Full Interview

Mr. President, thank you so much for sitting down to talk with us.

Lisa, thank you for having me.

So we invited the WebMD community to submit questions for you about the Affordable Care Act. And we got a huge response. We received questions from people from all 50 states. We got questions about policy. We heard from folks with concerns, others who wanted to thank you for putting the law in place. And we also heard from a fair amount of people who are still confused about the details of the law and the impact. We have a lot of questions. And people are really eager to hear your answers. And so if you don't mind, I'd like to--

Let's dive in.

Dive right in, fantastic. OK. So we received literally hundreds of questions from people like Becky from Maryland, Connie from Pennsylvania, and Tiffany from Tennessee who believe they need to make a choice between buying health insurance and paying for other necessities. What can you say to those people who believe that health insurance still isn't affordable, and they're concerned that if they don't purchase it they'll have to pay a penalty?

Well, the first thing is making sure everybody has the right information, because there's been so much politics swirling around this that I think a lot of folks still aren't sure what exactly is available. My most important recommendation is for people to go to the website healthcare.gov and look for themselves at what plans are being provided. And the website helps you calculate whether or not you qualify for a tax credit.

If you do qualify for a tax credit, then I think a lot of people may end up being pleasantly surprised, because for a large portion of those folks, health insurance may end up costing $100 or less. It may end up costing less than your cable bill or your cell phone bill. And if you are young, it may end up costing as little as $50 for good, solid coverage that not only protects you in the case of illness or accident, but also allows you to get free preventive care-- routine mammograms or making sure that you're getting your flu shot for you and your family.

In some cases, people may also find out that if they're really suffering some financial hardships that they qualify for Medicaid, or their children qualify for the Children's Health Insurance Program, all of which give them high quality health insurance. And finally, what I think is important for people to understand is that if, in fact, they still can't afford it, there is a hardship exemption in the law that means that they may not be subject to a penalty.

The penalty really applies to folks who clearly can afford health insurance but are choosing not to get it and then, essentially, they are relying on you and me and others who are paying our insurance premiums to subsidize them when they go to the emergency room if, heaven forbid, something happens. But I think that a lot of people have initially been skeptical when they've gone online at healthcare.gov. They've discovered that, in fact, they've got some good options there that they can afford.

Well, we heard from some other folks who have taken the time to go on the website. We got a question, for example, from Rose in New Jersey. She says she qualifies for a subsidy. And she actually seems pretty pleased with the premium that she's paying for insurance. But she asked this-- she says, if the purpose of the Affordable Care Act is to ensure all Americans have health care, why do most plans have such a high deductible?

Well, essentially what we've done is to create a marketplace for private insurance. And each insurer is pricing it. Some have lower deductibles, but that means then it may be a higher premium. Some of them may have higher co-pays but a lower premium.

And so what we've tried to do is to say, here are a range of options that are available to you through traditional private providers. And you choose what you think is best for you. Now obviously, there are other countries that have government-run health care or have a single payer plan, in which case the government really controls much more tightly how health care is distributed. That's not the system we've traditionally had.

There are pluses and minuses with having a private insurance system. But what we have tried to do is to make sure that everybody has a range of options, and they can see what's going to be most suited for their family. And some people may say, I'd rather have a higher deductible but lower premiums. Some people may say, I'm going to use health care fairly often, so I may want to keep my deductibles lower. Part of why this whole initiative has been so important is from now on, folks cannot be prohibited from getting health insurance because of a preexisting condition. And that is something that is going to give a lot of people out there a lot of assurance. And I suspect a lot of people who view this program will say, that's a relief for me.

But what we haven't done is ended completely a private insurance system, although if you qualify for Medicaid, obviously that whole issue would not apply.

Yes. Because we do hear consistently from a lot of people who do feel that the out-of-pocket costs, the deductibles, as Rose mentioned, but also the co-insurance and the co-pays that come with it-- and in some cases are feeling like they really want health insurance, but actually going to the doctor just simply becomes too costly for them, because they have to lay out, in some cases, $5,000 or $6,000 before getting help, with the exception of preventative services.

Well, the important thing though, Lisa, as I think you're familiar with, is that all these private insurance plans typically have some sort of deductible and some sort of co-pay. And so what we are trying to do is to say, given the marketplace that's out there with private insurance, here is how we're going to help to make sure you can afford it.

