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America’s healthcare system is broken–not because someone broke it, but because it was built haphazardly to begin with. But why was it built that way? A recent episode of NPR’s “Throughline” podcast, which “goes back in time to understand the present” explored how a series of choices throughout the 20th century doomed us to our current system. Abdul sits down with their hosts, Ramtin Arablouei and Rund Abdelfattah to explore those choices and the system they’ve left us with now.

Transcript

Dr. Abdul El-Sayed: A leaked draft of the forthcoming Supreme Court opinion is set to upend Roe v Wade and opened the door to waves of abortion bans in 26 states across the country. The W.H.O. estimates that the global COVID 19 death toll is about 15 million people, nearly three times as high as previous estimates. Across the U.S., COVID cases and hospitalizations continue to tick upward, even if slowly. Meanwhile, scientists have identified yet more Omicron sub-variants. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. Friends, before we get to the episode that we’d had planned for you, I want to talk about the bombshell news that dropped last Monday, a leaked draft of a Supreme Court opinion in a case that could spell the end of Roe v Wade. By now, you’ve heard all about the legal aspects of this screed of an opinion penned by Justice Alito from our friends at Strict Scrutiny. You’ve heard all about the politics, from our friends at PSA, and all about the consequences for women across the country, from our friends at Hysteria. Here, I want to focus on the health consequences. In medical school, you see a lot of gruesome pictures, but some stay with you more than others, one that will always haunt me is gas gangrene of the uterus. It occurs when an anaerobic bacteria, usually Clostridium perfringens, is introduced into the soft tissue of the uterus. As it infects the organ, it releases noxious gases that bubble through it, killing it, and leaving it boggy, oversized and putrid. If untreated, it’s fatal. But the treatment means hysterectomy, removal of the uterus, and infertility for the rest of a woman’s life. Thankfully, gas gangrene has been rare since 1973, when the court enshrined the right to an abortion through Roe v Wade. And that’s because the most common cause of gas gangrene is what we’ve come to call “back-alley abortions” and thankfully, unsafe abortions have been virtually unheard of since Roe made safe abortions legal. Abortion is health care, and that’s all but lost in these abstract discussions we keep having. Consider a third trimester abortion, the ones that conservative anti-abortion activists love to bring up. First, they’re exceedingly rare. Only 1% of all abortions. But zoom in and ask why someone would abort a fetus in the third trimester. These are fetuses that were intended to be carried to term, would-be parents had bought cribs, decided on names, prepared to bring an infant into their homes and into their lives. But that becomes impossible. Usually because of horrific news about the impending health risks to the mother or the fetus. And yet, the fall of Roe would open the door to even stricter abortion bans that force women to carry these pregnancies to term, put her life at risk, or face the legal consequences. It turns a uterus into a loaded gun that could kill a woman, every sexual encounter into a twisted form of Russian roulette. And like all policies designed to put the comfort of a few over the needs of the many, this falls hardest on the poorest women, often women of color who cannot afford to travel for abortion services. But make no mistake, they won’t forgo abortions. They’ll just be forced to resort to the kind of unsafe abortions that cause gas gangrene. But, you know, there is a way to prevent abortions that doesn’t rob women of the right to dictate what happens in their own bodies. It’s called contraception. But the same people who have been architecting this moment for decades have at every turn defended contraceptive access too. Just like they defunded the child tax credit, which cut childhood poverty in half, and Medicaid, which millions of children rely on for their health care services. Some kind of pro-life movement that is. Next week, we’ll be doing an episode focused specifically on the health consequences should Roe fall. Until then, I hope you’ll check out previous episodes we did with Alexis McGill Johnson, President of Planned Parenthood, and Nancy Northup, President and CEO of the Center for Reproductive Rights. And make sure to check out recent episodes of Strict Scrutiny and PSA for more. Finally, if you haven’t already, I hope you’ll donate to Vote Save America’s Fuck Bans Action Plan at Votesaveamerica dot com/roe. Now to the show that we’d originally planned for this week.

