MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Millions more Americans have health insurance today because of the Affordable Care Act. But discontent over what's covered and cost remain strong. Yesterday, the Supreme Court declined to weigh in on challenges to the law brought by religious employers. Here with me to talk about the Affordable Care Act three years in, Stephanie Armour with The Wall Street Journal and Julie Rovner with Kaiser Health News.

MS. DIANE REHMJoining us from a studio in Cambridge, Massachusetts, Susan Dentzer with the Network For Excellence In Health Innovation. I look forward to hearing your calls, comments. Our number, 800-433-8850. Send us and email to drshow@wamu.org. Follow us on Facebook or you can send us a tweet. And thank you all for joining us.

MS. STEPHANIE ARMOURThank you.

MS. JULIE ROVNERGreat to be with you, Diane.

MS. SUSAN DENTZERThanks so much for having me.

REHMSusan Dentzer, yesterday's ruling by the Supreme Court seemed rather confusing. Can you straighten it out for us?

DENTZERSure, Diane. So the Supreme Court was asked to take up actually several different lawsuits that have been brought forward by religiously affiliated employers, as you've said, who have said that the compromise that the Obama administration crafted around contraceptive coverage under the ACA was...

REHMWhich was? Which was?

DENTZERWhich was very complicated, but I'll try to be brief about it. So if employers objected to offering contraceptive coverage to their workers, they could notify -- they would notify their insurer or the government in writing of their objection.

REHMRight.

DENTZERAt which point, the government would step in and provide contraceptive coverage at no cost to the employer for those workers who wanted it. So that was the compromise that the administration offered several years ago. Suits followed because some of these employers said even that compromise went against their religious objections.

REHMWas not enough. Yeah, exactly.

DENTZERThat's right because notifying the government meant that would then trigger the process of providing coverage was, in fact, asking them to be complicit in this sin of providing contraceptive coverage. So they sued. These cases, seven different lawsuits, worked their way up through the courts. Eight federal appeals courts sided with the administration, but this went all the way to the Supreme Court.

DENTZERAnd the Supreme Court, 4-4, couldn't reach a conclusion on this and said -- and that tells us, frankly, that there were four justices that agreed with this compromise and four who disagreed. So failing to reach any kind of conclusion, they've now kicked it back to the lower courts and said, work it out. Find a compromise that will work. And here's one, the court said, that we have in mind.

DENTZERLet's have the employer tell the insurer that it objects and then the insurer will notify the employees that it will provide coverage so that there doesn't have to be this explicit statement in writing and sort of that degree of "complicity" in this sense. So that's where things stand. It will now go back to the lower courts to work out this compromise.

REHMAnd Stephanie Armour, do you think the lower courts are prepared to do exactly that?

ARMOURI think that, you know, the lower courts, so far, have sided with the Obama administration. I think that, basically, in this case, the Supreme Court is sort of acting almost like a referee and -- if you will, and where it's going to go next, I think, it will be interesting to watch. I do think that both sides -- it's interesting that both sides really see this as a victory, that the Obama administration is saying, you know, that these women will continue to get the contraceptive coverage and the employers are saying that they listened to us and that there is -- that they're being acknowledged for their concerns.

ARMOURSo it's interesting that both are...

REHMAnd that's what's quirky here, Julie Rovner. Will women continue to get contraceptive coverage under this quirky compromise?

ROVNERSome of them may actually get coverage for the first time because a lot of these, even though the lower courts had sided with the government, a lot of those requirements were stayed pending what the Supreme Court was going to do. So now, what the Supreme -- what it says in the order, and it was a little bit hard to tease out, is that all of the organizations that have sued have done two things. They have notified the government of their objection, hence they sued.

REHMRight, right.

ROVNERAnd in the process of the lawsuits moving forward, they've identified who their insurers are because the government had been saying, it's not just that we need to know that you object. We need to know who your insurer is so we can arrange for coverage. Those two requirements have now been met so what the Supreme Court order said is that while you try to work this out, the government can go ahead and offer coverage to the employees of all of these organizations.

ROVNERThe government cannot fine the organizations for not providing the notification, excuse me, but in essence, they already have. So then, the question got raised, what about organizations that don't want to do this that haven't sued. That is sort of an open question. But I have to say, you know, in the order, it was very brief opinion and it implied -- it said, well, they asked for supplemental briefing when it was clear they were tied. Just a week after the argument, they said we want some more briefs and here's a possible compromise.

