This week, Dr. Abdul El-Sayed joins Nick and Goldy to discuss how the recent assassination of United Healthcare CEO Brian Thompson has thrown a harsh spotlight on the public’s visceral anger toward our exploitative healthcare system. Dr. El-Sayed outlines the stark contrasts between the profit-driven U.S. healthcare system and those of other developed nations, arguing that we need a public option to alleviate the burdens of skyrocketing costs and access issues. Goldy also explains how the warnings from Nick’s viral POLITICO piece from 10 years ago, “The Pitchforks Are Coming For Us Plutocrats,” feel eerily prescient, as the public reaction to Thompson’s death was a mix of hailing the shooter as a hero, outrage, and people sharing their personal healthcare horror stories online. Is it possible that America’s healthcare system is having its own pitchforks moment?
Dr. Abdul El-Sayed is a physician, epidemiologist, and public servant whose work focuses on health equity, resiliency, and environmental justice. He is the host of America Dissected, Crooked Media’s podcast that explores the intersection of health and society with leading experts in science, public health, and policy. Abdul is also the author of Healing Politics and Medicare for All: A Citizen’s Guide, and he serves as a visiting scientist at Harvard’s FXB Center for Health & Human Rights, as well as a Scholar in Residence at Wayne State University and American University.
Social Media
BlueSky: @abdulelsayed.bsky.social
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Threads: abdulelsayed
Twitter: @AbdulElSayed
Further reading:
Healing Politics: A Doctor’s Journey Into the Heart of Our Political Epidemic
Medicare for All: A Citizen’s Guide
Nick’s OpEd in POLITICO: The Pitchforks Are Coming… For Us Plutocrats
Nick’s Ted Talk: Beware, fellow plutocrats, the pitchforks are coming
Website: https://pitchforkeconomics.com
Instagram: @pitchforkeconomics
Threads: pitchforkeconomics
Bluesky: @pitchforkeconomics.bsky.social
Twitter: @PitchforkEcon, @NickHanauer, @civicaction
YouTube: @pitchforkeconomics
LinkedIn: Pitchfork Economics
Substack: The Pitch
Nick Hanauer:
The rising inequality and growing political instability that we see today are the direct result of decades of bad economic theory.
President Biden:
It’s time to build our economy from the bottom up and from the middle out, not the top down.
Nick Hanauer:
Middle out economics is the answer.
President Biden:
Because Wall Street didn’t build this country. Great middle class built this country.
Nick Hanauer:
The more the middle class thrives, the better the economy is for everyone, even rich people like me.
Podcast Announcer:
This is Pitchfork Economics with Nick Hanauer, a podcast about how to build the economy from the middle out. Welcome to the show.
Goldy, David Goldstein:
The name of this podcast, Nick, Pitchfork Economics, most of our listeners know it comes from a piece you wrote 10 years ago in Politico titled, “The Pitchforks Are Coming For Us Plutocrats.”
It was a warning to your fellow plutocrats that if income inequality kept increasing, bad things were going to happen. And a bad thing did happen recently, which has brought attention back to this piece. And the Ted talk you did that followed it up, the shooting of a UnitedHealthcare CEO in New York.
Nick Hanauer:
I think what was most interesting about that assassination was not so much the fact that it happened. In fact-
Goldy, David Goldstein:
Right. Because shootings happen all the time.
Nick Hanauer:
My God, yeah.
Goldy, David Goldstein:
I mean, we have school shootings and they are-
Nick Hanauer:
Yeah, I think there have been 83 school shootings so far, mass school shootings this year so far, and there haven’t been 83 CEO assassinations.
Goldy, David Goldstein:
Right. And those school shootings don’t really even get the media play that they used to. This is one, I mean, this is tragic. Look, our office, Civic Ventures, we are dedicated to addressing income inequality and gun violence.
Nick Hanauer:
Right.
Goldy, David Goldstein:
Gun violence has always been a really big part of our portfolio. We are opposed to gun violence. We see this as part of the gun violence epidemic, whether it’s a school shooting or a CEO shooting, we are opposed. It is a bad thing.
Nick Hanauer:
Yes. It is.
Goldy, David Goldstein:
But what’s fascinating about this is not the shooting itself, which is, unfortunately, and tragically unremarkable in the United States of America in 2024. What was fascinating and disturbing and telling was the public response.
Nick Hanauer:
Yeah. People apparently enjoy CEO assassinations a lot more than school shootings based on the public reaction to it.
Goldy, David Goldstein:
Right. There appeared to be a lot more empathy for the shooter than for the victim and his family.
Nick Hanauer:
Yes.
Goldy, David Goldstein:
Which, I don’t know, I guess I found surprising. Not surprising.
Nick Hanauer:
It wasn’t exactly surprising, but it was kind of remarkable how visceral the reaction to it was.
