Medicare for Al‪l‬ Benjamin Day and Stephanie Nakajima - Healthcare-NOW

Is the supposedly “private" Netherlands healthcare system a model for the US? And what would it take, politically and in terms of concrete policy, to transition to this system? Dr. Kieke Okma, an expert on healthcare systems around the world, joins us to discuss how exactly the Dutch healthcare system works (to start: its 80% publicly financed), the nature and extent of the privatization reforms made over the past 15 years, and the effect those reforms have had on the healthcare system. We discuss more broadly the role of government in any healthcare system and what the private sector can and can not deliver in the health insurance sphere.















You can find a copy of her upcoming book, Health Reforms Across the World: The Experience of Twelve Small and Medium-Sized Nations with Changing Their Healthcare Systems, by clicking the title.







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This week we chat with Dr. Bita Amani, an epidemiologist and Associate Professor for Charles R. Drew University of Medicine and Science and Lead Co-Chair of the COVID-19 Taskforce on Racism and Equity which is housed in the UCLA Center for the Study of Racism, Social Justice, and Health. We talk about how health played a role in the invention of race, and what structural racism in our healthcare system looks like right now. We also talk about health inequities and what Medicare for All will fix (and also what it won’t fix!)























Show Notes







We start with the basics: Dr. Amani is an epidemiologist. What IS epidemiology? It's the study of the distribution and patterns of disease - meaning: who gets sick, and what causes some groups to get sick while others don't? Specifically, she's a "social epidemiologist," which focuses on how major structures - like housing, the workplace, and HEALTH CARE - impact the distribution of disease. She is exactly the expert you'd want to ask about the COVID-19 epidemic, and it turns out that race and racism plays a major role in who gets sick and who doesn't.







To understand how racism impacts health, it's important to understand that we're talking primarily about "structural racism" - such as the systems of mass incarceration and policing in the United States, systems where you'll be treated differently based on your race. This is different from defining racism as the things that bigoted, racist people say and do. Although there are plenty of bigots, and people with explicitly racist ideas out there, a system of structural racism doesn't need them to create different outcomes based on your race (in criminal justice, in housing, in healthcare, etc).







As it turns out, medicine played a crucial role in creating the concept of "race" - which has no biological basis - and convincing the U.S. population that people belonged to different races characterized by fundamentally different bodies and mental facilities. This role of early medicine was particularly important for maintaining slavery, and formed the basis of white supremacy.







So how has this legacy of our healthcare system supporting structural racism carried over into the present day? The geography has carried over for one, leaving communities of color in "medical deserts" - areas without enough access to care. This problem has been getting worse with the closing of hospitals that serve communities of color, which is even happening during the pandemic. Or look at health insurance coverage - which is linked to employment and the racial inequities in access to good jobs - where black people are twice as likely to be uninsured as white people.







If we won Medicare for All in the United States - which would guarantee at least universal access to health insurance - what impact would that have on racial inequities in healthcare? It would obviously de-link your healthcare from your job, which would be a major victory for insulating healthcare from one major system of structural racism. A victory like this in healthcare coverage could also be a real tipping point for addressing broader systems of structural racism, if we don't have to worry about our healthcare.







However, Medicare for All would not end - or even possibly make a big dent - in racial inequities in health outcomes. That's because our health outcomes (whether and how often we get sick, how long we live, etc) are impacted not just by our access to healthcare, but by housing, education, our access to social supports, etc. M4A wouldn't even necessarily end racial inequities at hospitals and physicians offices themselves, where we know that people of color are treated differently (worse). So Medicare for All can't be an end-goal for a movement for health equity,

Public Citizen’s Eagan Kemp joins us as we dive into the history of the individual mandate (spoiler: it’s a conservative idea), why it disproportionately punishes low-income people, and how progressive taxation under a single payer plan would be much more equitable than our current flat premium system. We look back at how such a regressive idea came to be championed by Democrats, and then forward at the continuing legal challenges to the ACA that center around the controversial mandate. If the ACA survives this latest attack, will a Biden administration try to reinstate the tax?























Show Notes







Why are we talking about the "individual mandate" in healthcare? Two reason! 1) The mandate is at the center of a lawsuit challenging the Affordable Care Act, which many are worried may succeed after Amy Coney Barrett tilts the Supreme Court to the right; and 2) Republicans essentially eliminated the mandate back in 2017, and if Democrats retake Congress and the Presidency in 2021, this raises the question of whether Dems will - or should - reinstate the mandate.







We start off by asking Eagan the hard questions: like what the hell is an individual mandate?? It is a requirement that you obtain health insurance, or you face a fine (usually when you do your taxes).







At this moment in our country's political history, the individual mandate is generally supported by Democrats (as personal responsibility and a way to get healthy people to pay into the healthcare system) and opposed by Republicans (as an infringement on personal liberty and the right to choose whether you buy insurance or not). But it was not always so! The individual mandate was originally a conservative proposal - championed by the Heritage Foundation and offered by Senate Republicans as an alternative to Hillary Clinton's health reform plan, which was based on an employer mandate.







