Apr 23

Apr 23 Episode 493: Dr. Abdul El-Sayed

In conversation with Epidemiologist and Former Detroit Health Director Dr. Abdul El-Sayed, about the new book Medicare for All: A Citizen's Guide, that he co-authored with Dr. Micah Johnson.

Musical credits:

"Are You Listening" from Elephant Shaped Trees by IMUNURI.
Released February 3, 2018.
Composed by André Pilette, with the help of Adam Garcia, Stephanie Leary, and Dan Wilson.
Lyrics written by Stephanie Leary.
Produced by André Pilette and Stephanie Leary.
Mixed by Brett Ryan Stewart of The Sound Shelter in Nashville, TN.
Mastered by Michael Fossenkemper of Turtle Tone Studio in NYC.
Song used with permission by the band.

Episode Transcript

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Teddy 0:00

Hi, this is Teddy. And today you're listening to Dr. Abdul El-Sayed, author of Medicare For All: A Citizens' Guide on Two Broads Talking Politics. Get your vaccine.

Sophy 0:32

Hey, everyone, welcome to Two Broads Talking Politics. I'm Sopphy, and I'm here with my co host, Kelly. Hey, Kelly.

Kelly 0:40

Hey, Sophy.

Sophy 0:42

And joining us today is Dr. Abdul El-Sayed. He is the former Detroit Health Commissioner, a progressive activist, a doctor, the author of The Incision on Substack, and the author of a new book Medicare For All: A Citizens' Guide. So welcome.

Dr. Abdul El-Sayed 0:59

Thank you so much for having me. I'm excited to be with you.

Sophy 1:01

Thank you so much for joining us, I'm really excited to talk to you about Medicare For All. It's been a really important part of politics for a while. And it's really important to what I do in my work and to, I think, a lot of people's jobs in healthcare. But first, I'm wondering if you can just sort of talk to us a little bit about sort of how your book came to be kind of how did you decide to write about Medicare For All?

Dr. Abdul El-Sayed 1:30

Yeah, I've been a proponent of single payer health care since I was in medical school. And, you know, into the debates about the Affordable Care Act. And then thereafter, when it was clear that the Affordable Care Act, though it did some amazing things for a lot of people, it just didn't quite capture all of the potential change that we need to to achieve the kind of healthcare system that we deserve in this country, that's more just equitable and sustainable. And I was the Health Commissioner in the city of Detroit, a city where 50% of our population is on Medicaid, many of those folks got access to Medicaid because of the ACA. But we're still a city with one of the highest uninsured and underinsured rates in the country. I ran for office. And when I ran for office, I made single payer health reform in Michigan, one of my key platform planks, because I do think that it is critical for us to be able to achieve the kind of healthcare system where our bodies are not profiteered off of. And then I was also a surrogate for Bernie Sanders, when he ran in the primary. But through the process, I came to appreciate that the policy justification for Medicare For All single payer health care, was that that brought me to it, wasn't really where the space of the debate was. Instead, we were having a far more politicized debate within the political arena. And so I worked with Dr. Micah Johnson, my co author, who also helped me architect, the mission care plan that I ran on in Michigan. And we said, you know, you know, it would be great if we were able to de-politicize this question, and bring this conversation back to the kitchen table conversations that so many people are sharing about their health care, because one of the ways that the healthcare system benefits is through opacity, right. They know that a lot of folks don't really understand how this very complex system works. And so they don't connect the brokenness that they feel every day, to the brokenness inside the system in this book was about doing just that. And then mapping how Medicare For All would solve that to the current system, and talking a little bit then about the politics of it. Hopefully, in having engaged people to see healthcare for what it was in their own lives, bring them back to the political and ask, are we now willing to fight for a system that truly does solve so many of our problems personally.

Kelly 4:04

Can you talk some about the ways in which this a pandemic that we're in right now, the COVID-19 pandemic, how that changes the way people think about health care, and health insurance and what that might look like and how we can sort of use this as a way to really dig into this conversation about Medicare for All.

