Tangle - INTERVIEW: Isaac talks with Andy Slavitt

Episode Date: March 22, 2024

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 Care, a national nonprofit health advocacy organization, and the founding partner of Town Hall Ventures, a health care firm focused on underrepresented communities.Perhaps most notably, Slavitt was one of the central figures 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. You can watch our latest YouTube video, The Zionist Case for a Ceasefire, here.On Sunday, we released Episode 1 of our first ever limited podcast series: The Undecideds. We're following five voters — all Tangle readers — who are undecided about who they are going to vote for in the 2024 election. In Episode 1, we introduce you to those voters.You can subscribe to Tangle by clicking here or drop something in our tip jar by clicking here. Last week, we released more tickets to our New York City event on April 17th, and they got gobbled up quickly. Our general admission tickets are now sold out; but we still have some VIP seats left for purchase. Get them here. Tangle is looking for a part-time intern to work as an assistant to our YouTube and podcast producer. This is a part-time, paid position that would be ideal for a college student or recent college graduate looking to get real-world deadline experience in the industry. Applicants should have: Proficiency in Adobe Premiere — After Effects a plus. Minimum of one year of video editing (Adobe Premiere) Minimum of one year of audio editing and mixing (Any DAW) Good organizational and communication skills Understanding of composition and aesthetic choices Self-sufficiency in solving technical problems Proficiency in color grading and vertical video formatting (preferred, not required)To apply, email your resume and a few paragraphs about why you are applying to [e-mail] and [e-mail] with the subject line "Editor opening"The job listing is posted here. Preference will be given to candidates in the greater Philadelphia area. Our podcast is written by Isaac Saul and edited and engineered by Jon Lall. Music for the podcast was produced by Diet 75. Our newsletter is edited by Managing Editor Ari Weitzman, Will Kaback, Bailey Saul, Sean Brady, and produced in conjunction with Tangle’s social media manager Magdalena Bokowa, who also created our logo.--- Send in a voice message: https://podcasters.spotify.com/pod/show/tanglenews/message Hosted on Acast. See acast.com/privacy for more information.

Based on Charles Yu's award-winning book, Interior Chinatown follows the story of Willis Wu, a background character trapped in a police procedural who dreams about a world beyond Chinatown. When he inadvertently becomes a witness to a crime, Willis begins to unravel a criminal web, his family's buried history, and what it feels like to be in the spotlight. Interior Chinatown is streaming November 19th, only on Disney+. The flu remains a serious disease. Last season, over 102,000 influenza cases have been reported across Canada, which is Chinatown is streaming November 19th, only on Disney+. yourself from the flu. It's the first cell-based flu vaccine authorized in Canada for ages six months and older, and it may be available for free in your province. Side effects and allergic reactions can occur, and 100% protection is not guaranteed. Learn more at flucellvax.ca.

From executive producer Isaac Saul, this is Tangle. Good morning, good afternoon, and good evening, and welcome to the Tangle podcast, a place we get views from across the political spectrum, some independent thinking, and a little bit of my take. I'm your host, Isaac Saul, and on today's episode, we're going to be talking to Andy Slavitt. From 2015 to 2017, Andy served as the acting administrator for the Centers for Medicare and Medicaid Services under President Barack Obama. He was overseeing Medicaid and Medicare and the Children's Health Insurance Program and the health insurance marketplace, where he also oversaw the healthcare.gov turnaround and rollout in 2013. He was also President Biden's White House senior advisor for the administration's COVID response after Biden won the election in November of 2020.

