This week, Biden-Sanders unity task force appointee Dr. Abdul El-Sayed walks Nick and Goldy through the Biden transition team’s health care plan.
Abdul El-Sayed is a physician, epidemiologist, public health expert, and progressive activist. He is the Chair of Southpaw Michigan and a contributor at CNN. He is the author of ‘Healing Politics’ and the co-author of the upcoming ‘Medicare for All: A Citizen’s Guide’. He also hosts “America Dissected,” a podcast by Crooked Media.
Twitter: @AbdulElSayed
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Further reading:
Coronavirus is exploiting an underlying condition: our epidemic of insecurity: https://www.theguardian.com/commentisfree/2020/mar/19/coronavirus-insecurity-anxiety-us-epidemic
Biden-Sanders Unity Task Force Recommendations: https://joebiden.com/wp-content/uploads/2020/08/UNITY-TASK-FORCE-RECOMMENDATIONS.pdf
Healing Politics: https://www.indiebound.org/book/9781419743023
Health insurance and the COVID-19 shock: https://www.epi.org/publication/health-insurance-and-the-covid-19-shock/
Website: https://pitchforkeconomics.com/
Twitter: @PitchforkEcon
Instagram: @pitchforkeconomics
Nick’s twitter: @NickHanauer
Speaker 1:
Real quick, we wanted to tell you about another podcast, called Economics Detective Radio. On it, you’ll find answers to questions you didn’t know you had like, “What can the Volkswagen Emission Scandal tell us about car exhaust and public health? What’s the relationship between maritime trade policy and the merchant Marine? What can a 1920 border closure tell us about immigration and the economy?” Find out more on Economics Detective Radio. Available now, wherever you listen to podcasts.
Nick Hanauer:
We absolutely have to find a way in this country to totally transform our healthcare system into something that works for all citizens.
David Goldstein:
In a post-COVID world, where anybody with a COVID antibody is potentially denied a claim based on a preexisting condition.
Dr. Abdul El-Sayed:
There is just a huge political fight ahead of us. I mean, these may be the most important 40 days for the future of our democracy that we might’ve ever had.
Speaker 4:
From the offices of Civic Ventures in downtown Seattle. This is Pitchfork Economics with Nick Hanauer. It’s like Econ 101, without all the BS.
Nick Hanauer:
I’m Nick Hanauer, founder of Civic Ventures.
David Goldstein:
I’m David Goldstein, Senior Fellow at Civic Ventures.
Nick Hanauer:
Since the onset of the COVID-19 shock to the economy, roughly 6.2 million workers have lost access to health insurance that they previously got through their employer, according to the best measure of net employment change, which is just, it’s just staggering, right?
David Goldstein:
Yeah. And it’s nuts. It’s crazy. It’s not a way to run an economy. It’s not a way to run a healthcare system.
Nick Hanauer:
It dwarfs the loss coverage, that we experienced during the biggest job losing period of the great recession. We absolutely have to find a way in this country, to totally transform our healthcare system into something that works for all citizens and in the context of the broader economy, and at all times. The pandemic has proved, I think, beyond a shadow of a doubt, how idiotic an employer-based healthcare system is right, because in a circumstance where millions of people are losing their jobs and thus their healthcare, during a healthcare crisis.
David Goldstein:
Right.
Nick Hanauer:
Right, because of a healthcare crisis. That’s a great way to prove yourself that having an employer based healthcare system is idiotic and counterproductive. Today, we get to talk to this fantastic guy, Abdul El-Sayed, who’s a physician and epidemiologist, a public health expert. A really interesting character.
Dr. Abdul El-Sayed:
My name is Dr. Abdul El-Sayed. I am a physician, epidemiologist and progressive activist, and just wrote a book called Healing Politics: A Doctor’s Journey Into the Heart of Our Political Epidemic . Early next year, in February, I’ve got another one coming out with my co-author Dr. Micah Johnson, Medicare for All: A Citizen’s Guide. I hope folks will check them out.
