Republicans Want To Get Rid Of Obamacare. But Then What?

DAVE DAVIES, HOST: This is FRESH AIR. I'm Dave Davies, in for Terry Gross. While President Trump clashed with some Republicans over a variety of issues in last year's campaign, one thing they all seemed to agree on was the need to repeal the Affordable Care Act, known as Obamacare. Now that congressional Republicans have a willing president and the votes to scrap the health care law, they're finding the task a little more complicated than it seemed. Republican lawmakers have a wide range of ideas about what they might replace Obamacare with. But a secret recording of a Republican policy meeting in Philadelphia revealed many are worried about the political cost of removing coverage from those who've come to count on it.

For some perspective on what's happening in Washington and how it might affect our health care, we turn to Sarah Kliff, a senior policy correspondent at vox.com. Before joining Vox, Kliff covered health policy for The Washington Post and for POLITICO and Newsweek. She co-hosts a policy-oriented podcast for Vox called "The Weeds." Kliff and co-host Ezra Klein recently interviewed President Obama about the debate over health care and the possible repeal of the Affordable Care Act. I spoke with Sarah Kliff Tuesday.

Well, Sarah Kliff, welcome to FRESH AIR. You know, there are a lot of things about the Affordable Care Act, or Obamacare, that people like to talk about. I mean, 20 million more Americans are covered, preexisting conditions are covered, kids stay on their plans - their parents' plans longer. What is it that Republicans so hate that they must repeal it?

SARAH KLIFF: Well, one is that it was a big political win for Democrats - right? - that they have this big thing that they did. They covered millions of people with insurance. And it really has been incredibly, surprisingly unified on the Republican side since seven years ago, when the law passed, that they have just remained incredibly unified on repeal. So I think part of it is politics, that it's not great to have the other side have this program that covers 20 million people. And part of it are actual policy concerns with the law. I think there are concerns about premiums going up, about too few insurance plans participating in the marketplaces.

And just generally, I think there's a philosophical disagreement about the role government ought to play in health care. Sometimes I question how genuine some of those concerns are, particularly when I see what the Republican replacement plans would do with them. So, you know, I really see it as a mix of policy and politics that kind of lead to this position on - that Republicans have of really uniformly opposing the Affordable Care Act.

DAVIES: You were out in the field recently kind of sampling opinions on what people don't like about Obamacare. And you went to Kentucky in a particular area of the state, in southeastern Kentucky. Why there?

KLIFF: I was covering the health care law in 2010 when it passed, and I expected, like many people, that as all the hubbub died down that it would get more popular. And it didn't happen. And in fact, you saw a lot of places where people had signed up for Obamacare in really high numbers that they voted overwhelmingly for Trump, for a candidate who promised to dismantle the health care law. So I want to understand that a little bit better, so I decided to go to southeastern Kentucky, which is one of the areas of the country that has benefited most from the law. The uninsured rate there has fallen by about 10 percentage points from 25 percent to 15 percent because of the health care law.

But this is an area that just overwhelmingly, depending on the county, 80 to 90 percent voted for Trump. And so I was very curious about, you know, were these Obamacare enrollees who voted for Trump? And the answer I found overwhelmingly was yes. Everyone I talked to who was using Obamacare, over the course of three days, was a Trump supporter. And it was really surprising to me what I learned there. There was an expectation that this was all campaign bluster, that, yes, Trump talked about repealing Obamacare, but he wouldn't actually do it because who takes away someone's health insurance? I thought people were maybe confused about the program they were using because Obamacare often doesn't go by the name Obamacare. In Kentucky, for example, they called their private insurance marketplace Kynect. They also expanded Medicaid, so that goes by a different name.

You know, the former governor, Governor Beshear, who set up Obamacare in the state, he said he was really conscious about not using the word Obamacare because the president was so unpopular in his state. So I had thought, well, maybe when I tell these people this is part of Obamacare, they'd be surprised. But that wasn't the case at all. In fact, the Obamacare enrollment worker I was shadowing, she had voted for Trump, and she clearly understood what Obamacare was. And she just - she saw some real problems with the health care law, and she expected that Donald Trump was going to fix them.

DAVIES: Right. So it wasn't like these people didn't think they were getting Obamacare. They understood that. Talk about the woman that you spoke to who was a recruiter. She signed people up for Obamacare. In fact, you brought her to Washington for your interview with with President Obama, and she explained why she voted for Trump. What were her issues?

