lo and behold, there had been a plan in Massachusetts 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. I would have thought — since this was an idea that had previously gotten a lot of Republican support — it would continue to get a lot of Republican support. And yet magically, the minute we said, “This is a great idea and it’s working,” the Republicans said, “This is terrible, and we don’t want to do this.”

I say this, Ezra, to make something very clear. From the earliest negotiations in 2009 and 2010, I made it clear to Republicans that if they had ideas that they could show would work better than the ideas 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 to seven years, there was an argument that “we can provide a replacement that will be much better for everyone than what the Affordable Care Act is providing.” And yet over the last six to seven years, there’s been no actual replacement law that any credible health care policy experts have said in fact 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 now is the time when Republicans 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 or McConnellcare or Ryancare — if it actually works, I will be the first one to say, “Great; you should have told me that 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, there are certain baseline things you’ve got to do.

Number one: Health care is not cheap. And for those who can’t afford it or can’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 people can get health insurance even if they have a preexisting condition — it turns out the only way to meet that guarantee is to either make sure everyone has some modest obligation to get health care, so they’re not gaming the system, or you’ve got to provide huge subsidies to the insurance companies so they’re taking in people who are already sick.

And I think what you’re going to see now that we have a Republican president-elect, you have Republicans control both chambers in Congress — that all of the promises they made about how they can do it better, cheaper, and that everyone is going to be satisfied are going to be really hard to meet. This is why this 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 from people who say, “I’m terrified, because my son’s or daughter’s insurance, their ability to get life-saving 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, the Republicans need to put forward very specific ideas of 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 they can do it better, they shouldn’t be afraid to make that presentation. It is really interesting to figure out why they are trying to rush the repeal so quickly. 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.

They have said absolutely, adamantly, that they can do it better. I am saying to every Republican right now: “If you can in fact 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 —

Ezra Klein

We’d be happy to, yes —

President Obama

— to just evaluate. And the public will not have to take my word for it. We can designate some referees. And if they show they can do it better, cheaper, more effective, provide better coverage, why wouldn’t I be for it? The idea that this is somehow 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 toward me in their party as an organizing tool, as politics. But I don’t have 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’d advise every Democrat to be for it — but you have to show that it’s better. That’s not too much to ask. And that’s the challenge.

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’s going to replace it? Because the majority of Americans have been very clear that they think that’s a bad idea.

You now have Republican governors, and some Republican senators, who have said, “We don’t think that’s a good idea.” And there’s been no real explanation why you would actually do this before the new president is even inaugurated.

What actually is this rush? Particularly if you’re going to delay the actual repeal. If they were making the argument that this is so disastrous, we actually think we have to repeal it completely, today, because it’s just terrible, I’d disagree, but at least I could understand it.

But here, you’re saying, “We’re going to vote to repeal it, but we’re going to delay its effects for a couple of years.” But why, if it’s so bad? If the answer is, “Because it’d be disruptive, and we don’t want to take people’s insurance away right away,” that means you have time to show us — and, more importantly, show the American people who need health insurance — exactly what it is you’re replacing it with.

In that sense, Ezra, the answer is — I know that was a long answer here — 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 provides benefits to every American who has health insurance, even if they’re getting it through the job. And they haven’t shown us what 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’s an irresponsible thing to do.

What President Obama told Trump about replacing Obamacare

President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017. Kainaz Amaria/Vox

Sarah Kliff

Let me follow up on the congressional fight. Yesterday, President-elect Trump said on Twitter, “It’s time for Republicans and Democrats to get together and come up with a healthcare plan that really works.”

I remember you saying similar things in 2009 and 2010 when I was covering this debate. Knowing what you know now about partisanship — being a president who has tried to do this but been unable to get Republican votes — what three pieces of advice would you give to someone trying to pass a bipartisan health care law?

President Obama

Look, I think I sort of gave the advice just now. Which is: If in fact this is not about politics but 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 there are some things you think do. Republicans keep on saying, “We want to keep the things people like and are working well.” So they think it’s a good idea that Obamacare says kids can stay on your health insurance plan till you’re 26. They think that’s a good idea.

They think it’s a good idea that if you have 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 things that, as terrible as Obamacare is, they actually 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 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 that we would love to see even higher subsidies to relieve the costs even more. 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. One way we’ve suggested you 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 people are frustrated about with Obamacare, 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. I’m happy to provide both of those things. I’d sign on to a Republican plan that would say, “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 thing: I don’t think that’s something they’d want to do.

