Speaker 1: 0:02

15 years after ACA passed, what does one of its authors think about the 10 years since implementation and what does he see for the future of US health care? We'll find out on this episode of Shift Shapers.

Speaker 2: 0:17

Change either energizes or paralyzes. The choice is yours. This is the Shift Shapers podcast, bringing the employee benefits industry interviews with individuals and companies who are shaping the industry's shifts. And now here's your host, david Saltzman.

Speaker 1: 0:39

And we are honored to have with us former New Jersey Congressman Rob Andrews. Rob is the fellow I was talking about, who was intimately involved in drafting portions of the ACA, and he'll answer those questions, dan, I'm sure a few more. Welcome, rob, how are you today?

Speaker 3: 0:53

It's great to be with you. Thank you for the invitation, David.

Speaker 1: 0:56

Our pleasure. So let's start with a level set. We always like to talk about people's journeys and how they ended up doing what they were doing, because, as you and I both know, life is never a straight line. How did you find your way to Congress and then into the craziness that was ACA?

Speaker 3: 1:12

I wanted to be a sports writer. When I was a teenager, I loved the idea of broadcasting or writing about football or basketball games and whatnot, and so I wrote a letter to the publisher of the local weekly newspaper asking for a job, and he gave me one at the age of 14. But he must not have read my letter as carefully as I thought, because instead of assigning me to cover sports, he assigned me to cover news. Instead of assigning me to cover sports, he assigned me to cover news. So here I was. I was 14 years old and I was covering town council and school board meetings and whatnot in southern New Jersey, where I lived, and I was enamored of the fact that people who ran the towns could figure out how to make the parks better or ban overnight parking or take care of whatever problem existed. The government could be a problem solver. That really interested me. Along.

Speaker 3: 2:16

About the same time in our family life, my dad, who had worked at a shipyard for nearly 40 years, lost his job, and he was 61 years old, and I was 14 years old, and it seemed to me that our family had this massive problem and government, which had the ability to solve problems, wasn't addressing our problem. And so I put those two things together and got interested in politics and wound up having the opportunity to run for county office in my home county in 1986 when I was 28. And I became the chairman of that governing body in New Jersey when I was 29. And then my predecessor in the Congress got elected governor of New Jersey in Jersey when I was 29. And then my predecessor in the Congress got elected governor of New Jersey in 1990 when I was 32. And I had the opportunity to run for his seat and I was fortunate enough to be elected. So it was a very crooked line. You talk about straight lines. It was a crooked line from caring a lot about being a sports writer winding up in the House of Representatives.

Speaker 1: 3:27

Just a sport of a different sort, I would hypothesize. So how did you find your way ultimately into the ACA craziness? Was the health thing always something that was kind of a passion of yours or something you'd worked on when you were at the local level?

Speaker 3: 3:40

Yeah, I mean, I think everybody who cares about their community cares about health care in one way or another because it's so intensely personal and so very, very important. In Congress, though, it was almost an accident of jurisdiction that in the House there's three things that matter Party, seniority and jurisdiction. Seniority and jurisdiction. So if I were as a freshman congressman, if I wanted to affect corn price supports, I was one for three. I had party, I was a Democrat, we were in the majority, but I had no seniority and I wasn't on the Agriculture Committee. By the time we got to 2008, when President Obama was elected, I was three for three. I was a member of the majority party. By that time I had 18 years of seniority and I was on what was called the Education and Labor Committee, which had jurisdiction over the health care law that affects employers, which is called ERISA, the Employee Retirement Income Security Act. So it was a good fortune that those three things for me came together and it gave me very much a prominent role in writing. The ACA.

Speaker 1: 5:02

Well, ERISA has certainly been more and more in the news, especially when it comes to health and welfare funds these days, with the lawsuits and such. But let's dial back to ACA. Aca, in my opinion, broke a lot of industry stuff that desperately needed to be broken, because it kind of created an opportunity for folks to innovate and rethink and build new things. So three questions One from your perspective what's worked well?

Speaker 3: 5:30

What's worked well is getting people covered who didn't have coverage, through a combination of Medicaid expansion and the extension of subsidies to help people buy insurance are not covered by their employer or some other plan. I think I read in late 2024 that we had reached 50 million people since the ACA that had gotten coverage that would not have had it before. So that's worked well. Another thing that's worked well, in my view, is the improvement of rights for those who were covered. If you had a pre-existing condition, which almost all of us did, the way that was defined, you now cannot be denied coverage or charged more for it. If you wanted to keep, or needed to keep, your son or daughter on your policy until they were 26, you can now do it.

