Andy Slavitt discusses recent developments in the COVID-19 pandemic and the US response. Slavitt was Former Acting CMS Administrator in the Obama administration, board director at the United States of Care in Washington, DC, and a Distinguished Health Policy Fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania in Philadelphia. Recorded October 16, 2020.
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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner. Once again, it is Howard Bauchner, editor-in-chief of JAMA, and I'm here with Andy Slavitt. And-- so when I talk to my colleagues who do health policy, conservatives or liberals, they always say you want to talk to Andy. He's really, really smart. He's incredibly accomplished. So, Andy, thank you for joining me today.
>> Andy Slavitt: Thank you, Howard.
>> Howard Bauchner: And just to remind our listeners and our viewers, Andy's a forming-- a former acting administrator of the Centers for Medicare and Medicaid, CMS, 2015 to 2017, but before that I think you rescued healthcare.gov, Andy. What was that like when you were asked to kind of rescue the ACA rollout or certain aspects of it? What was that like?
>> Andy Slavitt: Oh, it was a piece of cake. First of all, it wasn't me, it was a whole--
>> Howard Bauchner: Yeah, I know it was your whole team.
>> Andy Slavitt: I was fortunate enough to be involved, but it took every one of us. Look, I, you know, it's funny how that happened. I actually called Washington after the website crashed and just offered to help and said, hey, if you need some help, I'm glad to come lend a hand. Of course, I assumed that hundreds of people were making that same phone call. It turns out that I probably got tagged to do this by process of elimination. I think I was the only one that made the phone call and two days after they announced in a public that I would leading that effort to be the chief firefighter and then they ended it by saying and it will be fixed within five weeks, which was news-- which was news to me. But it was an incredibly stressful and exhilarating and important period. I think we have a lot at stake, you know, millions of people who had never had insurance for the first time were kind of hanging in the balance. I think the entire-- in some respects, confidence in government to implement big programs was in the balance, and, you know, politically, I think President Obama needed it to work for presidency, but, you know, at the end of the day, just say that you learn a lot about fighting crisis and about how all of these pieces work and come together and can come together.
>> Howard Bauchner: Yeah. I think that notion of a crisis of what government can do has reached a kind of record level this year. I'll have some questions towards the end about what you learned when you were at CMS, but I'd like to obviously focus on the very painful period of the last nine or 10 months. I know you've reached out to the Trump Administration to help and have been asked to help. I know you've been consulting around the country. What have been the successes, Andy? Let's start-- let's start with what you think the successes have been.
>> Andy Slavitt: You know, I think in some respects we're doing pretty well at the hard sciences-- what I would call the hard sciences-- vaccine research, the kind of continual learning process that your publication and others continues to roll. I mean we are a lot smarter than we were nine months ago. We know how this thing spreads. We know how to avoid it. Generally speaking, we have we still have holes in our knowledge around what makes people susceptible, how immunity works, and we're completely flummoxed with what this thing does once it gets inside the human body, but that's a fair amount of progress because it helps us understand that, look, as citizens of the world, without a vaccine, we and how we relate to one another in our communication is our medicine. Our ability to avoid infecting one another and getting infected ourselves is our only medicine. And I would venture to say that as a global community we understand how to do that. So, if you want me to spin this as a positive success, I don't think it's a big mystery at this point how to avoid more casualties, more losses, more suffering. The question of course is why aren't we doing it.
>> Howard Bauchner: Right. You know, I do get to see and read a lot of interesting material. I would say I think your comment about the hard sciences is interesting. I think the vaccine development, you know, Tony Fauci had predicted rapid vaccine development in JAMA three-and-a-half years ago. I don't think even he thought six months, nine months, or 12 months was possible. So, I think-- assuming we have a successful vaccine sometime early next year-- and we'll return to that-- I think would even surprise Tony at this point. Pleasantly surprise him. And I think the decline in mortality rates, even accounting for age and fragility, really has strongly suggested that the clinical community is doing a far better job at care. Obviously, the tremendous impact of steroids, 10-15% reduction in mortality is really welcome. It's inexpensive. It's widely-available. It doesn't have many side effects. Andy, what states have done well and what states are struggling?
>> Andy Slavitt: Well, let me start with the globe, first.
>> Howard Bauchner: OK.