Back in college, I didn’t cook much but when I did, it usually want something like this. I’d buy some exorbitant amount of meat, usually chicken breast or stew beef, then I’d start cooking. No recipe, no guidance. I’d just start adding spices and sauces and then I’d adjust from there. Sometimes it would turn out okay. Other times it would be objectively awful. But because it was my awful, I felt compelled to finish the whole dish just to prove that my cooking wasn’t as bad as anyone else who tasted it would definitely say it was. Since I’ve come to appreciate the value of a good recipe, learning from the hard-won wisdom of others to create something that tastes great. And over time, you can build upon it, add your own flourishes here or there to create a recipe that’s even better than the one you found to begin with, tailored to your own tastes. Making a meal that way when you’re in college, that’s one thing. After all, the meal either ends up in your belly or in your trash can. But it’s one meal. But maybe that’s not the best way to build something like your entire health care system. But that’s basically what we did in America. Let me explain. Medicine wasn’t always as effective as it is today. That didn’t happen until we started to base medicine on science, using rigorous experimentation to understand what worked and what didn’t work. But as science became a bigger part of medicine, the costs of training physicians and equipping them with clinics and hospitals that allowed them to provide care increased too. But then, so did demand for health care, which was for the first time, truly effective at healing people who got sick. This created a financial challenge for both patients and their providers. How could people seek the care they needed without pitching themselves into financial hardship? On the other side, how could doctors keep them going out of business if nobody could afford their services? That’s where the first health insurance program kicked in. An agreement in 1929 between the Baylor University Hospital and a local teacher’s union. Teachers could pay $0.50 a month–that’s $7 in today’s dollars a month–to insure them against any hospital care they might need. That’s how Blue Cross Blue Shield was born. This employment-based health insurance took off around the country. And during the World War II, as employers were looking for ways to attract a limited worker pool, they began offering these benefits to sweeten the pot. The war left the U.S. a dominant global power, but it wreaked havoc on Western Europe. These governments were looking for ways to ease the hardship of the war and its economic aftermath on their people and to stave off the growing influence of communism, so many of them built large, thriving social safety nets, including government health insurance. These countries followed a recipe. But not in America, though President Truman made achieving national health insurance a key part of his platform, it was widely panned by the American Medical Association, who hired the country’s first strategic campaign consultants, Campaigns, Inc, to destroy the plan, spending millions of dollars to turn public opinion against it. President Dwight Eisenhower drove the final stake in the heart of government health insurance in America when his administration made employer health insurance benefits tax free, in effect, cementing the system we have in place now, one where private employers pay private health insurance companies to pay private health care providers for health care. There was no turning back on the hodgepodge system that we created. Sure, LBJ’s Great Society led to the creation of Medicare, a national health insurance program for seniors, and Medicaid for low-income Americans, but the fundamental flavor profile of our private, for-profit system, it remained off. But over time, as the cost of health care began to rise with no government check on it, there have been many efforts to fix it, including this one:

[Clip of President Clinton] Tonight, I want to talk to you about the most critical thing we can do to build that security. This health care system of ours is badly broken and it is time to fix it.

Dr. Abdul El-Sayed: And this one:

[Clip of President Obama] And we have now just enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care.

Dr. Abdul El-Sayed: The Affordable Care Act was a really important piece of policy. It didn’t fix the fundamental problems with our system, but it did curb its worst aspects, like the fact that health insurers could exclude patients with preexisting conditions. But that fundamental brokenness of our system, the fact that we still rely on private corporations to provide us health care, that remains. Since, more and more of our health care costs have been pushed back on people themselves in the forms of rising deductibles and co-pays. Deductibles are paywalls in front of health insurance you already paid for. It’d be like going to watch a movie on Netflix and being charged 19.99, even though you already paid your monthly premium. The median family of four earning about $70,000 a year, faces a deductible of nearly $3700, more than a biweekly paycheck. During the 2020 primary, we had yet another debate about how to fix our broken health care system.