And we're also making sure that there aren't lifetime limits. That's true for all insurance plans now. There are a number of consumer protections that we've put in place that assure that people are getting a better deal than they're often getting in the private marketplace. But what I would suggest for most folks is that having good, solid insurance with some deductibles and co-pays is better than no insurance at all.

And what I think people will often find is that if they go on the website, their options are going to be much better than the options that they might get if they were simply shopping on their own in the individual marketplace without deductibles, in which case, they might on paper look like they're getting great insurance until they get sick. And then they find out, with all the fine print, it doesn't pay for hardly any of the hospitalization or doctor care that they need.

You mentioned a few minutes ago those who are eligible for Medicaid. Obviously, as you know, there are millions of people living in states that have chosen not to expand Medicaid. We heard from folks like Emily in Alaska, Sarah from Texas, and Pat from Georgia. And Pat says that she hardly makes enough money to pay her bills. She asked, is it possible for me to get coverage, or am I one of the forgotten? And Steven from North Carolina asked a little bit more pointedly, can't you reinstate the Medicaid expansion by executive order?

This is a source of great frustration for me, because what the law does is it says to states, expand Medicaid for the folks that just wrote you those letters, and the federal government will give you a 100% match, meaning the state won't have to put out any outlays, and your citizens will be insured. And for political reasons, a number of the states have chosen not to take us up on that. And the Supreme Court said we could not condition other programs, like existing Medicaid programs, on them accepting it.

So we don't have the ability at the federal level to pressure these states to do what they should be doing. Hopefully, citizens in those states, as they look at neighboring states that are expanding Medicaid, will say, well, why would you, Mr. Governor or members of the state legislature, choose deliberately to leave people in our states uninsured, particularly when it doesn't cost the state any money?

So in the interim, the best we can do for those unfortunate folks who are caught in this situation is to say to them that they will not be subject to a penalty for not getting health insurance. It's not their fault that the state is not doing what it should do. But in the meantime, that means that they're still relying on emergency room care or a free clinic or just forgoing care, which is bad policy. It's bad for those families. And I hope that everybody who's watching, as time goes on, is continuing to put pressure on those states to do the right thing.

We've seen some states where Republican governors have said, this is the right thing to do, even though I may not agree with the president. And they've gone ahead and done it. And people have benefited from it.

And I hope that that ends up being true in all 50 states. Right now, it's not true in a number of states, including some big ones like Texas where a lot of people are being impacted.

Yeah. Well, we've talked about some of the folks who are eligible to buy coverage in the exchanges and Medicaid. We've also received questions from a lot of people who are angry, because they believe the Affordable Care Act is responsible for making their employer-sponsored plan more expensive. We got a note from Dan from Nevada who works for a large corporation. And he writes, since your health care plan, my insurance costs have skyrocketed. Is Dan right to blame this on the Affordable Care Act?

No, he's not. A lot of people have looked at this. And there's nothing in the Affordable Care Act that would impact an employer-sponsored plan other than making sure that the employer-sponsored plan is actually providing a certain basic level of coverage. Now I don't know the particulars of his employer's plan.

But what people forget is that the average premium was going up 15% a year before the Affordable Care Act. Health care costs overall are actually going up more slowly over the last three years than any time in the last 50. And that's true in the private insurance sector. It's also true for Medicare and Medicaid.

So what we actually know is that premiums are going up more slowly, not more quickly, than they were before this law was passed. That doesn't mean that somebody might not still be frustrated when they see their particular plan or their cost going up. And what a lot of employers have been doing for quite some time is offloading more and more costs onto their employees in the form of higher deductibles or higher co-pays.

But one of the challenges of passing this law, which we knew would happen, would be that anything that isn't working well in the health care law, or in health care generally, can suddenly be blamed by somebody conveniently on the Affordable Care Act. The fact of the matter is that most private employers, their plans have are unchanged. They are making decisions based on their own business decisions. And they're not mandated to increase premiums for their employees.

Well, you've talked recently about the process for signing up insurance and how it's much improved. We know that the website has gotten better. At the same time, people like Kerry from Illinois said that the navigators-- the folks who've been hired to help people-- that she's encountered couldn't really answer her questions.

And Katie from New Mexico wrote in to express her frustration with healthcare.gov. She's still facing some problems. And she asks, how can you impose deadlines and fines when people are sincerely trying to sign up and the federal online site is still dysfunctional in some cases?