How on earth did this conservative alternative to "Hillary Care" become a central plank of the Affordable Care Act (ACA)? First, as Eagan points out, the mandate is beloved by the health insurance industry - it's basically a law that compels people to buy their products, and it's great for profits. The insurers give a lot to both parties, so it's not a shock that both have championed the idea at different times.







The shift from a Republican to a Democratic policy really began in the Massachusetts Health Reform law of 2006 - which became the model for the ACA - and included an individual mandate as a compromise between a Democratic state legislature and Republican Governor Mitt Romney.







Ironically, in the election that followed, Hillary Clinton and John Edwards both supported the individual mandate during the 2007 Democratic Presidential primaries, while Barack Obama opposed a mandate. But it was included in the Affordable Care Act anyway - probably to placate the health insurance industry - at which point Republicans decided it was the devil's work.







It's also important to understand that the individual mandate is a regressive way to pay for expanding health insurance coverage, when compared to creating a new tax and then expanding public insurance coverage. When you pay your Medicare payroll tax, for example, you pay 2.9% of your wages - which will be a high amount for really rich people, and a low number for someone being paid a minimum wage. The individual mandate requires everyone to pay a flat premium, regardless of whether you're a billionaire or just scraping by on a lower income. This is why studies find that Medicare for All would create huge savings for working class and middle class people.







Beyond being a regressive way to pay for healthcare coverage, the mandate is also different from using taxes b...

This is how intertwined the Medicare for All and public mail movements are: if we had a national single payer system in place for the last decade, the USPS would be running a surplus. Steve DeMatteo of the American Postal Workers Union joins us to discuss the surprising connections between the postal service and our healthcare system, the political and financial obstacles that the USPS has faced under the Trump administration, and also how you can fight to protect this vital public service.























Show Notes







This week we welcome to the podcast Steve DeMatteo from the American Postal Workers Union (APWU)! The postal service has become crucial for our democracy during the COVID pandemic, as many voters shift to using mail ballots for safety concerns. TOTALLY COINCIDENTALLY, the Trump administration has also attempted to undermine and privatize the postal service in the run-up to the November elections.







We invited Steve on to talk about the important and, for most people, surprising ways in which protecting our public postal service and establishing healthcare as a right are intertwined.







The APWU and its President Mark Dimondstein are among the leading advocates for Medicare for All in the labor movement. Why? As Steve says, postal workers are in a similar position to many workers. Although the APWU has won fairly good health benefits for their members, the rapidly rising costs of healthcare are brought to the table by their employers (the postal service) every contract, and used as a counterweight for winning decent wages and other important benefits for postal workers.







What is the scale of the United States Postal Service (USPS), and how is it different from private mail companies like UPS or FedEx? The postal service employs more than 600,000 workers across the country (second only to Amazon as a national employer!), at 30,000+ post offices around the country. The USPS is also the largest civilian employer of veterans in the country. It is the only service explicitly mentioned in the U.S. Constitution, and the USPS actually predates the Constitution - in 1775, Benjamin Franklin served as the first Postmaster General.







In contrast to this history, in which the USPS has served as an integral part of American life since the country's founding, for-profit mailing companies like UPS or FedEx operate on a very different model. USPS service is universal, and does not charge discriminatory rates depending on whether you're rich or poor, or whether you live in an urban or rural area. For-profit mailing companies, like healthcare corporations, will not mail to unprofitable areas, and will charge every consumer as much as they can. In fact, about 25% of mail sent by UPS and FedEx are dropped off to a public post office for the final leg of your delivery - since for-profit mailing companies won't service the final address! (See this IPS study on how 70 million Americans are up-charged by UPS and FedEx because they don't live in a major city.)







Now that we understand what the postal service is, how do we explain the fact that the USPS has struggled financially in recent years - even before coronavirus? Most people will never hear about it, but almost all of the USPS's losses stem from a 2006 law called the "Postal Accountability and Enhancement Act," which required the postal service to pre-fund retiree health benefits 75 years in advance (!!!). That means the USPS has to pay, right now, for the health benefits of future USPS retirees who haven't even been born yet. No other government agency, and certainly no private corporation, has to pre-fund their healthcare benefits three generations in advance, and it created an impossible financial situation. If you read or watch mainstream news on why the posta...

This week we host Dr. Monika Dutt, Board member of Canadian Doctors for Medicare and a public health and family physician in Nova Scotia. She fills us in on the historic legal challenge to the Medicare program that was just decided by the Supreme Court of British Columbia. The plaintiff, a for-profit surgery clinic, sought to allow patients to pay more for quicker treatment; it would have opened the door to a two-tiered health care system that would draw resources away from the public system and disproportionately affect the most vulnerable patients. Dr. Dutt talks about the ramifications of this victory for Canada’s single payer system and what’s next in the fight for a better Medicare.