ROVNERThey said in yesterday's order, well, it's clear from the supplemental briefs that there's a possible compromise. And I went back yesterday afternoon and I reread the supplemental briefs and I don't know what compromise they're seeing, but I sure didn't see it in the briefs. So I think, basically, the court was saying, we can't resolve this. We don't want to deal with it. We're gonna send it back and hopefully, it won't come back until we have nine members.

REHMSo did it -- did they say, 8-0, let's send it back?

ROVNERWe don't know that. It was what's called per curiam decision, which just means order of the court and a lot of people sort of took that to mean unanimous and most per curiam decisions are clearly unanimous. They're usually on noncontroversial things so I actually asked and I went to SCOTUS blog, who I consider sort of the arbiter of all these things, and I was assured that, no, per curiam is usually unanimous, but not necessarily.

ROVNERSo it may just have been that it was the four conservatives who got Sotomayor and Ginsberg, Justice Sotomayor and Justice Ginsberg, to go along. They wrote a concurrence making it clear that we have not -- that the court has not decided anything on the merits and that the lower courts are free to basically find for the government or find for the plaintiffs or do whatever they want. So it's a big messy.

REHMSo Susan, do you think that we have clarified the issue or is it just for now we're okay?

DENTZERWell, nothing ever seems to be final with the litigation over the Affordable Care Act at one level. Stephanie used a great word, referee. The Supreme Court now is acting like a referee who doesn't know how to call the game and is sending it back to another set of referees to try to call the game. So we'll see. I think, given that the eight federal appeals courts sided with the administration that we are probably on our way to a compromise maybe along the lines that the court -- some of the members of the court describe.

DENTZERMaybe it's the compromise that the administration set forth or something close to it. But I think -- I would hazard a guess that we're getting there.

REHMWould you anticipate, Stephanie Armour, that perhaps the groups that don't want to provide contraception to women on religious grounds would somehow create yet another objection that would find its way back to the Supreme Court or is this a real compromise?

ARMOURI don’t think we're at the real compromise yet. I certainly think that should those groups not be appeased or pleased by whatever comes out of that, that it's very possible that there could be continued litigation. It may be a situation where the Obama administration comes out with some sort of a regulation that brokers a compromise and these employers could say that that is still not something we're comfortable with and certainly it could continue.

ARMOURI think that hopes are certainly high that this -- it has been a long drawn out fight and I think there is strong hope that perhaps this can lead to a broker that will appease both sides. But that has yet to be seen.

REHMJulie?

ROVNERYou know, a lot of religiously affiliated organizations -- and we should point out that churches, houses of worship, are exempt from this requirement. We're talking here about, basically, religious nonprofits, hospitals, colleges and universities, that sort of thing, places that employ people of all faith. And many of them, in fact, I would hazard a guess to say most of them, have gone along with the compromise. So there's a lot of coverage now being given.

ROVNERWhat these organizations were saying -- and it was at the Supreme Court, they kept using the word -- we don't want you to hijack our health plan. They don't want women to get the coverage through the health plan that the employers, you know, have created for them. And that's the big question the government and women's advocates say if it's separate, it will put up barriers. It will make it harder for women to get this coverage. It really needs to be part of the health plan.

ROVNERNow, there are Catholic health plans that already do this, that they manage to contract out to have someone provide this coverage so they're not doing it. So there is an extant, you know, model for this to happen. The question is, you know, at what point someone's going to say, okay, it's enough.

REHMWhat do you think, Susan?

DENTZERAs I say, I think we're inching our way there. I would just point out probably everybody in this -- all three of us or all four of us, the women on this show today have Catholic friends who use contraception. So women are finding ways to get contraceptive coverage. And, in fact, the litigants in this case made that point as well. There are other avenues to get coverage, but I think we're on our way to a compromise through the ACA on this question.

REHMSusan Dentzer, she's president and CEO of the Network for Excellence in Health Innovation. Short break here, when we come back, we'll talk about the ACA three years in, what it's done and has not.

REHMAnd welcome back. We're talking about the Affordable Care Act. We have just been talking about the ruling from the Supreme Court that came down yesterday. Now, let's turn to what the Affordable Care Act has managed to accomplish. There were other legal challenges last week, Stephanie, when a federal judge sided with House Republicans over the law. What that all about?

