Next Steps in Health Reform: An Interview with Kathleen Sebelius

Kathleen Sebelius served as U.S. Secretary of Health and Human Services from 2009 to 2014, where she was instrumental in the rollout of the Affordable Care Act (ACA). Prior to her service in the federal government, she served as Governor of Kansas from 2003 to 2009. We asked Secretary Sebelius to look back on the beginning of the ACA and comment on its future.

How could the ACA have been presented differently? What do you think is the best way to make a persuasive yet honest case for such a complicated policy?

There was always going to be a period of time between the law being signed by the President and the time that people actually got their benefits. It was really impossible to say anything other than this is what the law does, here is what it’s going to look like. We couldn’t point to anything until the full implementation occurred. [The issue was] how to fill that vacuum when the other side was determined to do anything they could not to have the law begin.

If you could make one change to the ACA, what would your highest priority be at this point in time?

I would go back and create a few Republican votes for it—that would be very helpful. It has always been problematic that the opposition can say this was jammed through with only Democrats. Having some Republican support would be important, but in spite of hundreds of hours of hearings and debate, we didn’t get there. I would say the other big hole, and not in the way the law was written, was what happened after the Supreme Court and the optional decision about Medicaid expansion. I wish we had written [the law] differently so it would have been mandatory from the get-go, and then every state in the country would have participated. As a consequence, we have 19 states that have decided not to take advantage of [it], and millions of people are on the sidelines. They don’t get any benefits because they are too poor to qualify for the subsidies, and that, to me, is one of the great inequities being carried out.

Switching gears a bit, we want to ask you [about] social determinants of health and health equality. What are your thoughts on how the country can better address social determinants of health, such as housing and transportation, and how they contribute to high health costs?

There are lots of other pieces of the [ACA], and one of them was a cabinet-wide enterprise where all the federal cabinet officials were required to bring the access they had in their portfolio to try to improve the health of Americans. For instance, [Housing and Urban Development] started to offer smoke-free housing facilities for people who qualify for public housing. The Department of Transportation [started to mandate] that when you funded any kind of public transportation or road you had to set aside funding for bike trails or walking trails to have exercise promotion areas. Across the cabinet, people were assigned to think about how to use their taxpayer assets to actually improve health conditions. The Department of Agriculture did a whole series of things—mapping food deserts, working with various enterprises to promote healthier eating habits. The Department of Education did work to reintroduce physical education in classroom curriculums [and] redid the menu around school lunches and school breakfasts to make them healthier for children. Those kinds of enterprises all dealt with the social determinants of health and recognition that, in order to really impact the health of individuals, you had to look much more broadly than the intersection between an individual and the medical system.

Why do we see these variations in health care quality across the country? Are current provisions sufficient, or should other measures be implemented?

[One provision of the ACA was to] move Centers for Medicare and Medicaid Services from a passive payer into an active purchaser. The agency was directed to begin to pay based on quality outcomes. That’s a huge change from the old fee-for-service [model], where the more stuff you did, the more you got paid. The pace of change in the Obama administration was really accelerated. So, in 2011 zero percent of Medicare payments had anything to do with quality outcomes. The goal was that by 2018, 50 percent of Medicare payments would be based on quality measurements and outcomes. The department was on track to be ahead of that timetable. When Secretary Price was confirmed, he immediately froze some of those payments and quality measures, and it’s a little unclear what the next step will be.

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