Goldy, David Goldstein:
Right.
Nick Hanauer:
And how, yeah, so many people were like, “Yay.”
Goldy, David Goldstein:
Yeah. And the iconization of the shooter, the how many people were rooting for him to get away with it, and were disappointed that he was turned in. And it certainly took a lot of serious people by surprise.
It took the media by surprise. It took politicians and pundits by surprise, and it exposes an incredible amount of anger at the health insurance industry and an incredible amount of, I don’t know, self-awareness amongst people that they have been victimized by this health insurance industry in a way that people feel like it has committed violence to them and to their families.
Nick Hanauer:
Yeah. When you hear the stories of people’s experiences, it’s not hard to understand how somebody would become, how should you put it, homicidally angry. Right?
Goldy, David Goldstein:
Clearly this guy had mental health issues.
Nick Hanauer:
Yes.
Goldy, David Goldstein:
And as well as health issues.
Nick Hanauer:
But if you have a loved one who’s suffering and your insurance company is dicking around with you over a paperwork problem or whatever it is, it definitely would make you want to kill somebody.
Goldy, David Goldstein:
Or, at the very least not feel so bad about, yeah. Because we don’t want to make light of this in any way.
Nick Hanauer:
No.
Goldy, David Goldstein:
And so, within a day of this, Nick, people were like, my daughter sent me something. Young people had discovered this. There were TikToks cutting up your TED speech.
And this is the thing, when you wrote that piece, when you did that TED talk, it wasn’t a threat. It was a warning that this was unsustainable.
Nick Hanauer:
Yes. Yeah. And the other thing about this particular event is, and the healthcare industry, is that the context, because the healthcare industry is not the most exploitive industry in the country.
The problem is is that it’s the banking industry, financial services, and everywhere you go at every turn you make, big companies are taking advantage of consumers in really unfortunate, distasteful, unfair ways, which just amps up everybody’s anger about everything all the time.
Goldy, David Goldstein:
But when you get exploited by the financial industry, it’s not necessarily a life and death situation the way it is with the healthcare industry. And so, to talk with us today about how exploitive the healthcare industry is and why people are so justifiably angry about it, we have returning to the pod Dr. Abdul El-Sayed.
He is a physician, an epidemiologist, a public servant. He is the author of the books “Healing Politics” and “Medicare for All: A Citizen’s Guide”, and a co-host of Crooked Media’s podcast, “America Dissected” that explores the intersection of health and society with leading experts in public health and policy.
Dr. Abdul el-Sayed:
My name is Dr. Abdul El-Sayed. I am a physician epidemiologist. I currently lead Wayne County’s Department of Health, Human and Veterans Services. And I also host the podcast “America Dissected” alongside my co-host Dr. Kaitlin Jetelina.
And I am the author of a book called “Medicare for All: A Citizen’s Guide” alongside Dr. Micah Johnson. And I’ve been thinking quite a bit about American healthcare and all the ways it could be better, which I’m glad to be thinking about alongside all of you.
Nick Hanauer:
Abdul, what was your reaction, first reaction to the news of the UnitedHealthcare CEO, Brian Thompson’s, assassination and in particular the surrounding discourse? What does this moment reveal about the growing tension between the public and the healthcare industry?
Dr. Abdul el-Sayed:
Yeah, first deeply saddened for the Thompson family. I mean, this is a man, a father of two people, a husband who was shot in cold blood. And that’s wrong. That’s always wrong, and we should always, always call it wrong. You don’t kill people no matter the circumstances. That’s not how we want to operate in a civilized society.
And at the same time, I also, as you think about the reaction to the reaction, this has brought up a lot of frustrations for people, and I think has misled us in terms of the directionality of our frustration.
It’s not about individuals, but it’s about a system that we’ve allowed to continue to fester in this country where patients in their worst moments when they’re sick or injured, are profiteered off of by many different sectors of one gigantic industry, which is the healthcare industry.
Whether you’re talking about pharma and the exorbitant prices we pay for our medications; you’re talking about providers and the fact that healthcare costs continue to go up; whether you’re talking about clinical visits or hospital stays; and, of course, when you’re talking about insurance, which is a sector that does not really add any real value, particularly considering the fact that it was designed to protect you from financial loss when you get sick, which, actually is what it ends up exerting upon you when you get sick in the forms of deductibles and co-pays that are putting people into debt in this country.
And so, it’s two very sad things. I think people are connecting them, but we have to always remember that murder is wrong and we do not condone that. And also, a system that profiteers off of sick people’s bodies is also wrong. The one doesn’t justify the other, but it does create a space where we have to talk about both wrongs and consider what we can do.
We’re never going to be able to bring Brian Thompson back, but we certainly can fix the healthcare industry and the healthcare system if we’re willing to look at it in the eye and ask what kind of collective society-making can we bring to bear on this problem?
