This week New Jersey Rep. Frank Pallone, the chair of the powerful House Energy and Commerce Committee, gave the legislative push for single-payer health care a major boost by announcing that he would be co-sponsoring the proposed Medicare for All bill and holding a hearing on it sometime in the current term. Rep. Pramila Jayapal, chair of the Congressional Progressive Caucus, and Dr. Abdul El-Sayed join Ryan Grim to discuss the prospects for universal health care in the United States.
Ryan Grim: This is Deconstructed. I’m Ryan Grim.
On Tuesday evening, New Jersey Congressman Frank Pallone, the chairman of the powerful Energy and Commerce Committee, found Pramila Jayapal on the House floor and casually shared with her news of what is arguably the most consequential development in the legislative history of the push for Medicare for All.
Jayapal represents the Seattle area and is chair of the Congressional Progressive Caucus. She had scheduled the unveiling of her Medicare for All bill for the following morning, and had spent the past few months rounding up co-sponsors for it. Momentum is everything on Capitol Hill, and backers of the bill needed to show a substantial amount of support to keep it going. When Pallone saw her, he told her not just that he would be co-sponsoring Medicare for All, but that he would be holding a hearing on it this term.
That night, news of his sponsorship ricocheted privately through the world of activists and organizers who’ve spent years working on the legislation in the wilderness. Jayapal would come to the virtual podium the next day with 113 co-sponsors — that was six more than she had the last time around, even though there were many fewer Democrats in the Caucus this time. It’s still, though, more than 100 votes short of what you need for a majority to pass it.
We’ll talk with Congresswoman Jayapal later in the episode, as well as with physician Abdul El-Sayed, co-author of the recent book “Medicare For All: A Citizen’s Guide.”
First though, an update on a few developments on two big questions that come before anything else, because without answering these, nothing as substantial as Medicare for All has a chance of making it through Congress. I’m talking about the fight over the filibuster, and the related battle over H.R.1, the For the People Act, which rewrites election and campaign finance laws. We did episodes on both of those back in early February.
This week, H.R.1 was introduced in the Senate as S.1, and before the month is out, it’ll get a hearing in Amy Klobuchar’s Senate committee. Chuck Schumer, meanwhile, has promised it will get a floor vote. But it can’t get through without busting the filibuster.
Our episode on the filibuster looked into the push to reform it, and I say reform rather than abolish because everybody involved is committed, for now at least, to the idea that some version of the filibuster has to remain, but what needs to be reformed is a minority’s ability to veto any legislation it doesn’t like.
The linchpin in the debate is Joe Manchin, and he recently shook up the conversation by shifting his tone on the filibuster. He went on Fox News with Bret Baier back in February, and here’s how he put it then:
Bret Baier: Under what conditions would you vote to end the filibuster?
Senator Joe Manchin: I don’t think there is any.
RG: Since then, though, Manchin appears to have evolved a bit in his thinking. Here he is recently on Fox News Sunday:
JM: The filibuster should be painful. It really should be painful, and we’ve made it more comfortable over the years — not intentionally, maybe it just evolved into that. Maybe it has to be more painful. Maybe you have to stand there. There’s things we can talk about.
RG: When he says “maybe you have to stand there,” Manchin is talking about bringing back the “talking filibuster”, where Senators in the minority would be forced to actually stand on the Senate floor and talk, endlessly, in order to prevent a bill from coming to a vote. That’s a huge shift for Manchin, and Bret Baier had him back on to press him on it.
BB: So, what does that mean?
JM: So basically —
BB: Is there an adjustment?
JM: No, no — well, you have to look at everything you can. Because we have evolved. And from evolving is this: I will never forsake my beliefs that the minority should have input. They should be involved in this process.
RG: Now, what’s so crucial about that answer, which very much did not satisfy Fox News, is that there are many ways to make sure the minority is involved without giving them a full-fledged veto.
JM: You have to give the minority the ability to object or involve themselves.
BB: But still 60 votes.
BB: You’re not taking it down to a different bar.
JM: No. No. No, no, no, no. I am not, and will not, on that. No, 60 votes. But there’s different ways to get to that 60 votes, and people have to make sure that they’re willing to — it’d be great, don’t you think, if someone was down there telling you why they’re objecting. If I was in the minority, I’m telling you I’m objecting to something that the majority wants, and I should be able to speak to that.
BB: I’ll just say, Senator, people hear different things in what you’re saying. And is there something, like specific issues, that you drop the filibuster and others that you don’t?
