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

The 2022 midterm elections are MOSTLY in the books - thank again Georgia, for the endless run-offs that keep on giving, every two years it seems like. You’ve heard the national narrative: Democrats did surprisingly well, given how parties in power usually take big losses during the mid-terms, and particularly when Biden has such low approval numbers.







Today we'll talk about how healthcare did on Election Day, and how the fight over Medicare for All within the Democratic Party affected those results.

















https://www.youtube.com/watch?v=fuqxhi7mGtU

















Show Notes







First the good news, some wins on single payer healthcare ballot measures:









Oregon: voters approve Measure 111, a constitutional amendment enshrining access to affordable healthcare as a fundamental right. Oregon is now the first state with a constitutional obligation to provide healthcare to constituents. The amendment states that Oregon is obligated to "ensure every resident has access to cost-effective, clinically appropriate and affordable health care as a fundamental right,” but not does define what health care access looks like or how the state will fund it.







South Dakota: voters approve Constitutional Amendment D, expanding Medicaid eligibility under the ACA, covering 45,000 more South Dakotans. Anybody in making less than 133 percent of the federal poverty level (about $18,000 for an individual or $36,900 for a family of four) would now qualify for Medicaid coverage. There were 12 states left that had not expanded Medicaid - and now there are 11! South Dakota is the seventh state to approve Medicaid expansion via the popular vote. (Medicaid Expansion has passed all seven times.) Some experts predict a slow rollout/implementation similar to that seen in Missouri.











Arizona: voters approve Proposition 209, or the Predatory Debt Collection Act, which cuts down on interest rates on medical debt and increases the amount of assets protected from creditors. The average Arizonan with medical debt has $1,903 in collections and while 20% of white Arizonans have medical debt in collections, that number for communities of color is much higher at 39%. In Arizona, interest rates for medical debt increase by as much as 10% each year - this legislation caps the interest rate at 3%. It also protects homes, household furnishings, vehicles and bank accounts from collections or forced sale.



Run by Healthcare Rising Arizona, a grassroots, labor-backed organization, this law is the first of its kind. Of course the interest groups backed by collection agencies launched a legal challenge against the ballot initiative. Sadly for them, it failed. The proposition passed by with 75% support.







While it doesn't address the main issue of high medical costs, the new law will provide real relief to people struggling with medical bills.















Massachusetts: a non-binding ballot policy question in favor of M4A passes in 20 state house districts. Our friends at MassCare put single-payer on the ballot, instructing state representatives to support Medicare for All. The question passed in all 20 districts. Most states don't have this tool; it doesn't require the legislator to sponsor a bill, but it can be an effective pressure tool for legislators who aren't supporters of M4A yet. Great work by our comrades at MassCare, especially former Healthcare-NOW Communications Director/current Executive Director Stephanie Nakajima.



Our own Ben Day organized around this question in his own neighborhood. He found talking to voters about this ballot measure was a great way to bring new people into the movement and hear new stories about the hea...

Today we're talking about the relationship between taking your vows and taking your medicine. In 2020, more than a quarter of folks who got married said they took the plunge because one of the partners involved needed health insurance, and it seems like some couples are staying together for the insurance as well. In this episode we’ll break down how our healthcare system is set up to get us paired up and how Medicare for All could save you a trip down the aisle.   









https://www.youtube.com/watch?v=GQdctwkzwNA

























Show Notes







Trigger Warning: On today’s episode, we’re also going to be discussing some of the dark side of marriage, including domestic violence, which we know is a topic that can raise some traumatic feelings in survivors and might not be appropriate for any kids you have in the room. Of course, we also want to remind you that if you or someone you love needs help with a DV situation, you can call the National Domestic Violence Hotline at 800-799-SAFE (800-799-7233) to find resources in your area.







People Don't Really Get Married for the Health Insurance Do They?









A survey by Affordablehealthinsurance.com found that 26% of American couples married in 2020 said they got hitched because their partner needed the insurance.







This number spiked in 2020 because of the COVID-19 pandemic.



7.7 million people lost their jobs and had to find an alternative source of health insurance. 







We can’t assume people ONLY got married for the insurance, but a life-altering event like COVID and the associated economic turmoil probably sped up their timelines to the altar 











In that same survey, 28% of respondents making less than $50,000 a year reported they did so for the insurance. Overall income brackets are a factor here. 