of 2020. He's the founder of United States of Care, a national nonprofit health advocacy organization, as well as a founding partner of Town Hall Ventures, a healthcare firm that invests in underrepresented communities. Andy is a super interesting guy because he's been around through two very, very important administrations, Barack Obama's and now Joe Biden's. He's been on the front lines of two very, very important American policy issues, Obamacare and then the COVID response after Trump left office. So I was super excited to speak to him. This interview took place about a month ago at the end of February. So you'll hear Andy talking about running into President Biden the night before. That was during one of Biden's trips in California. So a couple of comments here and there might be a little bit dated. So I want to

give you that context that this interview happened just about a month ago. But I thought it was a really fascinating conversation. I appreciated how candid Andy was with some of his experiences, and I hope you guys enjoy. Andy Slavitt, thank you for coming on the show. I appreciate it. It's great to be here. So there's a ton of stuff we could talk about. I have a million questions for you as 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 15-year anniversary of the Affordable Care Act,

commonly known as Obamacare becoming law. You were, you know, a central figure in its infancy. I'm curious if, for our listeners, maybe you could give a bit of your view on where the ACA is today, how you view its current state. What are some of the top line headline things Americans should know about where it's at right now? You know, it's such a poetic narrative from, you know, how it passed in a, you know, how it passed in an incredibly nail-biting 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 kind of like humble beginnings where it was unpopular around, to kind of like 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 be able to get health care, 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? Like 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. So talk to me a little bit about that politicization, I guess, 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. Well, there's no real public opposition. I mean, if you ask Americans, if you pull 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 within your parents' 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% of the public says, yeah, that's a good idea. I like that. And even the law itself is popular. popular. 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, you know, it's fine to criticize. It's fine to try to improve. But to try to take something away without anything that replaces it, like, is a really bad political strategy. Having said that, you know, 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. 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 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 at anything. It ended up solidifying the support in the ECA. I'm curious, I guess you mentioned on the top of the show, you know, all the things that you came in to fix, really. I mean, the rollout and some of the issues that we were having. I think, you know, the famous one that everybody probably knows about or remembers is the website, which I want to talk to you a little bit about more specifically, but I'm just curious, you know, broadly speaking,

looking back on the crafting of it and the rollout, when you think about things you might change, if you could go back and do that time period over again, what comes to mind for you? 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. Oh, this part is a problem. Let's fix it. You know, we had things that were literally language glitches that Congress said, we're

not fixing it. Even though it's going to cost the country more money, hurt more people, leave people behind, create unfairness, we're not going to 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 reasonably anticipate it at the time. 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 is, and it's pretty clear to me

at this point, is that the law was great for people that were in this period, in this place where they're above the poverty line, don't qualify for Medicaid, but not quite middle class and without very stable jobs. You know, they may bounce around, and I think that people in the younger generation, gig economy, whatever you want to call it, people in the younger generation, gig economy, whatever you want to call it, hits that mark nicely because the insurance is very affordable, the insurance people get care and coverage, and I've got literally hundreds of letters written to President Obama of people's stories and situations that have literally saved their lives,

saved the lives of their parents and their siblings. So it hit the mark for that audience. And what it did not do at the beginning, and this has since been fixed, but is if you made over 400% of the poverty level, which to translate that as for a family of four, about $100,000 in income, which in this day and age, that's not rich. 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, incredibly expensive because you had no subsidies. And that was the number one thing that needed to be fixed.

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 are lower on the economic spectrum. And I think that's not smart. You know, 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 was able to gain some political, the ACA opposition was able to gain some momentum was 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. And, you know, it may be popular for Democrats to say, let's focus, you know, on people who have less. And I think there's, 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, it's not a great way to look at things. But it also creates divisions. And so they fixed that with the following legislation. It's not a permanent fix. It's a three-year fix. But that also helped a ton of people.

