Though its opponents would say the ACA has already disrupted American health care enough, Burwell says she’s going to work right through the end of the president’s final days in office to keep the changes rolling, hoping to make it easier for patients to get preventive care and easier for physicians to work together. Burwell is eager to tout the progress already made, such as nearly half a billion Medicare savings recorded between 2009 and 2014. That work could become significantly more important if presumptive Republican presidential nominee Donald Trump wins in November amid promises to repeal the health care law and shake up the entire health system again.

Burwell spoke with POLITICO about what the administration wants to do in health care over the next six months, why she’s not worried about GOP pledges to repeal the health law and how she responds to Obamacare rants in her off hours.

This interview was edited for length and clarity.

The Affordable Care Act’s big success so far has been expanding access to health insurance. For a next act, you talk a lot about delivery system reform — or reforming the actual delivery of health care, the experience between patients and their doctors. What are you trying to accomplish?

For different pieces of the system, it means different things but, at its core, what it means is an engaged and empowered consumer. If you’re a health care provider, you’re actually going to be able to practice more in the way you actually went into the field to practice, because you’re going to be paid for the outcome for that individual: their health.

If you are a customer, it will mean there is a greater focus on prevention and wellness. Health care is not about what happens when something goes wrong. It’s about a continuum of your health and your life. And that’s a change. That’s why the ACA is important in terms of the no-cost preventative services. You, as a consumer, are going to have to behave differently. You’re going to have to engage in that part of your health care as well.

Your care will be more integrated, more coordinated, and that results in both better quality. For instance, a Medicare bundling program ensures that the behavioral health person is working with the physical therapist and the anesthesiologist for a hip replacement. There is a person who comes to your mother’s house to tell her to put the dishes on the counter before she has her hip surgery because during that initial period after, she can’t reach the kitchen cabinets, so they tell you, “put the dishes on the counter” and they walk through the house and they say, “get rid of that rug.” That person and the anesthesiologist and the surgeon and the PT all have aligned interest in better care.

The path we as a nation were on in terms of health care costs was not sustainable.

A big part of this is finding pilot programs in local hospitals or health systems and figuring out how to scale that up. How hard is it to find good examples?

Another president that I worked for used to say that there is somebody solving any problem in America right now. That’s true. There are challenges, and one of the biggest challenges is measuring quality.

So we have to start in the places where you can measure the quality. One of the most important things that the ACA gave us was the Centers for Medicare and Medicaid Innovation, which gives us the opportunity to test things and ask the right questions about scale. Some things are more scalable than other things — that’s the ballgame. Whether I was at the Gates Foundation or here — I mean, the ballgame is scale. And there are two ways things scale: government or markets.

Well, now you are the government. You have the power.

That’s why it was so important for us to set the goal and for us to achieve the goal on Medicare dollars because that’s a huge scale play. What we do in Medicare influences the rest of the health system. That is why it was so important in this whole space to figure out three things: where should we lead, where should we get out of the way, and where should we be the convener.

That is why it was so important in this whole space to figure out three things. Where should we lead? Where should we get out of the way? And where should we be the convener?

Where do you feel like the government is leading best right now and where does it need to do better?

Setting the goals is very important in terms of leading, because it leads the direction of the market. Yesterday I was at the Yale CEO forum in New York made up of leaders of all sorts of companies. It was amazing. One CEO said, “When you set the goal, when you made public that Medicare was going to do this, everybody knew.” You know it was probably controversial — the idea that I’m setting a goal for Medicare and that I’m setting a goal that we would achieve before we leave. So that was very important in terms of the things of the places we were leading. Working in the ACO is taking it to the next level — the bundles are three of the primary ways.

Where are the ways we can do more and better? I think some of those things involve the Congress. You know they’re negotiating on a Medicare pilot program [to test new ways to pay for certain drugs in Part B.] We believe that’s another place in terms of continuing to move us in a space to pay for value. That’s a place where I’d love to see us be able to do more, and we believe there are more steps to take and we’re going to continue to focus on that in our last seven months. You know we got a complete MACRA, the new Medicare payment formula. That needs to be completed.

You’ve enrolled millions of people in Obamacare, but there’s a big concern that the plans aren’t affordable enough, or that people are finding out-of-pocket costs higher than they anticipated. For both consumers and national health costs, did the ACA fall down on affordability?