David Goldstein:
With a Supreme Court nomination battle heading our way, it looks like Republicans are planning on confirming a new justice, just before they hear a contest against the Affordable Care Act. If you could just start off, at least talking about what’s at stake here, if they were to throw out Obamacare, and protections against preexisting conditions, and all that.
Dr. Abdul El-Sayed:
Yeah. Well, basic healthcare access for 20 million Americans, the ability for health insurance corporations to discriminate against people with pre-existing conditions and basically deny them healthcare coverage, because they are sick and the healthcare economy, as we know it. I think in so many ways, this is a moment that speaks to the worst in the way that our system is so fragile, and leaves people so insecure.
There is just a huge political fight ahead of us. I mean, these may be the most important 40 days for the future of our democracy, that we might’ve ever had certainly in times of relative peace. It really is a scary time, as a former health director, I’m often reminded that numbers don’t do as good a job in explaining what’s at stake, as the stories of people’s lives. We have to remember when we talked about that big number, 20 million. Every one of those people is somebody with a particular set of precarious circumstances, who has joys and fears, and people who love them and people they love. We can’t forget that those are 20 million different stories of folks who could very well be failed by our government right now.
David Goldstein:
In a post COVID world where anybody with COVID antibody, is potentially denied a claim based on a pre-existing condition?
Dr. Abdul El-Sayed:
That’s right. We don’t know what the long-term consequences of COVID-19 are going to be. This disease has only really been in humans now, for about nine months, and we don’t know what the implications are. So, you can imagine a moment where even people who had asymptomatic, COVID-19 are experiencing complications of that infection 3, 10, 20 years on. In a world where we have private health insurance corporations, who then are allowed to discriminate against them, you could imagine a circumstance where a large swath of Americans are barred from being able to get health care, because of the consequences of the same party that barred them from having healthcare, failing to take on this COVID-19 pandemic.
On one side of their mouths, they’re talking about herd immunity, this extremely wayward, scientifically unsubstantiated approach to taking on this disease, and on the other side of their mouth, they’re talking about taking away people’s healthcare in the context of the pandemic that they are actively facilitating, because of their choices. It is absurd, and it’s just so cynical about feeding the interests of those who have money at the costs of those who don’t.
Nick Hanauer:
So, your book starts with this really interesting quote, “Medicine is a social science and politics is nothing else, but medicine on a large scale.” So, explain that, translated into at least pandemic terms.
Dr. Abdul El-Sayed:
Yeah. It’s easy to look at medicine, especially nowadays given how much science has given us as a sterile scientific endeavor, but let’s not forget that we’re talking about healing people, and that has deep social implications. Frankly, even to practice medicine well, is not enough just to understand the science of why people get sick. One also has to understand the social science, of why people get sick. After all, this pandemic has taught us anything, is that, it’s not just about the pathophysiology of this virus underneath our skin. It is also about the pathophysiology of our society, in ways that happen above our skin, right? Who gets access to a good job that pays a living wage? Who gets access to health care? Who’s allowed to stay home and work from behind the computer screen? Who has to go to work in the midst of a global pandemic?
These are questions of social pathology, not of simply biological pathology. If we’re serious about healing, then we have to take on the social dimensions. It’s a quote from Rudolf Virchow, who operated on both fronts. He frankly, is the father of modern pathology, the mapping of biological failure to the symptoms that we see when people get sick. Also, he was a leader in the liberal party in Austria. Actually he faced off against Otto Von Bismarck, multiple times as Bismarck wanted to enact policies that benefited the ruling class, Virchow was always there in opposition.
There’s actually a really fun story I shared in the book, about a duel that Bismarck challenged Virchow to. Virchow said, I don’t duel, but I’ll challenge you to a sausage duel, which meant they’d have two sausages. One of them would be loaded with round worm larva, and whoever ate the poisoned one would end up getting sick. Bismarck was like, that’s too far from me, bro, and so, he backed off. This is someone who recognized that it’s not just about the science. It’s also about the social science, and about recognizing the social dimensions and the political dimensions of how people get sick and why they get sick in societies.