ARMOURYeah. This is the litigation over the ACA certainly continues and this was a decision by a judge that basically said that the decision by the Obama administration to provide payments to insurance companies for something known as cost-sharing subsidies. These are subsides that help consumers specifically with their out-of-pocket costs. So it's not the premium tax credits. This is a different, but it's for lower income consumers who purchase plans on the exchange, the silver plan.

ARMOURAnd basically said that, no, the Congress had not appropriated funds for paying this and that the Obama administration was not entitled to be using that for this program.

REHMSo it was overreaching somehow.

ARMOURRight. That was basically -- and they did stay their decision anticipating an appeal from the Obama administration so at this point, the cost-sharing subsidies still stand, but whether they will in the future is causing a lot of anxiety.

REHMSusan Dentzer, it seems to me we have seen, what is it now, 47 votes in the Congress to overturn the Affordable Care Act, all of which have failed. Can you talk about what you believe the ACA has accomplished in its three years and what it has failed to do?

DENTZERWell, as we know, there were two major parts of the coverage expansion under the Affordable Care Act. One was allowing people who didn't have coverage previously to purchase that through federally or state-based health insurance exchanges, purchased private health coverage with the aid of those subsidies that Stephanie mentioned, both the premium subsidies and the cost-sharing subsidies, depending on their income.

DENTZERAnd then, the second part was the expansion of the Medicaid program for people who were between 100 percent of the federal poverty level, 138 percent of the federal poverty level. Now, as we know from the Supreme Court decision back in 2012, that Medicaid expansion was made optional for the states and so now we have a situation where two out of every five states have elected not to expand the Medicaid program, even to this day.

DENTZERSo what we have is a situation where about 20 million American adults are newly covered through portions of the Affordable Care Act. A number of children have also become covered as their parents have become covered. A number of those individuals, almost 13 million, have purchased coverage through the health insurance exchanges so they're now in private coverage. The balance are in the states that have expanded the Medicaid program.

DENTZERSo, essentially, we've managed to get 20 million people signed up one way or the other through expanded coverage and then, of course, other provisions have also kicked in. Young adults can now stay on their parents' coverage up to the age of 26, et cetera, et cetera. So we've done a lot in several years to expand coverage under the program. We've also done a great deal under other aspects of the Affordable Care Act to begin to shift the way we provide healthcare and pay for healthcare in a way that many are hopeful will make care more affordable over time and improve the quality of the care.

DENTZERThat's a long, slow process, but it's also very clear that under the law, that has begun.

REHMAnd Julie, you've got the latest stats on it.

ROVNERYes, out today from the National Health Interview Survey, which is one of the federal surveys of health insurance. And it found that in 2015, so last year, there are 28.6 million people without health insurance. That's 9.1 percent. That's way down. And actually, the number is down 7.4 million from 2014. So 7.4 million...

REHMWho do not.

ROVNERRight, well, but no, 7.4 million more people got insurance in 2015...

REHMRight, exactly.

ROVNER...than had it in 2014. So definitely the trend in coverage is going in the direction that the law had hoped and anticipated. As Susan mentioned, there have been some blips in that Medicaid is not expanded in, you know, basically a third of the states. So there is potential for more. But it's certainly -- if you can talk about the things that the Affordable Care Act has done, one of the things that it definitely did do is increase coverage for people who previously didn't have it.

REHMAt the same time, you've got the number of health insurers, Stephanie, actually dwindling.

ARMOURYeah. What you're really seeing is there's sort of two issues, I think, on the ACA. One is the cost issue. For consumers, there may be more coverage, but a number of consumers I talked to say they just can't afford it when they do get sick. They can't afford their deductibles. At the same time, you have insurers who are leaving some of the exchange markets, like United Health, Humana. And in a number of states, you're seeing that there are only one insurer that is on the exchange and in some other states, just counties with only one insurer.

REHMAnd why is this happening?

ARMOURWell, a number of insurers say that they've lost money on the exchange, United among them. There was a recent study that came out that showed, I think, a significant loss for some insurers. Largely, they may have priced their plans too low not anticipating that the population would be as sick as it was.

REHMSo is the population that has allowed itself to pay into the Affordable Care Act, are they sicker? Are they less healthy than those in the private insurance industry?

ARMOURIt's not that the people themselves are sicker. It's that the insurers didn't get the number of healthy people that they needed to offset those costs.

REHMI see, I see.

