This morning, the U.S. Supreme Court largely upheld the Patient Protection and Affordable Care Act. Now, local and state officials are scrambling to digest the ruling and comply with upcoming deadlines. Maryland and the District have already spent millions setting up the insurance exchanges mandated by the law. Virginia, which challenged the law in federal court, will have to accelerate preparations. We get local reactions to the Supreme Court ruling.


  • Donald Kettl Dean, School of Public Policy, University of Maryland; nonresident senior fellow, Brookings Institution
  • Alan Weil Executive Director, The National Academy for State Health Policy (NASHP)
  • Douglas Gansler Maryland Attorney General (D)
  • Mohammad Akhter Director, DC Department of Health
  • Andy Harris Member, U.S. House of Representatives (R-MD, 1st District)

Related Video

Rep. Andy Harris (R-MD) responded to a caller’s question about whether there is real potential for a repeal of the Affordable Care Act. Harris said the law would be repealed if presumptive Republican presidential nominee Mitt Romney wins the election and if Republicans gain a simple majority in the House of Representatives in November. Maryland Attorney General Douglas Gansler said Republicans are in a “political conundrum” because Americans will have had more exposure to the law by 2013, making it more difficult for them to repeal the measure.

Supreme Court Decision On Health Care Reform

The full text of the Supreme Court opinion in National Federation of Independent Business et al. vs. Sebelius, Secretary of Health and Human Services et al.:


  • 12:06:42

    MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Health care reform has survived its test at the Supreme Court. Now, officials from around our region are scrambling to figure out what comes next. By any standard, the Patient Protection and Affordable Care Act of 2010 was a sweeping piece of legislation. It expanded health safety nets, established health exchanges, eliminated lifetime caps and most controversially imposes an individual mandate.

  • 12:07:23

    MR. KOJO NNAMDIThis morning, the Supreme Court weighed in, largely upholding the law and the idea of an individual mandate. Now, local political leaders and state health officials are facing a daunting and fast-approaching deadline. State health exchanges must be up and running by Oct. 1, 2013. Joining us now in studio to discuss this is Douglas Gansler. He is the Maryland attorney general. Doug Gansler, thank you so much for joining us.

  • 12:07:50

    ATTY. GEN. DOUGLAS GANSLERThanks for having me.

  • 12:07:51

    NNAMDIAlso with us is Mohammad Akhter, director of the D.C. Department of Health. Dr. Akhter, good to see again.

  • 12:07:58

    DR. MOHAMMAD AKHTERThank you. Good to be here.

  • 12:08:00

    NNAMDIAlso in studio with us is Donald Kettl, dean of the School of Public Policy at the University of Maryland, a nonresident senior fellow at the Brookings Institution. Don Kettl, thank you for joining us.

  • 12:08:09

    DR. DONALD KETTLGreat to be with you, Kojo.

  • 12:08:11

    NNAMDI800-433-8850 is the number to call. If you would like to join the conversation, 800-433-8850. Joining us by phone is Alan Weil, executive director of the National Academy for State Health Policy. Alan Weil, thank you for joining us.

  • 12:08:27

    MR. ALAN WEILMy pleasure.

  • 12:08:28

    NNAMDIAnd at some point during the course of this conversation, we know that President Obama will be making a statement on the Supreme Court upholding the law, and at that point, we will be breaking, going to NPR News so that you can hear what the president has to say. But here is what we know: The individual mandate has survived but not under the Commerce Clause.

  • 12:08:48

    NNAMDIThe majority said it could stand up under taxing power. The court has also ruled that the expansion of Medicaid, the program for low-income Americans can proceed, but it ruled that the federal government cannot withhold funds to states that do not follow their desired policies. Doug Gansler, I'd like to hear first your reaction.

  • 12:09:09

    GANSLERWell, I think it's obviously a good thing for Americans. I mean, the whole idea here was to increase the number of people who are covered -- that actually have health insurance and decrease the costs. What we -- what you constantly hear, I imagine, when we get to our callers on this show is there will be a blurring of whether or not the Affordable Care Act is actually a good thing or a bad thing to achieve those goals versus what is the law.

  • 12:09:35

    GANSLERAnd what the Supreme Court decided here was that under the law -- and I don't think most Americans care whether they decided under the Commerce Clause or the Tax Clause. What they decided that is that the Affordable Care Act is indeed constitutional, and it will go forward. So I think we have to parse out what the Supreme Court decided today versus whether or not the Affordable Care Act is a good thing or a bad thing.

  • 12:09:58

    GANSLERI think what happens next is in Maryland we've been going forward, assuming this was going to happen from the beginning. I actually had been talking about it over recent weeks. I thought it was going to 6-to-3, not 5-to-4. I did think Chief Justice Roberts was going to write the opinion. But be that as it may, we've been setting up, getting ready for the exchanges, get it -- we're very far ahead of the curve.

  • 12:10:18

    GANSLERWe've spent about $34 million in federal funds to get ourselves ready for the implementation of the Affordable Care Act. And it's going to be a good thing for Marylanders. It's going to bring down costs of health care, and it's going to help us with our hospital basic costs as well.

  • 12:10:33

    NNAMDIMohammad Akhter, does this make life a little easier or a little more difficult for you?

  • 12:10:38

    AKHTERWell, we are delighted with the decision of the Supreme Court. You know, if there's a victory, it's victory for the American people. Certainly, it helps the city a great deal. The Gray administration has been in the forefront of implementing health care reforms. We are number two in the nation. Ninety-six percent of our children and 93 percent of our adult already have health insurance. We want to make sure we continue this progress to make affordable care available to all our citizens.

  • 12:11:06

    NNAMDIAlan Weil, could you give us a kind of survey of where the states are on this issue?