Nick Hanauer:
Yeah. If you would, for our listeners, just, obviously, most people sort of understand this intuitively, but I spent a bunch of time, not my career in the way that you have, but I did spend a bunch of time at one point on a business that was designed to reform the healthcare system.
And so, there was a time at which I knew the facts very, very well. The differentials between what Americans pay, for example, for a colonoscopy and what everybody else in the developed world spends for a colonoscopy, what we pay for, ordinary drugs and what everybody else pays.
There is a reason that the American citizen pays twice as much per year for healthcare as people from every other advanced society with worse outcomes. Can you detail some of the most egregious differences between our healthcare system and other healthcare systems that other advanced societies use?
Dr. Abdul el-Sayed:
Yeah, let me offer a couple of what’s, and then talk quickly about the why. My office, I work in the city of Detroit and Detroit’s the only place in the country where you can go south to go to Canada. And so, my office overlooks Windsor across the Detroit River.
And when I look out my window, I’m looking at a place where they spend about 11% of their whole economy on healthcare, where we spend between 18 and 19% of every dollar spent on our whole economy on healthcare. And that, for them, that 11% buys them two years extra in life expectancy compared to us. And in survey after survey, they’re happier for it.
But then there’s a part that the overall statistics tends to miss, which is in our system that is predicated on profit-making for every piece of the healthcare sector, our system discriminates against the poorest people.
So, there’s not a situation in Canada where you don’t have access to basic healthcare. Whereas, in the United States, nearly 10 million people are uninsured. And then nearly 40% of our country’s what’s called underinsured, meaning you have insurance, but the price of your deductible or your copays are too much such that you don’t actually get the healthcare that you need.
In Canada, there’s no such thing called medical debt. In America, our collective medical debt is bigger than the GDP of 50% of the states in this country, the collective debt we just owe for paying for healthcare. And to think about that, to just put an exclamation point on that number, nearly two-thirds of people who get a cancer diagnosis are going to declare bankruptcy as a function of that.
I want you to think about what that means. Nearly two-thirds of people. So not only is this cancer eating your body, but it’s also going to cost you your financial future. And that doesn’t happen in Canada.
If you want to give birth, chances are you’re going to be paying thousands of dollars out of pocket to have a baby. Which, by the way, we are having fewer and fewer of them. And in Canada, that’s free. So, that’s just our system compared to the Canadian system.
But, the consequences for equity, the consequences for who gets healthcare and who doesn’t, the consequences for the 10 to 12 year life expectancy gap in our country compared to far smaller gaps in other countries, those are things that sometimes go unsaid.
And that is a function of the fact that we allow every piece of healthcare to be done for profit in this country. And so we end up paying way more and we end up getting worse outcomes for it.
Goldy, David Goldstein:
This is an economics podcast, and one of the things that was remarkable about the election we just had is how uninformed the American public seemed to be about the economy, and their own economic interest, and how these economic policies were impacting them.
And, yet, the outrage that we’ve seen, and it’s not outrage at the murder, but at the victim and the industry he represents. That tells me that the American public seems to understand this. I mean, are they as informed as they appear to be? And what is it about healthcare that leads people to be more in touch with their own self-interest?
Dr. Abdul el-Sayed:
Yeah. I think on the one hand, people are really quite informed about how broken our system is because I think too many people have had the experience of needing healthcare and then having to worry about whether or not they could afford it. Or, getting healthcare thinking that they were insured only to realize that the sure part of insurance didn’t really exist for them, and that they had to fight some nameless, faceless person on the other side of the line to get access to the care that they thought they already paid for.
And the other side is to blame this on one individual who is a cog in a far larger system is misguided. And I think what we saw was this outpouring of rage at the insurance system. And as people tend to do, we tend to personify systems, which is probably unfair.
It’s definitely unfair to those individuals, but it also, it betrays a sort of lack of understanding of how the system is architected and why the system tends to screw us. And to your point, Goldy, it is a system. It’s just a system that’s not built for our healthcare. It is a profit making system for a set of very, very large industries.
Nick Hanauer:
Yeah. It’s built for the shareholders of insurance companies. That’s what it is. And, if I may, again, I’ve thought about this for a long time. The problem with private insurance is that it creates economic feedback loops designed to turn mole hills into mountains.
Because if your business model is taking 15 or 20% of every transaction, the bigger the transactions are, the bigger your business is, the more money you make. So the whole system is geared towards generating the largest expense. And the system makes the most money the sicker you are.
So the whole thing isn’t a healthcare system really. It’s a system designed to exploit people’s sickness.
Goldy, David Goldstein:
And US healthcare is profiting from this at multiple parts of the system. They’re not just an insurance company. I realized, after the fact, that the medical group that I’ve been going to for years, Polyclinic, I knew it had been acquired by somebody, but they recently rebranded as Optum. Which, then I realized, “Oh my gosh, that’s US Health Care.”
