President Obama announces the nomination of Sylvia Burwell as the next secretary of Health and Human Services. (Nicholas Kammnicholas/AFP/Getty Images)

Hard to believe that just a year ago, as the nation endured the government shutdown (thanks, Sen. Ted Cruz!), HealthCare.gov was melting down. Things are working infinitely better now, but the coming open-enrollment period will bring a new, more rigorous test for President Obama’s signature legislative achievement, the Affordable Care Act. Just don’t call it “Round Two” of Obamacare.

“This is Round One because we never had to have reenrollment and open enrollment together,” Health and Human Services Secretary Sylvia Burwell told me last week in her spacious sixth-floor office suite, whose design is a chic relic of the 1970s, overlooking Constitution Avenue. In addition to the challenge of getting more people without health insurance covered, Burwell emphasized the need to reenroll as many folks as possible. “All those 7.3 [million who signed up during the initial open enrollment and paid their premiums]? We need them back in,” she said.

Complicating that task is that it all has to be done “in half the time,” Burwell reminded. Because of glitchy.gov last year, the initial open-enrollment period was extended to six months. The upcoming open-enrollment period is three months, from Nov. 15 until Feb. 15.


A woman looks at the HealthCare.gov insurance exchange site last Oct. 1. (Karen Bleierkaren/AFP/Getty Images)

To ensure there is no repeat of last year’s disastrous rollout, Burwell told me that she and her team are testing the hell out of HealthCare.gov’s capabilities. They are looking at how consumers and insurers interact with the Web site. They are testing its security. And they are load-testing the site to see if it can handle the crush of traffic that caused far too many crashes during the last open enrollment. In addition to the importance of testing, Burwell said federal officials learned “that the consumer waits until the last minute.” That has implications not only for messaging but also for site traffic as the Feb. 15 conclusion of the enrollment period approaches. Burwell is confident the mistakes of last year will not be repeated.

Burwell’s résumé is filled with public-sector and private-sector experience. She held various positions in the Clinton administration, including deputy director of the Office of Management and Budget (OMB). She had the top job under Obama. Before taking that job, Burwell was the president of the Walmart Foundation and was once the chief operating officer at the Bill & Melinda Gates Foundation. All this explains why a conversation with Burwell about the ACA is a series of lists.

When it comes to measuring the success of the ACA, Burwell said, “[T]here are really three fundamental ways with regard to the Affordable Care Act and that is quality, access and affordability.

While everyone is focused on the 7.3 million people who have signed up for health care and paid their premiums, Burwell said, “[W]hat I believe should be the real access measure is actually the uninsured because that’s the problem you’re trying to solve.” The National Health Interview Survey released last month showed that the number of insured Americans dropped 8 percent to 41 million.On quality, Burwell believes “that’s probably the place where progress will take a little longer.” But she was quick to note, “[W]e are already seeing 150,000 fewer readmissions.”

As for affordability, Burwell broke down that category into “three different tiers: the government, the private sector and the individual.” The secretary pointed to the “$116 billion that’s been saved in Medicare spending between 2009 and 2012 compared to what it would have been had 2000-2008 trends continued” and “the Congressional Budget Office now estimates that federal spending on Medicare and Medicaid in 2020 will be $188 billion below what it projected as recently as August 2010.” For the private sector, Burwell highlighted “the decreasing growth that we’ve seen in health care costs overall and what that means to the bottom line.” And for individual affordability, she pointed to the $11.5 billion Medicare recipients saved through the closing of the prescription-drug doughnut hole and the requirement that insurance companies spend 80 percent of health care premiums on actual care.


(Courtesy The Henry J. Kaiser Family Foundation)

Burwell’s overall goals for the agency are a four-point list.

  • Make sure the marketplace is working;
  • Make progress on dollars-well-spent and quality in the health-care space;
  • Continue the expansion of Medicaid;
  • Make sure people know how to use the health care they are receiving, both in terms of their overarching wellness and how they can access things that help them in terms of affordability.

For many Americans, the only way they could get health insurance is through the expansion of Medicaid. Right now, only 27 states and the District of Columbia have expanded Medicaid. Burwell was happy about Pennyslvania’s recent move to do so. “That’s another potential 500,000 people who are uninsured who could get insurance,” she said. Yesterday, I showed how states not expanding Medicaid hobble the fight against HIV/AIDS because some of those states are also home to some of the highest concentrations of HIV infections and those living with HIV/AIDS.

Burwell was upbeat about her efforts to get the remaining 23 states to expand Medicaid. “It is my experience, both in governing and many years ago when I did campaigns, that actually substance drives politics,” she said. “The facts are this is working. The facts are we have slowed health-care cost growth. The facts are the quality of your care whether you’re employer-based or whether you’re uninsured is better.”

At one point during our 30-minute conversation, I asked Burwell if it was frustrating to be peppered with “all these ideological, partisan questions.” She said no because it’s part of the dynamic, but added, “I really want us to move beyond the politics.” Saying that the ACA had become “an ideological lightning rod,” Burwell said, “I just think the American people deserve for us to move beyond that.

“If we can start with the fact that people believe people should have access. People believe you should have affordability and people should have quality. Okay, can we just start where we agree and then start moving through?”

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