RG: Two important things to pull out of that. First, notice how he said allow the minority to object or be involved. Like I said, involvement can mean anything: it can mean making a speech, getting to offer amendments, that sort of thing. And then notice when he talks about 60 votes, he says there are a lot of ways to get there.
In an interview this week with George Stephanopolous, Biden backed the same idea:
President Joseph Biden: I don’t think you have to eliminate the filibuster. You have to do it what it used to be, when I first got to the Senate, back in the olden days, when you used to be around there. And that is, the filibuster, you had to stand up and command the floor. And you had to keep talking along. You couldn’t call for — no one could say a quorum call. Once you stop talking, you lost that, and someone could move in and say, “I move the question up.” So you gotta work for the filibuster.
George Stephanopolous: So you’re for that reform. You’re for bringing back the talking filibuster?
JB: I am!
RG: There are a handful of ways you could design the kind of rules that Biden and Manchin are talking about here, where the minority would have to be on the floor to object to a bill, and if they’re not, the majority, for instance, could be able it to move it to a final vote with three-fifths of those present and voting, rather than the current rule, which is three-fifths of the Senate. So, for example, you would only need 60 votes if all 100 senators were present: If Democrats had 50 votes on the floor, Republicans would still need to have 34 votes on the floor or close by at all times. That could be hard at 3 am every single night. That’s the kind of thing people mean when they talk about making it more painful for the minority, but still giving them a chance to fight.
Manchin has since backed off his comments slightly, though that’s to be expected as this unfolds. A group of 20 senators — 10 Democrats and 10 Republicans — have formed a group they’re absurdly calling the G20, and they say their goal is to save the Senate. Their unspoken goal is to save the filibuster. I suspect the Republicans involved in this effort are just trying to run out the clock long enough that they get close enough to the midterms that Democrats abandon the idea. Mitch McConnell, this week, lashed out furiously at Manchin and other Democrats.
Senate Minority Leader Mitch McConnell: Nobody serving in this chamber can even begin to imagine what a completely scorched-Earth Senate would look like. The last time a Democratic leader was trying to start a nuclear exchange, I remember offering a warning. I said my colleagues would regret it a lot sooner than they thought. And just a few years, and a few Supreme Court victories later, many of our Democratic colleagues said publicly that they did.
Touching the hot stove again would yield the same result, but even more dramatic. As soon as Republicans wound up back in the saddle, we wouldn’t just erase every little change that hurt the country, we’d strengthen America with all kinds of conservative policies with zero input from the other side. So the pendulum, Mr. President, would swing both ways. And it would swing hard.
RG: McConnell, of course, is contradicting himself here, saying on the one hand that he will blow up the Senate and Democrats will get nothing done, and then on the other hand, that when he’s in the majority, he’ll push through everything he wants. Both things can’t be true.
What filibuster reform would likely mean in practice is that the majority party would be able to push for a simple-majority vote on issues that are big enough priorities, such as H.R.1, the democracy reform legislation, or H.R.842, the PRO Act, which expands collective bargaining power. Or, eventually, one day, Medicare for All.
Joining us now to talk about her new legislation is Pramila Jayapal.
RG: Congressman Jayapal, thank you so much for joining us on Deconstructed.
Representative Pramila Jayapal: It’s so great to be back with you.
RG: So we’re talking on Wednesday. Today was your Medicare for All rollout. This is the second time that you have rolled out this bill. Besides the fact that we’re in the middle of a pandemic, what felt different about the momentum behind it?
PJ: It felt so amazing. I have to say I got emotional once or twice during our rollout because it was such a comprehensive rollout. We have built so much support within Congress this last session with our historic Medicare for All hearings that I think really helped convince people that this was the right thing that they were doing, and we were able to get some new members on — not new members to Congress, but members who had been in Congress, had not signed on before and signed on now — including Frank Pallone, the powerful chairman of the Energy and Commerce Committee. And so we’re starting out the introduction with 113 co-sponsors — that is over half of the Democratic Caucus. If you remember the last session, we ended up with half of the Democratic Caucus on the bill.
PJ: But now we’re starting with over half of the Democratic Caucus. We have 14 committee chairs that are on Medicare for All; we have five of the six committees of jurisdiction, the chairs of those committees, are on Medicare for all; we already have a commitment from Chairman Pallone and Chairwoman Velázquez to do hearings on Medicare for All in their committees, both small business and Energy and Commerce; and then on the rollout, the work of the last two years in on the outside really came through. So all of these different pieces really came together. And I think we have both the movement on the inside and the movement on the outside strong and powerful in the wake of a traumatic time for our country, but clearly shining a light on the need for Medicare for All.