ARMOURAnd there are a whole host of reasons that that happened. One of them, remember the big uproar about if you like your insurance, you can keep it. So we have what are called grandmothered plans. So people who already were in the individual market who had their own plans didn't come into the exchange markets. They kept their own insurance and those are, as I mentioned, those were, by and large, healthy people because you couldn't buy your own insurance if you're weren't healthy prior to the ACA.

DENTZERBut, Diane, it is the case that the population coming into the qualified health plans and the exchanges is sicker on average than the average other private coverage, those with employer-provided coverage. There was a big Blue Cross/Blue Shield association study released recently that showed that across the board, the people signing up for coverage through the -- on the exchanges have two and a half times higher rates of HIV, 60 percent higher rates of diabetes, depression, other chronic illness and they're costs, overall, are about 19 percent higher than the average employer-provided population.

DENTZERSo these are sicker people and that would follow because these are people who could not get coverage before.

REHMCouldn't get insurance, yeah.

DENTZERBecause they had preexisting conditions. So, but that's not a big surprise. That's been known for some time that this population was going to be sicker. As Julie and Stephanie have said, insurers had to guess at how sicker, how much should we charge for premiums to basically cover the cost of the sicker population. And that's what's being worked out now as insurers do or do not increase premiums, do or do no decide to stay in markets. And some of these markets, it must be said, are very tiny markets where, you know, very rural, small markets.

DENTZERIt's very hard for an insurer to make it in a market like Alaska where only 27,000 people are eligible to sign up on the exchange.

REHMBut hold on one second. Are these companies still making money? That's what I want to know.

DENTZERMany of them are losing money hand over fist.

REHMAnd you're saying they're not making any profits overall because of these...

DENTZERNot overall, but on this particular line of their business.

REHMThat's what I thought.

DENTZERCovering these people in the Affordable Care Act.

REHMYeah, Julie.

ROVNERYes, you know, everybody got very excited when United Healthcare said that they were going to pull out. Well, United Healthcare has never been a big player in the individual market. They got in because they thought they might be able to make some money. United Healthcare makes lots and lots and lots of money in the employer market where they're very large, where they are the largest health insurer. They were never the largest health insurer in the individual market.

ROVNERThey never even really participated in it very much and there's an argument that, well, why can't they, you know, offset the losses from here with the profits from there and that's not how the insurance industry works. They want to make money in each...

REHMEverywhere.

ROVNER...well, in each segment of the market where they are.

REHMAll right. Here's an email from Catherine in New York and we've had several like this. She says, "my husband owns his small business. Since the ACA went into effect, our premiums have stayed the same, $24,000 a year, but our deductible just skyrocketed from 200 to $4,000 per year. So now, we avoid going to the doctor at all cost knowing we would pay out-of-pocket for exams, procedures, medications. For the first time in my life, I feel uninsured. Our insurance broker showed us all available group options and this is what you get." Susan.

DENTZERThis is a real problem. So it's the Affordable Care Act, right? So the whole point was to make it affordable for consumers and for the nation and for taxpayers who are paying for it. But those goals are not always mutually consistent, right? And one way that insurers keep premiums down is to raise deductibles and other out-of-pocket payments for people. So as the markets have evolved for people shopping for premiums, which they want to be low, many insurers have compensated by raising deductibles and co-payments and these out-of-pocket costs that consumers have to pay.

DENTZERAnd that does create the bind that the caller, the viewer described, the listener described. So how are we going to work our way through this? Some states have said, first of all, pointed out that preventive services are covered with no out-of-pocket cost under the Affordable Care Act. So if people want to go get mammograms or other things, they do not -- those are not held against their deductibles. That's point number one. But there's been discussion about having plans evolve so that some minimum number of physician visits could be covered before the deductible kicks in.

DENTZERSome of the states' exchanges are moving in that direction. So we're working all of this out, but it does leave people, for the moment, who have these very high deductibles, vulnerable to these out-of-pocket expenses up until the limit kicks in and that limit now is in excess of $6,000 of out-of-pocket costs that people have to bear before they're completely sheltered from those costs.

REHMOkay. I'm going to open the phones now. Here's a call from Ft. Wayne, Indiana. Troy, you have a story. Go right ahead.

TROYYes, hello, Diane. Am I on the air?

REHMYep, you sure are.

TROYAll right. Great. Thanks for taking my call.

REHMSure.

