Leading a mission for equitable, affordable access to health in US: Q&A with HHS Secretary Sylvia Burwell
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* Natalie McGill

As secretary for the U.S. Department of Health and Human Services, Sylvia Burwell has the health of the nation in her hands.

From work championing insurance coverage under the Affordable Care Act to ensuring that U.S. children have opportunities for health, Burwell has overseen a range of public health issues since she became secretary in June 2014. Burwell spoke with *The Nation’s Health* about how her experiences prepared her to become a leader in U.S. health.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/45/6/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/45/6/1.2/F1)

HHS Secretary Sylvia Burwell testifies before a House committee in June on the agency’s budget and implementation of the Affordable Care Act. As head of the department, Burwell oversees more than 77,000 health workers.

Photo by Alex Wong, courtesy Getty Images

## More than 16 million Americans have gained health insurance coverage through the ACA. Where are the greatest successes?

When it comes to access, affordability and quality, the Affordable Care Act is working.

For access, we have the historic number of people who are now covered, thanks to different aspects of the law. Since the law was passed five years ago, about 16.4 million uninsured people have gained health coverage. That’s the largest reduction of the uninsured in four decades.

And that progress was made in part to the greater affordability of coverage. Nearly 80 percent of 2015 marketplace customers who selected a plan using [Healthcare.gov](http://Healthcare.gov) could purchase coverage for $100 or less after tax credits. Children can stay on their parents’ plans until age 26, preventive services like screenings and well-woman visits are covered at no out-of-pocket cost and lifetime caps on coverage are a thing of the past.

## Many Americans have gained insurance recently because their states have expanded Medicaid coverage. What is HHS doing to reach states that have not expanded coverage?

One of my first meetings as secretary was with a group of governors from both parties. I told them I hope to work with all of them to bring more states into the fold on Medicaid expansion. I also told them I understand that every state has different needs. Twenty eight states and D.C. have now expanded Medicaid.

Expanding Medicaid is primarily about two things. First, it improves the health and financial security of individuals by increasing their access to quality, affordable health care. It also benefits the economies of states, communities and providers. Medicaid expansion reduces costs for hospitals that were otherwise typically passed on to taxpayers and already insured individuals. By greatly reducing the number of Americans who are uninsured through the establishment of the Health Insurance Marketplace and by facilitating states’ expansions of Medicaid, the Affordable Care Act has reduced hospitals’ uncompensated care costs. I am personally engaged with governors and legislatures from both parties across the country…We welcome these conversations as we work together to move forward.

## How can we engage more people and make them aware of their health coverage options?

During this past open enrollment, I traveled to 17 cities to spread the word, logging more than 22,000 miles. I had the opportunity to speak with folks who were in the process of signing up, folks who were newly insured and the dedicated Americans helping them.

I saw the power of stakeholders like assisters, volunteers, navigators, national organizations and call center employees across the country. These stakeholders are essential in engaging people to become educated and empowered in making health coverage decisions.

Many of those newly insured are navigating coverage for the first time in their lives. We want to make sure that everyone who has health insurance knows how to use it. That’s why we’ve launched the Coverage to Care campaign. This effort includes a roadmap that explains what health coverage is and how to use it to get the primary care and preventive services that will help families live healthy, productive lives. We are working with a wide variety of partners, including community health centers, faith-based organizations, enrollment assisters, regional teams, consumer advocate partners and over 70 local stakeholder coalitions to engage consumers on using preventive services for health and wellness.

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HHS Secretary Sylvia Burwell tours the Food and Drug Administration White Oak Campus in Maryland in June 2014.

Photo by Chris Smith, courtesy HHS

## There is a growing awareness of inequity in the United States and how it affects health. How can this be addressed?

While there are many important steps, increasing access to coverage is one of the most impactful. At HHS, we see how important health is to employment, education, family stability and financial opportunities. But for many, that foundation has been hard to establish. Today, African-Americans have the highest mortality rate of any racial or ethnic group for cancer generally and they are twice as likely to be diagnosed with diabetes. African-American women are 40 percent more likely to die from breast cancer — even though they are 10 percent less likely to be diagnosed with it. And the statistic that exacerbates all of these health realities: African-Americans, like Latinos and other minorities, are more likely to be uninsured than white Americans.

We’re attacking inequity and health disparities on many different fronts, including increasing opportunities for healthy starts through Head Start and early childhood initiatives, promoting diversity in biomedical research and increasing access to quality health care coverage.

Although we still have far to go, we are seeing progress: For example, since 2013, the uninsured rate has declined 9.2 percentage points for African-Americans, resulting in 2.3 million adults gaining coverage, and 12.3 percentage points for Latinos, resulting in 4.2 million adults gaining coverage.

## You have been a proponent of initiatives that improve the health of U.S. children, such as Head Start, which you benefited from as a child growing up in West Virginia. What are your priorities as HHS secretary to boost the health of the nation’s kids?

Prenatal care to mothers, newborn and childhood health assessments and care and early learning opportunities are all priorities for boosting the health of the nation’s kids. The Affordable Care Act is now working to provide more families than ever access to prenatal care, routine childhood checkups, immunizations and other preventive services to children. Home visiting programs improve maternal and child health, help prevent child abuse and neglect, encourage positive parenting, promote child development and school readiness.

Head Start has served more than 32 million children, birth to age 5, and their families since its inception 50 years ago this past May. I’m proud to be one of those Head Start kids. Our priority now for Head Start and Early Head Start is to continue to improve the quality of community programs based on the latest research and community experience.

## You’ve been both president of the Bill and Melinda Gates Foundation’s Global Development Program and director of the Office of Management and Budget. How do your previous posts drive your work as HHS secretary?

There were two words everyone at the Gates Foundation and OMB heard from me every day —“impact” and “boss” — and I brought those words with me to HHS. My passion is for delivering impact to those we serve.

Since working at the Gates Foundation, I have kept a picture in my office of a little Senegalese girl sitting in a blue bucket. At Gates, I would give a copy to every one starting on my team with a note saying, “This is your boss,” and every action we take should be for her benefit. To this day, that photograph continues to remind me to focus on the people we are here to serve and the impact we want to deliver — whether it’s the father who learns how to manage his diabetes so he can watch his kids grow up, the young mother who can finally afford health insurance, or all of our friends, families and neighbors who will never have to know how devastating a viral outbreak could have been. Our jobs are about one thing: delivering for “the boss.” And our bosses are the American people.

## APHA has the goal of creating the healthiest nation in one generation. Looking to the future, when Americans look back on your term as an HHS secretary, what do you hope they will say you did to help reach that goal?

Right now, we have a historic opportunity to transform our health system into one that works for the American people.

Our plan is to make that a reality starting with the Affordable Care Act’s promise of accessible, quality and affordable care for all.

We also need to bring together businesses, providers, advocates and policymakers so we can build a health care system that delivers better care, spends our health care dollars in smarter ways, and helps educate, empower and engage patients in their care to keep them healthy.

If we can do this, I believe we will fulfill our mission: providing the American people with the building blocks for a healthy and productive life.

*   Copyright The Nation’s Health, American Public Health Association