In terms of the national question, former OMB Director Peter Orszag said yesterday that he would have been laughed out of the room if five years ago he had said that we would have done the $473 billion in savings in Medicare by now. And he said, “I would have been laughed out of the room if I said, ‘In 4 out of the 5 next years, you will have the slowest employer premium growth.” Here’s the thing that I think people forget: where we were when the ACA passed in 2010.

On the marketplace, for most people, they can find a plan for $75 per month or less. Is it good enough? No, which is why you hear my enthusiasm and excitement and why I spend so much time talking about delivery system reform, is because we’ve got to take the next step. We have to start with 20 more million people having insurance, and the majority of those, in terms of when we look at the surveys, are satisfied. The number of people who can’t afford their health care has gone down for the first time. Can we do more? Can we do better? Yes. But the basic trajectory, and has there been a market change? Yes.

I think your question is indicative of why we are so focused on the next set of changes, because there’s still, even for those who are in the marketplace, and those who haven’t come into the marketplace because of affordability — we know those people exist — figuring out the ways to improve, like downward pressure in the marketplace. Specifically, we issued new regulations on risk pools, special enrollment periods and risk adjustment. Progress has been made, but we know and are focused on making more.

Donald Trump has promised to undo all of this if he’s elected. How much of your seven months remaining here is going to be about shoring up the ACA against repeal efforts?

The most important thing to do is to continue on the path of what I call “putting points on the board,” adding to the substantive success. Why I believe that repeal is not an option is because this is in the fabric.

The idea that you are going to pull out the thread of insurers not being able to deny over preexisting conditions? Don’t think so. The idea that you are going to pull out the thread of 20 million people who have coverage? The idea that you are going to pull out that thread of, “Oh, you’re going to go back to paying for your contraception, and you’re going to go back to paying for your flu shot, and I’m going to pay for my kids’ wellness visits?” No.

The thing that I can do — and it’s most important whether there’s a Democrat or a Republican — is to just keep building on the changes in access, affordability and quality. That’s the most important thing I do. Because in the end, it isn’t about this name of this thing. It’s actually about the substance of what people care about, and what people were talking about a year ago at this time on, did they really want to win the King Supreme Court case [which would have put exchanges subsidies at risk]?

People who want to repeal the law say, “I don’t like the Affordable Care Act,” but then they say, “We’ll keep people’s coverage. We will keep this piece. We will keep that. We will keep the other.”

So the prospect of you handing the keys over to a Trump-appointed HHS secretary and walking out the door on Jan. 20 doesn’t keep you up at night?

Because of the Hatch Act, I cannot speak at all to any candidate or any election. What I can say is it is an extremely important thing for the American people, as they think about how they express themselves through their voting, to think about the substance of the issues that they care about. What I had just outlined is when that substance is presented to the American people — and the polling shows, if you poll each of those things, yes, they care deeply about them.

My job is to keep building on those. And in terms of making that ready for a step function improvement for those that come behind us, and preventing anyone who would want to do harm to that, because the American people care about it.

The work on open enrollment, finalizing the MACRA rule, will be extremely important. It is about the work of the department to implement, continuing with CMMI and the work that we’re doing in all of those spaces. Some of those are just resolving issues like how we’ll do open enrollment going forward or our partnerships with governors. Some of those are our partnerships with the issuers, in terms of we think it’s important for people to retain customers.

It is actually about the substance, and that’s why it is so important to get the conversation back to the substance, because that’s the tool. I’m confident in the American people. That’s the tool they need, though. We all owe them substantive information to make good choices.

You mentioned your Medicare Part B drug proposal, in which the administration wants to test a program designed to reduce the reimbursements for high-priced drugs. I’ve been surprised at the amount of pushback that you’ve gotten from Congress, particularly from lawmakers of both parties who say they want drug prices addressed. The presidential candidates talk about it. Is this something that you feel like you can still move forward with, even with the blowback from Republicans universally but even some Democrats?

Because we’re in the middle of a rulemaking, I can’t comment in terms of that issue. But what I can comment on is it is important to make progress. Everybody says they want to make progress in this space.