And I’ve joked in the past that they’re like a reverse HMO because I have good insurance. They’re constantly trying to get me to buy services. They’ll send me to any specialist I want as long as it’s within their group because they’re making money off of that, billing the other insurance company.
Perhaps if I had their own insurance, they would be a little stingier. I don’t know.
Dr. Abdul el-Sayed:
That’s an interesting point, and there’s a couple of pieces that you all highlighted there that I want to pick up and maybe offer a name to. Insurance companies, it’s interesting. You pay so that they’ll pay for your healthcare when you need it.
But their incentive as a company is to do exactly the opposite. And that’s counterposed to most business models. If you are a manufacturer of chips, you make money when you sell chips. But insurance companies lose money when they provide you the thing that you actually entered into a relationship with them to do.
To your point, Goldy, right, we tend to think of ourselves as consumers of healthcare, as customers. When you’re a customer, you offer tender for a service that you get. Right? But if you think about how the insurance system works, you are a reason that someone else offers tender for a service that you got.
And so, rather than being the customer in this scenario, you’re actually kind of more the product. You’re the reason money changed hands between folks. And, Goldy, for you, you are an account that is billable for Optum. So their goal is to bill for everything they possibly can bill for you. Whereas your insurance company is like, “No, no, no, no. It has to be necessary care.”
But this sets up a really problematic situation because you all are economists, so I can use this kind of language here. In healthcare, we have what is, ultimately, the ultimate information asymmetry problem.
We rely on doctors and hospitals to tell us what we need and then sell it to us, which means they have an incentive to sell us things that we may or may not need. It’s like going to a mechanic. I’m a Detroit kid, so I like to pretend that I know things about cars.
So if I were to take my car to a shop and the mechanic looks at me and says, “Ah, it’s clearly a sprocket flywheel.” I’d pretend to know what he’s talking about, shake my head, and end up paying way too much money for a thing that doesn’t even exist.
Whereas, when it comes to our healthcare, we just know that it hurts. We don’t know why it hurts. And so, we leave it to our providers to tell us why it’s hurting and to solve it, which creates a whole bunch of problematic incentives.
And in theory, insurance should be able to protect you from getting taken advantage of. But in the end, for them, it’s just this delta between how much money you give us and how much money we get to keep. And because no one insurer is big enough aside from Medicare, which, of course, we can get to is, is basically legally barred from doing this well.
No one insurance is big enough to have the market power to actually negotiate with big healthcare providers, so they’ve just created ways to pass the cost back onto everyone else. So they create these cost sharing mechanisms like deductibles or co-pays, which are just ways to get you to pay for the thing you thought you already paid for.
I always explain this when I teach as like imagine you paid for Netflix every month and you go to watch that finale episode of your favorite show, and then all of a sudden you got to pay $19.99 to get it.
You’re like, “Wait, I thought I already paid every month.” They’re like, “No, no, no, no, no, no, no. This one’s $19.99 on top of it.” Right? We’d all feel some kind of way about it, but that’s, basically, how insurance works these days.
Goldy, David Goldstein:
And it’s totally non-transparent, the pricing. I had my gallbladder out this year, and at one point I asked what something would cost, and they had no idea. They couldn’t even tell me what it was going to cost.
Dr. Abdul el-Sayed:
And to be honest, Goldy, the reality of is the cost really was a function of what insurance you had-
Goldy, David Goldstein:
Oh, absolutely.
Dr. Abdul el-Sayed:
… because it’s a different deal for every insurance company. These are all what they call, trade secrets.
Goldy, David Goldstein:
And in that case, it’s not even really insurance. It’s kind of like a prepaid discount card that if it’s a covered, if it’s covered, then you get the negotiated price. If it’s not covered, then you pay this inflated retail price, which is something I learned, Nick, before I went to work for you and had crappy insurance.
And some things were covered and some things weren’t. And I had no idea, and they never gave me a price list. It’s just so you’d see this bill at the end, oh, it’s $141 for this test. The negotiated price is $52, and that’s what the insurance company paid.
Then this other test, it’s $164. Oh, this isn’t covered. So you pay $164. You don’t get the insurance company’s price. You get the list price. How is anybody capable of being a savvy consumer in that type of so-called market?
Dr. Abdul el-Sayed:
Yeah. It makes nearly impossible. And then the other problem with it is, most of the time when we’re getting healthcare, we can’t even shop it. Right? And I think price transparency is really important.
But if I started clutching my chest, I hope somebody around me will call 911. But I don’t get to decide what hospital I go to. I’m not going to sit here and debate the doctor about what treatment I need. At some point, I’m just going to get what I get and hope I make it.
