He might have become a doctor like his father, but a grad school (Harvard) summer job researching health policy changed all that. Now as the head of the Kaiser Family Foundation, Drew Altman deals not with lab numbers for a few patients but with healthcare data for millions. For years he headed up state and federal programs on welfare reform, homelessness and
The administration says don't confuse the mechanics of the Affordable Care Act with the program, but at the outset, don't the mechanics become the program?
There's no question that people are mightily confused, [as] we see in our monthly tracking polls. People have been witnessing a three-year slugfest of a debate, and only now is the law becoming real — with a horrible rollout of a website. Add to that the fact that the law is complex and affects different people in different ways. Early next year we'll get a better fix on how this is doing. Ultimately this isn't about the website, it's about people who get coverage [answering] one question: Is this a good deal for me or not?
In the first year, it'll be 15 or 16 million people who get coverage [according to government estimates] — not a lot in a country of 300 million, so we'll be making a judgment based on a relatively small number of people. A lot is going to turn on what the news media do; this law is ripe for death by anecdote. The Kaiser Family Foundation has our own news service, but there's a serious challenge for the news media to get out and see how the law is working and not just find one juicy story that makes headlines.
What is the foundation's mission?
Being an independent source of information. We may not be appreciated by everybody because facts are sometimes annoying to all sides, but we're credible with everybody. The facts aren't a magic wand in a polarized, super-heated political system, but they certainly help.
Who's doing the ACA right?
California is absolutely a leader in embracing the ACA and implementing it. As California goes, so goes the nation. We're tracking 2,000 uninsured [California] families to see how they're affected by the ACA. If the challenges can be met in California, they can be met anywhere.
You're friends with former Health, Education and Welfare Secretary Joseph Califano, who created the agency that runs
Medicare was attacked by the right, treated as a socialist plot. I think he would say the heat is really turned up because of the toxic polarization in our political system, but this isn't the first time we've had controversy around the rollout of a big program.
There was partisan rancor in 1989, when President
It is true. I worked for Democrat
Could a workable ACA make all that much difference?
People are terribly worried about their healthcare bills, especially [the] uninsured. They desperately want coverage, and that's true of young adults, who everybody thinks don't want coverage. At the level of families around the kitchen table, it's not about Obamacare as a political symbol; it's about, does this make sense for me?
People don't understand the connection of health insurance to their lives and budgets. It's not only that [they] will have coverage, but because they will have a way to pay for healthcare, it will be easier to pay for food, for clothes, for rent, for gas to get to a job. That is the most profound effect.
The ACA also eliminates the worst abuses in the health insurance system: people with preexisting conditions now don't have to worry that they'll be excluded from coverage or their rates jacked up. That's a big deal. Roughly half the American people say they or a family member has a preexisting condition.
Can anything hold down medical costs?
There is no magic answer. We have a fragmented, wasteful system which we're wedded to, and it makes it hard to control overall spending. We are in a historic slowdown in healthcare spending right now, mostly due to the weak economy but also due to changes in health delivery — more cost-sharing, higher deductibles, more out of pocket. Nobody knows when healthcare spending will shoot up again and by how much.
What about experiments like CalPERS capping payments for knee and hip surgery and letting the patient make the choice and pay extra?
I think we've got thousands of flowers blooming out there. We also have changes in payment and delivery being driven by Medicare. The potential for these changes to reduce spending — there are lots of hopes and claims, but the jury is still out. We have to see what the evidence is and whether these can be scaled into policy so they really affect spending overall.
Were the policy cancellations a surprise? Could insurance companies be using the ACA for their own ends?
All of the above is probably true. Experts knew [cancellations] would happen, because of the way the ACA was set up. We also know insurers game the system whenever they can. The individual market was always the most broken part of our health insurance system. So it absolutely needed to be replaced with something better, and it is under the ACA. The law provides for a transition to the new policies, and for some people those policies are going to be a better deal and for some they may not be. An expert can look at a policy and say, "This is a better deal for you," and a [consumer] can say, "I don't really care — I liked my old policy."
Did the president's likening the website to buying on Amazon invite problems?
The website is not just a matter of people choosing the policy they want. It's not Travelocity. Some of the uninsured have never had health insurance. Some don't know what a deductible is, they don't know what a premium is. A significant percentage have no bank account, no experience with computers. For them it's about someone who can help them navigate the maze. Everyone craves the healthy younger person to make the insurance pool healthy. In terms of achieving the social objective, it's the long-term uninsured who are sick who we want to get into the system as well.
As a footnote, I read that you're a Red Sox fan. Congratulations on the World Series.
If the Red Sox can go from chicken and beer [blamed for the team's 2011 collapse] to first in a year, let's see what happens to Obamacare in a year!