Sarah Kliff

I don’t think so, no.

President Obama

[Laughs] I guess my point is this: It is possible for people of goodwill to try and come up with significant improvements to the law we already have. But it does require being specific to what about the law you think needs to be changed. And that, so far, has not happened.

My advice to the president-elect — we talked about this when I met with him for an hour and a half 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 things better for people.” And if they’re convincing, I think there are a lot of Democrats out there — including me — who would support it.

Ezra Klein

I think Obamacare has exposed an interesting tension between controlling costs in the system and controlling economic pain for individuals.

The law has, until now, come under budget. But the way it’s done that is higher deductibles than people expected, higher copays, narrower networks; in a couple of years, the excise tax on high-value insurance will come into play, the individual mandate. These things to individual people while they keep the usage of health care down, they make health care feel more expensive and they make health care feel unusual.

Do you think the Affordable Care Act got the balance right between controlling system-wide costs and insulating individuals from their health expenses?

President Obama

First of all, let me make a couple of distinctions. Part of what happened at the beginning of the marketplaces — and for those who aren’t wonks, I was teasing Ezra and Sarah, I was saying that this is like a “wonkapalooza.” This is some serious policy detail.

The marketplaces are where the insurance companies put up the insurance package we’re offering. You can choose from a variety of different packages; once you’ve chosen, you can figure out the subsidies you’re qualified for, and it will give you a sense of your out-of-pocket costs.

What we discovered was that a lot of insurers underpriced, early on, because they had done surveys. And look, people purchasing health insurance are like everybody else — they want the best deal for the lowest price. What makes purchasing health insurance tricky is that when you buy a TV, you can kind of see what the picture looks like; when you’re buying health insurance, it’s tempting to buy the cheapest thing until, heaven forbid, you get sick and it turns out, gosh, I can’t see the doctor I want, or the specialist I want, or this is more inconvenient than I expected.

So what ended up happening was people bought, oftentimes, the cheapest insurance they could. Insurance companies wanting to get as much market share as possible ended up creating very low-cost plans. But those are going to have restrictions on them — that’s not just if you’re buying health insurance in Obamacare; that’s generally how it is even when employers buy health insurance for their employees.

Now, I think that what we’re seeing is insurers making adjustments, saying, “Okay, we need to charge more.” And that is something that, the good news is, appears to — may have stabilized might be kind of a one-time thing, and now we're in a position to be able to do an evaluation of have we gotten this balance right, as you say.

We can’t get health care for free. You’re going to have to pay for it one way or another. Either the government will pay more, so people don’t have as many out-of-pocket costs — and that means, in some fashion, higher taxes for somebody — or individuals will have to pay more out of pocket, in one way or another.

The same is true for employers. Either employers pay more for a really good health care package, but that takes something out of the employers’ bottom line, or they’re putting more onto the workers in the form of higher deductibles and higher copays.

And I think that a lot of the good work that can be done in lowering costs had to do not with cost shifting but with actually making the system work better. And we’ve done a lot of work on that. What I referred to earlier — incentivizing a system where instead of ordering five tests because doctors and providers are getting paid for the test, you now have a system where you’re going to get reimbursed if the person gets healthy quicker and doesn’t return to the hospital. Well, it turns out that that can, over time, be a real cost reduction.

Those are the kinds of things we’re implementing in the system as a result of Obamacare. The more we do that kind of stuff, the less we’re going to see this cost shifting. But the intention has never been: Let’s make it more expensive for people to get health care, so they can access the system more. And I think the proof of that is that even though per-person costs have not gone up a lot, the overall spending on health care has, because more people have come into the system. We want people to use the health care system — just not in the emergency room. We want people to stay healthy, and smoking cessation plans, and making sure they’re getting regular check-ups, and mammograms — those are the things that will save us as much money as we can.

What does Obama think should be done to control prices?

President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017. Kainaz Amaria/Vox

Sarah Kliff

I have a wonky follow-up question.

President Obama

There you go.

Sarah Kliff

What about controlling prices? We have some of the highest health care prices in the world — most other developed countries regulate how much you can charge for an emergency room visit, for an MRI, for an appendectomy. That seems like it’s at the core of this tension, the fact that we have these very high prices.

That’s something the health care law did not tackle. And I'm curious to hear you reflect on that and what you would think about the role of price controls in American medicine.

President Obama

Look, this is the irony of this whole debate. About the Affordable Care Act — things that essentially in other countries are solved by more government control, not less.