TROYYeah, I'm a 45-year-old male that tried to live a relatively healthy life and the one thing that I've found has happened since the Affordable Care Act came into play was that I feel like I'm being forced to buy insurance and buy into premiums and coverage that I don't ever really use. You know, I visit the doctor once a year for a checkup and I stay pretty healthy. And so, at this point, how I view it is that financially it doesn't make any sense for me to even get insurance based upon the fact that with the cheapest plan I can get is about $250 a month so that's...

REHMTroy, let me ask you a question. How old did you say you were?

TROYI'm 45.

REHMAnd you have no health problems currently.

TROYCorrect, correct. And doesn't mean I won't at some point in my life, but right now, I don't. I don't take any medications. I'm not...

REHMSo you're thinking you'd rather pay the fine than pay the $250 a month.

TROYThat's correct.

REHMHow long can that go on, Julie? Suppose Troy develops some problem, then what's it going to take for him to get in?

ROVNERWell, right now, you know, one of the complaints that the insurers had been making about, you know, why their populations are -- why they're losing money, why their populations are sicker is that sick people would buy insurance, pay a couple of months premiums, use a lot of services and then stop paying the premiums. And then, you know, there were all these ways that you could sign up outside the open enrollment.

ROVNERWell, the government is, at the insurers' request, cracking down on that. it's going to be much harder to get insurance outside. And the open enrollment has been, you know, it's been shrunk. It's now only a couple of months. So you need to get it when you have it to the point, though, and this is, you know, part of the overall debate about is it worth it. Why do I have to buy insurance that covers things I will never use?

ROVNERYou know, men say, why do I have to have maternity care? And the answer is that's what insurance is about. You buy insurance for your car not hoping that you're ever going to use it and have an accident.

REHMAnd you're listening to "The Diane Rehm Show." Troy, that's a good question, if you're still there.

TROYYes.

REHMDo you own a car?

TROYI do not. Actually, I have an automobile through my work. A work for a small business so I'm provided with a vehicle. But I understand that -- I understand exactly what you're saying. It just feels like the healthy get punished with the situation being is that people that live healthy lives are still forced to pay into this system, which essentially is there -- 'cause earlier it was mentioned that insurance companies maybe didn't plan on having enough healthy people to cover for all of the unhealthy people that are going to come into the plan base.

TROYAnd so at the end of the day, for me, it just feels like the healthy people kind of get punished for being healthy and be forced into the system, you know, versus a single payer system would be different.

REHMSusan, what do you think? Are healthy people being punished?

DENTZERWell, let's just point out that so Troy is 45. One out of every two men in this country will be diagnosed with cancer over the course of their lifetime so he's got a 50 percent shot of being diagnosed with cancer in some time over the next few decades. Do you want to have coverage in case you're diagnosed with cancer? I would say, as a health policy expert, yes, you do. You also have a lot of benefits in the Affordable Care Act that you should be using, your preventive benefits.

DENTZERIf you're 45, in five years, you're going to need a colonoscopy, right? That's going to be paid for -- covered through the Affordable Care Act. So there are benefits in here that people are not commonly aware of, as point number one. Point number two is if -- Troy just said single payer would be different and single payer, all taxpayers pay for coverage, whether they need it or not. We're paying now to provide Medicare.

REHMExactly.

DENTZERI'm not collecting Medicare benefits right now. So the whole notion of insurance is that the healthy people subsidize the sick people at any level of insurance coverage and that's really what's going on here in Affordable Care Act, as well as broadly through our health insurance system.

REHMQuickly, Julie.

ROVNERAlso, healthy people have accidents. Almost by definition, healthy people are out doing things and, you know, they fall and break an ankle or, you know, they pop a, you know, an ACL. I mean, that's -- healthy people are the ones that tend to then have fairly expensive health bills.

REHMBut Troy might say, as long as I'm healthy, can't I wait until something like that happens and then get insurance.

ROVNERSure, but A, he'll have to wait and, B, he'll have to pay the fine in the meantime.

REHMExactly. All right. We'll take a short break here. When we come back, we've got lots of callers. I'll try to get to as many of you as we can.

REHMAnd we have an email from Susan in Bloomington, Indiana. Please ask if there are any stats on how many employers dropped coverage that they previously provided, high deductibles or not, after the ACA passed, causing their employees to have to go to the ACA for coverage? What do you think, Julie?