fix. It's a three-year fix. But that also helped a ton of people. And, you know, we've got this very patchwork system, Medicare, Medicaid, ACA, ACA with subsidies, ACA without subsidies, employer-based insurance. And, you know, all that means, and this is the way laws develop, is that they don't 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. As much as possible, we should be wiping out those little pockets and corners

because they represent people's lives. Yeah, it's interesting to me. I mean, I think 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 or something, that their argument tends to be that the Affordable Care Act just made health insurance more expensive or that premiums have continued to get more expensive, you know, from 2012 to 2019. I know

they had some research claiming that it was, you know, above 100% growth in these premiums for Americans from across the country. Do you look at that and think that's a product of legislative mistakes that were made? Or do you look at that and think it would have been worse had there not been an Affordable Care Act? I mean, how do you think about that? Because I think every American senses like health insurance is really, or most Americans sense health insurance is really expensive and it still doesn't feel like it's doing totally what it should

for a lot of people. Yeah. Well, there's a lot wrong with that analysis, and we can pick it apart, but it can get pretty wonky. But let me extract a higher altitude to answer the question. If you were to go approach a conservative member of Congress or their policy team and say, you know, what are the goals for the healthcare system? You might say, it's to reduce costs and improve access. And they'd nod their head. And if you were talking to a liberal or progressive or Democrat, they might say, it's to improve access and reduce costs. So exact same thing, flipped differently. And I think one of the criticisms from the political right is this bill, let's just say,

put that in an analysis aside because it's problematic, but say it didn't do much to reduce costs. That's fair criticism. Now, what they're really saying is a subsidy paid by the government may reduce costs for people, right? But it doesn't actually reduce the system-wide 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. And it used to be that it was only, as I said, people who made under $100,000 a year. Now it's for everybody. So it has reduced costs. The key is, and what I think the political right complaining about is, you're covering 30 million plus more people, and you're not doing it more efficiently.

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 bringing the fiscal health. Now, interestingly enough, if you look at—we can talk about this—if you look at conservative ideas to reduce cost, they don't actually reduce cost. They just basically put a cap on things and exclude people and exclude hours, exclude different people based upon whether or not they're worthy of getting care. And that's how they choose to reduce cost. 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 things and seeds planted in the Affordable Care Act for accountable care organizations and other types of things 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 going to reduce costs, that means somebody, big pharma, insurance companies, hospitals, somebody is going to have to make less money. So it's not that, it's a criticism of any healthcare legislation. This case, it happened to be thrown by conservatives because the Democrats passed it. But it is a very valid criticism, everything we do in healthcare, that it doesn't

really get at reducing baseline costs. So that's, I think, a very cogent response to a very common criticism from the right. In the more lefty circles that I observe, I think the other side of the spectrum is, you know, ACA isn't the right answer to our healthcare problems. A lot of people advocate for, you know, 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 maybe are on a more progressive political spectrum when it comes to health care? 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 guys have pursued is actually just superior on the merits? My advice is 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. I think, 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 accept the fact that this is a very split country from a political standpoint, 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 capture and 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 from the ACA. And people I know who live with disability would be offended and fight to

the death to say, 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. And he's like, Andy, if I don't push for everything, will get, our chances of getting anything are much lower so I'm going to push for everything but do I expect to get everything? not all at once

but eventually and 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. Like, those are, there's roles for all of that in making things work better. The reality is,

in my view, the most important pending potential legislation is childhood tax credit. Childhood tax credit would transform the lives of children and families in poverty as much as anything else. And that'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 they said, you're going to put hundreds of dollars a month more in my pocket, 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 line, are much more realistic and much less idealistic than people who have the privilege of kind of looking at things with a little bit of a rose-colored glasses or ivy-towered kind of approach. We'll be right back after this quick commercial break. So, I'm curious to hear your perspective on the last few years. I mean, President Biden's 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, you know, readers and listeners should know about? And how do you view his healthcare policy as president? I mean, what's changed for the better or for worse

over the last few years since he's been in office? I saw the president last night, as a matter of fact, here in LA. And he went in after we chatted, he went in and 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. 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 this, the way health care works. I mean, look, I think it's really interesting to remind ourselves, the three people 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. 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 climate bill passed. And we got prescription drug bill passed. That was all under President Biden. And I can argue all three of those relate to health. They all three relate to our health, our ability to survive in this world and have gains. Now, can you look at all three of those gains and say, could they have been better? Could we have done more? Absolutely. But 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 they couldn't before.

