Most people believe that the GOP , its Senators and Congressmen have been the only group that wants to change the Affordable Care Act. However, I believe that those in command of the feedback, statistics and financials realized the great steps forward, but also the non-sustainability including, as I have been pointing out, the closing of Exchanges and the increasing premiums and deductibles that the average Americans have been faced with since the passing of the ACA. Shelby Livingston wrote that acting CMS Administrator Andy Slavitt , a person that I believe has done nothing to improve the ACA, recently urged all lawmakers to improve on the progress made by the Affordable Care Act, rather than plunge the healthcare industry into chaos if the ACA is repealed and inadequately replaced, or isn’t replaced at all.

“There should be no pride of authorship,” Slavitt said. “If we can improve upon the things that were started in the ACA, we should do it. It doesn’t matter if that comes from a Democrat. It doesn’t matter if it comes from a Republican. I would encourage people on both sides of the aisle to say, ‘Let’s take a step forward, and let’s focus on the things that haven’t been working.’”

Slavitt spoke Wednesday morning at Modern Healthcare’s 2016 Leadership Symposium in Chicago during a one-on-one interview with editor Merrill Goozner.

Slavitt said the ACA has helped lower the uninsured rate to 9.1% and expand health insurance to people previously denied coverage for having pre-existing medical conditions. He also said the ACA has been instrumental in improving quality of care measures and bending Medicare’s cost curve.

But now as the new administration under President-elect Donald Trump takes control of the White House, the future of the ACA is on increasingly shaky ground. Congressional Republicans have vowed to repeal and replace the ACA, but have given few details surrounding a replacement plan. Republicans in Congress plan to move almost immediately next month to repeal the Affordable Care Act, as President-elect Donald J. Trump promised. But they also are likely to delay the effective date so that they have several years to phase out President Obama’s signature achievement. This emerging “repeal and delay” strategy, which Speaker Paul D. Ryan discussed this week with Vice President-elect Mike Pence, underscores a growing recognition that replacing the health care law will be technically complicated and could be politically explosive.                                                                 Since the law was signed by Mr. Obama in March 2010, 20 million uninsured people have gained coverage, and the law has become deeply embedded in the nation’s health care system, accepted with varying degrees of enthusiasm by consumers, doctors, hospitals, insurance companies and state and local governments.

Insurers are unsure how to set premium rates for 2018, which are due in the spring. Hospitals are concerned the progress they made toward value-based care will be stripped. And consumers have made thousands of calls to the HealthCare.gov call center asking what will happen to their coverage.

“We’re dealing with a third of the economy,” Slavitt said of the healthcare industry. “If you want to do a do-over, which is the other alternative to building on our progress, you’re going to take a third of the economy and thrust it into some deep uncertainty.” This is my thought exactly even though I dislike Slavitt and what he has done and not done for the health care system. But enough with my dislike for Slavitt, let’s carry on here.

Slavitt had warned that lawmakers could move the healthcare system backwards, and a replacement plan should be judged by a four-question test. Will the new plan provide coverage for as many people? More than 20 million people have gained coverage under the ACA as I stated previously.

Does it provide the level of protection under the ACA? Is it affordable? Slavitt pointed out that most people enrolled in exchange coverage can find a plan for $75 a month (if you receive subsidies from the government), although millions of people who buy coverage off the exchanges have to pay full freight without any subsidies. Finally, is the replacement plan fiscally responsible?

Slavitt also touched on the future of Medicaid under the incoming administration. Rep. Tom Price (R-Ga.), Trump’s pick to lead the HHS, has supported turning Medicaid into a block-grant program with a per-beneficiary cap.

That “would be disastrous,” Slavitt said, warning that block grants would require funding cuts that could harm children, seniors and people with disabilities.

On the ongoing shift from a fee-for-service system that pays for every procedure to one based on paying for quality and outcomes, Slavitt said the U.S. is moving slowly to test programs, but it’s making progress.

We’re only on “the iPhone 2” version of accountable care organizations and medical homes, he said. “They are going to get a lot better…provided CMS does its job right.”

Prescription drugs—especially specialty drugs, which have grown heavily in cost—are an opportunity for value-based reimbursement arrangements. But the greatest tool in reining in drug prices is transparency, Slavitt said.

The CMS is slated to release information Wednesday on more than 5,000 drugs and their pricing history over the last five years, Slavitt said.

“It’s important not to use it as a cudgel,” he said, but instead “to get away from the world of anecdotes” surrounding drug price hikes.

Reported in July of this year, the agency, CMS, under Slavitt issued draft rules carrying out what’s intended to bring transformational change to the way Medicare pays physicians. It also rolled out a slew of experiments with payment and delivery reforms, including its first mandatory demonstration programs. In the process, Slavitt has become highly visible on social media and in person, and he has developed a reputation for unusual candor in conversations with healthcare leaders and clinicians. Slavitt spoke with Modern Healthcare managing editor Gregg Blesch. Regarding his thoughts on what is needed in the transformation.

Slavitt stated that he didn’t believe that his time was running out because of the election and the he and his TEAM would be working on Jan. 20, and one of the things he felt really good about was that virtually his entire team was still in place, because there is a lot of important work and everyone’s really excited about it. And it is work we’re executing hand in hand with hospitals, physicians and others. Having said that, he stated that it wasn’t his intention to drop a bunch of stuff off at the end of this administration and leave. It’s to create a launching pad for whoever comes next so that we’ve planted the appropriate seeds in the appropriate lanes. For example, in their cardiac work his team did a medical bundle for (myocardial infarction), which is an innovation. That’s an example of not just feeling the market was ready and it was the right thing to do, but also leaving tracks that others can follow.