And so, even in the system, we don’t have an approach to being able to actually ask or to think through, what is my cost outlay going to be? Like you, I had to have surgery this year and I literally write books about this stuff. And I had to sit back and say, “Okay, given my deductible, I’m going to have to stash away a certain amount of money.”
I ended up maxing out all of my out-of-pocket costs to get the surgery. But then I thought about it. What if there’s an emergency situation where had I not gotten the surgery in time, I could have had to do it as an emergency? I wouldn’t have been able to save the money up and it really would’ve been an issue.
And then I think about a lot of my employees who don’t make as much as I make, even if they needed to save up, it might take them years to be able to save up and then wind up in a situation where they have to have the same surgery under the gun.
And so, you don’t really know what you’re going to have to spend, even if you are like me, I’m 40 years old and in pretty good health. But, you never really know what’s coming around the pike.
Goldy, David Goldstein:
Well, this is why we all need a medic alert bracelet that says, “Please take me to an in-system emergency room.” Right, because I don’t want to keep-
Dr. Abdul el-Sayed:
QR code with all your systems.
Goldy, David Goldstein:
That’s right. Yeah. This is, I want one of the ones that my insurance company covers.
Nick Hanauer:
Yeah. And the other really crazy, screwed up thing about the private insurance model as a way of giving you healthcare, is that insurance, literally, only makes sense in the cases where something is rare, unpredictable, and catastrophic.
But 80 or 90% of healthcare transactions in your life are routine things, whether getting a wart burned off your pinky, having a cut stitched up, getting a colonoscopy, having your physical, whatever it is.
Goldy, David Goldstein:
Getting older, Nick.
Nick Hanauer:
Yeah, whatever. But whatever.
Goldy, David Goldstein:
There’s the alternative.
Nick Hanauer:
No, no, no. But all these things, most healthcare transactions are predictable and non-catastrophic. But because insurance mediates every single one of those transactions, the paperwork that is required to execute those transactions dwarfs the cost of doing the actual transactions.
Dr. Abdul el-Sayed:
Right. You’re absolutely right.
Nick Hanauer:
Right? Doctors employ teams of specialists who do nothing but insurance paperwork to just get reimbursed for doing the simplest of things. And this is why they’re always pushing you towards specialists because you can turn a cheap transaction into a profitable transaction by jacking it up.
Again, why would you spend 25 cents to burn a wart off a pinky when you can send somebody to a specialist and turn it into a thousand dollar transaction?
Dr. Abdul el-Sayed:
Nick, to your point, people don’t think about hospitals as being these individual business units. But in every hospital, there are some units that subsidize others. And what happens with the units that end up getting subsidized is some business consultant somewhere realizes that these are cost centers that aren’t making money, so they shut them down.
Which is why a lot of what you’re seeing get shut down are primary care clinics, psychiatric clinics, emergency rooms. And you think about, okay, so how is this in the public’s interest? Well, it’s not.
It’s just that to your point, because the financial transaction cost itself of healthcare is so high, the value of this less procedural, but critically important medicine doesn’t actually adequately come out. And so, they end up just excising these units because they’re not making enough money and you need to be doing major surgeries like knee replacements or hip replacements. That’s where the money is.
And you have to ask yourself, it’s not just that this doesn’t serve us well because we are paying through the nose or not getting healthcare at all. It doesn’t serve us well because we’re not actually putting money into the parts of medicine that add the most value.
None of us want to get sick. In our world, if you need a knee replacement, you want to get a knee replacement. But you’d rather be in a situation where you never needed a knee replacement in the first place.
But we’re dis-incentivizing and dis-investing in that and waiting until you need that knee replacement than giving it to you and then saying, “We did a good job.” And in the end, we’re all the sicker for it. And who’s getting wealthier off of our backs? Well, it’s the industry.
Nick Hanauer:
If we do feel bad about health insurance executives being assassinated, what would we do to avoid more assassinations in the future? How can we change the industry so that people are not quite so angry?
Goldy, David Goldstein:
Yeah. Instead of calling it Medicare for All, you can call it the Health CEO Protection Act. What would it look like?
Dr. Abdul el-Sayed:
Well, we would never create a situation where there was such a lucrative opportunity for somebody to make money off of the back of denying people the healthcare that they thought they already paid for themselves and their family.
And, the way you do that is to do what we’ve already done for actually the majority of healthcare transactions in our country. This is the thing people don’t appreciate. The majority of healthcare transactions, the majority of healthcare dollars are dollars spent via government healthcare because, well, people tend to get sicker and need more healthcare as they get older.
We do this crazy thing where we insure people through the federal government after they turn 65, rather than extending that pool out to everybody, both making Medicare more sustainable, and also being able to secure access to healthcare that you don’t lose when you turn 26, or you get married, or you get a different job, or you lose a job.