[Clip of Sen. Bernie Sanders] As somebody who believes there is something very wrong when the United States of America is the only major country on Earth that does not guarantee health care to all people as a right.

Dr. Abdul El-Sayed: But those candidates didn’t win the election. And since we faced down the worst pandemic in modern history, one that saw 15 million Americans lose their employer-sponsored health insurance as businesses closed in the first days of the pandemic. The story of how we got here is rarely told. The haphazard, Abdul-making-chicken-without-a-recipe nature of all of it hidden on purpose, to pretend like our system is perfect as it is. And that’s why I was so excited when one of my favorite podcasts, NPR’s Throughline, did an episode on just that. If you don’t know about Throughline, they’re a show that goes back in history to explore the present. This episode, The Everlasting Problem, is expertly told, tracing the odd, even accidental twists and turns that led us here. They recently re-aired the episode, so I wanted to invite their hosts, Rund Abdelfatah and Ramtin Arablouei to share why they made the episode, what they learned, and what it says now. Here’s Rund and Ramtin.

Ramtin Arablouei: All right. I’m ready. Ready to go. Got it.

Dr. Abdul El-Sayed: So, everybody recording?

Ramtin Arablouei: Yep.

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

Ramtin Arablouei: I’m Ramtin Arablouei. I’m one of the co-hosts and producers of Throughline from NPR.

Rund Abdelfatah: And I’m Rund Abdelfatah, and I’m also a co-host and producer of Throughline from NPR.

Dr. Abdul El-Sayed: So y’all know I’m a big, big fan of your show, and I feel like I’m like in one of your episodes, but actually, you’re in one of my episodes, right? It’s just mind blowing. And who knew that we’d have three Middle Eastern folks on a podcast not talking about anything having to do with the Middle East?

Ramtin Arablouei: I love it. I love it.

Dr. Abdul El-Sayed: But, hey, you know, in America in ’22.

Ramtin Arablouei: It’s real. Yeah, for sure.

Dr. Abdul El-Sayed: So tell us about, tell us about your pod.

Ramtin Arablouei: So Throughline is a long-form narrative show that basically tells stories from history that explain what’s happening in the present. And we do that using cinematic-style producing basically. We try to make each episode feel like a cinematic experience so that the listener’s learning about the past but they’re learning through stories and they’re learning in a way that feels good and feels not only like vegetables, but something delicious that you’d want to want to take in. So this show began as a passion project of Rund and I’s. We worked together on two other shows, “How I Built This” and “TED Radio Hour” back in 2015. Rund had already been at NPR a few years and I had just started, and we became friends. And in the process of working on the shows and hanging out, we kind of found that we both had a real passion for history, we had a passion for world events, and we felt like there wasn’t enough historical context in a lot of the news stories we were seeing, mostly because of the limitations of news, right? You’re doing a segment in only so many minutes and it’s really hard to provide that back story. And that particularly was the case when we talked about the Shia-Sunni divide in Islam. Because I grew up Shia, she grew up Sunni, and for us, like just a basic reading of history we were raised with, it didn’t jive with the general kind of media narrative around it. You know, one thing we pointed to was that President Obama in one of his State of the Union speeches called it a kind of a millennia old conflict that the U.S. can do nothing about, and painted it in these primordial terms. And so we investigated that in our first pilot episode. We went around talking to experts and we found that like, that’s actually not the case. That you should understand the division between Shia and Sunnis in the context that you would any other division over power that kind of played out in medieval Islamic history all the way up ’til today. And that was really powerful for us. And that’s how this show was really born, is to try to perform that kind of mission on a range of topics. And it really is something we both love, and brought us together as friends and still provide that connection and that fun in our friendship.

Dr. Abdul El-Sayed: And what are some of your favorite episodes?