Sometimes people do this not because they lost a job, but because their employer’s insurance changed/decided to skimp on coverage (check out this reddit story and subsequent comments: https://www.reddit.com/r/relationship_advice/comments/okjhck/married_for_insurance/)









How does getting married impact access to health insurance?







Marriage changes how you qualify for health insurance subsidies under the Affordable Care Act. Once you're married, your combined income determines if you are eligible for help.







As a couple, you can earn a joint income of up to 400% of the federal poverty level, or $69,680, to qualify for premium subsidies. If you earn more than $69,680, you might qualify for an extended subsidy that limits your insurance cost to no more than 8.5% of your household income. The extended subsidy is in effect through 2025.







Family deductibles (and out-of-pocket costs) tend to be about twice as much as those for individuals







The Kaiser Family Foundation found that on average, health spending by families with large-employer health plans has increased two times faster than workers’ wages over the past decade. More costs have been pushed onto employees in the form of deductibles







Interestingly, in that same survey mentioned before, 69% of the couples married in 2020 for health insurance said they wished they could have stayed on separate plans! Likely because of costs.







The stories of people getting married for health insurance (and love) are on the rise. Some examples: 









In 2020, journalist Francesca Fontana wrote about her story of marrying her boyfriend so they could subsidize his autoimmune disease care costs (WSJ): https://www.wsj.

Everything is bigger in Texas, including medical bills and the uninsured population. The Lone Star state has the second-largest population in the country, and is among the fastest-growing as well, but all those people are stuck with THE worst healthcare system and very poor health outcomes as well. The uninsured rate is more than twice the national average.







Our guest today is Sofia Sepulveda, an activist based in San Antonio, Texas, organizing for healthcare justice, environmental justice, and trans rights. She is co-chair of San Antonio’s Healthcare-NOW coalition. In 2021, she was part of a successful campaign to pass legislation that expanded Medicaid for new mothers in Texas from two months to six months. She is also the co-founder of Trans Power San Antonio and sits on the board of the Transgender Education Network of Texas and the Community Advisory Board for Centro Med in San Antonio. Most importantly, she is on the board of Healthcare-NOW, the organization that hosts your favorite podcast!

















https://www.youtube.com/watch?v=fQjkPYi25MM

















Show Notes







What's the Lone Star version of our crappy American healthcare system? First, they are one of only 12 states that haven't expanded Medicaid. That means that the only the neediest people qualify for Medicaid.







Texas has the highest uninsured rate in the country at 18%, more than twice the national average of 8.6%. That rises to 30% uninsured among Hispanic Texans and 17% among African Americans. 11% of children in Texas are uninsured. Only 5 other states have more than 12% of their population uninsured (AK, FL, GA, MI, OK)







Texas also has the largest number of residents who said they skipped healthcare they needed because of costs and fewer residents who report having a regular source of healthcare. In Texas, health insurance costs comprise a larger portion of the median income in Texas than in other states. Premium contributions were 8 percent of median income or more.







Mortality rates in Texas are higher for treatable conditions, and is 74% higher among the Black population. A friend of Gillian's once said "in Texas we don't go to the doctor; we just die."







Texas is ranked dead last in access to mental health care. 







Why won't Texas expand Medicaid???







Around 750,000 Texans fall into the Medicaid “coverage gap” - too poor to qualify for ACA marketplace assistance, yet ineligible for Medicaid because Texas is one of only 12 states that have opted out of the expansion.







In some other states, voters have bypassed elected leaders via ballot measures to adopt Medicaid Expansion. Not a thing here. Even though 64% of Texans approve of Medicaid expansion (82% of Democrats).







Legislation to adopt Medicaid expansion has been introduced consistently in Texas state legislature with no success. Despite huge public support for Medicaid expansion, without support from the Governor, the bills are DOA.







One bill sought to give counties or cities the right to accept the funds allocated by the CMS 







Another (called the “Texas Solution”) would have set up a system where the state could receive block grants to enroll individuals in private plan using a sliding scale subsidy, rather than expanding Medicaid to cover them - this was also DOA.







Structural Racism







Racial health disparities exist across the US, but in Texas they are exacerbated by geography, distance, environmental factors, and a shortage of physicians.  







Texas ranks last in so many healthcare measures due to structural rac...

Today we’re tackling Medicare Advantage, which is the option Medicare enrollees have to use a private insurance company to administer their Medicare benefits instead of the traditional public Medicare program. Almost HALF of all Medicare beneficiaries are now enrolled in Advantage plans, which represents a historic level of privatization of the almost 60-year program.