Dr. Abdul El-Sayed 4:26

Well, you know, at the top of the pandemic, 15 million people lost their health insurance. And that didn't happen in any other country in the world. Not only that, but we were watching our brave nurses and in doctors and hospital employees trying to care for the sick and dying, wearing garbage bags because their hospitals are run on a profit margin that dictates that they shouldn't stockpile these basic personal protective equipment And beyond that, 47 hospitals in 2020 either went bankrupt or shut down completely. That also didn't happen in other countries. All of this because we, we allow our healthcare system to operate on a profit margin, both for insurance and also for providing health care. And together, that leaves us paying more, that leaves us more insecure. And that leaves our system, the most expensive system in the world. And all of that doesn't have to exist. And I think COVID-19 it shone a new light on some of the ways that our systems, healthcare being one of the principal ones, have just been so brittle and so fragile to these kinds of situations. And, you know, folks can look at that and say, well, COVID-19 is a once in a century pandemic. That may be true, right. But if it can't protect us in a pandemic, what can it do? And so I think that folks are starting to ask these questions in a new light. And I think it is really important for us to be continuing to have this conversation about why our system is broken, and about what we could do to fix it.

Sophy 6:04

I want to take a step back and see if we can define sort of what Medicare for All is, because I remember back into primary health care was a huge issue in the Democratic primaries for 2020. But there was a lot of confusion about what Medicare for All actually was, and whether what what that actually constituted and what people were advocating. So can you talk a little bit about sort of what you are describing when you talk about Medicare for All?

Dr. Abdul El-Sayed 6:36

Yeah, let's simplify the healthcare system into two basic parts. The first is the insurance system. Those are the folks who are supposed to be there for us to pay for our health care if and when we get sick, we pay for that if if we're privileged enough to have private insurance. Remember, 10% of Americans don't have insurance at all, we pay for that in the form of premiums that come out of our paycheck and are also subsidized by employers every two week or two weeks or every month. And then that we also pay for it in the deductible, which is some amount of money that we have to pay to get access to the insurance we already paid for. If and when we get sick. And then finally coinsurance or co pays some proportion of our costs, that we paid the point of care, that's insurance. But then health care itself, the part that we mostly interact with, is the providers, whether that be a clinic or a hospital, you go, you get your care, and they bill, they bill your insurance for that care. What we have in this country right now is a multi payer system, we have about 700 insurers and then don't forget, the biggest insurer in the country is Medicare, the Federal Insurance Program for the elderly, and people with disabilities, and then Medicaid, which are state operated public health insurance programs for people with low income. What Medicare for All is, is a single payer system. So imagine Medicare rather than just simply being for people over the age of 65, was extended to everyone. And it became the only insurer, right? If it did that there are so many benefits. Number one, the 10% of people who are excluded for the system today would have health insurance, that's a big deal. But number two, a lot of the overhead costs of our health care system exists in the crosstalk between all of these different providers of health care, and the 700 different insurers. If you have one insurer, a lot of that overhead cost to figuring out how to bill which insurer when, that goes away, because there's only one insurer. But then beyond that, you also have a situation where right now, each of our each of the providers and/or payers have an incentive to negotiate prices for for care that allow them to out compete their competitor. So if you're a payer, if you're an insurance insurance company, you're trying to out compete other insurance companies, if you're a provider, you're trying to out compete other their providers. And what that means is that it tends to lead to a monopolization in the system, a certain consolidation because the biggest providers of the biggest insurance companies get to command better rates. And that's led to a lot of the consolidation that we've seen big systems buying up smaller hospitals and outpatient providers, consolidating as well under the system umbrellas. And so that would reduce the kind of price negotiation that tends to benefit these corporations, but tends to leave our healthcare so expensive. And then lastly, the benefit that that I tend to be focused on as a former Health Commissioner, is the one where right now because there are 700 different insurers, there is no incentive to really invest in prevention, simply because the probability is that by the time that investment in preventing a certain outcome actually manifests, you're on to a new insurer or ultimately Medicare because after you turn 65, that is your insurer. But if we have one, one insurer, that insurer would be incentivized to prevent disease from the beginning. Because, you know, Medicare would be your insurance company yesterday, today and tomorrow. And so there's a lot of incentive to really go in and prevent disease on the forefront. So you don't have to pay it, pay for it on the back end. Because you're the only payer in town under Medicare for all,

Kelly 10:21

It's been an interesting watching the rollout of vaccines and thinking about how different that is from every other type of health care that I get. So you know, I have very good health insurance through my employer, but everywhere I go, every time I go, it's, you know, show us your insurance card, what kind of insurance do you have. And getting a vaccine, being able to just sign up for it, where I could find it, show up and get a shot, not pay anything. It's been kind of remarkable. And I wonder if that experience will change people's thoughts at all, in terms of at least some measure of this is a public good of public service, with a good public outcome. There's certainly plenty that hasn't rolled out well, getting vaccines and finding them. But but that piece of it seems so important to me that people can experience that.

