Episode One – Flexibility Is Code For Cuts To Medicaid

DREDF’s Interview with Former CMS head Andy Slavitt

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Andy Slavitt was appointed by President Barack Obama as the Acting Administrator of the Centers for Medicare and Medicaid Services from 2015 to 2017. He led the team that repaired healthcare.gov after its highly publicized, problematic rollout. He’s an outspoken critic of partisan efforts to dismantle healthcare.

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Andy Slavitt: Everything I’ve learned along the way, around the needs of the disability community in the visits that I made to various places around the country, helped educate me and helped me make better policy.

Lawrence Carter-Long: Coming up on THE DISPATCH, your questions for Andy Slavitt, former Acting Administrator of the Centers for Medicare and Medicaid Services, and leader of the team which repaired healthcare.gov after its highly publicized, problematic rollout. He’s an outspoken critic of partisan efforts to dismantle healthcare and his unrelenting advocacy has earned him a whopping 139,000 Twitter followers.

Andy Slavitt clearly isn’t giving up on health care without a fight and he joins us here today, on the first edition of THE DISPATCH from the Disability Rights Education and Defense Fund, DREDF—that’s D-R-E-D-F—to take questions from the disability community. I’m your host, Lawrence Carter-Long. 

The underlying thread in all DREDF’s healthcare policy work and litigation for more than a decade has been to ensure that people with disabilities can get in doors and on the exam tables of medical providers and to obtain and maintain public and private insurance coverage of essential services used by disabled people. There has been no greater threat to the delivery of these services than recent attempts by the GOP to repeal key provisions of the Affordable Care Act.

The latest proposal to eliminate Obamacare as we know it, written by Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA), seeks to turn federal health insurance funding into state block grants thereby limiting essential Medicaid funding for long-term supports and services that people with disabilities rely on to do things like go to school, work, and even get out of bed, go to the bathroom. or eat.  Last week, Jill Jacobs of Virginia and Karen Scallan, of Louisiana, had some questions about how the latest of seemingly never-ending efforts by the GOP to repeal the Affordable Care Act would affect people with disabilities and posted them to Facebook. That got us wondering, what would former CMS head Andy Slavitt think about that? So, we asked him.   

The following interview was recorded on Wednesday September 20th at 7:30 AM Pacific. Depending on when you listen, things may have changed and probably have.

What do we know as of right now?   

We know that according to a spokesperson for Senate Majority Leader Mitch McConnell (R-Ky.) that the Senate intends to vote on Graham-Cassidy as early as next week in an attempt to beat the Sept 30 deadline.  

We know that Graham-Cassidy allows insurance companies to discriminate against people with pre-existing conditions that’s code for disability, by forcing us to pay more for the same care other people get for sometimes thousands of dollars less. What good is health care insurance that you can’t afford? It’s good for nothing. Literally.  

We know that Graham-Cassidy cuts health care funding for states by $4 trillion (that’s with a “T”), including vital long-term supports and services for children and adults with disabilities, including mental health services. And we know that Graham-Cassidy eliminates health care coverage for 32 million Americans, 15 million in the next year alone.  

On this, the first edition of THE DISPATCH from Disability Rights Education & Defense Fund, we talk with former Acting Administrator of the Centers for Medicare and Medicaid Services, Andy Slavitt, about how these concerns stand to harm millions of disabled Americans. Thanks for joining us, Andy. 

Slavitt: It’s great to be hear Lawrence, thanks for having me. 

Carter-Long: Let’s get right to it. Our first question is from Ari Ne’eman from MySupport.com.  

Ari Ne’eman: Hi this is Ari Ne’eman from My Support.com. Andy, as you know, over the last two decades people with disabilities have benefited from the expansion of Medicaid funded home-and-community-based services. With Graham-Cassidy threatening to severely limit access to Medicaid funds what should we expect about the consequences for people with disabilities, seniors, and families across the country?  

Slavitt: Well this is a great, great question Ari. Thank you for asking it. So, unfortunately the Graham-Cassidy bill has a very significant impact on federal funding to care for people living with disabilities. In fact, over the next 20 years Graham-Cassidy would cut 15% of all federal funds to go to people with disabilities. and that that simply means that people who are benefitting from home-and-community-based services would just simply have to have those services cut or worse people would not be able to afford to be living independently. So, this is an element of Graham-Cassidy that I wish had been getting more consideration   

Rebecca Vallas: Hey Andy, it’s Rebecca Vallas host of Off-Kilter. Appreciate you taking questions from Lawrence about this latest zombie Republican effort to repeal the Affordable Care Act and decimate Medicaid. We keep hearing Republican proponents of the bill say that somehow it is gonna help people with disabilities and that Medicaid expansion has actually been hurting people with disabilities. I know that’s a myth but I’d love to hear you a little bit more about why we shouldn’t listen to them when they say that.     