  • 12:11:12

    WEILWell, you've just heard from two, state and the District, that are actively pursuing implementation of what the law asks states to do. That represents one end of the spectrum. There are a small number of states at the extreme other end that are resisting pretty much any steps associated with implementation. But the vast majority of states are sitting right in the middle, have been waiting for today, but doing their homework, getting ready for moving forward once the path was clear.

  • 12:11:45

    WEILAnd although the decision today does have certainly some twists and turns in it, the overall conclusion is that the general structure of the law is intact, and states have a central role in implementing the law. And now is the time, as they've been analyzing their options, to make the final decisions necessary to take them to where they want to be in respect to their roles of implementing the law as of 2014.

  • 12:12:12

    NNAMDIWell, we've heard from Maryland and the District of Columbia. The conventional wisdom has been that Virginia is dragging its feet. Virginia's General Assembly passed a state law banning the individual mandate. And its attorney general went to federal courts to try to stop it. But the notion that Virginia is dragging its feet might not be exactly true. When we spoke with Dr. Bill Hazel, the secretary of health in the Commonwealth, he hinted that plans are in place. They just hadn't been applied.

  • 12:12:41

    DR. BILL HAZELA health benefit exchange is going to be built in Virginia. Virginia would like to essentially operate its own exchange. And to that extent, we've done a significant number of planning to prepare for whatever the Supreme Court decides. That includes going so far as having the planning -- the grant application prepared so that we can apply for level one implementation should it be necessary.

  • 12:13:12

    NNAMDIThat was a conversation we had earlier this month with Dr. Bill Hazel, the secretary of health in the Commonwealth of Virginia. Don Kettl, he says he has his applications prepared. And we have talked about the District of Columbia. We've also talked about Maryland. But this has probably been one of the more controversial, if not the most controversial, public policy issue that we have seen during the Obama administration. I'd just like your thoughts on what happened.

  • 12:13:36

    KETTLIt's stunning. It's probably the most complex and controversial issue that we've had in a generation because we're talking about health care for every American and something that affects every state government in the country. The interesting thing that's already becoming clear, though, is that the idea that this is a massive federal takeover of health care is the furthest thing from the truth.

  • 12:13:55

    KETTLSo much of the real work of health care reform now rests on the states. And the fundamental question is whether or not some states are going to move out so much faster than others, like Maryland, and some states are going to be dragging back, like Virginia, that we're going to have inequities in health care across the country. And that's the next set of really big questions that we're going to have to confront as we think about what's going to happen with health care reform here.

  • 12:14:17

    NNAMDIAlan Weil, can you talk a little bit about what's happening in red states generally, those who have opposed the health care law?

  • 12:14:25

    KETTLWell, with the exception of a few states where opposition has really translated into sitting tight, I think the example of Virginia is quite representative, as we heard from Dr. Hazel, a state that has a clear opposition at the gubernatorial and attorney general level but also a very realistic picture of the challenges that the state confronts in health care: growing costs, challenges with respect to the quality of care and access to services. And they've been working very hard.

  • 12:14:59

    KETTLIt just hasn't been quite as visible, and it hasn't been as visibly endorsing a law that they oppose. It's much more of a what do we in our state need to do to prepare for the future and looking at the Affordable Care Act as a component but not guiding the state because that's not the guide star they want to follow. I think that's a -- I don't want to say that it's all the same, but I think that that's a picture you're like -- you would see around the country of people working on implementation without embracing the law.

  • 12:15:36

    NNAMDIDaniel in Great Falls, Va. has a political question. I suspect, Doug Gansler, you're going to have to address this. The president, however, has now started speaking, so we'll go directly to NPR News. Daniel, we'll get back with you. Here's the president of the United States.

  • 12:15:50

    PRESIDENT BARACK OBAMAI know there will be a lot of discussion today about the politics of all this, about who won and who lost. That's how these things tend to be viewed here in Washington. But that discussion completely misses the point. Whatever the politics, today's decision was a victory for people all over this country whose lives will be more secure because of this law and the Supreme Court's decision to uphold it.

  • 12:16:14

    PRESIDENT BARACK OBAMAAnd because this law has a direct impact on so many Americans, I want to take this opportunity to talk about exactly what it means for you. First, if you're one of the more than 250 million Americans who already have health insurance, you will keep your health insurance. This law will only make it more secure and more affordable. Insurance companies can no longer impose lifetime limits on the amount of care you receive. They can no longer discriminate against children with pre-existing conditions.

  • 12:16:45

    PRESIDENT BARACK OBAMAThey can no longer drop your coverage if you get sick. They can no longer jack up your premiums without reason. They are required to provide free preventive care like check-ups and mammograms, a provision that's already helped 54 million Americans with private insurance. And by this August, nearly 13 million of you will receive a rebate from your insurance company because it spent too much on things like administrative costs and CEO bonuses and not enough on your health care.

  • 12:17:17

    PRESIDENT BARACK OBAMAThere's more. Because of the Affordable Care Act, young adults under the age of 26 are able to stay on their parent's health care plans, a provision that's already helped 6 million young Americans. And because of the Affordable Care Act, seniors receive a discount on their prescription drugs, a discount that's already saved more than 5 million seniors on Medicare about $600 each. All of this is happening because of the Affordable Care Act. These provisions provide commonsense protections for middle-class families, and they enjoy broad popular support.

  • 12:17:51

    PRESIDENT BARACK OBAMAAnd thanks to today's decision, all of these benefits and protections will continue for Americans who already have health insurance. Now, if you're one of the 30 million Americans who don't yet have health insurance, starting in 2014, this law will offer you an array of quality, affordable, private health insurance plans to choose from. Each state will take the lead in designing their own menu of options, and if states can come up with even better ways of covering more people at the same quality and cost, this law allows them to do that, too.

