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Voices of HHS

CMS Administrator Seema Verma

Thursday, July 16, 2020

On this episode of “Learning Curve”, Caputo sits down with CMS Administrator Seema Verma, to discuss the ongoing efforts around nursing homes, telehealth expansion, and getting back to healthcare during COVID-19.

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Michael Caputo: Welcome to Learning Curve. I'm Michael Caputo. I am the Assistant Secretary for Public Affairs at the United States Department of Health and Human Services. On this podcast, I introduce you to all the smart people that are teaching me everything I need to know about healthcare and especially about the coronavirus. Here at the Department of Health and Human Services -- I've only been here a couple of months, but I have met some of the smartest people I've ever known in my life. I've had a lot of those people on this podcast. I decided when I first started here that while I was learning from these folks, that I would share some of their knowledge with you – introduce you to them because, why keep it to myself? I can share that knowledge with you. And today, we've got the administrator of the Centers for Medicare and Medicaid Services, Seema Verma.

Seema is someone I've gotten to know pretty well here. She's here in the Humphrey building with me in Washington, D.C., and she's responsible for -- I guess, Seema, it's the biggest share of the budget here.

Seema Verma: It is. It's about 90 percent of the HHS budget.

MC: So, you are you going to tell us what that number is?

SV: [laughs] Yeah, it's about $1.3 trillion; so, bigger than the Department of Defense.

MC: Wow. Isn't that something? And it -- really Medicare and Medicaid, they -- Medicare and Medicaid supports a lot of Americans. How many people?

SV: We have about 130 million Americans. So, it's Medicare, Medicaid, and it's also the individuals that are on the exchanges or the Affordable Care Act.

MC: [unintelligible] me. I joke about it, but it's true. Everything I know about healthcare, I learned from the Obamacare website. So, I have a steep learning curve. And I know you actually were involved in implementing Obamacare when you served in Indiana. Tell us a little bit about your background in Indiana, because you are pretty close with the Vice President and came here with him.

SV: Sure, so my background was as a healthcare consultant. So, in that role I got to work with a lot of different sectors of the whole healthcare system. So, started my career early working in a public health department and a public hospital, and then went on with this -- with my consulting business -- just worked with a lot of different providers. So, whether it was IT companies, worked a lot with state, so whether it was their departments of insurance, their Medicare agencies. And when Obamacare was passed, I was working on behalf of a few states to help them implement the Affordable Care Act. So, a lot of my responsibilities were reading the regulations, making sure states understood the impact.

MC: Busy. Really busy stuff.

SV: It's a busy time.

MC: But suddenly, you're here as one of the leaders of the Department of Health and Human Services. It's much busier, isn't it?

SV: It is much busier. A lot more fun.

MC: A lot more fun? My God. I don't know about your sense of fun. I have no idea.


SV: I guess that makes me sound like a boring person, but I've always loved health policy.

MC: Well, I mean -- and, you know, we have -- a lot of people here in the department are focused very much on policy, and here in the department people recognize you as one of the, kind of wonkiest folks who understand policy and advocate for policy at all levels here in the building, among your colleagues, among your staff, and also at the White House where you serve on the Coronavirus Task Force.

When you -- you've been here a little while. You're not like Dr. Hahn of FDA who showed up when -- in December and like a week later he was in the middle of the coronavirus. You had a lot of time to work on the issues that mattered to you and to the constituency that you represent, the folks who are especially involved in Medicare and Medicaid, and then suddenly the coronavirus hit. And what most people don't know is that one of the primary, let's say, constituencies who were impacted by the coronavirus are basically under your care --

SV: [affirmative]

MC: -- and that's the people who are served by nursing homes. When the coronavirus hit, as a person responsible for basically regulating nursing homes, what were you -- it must have just absolutely shocked you and you had to just dig in.

SV: Well, you know, I think one of the things that I'm very proud of is that we had been working on trying to improve quality of care in nursing homes, even before the coronavirus we'd put out a five point strategy around nursing homes' transparency, really looking at -- on our enforcement efforts also, trying to, you know, make sure that we're reducing burden for nursing homes so they could actually focus more-so on the patients. So, we actually started with a strong foundation. We had re-organized, you know, CMS to make sure that all of the folks in the regions that have -- that oversighted the nursing homes were reporting up to our central office. So, I think one of the things that I'm really proud of is that we have a strong infrastructure going into the coronavirus.

That being said, we were watching what was going on in China, watching those media reports, and we could see that something was, you know, very wrong. And that -- so we were starting to prepare for that very early on. Even in early February, we kind of doubled down. We put out, you know -- actually, reissued all of our guidance, and telling nursing homes, and telling the whole health care system, "Hey, you all need to double down on infection control policies because this has the potential to impact the nursing homes."

