Andy Slavitt gives us a COVID check-in from 40,000 feet

Note: Most of this transcript is machine-generated, so it’s NOT letter-perfect— oh man, and how. I’ve made some corrections, but there’s a lot I didn’t get to, and punctuation/capitalization are a big problem this time out.

Plus, a lot of this episode is an actual conversation, and both my guest and I do a LOT of “uh” and re-starting sentences in the middle. It sounds OK as audio, I think—like a real conversation between two people thinking something through— but it reads like crap on the page. We’re doing our best! Thanks for understanding.

Also, I’ve left off the list of new donors at the conclusion. (I spell some of them phonetically in the script, so I can try to avoid screwing them up, but you don’t need to see that. Also, not everybody wants their name on the Internet.) – dw

Andy Slavitt: My name’s Andy Slavitt. I was in the Obama administration, overseeing, uh, much of healthcare. Uh, and now I’m a podcaster just like you, at a show called in the bubble.

Dan: Yeah, not just like me. I never ran anything for any presidential administration. Here’s the story:

I first took notice of Andy last march, early in the pandemic, on twitter. He’d post these long threads every evening saying, “here’s the kinds of folks I was talking with today.” And they’d be like governors, and public-health officials, and hospital administrators— and he’d be like, “here’s what I learned.”

And it was all this info I wasn’t seeing anywhere else.

Because he was plugged in. He’d worked in the obama administration, and done a bunch of business-side stuff. So he knew who to call, and they took his calls, and he was putting out all this information in real-time.

And then he started a podcast called “in the bubble”— a kind of an extension of that twitter report, one conversation at a time, on tape. Political leaders, infectious-disease experts, public-health experts, journalists. Just keeping a conversation going: what do we know? How do we stay safe? How do we keep our heads together in the meantime?

So this fall, I was talking with my collaborators—Daisy Rosario and Marian Wang, who guide this show— about how in december we would want to look back at the coronavirus pandemic so far, and ask what we’d learned, from like 40 thousand feet up, and what we could maybe expect. We were like, “who would we want to talk to for that?”

And I said, “um, I was kind of thinking of Andy Slavitt.”

And there was a beat, and then they both said, “i was kind of thinking of him too.”

So, we asked him. And he said yes!

This is An Arm and a Leg—a show about the cost of health care. I’m Dan Weissmann, I’m a reporter, and I like a challenge. So my job here is to take one of the most enraging, terrifying, depressing issues in american life— but, you know, just one of them— and bring you a show that’s entertaining, empowering, and useful.

Talking with Andy was great— we got that big-picture summary of where we are. We got into the money side of what we can expect with vaccines and testing, and treatment— which wasn’t always pretty but wasn’t all bad news— and we ended up with some really big-picture questions about the profit motive in health care. Here we go…

so thank you. Thank you for coming

Andy Slavitt: great to be here.

Dan: you’ve been talking to people across a political spectrum. Like you’re a former Obama administration guy. You’ve been talking with and promoting a lot of folks, in what I would think of as that like centrist democrat world. Uh, but you’ve reached out outside of that. Like you’ve published op-eds with Scott Gottlieb, who was a Trump administration official. You have people like Bernie Sanders and Andrew Yang on your podcast.

Andy Slavitt: if there’s ever a time, when you can put your political identity aside for five minutes, you would think a global pandemic might be that time. If not now, I don’t know if we ever can and I’m not sure we’ve been able to do it, but it’s at least the thing we ought to be trying to do.

Dan: when you agreed to come on, there was a lot of stuff we did not know.

Like this was in october when we reached out to you. So we didn’t know like. How’s the presidential election going to come out and there were scenarios. We, we, it might not even be clear by the time we taped, uh, what the outcome might be. And we kind of have that answer. Now .

and then we’ve also got this other big news three big vaccine projects, right. Have announced preliminary results are really promising. Um, and there’s like some not great news. Right. Like there’s a lot of coronavirus cases, all over the country, hospitals are getting full healthcare.

Providers are getting burnt out. A lot of them still don’t have ready access to the personal protective equipment. They need to keep them safe. And a lot of people still aren’t wearing masks. And a lot of people did a lot of traveling and visiting for thanksgiving so we can expect the number of people getting sick and needing medical attention to get even bigger in the next few weeks. And meanwhile, congress did not seem to be focusing on doing anything. The current presidential administration still in charge to late january, also not super focused on controlling the pandemic or helping people through it. Right.