So Republicans are pointing at these things to stir up dissatisfaction, and when it comes to the solution, their answer is less government regulation and letting folks charge even more and do what they want and letting the marketplace work its will.

There are strengths to our system because we have a more market-based system. Our health care system is more innovative. Prescription drugs is the best example of this. It is true that we essentially come up with the new drugs in this country because our drug companies are fat and wealthy enough that they can invest in the research and development. They make bigger profits, which they can plow back into drug development. And we have a lot of other countries that are free riders on that system. So they can negotiate with the drug companies and force much lower prices, but they don’t have a drug industry that develops new drugs.

That’s true. This is an example where you probably do want some balance to maintain innovation, but to have some tougher negotiations around the system as a whole. We are trying to use Medicare as the place where, since there’s no health care provider or stakeholder in the health care industry that doesn’t in some ways want to get Medicare business, we’re trying to use Medicare as a lever to get better deals for consumers — not just those in Medicare but people throughout the system.

But as I said, the irony is when we try to do that, the people who are most resistant are the very Republican members of Congress who are criticizing us or at least telling the American people that you should want lower prices on various procedures. If we want to control prices for consumers more, then the marketplace by itself will not do that.

The reason is because health care is not exactly like other products. It’s not like buying a flat-screen TV. If you’re sick or if your kid is sick, you’re not in a position to negotiate right then and there. You can’t walk out of the store if you can get a better deal. When Sasha got meningitis when she was 4 months old — make my child better, and that’s all, and I’ll worry about the cost later. That’s the mentality most people have when it comes to health care.

So the traditional models of the marketplace don’t work perfectly in the health care system. There are areas where we can increase market competition, there are ways we can make it work better, but ultimately, if we want to get at some of these costs, there has to be some more extensive regulation in certain areas than we currently have.

An Obamacare enrollment worker talks to Obama

President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017. Kainaz Amaria/Vox

Sarah Kliff

So I recently took a trip to an area of Kentucky — on a slightly different topic — I saw some huge coverage gains under the health care law, but also voted overwhelmingly for President-elect Trump. And one of the people I met there was Kathy Oller, who’s here with us today. She is an Obamacare enrollment worker who has signed up more than 1,000 people for coverage. She supported you in 2008 and 2012 but voted for President-elect Trump in 2016, and expects him to improve on the Affordable Care Act. And she would like to ask you a question about that.

President Obama

Go ahead, Kathy.

Kathy Oller

Hello, President Obama, I’m very excited to meet you.

President Obama

It's good to see you.

Kathy Oller

Thanks. I'm a little bit nervous, as you can see. But over the years, I’ve enrolled and talked to numerous Kentuckians and have signed up some the first time — so it was working --

But recently we found out there were fewer choices in our areas, and the increase in the premiums and deductibles — some of our facilities aren’t even taking them. Many Kentuckians are looking at the Affordable Care as unaffordable and unusable.

And I have the opportunity to ask you a few questions that you have probably went over, but how do you think this happened? How can we fix it? Do we start all over again? What do you think we should do?

President Obama

First of all, Kathy, I want to thank you for enrolling people — that’s been hugely important.

The second point I would make is that Kentucky is a place where this has really worked. And it’s worked for two reasons. One is that Kentucky expanded Medicaid. We haven’t talked about this, but a big part of Obamacare was just making Medicaid accessible to more people.

And those states that expanded Medicaid have seen a much bigger drop in the uninsured than those that didn’t. And, by the way, those that didn’t didn’t do so just out of politics. I’ll be very blunt. Because the federal government was going to pay for this Medicare expansion. And there are some states that because they had all this uncompensated care ended up making money by providing more insurance to your people.

It was a hard bargain, a hard deal to turn down. And yet you got a bunch of states that turned it down mainly because Republican governors and Republican state legislatures didn’t want to make it work. Kentucky, under Steve Beshear, was one of the places that did expand Medicaid, that had a really active program. Because I don’t poll that well in Kentucky, they didn’t call it Obamacare; they called it “Kentucky Connect.”

And so there were a whole lot of people who said, “I don’t like Obamacare, but I like —” and you signed people up; you didn’t tell them it was Obamacare all the time. And it’s actually worked. Right?

Now, what is true in Kentucky is true in some other states. You had a governor who ran explicitly on the idea of rolling back Obamacare, even though it was working. And so the state marketplace — the state exchange — he dismantled, which means we had to shift everything to do the federal exchange. Most people got shifted, but it indicated a lack of effort and interest on his part in making the thing work.

