Do you ever go to a bakery and become utterly paralyzed by all the possibilities in the display case? A chocolate chip muffin sounds good, but so does a croissant. Are they gluten free? Made fresh daily? Unraveling the 2020 candidates’ healthcare plans can sort of feel the same way, just a whole lot more daunting. In this final episode of America Dissected (we’re crying too), Dr. Abdul El-Sayed walks us through each of the major healthcare plans, including Medicare-For-All, the public option, and Medicare-for-America to help us assess how each of these plans would have helped Lisa (or not). Finally, Dr. El-Sayed speaks with Friend of the Pod Ady Barkan, an inspiring activist who wants every American to have the right to lead a full, healthy life.

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ABDUL VO: Last episode, Lisa Cardillo — a mom from my home state of Michigan, who tragically experienced a heart attack at the age of 34–shared her story with us. Through her experience, we diagnosed the American healthcare system’s many problems. See, Lisa’s heart attack — or her husband’s cancer before — weren’t their biggest worries…

TAPE LISA:  [00:25:32] Cardillo_Lisa: I’m not sure. I have an answer for that. I think it’s so complicated. I just. You know what I say? – is that when your medical bills become more stressful than your husband’s brain cancer diagnosis, something is not right 

The system is sick. And we outlined 5 different ways. Let’s recap. 

First and foremost, our healthcare system is a business–with multiple industries profiting when we get sick. That leaves Americans paying for healthCARE rather than the health we actually want. 

Second, the illusion of choice – we think we have choices in healthcare, but really, we’re restricted to getting care where we are–and meanwhile, our choices are declining. 

Third, the system leaves us relying on the same folks to tell us what’s wrong and to sell us the solution–allowing them to upsell us. 

Fourth the third party payer problem means that we’re stuck having to ask insurance to pay for the healthcare we need after the fact. 

And fifth, costs are out of control, and rather than fight to reduce them, health insurers have just figured out ways to pass those expanding costs back on to us.

Today, we’re going to talk about how politicians are proposing to fix it. 

ARCHIVAL: Candidates saying our healthcare system is broken. 

Castro, Warren, Harris… Sanders, Booker, Biden, Buttigieg…. All of the candidates agree that there is something fundamentally wrong about the American healthcare system. 

Even the GOP wants to overhaul it. 

ARCHIVAL: Repeal and replace Obamacare

ABDUL VO: Okay, yeah – they don’t really have a plan. Because their plan? It WAS Obamacare–which was originally a healthcare plan born out of the conservative Heritage Foundation and beta tested in Massachusetts as RomneyCare. 

Republicans, y’all can get some more airtime on my podcast when you come up with an actual plan. Until then, I’ll read you my favorite Crooked Media shirt: “Repeal…and Go Fuck Yourself.”

Now back to folks who have plans. 

ARCHIVAL: Testy debate exchanged on healthcare among Democrats at debates. 

ABDUL VO: Our 2020 candidates may all agree that the American healthcare system is failing people like Lisa. But the question isn’t whether or not healthcare is broken. It’s how we’re going to fix it. 

Today, using the problem list we generated during our last episode, we’re going to look at some of the more popular plans, and consider how they solve–or don’t solve–the problems of American healthcare. Oh, and we’ve got a really special guest to remind us what’s at stake in this whole thing. 

This is America Dissected with Abdul El-Sayed. I’m your host. 

>> SERIES TITLE & THEME

ACT 1: The plans and how they stack up 

ABDUL VO: In America, healthcare is big business. Those businesses – and not the patients – are the big winners in our current system. And as such, they’ve tried to tank every single effort at real reform in American history.

In the lead up to the Clinton-era health reform fights, for example, this ad, featuring the now infamous Harry & Louise helped destroy public support for the plan:

ARCHIVAL: Harry & Louise

That ad was paid for by the Coalition for Health Insurance Choices. And we’ve heard all the Obamacare scare ads since. It’s nothing new. 

In fact, it goes all the way back to the first serious push for a national health insurance plan under Harry Truman, way back in 1945. That was stymied by a huge advertising campaign by the American Medical Association, the once powerful physician lobby who feared they’d lose money under a nationalized plan. Truth be told, they were the first to popularize the term “Socialized medicine.” 