Including people at all kinds of risks. So like expiring january 1st, extra unemployment benefits, student loan, forbearance, and eviction moratorium from the cdc. Right. So in terms of big picture context, uh, you’re the 40,000 foot guy. What am I leaving out? Okay.

Andy Slavitt: you didn’t even need me. You didn’t need me. No, you’re you’re right. And you know, the information that you just gave me, it’s much more accessible today. You know, when I started doing, been on twitter, uh, last march, you know, everybody was disoriented.

Nobody knew it, 10 was up, there was no public data out there. You couldn’t have done that little run. You just did of events would have been very difficult to do because there was so much uncertainty. And so I started doing this because I was literally spending the day trying to solve problems. And then in the evening, um, I was like, what should I share?

And my answer was, well, all of it. And if people don’t want — too much stuff, then, you know, fine. But I literally, I’m kind of like an insider and outsider at the same time. And then, you know, i, i, I do know these folks and people will return my calls. But I also don’t give a shit.

If any of them are friends. I just want to get sort of, you know, answers and get stuff done. So, you know, I tried to do that every night now, today. It’s not as needed because as you just went through, people have a pretty good read of why we are, where we are.

Uh, and you know, different people have their own bent on it and their own theories, but, you know, we were in a dark period, uh, but fortunately we’re in a dark period, uh, where we will have a, uh, , um, around the corner. And I think that’s quite remarkable.

Dan: yeah. I mean, there’s the light and the dark. Great. How does it all leave you feeling

Andy Slavitt: it’s like that expression, the darkest, before the dawn, is that thing you tell people when life is just really shitty, right? It’s like, hey, but the stark is before the dawn. And usually you say that you have no idea of when the dawn is going to be, right. But the truth is, this is really unusual because things are bad. But we actually do have a very high degree of confidence when they’re going to stop being bad that is remarkable in a, in a couple of ways. One is just a remarkable feat of science.

Uh, but it’s also remarkable in that, you ever like know someone who they lost a job and they’re looking for a new job and and, you know, they find the job, but then they say to you, boy, if I didn’t know it was going to be, so we to find the job, I would have enjoyed my time off. Um, and, and, and so someone could promise you in four months, you will have the best job of your life. You would spend those four months in a different way, and I’m not saying. That you could enjoy a pandemic. What I am saying is there israel, meaning during hard times, there’s real meaning during times of sacrifice, there’s real opportunity to find meaning helping others because after the pandemic, so over like today, you could do things and literally save people’s lives because people are dying everywhere.

You could do something to literally help people’s mental sanity, because so many people are on the edge. You do things and help people who aren’t having enough to eat because of the reasons you described. If you do those things and then this is over and you look back and you kind of go, boy, I speak for myself.

What regrets do I have? What opportunities didn’t I take while this was going on?

We haven’t always been our best selves as a country. We’re totally honest. Uh, but we have an opportunity to do that.

dan: yeah. Um, that’s very moving.

we’re talking on november 30th, uh, you released an episode of your podcast today, and I heard the dean of brown university school of public health say, yeah, there’s vaccines coming.

And you talked about, other things like more options for testing, which opened up, options for opening up, right? Maybe as soon as you can get like a 15 minute antigen test and it’s affordable and you could take it before going to the restaurant you were thinking of going to, or before going to work, and he talked, I think about prophylactic treatments

In addition to vaccines, so, you know, one question I didn’t hear addressed there, which is like the primary question of my —it’s like always my primary question was like, what’s it going to cost? Like, what’s it going to cost us as individuals out of pocket, who’s going to have access to it without having to worry about costs? What are the prices going to look like? First, about like vaccines, what’s that going to cost me?

Andy Slavitt: per the aca, vaccines are supposed to be free. So it shouldn’t cost you anything.

Dan: if I have insurance

Andy Slavitt: um, no, nothing to do with whether you have insurance or not .

Dan: are you saying there’s a part of our healthcare system? That’s actually organized to make sure that there’s like universal access and that is less expensive for us as a society in the long run. Are you saying that that there’s actually part of our healthcare system that does that.

Andy Slavitt: very very small part. Yeah. There are provisions …

Dan: small, but kind of important right now!

Andy Slavitt: yeah. Yeah.

