Kai Ryssdal: Up at the top of the show, we heard from Republican Congressman Phil Gingrey, who also happens to be a medical doctor. Now to one of his professional peers in medicine, if not politics.
Dr. Ezekiel Emanuel used to be a health policy adviser under Clinton. He's a bioethicist at the University of Pennsylvania now. Welcome to the program.
Ezekiel Emanuel: Nice to be here.
Ryssdal: So what'd you think when you saw the ruling this morning? Is this the way you expected it to go?
Emanuel: Absolutely not. I expected us to have the mandate upheld, but not to have a 5-4 vote with Justice Roberts being the deciding vote, and it looks like a last-minute switch.
Ryssdal: Yeah, you worked with the White House to help frame this law, at least in the early days. Did you expect the twist on the mandate versus the tax thing to go this way?
Emanuel: No. I mean, I thought that was actually splitting hairs, to be honest. Even when we were developing it, whether we called it a mandate with a penalty or a tax. I think it's appropriately understood as a mandate and you've got a penalty which we're collecting through the IRS. If that looks like a tax, you know, as far as I'm concerned, that's fine. I don't think much is going to be made out of this being a tax.
Ryssdal: Wait, wait, wait, come on, wait, really? OK, so we just talked to Phil Gringrey, a Republican congressman from Georgia, who called this the biggest tax hike on Americans ever. You don't think the Republicans are going to play this in the fall?
Emanuel: They might try to play it, but remember, Gov. Romney then would have had a tax hike in Massachusetts too. So you know, I don't think that really has a lot of traction. Under those views, Medicare is a huge $500 billion tax as well, because it's requires people to pay in. I mean, I think we've got to talk about the substance, not the label.
Ryssdal: One last question on the politics of this: The Republicans are going to have a repeal vote in the House on July 11th -- you worried about that at all?
Emanuel: No. They're going to probably repeal it along party lines, it's going nowhere in the Senate because they would need 60 votes. And secondly, from a budgetary standpoint, they would have to figure out how to going to find all the money, because remember, the ACA actually reduces the deficit. So they would actually have to plug a big financial hole. And I would say that the more important issue is to press them on what are they replacing it with.
Ryssdal: What in your mind is the most important thing that was upheld today? Is it the mandate itself? Is it the no pre-existing conditions? Is it kids on parents' insurance? What is it?
Emanuel: Well, I think it's the whole package. As I've often said, I think this is really a package in the fact that they basically upheld the whole law as consitutional and this one Medicaid provision saying that the federal government couldn't threaten to take away all of Medicaid. That they were really enacting a different kind of program in the law is, I think, in the end going to turn out to be a relatively minor issue, except some states may, for ideological reasons, try not to expand.
Ryssdal: Are we done with health care reform now, or what else -- well, what else has to happen then?
Emanuel: No. Absolutely not. Look, this is a $2.8 trillion part of the American economy. You are never going to be done. This is a constant work in progress.
Ryssdal: Dr. Ezekiel Emanuel, former White House health policy adviser, now at the University of Pennsylvania. Doctor, thanks very much for your time, sir.
Emanuel: Thank you.