Why The Nation’s Premier Health Care Wonk Has Given Up On Congress
Nothing quite prepared Andy Slavitt for the pile-on that he endured from the online earlier this month.
For years, Slavitt had enjoyed a technocrat’s exemption from personal political drama. The 51-year-old Minnesotan founded a successful digital health care company, held a top post at a health insurance giant and went on to lead the rescue of the Affordable Care Act’s website.
Most recently, the former Obama administration Medicare and Medicaid chief served as de facto point man in the public and private fight to protect the ACA from Republican repeal efforts.
But when he unveiled the United States of Care, a bipartisan health care initiative that would advance the cause of universal coverage by “putting health care over politics,” progressive activists pilloried him.
Slavitt’s critics saw the new nonprofit organization as, at best, yet another naive attempt at transcending partisan politics and, at worst, a corporate-backed Trojan horse designed to suck the air out of the nascent movement for single-payer health care. It certainly didn’t help matters that the group’s founding council included insurance and hospital executives, former Republican lawmakers and veteran conservative policy experts.
I shared many progressives’ suspicions about the strategy and motivation undergirding a group whose three principles included a rule that affordable health care policies must be “fiscally responsible and win the political support needed to ensure long-term stability.”
So I decided to press Slavitt on some of these questions in an interview.
We can work alongside advocates of all stripes.
Andy Slavitt, the United States of Care
Slavitt claimed that he had no illusions about overcoming the political or ideological barriers to universal coverage in Congress or Donald Trump’s White House.
“It doesn’t make any sense to spend any energy right now at the federal level,” Slavitt said. “There is a logjam that’s not going to get broken before 2020.”
Instead, the United States of Care aims to serve as a kind of brain trust and troubleshooting resource for state governments seeking to expand coverage. A potential target audience for the group’s work might include Republican governors who have proved less inimical to Medicaid expansion. Some states are also struggling to forge health care compromises between Democratic governors and Republican legislatures, and vice versa.
Thus far, the United States of Care’s modest body of work reflects this mission. The group’s first paper is a nine-page primer on efforts to expand health insurance coverage in Massachusetts, Vermont, Colorado, California and Nevada. The pamphlet analyzes what made each effort fail or succeed from a policy and political perspective. For example, it claims that the single-payer bill that passed the California Senate last year faced political opposition because of the lack of a concrete plan to finance it.
Slavitt maintains that it is not his intention to get in the way of the “Medicare for all” movement, and he sees his work as a complement rather than a substitute for all kinds of universal health care advocacy.
“We can work alongside advocates of all stripes.”
He envisions the group being as willing to provide supportive policy and political advice to the effort to pass a state-level single-payer plan in Washington state as it is to help implement more modest coverage expansion initiatives in places like Virginia.
To achieve this goal, he hopes to hire a staff of experienced policy experts and political hands to advise state governments. The people on the founders’ council, he emphasized, will help open doors for the group but not conduct its research.
“The reality is there’s unsexy hard work that hasn’t happened on the ground to get these things passed, and those are things that the people we’re hoping to hire, and have hired already, understand well,” he said.
I asked whether he could be trusted not to rule out certain policy options, given the blessing that health care industry players and Republicans have bestowed on his group.
Slavitt maintained that the group was “not beholden to anyone.” To that end, he said, it would not take money from insurance companies, for-profit corporations or political action committees.
The assertion is hard to verify, however, since United States of Care is declining to name its donors unless they choose to identify themselves. Thus far, Slavitt; Dr. J. Mario Molina, CEO of Golden Shore Medical Group; and the Catholic nonprofit hospital Providence St. Joseph’s Health have disclosed their financial support for the organization.
I also asked him to respond to skeptics who believe that a fund he has started to invest in health care innovations for low-income people represents a conflict of interest.
“I don’t think [my investment fund] has anything to do with my role as a board member of the United States of Care,” he said.
Below is a lightly edited and condensed transcript of our conversation.
Ventures that try to get beyond partisanship are almost a kind of cottage industry in D.C. No Labels is probably the best example. Many people would argue that those ventures either die a natural death or they stick around but don’t have a major effect on the policy conversation. Why is your venture different?