I think we had a strong start going into this, and we just hit the ground running, you know. We continued to put out a series of guidance to our nursing homes. We've partnered with the CDC; as CDC was doing investigations, we were also on the ground with them doing our surveys, identifying those best practices, and then pushing that out to the nursing homes.

We've also had a strong focus on families. You know, it's been a very difficult time for people who are in nursing homes and their families. It's such a hard decision when you put someone into a nursing home. You want them to be safe, and you want to make sure that you remain connected to that person, and obviously with coronavirus, we said there shouldn't be visitors in nursing homes because we were concerned about people bringing it in to the nursing homes. So, we focused on transparency: making sure that the nursing homes were telling patients and their families if there was coronavirus in the nursing homes. We also worked with CDC to set up a brand-new surveillance system. And we continue our efforts to do everything we can to bring the best knowledge, the latest innovation, to the nursing homes.

One of the things the president as done is set up the Coronavirus Commission on quality and safety, so we're bringing together national experts to review all the regulations and think about, you know, what do we need to do to improve our response to not only keep people safe but also to make sure that we're dealing with their mental health issues and that the people in the nursing homes have the best quality of life?

MC: I never told you this. I've been saving it for this show, but I have nursing home experience. It was one of the first jobs I ever had. I was hired by a nursing home in the little village where I live --

SV: [affirmative]

MC: -- at 16 years old to basically empty bedpans, and to change linen, and to keep the place clean. And really nursing home care over the years has changed quite a bit. From the days when I was pushing my cart from room to room in the nursing in my little village to today, the quality of care there has gone through the roof, hasn't it?

SV: Yeah, and I think, you know, it's important -- I'm glad you said that because I think sometimes you don't always --

MC: You're glad that I worked in a nursing home?

SV: Well, I'm glad that you mentioned that because I think that people that do work in nursing homes -- it's a calling, it's difficult work --

MC: Yeah. It's hard.

SV: -- and it really -- just hard work, and it takes a special person to take that on and, you know, we've heard a lot of acknowledgment of our health care workers on the front lines and, you know, to me that also means those nursing homes that are working really hard to keep those patients protected, so --

MC: I remember, I had a woman -- her name was Bessie -- who was one of the nurses traveling between room to room, and she treated those patients like her own parents. And I recognize that as something that a lot of those nursing home workers do. They go in there and treat them like their own parents, their own grandparents. And to watch so many people come down with the coronavirus as one of those workers who really do care -- and, by the way, they're not making a lot of money doing it. They're in there because they're devoted. To watch people come down with it -- the nursing home in my village was just absolutely decimated by it. And it happened across the country, didn't it?

SV: Yeah, I mean, you know, I think a couple things there. We did have lots of nursing homes that did well, you know. Around 65 percent of nursing homes haven't seen any cases.

MC: How many nursing homes do we have?

SV: We have about 15,000 nursing homes across the country -- about 15,400. But the vast majority of our nursing homes didn't see any cases and didn't see any losses and I think that does speak to the high quality of care that is provided in some nursing homes. Some obviously have had challenges. Obviously, if there's a lot of community spread -- if it's spreading in the community, it's going to come into the nursing homes, and that's why we've really doubled down on efforts on testing. But, you know, going back to those nursing home workers, one of the things that we're really impressed with was they did need to stand in. You know, for our nursing home residents to not be able to visit with their loved ones, it was really hard, and we saw nursing home workers come up with innovative ways to make sure that they could stay connected with their loved ones, you know. They've made iPads available -- Skype. And, you know, for a lot of people, that was the first time they'd ever used that type of technology. But it was the nursing homes that have tried to be innovative to figure out how to care for the holistic needs of patients.

MC: And it really -- I mean, a lot of people that have no idea about nursing homes, who don't have grandparents or parents in nursing homes right now, they hear this and they recognize that it was really the -- kind of the -- since this virus really does attack the elderly, the nursing homes were ground zero for the virus. And I know -- you get, you know, as this person who's in charge of most of this budget here at Health and Human Services -- a bigger budget than the Pentagon -- taking care of a hundred million people, you get a lot of criticism. You -- there are people who I think unfairly criticize you. And, in the end when you read what they say or hear what they say, you understand -- now that I've been here for three months, I understand they really don't know what they're talking about. They don't have the details.

I saw an article this week where you were criticized by a guy who used to be a Congressman, got beat two-to-one in an effort to win his seat, and who went on to represent dictators --

SV: [affirmative]

MC: Not really someone who knows anything at all about nursing homes. Not really someone I really care to hear about criticizing other people. But the facts are really important, aren't they? When you don't know what's going on in a situation like a nursing home environment, you can misinterpret it pretty quickly, couldn't you?

