The second time I interviewed Sylvia Mathews Burwell, secretary of Health and Human Services, I realized she had a good sense of humor. The first time had been all business — open-enrollment season had just kicked off and Burwell wanted to tout the achievements of the Affordable Care Act. I wanted to delve into those, but wanted to probe her, too, on why it seems that its costs are on the rise, that the choices it offers are fewer, that it hasn't quite lived up to all of our low-premium-laced expectations. It was a good conversation — informative, critical, honest.
But it wasn't until two weeks later that I heard her crack a joke. Between our conversations, America had elected a businessman who'd never held public office and ran on discrimination and hate and a definitive promise to repeal and replace the law that Burwell has advocated for since 2014. The heartbreak was so deep, the shock so fresh and terrible — what else could we do? We laughed. Aptly, hospital humor. And then Burwell led us back on track. Because millions of people will have to live with the choices the new administration makes about Obama's health-care law. Because people, even people who voted for Donald Trump, are scared they soon won't be able to pay for their medication. Because Representative Tom Price, whom the president-elect has tapped to fill Burwell's seat in the Cabinet, has spent more than six years trying to gut the Affordable Care Act. And now he'll have more power than ever to do it.
But Burwell, who was president of the Walmart Foundation, worked at the Bill and Melinda Gates Foundation, served in the Clinton administration, and was a Rhodes scholar after she graduated from Harvard, hasn't given up yet. She takes her cues from her constituents. Within three days of the election, more than 300,000 people had signed up for 2017 health-care coverage. Within the first 12 days of open enrollment, over a million people selected insurance plans. The demand, Burwell insists, is there. How Trump decides to meet it, whether he will rejigger the law so that women have to pay more than men for the same health care, so that people with preexisting conditions can be turned away by insurance companies, is anyone's guess.
When I reread our initial interview in our new upside-down universe, I expected to find at least some sense of false assurance, a few mistaken assumptions about a warmly lit, woman-led future that I'd need to cut out. But there were none. No wonder: Burwell has watched Congress try to repeal the Affordable Care Act more than 60 times since the Supreme Court upheld the law in 2012. For over two years, she's needed to make a case for it — to insurers, to hospitals, to Americans, to recalcitrant Republicans. She never presumes. Burwell is an avowed optimist, but a clear-eyed realist all the same: She never believed the battle was over. Now more than ever, she's ready to fight like hell.
Part 1: Before the Election
Mattie Kahn: Given that we're in open-enrollment season, give me the hard sell: What progress can you point to that proves that not only is the Affordable Care Act working, but it's working better than we expected?
Sylvia Mathews Burwell: First, let's start with the fact that there are 20 million fewer uninsured [people] in our nation, and that [of] those that are in the marketplace, we know that their customer satisfaction is the same as those that have insurance provided by their jobs.
Beyond that, because people talk about the Affordable Care Act as a whole around open enrollment, we have to look at the changes it's made that are now in the fabric of health care in the United States. The fact that no one is going to go back to a place where preexisting conditions can keep you out of insurance. No one is going to go back to a place where women could be charged more than men for insurance. We're not going to go back to a place where we don't support preventative care and make people pay for vaccinations or precancer screenings or "well woman" exams with additional out-of-pocket costs.