United States of Care Founder Andy Slavitt on the ACA, Expanding Coverage and Fixing US Health Care

Andy Slavitt

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Female : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation , health policy , care delivery and the great minds
who are shaping the health care of the future. This week Mark and
Margaret speak with Andy Slavi tt , former Acting Administrator for the
Centers for Medicare and Medicaid Services under President Obama
and founder of United States of Care, which is dedicated to making
health care accessible to a ll Americans. He talks about the short and
open enrollment period underway right now and the political
kryptonite of GOP efforts on the federal and state levels to undermine
the ACA and how voters are fighting back.

Lori Robertson also checks in , the Manag ing Editor of FactCheck.org
who look s at misstatements spoken about health policy in the public
domain , separating the fake from the facts, and we end with a bright
idea that’s improving health and well - being in everyday lives. If you
have comments please e - mail us at [email protected] or find us on
Facebook , Twitter , or wherever you listen to Podcast . Y ou can also
hear us by asking Alexa to play the program Conversations on Health
Care . Now stay tuned for our interv iew with former CMS
Administrator , Andy Sla vitt on Conversations on Health Care .

Mark Masselli : We ’re speaking today with Andy Slav itt , Board Chair of the United
States of Care a nonpartisan , nonprofit organization dedicated to
expanding health care to all Americans. He is former Acting
Administrator for the Centers for Medicare and Medicaid Services
under President Obama. Mr. Slavi tt serves as senior advisor to the
Bipartisan Policy Center, frequent contributor on health policy to
JAMA, USA Today, CNN , Fox and MSNBC . He earned his BA at
Wharton School of Business, his MBA at Harvard Business School.
Andy, welcome back to Conversations on Health Care.

Andy Slavitt: It’s good to be here.

Mark Masselli : We're weathering the change of climate , and speaking of change of
climate, lots have happen ed politically . I n spite of the attempts by the
current administration and a number of state governors to eliminate
the ACA , y ou say it's become the kryptonite of those attempting to
d e rail it , and certainly all eyes are still on Kentucky w here
conservative Matt Bevin was unse eded by Democrat , Andy B eshear .
Many people are sort of looking at what Bevin did on the ACA, which
didn't seem to sit well with voters there . I'm wondering what these
trends both in Virginia and Kent ucky bode for health reform.

Andy Slavitt: Well Matt Bevin, I think was before Trump when it came to health
care. I think he was the first one to come out and publicly start to say
we need to be cutting back on people's health care. He ended a very

Andy Slavitt

success ful exchange. He started to try to cut people out of Medicaid
expansion. People have a very interesting relationship when it comes
to their health care and the way politics interferes with their health
care. People fundamentally want some thing s very simpl e, which is
they just want to be able to take care of their families, somebody gets
sick if they need to use a doctor , and if someone threatens their
ability to do that, as Matt Bevin has done, as Donald Trump has done
as largely a R epublican party in Wash ington has done. P eople get very
agitated because health care -- being able to afford health care is
what keeps you in the middle class. A ny threat to that is a really,
really big deal. The people who are see n to be threatening to take
away people's health care, as I think we saw in the 2018 election, and
as we saw in this -- was in Kentucky, and I think in some several other
places really do that at their own political peril.

Margaret Flinter: Well, Andy, you came into the national spotlight quite dramatic ally a
few years ago, having been brought in to help fix what was then the
nascent online health insurance portal healthcare.gov. It had a rocky
start, you did a good job resolving it . B ut here we are in the middle of
open enrollment. The current administr ation has really pretty
dramatically shorten ed the open enrollment period . T he marketing
budget just about eliminated which was really how people heard
about the opportunity to use the exchanges. What's been the impact
of this on consumers ? A nd what if any thing can be done to minimize
this impact during this open enrollment period?