KLIFF: I was pretty surprised to find someone who's job for three years it has been to sign people up for the Affordable Care Act who says she knows more people who have benefited from the health care law than have been harmed by it - I was pretty surprised when she told me that she had supported Trump in the election. And what she would tell me is that at first she was really happy with the health care law. She saw people getting insurance for the first time. That was great. But over the past year - and this is what she asked President Obama about - she's seen the law be - work less well for the people in her area. She has seen the choice of insurers go down. She has seen premiums go up.

And that really is a national story. That is not a story specific to Kentucky. I think it is fair to say while the health care law is covering 20 million people, it has also kind of struggled in terms of getting insurers onto the marketplace, in terms of keeping premiums under control. So when she came to D.C. - and one other fascinating twist about Kathy, this enrollment worker, she had actually voted for Obama twice. She voted for him because she wanted the expansion of health insurance, so it was a real turnaround to vote for Trump. She basically said, you know, I like the idea of insurance, but I also see that the law increasingly doesn't feel like it's working for the people in my state, and that's why I decided to vote for Trump.

DAVIES: Yeah. Well, let's talk about what's happened lately in the law a bit because I covered the presidential campaign and a Senate campaign here. And Republicans, at least within the last year, have loved to talk about how premiums have gone up for those on the health care exchanges and insurers have gotten out of the market, I think, in a third of the counties across the country. Now there's only one choice for those who get insurance. Why are those things happening?

KLIFF: Yeah, I think it is - I don't think the marketplaces were collapsing, as Republicans say, but I think they certainly were struggling. And there were problems that a Trump administration or a Clinton administration were going to have to address with the law. Some kind of changes were going to have to be made. So the biggest challenge, I would say, is that you saw the insurance marketplaces, these exchanges that Obamacare set up, becoming a less desirable place for insurance plans to sell.

One of the gambles that the legislators made when they passed Obamacare is they decided to work with these private partners. They decided health plans would sell and compete. If you remember, there wasn't enough political support for a public option. It would really come down to these private carriers. And I think private carriers, you know, big insurers like Aetna and United, they were willing to dip their toes in the water. One of the things they found is that the people who signed up for insurance in the marketplace, they were sicker than they expected. They had higher bills than they expected. And that was one of the reasons you saw some insurance premiums really going up quite significantly in 2016.

Insurance companies had underpriced for two years and were trying - now that they had some data for the first time about who buys insurance on these new marketplaces, they were adjusting their premiums upwards. You know, one thing I will add is that the premiums actually came in lower than the Congressional Budget Office expected in 2014 and 2015. Initially, there was some celebration in the Obama administration, saying, look, this is great. People are charging even less for insurance. And then the premiums spiked up to where CBO expected they would be, this nonpartisan budget-keeping agency here in D.C. So it kind of bit the law a little bit, that insurers underpriced at the start and that meant they really had to do a very large premium increase in 2016.

DAVIES: All right. So there really were some setbacks for those who were on the exchanges. But of course, those who qualified got subsidies. To what extent did the government subsidies compensate for the increases in premium costs?

KLIFF: So to a pretty big extent on the exchanges. I believe it's about 85 percent of people who buy coverage on the marketplaces are getting some kind of subsidy to buy it. And it's a little bit wonky, but it's important to understand how the subsidies work because they basically say you only have to spend X percent of your income on health insurance. The X percent is a little bigger if you earn more, a little bit smaller if you earn less. And they say you spend X percent, government will cover the rest. So premiums are capped for people who are getting subsidies. They are essentially shielded from a big increase. And that's true of 85 percent of people in the marketplace.

However, there are still a good number of people who are generally higher income who don't get subsidies, and they buy coverage off the marketplace. And they really had to bear the full brunt of these premium increases. So there is a sizable contingency of people - maybe like an 8 to 10 million range - who were paying the full amount of these premium increases. And those people were understandably quite frustrated. And they got notice of their premium increases right before the election, right in this past fall.

DAVIES: You know, nobody likes growing health care costs. Can we say overall whether the onset of the Affordable Care Act - of Obamacare - had any noticeable effect on health insurance prices overall in the economy. Where - I mean, 'cause my recollection is they were probably - they were rising a good bit before the act. Was there any noticeable trend there?

KLIFF: Yeah, so that's a great point, is that it's not like insurance premiums were just flat or going down before the law passed. We were used to these kind of big increases. We didn't have as much good data because the government was much less involved in the individual market. There are a few analyses from The Commonwealth Fund that suggest premiums have gone up slower since the Affordable Care Act passed.

And there is more regulation around insurance premiums under the ACA. Regulators put more scrutiny towards any double digit premium increases and they did before. So there is some data that on average premiums have gone up slower than they did before the ACA. Most of that data is pre-2016, so it does not get this recent year of pretty significant increases.

