David Remnick and Atul Gawande Discuss the Problems of Repealing Obamacare

Summary

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Podcast Summary

The Political Scene | The New Yorker

Episode: David Remnick and Atul Gawande Discuss the Problems of Repealing Obamacare
Date: February 6, 2017
Host: David Remnick
Guest: Atul Gawande

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Brief Overview

This episode features a conversation between The New Yorker’s editor David Remnick and renowned surgeon-writer Atul Gawande. Together, they explore the potential consequences of repealing the Affordable Care Act (ACA), the ongoing political battles over American health care reform, and the overlooked value of primary care. Gawande offers a candid, expert perspective on what works, what doesn't, and what's at stake for millions of Americans if major changes are made to the health coverage landscape.

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Key Discussion Points & Insights

1. The Undervalued Role of Primary Care

• Gawande explains why primary care has traditionally been seen as less “heroic” than specialties like surgery.
  • “I like problems you can solve in three or four hours, not in a lifetime.” (Gawande, 02:32)
• Shift in perspective: Primary care’s importance has only recently been scientifically demonstrated.
  • “It's only been in the last decade or so that it's been demonstrated that having a regular source of care...added years to your life and health in a way that simply seeing the best possible specialist...was not generating.” (Gawande, 03:31)
• Personal connection: Gawande describes his son’s lifelong medical journey as illustrating the crucial, often underappreciated, work of primary and ongoing specialist care vs. one-time surgical “rescues.”
  • "His cardiologist and the physician assistant who works with her have been paid a fraction of what that cardiac team...but they have been equally important, in many ways absolutely essential.” (Gawande, 04:23)

2. America’s Unequal Access and the ACA’s Impact

• Remnick observes: Most Americans lack continuous, informed health care; only a privileged few have reliable primary care.
  • “Very, very few people have a doctor like that or a medical circumstance like that.” (Remnick, 05:15)
• Gawande responds: The disparity is most pronounced in conservative states that rejected Medicaid expansion under the ACA, leaving millions without access.
  • “We have 19 states where the Affordable Care Act was not accepted...so you have 15, 20, 25% of the population...who do not have regular access to care.” (Gawande, 06:08)

3. Flaws of Obamacare and Dangers of Repeal

• Acknowledged shortcomings: Obamacare left millions uncovered and many plans are still too expensive for low-income Americans.
  • “43% of people who got a health plan on the exchanges under Obamacare have a $2,500 deductible or more and often can't afford to pay that deductible. So the subsidies aren't that generous.” (Gawande, 07:35)
• Criticism of Republicans: Many flaws existed because of conservative pressure to keep subsidies low.
• Warning: Simple repeal without replacement could collapse insurance markets and drastically increase the uninsured population.
  • “If they repeal without replacing or promising that the replacement will come, the danger is that the insurance market that we've got or the subsidies that we have...could collapse.” (Gawande, 08:28)

4. The Politics Behind Health Care Reform

• Not just about values, but about cost and who pays.
  • “The political battle is over who's going to pay for it and how. And Obamacare, at the end of the day, was a tax increase. It was a significant tax increase on the wealthiest part of the spectrum in order to pay for health care that ended up guaranteeing coverage.” (Gawande, 09:55)
• Identifies clear winners and losers: Those who gained coverage and security vs. high-income earners who paid more in taxes.

5. Pre-existing Conditions, Risk Pools & Policy Proposals

• Nearly everyone has or will have a pre-existing condition – it's part of being human.
  • “All of us, in a sense, have a preexisting condition. It's called being alive. It's called facing mortality.” (Remnick, 10:46)
• Discussion of ‘risk pools’ and why current models have failed—often expensive, capped, and exclusionary.
  • “The risk pools that we've had at the state level...often have a six month period of pre existing condition exclusions themselves. They have caps as low as $75,000...they have very steep premiums.” (Gawande, 12:33)
• Practical alternative: Expand Medicaid or Medicare for the sickest, instead of creating new, imperfect risk pools.

6. The Trump Factor and the Uncertain Future

• Gawande expresses deep uncertainty about the Trump administration’s next steps:
  • “Trump is so unpredictable. Basically, the existence of Trump as a decision maker...has widened the range of possible outcomes, outcomes that could have tremendous damage and really roll back gains that have appeared.” (Gawande, 13:19)
• Potential irony: In seeking “repeal,” conservative states might expand coverage if granted flexibility and federal funds under a new guise.
  • “One of those outcomes could, weirdly enough, be that there is an increase in coverage because conservative governors start opening the gates to letting people have coverage paid for by the federal government.” (Gawande, 14:16)

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Notable Quotes & Memorable Moments

• On the value of incremental care:
  “The heroism of incremental care is really clear in my son's life.” (Gawande, 03:43)
• On universal vulnerability:
  “All of us, in a sense, have a preexisting condition. It's called being alive.” (Remnick, 10:46)
• On political gamesmanship:
  “It's politics less than values.” (Gawande, 09:55)
• On the unpredictability of Trump policy:
  “The existence of Trump as a decision maker...has widened the range of possible outcomes.” (Gawande, 13:19)

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Timestamps for Major Segments

