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Senate Majority Leader Chuck Schumer has promised action on President Biden’s Build Back Better agenda, a sweeping package of legislation that would transform the American social experience. Along with critically important investments like universal childcare and paid family leave, the version that passed the House includes a slew of healthcare reforms. Abdul speaks to Jonathan Cohn, National Correspondent at HuffPost, and author of The Ten Year War, about the fight over protecting the Affordable Care Act, about the potential impact of the legislation.

Transcript

Dr. Abdul El-Sayed: Omicron is surging across Europe and early data from the US shows it’s picking up steam here, too. Pfizer announces that its anti-COVID oral pill is 90% effective against severe COVID-19 if taken within three days of the onset of symptoms. German police detained anti-vaccine extremists who are plotting to assassinate the state governor of Saxony over his support of vaccine mandates. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. Try to have a happy holiday, please. To the start today, I’m going to take you back to the bad old days for a minute, back before the Affordable Care Act. Health insurance companies could force people with preexisting conditions off their health plans, effectively blacklisting the people who most needed health insurance from getting it at all. Medicaid was severely limited, so low-income people routinely went without health insurance. Nearly 20% of Americans went without health insurance at all. The ACA ventured to fix that in a few key ways. First, it required insurance companies to insure people with preexisting conditions, and in order to support the added costs the insurance companies would take on, it mandated that people have insurance, forcing the young and healthy people who often choose not to have it into the insurance pool. Finally, it subsidized insurance for folks to make it more affordable, hence the Affordable Care Act. It also expanded Medicaid for people earning less than 138% of the federal poverty level, but it left it to state governments to elect whether or not to expand Medicaid. Crucially, 12 states still haven’t expanded Medicaid, literally leaving federal money on the table and more importantly, leaving millions of people who could otherwise have health insurance paid for by the federal government without it. The ACA was always a patchwork fix. It met the health insurance industry where it was and tried to sew up the holes. But there are still holes. Indeed, health care costs have continued to skyrocket. Deductibles, the money you have to pay for your health care before your health insurance actually kicks in to pay for your health care, has doubled since 2010. And more people are finding health care unaffordable. This was President Joe Biden on the campaign trail last year, talking about how he wanted to fix that:

[clip of President Biden] What I’m going to do is pass Obamacare with a public option, become Biden care.

Dr. Abdul El-Sayed: The public option is a government health insurance program that was intended to be able to compete with the private plans, helping to drive down the prices. But it was left out of the ACA at the last minute. In addition to a robust public option, President Biden ran on a few other things. He promised to fix the holes that Republican state legislators have left in Medicaid. He also promised to lower the Medicare eligibility age to 60 and to empower Medicare to negotiate prescription drug prices on behalf of every American. I should know, I was appointed by Senator Bernie Sanders to be a member of the 8-person Unity Task Force that helped to negotiate the Biden agenda. Though it wasn’t the Medicare-for-all that I would have loved to see, it was an important step in sewing up the holes in the Affordable Care Act, an important, if deeply imperfect package of legislation to offer more people health care. After four years of Trump, the ACA had taken a beating. But because of the filibuster, an arcane Senate procedure hailing back to the Jim Crow era, President Biden has had to fit his entire agenda into a single budget reconciliation package. And he can’t lose a single vote, which is why all of us keep talking about this guy:

[clip of Senator Joe Manchin] I, for one, won’t support a multitrillion dollar bill without greater clarity about why Congress chooses to ignore the serious effects of inflation and debt that have on our economy and existing government programs.

Dr. Abdul El-Sayed: Yeah, that’s president, I mean, Senator Joe Manchin, the swingiest swing vote in the Senate and the reason why this Build Back Better package keeps getting whittled down. The House has passed a version of the bill and is now waiting for the Senate to act. To understand just how impactful passing Build Back Better might be for health care in America, for sewing holes in our health care system, consider what’s in the package the House just passed. It would allow Medicare to negotiate the prices of 10 of the most expensive, most common prescription drugs, though that’s less than the original package of 250 drugs that were initially in consideration. It would also cap the out-of-pocket prescription drug costs of seniors to $2,000 a year, which is a huge deal for the one million seniors who pay more than that every single year. It also caps the price of insulin at $35 a month for everyone. That alone is a big deal too, considering pharmaceutical companies have been spiking the cost of that drug for people with diabetes who absolutely need it to survive. To shore up the ACA, it increases those all-important subsidies, both increasing them for low-income people, and it keeps subsidies in place for middle-income Americans who first saw them put in place in April when the pandemic relief law passed. It also offers health insurance coverage without premiums for people in states that didn’t expand Medicaid. Finally, one of the most transformative packages is for home and community-based services, critical health care that allows seniors and people with disabilities to get services that enable them to participate in society in ways that don’t leave them relying on institutions. Because the people who do this work, most often women and women of color, tend to be vastly underpaid,. It’s a critical investment in key jobs that address profound earning inequities in our society. To help us make more sense of what’s in the House bill, whether or not we’ll get a Senate bill, and what it all means for the future of health care, I invited Jonathan Cohn to come chat with me. Jonathan is a national correspondent at HuffPost and author of the recent book “The Ten Year War” about the fight over the ACA. More Jonathan Cohn after this break.

