I’m Isaac Saul, and this is Tangle: an independent, nonpartisan, subscriber-supported politics newsletter that summarizes the best arguments from across the political spectrum on the news of the day — then “my take.”

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Few people have had a closer look at the inner workings of our government than Andy Slavitt.

In 2013, Slavitt oversaw the turnaround of healthcare.gov after its disastrous rollout. He then worked as Acting Administrator for the Centers for Medicare & Medicaid Services (CMS) under President Barack Obama, which meant he was overseeing the Children's Health Insurance Program and the Health Insurance Marketplace, as well.

In January of 2021, he was brought into the Biden administration as a Senior Pandemic Advisor to the Covid-19 pandemic response team, a role he stepped down from in June of 2021.

A graduate of the University of Pennsylvania and Harvard Business School, Slavitt is now the founder and Board Chair Emeritus of United States of Care, a national nonprofit health advocacy organization, and the founding partner of Town Hall Ventures, a healthcare firm focused on underrepresented communities.

Perhaps most notably, Slavitt played a leading role in the implementation of the Affordable Care Act, also known as Obamacare, which will be 15 years old next year. I wanted to talk to Slavitt about that anniversary, the state of health care in the U.S., his experience during the pandemic, and whether we are prepared for the next one. In our conversation, we also discussed the positives and negatives of how the Trump administration responded to Covid, future health emergency preparedness, and how he thinks Biden is doing so far on healthcare-related issues.

We met up in mid-February and spoke for nearly an hour. Today's interview has been edited for clarity and length. You can also listen to it here.

Note: You are on our free mailing list. This is a preview of our members-only Friday editions. To read the whole thing, you'll have to become a paying Tangle member, but you can keep reading Monday-Thursday for free. 

Isaac Saul: Andy Slavitt, thank you for coming on the show. I appreciate it.

Andy Slavitt: Isaac, great to be here.

Isaac Saul: So there's a ton of stuff we could talk about. I have a million questions for you since you’re somebody who's been around so many important White House officials and so many important policies that I think are impacting a lot of Americans today. One of the big things that's coming up is the 15th anniversary of the Affordable Care Act, commonly known as Obamacare, becoming law. You were a central figure in its infancy. I'm curious if you could give your view on where the ACA is today and how you view its current state. What are some of the top-line things Americans should know about where it's at right now?

Andy Slavitt: It's such a poetic narrative from how it passed in an incredibly nailbite-y fashion; to how botched up the first implementation was and all the bad press (and that's how I got involved, leading the effort of turning it around); to humble beginnings where it was unpopular and a third rail; to the effort to take it down, which was so misguided in reading the mood of the public for being protected against very reasonable and important things like being sick and still being able to get healthcare, even if you're sick; to it then solidifying, growing to the point where it's now really meaningfully sized and it's on its way to becoming part of the architecture and infrastructure of this country. If you went back to 1965, I wouldn't be surprised if the passage of Medicare and Medicaid had a similar journey as any established program goes through. It's good, it's doing great for a lot of people. It could be better if it was not as politicized and if people from both parties said, “Hey, let's figure out how to support this and make it better.” But it's fought and won. It's like that toy you play with as a kid, that Weeble. Remember that Weeble Wobble? You can knock it around and kick it and drop it from a high building, and it just stands up again. That's where we are.

Isaac Saul: So talk to me a little bit about that politicization in 2024, where we sit now. Is there still a strong opposition to the expansion or implementation of the Affordable Care Act? Along what lines are we seeing that divide these days? Because I'm sure it's changed a bit now from where it was 15 years ago.

Andy Slavitt: Well, there's no real public opposition. If you ask Americans, if you poll the features of the ACA — and you don't even use the word ACA — but you said, “How do you feel about being protected against a pre-existing condition? How do you feel about being able to be insured with your parent's plan until you're 26? How do you feel about having wellness covered? How do you feel about all of these things?” Somewhere between 70 and 90 percent of the public says, “Yeah, that's a good idea.” And even the law itself is popular [Editor’s note: These numbers are roughly accurate]. 

And I think the opposition to it in 2017 and 2018, Paul Ryan — who's gone — and others (and I've talked to Paul since then), they learned a valuable lesson that it's fine to criticize, it's fine to try to improve, but to try to take something away without anything that replaces it is a really bad political strategy. 