ROVNERWell actually, this has been one of the big surprises about the law. Everybody assumed that some number of employers would simply think oh, thank goodness, I don't have to do this anymore, I'll give you a raise, you can go get a tax credit on the exchange. That hasn't happened. So the exchanges are much smaller than the Congressional Budget Office and others estimated because so many employers have not stopped offering coverage.

ROVNERNow that may be because the exchanges got off to such a difficult start in 2013. It's hard to know why. But that's one of the things that has made the exchanges sort of so small and so sick is that they haven't had this influx of people from businesses that stopped providing coverage.

REHMStephanie, do you want to add to that?

ARMOURI think it's a good question because it is a misconception that is still out there, that one of the aspects of the law caused employers to drop coverage, and it's completely correct, they have not, and that is one of the reasons the Obama administration has struggled with some of its enrollment goals, simply because there's not as many people as they thought that had been dropped.

REHMSusan?

DENTZERAll of that is right, and I would add that employers, many of them, have discovered all over again how valuable offering coverage is as a recruitment tool. Labor markets have tightened. The unemployment rate has fallen. If you want to get the best employees, you want to offer health insurance coverage, and you don't really want to take the risk of having your -- having it be perceived by your employees that you're dumping them into the health insurance exchange.

REHMRight. All right, here is a caller in Paw Paw, West Virginia. Hi there, Russell, you're on the air.

RUSSELLGood morning, Diane, and I have to say that I'm very upset about the health insurance system in the...

REHMTell me why.

RUSSELLI'll tell you why, but first I have to tell you that a group of us are -- single payer supporters are going to Washington next week to join with Ralph Nader's Breaking Through Power four-day gathering because we want to secure single payer for the American people. And the Washington Post this morning had an article reporting on a Gallup Poll from yesterday, saying that most Americans, including a large number of Republicans, want to replace Obamacare with single payer.

RUSSELLI have my own personal story on Obamacare. Yes, I have it, but it's an $8,000 deductible, and I believe Susan said oh, but the screenings are free. Yeah, but if you say anything's wrong, it moves from a screening to a diagnostic, and they charge you for it. So it's driving people absolutely crazy. And Nader did this great piece, 21 reasons why Canadian health care is better than Obamacare, and I think one of the things that gets people really upset, Diane, is for example, Susan, who's on your panel, the name of her group is the Network for Excellence in Health Innovation, but if you look at her board of directors, they're all corporate types from insurance companies, from drug companies.

RUSSELLSo I think we have to break through the media, we have to secure single payer because that's what the American people want.

REHMAll right, to what extent, Susan, do you agree that single payer, that certainly Bernie Sanders has been talking and Hillary Clinton floated, to put everybody under Medicare at age 50, to what extent do you agree with our caller?

DENTZERWell first of all, I just want to correct the record on NEHI. We have everybody in our coalition, including patient groups. So we are not entirely a creature of...

REHMSimply a corporate, yeah.

DENTZERYes, corporate. So that's point number one. On single payer, first of all, let's point out we are -- we have the biggest single payer system in the world right now. It's called Medicare. And Medicaid is obviously a form of single payer, as well. So we have more "single payer" insurance in this country than in any place in the world. So that's point number one. Do we want to expand that even further is a very important political debate right now.

DENTZERI will just point out that Bernie Sanders' Medicare for all program does -- would create a single payer, Medicare for all system. It has very large payroll tax increases and income tax increases in it to fund it. So a legitimate question is, is the American public ready to move from the system that we have now, where yes, we have high deductibles for many people, yes, we're paying high premiums, are we willing to move and float all of those expenses through the government coffers and pay much higher payroll taxes and much higher income taxes.

REHMAnd?

DENTZERIt is a legitimate question for discussion and debate.

REHMAbsolutely, and what would Bernie Sanders' idea cost, Julie?

ROVNERWell, a lot more than he has floated in income tax increases. The Urban Institute last week estimated that it is $18 trillion short of paying for itself. Now it's important to know that what Bernie Sanders is proposing is not what Medicare is. Medicare as it exists today has lots and lots of requirements for patients to have, you know, for co-pays. Yeah, the deductibles are not that high in Medicare, although the hospital deductible is substantial, but the ongoing out-of-pocket costs can be enormous. That's why most people who have Medicare have supplemental insurance.

ROVNERNow what -- what Bernie Sanders is talking about is that there would be no need for supplemental insurance, that this new Medicare for everyone would pay pretty much for everything. That's what would make it so expensive, and that would be a level that even other countries that have single payer plans don't have.

