Robert Yates
Hello, and good afternoon to Chatham House members. Welcome to Chatham House and this second members’ event looking at key developments in the US election, and I’m sure you can’t have failed to notice in the news this morning that we had the first Presidential debate on television last night, people still reeling from that. And one of the big issues that was discussed very early on in the debate and led to some of the most heated exchanges was that of healthcare and the future of healthcare in the United States. So, we thought it very opportune to have a discussion, a members’ event, looking specifically at the healthcare debate in the United States, which, of course, has been really magnified in its importance by the COVID-19 pandemic, which has hit the US very hard with, I think, in excess of 200,000 fatalities already, sweeping across the US.
So, today, I’m absolutely delighted to have two wonderful presenter speakers, who I know very well and they’re great, sort of, pioneers of universal health coverage in the United States. We have Dr Abdul El-Sayed, who is the author of a fantastic book called Healing Politics: A Doctor’s Journey Into the Heart of our Political Epidemic, and was the Head of the – of Health in Detroit and ran for Governor of Michigan on a progressive ticket, very much focusing on access to healthcare. So, Abdul’s been right in the thick of the debates going into the election campaign. And also, we have Cheryl Cashin, who is the Managing Director of Global Health Practice, Results for Development, and is an expert on health systems across the world on particular health financing, and has been very active in the debate about particularly the future of healthcare in New York, where she’s based.
I should say today’s meeting is on the record, so it’s not following the Chatham House Rule, we’re on the record, and we very much welcome members to ask questions through the ‘Q&A’ function, and I’m glad to see someone’s asked their question immediately, which is always lovely for the Chair to see. And we’re asking for people to ask their questions, and if there’s a particular question that you like, if you can upvote it and that will, sort of, promote it up the list and, if you like, we’d like to bring you on air, as it were, to ask your questions directly. But if you haven’t got the technology lined up for that or you don’t fancy it, we’ll ask the question on your behalf.
So, yes, well, without any further ado, I’d like to bring in my panellists, and I’d say who are tremendous experts on the US health system, and really, to, sort of, set the scene, if I may, ask you for your thoughts on what are the problems with the US health system, and how would you ideally like to see it reformed? We heard a lot of mention about this last night in the debate, and lots of, sort of, talk about different options for the US health system. So, Abdul, maybe if I could start with you and ask, you know, that, were you President of the United States, and perhaps one day you might be, how would you like to reform the US health system?
Dr Abdul El-Sayed
Don’t wish evil on me, alright, Robert? I – look, I – there are a lot of problems with healthcare, and let me just start by telling you a story of a woman who I got to interview for a podcast I host called America Dissected, and I think she’s emblematic of so many of the challenges that we face. Her name is Lisa, and she was 33 years old, she was on vacation with her husband when she felt a sharp chest pain, and it turned out she was having a very serious, but very rare form of a heart attack that’s uniquely suffered among young women. And, thankfully, she got the lifesaving care that she needed, but she was in a rural community and happened upon – the closest hospital happened to have a cardiac unit, which she was very lucky to have because many times, first of all, rural hospitals are closing, and, second of all, very rarely do they have specialty care.
Her family is insured. They have private health insurance through her husband’s employer, but, three years before that, her husband had a brain cancer, and he has to have quarterly MRIs to make sure that the cancer hasn’t recurred. That means that they chew through their deductible, which is the amount of money you have to pay after you pay what they call a premium, which is every two weeks or every month, to the insurance company to keep your insurance coverage. Their deductible is, like, $7,500 a year, and, when he had first had his brain cancer, it was about $14,000. They had gone so far into debt just to pay down that deductible the first year that their family had to have an in-person fundraiser and they launched a GoFundMe, but every year now, they are stuck paying that added deductible, and all of this is because the cost of healthcare in America has increased. And, in order for there to be a – you know, a reduction in the sticker price, they’ll say, what has happened is more and more of that cost has been pushed back in the form of these cost-sharing mechanisms that include a deductible or co-insurance or copays, meaning money that’s coming out of people’s pockets. And all of this is because in our system we have multiple payers and multiple providers. And, you know, you, sort of, think of yourself as being a customer of healthcare, and Americans love to think of ourselves as customers for things, and the problem with that is be – is that, you know, when you go to the grocery and you want to buy, let’s say, a head of lettuce, right? You pick your head of lettuce, you take it to the grocery clerk, they scan what it is that you bought and then they ask you for money. The financial transaction happens between you, the customer, and the grocer, who’s the seller.
In the American healthcare system, you aren’t exactly the customer because, every time you get sick, there is a financial transaction, but it doesn’t happen between you and the seller of the good, it happens between some insurance company and the seller. And so, if you’re the reason why a financial transaction occurs in the current system, you’re not actually the customer, you’re the product. You’re more the head of lettuce than you are the person buying the head of lettuce. And as negotiations occur for prices, because you have multiple payers and multiple providers in the system, this negotiation is not incentivised to reduce the cost for you, ‘cause you’re the product, right? A head of lettuce doesn’t care what it costs. It’s incentivised to increase the competi – or to decrease competition and to try and consolidate your role in the market, which means the costs then continue to go up, and so that you’re none the wiser, they change the sticker price on you by adding these deductibles and copayments, so that you still think that you’re paying a – you know, a cost that is affordable, when, in fact, it just hits you on the backend when you get sick. So, all of that leaves us less insured, 10% of people are uninsured in our country, the costs of care are too expensive and continue to go up, there’s no incentive for prevention of your care, and it’s the leading cause of bankruptcy, even among people who are insured in our country.
