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Listen to Health Affairs Editor-in-Chief Alan Weil interview Katie Keith on the latest Affordable Care Act news and explore the law's successes, shortcomings, and unfinished work.
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
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Hello, and welcome to A Health Policy. I'm your host, Alan Weil. March 23rd marked the 12th anniversary of the passage of the Affordable Care Act. This landmark legislation expanded health care access to millions of Americans and accelerated changes in how we organize and pay for health care. Having survived numerous legal challenges and strong political opposition by some, it continues to be the centerpiece of domestic health policy.
Speaker 1:Now if you want to understand the evolution of the Affordable Care Act from enactment to today, there's no one better to learn it from than today's guest, Katie Keith. Miss Keith is director of the Health Policy and the Law Initiative at the O'Neil Institute For National and Global Health Law at Georgetown University Law Center. She's a regular contributor to health affairs following the ACA Forefront article series and the recently launched health reform newsletter series. Most recently, she's written about the No Surprises Act rule, the Department of Health and Human Services' response to anti trans youth policies, and delay of the sunset rule, and much more. In today's episode of A Health Policy, we'll dive into the latest ACA news and explore the law's successes, shortcomings, and unfinished work.
Speaker 1:Miss Keith, welcome to the program.
Speaker 2:Thanks so much, Alan. I can't tell you how much I've been looking forward to joining you.
Speaker 1:Yeah. I've been looking forward to this for quite a while as well. I think the 2 of us could probably talk about the Affordable Care Act longer than anyone who would want to listen, but, let's try to keep their interest for a little while. You know, the first question that comes to my mind as I think about where we are hitting the 12th anniversary is, can we finally think of the Affordable Care Act as settled law? Are we done with the existential challenges legally and politically, and now it's time to figure out how to make this work?
Speaker 1:Or are we still in the, well, there just might be one more shoot it drop phase of the ACA?
Speaker 2:Yeah. It's a great question. I think we have to treat it as settled law. Normally, I think a law that's been in place for 12 years, we wouldn't even have to ask that question, but you and I both know and many of the listeners know that there has just been this ongoing political and legal battle over the, you know, sustainability of the law. I always refer to the law, as very, oh, man, what would you call it?
Speaker 2:Resilient is the word I was looking for. An extremely resilient law, I think, sort of been attacked on on all sides, but remain standing, and and I think it really underscores the need for this type of coverage, the need for the reforms that were in the law, and just the demand for the changes that the law made, particularly to the individual and small group insurance markets, as well as Medicaid expansion and a whole host of other things. So I guess one caveat to that on the legal side, I never say never that we we won't see another sort of broad side challenge, But the Supreme Court has now rejected these types of broad challenges 3 times, the last one as recently as last year. And, each time, more justices vote in favor of upholding the Affordable Care Act. I think that's really a reflection of the strength or lack thereof of the legal claims that are being made, to challenge the law, but you could see something.
Speaker 2:The last point, I mean, even politically, I think there was senator Ron Johnson a few weeks back sort of maybe said we need to think go back and rethink about repealing and replacing the Affordable Care Act and almost immediately sort of walked those comments back. I think got a lot of criticism, which really shows you. I I think Republicans ran on, you know, repealing and replacing AC for almost a decade and, could not do that in 2017, and sort of here we are. And just last year, the Democrats in congress were able to build on the law and we're sort of seeing record high enrollment as a result of that. So I I would like to think, the fight is over and and well, and we've, you know, the No Surprises Act, we've actually seen some bipartisan work, from Congress on coverage issues, which we had not seen until recent years, given Affordable Care Act politics.
Speaker 2:So, hopefully, fingers crossed.
Speaker 1:So I'm certainly with you in the never say never, but let's, take your statement at the outset. Let let's treat it as settled even though things can change. But right at the end of your last comments, you noted recent changes and growth in the programs associated with the ACA were at high levels of enrollment. One of the things I wonder about is, you know, we went through the early phases and it grew and then there was a period where it sort of settled in in opposition by the Trump administration. We'll walk through all of that later.