SV: Absolutely. And I think people, also -- to give it some context, I'm very proud of the work that the CMS staff has done to address nursing homes. I can tell you that the team we have has worked seven days a week, 15 hours a day. Normally, when CMS puts out regulations, it can take us a year or two years -- the amount of guidance and regulations that we put out in a very short time really spoke to the hard work of these career civil servants that have just been working round the clock to support a response. They really care about the people in the nursing homes and we wanted to get rid of regulations that were standing in the way. For example, one of the things we did was waive regulations to allow telehealth across the entire nation. I mean we stood up telehealth in Medicare in a couple of weeks.

MC: Can you describe what telehealth is?

SV: Sure, I mean, telehealth is basically, you know, you're able to talk -- communicate with your doctor, not only over the phone but through two-way communication. So, Skype, people use Zoom. That has been critical, that has been a lifesaving effort. It has meant that our Medicare patients could stay in touch with their medical providers and they didn't need to leave their homes.

MC: Which is important. Medicare, that's elderly.

SV: Absolutely, it's our elderly people. They were afraid but they still need medical care, even if they didn't have the coronavirus, there's diabetes, there's heart disease, there's all kinds of issues. And so, telehealth really became that lifeline for them to work with their providers. It also helped the provider community. It kept doctors and nurses safe, it allowed them to conserve protective equipment. And also, at a time when many practices had to shut down -- they weren't providing elective surgeries -- this also provided some revenue. It's actually been, you know what I would say: lifesaving. and the fact that CMS was able to do this in a matter of weeks and stand it up and have that widespread adoption. And it wasn't just standing it up. We had to comb through pages and pages of regulations that stood in the way of telehealth being actually offered. So, things like: Which providers can offer telehealth?

MC: Right.

SV: What settings? I mean, even in nursing homes -- we allowed telehealth to be provided in nursing homes. Which was critical because before, they were only able to have one telehealth visit a month, and obviously in this situation they needed more. So, we just -- we worked with the community, we talked with healthcare providers, they told us about the things that they needed us to do, and we very quickly responded. So, I think people that know CMS and follow CMS have understood that the rapid action that we took across the board, not only for nursing homes, but also for hospitals, for telehealth, really has been instrumental and, you know, I appreciate the praise that we've gotten for our rapid response.

MC: I'll tell you, after being in the federal government for three months, I know things move at the speed of molasses here, and -- but you're just not -- you're not tolerating that speed are you? The things you're doing are happening, you know, just at speeds people haven't seen before. Is it because of the coronavirus? Or is that just the way you're trying to approach being in charge of so much of this?

SV: You know, I think that I came from the private sector, so I'm used to things moving quickly, and I think our healthcare system requires that type of rapid change. You know, the President has been focused on making healthcare more accessible and affordable, and those aren't things that can wait for somebody that doesn't have health insurance or, you know, can't get to their doctor if you're living in a rural community. Those are not things that can wait. And so, we've tried to approach everything that we've done with speed.

Coronavirus, I think, just accelerated, obviously, some of the work that we had already been working on. But I think the agency, even going into coronavirus, was already equipped to start addressing these issues. One of the things that we worked on, or we developed was a response to the president's work. President talked about cutting the red tape across the entire federal government, and what CMS did in 2017 is something called Patients Over Paperwork and it was an effort to get rid of all those burdensome regulations, outdated guidance, that really stands in the way of doctors being able to provide high quality care. So, we were already doing that, so when coronavirus came, we knew exactly which regulations needed to go so that our providers could, you know, be able to function in a crisis environment.

MC: [affirmative] You know, I -- before I came, before I was even invited -- actually no. A couple of days before I had gotten the car to drive to Washington to be Assistant Secretary, I went through a telehealth appointment.

SV: [affirmative]

MC: I had no idea I was going to meet the person who stood that whole system up. But it was really helpful because at the time I was quite -- you know, a lot of us were really worried about what exposure meant, and going to a doctor's office, who knew, right? So, I went through it, and I actually had an infected finger and my doctor had me hold up to the camera. And I thought, "Is that even possible?" And she -- I heard her clicking, she was focusing more on it. There's really capacity --

SV: [affirmative]

MC: -- in telehealth.

SV: [affirmative]

MC: Is this something that's going to stick around now?

SV: Well I hope so, because I think telehealth can address a lot of issues. You know, first of all we know that our rural communities are having difficulty accessing care and the quality of care, so if they can't access care obviously quality isn't going to be as strong. We have great rural providers, but their capacity would be enhanced if they were able to access providers that may not live in their area. So, think about some subspecialist -- maybe need a pediatric neurologist that may not be available everywhere across the country. So, we could improve access to care for a lot of specialists that aren't necessarily available. So, it solves things for rural health.

For mental health, we know that it can be very strong. We're hearing across the country that sometimes people feel more comfortable using telehealth because there's a stigma that's associated with mental health, unfortunately, and people don't always feel comfortable, so it could actually increase access to mental health services.

