By John Reichard, CQ HealthBeat Editor
May 17, 2013 -- There's something about Marilyn Tavenner that the White House could use a whole lot of right now as it absorbs successive waves of Republican criticism of its implementation of the health care law.
She clearly has the ability to engage opponents of the overhaul and to earn their good will, as last week's overwhelming Senate vote confirming her as Centers for Medicare and Medicaid Services (CMS) administrator attests.
And her two decades of experience as an executive with the nation's biggest for-profit hospital chain are reassuring to the big companies whose cooperation the Obama administration is counting on to implement the historic law.
She's got a third advantage as well: her clinical training and experience as a nurse.
In an exclusive interview with CQ HealthBeat at her office the day after she was confirmed, Tavenner outlined her priorities and discussed the many challenges she faces in carrying out the overhaul. She didn't dispute the first two advantages, but she made a point of mentioning the third.
She sees her firsthand understanding of what it takes to deliver care as a plus in dealing with hospitals and doctors who face many changes under the overhaul, including getting paid less if they deliver inefficient, substandard treatment.
But her nursing background suggests other qualities that also may play into whatever success Tavenner has in the coming months in reducing unease about the complex law. A former emergency room nurse who has guided patients through medical crises, she's a reassuring presence amid shifting circumstances. To many, she projects calm and efficiency under pressure, though she said in the interview that she doesn't feel calm at all.
Lessons of the Confirmation Process
Asked about the advantages of Senate confirmation, Tavenner doesn't oversell her new status. Nor did she make too much of the strong support she got from Republicans, 38 of whom joined 53 Democrats and independents in the recent 91-7 vote to confirm her.
"I'm not saying I can talk the Republicans into the Affordable Care Act,'' she says. "I think we all pretty much know that's not going to happen." What the confirmation process taught her, and perhaps what helped her garner so much support, is that "people just want you to be honest about what the issues are," she says.
But GOP praise for Tavenner, a southern Virginian who was long a part of the heavily Republican world of for-profit hospital executives, is genuine. While Tavenner received many congratulatory emails after the vote, House Speaker Eric Cantor, a fellow Virginian, called her personally to congratulate her.
But most important, Tavenner says, were the congratulatory emails she got from CMS staff, one of whom exultantly tweeted after the vote: "I HAVE A BOSS!"
There are more than 5,000 people who work at the agency, she adds. "And those folks are looking for a permanent administrator so they know what is expected of them each day and understand what the strategy is for the next one, two or three years."
Such stability has been missing since 2006, the last time CMS had a confirmed administrator. "I can't imagine running a private agency or running a private business with an acting administrator for seven or eight years," Tavenner says. "You wouldn't do that. You'd want someone in place who could say, 'This is our vision, this is where we are going.'"
Stability also is important to corporate executives and provider groups, she adds. Organizations such as the American Medical Association, the Federation of American Hospitals and the American Hospital Association "want to know who they're dealing with as we go through a lot of changes over the next few years."
Confirmation also tightens her links to Congress. It "means they can call me over and hold me more accountable, and I certainly expect that and look forward to that. But that wasn't done so much in an acting role. So I'll have a stronger interaction with members of Congress, and that's important."
No Time Off for the Next 139 Days
Asked the top two or three ways she thinks she can be most productive in the four and a half months before enrollment in the health care law exchanges begins Oct. 1, Tavenner glances at the calendar and interjects: "One hundred and thirty-nine days. That includes weekends and holidays, because we're working all of those.
"Obviously, one big area is doing regular updates with members of Congress. First of all, I want to build on the good will that has started. Second, there is a lot of information that we will need to be sharing over the next 140 days, information they can take back to their constituents, information about what happens inside the exchanges. Over the summer there starts to be a lot of this granular detail that folks will need to understand.
"The second way that I want to spend the next four months is obviously making sure that we're on target with the mechanics of opening the exchange, and I'm feeling good about that.
"The third area is outreach and education. We talk about people who are going to sign up for health insurance; well, that's one stakeholder. But we've also got folks like the Chamber of Commerce in key markets who can be very helpful in this, particularly in reaching smaller businesses.