Speaker 3: 6:32

If you're one of the people who, god forbid, suffered a horrific injury or illness and ran into what used to be called lifetime or annual policy limits where your coverage ran out, those are no longer in effect. So I think those are things that have worked well. What I think has not worked well and it was, frankly, a deliberate choice at the time um, it was good to get more people covered in the system. It wasn't good to address the underlying flaw in the system when it comes to cost, which is that providers are rewarded for the number of procedures. They do not for the outcomes that they produce. The Affordable Care did a little bit on that, but not enough.

Speaker 1: 7:19

Well, we'll dig into that more in just a little bit. I'm curious when you all were sitting in a room writing all this stuff, did you think that this was a starting point and that over time things might be improved or added to ACA? And if so, kind of what were those thoughts?

Speaker 3: 7:37

Definitely. We thought it was a starting point and it still is. There's no law that couldn't be refined and improved, and I know that those of us who are involved in this certainly wanted to address that cost question I just made reference to. I know that there is a desire to try to strengthen services like behavioral health and substance abuse that are covered in theory but too often not in fact. I know that there was an interest in trying to do more to encourage the development and funding of preventive mechanisms. And how do we get more people to quit smoking? How do we get more people to pay more attention to diet and exercise and nutrition? To pay more attention to diet and exercise and nutrition? Look, the development of health policy over time is a never-ending story done right.

Speaker 1: 8:39

So I think that all of us had the aspiration and hope that there would be improvements. And now a word from our sponsor. Hey, let's take a moment to thank our sponsor, hatcher Media. You know, if you're considering launching a podcast or you're just looking to enhance your current one, hatcher Media's got you covered. But that's not all. Josh Hatcher and his team also offer exceptional graphic design services to make your brand shine across all platforms. Josh is our go-to expert here at the Saltzman Group and Shift Shaper Strategies. With decades of experience in marketing, media and production, josh and his team offer a comprehensive range of services, including podcast production, marketing, viral-ready short-form content and eye-catching graphic design. Hatcher Media can bring your vision to life. Whether you need a polished logo, stunning cover art or promotional graphics, if you're ready to elevate your brand and your podcast, hatcher Media can help. Learn more at Hatcher Media. That's H-A-T-C-H-E-R medianet, and for a limited time, hatcher Media is offering special pricing for Shift Shapers listeners just like you, so let them know. You heard about them here.

Speaker 1: 9:47

And now back to our interview. Last question about ACA If you'd gone in with a laundry list, you and your fellow Congress people had gone in with a laundry list of things that you wanted to add. Sky's the limit, no big deal. What percentage of those did you think?

Speaker 3: 10:04

actually you got where you were able to get About two thirds OK, two thirds which which again was getting almost everyone covered, at least having a reasonable opportunity to be covered. I realize how tough it is that if you're a person making 40 or forty five thousand dollars a year, which you probably don't qualify for Medicaid, and if you work for an employer who isn't covering you, yeah, you have the right to buy through an exchange, but it's really expensive and really difficult. So that was one major objective I think was accomplished by and large, and the second again was a better deal for consumers on things like pre-existing conditions and lifetime and annual policy limits and caring for your offspring who are 26 and under. So again, I think what was missing was largely the cost control idea by better aligning payment to performance the mental health piece is still a challenge.

Speaker 1: 11:10

Um, I know that it was a a keen interest of the, as we were recording this now outgoing biden administration. The mental health, parity and addiction equity act has just come out last fall with some with some new regs, but there's there's a provider shortage and I know it's something that we talked about, um, in our pre-interview a little bit. It's not just in the mental health side, is it?

Speaker 3: 11:31

No, I think it's primary care across the board. But by primary care I mean who's the first caregiver that a person encounters when they have a problem, and I don't just mean doctors. It could be lots of different people, but yeah, that there's a problem. And I don't just mean doctors. It could be lots of different people, but yeah, that there's a problem across the board. It's not hard to figure out.

Speaker 3: 11:53

Obtaining an education is incredibly expensive. Most people have to put themselves very deeply in debt and when they look at that debt along with their desire to buy a home and a car and raise children and pay for their education, it naturally pushes them toward higher paying specialties. So there's a lot of demand for residencies in dermatology. There's high demand for all our residencies, frankly, but the highest paying ones draw the most attention. The way to fix the problem I'm not suggesting it's simple or easy, but it is pretty clear Pay the primary care physicians more.

Speaker 3: 12:36

And if you have a system where the provider is ultimately rewarded on the basis of the outcome, how many people properly manage their diabetes? How many people avoided it in the first place? How many people didn't have a stroke or heart attack because they got proper care? If that becomes the mode of payment, then the income for the primary care providers will rise and there will be more primary care providers. Now, ancillary to that, I do think we need more slots in residencies. I think we need more nurses and therapists being able to practice at the top of their license. I think there's other things that have to be done, but fundamentally, in the US economy, people will do what they get paid to do, and if you make the primary care professions more rewarding in a financial sense, you'll get more men and women drawn in that direction, and I think that that's how you deal with the shortage, and the same as everything I just said is also true in behavioral health.