Speaker 1:But in the last couple of years with COVID, there have been a lot of policy changes associated with COVID that have propped up or potentially artificially inflated what looked like the successes of the ACA. So since you follow this so closely, I wonder if you can help me disentangle. Are we seeing a well established, well grounded ACA program or are we seeing the ACA maybe having made it through this these political legal challenges, but still kinda shaky only held up because of some of the emergency provisions, that were adopted around COVID?
Speaker 2:No. It's such an interesting and, I think, really important question. You know, just to to maybe step back, you sort of said this, when the Affordable Care Marketplace has opened in 2014, you sort of saw, you know, initial enrollment, I think, was around 8,000,000 and then it gradually grew and grew under the Obama administration. It peaked, in 2016 with about 12,700,000 people. And then under the Trump administration, you saw this sort of slight but steady decline year over year and it bottomed out right around 11,400,000.
Speaker 2:That increased, you know, sort of for 2021 during 2020 and for 2021 to your point because of the pandemic. Right? Folks are losing their job. They're losing their health insurance. They're finding their way to the marketplace.
Speaker 2:They're being judged eligible, some folks eligible, some folks are going into Medicaid. But you did see, you know, sort of the last year of the Trump administration was the only time enrollment increased, during during President Trump's tenure. Fast forward 1 year, and you've seen enrollment jump to 14,500,000 people for 2022. And so I think certainly some of that is COVID. I think the levels of economic disruption and coverage disruption are still there.
Speaker 2:Some of that is the Biden administration came in and supercharged the law. They, you know, put out a ton of marketing and advertising money right away. They opened a 6 month special enrollment period. We had enrollment for half of the year in 2021 to get new people in the door and really make sure that it was a sort of safe place for people to land. And then you also had the American Rescue Plan, which passed in March of 2021 that, you know, did a whole bunch of work supercharging it by really increasing the marketplace tax credits, those subsidies, both for existing enrollees, people who already qualified based on their income, and then also extending subsidies up for sort of middle and higher income people who were stuck at sort of the subsidy cliff under the original ACA.
Speaker 2:To your point, subsidies are temporary. They expire at the end of this year, and so we are dealing with a real cliff in terms of affordability, and and there could be a significant amount of premium shock. I I wanna talk more about that as we go along. I've got some data some data on that to share maybe for listeners, but, I mean, back to your question, like, how much of this is COVID or how much of it is the ACA is on solid ground? And I think it's a mix of both.
Speaker 2:I think, you know, to to me watching what happened under the Trump administration, we sort of bottomed out at about 11,400,000. Right? There was very little care, given to the marketplaces and still enrollment didn't decline significantly. I think it's once you get people in the door, they automatically are re enrolled and people have that coverage. So we could only go up from there, but the idea that you've sort of already surpassed the previous record, from 2016, I I think is remarkable.
Speaker 2:Certainly, the the enhanced subsidies are doing some work there. I guess the other point I would make, I think marketplace enrollment could be even higher if not for this Medicaid, maintenance of effort requirement that states have to comply with.
Speaker 1:I was gonna come to that topic because, you mentioned growth and, of course, the Medicaid means of effort is also leading to higher enrollment under the ACA. But you're about to go in a direction I hadn't really thought about, so I can tell where you're going. Take us there.
Speaker 2:No. That's right. I think, you know, we have record high Medicaid enrollment because of this. And, this was a provision under one of the bipartisan COVID relief packages passed in 2020, the Families First Act, and it's this idea that states can't be doing eligibility redeterminations for folks who qualify for Medicaid during the declared public health emergency, which continues to be in effect. We'll we'll see where we are when this airs, but at least today it's still in effect.