He promised to roll back Medicaid, but he started realizing that wasn’t as good politics when he started running, so he hasn’t done that.

But what is also true is — and this is my main criticism of Obamacare, of the Affordable Care Act — is that the subsidies aren’t as high as they probably should be for a lot of working people. If you don’t qualify for Medicaid where you don’t have to pay, for the most part, for your coverage, and instead you’re buying health insurance on the marketplace — so you’re a working person but you don’t have a lot of money, and particularly if you are older, where you use the health care system more and you need a better benefit package than somebody 18 or 20 might — then there are families where the premiums are still too high.

And as I said earlier, there are some parts of the country where there are only a handful of hospitals and a few doctors and where you don’t have a lot of competition. And the insurers are looking, saying, “We’re not going to make a lot of money there.” So you don’t have a lot of insurers in those areas.

So the two things we could do that would really make it work even better for people in Kentucky would be, number one, to provide more subsidies to folks who are working hard every day but still find the premiums — even with the subsidies — hard to meet.

And number two, we could have the public option for those communities where they’re not getting a lot of competition and Republicans aren’t coming in. The problem is that’s not what’s being proposed by Mitch McConnell, the senator from Kentucky.

Instead what he’s proposing, I gather, is that you’re going to repeal the law, then you’re going to come up with something. The way we’re paying for the subsidy is we’re taxing wealthier folks a little bit higher. So he wants to cut those taxes, and that money would be gone right away. And then he’s going to promise you, or the people you’ve been signing up, better health care. Except there won’t be any money to pay for it.

And nobody’s explained to me yet how that’s going to work. And that takes me back to the point I made earlier: If, in fact, the people you’ve been signing up and the folks in your communities are not fully satisfied with the benefits they’re getting now and are hopeful for something better, then at the very least you should be putting pressure on your members of Congress to say, “Show us exactly what the deal is going to be for us before you take away the deal we’ve already got.” Because the people you’ve signed up, they may not be exactly as happy as they’d like, but — tell me if I’m wrong — they like it better than not having any insurance at all.

Sarah Kliff

Some folks didn’t even have insurance.

President Obama

And some people didn’t have insurance. Because I get letters from folks who say, “For the first time in my life — I have had a bad hip for 15 years, and I’ve been pain-free for the first time because I finally got insurance.”

The answer is not for them not to have insurance. If we go to a system where they have to buy it on their own, they won’t have insurance, because they’ll have even less of a subsidy.

Ezra Klein

One thing we haven’t touched on yet are the delivery system reforms, which are a big part of the law. What’s an experiment or change that has overperformed your expectation, and what hasn’t panned out as you’d hoped?

President Obama

One that’s worked better than we’d expected — or at least as well as we’d expected —was the issue of hospital readmissions. Now, it turns out that a lot of times you go to the hospital, let’s say you get your appendix taken out. Then you go home and there’s a complication, and you have to go back to the hospital. That’s inconvenient for you and expensive for the system as a whole.

And there’s a few things you can do to help reduce people being readmitted. First, make sure the procedure go well. And secondly, make sure there’s good follow-up. So it might that be a hospital or a health care system pays for, when you do get home, you just getting some phone calls to remind you to take the medicine that you got to take to make sure you heal properly — because they may have done a study and it turns out that people forget to do what they're supposed to do, they don’t follow exactly their doctor's instructions, and they can't afford to have a nurse in their house who's doing it for them.

Well, maybe there are just a few things that can be done to help make sure that they do what they are supposed to do, and that way they don’t have complications.

What we've seen is a significant reduction in hospital readmissions over the course of this law just by doing some smart incentivizing, just saying to the hospitals, “We'll reimburse you,” or, “We'll give you some other benefit for doing smart follow-up.” That's an area where I think we've made some real progress.

The other place, and this is connected, where I think we've got some good bipartisan support is just encouraging what's called what’s called — shifting from fee-for-service payments, where you get paid by the procedure. Which means that you may end up getting five tests instead of one test emailed to five providers who are treating you. And we’ve started to see some real movement when we say to the system as a whole, “We’re going to pay you for outcomes.” Did the patient do well? And that has been helpful.

In terms of areas where we haven’t seen as much improvement as I’d like, one thing that comes to mind is on the electronic medical records. If you think about how wired and plugged in everyone is right now — you can basically do everything off your phone — the fact that there are still mountains of paperwork and you don’t understand what these bills are that get sent to your house. And the doctors still have to input stuff and the nurses are spending all their time on the administrative work.