Well, I have to tell you, obviously after a really bad first month with the website where it just didn't work and it was inexcusable, and I think I've publicly apologized to everybody for the fact that it should have worked, it got fixed fairly rapidly. And if you go to healthcare.gov today-- and a lot of people who are watching this will be able to immediately access it-- what you'll find is is that it works pretty darn well.

Now sometimes what may frustrate people is it's not so much that the website's not working as it is that they may have a particularly complicated situation. They may not know all their tax information. In order for them to qualify for the tax credit, the Treasury Department and the IRS essentially have to calculate what their income is.

And that ends up being a little bit complicated. And some people may need some help on that. Keep in mind, though, that you have to compare this to blind private insurance. Most of us are lucky enough to get health insurance through the job. So somebody from HR hands you a form, you read it through, and you sign something.

But if you ever actually try to buy health insurance with an agent by yourself, it's a complicated process that actually takes a lot longer than signing up on healthcare.gov. So we haven't been able to eliminate any inconvenience. It's still a big transaction for families to sign up for health insurance.

But the website itself actually at this point is working quite well. And people have until the end of March 31 to sign up. And we know that it's working, because we've got 4.2 million people who've already signed up.

On a daily basis, we're getting tens of thousands of people who are signing up. We're able to monitor whether there are long wait times on the website, whether things are getting stuck. Ever since the terrible experience back in October and early November, there's somebody watching the screen at all times-- an entire team of techies. And if they see something get stuck, they're right on top of it.

Now as one of the people who wrote mentioned, we also have what are called navigators. These are essentially people in community centers or nonprofit clinics or affiliated with a church who are supposed to be helping walk folks through the process. And those folks are trained. They're supposed to have the answers.

But as is true with any service when you deal with somebody, if you've got a complicated situation and you say, well, I had this job. My income is here. I'm not sure exactly what my income is going to be there-- working through how they qualify for the tax credits and what plans may be available may be sometimes a little bit complicated. But I would start with healthcare.gov.

If you don't find that that's convenient, then you can call a 1-800 number-- 1-800-318-2596. And if after either using the call center or the web site your questions are still not answered, then the web site or the call center can direct you to a place in your hometown where somebody will actually sit there and walk you through the process. And I think that most people will find that at least since that first month and a half or so when things were really not working well that now it's actually working quite well.

Well, we also heard from individuals like Sandra who lives in California and Claire from Illinois. They're troubled by the limited number of doctors and hospitals that they're finding take their insurance. How do we get more doctors and hospitals participating in these plans?

Well, again, these are private insurance plans, which means that they're going to have networks. That's pretty much true of any health insurance plan you got out there right now.

If you're signing up for a Blue Cross plan, let's say, in Florida, then they have a pretty good network of doctors and hospitals. But they probably don't have 100% participation of every doctor hospital. So that's not unique to the Affordable Care Act.

What we have said is, for example, if you're in the middle of life-saving treatment with a particular doctor, then we will work to make sure that you can keep that treatment and not shift. But for the average person-- many folks who don't have health insurance initially-- they're going to have to make some choices. And they might end up having to switch doctors, in part because they're saving money.

But that's true if your employer suddenly decides, we think this network is going to give a better deal, we think this is going to help keep premiums lower. You've got to use this doctor as opposed to that one or this hospital as opposed to that one. The good news is in most states, people have more than one option. And what they'll find, I think, is that their doctor or network or hospital that's conveniently located is probably in one of those networks.

Now you may find out that that network's more expensive than another network. And then you've got to make a choice in terms of what's right for your family. Do you want to save on cost? Or do you want to save on convenience?

But these are all high quality plans. These are the same plans you would get if you were buying insurance not using the Affordable Care Act or if your employer is out there buying insurance.

You talked about the insurance companies. We also heard from people like Rick from Utah who say he thinks that insurance companies are actually the reason why it's hard to find doctors, hospitals, and pharmacies. Some of the plans do seem to have narrower networks than perhaps those sold outside the exchanges.

And Mark from Wisconsin asks, are insurance companies sabotaging Obamacare? And would we be better off taking them out of national health care altogether?

Well, this is an important debate. I think that there is no doubt that there are some terrific insurance plans out there and companies that try to do the right thing by their customers, have good networks, and they're prioritizing providing good care. There are some that don't do a great job.