DAVIES: You spoke to a woman who owns a furniture store who has an interesting story because she's somebody with a pre-existing health condition. Tell us about her.

KLIFF: Yeah. So this was a woman named Debbie, who - her husband actually got sick a few years with non-alcoholic cirrhosis of the liver. And they are a couple who generally have been pretty happy with Obamacare. They used to buy their own insurance before the health care law passed. And it got too expensive, so they went a few years without coverage. And when I talked to Debbie in Kentucky, she talked about how they were really grateful for the coverage because her husband got unexpectedly sick. He now needs a liver transplant, and that they can rely on this health insurance to cover it. And they were generally OK with the size of their premiums.

So we spent a while talking about that, and then I asked her who she voted for. And she told me she voted for Trump. And again, I was just kind of floored that someone who not only, you know, understood this was Obamacare - was happy with their coverage, voted for Trump. And again, she kind of heard this - she gave this explanation that I'd heard before that she, you know, has seen some jobs disappear in the area. This is an area that used to rely a lot on coal mining. And they see revenue in their furniture store go down when there's fewer coal miners buying things there. And she felt like Trump was the candidate who's going to bring back the coal industry, who was going to bring back jobs. And she watched the debates. She heard the talk about Obamacare, but she just didn't think that someone would take away her health insurance because why would someone possibly do that?

And that was, you know, one of the harder interviews I did during that story because I started talking about, well, they plan to repeal it, and we don't really know what they're going to replace it with. And it seemed to kind of dawn on her in the interview that their health insurance was at risk. And she was someone who seemed more nervous after we talked about what their future might look like.

DAVIES: Sarah Kliff is a senior policy correspondent at vox.com. She's currently focusing on efforts to repeal Obamacare. We'll continue our conversation after a short break. This is FRESH AIR.

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DAVIES: This is FRESH AIR. We're speaking with Sarah Kliff. She's been reporting on health care policy for many years. She's currently a senior policy correspondent for vox.com. She also co-hosts a policy-oriented podcast called "The Weeds." So now Republicans after all these years have the White House, and they have Congress, and they can move to repeal Obamacare as they have promised for so long. It appears this is a bit of a political dilemma for them. We'll talk about this. I'm interested what they're hearing from their constituents about this subject.

KLIFF: They are hearing a lot from their constituents about this subject. One of the things that's been interesting to me as someone who's covered this for a while and - is that it almost feels like 2009 when the Democrats were pursuing health care, except the tables have turned. It seems like Republicans are right now facing a lot of outcry at town hall meetings. They're hearing from constituents who have coverage who don't want to lose it.

There were multiple town hall meetings - I believe one in New York, another in California - that attracted over a thousand people, generally supporters of the ACA saying don't take my health care away. I think things change a little bit when people gain coverage. This is one of the theories that, you know, we talked about some of the theories that were wrong about the Affordable Care Act, that it would get more popular. I think one of the theories Democrats did get right but we're just learning it now is that once you roll out benefits, they're quite hard to take away.

And I think once there's actually been this quite real threat, there has been a lot of negative sentiment expressed towards legislators. And at least the ones I've talked to, you know, do say they're getting a lot of pushback, that they're hearing from people who don't want to lose their insurance. And you'll see a lot of interviews about this in my stories and others of legislators saying that they need to be responsive to those people who are worried about losing their coverage and make sure that they're able to do something for those people.

DAVIES: And there was that Republican policy meeting in Philadelphia where somebody got in and got a recording of events. And it appeared that leaders of the health care reform movement in the Republican Party are concerned about this.

KLIFF: Yeah. I think they, you know, that recording really showed that they're hearing from constituents who are unhappy about not only the Affordable Care Act, but Planned Parenthood. That's another issue they were hoping to roll into Obamacare repeal was also defunding Planned Parenthood. And you heard in those leaked recordings that you even have one legislator saying, like, why do we have to take on Planned Parenthood right now? I'm dealing with enough on the health care law.

And I think, you know, those tapes also showed that Republicans, you know, they aren't quite sure what to do with the position they've found themselves in. I think they were just as surprised as many of us were that Trump won the election. They did not expect to be in a position where they could repeal the Affordable Care Act. And while they spent seven years, you know, campaigning on it and promising to repeal and promising a replace plan, they are very, very far from agreeing on how actually to do that, and what a replacement plan looks like.

DAVIES: So what approach that some Republicans have taken is to say, well, let's repeal Obamacare immediately and then plan to replace it two or three years down the road. What does that mean?