ARCHIVAL: Socialized medicine radio ads. 

Because of politicians’ fears that Big Healthcare will spend millions on ads like these to scare the public, many of the plans we’ll discuss in this episode try hard to accommodate Big Healthcare. But if the central problem with American healthcare is that it’s run like a business…well, you can see how this becomes a real obstacle for meaningful reform. 

Okay, so nearly every Democrat running for president has announced their support for some kind of plan. You’ve heard terms like Medicare-for-All, also known as “single-payer,” or “Medicare-for-America,” or “Medicare buy-in, also known as a “public option” All of these plans are built on the same idea: trying to solve some of the problems in our healthcare system. But how they go about it differs. And so does who wins and who loses. And yes, there are winners and losers. We’ll get to it.  

So today we’re going to tackle three different plans: 1) a public option, 2) Medicare-for-America and 3) Medicare-for-All. There are of course other plans — things like medicare expansion or a voucher systems — but these are the three main ideas being discussed by candidates right now.

Before we explain these programs in detail, let’s define some terms. You tend to hear the word “Medicare” thrown around a lot. Right now, Medicare is a huge national healthcare program that covers basic healthcare for Americans over 65 and with certain disabilities. It’s a great program. When people talk about Medicare for all, or Medicare for America, what they’re advocating is expanding Medicare to cover more people in more ways. 

So let’s dive in. 

And let’s start with the least reformy of them all. Medicare buy in, or the public option. 

ARCHIVAL: Candidates supporting a public option – Mayor Pete, Joe

ABDUL VO: This means that rather than just allowing Medicare to be insurance for people who are over 65 or with certain disabilities, the average Joe or Sally could buy into Medicare–the government insurance program. That’s why this is a “public option,” you have the option to buy a government health insurance plan.  It’d be like paying to have Medicare — rather than paying to have Blue Cross Blue Shield. But you could also still choose to pay Blue Cross Blue Shield, instead. Your choice.

ARCHIVAL – JOE BIDEN: If you like your healthcare plan — your employer based plan — you can keep it. If, in fact, you have private insurance, you can keep it. If you have no insurance at all, you are in the exchange, or you can buy in to the Medicare-like exchange – that is the add on to Obamacare. 

ABDUL VO: If you have private health insurance nothing would change. You’d just keep plugging along under your plan. Essentially if you switched jobs or got divorced or got kicked off of your parent’s insurance, you’d have the ability to buy a plan run by the government right there. And because there is no profit motive, the government plan would be cheaper–and probably outcompete private plans. But because you’d still have to pay for it out of your own bank account, offering this kind of a plan wouldn’t likely raise taxes across the board.

A public option isn’t a new idea. In fact, it was an original part of the plan for Obamacare. 

ARCHIVAL-OBAMA Dems supporting public option around 2009

ABDUL VO: However, as Democrats adjusted the Affordable Care Act to make it more palatable for the GOP, the public option was left on the cutting room floor.

A public option comes off as the compromise plan, but it’s got it’s faults….

Here’s what it solves: it offers more people an affordable healthcare plan. And because it competes with private health insurance, it might force health insurance companies to start to contain costs.

But here’s where it fails: because it keeps in place the private insurance system, it doesn’t really solve the healthcare-as-business problem, and it also sustains the third-party payer problem. Also, many doctors and hospitals won’t accept it (like they don’t accept medicare now), and because enough people will still be on private plans, they won’t have to. So it doesn’t offer patients more choice in what doctor you can see or hospital you can go to. 

There’s no doubt that a public option would be better than what we have now. And so it might make many people’s lives better. But not people like Lisa. Why? Because it doesn’t do anything about the janky private insurance system that’s got her in such a bind. 

MEDICARE FOR ALL

On to the next plan: Medicare for All. 

ARCHIVAL: Candidates speaking for Medicare-for-All – Bernie/Warren

ABDUL VO: Medicare-for-All is a single-payer healthcare plan. That means that under Medicare-for-All, the federal government is the only payer–hence single payer–for healthcare to everybody in the nation. 