>> Andy Slavitt: Let me point to Africa, 1.3 billion people, to this point, about 35,000 deaths. So, what's the lesson from that? If you knew nothing else, you would probably assume the answer is not extremely high-tech. It's not beyond our grasp and, you know, what's different about Africa and African nations, one is they have experience in public health crises, more so than the private health care system. We've got a lot of investment in the private health care system, not so much in the public health system. Secondly, if you look around the world and you were to kind of in your head just mentally shuffle countries into individual rights and freedoms and entrepreneurial versus communal and society-oriented-- and I'm not making a value judgement between the two. We value a lot of the reasons why we're in the first category, but the countries in the second category have done far better. Because, again, no one has a vaccine. Your ability to have a unified message, to listen to scientists, to get everybody, relatively speaking 80-90% of people on board, is just easier. We have these cultural tensions around our rights and our freedoms and our-- and so forth and that puts us in categories with countries like Brazil, like Russia, and it's a-- it's too-- it's not necessarily clear that there is a cause and effect, but there certainly is a correlation there that appears. Within the U.S., look, I think-- I would venture to say that most governors are taking this seriously, although they are taking different approaches. I would say that, [inaudible] states are not designed to fight major public health crises. Now, there are some places with remnants of public health infrastructure, of course, like San Francisco and New York and so forth and so I think that-- in particular in San Francisco because of the HIV and the AIDS crisis, I think they've been, you know, all-- Mayor London has been all over it and I think there have been very strong responses, but it's not easy. In other parts of the country, I think you've got states ranging from New York to Massachusetts to Ohio to Kentucky, none of which have done a perfect job, but all of which have public health teams that really understand what's happening. The challenge is for these governors and that is that they too don't doubt-- with very few exceptions-- that wearing a mask will dramatically reduce transmission and that-- and that there should be a mask mandate. What they have trouble with, both republican and democratic governors in many states is that-- is that there are-- particularly as you get out of the urban and suburban areas, there is a rebellion-- I think it was skepticism and I think now it's closer to a rebellion than skepticism-- against public health and public health measures. And some of this is driven by the fact that their lived experience has been this has been a very inconvenient virus, but not necessarily a deadly one. I have heard Ed Young refer to this as the reverse Goldilocks virus. It's not so deadly that everyone has to take action, but it's still doing a tremendous amount of destruction and it sits right there in the middle and if you live in a community in the rural part of Ohio where you haven't seen it very much yet, you're not necessarily a believer. Once this comes through your town, it has an effect. You know, Arizona, I think, had been that way and they responded well. They-- you know, I think a lot of people responded poorly at first, New York and Arizona, and then they responded, I think, quite well after the fact. I also think it's hard-- I just want to give you one more thing. I think it's hard to judge this based on the numbers alone and here's what I want to say about that. This virus is-- this virus is the enemy. It's not our-- it's not our political leaders, it's not our governors, it's certainly not each other. And the virus goes where it hasn't been before and where it has the most friendly environments. We're not doing a great job reducing the number of friendly environments. We're being quite a good host to the virus. But if you sit here in a state where the virus hasn't come yet, you can get the impression that somehow you're doing something right, you're immune, or it's been overblown, and as it makes its way through the country and gets to your part of the country, you know, people are fatigued. So, we have to understand this human dynamic-- these-- and I will use the term the soft sciences-- sociology, psychology, communication, all these things. Those are the most challenging areas right now.
>> Howard Bauchner: The number of cases the last week or so have been what has raised individual's concerns. It's gotten chillier around the country. You know, I was just in Maine and, you know, one day was 22 degrees. It's going to force people inside. Case numbers reported yesterday were 65,000 I think, 53,000 the day before. Thankfully, the ratio of cases to deaths remains lower than it was, obviously, in March and April. I feel like we're in suspended animation until the election. That it's three-- I think three weeks away-- what would reflection-- what would President Trump or President Biden need to do on November fifth, sixth, seventh, or eighth to move the country to a healthier position? Regard-- obviously, if Vice President Biden is elected, it wouldn't be until January 20th, but where do we need to go in November, December, January, and February?
