overturn that. the vaccine mandate will stay even though as i said earlier the courts have sort of put a pause on actually implementing it. host: what was the a tide of the minority leader, mitch mcconnell, in going along with these efforts by the senators? guest: he was opposed to it. he was telling reporters on tuesday we are not going to shut down the government. no questionable terms. he was on fox news on thursday basically saying that this gambit by people like marshall, lee, cruz was a bad idea. that it wasn't going to get an outcome. it could cause a shutdown and there was going to be an outlet for senators to a proper forum for addressing the vaccine mandate. that was through a stand alone mention i mentioned from senator braun. and >> we'll leave this program here. you can finish watching it any time at our website, c-span.org. we'll take you live to a virtual discussion with the deputy director for medicaid and chip

services. >> more than 40% of all children and many older adults. medicaid is the largest player for long-term service and support and the largest payer for public mental health services, including for individuals with serious mental health problems. my guest today is daniel tsai, who is the director of medicaid and chip services. i'll introduce him in a moment. before we begin, a reminder that policy spotlight is a series of virtual events that health affairs launched this spring featuring in depth conversations with policy experts. previous spotlights featured c.m.s. administrator, the c.m.s. innovation director, liz fowler, and others. all these spotlights are recorded and can be viewed on our website. today's event will also be recorded and we'll post the video within a couple of days.

if you're watching live you can submit questions during the event using the q&a box on your screen. we'll try to get questions in. but i already have quite a few and time is limited. we'll do our best. it now is my great pleasure to introduce to you dan tsai, director of medicaid and chipper is virks cmcs. cmcs is low kairted within the department of h.h.s. and serving children, seniors and people with disabilities who rely on the programs run by c.m.s. before coming to c.m.s. we was director of health for the commonwealth of massachusetts, he helped lead massachusetts' medicaid through its most significant restructuring since the 19 90's, through its handmark 23016 section 1115 waiver which implemented a major

shift toward value based care. director tsai earned a bachelor in applied mathematics and economics at harvard university. pleasure to have you on the show with me today. daniel: thank you. alan: it's easy to have an outline for today's conversation because you, with administrator chiquita brooks-laseur published an outline of your vision. i want to use that as an outline of our conversation today. maybe tuck just give a quick sense of what the major priorities are for you and the administration and then we can talk a little bit more about what that means. daniel: terrific. it's great to be here, looking forward to the conversation today. it's an exciting time to be working in medicaid and chip for many reasons. federal level, state level, providers, plans, advocates, and

the blog does really note, in fact, when i talk with folks who are in the details of medicaid, the percent of kids covered, the percent of long-term care and service and supports covered by medicaid people often do a double take and the question really is, is medicaid really that much of both a safety net and fabric of coverage in the country. so it's a really exciting time to be in medicaid. we've outlined three major policy priority areas really to help advance in a very proactive stance in partnership with states and many others and first, coverage and access tantamount to everything we do. we can talk much more about cases underneath that. second is equity. which the administrator and administration emphasize very substantially in being front and

center at the beginning of every policy operational decision versus at the back end. and third innovation and whole person care, of which there's a tremendous amount of that across 56 states and territories as well as great opportunities to make progress. those three things intersect but are not mutually exclusive. part of the posture is how do we outline a very proactive agenda for where medicaid and chip is going and how do we do so in partnership, recognizing the diversity and on the ground experiences of the different states and territories are. alan: as you say it's a comprehensive and ambitious agenda. i'm not going to take it exactly in order but i'll start with coverage and access which is the center of these programs. i want to start with a topic that is very much on the minds of a small number of people but

probably should be on the minds of many more. which is what happens at the end of the covid-19 public health emergency? i feel like as i said this is not -- this has not gotten a lot of attention outside of certain circles. i wonder if you could say a little by about what the implications are of when the more than comes to an end and then more important, what is c.m.s.'s role in making sure that that is not a terribly disruptive moment. daniel: it's a great point for many us, not just at c.m.s. on the federal level but in the space. it is what happens at the end they have public health emergency and it is consuming a very, very large amount of planning, preparation, worry, excitement all at the same time. together. and as context for folks, i think many folks are probably aware, during the public health

