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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Governor Andrew Cuomo has now lifted the COVID state of emergency for New York. The local press keeps landing on the fact that that means "Take out cocktails. Now go back to being illegal." It's also an uncertain time in many ways. The country will miss President Biden's goal of 70% of adults getting a vaccine shot by the 4th of July. New York has already reached that number. Some other states are wallowing below 50%.

Madison Square Garden just had its celebratory first concert at full capacity. It was a Foo Fighters, and all 19,000 fans had to show proof of vaccination. Yankee Stadium and City Field, on the other hand, just ended vaccine requirements, as they went back to full capacity. New York-Presbyterian Hospital wants to require COVID vaccines for all staff, like they already require many other vaccines, but the Healthcare Workers' Union is opposed. All this as the Delta variant spreads in the United States with 95% of the cases among unvaccinated people so far, and there's other countries that are at the peak of their outbreaks right now, even as the US holds reopening fireworks and ticker tape parades, the Tokyo Olympics is struggling with whether to admit spectators only from Japan, from all participating countries, or from nowhere at all. With all this as backdrop, one of the most important COVID and health insurance leaders in the US over the last 12 years and more has a new book.

He's Andy Slavitt, until recently senior advisor on COVID to President Biden. You may also know him as President Obama's head of Medicare and Medicaid, and a chief architect of the Obamacare Rollout. By the way, another headline "Enrollment in Medicaid," which more people became eligible for because of Obamacare just hit 80 million Americans up from 70 million before the pandemic. Andy Slavitt's book is called Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response. We also hosts the podcast In the Bubble, right, In the Bubble. Andy, thanks for making this one of your stops. Welcome back to WNYC.

Andy Slavitt: It's great to talk to you again.

Brian Lehrer: Let me start with some news, if I may, then we'll take a deep dive into your book. We won't make it to 70% vaccinated by July 4th. Why not?

Andy Slavitt: I think the difference between 67% and 70%, 72% is not consequential. What is more consequential, if you alluded to this is, we'll have Arkansas probably at 50% and Vermont at 90%, and that is a stark difference. I think those communities that are like Arkansas and in-state communities in Arkansas and others like them, are much more risk, and so it's that unevenness that concerns me more. I think the country should be applauded overall for getting to a really strong goal, and final thing I'd say is, it looks like the number of people over 30 and even in the high 20s will be over 70%. What we're seeing is 18 to 25-year-olds for the most part, that are behind.

Brian Lehrer: What do you think about vaccine requirements in healthcare settings, like hospitals in New York and Houston going for it, and the resistance, including, and it may surprise some people, what I read in the intro, the Healthcare Workers' Union in New York, 1199 is among those opposing that.

Andy Slavitt: As long as somebody shows me a negative test and they're willing to get tested three or four times a week, then I would be fine with them. Not choosing to get vaccinated, then why you'd want to get- go for three or four tests a week, and maybe carry other precautions like mask-wearing? Look, I think there's ways to give people some choice, but still tell them that their first obligation is to protect their people around them.

Brian Lehrer: How do you understand that resistance to vaccination among healthcare workers, who, of course, lost so many colleagues to COVID, and yet the non-vaccination rate among healthcare workers, from what I've read, seems to be about the same rates as the general population?

Andy Slavitt: I'm not sure that I do understand it, other than to say that for some people we have to allow for the fact that it is a more considered decision, whether to get vaccinated. They're not necessarily anti-vaccine. They've taken very likely, almost all of them have gotten all the rest of their vaccine shots. What they did, they have maybe outstanding questions that they want answered, like everybody else, before they put something in their body. We should respect the fact that people have these questions. We should try to get them clear answers to those questions.

I think the other thing that's gone on is, or a little bit of a victim of our own success, in that people don't feel the urgency that they felt in January, February, March, and April, because the incidence rates are much, much lower. It becomes a little bit more of a challenge to give it to people to make this a priority.

Brian Lehrer: On other vaccines being required, this morning I looked up the University of Florida and, of course, Florida's governor DeSantis, who you write about in the book, is one of those who will not allow private businesses in his state, even private businesses, to have a vaccine requirement for people wanting to come in for shows, or indoor dining, or whatever.