>> Andy Slavitt: So, look, I think the country does feel like it's in suspended animation, but I want to challenge it a little bit. And certainly I believe that one outcome for the election will be far better for our response, but I'm not going to start there. Where I'm going to start is every day in this pandemic we have an opportunity to save the next life. So, you know, even though 235,000 sounds a lot closer to 230,000 than 5,000 does to zero, that opportunity is in front of us every day. And so I kind of refuse to live in this sort of suspended state in large part because I also know that our elected leaders, even if we have the right ones, can't do it without our help. So, you know, I have this sort of-- I think the right philosophy is save the next life, 205,000, 208-- whatever the number is, we will do disservice to the people we have lost if we continue to allow more people to die because we are somehow giving up. This is not humanly impossible, as you know. It's been done around the world. It's not easy. I'm not going to suggest that it's not filled with-- that it's not easy, but I'd say we're novices at it here. We're making it harder than it should be and we have it within our power to come together and do this and, you know, I have plenty of people that say you're just too much of a sunny optimist if you think this can happen. You know, the other-- that may be the case, but the other choice is accepting it. And, you know, I don't think-- I'm not-- I don't think we should be ready to do that. I mean I think at any given moment we can rewrite the way this history ends, no matter who is the president. Now, it will be easier if we have a president who implements some of the things like paid family medical leave so that if people are feeling sick they don't have to go to work. Enough testing and contact tracing resources that people can go back to school and work safely. Then we can open up slices of the economy that matter, like people being able to travel, sign leases, hire people again, because they feel safe. So, there are a bunch of things we could do from a policy standpoint, but even if we do all of those things, you know, the three ingredients that we need in a president and in any leader in this crisis are, number one, competence. Pulling that off. Number two, compassion, because this is being felt in communities around the country that are a little bit on the margins. Farm labor communities. People in jails. People in congregate housing. People in public housing. So, you have to have enough compassion. And third is the communication to bring the country together and that may be the most challenging. Whoever the president is-- if Trump woke up tomorrow-- I don't think he'll do that, but if he woke up tomorrow and said I really want to unite the country to fight this, it would be very difficult. And if Biden is president, I think that will be an enormous challenge, but I think he recognizes that challenge and I think whoever it is we just have to-- we have to support it.
>> Howard Bauchner: Andy, a question came in and people have asked me this before in a different way. So, I think you know on Monday of last week we had published a series of articles-- Monday of this week-- two research letters. One describing how the U.S. has done in comparison to 19 other countries-- poorly, by every metric and every time period, not just early on, but over the summer. Another research letter, a follow-up by Steve Wolf, 235,000 excess deaths. So, very good numbers comparing number of deaths this year to last year, projects out to anywhere about 400,000 by the end of the year, similar to the number of deaths of World War II. Then a collection of viewpoints and editorials. But the question that has come in and that comes up for me that people ask me directly, well, many of these people were going to die anyway. They're just dying a year earlier or two years earlier. How do you think about that? I know it-- it is a question that comes to me. The actual question is how can we challenge the notion propagated by some in politics that some lives are worth less to save or are not worth saving? How do you think about that? Or is it just beyond the way you conceive of fairness in life?
>> Andy Slavitt: You know, you can't make people care about other people and you can only control what you can control and if you walk around with the burden that I have to change everybody's mind, you know you're going to be pretty frustrated. I mean some of the facts are that-- and look, I don't know if this is the most recent data, but that the average life expectancy-- the people we're losing are losing an average of 10 years off of their life. You know, my wife's grandmother lived for a dozen years in a congregate care setting. My mother is well over the average age of when people die and she walks 7 miles a day and loves her life in the city of Chicago and gets pleasure every day and she hasn't-- she only has two grandkids and she doesn't have any great-- so, like, you know, I mean at some level in the abstract you can say, well, god, at least it's not kids. Right? But the truth is, first of all, it could be kids. It's just the luck of the draw. This could be measles where we lost millions of people every year in the late 50's and early 60's. It could be measles. It's not. Secondly, I mean we're all going to be there some day. You know? I mean-- so, this-- these are generations that if you think of what they lived through, they-- some of them lived through World War II, they lived through, like, the Korean War, they've lived through a lot of unrest. They sort of brought us where we are. So, to some respects, you know, there is a societal question. What do we owe them? You talk to people in, you know, the tribal reservation lands and, you know, they would tell you that the way you treat your elders is exactly who you are as a society. But I, you know, I don't-- I don't know that the moral argument works. I think what people are saying when they say that is I want to go back to my normal life. I don't want to be inconvenienced. And to have-- show a little bit of empathy for them, perhaps they started a restaurant 15 years ago and it was their life's dream and they had to close it and they believe that they closed it because, you know, there was the pandemic, but maybe they thought they overreacted to the pandemic because in their community, you know, it didn't happen and that's kind of their lived experience. So, what I find is that if I take a deep breath and listen to someone and ask them questions-- which you can't do on Twitter, you can't do on social media very easily, but you stop glaring at people who aren't wearing masks and, you know, personally, your own blood pressure goes down a little bit. Second of all, you're this completely-- I've never seen it be effective to try to shame somebody or convince them that they're stupid or that they don't have values. And, you know, we've kind of lost the ability to have a discussion about this stuff rationally. I know that I get hyped up. We all get hyped up about these topics because we believe people are being cruel, but, you know, the end of the day, you know, the art of this that's failing us is our ability to connect and agree on these things.