Dr. Abdul El-Sayed 11:13

You're absolutely right. I mean, imagine in America, just rolling up getting the service that you need, and going about your merry way, that is no one's experience with health care, it's the first time we've experienced this. And at the same time, right, the point that you made about some of the hiccups of the vaccine rollout, they really demonstrate what happens when we don't invest in the public good of public health. I mean, we were able to pull off a medical marvel in this country, by going from soup to nuts on a new vaccine for a new virus that we didn't even know existed 16 months ago, and it was like, we developed this, you know, super powered engine, and then dropped it into the body of a Ford Pinto, right, because we just haven't invested in public health. It's part of the reason why we've suffered so greatly in this pandemic. And so it, this demonstrates both the upside of government healthcare, and because we have not invested in that infrastructure in the past, the downside of the private system where we have in effect in anemic public health infrastructure, so much of that could be the best of that could be captured under Medicare For All and the worst of it could be addressed. And that really should remind us what we have at stake, and that this could be so much better than it is. The last point I want to make on this right is that we have to remember that, that that that status quo bias is a real thing. And our status quo was terrible, but it is our status quo. And because in our country, we have watched as the systems of our public goods have crumbled over the past 40 years, anytime anyone who proposes a change, we assume it's going to be more of the same, which is worse. But it doesn't have to be that way. And part of that is just our sort of PTSD from a 40 year governing consensus that tells us that the that a corporation can do public goods better than government. And so that has left us being excluded or extracted from by these corporations, we can do better. And this is an opportunity for us to fundamentally and finally rethink the system as it exists.

Sophy 13:22

Speaking of rethinking the system as it exists, I think one thing that comes up a lot when people talk about Medicare for All is the fact that the United States has the most expensive health care system in the world, spends the most of any country and has such a different system than most other countries in the world. What lessons do you think we can take from other countries in the way they do their health care systems to build a good health care system here in the United States? What do you see that works really well in other countries' healthcare systems? And what do you think that we should sort of change or not adopt from other countries healthcare systems?

Dr. Abdul El-Sayed 14:03

Well, the principal point is that they just have substantially more engagement on the part of government and they've recognized that ultimately, if you leave something as critical as healthcare to private entities to profiteer from that's exactly what they're going to do. And just to just to make the point here, if I offered you five MRIs for $500, right now, my guess is that neither of you will take the deal. Either of you guys gonna take that today?

Kelly 14:33

I don't want any more MRIs than I need, but no,

Sophy 14:37

No, no,

Dr. Abdul El-Sayed 14:38

Exactly right. You're not going to buy it because you know, chances are, you don't want to waste 500 bucks on something you don't need. But if one of you were to be out playing soccer, with, with with with with, you know, a loved one or friend, a group, and this was socially distant soccer, of course, wearing masks unless everyone was vaccinated, and you were to feel a pop in your knee, then I might come back to you and say, well look, my five for 500 deals that's off the table. I'm gonna give you one for 5000. You think you'd buy it?

Kelly 15:09

Possibly?

Dr. Abdul El-Sayed 15:11

Yeah, you probably would. And the reason why is because that's the point at which you need it. And the point that I'm trying to make here is that there's a fundamental point or thesis inside medicine, which is that people don't want health care, what they want is health. Health care is just a means to getting health back once you've lost it. And these corporations understand that and so there's no incentive to prevent at all. And there's every incentive to keep raising prices, because your demand is fundamentally inelastic. And so that's exactly what corporations do in this country. And the only way to stop them from doing that is to force them not to, which is what government's role tends to be whether that's to be everyone's health insurer, or to be everyone's healthcare provider, as is the case in the UK, or to vastly regulate the industry in ways like they do in France or Germany. So we need more government in healthcare, certainly not less. And I think that the best lesson is, it comes from our neighbors to the north, in in Canada, where they have a single payer health care system. They live on average two years longer than we do. In survey after survey, they're substantially happier with their health care than we are. And it costs them substantially less. We spend 18% of our entire economy on health care. They spent 11%, they get better care, they live longer, and they're happier for it.

