‘If I were a chil­dren’s hos­pi­tal, I’d be scream­ing from the rooftops’

Modern Healthcare - - NEWS - By Mara Lee

Andy Slavitt knows a thing or two about sav­ing a sink­ing ship. In Oc­to­ber 2013, Slavitt, then an ex­ec­u­tive at Unit­edHealth Group’s Op­tum di­vi­sion, was asked by the Obama ad­min­is­tra­tion to help res­cue the fal­ter­ing Health­Care.gov. As prin­ci­pal deputy ad­min­is­tra­tor and then act­ing ad­min­is­tra­tor at the CMS, Slavitt was unusu­ally di­rect. Since leav­ing the agency this year, he’s even more out­spo­ken and is one of the most prom­i­nent voices op­pos­ing the GOP’s ef­forts to re­peal and re­place the Af­ford­able Care Act. He’s strongly ad­vo­cated for sav­ing Med­i­caid and en­sur­ing that the in­di­vid­ual mar­ket re­mains ac­ces­si­ble. Slavitt, now a se­nior ad­viser to the Avia In­no­va­tor Net­work, re­cently spoke with Modern Health­care re­porter Mara Lee about the on­go­ing re­peal-and-re­place de­bate. The fol­low­ing is an edited tran­script.

Modern Health­care: What was Oba­macare’s big­gest mis­take?

Andy Slavitt: Not creat­ing enough of a sub­sidy; be­ing too stingy on sub­sidy lev­els in the in­ter­est of be­ing fis­cally pru­dent.

MH: A re­cent Har­vard study showed that even ask­ing low-in­come peo­ple to pay $39 a month causes 25% to de­cide not to buy in­surance. Charg­ing about $ 80 for slightly higher earn­ers causes half to drop out of the mar­ket. What does that tell us about the in­di­vid­ual mar­ket?

Slavitt: That study re­ally demon­strates how many peo­ple who are on very low and fixed in­comes—even an ex­tra $5, $10 or $20 a month, it’s sub­stan­tial.

Many peo­ple con­sider health­care in­surance a lux­ury.

As we look at the ACA, if we had been more gen­er­ous on sub­sidy lev­els, we would’ve had cov­er­age lev­els sim­i­lar to Mas­sachusetts. (Mas­sachusetts charged $39 a month; in the ACA, a sim­i­lar level of cov­er­age at the same in­come level cost $83.)

Look at the Amer­i­can Health Care Act, where sub­sidy lev­els are dra­mat­i­cally re­duced. I hope the Se­nate looks at that, and takes that very se­ri­ously.

MH: What do in­sur­ers want out of ACA re­form?

Slavitt: What they want mostly is for the ad­min­is­tra­tion to stop the non­sense. Fund the cost-shar­ing re­duc­tion pay­ments. Stop talk­ing down the mar­ket. The in­sur­ers want the bills to die a slow, quiet death with­out them hav­ing a hand in it.

Mostly, they want to see us not flop back and forth ev­ery four years or eight years. We’ve lived through this seven years of painful ob­struc­tion (to the ACA), and now we’re liv­ing through the first quar­ter of painful sab­o­tage. That’s not good for in­sur­ers, but mostly, that’s not good for Amer­i­cans.

MH: How should Med­i­caid change?

Slavitt: I con­sider the Med­i­caid pro­gram of old to be typ­i­fied by no ac­count­abil­ity for hos­pi­tals, a lim­ited fo­cus on ac­cess. Demo­cratic states and a num­ber of Re­pub­li­can states are be­gin­ning to move to Med­i­caid man­aged care that is qual­ity-driven and starts to fo­cus on so­cial de­ter­mi­nants of health. A truly cap­i­tated model achieves cost man­age­ment bet­ter than per-capita caps. All (caps) do is fix the fed­eral gov­ern­ment’s obli­ga­tion and put it on the state and ul­ti­mately, the ben­e­fi­ciary.

MH: Democrats are in­sist­ing they won’t par­tic­i­pate in ACA re­form un­til Repub­li­cans stop try­ing to re­peal it. But when Se­nate Repub­li­cans are talk­ing about keep­ing some of the taxes that fund it, and keep­ing an in­come- and age-based pre­mium sub­sidy, isn’t it some­what a ques­tion of se­man­tics?

Slavitt: Some of it is se­man­tics, but in my mind, un­less you take Med­i­caid cuts off the ta­ble, it’s a non­starter. First of all, it’s not the prob­lem the Amer­i­can pub­lic hired the pres­i­dent and Congress to solve. Peo­ple wanted the de­ductibles to go down and the pre­mi­ums to go down, and they didn’t want to lose cov­er­age.

Med­i­caid is the in­surance that cov­ers half the births; that cov­ers half the long-term care in the coun­try; that is es­sen­tial for any­body you know who lives with a dis­abil­ity. I don’t think we’ll go any­where on a bi­par­ti­san ba­sis as long as that’s on the ta­ble.

My gen­eral sense is that bi­par­ti­san­ship will hap­pen if peo­ple view par­ti­san­ship as a dead end, or some­thing that would drive the party off the cliff. I be­lieve that’s where we are, and a grow­ing num­ber of Repub­li­cans see that.

MH: Are hos­pi­tals re­ly­ing too much on their as­so­ci­a­tions to lobby for the ver­sion of ACA re­form they want?

Slavitt: They think (lob­by­ing by) the Amer­i­can Hos­pi­tal As­so­ci­a­tion or the Fed­er­a­tion (of Amer­i­can Hos­pi­tals) is enough. It’s not. I don’t think hos­pi­tals are be­ing vo­cal enough. If I were a chil­dren’s hos­pi­tal, I would be scream­ing from the rooftops. I think the Catholic hos­pi­tals are do­ing a good job. There’s a lot of group­think that goes on in Washington. The only way to break through the group­think is for con­stituents of all sorts to talk about what’s im­por­tant to them.


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