Nick Hanauer:
So you’re part of the Biden, Sanders, unity taskforce on the future of healthcare. Tell us about the glorious future, should Biden get elected.
Dr. Abdul El-Sayed:
Well, I could have told you a lot more, of course, before the passing of the late great Justice Ginsburg, because right now, the future of the ACA itself hangs in the balance. Then of course, if the ACA is deemed unconstitutional, it’s going to mean that we’re not only going to have to claw back what might have been lost, but also to think differently. It really may change the approach, that a future Biden administration could take to healthcare. Assuming that the ACA stays in place, which I think is a very tenuous assumption, the plan was to create a far more muscular version of a public option, than the Vice President initially ran on in the primary.
Now, to be clear, I support Medicare for All. It’s one of the reasons I got into politics and the reason I co-wrote a book about it, but recognizing that Bernie Sanders did not win the primary, the question that I had, as well as my colleagues who were Sanders appointees, including Representative Jayapal, Pramila Jayapal of Washington, who is the lead sponsor of the Medicare for All bill in the House, as well as Don Berwick, a former Centers for Medicare and Medicaid services administrator, our goal was to ask, how do we build the case for stronger public health care? How do we provide healthcare for folks, who right now cannot afford it? How do we take on the power of corporations that have dominated it?
A lot of the recommendations that we were able to come together with representatives on the other side, folks who were really leading the fight for Joe Biden’s health care plan, and ask, how do we do this thing together, even if we may disagree on the central premise of what we ought to do? What we were able to come together on, is a public option that’s a lot more muscular. It’s fully funded and subsidized for folks earning less than $52,000 a year for a family of four, 200% of poverty. It is deductible free. It would be truly a public option, meaning corporations could decide to, rather than buying private health insurance for their employees, enroll them on the public option. I think probably most critically, it would allow CMS, Medicare to negotiate the price of prescription drugs on behalf of every single American, which of course is illegal right now, because of pharma lobbying.
These are really important investments in public health care, that really would provide health care to a lot of folks who don’t have it, but at the same time, to me, you look at the issues that we have in our healthcare system. I don’t see how Medicare for All is not the most elegant, most simple, most politically palatable approach, to solving them all. We may maintain disagreements on that front, but I think it’s really important, right now to recognize what the alternative is, which is Donald Trump. He has no healthcare plan, despite the fact that he keeps dangling one from a string. He has not intended to have a healthcare plan. He simply wants to undo what his predecessor did. In so many ways, this very cynical approach to appointing a Supreme Court justice, to replace one of the lionesses of justice in our society, Ruth Bader Ginsburg, is a ploy to just undo what Obama did, without any real investment, and even thought into how to take on this very naughty and complex problem.
David Goldstein:
I’m going to uncharacteristically strike an optimistic note, and wonder if ironically, if they strike down the ACA, does that leave Medicare for All as, the only constitutional option? Unless, they also strike down Medicare, which I wouldn’t put it beyond them, but if Medicare is constitutional, certainly Medicare for All is. You’re just expanding it to everybody.
Dr. Abdul El-Sayed:
Well, it’s a very simple solution. You’re basically taxing people, and then providing a good. If you struck that down, basically you’d say government can’t exist anymore because that’s what government does.
David Goldstein:
Well, they’re going there.
Dr. Abdul El-Sayed:
They’re trying, they certainly are trying. What I will say is though, is that if we lose the Supreme Court battle, I worry a lot, not just about the ACA, but about Roe V Wade, for example, which is critical to providing healthcare for people with uteruses. You think about all of the other laws and policies that have tried in this country to promote more justice and more equity and more sustainability. I worry a lot about their future. This is a fight that I think starts with healthcare, but could go a long, long way beyond it. There’s a lot we need to be fighting for.
