Steve Munnelly is a healthcare expert who worked on federal regulations for the Affordable Care Act and the Children’s Healthcare Insurance Program (CHIP). Though he currently finds himself at a crossroads, he realizes that, sometimes, the love in our lives is what keeps us the healthiest.
I grew up in maybe the most stereotypical family in Massachusetts. My dad came from money, my mom came from nearly nothing, and they created this nice upper-middle class life for my siblings and me. From a young age, I knew that a lot was expected of me. Before I was five, I have a very vivid memory of giving my friends their shots using my plastic Fisher Price medical kit and making sure they weren’t scared about it. So I always knew that I wanted to do something in medicine.
My mom was a nurse growing up. She was an LPN (Licensed Practicing Nurse) and she went into dialysis, so she was always working with the sickest people. I got to college, was pre-med, and I loved all the sciencey stuff, but it was the stuff I was worst at. I had decent MCAT scores, but something about me, if you haven’t already figured out, is that I do not accept mediocrity – especially in myself. I was aiming for very competitive programs, and I needed something that was going to set me apart from the applicants who appeared just like me. So I decided to get my Master’s in public health first. I always knew I wanted to get into something population health-based so I can affect the health on a larger scale. Something that has always bothered me is that there is very little focus on prevention in Western medicine, but a whole lot of money spent on treating conditions. I got into four programs, and George Washington University gave me some money, so I decided to go there.
This was in 2010-2011, when the ACA had been passed, but had not been implemented yet. All the regulations were still being created. A friend of mine from undergrad got me an internship at the Centers for Medicare and Medicaid Services (CMS). He happened to be working in the group of 150 people that were creating Healthcare.gov. Very quickly, I went from being a lowly intern to, “Okay, cool, we need your help in writing this regulation/guidance.” I was working with three other people to design how to coordinate between different federal departments to make sure if someone is a citizen, naturalized, a permanent resident, and whether they were or were not eligible for certain tax credits. We sat at a white board drawing how that was supposed to work, based on a single line of text in the ACA.
Can you help me understand your authority to interpret the text of the ACA, in order to create those regulations?
Certainly. The ACA was literally hundreds upon hundreds of pages. And the staff in Congress basically agreed on the main parts of how the law was supposed to function. And then they handed it over to the appropriate arms of the executive branch (mainly CMS, where I worked) to figure out what that looks like in action.
And this was all while you were a graduate student?
Yes. I would work from 7-3 on the days I had class, and I had timed it to the minute to get to class at 3:15. I would have class from 3:15 to 9PM. On the other days, I’d work 16-18 hours. And eventually, there was a federal hiring freeze, so they couldn’t hire me permanently after my internship. I worked with them for about 10 months.
You were there at the time Healthcare.gov launched, which, as we all know, was a mess. What was your inside perspective?
While I was there, the train was barrelling towards October 1 [the launch of Healthcare.gov]. I remember the day my boss walked out of this massive conference room. She was always this tall, confident glamazon, but this day her face was ghost white. She pulled our whole team into a room and said, “They’re in the process of firing the website contractor for breach of contract and not delivering on the promises they’d made. You need to continue doing your work. We’re bringing in another contractor, but this is a disaster.” There was a point where, in my down time, I had to perform software testing on the website. I would use a link and try to apply for insurance, and I would have to take screenshots and log where I got stuck. And I thought, “This is not what I thought I would do with a policy degree.”
This one company was at fault, but we all were also working with a new program that had literally never been done in that way before. The way the law was written, we had to verify citizenship, income, and that they weren’t part of any other healthcare program. There were five federal agencies that had to be part of this, but were not part of the team that was creating it. The fact was that the law had gotten so complicated to appease some of the people who were originally opposed. To make them agree to it, the law became a hodgepodge of conflicting ideologies.
There was so little that I could talk about. It was kind of exciting – even though it was stressful watching something implode from within – having inside knowledge of something that was so massive and so public. But I couldn’t use my experiences in any of my papers, or classes. If something came out publicly, that would’ve been the end of my career.
And in the years following, I know that you worked for MACPAC, which provided Congress with policy recommendations regarding CHIP [the Children’s Health Insurance Program], and then made your way into private consulting. I’ve heard about the prescriptive, procedural aspect of what you’ve done, but I want to take us back to your passions. Could you humanize that experience a bit more for me? Could you tell me what you think you were able to accomplish for people, and how it inspires the work you think you can do moving forward?
I have to caveat my response with the fact that, while I did come from a very privileged upbringing and had a charmed life, my parents did make some bad financial decisions, so I didn’t have college paid for. I signed on to, between my undergrad and masters, nearly $200,000 in student debt. I went to private schools, and I needed to take out money for living expenses in Boston and D.C. I’m at about $50,000 left, and I’ve paid well over $200,000 toward my loans so far. So I’ve had to make a lot of decisions where, in situations where one job is more altruistic, and another pays more money, I’ve had to choose the money. But I will say that there are a lot of ways to make a good impact in the system. Sure, you can see being highly paid to consult for insurance companies as part of the problem, I like to see it as being an impartial, outside voice to help them fix their problems, to help them do the good they can and not be as negative an influence as they could be in the system. Harm reduction.
Our healthcare system continues to be more complex and makes it more difficult to be healthy. Even though there’s value-based care, HMOs, and other ways that control cost, our system is still largely volume-based and profits-driven. If you look at the Fortune top 20 companies, about half of them are healthcare companies — publicly-traded entities focused on profits. For them, there’s a bit of a reverse incentive. The sicker the people are, the more money they’re able to make.
A lot of what I’ve done in my career is help people to solve problems within the confines of the system that we have. I’m learning enough about our system so that, one day, I can be a force of change within it. Part of that is also making sure that I’m financially stable enough so that if I ever take a job at a nonprofit, I won’t have to worry about paying my mortgage.
Which brings me to a slightly darker question. I was so sorry to hear that you were recently laid off at Salesforce. That must be devastating.
I am sad. I’ve gone through the stages of grief a few times. I take things very personally…I’m very emotional. There’s always a really easy way to see the negativity in something. I’m privileged and lucky to get a severance that affords me some time to find what I want to do next, but I definitely am in a constant state of mild panic these days.
But I have a wonderful husband. And an amazing dog. And a beautiful house. And I finally feel settled here in Minneapolis. Had I not had this group of friends in the Chorus, I would be in a much darker place. I remind myself constantly that I live a very lucky and wonderful life. While I can turn around and say, “Yes, I’m stressed out, yes I feel like I’m floating in space,” I still have things that are grounding me.
So who knows where this is going to take me? I’m sitting at a crossroads right now, and there are a lot of great paths I could take. I never know where any of those will lead me, but I can guarantee it’ll be toward healthcare somehow.
I mean, our system isn’t fixed yet, right? So I still have some work to do.
Josh Elmore (he/him), singer and member of our small ensemble OutLoud!, created Humans of TCGMC in 2018. He graduated from Carleton College with a B.A. in Linguistics and has since worked in sales, higher education, and, most recently, as a bilingual insurance agent (Spanish). Endlessly curious, he has dabbled in improv theater, stand-up comedy, sword fighting, the cello, and modeling for fantasy-themed photo shoots.