I mean, remember the facts that we know. Our one in three Americans doesn't fill a prescription every year because they can't afford it. Remember that 40% of Americans who get diagnosed with cancer because of the cost of the medication spend through their life savings within two years. That's the world we live in. And prescription drugs were not a thing when we created Medicare and Medicaid, right? That wasn't how things were treated. Things 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, that passed. Now, some of the features, some of the far-reaching features are going to take a couple 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. I want to make a small pivot. I mean, still in the healthcare space, but I think another kind of 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. It's obviously, I mean, COVID-19 is like 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, you know, in the spring of 2022, a million people have died, had died of or with COVID, you know, 400,000 under Trump, 600,000 when Biden was in the White House. There's still 300-ish people dying every week, which, you know, somehow I think sort of slips through the cracks in a lot of news coverage. 300 people dying every day, excuse me. 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. I'm curious, from your time sort of advising the White House on this issue, what did you take away about our country's ability to navigate a crisis like this? I mean, how do you reflect on the United States and its ability to operate in a pandemic after seeing and experiencing some of the things you've seen and experienced? Well, first, let me just comment on numbers you ran by, folks, and just give a little bit of my take on where we are right now.

So this is roughly consistent with the numbers you just quoted, but I had talked to the head of the CDC earlier this week, and she confirmed these numbers. We're on a clip to lose about 100,000 Americans a year from COVID-19 kind of as our current steady state. Now, put aside, things could change for either direction, but that seems to be the clip we're on. The other, and so how do you benchmark that? How do you think about 100,000 people dying from a disease? It's a new disease. Many of those people wouldn't have died otherwise. So like that's an addition.

About 40 to 50,000 people die every year from the flu. That's kind of underreported, underthought of. So think about it as twice as bad as the flu. Maybe it ranks it as a top five, six, or seven disease from a mortality standpoint in the U.S., something like that. By the way, the ones ahead of it are all preventable diseases too. So we could be spending a lot of time talking about cancer prevention, cardiac prevention, diabetes, illness prevention, death from kidney disease.

We could be talking about those things too. We could be talking about Alzheimer's, where we not only lose people, we lose valuable years of people's lives. Lots of them. Many more than from COVID, sadly. We don't know any of these things, and they're all important, and not one takes away from the other. Based on Charles Yu's award-winning book, Interior Chinatown follows the story of Willis Wu, a background character trapped in a police procedural who dreams about a world beyond Chinatown. When he inadvertently becomes a witness to a crime,

Willis begins to unravel a criminal web, his family's buried history, and what it feels like to be in the spotlight. Interior Chinatown is streaming November 19th, only on Disney+. The flu remains a serious disease. Last season, over 102,000 influenza cases have been reported across Canada, which is nearly double the historic average of 52,000 cases. What can you do this flu season? Talk to your pharmacist or doctor about getting a flu shot. Consider FluCellVax Quad and help protect yourself from the flu. It's the first cell-based flu vaccine authorized in Canada for ages 6 months and older,

and it may be available for free in your province. Side effects and allergic reactions can occur, and 100% protection is not guaranteed. Learn more at flucellvax.ca. The other thing that happened, and I think we're going to see, I'm previewing what's going to come, news that's going to come shortly. So you are breaking news on your show. going to come, a news that's going to come shortly. So you are breaking news on your show. But the link between COVID cases, which is best measured now by wastewater surveillance, okay,

because the testing is too irregular, but we have really good wastewater. The link between wastewater measurement of COVID cases and deaths and hospitalizations has been broken. Why is that important? Because it used to be, 2020 to the 21st, you see cases go up, you see hospitalizations and deaths go up correspondingly. Today, thanks to a lot of people, a lot of science, a lot of things, between testing, vaccines, prior infection, medications, therapies, you can actually say the words, if you have COVID, you should survive if you use the tools available. have COVID, you should survive if you use the tools available. Okay. That's a pretty remarkable place to be. But even if you're quite old, less than a 1% death rate, if you get the vaccine, it's less. And if you get the therapeutics, if you're eligible, you can divide that by 100.