Slavitt: You know, I think one of the tactics of the proponents of the bill is very simply to pit people against one another, and to say yet we can’t make people healthier and expand coverage from people because we’re going to hurt other people, and that’s simply not true. You know this country when we’re at our best, it’s not a zero-sum game the very specific thing you’re talking about Rebecca, is just simply a lie that was made up about the Ohio Medicaid program. Governor Kasich, who as many of you know as a Republican, as well as Republicans and Democrats from across the state, objected to that characterization, which was basically that people were going to have longer waiting lists if, because of Medicaid expansion when it turned out of course that wasn’t true at all. So, you know we’re past the point of being able to trust the rhetoric of people who want to repeal the Affordable Care Act  

Carter-Long: Next up we have a question from Julia Bascom of the Autistic Self Advocacy Network of an often-ignored aspect of healthcare repeal.

Julia Bascom: Hi my name is Julia Bascom, I’m with the Autistic Self Advocacy Network. Nearly 30% of people on the Medicaid expansion have a mental health diagnosis, a substance abuse disorder diagnosis, or both. What will this Graham-Cassidy bill mean for their access to care?     

Slavitt: Well, this is a great question because Graham-Cassidy does is it is it takes one of the most important features of the Affordable Care Act which is that we have a set of defined benefits that includes mental health services that everybody gets no matter what when you buy an insurance policy. What Graham-Cassidy would allow for is back to the days of Swiss-cheese policies where insurance companies will decide what to cover and people will have to figure it out. So that’s one, I think a really significant part of this of this bill. The second thing is I think you know because Medicaid funding would get cut by over a trillion dollars we have to remember that substance abuse disorders they’re treated 30% of the treatment comes from Medicaid treatments so this is going to devastate our ability to deal with substance use disorders. You know and I and I just make a final point that when it comes to all of these cuts and all of these services the ability for us to afford to invest in things that help integrate care, that make behavioral services and physical services possible will be wiped away. And so, I think this is a sad, a very traumatic impact on people who rely on mental health services and medications.

Carter-Long: It’s a sadly ignored aspect of marginalized communities within the disability community that really deserves a lot more attention.

Slavitt: I agree 

Carter-Long: Next up we have a question from ADAPT, the direct-action disability rights group that really did protests and sit-ins, keeping this issue alive while the rest of the country caught up. This is Erika from ADAPT.

Erika Jones: This is Erika Jones, I am from ADAPT in Rochester, New York. The question is, how will the proposed bill impact long-term services and supports for people with this most significant disabilities who want to live in the community? Will this bill reinforce the institutional bias in Medicaid that tends to push disabled Americans into institutions instead of being able to receive the services we need in the community?   

Slavitt: Well first of all I want to give my thanks to the ADAPT team and the tremendous leadership in the tremendous work that they’ve shown. It’s made a huge difference and a huge impact and this question picks on something that is exactly, exactly right, which is when states get their funds cut and I’ll repeat this as I said earlier. 15% of spending and people with disabilities will go away under Graham-Cassidy. When that happens the first services that I think states will tend to cut will be home and community-based services and that will push people back into institutions. And you know, and I think as the ADAPT team has educated me over the years when I was in the Obama administration, the funding is barely enough as it is today to provide enough services for people who need them with personal care and all their home care needs. So, this will take a situation which already I think is not where we want it to be, and put it in significant hardship  

Carter-Long: Founder of the Disability Visibility Project and board member of the Disability Rights Education and Defense Fund and Twitter icon in her own right, SF Direwolf Alice Wong has the next question   

Alice Wong: Hi Andy, my name is Alice Wong I’m a disabled person who receives consumer-directed Medicaid HCBS in California. I follow you on Twitter and thanks for your Tweets about the ACA. They’re really informative. I’d like to hear your thoughts about the Disability Integration Act, a bill that has bipartisan support in the House, and how it intersects with Graham-Cassidy and other efforts to dismantle Medicaid?  

Slavitt: Well, hi Alice. Alice is actually one of my favorite Twitter followers.  I read her tweets a lot, and is in one of the groups that I set up to make sure that I know what’s going on in the real world, and so Alice is terrific.

I mean look this is a matter of civil rights and protecting civil rights and I think we cannot allow ourselves to go backwards. And I think cutting 15% of care of costs for people with living with disabilities is an enormous step backwards. Integrating folks into the community, giving them rights is the direction that I thought we were headed as a country and we need that as a country and we need to head there quickly, and I’m grateful to Alice for all her work in this area.

Carter-Long: As an activist, I’d say that effective advocacy has as much to do with strategy as it has to do with policy and for a question on how we move forward, here’s Steve Kaye from the University of California San Francisco   
Steve Kaye:  Hi this is Steve Kay from the University of California, San Francisco. How do we convince Congress that Medicaid home-and-community-based services are the solution and not the problem?  Thank you.