Andy Slavitt: Well, I'm so glad you ask 95% of the uninsured don't know the date
th
that the open enrollment period ends, December 15 . Only 5% of the
th
uninsured are aware of that. What that means is if it's December 16 ,
and they want to get coverage, they're going to have to wait another
year unless there's an event in their family. The good news is that , the
average American , every plan that they buy, if they buy an ACA plan
will have preexisting condition coverage protection , will cover 10
essential benefits , will outline insurance companies from setting
lifetime caps and limits . I n fact, the average premiums have dropped ,
s o there's a lot of good news if people were made aware o f it, that
people do have to be a little bit aware and th at Trump has introduced
these junk plans, which I think deceptive marketers are trying to sell
a s ACA plans under Trump's guidance . I think people should just be
careful if you want to make sure you avoid that just go to
healthcare.gov and people will be able to get their coverage .

Mark Masselli : Oh , that's very important message . A s you've been thinking about the
Affordable Care Plan, certainly one of the areas that has gotten
people riled up is the individual mandate. Obviously, the Trump
A dministration eliminated the mandate that's led to fewer people
purchasing coverage. I wonder if you could talk about the other value
added benefits and strengths of the Affordable Care Act and certainly

Andy Slavitt

highlight some of the weaknesses and maybe where do you see
opportunities for improvement?

Andy Slavitt: It's a really important question , a nd five years after the ACA rolled out
it will actually have data that we can point to . W hat we've seen across
the country is reduction to premature deaths , e arly diagnosis of
cancer , reductions in heart rate s, r eduction in disparities between
African - Americans and white which is sort of amazing , increase in
homeownership. A lot of these big broad outcomes, which shouldn't
be sur prising to us, if what we're really doing is saying that there are
people who are marginal income, who were not able to afford
insurance. We know the numbers 20 million more people are insured.
There's been a psychological change as well in this country .

T he bargain for the American public used to be , if you get sick or if
you can't afford coverage, that's just too bad . T hat has changed to, it
doesn't matter if you've ever been sick before, if you've got a
preexisting [ inaudible 00:06:42] , if you lose your job, if you change
jobs, you'll still be able to get health care coverage , t hat's a dramatic
change. It's a change in the bargain of how it works. It used to work --
designed to work for insurance companies and people had to wrap
their lives around it. Now it's supposed to work for people, insurance
companies are supposed to wrap their life around it.

Now any major piece of legislation should get it about 80% right th e n
after a few years, let's take the things that didn't work and let's adjust
them. I think the major political disappointment with the ACA is this
Congress just refused to act on any of the things that it saw that could
have fixed. Not only that, it actually tr y to make political hay out of
anything it found that was wrong, and tried to use tha t to repeal the
entire law and including the good parts . We're not going to get it
perfectly right , and there are bil ls in the Congress right now if
Congress chose to act on point to one by Representative Laur en
Underwood, that would actually cut premiums in half for people who
are making up to $ 1 50,000 and it would cover three or three million
more people. It's a really good bill, it's as a common sense bill .

O ne of the things we're going to have to do as a country is come to
grips with the fact that we ca n't work on things. We've got to be
willing to work on things that make the public better . I had this
conversation directly with Paul Ryan. He pointed out some things he
didn't like about the ACA and I pointed out that he and the Congress
would sit back an d point to things they didn't think were working as
well as they should, when they could have actually done some things
about them. The law could be work ing for many, many more people.

Margaret Flinter: Well Andy, I am really glad to have you si ght all of those dramatic
positive impacts on the health of the American people as a result of
the ACA. But after your term as CMS administrator, you launched a

Andy Slavitt

whole new organization called the United States of Care, a
nonpartisan think tank that was really dedicate d to expanding health
coverage for all Americans. You're also a senior advisor to the
Bipartisan Policy Center , and this push to engage people on both sides
of the aisle has really characterized your work. What are the policy
initiatives that you see as ha ving the potential to find common ground
in this quest to make sure that Americans can achieve those great
outcomes we just talked about ?