We can do that by extending healthcare coverage. What that would mean is that the federal government can be all of our insurer. It can act as that negotiator to bring prices down and actually exhort a level of force against providers.
It can reduce the overhead costs of healthcare transactions because it’s the only insurer in town, rather than having to have armies of billers both on the payer side and the provider side. And, it can make sure everybody in our country has access to affordable, accessible healthcare. That is the idea behind Medicare for All.
And the irony of this moment, I got to say it, because I know I’m among friends here, is that you have one conversation that is about how progressives have missed the boat on talking about critical meat in potatoes, economic issues. And the same folks who are having that conversation are pointing to this moment and saying, “Well, it’d be crazy if we pass Medicare for All. That’s a loser of an idea.”
And, if you talk to any family, here in Wayne County, we’re working to forgive $700 million of medical debt, and that’s just one county. You think that’s not a meat and potatoes issue that folks working on the line in Warren or in Dearborn are not talking about? That is the central one.
And so, we’ve got to get past the spin of the industry that tells us that we really, really love our private insurance and we couldn’t do anything better. And if we want to win on an issue, this is the one. This is the one because everybody’s got a body and everyone wants that body to get the healthcare it needs if it gets sick.
Nick Hanauer:
Yeah, interesting. So, you think that Medicare for All is the best path towards a reform?
Dr. Abdul el-Sayed:
Look, I think that there are ways to get there that will take time. And look, we’re talking about 20% of the entire economy here. And anybody who thinks that there’s a switch in the White House that you can just flip and all of a sudden Medicare for All turns on, that’s not how it’s going to work.
And so, there’s going to be, have to be a phased in approach to thinking about how you start to extend this. That’s a technical question. And look, we’ve done a lot of the thinking on how to do that, but it’s going to take some time, but it has to be the direction we go to.
But the challenge is this. I see people running away from the central set of issues in healthcare economics and in healthcare policy. We almost seem unwilling to have conversations about the central issue of the fact that our prices keep going up, that we are the only high income country in the world that has this fully privatized health insurance system between the ages of basically zero and 64.
And, instead, we think about these little edge cases about ways that we can save a couple of dollars here or there. And I just think we need to run at the problem and talk through the central issue at play here and face it up.
And look, whatever name you want to call it, I’m not stuck on Medicare for All. Right? But engaging with real government responsibility to provide access to health insurance in a way that the privatized system is failing to do, we’ve got to have that conversation in plain language and face up the fact that the industry is the reason why we are unwilling to have the conversation.
Nick Hanauer:
Yeah, I’m afraid that the Obama folks set us back because the Obama approach to healthcare reform was, take the world’s worst healthcare system and make it bigger. That’s what we did effectively. America’s healthcare system, I think, is best understood as the world’s largest price fixing scheme. And we just extended that model to more people.
Goldy, David Goldstein:
We gave more people access to it.
Nick Hanauer:
Yeah. We gave more people access to that terrible system.
Goldy, David Goldstein:
Which, to be fair, look, improved a lot of people’s lives over what the previous system was.
Nick Hanauer:
It did. It did, and we did some other minor things at the margins. We constrained the VIG that insurance companies could take. We made sure that pre-existing conditions-
Goldy, David Goldstein:
Pre-existing conditions was a big one.
Nick Hanauer:
… there some other couple of things. Right.
Goldy, David Goldstein:
Because that was catastrophic for people.
Nick Hanauer:
That’s right. But it was not healthcare reform.
Goldy, David Goldstein:
It was reform. It wasn’t enough reform.
Nick Hanauer:
No.
Goldy, David Goldstein:
But, Abdul, the last time we talked to you was in September of 2020, about six weeks before the presidential election. And we approached that conversation with a lot of optimism for the next four years. And we’re recording this in December of 2024, about six weeks after the presidential election and a few weeks before Trump is re-enthroned.
Can you approach, is there any optimism?
Dr. Abdul el-Sayed:
Let me try. So, just on the ACA, look, any effort to extend more and better healthcare to people is a good thing. But to your point, Nick, the challenge was that we tried to stabilize what is ultimately an industry designed system.
And so, if we were only going to do what industry assented to doing, of course, they were going to make sure that they made a lot of money off of it, and they did, and it did not contain prices. So I’m not against the ACA. I think we can continue to improve it. That being said, structurally on its own terms, it was never going to solve the problem.
I think there is hope in some respect because, look, I served on the Healthcare Unity Task Force that now President Joe Biden put together. But I also had an inkling that there wasn’t going to be much movement on healthcare in large part because nobody wanted to talk about health anymore.
After the pandemic, the pandemic itself became the thing that you politically could not touch. Republicans pretended that it didn’t happen, and Democrats pretended that it was over. And this despite the fact that it persisted well longer than the period in which we were able to talk about it.
