Aside from the bartender who recorded the notorious “47 percent” video, Jonathan Gruber may have become Mitt Romney’s least favorite person during the 2012 campaign. Gruber damned the former governor of the Bay State with praise that certainly did little to shore up his standing in the Republican base: “He is in many ways the intellectual father of national health reform.” 

Today Gruber, a Massachusetts Institute of Technology (MIT) economics professor who has advised the Department of Health and Human Services, is among health care reform’s most passionate, informed defenders. When the furor over cancelation notices began, he helped illuminate how small a percentage of insured Americans will actually be hurt by the effort to make a fair market for all Americans. Within hours, his comments were turned into a pie chart that quickly went viral. 

Recently, Gruber spoke with National Memo executive editor Jason Sattler about how the Affordable Care Act transforms the health market to end discrimination against those with pre-existing conditions, why he is disgusted by Republican states rejecting Medicaid expansion, and how the president could have better phrased his ill-fated promise, “If you like your plan, you can keep it.”

Jason Sattler:  You’re estimating that a few million of the insured are in that so-called “losers” category. And you’ve recently described these people as winning the “genetic lottery” — suggesting they’ve been underpaying in the past?

Jonathan Gruber:  So basically there’s two different issues. One of them is, what does it mean to be a “loser?” …How many people are being asked to find more generous plans than before? That’s probably about six million people, two percent of the population. The other issue is, how many people going to end up paying more than they did before? That’s probably about four million people, because some of the people forced to buy up will pay less. About four million will be asked to pay more. They’re just sort of healthy people who are going to have to pay more. The “genetic winners” comment was sort of loosey goosey…The point is that a lot of people who are healthier have benefited from existing discrimination in the market.

Sattler: Was there a discussion of “winners” and “losers” when Romneycare rolled out?

Gruber: Not really. There just wasn’t this kind of toxic environment. It was also different in Massachusetts because we had already reformed our insurance market, so prices were going down for most everyone. But some people had plans taken away, plans changed. It was just sort of viewed as, “these were sub-standard plans” and it just kind of happened. There wasn’t a lot of press around it and there isn’t the kind of opposition we’re seeing now.

Sattler: Is the refusal of 25 states to expand Medicaid distorting the market?

Gruber: I think in those states, by my own estimates, it’s going to raise premiums by about 15 percent in the exchange because sicker people will be in the exchange. I think it’s really disgusting that these states aren’t providing their poorest residents free insurance [financed] by the federal government. It’s pretty amazing that they can get away with that.

Sattler: What do you think about the right-wing argument that having no insurance at all is better than Medicaid?

Gruber:  It’s just incorrect. There’s no credible evidence to support that. There have been dozens of studies over the years that show that giving Medicaid to patients improves their health. Most recently a study I was involved with in Oregon just sort of randomly assigned Medicaid to people and found significant improvements in mental health.

Sattler: Do you expect more states to expand their Medicaid programs?

Gruber: Right now we’re at about half the states expanding. That’s going to grow over time. But we’re going to have a hardcore group of states that don’t want to expand, and I hope there’s pressure to do so.

Sattler: If Healthcare.gov were functioning properly, or closer to properly, do think there would still be a hubbub over cancelations?

Gruber: I think it would have been less likely if the website had rolled out properly. I think there’s sort of a double whammy with the website not working properly. You’ve got all the bad press about the website itself and you don’t get to demonstrate the “winners.” The “losers” suck all the air out of the room because there are no winners to point to.

Sattler: Do you have any reaction to the bill from Rep. Fred Upton (R-MI) that just passed the House, which would allow insurers to continue selling plans that don’t meet the Affordable Care Act regulations?

Gruber: I think it’s a terrible piece of legislation that represents a fundamental misunderstanding of how insurance markets work. Americans, by large margins, would like insurers to stop discriminating against the sick — but what’s not recognized is that if you’re not discriminating against the sick, that means the healthy have to pay more. There’s no way around that, and I think these bills represent an effort by congresspeople to undercut the law by pretending the unhealthy can be covered without the healthy paying more.

Sattler: Does the proposed bill from Senator Mary Landrieu (R-LA) have the same problems?

Gruber:  The Landrieu bill is not quite as bad. The Upton bill is the Landrieu bill with another poison pill, which is to allow the same crappy insurance products they’ve been selling [to continue] in 2014.

Sattler: Does 39 Democrats voting for the Upton bill mean much?

Gruber. That’s a bad sign. It’s just a fundamental misunderstanding about the goals of the Affordable Care Act. I think that’s problematic.

Sattler: Do you think the fix the president has offered that will allow people to keep their plans through 2014 can work?

Gruber: I think it’s not a question of whether it can work substantively. It’s a question of whether it can work politically. Substantively, there isn’t a problem. Substantively, this law is working exactly as it’s intended to, which is to fix insurance markets and get rid of substandard plans and have equal access for the healthy and the sick. The problem is purely political, which is that the politicians want there to be all winners and no losers. The question is whether this provides [Obama] with enough cover, because Republicans just want to kill the law. They have no interest in trying to be good partners to try to fix it. They just want to kill it. The question is whether this gives enough cover to Democrats, which is why the 39 votes is kind of problematic.

Sattler: What would success for this law look like?

Gruber: We’re looking for several million people to sign up by March 31. And we’re looking for a reasonable mix of not just sick people, but also healthy people joining too. I can’t give you exact proportions. I can’t give you exact numbers. I can just say we need several million people and we need them to be a good mix of sick and healthy.

Sattler: What did the proportions look like in Massachusetts during the first year?

Gruber:The New England Journal of Medicine study [that] I was part of found that the healthiest people tended to wait until the very end. There was a huge spike among the healthy right near the end of the enrollment period.

Sattler: Could the president have phrased the “If you like your plan, you can keep it” promise in a way that would have worked to sell the law?

Gruber: He could have said that the vast majority of people will get to keep their policies. He could have said [then] what the president said Thursday: This is the least disruptive way possible to get to the goal of fair insurance markets in America. That’s what he said [Thursday] and that’s exactly right.

Photo: Jonathan Gruber at MIT