Andy Slavitt: Ye s , as soon as we stop being willing to get into a room and listen to
one another, the sooner it become s even more difficult to get
anything done. I think United States of Care, its core believes that it
needs to be Democrats nor the Republicans that should decide b ut it's
actually the American public . T he American public, regardless of
political affiliatio n i s quite unified . They want to access a regular
source of care. They don't want to be forced to choose between
paying for medical expense and any other need in their life. They
want this done once and for all . They don't want to pass by one party
and und one by the next party. There are areas of common ground,
mental health , both party can claims to be care about and be focused
on mental health, addiction and the addiction crisis. It was in q uestion
for a while but children's health insurance , changing the way we pay
for care, value based care.

I think we have to remember that is upon some of these things that
eventual progress is likely to get buil t . If tomorrow there was a cure
100% cure for child with leukemia , the country would demand that
we figured ou t a way to pay for it. It took us all through the 80s before
we finally pass legi slation to take on HIV. But when we did it, we have
dramatically reduced death. I would invite Congress, we need to fund
mental health in a much more significant way. We will reduce misery,
we're seeing suicide rates dramatically higher , suicide rates among 10
to 14 year olds has tripled in the last decade. I think both parties to be
able to get around that and put some money to that , there's nothing
wrong with fixing pieces of it that are broken whi le we work on bigger
solutions.

Mark Masselli: We're speaking tonight with Andy Slavi tt , Former Acting
Administrator for the Centers for Medicare and Medicaid Services ,
Board Chair of the United States of Care and f ounder of Town Hal l
Ventures. Andy, I really liked your optimism. The political question, I
guess is that are there any places is around the country, any states,
which are always the engine for innovation where they're coming
together on issues that might be a bellwether fo r things t hat might
happen in Washington?

Andy Slavitt: It's a great question. Colorado would be a great example. The new
governor signed a bipartisan piece of legislation that in a fact is a buy -

Andy Slavitt

in option for Medicaid. It is essentially a public option an d public
private option. As you said earlier about Massachusetts, the model
my come from a state. Minnesota has a split legislature g overnor and
they passes significant health care bill. In fact, United States of Care
tracks 14 different wins for the Ameri can public during the last
legislative cycle. Now r emember, this is coming off of the 2018
election, which was health care elections, and we sought 14 different
states to make influence more affordable to outlaw to price medical
bills. These things are -- they are more popular when we focus not on
the political to and fro, but on the real effects of people's lives . T he
closer people are to seeing the effects the better we are . T hat’s why
we recognize d we're at a time of massive disagreement in this
country.

I also believe if we listen better, we would understand that there is a
lot more commonalit ies, the politicians that are behind it at the time.
I can give you an example , if you say to a Democrat, we need to
increase access to care and reduce costs , t hey' ll nod their heads. But i f
you say to a Republican, we need to reduce costs and increase access
to care , t hey'll nod their heads . Even among the political class there
are a common set of points to point to and the better job the
American public does of spe aking up on these issues the more likely it
is that we're going to see something eventually happen that is
permanent.

Mark Masselli: I just wanted to add one coalition to the list that you did which are
community health centers which famously had Ted Kenne dy and
Orrin Hatch, both on the same side of the aisle both supporting on it ,
so .

Margaret Flinter: That’s exactly right.

Andy Slavitt: Yeah, there's even a building consensus around the cost of
prescription drugs that's becoming harder and harder for the
traditional champions of Republicans have historically, particularly
when Hatch was head of Senate Finance Committee w as the big
defenders of and even with some of the rhetoric out of the White
House . I t's becoming much more difficult to justify one way
pr escription drug cost. As I've written, drug prices are the new gas
prices when it comes to electoral politics.

Margaret Flinter: Andy, I had the pleasure of reading your very compelling piece in The
J ournal of the American Medical Association not too long ago and you
were framing a look at th e big threats to achieving the Triple Aim in
health care lower cost, better outcomes, better patient experience .
B ut you frame those threats one of the major ones being health
disparities, which of course is s omething w e see every day. But also
corporate revenue streams and this politicization of health care and
the issue of prescription drugs comes up over and over again and

Andy Slavitt

you've certainly sounded the call that unless we address these
underlying issues we're not going to see meaningful change going
forward. M aybe just talk a little bit about what should people be
looking at that might be doable?