REHMBut do you agree that most people are saying that's what I want, Stephanie?

ARMOURI think it sounds great in theory, and I think that there is strong support for it, but the strong support that may be out there in the public is far different than what's going on in the Hill, and this is an idea that has intrigued people and had support for decades, really, but it has never gotten a majority support, and in fact I think in the current political climate it would be very difficult.

REHMYou know, I wonder how long ago it was that people had ideas, and the Congress simply had different ideas, and yet they are supposedly there to represent what it is the people want. How long ago did that division occur?

ROVNERWell, I think it's -- with single payer, which has been -- you know, during the Bill Clinton health reform debate, there was a big faction that wanted single payer. In fact Bernie Sanders was a member of that faction at the time.

REHMRight, right, right,

ROVNERAnd the problem with single payer is that it has always had strong support, but it's always been a plurality and not a majority, and I think that's -- even if the Congress were to try to take it up, there simply isn't, you know, 50 percent plus one for single payer, and there hasn't been. Now maybe at some point there will be, and then Congress will try to have to figure out how to implement it, but right now, yes, it has -- it has strong support, it has had strong support for, what is now, almost 30 years. The question is when will it -- or if -- will it ever get over the hump.

ROVNERIt's -- the other thing that's going on now, and we're seeing, is that what we're trying sort of by accident is the other side, the sort of conservative idea of give people more what they call skin in the game, make them pay more of their own health care bills, and maybe they'll shop better. We're seeing that now, and people are not so much shopping better.

REHMAll right, to David in Tulsa, Oklahoma, hi there.

DAVIDHi, Diane, it's an honor to be on your show.

REHMThank you.

DAVIDThank you very much for having me.

REHMThanks.

DAVIDI just wanted to talk about how the ACA has affected my life, and I was -- I used to be addicted to opiates at one point in my life, and whenever you have an opiate addiction, your entire day is dedicated to, you know, finding -- finding, you know, opiates so that you don't get sick. And when I signed up for the ACA, I was finally able to afford medication that would allow me -- which is Suboxone by the way, that would allow me to wean myself off in a doctor's office setting. You weren't looked down upon like, you know, you do -- you see with some methadone users and other things like that.

DAVIDAnd it basically -- I mean, the ACA saved my life, and I really wanted to -- in fact -- I mean, it was such a big deal to me, I wrote a president to -- or I wrote a letter to the president and thanked him for it. Anyway, I wanted to say that, you know, despite the high deductibles I get or the high, yeah, deductibles, most of them are not, you know, for doctor office visits. The high deductibles come from when you want to go to the emergency room, and that's -- at least that's what it is with my case.

REHMYeah.

DAVIDI don't -- I'm not sure it is...

REHMOkay, David, well I'm glad to hear that you made it through that process. I'm glad you feel it saved your life. Probably a lot of other folks out there feeling the same way.

ARMOURWell, what I think is really interesting about what David pointed out is sort of the challenge of this law. There are people you hear from, where having coverage for the first time has changed their life, has allowed them to get treatment they would never have had before or would have been denied from. That is absolutely true. You also hear from people like I believe our first caller, who are struggling with deductibles where they say suddenly are under-insured, they can't go to the doctor, whereas before they could.

ARMOURSo that's why I think you're seeing such polarized support for this law. It really depends on where you live and how you're personally affected.

REHMAnd here's an email from Stuart. He says "I'm interested to hear whether any of you believe the good intentions of the ACA are being held hostage by individual states refusing to establish their own marketplaces and insurance companies withdrawing from both state and federal marketplaces," Julie?

ROVNERWell, I think it doesn't matter at this point whether the state or the federal government is running the marketplace. That sort of -- that's become, now that healthcare.gov sort of works, that's really not an issue anymore. You know, everybody -- this -- a law of this magnitude would normally have had four or five rounds of what they call technical corrections at this point by Congress, where they would have come in, seen -- I mean, everybody knew that there were going to be unintended consequences, and Congress would have dealt with them.

REHMSure, sure.

ROVNERAnd that because of the political polarization on Capitol Hill, that hasn't happened, and I think that's part of the difficulty here is that Congress has not really had a chance to fine-tune some of these things and, you know, in places where the law sort of went off to one side that they weren't intending to sort of bring it back to center. And that's one of the, you know, the many, I think, difficulties about something, about a change of this magnitude.

REHMBut what about states refusing to create their own Medicaid programs?