  • 12:18:24

    PRESIDENT BARACK OBAMAAnd I've asked Congress to help speed up that process and give states this flexibility in year one. Once states set up these health insurance marketplaces, known as exchanges, insurance companies will no longer be able to discriminate against any American with a pre-existing health condition. They won't be able to charge you more just because you're a woman. They won't be able to bill you into bankruptcy. If you're sick, you'll finally have the same chance to get quality, affordable health care as everyone else.

  • 12:18:55

    PRESIDENT BARACK OBAMAAnd if you can't afford the premiums, you'll receive a credit that helps pay for it. Today, the Supreme Court also upheld the principle that people who can afford health insurance should take the responsibility to buy health insurance. This is important for two reasons. First, when uninsured people who can afford coverage get sick and show up at the emergency room for care, the rest of us end up paying for their care in the form of higher premiums.

  • 12:19:24

    PRESIDENT BARACK OBAMAAnd, second, if you ask insurance companies to cover people with pre-existing conditions but don't require people who can afford it to buy their own insurance, some folks might wait until they're sick to buy the care they need, which would also drive up everybody else's premiums. That's why, even though I knew it wouldn't be politically popular and resisted the idea when I ran for this office, we ultimately included a provision in the Affordable Care Act that people who can afford to buy health insurance should take the responsibility to do so.

  • 12:19:55

    PRESIDENT BARACK OBAMAIn fact, this idea has enjoyed support from members of both parties, including the current Republican nominee for president. Still, I know the debate over this law has been divisive. I respect the very real concerns that millions of Americans have shared. And I know a lot of coverage through this health care debate has focused on what it means politically. Well, it should be pretty clear by now that I didn't do this because it was good politics. I did it because I believed it was good for the country. I did it because I believed it was good for the American people.

  • 12:20:30

    PRESIDENT BARACK OBAMAYou know, there's a framed letter that hangs in my office right now. It was sent to me during the health care debate by a woman named Natoma Canfield. For years and years, Natoma did everything right. She bought health insurance. She paid her premiums on time. But 18 years ago, Natoma was diagnosed with cancer. And even though she'd been cancer-free for more than a decade, her insurance company kept jacking up her rates, year after year.

  • 12:20:58

    PRESIDENT BARACK OBAMAAnd despite her desire to keep her coverage, despite her fears that she would get sick again, she had to surrender her health insurance and was forced to hang her fortunes on chance. I carried Natoma's story with me every day of the fight to pass this law. It reminded me of all the Americans, all across the country, who have had to worry not only about getting sick but about the cost of getting well. Natoma is well today. And because of this law, there are other Americans -- other sons and daughters, brothers and sisters, fathers and mothers -- who will not have to hang their fortunes on chance.

  • 12:21:37

    PRESIDENT BARACK OBAMAThese are the Americans for whom we passed this law. The highest court in the land has now spoken. We will continue to implement this law. And we'll work together to improve on it where we can. But what we won't do -- what the country can't afford to do -- is refight the political battles of two years ago or go back to the way things were. With today's announcement, it's time for us to move forward, to implement and, where necessary, improve on this law.

  • 12:22:07

    PRESIDENT BARACK OBAMAAnd now is the time to keep our focus on the most urgent challenge of our time: Putting people back to work, paying down our debt, and building an economy where people can have confidence that if they work hard, they can get ahead. But today, I'm as confident as ever that when we look back five years from now or 10 years from now or 20 years from now, we'll be better off because we had the courage to pass this law and keep moving forward. Thank you. God bless you. And God bless America.

  • 12:22:40

    NNAMDIPresident Barack Obama responding to the Supreme Court's decision this morning upholding the Affordable Care Act. We're going to take a short break, but this is Washington, and so there will be politics. When come back, we will talk about the response of the presumptive Republican presidential nominee Mitt Romney.

  • 12:22:57

    NNAMDIAnd we'll also talk with Andy Harris -- he's a member of the House of Representatives, a Republican from Maryland -- and our studio guests, Douglas Gansler, Maryland attorney general, Alan Weil, executive director of the National Academy of State Health Policy -- he joins us by phone -- Donald Kettl, dean of School of the Public -- the School of Public Policy at the University of Maryland, non-resident senior fellow at the Brookings Institution, and Mohammad Akhter, director of the D.C. Department of Health. I'm Kojo Nnamdi.

  • 12:25:20

    NNAMDIWelcome back. We are discussing health care after today's Supreme Court decision upholding the Affordable Care Act. By the way, you can hear NPR analysis of President Obama's remarks and the Supreme Court decision on Intersection, WAMU 88.5's HD channel 3 that's streaming at In our studio with us Douglas Gansler, Maryland attorney general, Donald Kettl, dean of the School of Public Policy at the University of Maryland, a non-resident senior fellow at the Brookings Institution, and Mohammad Akhter, director of the D.C. Department of Health.

  • 12:25:54

    NNAMDIJoining us by phone is Alan Weil, executive director of the National Academy for State Health Policy. He joins us by phone. And as I said, this is Washington, so there will be politics. First, a response to the Supreme Court decision from the presumptive nominee of the Republican Party for president, Mitt Romney. Here he is.

  • 12:26:12

    MR. MITT ROMNEYI disagree with the Supreme Court's decision, and I agree with the dissent. What the court did not do on its last day in session, I will do on my first day if elected president of the United States, and that is I will act to repeal Obamacare. Let's make it clear that we understand what the court did and did not do. What the court did today was say that Obamacare does not violate the Constitution. What they did not do was say that Obamacare is good law or that it's good policy. Obamacare was bad policy yesterday. It's bad policy today.