[ad break]

Jonathan Cohn: Yeah, I got one going, I got two going, I got Zoom going. We’re happening.

Dr. Abdul El-Sayed: All right. Can you introduce yourself for the tape?

Jonathan Cohn: Sure. I am Jonathan Cohn, senior reporter at HuffPost, author of two books, one of which is called “Sick” about America’s health care system, and most recently, “The Ten Year War” which is the story of Obamacare, the unfinished crusade for universal coverage and a parable for, or a look at how we passed legislation in this country.

Dr. Abdul El-Sayed, narrating: Jonathan Cohn is one of the most astute U.S. health care watchers I know. He’s been covering U.S. health care for years from his post as national correspondent at HuffPost. I can think of no one better to help us walk through what Build Back Better could mean for U.S. health care and what it says about the Biden administration’s approach to health care overall. That is, of course, if it passes.

Dr. Abdul El-Sayed: I really appreciate both books. I remember reading Sick back when it came out, and then I think The Ten Year War is a really important opportunity for folks to sort of catch up on how we got to where we got and where we go from here. I wanted to invite you on because I can think of nobody better to sort of tell us where we sit in this moment of limbo of health care purgatory when it comes to Build Back Better. As of this taping on December 16th at 3:35 pm Eastern Time, let’s sort of get an update on where we are on Building Back Maybe.

Jonathan Cohn: Yes. Oh, I like that, Building Back Maybe. That’s a very good way to put it. So I mean, you know, for listeners who are catching up and your listeners probably reasonably up to date, but you know, the short version, right, is that this big piece of legislation that has ,it has a climate piece, it has a sort of families and social welfare piece, it has a health care piece. The House has passed a version. We are waiting, the Senate is now considering it. The Senate was supposed to be pretty close to ready to pass the House version, at least at the moment, and this is where the news is breaking so who knows where it will be in a couple of days. But last we heard, Joe Manchin was making very clear that he was not ready to vote yes on this and in fact sounded like he was pretty far away from voting yes. He wants some big changes. Democrats have only 50 seats. There are no Republicans voting for this in the Senate, so they need everyone. And so there’s a negotiation. And as of yesterday, they were talking about pushing back, you know, the likely voting date. Not just past Christmas, which I think a lot of us had already expected. I think we were getting to this, you know, until January. I heard a word I had not heard before, a month I had not heard before, which was March. So it sounds like, you know, who knows? You know, the news changes fast and maybe they’ll come together, but it certainly seems like they have a ways to go before they get to yes. And then whatever the Senate passes, remember, it’s going to have to go back to the House. The House is going to have to sign off on it too.

Dr. Abdul El-Sayed: Habibi Joe Manchin. Bless his heart. So there is a lot riding in this package. You talked about some of it, everything from climate change to paid family leave maybe, to universal child care, to home-based community based care for people with disabilities or for seniors. Let’s talk a little bit about the health care highlights. What do you see as the big health care pieces, the defining health care pieces? Of course, in the context of the fact that, you know, President Biden ran on this idea of sewing up the Affordable Care Act. And I talked a little bit in the intro about what the Affordable Care Act does and what the holes are in it. Where do you see Build Back Better offering, you know, a needle and thread to be able to sew up our health care system?

Jonathan Cohn: Yeah, yeah. So if I can, if you’ll forgive me for mixing or switching the analogy a little bit, you may remember when they passed the Affordable Care Act, the catch phrase was “it’s a starter home.” Right? This was they were going to build on this, you know, it was it was a big step towards universal coverage, you know? I tend to think about it in my book about how I see it as part of the journey that there was a big step forward with the creation of Medicare and Medicaid. You had the Affordable Care Act and everyone knew they were going to have to keep working on it because of politics and the way it was. They actually spent most of the last ten years trying to keep the starter home from getting demolished.

Dr. Abdul El-Sayed: Eminent domain?