Dan: So, side-note: I looked this up. Andy said the affordable care act makes vaccines in general free for everybody, no matter what your insurance is? Um, not exactly, and of course it’s complicated. But: the feds have announced that covid vaccines will be free, for just about everybody, insured or not. Like covid tests are supposed to be. In our last episode we got into where folks run into potholes with that sometimes. So, you know, we’ll keep our eyes open. But mainly: yep, free vaccines. That’s the plan.

Dan: what about all these tests that would be so useful for everybody? Like, oh man, it would be so dope if I could like. Take a spit test before leaving home and know that it’s okay for me to get on the subway and, be in the office and that I’m not a risk to people. That’d be cool. Uh, what’s that going to cost? Who’s going to pay for it?

Andy Slavitt: so people haven’t figured out how, how, what they call asymptomatic tests. But let’s say you want to go to a concert, uh, to get in, like, you know, there’s no one’s insurance is going to pay for that. Or if your company wants to. , Sample tests, everybody once every two or three weeks, the company’s probably going to have to end up paying for that. So it hasn’t all been worked out yet, but here’s the thing that I’ve been working on, is they’ve been charging $150 for a lot of these tests.

And so I’m like, okay, I want to go figure out what it costs to make one of these tests and guess what? It doesn’t cost all that. You look at the materials: there’s some chemicals which are a couple of bucks. There is a big machine that things have to be processed in two, but people are running huge volumes through these machines already anyway. So it depends how much they want to charge you for using that machine.

Uh, but people are making lots of money on it. So I got together with the nba. That’s the national basketball association. And, uh, with yale university, we created a, uh, open source saliva test. That any lab in the country could do that we got approval from the fda on and that people are charging like five bucks, seven bucks, 10 bucks, whatever they, whatever they want to charge, they can, but it’s because we don’t make a profit, we ask them, to also do it at cost. And most people do that — most of them are academic labs.

Dan: and the equipment is like off the shelf stuff. Like the home-depot-equivalent for research labs.

Andy Slavitt: kmart, kmart, kmart,

Dan: ok, he’s joking. Not really kmart. We tried to out-dad-joke each other for a minute, didn’t really work, you do not need to hear it.

So. We learned: vaccines are supposed to be free— we’ll keep an eye on it— and there should be some low-cost testing options. So far so good. But there’s still gonna be a lot of people needing treatment for covid. People are already racking up bills.

Andy’s a connected guy. We’ll get his take on what we might expect, in just a minute.

This episode of an arm and a leg is a co-production with kaiser health news. That’s a non-profit news service covering health care in america. Kaiser health news is not affiliated with the big health care outfit kaiser permanente. We’ll have a little more information about kaiser health news at the end of this episode.

Ok, back to the conversation with andy slavitt:

Dan: so given all the things we don’t know, , you know, insurance companies have said, hey, we’re waiving all your out-of-pocket stuff for covid related care. Right. But that’s all voluntary. And if it’s, if you get your insurance through your job, for many people who get their insurance through their job, their employer has to sign off on it.

Not everybody has insurance. So there’s a lot of people at a lot of risks, right? I mean, I talked to a guy over the summer who was in the hospital for months. And he was like, he hit the jackpot. He was like out for months and he hit the jackpot twice: One, he woke up and he’s now walking around. And two, his insurance actually covered his million dollar plus bill. Right?

But like, the idea that you have to like hit the jackpot to both devote, to both survive a disease like this and to survive it financially is, you know why I do the show.

Andy Slavitt: It’s insane. It’s insane. I mean, you know, —it’s worse than that. Because if people get sick and they don’t like—so I just have this, I have a book coming out called Preventable and I wanted to talk to a lot of people who kind of lived through this, so I could tell their stories.

This is one guy, um, lives here. He’s got a two bedroom apartment and he’s got seven daughters. He works at Amazon warehouse. He got covid. He got two weeks of paid sick time. After two weeks, they said “you can —only way you could get paid —more paid sick time —is if you have a covid test. there were no covid tests in the entire place. So he went without pay. The only other income in the family was, he had a daughter who worked at a pharmacy. She called the pharmacy and said, I don’t think I should be coming in because I might be infectious. The pharmacist said, if you don’t have a covid test, you don’t get paid. She said, I can’t get a test. She didn’t get paid. they couldn’t afford medical care, you get worse and worse and worse. And that story is in the book. Not because it’s such an unusual story, but because it’s such a common, representative story.

Dan: So, what do you hope a Biden administration will do? And what do you think a Biden administration can do? And what’s going to require congress to act?