  • 12:26:52

    NNAMDIThat's Mitt Romney who is expected to be the nominee of the Republican Party for president. Joining us now by phone is Andy Harris. He is a member of the U.S. House of Representatives. He's a Republican representing Maryland's 1st District. He's also a medical doctor. Andy Harris, thank you very much for joining us.

  • 12:27:10

    REP. ANDY HARRISIt's a pleasure to be with you again.

  • 12:27:12

    NNAMDIWe heard the president say that the country cannot afford to refight old political battles. I'm assuming you don't see it that way. What are the politics of this issue from your perspective?

  • 12:27:21

    HARRISWell, we can't afford not to fight this political battle. This president's affordable care act is hamstringing American businesses. You know, I meet with businessmen and women all the time who are not hiring because of the uncertainty that is imposed on them by the Affordable Care Act. We are in a bad economy. We can't afford not to discuss the wisdom of the president. The president in his address also said, well, you know, we shouldn't be taking up time on this. We should be discussing jobs.

  • 12:27:50

    HARRISWell, why didn't he do that two years ago while he was taking time on this, actually passing a bill that if you talk to the Chamber of Commerce or the mom and pop store down the street, they will tell you they are worried about the Affordable Care Act and its effect on American business and job creation?

  • 12:28:07

    NNAMDIWhat do you see happening in the Congress going forward?

  • 12:28:11

    HARRISWell, we're going to do -- look, the House has already taken that. We knew that this was a job-killing bill that actually impaired Americans, Americans' liberties as well. So we repealed it already. We repealed that in our first week here. We're going to do it again next week, week of the 11th after the July Fourth holiday week. We're going to come back, and we are going to repeal it one more time. I think Americans now know that it's not only a bad idea. It's actually a tax. We've been telling them that there are many taxes in the bill.

  • 12:28:40

    HARRISNow the -- you know, the chief justice writing for the majority said yes, and that's the only justification for it is because Congress actually put another tax on you. I don't think people like the idea of taxes right now. I think they resent that that was the back doorway of imposing this mandate on people. And I think it sets -- honestly, I think the court set a new policy now whereby not doing something, you actually have a tax imposed on you.

  • 12:29:05

    NNAMDIDoug Gansler, we hear the Maryland congressman referencing job-killing laws. You're talking about this as a practical solution. Will this play out as a political battle in Maryland?

  • 12:29:16

    GANSLERI don't think so Maryland so much because we're a fairly Democratic state. But, I mean, on the politics of it, it's interesting. You know, President Obama didn't mention the court decision at all. He mentioned the Affordable Care Act and what it does for people. He said that the highest court has spoken, and that was exactly all he said about the Supreme Court decision, didn't parse out, you know, what this justice said or that justice said or the justification for the decision.

  • 12:29:40

    GANSLERThough this case should be a reminder to everybody that one of the most important things we do when we elect a president is we are allowing them to pick our Supreme Court justices, and it matters who you pick because there was clearly politics or at least ideology in the decision that was rendered, the 192-page decision. What's interesting about Mitt Romney's comments, of course, is he says the -- he's constantly said this, the first day I become president, I'm going to repeal Obamacare.

  • 12:30:07

    GANSLERHe actually, turns out, doesn't have that authority based on separation of powers in our country. And he also -- when he was at Bain Capital -- clearly he didn't go to law school because he thinks the Supreme Court is supposed to determine whether some things are good policy or bad policy, rather than whether it comports with the law. You know, you mentioned when you're talking earlier, Kojo, that this is a very controversial issue.

  • 12:30:30

    GANSLERWhat I've always found very ironic and interesting about the Affordable Care Act in terms of the political side of it is I would guess 99 percent-plus of Americans haven't read one paragraph of what the Affordable Care Act actually says. Yet it has become a very polarizing, controversial issue where it doesn't seem to address sort of the bigger overlying factor of this is 18 percent of our GNP. Health care is dragging our economy down. We need to have a solution. They may not love this solution, but it's a solution. And it'll save taxpayers and people in Maryland a lot of money down the road.

  • 12:31:05

    NNAMDIDon Kettl, talk a little bit about the kind of pressures facing states right now before I get back to Andy Harris in his role as a doctor to talk about health exchanges.

  • 12:31:12

    KETTL'Cause we have these new things that we're calling exchanges, we bet the future of health reform on the states devoted to create these things. And we have -- we're in the process of trying to figure out what those things are, how they ought to work. They are these extremely complex entities that the federal government says states have to create. The states have to try to find a way to do it.

  • 12:31:31

    KETTLThey are a combination of private and non-profit organizations all banding together. This is not government control. It's a very complex public-private partnership where the states are going to be trying to find ways of creating and managing a system of private insurance that is going to be going to provide private care for individuals.

  • 12:31:49

    KETTLSo the challenge of trying to figure out and describe to people what this is given the complexity and given the effort for the federal government to avoid a true single payer system is one of the things that makes it that much harder for people to get their arms around this thing now. It's going to have enormous impact on everybody, has enormous complexity, but in the end is going to be providing health insurance to everybody.

  • 12:32:11

    NNAMDICongressman Harris, put your stethoscope on and tell us what you think of as a doctor about how these health exchanges will or will not work.

  • 12:32:20

    HARRISWell, I -- you know, I personally have supported the idea of health care insurance exchanges for years now. I just don't think that, you know, one of the things that the Supreme Court did decide is they're -- they, you know, they have a decision on the Medicaid component, and, of course, the entire system of exchanges only works if you really allow that, you know, Medicaid to be one of the players and one of the options for insurability. You know, the problem with the exchanges are that the government is going to mandate benefits.