Speaker 2:And, you know, that has really kind of swelled the the Medicaid rules. So folks who basically have been eligible at any time since that law was passed in 2020 for Medicaid have stayed on Medicaid. And there's all kinds of efforts right now about, you know, how do you transition people off when the public health emergency ends and all that, but some of the estimates I've seen is that it's not that surprising given how people's income fluctuates, but of the folks who would lose Medicaid at the end of the public health emergency, about a third are expected to be eligible for, marketplace subsidies, you know, premium tax credits that they could get through the marketplace. And so there's gotta be this huge coordination of how do you, you know, help people navigate from Medicaid coverage over to the marketplaces. But, you know, if that just I guess the counterfactual, if the if the, maintenance effort requirement hadn't been in place, a lot of those folks, I think, would have qualified for marketplace coverage and maybe enrollment would be even higher.
Speaker 2:So who who's to say? But, we could see it, you know, grow even further after the the public health emergency ends as
Speaker 1:well. You know, it's funny as you describe this and and sort of the low watermark, of enrollment in the marketplace in the Trump administration. It reminds me of both the legal and the political dynamics of the individual mandate and how when the ACA was enacted, there was so much attention to the mandate as the linchpin of an effective subsidy and marketplace structure. And it just seems like over and over and over what we're seeing play out is that the linchpin for an effective marketplace is subsidies. And when you offer people subsidized coverage, they can afford it and many will buy, not all.
Speaker 1:And when you have something like the Rescue Plan increasing those subsidies, enrollment goes up. There's been no change in the mandate but there is an increase in subsidies. And so really so much of what the ACA is about is making health insurance options affordable. Now, obviously, they're affordable because they're subsidized by the taxpayer, it's not free, but, that to me seems like the dominant story. And when people when the public health emergency ends and Medicaid MOE goes away, those folks you're talking about will be eligible for subsidies.
Speaker 1:It's not just that they could go in the marketplace and purchase coverage, but, presumably, their income's at a level where they would be able to get subsidies. So this is really so much about affordability and our changing policies around the levels of support for people to buy health insurance.
Speaker 2:Yeah. People want affordable comprehensive coverage. You know? A little surprised.
Speaker 1:So you've alluded to the slow but distinctive declines in marketplace enrollment during the Trump administration. Talk to me a little bit about what you see as the primary implications of the move from an administration that was openly hostile to the law to a Biden administration that, contrary to some of the other participants in the Democratic primary, said explicitly we wanna build on this law and not replace it with something else, a very slender majority in Congress. How is that played out in terms of what the law looks like?
Speaker 2:I guess I should start by going back to the resiliency of the Affordable Care Act because I think even even when you didn't have an administration that wanted to tend the store, you know, or sort of use the Affordable Care Act as a tool in its toolbox even during the pandemic. I think the hostility to the idea of leveraging Obamacare was still too much. I remember thinking throughout 2020, there was so much pressure and and frankly bipartisan support for the Trump administration to open up a special enrollment period. It just allowed you know, I think virtually every state based marketplace did that. You had letters from governors and business leaders and all kinds and I I think even support on the Hill for doing that and it was one of those Perhaps the simplest thing you could have done to allow people to get coverage and make things really easy, and there just wasn't even appetite to do that.
Speaker 2:It was also occurring at a time where the Trump administration fully backed the the supreme court challenge that we saw in California versus Texas. So they were arguing that the entire law should be thrown out. That said, I think it's important to, really talk about how the Trump administration did leverage at least legal authority under the Affordable Care to do some of the biggest things that they wanted to do. So a lot of the prescription drug changes that was a huge priority were pushed out through the Center For Medicare and Medicaid Innovation, which was created under the Affordable Care Act. The Trump administration really focused on transparency, both for hospitals and for insurance companies.
Speaker 2:All of that is leveraged from Affordable Care Act legal authority. It actually comes from the medical loss ratio provision of all things, and they sort of read in this this authority. And and, you know, that's something the Biden administration has continued. You know, we could talk in detail about some of the sort of regulatory policies the Trump administration put in place to undermine the Affordable Care Act. I think the way to think about this is ideologically, I guess.
Speaker 2:They want to create options or alternatives to the Affordable Care Act. Right? And this idea that, I think some of the things that Republicans really push or conservatives or opponents of the Affordable Care Act, I should say, push back against, is having sort of less regulated private health insurance, right? Being able to go back to underwritten coverage, if you're healthier, why should you pay more? Really having your premiums determined by your personal risk as opposed to much more of a sort of social solidarity structure, And so they created a lot of options that would have allowed that.