I think generally, though, it's -- it just makes care more accessible for people and in today's busy life, affordability, accessibility, convenience -- all of those things matter. Now, it's not going to solve every problem, and you're not going to be able to use it for everything, but it gives our providers another tool in the toolbox, and especially for our Medicare beneficiaries.

It's not always easy for them to get in a car and drive, or, you know, maybe they're relying on a caregiver or family member to take them to a doctor's appointment. So, it gives them a level of independence. If they need to meet with their doctor, they can do that. Now, they may still need to come in for a visit, but it just gives them more options and it makes healthcare more convenient.

You know, as a busy mom, for example, if my kid was sick, it would be nice if I could be able to have that telehealth visit. You don't necessarily -- maybe you're not able to leave work and your kid is with you -- it just gives us all more options and more convenience.

MC: I want to return for a moment to the topic of nursing homes, because I can tell you -- you know, I've told you -- I've worked in nursing homes. It's been a long time, you know, it's been 40 years -- more than that, I don't even want to say. But, before I came to Washington, I had a friend of mine, a very dear friend of mine, a young -- since I was a boy. His name is Chuckie, and Chuckie has brittle bone disease. And he has gone through serious health -- probably 70 operations in his life. He's a double amputee -- cancer survivor. He's been through a lot. Brittle bone disease is tough, and nobody expected him to live into his 60s, but here he is, he's 60 years old. And, he has one arm, one leg left. We go to all our Buffalo Bills games together, he's my best buddy and right before I, you know -- right as COVID hit, he was told that he had to have part of his remaining leg removed. And he went without any time to get prepared -- we know, amputation is a big deal. And they rushed him into the hospital because it's COVID, it's coming, we didn't know what it was. We were all freaked out. And they promised he was going to go in, get his operation, and come out and recover at home. We all would care for him like we always do. But as he was recovering, it was a little rougher than -- because he was under for too long. They said, "You're going to have to go to a nursing home."

We all freaked out -- completely freaked out. "Just go to a nursing home and recover." We -- there was no way we were going to let that happen. We were able to stop that. But we were really afraid because we -- because the nursing homes were on fire at the time. I had just lost -- my friends had just lost their father in a nursing home who had just gone there to rehab there after a hip surgery --

SV: [affirmative]

MC: -- and he died of COVID. But it's different now, isn't it? I mean, people shouldn't be so afraid of what's going down in nursing homes. I mean, your organization has worked closely with states to get this under control. Can you talk a little bit about how you feel about nursing homes today?

SV: Sure. Well, first of all, I think it's important to understand the spectrum of nursing home patients. I mean, I think a lot of us think of it as they're caring for people with dementia or Alzheimer's, but you're exactly right, there's a lot of people that --

MC: A lot of Chuckies.

SV: -- go to nursing homes, yeah, that go in there for short term stays. Maybe they've had a stroke, maybe they've had some type of injury, and they're in the nursing home for a short time while they recover.

MC: There's a lot of that.

SV: So, there's a lot. There's a spectrum and there's different needs of nursing home patients, and I think that's an important thing remember.

One of the things that we've worked on, and I think this is important -- it's information that I would want to have. If I had to put one of my parents -- God forbid we were at that point -- but if we were at the point where you needed to think about nursing homes -- I kind of approach my job thinking in terms of, what would I want as a consumer, as a family member for myself or for my loved ones? And that's why we've pushed really hard on transparency. You know, transparency's been a big issue for the President, whether it's price transparency, but also quality transparency, and we've really tried to make sure that we're putting gout as much information as possible. So, if you are going to have a stay in a nursing home, you know how that nursing home has performed. In the case of coronavirus, you know, we fought to make sure patients had that information -- and their families. But now they have to report if they've had coronavirus in the nursing home.

We also put up -- you know, there's an icon there if there's been abuse and neglect in the nursing home -- that we actually changed our website so that patients and their families and people that are looking at nursing homes could very easily identify those nursing homes that have had problems, and we publish all the inspection reports.

And so, I say that because I think it's important when you're thinking about making this decision that you really do do the research. We have something called the Nursing Home Compare website and that's where we put up all this information. I can tell you, I fought as much as possible to put everything out there. I think it's important for consumers to have that information.

MC: Well you've got -- you've brought in a lot more data now and in the, you know, in the midst of coronavirus you're bringing in not just cases but you're requiring states to do --

SV: [affirmative]

MC: -- you know, surveys and inspections to establish the status of these nursing homes. And that data has been released.

SV: Absolutely, and that's an important point. From the very beginning, the president was very clear. We knew that nursing home residents were going to be vulnerable. And so, in March the President gave the directive: We want all of our surveyors across the nation to go out and inspect these nursing homes.