Speaker 1: 13:42

There's a problem all the way around. Do you foresee an opportunity for the government to say to someone who wants to go to med school I don't want to date myself but I don't want to go all northern exposure on the audience but to say you know, those of you who are not of a certain vintage, you can Google that to say you know we'll absorb your med school debts but you're going to go practice for three years in one of these underserved areas of which heaven help us.

Speaker 3: 14:11

We have a lot of them. You know there are some initiatives in that regard, but they're not strong enough and broad enough. Yeah, and look, I think it is a combination of incenting students to go to primary care and other areas by debt relief. I think that makes good sense, but it also has to be coupled with higher compensation. I'm not suggesting here that all, or even most, physicians are motivated all the time by compensation. I think most people I know are physicians, including my daughter, are motivated by their hearts being in the right place, really caring about trying to alleviate suffering and make people healthier. But they do have bills to pay, and I do think we have to be sensitive to the fact that if we attach compensation that's very high and very rewarding to things like proper management of diabetes and proper weight control, we'll get the better outcome. There's not a whole lot of mystery to it.

Speaker 1: 15:13

So you're essentially advocating for what we broadly call value-based health care. You bet Dig into that a little bit more. I mean, that means different things to different people. Can you give me your definition?

Speaker 3: 15:28

to different people. Can you give me your definition? My definition is that and I'm going to be a little wonkish here, excuse me that on a risk-adjusted, clinically sound basis. Risk-adjusted meaning you have to take into account the circumstances of the patient who's walking in the front door or being wheeled in the front door. And clinically sound means don't ask people like me, ask people like you who are clinically competent people, to define what a good outcome is, but to basically reward people for good outcomes.

Speaker 3: 15:58

So if the data show that, if someone can better manage their diabetes, they cost $6,000 a year to take care instead of $18,000. Take that $12,000 of value that is produced and share it with those providers in a meaningful way. You know the payer, the employer, should get some of it. The consumer should obviously get a lot of it, but take some of that money and share it with the people who are producing it. That's what I mean by it.

Speaker 3: 16:29

Now, again, this is important to me. I do not mean that I am the kind of person who should be defining an excellent clinical outcome. I'm not competent to do that but it needs to be people who are. If a patient is discharged from a hospital, a senior citizen with a hip replacement and she's going home to a loving family that has three people and they're going to bathe her and help her eat and help her walk around and get her to her doctor's appointments. That's a very different patient than someone who's discharged to be home alone out of the rehab center and where she's on her own to get all those things done. And I do think, if we're looking at things like hospital readmissions, which are a value-based kind of calculation, that we have to be sensitive to the risk adjustment for the patient.

Speaker 1: 17:21

So we're talking a lot about quality. How do you go about measuring quality? Is it just outcomes? Do we take quality metrics from patient perspective and patient diaries? Do we look at adherence? What are the things that the metrics that we look at to get a really good measure of quality?

Speaker 3: 17:38

Metrics should be quantitative and empirical and outcome-based. So I do think we can look at things like how long could the person walk comfortably after the knee replacement? I do think we can look at things like did the A1C level drop for the diabetic? But I don't think those should be exclusive metrics. I certainly think subjective measures of patient self-evaluation are meaningful. I think they're meaningful. I think that it's also important that we look at some input measures. I would call it adherence to follow-up visits, meds and so forth. But at the end of the day, what I think we ought to be asking is that when Fred or Sally had the knee replacement, how functional were they, how soon after the operation? And we should take into account again whether Fred has a supporting family or not and whether Sally has a high income or not, that she can get some help. But taking those things into account, that's what we should be asking.

Speaker 1: 18:53

You know, as we wrap up, the one question that I haven't asked you is what are you up to these days? Are you retired, allegedly, or you still got your hand in?

Speaker 3: 19:01

No, I'm the chief executive officer of the Health Transformation Alliance, which is a cooperative of about 70 major US companies that pool their data and their dollars to buy health care, and what we're very much about is putting into action a lot of things. We've talked about here, david, that our goal, in one sentence, is to maximize the number of those dollars that flow into value-based arrangements, and our members collectively spend over $35 billion a year.

Speaker 1: 19:35

That's a great place to start and a great place to finish our conversation for today. Rob Andrews, thanks so much for your insight and the historical background on ACA and we look forward to chatting with you again as things kind of move forward.

Speaker 3: 19:48

David, I'd love to come back and I wish you the very best with your work. Equally so.

Speaker 1: 19:58

I want to give a quick shout out to our sponsor and our producer, hatcher Media. Hey, if you need podcast production or professional graphic design, josh Hatcher is the expert to contact For more information. Visit him at hatchermedianet. That's H-A-T-C-H-E-R medianet.

Speaker 2: 20:16

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