Jonathan Cohn: Yes. You know, in the book I interviewed Obama and that was his comment. He’s like, Well, you know, we really had to spend, the house has gotten vandalized and it’s taken some damage, but it’s still there and now maybe we can finally move on to sort of really trying to do the improvements we want, always wanted to do. And that’s what Biden promised. You know, there’s a couple in there, the most obvious one is one that’s actually in place already temporarily, which is adding money to the program, just making it more generous. So a big part of the Affordable Care Act, really the part that most people have heard about on the news and some extent have experience is, you know, if you don’t have employer insurance, right, you can go to these online marketplaces. If you live in Michigan, which is where we live, it’s through healthcare.gov, and that’s what most states use. Some states have their own version. California has Covered California. And you know, you buy these plans that you know, they can’t lock you out for preexisting conditions, they have to meet certain minimum standards. From the get-go, the problem with these was they were pretty generous for lower-income people but the financial aid you got, you know, they come with subsidies, right? So, you know, based on how much income you make, you get some help from the government, it would make the premiums cheaper, sometimes your out-of-pocket costs would come down. And that really tapered off pretty quickly as you went up the income scale. So you had a lot of middle class people looking at these plans and even some lower middle class people and certainly some upper middle class people like, you know, thousands of dollars a year in premiums for a plan that then had thousands of dollars in out-of-pocket costs and it had a narrow network. And the root cause of that was the program was underfunded. They didn’t put enough money into it. And that’s a whole other political story why that happened. So as part of the COVID relief package, everyone, you know, it was a brief moment in this America that appears to be over, but there was that brief moment in political time at the beginning of 2021, when people got less uptight about spending money on, you know, worthy causes, and they just sort of opened up the checkbook. And one of the things they do is they said, All right, we’re going to make this, we’re going to make this program more generous. So if you if you’re already buying these subsidized plans, you going to get a big subsidy. So the premiums will come down, the out of pocket costs will come down. And by the way, if you’re one of those people you made, you know, a family of four making like $110,000 a year, the old days, you didn’t get any assistance. Now you’re going to get some. And it made the plans, I don’t know it made them perfect and they were still pretty hefty out-of-pocket costs in a lot of them, the premiums raised, still the narrow networks, but they were certainly a much better deal than they had been. Thing was, it was a very temporary extension. So they wanted to extend those into the future and we’ll talk for a second about how long into the future. So that’s piece number one: the plan, the private plans get more generous.

Dr. Abdul El-Sayed: So that’s like the foundation, right? That is . . .

Jonathan Cohn: That’s the foundation, yes.

Dr. Abdul El-Sayed: Working on that part of that three-legged stool, giving more generous subsidies, of course, one of the legs knocked out but like, you know, this is the baseline. All right. So what else?

Jonathan Cohn: Yeah. And I think very, I think very perceptible, right? I mean, this is like, this is, you see this. Like the premiums came down. Or you pay the same premium but you got a much better plan, right? So I mean, this is something you could really see. Now this a few million people, you know, it’s just people buying coverage on their own, you know? If your employer coverage, this doesn’t affect you. Second big piece, you know, we have what I always thought was the most important part of the Affordable Care Act, arguably the most successful where it happened was the expansion of Medicaid. I mean, we basically took Medicaid, which in the old days depending on where you lived, you know, you had to be in a certain category. You had to be, you know, it was only for pregnant women, or it was only for young children. Your income had to be below a certain amount. And there was this and that and then they basically said, Hey, anybody with income below the poverty line or a little bit above the poverty line, you can get Medicaid. And where that has happened, it’s been quite successful. Again, Medicaid, not a perfect program by any stretch of the imagination, and you and I, you in particular I know, I bet more than I could, could list off all the problems with the Medicaid system as it works today. But the fact is it did get coverage to a lot of people. We’ve got pretty good research on it. It made a big difference. Here in Michigan there’s been, as you know, there’s been a lot of studies of the impact of Medicaid expansion on the low-income population in Michigan. There’s a lot of evidence to say people are better off, they’re getting more medical care, they’re better off financially. Again, not everything you would want necessarily, but certainly an improvement. The big problem was we still have a dozen states that haven’t done it. Because it was up to the states to do it because the Supreme Court decision in 2012. They’re almost all in the deep south. It’s Florida, Texas, North Carolina, Georgia. And this, the second piece of Build Back Better basically gets insurance to these people who are low income, were supposed to get Medicaid expansion and couldn’t. Interestingly, the way they do it, we could talk about why if you want, is basically we give them access to the same private plans they can buy in healthcare.gov, but they’re very, very heavily subsidized. So they basically are free. So that is, I would say that, you know, the second big piece of, you know, shoring up the Affordable Care Act.

Dr. Abdul El-Sayed: To your Medicare, to your metaphor here since we’re doing this, the way I think about Medicaid is like giving people who were about to die of thirst, a bit of water a little bit at a time, in a daily allowance. So is not great, right? You want to have access to great water any time whenever you need it, but it’s water for people who otherwise would have died of thirst. And so it is a really critical program and in that way, really important. I think that what I’m trying to do here is highlight both how absolutely fundamental Medicaid expansion has been to getting health care to people who didn’t have it, but also some of the major holes in the program. So it’s a great program that is profoundly imperfect and is only great considering how broken the health care system is at baseline.

