Andy Slavitt Closes World Health Care Congress by Urging New Federal Leaders to Meet the Needs of Americans

In the closing keynote at the World Health Care Congress, Andy Slavitt, former Centers for Medicare & Medicaid Services (CMS) Administrator, reflected on the successes and failures of the Affordable Care Act (ACA) while keying in on how new healthcare policies could meet the expectations of the American public. 

Slavitt, who headed CMS from March 2015 until January 2017 as an Obama administration appointee, looked back to 2013 when he called officials in Washington, D.C., offering them help fixing the problematic rollout of healthcare.gov. "I thought there would be 20 other people calling [to offer help], but I think I was the only one," Slavitt said to a room full of laughing attendees. 

Slavitt said they key to healthcare reform is not as simple as having a big idea or a set of policies, but rather executing on them and having the various stakeholders working together to figure out how to make healthcare work better. "Whatever we do in healthcare will work or not work based on if you execute it well. I'm a believer that [most things] are 90 percent about how you execute," he said. As such, the idea in the Obama administration was to make the next leg of reform about execution. "We talked about healthcare year after year, but nothing was changing. Then we got the ACA, which I think accomplished some things but not other things," he said. 

Speaking to the healthcare law's successes, Slavitt said that for years and years the number of uninsured people in the country stayed constant for as long as he could remember, but then all of a sudden that changed. "Ultimately, that uninsured rate cut in half. Every day when I was at CMS, I would wake up and check my email box and would read emails from Medicare, Medicaid, or ACA beneficiaries, reading about their lives. These were long emails and tough issues. But you could get a real feel for things and the peace of mind [that having coverage] gave [people]." 

Slavitt also noted how, under the ACA, a positive dent was made in healthcare costs, trends, and quality. "We have a long ways to go and one would hope that's our major area of major focus as a country, but we have had the lowest medical cost trend over the last seven years and for the first time, 90 percent of our quality measures have improved every year, seven years running. So we didn't sacrifice those things in order to cover people," he said. 

Showing fairness, Slavitt also touched on what did not work with the ACA—failures which he said are too much the focus of Congress right now. For one, the ACA didn't you go far enough to provide subsidizes and support to the middle class, which was a result of the ACA's creators instead wanting to put $100 billion more toward the federal surplus. "That was a mistake," Slavitt admitted, adding that the risk pool was sicker than what was expected. Second, he noted how the ACA didn't figure out competition very well. While the ACA is a free market model, even full-on believers of free markets know that markets break, are not perfect, and don't always have enough competition, he explained. "Healthcare is not one market, but 305 little geographic markets, so you can look at different parts of the country and see that in rural Alaska and rural Nebraska, there's just not enough competition. What's the fallback mechanism? Last year it was [us] picking up the phone and asking insurers if they would enter [these] markets." The third thing that the ACA failed at, according to Slavitt, was that it did not prevent all of the people who wanted to take part in the ACA from doing so. 

In his time at CMS and since, Slavitt said he has spent lots of time on the road meeting with communities of people and hospital leaders. "So we look at this and say, what are the things that Americans expect from the government? How do we expect the government to behave to make these new initiatives work? Slavitt asked. "People expect that we will pull together, and the word [we] hear the most is that they expect 'cooperation' out of D.C. People tell me that they don't want to have to pass a loyalty oath to either Trump or Obama in order to make healthcare work in their community. But they feel like they have been put in that spot, that they can't begin to make healthcare better until they take a political position," he said.

Adding to the expectations that Americans have for the government, Slavitt said that the country doesn't need or expect it to be perfect, but they want to know that it's looking to improve and make things better. "When people heard the words 'repeal and replace,' they expected that this would improve the ACA and reduce their own deductibles.  "But there was never that level of specifics [in the repeal and replace plan]," he said. Slavitt also said that there is an expectation of Congress to reflect the needs and concerns of Americans. "In a very short amount of time, the American public has gotten much more educated and involved in their health and policies that affect their health. When you have a time when only one in five members of the majority party even hold a Town Hall, that frustrates people," he said. 

At the end of the day, Slavitt said he—and others—will get on board with any healthcare plan that covers more people, protects them better, and makes care more affordable for them. "When you look at this healthcare bill [put out by the GOP], the question becomes, are we meeting those metrics? The bill has the support of just 17 percent of Americans. It takes more people off coverage and has the potential to reduce protections, and people don't like that. That doesn't fit with the expectations of our government," he said. 

Slavitt noted he has been asked the same one question from some 20 different reporters, and others: What can the government do to purposely screw up the exchanges? To that, Slavitt said, "First of all, failing is a lot easier than succeeding. And [second], in addition to all the other expectations of government, we now have to ask the  question, is the government acting in good faith? We have never been in a place before where we have had to answer this question. This question almost supplants every other [one]." 

Closing his speech, Slavitt said there are five questions to ask in this current policy moment: 1) What do we expect the role of the various parties in healthcare to be? 2) What do we believe is the role of the safety net? 3) How do we take healthcare back from the D.C. politicians? 4) How do we make the changes that we need to make in the healthcare system? 5) What's my accountability for this mess that we're in? 

Keying in on a few of those points, Slavitt said that at CMS, with the meaningful use program, the first thing he said when he was brought in was that the program was wrong; the government had lost the hearts and minds of physicians due to over-regulation. "That was the first step to making progress," he said. He said it was the same idea with ICD-10 in that when he came into CMS his team asked physicians what they would need to be comfortable in their implementations of the new coding set. "I told my team to give physicians everything they asked for to make their lives easier. We did that, we implemented [ICD-10], and it worked. We need to a ask ourselves those questions [going forward]."

What's more, regarding changes to the ACA, Slavitt said, "We'd be better off with a half a loaf that everyone owns compared to a full loaf that one party owns and the other will be free to criticize. It wasn't great for the Democrats in the past and I don't think it will be great for Republicans." He also said that his motto at CMS was to figure out how fast people were comfortable with change, and then go 10 percent faster to push that level of change, offering smaller physician practices adapting to value-based care as an example. And finally, he noted how stakeholders are quick to point fingers at others for system failures. "One skill in healthcare everyone has is being able to do a great description of why it's everyone else's fault. I always ask, what part of this is your fault? At what point will we make this something bigger than ourselves?"