Speaker 2:So really expanding short term limited duration insurance, which is fully underwritten and is is not quite individual market coverage, but is operating in parallel to the Affordable Care Act. They tried to do something similar with association health plans. There is a whole that was sort of their philosophy was to, create these alternatives, sort of create parallel markets, and we're still seeing the impact of some of that, and and some of those are areas where the Biden administration has not yet tread, and I'm sort of watching and waiting to see if they will close down some of what I think are loopholes in the Affordable Care Act, that were really exploited by the Trump administration and some some bad effects that we've seen both for individuals who end up in those plans and then also for the sort of broader risk pool for the Affordable Care Act.
Speaker 1:I wanna spend a little more time on that sort of ideological divide. Let's have that conversation after we take a
Speaker 2:short break.
Speaker 1:The Rural Health Research Gateway is your preeminent resource for free, timely, and relevant rural health research funded by the Federal Office of Rural Health Policy. Visit gateway at ruralhealthresearch.org and subscribe to Gateway's research alerts to be notified whenever new rural health research is published. Follow Gateway on Twitter and Facebook at rhrgateway for key research findings. This message was paid for by the Rural Health Research Gateway at the University of North Dakota School of Medicine and Health Sciences. And we're back.
Speaker 1:I'm speaking with Katie Keith about all things the Affordable Care Act. Before the break, you introduced this notion of undermining some of the foundations of the Affordable Care Act, but you presented it as an ideological position that I think really warrants some examination. Insurance is this sort of funny product. It's not like a a cardin of milk that you go to the grocery store and buy because it's a pooling mechanism. And who's in the pool and how the pool works affects the price of the product.
Speaker 1:Whereas if I buy a carton of milk and my neighbor buys a carton of milk, it doesn't really matter whether we're similar or different people. We both pay the same for a carton of milk. This notion of creating I liked how you said it. I'm not gonna get your words exactly right. But it seems to me that philosophically, what the Trump administration was reflecting was the notion that there should be ways to purchase insurance that don't follow the highly structured and regulated products that come out of the Affordable Care Act.
Speaker 1:We tend to focus a lot on numbers of people covered, what you're covered with, how comprehensive the coverage is. These things matter a lot when you have insurance. So I just wanna spend a moment here on this notion of what did the individual insurance market look like before the ACA? I suspect many of our listeners may not have been around or paying a lot of attention then. What were the changes ushered in and why might some of those changes be viewed ideologically as inappropriate if you're trying to give people choices around health insurance?
Speaker 2:That's a great question. And I'm very familiar with this discussion because I teach this topic to students and many of whom, you know, don't have much awareness of a sort of pre Affordable Care Act world. They've always thought pre existing conditions should be covered. Right? And so, you really do have to go back in time, not even to pre Affordable Care Act, but really pre 2014.
Speaker 2:Right? You still had products in the market that were, medically underwritten. So, you know, it was this this process where you it was up to the insurance companies and and state law in some cases, but really up to insurance companies about whether you would be covered, how you would be covered, how much you would pay, certainly exclusions for preexisting conditions, but you would have to fill out, you know, medical questionnaires and all this information they'd ask you about your medical history, your family medical history. You would send it off to each individual company, sometimes pay a fee, and then you would get the response back. Sometimes it would be, no, we won't cover you at all.
Speaker 2:That was, you know, there there's some great research folks with HIV who are just considered absolutely uninsurable. Other folks would come back and they'd say, well, we'll cover you, but it's gonna cost you this much more money because you have a family history of cancer. Or if you're a woman of childbearing age, yeah, you're definitely gonna pay a lot more. Sometimes they would say we'll cover you, but you have, asthma, so we're not gonna cover your respiratory system. We'll cover all the other parts of your body, but not that.