Robert Yates
Yes, that’s pretty bad, isn’t it? And, you know, the – and it’s ironic because, you know, the idea is it’s a, sort of, free markets and competition, you know, this is meant to drive pricing down, you know, this is the [inaudible – 10:27], this is – and I think I’m – you know, lots of people find it quite extraordinary that all this multiple purchases, and this is meant to be one of the great features, you know, this idea of choice, can actually push prices up. Cheryl, if I can maybe bring you in on the – you know, this. You’re a health governess. What’s your take on the ills of the system, and maybe how it should be reformed?
Cheryl Cashin
Great, and thanks Rob, thanks, Abdul, and hello, everyone. I think you just said it really nicely, Abdul, what the consequences are for people like us of our system, and it’s just dreadful to have to need to use healthcare and not to know what kind of financial risk you’re entering into, it’s just – the consequences are a nightmare, and maybe I’ll talk a little bit about the causes. And I think working globally and working in many health systems at all income levels, I can say the US is the only healthcare system that does two things. One is to tie your coverage to your life circumstances. Are you employed? If yes, good for you, you might get that kind of coverage. Are you elderly? Good for you, you might get that kind of coverage. So, your life circumstances determine whether and what kind of coverage you get, and that’s a big problem, as we’re finding, especially in the time of the pandemic, when 30 million lost their jobs.
The other feature of our healthcare system that I have never seen in any other country where I have worked, and that is financing it through a for-profit mechanism. Health financing for profit through private insurers. That’s not a part of the system where you make a profit in other countries, for a lot of reasons. And then that ties to our for-profit service delivery side as, you know, the higher levels of that where there are big corporate hospitals and conglomerates, that they are really working together hand-in-glove in private insurance and the private providers, and that helps to drive up the costs. And these are not features, you’ll find in any other country, for all of the reasons that Abdul says, the consequences of that are just terrible for healthcare and for the financial health of families.
So, I’ve been, kind of, working on the periphery or deeply engaged in health reform way back to the mid-90s where most of my mentors, in the mid-90s, were working on the Clinton health plan, and that failed obviously, you know, fast-forward to the Obama Affordable Care Act, and it’s a series of attempts to twist our health system around this private insurance sector and try to make it work, with regulation or something, you know, that we have to – we accepted as a given that this layer has to be there. And I do not accept that anymore. I think, at this point, I am convinced that there is no way to keep a role for the main part of our essential health coverage to be with the private insurers, they will always find a way. They made bigger profits than ever after the Affordable Care Act, only until recently, when they made even bigger profits because of the pandemic. So, as they collected their premiums and didn’t pay out to hospitals and Doctors because no one was utilising care, elective services were delayed, they kept those profits. And so, I think I don’t agree anymore that we can make that work, and so I would like to see a single-payer system like is being proposed in Bernie Sanders’ Medicare for All bill that is envisioned in the New York Health Act that I work behind, that we have good evidence in our country that Medicare works. It’s efficient, people get good quality care, and people are satisfied with it, and I think we can talk later whether – you know, how politically feasible that is, in the current climate, but I feel very strongly that we need to move away from the idea that we can make it work with private insurance.
Robert Yates
Thanks, Cheryl, and, Abdul, I know that you’re just about to publish a book called Medicare for All: A Citizen’s Guide, so could you, sort of, give us a – to our citizens, our Chatham House members, just a very potted version of, you know, like, what it’s going to involve in the US to move to a Medicare for All, single-payer system.
Dr Abdul El-Sayed
Yeah, and I really appreciated Cheryl’s point, you know, the challenge we’ve had, for a long period of time, is this governing consensus in the United States that the market has to be part of the solution, when, in fact, that has meant the destruction, at every turn, of public goods to offer solutions to people, particularly low-income people, but everyone and, you know, rising costs across the board. And it’s not just healthcare, I mean, healthcare is one example of it, but, you know, you – when you talk about infrastructure or housing, or the economy itself, you’ve seen this same governing consensus that has led us astray.
So, what is Medicare for All? It is, as Cheryl talked about, a single-payer healthcare system, and what does that mean? To use that analogy that I used about the grocery, you have payers on one side, there are 7,000 of them or so in the United States, and then you have providers, like, they’re the folks who actually give you healthcare, the Doctors, and the hospitals. And right now, what’s happening is that you have this negotiation over prices between payers and providers that leaves the actual people who get healthcare left out, and what a single-payer system does is to say, instead of having 7,000 of these folks who are motivated by profits, what if we just had one payer, and that payer was the Federal Government, a single payer?