We put a big slug of money to encouraging everyone to digitalize and catch up with the rest of the world here. And it’s proven to be harder than we expected, partly because everyone has different systems, they don’t all talk to each other, it requires retraining people in how to use them effectively, and I’m optimistic that over time it’s inevitable it’s going to get better because every other part of our lives, it’s become paperless.

But it’s a lot slower than I would have expected; some of it has to do with the fact that it’s decentralized and everyone has different systems. In some cases, you have economic incentives against making the system better; you have service providers — people make money on keeping people’s medical records — so making it easier for everyone to access medical records means that there’s some folks who could lose business. And that’s turned out to be more complicated than I expected.

Sarah Kliff

Do you have any closing remarks? One thing I’m interested in is how you see your role moving forward.

President Obama

I think it is important to remember that just because people campaigned on repealing this law, it is a much more complicated process to repeal this law than I think was being presented on the campaign trail, as my Republican friends are discovering.

The way this process is going to work — there’s this rushed vote that’s taking place this week, next week, to “repeal Obamacare.” But all that is is a resolution that is then instructing these committees in Congress to start actually drafting a law that would specifically say what’s being repealed and what’s not. And after that, they’d have to make a decision about what’s going to replace it. And how long is that going to take?

And that stretches the process out further. Whether you originally supported Obamacare or you didn’t, whether you like me or you don’t, the one thing I’d ask the American people to do is adopt the slogan of the great state of Missouri: Show me.

Show me. Do not rush this process. And to Republicans I would say: What are you scared of? If you are absolutely convinced — as you have been adamant about for the last seven years — that you can come up with something better, go ahead and come up with it. I’ll even cut you some slack for the fact that you’ve been saying you could come up with something better for seven years, and I’ve never seen it.

But we’ll restart the clock. It’s interesting we’re in Blair House, because this is where I met in front of the American people with Republicans who had already indicated their adamant opposition to health care. And I sat with them for a couple of hours — eight hours. Kathleen Sebelius, my secretary of health and human services, remembers, on live TV, to talk about here’s why what we’re trying to do here, and challenging them to try and come up with better answers than what we’d come up with.

And I would think that given that we now have proof that 20 million people do have health insurance, that we're at the lowest rate of uninsured in our history, that health care costs, rather than spiking way up, have actually gone up slower than they have in 50 years; given that the vast majority of people who get health insurance through Obamacare have said they're satisfied with their care and that they're better off than when they didn’t have care; given that even though a lot of people don’t know it, even if you're not getting health insurance through Obamacare, you've benefited, because if you get health insurance on the job, it now doesn’t have a lifetime limit, it doesn’t have fine print that could end up costing you a lot of money — given all those things, I would think that you'd at least want to explain to the American people what it is that you want to do.

And that I think is a minimum expectation out of this Congress and out of the president-elect.

I’ll make a second point. We just worked on a bipartisan basis to sign something called the Cures bill that included two really important bipartisan priorities — one was Joe Biden’s cancer moonshot initiative, because we’re seeing so many breakthroughs in so many areas that we have an opportunity to make a real dent with cancer, which affects everybody in some fashion. Somebody’s been touched in your family with this terrible disease. We got a lot more money for researching that, and the bill also contained a big investment in the opioid challenge. As many of you know, we’re seeing more and more communities being ravaged initially by prescription drugs, and that ends up being a gateway to heroin, some of which — like synthetic heroin being produced like fentanyl — has terrible rates of overdose death. This is not an inner-city problem, per se, but it’s reaching every community and is in some way worse in a lot of rural communities. There was a bipartisan effort to put more money into that.

But here’s the thing. If we just put more money into cancer research and into dealing with the opioid crisis, and now we’re taking away money providing drug treatment services in those very same communities by repealing Obamacare and taking away the ability to access a doctor to get new cancer treatments, then we’re not really helping anybody. So that’s a second point I want to make.

A third point I want to make is I want to encourage local communities to get involved in this process. Part of the problem with this whole law is that the people who benefit aren’t out there making noise; the people who ideologically oppose it have been very loud. And now’s the time for people who have benefited or have seen their families benefit to tell their stories. Because ultimately, this is not a political game. This is really something that affects people in the most personal ways.

My friend Natoma Canfield in the front row. Some of you heard her story before — where a cancer survivor because she had a preexisting condition was faced with either keeping her health insurance at such a high rate the only way to get it was to pay so much that she couldn’t afford the mortgage on her house. I remember her writing to me. I thought, “That could be my mom; that could be yours.” And that’s not a choice people should have to make.