It's important to understand that the oversight of nursing homes is both a state and federal partnership. The federal government sets the guidelines, we set the safety requirements, and we also fund the surveys. But it's actually the states -- they are the boots on the ground. States actually license these facilities. We can penalize them with monetary penalties, but it really is the states -- they are boots on the ground. They are the ones that go in and see what's going on in the nursing homes, and that's why we wanted all of the governors to have their surveyors go into nursing homes. Don't look at the entire nursing home because we're under this crisis but focus on infection control. And so, we ask the governors to do that we could focus on nursing homes - identify problems. It wasn't supposed to be punitive, but it was about: let's work in partnership with nursing homes. If we see a nursing home that's not performing appropriately, let's give them the appropriate technical assistance to get them back into compliance.

MC: And it's different from state to state, quite different, right?

SV: It is different. You know, we've seen some governors do a great job and inspect all of their nursing homes, and you've seen some that haven't. And I think that's where -- that's going to be the difference, especially as we're hearing about new cases in new parts of the country where they're seeing surges.

It's so critical that we double down on our efforts to keep vulnerable Americans safe -- cannot say that, you know, more clearly or enough or often enough. When there is community spread, it means that nursing homes are vulnerable, right? Because you've got workers that are coming in and out of the nursing home, and that's why, you know, the vice president, the president, has said, "Let's test everybody in the nursing homes." We want all nursing home workers to be tested every single week so we can make sure that the workers aren't bringing it into the nursing homes.

MC: Is that happening now?

SV: It's happening across the country in various ways. You know, we've heard that some governors have been a little bit behind. Some governors -- actually, Texas did a really good job of testing their nursing homes. But we see some of them are lagging, and I think nursing homes have to be the priority. We're seeing in our numbers -- and they fluctuate as our reporting is getting better -- but you know, the numbers are 30-35 percent, somewhere in that range that that's where the losses have occurred and that's why we think it's important to just double down on the nursing homes because that, unfortunately, was where we experienced the most losses in this country.

MC: On March 25th, New York Governor Andrew Cuomo signed an executive order to move patients from hospitals -- coronavirus positive patients from hospitals to nursing homes because he was worried that hospitals were going to be over capacity. Basically, mandated it and did it without making sure that the nursing homes who didn't have the capacity to protect their residents from the infection -- and in fact during the time before he pulled his executive order on May 8th, he transferred 6,326 COVID-19 positive patients from hospitals to 310 nursing homes, including the one in my little village. It killed a lot of people. A lot of us from New York are very upset about this. Governor Cuomo -- like I said, you're always, somehow or another, in the target zone -- Governor Cuomo turned around and said, "Actually, it's the Trump administrations fault," which puts you right in the crosshairs -- saying that we -- our director said that he needed to do that. Was he telling the truth?

SV: Absolutely not, and I think that's what's been so concerning. It was concerning that they implemented this policy, but more-so to try to blame it on the federal government when our guidelines couldn't have been more clear. It says -- CDC says this, and CMS says it: look, if you cannot keep -- if the nursing home cannot keep that person safe -- if they're not able to implement the infection control guidelines, then they shouldn't accept that patient. So, nursing homes can take people that are COVID positive that are coming out of the hospital to recover but they shouldn't be required to do that. And that's where, also, the inspections were really important as well.

MC: How did Cuomo do on his inspections?

SV: Yeah, they weren't as strong. They were way below the national average, so not only were they forcing these nursing homes to take these patients, but they hadn't even inspected these nursing homes to make sure they had the capacity to take these patients on. A couple of things that were also concerning to me is that, you know, a lot of states -- other states when they were dealing with the same problem: How do we get patients out of the hospital? And that's important, you want to keep the hospital as open as possible to deal with more people coming in, so that's understandable. That being said, CMS also changed the rules. We said, "If you want to keep the person in the hospital, even though they may not meet the hospital level of care, we'll pay you as if they were in the nursing home." So, that was an option as well. Also, in New York, they also had The Comfort, you know. The president sent The Comfort there -- the big ship --

MC: The ship, yeah.

SV: -- yeah, to receive patients.

MC: And they -- and we built a hospital.

SV: Javits Center. Yeah, exactly. So, there were options --

MC: Completely empty.

SV: -- available. Completely -- and there were options available for New York that other states didn't have. You know, Governor DeSantis in Florida set up COVID positive facilities, nursing home facilities, so that was their effort to keep, you know, patients isolated and safe.

My main concern, now, is that, you know, we're creating confusion. The federal guidelines were clear, and we need to make sure that nursing homes -- don't take a patient if you're not prepared to take care of them. Because not only that, you could be infecting other patients, but even the healthcare workers that are taking care of those patients. So, the nursing home would say, "I'm not prepared," you know, "I don't feel comfortable" or -- staffing. We know that a lot of nursing homes didn't have staff in place. A lot of their employees were scared, weren't coming to work, and they've actually seen a decrease in the work force.