And what that single payer does is a couple of really, really important things. Number one, it covers everybody. Everybody would get healthcare through the single-payer, decoupling, as Cheryl, I thought, really eloquently put, decoupling your life circumstances from whether or not you can get healthcare. Number two, though, right, you now have what’s called a monopsony. Everybody knows about a monopoly, right? A monopoly is one seller of a good who can then fix the price ‘cause they’re the only place you can buy it. A monopsony is one buyer of a good, who can also fix the price because they’re the only people buying. And so, if the government becomes a monopsony for healthcare, what that does then, is it holds these payers accountable to rates that are fair and it addresses this, sort of, playing off of each other that’s happened in the multi-payer market to raise the costs overall.
But then the other part of this is that, you know, having worked in healthcare as a student, right, you see the army of billers that has to exist for 7,000 different insurance companies with 7,000 different codes, and, you know, the 100s of 1,000s of different hospitals and Doctors, each of them, right, is paying an army of billers to be able to crosstalk. But if you have one buyer of healthcare, right, that army goes away on both sides, and so that reduces a lot of the overhead costs of American healthcare, which are so high. And then, the last point, right, is – and one that I’m really passionate about as a former Health Director, is that in our American system, there is no incentive to invest in prevention, at all. Why? Because, you know, to use that grocery store analogy, right, for there to be money exchanging hands, which, of course, if both sides have a profit motive, you want to do, people have got to go to the market in the first place. That means people have got to get sick.
And so, there’s really no incentive to prevent disease in our system, and you see the consequences because we were flatfooted. Our public health apparatus has not been invested in, in a meaningful way, over the past 20 to 30 years, and our public health apparatus was caught flatfooted, and part of that is because we have a President who doesn’t know what the hell he’s doing, but part of that is also because the agencies themselves have been underinvested in and underfunded. And so, the reason why we have no incentive is because you have 7,000 different insurers, and if people are going to jump between these insurers, if one insurer were to make an investment upfront in preventing disease down the long-term, the high likelihood is that that money saved is going to accrue to another insurer. So, you have this collective action problem around prevention. And so, in a single-payer system, where the government is both the one who would save on prevention and also the one who would invest in prevention, there’s far more incentive across the system to be investing in preventive care. So, it reduces the cost of healthcare, covers everybody for curative healthcare, and creates an incentive for prevention.
Robert Yates
Hmmm hmm. Thank you. Thanks very much, Abdul, and just to remind members that do please ask questions. If you go into the Q&A and ask questions, and then I’ll come to these in a second. But I’d just like to, sort of, pose another one to you about the – what’s likely to happen, you know, the probability of, sort of, moving towards this universal, publicly financed system that you’re both advocating. And, of course, a system that we’re very familiar with in the UK, when you’re, sort of, describing this phenomenon of a single-payer and not having to worry about healthcare costs, you know, depending on your circumstances, you know, sort of, we in, the UK, that’s what we’re – they’re used to, you know, the – sort of, the cradle to grave, you know, coverage of the National Health Service.
But the US health system is very, very unusual. You mention it yourself, Cheryl, you know, people, sort of, I think, tend to assume that a model of private insurance is quite common. But there are very few countries, you know, and one thinks of the United States, South Africa, to some extent, you know, which is a hang-up from the apartheid years, there are only a few other countries where, you know, the private insurance has become so dominant. So, you know, the big question is, you know, how is this going to change? Do you think it is likely to change, you know, sort of, you might, sort of, say that’s going to depend on what happens in the election in November? But I’m even wondering, and specifically to you, Cheryl, you know, that might it come in state-by-state, you know, that one’s seeing one or two progressive states, sort of, maybe, sort of, getting ahead of the pack, really, in, sort of, pushing through acts at a state level? Do you think that’s a feasibility? How do you think the US might move towards Medicare for All?
Cheryl Cashin
Well, there’s what I hope happens and what is probably more likely to happen. I think the sense is, at least – well, I mean, I just spoke to our elected official yesterday in New York, our local official, and the sense is that Medicare for All versus, you know, improving upon the Affordable Care Act was adjudicated in the Democratic primaries, and Medicare for All lost, and, you know, that’s their sense, politically. And I think, you know, that may be true, you know, across the country, and when I’m out working on the New York Health Act and speaking to people where they get stuck, where the narrative has been affectively taken against Medicare for All, is three things.
Like, one is that it’s socialised medicine, that we haven’t communicated well enough that we’re talking about financing. We’re not talking about the service delivery side, which will hopefully be better organised, better utilised, more efficient, but we’re not making that public in these proposals, but people can’t make that distinction between, you know, a government-run plan financing versus service delivery.
And then the second place where we failed to communicate effectively is on the issue of choice, that somehow the message has gotten through that Medicare for All reduces choice. Yes, it reduces choice of insurance plans, but that’s not where people want choice, you want choice of your Doctor and hospital, which is actually much broader under, you know, Medicare for All, where every Doctor in a hospital is in that one plan. They’re all in network, so to speak.
And I think the third place where we have lost the narrative is on how you pay providers, that there’s this idea that we would starve them. Everyone’s going to get paid government rates, so our top-notch hospitals will not be able to succeed, or they, you know, will leave, and if we put 18% of our health spending back into healthcare, not into profits for private insurers, that gives us a lot more money to work with to pay effectively, and, you know, no-one wants to – and I spoke again to our elected official yesterday, he said, “Cheryl, I would not support a health plan that starved our community hospital. It won’t happen.” But we just haven’t communicated that effectively, so I think we may have lost the narrative for now.
