HealthWatch Wisconsin's Pulse Newsletter Editorial staff spoke with former CMS Administrator Mr. Andy Slavitt on January 30. The conversation covered recent Medicaid Demonstration and ACA Innovation waiver proposals and plans out of Wisconsin Governor Scott Walker and the Republican-controlled State Legislature, Medicaid Expansion, uncompensated care, and innovation and creativity advancing access to health care and coverage. Excerpts of our conversation begin below.


HWW: What we’ll be talking about today is your perspectives on The Health Care Stability Act proposed by the Walker Administration and some other issues related to health insurance and coverage outreach and education for Wisconsin folks and our newsletter subscribers.

AS: I think you guys [at ABC for Health and HealthWatch Wisconsin Pulse] do important work.

HWW: Thank you. Initially, we're interested in your perspectives on Governor Walker's recent proposals. You may have seen in the news his Section 1332 Waiver looking at a reinsurance program similar to the MN program-but putting in less money.

Gov. Walker also announced preexisting condition provision in Wisconsin law that is less comprehensive that current ACA protections.

From your perspective both from MN where you reside and your national experience with CMS, how should people in Wisconsin and our Pulse newsletter subscribers respond to the proposed Sec 1332 wavier?

AS: We have to try and understand the outcome. At the end of the day, are more low income Wisconsinites going to get covered, or are more low income Wisconsinites going to lose coverage? And what is going to be the effect on affordability and cost? And what is going to be the effect of this on the comprehensiveness of their coverage? Are they going to be not covered for things they are covered for today or expected to be covered for?

Let’s start with this: Health care is a hard problem. Health care is expensive if it goes to the state it's expensive for individuals or families. It’s easy to start with "bad guys and good guys" but to a certain extent, recognize that everybody is trying to solve a problem that’s difficult, expensive, and challenging.

Having said that, people will have to look for what the objective of these policies are. I'm not intimately familiar with what's in the waiver proposal. I can tell you that if there are things in the waiver request that get in the way of people getting coverage-like drug testing requirements or requiring people have a job or something before they can see a doctor or dentist or get their prescriptions filled-that is obviously concerning. If there are things, on the other hand, elements of the proposal that bring costs down by using some smart tools like reinsurance, those are encouraging. It's worked in Alaska and in Minnesota.

I haven't studied the pieces around preexisting conditions but I think it's taken a lot of work and a lot of effort to get us to a point where Americans can "take for granted" that if they've been sick before, ever been sick, or someone in their family has been sick-which describes 130 million Americans-then that's not going to cause them to get charged an exorbitant sum for health care coverage.

The things that create two risk pools, one for healthy people and one for sick people, and then raise the cost to people who have had preexisting conditions, are ultimately not good for anybody. They make people who are sick pay more and then people who think they are getting a better deal, come to find out that when they get sick, are not covered for as much, and they can lose coverage. Those are, I think kind of principle things that I would look for.

HWW: The governor's preexisting condition provisions for Wisconsin are actually less comprehensive than current law under the ACA. So it looks like a move for political purposes than for actual fundamental protections. The proposal was originally a democratic proposal, modified by assembly republicans to serve as a backstop if Congress and the President repealed the ACA provisions. It's kind of a zombie provision that would come to life…

AS: Don't be so sure. Idaho has just put out something where they are essentially allowing their insurance companies to offer plans in the state that don't meet ACA compliance levels. Hard to understand how that could possibly be legal-and it would be hard for me to understand how it could be legal in Wisconsin either-but that doesn't mean that states and the federal government won't pretend to do this.

HWW: Let's discuss Medicaid. As you know, Wisconsin rejected federal funds for Medicaid Expansion and instead created a more expensive BadgerCare Plus program for childless adults up to 100%. Most of the state newspaper editorial boards in Wisconsin said take the money. Most policy experts have said Wisconsin should take the money. Most of the states within in the Great Lakes Region have taken the money, in fact all of them, but we are in an election year and our governor has said he won't take in the money because the feds might renege.

Interestingly, Gov. Walker is willing to take the federal Sec. 1332 reinsurance money which he's estimated at about $150 million in federal dollars. But he's also been opposed to creating dependency in the marketplace. Some commentators have called Gov. Walker's failure to take the federal funds gubernatorial malpractice. We wanted to know your perspective on Wisconsin and the Medicaid Expansion debate.

AS: You know, I just traveled to Michigan which is a state that unlike some people think, is actually similar enough to Wisconsin. It has a Republican Governor and very conservative legislature. They passed Medicaid Expansion and I met with Democratic and Republican legislators as well as the Medicaid Director-and they're thrilled. They couldn't be prouder of what they've accomplished.

Quite honestly, in that particular case, put national politics aside, it's a very sensible decision. It's not a political decision. You have got a lot of people who you're going to end up paying for their emergency room coverage when they go undiagnosed for a long time anyways. The ability to cover them for the preventive services and so forth is quite beneficial. Ohio similarly, Louisiana-an even "more red" state, North Carolina, I've traveled up there to meet with the Governor and the team.