And after that, there was, I think, Joe Biden had scar tissue around his experience from the ACA and didn’t feel like he wanted to squander any of his political capital on healthcare reform. And so, in some respects, I think right now as Democrats are searching for where we go from here, I actually think that there’s an opportunity, ironically, to come back to the biggest single festering issue that continues to bedevil the American public, which is healthcare.
If we’re looking for an issue that unites people, clearly this is the one that unites people. And they are outraged about it. And the truth of the matter is, and we got to just speak plainly here, whenever you see a public consensus that is deeply misaligned from a political consensus the delta between those two is somebody’s money.
And if you look, go to Open Secrets and look at lobbying by sector. The number one biggest lobbyist by sector is pharma. Number two is insurance, and number eight is hospitals and healthcare.
So collectively, when you think about the behemoth that is healthcare, no industry spends more money to make sure that they can continue to make money. And, unfortunately, because of the porousness of the firewall between our economy and our politics, the ability to continue that flywheel forward continues on the backs of everyday people.
So, it is going to be some pain in speaking honestly about healthcare, and that’s going to be being willing to stand up to the influence peddling of the industry. But I think there’s political gold in them, there’s hills.
And more importantly, anybody who’s ever run for office, anybody who’s ever gotten into public service did it for some reason to solve people’s problems. This is for so many people, the number one, two, and three problem.
So this is an opportunity to do the thing that public servants say they want to do, which is to solve people’s problems. So let’s go get it and be willing to have some boldness. And maybe while we do that, we’ll find our authenticity in the process because this is authentically a problem for people.
Goldy, David Goldstein:
Yeah. I don’t know about the next four years.
Dr. Abdul el-Sayed:
Donald Trump’s never going to do this.
Goldy, David Goldstein:
Right.
Dr. Abdul el-Sayed:
Donald Trump’s never going to do this, but I do think that maybe there’s a forcing function among Democrats, which shows us that we’ve got to speak to real issues. You can’t talk in euphemisms to people. I mean, in a room like this where a bunch of folks have been thinking in abstractions about complex problems, euphemisms mean something.
But if you are talking to folks in the community like the one I serve, they are asking you about meat and potatoes issues. What does this mean for the bottom line number that my family has to pay to get the basic things to make sure my little Charlie can get the healthcare that they need, to make sure that I can get the medications I need, that my mom gets the healthcare that she needs? What’s that bottom line?
And we’ve just got to speak to that, and we’ve got to be honest about why that bottom line keeps getting bigger and bigger and bigger. And we keep saying we’re going to do something about it, but nothing really changes. And so, we can decide that actually we’re going to do something and we’re going to fight the industries that keep us from doing something. But it’s going to be in a fight.
Nick Hanauer:
We always ask a couple of final questions. One of them is the benevolent dictator question I think you’ve answered, which is, if you were in charge of the healthcare system, what would you do to fix this problem?
Dr. Abdul el-Sayed:
I would set us on a path to Medicare for All.
Nick Hanauer:
Okay.
Dr. Abdul el-Sayed:
And, I just also want to be, say one more thing. I started my career in public health. And in public health, our whole goal is about collective action for public good.
I only really got into healthcare because I realized that so long as we continue to spend 20% of our whole economy on the back end of healthcare, we’re never going to invest in public health.
So, to me, it really is about fixing this self-perpetuating flywheel of healthcare costs so that we can get into the business of investing in the things that keep people healthy in the first place. Because none of us want to, like we all want the healthcare we need when we get sick, but none of us want to get sick in the first place. So that has to be where we go.
And I just want to situate this within the broader goal of what we really ought to be thinking about when we think about health.
Goldy, David Goldstein:
Yeah. I’m 61 years old, so I just hope we’re still on the path to Medicare for me because I’m not sure we’ll be there by the end of this administration.
Dr. Abdul el-Sayed:
Well, look, Goldy. God help us. The best way to keep Medicare sustainable is to put more younger people on Medicare.
Goldy, David Goldstein:
I agree.
Dr. Abdul el-Sayed:
Right? That’s the best single way. This is just an insurance pool. So you need younger, healthier people who end up subsidizing the whole system. That’s how the system is supposed to work.
So it’s kind of crazy to create a pool where you just take care of the costliest people. It makes no sense on its own terms, but here we are.
Goldy, David Goldstein:
Okay. And the final question, Nick?
Nick Hanauer:
Why do you do this work?
Dr. Abdul el-Sayed:
My family comes from Egypt and my folks there were poor. My grandfather sold vegetables at a fish market. My grandmother was illiterate. And I used to spend a lot of my summers there living the alternative of what my life should have been but for the accident of history of my dad moving here.
I have an aunt and uncle I never got to meet because they died in infancy. And my dad was the eldest. He watched both of his siblings die before the age of one before he turned five years old.