If Joe Biden wins, inshallah, we will have an opportunity to improve upon the Affordable Care Act, and I think that’s the most likely direction, and that will probably make it harder for us to get the New York Health Act passed, at least in the next year or so. But, if he loses, which I shudder to think, you know, the – we will probably have a lot more opportunity to work at the state level. So, I don’t know. I mean, yeah, I hope for the first one, and using the opportunity to continue to work in New York, to continue to show that single-payer system is feasible, even if, at the national level, our most likely opportunity is to improve upon the Affordable Care Act.
Robert Yates
Sure, and if I can ask…
Dr Abdul El-Sayed
Can I…
Robert Yates
…you both maybe, you know, sort of, I was looking at the debate last night and, you know, hearing the discussions about the public option and, you know, what that means for the, you know, people’s, sort of, choice to stay on their private insurance and move to a public option. Do you think that the – sort of, the tactics are that, if one makes the public option very attractive and subsidise it a lot, that, almost by stealth, people are going to switch over time and you’re going to see the change of ballots? Is it – is that the strategy, would you say, Abdul? Because, you know, sort of, one feels that it’s still, sort of, tinkering around the edges a bit, but are there ways, do you think, the public option could become, you know, the most popular option very quickly?
Dr Abdul El-Sayed
Yeah, I want to echo one of the key points that Cheryl made, which is that, you know, this debate has been framed largely by the insurance corporations, and one of the things that folks have to understand about why our healthcare system is so broken is that it is fundamentally connected to why our political system is so broken. And that’s that it costs millions, if not billions, of dollars to run election campaigns, and there is a very devastating Supreme Court ruling, which means – which basically interprets money to be speech and corporations to be people. And, therefore, disallowing corporations to put money into electioneering would be like robbing somebody of their free speech and robbing them of their First Amendment rights under our Constitution. And that is an extremist interpretation of both the First and Fourteenth Amendments, and it has hijacked our political process to allow literally billions of dollars of financing from corporations to, in effect, buy off our politics.
Now, to put this in perspective, over the past 20 years, the number one and number two biggest lobbying industries were the pharmaceutical industry and the insurance industry. The pharmaceutical industry spent $4.4 billion lobbying Politicians, over the past 20 years, and the insurance industry spent $2.6 billion lobbying Politicians, and that’s not including electioneering spending, that’s just lobbying spending. And so, you know, the power of corporations to shape the debate, through what they’ve done to lobby Politicians, but also through what they’ve done just to frankly advertise and frame the debate, has left people, you know, talking these, sort of, broken talking points about, you know, it taking away choice, or it costing us too much, or it bankrupting hospitals.
And you have to understand the way that the system works is that it feeds that conversation and people then take those talking points and use them against Medicare for All. Nevertheless, right, if you look at poll after poll after poll, particularly in the context of this pandemic, Medicare for All and single-payer healthcare, right, literally government healthcare, and that’s – they ask it in certain polls, has never polled better. You know, 60% of Americans think that this is a great idea. The challenge here is to shift the politics, so that they match what the population believes, and, you know, if you, sort of, take that Citizens United Supreme Court case and recognise it for what it is, which is a violation of the terms of our democracy, that it explains the decoupling between public opinion and what our politics is doing.
I do agree, though, that we have an opportunity moving forward. It really does depend on what happens in November, and, you know, if you look at – I was one of eight people who served on the taskforce that brought together, sort of, the Bernie wing of the party and the Biden wing of the party to sit down and think about where we’re going next. And the way that those of us who believe in Medicare for All thought about what the platform ought to do is, number one, we know that Joe Biden is not Bernie Sanders, however much, you know, you had to sit through that. All of you, I’m really sorry that you had to sit through that debate, if you watched it, but, you know, as much as Joe – as Donald Trump is trying to label Joe Biden as Bernie Sanders, we assure you, he is not. And also, there – the question that we wanted to ask ourselves was, number one, what takes down the vice grip of corporations on our healthcare system? Number two, what provides most people access to coverage? And number three, what expands the public footprint of healthcare? And then number four, what decouples the employment system from the healthcare system?
And the public option that Joe Biden is running on is a truly public, public option, meaning it’s not just a programme that corporations can buy into, it really is owned and operated by the Federal Government. Number two, it would be fully subsidised for people earning less than 200% of poverty, so a family of four earning, like, $52,000 a year would basically get it for free at the frontend, and it does create an option for anyone, independent of their circumstances. Now, do I believe that it goes far enough? No, I don’t, because it leaves in place those 7,000 private health insurance companies who are the reason why our costs continue to go up, but it does move the ball down the field in that direction, and, you know, if you compare it to what Donald Trump wants to do, which is, you know, obliterate the ACA and not really replace it with anything, which would leave millions of people without healthcare, 23 million, in the middle of a pandemic. It is clear to me that it is a step very much in the right direction, considering I’d rather be walking for – I want to run forward, but I’d rather be walking forward, versus being dragged on my rear end backwards, if given the choice.