RG: Right. It’s almost as if our system was built exactly backwards for the pandemic, because the people who were most likely to keep their jobs and therefore, the most likely to keep their insurance also were the ones in the white collar jobs that could go into their basements and into their home offices, and work on Zoom. And the people that were most likely to lose their insurance were the ones who were going to be, you know, thrown out into the maw of the economy bringing things to those people who are staying in their homes. So it makes sense then that you see those disproportionate numbers of people testing positive and dying, who didn’t have insurance. Because that’s a much higher number than the overall population that was uninsured, right?
PJ: That’s right. No, that’s exactly right. We had been saying for some time that it was disproportionately black, brown, indigenous, poor workers who were uninsured, but the numbers of underinsured were also enormous, as you know: 87 million people that were uninsured or underinsured before the pandemic ever hit.
The other thing that has been really interesting over the last year is hearing from other countries who did have single-payer health care systems. I mean, there was just an article, I think it was in The Washington Post about why Australia was so successful. And one of the reasons that they give for why Australia has been so successful in tackling this pandemic is because they had a single-payer system, and they actually say, like the Medicare for All system that’s being proposed here. Because when a government can centralize control of making sure people get PPE, vaccines, testing, the health care that they need, they don’t have to negotiate with insurance companies about whether or not somebody’s going to get charged for their test or any of those things. And people know, they expect that they can get health care, they trust the government to deliver that health care to them, and they go, and they’re much more likely to get tested or to do whatever it is that is going to help us to control the virus.
RG: And so getting Frank Pallone on the bill, the chairman of the Energy and Commerce Committee, feels to me like maybe the biggest sponsorship that Medicare for All has ever gotten. I mean there are, you would know this better, but at least what, six committees or so that it would have to go through, but Energy and Commerce is one of the big dogs, that and Ways and Means. How do you think he was ultimately persuaded? I know there was a lot of work done in his district. What arguments did you make? What did you find was resonating? What moved him?
PJ: Well, you’d have to ask him that. But I think that it really is the combination of the education work that we’ve done on the inside with our members. The hearings really helped. I mean, people sometimes want us to take a massive bill like Medicare for All straight to the floor. And I’ve tried to say, part of what we have to do with any transformative legislation is we have to go through the legislative process, because what happens is in that legislative process, the lies are sought out, we have the ability to take them on, the myths, we have the ability to overturn those myths and come up with facts. But we also have the opportunity to educate our colleagues on what we’re talking about, what are the facts, how did they respond to some of the things that they hear from private insurance companies, the ads that are blasted across the TV. People are always anxious about doing big things without understanding the full context of those things?
RG: How many people did you lose, either from losing their re-elections or they retired, and how many are still in there that decided not to sponsor? Did Jared Golden re-up this time? He is not on the bill this time. There’s very few that aren’t — I think it might just be two or three — and I believe we will still get a couple of those, if not all of them.
RG: I want to cut into the interview for a moment here with a bit reporting. After I spoke to Jayapal, I compared the current sponsorship list with the last one, and some names are missing because they’re no longer in Congress: Marcia Fudge and Deb Haaland are in the Biden administration, for instance, and their replacements haven’t been elected yet.
But five sitting members have dropped off the bill, though some may still co-sponsor again later. We mentioned Jared Golden, who serves in a swing district from Maine, but he’s not the only one to drop off based on what appear to be electoral implications. Tim Ryan, who represents Youngstown, Ohio, was an original co-sponsor in 2019, but this cycle he’s running for Senate, and he clearly thinks the bill could hurt him there. Vicente Gonzalez is another. He won his first two elections in Texas by 20 points each, but last cycle he got a scare and won by just three. If the Senate doesn’t pass the For the People Act, which bans gerrymandering, Texas Republicans will redraw his district and he’ll be in real trouble.
These three men in retreat may or may not be right about the political implications of sponsoring Medicare for All, but the fact that Ryan, Gonzalez, and Golden seem to think it is a political problem for them means movement has a ton of work left to do. To get to 218, you’ll have to get swing district members to see the bill as a winner, not as a risk — or, at least, as less of a risk than voting “No.”