emergency with the range of different reasons, states in order to access enhanced federal funding for medicaid were not able to terminate or conduct redeterminations that are standard course of business in medicaid during the curation of the public health emergency that has been critical in seeing medicaid really as a back bone of coverage during the pandemic and covid. the enrollment for medicaid has grown substantially by about 15% over the course of the pandemic. and a lot of the concern is making sure that folks that are certainly, you know, no longer eligible for these processes need to happen. the concern is making sure that eligible individuals, folks eligible for medicaid coverage, don't unnecessarily lose coverage as a result of administrative, you know, the

processes, renew on the mail and folks eligible for other subs diedz or highly lo cost or no cost subsidized coverage through the marketplace are able to transition there as well. so our goal at c.m.s. is to make sure that everyone maintains some form of coverage that they're eligible for, whether it be in medicaid, marketplaces, some folks will be eligible for commercial insurance, things of that sort. it's a big area focused side-by-side with states, with substantial operation things on the ground for states, but a lot of policy and other planning for how does one think about what has always been with us in medicaid, a lot of what we call administrative churn, folks not responding to a piece of paper, losing coverage for two or three months. that is front and center of a lot of work and working through side-by-side with states to see how we extend some of those timelines and make sure we're doing everything possible to maintain coverage for folks.

alan: in that vein, what are your expectations -- i get that the goal is everyone land somewhere. it's good to have ambitious goals. but in terms of an operational perspective, what support can you give to states, and i should say counties, in many states it's counties that are doing administration. of course there's a whole technology back bone to a lot of processes, many of them still rely heavily on paper. and it's going to take time for it to roll out. so i guess part of my -- one of my questions is how will you monitor at the front end and get yourself ready for -- for if things aren't going as well as maybe we all hope they will? daniel: i'd say a few things. i think at the outset, there are silver linings as a result of the pandemic. one they have silver linings is

c.m.s., the federal government working side-by-side in partnership with states in a way that hasn't been seen before, experience prior to several month noog my role at the states, now from a c.m.s. standpoint, underlining has been case in point on that. fundamentally, one can debate a range of policy parameters, there is a giant operational apparatus in order to best maintain and preserve coverage for roughly 84 million individuals that have to go through an eligibility renewal. that's never happened in the history of medicaid with this amount of time that's passed between, and this much of a volume of a caseload of renewals happening over a period of time. so we have, from a c.m.s. standpoint, been working almost daily side-by-side with an entire group of states outlining certainly some of the priorities and operational considerations. but problem solving hand in hand. there are operational realities on the ground that we have to be cognizant of in helping states

where they are in addition to providing technical assistance, encouragement and policy. so that includes putting out things like, what we call a punch list we put out for states the other week, there's a set of activities that states have been doing that can be effective in reducing administrative unnecessary loss of coverage where you can literally go through and checkmark what you're doing. i asked the team also to start on a menu, what are the chef specials, things that will be most vail yent, impact. to think about. that type of partnership, i think, is going to be critical on the ground between the state, federal partners and i think providers and health plans and others in the community will play an important role in this as well. alan: we can talk a lot more about access but we do have a lot of topics to -- i'm sorry,

coverage. i want to move to another area, access. long standing concerns often more retorical than evidence-based about access to care for people who receive -- have medicaid coverage. but that said, there really are longstanding questions about what is an appropriate level of access for people in medicaid and that was one of your priorities in the blog post. we have -- we have a statutory and regulatory regime that talks about comparability, talks about access standards. to what -- so what's missing from the current regime to give us the confidence that people who have medicaid coverage can actually get the services that they need? daniel: it's a -- this is a fun topic. fun with an as risk meaning the fun things are usually the

hardest things. taking one step backwards. i think from an access standpoint we are trying to very consciously define access in a relatively broad base. certainly there's access to certain types of providers who have in network, that type of thing. that's critical and important. another part is coverage elements and inclusive of some of the things mentioned around whether or not there are gaps in coverage unnecessarily for folks. so when you have folks that are not enrolled in a program like medicaid, how do we work to advance and modernize the pieces. medicaid is very paper based. i think if i experienced my health care coverage in the same way, i would lose coverage every year. i don't go through my mail

nearly enough. last lot to do on that front from access to providers, the comparability piece. that is an important piece. our -- one interesting note is 70% of individuals involved in medicaid get their care through some sort of managed care health plan delivery system. and they're really strong benefits of that, of how states can use managed care. there's also folks know that managed care have the same level of transparency and understanding of what networks and providers are in network and folks have access to. so there's also questions how do we think about what it actually means to have access. many of the historic standards looking at access, how many p.c.p.'s you have within a certain radius are great when you look at things in the spread sheet but don't give any sense of whether or not an enroll yes -- an enrollee can access