>> Howard Bauchner: Yeah, I-- something you said, I put so much emphasis on civil discourse even when we're discussing manuscripts and we disagree. People know my expectation is that it will be done with a great deal of respect for the other person's opinion. We've just lost that. You know, you had talked about sociology and psychology. You know, I've been fortunate to interview many people, have conversations with many people-- Bob Redfield, Tony Fauci, a lot of the leading public health epidemiologists-- and you mentioned it earlier, you know, masking, social distancing, hand washing-- other countries have done it. How do we get there? It's become so politicalized. You know, it was interesting to see the governor from New Jersey, I've forgotten his name for a second.
>> Andy Slavitt: Chris Christie.
>> Howard Bauchner: Chris Christie said he should have masked when he didn't. We had the superspreader event at the White House. Clearly, superspreader event. You know, how do-- how do-- is a mandate the route to go or how do you begin to think about individuals saying it's a we versus I and if we do this the benefit is for you, both personally as well as economically? How do we get there?
>> Andy Slavitt: Yeah. Well, look, I mean I think it's a mandate plus or a mandate with an asterisk. You know, every governor that I have talked to realizes that if they drop the mandate they actually feel like they're communicating to people that they don't need to wear a mask. So, they don't-- they adamantly-- and they have data to show it-- that when you wear a mandate people will more likely to-- be more likely to wear masks. You know, and if our goal, you know, and I think [inaudible] said to me that the goal, you know, that we're at about 50% mask compliance in the country, which means probably 80-90% in some communities and very, very low, if any, in others, but on average we're about 50% and we need to be as a country at about 80%. And I think, you know, when people were-- there was this period of time when people were doubtful that it worked or even maybe the next level felt like, hey, I don't like the government telling me what to do.
>> Howard Bauchner: Right.
>> Andy Slavitt: You know, that this-- I-- this is a problem. It's taken to I think a slightly more dangerous place that I hold the president accountable, to be frank, which is he has turned it into a symbol of some sort of resistance against experts, public health. You know, every time-- if you notice, every time he says you're OK to wear a mask, he will do some subtle thing soon after that like a tweet which says liberate or he'll rip the mask off and people view these things symbolically. And, you know, he's a-- he's a-- he's not just the president. He's a very influential leader of a very strong set of followers. There is a movement behind him and I think people are getting pretty dug in, you know, to that issue. And that's unfortunate because otherwise I would say, look, the U.S. is defined in this pandemic by this being really our first real experience. It's kind of our starter bug. And so you can give us a little bit of a break for not getting it, but I don't think the scenario where something so simple and straightforward gets so politicized is the difference. I mean what I think you've got to do and look at this as you have to think about what you can affect and how you can affect people in your community and, you know, I get all kinds of people asking me how to deal with people in their lives who won't wear a mask-- family members, coworkers. And, you know, I think-- I mean we had an episode of this on our podcast and we discussed it and it turns out that the most effective approach, which isn't foolproof, is about 180-degrees different from what my instinct was. And in some respects the truth was people had more success if they gave people back some agency, ironically, and said I just want to understand why-- what your thinking is, and why you don't like it, and then let me why I do it. And not judge them. Not threaten to end your relationship, not-- but say, yeah, I have a mother at home and this is our situation and this is why I do it and this is why I try to only be around people who are doing it and then through that-- through that dialogue one by one, it's not perfectly effective, but walking around glaring at people all day long and breaking longstanding relationships with family members and friends feels like it's not the answer either.
>> Howard Bauchner: I was reading something yesterday where someone said and I'm old enough to remember when we introduced seatbelts and, boy, there was a lot of resistance to seatbelts.
>> Andy Slavitt: Oh, yeah.