So you're talking about fractions of a percent. Now, people still die from respiratory illnesses, people in particularly congregate settings like nursing homes who are old and frail. They get a bad infection like a flu, like COVID for sure. What else am I thinking? I'm thinking of the other thing that just went around. Like, that'll be, that's enough to finish people off. But that's a much, much better place. And

look, we could be talking a couple years from now, and there could be a new variant or a new change, and that can always happen. It can happen with the flu, it can happen with anything. But I'm not trying to minimize things. And what I'm trying to do is contextualize the progress that's been made. And where we sit today, of those 100,000 deaths, most of those people aren't vaccinated. And many of them refuse to take some of the basic treatment available. Some of them are just old and it's sad and they're dying. But we have the ability, if you or someone you know and love in your life, including someone with a suppressed immune system gets COVID, we have the ability to keep them alive in the vast, vast, vast, vast, vast, vast majority of cases. That's a tremendous

win for science. Remember, remember, when we went into this pandemic, it was a seven-year estimated time horizon to produce a vaccine. That means we would be still waiting until 2027 at normal course and speed before we had vaccines. And thanks to work that got started like 25, 30 years ago, in part, on an mRNA platform and investments made by Tony Fauci and the NIH in this mRNA platform, we were ready. Thanks to scientists who could rapidly share information and do rapid clinical trials, we were able to go much, much, much faster. So I'll go to the other part of your question. What have we learned about how well we do with these? And my answer is I think if we were in school, I would give us an A in science and a D in the social sciences,

meaning the hard sciences came through a flying color. The social sciences, sociology, economics, psychology, that whole element of it, we proved to be really pretty bad at as Americans. For our first major pandemic that we lived through, not the first in our history, but the first one that all of us have lived through, major pandemic that we lived through, not the first in our history, but the first one that all of us have lived through, we became political, we fought about it, we took it around political

lines, masks became a big disputing dispute point, we stopped caring about other people's getting sick, we stopped caring about schools, we stopped caring. There's a lot of craziness in our society that was all there that surfaced itself that was pretty ugly. And as a result, we didn't manage the pandemic well enough. And I'm not even mentioning the single guy who could have saved half the lives in this country if he had behaved differently, which is President Trump. He very simply said in January and February, as soon as he knew, hey, guys, be more careful. We've got something on our hands as opposed to I want to minimize this case count and pretend like this was going to go away. The whole curve would have started much later.

We would have saved a lot more lives. The math is that there would have been a lot fewer deaths. Now, a lot of bad stuff still would have happened because we had variants and we had a whole bunch of other bad surprises, and we couldn't have avoided it entirely. But we could have done a much better job with some goodwill from the White House, and we could have done a much better job, and I hope we will next time, treating each other better and not devolving into kind of this crazy fight. But be that as it may, where we sit today this crazy fight. But be that as it may, where we sit today in the beginning of 2024 is about as good as we could have imagined, in my opinion. I'm curious if you could maybe play devil's advocate for me and make the case for some of

the positives in how Trump handled the pandemic. I mean, you mentioned the speed with which we got vaccines. Certainly, I think he would take some credit for that, for, you know, quote unquote, cutting red tape. Whether you buy that operation, whatever it was, space warp speed, operation warp speed. Warp speed, yeah. Operation warp speed. I mean, that kind of Andy, do you tip your hat to Donald Trump for the launch of Warp Speed? And they were expecting me to say, you know, hell no, I'm making it very political, et cetera. And I said, yeah.

I said, honestly, so many people have had their hands in the success and the successes we've had that nobody should be deprived of credit. And this goes back beyond for Trump's time. It goes back to George W. Bush's time when they were really funding pandemic preparedness and to Obama's time when we invested in the mRNA platform really significantly. And I think the thing that the Trump administration did well was they bet on a portfolio of drugs. was they bet on a portfolio of drugs. They picked a few.