It’s like we gave Medicare to everyone–hence Medicare for All. I want to clarify something here–people love to talk about how the government’s going to be your doctor. 

ARCHIVAL: Republican scare talking points. 

ABDUL VO: Nope. That’s not true–under Medicare for All, doctors and hospitals stay private–the government doesn’t become your doctor, only your health insurer.

Under Medicare-for-All, every single American is enrolled in Medicare. Rather than paying for your healthcare through copays, deductibles, and the premiums, you’d pay for your healthcare through some combination of taxes. But because the government is way more efficient at providing you healthcare–no marketing costs, no millions of dollars in CEO pay– the overall costs of healthcare would be way lower. 

More importantly, Medicare for all solves most of the problems we laid out. First, while doctors, hospitals, and pharmaceuticals stay private, it solves the healthcare as a business problem when it comes to health insurance. And by doing that, it can really reign in healthcare as a business problem everywhere else too. 

Here’s how: In becoming the single payer, the government becomes what’s called a monopsony. It’s like a monopoly–where there’s only one seller of a thing–but in this case, there’s only one BUYER of a thing. As the only buyer, the government can dictate the price of care from doctors and hospitals – and in doing so, force healthcare costs down. If the government is the only buyer of prescription drugs, it can force prices down for those, too. And so on. No more prices inflating and inflating.

What about choice? Well, medicare for all can’t magically transport you to the best hospital for your care right before you get a heart attack. But it can make sure more hospitals stay open, because it can pay doctors and hospitals a little bit more in communities where they might be at risk for closing. Because, again, it gets to dictate the costs. And you really can see any doctor you want–because if Medicare is the only insurerer, doctors and hospitals have no choice but to accept it. 

Here’s who loses: Big Healthcare. And, as such, they’re doing everything they can to fight Medicare for all. In fact, they’ve formed a new consortium–the partnership for America’s healthcare future–who’s already running ads to try to scare you.

ARCHIVAL: Partnership for America’s healthcare future ad

Sound familiar?

MEDICARE-FOR-AMERICA

Which gets us to Medicare-for-America. Bare with me, cuz this one’s kinda hard to explain:

ARCHIVAL: Candidate supporting Medicare-for-America plans – Beto, Kamala

ABDUL VO: Medicare for America–what at least one of the candidates is disingenuously calling Medicare for All–is an attempt to get to universal healthcare while playing nice with the private health insurance industry. 

ARCHIVAL: Harris explaining her healthcare plan

ABDUL VO: Think of it as Medicare-for-everyone-who doesn’t-have-employer-provided-health-insurance, plus a public option–option–for those who do. 

How does it work? Starting on day one, Everyone who doesn’t get healthcare through an employer gets enrolled on Medicare. And everyone born after day one is automatically enrolled on Medicare, too. But everyone who has employer-provided private health insurance on day one has a choice–they can stay on their plan or they can jump into the public option. Their choice. But everyone is either on a private plan or the public plan.

There’s another big difference–how it’s paid for. True Medicare-for-all pays for itself through a combination of taxes. Medicare-for-America would require people who can afford it to pay the government a premium for their government plan. So instead of paying your insurance company, you’re paying the government. 

This plan would certainly get us to universal health coverage. But it goes out of its way NOT to solve the healthcare-as-business problem. And so it can’t do much about expanding costs, and it can’t do much to increase choice for patients – because private insurers are left to do as they will. Sure, they may face pressure trying to compete with the public plan, but they still call too many of the shots in the system–unlike in Single-payer Medicare-for-All, where the government plan becomes the only buyer. 

So those are the technical aspects of each of these plans. After the break, we’ll have a special guest who’ll make the moral case.

MID-ROLL BREAK

ACT 2: Ady Barkan

Before the break–we broke down the technical aspects of three popular proposals being discussed by the Democratic candidates for President. The public option lets you buy a government healthcare plan if you want it. Medicare-for-all guarantees you a public healthcare plan and eliminates your private one. Medicare for America tries to do some of both. 