KLIFF: Yeah. So repeal and delay was kind of the hot, new strategy I'd say about a month ago because it seemed politically easier, right? You could deliver a political win, and you could give yourself a two or three-year runway to pass a replacement plan, which Republicans really need because they have not settled on what a replace looks like on their end quite yet.

That plan has kind of gotten a lot of pushback and kind of fallen off the radar a little bit for a few reasons. One is President Trump has said he wants to do it at the same time. He doesn't want to rate (ph) on replacement. And most of the experts on health policy - both those who support and oppose the law, thought this was a really, really bad idea because, you know, as I mentioned earlier, the insurance marketplaces in Obamacare - they rely on private insurers like Cigna, Aetna, all these carriers we're familiar with. They rely on those folks showing up and selling insurance policies on the marketplace.

If the Republicans were to say these marketplaces are closing in two years, there's a real substantive fear that insurers would say, well, why are we going to stay around for this weird two-year period? You know, if this is closing, we're going to close up shop here, and, you know, call it a day. So I think Republicans like the idea of giving themselves like a two-year kind of pause button. But it turns out there isn't a pause button you can press. When you say Obamacare is going away in a few years, you change how different actors participate, and that could really unravel the law quite quickly.

DAVIES: So let's talk about what the Republicans might have in mind for replacing the Affordable Care Act. And I thought we'd begin by listening to a TV ad that is running now paid for by a conservative group called the American Action Network. Let's listen.

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UNIDENTIFIED WOMAN: Rising premiums and deductibles, Washington intruding between doctors and patients, expensive mandates that destroy jobs. Our health care system isn't working. Republicans have a plan to fix it - better care, more choices, lower costs, peace of mind for people with pre-existing conditions, tax credits to help families buy insurance. Small businesses pulling together to drive down costs even more and Medicare strengthened. Tell Congress to pass the patient centered health care your family deserves.

DAVIES: Now, that sounds mighty appealing. Republicans have a plan, great things. Do they have a plan?

KLIFF: So you have incredible timing because I was literally emailing with the group behind this advertisement earlier today and asking them because I didn't think Republicans had a plan. We haven't seen them really coalesce around one option. The group behind that plan says that that ad refers to something called Better Way which is Paul Ryan's, the House speaker's, proposal to repeal and replace Obamacare.

And I think it's a bit of an overreach to say Republicans have a plan. I'd say Paul Ryan's plan is one among many being considered by Republicans right now. And there really isn't anything to pass yet. You know, that ad says call on your congressmen to, you know, pass this plan. The plan as it exists right now is - I think it's a 28-page white paper that outlines some broad strokes about what Republicans would do.

But there is no law, there's nothing written in legislative language to support. And I think one other thing that kind of jumped out at me about that particular ad was they said that the plan would not be disruptive to anyone's health care, but Better Way actually make some changes that would be quite disruptive to millions of Americans' health care. Some people would find that disruption good. It has winners, and it has losers. But the winners and losers are quite different than the winners and losers of the Affordable Care Act.

DAVIES: Sarah Kliff is a senior policy correspondent for vox.com. After a break, she'll talk more about how Republicans proposed dealing with health care challenges such as insuring people with pre-existing medical conditions. And Maureen Corrigan reviews the highly anticipated first novel from George Saunders. I'm Dave Davies, and this is FRESH AIR.

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DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross. We're talking about what happens if Republicans repeal the Affordable Care Act or Obamacare with Sarah Kliff senior policy correspondent for vox.com. She's covered health policy for many years for the Washington Post and other publications. She says Republicans aren't united on just what they'd replace Obamacare with, but many like the idea of expanding individual health savings accounts.

One of the arguments for having people have health savings account - assuming they can afford them - that they put money away that's tax deductible so that that's available for their health care and then having a plan which has a high deductible. So you're responsible for the first several thousand dollars of what you spend. Part of the argument is that if the consumer has a stake in it - skin in the game is the phrase - they will be better shoppers and that will, you know, take advantage of competition in the marketplace. People will have to give them good care at good cost. To what extent is this realistic to think that consumers will be effective shoppers for health care?

KLIFF: So I think you'd really need to change the health care system pretty seriously. One of the things that makes it very hard to price shop right now is there's just such a lack of transparency in the health care industry. I've written a few stories recently about bills that people got in the emergency room. They include an emergency room that charged $629 for a Band-Aid. I just published a story this week on Vox about a college student who got some stitches in his finger and then received a bill for $2,800. It was, like, a five-minute procedure. And in all these cases, they couldn't get the prices in advance. They asked how much this would cost. They were told we don't have that information. They got the service. And then later they got a very big bill.