I looked up the mandatory immunization health history form for the University of Florida, and this lists the measles mumps, rubella vaccine required for everyone born after 1956, hepatitis B vaccine, students are required to receive this vaccine, it says, the MCV4 vaccine, it says, currently recommends this vaccine for freshmen planning to live in campus, dormitories, and residence hall, required to receive this vaccination, or read the CDC's vaccine information statement, TD or the Tdap vaccine, booster shot within the last 10 years, chickenpox required, tuberculosis screening required, only not the COVID vaccine. How does this make sense?

Andy Slavitt: One might think that DeSantis, and he's not alone in this, playing a little bit of populous politics, and playing a little bit to the crowd, but of course, he understands that the cruise line and the cruise companies is very important for them to know the vaccination status of people getting on board to cruises. Of course, they had a confrontation where they suggested they would have to move their ports to other states if DeSantis didn't find a way to come along.

Desantis, in that instance, is trying to find a way to look like he wasn't compromising, because I think he loves to talk about-- I think the latest statement he made was that he's for freedom, that Fauciism, even though of course Fauciism is what got him the vaccines in the first place. There's been a little bit of a temptation for folks to play politics with this, and rather than simply talk to people from a public health standpoint about what matters.

Brian Lehrer: Related. I don't know if you deal with this in the book, but when Biden came into office and vaccine resistance was starting to bloom among Trump supporters, I wondered why Biden didn't embrace and even celebrate Trump out loud, just on this. Like, "I disagree with Trump on so many fundamental things about our country, but we thank him for launching operation work speed and helping get us to this place so quickly. Now I'm going to pick up that mantle and run the implementation," and identify the vaccines with Trump to his COVID disbelieving supporters. Did you and he ever consider doing that?

Andy Slavitt: When we came in, recall that the vaccine acceptance rate was about 40%, and of course, now, we're close to 70% of adults. What we learned when we looked at the data was that endorsement by a politician really doesn't matter, whether it's a Republican or a Democrat, the people that were on the fence actually thought that the vaccines were too politicized.

The idea that a politician would come out and say, "Get vaccinated," doesn't move the needle as much as people might think it does. What people want to hear from is actually their local doctors and their local pharmacies. People are distrusting the government, of politicians, of pharmaceutical companies, but they really believe that if their doctor, or other people they trust locally, tell them that kind of thing will influence them more. I think that the President Biden showed quite a bit of restraint at not tagging President Trump with a lot of the misdeeds that caused us to be here. One thing we had to do was, we inherited no vaccine supply when we got there in January 20th. Of course, President Trump had promised that, by the end of January, 100 million people would be vaccinated. We were so far from that that we had to do our best to level set with the public, that we were starting much further behind than the Trump administration had promised.

Brian Lehrer: Listeners, If you're just joining us, my guest is Andy Slavitt, who, until this month, was a senior advisor to President Biden on COVID. He ran the Medicare and Medicaid systems for awhile under President Obama. He's got a new book called Preventable. We can take phone calls for Andy Slavitt on anything related. 646-435-7286, 646-435-7286, or tweet a question for Andy Slavitt, @Brian Lehrer. Your book is called Preventable.

We've now lost more than 600,000 Americans to COVID 19. It's amazing to me how that last 100,000 completely dropped out of the news. It was such a big thing when we hit 500,000, but with vaccines dominating the media landscape, we've lost another 100,000 people with barely notice. If the US had done everything right, once the virus reached our shores, how much lower could that number have been, in your opinion?

Andy Slavitt: Of course it's impossible to do everything right. We had to make allowances for the fact that it was a novel virus and we had the fog of war people are making decisions, but if we would've made simply what I would consider to be honest mistakes, in other words, if we would've leveled with the public, told them the truth, followed the science, not politicized this, we would have probably looked more like Germany, where the per capita death rate in Germany was about 70% to 80% lower than the US. Germany was really more middle of the road.

That would have been- call it 400,000 lives saved. A lot of them were some simple things. When Trump knew that we had a pandemic coming here in January, if he would have simply said, "Hey, folks, prepare yourself, we have a problem. We have a challenge." People would have taken precautions. He didn't. In fact, time dragged on, and he went to bed every night knowing this. It wasn't until the NBA went out and then the stock market tumbled.

It was mid-March that he was forced to even acknowledge the pandemic. Until then he kept saying it'll go away, it's nothing. That alone is probably responsible for a great number of people who lost their lives, because we just simply weren't prepared and we're told to the contrary.