that. i would emphasize this is a dialogue we're looking forward to having in partnership with states and many in the community to think about how dewe define what we're trying to achieve on this and maybe think about a place where we can strengthen what is a minimum standard of how we think about access across the medicaid program, recognizing there's tremendous variation in unique situations at the state level. alan: you made reference to behavioral health and also referenced in the blog, this seems like a -- an excellent area where on the one hand, medicaid is affected by the same factors as the rest of the health care system. we have a shortage of mental health providers in lots of places other than medicaid. but medicaid also has this unique role. it's the dominant payer on the public side and it serves people with very profound needs. how do we leverage the dominant role that medicaid plays to help

medicaid enrollees but also address what is a system-wide h health care problem? daniel: i wish i knew the answer to that. i hope other who was the answer can tell us. but i -- you hit the nail on the head. when you look at access to behavioral health services, outpatient therapy, a range of behavioral, mental health and addiction treatment services on a continuum and you look at access to that across commercial insurance, medicaid, medicare, there are challenges from that standpoint across the board. there are some states where 50% of clinicians don't even accept insurance, self-pay only. so we have some fundamental issues there. but it's a very unique issue as well as for medicaid where for, if we note some of the staff in our blogs, individuals with serious mental illness, serious emotional disturbance, medicaid set of various coverage in network is the predominant

source of coverage for that. that's both a solemn responsibility, it's also a chance to think about how we shape an entire market in terms of reimbursement level, how we think about human health, physical health care services, how we think about a behavioral health being incorporated into primary care settings in a much more standard sense than how reimbursement and other network development flows along with that. those are not easy things where the federal government can write a requirement and it magically will happen. i would not anticipate we take an approach where we put out a piece of paper and assume it's solved. i think this will take a lot of very concerted investment, partnership of providers, and others, thinking about how to advance these things and how that differs across populations. kids, adults, etc. alan: i think you have more of an answer than you gave yourself credit for.

let's go to another sort of perpetual issue in medicaid, which is oral health. here of course you have access barriers but medicaid is not the dominant payer. and you also have states that have adult dental as an option and sometimes they cover it and sometimes they let it go and bring it back. so there's all this churn around policy. we have this same coverage. how do we start bringing some of these together, these all profoundly affect people's health? daniel: it's interesting when you say the state and federal government, look at the tools you have to influence and to advance some of these pieces and when it comes to oral health, and we were just having an entire discussion about this yesterday actually, yesterday or the day before, one element of

it is, the need for oral health access integration, impacted health outcomes, impact on cost actually when we look at the e-visits and things is quite clear. the data is stark. i was looking at charts, it's hard to imagine charts that show things as clearly as some of that. as well as when you look, unfortunately, at charts, how many dentists and oral health providers accept medicaid and not just accept medicaid but when you look accept more than one medicaid patient. actually have some meaning. volume of medicaid. i think there's a whole body of work where we in partnership with states will help plans and providers think about how to advance some of that from a policy standpoint, identify where folks look at things that have worked, how to achieve that integration on a delivery system level, how to think about what's covered in various health plan structure, lots of opportunity for that. on the other hand, kind of in

our earlier discussion, points around access, i think there is opportunity to figure out how to think about, again, what it means to have a definition and a floor of access around some of these pieces. pediatric dental access well documented in child step measures for medicaid is very level. that's not an issue that is specific to a few states. it's across the board. we are very eager to work with states and providers and some of the health plans that provide a lot of dental coverage to think about ways to both measure that level of access and to think together about how to address that. reimbursement will always come up as an issue but there are things beyond reimbursement that can get us into that as well. alan: i hope you'll forgive me for peppering you with topic after topic but i'm going to add yet another, which is vaccines, particularly around covid. here we are. you're responsible for the program that covers the largest

share of children in the country. we have vaccines approved down to age 5. medicaid serves a particularly vulnerable population. we have a vaccine for children program. i realize responsibility for covid is spread around the federal government in different parts of h.h.s. but when you sit in your seat and think about the risks for the children that medicaid and chip serve, what is the role of cmcs in promoting access to vaccine, any other sources of support for young children, and although we have -- daniel: it's an integrated team effort, not just at the federal level but state and many others. we have had the states many, many different problem solving discussions involved with a lot of guidance being exchanged. we all know unfortunately