"I want to meet with different chambers of commerce, and I've got a couple lined up. I'm doing Florida next week, I'm doing Virginia in June. There are a couple of other states that have reached out. That's a good way to get to businesses about what's going to happen and, just as importantly, what's not going to happen."
Tavenner adds that she intends to visit hospital boards in key markets to encourage them to help with outreach. And CMS has 10 regional offices across the country with a workforce that can help. She says she intends to visit each one of them to "give them a chance to ask details around the opening of the exchanges and Medicaid expansion but also solicit their support and help, which is important."
The priorities are "how to get people engaged and involved. And we've deliberately waited until summer." If administration officials start talking now about what will be available in terms of coverage, people who want to help will want to have something to hand out right away and people who need health insurance will want to be able to sign up, and they won't be able to do that before fall, she says.
Tavenner's big push on the health care law (PL 111-148, PL 111-152) is sure to spark criticism from Republicans that she is neglecting Medicare and Medicaid to the detriment of seniors and the disabled. In voting against her confirmation, Senate Minority Leader Mitch McConnell, R-Ky., praised Tavenner but said the health care law's implementation means she'll neglect the other two programs.
Tavenner may have had that in mind during the interview when she said that she only devotes half of each day to the health care law and the other half to making sure Medicare and Medicaid are running properly.
Dealing With the Doubts
Tavenner said coverage expansion will succeed despite stories in the press expressing doubt, but she adds that it won't happen overnight.
"I have confidence," she says. "The proof is going to be in the actual execution, and I think we are going to be prepared for that.
"There's two parts to that. I have confidence that we'll open for business on Oct. 1. So that's the first piece. Will we learn things as we go along and make adjustments? Of course." As with the opening of any big new project in business or government, "you're going to make changes as you go."
"The second piece, which is how do we go out and get folks to sign up, really is in three or four different categories." For example, there are people who have pre-existing medical conditions or have been unable to afford coverage and are just waiting to get it. "I think they'll be anxious; we've just got to help them out." In other cases, there are people who have never had health insurance. "So we'll have a targeted strategy for them. So we'll have different strategies depending on which part of the market we're trying to attract, and we're trying to attract everyone we can, obviously."
Also helpful will be the lengthy open enrollment period to sign up for coverage in the first phase of the expansion: six months. "This was done with the intention that not everyone is going to be at the door Oct. 1."
Tavenner adds that "it's like any other new program. It'll take a while for folks to understand, know what to do and get signed up." But, she said, "I think it will be well-received."
Medicaid Expansion
Tavenner is candid about the pace of the Medicaid expansion. Only about half the states say they will expand on Jan. 1. Asked whether she can help get that up to two-thirds, she says, "Realistically, I think most states that are going to expand by 2014 have to have made that decision by now" because of legislatures that are going out of session.
A few more states may yet opt for expansion in 2014, but "premium assistance," the model Arkansas plans to implement in which the Medicaid population gets subsidies to buy coverage on exchanges, won't open the floodgates, Tavenner says.
Arkansas now needs a CMS waiver. "They have started to send us information, and we're working with them and we're very encouraged by it." Tavenner adds that "there will be a couple of states that watch Arkansas and maybe try to do that model, but I think it's a handful of states."
She says she's hopeful that other states will come on board in 2015.
"A lot of that work goes on at the state level," with medical associations, hospital groups and advocacy groups continuing to work with governors and state legislatures. "I think most of them understand that if it's not this year, they're going to try to work strategically with the idea of 2015.
"The good news is we have it set up so folks can come in when they are ready. It's not like they have to come in by Jan. 1 of 2014—or tough. It's whenever you can get through your approval process."
Getting Past the Rhetoric
Tavenner says that when she talks to people about what the law will do they respond positively. That's what happened, she said, when she met with a business group in Tennessee a couple of weeks ago.
"When I sit down and talk with individuals about what this is going to do, it's actually very well-received. If you can get underneath the rhetoric of the Affordable Care Act or 'Obamacare' and get down to 'this is what it does for you, this is how it works,' then it is very positive.