Brian Lehrer: The press release for your book says it was written in the tradition of The Big Short, which, I'll remind people, was the Michael Lewis book and then a movie about the financial crisis of 2008 caused by the Wall Street-driven housing bubble. What's the parallel between The Big Short and COVID?

Andy Slavitt: The book is really a character-driven book about my experiences, over the course of the year. In early March of last year, when President Trump decided that he was going to open up the country for Easter Sunday, which we thought was a bad idea, I picked up the phone and called Jared Kushner, who I didn't know at the time, and so began a relationship with Kushner, Deborah Birx, Tony Fauci, many people in the Trump administration, as well as there are people in the book, like Ahmed Aden, who is an Amazon warehouse worker, who had the triple indignity of getting COVID, not getting paid by his company, not having health insurance, and not being able to get a test.

The book, rather than hitting you over the head with a lot of health policy ideas, which I could have done or could have been written, it much more follows the story of people who were going through COVID-19, both inside the White House as well as in the country, and pulls up some of the critical lessons, and it's such a dramatic set of events, and an interesting set of people that the story tells itself in a way that, I think, people will find themselves able to look to read in one sitting, and I think without being hit over the head with the lessons in there, and I think that's what the publisher had in mind.

Brian Lehrer: Since you write about Jared Kushner, and you just mentioned that you met with him around this issue, how do you describe his role in the big picture of the Trump administration? A lot of people thought that Jared and Ivanka were going to be moderating influences on the president, maybe not so much as it turned out, maybe they went more all in on Trump isn't than people expected them to, at the beginning. What about Jared Kushner and COVID?

Andy Slavitt: Look, I'm no fan, to start with that, but I will say this, I tried hard not to write anybody, as anything other than true to how they were and true to life and not to their caricature. I found Jared, and I found everybody actually very much, hard to tell what they were like individually, because they were such a reflection of the man they worked for. In Jared's case, his job was to deflect any accountability for what happened with the pandemic on his father-in-law.

If I talked to Jared about an issue that could be done in the background, where the Trump administration wouldn't have to take any responsibility, he was open to that conversation. As soon as I talked to him about anything that would have required the president to take some accountability or embrace something in a way that he could be responsible, there was not a place that Jared would go.

There were key moments in the book when Jared would call and told me that they were- as soon as the state- that the president opened up the country at the end of last April, that the president would claim credit for that and that everything that happened after that, which would be closing the doors, not having enough tests, having to pull back was going to be on the governors.

He thought he would be able to escape, accountability that way. I told him that was both a recipe for disaster, and it probably wasn't good politically either, because, at the end of the day, I don't think you can escape accountability when you're the man in charge.

Brian Lehrer: Let's take a phone call. Here's Cheryl in Irvington, New York. You're on WNYC. I say Irvington New York because we also get calls from Irvington, New Jersey, but Cheryl, hi, you're on WNYC.

Cheryl: Hi, Brian. Hi, Andy. Thanks for taking my call. I just wanted to express my opinion about mandatory vaccines for healthcare workers. My mom is in a nursing home in Long Island, where only 35% of the staff has vaccinated. Currently, there's a new outbreak among the staff at the nursing home. They're closed for visitation. I feel when you have a vulnerable population, like in a nursing home, that should be one of the categories and industries that should be mandated. I'm happy to see the New York hospitals that are leading on this by mandating vaccines for their population.

Brian Lehrer: Andy, did you hear the question?

Andy Slavitt: Yes. Look, that's a very reasonable point of view. I think the only thing that I offered in addition to that is if someone could come in and have a negative test that they could demonstrate every day, then that would be the alternative, but certainly they should not be exposed to your mom or any vulnerable patients, unless they can demonstrate that they don't have COVID in a satisfactory manner.

Brian Lehrer: Are they doing that in healthcare settings in general? You brought this up before when I asked you about mandatory vaccinations for hospitals, you said, "They don't need them if the staff is getting COVID tested two, three times a week," is that happening?

Andy Slavitt: In some places it is. Look, the truth is that health care environments and other employers where people are exposed to the public, the public has a right to understand whether or not there are policies that keep their employees and therefore the customers free from COVID, and the public has to be persuaded. Now, allowing for the fact that we've got different cultures and different people respond better to different things, but my point is simply that there's more than one way to get there. We never had enough tests to do what I talked about before, so it wasn't practical, but now that we have enough testing capability and enough rapid testing capability, there is an alternative.