vaccination rates for the medicaid population are much lower, in many cases, than the overall community's or overall state level. that's something we are putting -- we are focused on. when it comes to the pediatric population, we rolled this out earlier this week, it was announced, think about what are the sources that are trusted sources for individuals in the community in underscerved unt -- underserved communities and for kids how do you think about that and what -- with parents and families as well. primary care doctors, pediatricians, providers are trusted sources as well as other community health workers and so on. so we have updated guidance that ensures we clarify for folks how pediatric vaccine counseling is covered within medicaid. it has been an option for states. we are clarifying that it is actually as part of epstd mandatory coverage and also during the public health

emergency eligible for 100% federal match. we are very hopeful it will help also in the role of providers and many others in engaging directly with kids and families around vaccine uptake. that's one example of a set of things, i think housing department with pro-- i think departments with those on the ground talk about how best to reach some of the communities we're talking about. alan: i want to move into the third of your topics. we'll come back to equity. i feel like it's best discussed sort of as a theme. but innovation and accountability. you have set a goal and earlier administrations have set goals about moving people into alternative payment and accountable systems. you set a goal around medicaid enrollees receiving accountable

care. we've published a lot on accountable care organizations and all sorts of things. at health affairs. it's a term that sounds good. but -- a lot depends on what we mean by it. when you say you want people receiving care through an accountable system what does that mean to you? daniel: this is a narrative where we are partnering very much, this is not just a cmcs piece, not just an innovation piece. it is us thinking about this holistically across ther board. as you probably heard from your discussions with liz fowler, we are trying to, from an equity standpoint, make sure the types of providers, systems engaged, beneficiaries and enrollees reflect much more of the safety net and medicaid population. i think from a medicaid standpoint, we have much left os

much less about a precise definition of what you must do to satisfy requirements for accountable care. it's more thinking about, we know that frag. ed fee for service care doesn't work well. we know that having wraprarnds or engaging folks out of a 15-minute office visit with competent, linguistically tomp tent -- competent support are critical to engaging in health. we also think of value as more than just a cost equation. equity and disparities when you strategy quality and outcome metrics also for how we think about this this is a push for us across an entire system to think about these things beyond how we traditionally thought about the portions of health care. i think we would love nothing more than when you sit down with any c.e.o., c-suite, clinical, administrative, otherwise of any

provider system, the set of folks that, the set of things that folks are worried about, thinking about, arguing about are, you know, what are my disparities, how do i improve population helicopter and care. things of that sort versus other arguments that might happen from a fee for service standpoint. that will only help us in lieu of being health care forward and having it ultimately work better for enrollees an individuals. so it's much more about what is the ultimate experience of care and outcomes that we're looking for and moving the dialogue in that way than any philosophical piece around exactly how an arrangement needs to be structured in order to meet that. so it's a topic of a lot of, again, fun with an asterisk, challenging discussion to think about how to think about that across many different settings and contexts. alan: i want to spend some time here, this is an important, and it is fun, but it's such an important topic.

daniel: fun with an asterisk. alan: fun with an asterisk i'll use that again sometime. i want to go a couple of different directions. it's not hard to acknowledge that fee for service with its, in a fragmented system or nonsystem is not the best kind of care. we think of managed care and again that term describes a lot of different things as a place for exactly the kind of conversations you describe.

is that a fair starting point? daniel: being in a managed care plan or fee for service medicaid state, you know, run option. at the end of the day it if providers are still thinking about care in a very fragmented way, if there's not the same focus around engaging folks outside of the tradition 15-minute increment of care, that victim consumer beneficiary, enrollee, member, pick your term around that, looks the same. it's a distinction of how things are financed. there's an important role for managed care. and states take different points

of view on that. hold it for discussion around that and the role of managed care and how best to think about that. structure within medicaid. that to me is separate. important but separate question from how to think about value-based care on the ground and the experience of what individuals have. so that's one starting point, i think in our discussions. alan: that's really helpful. i think we have a lot of evidence that states are reasonably good at engaging with managed care companies, as you note the data but probably a lot of variability in their ability or maybe their desire to push to the next level which is not just that you have a contract with an entity but that you're actually then overseeing and demanding and encouraging real improvements in care for the enrollees. your state experience in