Jonathan Cohn: Yeah, yeah. I think that makes more sense. And like a good example of two sides of that, right, are on the one hand, you know, almost every state, like enrollment, it’s easy to fall off enrollment. I mean, I just, that whole administrative process of saying is very difficult. And as we both know, lots of people, lots of people are eligible for Medicaid and don’t get it and they need it and just because it’s so complicated to get on, stay on. The flip side is for people who are on it, I mean, and again, you know this better than I do, but like some of the screening programs that have funds, like for young children for like lead poisoning, I mean, so essential. Right? I mean, I always think of things like lead poisoning just because of all the things health hazards for young children, it’s something that’s so preventable and has such a profound effect that, you know, Medicaid screening program, not perfect but reaches a lot of people. And I know, you know, with the Flint . . . who was I talking . . . Mona?

Dr. Abdul El-Sayed: Dr. Mona Hanna-Attisha.

Jonathan Cohn: Yeah, she’ll tell you that, you know, the data from the Medicaid was was a big part of how they discovered, you know, back in the day that they had the problems. And so it’s essential and not nearly enough, right? I mean, that’s the story of Medicaid. Yeah.

Dr. Abdul El-Sayed: Yeah. And tell us a little bit about what it does for Medicare. Which is, of course, just for folks, a little shorthand for folks, you know, we talk about Medicare and Medicaid. It’s really hard to keep them together. I always think about aid the poor and care for the elderly, right. Medicare is for seniors and Medicaid is for low-income people. So what does Medicare do? Or excuse me, what does Build Back Better do for Medicare?

Jonathan Cohn: Yeah, yeah. I like that. I’m going to use that, by the way. Can I borrow it?

Dr. Abdul El-Sayed: Of course.

Jonathan Cohn: I’ll make sure to give you credit. That’s a good, that’s a good, nice way to put it. And so there was a lot of talk about doing a lot with Medicare when this started you may remember. Bernie Sanders in particular was very, you know, he, when his original vision for what they would do with Build Back Better, they were going to add a hearing benefit in a vision benefit and a dental benefit. Dental in particular. Such a huge need for seniors. So many seniors don’t get dental care. That’s all dropped out. That’s, there’s a hearing piece, a small hearing piece. And for a variety of reasons, among other things, you know, they were limited on how much they could spend on this bill, and they had to make some tough choices, not some of the things that came out. There had been talk about lowering the eligibility age for Medicare, which is not, which is both something you would do both to help younger older people, people who are, you know, kind of near retirement age. As you know, you’re sort of in that 55 to 65 range, just starting to get more health problems. A lot of these are the people who have had trouble getting health care health insurance in the past. But in addition to that, if you’re thinking long-term, you want to get to a system where someday you have a government health program for everybody, you know, one way you get there is by gradually getting more people into Medicare. So this is, you know, a nice stepping stone along that. That’s not in there, either. That also got nixed. What is in there? And I do think it’s actually fairly important. And I would say among the most underappreciated parts of Build Back Better is a redesign, and it sounds real wonky, but a redesign of the Part D benefit. Now Part D is the part of Medicare, is the drug program, drug insurance. And it’s, you know, it’s a program they passed when George W. Bush was president. It looks like a conservative’s idea of how you do universal, not even universal, but how you do health care so it’s, you know, it’s channeled through private health companies and it’s got lot,s all the issues with that. But you know, keeping with our theme today, you know, it does provide drug coverage for seniors who desperately need it. There’s been, the coverage itself has always been incomplete, it had a big gap in it. Something called the donut hole. Like you would send so much money and then you would lose your coverage and then you’d get some coverage back. But the result was, among other things, for seniors with serious chronic multiple conditions were often paying thousands and thousands of dollars in out-of-pocket costs every year for their medications. You know, seniors on a fixed income $40,000 a year, you’re spending 8, $10,000 a year on a medication. That’s a, that’s a real problem. The bill would limit out of pocket expenses to $2,000 a year. It’s a big deal. And as a straight up, just, you know, we’re going to make this more generous and, you know, it’s simple. It’s not sexy, for lack of a better word, but actually, you know, when you talk about, you know, delivering progress to people, I think that’s something that seniors will notice. There is an addition to that, and this is part of Medicare although it’s not just Medicare, there’s the whole prescription drug piece we can talk about in a second because that’s also part of Build Back Better, giving the government, I would say, a little bit of broad authority to start regulating the prices of prescription drugs, both for Medicare and to some extent for people who are on private insurance. How much they can do is still up in the air, in part because this has to go through the Senate rules of what you can vote on and what you can’t and it’s been, it’s been a slog to get anything through. You know, this has been a fight with the drug companies. And so that is still an ongoing debate.

Dr. Abdul El-Sayed: And then there is a real investment in home and community based care and services. Can you tell us a little bit about that?