Now, I want to introduce you to a friend of mine who is advocating for one of these plans with every last ounce of his energies. He is a true American hero–and someone I look up to tremendously. You may remember his special shout-out in one of the Democratic primary debates… 

ARCHIVAL: Elizabeth Warren shoutout

ABDUL VO: That was pretty cool.

I met Ady on the campaign trail when I ran for Governor of Michigan in 2018. He was gracious enough to put his weight behind my campaign. After all, he’s been a leading voice to promote something we both feel really strongly about… 

ARCHIVAL – Ady speech on campaign trail for Abdul – focusing on healthcare

ABDUL VO: He inspired me then–and he inspires me now.

INTV – ADY: [03:14] Hey there, my name is Ady Barkan. I’m 35 years old and I live in Santa Barbara California with my wife Rachel and our young son Carl. I am speaking to you through a computer because my tongue and diaphragm aren’t up to the task for the past three years. I have  been living with ALS. A deadly mysterious neurological disease that has paralyzed me almost completely.

ABDUL VO: Ady was diagnosed with ALS in 2016. It’s a debilitating disease that attacks the nerves in your body that control movement. Without the signal to move, your muscles begin to deteriorate–locking you inside. So Ady sits in his wheelchair. A few feet in front of his face is a computer screen with a keyboard on it – By looking at the letters on the screen, he forms sentences–and speak to us.

Though his voice may *sound* different, his message hasn’t changed: 

ARCHIVAL – Ady advocating against 

Ady’s always been a passionate advocate for healthcare, a just economy, and worker rights. He made it his life’s work as a community organizer for the Center for Popular Democracy.

INTV – ADY: [03:52] I had a pretty perfect life before ALS Rachel had just given birth to this ridiculously cute and friendly boy. We had bought a house in paradise Santa Barbara. And I had great job as an organizer and campaigner at the Center for Popular Democracy fighting for economic and racial Justice. We went to bed happy almost every night and we could see Decades of Happiness stretching out before us.

INTV – ABDUL: [04:21] And how did you know that something was wrong?

INTV – ADY: [04:32] My left hand started getting weak. I had trouble turning the house key my fingers got tired after 10 minutes of playing the guitar. I assumed it was carpal tunnel or some other manageable problem that had resulted from my holding baby Carl in my left hand so much but a doctor friend of mine took a look and told me that I had to see a neurologist. Within a week. I was given my death sentence and told that I had about three to four years left.

INTV – ADY: [05:13] It’s exhausting and infuriating. It stripped me of my dignity. It inserts itself into every moment of my life. It prevents me from doing 95% of what I want to do in short. It sucks and I don’t recommend it to any of your listeners.

ABDUL VO: In a cruel twist of fate, Ady’s own healthcare experience has given him special insight into the brokenness of our healthcare system – allowing him to be that special kind of advocate.

INTV – ADY: [06:07] Well, unfortunately, there is no real treatment for ALS a couple drugs have been approved by the FDA, but they didn’t slow down my paralysis or help in any other way. The biggest cost for us is the personal care that I need and which isn’t covered by insurance. I basically need someone by my side 24/7 to do everything from Bathe wash and dress and feed me to adjusting my hands and feet when I get uncomfortable. That’s our biggest expense. We’re paying nine thousand dollars every month. It’s pretty nuts. 

INTV – ABDUL [06:42] That is nuts. and how does your access to the treatment that you you get whether it’s the personal care or or the treatments that you’ve tried to take that actually halt the progression of the disease. How does that compare to others with ALS?

INTV – ADY: [07:00] Most people can’t afford that care so people with ALS have to. Well most families in the United States can’t afford that care. So people with ALS have to move to a nursing home or they choose not to go on the life-supporting ventilator and they got in Japan where everyone has access to long-term care many more people with ALS choose to get ventilator. And so they live much longer and better lives than  in the United States.

ABDUL VO: I asked Ady what tackling ALS has taught him about what we need to do to fix healthcare in America.

 INTV-ADY: [09:46] Thank you for seeing that Abdul. Thank you for saying that Abdul.

That is an interesting question. I think one fundamental truth is that our Health Care system is far worse than we deserve we are the wealthiest country in human history and yet we haven’t managed to use that wealth to build a healthy society  

ABDUL VO: Ady puts the blame squarely at the feet of the insurance corporations operating for their profits. 