Robert Yates
Yeah, thanks very much. In fact, you’ve just answered one of the questions that Dina Mufti asked about pharmaceutical and insurance companies lobbying Congress, and that that’s affecting the decision-making, and you very eloquently put the scale on that. I think, you know, it’s up there with the gun lobby, as well, isn’t it, you know, in terms of, you know, the most lobbying? So, thanks for asking – answering Dina’s question there. She actually asks another one, as well, that I’d perhaps like to put to Cheryl, that, you know, “Which, sort of, country do you think the US could move – you know, model its health system on?” And, you know, sort of, bearing in mind where you are at the moment, maybe to lurch over to a UK-style NHS might be, you know, sort of, too much in one go. Abdul’s already, sort of, mentioned some options about, sort of, getting there, but, I mean, do you see, from your international experiences, maybe a – sort of, a halfway house that you think the US could move to quite quickly?
Cheryl Cashin
Thanks for that question. I think it’s been a really interesting discussion; you know, how much Americans are willing to look at international experience to get inspiration to reform our own systems. And, coming into the domestic dialogue from the global perspective, I’ve been shut down quite a lot, trying to make those comparisons, you know, like, what can – who can we look to? And I think looking at features is a – probably a better way, and what features can we adapt to the realities of the US health system, and when we looked at – I think I read some of the congressional testimony, when the Affordable Care Act was being debated, and they were really looking to the Netherlands, that this is, like, the closest thing, and they have private insurance, they’re able to tightly regulate them, and they’re able to do all the things of a single-payer system, but with these private players. That doesn’t work, and I think we, kind of, went down that road, and so, I don’t think trying to model ourselves to get closer to the Netherlands, we’re never going to be able to regulate the private insurers the way they can in the Netherlands.
So, looking at some of the features, you know, looking at the countries that have universal access with lower costs, they have a single or fewer payers, they have, you know, some of these features that just take you back to Medicare. Like, we have the system, it’s there, you know, it works, and so I think how we get from that, you know, just serving a fewer number of people to serving more, and, Abdul, I really, really congratulate you guys on that proposal that Joe Biden – that compromised position. I think, you know, looking at the numbers, you are getting closer, in a lot of ways, expanding the subsidies, expanding the number of people who are eligible, I think the numbers that I saw that there would be quite a significant number of people who would actually pay less joining the public option than they currently pay through their employer, so you could probably even peel away some people in that situation. So, I feel like we have to take the part of our system that works and try to get more and more people, you know, in that direction.
Robert Yates
Great, thank you, and if I maybe go to one of the audience members. If Carolyn is happy to, sort of, ask her question, or otherwise I can ask it on her behalf, so I’m not sure if we’re – it’s possible to unmute Carolyn, Carolyn Kline.
Carolyn Kline
Yes. Yes, that’s me. Can you hear me?
Robert Yates
Yes, very well, thanks, Carolyn. Please ask your question.
Carolyn Kline
Yes, well, my question is, given the current pandemic, what are some of the consequences for the US healthcare system should, hopefully not, Donald Trump get re-elected?
Robert Yates
So, the Doomsday scenario. What happens November the 4th, if Donald Trump’s re-elected, to the US health system?
Dr Abdul El-Sayed
So, there is a – well, two weeks ago, we lost an incredible human being, and one of the greatest Jurists in our country’s history, in Supreme Court Justice Ruth Bader Ginsburg. That kicked off a violent effort to undo the precedent that they had set when they denied President Obama his constitutionally mandated Supreme Court pick. And the Republicans decided that, even though they had said that, because he was in his last year, they wanted to leave it up to the American people to decide, they are now rushing through a Supreme Court pick. Donald Trump has nominated a Lower Court Judge named Amy Coney Barrett, who has a record of decrying the Affordable Care Act, and also Roe v Wade, which protects abortion rights in the United States. And, on September 10th, the Court is set to hear a case called California versus Texas, which in both lower court rulings has deemed the Affordable Care Act unconstitutional. If they fill the seat and they have the votes to fill the seat before Election Day, the Judge, the new Justice, would be sitting on the court that would then be hearing that case.
The last two challenges to the ACA in the Supreme Court upheld the ACA, but by a five to four decision, and one of those five was RBG, Ruth Bader Ginsburg, and she would have then been replaced by this new Judge, which all indications show will side against the ACA. If that happens, the ACA will be deemed unconstitutional, and will be struck down. So, even independent of the election, there may be a time where the ACA is no longer the law of the land.
If Joe Biden were to win, that would then leave the next administration hopefully with a Democratic Senate majority as well, in a position to pass comprehensive healthcare reform that would likely, you know, go beyond what the ACA did, in terms of providing public care, but if – you know, if he doesn’t win, the high probability is that they will not be able to pass any real healthcare legislation, meaning we’ll be going back to the bad old days. All of that suggests that about 30 million people, including the people who lost their health insurance during the pandemic, plus the people who would lose their coverage to the ACA, would have been added to the uninsured rules, meaning that we doubled the number of people uninsured in our country from 10% to 20% right there.
Cheryl Cashin
If I could add onto that, please. Abdul…
Robert Yates
Thank you, yeah.