Nick Hanauer:
I’ve been thinking hard about healthcare, for a long time. In my role as a technology entrepreneur, tried to build essentially an alternative pathway for providing people healthcare, some time ago. It failed for a variety of reasons, most notably because the insurance industrial complex hated it, but it definitely taught me that progressives are great at talking about providing healthcare for everyone, without providing a plausible, either a plan or a narrative that explains to people how we’re going to do that, in a more affordable way.
The healthcare problem in America is two fold. The first is not everybody has it, but the fundamental problem is costs roughly twice as much per person, per year, to do healthcare in the United States, as it does in every other industrialized nation. That is the fundamental problem, is the economic arrangements that are in place, that lead a colonoscopy to cost $500 in Germany, and $5,000 in the United States. This is the problem.
Dr. Abdul El-Sayed:
You’re spot on.
Nick Hanauer:
Right? By the way, I don’t mean the price you’re charged. I mean, the fundamental cost of the operation, right? I certainly haven’t heard anything about what we do to rearrange the economic feedback loops, in the healthcare system, to bring the cost of doing things down enough so that we can quite easily afford to provide everybody with healthcare.
David Goldstein:
Right. I guess to sum up that question, apart from negotiating drug prices, would a robust public option dramatically bring down costs?
Dr. Abdul El-Sayed:
Well, I think that the challenge, right, that those of us who support Medicare for All have, is exactly this one, is how do you address not just the high cost, but the system that created the high cost? The reason why Medicare for All is so effective to doing that, is because it creates a government monopsony right? A lot of folks know what a monopoly is. It’s a single seller of a good, a monopsony is a single buyer of a good, in both a monopsony like a monopoly, has the power to set a price. If the government is setting the price for healthcare, it eliminates this adverse feedback loop, whereby both the insurance corporations and the healthcare provider corporations, have more incentive to negotiate using each other against their competitors, than they do to negotiate on behalf of the ostensible customer.
That leaves us in the system more like a product than a customer. Medicare for All solves that, by basically eliminating all of the insurance side of it, and setting a singular price, which also eliminates a lot of the overhead, that inflates price in the United States as well. There are ways to get through there, which we talk about in the plan and I know that the Biden team is interested in engaging with, which is price setting, right? If you know that one of the reasons that the costs continue to go up in the system, is because the prices can go up, one of the ways to do that is just for the government to set the price, to say, basically, this is the price of an MRI, no matter what the provider is, or who the insurer is that you set that price.
That being said, it’s a lot more elegant to do under Medicare for All, because you do it naturally by leveraging market laws, but by doing that by basically making one buyer of healthcare, which is the government. There’s a way to do it. It’s just a lot more complex and it’s hard to explain. This is the bigger picture here of healthcare, is that it is so complex to explain to folks, because most folks… I mean, I’m a doctor, my wife’s a doctor. When it comes time for us to buy our insurance through her employer, half the time we have to sit down and actually negotiate, leveraging an actuarial table, what we think is the best rate, right? This is as a physician epidemiologist. If it’s opaque to me, I can’t imagine how opaque it is to the average user. We’ve just got to do a lot better about being simple about it.
One of the things that Medicare for All does, which is so important is to simplify the process for people. If the only insurer in town is Medicare, it changes the conversation. Now a lot of doctors would say, well, I wouldn’t be able to exist if all I was able to bill is Medicare. The problem with that argument is that, underlying it is a certain lack of imagination, right? You could change the reimbursement rates as you needed, to make sure that doctors are made whole.
There’s a second order of peace here, if we want to get really into the weeds, that I also think is really important. One of the things that we’ve seen across the healthcare industry right now, is deep consolidation, both on the insurance side and on the provider side. Particularly on the provider side, as the larger providers have been able to negotiate better rates per unit care, they’ve been able in effect to out-compete the individual doctor who’s got their shingle out. It’s forcing those doctors to in effect, rather than being owners of their own business, to become simply employees, of a much larger corporation.