Andy Slavitt: free testing, I can’t say that under every circumstance— like if you’re at home and you want to go visit your grandmother and you want to go get a test to do it, like— I can’t, I can’t say that they’ll figure how to do it in every circumstance, but I think they’re going to national drive through testing sites that you can go through, that will be free. I think that’s their goal. .

Dan: that’s testing. What about treatment? I mean, there’s a lot of people, super sick. Um, people with bills piling up. What can, what can a Biden administration do with, or without a democratic house and senate do, uh, I mean, it’s just it’s. I mean, we already have right. Unbelievably crushing bills, unbelievably crushing debt for so many people. What’s what’s what’s on the what’s on the table.

Andy Slavitt: It’s a good question. Um, and I think you’re, you’re right to point to what happens in congress. The open question, no one knows the answer to is what kind of bill can biden work out with mcconnell, assuming McConnell is still the majority leader. It is possible that the democrats take the majority by the narrowest of margins, in which case they get more done. But I don’t think they get all of those things, even in that circumstance. Because having a one vote majority, you’ve just basically —think about it. You’ve just made 50 people, the most powerful person in the country. Right. So anybody can kill any bill. it’s either a recipe for a really bloated bill. Um, or it’s the recipe for something that just doesn’t get done. Now Biden’s a skilled legislator. . If you’re asking for what I predict and tell you that. The way these deals tend to work is if you want something, you have to give something. So what, when joe biden was going to doing it without good deal, makers are doing is sitting down with mitch mcconnell.

Not saying “I want X” but “mitch, what do you want?” Now? That premise works great. As long as mcconnell wants something. The problem is republicans often usually want a lot less than democrats want, they want to do less. So, I think under those terms, I don’t think you get everything you’d want or close to it.

Dan: So what I’m hearing you say is, uh, one. If mitch mcconnell remains the majority leader, um, democrats do not take these two senate seats in georgia. , You only get a very small amount of what you hope for

Andy Slavitt: yeah, uphill battle.

Dan: and, and, and if on any other scenario, uh, democrats take these two, uh, outstanding senate seats in georgia. It’s still a very narrow walk, because every senator is a potential deal breaker.

So what I’m hearing you say is, andy slavitt, is then. Okay, great. Like we’ve got some big tools coming. You know, the pandemic may not like keep us all at home, the rest of our lives, but like the, this darkest before the dawn, I mean, there’s still a lot of darkness in terms of, of the world we’ll be stepping out into, and you know, the price we’ll be paying, continue to pay for medical care .

It’s a, it’s not uh— it’s not a bright, shiny morning.

Andy Slavitt: so look, the, there was a bunch of stuff that was broken before the pandemic the fact that people can’t, not, everybody can pay for their healthcare. The fact that kids have to go to school in order to get lunch. The fact that somebody’s kids can’t do their homework because they don’t have an internet at home.

All these things were true before the pandemic. And they’re going to be true after the pandemic too, unless people do something though things happen when a bunch of people get pissed off enough. And the ability to grassroots agenda to build public support and they change things and it takes time .

Dan: so, um, one more question. It’s a really big one.

Andy Slavitt: that sounded like a dare the way you said it. Yeah. This is evil. Look in your eyes. I got a big question for you. Don’t throw me back— throw a brush-back pitch at me.

Dan: okay, great. Right? You run a venture capital fund that backs healthcare startups, and for this shit. Right. I mean, right. Is that a,

Andy Slavitt: keep going, keep going,

Dan: there’s folks who think, you know, profit motive in general, maybe a part of the problem with our healthcare

And… I kind of overdid things setting up this question, which made the rest of our conversation… A little weird.

I took note of some things I’d seen in andy’s bio for that venture-capital fund, and for other companies that he advises:

That his pre-government career included a lot of places that don’t have such great reputations these days among people who think that maybe capitalism isn’t the answer to every problem. Mckinsey consulting, goldman sachs, united healthcare.

Which seems fair for a show that spends a lot of time looking at how we get ripped off by big enterprises, but I also referred to specific bits of ugliness we associate with those names right now— stuff Andy wasn’t personally involved with at all.

Which, in retrospect, was going overboard to set up this actual question…

what do you say to folks who questioned whether market incentives are a good way to approach healthcare? Is that, you know, your idea of the best approach? Is it your idea of like the best we can and do given the system and the politics that we have in this country and have your thoughts on that changed based on what you’ve seen

Andy Slavitt: .Yeah. Yeah. Well, look, i, I think you’re right. I think there is, um, uh, huge abuses and successes that I tried, trying to point to as much as possible. Uh, particularly, um, the for-profits I’ve done even be for-profit non-for-profits, um, there’s all kinds of, uh, things that, um, that people suck money out of the system. Doesn’t it? A patient care,

I will say you completely butchered my background.