Cheryl Cashin
…thank you for that, just, you know, what we lose sleep about, all of us. I did discuss this with our state legislators yesterday. In the event that the ACA gets struck down and Joe Biden doesn’t win, does that also mean that the state level initiative would be unconstitutional? And he said, “Absolutely not.” He said that we would be able to – under the state’s rights, you know, that they do have the right to protect the health and safety of their residents, and so, a law like the New York Health Act could still go through, so the action at the state level at that point would become very, very important.
Robert Yates
Hmmm hmm, and could I ask, I mean, one looks – I mean, I’ve been, sort of, following the debates in the US, including in New York, but what other states might be able to do something about that? I mean, one’s conscious that, you know, people like Governor Gavin Newsom in California, sort of, came to power on a very progressive health ticket. What would be the other states, do you think that – you know, to watch, that might, sort of, go it alone?
Dr Abdul El-Sayed
So, I would say California is the one to watch, and, you know, California has 53 million people. They’re the fifth largest economy in the world, so that’s a huge deal right there, and the others might be Oregon, I could see trying to do it. I could see, you know, New York, of course, in a nod to Cheryl’s groupwork. You know, when I ran in Michigan, we ran on a single-payer platform, obviously I didn’t win, but I think you’re going to start seeing a lot more interest in doing something like this, particularly if the ACA falls, because the forcing function is critical. There is one point, and I’d love Cheryl’s perspective on this, because it’s a point of – a technical point.
The – there is a waiver called a 1332 waiver in the ACA that allows the Federal Government, through the centres for Medicare and Medicaid, who run the Federal Government’s public insurance programmes for this – for the elderly and for low income people, to basically take all the money that the Federal Government gives to a state, bundle it up and allow the state to offer, you know, a single-payer programme or some other innovative approach to healthcare. The hard part as a state for being able to flow a single-payer programme, without that waiver, is that states constitutionally are mandated to have a balanced budget every single year. They can’t take on debt. And if you can’t take on debt, financing healthcare becomes really, really a lot harder, and what 1332 allows government, in effect, to do is to take the debt that would be generated and push it off to the Federal Government, so that you can have this kind of approach and you have the, sort of, Federal Government as a bank, helping you to finance.
The question, you know, is, in the absence of the ACA, depending upon how broad the ruling is, what happens to 1332, and what is the participation of the Federal Government in doing it? And one of the pushes back, just, you know, as a point, was that, when I ran on my single-payer platform, they said, “Well, you’re never going to get the Trump administration to give you a 1332 waiver, right, to be able to pass this forward.” So, how you go about promoting a state-based, you know, insurance reform, really, in some ways, is – it ties to what the Federal Government is interested in doing. And so, Cheryl, I’d love, you know, to hear a little bit more about how you guys are thinking about doing that in New York, in the absence of that waiver, or, you know, if there’s an alternative way to think about it.
Robert Yates
Yeah, Cheryl, please, have you addressed this? Where are you going to get the money from?
Cheryl Cashin
Yeah. No, thank you, and thank you, Abdul, this is something that we struggle with. We were actually struggling with it two years ago, when we thought we were going to try to pass something while Trump was still President, and this issue came up front and centre, how are we going to get the waiver? And so, the legislators have been working on workarounds. I’m not sure that they addressed the issue that you raised about the debt, but they did try to come up with something where, even if you couldn’t pool all the funds, you couldn’t actually have everything behind one plan, you could make Medicare and Medicaid, all of this, adjacent. And somehow – and we call it virtual pooling in our world, but somehow make it operate like a single plan, even without a waiver. But I have to follow-up on that question about the debt. I don’t recall that being specifically discussed, so that would be, you know, really a big challenge, but I will look into it.
Dr Abdul El-Sayed
One interesting…
Cheryl Cashin
And that’s…
Dr Abdul El-Sayed
…approach…
Cheryl Cashin
Yeah, ‘cause you know we’re not going to count on a waiver if he’s there, sorry.
Dr Abdul El-Sayed
Yeah. No, no, one interesting approach that, you know, we’d, sort of, thought about is, like, regionalisation. So, you can imagine, right, the pool of money that allows you to – you know, to create a cushion, it gets bigger the bigger that, you know, that the pool is. I mean, you’re basically generating an insurance pool, the bigger the insurance pool, the more laxity you have in the insurance pool, and so, it’s interesting, right, to think about, like, what would happen if you had regional governments come together, or even just coalitions of states that don’t share borders come together to try and create some sort of sharing.
One thing that, you know, was really interesting is that, thinking about, you know, on the pharmaceutical front, right, there has been – one of the big issues in our country is that Medicare, who is the single biggest buyer of prescription drugs, cannot – is legally mandated to be unable to negotiate with pharmaceutical companies for the price of drugs. And one of the things that, you know, Joe Biden is running on, that we were able to come together around, was addressing that, so that, in fact, Medicare could negotiate prescription drugs for everybody. But one interesting question is thinking about, you know, can you get a compact of states who come together and negotiate together for prescription drugs? And – you know, and so, some of these – sort of, these coalition-building exercises that unfortunately we’ve had to see happen to get any sort of purchase on COVID-19, in the absence of federal leadership, may come into play in the, you know, worst possible scenario where, you know, Donald Trump takes a second term, and I use the word ‘takes’ in – you know, and very purposely.