The other two who dropped off are Zoe Lofgren and Joyce Beatty. Beatty, from Ohio, if I had to guess, is angry at the left for trying to oust her in a primary last year. She was an original co-sponsor, and still got attacked. She held on, and if you come at the queen, as they say, you best not miss. Zoe Lofgren, meanwhile, is in a comfortable blue seat but in the past she has expressed a preference for a public option over a Medicare for All bill that effectively eliminates private insurance. She came around last time, and I suspect she’ll eventually sign back.
Okay, back to the interview.
PJ: I think that we feel very good that not a single co-sponsor of Medicare for All lost the race in the last election, every single one won their race. And so we didn’t lose any people because they lost the races.
We do have some members who left and have been replaced by a member who may not be supportive of Medicare for All — yet, I would just say yet. And so there are a couple of those. I’m thinking of Elijah Cummings, we lost, and he was replaced by a member who is not on Medicare for All. Same thing with Joe Kennedy. And so we’re going to have some work to do there. But at the same time, we added not only Frank Pallone, but we added some great new members, or great members, who weren’t on it last time, like Ted Deutch and Tony Cárdenas, both of whom are not very Progressive Caucus, but I’ve been working with them. And we’ve been talking to them over the last year. And we were thrilled to welcome them on.
So I think these are really important conversations we’re having.
RG: So when you think about the roughly 115 or so members that you would need to get on to the bill, to get it to 218 and to get it to passage, how many of those in your mind are our hard “no”s? And how many of those are persuadable?
PJ: I think there’s very few that are hard “no”s. I mean, I had a couple of conversations today on the floor, because a lot of people had heard about the Medicare for All rollout today, and we took a picture with Medicare for All masks on the steps of the Capitol. And so people saw us. And I had a couple of conversations with people who are not on the bill, some of whom said, “Look, if this thing came to a vote, I would probably vote for it. I’m not quite there in terms of signing on because I need to know more details.” Some people were asking me questions.
I mean, this is the legislative process. It is just not as easy with a big bill like this. And you know this, Ryan, it’s much easier to get a bunch of people to sign on to a resolution that’s 19 pages, like H.R. 676 was, versus a bill that’s 140 pages and has a lot of detail about what that path looks like. And so that’s the work we’re doing now.
But I think there’s very few that are hard “no”s, to be frank.
RG: So, I guess, what’s holding members like that, who say they would vote for it, but aren’t ready to co-sponsor it. What’s holding members like that back?
PJ: I think it’s mostly the attack ads and sort of the public pushback that Medicare for All has gotten through these giant, for-profit company ad campaigns that they’ve been running, attacking not only Medicare for All, by the way, but also the public option. These status quo players, they’ve got real serious money at stake and they don’t want anything to change. And so they’re very effective and taking up big ad campaigns and running them in tough districts or more conservative districts, even if they’re Democratic districts.
RG: What was leadership’s posture this time around? You may have seen that Ralph Nader said that Nancy Pelosi had been discouraging members from signing onto the bill and encouraging them — ?
PJ: That was ridiculous. That was just ridiculous. It just wasn’t true. Nancy Pelosi has not said anything to me about it. In fact, I told her today that Medicare for All had a really successful rollout. And, you know, she smiled. I know it’s not her — [laughs] she’s been clear that her legacy is the Affordable Care Act. But she has never stopped me from doing anything. And, in fact, it was the negotiation with Pelosi, as you’ve reported on on this podcast, that allowed us to get Medicare for all hearings in the House. She used to have this phrase: “LOVE: Let Other Versions Exist,” Which was on health care, we all want to figure out how to get health care to people, there are different versions of how that can happen, and let’s let other versions exist.
RG: And so if a floor vote isn’t going to happen this session, is there a chance for some committee markups?
PJ: Yeah. And I never say never on a floor vote either. I mean, my commitment is to try to get it to the floor as quickly as possible. And it’s a very uphill task. I won’t lie about that. We have a 50-50 Senate, we have a very close margin in the House, and we have a president whose legacy is also the Affordable Care Act. So I want to be clear that I think it’s a very uphill battle. But I’m not an organizer of 20 years for nothing. I mean, I really believe that you never know when that tipping point is going to be and you have to organize, organize, organize, and do all the work to get everything together and to bring people in, to call people in.
RG: Now, we know that the bill doesn’t have to be totally paid for — that you can deficit finance some of this — but for the part that you don’t deficit finance, do you have a preference for which kind of menu of financing options you would prefer? And are there some that the Democratic Caucus has just said, there’s just no way that this type of tax or this type of financing is going to fly?