Having said that, Donald Trump is making noises, as many may have heard, that we need to repeal this thing again and replace it with something mystically, magically better. And I don't know whether that's just a guy who can't resist poking the bear, a guy who isn't good at learning a political lesson, a guy who's just talking, you know, out of the side of his mouth. But he certainly doesn't do himself any favors in this election by saying, “Hey, we're going to take this coverage back away from people again,” because the last time that happened, it didn't go over well; and if anything, it ended up solidifying the support of the ACA.

Isaac Saul: You mentioned at the top of the show all the things that you came in to fix, the [ACA] rollout and some of the issues that we were having. I think the famous one that everybody probably knows about or remembers is the website, which I want to talk to you about more specifically. Broadly speaking, looking back on the crafting of it and the rollout, what things might you change if you could go back and do that time period over again?

Andy Slavitt: First, let me give you some context here. It's unreasonable to expect Congress, no matter what kind of support they have, to be able to predict the future perfectly well. And it is reasonable to expect that a bill passes and then has a series of improvements that go on over the years. “Oh, this is working really well, so let's do more of this… This part is a problem, let's fix it.” We had things that were literally language glitches that Congress said, “We're not fixing it.” Even though it's gonna cost the country more money, hurt more people, leave people behind, create unfairness — we're not gonna fix it because we want the law to look bad. So that's something that I think the people who wrote this language couldn't have reasonably anticipated at the time. And I'm not saying that there weren't things that couldn't have been written better, but the basic construct of the law was pretty solid. 

The thing that was the biggest flaw in the law was — and it's pretty clear to me at this point — that it was great for people who were in this place where they were above the poverty line and didn't qualify for Medicaid, but not quite middle class and without very stable jobs. And I think that people in the younger generation, gig economy, whatever you want to call it, hit that mark nicely because the insurance is very affordable, and insured people get care and coverage. And I've got literally hundreds of letters written to President Obama of people's stories and situations where this literally saved their lives, saved the lives of their parents and their siblings. So it hit the mark for that audience.

What it did not do at the beginning — and this has since been fixed — was for people who made over 400% of the poverty level, which for a family of four was $100,000 in income, which in this day and age is not rich. [Editor’s note: For 2024, the federal poverty level (FPL) for a family of four is $31,200, so 400% would be roughly $125,000. In 2010 when the ACA was passed, the FPL was $22,050, so 400% would have been roughly $88,000.] That's comfortable depending on where you live in the country, but it's not rich. But if you made over $100,000 a year, your insurance was incredibly expensive, because you had no subsidies. And that was the number one thing that needed to be fixed. And it had the effect of creating political divisions, pitting middle-class people against people who were lower on the economic spectrum. 

And I think that's not smart. You want laws that people can feel good about, could feel maybe a little bit generous about, maybe they know it helps some people more than others, but they don't want to be disadvantaged. And I think that one of the reasons why the ACA opposition was able to gain some momentum — because you could find your local small business owner and say, “See how this has hurt him or her.” And in the crafting of any legislation, I think the lesson learned is: Pay attention to everybody. 

It may be popular for Democrats to say, “Let's focus on people who have less,” and I think that's an important policy aim. But if you help people who have less at the expense of people who are in the middle, that's not, first of all, a great way to look at things. But it also creates divisions. 

And so they fixed that with the follow-on legislation. It's not a permanent fix, it's a three-year fix. But that also helped a ton of people. And we've got this very patchwork system — Medicare, Medicaid, ACA, ACA with subsidies, ACA without subsidies, employer-based insurance — and all that means is laws don’t develop to fit together super neatly. And you could find yourself in one of these gaps where you make a little too much money or your job is a little too this or something's a little that, and it becomes hard for you. And as much as possible, we should be wiping out those little pockets and corners because they represent people's lives.

Isaac Saul: Yeah, it's interesting to me, there's a lot of criticisms of the Affordable Care Act from different sides of the political spectrum for different reasons. I think the way the right frames it — you know, a group like Heritage — tends to be that the Affordable Care Act just made health insurance more expensive, or that premiums have continued to get more expensive. I know they had some research claiming there was over 100% growth from 2012 to 2019 in these premiums for Americans from across the country. Do you think that's a product of legislative mistakes that were made, or do you think it would have been worse had there not been an Affordable Care Act? Because I think every American (or most Americans) senses that health insurance is really expensive and it still doesn't feel like the system is doing totally what it should for a lot of people.