Kelly 16:36

So you talk about in the conclusion of the book, that the reason that you wrote the book, in part is because the public conversation has been so so fraught, with so many other things besides, "How does this work? What does Medicare for all actually mean? What would it do?" And I think when you read the book, or when you have a conversation like we're having, you can parse out those nuances, you can figure that out. How do we though, change the public conversation? I don't know how to change the public conversation in anything right now. Everything seems so fraught, so politicized, how so how do we get to the point where we are talking to everyone about health and about healthcare and about what we can do to make the best system?

Dr. Abdul El-Sayed 17:24

We've got a a chapter in our book called organizing versus advertising, because in the end, this is what this is going to come down to. The healthcare corporations that profiteer off of our health care make so much money, and they spend so much of it, electioneering and lobbying and swaying public opinion. The insurance industry alone, they spent $151 million in 2020, lobbying across 845 lobbyists. That's nearly two lobbyists per member of Congress. And so the way we we we move this debate is through organizing, and I don't mean, you know, capital O organizing, and if folks are interested in doing that, there are so many amazing organizations doing it. But it's also just lowercase o organizing. What do I mean by that? If I had to choose between one person talking to 1000 people or 1000 people talking to one person each, I picked the latter. Why? Because those relationships matter. And organizing is about having those conversations, one on one with loved ones, people you care about people at church or the mosque, people you work with folks who are in your neighborhood about that their health care and asking questions, rather than just giving answers. Tell me about about your health care experience? Was your insurer actually there for you? What would it look like if if this could be perfect? What would that what would that look like? And how do we get closer to that? Obviously, perfect is impossible. But how are we closer to that? And I think in having these conversations, what we're doing is inuring one another to the disinformation that we're going to see across our airwaves from major corporations who stand to make a lot of money off the system as it is. And that is how we're going to get there. It's going to be a slow process. And the good news is that you only have to win once. I mean, think about Medicare. Medicare was attempted and failed over and over and over again until it succeeded. And today, it is still the law of the land. Because it turns out that when you provide people a stable, good, that is there for them, that buys them out of a tremendous amount of anxiety. They like it. And that's exactly what Medicare has done. That's what the ACA has done. And that's what Medicare for all would do, too.

Sophy 19:37

So I've had a lot of conversations with people in my hometown in northeastern Ohio, about Medicare For All and largely I've noticed that we are winning a lot of the messaging around government. When I was a kid and I was listening to the debate over the initial health care reform attempts in the 90s. And then when I was listening to debates over the ACA in the late 2000s, I noticed there was a lot more nervousness over the idea of, you know, big government and healthcare. Whereas now that I'm talking to people, a lot of that nervousness seems to have dissipated. I'm noticing less of the reaction to the word government. But I'm noticing more hesitation around what I would say like the practical aspects of Medicare for All. And so usually that comes in two flavors. People say, how do we pay for it? And people say, what do we do with all of those administrative jobs that are lost? Because, as you mentioned, there's so much of the cost of health care is centered around private insurers and sort of the the middlemen in healthcare. But that also means that we're employing a lot of people to do those those sorts of things that cost money. So I know you've talked about this a little bit in your book, but can you kind of summarize for readers sort of what a good response to both of those concerns would be when you're talking to people about Medicare for All?

