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Affordable Care Act Architect On The New Republican Plan


We've reached an architect of the Affordable Care Act, the health insurance law that Republicans now want to replace. Jonathan Gruber is his name. He's an economist at MIT. And before Obamacare, he helped to design a similar Massachusetts health insurance plan championed by Republican Mitt Romney. Mr. Gruber, welcome to the program.

JONATHAN GRUBER: Good to be here, Steve.

INSKEEP: So some people have derided actually on the right the Republican replacement as Obamacare light. How close is it to Obamacare?

GRUBER: I kind of prefer what Paul Krugman called it - Obamacare 0.5 because...

INSKEEP: (Laughter) You mean like half of Obamacare, less than Obamacare?

GRUBER: Exactly. Because light implies it has good features, like it's low-calorie - 0.5 is better. It's just worse on every dimension. There's really no point to this effort. What it does is it cuts help for the poor by replacing income-based tax credits, which make health insurance affordable, with flat tax credits, which make health insurance unaffordable.

INSKEEP: Oh, based on your age, you get a higher credit as you go up.

GRUBER: Exactly, but barely higher. So by one analysis, by the year 2020, those age 50 to 64 on average will pay $10,000 more a year for health insurance as a result of this law, this proposal.

INSKEEP: Let me just underline this. You're correct. We're talking here about getting tax credits of $2,000 to $4,000, depending on who you are. And health insurance can often be more expensive than that. So some people would have difficulty, according to numerous studies, in paying. But let me just ask, if you fiddle with the numbers a little bit, can the basic concept work? You buy your health insurance on the free market. The government gives you a tax credit to cover part of the cost.

GRUBER: Gee, that sounds a lot like Obamacare. That's exactly what Obamacare is. You buy your insurance through these exchanges. The government gives you tax credit. What is this proposal changing? It's saying instead of a tax credit, which caps as a share of income - what it costs you to make it affordable - it gives you tax credit that's a flat amount. So just to be clear, a 59-year-old for whom insurance costs $10,000 a year gets a thousand dollars more than a 39-year-old for whom insurance costs $4,000 a year.

So suddenly you've got health insurance which is unaffordable for the old and the poor. And you get a small tax cut for the middle class in return.

INSKEEP: Let me get you to address some of the things that Republicans are saying about Obamacare. There are key phrases they use again and again in interviews on this program and elsewhere. They say that Obamacare is failing, that it's collapsing of its own weight, that insurance providers are pulling out, that in many counties and different states across the country there are very few insurance providers available on the exchanges, maybe even just one. Is it correct that Obamacare has to be replaced with something to avoid a disaster?

GRUBER: No, that's not correct. Obamacare actually is working very well, in particular in the states that have actually done what the law says to do. In the states that have expanded their Medicaid program, therefore providing free insurance for the poor and pulling many sick people out of the insurance pool, and which have actually encouraged enrollment, rather than as many states have discouraging enrollment in the exchanges, premiums are growing. They're still growing. Health care costs always grow.

INSKEEP: Yeah. They're going up.

GRUBER: But they're growing more slowly than they were before the law passed. So the law is actually working as designed in those states that actually implemented it as designed.

INSKEEP: Is there a long-term danger for the government if Obamacare stays in place? Because those health care subsidies do keep going up. As premiums keep going up, it costs more to the government.

GRUBER: Actually, the opposite - if you look at the Congressional Budget Office score, the nonpartisan Congressional Budget Office, Obamacare not only reduces the deficit, but it does so increasingly over time because Obamacare, unlike previous health care proposals, was budget neutral or actually deficit-reducing. It was designed as a balance mechanism to not only provide health care for millions of Americans but to do so in a fiscally responsible way.

So once again, why - what's the point of this alternative? This alternative is going to cover fewer people, make poor people pay more and likely increase the deficit over time, all just to give a tax break to the rich.

INSKEEP: In a few seconds, if you had to change one thing about Obamacare, what would it be?

GRUBER: If I'd change one thing about Obamacare, it would be actually changing the law so states had to actually enforce it as it was designed, expanding their Medicaid programs to give health insurance to the neediest and actually encouraging healthy people to sign up for the exchanges, rather than discouraging them.

INSKEEP: Hey, Jonathan Gruber, thanks very much, really appreciate it.

GRUBER: My pleasure.

INSKEEP: He is an economist at MIT specializing in health care and one of the architects of President Obama's Affordable Care Act, which Republicans are now debating replacing. Transcript provided by NPR, Copyright NPR.