"And that's true regardless of party, usually regardless of occupation and pretty much regardless of age. People just need to understand what's inside. Health care's always been complicated. When I was in the private sector it was difficult to explain, and in the public sector it's difficult to explain. We have a complicated health care system."
Given that, isn't there is a limit to what Tavenner herself can do? she's asked. She may be well-liked, and she may be reassuring, but she's a second-tier government official, and there are only so many one-on-one meetings she can have.
"Exactly!" Tavenner replies, laughing. "That's why I need teams at regions who can help! That's part of the reason for the regional visits that I'm doing between now and September. We have over a hundred people inside each region. And they do everything from look at Medicaid waivers to answering FOIA requests, so they have real jobs, OK? So I'm asking them to help with this as well.
"But they have a history of that," she says, explaining that they handled much of the communications work when Health and Human Services (HHS) rolled out its program to foster adoption of health information technology through the "meaningful use" payment program, which has now spread widely throughout the health care system.
Regional staff "see it as their mission to get folks insured," and they know the key players in local health systems, Tavenner adds. "The good news is, when your opening salvo is, 'We live in the wealthiest country in the world, we are looking at making insurance affordable and accessible to all of our population, to all of our citizens,' that's a message I can start out with every time. And then I start to walk through how that works." People respond, Tavenner insists.
Outreach, though, has run into significant snags. First, Congress denied CMS almost $1 billion in fiscal 2013 funding for outreach to promote the federal insurance exchange. Then, HHS Secretary Kathleen Sebelius ignited controversy when she acknowledged asking industry groups and other organizations to contribute to the nonprofit Enroll America, created to help promote health care law participation.
HHS says Sebelius only asked "non-regulated" groups for actual financial donations, and not drug makers and insurance companies. But now there's uncertainty about how much Enroll America can raise, with all the questions from congressional Republicans about the propriety of her requests.
Tavenner deferred questions about Enroll America and the impact of the Sebelius requests to HHS.
"For us, our strategy inside CMS has not changed," she says. It's a plan, she says, that includes providing grants for the navigators and others to give personal assistance and working with people in the states, such as hospital associations and insurance companies, to help get out the word on enrollment.
Coping With the Pressures
Anyone who has observed Tavenner since she first joined CMS in early 2010 as its top operating official can't fail to notice how much work she has done to issue the huge volume of regulations that have been published under the health care law. She has a lot left to do.
Much of this has occurred and will occur in an environment of intense criticism, with Tavenner maintaining a reputation for staying calm and focused throughout. How? And who or what inspires her?
"You're assuming that I'm calm and focused!" Tavenner objects. "Putting that aside, I start out every day with 30 minutes of exercise. That helps. But second, I have always, whether in the public sector or the private sector, depended on a strong team.
"I've also tried to create an environment where people could come talk to me about what the problems were and not be concerned that I was going to not be calm and focused. So I've encouraged a lot of communication, which I won't say helps prevent all problems, but it does help identify them earlier, and you can work through them before it becomes a crisis.
"There are people who inspire me," she adds. "I've had a couple of good bosses in my life. I find the president inspirational, and I'm not saying that because I'm a political appointee. I think he's taken a lot of pressure on the Affordable Care Act, tried to do it for the right reasons. But probably the thing that is most comforting for me, not to sound too silly, is I think we're headed in the right direction.
"I spent years watching folks, good folks, who couldn't get good health insurance for whatever reason find themselves financially strapped. And I tried to help them whenever I could when I worked for Hospital Corporation of America (HCA). And HCA was great about having a very generous discount policy. But I always wondered about the people I didn't know about who were struggling to make ends meet.
"So it really helps to know that you're getting close to an endgame where you're really going to provide—I think the Congressional Budget Office's latest estimate was 25 million—that much coverage, decent coverage to that many people," she says. It's "a once-in-a-lifetime opportunity, and that means a lot to me."
At the same time, millions of equally sincere Americans are convinced that the health care law represents a damaging level of government intrusion in the economy and in health care itself. There's no reason to think that is going to change for a number of years. Like Tavenner, opponents of the overhaul are also in it for the long haul.