Just this weekend, the New York Times published a blockbuster front-page report on everything that is wrong about Advantage plans. We'll get into all of that with our guest, Dr. Susan Rogers. Dr. Rogers spent most of her career at Stroger Hospital of Cook County (fka Cook County Hospital, the basis for blockbuster TV drama "ER") where she was a Primary Care Physician in a neighborhood clinic before becoming a hospitalist and Director of Medical Student Programs for the Department of Medicine. She is a past co-president of Health Care for All Illinois. She retired in 2014, and is now president of Physicians for a National Health Program (PNHP), a national organization of over 25,000 physicians and health professionals whose mission is to advocate for Single Payer Healthcare/Medicare for All. 

















https://youtu.be/oi1BUAhbx3U

















Show Notes







Dr. Rogers tells us her advocacy for Medicare for All grew from her experience training and working at a large public safety net hospital where providers and patients made decisions about care based on need, not ability to pay. It was the best way to learn to provide care, and the best way for patients to receive care.







What's the difference between Medicare and Medicare Advantage?







We dig into Medicare Advantage (aka Medicare Part C) plans, and how they differ from the traditional public Medicare program. Traditional Medicare is funded by payroll taxes. Hospital coverage (Part A) is free for eligible people. There are no networks. It's a fee-for-service plan, so providers are paid for each service they provide that's medically necessary.







The narrative began in the 1980's that fee-for-service was responsible for "overuse" of healthcare services. (To paraphrase Minnesota single payer hero Senator John Marty: as if people go get an extra colonoscopy just because it's paid for.) The solution was to put private insurance between the doctor and patient to prevent overuse.







Medicare Advantage evolved from the introduction of private insurance into the Medicare system, resulting in every insurance company in America skimming massive profits off the top of a taxpayer funded federal program, while providing no actual care.







Medicare Advantage plans are required to cover all medically necessary care, but the definition of medically necessary is defined by the insurance company based on cost, not by the physician based on medical expertise. Medicare Advantage replaces the doctor/patient relationship with someone in an insurance company office - potentially with no healthcare training - deciding what's medically necessary.







Gillian shares some stories from Healthcare-NOW members who have been enrolled in Medicare Advantage plans. Common themes were delays in care, denial of coverage, limited networks, and limited pharmaceutical formularies. These features (not bugs) of Medicare Advantage can lead to serious, even deadly deterioration of a patient's health. We also heard stories of patients in need of specialty care for conditions like cancer, but few of the large academic centers or cancer institutes accept Medicare Advantage plans.







The overhead cost to run traditional Medicare is about 2%. That means approximately 98% of the money in the traditional Medicare pot goes to providing c...

In this episode, we unpack Amazon’s efforts to “disrupt U.S. healthcare” (apologies for the new age business lingo!). And after their spectacular failure to disrupt anything, we talk about Amazon’s pivot from “disrupting” the healthcare industry to joining it. About a month ago, Amazon purchased One Medical, an in-person and virtual subscription-based healthcare service (the so-called “Netflix of healthcare”). What does Amazon’s move into the healthcare industry mean for patients, and how could it impact the social movement for Medicare for All? Are we moving toward a future where you have to ask Alexa to take a look at that potentially cancerous mole on your ass?









https://youtu.be/YdrQywbwjU8

























Show Notes







Amazon has been trying to break into the healthcare industry for some time now. What exactly are they trying to do and how successful have they been?







In 2018, Amazon forms Haven with JP Morgan and Berkshire Hathaway, claiming they will “disrupt” healthcare industry by lowering costs and improving outcomes. Had completely insufficient market power or leverage to do that effectively. So then in 2019 Amazon launches Amazon Care, a “concierge care” service for its employees, quickly expanding to other employers (like Whole Foods and Hilton) who could offer Amazon Care as part of their own business’s employee benefits package, and then eventually to the general public. (This is a common strategy at Amazon – they created Amazon Web Services to satisfy their own customer service needs then started selling it to other companies and now it’s one of their most valuable assets.) It was abruptly shut down in late August 2022 after the One Medical merger.Most recently in July 2022, Amazon buys One Medical in an all-cash deal worth 3.9 billion One Medical has had its own problems that sound eerily familiar to the issues doctors had with Amazon Care – a model that once again stresses profits over healthcare.Basically doing with healthcare what they did with groceries by buying out Whole Foods - when Amazon Fresh wasn’t catching on they simply bought out one of their biggest competitorsYou could sort of call One Medical the Whole Foods of health care rather than the “Netflix…” mostly rich people use it.