So, a nursing home, despite their best efforts, just might not have had the capacity to take on new patients. They shouldn't be forced. And I want to make that clear, because I want to make sure it's not happening in New York, and that it doesn't happen in other states, and that we don't create confusion.

MC: Well, interestingly enough, we can all rest easy now because there was a report out of the Cuomo administration yesterday that found that Cuomo policy did not blame -- I'm sorry, Cuomo policy is not to blame for nursing home deaths. A report written by a Cuomo agency, headed by one of Andrew Cuomo's best friends. Apparently, at the end of the report, they also found him to be the most handsome man in the world and the free-throw champion for the state of New York.

I think it's ridiculous. And in this report, he blamed the visitors who were visiting their parents for bringing the virus with them, and the workers. Somehow or another, his own failures didn't make it into the report. But we all can rest easy, thankfully, now that we know that Andrew Cuomo is perfect.

But at the same time, I think it's important for all of us to understand that things have turned around a lot for the nursing homes. And, I know, you know, of course I'm a fan of the president, but you guys have been on top of this from the very beginning. The people who are critics really don't know what's going on. And the steady march of things that you and the president and the vice president to make sure the nation's elderly were being cared for properly, that continues, doesn't it?

SV: Absolutely. I just last week, I met with the nursing home associations in Texas and in Arizona. We also talked to some national nursing home operators as well, just to kind of get a sense of what they were seeing across the country, and that really speaks to the type of what I'd say stake-holder engagement that we've had around the coronavirus from the very beginning. You know at CMS I can tell you every day we're meeting with stakeholders. We want to hear from hospital administrators on the front lines. What are the problems? Are there rules -- are there regulations that are standing in your way? You know, for example, in Texas -- Texas has freestanding emergency rooms all across the state and that's a part of their healthcare system. The Medicare program doesn't recognize a freestanding emergency room, so they weren't able to get reimbursement, but we waived that regulation. We did that weeks ago and I'm glad that we did because that is helping Texas to address the surge that they are seeing. It's increasing their capacity. And so again, that speaks to the type of work that we're doing where we're talking to stakeholders every single day. Talk to the nursing homes at least once a week. We talk to the home health agencies. We talk to hospitals. We talk to doctors because we want to have that engagement. We want to hear from them: What are the challenges you're facing? How can we support your work? And that's why CMS has issued, you know, over 100 different waivers of regulations to support our frontline workers.

MC: We're seeing some resurgence in cases of coronavirus across the country. Is that happening in nursing homes?

SV: You know, we continue to monitor that. In some areas of the country, I will tell you that that's why we're so focused on the nursing homes. One of the things that we just decided to do -- we've had these quality improvement organizations across the country helping nursing homes, but I want them to go into every nursing home in a hot spot, you know. Eyes on the ground, boots on the ground, so we can actually see what's going on and help those nursing homes, making sure that they're doubling down on everything they need to do to keep people safe. It's not a one-time thing. You know, a lot of times you go in there for a survey and you may observe a couple things; maybe everybody's doing things perfectly, but you leave the nursing home. And then, folks aren't washing their hands, or they're not doing the types of things that they need to do. So, it's not something that we can just turn away from. And we're urging governors, you know, please make this a priority, please give them the support.

A lot of our nursing homes, you know, are saying, "You know, look, in terms of testing -- we need help paying for the testing." The federal government under the president's leadership -- we have provided over $11 billion in testing and we're urging governors to help their nursing homes so that they can test their healthcare workers every single week to make sure that they're safe.

MC: We say, we aren't out of the woods on coronavirus. We're still in the woods, by far. And those of us here in the Health Department, we understood that it was going to be a longer haul than perhaps some others in the country. It's hard to understand that something is difficult as a lockdown that we all went through was not going to be just lifted and everything is going to be fine. That's really not how this works, but as we go forward, the elderly are the -- are among the most vulnerable. Certain -- perhaps, the most vulnerable as well as people who have other health challenges. As we go forward, how are we going to care -- how are we going to protect our elderly?

SV: Well, first of all, it starts with a focus on them, right? Identifying them. That's why we've been sending packages of PPE to nursing homes, that's why we've been getting gout information to our vulnerable populations. That's why we've been having telehealth. That's why we've been, you know, waiving co-pays for testing and making sure Medicare's policies make testing convenient and accessible. You know, one of the things I think it's important to recognize is that you're right, we're not done with this. The virus is still there. And even though it's raging in some areas of the country, there's other areas of the county where they're seeing declining cases.

But it's important that the American people not be complacent. Until we have a vaccine, we're going to have to take those precautions. You've heard the president say, "Wear a mask." If you're in a situation where you're going to be -- you can't socially distance, then you need to wear a mask, you need to wash your hands, and you need to try to keep six feet away from people. Those are things that are really important. And I say that because I think it is incumbent on every single American to play their part in this. We want to keep the economy open. We need to do that. The economy -- having a strong economy is important to having a healthy community. When the -- when we went through that shut down, people lost jobs, and if they're losing jobs that means they may not have income to pay for their health insurance. They may have lost their health insurance. They may not have access to health care, and that's going to create all kinds of other health care issues.