>> Howard Bauchner: And now it's the norm behavior, just-- it just became the norm. And I'm impressed, I walk to and from work in Chicago and the vast majority of people are wearing masks in Chicago. It's become more of a norm.
>> Andy Slavitt: Do you think if seatbelts weren't the law that they would have the same level of compliance?
>> Howard Bauchner: I think we're far enough along now, but not when they were first introduced. Andy, if Vice President Biden is elected and he takes office sometime in January, what would you expect him to do vis-a-vis the pandemic in the first few months after he's elected?
>> Andy Slavitt: Well, he had a great chance to address this last night and he did and-- look, I think-- I think the thing I'd want to point to is it's not a theoretical question. We can actually answer it. Just as Trump has had experience with COVID-19, we saw Biden who was very involved in leading the effort around Ebola to know that he is-- and look, I've talked to the team who briefs him everyday and, you know, he is into the details. He is-- listens to the scientists. He asks tough questions and he knows that there are a few big things that will really work. And as I've said before, I think allowing people to have paid leave is vital. Having enough ability to do contract tracing and testing, which I think he will amp up dramatically and at no cost. I think protecting businesses and getting a bill passed so that, you know, businesses who are facing hardship can make it through without having struggle. And I think there is just a lot of public communication. A lot of just consistent public communication that is required and a lot of listening and understanding people and talking to people about why to take the compliance steps around masks. I think a vaccine distribution program will be something that is obviously not to be underestimated how complex it is, how to do it right. It's something that I think he's been thinking about since at least May or June with a series of experts and there are some also difficult questions to answer as you do that and I think, you know, he's being, you know, being thoughtful about that. I think he's going to try to appeal to the country. He would try to appeal to the country to say, look, let's try to get beyond whatever ranker we've had. Let's just kick this thing in the butt. This is our chance for victory. There's a-- we're going to ask everybody to sacrifice a little bit, which these generations haven't' done, but for a short period of time and there's a light at the end of the tunnel. And I think he'll bring that competence, I think he'll bring the compassion, and I think, again, his big challenge will be can he communicate with the public in a way that gets people who were not his supporters on board.
>> Howard Bauchner: It's interesting, your comment about vaccines. I-- Michelle Williams and Larry Gostin published a viewpoint with us about distribution of vaccines and why if it's based on race it will probably go to the Supreme Court and potentially would be found illegal. I think people-- the National Academy of Medicine and I know ACIP and we will shortly be publishing a recommendation-- theoretical recommendation. Until they see the vaccine, they don't want to finalize it. You know, the first 20 million doses will go to health care workers, likely through hospitals, that will likely be effective. Hospitals can store vaccine and distribute vaccine. They do it all the time. But beyond the 20 million it gets far more complicated and it could become far more controversial.
>> Andy Slavitt: Right.
>> Howard Bauchner: And Michelle-- I was surprised. Michelle and Larry both offered concerns about whether or not we would prioritize the right people, populations, and how would we do it so that it would not be found unconstitutional. They both recognize it's going to be done at the state level. How vaccines make it to the states and how it's distributed amongst the states remains unclear and vague. Do you-- do you have a sense of the vaccine rollout after the first 20 million? As I said, I think the first 20 million will be easier because the focus will be health care workers and hospitals. It's the next 100 million that will be really complicated.
>> Andy Slavitt: I think the other thing that the first 20 million accomplishes is it will send a signal to Americans that the people they trust, the medical professionals, find this vaccine to be safe. And I think those are important signals. I mean, look, there is a case to be made-- I haven't heard a lot of people make it and I'm not the one making it here-- there is a case to be made that is give it to the college kids. Give it to the superspreaders. Give it to the kids so we can-- if you want to reduce the transmission of disease, give it to the people that are transmitting it and that, you know, we have a sad history in this country, as you know, of experimenting on population with vaccines and, you know, targeting a minority population to go first, putting aside the constitutional questions, for a brand new vaccine that has not really, you know, been-- lived long with people I think could be problematic for other reasons as well. So, I think, you know, you have to get the people that are at highest risk, but if you think about what a vaccine does-- I mean most of the public doesn't understand that a vaccine is not-- these vaccines do not prevent COVID-19. These vaccines lessen the virus if you-- when you get it, helps you defeat it, helps you build antibodies, and hopefully helps you not transmit it for some period of time. That's a very different rubric than MMR, right, where it's just like, hey, I got a vaccine-- which is I think how some people have been taught to think about this. Given that, you know, people all-- people have the sense that personal protection or protecting their family members from the vaccine when the goal of the vaccine is to have a safe herd immunity. I never thought I'd say the word safe in front of herd immunity, but with all the whack jobs out there saying we should just-- everybody get sick, I've got to say this. Safe herd immunity. And so, reducing the transmission may be the most high-leverage place to send those vaccines. And so, if it is among people in settings like, obviously, health care workers, like jails and other places like that, fine, but if there is also people who are patient zero in a community and you'd have to understand through contract tracing who that is and it may be college kids. And then if you cut it off there, that could be the number one thing you can do to make these communities safer.