And when most people, even if they’re not Obama supporters, hear Natoma’s story or the stories of other people who have been helped, they know it’s wrong to just take away their health care. It becomes less about who is winning here in Washington but about how we’re doing right by our fellow Americans.

But those stories have to be heard. And I would just encourage people to start telling their stories, and to tell their stories — you won’t always get a lot of attention here in Washington, because they want to know about “this vote” or who insulted who back and forth between whoever. But tell that story in your local newspapers; talk to your local reporters, congregations that are involved in caring for those in need. Make sure you’re telling stories in church and in services so people know.

Because the one thing that I’m convinced about is that the American people want to do the right thing. It’s hard to get good information unless you’re reading Vox every day, which is hard to do.

Ezra Klein

It’s not that hard to do.

President Obama

Yeah. Getting the details of all this policy is hard. It’s complicated. You don’t know what’s true, what’s not true. Those folks in Kentucky that you’ve signed up. There are a lot of people who voted for not just president but also a member of Congress who said, explicitly, “We’ll eliminate this.”

I understand why people might think, “Okay, he’ll eliminate this, but he’ll give us something better.” But this is hard. And you don’t want a situation where they make a promise that they can’t keep. I worked on this a long time — if we had a better way to do this, we would’ve done it.

It would have been in my interest to do it. Because I knew I was going to be judged by whether or not it worked. And those areas that don’t work had to do with they’re not getting enough money in the system and not having a public option. I’m more than happy to put those options in place, anytime, anyplace. But that’s not, so far, what the Republicans are proposing. You deserve to know what it is that they’re doing.

On how Obama sees his future role defending Obamacare

President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017. Kainaz Amaria/Vox

Ezra Klein

Sarah asked about your role going forward.

President Obama

Well, look I do deserve a little sleep. And I’ve got to take Michelle on a vacation. I’ve said consistently that the most important office in a democracy is the role of a citizen. I will still be a citizen who remembers what it was like when his mom died of cancer younger than I am now, and who didn’t have all the insurance and disability insurance and wasn’t using the health care system enough to have early detection that might have prevented her from passing away.

Michelle’s dad had multiple sclerosis, MS, but was part of that generation that didn’t have a lot of expectations about health care so just suffered for years. Those are our stories, so it’s not like I’m going to suddenly fade away on this. I will be part of the work of our fellow citizens in trying to make sure the wealthiest country on Earth is able to do the same thing every other advanced country is able to do. It’s not as if this has never been done before. If you’re in Canada, you got health care. No matter who you are. If you’re in France, you got health care. IF you’re in England, you’ve got health care. If you’re in New Zealand, you’ve got health care.

I remember talking to my friend John Key, who was the prime minister of New Zealand. He is part of the conservative party in New Zealand, and he said to me in the middle of this health care debate, “If I proposed we took away people’s health care, that we repeal it, I’d be run out of office by my own party.” Because it was just assumed in a country this wealthy that this was one of the basic rights — not privileges — of citizenship in a well-to-do country like ours.

So I’ll be working with all of you. But my voice will be less important than the voices of those who will be directly affected. So I would urge everyone to make your voice heard. Now is the time to do it. The people who opposed it were opposing this not based on facts but on an ideological concern about expansion of the state and taxes on wealthier people that are helping people who don’t have as much money. I respect their role in the democracy; they’ve been fighting hard. Folks here have to fight just as hard.

My final piece of advice would be to the news media. Generally speaking, when Obamacare has worked well, it wasn’t attributed to Obamacare. And when there were problems, they got front-page headlines. Hopefully now is the time — this doesn’t apply to Vox, by the way — but I think it’d be a good time for people to be a little more measured and take a look at the facts of this thing, because stakes are high even on this whole premium increase issue right before the election.

It is true that insurers adjusted and hiked premiums. But I kept on trying to explain, “One, if you’re getting a tax subsidy, this isn’t affecting your out-of-pocket costs,” but nobody heard that. And, number two, these premiums only apply to people buying people on the exchanges — 85 percent of the people don’t get health insurance through Obamacare. And for you, your premiums have actually gone up a lot less since Obamacare was passed than before Obamacare was passed. The average family has probably saved about $3,000 in lower health care premiums than if you’d see those health care cost trends increase at the rate before the law was passed.

I didn’t see a lot of headlines about that, which I understand because it’s not controversial enough or a little too complicated to get in a sound bite. That’s why individual voices are so important, and I’m so appreciative of journalists who actually know what they’re talking about.

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