Show Notes







Canadian Doctors for Medicare, which Dr. Dutt sits on the Board of, was founded about 10 years ago to defend Canada's single-payer healthcare system, and also to improve and expand upon it. It may be confusing for some in the United States, but "Medicare" in Canada refers to their entire universal healthcare system, whereas here in the U.S. "Medicare" is a healthcare program only for seniors age 65 and older.







Although the entire system in Canada is referred to as "Medicare," in reality each province and territory runs their own single-payer health insurance plan. They all have to meet the requirements of the Canada Health Act, though, which outlines the core principles of Medicare, including universality.







While you can buy private health insurance in Canada for services not covered by the public single-payer system (like dental care, some medications, and other specialty services depending on the province), private insurers are not allowed to compete with Medicare by covering the same care that Medicare already covers.







This principle, and what happens when you allow a "two-tier" system of public insurance competing with private insurance, is exactly what was at stake in a major lawsuit that was just ruled on - Cambie Surgeries vs. British Columbia. This case started in 2016, when Cambie Surgeries sued British Columbia's single-payer system, trying to win the right to do three things:







"Extra billing" (called "balance billing" in the United States), or allowing providers to charge their patients above and beyond the rates they receive from Medicare, which would open the door to preferential treatment for patients able to pay more;The ability to bill private insurers for basic healthcare that is covered by Canada's Medicare program, which would allow the creation of a two-tier system where people willing to pay more for private insurance could gain access to better and faster care; andAllow providers to be reimbursed by both private and public insurance. Providers in BC who participate in Medicare currently cannot accept private duplicative insurance or be paid out-of-pocket for any services covered by Medicare. BC physicians are free to not enroll in Medicare, in which case they can bill patients out-of-pocket, but they cannot also bill the public plan.







If the lawsuit was successful, it would have allowed those who are healthier and wealthier to buy preferential treatment, and to get treated first - exactly as they are allowed to in the United States. However, just this past week British Columbia's Supreme Court ruled against Cambie Surgeries, relying on a mountain of evidence submitted by experts around the globe showing that allowing two-tier systems undermines care in the public system and... does not improve wait times. (More on this shortly!)







Expert witnesses were brought in from Canada and other countries with single-payer healthcare systems. The Judge's final ruling, which considered all of that testimony, is 880 pages long (!!),

Barbara DiPietro is the Senior Director of Policy at the National Health Care for the Homeless Council. She joins us this week to talk about what homelessness looks like in the United States, the wildly disporportionate incidence of COVID-19 in people currently experiencing homelessness, and how the dual crises of rising unemployment and insurance loss are making people more at-risk for becoming homeless. She explains why Medicare for All and the fight to make housing a right are interrelated struggles.























Show Notes







In the United States, both our healthcare and our housing systems have failed to protect us during COVID-19, and the two systems can interact in dangerous ways. To talk specifically about this intersection, we welcome Barbara DiPietro to the program, from the National Healthcare for the Homeless Council.







Stephanie starts by asking what homelessness really looks like, and to address any myths people might have. Barbara says that most Americans when they picture homelessness will conjure to mind a street-homeless man who is a chronic alcoholic, but that description represents only about 10% of the homeless population. In fact, the homeless population is primarily low-income, working families and adults, and 1/3rd to 1/2 of shelter stays are children. Even families that work full-time, earning above minimum wage, often do not earn enough to afford rent in addition to meeting their food needs and other basic expenses.







On any given night in America, there are about 1/2 a million people who we can count as homeless (many more are not counted). Over the course of a year, at least 1.5 million people use the shelter system, and possibly 2 million more are experiencing housing instability or doubling up.







Barbara mentions that health issues and healthcare costs are actually one of the leading causes of homelessness in America. Medical debt and hospital bills can quickly overwhelm income, and leave people without cash to pay rent. However, other important issues can also lead to homelessness: domestic violence, fires, losing your job, etc, can all lead to losing your housing. Right now during COVID-19 we have millions of people losing their jobs, and unemployment benefits running out, along with a very vague national eviction order.







What about the common notion that Medicaid is likely to cover everyone who becomes homeless, or that you can seek care in an emergency room? As Barbara mentions, your ability to access Medicaid depends entirely on the state you're in, as 15 states still have not expanded Medicaid to cover low-income people without meeting other requirements. Even in states that have expanded Medicaid, many people are churned in and out of the program.







While it's technically true you can receive life-saving care at an emergency room, it doesn't mean you won't be billed for that care, or that you'll be treated with dignity. That care also won't be coordinated, and the emergency room is not the right place for providing primary and behavioral health in the community. Barbara would like to see more hospitals advocating for Medicare for All, since it would move these patients out of the ER and into appropriate primary care settings, which could really help with ER volume and capacity for all who need it.







What would a public option do for healthcare access for homeless populations? Barbara says: well, it's better than nothing. We have to be honest though: the public option is primarily about incrementally increasing health insurance coverage. As Stephanie mentions, if an ACA marketplace plan (bronze, silver, or gold) is unaffordable to you, a public option plan will likely be as well.