One of the things in the Affordable Care Act that we did was put together all these consumer protections that apply to everybody. I mentioned some of them-- making sure that your child can stay on your plan until they hit their 26th birthday-- three million young people now benefit because of that provision-- making sure that there aren't lifetime limits, making sure that you can't be barred from getting health insurance because of a preexisting condition-- those are all things that were designed to ensure that insurance companies do a little bit better by their customers.

One other provision that was in the Affordable Care Act says that insurance companies now have to spend 80% of the premium that you pay on actual health care, as opposed to administrative costs and CEO salaries. And if they don't do that, at the end of the year, they send you a rebate. And in fact, several billion dollars in checks have already been sent out in rebates. People may have gotten those checks and not knowing that was because of the Affordable Care Act, but it was.

But what is true is that as long as you've got a private insurance plan, then there are going to be some decisions that those insurers make about who's in a network, what their costs are, what their co-pays are that may not satisfy everybody. There are other countries like Canada that have a single payer plan. And by definition, every doctor and every hospital is part of that network. If you're part of Medicare, you have a very broad choice, just because it's such a huge program that almost every doctor and hospital has to be part of that network if they want to have a lot of customers.

I think that as the Affordable Care Act grows and more and more people are signing up that you may see insurance companies starting to add more doctors to the networks, putting more options on the table. But keep in mind that what this is really designed for is not to replace people who've got a good deal through their employers. What it's really designed to do is to deal with the 40 million people or so who don't have health insurance at all or people who are in the individual marketplace that are not getting it through their employer and so do not have a lot of leverage and may not be getting a good deal through their health insurance companies, because they really don't have the ability as part of a group to negotiate a better package.

And I think what you'll find is that the private insurance that's available on healthcare.gov is going to be as good or better as what you could get outside of the Affordable Care Act. And when you add the tax credits or subsidies that you may qualify for, it's going to be a really good deal for a lot of people. And I get a bunch of letters every single day with folks saying, I saved $200. I saved $500 a month-- small businesses who say, I'm saving tens of thousands of dollars covering my small group of employees.

And what I really want to just urge everybody to do is check it out for yourself. Go to healthcare.gov. The website's working. See what options are available for you.

Well, we did have a number of people like Jane from Washington state who says she isn't planning on purchasing a plan, again because of the issue of cost, which was a large percentage of the questions we got. She says it's cheaper to pay the penalty. If a lot of Americans follow Jane's lead, what impact will this have on the ACA, people want to know.

Well, at this point, enough people are signing up that the Affordable Care Act is going to work. The insurance companies will continue to offer these plans. We already have over four million people signed up. It will be a larger number than that by the end of March 31-- the deadline to get insurance this year. If you missed the deadline, by the way, on March 31, you can get insurance. But you'll have to wait until November of this year to start signing up again.

The impact, in terms of the program, has always been based more on the mix of people who sign up. Do we have a mix of people who are gray-haired like me and may have small basketball injuries and aches and pains, along with young people who are healthy and don't really have any issues right now? Do we have a good mix of gender, in terms of men and women, because one of the things that I didn't mention earlier-- in traditional insurance, women have been charged more than men. Essentially, being a woman was a preexisting condition, and it justified higher premiums. And we've eliminated that not just for plans under the Affordable Care Act, but for plans generally. You can't discriminate against women, in terms of how you charge folks.

But what you'll find, I think, is that the marketplace will be stable. And the premiums are going to be reflective of the fact that there are a lot of people who've already signed up. Now the larger these marketplaces get-- a year from now, two years from now, three years from now as the program develops-- potentially that brings the cost down even more.

So if all 40 million people who didn't have health insurance all signed up by March 31-- in which case there probably would be a line a little bit, in terms of signing up-- but if all 40 million people signed up, then you could assure that probably the premiums would go down significantly next year, just because the pool would have gone beyond what the insurance companies anticipated.

The basic principle insurance is pretty straightforward. The more you can spread the risk with more people, the better deal you're going to get. And now the pool is already large enough. The number of people who've signed up is already large enough that I'm confident the program will be stable.

But we look forward to seeing more and more people take advantage of it as some of the politics of the thing get drained away, as people start feeling more confident about the website, as folks like you spread the word, in terms of giving people accurate information. Then over time, I think a lot more people are going to take advantage of it.

Well, Mr. President, on behalf of the WebMD community, I want to thank you so much for your time today.

Well, thank you very much. As I said, go to healthcare.gov and take a look for yourself. See if it works for you.

Thank you.

Appreciate it.

Thank you so much.