Speaker 2:And so you sort of go through this process plan by plan. This is just what medical underwriting sort of looks like. It's up to the insurance company to decide, and it's really The idea is to make you as the individual pay exactly what your risk should be, as opposed to that sort of social pulling mechanism where, you know, which really relies on the idea that anybody can get sick. And we should, you know, the frankly, the healthy should should help subsidize the sick. This pre ACA market was not like that.
Speaker 2:It was very much pay your own risk. We call it actuarial fairness, is sort of the model, that I use at least with my students and that's sort of the the theory behind it. And so, you know, that translates to today. One of the ways that states dealt with that and this is sort of always a prominent idea. The Republicans push it with something that's being pushed during repeal, something that the, I think, the Trump administration was in favor of, was going back to high were called high risk pools.
Speaker 2:And so that idea of where do you put healthy people versus sick people, you know, pre pre affordable care act. Sick people who got that letter saying they were uninsurable could, if your state have one, go to a high risk pool, which was all the sick people who were all uninsurable. Premiums were very high. Many of these high risk pools, you know, still excluded preexisting conditions. It was not a great place to be, but it was something for folks and, you know, part of the reason But it was very, very expensive.
Speaker 2:So when you concentrate all the sick people as opposed to kind of subsidize using healthy people to subsidize the sick, it gets very, very expensive. And But even now, Republicans push to go back or or propose going back to sort of a high risk pool structure. It's something that could work, but we've known it it will take an incredible amount of federal and state funding to sort of hold people harmless. And I, from what I've seen, they've always been what is underfunded from my perspective. So there are multiple ways to do this.
Speaker 2:You know, that ideological sort of divide over how much you should pay for your own risk versus a much more social risk and social pooling, I think, does animate a whole lot of this.
Speaker 1:Right. But it also, I think, underlies the numbers game around the number of people who have or don't have health insurance. By pooling, you do raise the cost to each member of the pool, including people who may be younger, may be healthier, and who in a less regulated market probably could find a product for a lot less money. And if you also add the age band limitations under the Affordable Care Act, you could make a reasonable argument that there are a lot of people who we are pushing into more expensive products that is a real strain on them financially. And why not just give them a product that's a little bit more affordable?
Speaker 1:Sure, it does create some issues for some other people, but we're we've also now created some issues for a whole lot of people. That's not a right wrong decision. That's a values choice about who's gonna bear the burden. Is it going to be a large number of people who are paying more than they might otherwise? Or is it going to be the smaller number of people whose health care costs are higher?
Speaker 1:That's a value choice.
Speaker 2:I think that's right. It is interesting, though I think the idea that you would go back to not covering preexisting conditions, though, is an. Right? So, yeah, I it definitely is a values choice. I think in some ways, those values have affirmed from the fight over Affordable Care Act repeal in 2017 and other You know, the Trump administration did create these options that do look like that.
Speaker 2:Medically underwritten, probably cheaper for, you know, younger healthier people who can actually get into them. And there's certainly been some take up. Right? There's sort of debates about when the effect has been on the marketplace. And so, you know, the idea of choice has been introduced, but you still see such strong enrollment and and demand, I would say, for the sort of comprehensive affordable coverage under the you know, the truth is I think some of those underwritten products, the coverage is not gonna be as comprehensive.
Speaker 2:So even those healthier people who might be paying more when they need it, it would kick in and and sort of be covered. And so just the idea of going backwards, of reintroducing annual lifetime dollar limits, of excluding preexisting conditions, of charging women more, it does feel like we're we're sort of past that and maybe those values judgments have already been made. We'll see. Maybe maybe I'm being naive about that. I don't know.
Speaker 1:But No. But I think you you make an important point, which is that in the repeal and replace movement, part of why it was impossible politically to come up with a replacement is that politically people want the protections, the consumer protections that we talk about. And once you do that, you have a part of a puzzle and the rest of the puzzle requires some of the other elements of the ACA. And as was made, I think, abundantly clear in those debates, you can't eliminate preexisting condition exclusions, you can't eliminate annual and lifetime limits. You can't provide comprehensive coverage and then not have subsidies and not have marketplaces and not have these other things.