>> Howard Bauchner: Andy, I want to change focus because this is going to become a critical issue next year. State finances are in shambles. Incomes at the state level are dramatically down. Medicaid consumes about 30% of many state budgets and then health care consumes another 10 or 15% because they have health care for their state employees as well as the pensioners. So, for some states, they are spending 40% of their income on health care, insurance. My sense is that most states, because of rainy day funds, moving some expenses forward, some cuts will get through 2019-- rather 2020-- but 2021 could be an entirely different story. You ran CMS, the largest insurer in the United States, which people forget. Medicare is about 55 million. Medicaid now is up to almost 75 million. So, 130 million people are insured by CMS. What was that like?
>> Andy Slavitt: Well and Medicaid alone is the largest insurer in the world. Medicaid.
>> Howard Bauchner: Medicaid-- 75 million would make it the largest insurer? OK.
>> Andy Slavitt: In the world, yeah.
>> Howard Bauchner: What was it like knowing every day you come to work you're kind of running an insurance company for 130 million people.
>> Andy Slavitt: I'll tell you what, it was the greatest honor and experience I'll have and I just, you know, relate to you that, you know, first of all, on a practical level, when you control 25% of the federal budget, about $1 trillion, you're awfully popular in Washington.
>> Howard Bauchner: A lot of new friends, Andy? A lot of new friends?
>> Andy Slavitt: A lot of new friends. Lot of people want the money, insurance companies, pharmaceutical companies, and, you know, if you're careful, you don't hear from the only people that matter, the patients and the taxpayers and the beneficiaries very often. So, I made a habit of starting every day-- I lived right across the mall from HHS. I'd wake up in the morning and I would read emails that intrepid people had bothered to send to the CMS administrator and every morning I'd wake up and read these emails and some of them were like three- and four-page stories from very sad situations to very peculiar, you know, someone's wheelchair ran out of a battery and they were stuck in the kitchen and they wrote-- and they emailed the CMS administrator to, you know, people-- someone whose daughter they thought was being abused in a facility and it grounded me. You know? And then I walk through the door of the Humphrey Building with that great quote from Humphrey on the wall and I walk into my office and I tell you the first thing I noticed on the first day and I noticed it every day and the last day is that in your office is an American flag. And I don't know how to explain it other than it just gives you chills. It just gives you chills. You know what you're doing. So, we wanted to make progress for people. I wanted to make progress for the agency as a culture. I wanted to lift up the great career civil servants who actually often times, depending on the administration, get ignored but really know what to do and certainly far better than I did. You know, I think many administrators come in and many political appointees come in and want the career staff to prove that they're loyal. I had the opposite feeling. I needed to prove that I was worthy of--
>> Howard Bauchner: To them.
>> Andy Slavitt: To them. And I think that showed. And we got a lot of things done, you know, I, you know, I said, look, we're going to-- we have problems every day, but I only want you to do is I want you to separate every problem that we have into two categories. Real problems and fake problems. And of course they said, well, what's a real problem and what's a fake problem. Well, the people in Puerto Rico aren't getting health care or the people in Flint aren't getting water, that's a real problem. A senator is mad at me, that's a fake problem. Now, believe me, you need to deal with it professionally, you need to make people feel good. Congress speaks the voice of its citizens. I'm not telling you-- but I don't want you running in here hot and bothered because we took action against some company in someone's district and some congressperson is upset. I want you coming in my office if something is happening in this country and people aren't getting the health care they need and have that make you upset. And, you know-- and they know that colors everything you do when you send those kinds of signals because that's where people want to be anyway.