So I can tell you that if looked at through a lens where the politics go away, this actually is quite a great deal for states and quite a good federal-state partnership.

Now you have a Governor that has a national profile-both in the National Governor's Association as well as his own political brand. I don't know what impact that has on how he's governing. I wouldn't pretend to know. But I can say that to a certain extent states-certain states, certain governors-still have an allergy to things that they connect back to the original Affordable Care Act and President Obama because purely politically, that's how they want to be.

We have to give-and I think states should be able to-put their own flavor on things, disassociate themselves with the politics, and hopefully do what's right for the residents of the State of Wisconsin.

In my view it's a really great bet and really great partnership to cover more people through Medicaid Expansion.

HWW: One of the issues that you touched on is uncompensated care. In Wisconsin that totals about $1 billion a year in uncompensated hospital care. It was at about $1.5 billion in 2013 before ACA implementation. It's rising again. It dipped to below $900 million now it's a billion and rising. We are concerned about the fact that by creating a very difficult and challenging eligibility process for individuals, families, and children. Wisconsin created an eligibility corn maze that creates higher levels of uncompensated care.

HealthWatch and ABC for Health have educated our subscribers about uncompensated care, and the socialization and redistribution of medical debt to people because the expense ends up in everyone's bill.

What else should we be aware of as we look at uncompensated care and the impact of the ACA from your perspective?

AS: Well, I think you're smart to try and educate the public and make sure people are aware that there's is no free lunch. That if you don't cover people, if you don't cover our neighbors, if we don't cover our families, they go bankrupt; hospitals end up having to eat the cost. And if you wonder where those costs end up, you just look right at your own insurance premium.

It's not smart for anyone for us not to have basic affordable access to insurance for everybody, kids, adults, young adults, and people as they age, or they never have the financial underpinnings to really be comfortable in the middle class.

I think it's very interesting and important to educate people on, as is exactly how you started, which is that there are both existential threats, repeal and so forth, which are very visible, but there are many, many, many things that fall more in the category of death by a thousand cuts, like eligibility-what you call the corn maze, like making it more difficult for people to enroll if they have a change in their income level or household status, which you well know for people who are low income people or working multiple jobs, seasonal jobs, their live changes so frequently, their eligibility changes so frequently, that if you wanted to play an easy game of gotcha, and make it more complex for people to enroll or kick them out of a program if things happen and they didn't follow every single step of the procedure, it would be quite easy to reduce the roles.

Which is why I think it's important to haul back up to 30,000 feet and say what's been the effect of these changes. Not to get lost in the "is this a good idea or bad idea, a good principle or bad principle," but at the end of the day if there are tens of thousands of people who no longer have access to coverage for a policy it's not hard to see it's a bad policy.

HWW: What’s your vision as you look forward to supporting creative and innovative services directed at helping American people get and stay connected to health coverage, particularly those people affected by health disparities?
AS: We’re doing two things:
One – we are creating a brand new national health policy movement that is going to be very well resourced and driven across the country with the goal to work at the state level and then at the federal level to essentially build a national consensus for everyone in the country-every single American-to get access to affordable, basic regular source of care. And that no American will go bankrupt from medical bills again.
We’ll be forming a new organization United States of Care that will have broad national support and sponsorship and will be working to harness public opinion in a way that creates national policy change and then work on the nitty gritty technical elements of policies within states to help them make those advances.
[As Andy mentioned earlier in our conversation, “People should watch my Twitter feed, and on my Twitter feed they can sign up and get information about it [United States of Care]. They can leave an email and we’ll get them information about it.” (Follow Andy on Twitter: @ASlavitt)]
The other thing I’m working on is fueling an investment into start-up companies that are innovating in low income communities, historically lower access communities, and brining innovations to create creative interventions that will help people get cared for in their communities, address social determinants and keep people healthy, focusing on critical intervention areas like mental health, substance abuse issues, kidney care, and working with dual eligible and Medicaid populations.
So we’ll be investing in funding start-ups that are doing that work in. One of the start-ups we’ve already invested in called City Block Health.
HWW: Thank you so much for taking the time. We appreciate you talking with us. We respect and admire your determination and doggedness in pursuit of these issues. 
AS: Good luck to you. Thanks for all you guys do.


More on Andy Slavitt: Andy Slavitt is the former Acting Administrator for the Centers for Medicare and Medicaid Services under the Obama Administration. He oversaw the Medicaid, Medicare and CHIP programs in addition to the Health Insurance Marketplace. He oversaw the implementation of the Affordable Care Act and MACRA legislation. He is a Senior Advisor to the Bipartisan Policy Center and a member of its Future Health Care Initiative. He has decades of private and public sector leadership in health care, business, and technology.