Why would Amazon WANT to move into the healthcare industry, where they have zero experience? Money and hubris of course! This is the only industry in the US that always growing and seems to be recession-proof, and Amazon really believes they are capable of doing anything, even when they are batting 0-for-2 in their healthcare projects. Study in White Male Privilege!







Amazon’s business model emphasizes speed, convenience, and efficiency for the consumer above all else, and they seem intent to carry this forward into their healthcare ventures. What are the potential problems of applying this approach to healthcare? How is it going to affect patients?







Amazon Care is a good first case study:Even before it was shut down, there was some whistleblowing going on behind the scenes as medical staff complained that the company’s practices were putting profits over patients: From an August 2022 Washington Post Article: “While planning to expand Amazon Care beyond Seattle, Amazon managers wanted to avoid building a physical hub. Instead, they asked if nurses could store and dispose of medical supplies at home and stabilize patient blood samples using centrifuges in their personal cars, the two former nurses said. They said the staffers protested the ask.One Medical seems to be a perfect fit for the Amazon model, even before they were bought out:In 2021 Congress convened a special subcommittee to investigate companies like One Medical for using the pandemic to increase their revenue.

Any regular listeners of the podcast won’t be surprised to hear that Gen Xers and Millennials are going into debt for healthcare… but what if we told you that this time it’s for their pets! More Americans are spending more money on healthcare for their beloved pets, which means insurance companies are getting in on the action and cashing in! Today we’ll be digging into the wild world of pet insurance and what Peticare for All could mean for our four-legged friends (and zero-legged friends, and more than 4)!









https://youtu.be/HGzTtPLrwWk

























Show Notes







Why talk about pet healthcare? MOSTLY so Gillian and Ben can show off Coretta Scott Cat and Koda the Medicare for All dog. Obligatory cute pet appearances out of the way, Gillian introduces our guest for this episode: Chris Dupuis, DVM is a vet and owner of the Wheatland Animal Hospital in Neighborville Illinois.







Chris definitely saw an uptick in pet ownership during the pandemic. Today, about 70% of US households own at least 1 pet, and Americans are paying a total of $32.3 billion on vet care.







Gillian went down a research rabbit hole, and found that as of 2020 nearly half (47%) of pet owners had gone into debt for their pet, up from 36% in 2019. This average covers a huge generational divide, though: 66% of Gen X'ers have gone into debt for their pets, while only 23% of Baby Boomers have done so.







Chris notes that one reason could be that veterinary costs have gone up a lot over the last generation, much like College tuition. Chris's dad, who founded the clinic, originally charged $8 for an exam in the late 1980s!







For human health, of course most of us turn to health insurance to protect ourselves from large unexpected costs that might leave us in debt. What about pet insurance? Chris explains that pet insurance is very different: pet insurers directly reimburse pet owners for their (allowed) expenses, so vets generally don't get paid directly by insurance companies or have to deal with them at all. In Chris's experience, many of his clients buy pet insurance policies without realizing how little it actually covers, or the restrictions involved (a lot like Medicare Advantage plans!).







So how bad is pet insurance? Virtually no plans will cover pre-existing conditions (which was common in human insurance plans until it was banned by the Affordable Care Act), including breeds that are frequently prone to certain health problems. There is very little regulation of pet insurance, so exclusions, deductibles, and payment limits are rampant. Both premiums and deductibles are often decided by the species, breed, gender, age and location of an animal - older pets in particular are very expensive and difficult to insure.







Because of this, very few people have pet insurance: only 3.5 million (less than 2%) of pets in America were insured in 2020. Chris says that vets themselves are often not very educated on pet insurance options for their clients, in part because there are so many plans and the plan limitations are so complex.







As important background, Chris explains that vets are generally underpaid (combined with massive college debts), and vet techs are EXTREMELY underpaid - sometimes earning barely more than retail workers ($15-$21/hour). This puts vet clinics in a difficult position when they have clients who can't afford to pay for urgent or emergency care for their pets. Unlike human hospitals, which receive some "uncompensated care" funds from the federal government for treating patients who can't pay, vet clinics and hospitals receive no such funds for providing free or charity care, and have very small margins.