What that means is that their share of the earnings of their own work falls, and under Medicare for All, because there’s one rate. Now, if you’re a small private practice, or you’re a large system, you’re still getting the same reimbursement per unit care, which means that if you’re good at what you do, and you’re efficient and you’re effective, you can grow and you can have your own business too. I actually think it’s in doctor’s best interests, to be able to work in a system, where they don’t have to worry about the large health systems, swallowing up their practice, because they just can’t compete.
David Goldstein:
I hadn’t thought about that before, that it actually recreates an environment where doctors can choose to be entrepreneurial, if that’s what they want, instead of employees.
Dr. Abdul El-Sayed:
Right, that’s exactly right.
Nick Hanauer:
One of the questions we love to ask is the benevolent dictator question, which is, if you were in charge of America’s healthcare system, politics aside, what are the top three things you would do? How should we reconstitute this giant?
David Goldstein:
Fix this for us.
Dr. Abdul El-Sayed:
I would rapidly and very quickly establish a democracy clearly. I think the big three for me are number one, we would pass Medicare for All, because I think it addresses so many of the inefficiencies in the healthcare system, as it stands. It provides every single person healthcare, and it reduces the overall cost, and also the increasing rate of costs in our society. That’s number one.
Number two, though, I would massively invest in public health. In fact, I would put Medicare for All under the public health infrastructure in this country, because the best single thing we can do is prevent someone from getting sick in the first place. We spend so little on public health in our society, and it shows right? We’re in the midst of a global pandemic, and our public health apparatus was caught flat-footed in large part, because we have a president who’s an incompetent buffoon, but also because the institutions themselves aren’t geared to take the reins when they need to.
The third thing I would do, is I would really seek to reintegrate aspects of healthcare that I think we have wrongly cut away from the health care conversation, things like dental coverage, and mental health coverage, and long-term services and support coverage, because those are critical public health and healthcare services that ought to be a negotiated in the same package of goods, right? The notion that we, in the conversation cut the head off, right? No mental health care, no dental healthcare.
David Goldstein:
What’s the history of that? That’s crazy. How did that happen?
Dr. Abdul El-Sayed:
It is because we traditionally, sort of dentistry was practiced as its own thing, versus medicine. That’s sort of just an accident of history, but also, because the way that healthcare developed, was in reference to infectious diseases, right? You want to step way back, before we even had the germ theory of disease, right? The goal was to save lives and the thing that killed most people, was infectious diseases. So much of the advent of medicine, was built around protecting people from infectious diseases, rather than investing in the long-term functionality of a body, right? We just wanted to save your life at that point, right?
Now, we’ve come to a point where even chronic diseases are really about long-term care management, rather than lifesaving care in one point. Frankly, I would argue that the hospital itself as an institution is a bit of an anachronism, right? We still have hospital-based care, because we originated hospitals in a time when treatment was, you came in very sick, we treated you, and then you left as healthy as you were when you came in.
Now, you’re talking about the long-term management of chronic diseases, so everything’s about managing people’s functional abilities. We’ve sort of had this convergent evolution, and we look at these systems and say, well, why don’t we invest in making sure that people can see, and people can hear, and people’s teeth are healthy, and people are feeling good, and are well situated and functional in their lives through a mental health supports, in the same system that we care for their liver, and manage their diabetes, and make sure that they don’t have heart disease. It doesn’t make any sense, but in part it’s a function of the evolution of healthcare over time.
Nick Hanauer:
Crazy.
David Goldstein:
I’m sorry, I took you on a tangent. Did you have a third thing you would do is benevolent dictator?
Dr. Abdul El-Sayed:
Yeah. My third, after of course establishing democracy was to reintegrate mental health care, dental healthcare, vision, and hearing support and oral healthcare into the system.
David Goldstein:
Okay. Well, I vote for you, for benevolent dictator. Especially the restored democracy part. That’s always important, that we end with that.
Dr. Abdul El-Sayed:
I’m imagining this severe tautology here, where I re-established democracy, and then you’re like, no, be the dictator. I’m like no back to democracy, and then we’re just bouncing back and forth. I mean like, no, you, sir. No, you, sir.
