The Future of Obamacare

Zeke Emanuel, an architect of the ACA, has some thoughts.

Zeke Emanuel outside his office in the Eisenhower Executive Office Building in 2009.
Ezekiel Emanuel outside his office in the Eisenhower Executive Office Building in 2009.

Samuel Masinter/Wikipedia

To discuss the insane spectacle we just witnessed in the Senate and the future of Obamacare, I spoke by phone with Ezekiel J. Emanuel, an oncologist and bioethicist who worked for the Obama administration and helped craft the Affordable Care Act. He is now chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. (His most recent book is Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations.) During the course of our conversation, which has been edited and condensed for clarity, we discussed meetings he’s had with President Donald Trump about health care, how to make Obamacare better, and why this White House is unwilling or unable to make bipartisan policy.


Isaac Chotiner: What is the status of Obamacare going forward, and what will Republicans try to do now?


Ezekiel J. Emanuel: I think it’s the law of the land and will continue to structure the American health care system for the next 50 years, or 30 years, or for decades. But remember, they are now responsible. There is no blaming Obama. If exchanges wobble, it’s their fault. So I think they are going to actually act responsibly, and despite all the hyperbole and hyperventilation, they have done a number of things, such as putting a hold on the court case about subsidies, and a few other things, where they have been acting very responsibly.

“They” being the executive branch?


Yeah. I think in the end, the optimistic scenario—and I am nothing if not optimistic—is that after a few weeks of this settling in, and members realizing they aren’t going to get repeal, there is a chance we could get some bipartisan progress on some of the big issues, especially the one that seems to be motivating the most Americans, which is affordability.

So when Trump tweets or says that he is going to let Obamacare crash, you see that as blowing off steam, or a rhetorical strategy, rather than telegraphing a substantive move?


I wouldn’t dignify it with the word strategy. I think it’s an expostulation. The thing is that it’s not Obamacare. It’s become Trumpcare. He owns it. If things go south, the Republicans who control the House, Senate, and White House are responsible and will be blamed, and so I don’t think that’s the strategy they want.


How many times did you meet with Trump and his aides?

Well, if you include his aides, a lot more, but I met with Trump himself three times.

And what was your sense of his policy desires about health care?


Well, you know, the one thing you can be sure of is that he really does care about drug prices and wants to bring them down. That I’m sure of and don’t think that’s put on. I think that’s genuine, and I think he really cares about that. I think he would like to, if he knew how, expand coverage and get costs under control. But it’s a complicated landscape out there, and I don’t think he knows how, and I think he hasn’t been well-advised on that by the Senate or House, which haven’t pursued that as its main objective in crafting the legislation that has gone down to defeat.


But do you think he is aware that the bills he has voiced support for would not do the things you say he wants to do?

Well, he seemed to understand that the House bill was mean, mean, mean.

But not enough to veto it.

It never got that far.

Well, but we know what would have happened.

I agree. I don’t think he would have vetoed it. But anyway, I don’t know that consistency and attention to policy detail …

What do you think the people around him wanted in terms of health care?

Oh, I’m not going to, no. Next question.

That was a bad question?

I’m not answering that question.

Did you meet with anyone from Congress?


I met with many Democrats.

OK. If you were dictator, which is not going to happen—

Damn, I was hoping. Top of my list.

You can only be dictator if you actually answer questions.

I blew it.

If you were dictator, what policy fixes would you make to Obamacare?

I think there are probably three or four buckets of reform that need to be done. Bucket No. 1 is about strengthening the exchanges. They are not going away, but things can be done to help them—guaranteeing the cautionary subsidies is one. Vigorously enforcing the mandate is one. Better advertising to young and healthy people with things like Google ads, where you do know how much they make and where they live and what subsidy level they would be eligible for is another. There are other reforms: restructuring the areas insurance companies bid on, so fewer rural areas are left uncovered. Maybe giving a rebate or tax for an insurance company that goes into an area with one or no insurance companies.


There are other sets of changes I would make. There are a whole series of things you would do for cost-control reasons to transform the delivery of care and bring the prices of devices down, and make care more efficient. That would be vitally important. I think focusing on drug prices is another area where there is bipartisan agreement.

That makes sense, and along with something like infrastructure, it seems like the type of thing that would be good for Trump politically, and as you say be bipartisan. But they are not making any progress on that, and I was wondering why you think that is.

We know that there are tensions in the White House. As you point out, Trump has certain commitments that seem to be bipartisan and do seem like something both Democrats and Republicans can support. And yet what has gotten advanced so far seems to be much more ideologically at the conservative end of the Republican Party. I am not an expert on the functioning of the White House, but one thing you could note is that [Mike] Pence, the vice president, who seems to be responsible for a number of key jobs like Office of Management and Budget and a few other positions, is more of the right wing of the Republican Party and less the bipartisan proposals that Trump himself is enamored of. That’s a potential explanation and could explain why the things that have advanced that you would think, if you were trying to govern and create a legacy, would be the things you would do first.

Yeah, well, as you said, there are tensions in the White House. I am sure you read Ryan Lizza’s piece yesterday.

There are words there I have never heard in my life.

Wait, your brothers are Rahm and Ari Emanuel, and you have never heard those words …


OK, you have no comment on that.

Wait a second, I laughed. That wasn’t a comment?

I can put [laughs] in brackets.

I hope you will note the sarcasm in the tone of voice. Words don’t capture tone.