FAIR Health Board Access Interview with James Roosevelt, Jr.

The newest member of the FAIR Health Board of Directors, James Roosevelt, Jr., brings a unique perspective as a widely respected expert in healthcare policy and delivery systems, as well as Medicare and Social Security. Mr. Roosevelt recently stepped down after a 16-year career at Tufts Health Plan, including 10 years as the organization’s Chief Executive Officer (CEO).  He is currently Counsel in the Boston office of the Verrill Dana law firm. Notably, Mr. Roosevelt served under President Clinton as Associate Commissioner for the Office of Retirement Policy within the Social Security Administration (SSA), a program that his grandfather, President Franklin D. Roosevelt, established in 1935, and was appointed by President Obama to co-chair a review of the SSA. He also is a Past President of the American Health Lawyers Association. As part of the Board Access interview series, Mr. Roosevelt spoke with FAIR Health regarding the new challenges and opportunities posed by the current healthcare environment.

FAIR Health: How has your family’s history in policy and public service influenced your approach to our political system, and how did it affect your career path? Why did you ultimately decide to specialize in healthcare?

James Roosevelt, Jr.: I am blessed with a family history of public service and commitment to good public policy. Most people think of my family history in terms of my grandfather and grandmother, Franklin and Eleanor Roosevelt, and of my father, Congressman James Roosevelt. However, I would point out that my interest in public policy as it relates to healthcare also comes from my mother, Romelle Schneider Roosevelt, who was an operating room nurse at the Mayo Clinic before she married my father. The discussion around our family table as I was growing up was always about what was going on in the world and how it affected people’s lives, and particularly, how it affected people’s access to healthcare. My grandmother, Eleanor Roosevelt, wrote a six-days-a-week newspaper column about her activities of the previous day, called “My Day.” As a little kid, I thought that was how everyone kept up with what their grandmothers were doing. Of course, I learned later on that what I read about her activities, whether she was visiting troops in Korea or coal miners in West Virginia, was really about looking at the conditions of people’s lives and advocating actions to improve them. My interest in finding ways in both the public and private sectors to improve the quality of life and foster economic opportunity for people was really just a part of my upbringing.

FH: As the former CEO of Tufts Health Plan, you led a turnaround that resulted in the company being ranked by the National Committee for Quality Assurance (NCQA) as the #1 private health plan and #1 Medicaid plan in the country. From your experience, what new solutions should be considered on a national basis for achieving the goal of high-quality healthcare? How can we ensure that health plans will commit to making an investment in quality? Which group(s) of stakeholders (e.g., employers, insurers, patients, government entities) should be driving the quality movement?

JR: To give the American people the kind of healthcare promised under the goal of universal coverage, there has to be a dual focus on quality and cost. Contrary to what is widely believed, many provisions in the Affordable Care Act (ACA) are designed to reduce costs. That is important, and indeed it has been successful: The last seven years have shown the lowest average annual increase in healthcare costs of any period over the past three decades. However, there is also a lot in the ACA that calls for redesigning the way in which care is delivered and using currently available technology to pay greater attention to quality. These have to go hand in hand and, indeed, reinforce each other. Care that is more attentive to patients’ real needs, both physical and behavioral, and to the social determinants of health is more efficient, effective and compassionate and therefore less expensive; this translates into many aspects of “higher quality.” Health plans commit to investing in quality when they have data and information that are both applicable to the health plans and available to employers, insurers, patients and the government. There is no magic formula; it requires a continual focus on quality, cost and access to essential benefits.

FH: In a 2011 Op-Ed article entitled “Social Security’s Enduring Truths: Despite the naysayers, the system’s finances are sound,” you cited Social Security as the nation’s most effective and responsible government program. Though much of the political discussion has been focused on the ACA, do you think Social Security also is at risk of being subject to significant changes—such as privatization—in the near future? What can we do to keep the system solvent for future generations?