I think what employers are doing is saying, some employers are saying, "If you don't get vaccinated, come in for a test, but by the way, those tests are administered at seven in the morning, in a tent a couple blocks from the office," and with the hoping that people will not want to go through the bother of that, and it will help persuade them why they should be vaccinated, but one way or the other, the burden to prove how safe the environment is something that the employers are going to have to deal, particularly with at-risk patients.

Brian Lehrer: Andy Slavitt, who served President Biden and President Obama, is our guest. His new book is called Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response. Big pharma is the subject of your book. It's an interesting moment for our relationship with big pharma who people love to hate in general, because now people are so grateful for the vaccine. "Ooh, I got the Pfizer, I got the Moderna. What did you get?" You paint a more complicated picture. Where do you want to start with that?

Andy Slavitt: Look, let's just start with, the vaccines themselves are the product of 20 years of basic research into this mRNA platform that, as the book goes into at some level of detail, there were great people on Tony Fauci's team, including someone named Barney Graham and others, who really when they saw in the early 2000s the first SARS outbreak, there was a focus on getting the platform ready in case something like SARS re-emerged.

However you want to look at it, if you are a fan of the government in basic research, you should be applauding. If you are a fan of the private sector, the private sector in the case of Moderna had a big role in developing that, this happened under both Democratic and Republican institutions. It's a true success story. I think, at times of crisis, we should be applauding those who showed up, we should be applauding those who invested in. I will tell you that in working with Pfizer and Moderna when I was in the Biden administration, they were both terrific partners, very transparent, very productive, very willing to try to figure out how to scale their operations faster than they even thought was possible.

We got Pfizer to agree to a monumental agreement with Merck. All those things are true, but what can also be true is that if we can't make medications that people can afford, then ultimately it doesn't matter. Now, in the case of the vaccines, the federal government wrote the check for every vaccine, and so nobody has a co-payment, nobody has to worry about paying for the vaccine.

That's a fine way for it to work, but we've got to also vaccinate the globe, and we can't vaccinate the globe unless we do it without profit. We have to be able to take other things that come along and at reasonable prices there. The pharma lobby is one of the things I talked about in the book. It's probably one of the most accomplished organizations in the entire globe for being able to pull off the feet of convincing the US government and taxpayers through the Congress, not to negotiate their prices. That is truly an incredible feat that the pharma lobby has accomplished, and we've allowed them to accomplish. It doesn't make any sense to any illogical person.

Brian Lehrer: Spencer in Berkeley Heights, you're on WNYC with Andy Slavitt. Hi, Spencer.

Spencer: Good morning, Brian. Thank you for taking my call. Good morning, Andy.

Andy Slavitt: Good morning.

Spencer: My question, I guess, posed to both of you is, given the non-homogeneous nature of the vaccination rates in the country, Vermont's got a much greater percentage of vaccination, say the Midwest. If the disparity continues or if certain states don't enforce better vaccination protocols, or they continue to weaken protocols in the name of small business or big business, do you see a return to restrictions on travel to neighboring states or even interstate commerce, either at a state level or at a federal level to go ahead and try and set up firewalls to make certain that we don't have a return to a pre-opening state?

We've got more variants on the horizon. We've got still a situation where we don't have a unified stance on how citizenry should be responding to vaccinations at a gubernatorial level. We still have a high percentage of Republicans and the like who insist on not getting vaccinated at all. It seems to me that the one thing I really don't want would be a whole bunch of people with that kind of attitude flying into Newark Airport and traversing freely around in the New York, New Jersey metropolitan area. We have that, which means potentially we're all at risk, if the Delta, or the Epsilon, or some other variant decides to come a-calling.

Brian Lehrer: Andy, what do you think about all that? It might be good for you to include in your answer your understanding of the current vaccines' effectiveness against the Delta variant, which, from what I see, is like 95% just as with the older weaker variants.

Andy Slavitt: It's a good observation, but let me start by saying this, if you've been vaccinated, then your chances of getting COVID-19 through the Delta variant are very, very low, and your chances of it being a severe case are even lower. There are probably bigger risks you have in your life than the Delta variant, if you've been vaccinated. Even if someone from a state with low vaccination levels who has COVID comes to your community, they're likely to infect people who are unvaccinated and very unlikely to seriously impact people who are vaccinated.