massachusetts, my first state experience was also in massachusetts. and it's, you know, it's -- we all know all states are different but that as i worked in other states, i found that the infrastructure, that kind of oversight in massachusetts was stronger than it was in much of the rest of the country. of course my data are now very, very old. but i am curious sort of what's the federal government's role in pushing or helping the states move beyond that first layer of say, we've got managed care contracts, that's good enough. daniel: i would say this with great affection and partnership with the health plan community that i'm often chatting with, health plans can do an incredible amount. at the same time, i don't think, as we think about medicaid, whether thinking at the state level or federal level, where we are in 2021 with the goal of where we want to progress.

simply having a contract with a managed care entity, paying capitation, handing capitation over and assuming everything will happen, you've acknowledged the difference in state resources. there are times when that is actually massively supplementing state f.t.e.'s and resources to be able to do things. but generally just handing things over i think isless of what we're encouraging to be thinking about and us for thinking about around how does that not just oversee but fully utilize, partner with and effectuate care through managed care delivery system. certainly that includes a prior portion of discussion on how we think about access to services, networks, reimbursement and rates in the context of managed care, that's one piece. you're also touching on another piece, which is 70% of lives in medicaid are enrolled through a managed care product and we're

trying to advance the leverage system, fundamentally health plans are a critical part of moving that piece forward. so i think, there are times when the discussions become either-or health plan or this. i think there's plenty of opportunity, enough diversity at the individual state level, to say how do we all stack hands regardless of what delivery structure a state has figured out where they are to move the ball forward. especially when we talk about equity. there's so much opportunity and need for additional focus in investment and resources and ultimately for providers on the ground that instead of it being a zero sum this or that there's great opportunity for us to stack hands together and try to get a lot of very exciting stuff done which brings me to where i started which is this is a darn exciting time to be in medicaid thinking about what the objectives of medicaid are and what we can achieve. close to 84 million, 83 million people at this point.

alan: my biases are not a secret to anyone. i ran the national council for state health policy for 10 years. i believe a lot ostate-to-state learning. as the federal government played a role in that, i think about the state model programs, there are so many i could name, i wonder what your experience has been or what the discussions are within cmcs about supporting states in their ability to learn. i just feel like some of these concept, they're best learned by some leaders who are sharing on the ground very practical experience, not maybe through a regulation or oversight but just from shared lessons. daniel: it's -- it's a foundational point. i shared with many folks, i have been in my seat within c.m.s. for a handful of months now.

and i was at the state of massachusetts for six years. i wish that all of us, everyone at the state level, had a chance to experience being at the federal level and everyone at the federal level had a chance to experience being on the ground in the state with many policy priorities and many things you'd like to do and operational, fiscal and budgetary concerns, negotiations, those constraints and operating in that environment. i think for all of us on the administrative side, experience being on a frontline provider trying to make things work and vice versa, i think we'd all benefit from taking that, swapping chairs every now and then. so very much it's important nor administration, when we are thinking abmedicaid, medicaid is a jointly partnered program between the federal government and states. i can think of few camps where there's a greater beauty and challenge and balance of federalism between something

like the medicaid program. and it only works i think if we are all generally speaking collaborating and trying to problem solve and work through things together. everyone's got their different roles. at the federal level there are clear policy priorities we're trying to proactively outline that advance the ball forward across, you know, the entire country, all states and territories. but to do so in partnership with not just accounting for the reality os then ground but creating space and innovation in partnership with states to help drive that forward. so that is very much a point of view how we at c.m.s. are trying to operate we also hit on a another very good point, c.m.s. have certain requirements. there's regulatory requirements, it's an important function of the federal government to identify a common minimum standard that has to be met for medicaid and chip across the

country. there's also above and beyond that standard, things you can put out in requirements or regulation, a lot of room to collaborate, partner, think through things together as people sitting around a table versus saying you have to do this or please say yes to this. i'm reminded of how c.m.s. and the states have worked together through covid has been a really good example of how we might move more into that role of trying to solve a common -- we won't agree on everything but there's a common set of things we're trying to solve and it takes a lot of problem solving, figuring out who is doing things well, what we can port over from one police to another. that's pretty much how we hope to partner with and work together with those outside of the federal government. alan: before we lose this thread, we refer to 70% managed care, that's 0% do not when you think about accountability for