Pfizer wasn't one of them, but Moderna was. And said, we're going to bet on these three or four. We're going to fund all of them because we don't know which one's going to win. We don't know which one's going to work. And then there was a plan. It wasn't put forward by Trump, but it was put forward by Peter Marks and the FDA to say,

let's, instead of having pharma companies do a bunch of research and then send it to us, have us look at it and send it back, why don't we embed ourselves with the pharmaceutical companies and rapidly do this together? Because time is of the essence. So there are a lot of smart things that came out of the lifelong career folks inside of FDA and department and, you know, CDC didn't cover itself with glory, but there are a lot of people did a lot of good work there. And so I'm going to give Trump administration absolute credit for that. The administration, absolute credit for that. But, and here's the but, they suppressed the voices of scientists who wanted to tell the truth about what was going on. They fired people and took them out of the jobs. They threatened people that they couldn't go on TV because the president had said, I only want positive stories. I don't want negative stories about the pandemic. The only time he changed his tune was when the stock market was down 1,000 points. And Wall Street traders told him, you need to do what South Korea is doing and acknowledge this thing. And he did for two weeks. And then he stopped. And that's bad leadership. And it's not bad leadership because he made a mistake or handled it wrong. Everybody handled some of this wrong. But most people were of good faith and were trying to get things done. But to say you ship can't dock here because I don't want to add to the numbers of cases, that's not good

leadership. So I can say that the president did support an investment program in vaccines that he should get credit for without taking away from the fact that he's got blood on his hands. We'll be right back after this quick commercial break. I'm curious if we take everything that we learned from the pandemic, all the hard sciences you talked about, those advancements that we have right now. Let's create this little hypothetical world where we have all the tools we have, all the lessons we have, but we've never seen COVID before. And it arrives today, February 21st, 2024. And it arrives today, February 21st, 2024. What are the pillars of an Andy Slavitt plan to address it?

How similar would it be to what we did back then? How different would it be now? I mean, what are like some takeaways that you have? And how would you address a fresh pandemic with all the tools and research and learnings we have today. Yeah. So the book I wrote, which is called Preventable, eventually gets to that. I have this thing in the back called Exhibit N, and it's a list of like 15 to 20 things. And I call it Exhibit N because my point is N stands for never, because they will never happen until we decide to make it important, an important priority.

And a lot of it has to do with social programs and social policy. Can we keep people from having to go to work when they're sick, right? It's not starting where you think I might be starting, but today a lot of companies don't have paid sick leave policies. So infection spread is pretty crazy, right? I mean, so there's a bunch of things that we don't necessarily think about as being pandemic prevention, but are super important. I mean, look, let's make it real. They have been trying to develop the super germ for quite a long time. And you have two types of viruses. You've got highly lethal viruses that don't do a great job of spreading, like Ebola.

And you have highly infectious viruses that aren't very lethal, like the flu. And generally speaking, you haven't had something that's highly lethal and spreads rapidly. And part of the reason for that is because that's not a very fit virus. A virus is like to survive. And if you kill all your hosts, right, you're not going to survive. So we haven't seen what people would describe as the worst of the worst. But I think depending on whether you have something highly lethal, but not super contagious like Ebola, or something that is a little more like COVID, is how you want to basically manage your response. What's consistent is we know the universe of potential viruses to come at us, and we can put ourselves in a position where we can be six months away from producing vaccines at scale in almost every case. And that's an investment of,

put it in the tens of billions of dollars that we could make, and in fact, had been proposed to Congress, had been passed, and then the Republican Congress reversed it. But that's a very, so there's a very linear thing we could do on the hard sciences side to just be ready, and more ready than we are by having the available manufacturing capacity, by having all of the viral platforms available, we can create something that's more akin to a universal vaccine, etc. So between that and masks and testing and all that stuff, I'm confident we know how to do that stuff. That's not behind the grass. But we're missing a key ingredient. You do all that, and then what happens when a bunch of people say, I'm not taking this vaccine.