JR: Having served as Associate Commissioner of Social Security for Retirement Policy, I am very committed to the promise of a decent life—in retirement, or with a disability or with loss of a parent or spouse—for which Social Security sets the standard. We tend to forget that prior to the 1930s, people faced destitution, not just with injury or death, but simply with retirement. This meant that families could not afford to send their kids to college or save for their own retirement.   If there are no changes, and every economic program needs to be modified in response to changes in the economy, Social Security would not, contrary to the normal rhetoric, go bankrupt in 2033; rather, it would have to make a 21 percent cut in benefits and would still function for the rest of the century and beyond. However, Social Security has had, like most major programs, 10 sets of amendments to adjust to the changing economy since it began in 1935. There have been no such adjustments, however, since 1983, so what is called for is not privatization, but an increase in revenue for the program and an increase in benefits for those who are most in need, such as elderly widows.

FH: You have held leadership positions in many segments of the healthcare system. How are today’s debates regarding healthcare different from those that occurred when you first started? What are the most surprising and/or challenging aspects of the healthcare environment today? Finally, given the current political climate, what hope do you think there is for addressing these challenges in a bipartisan way?

JR: I sometimes point out that I am the only person—and this probably will never be allowed to happen again—who has chaired the Boards of both the Massachusetts Hospital Association (MHA) and the Massachusetts Association of Health Plans (MAHP) at various points in my career. Indeed, I continue to work with both organizations on issues of quality. Right now I am co-chairing a statewide work group on access to behavioral healthcare, together with the CEO of the MHA and a Massachusetts trial court judge who is an expert in this area. At the same time, I continue to be counsel to the MAHP.

The fundamental issues that all parts of the healthcare system are dealing with are the same: How do we improve the quality of care and make access to it financially possible both for society and for individuals? To me, what is surprising—and what has happened starting with Governor Romney and Speaker DiMasi here in Massachusetts, and then with the ACA—is that the debate has shifted from whether people should have access to healthcare for a reasonable financial cost to how. And, even though in the most recent Congressional debates, there is still a fringe group that continues to debate whether, the majority discussion in this country has shifted to how, and that is very gratifying.   Achieving real access and reasonable costs has always been challenging and will continue to be so. Our regulated yet capitalist-based system of providing both care and coverage produces the best combination of access and affordability. There is a lot of work to do to make it more affordable, however, and regulation is an important part of it. We have seen recently some bipartisan proposals that strengthen the ACA along the lines of the kind of revisions that I mentioned, in the way that every major economic and social piece of legislation needs to be as it is implemented into practice, but we are still in the midst of political gridlock.

FH: How has the role of cost transparency in the marketplace evolved over the past few years? To what extent has the current healthcare landscape impacted the way in which cost transparency is figuring into the national conversation on cost? What is the future of healthcare cost transparency?

JR: Cost transparency has received more attention partly just because we always have to look at the overall cost of healthcare to society, to individuals and to employers, but also partly because cost-sharing features such as higher deductibles, copays and coinsurance are utilized to try to affect cost and choices in healthcare. It is not fair to ask people to make these choices without data about what they are actually paying and what it costs to deliver care. The most controversial area that is screaming to be addressed is the cost of both traditional and new pharmaceutical and biological drugs. We are starting to see that increasingly enter into the conversation. Quite interestingly, some public officials who are great defenders of an unregulated system are starting to call for controlling the cost of pharmaceuticals. Now, it is important to understand that regulation does not mean restricting people’s access to pharmaceuticals, but rather considering whether there is any justification for increasing the price of a drug after it has been on the market for a long time or whether the price of a new drug so vastly exceeds its development and distribution costs that it jeopardizes access to healthcare. Data about the costs of research and development, marketing, manufacturing and distribution need to be a matter of public interest and public policy when you have a universal coverage system. We have a long way to go to make the cost of everything from primary care to acute care more acceptable and understood by both employers and individuals when they pay the bills.

FH: FAIR Health has continued to lead as a source of independent and objective price information. How do you see FAIR Health’s role in the healthcare sector and the value of claims data in addressing the system’s current challenges? Looking to the future, in what ways would you predict FAIR Health’s role will evolve?

JR: FAIR Health, partly because of its unusual way of coming into being and partly because of the effective methods that it has pioneered to use claims data, both to directly analyze costs and also to consider the implications of cost in such major issues as the opioid crisis, plays a very, very important role in the healthcare system. I do not see in the foreseeable future our healthcare system evolving to a strictly bureaucratic, governmental administrative function. Consequently, the role of FAIR Health will continue to be more and more important as people use data to achieve the right balance of incentives in our regulated market-driven way of paying for and delivering healthcare.