So I think in order for any of these plans to work, you really need very strong laws on price transparency, on giving consumers the actual price of care. And it's unclear if that would be enough or if you also might need to get into some price regulation, which is what, you know, most other - of our peer nations - they have a government board that sets the prices that different hospitals and doctors can charge. I don't think Republicans want to go down that path, but I think often I hear comparisons to shopping for other things. I was talking to Representative Phil Roe from Tennessee who said, you know, Americans are great shoppers. We'll drive across the interstate five lanes for, you know, three cents cheaper on our gas.

And I think there's something quite different about health care than other markets. You don't really get to choose when you shop for health care. You are often shopping for health care when you are unconscious and you're in an ambulance being taken somewhere. So I think it's a little bit different than cars and TVs, which we can make decisions to go without, versus, you know, lifesaving care that we often are not very good negotiators for because we can't really say no if it's something we really need.

DAVIES: When you ask Republican legislators what about the problem of, you know, patients with serious, chronic or preexisting conditions and leaving them alone in the private market might leave them shut out - as they were before - one of the things that Republicans say is, well, we can create a high-risk pool for patients with these chronic and preexisting conditions. What are they talking about? How would it work?

KLIFF: Yeah. So the idea there is that you have a handful of people who have really high medical bills who have quite severe health care needs. And one tradeoff you make by putting them in the individual market is that their costs get spread out among everyone. So if I, you know, a relatively healthy 32-year-old, am in the individual market, I'm helping pay the bills of, you know, let's say someone who's older and has cancer and has quite high treatment bills for that, and that drives up my premiums a little bit. So there's definitely a theory to the high-risk pools that makes sense. It says these are going to drive up the premiums for everyone. They're going to make the individual market less attractive. Let's segment off that risk and put it somewhere else, and we'll just have the government step in and subsidize it. It's that last step where a lot of risk pools have not worked especially well. These people have very high medical bills and requires a pretty significant funding commitment from the government.

DAVIES: And where have we seen those pools before?

KLIFF: We've seen them at the state level before - before the Affordable Care Act. And actually as part of the Affordable Care Act in the transition period between 2010 when the law passed and 2014 when the insurance expansion started, the ACA also had some high-risk pools, basically a bridge to coverage. And one of the things we saw with those ACA high-risk pools, they ran out of money really fast. They had to cap enrollment quite quickly. They didn't enroll nearly as many people as the Obama administration expected. But they ran out of their money very quickly.

And I think this is one thing we've seen in some state-level examples too, that you have to have a pretty robust funding commitment to make these work. And I believe the Better Way plan from Paul Ryan, it envisions spending $2.5 billion a year on these high-risk pools nationally. And, you know, I've talked to some experts, even, you know, conservative experts, who say $2.5 billion - like, try $25 billion to make this work. Like, you're going to really if - you can make risk pools work. You just have to be willing to spend a significant amount of money on them.

DAVIES: What happens to reproductive health care in the Republican plans?

KLIFF: Most of them would get rid of the mandate to cover women-specific preventative care. That is what's more popularly known as the birth control mandate, even though it covers a lot of other benefits. So in general - and this doesn't seem to be specific to that provision, which has been quite politically controversial. But more generally, Republican plans really want to pare back the number of benefit requirements. The Affordable Care Act has something called essential health benefits, which are 10 benefit categories that all insurance companies are required to cover, preventative benefits being one of them. The Republican plans - they think - and rightly so - they think this drives up premiums, this is making insurance too expensive. They would like to really get rid of that essential health benefits requirement. One thing that's a little unique about the birth control provision is that it's not actually written into the law that insurance companies must cover contraceptives. What Congress mandated was that insurers must cover preventative health for women. It was left to the Obama administration to then define, well, what counts as preventative care for women, and they included all forms of FDA-approved contraceptives. So one thing I'm actually watching for, because this has been a pretty politically controversial mandate, is whether Representative Price, when he does make it over to HHS, if he decides to rewrite those rules on what counts as women's health benefits. And if he decides to X out certain types of birth control or all birth control, that is something that the administration can do without Congress's help.

DAVIES: Sarah Kliff is a senior policy correspondent at vox.com. She's currently focusing on efforts to repeal Obamacare. We'll continue our conversation in just a moment. This is FRESH AIR.

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DAVIES: This is FRESH AIR. And we're speaking with Sarah Kliff. She's been reporting on health care policy for many years. She's currently a senior policy correspondent for vox.com. She also co-hosts a policy-oriented podcast called "The Weeds."

