AUDIE CORNISH, HOST:
Tonight, Barack Obama will give a farewell address and make his final case as president for Obamacare. At the same time, Republicans in Congress want to dismantle the law. But the question is timing. This week, some Republicans have raised concerns about repealing the law without a plan to replace it.
KELLY MCEVERS, HOST:
Donald Trump told The New York Times today he wants a vote to repeal the law as soon as next week and said the law will be replaced, quote, "very quickly or simultaneously." Here's what House Speaker Paul Ryan said on Capitol Hill.
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PAUL RYAN: We're going to use every tool at our disposal through legislation, through regulation to bring replace concurrent along with repeal so that we can save people from this mess.
CORNISH: Earlier, I sat down with Sylvia Burwell. She's the outgoing secretary of health and human services. She's been tasked with defending and implementing the Affordable Care Act to the end. And I asked her whether Ryan's choice of the word concurrent was meaningful to her.
SYLVIA BURWELL: It is a meaningful term. If you're going to take something away, you have to know what you're doing going forward. If you go ahead, we need to face the hard questions and the choices that we need to make as a nation. And doing those together will get us to that place.
CORNISH: Is it possible to do it piecemeal? For instance, we have heard lawmakers say, going forward, we want to find a way to hold on to this rule that says that insurers can't use pre-existing conditions against people. Can you do that - hold onto the aspects of it that you like?
BURWELL: You know, the system is a bit like the game of Jenga. There are pieces. And when you remove one piece, you could bring the entire tower down in terms of the way that game is played. And so it's important to understand the relationship between pre-existing conditions and the ability to pay for those. And so once you've determined that you want to really make sure that people with pre-existing conditions have access and can afford health care, there are other things you're going to have to do.
CORNISH: You know, you've had this past election and then, frankly, two past congressional elections that showed people have a poor impression of Obamacare, right? They supported lawmakers who said, we're going there to repeal it. Were you disappointed? Are you disappointed that many people who have gotten coverage through the Affordable Care Act have essentially voted against it?
BURWELL: You know, I think this is where we need to move from the rhetoric to the reality. When one looks at the polling and the information and actually asks individuals, if you use the word Affordable Care Act or Obamacare and ask their opinion, it's very different than if you ask them, do you want to go back to places where you don't have out-of-pocket limits, where pre-existing conditions can keep you out? Until up to 26, your kid can be on your policy. When you actually ask about the substance of what the Affordable Care Act has provided - and that's to people who are already insured, as well as those people who have gained insurance - you get a very, very different response.
CORNISH: So after these years, what do you consider a failure of the program? I mean, it feels like two completely different worlds, one where you have Democrats who say this is great. It doesn't seem to have that many problems, or the problems weren't as bad as they were before - and then Republicans who say there are serious problems here that need to be addressed going forward. And, meanwhile, you have insurers that, you know, in some markets, are fleeing left and right and complaining about uncertainty. It doesn't feel as stable and good, I think, as the administration describes it.
BURWELL: So I think, though, you need to - one needs to focus on, what are the big-picture issues? We have the lowest uninsured rate in the nation's history. Twenty million more Americans have insurance that did not have insurance before the Affordable Care Act. For many people, they consider it just a basic part of their health care that they can't be locked out of because of pre-existing conditions.
There are many fundamental things that have improved as part of the Affordable Care Act. There are places where we need to improve and we want to improve. And we look for partners to improve. That's one of the things - as we look at what's happened. One's ability to legislate improvements to the act hasn't occurred over the past six years. And so, hopefully, now we're at a place where that conversation can occur and will occur.
CORNISH: How would you like to see that conversation go forward?
BURWELL: We have articulated - the president and other Democrats have articulated what they believe are improvements that we need to have to our existing plan. And I think what we need to see is - what is the plan? As the president said earlier this week, if there's a plan that can do better on access, affordability and quality, he will support it. But right now it's been six years, and we have not yet seen a plan.
CORNISH: There are people who are hearing the conversation about repeal, seeing a president who is eager to sign one and maybe are worried about their access to care right now. What do you say to them?
BURWELL: You know, I separate the conversation into two pieces. Right now we're in the middle of open enrollment, the period when people can come in and sign up. They can shop, try and find a plan.
CORNISH: But why would I enroll if I hear every day that it's going...
BURWELL: Because there's a difference.
CORNISH: ...To be repealed?
BURWELL: It creates a difficult place for us to be in. But for '17 - that means coverage for people who are signing up right now for this calendar year - I think everyone - the insurance companies, Republicans on the Hill - we have heard from everyone that coverage will not be interrupted for the year of '17. But what is important is what's going to happen in 2018. And that's the conversation that's occurring right now.
CORNISH: Sylvia Burwell is the secretary of health and human services. Thank you for coming in to speak with ALL THINGS CONSIDERED.
BURWELL: Thank you so much for having me. Transcript provided by NPR, Copyright NPR.