Slavitt: Well tell you what I think. I think personal stories are what convinces people better than anything and I think this is what ADAPT and many of the other disability rights organizations do so well.

You know I often ask people if they know anybody on Medicaid if I’m doing a town hall or something. And some of the hands go up and some don’t. Well, then I ask people if they know anybody, any families where there’s someone in a wheelchair. And they’ll say well in fact I do, and there’s a family across the street that has a child in a wheelchair. And I say well, how do you think the mom gets a shower in the morning? How do you think she goes to work? How do you think the boy gets to go to the playground, and do other things? That’s all Medicaid. And they’ll say, well wait a minute, Medicaid isn’t a middle-class program and this is a middle-class family, how could they be on Medicaid?

And you know through those kinds of conversations which are one-by-one, people start to realize that these are vital, vital programs. And Congress ultimately responds to what they hear from their constituents and the people that put them into office. And so, helping people see and understand that these are real people that we all know folks that this is not invisible that we can’t sweep these issues under the rug ultimately, I think is what will make us more and more successful. I can certainly say that everything I’ve learned along the way around the needs of the disability community in the business that I made to various places around the country helped educate me and help me make better policy

Carter-Long: You know Andy I’m a media guy, a messaging guy and one of the things that we’ve been hearing from Republicans throughout, is that these deep federal spending cuts to every single state are something that gives States flexibility. I’m doing air quotes here. What are they trying to say? Are they saying that the States can choose not to provide Medicaid services at all or that they can choose to cut off optional services such as home-and-community-based supports. What are these senators actually saying when they use the word flexibility?

Slavitt: So, Lawrence, if I were asked, if I asked you to borrow $10 which you were about to spend on lunch and you gave me $10, and then I gave you a dollar back, and I said spend it anywhere you want, I don’t care how you spend it. Did I do you any favors? I think that’s, I think that’s what really this flexibility thing is all about, which is to say, and look no one will dispute that that healthcare is local and the decision-making needs to be local, and the people who focus their resources and their decision making locally will ultimately provide better services.

But that’s not what we’re talking about here. What we’re really talking about is a disguised cut. Furthermore, I’d also say that we learned yesterday that the Trump administration is stonewalling the state of Minnesota, a Democratic state, on a waiver that they applied for. It’s a waiver that’s almost exactly the same as a waiver that was applied for in Alaska, which is a red state, that was improved

Carter-Long: There was the governor of Minnesota which wrote a letter to the Trump administration basically saying what?

basically issued a letter saying that dealing with the Trump administration on quote unquote flexibility and innovation and waivers was nightmarish and, and I know a little bit about the process because I live in Minnesota. And I could tell you that there’s no reason that this waiver shouldn’t be approved.  But we don’t really have an Administration, at least that I’ve seen, that wants to make things more flexible for States leaver the Administration that is every bit wants to decide what they think is right and wrong and yet wants to use the word flexibility as a pretense for cutting funding to needed programs.

Carter-Long: So, a little bit of homework for people that they can take away when the Trump administration or the GOP uses flexibility. What would you say instead?

Slavitt: I think these are just these are just slashing the Medicaid program so that it looks nothing like the program we know.

Carter-Long: So, cuts to Medicaid essentially every time you hear flexibility. think cuts to Medicaid

Slavitt: That’s what I think slash health care, yes.

Carter-Long: A final thing. We tried to cover a lot of ground here in this short time that we’ve had I’m wondering if there’s anything that we haven’t addressed during our conversation, a thought that you’d like to leave the disability community with?

Well I’m overwhelmed with gratitude for people in this community, and what you’ve been doing, and what you’ve done already. And I know it’s made an enormous difference. I try hard to do as much as I can to just keep up with many of the people on this call. So, I’d ask you keep doing it. Everything you’re doing is effective, and unfortunately, sadly, it’s necessary, and I really look forward to the day when it becomes unnecessary

Carter-Long: That’s what we’re all doing here. Thank you, Andy Slavitt, former acting administrator for the Centers for Medicare and Medicaid Services. We appreciate you taking some time out of a busy schedule to spend with us here at THE dispatch see you out there on Twitter

Slavitt: You got it Lawrence.

Carter-Long: Thanks again. And it’s a wrap for this the first edition of THE DISPATCH from the Disability Rights Education and Defense Fund. That’s DREDF, d-r-e-d-f.  THE DISPATCH is written produced, edited, and hosted by yours truly, Lawrence Carter-Long.

We’d like to thank Ari, Rebecca, Julia, Erika, Alice, and Steve for their questions this week on The DISPATCH.  And a special thanks goes out to Jill Jacobs for the questions on Facebook that got the whole thing rolling.

Music for THE DISPATCH is provided by Gaelynn Lea, the 2016 Tiny Desk winner from NPR. You can find out more and listen to Gaelynn’s music from violinscratches.com.

Thanks again for joining us and we’ll catch you next time on THE DISPATCH.

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