Andy Slavitt: Well, there's a lot wrong with that analysis and we can pick it apart, but you can get pretty wonky. Let me extract a higher altitude to answer the question. If you were to approach a conservative member of Congress or their policy team and say, “What are the goals for the healthcare system,” they might say, “It's to reduce costs and improve access.” And if you were talking to a liberal or progressive Democrat, they might say, “It's to improve access and reduce costs.” So the exact same thing, but flipped. And I think one of the criticisms from the political right is that this bill didn't do much to reduce costs. That's fair criticism. 

Now, what they're really saying is that a subsidy paid by the government may reduce costs for people, but it doesn't actually reduce the systemwide costs. Important point, right? Because it means the government's paying a little bit more. For people, it is absolutely reduced costs. It's reduced costs dramatically. It used to be that it was only, as I said, for people who made under $100,000 a year, but now it's for everybody. So it has reduced costs. The key, and what I think the political right is complaining about, is you're covering 30 million-plus more people, and you're not doing it more efficiently. And so Democrats would say, “This is great. We got more people in the system, and they're all paying less.” 

But Republicans would say this isn’t bridging the fiscal gap. Now, interestingly enough, if you look at conservative ideas to reduce costs, they don't actually reduce costs. They just basically put a cap on things and exclude people, exclude hours, exclude different people based upon whether or not they're worthy of getting care, and that's how they choose to reduce costs. 

So real reform is saying things like, “How do we take care of more Americans before they get sick and go to the hospital in a lower-cost setting like their doctor's office or at home?” That's real reform. And there were some seeds planted in the Affordable Care Act for accountable care organizations that are the seeds of real reform and real cost reduction. But real cost reduction is harder because Congress doesn't like to take money away from interest groups. And if you're gonna reduce costs, that means somebody — Big Pharma, insurance companies, hospitals — somebody is going to have to make less money. So that’s a criticism of any healthcare legislation. 

Isaac Saul: I think that’s a very cogent response to a very common criticism from the right. In the more lefty circles, I think the other side of the spectrum is that ACA isn't the right answer to our healthcare problems. A lot of people advocate for an expansive approach, something like a single-payer system. You obviously have worked in Democratic administrations — how do you talk to people who hold that position, who are more progressive on the political spectrum, when it comes to healthcare? Do you think that that is a better answer, but there's no political avenue for it? Or do you feel like the system that you have pursued is actually just superior on the merits?

Andy Slavitt: My advice is to keep pushing for more, but keep expecting that progress will likely come incrementally. But keep pushing for more. Keep pushing. Go for the whole thing. 

First of all, there is no perfect system. So I could tell you the 20 flaws with any system, including a single-payer system. But there's also a lot of benefits. So let's not pretend like there's a nirvana, but also what you said is right. A very wise senator told me once, “You have to push for what's ideal and for what's possible at the same time.” And most Americans don't have to worry about what's possible. They should push for what's ideal. That's fine. But at the end of the day, in the halls of Congress and in the White House and everywhere else, you have to accept the fact that this is a very split country from a political standpoint, and it’s very hard to get to consensus. 

When you get to some consensus, you take it and run. When you get 60 votes in the Senate, you take as much as you can get. And then you go on and fight another day and try to get more. So I don't think it's inconsistent to say, “I don't think the ACA is enough.” I think it's irresponsible to say, “If I don't get everything, I want nothing.” That to me, I have a problem with. I can tell you Americans who are living with disabilities have had their lives transformed and changed by the ACA. And people I know who live with a disability would be offended to hear, “No, no, no, unless you can make it perfect, I don't want anything.” 

And so it's nice to be idealistic and young and say, “This is what perfect looks like.” There is an important role for that. I've had this conversation with Bernie Sanders often. He says, “Andy, if I don't push for everything, our chances of getting anything are much lower. So I'm gonna push for everything. But do I expect to get everything? Not all at once, but eventually.” There's an important place for idealism in this country. I think there's an important place for pragmatism in this country. And I don't think we should demonize each other for being on either side of that going, “I want progress, I want it all.” There are roles for all of that in making things work better.

In my view, the most important pending potential legislation is the childhood tax credit. The childhood tax credit would transform the lives of children and families in poverty as much as anything else. It’s not perfect, and if we get it, it's likely to be a little less than the last version we saw. Should we say at the end of the day, “Nope, not going to take it,” if we can get it across the goal line? Or do we compromise? And, you know, for people who are living in poverty, they might say, “Fight as hard as you can. Get as much as possible.” That's reasonable. But at the end of the day, if you're gonna put hundreds of dollars a month more in my pocket, and even if it's a little less than it would have been otherwise, do it. And people who live in the real world and, in my experience, people who live closer to the [poverty] line, are much more realistic and much less idealistic than people who have the privilege of looking at things with rose-colored glasses or an ivory tower kind of approach.