DENTZERThat is the area where I think it's fair to say the states are holding their populations hostage to it. With 19 states not having expanded the Medicaid program, if you map those states out, and then you look at a map that shows what areas of the country have the worst health outcomes, it's the same states.

REHMGive me an example.

DENTZERThe states across the South, the Southeast and even up into the Midwest and upper-middle Northwest. So that map is the same map as the states in which mortality among white, low-income populations is rising. These are states with serious health issues. If you look at the states that have expanded Medicaid, there's been a surge in diabetes diagnoses. Why? Not because they got diabetes because of the Affordable Care Act. These people had diabetes that wasn't diagnosed. Now they're getting diagnosed, they're getting treatment. Because they get treatment, there will be fewer amputations, less blindness, less death.

DENTZERAnd so you have these states that have basically said to a big swath of their population, I'm sorry, we're just not going to provide you access to health care.

REHMAnd you're listening to "The Diane Rehm Show." Let's go now to Birmingham, Alabama. You're on the air, Christine.

CHRISTINEHello, Diane, can you hear me okay?

REHMSure can, go right ahead.

CHRISTINEOkay, great. First of all, I want to say it's just such an honor to hear your voice today.

REHMThank you.

CHRISTINEI love your show. So I had a couple of points. I was the proverbial super-healthy 40-year-old and ended up having a routine test that showed blood in my stool. I was diagnosed with colon cancer last year, and I'm doing great now, thank goodness.

REHMThank goodness.

CHRISTINEBut, you know, for anyone who doesn't want health insurance, it happens, you know, and it's just -- it's a sad reality. You know, you think you're doing everything right, and cancer just sneaks in there. So for people who think it's not worth, you know, the money, I guarantee you it is. But a point I wanted to definitely make was my insurance company is sort of pushing us to third party vendors, if that makes any sense.

CHRISTINEI go to the University of Alabama in Birmingham, which is one of the pre-eminent cancer hospitals really in the world, and for my particular cancer, the doctor is one of the top five in the country. And my insurance company has a deductible set, when I go get my lab work done in the hospital in the facility so that my doctor can see my lab work within 10 minutes of me having my blood drawn, that's a $275 deductible every three months because of course they want to check my blood to make sure that my cancer isn't back.

CHRISTINEThey want to send me to a third-party vendor. They'll pay 100 percent, but that third-party vendor isn't on site, there's only one or two in the city of Birmingham, and I have no idea what that turnaround is. So my insurance company would rather -- and of course when I argued, they said, well, you have a choice, you can do whatever you want to do. Well fortunately, I'm very blessed financially that I can afford the $275 every four months or every three months. That's $1,000 -- that's a house payment. That's a car payment. That's sending your kids on a nice vacation.

REHMOf course, Julie?

ROVNERYeah, this is one of the issues that we haven't gotten to, because there are many issues you can get to, of -- I mean in this case, the caller knows about it, but we have these surprise medical bills, and one of the things that insurance companies have done to try to keep down costs is they have made their networks narrower, smaller. So they only have -- you know, they have fewer participating providers.

ROVNERWhat tends to happen is that you'll go to a hospital, the hospital will be in-network, but a lot of the people who work there aren't. In this case the lab is not in-network. You know, it happens -- it's more severe in emergencies, you know, but people have gone, even they've scheduled C-sections, and then all of a sudden there's an assistant surgeon, and they'll get a $20,000 bill for an assistant surgeon who's out of network.

REHMWow.

ROVNERSo that's another big issue.

REHMAll right, and last email from Dan in Sacramento, California. He says, wait a minute, aren't medical insurance deductible payments tax deductible? They are an initial burden until the end of the year, when Americans get to write them off, assuming one's deductions exceeds the standard deduction. Is that correct, Julie?

ROVNERNo, I actually think that health deductions now have to be 10 percent. So they -- that was one of the ways they paid for the Affordable Care Act is they raised how much you had to pay in medical expenses to be able to write it off. So yes, so if you are, you know -- the deductibles aren't medical expenses. Medical expenses are deductible but only after you reach the threshold for medical expenses on your taxes.

REHMAnd at that we'll leave it, but clearly many more issues, and time moves on, creating more issues. Stephanie Armor, Julie Rovner, Susan Dentzer, thank you all so much.

ARMOURThanks, Diane.

ROVNERThank you.

DENTZERThanks.

REHMAnd thanks for listening, all. I'm Diane Rehm.