Speaker 1:They they have to fit together. So it's a I I think you're right. We've we the the public did sort of tell us what their value choices are, and the high levels of enrollment also tell you what those value choices are.
Speaker 2:And maybe one more data point on that. You know, one of the things that the American Rescue Plan did was, I mentioned this, but lift that sort of subsidy cliff, right, the original Affordable Care Act ended subsidy eligibility at 400% of the federal poverty level, and so you had a ton of sort of Well, it was always older middle income people living in rural areas who had the highest premiums. That's where health care cost the most, and so, they weren't getting any subsidies or any help at all. And so when the rescue plan lifted that subsidy cliff, it extended, you know, the option for subsidies all the way up the the income scale. People still pay.
Speaker 2:It just you you can't pay more than 8 and a half percent of your income towards premiums, which is still quite a lot in my book, but you at least get some help. And we do have some data that we've seen higher enrollment among those folks over 400% of the poverty level in this most recent enrollment period. So, an uptick of at least a couple percentage points, but about 1,100,000 people who did not qualify for those subsidies before, but who again that demand for this comprehensive affordable coverage have come in and enrolled as a result of those subsidies.
Speaker 1:So I wanna look ahead. The law was really frozen in place for basically a decade in the battles around whether the law was going to stay in place. And supporters of the law often note that any complex piece of legislation would typically be recalibrated in the early years as you learn from it. None of those could happen politically. So as we work through what it means to build on the Affordable Care Act, as President Biden says he said he wants to do, what do you see as the primary areas where the law could use some updating?
Speaker 2:I think we have to start well, a, with this American Rescue Plan, they did do what I long considered some of the biggest unfinished business of the Affordable Care Act. I think it was sort of widely recognized when the law was passed. The subsidies were not as generous as folks might have wanted both because of this cliff and even for folks at the lower end end of the income scale, not having as as much financial help as maybe Congress would have wanted. This idea that we'll go back and we'll build on it earlier just never happened for all the reasons we've already talked about, and so I think the rescue plan was sort of a down payment on that. You know, for 2021 and 2022, we're gonna put in these subsidies, see how it works, and and I think it's reflected in that record high enrollment that we've been seeing, how much of a difference that has had or difference that has made.
Speaker 2:And that said, we're sort of heading for this cliff for 2023 where if those subsidies are not extended or made permanent, there's all kinds of debates over what they're gonna do. The most recent data I've seen is that premiums would increase on average by 53%. And so, you know, as you head into November, which is when open enrollment starts, folks would start getting these letters sort of in the fall right around midterm elections about some serious premium shock. So folks would still be many folks would still get subsidies, not all would, if these rescue plan enhanced subsidies expire, people will pay more because the sort of generosity goes down over time. The same study, this is a study from ASPE within HHS, estimates 3,000,000 people would go uninsured if the rescue plan subsidies are not extended.
Speaker 2:So goal number 1, I think, has to be sort of extending, or figuring out what happens with these enhanced subsidies and the clock is ticking, for congress to do that. We'll see what happens there. Beyond that, things like fixing the family glitch, which seems to be in the works from the Biden administration from an administrative perspective. I was thinking back to some of the the Patient Protection and Affordable Care Enhancement Act, which has passed the house several times in recent years in some of the, you know, the items in those bills. Some of it has been included in the version of Build Back Better that passed the house, I guess, last year at this point.
Speaker 2:Things like a a fund for reinsurance and subsidies for states, extra outreach and marketing, definitely always a family glitch. One one idea that I haven't seen get as much attention, but I think is still on the list of some folks, this is very wonky but very important, would be to change the benchmark plan from silver to gold, which would mean, you know, it would sort of increase the generosity of all the plans that folks are getting. It would also increase the premium tax credits and the cost to the federal government. So it's it's not one that I've seen get included in a lot of these bills, but it was something, if I'm not mistaken, was in the Biden campaign plan and a few other places. So I, you know, I think the ideas are are generally known.