I think it is one of those cases, changing the entire system and getting to a place of greater affordability and greater quality, it’s not going to be just like snap your fingers. We know that. It’s going to take us all working together and there are going to have to be changes.

Congressional Republicans tell me how much they like you as a person. But your agency seems to get more letters, subpoenas and hostility from congressional Republicans — mostly over Obamacare — than any other department. And now we see Zika, which we all thought was going to be noncontroversial, is proving to be partisan. The administration’s $1.9 billion funding request still hasn’t been approved. How high is your frustration level with congressional Republicans when you see something like Zika come down to a partisan fight?

I think it’s known that I have a lot of relationships with quite a few Republicans. There are so many that one works with and you get a lot of things done. Obviously on the Democrat side, I have clearer and strong relationships. There’s many people doing a lot of good things. Getting back to the facts, I think I’ve received 50 oversight letters since we asked for the Zika money. As one thinks about what I like to call “putting points on the board,” just thinking about the contrast of those things is important. That’s not to say there’s not many people doing great work on so many issues. But the body at large has to work together to achieve. I have come to this job with optimism. I believe that relationships are important.

We need the Zika money now. It is extremely important. Today, alone, I will have three Zika meetings, one being with governors. The delay — had we been able to issue the funding announcements? I don’t want us to wait, as a nation. I’m not sure why we need to wait to see the babies born [with brain damage.]. That’s not what we want. Our job is to prevent every single one of those that we can. The tragedy for the family, the cost that’s attached to it — there are so many parts of this. So I am hopeful that we are going to get that money and be able to move it out.

We are working very hard with our friends in Puerto Rico, where there’s an already complicated situation — it’s just sad to see the difficulties that they have economically, the difficulties that they have with Medicaid, because of the caps, and now this. But I’m hopeful we’re going to get that money. We need to get it.

You’ve made it a big priority to encourage more states to expand Medicaid under the ACA. But so far, 19 states have resisted, most because of political pressure against embracing the health law. How long do you think it will take before every state expands the Medicaid program under the ACA?

I’ve never actually thought of it in that way, interestingly, because I’m just so focused on getting the [next] ones: We’re still having conversations with a number of the ones that have been mentioned publicly. Then there are surprises. Georgia was in the news today. So I haven’t thought about when it will happen, because I’m quite confident it will. It’s not going to be a long, long time.

You’ve been in the administration a long time. You’ve been in this job two years and served as OMB director before that. Your name has been mentioned as a likely contender for Treasury secretary in another Democratic administration. You’ve done private sector, foundation, government work. Does the Treasury secretary job, or even staying in government, appeal to you?

Right now the thing that I’m focused on, as I think you can hear, we’ve got a lot to do in this last period of time, and then I am focused on spending some time with my 8-year-old, my 6-year-old and my husband, and as I think about the future, that is my big focus.

When I tell people that I write about health care and the ACA, I often get technical questions about how the law applies to that person’s life or an unsolicited political rant or rave. When you’re out and about living your life, in D.C. or West Virginia, what kind of questions do you get?

All of those questions that you get. At this point I’ll get Zika questions about “Would I get pregnant if I lived in X place?” or that sort of thing. Also, definitely technical questions — so does my family. When I got home last night, my husband was on the phone with someone who was asking about payment for a preventative service. My poor husband gets those kind of questions — all of those kinds of questions. My best friends in West Virginia, they get these all the time. My mother gets the questions!

Do you get rants and raves about the ACA?

Oh, yes. This is the “Department of the Kitchen Table.” These are issues people care about. The thing that I have found is it’s important to step back and go, okay, so why am I getting so many questions about this? Even when you’re getting the rants and stuff like that, people are passionate about it and they care about, because it’s important to them.

So how do you respond to the rants when you’re just at your kid’s soccer game or something and trying to enjoy a Saturday morning?

The thing is, I try to just keep the peace and listen and learn, because sometimes you’ll learn about something that you didn’t know about. I’m sure you can imagine, any time I hear this, I’m running through the different solutions or scenarios — such as, did you shop on the exchange. But generally speaking, I want to listen, I want to hear, because we want to do better. I’ve got that little picture of Sam Walton over on my bookshelf. I’ve got that little “customer first.” That is just a form of it, and when you have this job it is kind of 24/7. It is completely 24/7.