Andy Slavitt: Why haven't we gotten closer to achieving the Triple Aim since they
were -- and is well called out a decade ago . I was thinking until we
focus as a country on the elephant in the room, which are the things
that are really causing us as a health care system not to make
progress until we overcome those barriers I don't think we get there.
The first one I think is the story of our health care system is the
disparities in care because many of us get actually fin e care . I f you can
self - advocate and you've got enough money or employer sponsored
coverage, you can do far, far better. What your skin color is what your
income is, and what your zip code is, has a dramatic impact on what
kind of health care you're going to get.

What can we do about that? S top telling me how the average patient
is doing in your hospital . Tell me how the bottom quartile is doing and
tell me how th e top quartile is doing , and tell me how you're going to
improve care for the bottom quartile b ecause guess what people in
the bottom quartile , they don't have any more complex medical
conditions. They have more comp lex lives, going to a follow - up
appointm ent when they can arrange childcare, figuring out what the
doctor's instructions were when they don't speak English as their first
language. G uess what the good news is ? T hese are the very solvable
p roblems. There should be no reason why black women are fo ur
times more likely to die in childbirth than white women, yet it
happen s , s o we have to focus on that.

In terms of revenues , I mean I think if we're really honest with
ourselves even institutions t o put forward to support Triple Aim, they
wake up every d ay thinking about one thing how to bring in more
dollars, that is far and away the biggest driver of the decisions that
people make , because if you w ere so focused on the dollar you would
treat people with less expensive resources, and nurses and
community health workers and things like that. There are things we
can do all payer systems and other kinds of approaches which I think
help that.

Then the politicization I think the fact that we have major lobbies, like
the pharma lobby t hat spend $400 million a y ear, people who are
really not out for the best interest of the public health of this country
that are very, very powerful today to run a race in this country.
There ’s only 60 competitive districts in the country left and then in
those districts, it's a bou t $10 million to run a race. Until we solve the
politics, we're not going to get all the way there.

Mark Masselli: S peaking politics and health care we’re coming up to the Iowa

Andy Slavitt

caucuses and certainly the Democratic field, their conversations
animated by he alth care and you’ve got a number of camps, Medic are
for A ll, you've got the opt - in for Medicare for A ll and you have
advocating that we need to improve and build on the ACA. How is the
United States of care engaging in these conversations as well?

Andy Sl avitt: I think Democrats are universally all doing one thing very well and as a
field they're doing one thing, which I think is a really important failure.
What they're doing well is each Democratic candidate believes that
every single American and every s ingle American family should have
access to health care for their family. What they're not doing well is
they are arguing about that principle point, which everyone agrees
about. They're spending 90% of their energy arguing about how they
would actually ge t there . T he what is much more important than the
how , because you have Trump as President who's trying to use the
courts to get ri d of the ACA and get rid of pre existing condition
co verage protection.

Somehow Democrats know that it is more important to po int out the
Trump is a climate denier than to argue about whether or not some
element of the green new deal is better or worse, and that's what the
democrats are doing on health care. They a re allowing Trump to
effectively have the argument changed by allo wing him to get off the
ho ok for the very things that Andy Beshear in Kentucky pointed out .
Wh en the sky is gray, let's not spend all our time arguing over
whether we prefer to be powder blue or sky blue, let's get it blue.

Mark Masselli: Yeah.

Andy Slavit t: While the primary process is in part about talking about these
distinction , t hat should be 10 % or 20% of c onversation on h ealth care,
not 90% , b ecause the Democratic p resident will have one decision to
make which is will they push for and sign anything that comes across
their desk that guarantees coverage for the American Public and
h ealth care regardless of whether it was their first idea , because the
Congress is going to create what the next bill looks like. All of these
distinctions will not be as imp ortant as whether or not you got
someone sitting in the o val office who's willing to go [ inaudible
00:19:10] for the American public, and that's where they should be
resting the argument.

