Andy Slavitt understands the inner workings of the U.S. health care system better than most. From 2015 to 2017, he ran the Affordable Care Act, sometimes called Obamacare, as head of the Centers for Medicare and Medicaid Services. Since leaving that post in January, he's been an outspoken critic of the Republican proposals to dismantle it.
Yesterday, shortly after the release of the Senate bill, he tweeted, "It's the ugly step-sibling of the House bill." And this morning his message was, "We must start over. It's too important."
Slavitt spoke with All Things Considered host Kelly McEvers about the latest Republican plan, called the Better Care Reconciliation Act, and where the Affordable Care Act goes from here. This interview has been edited for length and clarity.
Fair to say there isn't anything you like in this new plan?
Well, it's hard to say that you like the uniforms of the team that's got the guns pointed at you, trying to kill you. And I don't mean to exaggerate, but in the main, it's very hard to be supportive of something that takes health insurance away from 20 million or so Americans. The details that we've seen, at least so far, aren't particularly good for people with lower incomes. They're not particularly good for people who are sicker, and they're not good for people who are older.
Supporters of the Republican plan say the Affordable Care Act's individual mandate forced people to do something they often didn't want to do. And that this new proposal would allow people to have more choice. True?
Well, the individual mandate is about as popular as vegetables are with my kids. We know that. And we know that there needs to be something that helps keep healthy people in the pool, because if we leave people to their own devices to buy health insurance when they get sick, that will just drive the cost up for everybody.
There are choices and trade-offs made within [the Senate] bill that we should acknowledge. If you are a 27-year-old person who makes $70,000 a year and has no illness, this is a good bill for you. If you are younger and don't get your insurance through your employer, your insurance will be cheaper. It will cover a lot less, but that may not be a problem to you. You may be OK with that.
The challenge of course is that if you're over 50, or if you're sick, or if you live in rural areas and if your income is low, you pay the price. In fact, people who are over 50, many of them would be asked to pay as much as 50 percent of their income [for health insurance], and that's all in order to make the policies cheaper for younger people.
The problem our country has is how to help people who are in the lowest economic straits, who have the most health challenges, get access to affordable coverage and, indeed, get well. The problem we don't have is how to help 27-year-olds get cheaper insurance. That's just not a national concern for us right now.
You've talked about how the Affordable Care Act isn't perfect. If the Republican proposal does not pass, what could and should be done to strengthen what's already there?
This is really an interesting question because I actually am a big believer in bipartisanship, in large part because I don't think our country deserves to go through the back-and-forth of changing our health care system every election cycle.
But the only way bipartisanship happens is if partisanship fails. If this legislation fails in the Senate, I do think we'll have an opportunity.
There are a number of things that we can work on constructively to make insurance more affordable for people, to make insurance more competitive.
I think if the people who drafted the ACA had it to do over again, there may be some things that would have been done differently. I think people would have liked to have had more enforcement of competition, more affordability for people in the middle class. I think there are plenty of practical solutions. The hard part is getting people to trust each other once again.
KELLY MCEVERS, HOST:
Yesterday Senate Republicans released their plan to replace the Affordable Care Act, a signature measure of the Obama administration. And we've been talking to a lot of people about the bill and getting a range of opinions.
Today we hear from Andy Slavitt. At the end of the Obama administration, Slavitt ran the Centers for Medicare and Medicaid Services. That's the agency that administers the Affordable Care Act. And while he did that job, he talked to Americans about their health care just about every day. So I asked him what he thinks will happen if the Republican bill passes and if Medicaid, the health insurance program for low-income Americans, gets cut back.
ANDY SLAVITT: I met a woman at a town hall that I attended. She was in her mid-30s. And she grabbed me by the arm, and she said, I have a mental illness, and I feel like since the Affordable Care Act, it's OK to say that. But my cost of my drugs are really what allows me to function and go to work. And if this bill passes and the ACA goes away, I don't know what I'll do because I am so dependent on this medication, and I won't be able to afford it without the Affordable Care Act.
These are the situations that I think we hear over and over and over again - millions of people across the country who now are in a circumstance where they really have stopped having to worry about disclosing their illness or being able to pay for their medications or worrying that if they get sick, they can't leave their job.
MCEVERS: The Republican plan would also affect Americans who buy their insurance on the exchanges that were set up by the Affordable Care Act. The Republican bill would reduce the subsidies that would help people buy these plans, but it would also eliminate the penalty if you choose not to have a policy, right? So how do you imagine that will play out for people?
SLAVITT: Well, this is really curious because one of the things that this policy does is it takes the portion of the insurance that is paid by the insurance company down from 70 percent to 58 percent, which means that deductibles are going to go up to somewhere between $6,000 and $7,000 on average, and that's quite puzzling given that the major criticism was deductibles were too high. So I think what we'll see is we'll see deductibles higher. If we don't have more people in the pool because there is no mandate, then I think we'll see premiums go up.
And then of course the waivers that are in this bill are probably the most deceptive and concerning thing about the bill as a whole because they allow essential benefits, cancer treatments and other things not to be covered. And so while it is true that they say people with pre-existing conditions can get coverage, what's the point of having a cancer patient get coverage if cancer treatments aren't covered?
MCEVERS: You talk about the mandate being in place to get more people into the pool. That was the reasoning behind it. But a lot of supporters of the Republican plan would say, but that forced people to do something that they didn't necessarily want to do and that this new proposal would allow people to have more choice.
SLAVITT: Well, look; the individual mandate is about as popular as vegetables are with my kids.
SLAVITT: And we know that. And we know that there needs to be something that helps keep healthy people in the pool because if we leave people to their own devices to buy health insurance when they get sick, it will just drive the costs up for everybody.
And I would say this. If you are a 27-year-old who makes $70,000 a year and has no illness, this is a good bill for you. And I want to be clear. If you are younger and don't get your insurance through your employer, your insurance will be cheaper. Now, it will cover a lot less, but that may not be a problem to you. You may be OK with that. The challenge of course is that if you're over 50 or if you're sick or if you live in rural areas and if your income is low, you pay the price.
MCEVERS: You talked about how the ACA isn't perfect. I mean there are improvements that can be made. If the Republican proposal does not pass, what could and should be done to strengthen what's already there?
SLAVITT: I think if the people who drafted the ACA had it to do over again, there may be some things that would have been done differently. I think people would have liked to have more enforcement of competition, more affordability for people in the middle class.
But I think the Republicans also have to take a very good look at themselves and say - over the last seven years, they did not only nothing to make insurance more affordable, but they took a number of actions that made insurance more expensive for people. They eliminated the rates stabilization funding, which took premiums up very significantly. They sued in the Supreme Court to get Medicaid expansion blocked. So look; if we decide as a country that we really want to work on this together, I think there are plenty of practical solutions. The hard part is getting people to trust each other once again.
MCEVERS: Andy Slavitt - he ran the Centers for Medicare and Medicaid Services, which administers the Affordable Care Act, from 2015 to 2017. Thank you so much.
SLAVITT: Thank you. Transcript provided by NPR, Copyright NPR.