Dan: oy, things got kind of uncomfortable for a while. I felt bad. But andy did steer us back to the main question…

Andy Slavitt: which is how do I feel about profits and healthcare, which I think is an important question because , you know, we’ve created some of the worst excesses, um, and we’re not getting the basic job done. Healthcare is not affordable to people. So, so it’s all broken.

I wouldn’t, I would, um, if I had to choose between a system that covered everybody a little worse, or even more, even worse than we do today, um, or a system is highly inequitable. It’s more expensive and a lot of people didn’t get care. I choose the first in a heartbeat. I’d be, I’d be I’m all over the socialist side.

If you asked me though, what do I think are the ingredients to a successful healthcare system? I would say it includes innovation.

Dan: so, okay. I mean, people who you know, are kind of for the system that we have—one of the big arguments where it’s like, well, don’t you want innovation? Right? Innovation is the, is the kind of key word, um, that I hear, in those arguments. And I hear you saying like, “man, there’s a lot of shit that’s super fucked up and I would trade the system in, but I think innovation is good.” And so like, are you saying that like, well, given the system that we have, where all the political realities that we live with, um, you know, innovation, that’s a good place for me …

Andy Slavitt: no, no, Innovation. I mean, look, it depends what you’re innovating. If you’re building a peloton, a nicer peloton, I don’t have any interest in that. , I don’t think innovation is the end all be all.

but I do think moving innovation away from people who don’t need it quite as much. Into communities that have long been ignored. That is one of my missions. And I think it’s, I think it’s working in concert combination. I talked to governors and medicaid directors. All the time and medicaid directors. They’re like, I just need better actors. I need people out there who will do stuff better for people.

Dan: Andy went on to talk about some really neat-sounding ventures that he now backs— companies that serve moms on medicaid, that train community health workers in low-income brooklyn neighborhoods, that create better access to gender-appropriate care for trans people. As a reporter, I’d want to look closer — but they did all sound pretty cool. Here’s how we left things:

Dan: so I’m seeing you as somebody who’s like, well, I’ve got this knowledge, I’ve got these skills. How can I put my knowledge and skills to work? And you’re seeing like, oh, there’s places where a for-profit company can fulfill a needed service. That a system like medicaid has needs that aren’t being met by existing actors and like, try to go fill those holes.

Andy Slavitt: uh, I think I’m a problem solver. And I think what I know —the problems, I understand the best are healthcare ones. But they’re kids, people in their twenties and thirties. Massive visionaries, incredibly talented, super mission oriented. And if I could spend my time with them helping them doing something that’s trying to close the equity gap, uh, that’s a good use of my time.

Dan: go forward. Well, speaking of time, uh, this is all the time you promised me. And I just want to tell you how much I appreciate it.

Andy Slavitt: I think I’m late for something which is entirely my fault because I’ve been pulling your leg and talking a lot, um,

Dan: Thank you. Thanks so much for the time.

Andy Slavitt: good luck, man and thanks,

Dan: likewise. Bye-bye

Yeah! So not exactly the complete dive into the role of private enterprise in health care. But maybe we can have that conversation another time.

And you can hear a lot more from Andy (and a bunch of smart experts” on his podcast, “In the Bubble”— and you can follow him on twitter @ASlavitt.

Meanwhile, I’ll keep thinking about one of the things Andy said early on: if the pandemic really isn’t going to last forever, what can I do now to be of service?

That is it for right now. We’ve got a couple more episodes coming up in December, they’re going to be great, and we’re already working on some stories for 2021.

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Till then, take care of yourself.

An arm and a leg is produced by me, Dan Weissmann, and edited by Marian Wang. Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard. Our music is from Dave Weiner and Blue Dot Sessions. Camila Salazar helped produce this episode.

This season of an arm and a leg is a co production with Kaiser Health News. That’s a nonprofit news service about healthcare in america, an editorially independent program of the Kaiser Family Foundation. Kaiser Health Hews is not affiliated with Kaiser Permanente, the big healthcare outfit. They share an ancestor. This guy, Henry J Kaiser. He had his hands in a lot of different stuff.

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