>> Howard Bauchner: I had extended invitations to both the Biden campaign as well as the Trump campaign to come on my show. There have been no takers, sadly. President Trump's plan seems under wraps, as it has been for a long time. I think many people are concerned that it's imaginary. Vice President Biden has filled in more details about health care proposals. The number of uninsured in the U.S. is once again increasing, sadly. It may increase dramatically, depending upon what happens with the ACA and the challenge through the Supreme Court. Do you think that Vice President Biden's plan to lower the age of Medicare to 60 is-- could pass Congress, Andy?
>> Andy Slavitt: Well, first of all, Howard, I think you clearly missed something. President Trump has rolled out his plan. You get sick and a helicopter will come to your house and fly you to a hospital where you will be treated by 15 doctors and compassionate use medicine. I think that's-- I think that's the plan.
>> Howard Bauchner: Returning to my question about Vice President Biden's plan.
>> Andy Slavitt: So, maybe that's not the-- you don't think that's the plan. OK. Alright. Yeah. So, look, I think-- here's the thing. There is the what and there is the how. I've been involved in so many campaigns and so many-- so much advice to so many political leaders and I will say that, you know, every democrat from Bernie Sanders to Senator Jones believes that every American should have health care, believes that no one should have to go to bed at night worried about whether they should pay-- they're going to be a medical bill if someone in the family gets sick. And virtually every one of their components-- opponents-- not everyone, but virtually all of their opponents disagree with them. That's the great divide. It's not a divide among the public as much as it is among politicians, interestingly. The public is generally on, you know, depending on what poll you believe, 70% or more believe in the first. So, then you're into the how.
>> Andy Slavitt: Then you're into the how. Once you believe the what, there is 1,000 ways to get to the how and it's not a single decision like Medicare for All or drop the Medicare age or public option. It's 50 decisions. It's how-- what role do we want private insurance to play? What role do we want private and public hospitals to play? What role-- how do we want hospitals to be reimbursed? How do we want physicians to be reimbursed? Where do people take risk? Where should individuals have relationships? What's the role of the employer and the tax structure that makes employers give coverage? You know, at what level should people receive subsidies? There is a whole bunch of questions and what we need as a country is a healthy process. Public hearings. Discussions. Conversations. Ordinary citizens. Experts. And I daresay-- again, here is the naive Andy coming out again, an effort to build some consensus and even attempt to build some bipartisan consensus.
>> Andy Slavitt: And I think we need to take that shot because we want whatever we pass to be sustainable and not argued over for the next decade. And I think Biden is a guy who is going to have an interesting choice to make because he has two sets of-- if he's the president-- not conflicting, but somewhat competing ideals. One is he absolutely believes firmly that we need to get health care to everybody in this country. On the other hand, I think he believes his role in the country as a president will be to be a unifier and he has a personal set of characteristics and relationships which cause him to want to reach across the aisle and build consensus. And the question is, if he's faced with a choice where he could get 100% of what he wants on a completely partisan basis or 75% of what he wants and win over republican votes, you know, which does he choose. I think there is no question that if he can't get anything done with republicans, I think he gets something done with democrats, but does-- is he willing to compromise or make a tradeoff in order to build something that has at least some republican support in the Congress. That will be a very interesting question and, you know, I don't know--
>> Howard Bauchner: Obviously influenced by what happens in the Senate.
>> Andy Slavitt: For sure. For sure. Without winning the Senate, he has no choice but to play in that latter world.
>> Howard Bauchner: Yeah.
>> Andy Slavitt: And if he's-- and remember if he's got to-- if he's got to reinstitute the ACA because of a court case, that changes dynamic entirely. He needs the Senate in order to be able to do that. If he doesn't have the senate, I'm very, very doubtful he's able to get that done.
>> Howard Bauchner: Yeah. You know, I'm frightened that, you know, by the end-- by the end of 2021, assuming it, you know, if he were elected president, he will settle in, and although this may be an important issue, it will take a long time to think it through. I'm concerned that by the end of 2021 we could see 40 million or 45 million individuals uninsured again in the United States and just recovering from that number is so difficult. I mean, you know, we were at around 30 million and I think at the-- at the best we drove it down into the 20's, 22, 24 million, and I know now it's back up above 30 million. I'm just concerned that because of unemployment and how long it may take to reach any consensus that we could see uninsured rates go back up into the 35, 40 million numbers.
>> Andy Slavitt: Particularly if the ACA goes away.