Speaker 2:A lot of them are things that would have to go through regular order, meaning not a budget reconciliation. But, you know, so the financial things they they could do through budget reconciliation, which would mean on a partisan basis, but some of the tweaks might take regular order. And so if you're looking at 60 votes in the senate, I don't know how likely some of those are. Maybe stepping back from just sort of core Affordable Care Act, individual and small group markets, I do think that there's gonna be an increasing focus or I hope there is on the employer market, which, you know, as you know, is where the vast majority of people get their private get their coverage period, but also get their private health insurance. And, there's a lot of, I think, really increasingly compelling data that, the employer market is not working as well as it was even when the Affordable Care Act was passed.
Speaker 2:I think Congress in the ACA made this policy decision of, like, employer coverage works really well, we're not gonna disrupt it, we're gonna preserve that system. Keep it if you like it, all of that. And, you know, I think there's something like 87,000,000 people are underinsured, and and many of them are in employer plans, for example. So deductibles are rising, premiums are rising, and there's some big questions maybe. Is is that where where Congress goes next?
Speaker 2:I think that might be a longer term thing, but we'll see.
Speaker 1:We've covered a lot of ground. I as we wrap up, I do wanna ask about your own ACA journey here. You have become sort of this one person rapid response team for all things ACA. We call upon you, but we're certainly not the only ones. And we've just launched the health reform newsletter and you're graciously the author of that.
Speaker 1:How has it come about that you've taken on this sort of identity and how does it feel to be in this role? Is this the professional journey you had in mind? I'd love to get your personal take on what it means to, you know, start a Twitter account and have thousands of followers within a couple of hours because everyone wants to hear your take on the ACA.
Speaker 2:Oh, no. Thank you for that question. No, I did not grow up as a young Katie thinking this is what I wanna do. I wanna write for health affairs with all things private health insurance, but I'm extremely glad to be here. I'm incredibly grateful to you, Alan, to Chris Fleming, who, you know, is a terrific editor of the blog and or of Health of Yours Forefront, excuse me.
Speaker 2:And, and Tim Jost, who's been just a terrific mentor and, you know, folks listening here know I very much inherited, the blog from him, and have tried to to do it justice, in my with maybe having my own spin on it too. So I'm entering my 5th year of doing the following the ACA series. And so it's been it's been quite interesting too to sort of start kind of covering the Trump administration and now transitioning to covering the Biden administration. So I mean, I love it. I think one of the things I'm most passionate about that I've learned over time both from teaching it and from writing is trying to explain really complicated things in a way that makes makes them understandable and comprehensible.
Speaker 2:And so I'm quite actually passionate about, breaking down really tough things, trying to do it very quickly, but I, it brings me a lot of sort of joy and focus. I also find the really satisfies my intellectual curiosity, which, makes me a total dork. But there's very few issues that I, I don't wanna wrap my head around. And once I start, I really wanna figure it out and then again try to explain it and make it understandable for folks. Something that's been most interesting to me about this journey that has really created the path for this new project I have at Georgetown Law, is the amount of litigation.
Speaker 2:So I I am an attorney, but I, am the furthest thing from a litigator. I always joke there's not enough money in the world to get me to go to court, and yet I have found myself because of following the ACA just reading so many briefs and complaints and court decisions and all these things that I've really developed this kind of expertise in litigation, particularly around sort of administrative law, and it's just led me in directions that I never would have dreamed dreamed of otherwise. So I'm incredibly grateful. I think it's a it's a lot of fun and just a total delight to work with you and the whole team.
Speaker 1:Well, the delight is mutual and I just want to add one dimension that you didn't capture, which is not only do you make it comprehensible, but something that I think is equally important is that although you are clear about your values and your views, when you're interpreting what a statute or regulation says, there's no creeping in of bias in that and so people can rely upon your explanation even if they might have a different point of view on the substance. And that's a particular talent, and one that we value a great deal at Health Affairs as well. Well, Katie, it's great to talk to you, it's great to be able to work with you, And, thank you so much for being my guest on Health Policy.
Speaker 2:It was a delight. Thanks for having me, Alan.
Speaker 1:Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a Health Policy.
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