Isaac Saul: I'm curious to hear your perspective on the last few years. President Biden has been in office now for a little over three years. Obviously, he was vice president when you were working closely with the Obama administration. What have you seen him do on healthcare in the last few years that you think readers and listeners should know about? And how do you view his healthcare policy as president? What's changed, for better or worse, over the last few years since he's been in office?

Andy Slavitt: Well, I saw the president last night, as a matter of fact, here in LA. And after we chatted, he gave a speech. And the first thing he said in his speech is, “We now have $35 insulin guaranteed across the country for people who are seniors.” [Editor’s note: Biden visited Los Angeles for a three-day fundraising trip on February 20, 2024. His remarks at the event referenced here aren’t publicly available, but the day after our interview with Slavitt, Biden spoke about his efforts “to make sure 35-bucks insulin is for everybody — not just Medicare, everybody.”] And he is the first person in the history of the country to take a dramatic bite out of prescription drug costs, something that every American wants and every American will feel in their pocketbook. Put a cap on out-of-pocket limits for prescription drug costs. Game-changing, life-changing, life-altering for every senior and for the way healthcare works. 

I mean, look, I think it's really interesting to remind ourselves of the three groups who controlled Washington for the longest time. I'll tell you who they are: The gun lobby, the oil and gas lobby, and the prescription drug lobby. The three most powerful forces in Washington for decades in a row. All three of them took losses last year. We finally got gun legislation passed. We finally got a climate bill passed, and we got a prescription drug bill passed. That was all under President Biden. And I can argue all three of those relate to health. All three relate to our health, our ability to survive in this world. Now, can you look at all three of those gains and say, “Could they have been better? Could we have done more?” Absolutely. Particularly, the climate bill and the prescription drug bill were enormous steps, but nobody thought any of those three things would happen. The going belief in Washington is you can never defeat those three forces. Never, never, never, because they pay for Congress's elections — those three forces — and they don't lose. And Biden gave all three of them defeats. 

And I think it changed the nature of what's possible. It changed the balance of power. And tens of millions of Americans are going to be able to afford prescription drugs that couldn't before. Remember, one in three Americans doesn't fill a prescription every year because they can't afford it. [Editor’s note: This number comes from a 2023 YouGov poll.] Remember that 40% of Americans that get diagnosed with cancer because of the cost of the medication spend through their life savings within two years. [Editor’s note: This finding comes from a study in the American Journal of Medicine.] That's the world we live in. And prescription drugs were not a thing when we created Medicare and Medicaid, right? [Editor’s note: The Medicare and Medicaid programs were established in 1965. Prescription drug expenditures in the U.S. were around $2.7 billion dollars in 1960 and have increased steadily over time, with the first major jump coming in 2000, to $122 billion; in 2022, prescription drug expenditures were $405.9 billion.] That wasn't how things were treated. People were treated in hospitals. 

So we had no answer, and the prescription drug lobby came along and said, “I like it this way. You shouldn't be able to negotiate with us. You shouldn't be able to control our costs.” And we're the only country in the world that doesn't have any negotiation on the cost of those prescription drugs. That changed. Now, some of the features, some of the far-reaching features, are going to take a couple of years to be implemented. So Americans need to know, need to understand, that is as transformational a change in people's lives (and healthcare) as any single healthcare policy.

Isaac Saul: I want to make a small pivot, still in the healthcare space; I think another top-level part of your resume over the last 10 or 15 years has been your involvement in the Covid-19 response. You were brought on under the Biden administration as a senior advisor on this issue. Covid-19 is the defining story, I think, of the 21st century so far. I struggle to imagine anything that's impacted people more than that. I pulled up the numbers just before we hopped on this call, that in the spring of 2022, a million people had died of or with Covid. 400,000 under Trump, and 600,000 when Biden was in the White House. There's still 300-ish people dying every day, which somehow sort of slips through the cracks in a lot of news coverage. And that's close to 10,000 people a month, 120,000 in a year. 

We're sitting here now in February of 2024, and I think for me, certainly, it feels like the pandemic's over, yet those numbers are all out there. From your time advising the White House on this issue, what did you take away about our country's ability to navigate a crisis like this? How do you reflect on the United States and its ability to operate in a pandemic?

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