Jonathan Cohn: Yeah. Yeah. This is another thing where I think is highly underappreciated part of Build Back Better, except for the people who deal with home and community-based services. Hugely important. So it’s one of these wonky to home and community-based services, HCBS. What that refers to are services and programs for people who are elderly, people with disabilities who need some kind of help and assistance to get through daily life. And that can mean any number of things. So it could mean I need home care aide because I need some help with daily tasks of life, washing, cooking, eating, getting around. It could mean a program that helps people with disabilities stay in school or get a job or live on their own with apartments. If you talk to people who interact with these services, they are absolutely vital. I, you know, just to give an example, there’s someone I wrote about this year and who I’d actually written about years before who he was a college student and was able to, you know, was going to Kenyon College, which is in, you know, that state down south. Great kid, he has cerebral palsy, so you know, he’s in a wheelchair and needs help, you know, with things like bathing and preparing food and things like that. But with the help of home care services, he went to Kenyon College. He lived at Kenyon College. He graduated with honors from Kenyon College. Is now studying grad school and Vanderbilt to become a teacher. All of that possible because of HCBS, you know? And you know, my mother who passed away two years ago, but you know, she had home care her last couple of years and they were vital. And, you know, Medicaid pays for that, but not nearly enough. And there’s not enough money in there. So lots of people wait for the services, they can’t get them. And when they do, the money isn’t good. And this, in turn, is, this was always a problem. The pandemic really highlighted how much because we got into labor shortages, and one of the problems it revealed was that this whole system of home care is really dysfunctional. In part because we don’t pay nearly enough to the people who do this work.

Dr. Abdul El-Sayed: That’s right.

Jonathan Cohn: And, you know, even if you were to just ignore what it means for the people who use these services, and you just look at the people providing them, you would be, this would be an imperative to do something about this because these are, this, you know, this is hard, hard work, right? So valuable to society. So you need the right people to do it and they are paid just horribly and you know, working conditions, and they are predominantly women, they are disproportionately women of color. And, you know, simply looking, if you were, if you could, you could justify doing something about this surely is like an economic initiative, to like left up this part of the workforce just to give them, you know, solid, or I mean, this is, you know, I always say to me, we think about rebuilding up America’s working class, and you think of like, what did it mean to be an auto worker? You know, we’re in Michigan, what did it mean to be an auto worker 50 years ago, right? You know, it was a good job for somebody, it was a trade, but you know, you got financial security, you had a way to move up in the world, you had benefits. This is the working class of today, care workers, and this is a place to invest. So Build Back Better puts a bunch of money into it. You know, this is going to be a common theme, you look how much money it would really take to do what I was just talk, to really kind of make these services available to everyone who needs them, really pay these workers well, it would be hundreds and hundreds of billions of dollars. They went in, they were hoping to get $400 billion over 10 years for this. The size of the package has gotten shrunk down, shrunk down, shrunk so now we’re about hundred, I forget, actually it was 155? Where did they land on it? 175? But it’s less than 200 billion. So about half of what they wanted. So on the one hand, you know, it’s a step along the journey, on the other hand, like that’s a historic investment compared to what we’ve done before. But this will make a difference even if there’s a lot more work to do.

Dr. Abdul El-Sayed: It’s like one small step for man and one small step for the home and community-based service economy. And to your point, right, the fact that we failed to reimburse properly the people who take care of our most vulnerable people says a lot about how we think about vulnerability in society. And the fact that this bill could correct that is a really important step forward. And you know, to your point about equity, one of the most important things we could do to equitable-ize our economy, to make sure that we are addressing the huge gaps in learning across gender and across race and ethnicity is to invest in home and community-based services. And then, of course, it is completely life changing for people. And it’s the difference between being able to live and be and do in society and to engage with the full capacities that you have, versus having to be in an institution where those opportunities are very limited to you. I want to, you know, move forward because one of the things that we’re not talking about right now is a public option. And of course that was one of the centerpieces of then-candidate Biden’s platform, and we’re not hearing much about that. Can you speak to why that isn’t even something that we’re considering, and why it seems like the administration has sort of walked away from that?