• [01:17] Podcast introduction and guest bio
• [02:32] Gawande discusses why he became a surgeon and undervaluation of primary care
• [03:31] Shift in primary care’s perceived value; personal health story about his son
• [05:15] Remnick on privileged access to regular care; Gawande on national disparities
• [07:10] Assessment of Obamacare, its flaws, and risks of repeal
• [09:35] The political battleground and the underlying reasons for gridlock
• [11:06] The debate over pre-existing conditions, risk pools, and policy failures
• [13:19] Outlook for health care under Trump, unpredictable outcomes, and possible scenarios

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Conclusion

This episode delivers an accessible, deeply informed discussion on the precarious state of American health care and health reform policy. Gawande and Remnick provide insights into what’s been achieved under the Affordable Care Act, why so many people remain uninsured, the political and practical obstacles to universal coverage, and what’s at risk in the uncertain political landscape of 2017. The conversation balances policy analysis, grounded examples, and personal narrative, making it essential listening for anyone interested in the real-world stakes of the ongoing health care debate.

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Transcript

[A]

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[B]

I'm David Remnick and on today's Politics and More podcast I talk with the writer and surgeon Atul Gawande. Gawande worries that the repeal of the Affordable Care act will lead to a decline in patients seeking primary care and a rise in preventable deaths. Atul Gawande is a practicing surgeon who also writes about medicine for the New Yorker, and his articles have legs. A 2009 piece he wrote about the out of control cost of health care was cited by President Obama while he was making the push for the ACA and passed around the West Wing. So Atul is concerned about the repeal of the law and in particular what happens if insurers can once again deny coverage of pre existing conditions. He wrote about that recently in a piece called the Heroism of Incremental Care. You grew up in a family of doctors. Your parents were specialists, a pediatrician and a urologist, and you grew up with this all around you. And you yourself became a surgeon. I'd love to know why, since this piece kind of valorizes primary care doctors. I wonder why you decided to Become a surgeon. And your parents were specialists, of course.

[C]

Well, it was. There were a couple reasons. Number one was, I think it suits my personality. I like problems you can solve in three or four hours, not in a lifetime.

[B]

When you were coming up as a doctor, was primary care considered kind of a dull thing, an ineffective thing?

[C]

Oh, yeah. Like, you know, all of the pressure was, you know, if you're smart, you know, how could you go into primary care? And at the time I was going through medical school, it was so easy to see what the impact was of surgery. Like, you go in an operating room, you see people save a life. And you said, wow, I want to be part of that.

[B]

So when was the inflection point? When was the moment at which primary care became something absolutely essential? You call it the heroism of incremental care. But was there a moment in time when things flipped?

[C]

Well, I would say we're kind of in the middle of that time now. It's only been in the last decade or so that it's been demonstrated that having a regular source of, of care from a clinician who knows you added years to your life and health in a way that simply seeing the best possible specialist you could find was not generating that. My son is an example. I tell the story of Walker, who has a congenital heart disease, a complex congenital heart disease. And the critical person in his life is his cardiologist. You know, he was saved by heroic rescue medicine when he, in 11 days of life went into congestive heart failure. We didn't know why.

[B]

How old is he now, Atul?

[C]

And now he's 21 years old.

[B]

Yeah. Amazing.

[C]

And he was rescued and saved on that in those first two weeks from complete organ shutdown, artificial arch of his aorta reconstructed, and open heart surgery. But then the next 21 years has been all about getting. Controlling his blood pressure, being able to address some learning issues that come along with this condition, being able to monitor and catch when the repair now was becoming too small for his 6 foot 1 inch tall body. And you know, his cardiologist and the physician assistant who works with her have been paid a fraction of what that cardiac team who worked for a few days to save his life. But they have been equally important in many ways absolutely essential to his realizing the value of all of that heroic work done at 11 days of age.

[B]

So I'm lucky. I have a doctor I see once a year, if not more often, have all the normal tests, EKG and all the pleasant and unpleasant tests that come with it. And then afterwards he takes me into the office and we go through all the major things that can go wrong. And he sort of assures me that I'm doing the right thing in terms of exercise or a statin or whatever it is, all through the list. And if I'm lucky, I leave the office singing a happy tune. But I know in my heart in this very big country that very, very few people have a doctor like that or a medical circumstance like that. What is the range of circumstances out there in the country in terms of people seeing their doctors, not having access to doctors, costs? What are the big things that are the barriers to the circumstances that you're hoping for in your article and beyond?

[C]

Well, this is where I think it's so important, because most people do not have a regular source of care from someone who knows them. And there are a variety of reasons for that. One of them has to do with the very issues we're debating right now around our national healthcare debate. We have 19 states where the Affordable Care act was not accepted by those states, by conservative states. And so you have 15, 20, 25% of the population there who do not have regular access to care. And one of the first things that people drop when they're short of money is having your regular clinician appointments and a routine relationship with a clinician goes out the window. You wait until the very last minute, until it's an absolute emergency, until you can avoid it, and that's when things are often out of control. And then that's where you have, you know, major reduction in life expectancy and in health.