those not in a managed care setting, is this a.c.o.'s in medicaid a.c.o.'s? i know you said at theout set you don't have an ideological, it must look like this. but i'm trying to get a sense of what it would look like. is it a.c.o.'s? is it something else? daniel: some of that is about the state and local environment. how fragmented, the appetite for taking on specification, for taking on a range of different types of accountability and when you think of the safety net there are, i think, one could make an argument that many parts of the safety net have historically been underfunded for a long amount of time. so thinking about accountability when there's a financial element should recognize that starting point so the things i mentioned, fee for various or managed care, it's the same soaft discussions i think because it's underlying the same set of providers and

whether or not one happens to be receiving claims payment, submitting things to managed care entity or a state mmis system is one set of policy discussions and we're very eager to engage with the states together with c.m.i. in our discussions with c.m.i., we would love to identify where states can -- are wanting to lean in and it's not only across different payors, medicaid and beyond, but solving some of these different pieces you raise. massachusetts, where i come from, has a certain provider landscape. we have a certain point of view, how to approach that in a way that we vns. i think very much recognize what works in massachusetts, you know, may not apply in many other states and vice versa. i think we're very cognizant of that. hence why this topic is fun with an asterisk. alan: i'm reminded of one of my

early appearances when i ran the state agency in colorado, trust of these intermediaries, whether it's managed care company or provider systems as they've evolved financially. isn't always at the highest level for some good reasons. i had a lot of folks who were enrolled in medicaid who would come to me and say, you know who the best person is to manage my care? you know who the best person is to be account snbl it's me. i know what i need. i know what i need and i don't need someone else second-guess, i don't need someone else's rules. and i think our ability to respect the knowledge of the enrollee and the patient in the systems that are designed around accountability sometimes does fall short. how do we make sure that the patient and enrollee voice is part of the accountability here and not just sort of, we're measuring how they're doing and that's what we mean by

accountability? daniel: yeah, i think -- part of what you see in the blog, it's not just one focus on accountable care, value-based care. there's many elements of it. these things all fit together. we're not trying to index on one piece or another. ultimately it is around person-centered care. i think i mentioned before. and how to make the experience of health care work better for folks. how to close some of that very clear disparity in health outcomes that we have. also when you think about for medicaid as well. medicaid unlike any other payer, we've got a fiscal health care delivery system. -- a physical health care system. mental health care, and then a long-term service and support, home and community based system. and many of the individuals with the most complex set of various

needs across the toledo mains, unfortunately have, dealing with care in any one of those for any one of us is complicated enough. health care system, the health care writ large. layer on top of that three different relatively standard systems, providers that don't know each other, don't always trust each other, completely different communities, folks suspicious of others around that. and you add in in some cases individuals that have both medicare and medicaid on top of that. you want health care to work the best for we layer on everything that would make it the most challenging uphill battle as possible. so when we think about what is true north of what we're trying to accomplish, it's much more around how we help address those things in the context of moving forward better -- moving toward better health equity. the rainening that get us are satisfactory and we partner with

these around us. first is, it has to look like x, it's about a specific payment arrangement. i think one of the means to an end around that. it's very important to us to keep what you mentioned front and center. that's why i emphasize there's not an ideological or a thing we're specifying in value-based care. that's not an end goal. it's to make how medicaid and the health care system works much better for the individuals that are enrolled and clearly there are opportunities for us to strengthen how that works and find a path on that. lay alan: i know we're in separate rooms but i think you were looking over my shoulder. my next go question is about dual-enrollees, those in medicare and medicaid. this is a program that serves a lot of folks with vulnerability. we have now an office to

coordinate between the two programs. what's your going-in assumption at this stage in the administration about what's possible? i have to tell you we've been trying to make care better for duals for decades. i think we've made some progress. but the fact that it remains out there as an issue unaddressed makes me feel like we still have a long way to go. what's your sense of what's possible? daniel: i feel like everything in medicaid is fun with an asterisk which is amazing why we all love medicaid so much. it's such a beautiful, challenging, meaning. place to be engaged in. we were just having a discussion on this exact topic. the meeting i came to immediately before this, and i think there's a continuum of things. we certainly talk about the entire, how do we think about the dual system? but there's also a lot of very near things we're partnering