[13:03] Try explaining to a six-year-old why we need massive Insurance Corporation in our health care System. You can’t do it and the our system of insurance radically distorts our system for care doctors and nurses spend their time with paperwork instead of with patients. I know you’ve seen this up close during your training and experience as a doctor. Right. 

INTV-ABDUL: [13:28] Absolutely and you see it everywhere in the Healthcare System. You see it in the decisions that are made by doctors when they’re treating patients. You see it in who gets care and who doesn’t you see it in whether or not we choose to prevent or not prevent disease. You see it in the way that we’ve organized Health Care the people who need it most in rural and urban communities [13:48] don’t get it in the same way that folks in Suburban communities who tend to be richer and whiter get it and you’re right. What’s the solution here Ady?

INTV-ADY: [14:09]The first most important solution is medicare-for-all. The solution is building a society where every single person rich or poor has access to excellent Quality Medical Care because we believe that healing shouldn’t just be available to CEOs. The solution is a society where we believe fundamentally that Healthcare is a human right and not a commodity like a car. That’s a society where we can all get the medical care we need and I firmly believe it’s within our grasp.

[15:08] No more getting on the phone trying to convince your insurance company to cover something. It’s all covered.

INTV-ADY: [18:00] This is personal for me. One of the things I’ve come to deeply understand over the course of this diagnosis is that our time here is the most precious resource we have. Should we really be spending the limited amount of time we have on Earth on the phone with Aetna? Why does it have to be that way?

 INTV-ABDUL: [18:23] I’ve been asking myself that question too. 

 INTV-ADY: [18:36] I think our party should seriously fiercely debate different approaches to our Healthcare crisis, but I’ve come to believe that fundamentally we need radical disruptive change to the status quo. The only plan I’ve seen that aims for that level of ambition is Medicare for all. I believe our Healthcare System just isn’t going to work for people instead of Corporation.

INTV-ABDUL: [21:10] So why are politicians hedging against Medicare for all? We see it everyday in the debates and the news…   

INTV-ADY: [21:28] Some of it is structural. The influence of pharmaceutical and insurance industry lobbying and electioneering on politicians is undeniable. Some of it is that members of Congress just don’t have any understanding of what a crisis our Healthcare System is for real people. They make a healthy, comfortable salary and have excellent health care.So politicians just don’t understand it as a crisis and some of it is they’re just scared. Politicians don’t generally do big, bold things that threaten the wealthy, monied establishments on their own, which is where we come in. We’re building a movement to force them to do exactly that and it’s working.

INTV-ABDUL: [25:10] People often push back they say medicare-for-all is too expensive. How do you respond to them?

INTV-ADY: [25:34] We are already paying far too much for our health insurance system. I would say it’s too expensive not to enact Medicare for all. It’s too expensive to keep paying the loaded salaries of insurance CEOs and pharmaceutical Executives who profit off of hiking the cost of prescription drugs and denying people necessary care.This is a broken status quo and it’s too expensive not to enact Medicare for all.

INTV-ABDUL: [29:32] And what mistakes in this conversation that we’re having right now about health reform are we making that we’re that is walking us down the same path?

INTV-ADY: [29:54] We need to stop negotiating with ourselves and pending ourselves into preconceived notions about what people are capable of understanding. We need to not be afraid to have a real conversation about health care policy in this country. Voters understand deeply and personally how broken the status quo is, so let’s not be afraid of what Fox and the right wing will say. When I see people argue that medicare-for-all will never pass because Republicans are going to call us socialists or attack us for raising taxes, that makes me sad. It’s an argument that doesn’t give voters enough credit. Yes, medicare-for-all will probably mean a new tax, but that tax will be less weigh less than how much we’re spending on Healthcare bills. Let’s make that argument. I think we’ll be successful.

INTV-ABDUL: [27:25]  You have a young boy Carl. What do you hope will change about this country for him?