Because of that, I think we have to understand that the communities that have lower vaccination rates are indeed at risk, and you can anticipate weddings later this summer or in the fall in the south, where you have outbreaks. Now, these outbreaks, I think, will be of a different nature than what we experienced in 2020. I think we're going to be talking about dozens of cases that are slightly easier to contain and that result in fewer hospitalizations based upon everything we can imagine. It won't be the terrifying spikes that we saw because we do have a combination of vaccinations and natural immunity, even if it's at 50%, 60%, 70% counting those things that'll make it more limited than we otherwise would.

I would say that COVID-19 overall is now in the category of what I might call a manageable challenge. It's not gone by any means, but it likely won't be the thing that dominates our society and our actions. We have plenty of manageable challenges in our life. This is just another one. Things could change, but I think we shouldn't necessarily live our lives in anticipation of things changing. We should live our lives based on what we see in front of us right now, which, if you're vaccinated, is a pretty good picture.

Brian Lehrer: On the theme of your book, Preventable, Republicans will be quick to point out that states with shutdown resistant governors like Texas and Florida and South Dakota, which you write about, did better than states like New York and New Jersey in particular, which had the worst outbreaks, and even a pretty bad third wave outbreak this past winter, despite their more aggressive shutdown approaches. I rarely get a good answer as to why. Do you have one?

Andy Slavitt: Look, the one thing that COVID-19 utter teach us is humility. It's humility in trying to pretend like we can find cause and effect between why certain outbreaks happen in certain places. Brian, the truth to the answer is one that will be satisfying to some and maybe not to others, which is that if you were to look at how COVID-19 spreads, there is a high degree of randomness. For example, a superspreader, we know that certain individuals spread the vast majority of COVID, a superspreader who got off of the plane at JFK instead of in O'Hare last spring could have made all the difference to why New York had a big outbreak instead of Chicago.

I know we'd like to tie it to governor actions and policy actions and what day did the bars close and all that, but a lot of that is retrofitting the data into our own belief systems. It happens both ways. There are, of course, certain things we could point to. We can point to the motorcycle rally in Sturgis, South Dakota, as an outbreak event. We can point to some things very specifically, but more broadly, there are too many things that we try to explain that we really have no business explaining because the virus spreads in so many ways that we can't measure given that we don't have the ability to real-time surveillance, real-time test.

Are there explanations? Yes. Are they always related to policy? No. They're often related to things that are well out of our control. Therefore, the governors that chose to be more cautious, we're following a principle of public health that's more well-worn, which is, protect the public as much as you possibly can, balancing it with everything else that you need. We have 50 governors, and not any one of them got it perfectly right. I don't think any one of them were trying to kill people. I think all of them were trying their best, and they tried it slightly differently. There are some things that I think aren't answerable in the sense that are going to be satisfying, and I'd be very wary of people who float these theories on Twitter and other places about who's better and who's worse.

Brian Lehrer: Interesting. Let me get one affordable care act question in our last minute before you go since you were so involved in that with President Obama. The ACA survived in the Supreme Court. Yet again, this month, but still gone is the requirement for everyone to get health insurance, which was supposed to be the financial underpinning of the system because the relatively well who used less medical care would be paying into the system not just older and sicker people who take from it. How much has the end of the mandate affected insurance premiums or the cost of care overall?

Andy Slavitt: Do you notice a theme here, Brian, between the mandate going away here and the vaccination mandate that we were just talking about? There's a cultural thing in this country that even for a cost, whether that cost is in other people's lives, whether that cost is in insurance premiums, that people value their own freedoms, or liberties, or however you want to put it to their perception of freedom to liberties, higher than we sometimes do the common good and the ability to-- Sometimes it comes at the expense of one another.

It's one of the things that's drawn out in Preventable, in the book which is looking at how we expose lots and lots of essential workers quite willingly while putting in place things that kept ourselves safe. It doesn't make insurance more expensive when there's people left out. Is that a cost that Americans appear to be willing to pay because they don't like to be told what to do? Apparently so. That's just an element of our culture that has positives, and it has a lot of negatives.

Brian Lehrer: Andy Slavitt's book is called Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response. Andy, we already appreciate when you come on with us. Thank you so much.

Andy Slavitt: Thank you, Brian.

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