Andy Slavitt: I would actually agree with that characterization. I’m no fan of bipartisanship for bipartisanship’s sake.
What I am a fan of is trying to figure out how we move the country past where we’ve lived [during] the past year, which is having constant needs of the American public that are ignored while, at the same time, no ability to have any way to break past the politics of the issue. And so we’ve never been further apart as a country from what the people of the country demand and what the politics are delivering.
So, to be clear, this is not an organization that is about assembling people from all points of view and siphoning out the lowest common denominator of ideas. This is about a commitment to putting the tangible ideas behind the passion that Americans have for health care and trying to get policies changed.
OK, so you come up with a policy with a group of folks. It might not be a policy that Bernie Sanders or other members of the progressive left think is awesome or ideal. But it’s a bipartisan policy. But there’s a reason that Paul Ryan and Mitch McConnell aren’t on the board of your organization …
You’re asking questions without having listened to my prior answer, which is this is not a group that is coming out with policies. Go back and listen to the first thing I said. This is not a group that is a policymaking body.
If you’re referring to the founders’ council, this is a group that said, “We need to break this jam.” They have a wide variety of their own opinions and solutions of which we couldn’t even chronicle, from the first lady of New York to people who have very different types of solutions. There is no possible way, nor is it our desire, to get that group to come to a consensus on policy. What we hope they will be is experts and resources for us when we need them, when we’re trying to get things done.
We may be, for example, working in a state that has a Republican legislature or a Democratic governor, or vice versa. We may be working in a whole variety of settings, and we want to demonstrate to people that we are focused on their interests and then turn them into good policy ideas.
I think a lot of people bring a lot of passion to health care. It is the most personal of all issues. And I think people are reading into the formation of our group some things that they’re reading into because they were unclear [about the group’s goals], which is understandable. And some are things that they’re reading in because they have passion for the issue and think that it’s set up to do things that it’s not intended to do.
To be very clear, our aim is to get every American health care coverage. And you can say that, but people will parse everything you say to say, “Well, that’s coverage, that’s not care,” or you can say, “It should be affordable,” or you say the word “access,” and everybody reads into all these words.
But go back and look at my Twitter feed for the last year. It’s not hard to figure out what I believe in.
You talk about states experimenting with this stuff, but Congress seems like a totally different animal.
And I think the reason this gets under people’s skin is that they basically saw eight years under Obama where people talk about this metaphor of “Lucy and the football” ― where Democrats would try to operate in good faith, whether it was on Obamacare in the [Senate] Finance Committee and how long that sat there, or on the Grand Bargain on the deficit and the debt. And the second Democrats would move to proverbially kick the football, it would get pulled away.
I wonder how effective taking politics away is when you have a Republican Party, at least in Congress, that refuses to take politics out of the equation and really doesn’t share the fundamental end goals?
And not only that, there’s been asymmetric polarization, so if you’re trying to reach a compromise with them and they’re continuing to move to the right, then compromise continues to move to the right as well.
Those are very fair questions, and it’s one of the reasons why it doesn’t make any sense to spend any energy right now at the federal level. There is a logjam that’s not going to get broken before 2020. Let me be clear: We don’t think we’re going to change that underlying politics for the moment.
Here’s the exciting thing: Over 70 percent of the people in both parties, or independents ― forget politicians, forget Washington for a second ― believe that every American should be able to have access to affordable health care coverage. That is very far from where the conversation in Washington is.
Our message is not that politics are not important. Our message is that when politics work, politics represent the needs of the public. And there’s a variety of reasons why they don’t right now. And we could probably go through a litany of them, and they include things that are far outside of health care. It has to do with things that you and I could probably both identify: the way money works in politics, the way districts are drawn ― all these things that are making us more polarized.
My perspective is that we can’t afford to live in that situation. I’ll give it to you numerically: There were 22 Republicans that voted no on the House bill [to repeal the ACA]. There were three senators. Imagine if that 22 were 40? Imagine if that three were 10? And those aren’t unimaginable things. Now they’re unimaginable in the next two years. But they’re not unimaginable over the long term, particularly if the populace of the American public makes it very, very clear that that’s where we need to go.