Rund Abdelfatah: Well, we’ve done so many episodes at this point that it’s hard, it’s like picking your favorite child a little bit. But gosh, we’ve done so many episodes covering so many different things. One of my favorites is, let’s from a couple of years ago, on the history of bananas and looking at how we this like one fruit that seems really innocuous and is pretty much on everybody’s kitchen counter transformed the world and transformed our economic system and the story of how that kind of came to be. Last year we talked to Radiohead, some members of the band Radiohead, and that episode was in some ways a departure, but in some ways a complete encapsulation of what the show does, which is like it transports you to a different time and place. And in that episode we were able to do it through the songs and the voices of Radiohead and looking at kind of the turn of the century moment, transitioning from the 1900s into the 2000s and how that felt, and it really like makes you feel deeply what that moment felt like. And then another kind of highlight from last year that just was such an important series for us was our series on Afghanistan. In the wake of the U.S. withdrawal, we did a series of episodes looking at, you know, trying to take, as Ramtin was saying, like a different approach than a lot of kind of the mainstream media was taking at the time. There was a lot of narrative on Afghans only as victims and nothing more to their history. And we were like, let’s take a step back. I mean, of course, that’s part of their modern history, especially. That is an important part of the story. But we were like, Let’s go way back, like, let’s go a thousand years back and really understand this place that has been at the center of the world for so long and has this rich cultural tradition, historic tradition, religious tradition. And we were you know, we were able to tell the story of Afghanistan in this different way from the way a lot of other people were approaching it in that moment. So I think we were really, really proud of that, that we were able to do that and tell those stories at a time when, you know, so many of the images on our screens were basically just you know, they were tragic, but it’s easy to lose sight of that long, long history, that long, rich tradition. So those are just a few. But, man, we’ve, I mean, we’ve we’ve done everything from, you know, domestically covering, you know, the history of Eugene Debs, the socialist who ran for president and was gaining traction in the early 20th century to, you know, then we did an episode looking at the Great Depression through only the voices of people who actually experienced it and like narrated in their words from their diaries and journals and writings. So we really try to take on lots of different topics and approach them in many, many different ways in terms of the storytelling.

Dr. Abdul El-Sayed, narrating: We’ll be back for more with Rund Abdelfatah and Ramtin Arablouei after this break.

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Dr. Abdul El-Sayed, narrating: And we’re back with more of my conversation with Rund Abdelfatah and Ramtin Arablouei.

Dr. Abdul El-Sayed: One of the pieces of what I feel like you guys get very much right is an understanding of how narratives that we feel are baked into our current understanding of the world got baked in there, and how sometimes going back and searching for where those narratives developed tells you a lot about why they’ve been so baked in, and then what might be different if we thought about the world in a different way. And the thing that makes narrative, narrative is that it’s emotionally powerful. It’s not just information, it carries a lot of information about morals and ethics and values and who should matter and why they should matter and when they should matter. And that aspect of taking folks back into those moments to appreciate the dynamics, the emotional and social dynamics that created a narrative that we take for granted today, I think is extremely powerful and it’s really helpful. And I really appreciated, as you can quite imagine and the reason that we’re having a conversation today is I really appreciated the episode that you did on our health insurance system and the way that it developed. And there are a lot of things about our system that we take for granted that are very much abnormal. And I wanted to ask, you know, what is it that led you to do an episode on health insurance as sort of an entree into our health care system to begin with?