Jonathan Cohn: Yeah, yeah. And it’s interesting, and I’ll preface this by saying one thing I’ve learned is that we probably won’t get the full story of what decisions were made about what’s in this agenda until after it’s all done, right. Then we have to go back and look. Because we know bits and pieces, but you sort of find out later as people, you know, reexamine and do interviews and people who were on the inside start to really talk candidly about what was going on. You know, to sort of set I think, let’s set the scene, right? So the 2020 presidential primaries and we had a bunch of candidates running on health care and you had, on one end you had, and it terms if you’re going to map them out on a spectrum, you had Bernie Sanders promoting Medicare for All, which I’m going to assume your listeners know what that is. If they haven’t, they should read your book, which I have on myself. But you had Bernie Sanders promoting a sort of, you know, a true version of Medicare for All. You then had on the other end of the spectrum, you had Joe Biden, who was basically saying, Look, I don’t really feel like we can do that. And it was a little cagey about how much of this was I don’t think we can get the votes for it, and how much I don’t think it’s a good idea. So he was kind of promoting this plan of, you know, building on the Affordable Care Act, as we were just talking about with a lot of the pieces that are actually in the Build Back Better bill. Now he did also talk about a public option. And the public option is something that was discussed in the beginning of the Affordable Care Act. It was supposed to be part of the Affordable Care Act in the original version that Democrats talked about. And the idea was that for people getting insurance, some, we can’t, you know, the theory of it was Democrats, broadly speaking, have been trying to get universal health care for 100 years. And for the first several decades of that, most of the energy, or a lot of the energy at least was around this idea of just doing a Medicare for all system. It wasn’t called it back then, but that’s, when Harry Truman wanted to do health care, that’s what he wanted to do, basically. And for a variety of reasons, you know, they eventually backed away from it. Partly there was some of it was substantive. You had, the party had a more conservative tilt on it, became skeptical. Partly, it was a “we can’t get the votes, it’s too hard to get the votes.” So, but when they came up with what would become the Affordable Care Act, it was this, we don’t want to totally give up on this idea. A. we think, we believe that public insurance is better. We want to give that option to people. And B, we believe that if we create a public insurance option that people can enroll in, it will thrive, it will be popular and we can then build on that and get to a true Medicare for all system in the long run. That did not happen in the Affordable Care Act. Politically, they didn’t have the votes. It was fought, you know, and there was a familiar dynamic of most of the party wanted to do it, but there was a small handful of more conservative Democrats who were against it. Fast forward to now. So Biden, in his plan, says let’s have a public option. His iteration changed a little bit during the campaigns, but at one point it was, that was going to be the Medicaid solution. What we were talking about before, you know, that’s how you going to get Medicaid in those states that haven’t expanded Medicaid. What was interesting was it kind of fell out of the conversation early when they were talking about, you know, when they went, when he was sort of formulating Build Back Better and that was a conversation with him and with the congressional leader, so Nancy Pelosi, Chuck Schumer, the committee, that option kind of fell out of the conversation early. My sense and somewhat informed by reporting is that it was a combination of it was the same, creating a public option always is going to run into political obstacles. And there are always going to be the, you know, familiar, you know, you are, the insurance industry doesn’t like it. We all know that. I think underappreciated by a lot of people is not just the insurance industry, hospitals don’t like it. Doctors don’t like it. Not all! I mean, you can find doctor, you like it, you’re a doctor. But you know, in general, the medical community as a whole, the hospital industry as a whole, the drug industry as a whole. The reason they don’t like a public option is the same reason they don’t like Medicare for All, which is also the reason why to progressives, one of the big appeals of Medicare for all, or at least the public option, is that you are starting to introduce more government power into controlling the price of health care. Which is what every other country does, is how they all, you know, whether they have a totally government-run system or one with competing plans, they always have some kind of global control over prices and spending. It’s how they keep their spending so much lower than we do.

Dr. Abdul El-Sayed: It’s how they have universal health care for everyone at a far lower price than we do.

Jonathan Cohn: Yes. That’s how they do.

Dr. Abdul El-Sayed: And are far happier and live longer lives.

Jonathan Cohn: Yeah. It is how they do it. And the industry in this country fights it tooth and nail. And I mentioned that it’s not just the insurance companies, not because I’m trying to like spare the insurance companies the grief just to be clear or, you know, people, you know, they are obviously a very big part of this. But you know, at least in my experience of reporting on health care, I’m always struck by how powerful the hospitals are. And you know, hospitals are powerful, not just because of the traditional they give money or whatever, but you know, every hospital, two things are true. Number one, they are typically the largest employer in every congressional district. And number two, the people who run hospitals tend to be in the same social networks as members of Congress, and they serve on the same boards. And you know, what happens is I’m representative Jonathan Cohn representing Ann Arbor, which I guess means Debbie Dingell isn’t here anymore being my representative, but not trying to, this isn’t about Debbie Dingell, it’s about me. You know, I want to do something like a public option that’s going to, you know, among other things, possibly start to bring down hospital prices. Hospital CEOs are going to walk into my office. It’s like, Hey, how are you? It was great to see you last night at the sort of board dinner, my wife is with your husband, da da da, going back and forth, and by the way, I hear you’re thinking this public option, it’s a terrible idea because like, it’s going to, you know, we’re going to close our emergency room, people will be waiting for services, and by the way, I won’t have to lay off 2,000 workers in your district. And you know, that’s like, you know, you throw in that, you throw in the money, you throw in all the other, it’s a very hard, it takes, you know, it’s a hard thing to do politically. Now we do hard things politically. You have to pick and choose what you’re going to do. I think the feeling was this was not the hill to die on if they could do other stuff. I thought my, I thought it was interesting and telling, my sense, and again, we’ll see, you know, in the after action reports if this was true, my sense was that actually, even people like Bernie Sanders made a decision early on that they had to prioritize. You know, what their, and so I think, so for Bernie Sanders or Pramila Jayapal, the sort of progressives who are most in favor of this idea, I think they really were trying, they put most of their energy into some other parts of Build Back Better, like the prescription drug coverage, like expanding Medicare benefits, you know? And some other pieces of, you know, this is a very vast bill so, you know, they also care about things like child care. They care about things like the child care tax credit, you know, taxing millionaires. And so, you know, it was at the end of the day, the advocates, it was not as high on the advocates’ list as some other items. The opponents were opposed. And you know, the reality is they have 50 votes in the Senate. They have a three-seat margin in the House. One of those senators is Joe Manchin. I don’t actually know that Joe Manchin per se say has a problem on the public option. I’m not, I don’t think, his name is not the first one that pops into my mind when I think of senators that are going to be problematic on that. There’s some other senators. I, you know, in the House, but you have a bunch of, you know, still have some conservative Democrats in the House. And I think just at the end of the day, you know, the base just didn’t have the support needed to get through.