Are there important ideas we haven't talked about among Republicans for changing the health care system?

KLIFF: Yeah. There's one change that I think sounds small on paper but is quite big and quite ubiquitous among Republican plans, and it's how these subsidies work. So I think one of things that's interesting about Republican plans is they do want to subsidize the individual market. I think Obamacare has moved the baseline a little bit, where they don't want to go back to a market where there are no subsidies. They want to help people buy insurance. But the way they would do it is really different, and it creates really different winners and losers.

Right now the Affordable Care Act has income-based subsidies. If you earn less, you get more. The idea is that lower income people need more help buying insurance. The Republican plans nearly universally would have age-based tax credits, which says that depending on how old you are you get a certain amount which means that, for example, Bill Gates would qualify for the largest tax credit because he would be in the oldest bracket. The idea behind age-basing is that premiums are usually higher for older people, so they should get a little bit more help. This could be a kind of - really problematic for low-income Americans. It would, you know, advantage people who are higher income who didn't qualify for a tax credit under the ACA, but it would really disadvantage people who are getting quite large subsidies.

So it sounds like this small kind of wonky change, you know, going from income-based to age-based, but it could be really different. And it could really, you know, when I think of that ad you played earlier from American Action Network, they were talking about how there wouldn't be any disruptions. I think this one change on how you structure the subsidies, that'd be pretty disruptive for a lot of people.

DAVIES: That's a huge change. I mean, it's like going from a progressive income tax system to a proportional one. It just - it changes everything.

KLIFF: Yeah. Yeah. And so I think these are the changes, like, they're really going to have to grapple with. These are changes that exist usually in, like, a white paper, and they're going have to figure out do we want to bring these into legislation? What are the consequences of bringing these into legislation? And it's going to be a struggle. This is one of dozens of policy provisions they're going to have to work through.

DAVIES: All right, so you've been writing story after story about these ideas being floated and debated. Is there anything approaching a consensus around anything or any clear mechanism for resolving this among the Republicans?

KLIFF: So I think there are some principles that exist among a lot of the leading health care plans. So I think right now it's fair to say there are kind of three leading outlines of what a Republican plan could look like. One is the House speaker's Better Way Plan. Another is a plan from Senator Hatch, who chairs the Senate Finance Committee. And then a third is actually a pretty detailed bill that was introduced by Representative Tom Price, who we know is now Trump's pick to lead Health and Human Services.

And so generally they envision a lot of the same changes. All of them, for example, include this change from income-based to age-based tax credits. And they generally have individual markets that advantage people who are younger and who are healthier, and that disadvantage people who are older and who are sicker. And there are a lot of different policy ways that they do this. One of the kind of surprising collisions we're seeing between policy and politics is that Democrats came up with a plan to really protect older and sicker people because they cared about them. They, you know, thought these people were historically locked out of the individual market. Those people aren't really their base generally. Those people tend to vote Republican.

Republicans, meanwhile, are really looking at plans that would disadvantage older and sicker people because they kind of want to ratchet back the amount of coverage happening. I think kind of one philosophical difference between Democrats and Republicans that will really guide this debate is Democrats saw health insurance as helping people get healthier, helping them have access to health care and go to the doctor. I think Republicans see it more as financial insurance. They want something that will stop you from going bankrupt. They don't necessarily feel compelled to make sure you get all the preventative care you need. They kind of see the government role as providing some kind of baseline, but that - aren't as committed as Democrats were to actually getting people into the doctor. And I - so I think when you come at it with those two different philosophies, you end up building very different health care systems.

DAVIES: And this then-controversial principle in Obamacare which is to require everyone to get coverage - the mandate - and impose penalties if you don't. I mean, Republicans don't like the government telling anybody to do that. Of course, the problem is if young healthy people decide not to enter the insurance pool, you know, the costs change. How do they resolve that dilemma?

KLIFF: Yeah. So the main way the Republican plans to deal with this - they do have a replacement for the individual mandate. They don't like describing it that way because they don't want anything associated with the individual mandate, but they envision something called a continuous coverage requirement. The idea of a continuous coverage requirement is that you can have access to the market and you will not be underwritten or charged more for pre-existing condition if you maintain continuous coverage.

So, for example, if I buy insurance when I realize, you know, I'm pregnant or I've just been diagnosed with a terrible disease, that's really bad for the insurance market because you get a lot of sick people. So the idea is saying you have to maintain continuous coverage in order to have access to the cheaper rates. And if you don't, insurance companies can charge you more. So, you know, you hear a lot about Republicans saying we're going to ban pre-existing conditions. And while that is true, insurance companies would be required to accept everyone under most Republican plans, they would not be required to charge everyone the same amount. They could charge the people who had a break in coverage a higher rate. So under the price plan you would have to pay that higher rate for a number of months before you could go back to the kind of normal continuous coverage rate.

