Doctor Jonathan Gruber, the architect of the Affordable Care Act, explains what the 2024 presidential election means for the healthcare of millions of Americans

By: Claudia Amendoeira

SPJ New England correspondent for Student News Live

Doctor Jonathan Gruber, the architect of the Affordable Care Act and an MIT economics professor, reflects on the impact of the ACA 14 years after its passage. Despite political attempts to dismantle it, Gruber argues the ACA has reshaped the U.S. healthcare system by expanding coverage to 25 million Americans and prohibiting discrimination based on health status. Yet, he warns that a potential expiration of subsidies and ongoing resistance could undermine these gains, leaving millions vulnerable in the upcoming years.

Amendoeira: This is Claudia Amendoeira, SPJ New England Student News Live correspondent and we’re joined by Doctor Jonathan Gruber, the Ford professor of economics and the chairman of the economic department at the Massachusetts Institute of Technology. He’s also one of the architects of the Affordable Care Act, also known as Obamacare. Professor Gruber, thank you so much for joining us.

Doctor Gruber: My pleasure.

Amendoeira: It’s been 14 years since President Obama signed the Affordable Care Act into law. How successful has the law been, and how big of an impact has it had on people’s lives?

Doctor Gruber: I think the law has been very successful. I’m biased because I worked on it, but I think if you look at the facts, it has accomplished a lot of what it wanted to do, we’ve covered about 25 million people with health insurance. Most importantly, we fixed insurance markets. Many of your listeners may not realize, but before the Affordable Care Act, the US was really the only country in the developed world where insurers could legally discriminate against the uninsured. They could say, I’m going to charge you more if you’re sick, or I’m going to charge you more if you’re a woman, or I’m just going to deny you coverage. They can’t do that anymore, and so now we’ve guaranteed all Americans can get health insurance coverage, even if they’re sick.

Amendoeira: I know some Republicans have tried to repeal the ACA in the past, but their efforts have come up short when the late Senator John McCain voted against scrapping the law. Do you think Republicans this time around, after this election, will try to scrape it again?

Doctor Gruber: I am fairly confident they won’t. The law, when they went after it last time, was less than 50% popular. Now it’s about 60% popular. So I’m fairly confident they won’t. But you know, everything’s a wild card now.

Amendoeira: And in case they did repel the law, how difficult would it be to replace the ACA?

Doctor Gruber: There’s no replacement. Let’s be clear, repeal or replace. You know, Trump said it best when he said he has concepts of a plan. You know, there is no replacement. If they repeal the law, 25 million people lose health insurance. It’s that simple.

Amendoeira: If Republicans are not able to repeal the law, do you think there’s other avenues that would  go to constricted or limited, or what might they do?

Doctor Gruber: Yeah, absolutely. One of the most significant pieces— of one of the most significant things the Biden administration did was they increased the generosity of the program. So one of the features of the Affordable Care Act is there are state marketplaces where you can buy health insurance, and individuals can get tax credits to offset the cost of that health insurance. One thing that President Biden did was pass a law which said that all Americans can get those tax credits, so that no one has to pay more than 8% of their income for health insurance. That law will expire at the end of next year, and when it does, the cost of insurance will go up for many, many Americans.

Amendoeira: And you don’t expect Republicans to pass something similar?

Doctor Gruber: I don’t know. I mean, it’s a pretty big hit to people. It’s going to hit red states harder than blue states. But the problem is that, you know, the status quo is powerful, and they wouldn’t have to repeal it, they just have to not approve extending it. It dies naturally, and that’s harder. Getting them to actively approve extending it will be a lot of work.

Amendoeira: So if that law expires, and say, the Affordable Care Act, for some reason, is repealed, what is the healthcare landscape looking like for most Americans?

Doctor Gruber: If the Affordable Care Act is repealed, we’re back to a healthcare landscape where if you’re an American who doesn’t get insurance from your employer or from the government, you are uninsured. You are basically unable to get insurance that will cover you and protect you when you get sick, you go back to a world of 50 plus million Americans without health insurance who are unable to get fairly priced health insurance for them and their loved ones.

Amendoeira: How worried do you believe Americans should be about that chance?

Doctor Gruber: I think Americans should always be keeping an eye on what’s happening with our healthcare system. It’s very complicated, and I think, once again, the particular odds that it all goes away, I think, are pretty low, but far too far from zero to be comfortable.

Amendoeira: What would you like people to know or like to highlight about the Affordable Care Act after this election cycle?

Doctor Gruber: I mean, I think I’d really like to highlight that people should educate themselves about what it does. One way to do so is I actually have a comic book that explains the Affordable Care Act, called health care reform, it’s available on Amazon. But generally, educate yourself about what the law does, and don’t be misled. The law, basically, for most Americans, doesn’t do a whole lot. For most Americans, you have health insurance through your employer, the government. The law pretty much leaves you alone, although there’s still some benefits. For example, if we repeal the law, students who can get health insurance on their parents plan at age 26—that will go away. So many listeners are getting health insurance on their parents plans. The ability to do that would go away in a number of states if we repeal the law. So there’s some features like that, but the main thing is, really the people who will suffer will be people who are sick and don’t get health insurance from their employer or the government, and now won’t be able to get health coverage. The whole idea of insurance is that we protect the sick. A world where insurers can exclude the sick is not really a fair world, and I think that’s the major thing people should know about a world without the Affordable Care Act.

Amendoeira: If you had a chance to still improve on the act because I know it didn’t get passed perfectly like you wanted it to at the time. What are some of the weaknesses that you’re hoping to improve, maybe not in this election cycle, but in the future?

Doctor Gruber: I think the main weakness is there remain many, many people who are eligible for free or low cost insurance but aren’t signing up. And I think it’s about getting information to those people, helping them sign up. I think we can do a lot more outreach. We can do a lot more to make people recognize the benefits that are there. I think, you know, we still have about 25 to 30 million uninsured Americans. Probably half of them could get health insurance for free tomorrow, and they’re not doing it.

Amendoeira: How so?

Doctor Gruber: Because we have, we have a Medicaid program which gives you health insurance for free and we have these tax credits which offset the cost of private insurance for lower income people. And so people don’t realize. So I think getting people information, helping them sign up, could go a long way to getting to the remaining uninsured population.

Amendoeira: Those were all my questions. Thank you so much, Professor Gruber, thank you for joining us.

Doctor Gruber: You bet, my pleasure, and certainly folks should look up—if you’re interested in learning more about economics, you can tell your friends and colleagues, I have an online AP economics class for people who want to learn economics, that’s on the MITx platform. If you want to take my MIT class, you can take it for free through the OpenCourseWare program at MIT.

Amendoeira: Awesome. Thank you so much.