ROBERT SIEGEL, HOST:
Senate Republicans will take their July Fourth recess without having passed a bill to repeal and replace the Affordable Care Act. It looks like we're in for a summer of trying to balance conservative Republican demands to get Washington out of the health care marketplace with more centrist Republican demands to deal more gently with Medicaid.
Atul Gawande has described both the Republican House bill that passed and the Senate bill that's been pulled as, in many ways, Medicaid repeal bills masquerading as Obamacare repeal bills. Gawande is a staff writer for The New Yorker, and he joins us from Boston, where he is also a surgeon at Brigham and Women's Hospital. Welcome back to the program.
ATUL GAWANDE: Glad to be back.
SIEGEL: You've written about the success of Medicaid and the Medicaid expansion. What are those successes?
GAWANDE: Well, the big ones just in terms of health - we actually as part of a scientific review looked at the past decade of studies, and they're especially in Medicaid. And a common criticism of Medicaid is that it is worth almost nothing because not all doctors take it and that people may not be treated as well as others. What we found, however, is that when people gain Medicaid, they have substantial improvements in their access to care of all kinds - primary care, preventive care, chronic illness treatment and needed medications.
SIEGEL: And it isn't a self-selecting group, that the people who are taking the effort to enroll are more likely to be concerned about such things.
GAWANDE: No. We in fact see that when people gain insurance of any kind, they all got substantial improvements in access to care. They report improvements in their overall health, both mental health and physical health. You have remarkable reductions in depression, improvements in heart disease and other conditions. And then if you wait long enough, four or five years out, you see measurable, substantial reductions in mortality, especially in the areas where you have chronic or semi-chronic illness like cancer, heart disease, HIV and other such conditions.
SIEGEL: How much would the Republican Senate bill alter Medicaid?
GAWANDE: Pretty dramatically. It would involve rolling back the expansion that was created under the ACA where it added coverage for people at the poverty line or near the poverty line and then cut it down even further below levels that would have been in place without the ACA being there at all. So it's a major transformation.
SIEGEL: Indulge me with a thought experiment here for a moment. If Medicaid is a very effective way of delivering medical care, what if it were the only way that we got medical care? What if there were no employer-provided health insurance benefits or no Medicare for the elderly? How would a nationwide Medicaid-for-all work?
GAWANDE: Well, it would be basically a lot like Canada, which is province-based health care. And Medicaid is state-based health care, and it's paid for with a fair amount of money from the national level. And so what we would have is a system that would be kind of state-based, single-payer health care. Having everybody in the system would mean that you would probably have all of the politics of what to pay doctors and everything else likely leading to people raising the amount of money that's paid to doctors and the health care system. It would be certainly a simplified system, and all the debates now we have about the single payer would be applied in that direction.
That said, Nevada actually created a system that passed and then was just vetoed by the governor that - the legislature passed a program that would have allowed anybody to buy into Medicaid. And that was the creation of a public option that very nearly became law and would have been an interesting experiment.
SIEGEL: Have you heard anything in the discussion this month over either the Senate bill or the House bill that the Republicans have passed or any of the discourse in Washington - anything encouraging at all to you in this discussion?
GAWANDE: No. And the reason it's discouraging is because at the end of the day, where the fundamental disagreement is isn't about the technical policy here. The fundamental disagreement is over, what is the goal? Is the goal to remove a trillion dollars in tax revenues from health coverage because you don't believe that is a good way to spend that money, and we ought to give it back as a tax cut for the wealthiest who've paid those tax revenues? Or should we keep that trillion dollars that have been allocated and raised for the purposes of providing health care coverage in order to provide these health benefits that I described?
I think the problem with the bill isn't just the 22 million uninsured. It's the vision of a health system where Medicaid is a shadow of what it used to be, and the average insured person is expected to have a $6,000 deductible and no primary care or chronic illness coverage. That is a world which is - it's not getting votes because for many people, it causes - it's a description of a health system that is a fundamental failure of a government purpose. And then for conservatives, it does not extract government from a role that they think it ought not to play at all.
SIEGEL: Surgeon Atul Gawande, who also writes for The New Yorker - and he's also a professor at the Harvard Chan School of Public Health.
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