So that's the mechanism they've kind of settled on. I think it worries some of the law's advocates because they worry - with the individual mandate, that was a fee you would pay at the end of the year. It was a one-time fine, whereas this continuous coverage provision, it could lock people out of affordable coverage for a pretty long time, that there could be some pretty severe consequences to going without insurance for a few months in your 20s, for example.

DAVIES: What do President Trump's statements tell us about his own views on this?

KLIFF: It is really hard to tell at this point. We've seen a lot of different statements from Donald Trump on the Affordable Care Act. One example that's indicative was around timing, where Donald Trump in early January expressed a very strong opinion - I believe in an interview with The New York Times - that repeal and replace be taken care of within the first few months of 2017. And then you saw - in a more recent interview with Fox News, he said that, well, maybe it'll go into 2018.

We have heard Donald Trump talk about the fact that he wants to pass a plan that'll cover everybody, that'll cost less. I think there's a lot of skepticism that he can achieve both of those things. The Republican plans offered by Congress certainly don't achieve both of those things. But this is actually a place where Trump as a candidate really set himself apart from the Republican field. He has talked a lot about this commitment to universal coverage, which not even Obamacare hit. Obamacare still leaves, you know, 20-some million people without coverage. He has talked a lot about wanting to cover everybody, but we have seen no policy details from his White House about what he would prefer.

DAVIES: Right. And at some point, he's going to have to engage these Republican proposals and analyze them and see what their effects would be. Do we know who has his ear on this subject, whose policy analysis he might rely on?

KLIFF: So I think Tom Price really comes to mind as the person he's relying on. This is Donald Trump's pick to run Health and Human Services who also happens to be the author of one of the most kind of detailed and thorough Obamacare repeal bills, which I believe he introduced in 2015. It is a plan that I think a lot of supporters of the ACA don't like, but it's a plan that was thought through. It was - I believe it's 242 pages in legislative language unlike these more broad white papers. It really is quite substantive.

You know, we've heard Trump say before that things will really get rolling after Representative Price is confirmed and you might see some executive actions. And I also think Mike Pence has some strong views on entitlement reform. He's done a lot of really interesting and unique work with Indiana's Medicaid program. So I think the two of them are both experienced health policy legislators who have some pretty strong thoughts about what they would change.

DAVIES: Dr. Price had confirmation hearings. Did we get a clue as to what he would favor?

KLIFF: You know, he was pretty quiet on Obamacare, and he kind of demurred on a question about, well, are you going to cover everybody? I think Republicans saw Democrats walk into this trap in 2009. You remember that quote from Obama that was played again and again about how if you like your health insurance you can keep it. I think Republicans, and particularly Dr. Price, are, you know, trying not to step in that same trap. So he really didn't reveal a lot in his hearings.

His hearings have also somewhat surprisingly, at least we didn't expect it, but they focused a lot about some possible financial conflicts of interest he had as representative. And health care reform hasn't - we haven't gotten a ton of details. But we also have a lot of details of what he thinks because he wrote a 242-page bill about how he thinks Obamacare should be repealed. So he's someone who I feel like I have a good understanding of his policy preferences on the matter.

DAVIES: And they don't exactly do what the president says he wants to do - right? - cover everybody.

KLIFF: They don't. They would definitely lead to at least a few million people losing coverage. I should point out, Donald Trump, he did release a health care proposal during the campaign. This is not when he was in the White House. But his campaign proposal - the Committee for a Responsible Federal Budget analyzed it and found that it would leave 21 million more people without health coverage. So Donald Trump's campaign plan was by far the worse - if you're judging just by number of people covered, it was a plan that basically repealed Obamacare and replaced it with very, very little - no tax credits, no reforms in the individual market, like most of these other Republican plans have. So, you know, I assume he's not planning to go forward with that plan. But, you know, we've seen him change his mind on the timeline a lot so far. We don't really know where he's at with the substance of health reform.

DAVIES: Sarah Kliff, thanks so much for speaking with us.

KLIFF: Thank you.

DAVIES: Sarah Kliff is senior policy correspondent for vox.com and co-host of a policy-oriented podcast called "The Weeds." Coming up, Maureen Corrigan reviews the first novel of George Saunders. This is FRESH AIR.