Ramtin Arablouei: So the origins of this particular episode really began during the height of the pandemic, when many people were seeking medical attention, obviously, because so many people in the U.S. and around the world were contracting, but particularly in the U.S., people were also, at that time losing their jobs. The pandemic had hit the economy so hard that many people didn’t have health insurance because they no longer were employed. And one of the questions we asked ourselves is kind of like, why is our health insurance so tied to our jobs? Why is it this thing that’s interlocked in the way that it is? And why is the U.S. so unique in having that system? You look at other countries around the world that have, let’s say, similar GDP or similar economic kind of development, many of those countries have opted for a different system, one in which the government takes more of a kind of role in providing that health care, using kind of the resources of the state, i.e., tax dollars to do it. And so that’s basically the question we asked ourselves: how far back does this employer-based health insurance system go and how can we understand it? So, like you said, we often assume that this is the way it’s always been or that this system that we have is some kind of inevitability of, you know, kind of American culture and American history. But instead, we wanted to understand what was the machinery of this? What were the decisions that were made by individual people that brought this system about? That’s generally what our show does. We try to dive into the kind of reality and the emotion, the kind of physicality of what it was to be in those moments of history, so that we can understand that things that are not always–there’s not inevitability, right–that these things were a result of actions. So that was the origin of the episode. That’s why we took on basically an investigation into how that kind of, how our system evolved and how it was created.

Dr. Abdul El-Sayed: Yeah. And one of the important context there that sometimes folks forget is that 15 million people lost their health insurance within a matter of weeks at the height of the single worst health care and public health disaster that we’d experienced in over a century. And that juxtaposition is somewhat crazy, and it didn’t happen anywhere else. You know, when we watched early days of the pandemic in Italy, it’s not like Italians were losing their health insurance just at the moment that they feared that they might need it. That is a uniquely American problem. And one of the things that I really appreciated is that, you know, you guys very quickly fingered the insurance industry rather than, you know, hospitals, doctors–and don’t get me wrong,-anybody who listens to the show knows that I’ve got a lot of somewhat harsh words to say for those institutions at times as well–but insurance in particular. What in your exploration of this history, stood out about the role of health insurance in creating the kind of, not just broken, but fragile system that we have in America?

Rund Abdelfatah: Well, I’ll say it like I think, you know, when you say fragile, you know, it is fragile. And I think it was always conceptualized, especially in the first half of the 20th century, it was conceptualized very piecemeal. It was like this puzzle where like people start putting the puzzle together before realizing like, what was the thing that they were making, right? And so that’s like an impossible puzzle to solve at that moment. And I think partly what was happening–you’re pointing to the field of medicine–the field of medicine was developing so rapidly in the first half of the 20th century. I mean, like, you know, before, you know, at the turn of the century, in 1900, you don’t have things like penicillin yet, you don’t have like people going to hospitals. The whole landscape of medicine just looks completely different, right? So as that starting to change, it’s just completely like, it’s an upheaval, like a mental upheaval for the country as to like what exactly does health care even mean. And what’s interesting, like we found that when it comes to health insurance, it really started as something called “sickness insurance” right, where people were like, you know, starting to work, not on farms but in factories and they’re like, oh, wait, if you’re sick and you can’t afford to like, you can’t go to work for that day, right, like you need something just to cover that basic costs for that time that you’re not at work, right? So it starts out very much as this like kind of small potatoes thing, right? It’s like we’ll cover, we’ll insure you for the days that you literally cannot work. It wasn’t so much thinking, are we going to cover your health care costs. Because health care costs, like, what did that mean at the time? It didn’t mean what we think of today. It didn’t mean major procedures in a hospital. It didn’t mean like preemptive care and things like that, right. But, you know, I think what was really fascinating is as you see this boom in medicine and as you see like medicine really offering people a chance at living 20, 30-years longer, right, starting to suddenly extend your life span, starting to like revolutionize what, you know, what exactly health could mean, health care could mean, yeah, that’s when you see health insurance become a thing, right? And again, like when it starts out, you, the first one, BlueCross BlueShield in Texas, you know, it starts out as sort of this like, you know, testing the water. They like launch it with teachers in Texas and were like, Here, like, let’s sell you this. And why did they decide to sell it to their employer, to the teachers, employers? Because they were like, This is quicker. This is more efficient. It wasn’t like some grand plan at the beginning to say, Oh, you know what? Like this is this is makes the most sense, like we should go through the employer. It was a business decision. And, you know, as you hear in the episode, there are at various points, you know, throughout the ’30s, ’40s, and ’50s, you have these sort of like in-the-moment decisions that are made that create temporary solutions to what becomes, as the episode is called, like an everlasting problem, a problem that we continue to deal with to this day. And I think that was something really striking for us, was that especially in those early days, that first half of the 20th century, there wasn’t a grand plan. It wasn’t like, you know, anybody came in and said, This is why we should, like, craft this, you know, employer-based insurance system. It was different interests at different times, pushing, you know, a small piece of the puzzle forward, and you basically end up by the 1950s with a puzzle that is missing some essential pieces, but that’s what you’ve got.