[B]

Now, I think we've been very disciplined, and we haven't mentioned the name Donald Trump, not once in this conversation yet. But that's about to end right now. The president, President Trump, declared that he was going to make good on his promise to repeal and replace. What were the flaws in your view of Obamacare and what is your concern about what's happening now in Congress, in the White House?

[C]

Well, the flaws. And the Republicans have hit on it, and they're not wrong about these flaws. Mitch McConnell pointed out, well, for all the 30 million who gained coverage, there's still 25 million who still don't have health care coverage. Number two, 43% of people who got a health plan on the exchanges under Obamacare have a $2,500 deductible or more and often can't afford to pay that deductible. So the subsidies aren't that generous. And so they're not wrong about those criticisms. The problem is the Conservatives in the negotiations with the Democrats pushed hard to keep those subsidies low. It was conservative states that refused to accept subsidies. Obamacare. And now we've come out on the other side. I think it would clearly be a fantastic thing for the health of the country that we repair and supplement what's there. I can see readjusting. You can't get there. And also reduce taxes on everyone, which is the vow that Trump is making. He's promising everybody a magic bullet. And there are trade offs here. And in a grown up world, we, we work our way through figuring out the trade offs that we're willing to make and not willing to make. And this is so crucially important because if they repeal without replacing or promising that the replacement will come, the danger is that the insurance market that we've got or the subsidies that we have for people could collapse.

[B]

Well, how is that not political suicide?

[C]

I think it is political suicide in that the expectation of people, whether it's focus group polls or just talking to people back in my hometown in Ohio, the expectation is Trump wouldn't do that. Trump would not make my situation worse.

[B]

Why can't we get this right? This is just an enormous problem. I don't imagine that conservatives don't share the value of having people be healthy in the country. Where is the great disconnect and why can't this be fixed more easily? Is it a matter of values politics? What is it?

[C]

I think it's politics less than values. The political battle is over who's going to pay for it and how. And Obamacare, at the end of the day, was a tax increase. It was a significant tax increase on the wealthiest part of the spectrum in order to pay for health care that ended up guaranteeing coverage and providing coverage for 30 million people. And that was a major political trade off. There were winners and losers. The winners were not only the 30 million people who got coverage, but everybody who might have a preexisting condition in their future that they had a system that they could turn to for care. But on the whole, those were the winners. And the losers were the people who paid the increased taxes, although they themselves were protected by this.

[B]

But you make the point that all of us, all of us in a sense, have a preexisting condition. It's called being alive. It's called facing mortality. If we can refer to one of your great books. And the conservatives have come up with this idea of risk pools. How does this work or not?

[C]

Right. So one of the things that you see conservatives trying to generate are alternatives to the ways that the current system that Obamacare has works for covering the people who have pre existing conditions. And you're absolutely right, that is increasingly all of us, because between genomics and new kinds of data, we can predict more and more who is going to have what kind of condition. The risk pool approach is to say, you know what, let's not require that insurers cover pre existing conditions and have an individual mandate, but instead say, look, if you keep your insurance coverage continually, then insurers have to cover your preexisting conditions. But if you have a gap in your coverage and you can't afford now the coverage of insurers who may raise your rates if you had a healthcare problem during that time, we'll create risk pools that'll pay for you. It's basically saying the government will take care of some of the sickest people in the system. And I don't think there's anything wrong with that. You know, 5% of the population accounts for 50% of the healthcare costs. And if you took the people who are chronically ill that the insurers are reluctant to cover and said, let's cover them through a government insurance pool, I think that actually could be a good thing. It would lower the insurance costs for other people. Here's where it goes wrong, is that the risk pools that we've had at the state level have been ones that often have a six month period of pre existing condition exclusions themselves. They have caps as low as $75,000 total. They have very steep premiums, usually up to 250% of what the regular costs are for anybody else. And so the result is people didn't often sign up for the coverage. Now imagine if we said, look, let's take these people who are high risk that are uninsurable in some sense, put them in Medicaid or Medicare.

[B]

Right.

[C]

That would be a way of putting them in a risk pool. And why create a whole new program when we have these other places to put them?

[B]

Do you have any optimism when it comes to health care and the Trump administration?

[C]

Well, two things. To me, Trump is so unpredictable. Basically, the existence of Trump as a decision maker is just, it's widened the range of possible outcomes, outcomes that could have tremendous damage and really roll back gains that have appeared. On the other hand, if there were a plan that passed, that was a quote unquote repeal, but it won't take action until we've replaced Obamacare and put that date off into the future, I could see that that could get passed and the reality is there is no agreement among conservatives about what replacement is. And so in the meantime, they'll sign lots of waivers to allow the 19 states with conservative governors who didn't take Obamacare to now accept the program. And you could, ironically, be in a situation where I said, again, there's a wide range of potential outcomes. One of those outcomes could, weirdly enough, be that there is an increase in coverage because conservative governors start opening the gates to letting people have coverage paid for by the federal government.

[B]

Atul, thank you so much.

[C]

Thank you. This is fun as much as it is painful.

[B]

All the best. That was Atul Gawande.

[D]

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[C]

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[D]

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[D]

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[B]

From.

[C]

Prx.