with on the administrative -- the administration has put a priority on. including things like access for folks across states to medicare savings programs. m.s.p. is for folks dually eligible that have a fundamental impact on access and affordability. i think it always shocks folks when you look at lower income individuals how unaffordable medicare can be. and it's not just for those dually eligible, there's a bunch of detail around that. nums, medicare and medicaid, how we come together, there are significant things that exist within the current framework, construct, that we can continue to make progress on that really, really will have immediate impact. someone who pays 30% of their social security check every month to health care at age 70 with very little left for other sus sentence can go down to 3%

of their income the next day. that is, it's hard to see things that have more immediate impact. clearly you're also referencing some broader things around how we structure some of the delivery systems and the payer pieces. maybe i defer that to the fun with an asterisk for a longer discussion. i think we are eager to make progress with states around that. there are exciting ideas we've been hearing from folks around that. want to engage. we have to believe that there's steps we can take to make health care delivery a little bit easier and a little bit more consumer or individual friendly than it currently is now for duals, dually eligible individuals. alan: i do want to pick up the equity theme which i always think is best discussed in the context of policies that are related to other things and not just sort of an equity agenda, which is why i put it here in the discussion so loop us back through coverage

access, through innovation accountability, and give us the sense of how you conceptualize equity being inherent in all of those agendas as opposed to being an equity agenda sitting over here on the side. daniel sps that's -- daniel: that's been one of the key things, equity is not just -- we need to put focus on equity. oftentimes when folks talk about health equity, we should pin down what we mean by that. ask 10 different people and get 10 different answers. we don't want equity to be sitting alone on its side as an afterthought or something on the side. it needs to be across every one of the other pieces. coverage and access for example certainly basic access to coverage and how we want to partner to think through things with states where they're still

considering medicaid expansion coverage. a fundamental source of equity, access to health care coverage. equity also applies when we talk about other elements. how we think about the types of providers, speed of access. how we look at outcomes measures that span, you know, services, relative to race, ethnicity, disability or ability status, sexual orientation and gender identity, things of that sort. you immediately start to identify parts of our health care system and the way x is structured that clearly can have focus. that's one way in which we think about the coverage and access policies and whole person care policies. one of the first and foremost questions are, are these policy going to help reduce and shrink some of the identified disparities and how much in the forefront can we be oen that

more broadly, we outlined a three-part framework about how to outline equity. one is measurement. two is policy together advanced. and three is accountability for closing those gaps. on the measurement we have a lot of leverage within c.m.s. states have a lot they can do as well. it's hard to be serious about equity if we don't try to measure and collect data like race, ethnicity and other factors from which we can both baseline starting inequities and track progress against us. that has not been a huge focus in the past. we want to make shah that a primary focus of everything c.m.s. does. whether it be through discussions we're having, through a whole bunch of regulatory and funding vehicles for states, have a list of the reporting and collection of that data, stratification of a common set of metrics to see where we are as coming across the board. and then we want to make some

investments in equity. that's where i think it gets interesting also. there are clear things where they're very identified evidence bases, do this, pay for this. and you can see an impact. there are clear populations like postpartum coverage where we want to work with states to take up 12-month postpartum coverage. there's stuff where it's much less clear. how co-you identify between black individuals and others. that's part of the holy grail of chronic disease management and thinking about some of the social determinants, if you will, around that. it spans a line of innovation of funding and support and encouragement on well documented areas and how we can get innovation and funding, but with health equity as kind of a first order question that we're trying to focus on. alan: i have a couple of

questions from the audience i'm going to weave together into something that's been an interest of mine for a long time. i want to stay at the 40,000 foot level of federalism but you referenced a range and you do in the blog, a range, everything from here's a regulation, federal level or a law, and the state must do it, to supporting kree atity in learning collaboratives to waivers which are another mechanism for sort of letting states do what they want. within the framework of the federal statute. when you think about that array of options, and i said i wasn't going to be a 40,000 feet, maybe this is 100, you know, how do you package together to get the best of the creativity that exists out there, while assuring, you know, accountability at the state level for this program.