Robert Yates
So, yeah. Now, I think we have another question from the audience. Nina, would you like to come on and ask your question to the panel?
Nina
Hi, yes, thank you very much. It’s actually been discussed already a little bit, so, if I may, I would change my question a little bit, in terms of we’ve talked about COVID-19 being some type of stress test for the US system. It’s shown to, sort of, lack in social protections for people. I think there was a Gallup poll around April that 13% of Americans would still not access treatment or testing. So, just wondering how this narrative can feed into advocacy for better health system for all Americans, and sort of, dispelling that myth of this private system being more efficient, which is a pervasive myth, as I often talk to American students about this. Thank you.
Robert Yates
Thanks, Nina. So, who’s first?
Cheryl Cashin
Well, I’m happy to just say, Nina, thank you for raising one of my biggest pain points in this era of the pandemic. If there were any silver lining, I thought it would be the chance to connect the dots between the failure to address the pandemic and our systemic failures in the health system, and people who are living through it could see that. That has not happened, and there has been a disconnect in the way we talk about this in the media, even the way the Politicians are talking about it, at least in my state, and I think it’s a really big lost opportunity. And what I was told is just that they think people are overloaded and can’t absorb all of that information and that big picture connection. I find it unfor – really unfortunate that – not to take this opportunity to make those connections.
Robert Yates
That’s extraordinary, isn’t it? Yeah, Abdul.
Dr Abdul El-Sayed
No, no, I was just going to say – I was just going to add I think, you know, it is – one of the ways that the Trump administration and his politics has succeeded in owning the message around COVID-19 is to treat it as an [inaudible – 43:38], like, just this thing that came out of nowhere, like a comet that hit the United States. And, you know, the virus is, you know, a biologically evolved thing that nobody created. The pandemic is manmade, and that’s something that I think we have to keep hitting and, interestingly, right, it’s not just – and I don’t use the word ‘just’ to minimise, but it’s not just that people were left without health insurance, were left without housing, or were left without employment, it was also the fact that the healthcare system itself failed the COVID-19 test.
I mean, there’s a great article in the New York Times that I recommend everybody read, about the political process and the corporate process around creating a ventilator stockpile. And the CDC had worked with a small company that they awarded a grant or a contract to create the stockpile of ventilators, and the – I mean, you can’t make this stuff up. The company that bought the smaller company decided that it was no longer profitable for them to continue forward in this line of work, so they just dropped the contract, even though they’d already used some of the money. Now, here’s the crazy thing. The name of the company was called Covidien. Literally, if you were going to write in a novel, like, you couldn’t write it any better.
All the PPE that we didn’t have, right, in our country, that is because we have allowed our system to function so clearly as a for-profit venture that, you know, you get Consultants who come in and say, “Well, listen, you shouldn’t be stocking this much PPE, you don’t need it. You need just-in-time supply.” Just-in-time supply means you have no time in the context of a pandemic. So, like, all of these ways that our healthcare system was broken, a third one, right? You had hospitals that were literally going bankrupt in the middle of the pandemic because they lost all of the money that should have come in through all of their elective surgeries that is their lifeblood, and so, the hospital’s never been busier and is now facing bankruptcy in the middle of the pandemic. Like, the system doesn’t work.
And so, there is a responsibility, I think, that people who talk about this and think about this have to continue to push and say, “This is not an [inaudible – 45:45], this is not a comet that just hit us and we weren’t ready, this was about our failure to prepare and to prevent, and we have a responsibility to fix that,” and it means that we’ve got to go back to the system and ask, “How do we make it better?” It shouldn’t be large corporations that just can buy a smaller corporation and then fail the government who’s given them a contract. There shouldn’t be a circumstance where your hospitals are going bankrupt in the middle of a pandemic. Doctors and Nurses and hospital staff shouldn’t have to wear garbage bags in the richest, most powerful country in the world. Like, these are things that should never happen, and we’ve got to keep talking about them that way.
Robert Yates
And if I might, sort of, just finish with – I’m afraid we’re – we’ve hit our time limit, but there’s a burning question that I’d love to ask you. You know, we sit here, sort of, incredulous at the situation, and really sympathise for the plight there. Cheryl, you’ve already mentioned, you know, this issue, the – you know, the reluctance maybe for people in the US to look outside, to look to other countries. Now, the whole world is signed up to universal health coverage at the UNGA, and, you know, that the trend across the world is undoubtedly towards a publicly financed, you know, health system. The US is this extraordinary out buyer, and being, you know, the biggest economy that hasn’t done this yet, but what can the global health community do? I mean, you know, we’d love to help, and I think, you know, were the US system to become a publicly financed system, it might stop polluting health systems in other countries with some of this ideology. So, it’s in all our interests, I think, that the US does move in this direction, but is there anything that we can do? Because it might even be counterproductive, from what you’re saying, if we start coming in suggesting that you say the old colonial power knows better and stuff like this. So, what do you think? Do we just, sort of, sit and wait for you?