DAVE DAVIES, HOST: This is FRESH AIR. George Saunders has long been celebrated for his short stories which have appeared in publications including The New Yorker and Harper's. Saunders has just published his much awaited first novel called "Lincoln In The Bardo." Our book critic Maureen Corrigan has a review.

MAUREEN CORRIGAN, BYLINE: Willie Lincoln was only 11 when he died in February 1862 of typhoid fever. The Lincoln's third son was said to be their favorite and after Willie was interred in a borrowed mausoleum in Oak Hill Cemetery in Georgetown, Abraham Lincoln returned to that cemetery several times. Newspapers reported that the president visited the crypt to open his son's coffin and hold his body. It's that image of Lincoln cradling the corpse of his beloved son in a Pieta pose that inspires George Saunders' first novel called "Lincoln In The Bardo."

Though it's early days yet, I feel pretty safe in saying that this is going to be one of the year's most acclaimed novels. "Lincoln In The Bardo" is searing, inventive and bizarre. This is George Saunders after all, whose imagination effortlessly mashes together the hell-fire visions of Hieronymus Bosch with crude middle school anatomical humor and the deadpan surrealism of Rod Serling. There's always method to Saunders' madness, and here, it forces readers to realize as if for the first time the ultimate oddness of our own existence, namely that there's an end to it, that we and everyone we love are going to die. The action of "Lincoln In The Bardo" is mostly confined within the iron gates of Oak Hill Cemetery which still exists, by the way, in Georgetown.

A voice, identified as one Hans Vollman, opens the novel with a reminiscence. On our wedding day, Hans tells us, I was 46. She was 18. Another voice, that of one Elise Traynor soon announces I was too early departed. Saunders' chatty dead are stuck in what Tibetan Buddhists call the bardo, a limbo-like state where the fears and desires they harbored when they were alive are magnified. Saunders goes on to amplify the central idea of being stuck, the newly interred Willie Lincoln is trapped in the bardo by his yearning to keep seeing his father during those heartbreaking pilgrimages Lincoln pays to the crypt.

Lincoln himself is stranded in grief. And, of course, the nation finds itself stalled in a transitional state mired in the blood and gore of the Civil War. The impossibility and yet the dire necessity of moving on are the opposing forces that wrestle with each other in this profound novel. If this overview makes "Lincoln In The Bardo" seem too static, too reminiscent of that sluggish classic "Spoon River Anthology," be assured that the wild plot swerves of Saunders' short stories have been transplanted and multiplied in his debut novel.

Old testament angels who may be demons in disguise pay the cemetery dwellers an apocalyptic visit. The ghosts of slaves rise up from their sick boxes as the dead call their coffins just outside the iron gates and integrate the lily white Oak Hill Cemetery. And in a moving, climactic scene, the legions of the dead swarm the unknowing Lincoln when he visits Willie. Saunders speaks in a hundred tongues here concocting words like skim walking to describe the peculiar way the dead navigate the cemetery and taking us deep into Lincoln's grief.

Here are some of Lincoln's staccato thoughts as he sits in that mausoleum holding Willie and grappling with his death and the mounting deaths of the Civil War. (Reading) He is just one and the weight of it about to kill me have exported this grief some 3,000 times, a mountain of boys, someone's boys - must keep on with it, may not have the heart for it.

One thing bothers me about this extraordinary novel - more of a question really than a quibble. Throughout "Lincoln In The Bardo," Saunders intersperses chapters packed with quotes from historical sources. He gives citations for these historical sources, and some are legit like Doris Kearns Goodwin's book on Lincoln, for instance. But other sources are made up. All the historical passages are tossed together indiscriminately. It's not like Saunders is doing anything new here. Novelists have been playing with historical narrative since the term postmodern was invented, but I wonder if just in the past couple of months our taste and tolerance for this kind of melding of fact and fiction has diminished. Like I say, it's a question. What's not a question is the achievement of "Lincoln In The Bardo." Like the president who graces its pages, it's monumental.

DAVIES: Maureen Corrigan teaches literature at Georgetown University. She reviewed "Lincoln In The Bardo" by George Saunders.

If you'd like to catch up on FRESH AIR interviews you missed, check out our podcast where you'll find our interview with the director of the documentary "Tower" which is about the 1966 University of Texas shooting when a sniper shot and killed 15 people and wounded 31 more.

FRESH AIR's executive producer is Danny Miller. Our interviews and reviews are produced and edited by Amy Salit, Phyllis Myers, Ann Marie Baldonado, Sam Briger, Lauren Krenzel, John Sheehan, Heidi Saman, Therese Madden, Mooj Zadie and Thea Chaloner. For Terry Gross, I'm Dave Davies.

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