We’ve seen this happen in other areas. We’ve seen this happen with marriage equality. We’ve seen this happen with lots of things that have changed over time, which is that the politics won’t change on their own. In fact, you could make the case that they’ll get worse on their own. But what I think is quite possible over the next medium term, not near term, is that we have a fundamental shift over how politicians are forced to think about these issues because the public is pretty firmly in this camp.
Will you campaign for Democrats in the 2018 midterms?
Yes, I am. I am hosting something for [Randy Bryce, an ironworker who seeks to challenge Ryan in his Wisconsin House district this November] at my house shortly. I just wrote a letter for [Senate candidate Beto O’Rourke] in Texas. I just wrote a letter for a candidate in Georgia.
I’m personally very active. Now that’s of course separate from my role as head of a nonpartisan organization. But who I am doesn’t change at all. Look at my Twitter feed the last few days? I haven’t changed who I am.
But I do believe that we need to get a force multiplier if we are going to change the equation in this country. I personally am very excited by all of the energy on this topic. I want to digest it and understand it all and figure out how to turn that into real victories.
So you do see taking back Congress and ultimately taking back the White House as a part of the policy solution here?
No one’s confused about what political party I’m in. No one’s ever been confused about that. No one’s ever going to be confused about that. And I’ve never given anyone a reason to be confused about that, so there you go.
It’s interesting that you mentioned marriage equality as a model you want to emulate. “Chapo Trap House,” a popular left-wing podcast, spent a lot of time criticizing your group. And they likened the push for ‘Medicare for all’ to the same-sex marriage fight ― that if you continue canvassing and building grassroots support, and educating people on the need to at least treat health care as a human right and, in their opinion, to make it free at the point of service, that, maybe not in two years or in four years but in 10 or 20 years, you’ll ultimately achieve your goal. And, in the meantime, you’ll move the Overton window, or range of politically acceptable views, to the left.
You’re someone with an enormous platform, and it seems like there’s an opportunity for you to also participate in this moving of the Overton window by backing a specific set of policies and maybe ones that are too radical for the current spectrum.
I don’t disagree with where [Chapo Trap House and other leftist groups are coming from]. I mean, I hesitate to understand why they are criticizing an organization that’s three days old. But that’s fine. I think the organization will learn from its critics.
But ultimately wanting to get to a place where everybody has coverage ― the way I think about it is, if my kid was lost in the park and I called the police, they would immediately start searching for him. They wouldn’t ask for my insurance card and my co-payment or any of those sorts of things. That’s the world that I think most Americans believe we need to live in ― where they’re not risking their financial security because of health care.
OK, well, what are the precursors to making that happen? I think there’s a couple. And everyone is free to agree or disagree with these, but one of them for us is indeed tapping into that body politic. A second is building models in states that can be replicated at the federal level much in the same way that [the Massachusetts health care law under then-Gov. Mitt Romney] was in the ACA.
And we see loads of opportunities and, quite frankly, loads of threats. If I look at what Sprinkle Care [a Medicaid buy-in proposal] was in Nevada last year, if I look at what’s potentially going to be on the ballot in Washington state, if I look at what potentially Virginia’s going to be considering, if I look at what New Mexico is trying to do ― if we can get some of those things done in the short term, then they can be helpful to the longer term.
And I think the one thing that this organization is wise to do is not say that there’s a single answer. Because the reality is I’ve assisted Sanders’ staff on their bill, I’ve read [H.R.] 676, I’ve read the [Sen. Tim] Kaine’s bills. I’ve read all the bills [pending in Congress that would expand health care coverage]. And nobody would say we’re yet at a point where we have a single answer.
And that’s the great news: Because we’re probably years away from looking at what’s going to be considered, we have time to mold it, we have time to shape it.
Right, but it takes time to build a political movement. So people have a rallying flag [in “Medicare for all”] they think is very exciting to people, and they see that laying the groundwork for a whole variety of different things.
I don’t think this works against it. The reality is, there’s unsexy hard work that hasn’t happened on the ground to get these things passed, and those are things that the people we’re hoping to hire, and have hired already, understand well.
I think we can work alongside advocates of all stripes.”