PJ: There are so many ways to pay for this. First of all, remember that Medicare for All, in the end-run, costs far less than what we’re spending now. But in terms of if we wanted to raise revenue here, there are numerous ways. In fact, the wealth tax that Elizabeth Warren and I just introduced has a provision where if we were to enact Medicare for All, there would be an additional tax paid for those super-millionaires and billionaires, the people that have over $50 million in wealth, that they would just pay a couple cents extra to help finance Medicare for All. That would probably do it right there.
Senator Sanders had put out a list of financing mechanisms during his presidential campaign. Those are still absolutely valid. There are lots of ways to finance this, including through employers who are already spending enormous amounts of money on health care — if they’re offering health care — we actually believe that you could still have them pay something, but still have them save and pay less than what they pay now, if they pay some of that per employee, to the government to finance Medicare for All.
RG: And so what’s the next step for this? Are we looking at any hearings in the near future that people can look for?
PJ: Yeah, my hope is to get at least one, maybe two in this next quarter, in the second quarter, and be able to really kick this off well in that way, and then to continue that work. But at the same time, through the Medicare for All Caucus, we also intend to have our own briefings and hearings where we can bring people in, even before we ever get to a hearing in a committee. Because this is all part of our grassroots campaign to really build support, and continue to bring other members on board.
And then, like I said, the organizing around the country is ongoing. And so that is a constant thing that’s happening that is also helping us.
RG: One last question about the Covid relief bill. There was a lot of pressure from the outside on the Progressive Caucus and on the Squad to draw a hardline and say that if the $15 minimum wage isn’t in this bill, then we’re voting this down. From your perspective, was that debated inside the caucus? And was there a line at which the caucus would have said, “We’re voting this down”? And why wasn’t that particular issue the line?
PJ: Yeah. With the $15 minimum wage, I can tell you from the very beginning, we knew that was a 50-50 proposition, that getting the parliamentarian to rule $15 in was a 50-50 proposition, but then because the White House had been so clear that they were not going to overrule the parliamentarian, even though you saw me on TV, I assume, every day pushing to overrule the parliamentarian, that it would be a very difficult thing to try to move forward as our red line.
So even Alexandria, Ro Khanna, and others had said they weren’t going to vote down a truly progressive, probably the most progressive legislation most of us have ever voted on, because $15 wasn’t in there. That would make no sense. Because the overall problem is we still don’t have 50 senators who were willing to vote for it. You saw Senator Sanders’ amendment. I think we lost eight senators — Democratic senators — on that amendment.
So we, of course, looked at what the possibilities were. But we were very clear that $15 couldn’t be a red line. That said, you notice we didn’t say that until our votes were being cast, because we wanted to try every possible thing we could do.
And I said from the very beginning, “We have to look at the whole package when it comes back to us, because that’s how we’re going to evaluate whether the things that we care about have been undermined so much that we want to leverage our votes or not.”
In the end, I think we felt very clear that we had won. This was a progressive piece of legislation.
RG: And Chuck Schumer said publicly that one way that he got Manchin to back down was by telling him that it was his understanding that the House would vote down the entire package if he pushed too hard on unemployment. Did you relay that signal to the Senate?
PJ: Yes. I did. I called Senator Schumer on Friday morning, as they were about to go into their vote-a-rama, and when I had heard about the amendment, the Carper-Manchin amendment, that ended up being the Carper amendment until Manchin came back on board 10 hours later, to say to the senate majority leader that we did not like the changes in my statement about the American rescue plan. You might have seen, I said that those changes were bad policy and bad politics. But at that point, my concern was that it was going to get weakened further, and that if it did, I could not guarantee that we would be voting for it as progressives. And so I needed to let Senator Schumer know that. And I think it was perfect timing, because I do think he understood that, and I think it was important to him to convey to Senator Manchin that there was going to be a place where there was going to be too much.
RG: My guess is that, frustrating as it probably is for members of Congress, some of the really loud criticism on social media probably actually made your threat to Schumer more credible, in a way. Schumer didn’t have to wonder whether or not you and the other progressives were feeling pressure. Do you think that’s right?
PJ: You know, to be honest, I didn’t really feel that much pressure — the pressure I feel comes from: Are we looking at the package in totality? Does it comply with what we said or priorities for us? And ultimately, how do we as progressives not step on what is a serious progressive win?
I mean, we are so used to, Ryan, as progressives, being downtrodden, left out, not at the table, losing. I think we’ve gotten kind of used to that, like we’re more used to that.