which tools are best suited for which applications, i suppose is the way i might ask. daniel: like all things with medicaid it's a mix. certainly on some of these pieces there are requirements and frameworks we can think about which we believe are really important and affirming the statutory kind of construct application of medicaid. if that's all we did it would start to get very narrow and wouldn't be the most -- it would be a much more restrictive set of things we would all have. so much innovation and thinking and learning does happen at the state and provider level. we want to make sure we foster the room for that. but we chose our words carefully around a proactive policy agenda to say here are the types of things we would love to see states go innovate and figure out to advance for the purposes

of advancing health equity. we're open for business and all ears. i think i made this request of an external meeting the other day with a lot of really smart people thinking together. the more folks can put concrete things down that are easy for c.m.s. to cut and paste and say these are excellent things, an example of, we want to see more of this we will lean in as much as we can on those things. i think that signals direction and provides space and room without being overly prescriptive from the federal standpoint which we can d try to do at times and i gaish tee we'd got it wrong around that. alan: as we come to a close i have to ask this question. how do you get from applied mathematics to director of cmcs? daniel: um, i always knew -- my college thesis was on h.i.v. and

other things in subsaharan africa. very public health focused. i knew i wanted to do something in health care around that. there are a variety of things when you start to see other parts of the health care system and want to stay focused on something in the safety net you get toward medicaid. and many of my paths in the public and private have been oriented around making it better from an access and p recovery standpoint and access scpt. medicaid is, i think, the most beautiful place in the world to work on that. so state, federal, anywhere else. that's the short answer. alan: i'm going to ask you for a slightly longer answer. talk about some of the choices you made along the way. i hope we have some early career folks watching and clearly you've had options available to you so explain sort of on the

interest side how you got interested but what are some of the key choices you made about where to put your effort that led you to this spot? daniel: i think -- i don't know if this is good advice or not, i never really thought to plan ahead what was next. you worked on things you cared about and loved and you do that with all your energy and you try to do that to the best extent possible and build expertise and experience and you work with folks and then, you know, phone calls happen. one thing happens. so i'm a firm believer of we all end up at different places for a reason. let's do the best we can in that. that sounds actually very cheesy. but that's how it works. at any point if folks ask, when are you leaving? i say i'm not leaving any time for a long time, i love this job. that's generally how -- i've

been very fortunate, i recognize, to have loved everything i've been able to do and to be able to feel like you have the right intersection of intellectual engagement and interest, skillset, with very importantly mission and what you're able to accomplish. ingalls evaluating yourself in the right mix of those is a good grounding for spending many of your waking hours and emergency. alan: it's funny, i don't know if it's good advice or not either but it's a surprisingly common answer. relatively few people i speak to, maybe that says more about who i talk to than anything else, had a plan, had a specific goal. they had an area, an interest they followed. most of them did just as you described. they followed passion and opportunity and enthusiasm. it wasn't planned out in advance. so i -- as i said, i don't know if it's good advice or not but

it's fairly common. daniel: that's good to know. alan: you're in good company. director tsai, thank you for taking the time to talk with me today, being my guest on the policy spotlight. i want to remind our audience that if you liked this, go to healthaffairs.org and sign up for future events. join our email list to hear about them as they're announced. listen to the prior episodes as i've described. you can even, if you like listening to me, subscribe to our podcast or listen to a health odyssey where i interview leading researchers in health policy every week we do have a few upcoming events we hope folks are interested in on thursday, december 9, we have a journal club looking at trends and the incidence of kidney failure at the county level. health affairs senior ed dor jessica bylander will host kevin young of the brown university

school of public health and they'll go into research methods, data and the like. on wednesday, december 16, 1:00 eastern, health affairs execkive producer james huber white will host an event on how something is doing after publishing. we'll go through tools available to authors to see who is looking at your work and who is using it. that's a nice professional development opportunity. register for these events and learn more about them. we're open to event sponsorship. feel free to reach out about that as well. to our audience, thank you for submitting questions and joining us, with us today. we hope you enjoyed this health policy spotlight. and i'm alan weil, editor in chief of health affairs. thank you again and we are adjourned.

[captions copyright national cable satellite corp. 2021] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy visit ncicap.org] >> thes how to -- the house returns tuesday at 2:00 p.m. eastern time. members will debate a bill to prevent abuses of presidential power and protect against foreign interference in elections. on the other side of the the senate will confirm several of president biden's executive nominations including jessica rosenworcel to chair the federal communications commission. and may take up the president's spending and social plan. you can watch on c-span2. watch online at krooip.org or on c-span now, the new video app. -- c-span.org or on c-span now, the new video app. >> at least six presidents recorded conversations in office. hear it on c-span's new podcast

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