A Conversation with Andy Slavitt

Slavitt on the ACA: It’s a Fixer-Upper, Not a Teardown

The former head of CMS takes Congress to task. The ACA is not perfect (no law is) but could be improved, in his view, if only lawmakers would show more political courage.

Interview by Richard Mark Kirkner
Contributing Editor

Andy Slavitt

In January 2017, as the Trump administration took office, Andy Slavitt cleaned out his desk as the acting director of CMS and headed into the private sector. But his post-CMS ride has been neither quiet nor off into the sunset. Slavitt, a former investment banker, formed a health care technology venture capital firm and helped launch the United States of Care, which bills itself as a nonpartisan group that advocates for affordable universal health care. Slavitt is active on Twitter and in the thick of many lively exchanges on health care policy.

At 10 years after its passage and five years from its implementation, how good is the ACA looking today?

All you have to do is look at the array of studies that have come out after five years to look at the success of the ACA. Bankruptcies are down, credit scores are up; cancer rates are down, early detection is up; bad debt is down, income levels are up; maternal and child mortality are down, medication compliance is up.

No law is perfect, but what the ACA accomplished is that it allowed marginal-income people, who were hundreds of dollars away from bankruptcy and therefore avoiding medical care, to take care of themselves again. It’s had an inarguably positive impact on lots and lots of people.

No matter how the appeals court rules in Texas v. United States, an appeal to the Supreme Court seems inevitable. The case would come to the court in the heat of next year’s presidential race. How could a ruling in that case influence voters’ behavior?

Fundamentally, people shouldn’t have to worry about being able to afford their prescription drugs or taking care of their families if someone gets sick. That’s the contract that has very significant favorability for the Democrats in places like Wisconsin, Michigan, and Pennsylvania. Democrats enjoy a 10-point advantage on health care, and I suspect as this case keeps moving forward that advantage can go even further.

You’d said you wouldn’t comment on individuals in the administration except President Trump. What do you have to say about him?

The president has betrayed his base, and he did it bowing to Republican orthodoxy. It’s not clear what he cares about.

He originally supported repealing the ACA in large part because he was told the only way he was going to be able to pay for a tax cut was to cut health care costs. So he went along with it and, of course, they did the tax cut anyway without paying for it. I think he finds himself in a position where he thinks he can enjoy saying one thing and doing another; saying he supports people with pre-existing conditions and taking the opposite action and hoping that either his voters or independents won’t notice or won’t care.

Medicare for all. Is it achievable?

Most people in America today believe that if someone in their family gets sick, they’re not sure they’re going to be able to afford to take care of them. The number one call to the American Cancer Society hotline is people saying, “I can’t afford to get cancer.” These are people presumably with insurance.

Indeed, within two years of a cancer diagnosis, 40% of Americans spend through their life savings. We also know from data that between one in three and one in four Americans can’t afford to pick up their prescription drugs.

Americans, I don’t think, are so focused on how or by what means they get access to affordable coverage; some are, but most Americans just want the system to work. They want to know that if someone gets sick, there’s no federal government, no insurance company claims examiner, no judge, no Congress that can stand in their way of their ability to take care of their family. And until they have that, they feel insecure, and it’s an existential crisis because not being able to take care of your family means not being able to stay in the middle class. People want this assurity, and whoever they believe can give them that assurity will have the most popular policies.

Was not including a public option a flaw in the ACA?

There’s one reason that there’s not a public option, and that’s Joe Lieberman. I think it’s only responsible to look at every major piece of legislation and say, “What could’ve been done better?” We know we’re going to get it about 70% to 80% right, and we should have a Congress that should be willing to make the changes that fix the things that aren’t working as well as they should.

Looking back, I think more things in the law that would keep everybody honest at controlling cost probably would’ve been good additions. But the good news is all of those are things that can be done now. And all of those are things that can be done both at the state level and at the federal level.

That’s where the ACA has been an aberration as major legislation. There’s been no tweaking of it.

And I say shame on Congress for the number of conversations that I’ve had with Republicans who said, “Boy I wish this part of the law worked better,” and I said, “Well you have the power to make it work better.” And their response was always, “I can’t be seen to be doing anything to help the Affordable Care Act.” That is a shame because once a law is on the books, historically people put away their sharp knives and say, “How do we work to make it better?” That’s what happened with Medicare Part B; that’s what happened with all major legislation.

Of Trump’s maneuvers to undermine the ACA, which do you think is the most harmful?

The Trump administration, in failing to repeal the law in Congress, has built on two principal things. One is that they used executive powers to basically have the impact of increasing people’s cost, and, of course, when they increase people’s cost it becomes less affordable and fewer people sign up.

The second thing they’ve done is that they’ve aimed for a full, entire teardown of the law. That is really dangerous because it has the chilling effect that people who are sick feel like the government is out to get them for some reason and they can’t quite figure out why.

What attempts by the Trump administration to undermine the law have been their biggest failure?

Before the 2018 election they tried to stop paying cost-sharing reduction payments. That was not only mean-spirited, but ill-conceived, and ended up costing the country more money. If you go back even further, I think the Republican Congress overturning rate stabilization before Trump was even in office was irresponsible because that essentially sent signals to the insurance companies that they would need to raise rates or get out of the market.

As far as pre-existing conditions go, the way the ACA handled that was well thought out. Is there a simple way to get mandatory coverage of pre-existing conditions without a mechanism for risk sharing or similar mechanisms?

There is, and it obviously increases everybody’s cost, and so you need a strategy for managing those costs. There are lots of strategies. Reinsurance is one approach; open enrollment periods another. Some sort of automatic enrollment is being considered. But if you start with the assumption that being sick doesn’t prohibit you from the health care you need, and then say, “How do we work around that?” you get to a better place versus starting with the presumption that we’re going to make the insurance profitable for insurance companies.

Of all the Democratic candidates, whose health care proposal aligns with your views?

I’m not going to answer that question because I have offered and have been providing whatever counsel any candidate would like to have. All of them essentially believe that all Americans should be able to afford to take care of their families if someone gets sick. The primaries are in some part about arguing how, and that’s fine.

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