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Tom Kise, United States of Care
Andy Slavitt, former acting administrator for the Centers for Medicare and Medicaid Services, leads a discussion with Utah health care advocates in Salt Lake City on Tuesday, April 17, 2018.

SALT LAKE CITY — Utah health care advocates looking to think up ways to reduce the cost of medical care in the state got a visit this week from one of the leading health officials of former President Barack Obama's administration.

Andy Slavitt, who served as acting administrator of the Centers for Medicare and Medicaid Services from March 2015 to January 2017 and was tasked with overhauling the federal health insurance marketplace website in the aftermath of its largely criticized rollout, visited Utah last week to share his ideas at an "affordability boot camp" organized by the Utah Health Policy Project.

Slavitt was joined at the two-day Salt Lake camp by other top executives of United States of Care, a health care policy nonprofit based in Minneapolis and Washington, D.C., where he is the chairman of the board of directors, in speaking with Utah medical providers, policymakers, think tanks, and patient advocates about reducing health care costs.

In an interview, Slavitt called Utah a place that has "always been one of the most thoughtful and enlightened and pragmatic states on working on, I think, the twin issues of how do we make sure that we take care of people in the state but also, how do we make sure that we focus on affordability and costs."

The affordability summit came the day after ballot initiative campaign Utah Decides Healthcare announced it had collected enough signatures to put full Medicaid expansion before the state's voters in November. Slavitt sat down with the Deseret News to discuss the initiative, state lawmakers' own more limited version of expansion, Medicaid work requirements, and more.

The following conversation has been edited for length and clarity.

Deseret News: There is a perception among many people that the rising cost of medical care is a runaway train, and many have accepted high costs as inevitable. Where do we start with reducing or controlling the cost of care?

Andy Slavitt: Everyone feels every health care problem is too big and they're powerless. So groups like this getting together today (are saying), "No that's not the case." No one individual, it's true, can affect the outcome, so that's why dialogue is so important. …

Rather than having all the nurses walking around the halls, how do we send nurses out to the home to keep people healthy? Because that's what's going to keep costs down — (to) stop getting people from getting admitted to hospitals. …

How do we keep people healthy? How do we recognize the issues, whether they're mental health issues, whether it's drug addiction, whether it's poor nutrition, whether it's lack of housing, whether it's other factors. We know how to treat most things people have (upstream). The problem is, the reason we don't is because people don't have regular access to the system and because we don't think holistically about what causes them to get sick.

DN: In your former role as the head of Centers for Medicare and Medicaid Services, you had an up close view of the effects of Medicaid expansion in some states. Can you tell me what expansion might do in Utah?

Slavitt: The overall cost of insurance comes down for everybody when Medicaid expands, because when people aren't falling into this coverage gap, the costs aren't getting passed along (by the uninsured). So we've seen an average of a 7 percent reduction in premiums across the country when more people are covered.

I think legislators and governors are rightly concerned about, "What's this going to do to my state, can we afford it?" We've now seen in many states … that it's been very good for their economy. …

(There's) a huge (coverage) gap, and I think this is a state that I think has the compassion and the intellect together to solve these problems and to see to those issues. And so I don't see a state like Utah wanting to let that rest.

And I recognize the Legislature and the general population and the governor, they may be taking different approaches, but (it's good) if they can get in a room and start to drive to consensus and actually look at what happened with the ballot initiative as the sign from people in the state that … this is something people want to have addressed. People don't want to see people left out in the cold.

DN: The Utah Health Policy Project is worried the Medicaid expansion proposal that the Legislature recently voted to submit to the federal government is likely to be rejected, since it requests a 90-10 federal funding match without extending coverage eligibility in the same way a full expansion would. From your experience, do you agree that such a request from the state has a strong possibility of failing?

Slavitt: I don't know whether or not the federal government will approve it. I just don't. I mean, I can't speak for them. But look, the state's trying to do something, and at some level this is an administration that should be deferential to states as they take their different approaches. But I don't want that to be read as my (dictating) what the administration should do. …

Ultimately, if this ballot initiative passes … that will supersede what the Legislature does. And I think people ought to pay attention to that. It's not every day that you get 160,000 signatures in a state like Utah for something like expanding Medicaid. … The country's paying attention to that. It's a national story.

DN: The Legislature's version does include a work requirement, which was a non-starter under the presidential administration you served in.

Slavitt: We at the Obama administration had the view that putting a barrier in front of somebody to get medical care is ultimately not good for their health, nor is it ultimately good for their employment, and that if people lose their jobs they shouldn't be losing their health care at the same time. (For example), if someone has depression, they miss work, they get let go, then they lose their health care coverage. It's not a good situation.

Having said that, there is a feeling that for most people, health care costs them something. So (for) most people who get their insurance through their employer, through an exchange or other places … there's perhaps a hunger to feel like if we're going to provide Medicaid expansion … that they want to make sure people are engaged in some way, that they're not taking advantage of the system.

That's a real sentiment and I think we'd be wise to pay attention to it. The question is how.

DN: Citing a desire for more flexibility with their finances, Utah policymakers have previously flirted with the idea of changing the way the state Medicaid program is funded by asking President Donald Trump's administration to dispense a preset block grant as opposed to maintaining an open-ended federal match. What is your view of giving a state a set amount of money and saying, "Here, you make the decisions?"

Slavitt: What's attractive to the states about a block grant is they feel like that means fewer strings are attached. They like that, governors like that. Governors don't want strings attached (from) Washington, but the reality is a block grant doesn't do a favor to the state. It does a favor to the federal government by essentially capping the allotment.

Comment on this story

Now, I got to oversee one block grant, which was because we have only one block grant in the country in Medicaid and that's to Puerto Rico. And it was a disaster, and I don't know a governor in the country that would want to be in Puerto Rico's shoes as they started running out of money. You get a natural disaster of any kind, you get an opioid epidemic, you get something you don't expect, and then a block grant … means that the federal government gives you no more money.

So where does the money have to come from? Well it either comes from the state, or individuals just don't get care, or you just pay physicians and hospitals less. None of those are great options.