One of the things that progressives look at in the Affordable Care Act is that they see something like the Medicaid expansion as the most successful part of the law precisely because it was unafraid to circumvent the private insurance industry. You talked about those 22 House Republicans who voted against repeal and the three in the Senate ― it was basically because of Medicaid expansion, and that was the most progressive part of the law.
Isn’t there at least a policy lesson there that the old RomneyCare/Obamacare, private insurance marketplace that is now being so viciously torn apart by Republican majorities is less politically sustainable than kind of a straight, liberal reform that people understand, that’s simple, that hasn’t been unaffordable for people?
I think that’s right. But look, if you want to tell your readers that Medicaid expansion is a public program and not private sector, go ahead and tell them that. You know that’s wrong.
But I do think there is truth to the fact that governors saw how well this worked in their states and understand that going backwards on that would be a horrible mistake. And I think that’s exactly the kind of momentum that needs to be built.
You don’t think that provides any policy lessons about the sorts of expansion that work best?
I do, I absolutely do. And look, I’m not, in the context of my prior comment, I wasn’t defending the ACA per se as the ideal. I actually think it’s kind of moved beyond where we’ve been.
We have to begin with what we have to do to get the outcome we want. And I think there should be participation and debate that we haven’t been able to have over the last seven, eight years because we’ve been playing defense against keeping the law standing up. It’s time to move past that and try to create a positive vision.
Your point is an excellent one, which is not one the United States of Care is in any way in opposition to, which is to say: What are the best ideas? What are the simplest ideas? What are the ones that make the most sense? I think it would be completely wrong to characterize the United States of Care to be against something that has those kinds of features.
Those have been wins. I’ve spent a lot of time with governors of both parties who would agree with you. The question is, how do you take that consensus, how do you take that lesson and how do you turn it into larger-scale wins and what’s applicable in the states, what’s applicable in different states, what’s applicable at the federal level? Those are all battles to be fought. And I think this is an organization that can hopefully be useful to that.
But keep in mind, this is not an organization that is in place of any of the other efforts. I think it hopes to assist in helping to get some of these things done.
One of the reasons that people are concerned that United States of Care will at least be constrained in terms of the sorts of options it will be able to promote is because of the presence of people from the private insurance industry who might not have a stake in certain kinds of solutions.
Yeah, so, well, we made a couple of important decisions. First of all, I understand the concern. So that’s something we are supportive of ― to make sure that we address that to people’s satisfaction.
The best 501(c)(3)s [the IRS designation for nonprofits] have highly diverse sources of funding. They’re not dependent on anybody. Nobody gets a chance to sway policy. And, you know, you’ve got to give the organization time to demonstrate that, but we’re taking lessons from the best of them. We felt it’s important not to take money from insurance companies, not to take money from for-profits, from PACs. Those are important.
And I think what’s important is to see the proof in the pudding. So, people are concerned ― they’re going to remain concerned until such time as the organization has the opportunity to do its work.
You said the proof will be in the pudding. What would the pudding look like in a few of the states where United States of Care is going to be active?
We still have a small number of people, and they’re still around getting outreach from states.
In the past three or four days, one of the really good things that’s happened is that a bunch of the people in states who are working on really exciting initiatives have sent us a bunch of information about it. I haven’t had a chance to evaluate it all. The team is still evaluating it.
But there are exciting things going on in Washington state. There are exciting things going on in New Mexico.
I will tell you that what Oregon did with their Medicaid program was highly innovative. I thought personally what [Assemblyman] Mike Sprinkle did in Nevada had shown a lot of promise.
The devil’s in the details. These are all things that sound good, but most of them don’t get over the finish line for one reason or another. We have to study why that happens and make that work.
The truth is most of this stuff is not that controversial. Most Americans want everybody to have the health care they need. It still isn’t happening. It still is not easy. So this organization has got to be about figuring out why.
It ultimately will be less defined by the policy positions, because I think the policy positions it’s going to support are going to be very much in line with where the public is. It’s going to be successful in changing our track record where most things just aren’t seemingly able to get done for one reason or another. [The group] helps them get done, and of course that means in partnership with all of those great advocates out there.
One of the principles of United States of Care references fiscal responsibility. The GOP just blew a $1.5 trillion hole in the budget. Fiscal hawks have also been warning about deficit issues for years, and the Fed keeps missing its 2 percent inflation target.