You shouldn't take this vaccine. Here's a bunch of misinformation about the vaccine. Let's spread some doubt. Let's spread some fear. Let's torment people who wear masks. Let's people who wear masks torment people who don't wear masks. Let's, you know, et cetera, et cetera, et cetera. And you can't fight an infectious disease with that level of disunity.

You know, you need a level of we're all in this together for it to work. And we don't have that in this country. We have an every man and woman is in it for himself kind of ethic in this country, which ain't all bad, by the way. But it doesn't suit us for that type of environment. Now, if something scares us enough, because it is like Ebola in terms of death and it spreads fast, people will whip into shape. But my experience with this past pandemic is, as soon as I can say to myself, okay, this is not going to affect me, it's going to affect Isaac, but not me, because Isaac is short, tall, skinny, fat, black, white, old, young, different than me.

And I feel safe. Then I'm wondering, why am I staying indoors? Why am I missing work? Why is my kid missing school? I'm not at risk. My kid's not at risk. It's only Isaac's at risk, and I don't even know Isaac. And when it becomes this unknown other as a society, we tend to say, I'm not playing anymore. And that's unlike countries around the world, Scandinavian countries, Asian countries, where there's a lot more solidarity, where there's a lot more, if it affects you, it affects me, for a variety of reasons. Again, not all of it is, I'm not saying it's harmonious in every respect, but it's for something like a pandemic, that's a real benefit. So I think our biggest challenge is going to be, again, on these soft science social issues,

the sociology stuff, the psychology, the economics, the political science stuff that is challenging, and social media doesn't help. And I don't know how to fix that other than to fix us, other than for us to just focus on building the society we want. Because a better society is going to translate directly into fighting this. And you can have all the science you want. You can have all of the great vaccines you want. But if you don't have that, I don't like our odds. You mentioned seeing President Biden last night.

And I think I thought it was really telling that one of the first things you said you talked about in this speech was the insulin price caps. Before you get out of here, I'm just curious, looking ahead, you know, the next few years in the health care space, What are some of the big stories that you're watching, both from this administration and whatever administration we have after 2024? I mean, we're coming out of the pandemic. You mentioned, you know, this news that's going to be coming out soon about some of the successes we're having in fighting the virus. We have record, you know, signups on the Affordable Care Act,

this development with Biden that you're talking about with insulin price caps. What's next? What are some big stories or threads that you're keeping your eye on heading into 2024 and 2025? The weight loss drugs, Zampic, Ligovic, etc., are both important in their own right and emblematic of the kind of disruptions that I think we can come to expect, whether it's in metabolic syndrome and weight loss or whether it's in something like Alzheimer's. something like Alzheimer's. But we could be 10 to 15 years away from the Alzheimer's equivalent of a statin, meaning something that reduces your risk of developing Alzheimer's. A diagnostic test you could take in your 40s and the ability to then take a maintenance medication that holds off Alzheimer's. I wouldn't be surprised if that happened in our lifetimes. You know, a 20% reduction in cardiac events from taking one of these weight loss drugs is pretty astounding. taking one of these weight loss drugs.

It's pretty astounding. Now, all the questions haven't been answered about these drugs, including long-term use, safety profile, side effects, people who, when they go off the medication, what happens, and price. So every answer begets 10 questions. Okay. But that's how progress works. AI is the other thing I'd point to in healthcare. And it's interesting.

I saw some data, and maybe that's even a stretch, to suggest that it's data, that people actually are more likely to tell the truth to a bot than their own doctor or human being. And so this question of like, the big, big question in healthcare, a lot of it is about trust. And how do you establish trust? And then how do you establish it at scale and cost and so forth? how do you establish trust, and then how do you establish the scale and cost and so forth. But if you think about reform, you think about if my mother were to get a medication and it was causing a side effect, a rash, a reaction, et cetera, and she wanted to call a nurse and say, hey, I'm having a problem. The chances of her getting a nurse on the phone to begin with are challenging.