INTV-ADY: [27:34] Well, that’s a big one. There’s a lot that needs to change. Most urgently I think we need to stop destroying the planet. I guess my fundamental hope for Carl is that he’ll get to grow old and watch his children and grandchildren inherit a more just and equitable and sustainable democracy than we have right now.

ABDUL VO: My daughter Emmalee is about the same age as Carl. She is my eye to future–and I measure every action I take by what it will mean for the world she inherits.

Ady may not be around to watch Carl grow up. And that’s why it’s on all of us to make Carl–and all our kids–our eyes to the future. Ady just released a book. It’s called Eyes to the Wind. It’s a beautiful, moving portrayal of his experiences–and his vision for what our future could be. I encourage you to pick one up at your local bookstore. 

Like Ady, I believe deeply in Medicare-for-all. As a doctor, I’ve seen what happens to people when they can’t afford their healthcare–up close and personal. After medical school, I made a choice not to practice medicine because I didn’t want to work in a broken system–a system that chews up and spits out people like Lisa and Ady in the hardest moment of their lives. That system was architected by the businesses who profiteer off of healthcare every day. I don’t believe we ought to be accommodating them any longer. And that’s why I believe in Medicare for All.

If we’re going to get there, our leaders have to find the courage to stand up to big corporations who have stood in the way for too long. But more importantly, we have to find the courage to resist their fearmongering and believe in a better system, rather than fear the change that people like Ady needed a long time ago.

This isn’t just technical work. It’s political work. It’s the reason I left medicine and public health to run for office in 2018. 

I didn’t win my race, but the work continues. For me: this podcast, of course. I also wrote a book. As an epidemiologist-turned-politician, I wanted to take a look at the political disease that I think is ailing us–and the politics we’ll need to solve it. It’s called Healing Politics. And you can pre-order it now at abdulelsayed.com/healingpolitics. 

For all of us, the work continues in 2020. We’re facing one of the most important elections in American history. I don’t have to tell you why Donald Trump is terrible. I don’t have to tell you what’s at stake on our Southern Border, for our economy, or our standing in the world.

But throughout this series, what I hope I’ve shared is what’s at stake when it comes to our health. Because health? Like we’ve discussed in just about every episode–is about science, *and* government. And both of them are under assault.

People like to say that science isn’t political. That’s bullshit–politics is how we allocate scarce resources. And science *needs* those resources to advance – to discover new antibiotics, to tackle the opioid crisis, and to understand how best to prevent children from being poisoned by lead. Federal funding for science has been falling for decades. But it’s gotten way worse under this administration: Trump was the first to propose deep funding cuts for key research branches, like the NIH and the NSF–despite an economy doing better than ever. 

The Trump administration is undercutting government’s role in public health, too. They specifically directed the CDC–the country’s health department–to stop using certain words–words like “evidence-based”. Meanwhile, they proposed cutting 10% of the agency’s budget.

Cuts to these critical agencies will continue to deteriorate the relationship between science and government that was so critical to improving and protecting American health over the past century–at a time where our health is already starting to struggle.

For science, for government–for the billions they help around the world everyday, get out there. Be a part of the action. Organize, knock on doors, make phone calls, send text messages, talk to your friends and neighbors–yes, even the ones with the MAGA gear–remind them what we have to lose, and all we have to gain.

America Dissected is a production of Crooked Media. Our producers are Austin Fisher, Cary Junior II, and Katie Long. Andrea B. Scott is our story editor. Our sound designer is Daniel Ramirez. Production support from Alison Falzetta (Fall-ZET-ta), Elisa (AY-lisa) Gutierrez, Kara (CARE-ah) Hart, Daniel Porcerelli (PORE-sir-el-ee), and Tara Terpstra. Fact-checking by Dr. Nicole Aiello (aye-YELL-low). The theme song is by Taka Yasuzawa (TAAK-ah Yaas-oo-ZAH-wah) and Alex Sugiura (SOO-ghee-er-ah). Our executive producers are Sarah Geismer (GUISE-mer) and Mukta Mohan (MO-haan). Special thanks to Jon Favreau, Jon Lovett, Tanya Somanader (SOW-men-ay-der) and Tommy Vietor. And I’m your host Dr Abdul El-Sayed. Thanks for listening.