Former Affordable Care Act chief offers health-care prescription

The Minnesotan who ran Obamacare for the last two years is looking for ways to save, rather than sack, the Affordable Care Act. Andy Slavitt has returned to his home in Edina after serving as acting administrator at the Centers for Medicare and Medicaid Services (CMS), the massive federal agency that has been responsible for implementing the controversial health law. The law's future is in jeopardy with Republicans vowing to repeal and replace it, but Slavitt sees the chance for bipartisan repairs instead. He has experience bailing out the Affordable Care Act (ACA), since Slavitt was the executive at UnitedHealth Group's Optum division who led a rescue of the HealthCare.gov website after its disastrous launch in 2013. Slavitt's not going back to his old job at Optum, and says he won't become a lobbyist. Instead, he's tweeting up a storm, granting media interviews, meeting with policymakers and seeking a stage in Washington D.C. from which he can promote health law fixes that don't sacrifice the quantity or quality of ACA coverage. It's a tall order. Even so, Slavitt is following the path of other CMS administrators who continued to influence health policy after leaving both Republican and Democratic administrations, said Dr. Mark McClellan, the CMS administrator during the second term of President George W. Bush. McClellan is now a professor at Duke University. "He's both a good communicator and a technical expert, as well as a committed supporter of improving health care," McClellan said of Slavitt. "So, all that's a good combination for having an impact."Slavitt, 50, joins a select list of Minnesotans trying to influence the next wave of health reform. Earlier this month, Stephen Hemsley, the chief executive at Minnetonka-based UnitedHealth Group, told investors he saw the potential for changes that promote state-based markets, flexible Medicaid programs and well-structured high-risk pools. In December, Dr. John Noseworthy, the chief executive of the Rochester-based Mayo Clinic, was among a small group of hospital CEOs invited to Florida to discuss the future of health care with Donald Trump, who was president-elect at the time. "It's time to do what's right for the American people, and get past all of the misdirection and rhetoric around the ACA," Slavitt said in an interview. The Centers for Medicare and Medicaid Services might not be as visible a perch as Mayo or UnitedHealth to many Minnesotans, but it arguably has a broader influence. CMS has an annual budget of nearly $1 trillion — far beyond spending at United and Mayo combined. The agency runs government insurance programs including Medicare that combine to cover more than 100 million Americans, more than twice the number covered last year by United, which is the nation's largest private health insurer. Mayo in 2015 treated about 1.3 million patients. "He's as knowledgeable about health care as anyone I've met," said Bill George, the former Medtronic chief executive who met Slavitt about five years ago during his Optum tenure. "He's one of the few people that can really integrate all of the aspects." Slavitt and his family moved to the Twin Cities in 2004 after United acquired his start-up company. He went on to work in Optum's business focused on data and analytics, and launched in 2013 a high-profile research collaboration with Mayo Clinic that pools data on millions of patients to study how to improve care and lower costs. A lot of political heat with the health law stems from changes to the individual market. It's a small slice of the health insurance world, primarily for self-employed people and those who don't receive coverage through their employer, but it's also a key resource for people who otherwise might not risk leaving a job with a large employer to launch a start-up or break out on their own. Premiums have spiked. Coverage often includes high deductibles. Health plans often feature tight limits on the doctors and hospitals that patients can use. During a conversation last week at a coffee shop in Edina, Slavitt prefaced his comments about the troubled individual market by pointing out the ACA has had a much broader impact. For Medicare beneficiaries, the law filled in the "doughnut hole" in the Medicare prescription drug benefit, meaning seniors now face far fewer out-of-pocket costs for medications. For people with employer health plans, the law eliminated annual and lifetime caps that previously limited how much coverage individuals with serious health problems might use. Millions of people have gained coverage via the Medicaid program for low-income Americans and those with disabilities. In the individual market, the health law eliminated preexisting-condition exclusions that outraged consumers. Insurers used the exclusions to screen out patients who might generate big costs, and several insurers have struggled to make the business profitable since they disappeared in 2014. Many have raised premiums or dropped out of the market as a result. In Minnesota, regulators last year granted huge premium increases to Minnesota health plans and let them limit their networks and/or enrollment to stem the red ink. "It's not working in Minnesota very well," Slavitt said. "That's absolutely true." Part of the problem, he argues, is that Congress failed to provide funding for one of the rate-stabilization programs within the ACA, that were intended to help insurers cover their losses while the market got up and running. Minnesota has a unique problem, he said, with its MinnesotaCare program, which predated the health law and provides coverage to lower-income residents often described as the "working poor." In most other states, people with incomes that qualify for MinnesotaCare are purchasing through the individual market, including new health insurance exchanges created by the ACA, In Minnesota, that population has stayed out of the individual market, and thereby contributed to the cost problems. "You're basically taking so much of the good risk away," Slavitt said. "If that were one risk pool, that would solve a great deal of the problem." Going forward, Republicans have talked about helping people with preexisting conditions by letting them buy coverage through high-risk pool programs. Slavitt said a return to high-risk pools would be a mistake, arguing it would be better to create a "reinsurance" program that would cover some losses for insurers if they attract people with costly conditions. But debating the merits of risk pools vs. reinsurance is the sort of discussion he would like to help inform going forward — one that's focused on policy particulars, rather than political fireworks. Even so, Slavitt shows plenty of partisan spark on the social media website Twitter, where he said he has added about 4,000 followers since he left Washington. Last week, he called out an amendment in the Minnesota House of Representatives that involved letting health insurers sell policies that don't include coverage for cancer treatments, diabetes and several other mandated benefits. Slavitt called the amendment "cruel" on Twitter, and suggested it showed what could be coming with an ACA repeal. Republicans say Slavitt misunderstood the amendment, since insurers already can sell those plans in Minnesota. If Slavitt wants to work in a bipartisan fashion, "he's not off to a good start," said Rep. Steve Drazkowski, R-Mazeppa, who offered the amendment and says he was deluged with calls and messages from across the country following Slavitt's tweets. On Thursday, Slavitt retweeted the link to an interview where he described past Republican efforts to stymie the health law as "borderline sabotage," particularly by pulling funds for the law's rate-stabilization program. A spokesman for U.S. Sen. Marco Rubio, R-Fla., who helped orchestrate the maneuver, issued a statement saying: "To now claim it would have worked just fine if only the Obama administration could have taken more money out of taxpayers' pockets in order to bail out big insurance companies is laughable."