RG: [Chuckles.] Mhmm.
PJ: And we always have to be up in arms about what we didn’t get. But here’s the reality of the situation we’re in: the House will always be, and I said this to some of our members, the House is always going to be more progressive than the Senate. That is the political situation we’re in. We have a more progressive House than we do Senate, which means that our job in the House is to pass the most progressive bill possible, to set very clear public and private guidelines with the leaders, and then to work every single day, which by the way, there was so much behind-the-scenes work on this package to make sure that these provisions stay in, coordinating with Senator Sanders, making sure that we got the minimum wage provision into the House, even after the parliamentarian’s ruling, because we wanted to be able to take the fight all the way to the end in case we could win it!
And so, to me, that is where the pressure comes from. And sometimes I think, progressives, what I didn’t want to do was lose the win.
PJ: [Laughs.] We had an enormous win here. And our members were very clear and are very clear that when the Senate does their work, it will probably include some changes — just because you can’t expect that a body of 50 Democratic Senators is going to keep the package exactly the same. So the question is: How do we make it so that the things we care most about are still there or not undermined? And that we keep the pressure on to keep it as progressive as possible, but if there are a few changes, and they don’t really affect the substance of the package, then to say: “We won!” [Laughs.] We just need to get used to saying “we won!” a few more times. Because I do believe we’re winning, and a lot of that is because of the movement across the country that has made so many of these ideas popular and populist.
RG: Well, Congresswoman, Jayapal, thank you so much for joining us on Deconstructed.
PJ: Thank you, Ryan.
RG: That was Washington State Congresswoman Pramila Jayapal, who re-introduced Medicare for All in the House on Wednesday. To discuss the on-the-ground details of what is currently ailing the American health care system and how Medicare for All would change it, I’m joined by Dr. Abdul El-Sayed. He’s a physician and was a candidate for governor of Michigan in 2018. He writes a newsletter on substack called “Incision,” and is the co-author of the new book “Medicare for All: A Citizen’s Guide,” with Micah Johnson. Dr. El Sayed, welcome to the show.
Dr. Abdul Al-Sayed: Thank you so much for having me.
RG: In your new book, you break it up into three different parts. First, you look at the American health care system, as it is today. Second, you look at Medicare for All and other policy approaches, and how they might solve or not solve some of the problems. And then in the third part, you talk about the politics of actually getting there. As somebody who is both a politician and a practitioner within the system, to you what is the biggest problem with the American health care system?
AA:The first book I wrote called “Healing Politics” was focused on this idea of an epidemic of insecurity. And I think one of the most devastating experiences that our health care system exposes people to is that insecurity of knowing that the word “sure” has been extricated from the word “insurance,” and so you don’t know when costs are going to hit you —
AA: — if and when you get sick, whether or not your health care is going to be there for you. And that’s if you’re one of the lucky ones who has private health insurance in the system. For 10 percent of Americans, they don’t have that at all. And for the folks who’ve graduated into Social Security and Medicare, there is a level of security that those programs afford them that is quickly being chipped away by the forces that have created and sustained a health care system that is so beholden to corporate power and so much less focused on the well-being of patients and their experiences.
RG: So when you talk about how Medicare for All will interact with the health care system, as you talk to people — other doctors, nurses, people in the pharmaceutical industry — other people in the health care system, what are their objections to it? What are their concerns? And how do you kind of try to allay those?
AA: It’s a fear of loss. We are so used to the broken system that we have, and so used to watching the systems that provide us the basic means of a dignified life or, for those of us who work in health care, our weekly bread, we’re so used to watching these things get undermined from beneath us that anytime we talk about what could be better, even if you’re talking about a system that is so fundamentally broken at its core, like our health care system, there is this fundamental fear of loss. So people are so busy protecting the brokenness that we have.
I’ll tell you what, though. I think that’s changing quickly, particularly among doctors. And the reason why is because, as Sandeep Jauhar who wrote a great book called “Doctored” notes, doctors have gone from being knights to knaves to pawns. There was a time when most doctors worked for another doctor, or own their own businesses as partners in health care practices. And today, that’s no longer the case. The median doctor now is forced into working for a major corporation. So in a lot of ways, doctors have gone from being business owners to being line workers.
AA: And that is because of the corporate power that is implicit in our health care system. It’s the same thing that keeps patients from getting the care that they deserve and knowing that it’s going to be there for them, and it has now really degraded the experience of being a doctor, whether that’s something as fundamental as the ability to actually care for your patients, or something like your paycheck.