Margaret Flinter: We've been speaking today with Andy Slavitt , the F ormer Acting
Administrator for the C enters of Medicare and Medicaid Services , and
now the Board Chair of the United States of C are, an organization
that's dedicated to expanding health care to all Americans. You can
learn more about his ongoing efforts to impact American Health
Policy by going to United States of C are.org and remember, y ou can
follow him on twitter @AS lavitt and @US of C are. And y we want to
thank you for your continued service for your fierce dedication to

Andy Slavitt

innovation and health care and for j oining us again, on Conversations
on Healthcare .

Andy Slavitt: Thank you guys so much , i t was a pleasure.

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Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about health care refor m and
policy. Lori Robertson is an award winning journalist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US p olitics. Lori,
what have you got for us this week?

Lori Robertson: Senator Bernie Sanders continues to make the misleading claim that ,
“T he average family of four spends $28,000 a year on health care. ”
That's the projected average cost for employer sponsored health
insurance for typical families of that size, but the employee paid
about 44% of that total amount in 2018 w hile the employer paid the
other 56%. About half of the US population receives insurance
through work. Sanders has claimed that his Medicare for all plan
would , “E liminate the $28,000 a year tha t the average American
family today is forced to pay to insurers .” But the figure Sanders
sighted is not the cost paid by the Family.

The Sanders campaign told us he was referring to the Milliman
Medical Index. The index showed that the average cost of cov ering a
typical family of four with an employer sponsored Preferred Provider
Organization plan was $28,166 in 2018, and $28,386 in 2019.
However, that is the combined cost to employees and employers . W e
did find evidence that at least some families of four may pay well over
$20,000 for their own health insurance on the non group or individual
market.

In Ju ly, the online health company e - Health Inc, published a report on
the average cost among its customers who applied for an Affordable
Care Act compliant pl an on e - H ealth . com without the help of
government subsi dies. The total annual premium p lus deductible for a
four person family was $25,000 . T hat's my fact check for this week.
I'm Lori Ro bert Managing Editor of F act C heck.org .

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Margaret Flinter: Fact Check.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at chcradio.com , we’ll hav e FactCheck.org's
Lori Robertson check it out for you here on Conversations on Health
Care.

Andy Slavitt

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Mark Masselli : Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Asthma is one
of th e leading causes of trips to the emergency room for children.
There are often a correlation between high density low income
neighborhoods and more trips to the hospital for treatment and
intervention . When officials at Boston Children's Hospital noticed a
spike in asthma outbreaks in certain neighborhood clusters , t hey
decided to do something about it. They launched the Community
Asthma Initiative , t hey realize d that if you could treat the
environment in the patient ’ s home that might reduce the need to
trea t the patient in the emergency room.

Dr. Elizabeth Wood : The home v isiting efforts work with children and families that have
been identified through their hospitalizations and emergency room
visits of having poorly controlled asthma and also it's a teachab le
moment .

Mark Masselli: Dr. Elizabeth Wood heads the program and says t he first step is to
identify the frequent flyers , those kids who make repeated trips to
the emergency room. Then they match with the community health
worker who visit their home sever al times .

Dr. Elizabeth Wood : They work on three areas understanding as thma itself, understanding
the medications and the need for control medications , and t hen
working on the environmental issues.

Mark Masselli: Families are given everything from HE PA fil ter vacuum cleaners to air
purifiers , and the homes are monitored for the presence of pests or
rodents. The r esult has been pretty dramatic.

Dr. Elizabeth Wood : What's remarkable is that there was a 56% reduction in patients with
any emergency depart ment v isits , and 80% reduction in patients with
any hospitalization .

Mark Masselli: While this program is expensive, there is a r eturn on i nvestment in
reduced hospital cost in healthier of children. The program has been
so successful , it’s been deployed in othe r hospital communities
around the country. The community Asthma Initiative , a simple re -
shifting of resources aimed at removing the cause of disease
outbreaks in the community, leading to healthier patient populations.
Now that's a bright idea.

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Mar k Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Andy Slavitt

Mark Masselli: Peace and h ealth.

Female : Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming li ve at chcradio.com , iTunes, or wherever you
listen to podcasts. If you have comments, please e - mail us at
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