Dr. Abdul El-Sayed 21:05

Yeah, well, let's take the cost question. First of all, the real question we should be asking is, how do we pay for our system now, because it's absurdly expensive and getting more expensive every day? You know that the challenge that a lot of folks have is that Medicare for All would require government to pay for it. But the truth is, is that every dollar that we spend on health care comes out of someone's pocket. And the real question that we all should be asking is, am I paying more for better, more secure care, or less for more and more secure care, and in the system that we have right now we're paying more for less secure and worse care than we could under Medicare for All where we'd be paying less for more secure and better care. Ultimately, right, this is going to come out of our paychecks in taxes, usually every two weeks, or every month in the same way that premiums come out now. The good news, though, is that it's going to be substantially less. And more importantly, it's not going to hit us in the times when are the most vulnerable. Right now, you look at out of pocket costs, the median deductible for a family of four earning about $69,000 a year is $3600. $3600 is more than a single bi-weekly paycheck. I don't know many families earning $69,000 a year that can afford a whole paycheck to pay for health care they thought they already paid for. The other point here is that we pay for things, our government pays for things all the time. And it pays for them by by basically creating currency. You think about how we pay for a war, it's not like, when we go to war, all of a sudden, the government passes the tax to pay for the war. It just generates a bunch of line items in a budget, and then we pay for it over time, it tends to either go into a deficit, or it shows up over time, in the tax dollars that we pay. It's a matter of choice in a government that that can create money, in effect that manages its own currency, what we choose to pay for it that way. If you look at great work from folks like Stephanie Kelton on, on modern monetary theory, their argument is that rather than just use this system of payment to pay for it, to pay for wars, we should be we should be using this to pay for health care. The last point I'll make is even if you don't agree with that approach, if we were to ask corporations, and the ultra wealthy to pay their fair share, there would be so much more money available to spend on things like health care, if we were willing, maybe not to spend as much money, creating bombs that we drop on other countries, and instead offering health care in our own, there would be a lot more money available, too. So there's a lot of ways to pay for it. The question is, do we have the political will to pay for it? And right now, it's not that we can't pay for it. It's that corporations who currently get that money right now, don't want us to stop paying them for it. That is the real political issue. The other question is about jobs. Look, 10% of Americans don't have health care at all right now. They don't have health insurance. Imagine how many jobs we would be able to create as nurses and hospital workers and doctors if 10% more people had access to health care, and so on net, Medicare for All will create jobs. What's going to happen is there's going to be a transition. Yes, a lot of the jobs that exist denying people their health care coverage in current HMOs, yes, they may go away, but not as many as you think. Let's not forget, we're still going to need to be able to provide and bill health, health services for 350 million people in this country. And so a lot of those jobs will stay. Some of the the jobs that exist on the periphery, in the advertisement budget, the you know, multimillion dollar CEOs that health insurers have, those those may go away. What I advocate for and every advocate for Medicare for All will say the same thing, is that we need to just transition. If we know we're going to lose some health insurance jobs, but we're going to gain tremendously more health care provider jobs, what we need to do is make sure that we are paying folks to go through the training that they need to be able to take up those jobs in the backend. The last point I'll leave you with is a story from my time on the campaign trail in Michigan. As I wrapped up a conversation about health insurance, a woman came up to me just just at the end of my town hall, and she said, you know, all these things that you're saying about the health insurance industry are true, because I used to work for a health insurer, one of the major ones in Michigan. And she said, I quit the day I had to deny a woman with breast cancer support for her health care. And I knew that that was going to put her in bankruptcy, and she had no other choice. And I was forced to deny her anyway. I quit. I went to nursing school, and now I take care of people with breast cancer. And it reminds us right that there's a true moral cost on the back end of our system, to the people who do this work, whether they're the health care providers who cannot provide the care that people need, because those folks can't pay. Or it's the folks working in the insurance industry, who have to regularly deny people coverage for the health care that they need.

Kelly 26:05

So I want to thank you for writing this book. Because I will admit, I was one of those people who didn't really, I knew I liked Medicare for All, but I didn't really know what it was or how it would work. So it was just a tremendous read and really informative for me to understand the the whole landscape of what this would look like better. Can you tell everyone how they can get the book and how they can also check out your newsletter and your podcast?

Dr. Abdul El-Sayed 26:35

Sure, folks can check out the book at MedicareForAllBook.com. You can check out our podcast America Dissected wherever you get podcasts and then my newsletter, The Incision is at incision.substack.com. And then folks can follow me at on twitter @AbdulElSayed, no dash, and also on Instagram at the same handle. And I'm at Abdul for Michigan on Facebook.

Kelly 26:59

We'll put links to all of that on our website. Was there anything else that you wanted to make sure we talked about today?

Dr. Abdul El-Sayed 27:06

No, I really appreciate you all having having me and for the conversation today about Medicare For All. It's going to take folks deciding that that we deserve better; we need and deserve health care in this country and organizing to make that possible. So thank you for being a part of it.

Kelly 27:24

Thank you.

Sonya 27:24

Thank you for listening to Two Broads Talking Politics part of the DemCast Podcast Network. Our theme song is called "Are You Listening" off of the album Elephant Shaped Trees by the band IMUNURI, and we're using it with permission of the band. Our logo and other original artwork is by Matthew Weflen and was created for use by this podcast. You can contact us at TwoBroadsTalkingPolitics@gmail.com or on Twitter or Facebook @TwoBroadsTalk, you can find all of our episodes at TwoBroadsTalkingPolitics.com or anywhere podcasts are found

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Apr 23 Episode 493: Dr. Abdul El-Sayed

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