And so, you know, it’s no coincidence that the median doctor now believes in single-payer health care. Of course, the AMA wouldn’t have you thinking that, but you poll doctors, especially young doctors, and they know that they have been victimized by the system that has been victimizing patients for decades now. And that this system, Medicare for All, could be so much better. So the tides are starting to turn, frankly, because the industry has just gotten so greedy profiteering off of patients and providers alike.
RG: One of the things doctors have been complaining about in the last few years — this might be counterintuitive to some people — and that’s electronic records. Electronic records sound like something we ought to have, and actually, of course, they are something we ought to have, you need to be able to share information between different providers and pharmacies, etc.
But the way it’s been rolled out in our system, from what I gather, and I’d love your perspective on this, is that it’s just an absolute nightmare that is cannibalizing a doctor’s time, and isn’t actually producing very useful records, as doctors end up just copying and pasting a lot of different things to kind of just cover their ass, so to speak. How could a more rational system of Medicare for All confront this problem of the busy work created by electronic records? And what’s been your experience with it and other other physicians who’ve had to grapple with this move into electronic records?
AA: You talk to any physician, any provider, and they’ll tell you the EMR is the devil itself. And part of this is because it’s being laid out by the same corporate system where you end up having turf protection in different EMRs that don’t cross-talk with each other. And so, doctors often will work in multiple different systems, so they have to learn multiple different EMRs that don’t cross-talk. And then when you’re trying to move a patient’s record across EMRs, that doesn’t happen. And, you know, barriers are placed by these companies to make that more difficult simply because they want to protect their turf.
The other part of this right is that there is so much litigiousness in our health care system, and so much profiteering by yet another industry, the legal industry, off of the system, that there is a lot of CYA — cover your ass — medicine that gets practiced. And that shows up in EMR too, because the EMR becomes in effect, a legal record that will testify against you, if and when someone sues.
And so Medicare for All could actually help solve that in a number of ways. Number one, you could imagine a single EMR for everyone that is a function of Medicare for All, that is provided by Medicare for All, that facilitates the billing to the single-payer system, which would be that new and improved Medicare.
And, you could imagine a system very similar to Canada’s where the government becomes your legal insurer. And so rather than having to worry about the overall cost of simple legal insurance, and the need to practice this kind of CYA medicine, you could imagine a system where the federal government in being an insurer also becomes a legal insurer for providers and takes a lot of that heartache and that headache out of the system for folks.
And so there are a lot of solutions that map to this one, big framework of a solution. And that’s the way I want people to understand Medicare for All. It’s not a simple solution to the insurance problem, or a simple solution to the price problem, or a simple solution to an EMR problem. It’s the framework to provide all of those things in a single approach that cuts the middleman, which is the insurance industry, out of our health care system.
RG: Everybody talks about the kind of awesome power of Big Pharma and insurance companies — and, to be sure, they’re an obstacle to Medicare for All, they draw an awful lot of water in Washington. But to me, one of the obstacles that people overlook is the much friendlier one — hospitals.
Every congressional district, I hope every congressional district, has a hospital, at least one hospital, and likely many more. Hospital boards have, have well-connected people on them. They’re well-liked in the community. They sponsor different organizations locally. They have a lot of pull with their local member of Congress. What do you think it will take to get hospitals either on the side of reform, or to get reform so powerful that it kind of runs over them?
AA: I think it’s important for us to be nuanced about what type of hospitals, right? And there are some really, really bad actors. One of them, for example, is the Detroit Medical Center used to be a public hospital. It was publicly owned and operated. It went from being a public hospital to being a nonprofit hospital. Now it is a for-profit hospital. A couple years ago, they got in trouble because they couldn’t even figure out how to autoclave their surgical instruments, and they were treating people with dirty instruments, which is just a travesty. And that’s because they were cutting costs and cutting corners. And ultimately, what that meant was they were providing worse care to a high-need, vulnerable population in Detroit.
These kinds of operators who are buying up these hospitals, they are the pits when it comes to the way that they operate and the ways that they try to profiteer off of the system. At the same time, you have some incredible safety-net hospitals who are trying to make ends meet in low-income communities, doing so in a way that is really for the best interest of the patients.