David Goldstein:
Yeah. Well, here’s hoping, speaking of democracy, here’s hoping you have a chance to help the Biden administration fix these problems.
Dr. Abdul El-Sayed:
I appreciate that. There’s a lot of problems to fix and as an epidemiologist, and former health commissioner, I have felt a little bit like a general who trained for the big war and now I’m somewhat missing it. I watch what’s happening right now, and I feel like there is so much we need to do to get it right. It’d be a privilege to be a part of that.
Nick Hanauer:
Well, thanks so much for being with us. It was a fantastic conversation.
David Goldstein:
Yeah. Thanks.
Dr. Abdul El-Sayed:
It was my privilege. Any opportunity I get to wonk out about healthcare, I never miss it, so thank you.
David Goldstein:
So Nick, on the one hand, talking with Abdul makes me feel really confident that there are competent people working with what we hope will be an incoming Biden administration, to get a handle on this crisis at the same time, oh my God, what happens? What happens if… I won’t say if Biden doesn’t win, if he’s not allowed to take office?
Nick Hanauer:
Always the ray of sunshine. Goldie, I mean, when you said that you had a glimmer of optimism, I never quite thought of it that way, but if these clowns do eliminate the Affordable Care Act, it may be the world’s best forcing function to get it right. It may be the world’s best opportunity to provide essentially Medicare for All, or Medicare for everyone who wants it.
David Goldstein:
Right.
Nick Hanauer:
Because, in the absence of an alternative, the Republican Congress is going to be looking down the barrel of 20 to 40 million incredibly pissed off people, and all the people who know those people.
David Goldstein:
Potentially no other constitutional option. If they close the door to an Affordable Care Act style system, then government health insurance may be the only thing that’s available to the federal government, to address this.
Nick Hanauer:
Correct.
David Goldstein:
Unintended consequences can always happen. I want to bring back… We’re talking about this within a COVID context and I wanted to get to some of both the economic issues here, Nick, and of course the racial and gender issues. I mean, even the CDC has acknowledged that COVID has disproportionately impacted people of color, both in terms of higher infection rates and in higher mortality rates. I mean, these are people who are disproportionately low wage workers, and therefore ironically essential workers, but also people who economically could not afford to stay home. They didn’t have that option. If their job was still there, they had to take it and they had to go to work and put themselves and their families at risk.
Nick Hanauer:
Yeah.
David Goldstein:
But it’s not just COVID. A couple of weeks ago, you and David Rolfe published your piece in Time Magazine, about the $50 trillion trans upward redistribution of income, from the bottom 90% to the top 1%. You write about how both in terms of COVID and an income in general, it disproportionately impacts women and people of color.
I want to bring this point up because I’ve been doing some research on my own, and it should not be surprising to anybody that when you track health outcomes, when you look and the number one outcome is longevity, what’s the best predictor of life expectancy? Wealth. The higher your income, the longer you live. The lower your income, the sooner you die across the board. So, anybody who tells us, oh, stop complaining about the American healthcare system. It’s the best in the world. Oh, sure, it’s more expensive than everybody else’s, but it’s providing the highest quality healthcare in the world. Yeah. For you, Nick. For people like you and for people like me. For the vast majority of Americans? No. The lower your income, the poorer your health, the shorter your life span and that is just totally immoral.
Nick Hanauer:
Yeah. It is heartening to hear from people like Abdul, who I think clearly understand these problems super well. In about what is it, 45 days, we’re going to find out if people like that are going to be in charge or not.
David Goldstein:
On the next episode of Pitchfork Economics, it’s another, “Ask me anything,” where Nick and I will be answering your questions.
Speaker 4:
Pitchfork economics is produced by Civic Ventures. If you like the show, make sure to subscribe, rate and review us wherever you get your podcasts. Find us on Twitter and Facebook at Civic Action and Nick Hanauer. Follow our writing on medium at Civic Skunk Works, and peek behind the podcast scenes on Instagram at Pitchfork Economics. As always from our team at Civic Ventures, thanks for listening. See you next week.