Cheryl Cashin
Well, Rob, I think something sums up the Americans’ attitude towards just solidarity, towards reaching out to global partners and experience is that the mask, a public health measure, which is to protect yourself and others, has become a symbol of freedom, and, “You can’t take away my freedom. I’m not going to wear a mask because you’re taking away my freedom.” So that just connects to every other thing that we’re talking about here because universal health coverage relies on solidarity, it relies on, you know, committing to something that is a joint objective. So, to take that even beyond our own borders and to think that we have a responsibility to other countries also to have a health system that functions and doesn’t pollute the health universe, we’re further away from that than we were even before the pandemic, and that’s something that makes me very sad. And I think, you know, using examples of what other countries have that we could afford, it just – I’ve tried it from every direction, comparing side-by-side, the Kore – South Korean response to the pandemic versus ours, ‘cause we had our first cases identified on the same day. None of it resonates, and so, I’m going to take up your question as a call to think about this, and how can we make better use and access to our global partners to help to change the conversation somehow in the United States, but, as of today, standing here, I don’t see that entry point.
Robert Yates
I mean, it’s interesting that the Elders, you know, both did events on UHC in New York and California, you know, where they were talking about their experiences, and I remember Ban Ki-moon, sort of, talking about the transition to UHC in Korea, actually, and – but that felt very much like preaching to the converted, you know, it was a largely Democrat audience that came along, and one just wonders what it takes to, sort of – you know, to change the dial. Abdul, have you got any thoughts on how collectively we can help, if at all?
Dr Abdul El-Sayed
Yeah. So, number one, I think we’re coming. Like, I honestly – I know that this moment, especially if you watched that debate last night, feels like it’s all going to be lost. I think we’re coming. I think – you know, I talk to young folks all the time and, you know, if you’re younger than 30 in this country, all you’ve seen is the system fail, and they are the future. Our job is to protect the democracy so that, as they come up, that they build the future that all of us, you know, need, deserve, require, and should have had a long time ago. There are uniquely American challenges to doing this. There are uniquely British challenges that you guys face. There are uniquely Korean challenges, and, you know, the challenge with being the country that we have been in the size and scale and scope is that, you know, when you fail, the world watches and takes notes.
I do think, though, that we are coming, and I think the way to be helpful, to be honest, is to continue to call upon America for leadership, and to note when it fails, right? Because I do think that there is something that we do pay attention to about this notion of our responsibility in the world, and, you know, so much of the painful history where we’ve gotten it wrong, but also some of the good history where we’ve gotten it right, and that we have an opportunity and responsibility to do this for our people, and also to do this to secure a – you know, a global health agenda abroad, right? Like, what COVID-19 showed us is that, you know, a virus that makes a jump into humanity in China can kill 100s of 1,000s of Americans, and so we have a responsibility to engage.
Now, if I – God willing, we have a leadership change in the next month, the next question will be how do we – and I think, you know, Biden’s called this, how do we build back better is going to be an open question? And we are going to need the international community to reach back out and to say, “Alright, here are the things that you guys got wrong the first time. This dude came in and broke them. Now how do we fix them, so that they’re not breakable, and that they are better this time around?” and I think you’re going to find a lot of willing people on the other side. I believe deeply in our country’s ability to correct. It is the thing that is – I think the most beautiful thing about our country is, you know, a son of immigrants who has – a junior during 9/11, and our country does – you know, we stumble sometimes, and we get it wrong, but we do have the capacity to get it right, and that work, I think, is the work of the future, so it takes all of us to do that.
Robert Yates
Fantastic, and…
Cheryl Cashin
Abdul, thank you…
Robert Yates
…thank you very…
Cheryl Cashin
…for making…
Robert Yates
Yeah, Cheryl.
Cheryl Cashin
…me feel optimistic. Sorry, I just want to say thank you for that. Thank you for making me feel optimistic for the first time, certainly, lately. So, I believe – and I believe in your work and your energy, and really, we look to you.
Dr Abdul El-Sayed
Yeah, well, I…
Robert Yates
And I…
Dr Abdul El-Sayed
…appreciate your leadership, too, and so…
Robert Yates
And I think you’re being very realistic. I mean, if you look at so many of the world’s great universal health systems came out of crises. I mean, the NHS came out of the ruins of the Second World War, as did the French system, the Japanese system, the Thai system came out of the Asian financial crisis. So, in many respects, it is at times of crisis that, you know, that countries do make the transition to universal health coverage. So, I think it is a pretty good bet, but we’ll just cross our fingers and wait and see. Well, thank you very much indeed, it’s been…
Dr Abdul El-Sayed
You’re welcome.
Robert Yates
…absolutely fascinating. I’ve loved chatting with you, and any way we can help to move things on in the United States, do please let us know. I hope members enjoyed it as well, I’m sure you did, and we look forward to seeing the future debates. Hopefully they’ll improve in quality next time round and, yes, we’ll wait and see November. Right, best of luck, thank you very much indeed for joining us.
Dr Abdul El-Sayed
Thank you and…
Cheryl Cashin
Thank you so much.
Dr Abdul El-Sayed
…thank you, Cheryl.
Robert Yates
Bye, all.
Cheryl Cashin
I’m looking forward to chat with you, thank you.
Robert Yates
Right, bye.