  • 12:32:46

    HARRISThey're going to drive up the cost of policies. We've already seen it. Seventeen hundred, 1,700 waivers have to be -- had to be granted just to keep the insurance that you have. And, you know, I can't blame the president for not mentioning the Supreme Court decision in his comments because the Supreme Court said, you know what, you've been telling American people and everyone this is not a tax, but, in fact, it's a tax. And that's the only -- that was the justification.

  • 12:33:10

    HARRISI can't blame the president for not going out and saying, you know, I agree with the Supreme Court. This is a tax, and I'm glad they decided it was a tax. But from the medical point of view, physicians are very, very worried about what this will do to the access and price of American medical care because we've already seen health care insurance prices go up in the first two years since this bill was passed.

  • 12:33:34

    HARRISWe know that every state that has mandated benefits like this had -- the prices of the products go up. And we also know that the access goes down because, as you expand Medicaid -- and I'm sure the attorney general knows this in Maryland -- it's hard to find a physician who will take care of a Medicaid patient because the government payment rates are so low. As you expand those programs, keeping those payment rates low, you're going to have -- you know, people will have insurance. They just can't find a physician to take care of them.

  • 12:34:01

    NNAMDIWell, let me bring another physician into the conversation. Dr. Mohammad Akhter, what have you been hearing from doctors here in the District of Columbia?

  • 12:34:08

    AKHTERThank you, Kojo. As a medical doctor, I know one thing for sure, that people need care, and access to care is a very important component. And I want to give example of the District of Columbia itself. We are -- we're taking advantage of the health care reform, the Affordable Care Act. We proceeded to put some 35,000 persons on to Medicaid program and also opened up five or seven clinics (unintelligible). The results have been astounding, astounding.

  • 12:34:40

    AKHTERThe death rate from every single cancer is down in the -- in Washington, D.C. Infant mortality rate, for the first time, dropped below eight. The rate of -- the availability of prenatal care to women was 97.3 percent. So when you provide the access to the people, the access to care, then the health status of people rises.

  • 12:35:07

    NNAMDIBut are you hearing complaints from doctors about having to accept rates of compensation that they think are inappropriate?

  • 12:35:11

    AKHTERI think it's -- all I have heard from the doctors is the uncertainty. What's going to happen? And I think with the Supreme Court decision, it's now pretty clear that we're going to move forward. We're going to implement it. We're going to be working with our stakeholders in the city to bring them along. We're going to have the insurance exchange. It's already aboard. It's been already appointed by the mayor. Everything is all ready. So on the 10th of July, hopefully we will have the insurance exchange established, and, by the October deadline, we'll be in operation.

  • 12:35:41

    NNAMDIAlan Weil, we have heard about the complexity of setting up these exchanges. Could you give us, from a macro perspective around the states, how difficult that's likely to be and how doctors are likely to respond?

  • 12:35:53

    WEILThe general structure of the exchange isn't really that complicated. There are public and private sector models already in existence. The idea is basically to solicit bids from private insurers, array those options in a usable way for consumers to figure out the implications of their choices and help them make a selection. Part of the complexity of the exchanges under the Affordable Care Act is that they come with subsidies based on your income. So if you're moderate income, you get a tax subsidy towards the purchase.

  • 12:36:24

    WEILWell, that's complicated, but not because an exchange is complicated, but because the subsidy structure is designed to keep the cost to the taxpayer as low as possible while helping people get access to services. So there is much work to be done. The details are mind-numbing. But I think states that have been working from the time of enactment of the law toward implementation are very far along the way to what they need to do to have their exchanges up and running so that people can obtain coverage in January of 2014.

  • 12:37:01

    WEILThose states that have been hesitant to move forward and haven't started answering some of the complex design questions necessary in figuring out how to design their exchanges will find that the timelines are quite short. The good news for them is that the states that went first have answered many of these questions. And so, as long as they're willing to make decisions and not just ponder their options, there's still time, although it's getting pretty tight.

  • 12:37:26

    NNAMDIHere is Sunjata in Cambridge, Mass. -- or Cambridge, Md. Sunjata, you're on the air. Go ahead, please. Hi, Sunjata, are you there? Sunjata apparently can't hear me, so I will go to Daniel in Great Falls, Va. Daniel, can you hear me? You're on the air.

  • 12:37:45


  • 12:37:45

    NNAMDIGo ahead, please.

  • 12:37:46

    DANIELHi, Kojo, your guests. How are you?

  • 12:37:48

    NNAMDIWe're well.

  • 12:37:49

    DANIELI wanted to ask something of a two-part question. First, given the nature of the political system these days specifically -- in specific regards to Congress, is there ever actually going to be a potential for a real repeal, not just posturing that doesn't really have any key to it, but actually the building repeal by both the House and the Senate with no filibusters impeding it?

  • 12:38:16

    DANIELAnd then, secondly, regardless of an outcome of a repeal, states that are noncompliant with at least the Medicaid expansion, according to the Supreme Court, can't have additional Medicare -- or I'm sorry, Medicaid funds allocated to them. But -- or, actually, I'm sorry, the former Medicaid funds can't be withheld, but new Medicaid funds can't -- don't necessarily have to be allocated. Is there a chance that without a stick and simply by withholding the carrot in this case, some states will simply choose to remain noncompliant for Medicaid expansion?

  • 12:38:53

    NNAMDIThe first question I'll put to Congressman Andy Harris.

  • 12:38:57

    HARRISSure. No. The first question is pretty easy. I mean, if we gain a -- if the Republicans hold the majority in the House and gain a majority in the Senate and Mr. Romney is elected president -- a simple majority because remember this bill was passed under what are called reconciliation rules. You only need a simple majority. We gain a simple majority in the Senate. We retain the House.