>> Howard Bauchner: Yeah. This is Howard Bauchner, editor-in-chief of JAMA. As I mentioned at the beginning, whenever I talk to people-- conservatives or liberals-- they say you should talk to Andy Slavitt. He is so talented, organized, and thoughtful. Andy was the former acting administrator of the Centers for Medicaid-- Medicare and Medicaid and, as I've said, helped rescue healthcare.gov. As he said, he had an entire team. I think he was a bit surprised to hear he only had five weeks, but it was probably one of your greatest challenges and one of the greatest successes of your life, Andy. You should feel unbelievably good about that.
>> Andy Slavitt: Thank you. I mean, you know, it's a-- it was scary as hell. I mean it was, you know, one of those things where the outcome was very-- was not clear while we were working on it and it was an honor to be a part of it. Didn't feel very smart that I had raised my hand for it, but I am so glad I did and, look, I think the same is true with anybody who has done some form of public service. It's hard, but they feel great about it and, you know, I waited until I was, you know, I was in my late 40's before I did it and so glad I got a chance to do it.
>> Howard Bauchner: Last question. Was there an aha moment? You walked in, there would be people around the table, and someone turned on the switch or showed you the website-- I'm not quite sure how-- and you go we did it. Was there an aha moment or was it slow? Was it gradually building?
>> Andy Slavitt: So, when we came in, almost everything was wrong because-- not because of the technical problem, but because when there is a problem like that everyone wants to run as far away as possible and there were like 30 or 40 vendors, all of whom had spent plenty of time trying to make sure that they were nowhere near this thing and they were pointing fingers in the press. And so the people who were building the software said it doesn't matter if we fix the software because the hardware won't hold it. The people who had built the hardware said it doesn't matter what our hardware looks like because the software will never get on-- will never work. And so it was a management challenge and it was interesting. I think the-- my approach was I think I said somebody just count up for me all of the software bugs and it came back and said there were 6,000. And I said, OK, we have five weeks, 6,000 bugs. Divide 6,000 by five weeks. I want one bug per day per developer. Get me enough developers so I can get those gone. Turned out there was-- the code wasn't documented, so I couldn't bring in new developers. So, I needed these firms that were there not doing much to do this. And I will tell you the day that, you know, we started October 26th, on November 12th, there were more bugs than the day I started because they-- every time you got rid of a bug, people uncovered downstream bugs.
>> Andy Slavitt: I called my wife and then-- and then we got a little bit more progress and then the hardware collapsed. And I called my wife that night. It was probably the first time I talked to her in two weeks. I had been living in a hotel, up literally 20, 21 hours a day, and I said I've made it worse. And she said, no, you didn't honey. I said, no, I made it worse. I said did you ever step in a-- like a canoe that's like paper thin and you put your foot through the bottom and then the water starts really pouring in, I'm like that's what I did and it's sinking pretty fast. And she was like OK. The next day, you know, we-- I called all the hardware vendors and said, you know, put all this stuff on a truck and said to assume it was going to get here by the end of November. And we went through the cycle where we started-- for every bug we took out, we created two. There's a cycle you go through because you're-- and you start-- and for the next 10 days, we got rid of like 4,000, 4,500 bugs. And then it-- right before Thanksgiving, I called the team together. We had another five days left. I said, OK, I had you working dumb, just we're working hard instead of working smart. Now bring me the best ideas to work smart. In other words, if we have, you know, 500 bugs left, I want to know the 100 most important ones. And so we reconstituted the team that day, we raced all the way through Thanksgiving, raced to November 30th, and we had-- when the instrumentation started, we-- you could literally see people moving through the site, getting to the end, and, you know, the most people we'd had buy insurance in a day was like 50, 75, 100 and, you know, the-- on December first there were-- I don't remember the exact number, but it was like 75,000 people got through the site and bought insurance. And I think I just stood there looking at it, you know, amazed, as did everyone else.
>> Howard Bauchner: You obviously remember many of the details of those five weeks. Andy Slavitt, former acting administrator of Centers for Medicare and Medicaid. Howard Bauchner, editor-in-chief of JAMA. It's been Conversations with Dr. Bauchner. Andy, I hope our paths cross again. Thanks so much for joining me today.
>> Andy Slavitt: Thank you so much. Thanks to everybody out there.
>> Howard Bauchner: Bye-bye.
>> Andy Slavitt: I know you're all working hard. Thank you.
>> Howard Bauchner: Stay healthy.
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