Dr. Abdul El-Sayed: Yeah.

Jonathan Cohn: Yeah. Didn’t make the cut.

Dr. Abdul El-Sayed: I want to sort of just think about where we go from here based in where we’ve come from. You know, you’re the author of The Ten Years War, which, by the way, is on my mantel here and you’ve watched the back and forth even after passing what has been a historic health care legislation. What do you think we have in store for us moving forward? You know, if we don’t pass Build Back Better, do you see this administration trying to move forward on anything from this package on health care? And if we do pass it, what do you think they’re going to try and accomplish from there?

Jonathan Cohn: That’s interesting. Because, you know, it’s funny, I’ve been mostly assuming something like this will pass. I still think there’s still, even now, I still tend to think that. I just feel like the incentives to do something are strong enough that even Joe Manchin at the end of the day would prefer a world where some legislation passes. I don’t know exactly what that legislation is going to look like. So if they didn’t, I mean, there are pieces of, the health care pieces of the, of the Build Back Better happen to be very popular. So, you know, extending the ACA subsidies, for example, is very popular and the kind of thing that no one really wants to let lapse. Even Republicans will think twice because, you know, at this point, you know, I’m senator, think of like a senator from, a Marco Rubio, so I’m from Florida. Now, i, you know, I’m a Rock Ridge Republican, I tried to repeal the Affordable Care Act, I tried to sabotage it. But you know, at the end of the day I got probably a million people, you know, in my state, I need to win reelection, who are buying these policies. And I don’t want to be the reason their insurance premiums jumped $400 next year. So that’s, you know, the kind of thing I think, you know, you would see you would see them try to do that. They would probably try to do something on Medicaid. I don’t know if they could. You know, it’s funny. The hardest part, the hardest on the health care agenda and Build Back Better, the politically most difficult part is also the most popular part, which is the prescription drug package. It’s mind boggling. Mind boggling is the wrong word, because I understand it. It does make your head want to explode though, which is that giving the government power, some kind of power to regulate drug prices, which again, every other country does, right, is something, I mean, it pulls super well. Even if you do the sort of careful polling where you get people thinking about the counterarguments. And I just say I’m one of those people, I don’t think it’s a crazy argument to sort of say, Hey, wait a minute, if we do this the wrong way, we could hurt innovation. I actually think that’s true. I think there’s a way to do government regulation of prices that could hurt innovation. I don’t think any of the things under discussion would do it. But I mean, you know, there’s a conversation to be had about how do you? You know, I remember when they were in the early stages of negotiating what ended up in Build Back Better, there was some thought given to the fact that, you know, today, most of the innovation happens with these small biotech firms that are startups, they have trouble. And there was actually discussion, they never did it but I actually thought it was a good idea, was, you know, to pump some, even if you’re having the government really start to do something, to bring down prices, create a pool of capital, it wouldn’t be that much money, available to real startups that are doing this innovative work. We have programs like that and like various across the federal bureaucracy today, and you could expand that. You know, have more NIH funding, right, for basic scientific research. That’s the foundation for this. So you could, you know, I, you know, I think there’s a reasonable argument to have over that. But at the end of the day, this is super popular. And it’s also the kind of thing where you don’t have to do that much to make progress. I mean, we spend so much on drugs and even like getting 25% of the way towards a really good regulatory process would save people a lot of money. And, but my God! I mean, it’s super popular. You can tell it’s popular because even a lot of vulnerable Democrats are for it. You know, we have, a House member in a district directly to the north of us, Elissa Slotkin has been a big proponent of this since the day she got to Congress. And you know, she’s in an R+3 district, right, a, you know, a rural Republican-leaning district, and she’s always campaigned on. And I’m not suggesting she doesn’t do this because she doesn’t believe it’s the right thing to do, but she knows the poll numbers. This thing polls great─

Dr. Abdul El-Sayed: Right.