We know that people were going without preventative care. Kids weren't getting immunizations. People weren't getting the surgeries that they needed. And so, if we want to have a healthy community, keep people safe from the coronavirus, but also keep people healthy generally -- we saw a big surge in suicide attempts. We also saw people suffering from mental health issues. And so, we need to think of the holistic health of the community and it's important that we keep our economy open so that we are addressing all of the health care needs. And that's why I think it's so important that everybody adhere to those basic things: wearing a mask, being socially distant.

As a mom, I can tell you I want to make sure that the schools are open in the fall.

MC: I was going to ask you about that.

Seema Verma: [laughs] Yeah.

MC: We talk about that. We both -- we talk about our kids. Do you think we're going to be able to --

SV: Well, you know --

MC: -- have our kids go back to school?

SV: -- I hope so. I think there's going to be a way to do this safely.

MC: There's a path.

SV: There's a path, you know. It's not going to be that there's never going to be any cases in the school, you know. So far, the data shows that, you know, a lot of young people aren't hit as hard. Not to say that there won't be outliers and certainly children who have underlying health conditions. I think the other issue is the kids may be okay and safe -- we want to make sure they're not coming home and then spreading it inside the home to, you know -- they have parents -- in my house, I can tell you, my husband has -- is at high risk. And so, you know, I worry about my kid going to school and then coming back and then giving it to him. That being said, you know, I want my kid to go back to school. I think that's important to his development. He needs that learning from his peers, learning from his teachers, all of the activities. There's just so many things that are important to his overall educational experience.

Today at the White House, they're talking about this. Secretary Alex Azar and Secretary DeVos, our Secretary of Education, are having a conversation about: how do we open the schools and keep our kids safe, our teachers safe, and our communities safe?

MC: It's interesting. My -- we -- I was home this past week and -- as you were -- and my kids hadn't seen their grandfather, my father, for a while. He's 83 and, you know, he has risks, and we decided to take them over there. They went, played in the backyard, swam in the pool, and my dad stayed on the deck. He's not a very touchy-feely person anyway. It's amazing for an Italian guy, but he's been locked down like everybody else. My father doesn't go to mass, even though it's now open again in New York, and it's one of the most important thing in his life, going to mass. But he doesn't. He's still concerned, and I think it's smart. But for weeks, he's been kind of down. It's pretty isolating. But we brought the kids over, and he perked up. I mean -- and my dad is like, you now, he's totally together. It's not like he's doddering around all depressed and upset, he's too strong for that. But the -- you know, for two or three days they've been going over -- swimming every day this week, and he's just completely enlivened by it. I didn't realize how important that interaction between grandkids and grandparents is, and coronavirus doesn't really mean the end of that, does it?

SV: It doesn't have to be, and I think that what we all need to figure out is we need to find our way through this and to be innovative and creative, right? Your dad was able to see his grandkids because you figured out, "well we can keep grandpa on the deck and people can be outside, and we're still going to stay six feet away." And all of those things make a difference. And, you know, I believe in the creativity and the innovation of the American people.

MC: Right.

SV: You know, if you look at the amount of work that's been done over the last seven months, you know, I think we've been talking about corona, we're tired of it, but we have to remember this just started seven months ago. And if you think about even our testing -- you know, we started out just doing a few thousand tests, and I think I saw the number this morning -- some 34 million tests. That is amazing and the fact that this was brand new -- we had to create a new test. And all these private innovators came up with the different ways of testing, and we stood this up and now it's widespread. And, you know, certainly there were bumps along the way, but if we look back and say, "Gosh, it's only been seven months." You know, the fact that the president negotiated deals with the private sector to increase manufacturing of ventilators and so every American who needed a ventilator got a ventilator. And you just think about all that private sector innovation where people stepped up to the plate. Walmart said, "We're going to start producing masks," and I think this really speaks to the spirit, the creativity, and the innovation of the American people and I think whether it's figuring out a way of connecting with our loved ones, or opening the schools, you know, I'm confident that we're going to find our way through that.

That being said, there will be cases. There will be, you know, a school that maybe has an outbreak. But I think we all have to say, "Look, we have to accept that we're going to have some bumps along the way but it's important to open our schools, it's important for our economy. It's important for the health of the American people."

MC: Do you -- I mean, you're a pretty frank person. Are we going to be all right? I mean, are we going to have the therapeutics and are we going to get a vaccine?

SV: We already -- yeah, we're going to have a vaccine. I'm really impressed with the work of Operation Warp Speed. We have some of the top scientists and top pharmaceutical companies across the country that are working day in and day out at Warp Speed to produce the vaccine. So, I -- and we've already seen some of those efforts. I mean, we have Remdesivir and we're using convalescent plasma, and those things are making a difference. You know, one of the things that --

MC: Getting -- making people well.