  • 12:39:16

    HARRISWe gain the presidency. This bill will be repealed by -- and I disagree with the attorney general because what president -- if President Romney is the next president, he will have a majority in the Senate. He will have a majority in the House, and...

  • 12:39:28

    NNAMDIWell, I guess...

  • 12:39:29

    HARRIS...he will sign the repeal on the first day because Congress will have sent it to him two weeks before then. We'll have sent that bill to the White House.

  • 12:39:35

    NNAMDIBut, I guess, House Speaker John Boehner said they're going for a vote on July 11. By then, the Republican Party will not be controlling the Senate, and Mitt Romney will not be the president. What do you think will happen there?

  • 12:39:47

    HARRISWell, I think that your caller assumes that Mr. Obama is not going to sign a repeal bill. So I assume he means, at some point in the future, can everything be done? And yes. On -- we will...

  • 12:40:00

    NNAMDISo is the July...

  • 12:40:01

    HARRISIf we have a Republican majority, we'll repeal the bill in January, and the president will sign the repeal. Mr. Romney will keep to his word and sign it the afternoon of his inauguration.

  • 12:40:09

    NNAMDISo the July 11 vote's merely symbolic?

  • 12:40:12

    HARRISWe've already -- absolutely. We were going to send a message to the American public that this tax bill is bad policy. Look, the American public already agrees. A majority agree that most or all of this bill should be struck down. If the Supreme Court isn't going to -- didn't do it today, we're going to come back. And on July 11, we're going to say, actually, the Republican-led Congress agrees with the American people.

  • 12:40:32

    HARRISThis is bad policy. It's bad for American liberty. It's bad for American jobs. It's bad for American businesses. It needs to be struck down, and we'll do that. And we will work to replace commonsense step-by-step reforms, not 2,700 pages.

  • 12:40:47

    NNAMDIOn that political question, Doug Gansler, by the time, if it occurs in the year 2013, citizens will have had more exposure to the Affordable Care Act. Will it make, therefore, repeal more difficult?

  • 12:41:03

    GANSLERYeah. I think the politics of it are actually quite interesting. You know, the Republicans have sort of become the party of no a little bit here. And what happens is they're in a little bit of a political conundrum now because people will start to learn about it. I mean, the fact of the matter is, in Maryland, for example, there was $1 billion of uncompensated costs by hospitals for people that are uninsured, you know? And who pays that? We do. So every time you go to the hospital, you're paying six or 7 percent higher in a surcharge to pay for the uninsured.

  • 12:41:31

    GANSLEROur premiums -- average family in Maryland -- are $1,000 higher a year. So people are going to start to learn this. You know, we're the only industrialized country in the world that doesn't provide health care for our citizens. And so, while the politics of this are, you know, the poor people are -- don't deserve health care somehow because they're poor, they're not going to be able to continue down that road that long without being able to come up with an alternative, which they never have done. So they're kind of in a little bit of a tight spot.

  • 12:42:00

    GANSLERAnd I think people are -- you know, I understand President Obama is also being political in some way, trying to sell the package. But the fact of the matter is people do have that certainty that was just discussed. They know where we are. We're going to continue to go forward. And we're going to be able to insure everybody, and it's going to decrease the cost to those who are currently insured and obviously those who are not insured.

  • 12:42:20

    NNAMDIDon Kettl?

  • 12:42:21

    KETTLTwo interesting points on this, too, Kojo. The first is that the Republicans are going to be repeating tax bill, tax bill, tax bill over and over and over again. But the interesting point about this law is that you don't pay a tax if you have the insurance. The tax is only the kicker to make sure that, in fact, you go out and buy the insurance that the law says that you ought to have so that the Supreme Court established the tax power as the way that the sword could be put over everyone's head to make sure the insurance is actually purchased. But it doesn't actually impose a new tax.

  • 12:42:51

    KETTLBut that's sort of a fine point that's going to be lost in the enormous political rhetoric. But the fact that Chief Justice Roberts found the tax provision as a way to try to justify it just dramatically changes the way the politics is going to operate. The second point on this is going to be that -- the public opinion polls show that a majority of Americans are not crazy about Obama's health care plan, but more Americans are opposed to the current system that we have now.

  • 12:43:17

    KETTLAnd so the problem for Romney is that if he comes out and says, I'm going to repeal this right off the bat, he also buys an obligation to say what he's going to replace it with because nobody's going to want to put their 23-year-old, kick him back off the insurance. Nobody's going to want to have people thrown off insurance because of pre-existing conditions.

  • 12:43:36

    KETTLThere are a lot of things in this that Americans are going to discover that they like. And so the problem for Romney is that if he says, I'm going to repeal it right off the bat, he's going to buy, at the same time, an obligation to figure out what he's going to replace it with. And that's a very, very hard thing politically to solve.

  • 12:43:50

    NNAMDIGot to take a short break. But, Congressman Harris, you get the final word here.

  • 12:43:54

    HARRISWell, I've got to tell you, Mr. Romney has the plan. I was surprised that not everybody is familiar with it, but I guess we're not close enough to the election. You know, it provides individual choice. It provides tax deductibility for individuals so they can obtain this. This is a new tax. It's $4 billion a year in 2017. And that's only one of the taxes. That's only the new individual mandate tax.

  • 12:44:14

    HARRISThere's also a medical device tax. There's also a tax on insurance policies. I mean, there are plenty of taxes in this bill. To say that there is no new tax imposed is pretty amazing 'cause last I looked today, you don't have a tax if you don't buy insurance. You will under this Affordable Care Act once the individual mandate's in.