I think about our responsibility as being able to provide the best access to a long, healthy life for everybody, and that means nationally and abroad. But the crazy thing is this, I didn’t have the language for it.
When I’d go from just outside Detroit to Alexandria, Egypt, I’d travel 15 hours, and 10 years difference in life expectancy. I could go 15 minutes into the city of Detroit and cross the same ten-year life expectancy gap. And we ought to be, as the richest, most powerful country in the world, in the business of addressing those gaps. And so, I decided to be in the business of addressing those gaps.
Nick Hanauer:
Well, thank you so much for being with us. It’s a fantastic conversation. It’s very timely.
Dr. Abdul el-Sayed:
Yeah, I appreciate y’all having me, and thanks for covering this.
Goldy, David Goldstein:
So just to reiterate, Nick, we are not pro-violence.
Nick Hanauer:
Correct.
Goldy, David Goldstein:
That was the-
Nick Hanauer:
And we spend a lot of time and a lot of money trying to reduce gun violence in the United States of America.
Goldy, David Goldstein:
Right. So, there’s certainly a role for responsible gun legislation here to address things like this. And, also, to be clear, we are not anti-market. Right? We’re not socialists. We don’t want to tear down the whole market capitalist system and have a state control of everything.
But, not all markets are the same. Not all markets function well on their own, and the healthcare market is clearly a market failure. And so there is room for an active role for government at the very least, in providing insurance, if not in running the healthcare system as a whole.
Nick Hanauer:
And, I think talking to Abdul just reinforces everything that I remember and have studied about how dysfunctional our healthcare system is and why it’s sensible and righteous to be really mad about the way in which it operates and be anxious to change it.
I do think that, look, the ACA is on balance a positive thing, but I do think that the Obama approach to healthcare reform set us back because we actually didn’t have a conversation about how to reform the healthcare system. We had a conversation about how to include more people in a very broken system.
And the whole thing left sort of a bad taste in people’s mouths because we did “healthcare reform.” And, again, acknowledging that a bunch of people that didn’t have access to the system now do. But for the majority of people, the system did not get materially better.
Of course, there are pre-existing conditions and a couple other knits at the margin. But, we still spend about twice as much per citizen, per year on healthcare as the rest of the industrialized world. And it’s still hard to get good healthcare, and our outcomes are still worse than most places.
So, for most people, it was not a success. It was not a win. It didn’t improve their lives. So, you know.
Goldy, David Goldstein:
Yeah. I think my biggest criticism of Obamacare, because remember, you have to remember it within the political context, the fight over it, how hard it was, how much Clinton failed when he tried to reform healthcare.
Nick Hanauer:
Yeah, absolutely.
Goldy, David Goldstein:
But, my biggest critique is that he refused to put any political capital into a public option. I remember at the time during this fight, Howard Dean, former presidential candidate, former Vermont governor, former head of the DNC, he was in Seattle for an event, and I had an opportunity to have a conversation with him afterwards.
And he basically said, “Look, the secret here is to get a public option, because all those arguments about a public option being a slippery slope to socialized medicine, it’s true. You get a public option through the door, and eventually it will triumph because the private industry can’t compete with it.
Over time, except for at the high end, wealthy people, they can afford to get their premium, whatever. But everybody else will end up in a public option, and it will be very efficient and it will deliver.” He didn’t use the term Medicare for All, but it would deliver the equivalent, it would be Medicare for 90% of the people, essentially.
And had Obama put his foot down and said, “Public option, there needs to be a public option as part of this.” Had we gotten the public option, I think Dean was right. I think that over the intervening years, it’s the public option that would have triumphed.
Nick Hanauer:
No doubt. No doubt. Yeah.
Goldy, David Goldstein:
And so, it was a missed opportunity. And I think, again, look, we love a lot of what Obama did. A lot of the Obama administration, our critiques with them is that they were never bold or courageous enough. He got things done that nobody else got done, but didn’t try to do more.
And had he, we very well may have been on that path towards Medicare for All that Abdul is talking about. But because we didn’t, we’re not, and in a way, we’re a setback. So maybe after everything collapses during the Trump administration-
Nick Hanauer:
Yeah, you can start over.
Goldy, David Goldstein:
… and we’re digging ourselves out of the rubble, maybe a public option is the first thing that we’ll get through the whatever replaces the US Congress.
Nick Hanauer:
Yeah. Well, that’s something to look forward to anyway.
Goldy, David Goldstein:
Yeah. I always like to end on a high note. If you want to hear more from Abdul, and we definitely encourage it. We’ll provide links in the show notes, so his podcast, “America Dissected”, and to his books, “Healing Politics: a Doctor’s Journey Into the Heart of Our Political Epidemic”, and “Medicare for All: A Citizen’s Guide”.
Speaker 6:
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