SV: -- yeah. And the other thing is our mortality rates, I think, you know, are low. If we think about where we were when this pandemic started, we were seeing some 2,000 losses a day. We heard about that in New York.

MC: And no way to cure them.

SV: That's right.

MC: No way to make them feel better. And now we've got, what?

SV: Numbers are down.

MC: We announced Regeneron today, right?

SV: That's right.

MC: We've got four.

SV: That's right.

MC: And we're going to have more therapies.

SV: That's right. And the numbers are down, and that's because of the work of Operation Warp Speed, so not only on vaccine, but also on therapeutics. And it's made a difference. I mean, our mortality rate has remained low and we're hopeful that it will stay that way. A lot of people that we're seeing now that are being hospitalized are younger people. And we have new therapeutics, and so that's contributing where our numbers are now in the hundreds, you know. And of course, every loss is a tragedy and I'm not celebrating that, but I am thankful that we've moved -- we are in a different place. We're not seeing, you know, thousands of deaths every day. And again, if we want to keep those numbers low, we need to all do our part in this. Wear our mask and be socially distant.

MC: It's tough to talk to people, sometimes, when you go home -- you to Indiana, me to Buffalo -- and people are scared. And they're -- I mean, I told the story the other day. There was a little kid in the barbershop back in east Aurora, the little village I live in, who was too afraid to take off his mask. There's going to be lasting impacts that have little or nothing to do with your physical health, aren't there?

SV: [affirmative]

MC: What are our kids going to do after this if they don't get to go back to school?

SV: Well that's why, I mean, I think it is important that we try to figure out a way. Of course, we want our kids to be save, we want their teachers to be safe.

But, you know, we've had some great conversations with universities that are coming up with strategic ways to do testing. We're supporting those efforts. So, I think everybody understands the importance of opening up. We don't want to go back to the days where we did have to shut down.

And, you know I'm encouraged about the innovation and the creativity. I can tell you many states across the country -- I want to say 49 states have already put out some guidance to -- for local communities on how they can open up their schools, and they're asking the schools to come up with their own plans. I can tell you that my kid's high school's already starting to have conversations. You know, requiring masks, putting hand sanitizers. Maybe we're not going to have the lunchroom. Maybe people are going to be eating at their desks. Maybe you're going to bring your lunch. So, I think there are ways to do this, you know.

The SATs, the ACTS -- those were cancelled. Those were supposed to happen this month. I was very disappointed and I'm hoping that they will figure out a way to allow those high school seniors to take their tests so that they can apply to college.

MC: You're a young mom with school age kids, but you're also on the Coronavirus Task Force. You're also a woman of Indian descent and it's a very unique position for you to be in. People always talk about how the United States government is all old white men. And you know, that's partially true if you look at Congress and everything, a lot of old white guys around. And you -- you're in a very unique position. How does that sit on your shoulders?

SV: You know, to be honest, I don't really think about it very much. I'm in there to --

MC: Oh, come on.

SV: -- do my job. Well, I'm in there to do my job --

MC: [laughs]

SV: -- right? And obviously what I bring to the table is I do understand what it's like to be a mom. I understand what moms are thinking about, what they're going through, what their concerns are. Honestly, when I'm making decisions, I think about it. And it's not just that I'm a mom. I also have, you know -- my parents are alive, my in-laws are -- you know, my father-in-law is almost 90 years old. So, you're dealing with kind of that sandwich generation of all ends of the spectrum. So, when we're making decisions -- when we think about it, I always think about patients first. You know, how would I feel about this if this was my kid? When I'm making policy for Medicaid, if I'm a -- you know, if my child's on Medicaid or I'm a pregnant mom, how would I think about that?

So, you know -- and in terms of being an Indian American or a woman of color, you bring that perspective. That being said, you know, I'm here to do my job. I was hired because of my abilities, not because of the color of my skin. It's a perspective that I bring to the table. And I appreciate working in this administration because they're supportive, you know -- they're supportive, they're respectful. And I don't feel like I've faced any barriers because I'm a woman or woman of color working with this team and in this administration.

MC: Seema Verma, ladies and gentlemen, administrator of the Centers for Medicare and Medicaid services. We call it CMS here because we gave more acronyms than the United States Navy here at the Department of health and Human Services. I'm Michael Caputo. I'm the Assistant Secretary for Public Affairs and as the Surgeon General said the other day -- Seema, you saw this -- he said, "It's hashtag COVID stops with me."

Ladies and gentlemen, please tune in -- turn in -- excuse me, tune in next week on Learning Curve. I'll have another interesting guest -- not as interesting as Seema Verma. Have a great day.

SV: Thank you.

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