Jonathan Cohn: With Republican voters. And yet the drug industry is so powerful.

Dr. Abdul El-Sayed: Yeah, $4.3 billion in 20 years. That’s what they’ve spent to try and defeat anything like this.

Jonathan Cohn: Yeah. And I mean, this was really held up in the end by like five members of Congress, you know, three in the House and two in the Senate. And I think they will keep trying to do that. I mean, the House did pass something two years ago. I think it didn’t get enough credit for actually getting a decent bill through. So I imagine they’d come back and try that again. And then, you know, over the long run, you know . . . I don’t know what the long run looks like and who’s in power two years, four years, eight years for now. I mean, we’ll see if we still have a democracy, right? I don’t want to laugh about that.

Dr. Abdul El-Sayed: Painful idea to end on? But you know, the point that you raise is a really important one around the power that major industry has in shaping an agenda. And you know, that was part of the story of why we didn’t get a public option, it was part of the story of why the ACA is built the way it does. It is incents to a particular power of the health insurance industry and a primacy of the health insurance industry in our system. And you know, I’d love at some point in the future to have this debate about innovation and where it comes from in the prescription drug space, but for now, I think the points that you ended on a really important, and as we move forward, I hope that listeners will pay a lot of attention to exactly where these, we’ll call them paradoxes, arise where the American people want something, a vast majority of Congress-people, even in swing districts, want something, and it doesn’t happen. And the ways in which the power of a set of large corporations in health care can stymie the well-being, really, of the American public. That was Jonathan Cohn, he’s a national correspondent at HuffPost and author of the recent book “The Ten Years War” about the fight over the ACA. Jonathan, thank you so much for taking the time to join us and walk us through some of this, and we’re wishing you a happy, healthy holiday, OK?

Jonathan Cohn: Thanks for having me on the show, and happy and definitely healthy holiday to everyone. Stay safe.

Dr. Abdul El-Sayed: Thank you. You too.

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. Omicron is surging:

[voice clip] It’s the very last thing any of us wants to talk about right now, especially nine days before Christmas. But frankly, tonight it’s inescapable. COVID cases are rising extraordinarily quickly, even in people who are vaccinated.

Dr. Abdul El-Sayed: In Denmark and Norway, health officials are predicting a massive surge of Omicron cases. In the UK, the government passed a new set of restrictions, including vaccine verification for public indoor settings, as well as a return to masking in anticipation. While the variant is decidedly far more transmissible than even Delta, which is more transmissible than variants before it, evidence suggests that it’s certainly not more severe and that it may be less severe overall. One study from an insurance company in South Africa based on three weeks of data, suggests that Omicron may cause fewer hospitalizations than previous variants as a proportion of overall infections. But don’t forget, this is a numbers game. Even if Omicron is less severe on average, it doesn’t mean that it’s not severe. If Omicron infects that many more people, it could ultimately cause more hospitalizations overall because of how transmissible it is. Nevertheless, I’ll take it as good news. Meanwhile, Pfizer announced final study results from its new anti-COVID pill Paxlovid. They showed that if taken within three days of the onset of symptoms, the medication prevents 9 out of 10 hospitalizations. That’s a big deal. A very big deal. I worry, though, that some folks may use this pill as a reason to forgo getting vaccinated. That’s a bad idea. Why? Because these pills still haven’t been approved by the FDA, though I suspect given the data, that they’ll be approved rather quickly. But access to these pills, particularly as cases rise, may be limited. Best approach? Get vaccinated. And if you do happen to get a symptomatic infection, which is rare, take the pill. But in a sign of just how crazy anti-vax hysteria has gotten, German police broke up a plot by a group of anti-vax extremists who began to stockpile weapons to assassinate the state governor of Saxony over a vaccine mandate. Here’s the thing, even if anti-vax extremists never got away with a plot as crazy as this one, they’re still responsible for a number of lost lives in the context of this pandemic. That’s because vaccines save lives and any effort to keep people from getting them, well, it does the opposite.

That’s it for today. On your way out, if you haven’t already rated and reviewed our show, please do. I’d really appreciate it. And if you’re looking for a great gift for someone who loves science in your life, or even yourself, I hope you’ll drop by the Crooked store for America Dissected drip. We’ve got our logo mugs and t-shirts, our Science Always Wins t-shirts, sweatshirts and dad caps, and our Safe and Effective tees.

Dr. Abdul El-Sayed: America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivier Martinez. Veronica Simonetti mixes and masters the show. Production support from Tara Terpstra, Lyra Smith, and Ari Schwartz. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, Michael Martinez, and me: Dr. Abdul El-Sayed, your host. Thanks for listening. This will be our last episode for the year, until January 4th, when we’re back with a special mailbag episode with guest host Tre’vell Anderson. I hope you’ll tune in. Happy holidays from all of us to you.