And so you’re right, though, right? Large pharma and insurance, they’re number one and number two when it comes to lobbying dollars spent. But hospitals are number eight, and they’re often on the wrong side of these discussions. And they have been leveraging this system to continue to consolidate buying up smaller and smaller hospitals — and you’re starting to see more and more of these hospitals — being run by either for-profit, hospital chain corporations or by private equity firms, all the while trying to leech out as much money as possible. And so it is really important for us to talk about them.
And you’re right, right? An insurance corporation or a pharmaceutical corporation tends to be this sort of faceless organization somewhere in Delaware, right? The hospitals tend to be some of the biggest employers in communities across the country. And so it is really important for us to be able to speak to the way that their money and their power locally — and their impact as an employer does shape their relationships with lawmakers.
The other side of this, though, bigger picture, we’ve got a lot of folks who are sponsoring Medicare for All, who are supporters of Medicare for All, who are still taking money from, forget the hospitals, are taking money from the insurance corporations and the pharmaceutical corporations. And so, we gotta get right on that. And I think all of us who believe in Medicare for All have got to get smart, and start holding our lawmakers accountable and saying, “Listen, you can’t get the shine of being a pro-Medicare for All candidate if you’re taking money from the very same corporations who see Medicare for All is an existential threat, and are spending millions, if not billions of dollars, to try and defeat it. You can either be on our side or theirs. But you can’t be on both.”
RG: What’s your take on the changes that were made to the Affordable Care Act in Biden’s recent Covid’s relief package, particularly this insistence that nobody will pay more than 8.5 percent out of pocket for health coverage?
AA: I think these are good things. And I will always support the effort to get more people access to affordable health care — always. As a physician, I took an oath first to do no harm. And I believe that oath means that you support getting people health care in whatever way possible.
At the same time, we’ve got to be smart about the fact that right now, whether it’s the ACA, or adjustments to the ACA, all of them are being made in ways that accommodate the fundamental rot at the core of our health care system. And at some point, we’re going to have to recognize that you can only fix a fundamentally broken thing for so long, you can only duct tape it for so long until you’ve got to get a new system. And Medicare for all is that reform that deals with the fundamental right at the core of the system. And without taking on the power, the wealth, and the largesse of the insurance industry, we are not going to be able to actually achieve the kind of outcomes we want without throwing more and more money at the problem and watching more and more people suffer as a consequence of that fundamental brokenness at the core.
RG: If there isn’t fundamental reform, how do you project out the health of the system 10, 20, and 30 years from now? Where do you think it’s headed absent significant intervention?
AA: I worry, because costs are going to continue to skyrocket. Insurance companies are going to continue to push those costs back onto patients in ways that show up when they get sick, in the forms of deductibles, and copays, and coinsurance. And we’re going to start getting less and less actual, meaningful care for our dollar, and more and more of the sort of corporatism in monopoly at the local level, as hospitals and insurance companies continue to buy each other up.
At the same time, though, that’s exactly the reason why I think we’re going to get real reform. And it’s because the greed of the system always falls back on real people. And people are seeing themselves in this fight in ways that they have not in the past. In the past, when we talked about health reform, it was almost always a conversation about how we provide health insurance for low-income people. Today, even people who have health insurance are seeing this system fall back on them in ways that are deeply devastating.
We talk about a woman in our book, who we got to meet, named Lisa Cardillo, and we share her story. Her husband had had a brain tumor three years before she had a very rare form of heart disease and heart attack. And they were in their 30s. And they had health insurance through his employer. And yet, they were being forced to pay tens of thousands of dollars sometimes out of pocket to pay for their care. And they got so desperate that their friends had to throw a fundraiser for them and sponsor a GoFundMe.
And these are people who are supposed to be winning in the system. Right? These are the folks who have that employer-sponsored health insurance that we’re all told it’s so great. And so as that starts to collapse onto itself, I think people are going to get very, very leery of the insurers who keep telling them that somehow the choice between two corporations, all of whom want to pay their CEO tens of millions of dollars at the expense of you getting your health care, is somehow a choice worth keeping.
RG: Well, Doctor Al-Sayed, thank you so much for joining us. I suspect we’ll be seeing you at a congressional hearing at some point over the next year. Do you have any sense if that’s gonna happen?
AA: You know, we’ll see. I believe deeply that we need change. I believe deeply that it’s possible. And I’m really grateful to leaders like Representative Jayapal and Senator Bernie Sanders who keep pushing this issue, and are on the right side of history on this. And I hope that I can join them.
RG: Well, thanks again for joining us.
AA: Yeah, thank you so much for having me.
RG: That was Abdul El-Sayed, and that’s our show.
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