Isn’t fiscal responsibility as a static concept or end in itself dead as a political goal? And, if not, shouldn’t it just depend on whether inflation is a problem at a given moment?
Here’s the thing with the economics of it: We spend $10,000 per person in this country on health care. And so we have to recognize that the way we pay for prescription drugs, the way we do Medicare Advantage bidding, the way we do lots and lots of things are done in ways that aren’t necessarily getting the best deal for the taxpayer or the consumer.
That’s not meant to be an exhaustive list. We published a paper, which I’m sure you’ve read, that looked at the five or six efforts toward either single payer or universal coverage, we published last week, and looked at what went well, what didn’t go well and are there any lessons to learn. One of the lessons to learn was unless you have a financing strategy, [passing reforms] becomes [a challenge].
So, I think what we’re saying here is not Washington-speak for “everything must be paid for,” but it’s the fact that we can’t provide our citizens and our residents of our country what we want if we don’t focus on costs, if we don’t focus on the fact that an emergency room visit costs several thousand dollars, etc., etc.
Do you think antitrust is a part of that toolkit? Because people look at how concentrated the drug industry, the hospital industry, the insurance industry are, and they say that that is one of the key drivers of costs.
Let me just say this, because I think it’s important to say this clearly: We’re not beholden to anybody except the right answer for the American public.
What I would tell you is, when you end up, as you had with the ACA and almost every other law, where … the insurance companies and pharma companies are sitting around the table quote-unquote bargaining for the end game, who represents the American public in that bargain?
And the reality is that we felt like that voice wasn’t strong enough. I spent this last summer doing town halls across the country ― I did 15 town halls in districts where congresspeople had refused to hold town halls ― in order to bring information to the American public. And what I saw is enormous unanimity around what it is that people want.
… It’s important for everybody to know that United States of Care will support the best answers and it will often be different answers in different states, and work on the solutions and [it] won’t be beholden to anybody.
Another thing that people are frankly a little bit suspicious about is your own startup investment fund and this idea that a solution to the health care problems facing low-income people is a for-profit investment fund.
I believe that we as a country innovate in entirely the wrong way when it comes to health care. And the reason I say this is because the vast majority of venture capital investors and private equity investors are 35-year-old white guys. And that’s why we have 14 Fitbits and investing in things like artificial intelligence and all these high-end things that people who are really not in great need of care ― I mean, people who generally are getting good care ― are getting all kinds of innovations.
And I can tell you from running the Medicaid program and the [Children’s Health Insurance Program], where we need to be focused on is: Are we investing in housing? Are we investing in mental health? Are we investing in transportation and nutrition in the community in ways that can help people get better access and care and stay healthier?
So I absolutely believe that we ought to be productively trying to solve those problems. I do believe there is a role to play for innovative people, and there are young companies, innovative millennials that are trying to solve these problems. I think that’s a good thing.
I don’t think [the investment fund] has anything to do with my role as a board member of the United States of Care. I suspect every board member and every participant is going to have their own set of activities. I happen to have a core belief that we need to refocus investment in underserved communities. And I’ve walked my talk, by the way, for a number of years, so you can take a look back at my track record.
Is there no situation you could imagine with this fund where an experiment is tried that is profitable for the company but does not have the results that were promised? Because sometimes when these things get started, it gets hard to walk it back. Would you sort of pack your things up and quit if you thought it wasn’t working that way?
If an innovation wasn’t working?
Not working in the sense of not meeting social goals, not in the profit sense.
Look, I’m 51 years old. I only want to work on the things that matter. I’ve been exposed to a lot of great things. I believe there are a lot of really critical things that need to be shown to work, like [the Program of All-Inclusive Care for the Elderly] and other kinds of things that would be good for treatments in different communities. Separately ― this is a different interview ― I could name you a couple companies that I have seen that I am impressed with.
Not all of them are going to work. But my interest is only in the ones that I believe are going to move the needle in that direction.
But it’s an imperfect process. And my investment is going to be tiny compared to the rest of the people. What I am going to do is draw attention to it, so the country changes the way it innovates and gets away from its love affair with creating a bunch of innovations that we don’t need.