  • 12:44:29

    NNAMDIGot -- Andy Harris, thank you very much for joining us.

  • 12:44:32

    HARRISThank you.

  • 12:44:33

    NNAMDICongressman Harris is a member of the U.S. House of Representatives. He represents Maryland's 1st district. He's a Republican. He's also a medical doctor. We're going to take a short break. When we come back, if you have called, stay on the line. We'll try to get to your call. We're discussing health care in the wake of this morning's Supreme Court decision upholding the Affordable Care Act. I'm Kojo Nnamdi.

  • 12:46:43

    NNAMDIWelcome back. We're talking about health care in the wake of this morning's Supreme Court decision with Douglas Gansler, Maryland attorney general. Donald Kettl is dean of the School of Public Policy at the University of Maryland and nonresident senior fellow at the Brookings Institution. Mohammad Akhter is director of the D.C. Department of Health. And Alan Weil is executive director of the National Academy for State Health Policy. Alan Weil, are you there?

  • 12:47:08

    WEILSure am.

  • 12:47:08

    NNAMDIOur caller had a second part to his question about states being -- not being penalized because they have chosen not to go ahead in support of the plan. And he seemed to suggest that even though they -- that funds cannot be withheld from those states, that the withholding of future funds might somehow adversely affect them. What's your take on that?

  • 12:47:32

    WEILWell, it's a confusing part of the ruling. And basically what the court said was the existing Medicaid program needs to be thought of separately as the expansion under the Affordable Care Act. So what the law calls for is that everyone with the lowest of incomes, below 133 percent of the federal poverty line, will be made eligible for Medicaid. And the federal government, in the first few years, picks up 100 percent of the cost, and that phases down to 90 percent after a few years in contrast to the current Medicaid program, where the federal government picks up a little bit more than half the cost.

  • 12:48:08

    WEILThe court said you can't require states to expand coverage to this new population by penalizing them if they don't do it in a way that takes away their already existing Medicaid programs, which are very large and very important. So it presents states with a new choice that they didn't think they had, which is whether or not they're going to expand coverage. The strong financial incentive for the expansion remains that the federal taxpayer does pick up the overwhelming majority of the cost.

  • 12:48:42

    WEILAnd although there are certainly challenges in finding a physician who will take Medicaid as a source of payment because, historically, payment rates have been below what others would pay, we have a lot of data from around the country that having Medicaid coverage does improve health incomes, relative to what you would be if you were uninsured. So it's not concierge medicine, but it's certainly an important source of coverage for those who otherwise would be without insurance at all.

  • 12:49:13

    NNAMDIDon Kettl, give us a sense of scale here about the pressures the states are facing in this.

  • 12:49:18

    KETTLA scale in a couple respects, first, is just the time because these exchanges have to be put together in relatively short order, and the states that have been sitting on the sidelines are going to have a lot of work to do in a hurry. It is true that the forward-leaning states have already and essentially sort of broken down some of the taller trees, but there's still a lot of complexity out there.

  • 12:49:39

    KETTLSecond is that we're dealing with not only a system that involves billions of dollars of federal money in Medicare and Medicaid but also 18 percent of the entire U.S. economy, and we're in the process of restructuring American's relationship with medicine, too, at the same time. So on virtually every respect, we're in the middle of a very, very fundamental debate.

  • 12:50:01

    KETTLThe one thing that ought to be said, too, is that, had the law been repealed, the one thing that most insurance companies were betting on was that something like this somehow, at some point some day, would have to have been done because we'd have to find a way to get most people into the pool to be able to provide people with coverage and to bring down cost.

  • 12:50:17

    KETTLAnd we know that we can't continue to do what we're doing now forever, or we'll bankrupt the country because we can't afford to do what we're doing. So we knew that we had to confront this question, and it's just a very hard nut to crack.

  • 12:50:28

    NNAMDIDoug Gansler, the basis of this is a philosophical question. Is health care a human right?

  • 12:50:33

    GANSLERIt is a human right. And just because somebody happens to be born with less money than somebody else doesn't mean that they should have to be sick, that their families should have to be sick and that they don't -- shouldn't get insured. I mean, it's interesting. It was just mentioned how we sort of have to look at medicine differently and what the costs are. This is really no different than when Medicare and Medicaid were put in either. I mean, people started looking at what is the government's role vis-à-vis, in the case of Medicaid, seniors? Or I'm sorry, Medicare, seniors.

  • 12:51:00


  • 12:51:02

    GANSLERYou know, we had a crisis where people are getting older, they were getting sicker, they were living longer. What is the government's role there because they're no longer generating income? Not that dissimilar to this particular situation here. This is -- we will -- and the president was right. We'll look back at this five, 10, 20 years from now and say, it may not have been the perfect way to do it -- and there'll be opportunities to tweak it -- but this was unsustainable.

  • 12:51:24

    GANSLERThe situation we're in right now with the drag on our economy just bringing our national economy down and not having -- and being the only industrialized country in the world where we don't take care of our sick people is just -- wasn't workable.

  • 12:51:37

    NNAMDIHere is Debra in Bethesda, Md., who has, what, I think might be a medical question. Debra, you're on the air. Go ahead, please.

  • 12:51:44

    DEBRANo. Actually, it's a -- I am a physician practicing in Maryland, and I guess it's a question, more of a comment.

  • 12:51:53


  • 12:51:54

    DEBRAI'm wondering if one way to improve patient outcome would be to create jobs in the U.S. by creating some kind of preventive health bureau or force that is separate from health care. I was talking to someone recently who had a baby in the Netherlands in the '90s, and she said that everyone, regardless of income, ended up on a track when you're having a baby, starting at nine weeks or so. And you have to -- everybody does it regardless of socio-economic status.