Slavitt went on to discuss The Innovation Center, which they set up had already been demonstrated to be a saver. As a result, he thought that it had become an important, permanent part of the infrastructure. He stated, “They, the GOP and the Democrats have a lot of work to do, so I think they’re motivated, and I’m motivated, by the moment and the inflection point. We’re always going to be going a little too slow for some and a little too fast for others. If we get it right, we’ll be giving opportunities for some to move fast, and that will move the market faster than anything else. And if we move smart, we’ll also be creating carve-outs for rural practices and rural hospitals and things like that so we don’t overwhelm areas.”

Slavitt suspected that there would be several tipping points and thought that the mandatory bundled-payment plan was going to be a tipping point.… “I talk to hospitals that are not even in the regions affected by some of these bundles and they’ve told me we’re using this as an excuse to get right with how we do post-acute care and rehab. That’s a tipping point, right? Because it’s tipping something else over. I don’t want to overstate it. There will be more tipping points ahead.”

Responding to the question as to the rapidity that should be expected regarding the additional mandatory demonstrations of bundles with other episodes of care, Slavitt stated that from a lot of the conversations that he had with specialists and specialty societies, he could conceive that almost every surgical or medical area will want something in that arena, and he thought that would be largely due to MACRA a new regulation about to become in effect. They made a very strong—he thought, hopefully—that they were going to want to look at their existing models and retrofit them as much as they could to qualify for an advanced APM, application performance management, which is the monitoring and management of performance and availability of software applications under MACRA. They didn’t want to just push the market. They wanted the market to pull them and show them when they would be ready. They would obviously keep consulting with all the industry participants to make sure that they do gauge it right, and he thought that they would go as fast as the evidence allows them to go.

The interviewer noted that The American Hospital Association’s statement on the new bundled-payment proposal expressed enthusiasm for the goals but also said Slavitt and his organization was risking the success of other initiatives by adding new ones so quickly.

Slavitt responded that he never expected one of the associations to be any more committal than they’ve been. That’s the reason they spoke directly to hospital CEOs—both the leaders and the people that don’t consider themselves leaders in this area. Slavitt stated, “I can tell you that many CEOs I talk to are guns blazing asking for what we just did. I won’t say that’s universal but there are many that are.”

Responded to Slavitt’s recent social media and in person comments regarding the community on MACRA, Slavitt stated, “There are a couple things at work. The first and most important is for us to listen and really signal we can listen. The most important job we have right now is to get it as right as possible coming out of the gate. And these things aren’t works of art. You don’t perfect them. But if we listen well, we’ll get it a whole lot more right and a whole lot better than we would otherwise. I think it’s absolutely true that most physicians don’t know what MACRA is—may have heard of it, may not have heard of it. What I can tell you is that every physician, no matter how disengaged they are, no matter their specialty, no matter their level of skepticism, has had their voice represented by other physicians. We’ve been very successful in making sure all parties are heard from and that when we hear things we go deeper. And we’re really overweighting input from the most skeptical, the least-resourced physicians—the people who might be the most frustrated. We’re not going to win back hearts and minds by trying to sell them an oversimplified vision. What we are going to be able to do is hopefully get this so it is as right as possible in terms of the four or five things physicians said matter to them, and then be able to make some good decisions in the final rule-making process. “

Slavitt believed that there would be accommodations for certain types of practices in the final rule-making to be announced. Their goal would be to make this successful for their beneficiaries and there would be no way to make it successful for their beneficiaries if they didn’t do it in a way that all physicians feel like they could be successful in that process. He didn’t intend to makes news when he said that they were going to find a way to get this off to the right start. That would not be the same thing as a delay. There are lots of ideas that have come to them and they were considering all of them.

So, maybe there is a way to start from what Slavitt has started and proceed from there. I know that the GOP and President-elect Trump ahs stated that they wanted to repeal the ACA, but we are now seeing a crack in the plan the repeal goal. The transition will be more difficult than imagined. Health Savings Accounts and Negotiating Across State “borders” for better, more affordable premiums will not be the answer. It will take more, with a coordinated transition, so that those covered using the ACA, subsidized by the ACA, numbering in the millions, don’t lose their health care coverage. Also, it will take more effort so that the average American doesn’t have to fear 25-125% yearly increases in their health care insurance premiums and huge deductibles in their futures.

My other concern is Slavitt’s answer to problems with the ACA using the bundling approach. If that is part of the future plan, solo practitioners, private practitioners not employed by hospitals, huge health care corporations and university health care organizations will be the medical delivery business models of the past and not the future. For the solo practitioner/private practitioner will be the last to be paid as the hospitals receive the bundled payment and prioritize and distribute the payments for services. Think about that!! I do as a surgeon in private practice. This is not the answer unless all physicians become employees of the larger organizations.

How did we come so far but lose sight of the total equation-the delivery of good health care to the patient at a reasonable cost in a free market economy where the participants delivering care can pay their debts and make a reasonably profit to allow them live comfortably and to plan for their futures?

Next what the new Secretary of the HHS has in store for the ACA and health care.