She might not even try. And the average cost of the system for a phone call like that starts at about $20 and goes up from there, even for a quick phone call. AI can answer that question for less than 20 cents. You gave me this prescription. You told me these things. I'm getting a rash. Should I discontinue it? Bot, is it red?

Is it puffy? Is it this? Is it that? Discontinue for today, see what happens. And by the way, so my big question was, okay, but is my mom really going to interact with some online chatbot in a comfortable way? Let's say it gives her a great answer most of the time and a more personalized answer. And I think it's got the capability to do that. And the answer seems to be that people feel judged when they talk to humans and don't feel

judged when they talk to these machines. And I like that. It's very fascinating. Maybe there's a germ in there, but you can imagine a bunch of situations where AI could be really helpful. Did you ever go to a doctor, get a whole bunch of instructions before surgery and it comes in this gobbledygook and or you get this lab result, and it's not even in English, and you can't understand it? I've seen applications where AI has sort of translated this stuff for you into really usable ways of understanding it, allowing you to ask questions and stuff about it. And all of a sudden, you can imagine people finding it less scary. And all of a sudden, you can imagine people finding it less scary.

And it'd be much easier for doctors. So I'm generally the kind of person who tends to be skeptical of new technologies really changing things. But in this case, I actually think there's quite a bit of promise that we're going to see some really good transformations. Now, those things I just talked about, AI, new drugs, et cetera, those aren't policy-related. A new question, I think, part of interpreting your question is, what are the big stories and what's going to be policy driven. My experience is that we are, we're on a cycle. We're about once every 10 to 13 years, we have a major health policy law that passes going back to the sixties. You can almost set your clock to it. And in the in-between times,

it's very, very difficult to, to do that level of transformation that much more quickly, even if they have the public appetite to do it. So what does that put us on schedule for? Sometime in the late 2020s, I think we're going to see some major reform on the coverage quality access side. I'm working on, with senators and others, ideas and bills and so forth and tossing stuff around. But I don't expect anything major in the next couple of years. Got it. Well, Andy, you've given us over an hour of your time. I really appreciate it.

Before you get out of here, where can people keep up with your work? What are you working on right now? Any projects you'd like to promote? I assume you're not going to direct people to your Twitter based on your answer earlier, but maybe there's something else you want to let our audience know about. Well, I don't really need to promote anything. I mean, I've written a book. It's called Preventable.

If you want to read it, I think it's a fun read. Talks about the last few years, my experiences in government. Other than that, I spend most of innovation efforts and a set of policy initiatives that I've got two different sets of people who lead those efforts. And that's kind of an important part of what I do. And that's kind of a little bit where my heart is. But if you're interested the non-profit policy group is called United States of Care the investment group

the innovation group is called Town Hall Ventures I love it. Andy Slavitt, thank you so much for the time. I hope to do it again sometime soon and appreciate you coming on the show You got it. Pleasure to be here you coming on the show. You got it. Pleasure to be here. Our podcast is written by me, Isaac Saul, and edited and engineered by John Wall. The script is edited by our managing editor, Ari Weitzman, Will Kabak, Bailey Saul, and Sean Brady. The logo for our podcast was designed by Magdalena Bokova, who is also our social media manager.

Music for the podcast was produced by Diet75. And if you're looking for more from Tangle, please go to readtangle.com and check out our website. We'll see you next time. inadvertently becomes a witness to a crime, Willis begins to unravel a criminal web, his family's buried history, and what it feels like to be in the spotlight. Interior Chinatown is streaming November 19th, only on Disney+. The flu remains a serious disease. Last season, over 102,000 influenza cases have been reported across Canada, which is nearly double the historic average of 52,000 cases. What can you do this flu season? Talk to your pharmacist or doctor about getting a flu shot. Consider FluCellVax Quad and help protect yourself from the flu. It's the first cell-based flu vaccine authorized in Canada for ages six months and

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