  • 12:52:25

    DEBRAYou could be standing in line next to someone who's very wealthy, next to someone of little means, but everyone goes through, you know, whatever steps are expected. And then the same holds true for immunizations afterwards for children, and they really prioritize this. And should we be focusing on prevention, separate from health delivery?

  • 12:52:46

    NNAMDIMohammad Akhter, I've heard people say in the past that what we have is not a health care system. We have a disease care system, that a health care system would embrace prevention as a crucial aspect of health care. What do you say?

  • 12:52:57

    AKHTERCouldn't agree more. I think it's absolutely essential, but we have to have the coverage for all people. So if you're just simply doing prevention alone, it'll take you up to a certain point. But where our people are, who are suffering from a lot of chronic diseases -- diabetes, heart disease, cancer and other diseases -- they need also the quality of care to be able to really live their normal lives.

  • 12:53:20

    AKHTERYou know, we are not talking about the folks who are healthy and well to do. We're talking about our entire society. So as a society, we need prevention. As a society, we need primary care. As a society segment, we'll need specialty care. What this law does is give us the tools that we can use at the state level to create that system. We are in the process of creating that system in conjunction with our stakeholders, the doctors, the hospitals.

  • 12:53:48

    AKHTERWe are working -- collaborating with them to create that, what will fit our own need. And every state, I guess, will do in their own way to meet their own needs. And that's the ultimate goal, to create a system in which nobody's dropped out. Everybody have the access to care, and the American people go about doing their business, raising their families and working their jobs.

  • 12:54:07

    NNAMDIThank you for your call, Debra. Here now is Sunjata who is in Cambridge, Mass., it's my understanding. Sunjata, you're on the air. Go ahead, please. Hi, Sunjata. Go ahead, please.

  • 12:54:19

    SUNJATAHi. Originally, I'm from India, but I've been a citizen -- a U.S. citizen for at least -- over 30 years. And I take my obligations as a citizen very seriously. My question was this: With this very conservative Congress making such a fuss about health care for everybody, where do they get their health care from? I know they have excellent health care. And it's all paid for by the government, and their whole family gets this care. I would like them to live at least for a year without this health care and see how they can get through with it like everybody else does.

  • 12:55:05

    NNAMDII'm afraid Congressman Andy Harris is no longer with us on this broadcast, but I would have been interested in hearing his response to that question. What she is accusing the Congress of -- or certainly those who oppose the Affordable Care Act -- Doug Gansler, frankly, is hypocrisy.

  • 12:55:20

    GANSLERWell, that's right. I mean, there's -- as if there's some sort of God-given right to people who are in Congress to have insurance in health care and those who happen to be poor not to, I mean, that's where the -- we've been talking at some length about the politics of this. You know, I guess the politics are that if you have health care and insurance, therefore, you're more wealthy. Therefore you're more likely to vote Republican. So why should we care about the poor people or the people who have, for whatever reason, been laid off because the economy or what have you?

  • 12:55:45

    GANSLERThey're not going to vote for Republicans anyway, so let's not worry about them. I mean, that's really sort of the politics of what this deal is all about. What happened today was not a political decision, interestingly. The chief justice of the Supreme Court upheld the constitutionality of the Affordable Care Act. He was -- certainly, he's not certainly a Democrat by any stretch of the imagination.

  • 12:56:02

    GANSLERBut the law is clear on this. And whether, you know, and I think the point is very well taken, which is everybody, whether you're in Congress or whether you're the janitor or whatever role you have, you deserve healthcare. Your family deserves health care, and it's a right that every American, as is the case in every other industrialized country in the world, has.

  • 12:56:22

    KETTLAnd this really boils down to two points.

  • 12:56:24

    NNAMDIDon Kettl.

  • 12:56:25

    KETTLThe first is if you ask people who already have health insurance and have health care, do you like it, 75 percent of Americans say yes. And it's hard to get Americans to agree about 75 percent on anything. But then there's a question of equity. What happens if you don't have insurance, if you don't have care? And that really gets down to the basic question that's at the core of this, an effort to try to extend insurance and therefore health care to everybody.

  • 12:56:44

    NNAMDIAlan Weil, from what we've seen so far, are state governments up to the task of addressing the complex work, both of engineering and/or policing the health market?

  • 12:56:55

    WEILWell, as with everything about states, it varies.

  • 12:56:58

    WEILAnd the Affordable Care Act is designed to reduce the differences across states in coverage and how the insurance market functions. But there were significant differences across states five years ago, and there will be five years from now. I do think it's clear that states are quite capable, if they choose to do so, to carry out the major functions that states have the choice of performing under the Affordable Care Act.

  • 12:57:21

    WEILThey can bring up exchanges. They can modify their Medicaid programs. They can change how they regulate the insurance market. These are all functions that states have, the ability to perform and the capability to perform. I won't deny that the timelines under the law are for states aggressive and that the handshake between what the federal government does and what the states have to do adds a layer of complexity...

  • 12:57:46

    NNAMDIGot about 10 seconds.

  • 12:57:47

    WEIL...that brings us to -- that makes it hard. But, yes, this is a law that states have a major role in, and they can implement it if they choose to.

  • 12:57:55

    NNAMDIAlan Weil is executive director of the National Academy for State Health Policy. Mohammad Akhter is director or the D.C. Department of Health. Donald Kettl is dean of the School of Public Policy at the University of Maryland, a non-resident senior fellow at the Brookings Institution. Douglas Gansler is Maryland attorney general. Tomorrow on The Politics Hour, we'll be talking with the Virginia Atty. Gen. Ken Cuccinelli. Thank you all for listening. I'm Kojo Nnamdi.

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