Dr. Abdul El-Sayed: I really appreciate the point that you made about the history of medicine itself. And we sometimes assume that in medicine, as we know it, has existed in some, you know, maybe even primitive form in the past. But there really was a revolution in medicine with the advent of the germ theory of disease, which is, you know, back in the day, the majority of diseases that people died of were infectious diseases. The minute we were able to identify what caused them and then how to treat them, it did two things: A, it made the practice of medicine effective, so people actually wanted it because, you know, people kind of know like, am I actually getting something useful here or not? And second, it made it a lot more expensive, right? Because you actually had to train people in how to do this thing. You know, as someone who spent seven years of grad school learning about about how to do this, it is an expensive undertaking. And so the cost of training people, but then also the cost of providing things like sterile surgical equipment, those those went way up. And those two things, people wanted it just at the time as as the costs started to skyrocket, you know, forced this sort of set of decisions about how do you pay for this thing sustainably. And you’re right, these were a series of experiments that were never really designed to scale, that then got baked in. I want to ask, there was a key decision that you guys point to in the show about the tax status of insurance benefits and the implication that that had over time for the permanence of our system. Can you speak a bit more to that?

Rund Abdelfatah: Yeah, I mean, well, this is one of those like ‘in the moment things’ that was done. So you have during World War II, right, like put ourselves in World War II for a second, right? I mean, like, this is you have a showdown between, you know, these axes in the world. And really in that moment, it’s like existential, right? That is the main concern. Everyone is like, what do we need to do to defeat this threat, you know, Nazi Germany, what do we do? And the U.S., as it gets involved in the war, is channeling all of its energy into that, right? All of its manufacturing power, everything, right? And Roosevelt, who’s president at the time, is, you know, saying we have to you know, we have to cap wages, we have to cap prices–like everything needs to basically be a concerted effort, a concerted war effort. And it’s in that moment where basically you get this proposal to offer health insurance through the employers. And, you know, it was partly something that, you know, was designed as sort of like an incentive for employers to say, like, Hey, we can’t attract you with better wages, but look, we can at least give you health insurance. And it happened so fast, it wasn’t taxed. And people were kind of like, we’ll worry about this later, right? Like, this was not something that was, again, it was sort of secondary to the big existential threat of the moment, right, which was winning the war. And so this decision in that, kind of in that key moment to not tax employer-based health insurance would eventually come back around after the war. And after the war, people, you know, the IRS starts looking at it and being like, Why are we not taxing this? Basically, right? And it’s at that moment, the President, Eisenhower’s in office, and he’s, you know, pushing this agenda of, you know, “the private way is the American way” and really trying to protect the interests of employers, and so he doubles down on this, you know, tax exempt status for employer-based health insurance and sets it in stone, and basically says, Yeah, we’re going to we’re going to protect this. And so what began, again, as this sort of piecemeal solution in a time of war, was later codified into law. And that’s really, you know, that becomes a really key signal for the future in terms of, you know, the idea that now we’ve arrived at like this being a done deal. Like what had for so long been a question, would we end up with national health care, universal health care eventually up to that point, at that moment–it seems like a minor thing, it being taxed tax exempt but that has massive implications, right, that now this remains tax exempt and employers are going to continue offering it. And all the momentum continues in that direction of employer-based health care and all the momentum for universal health care really begins to just dissipate.

Dr. Abdul El-Sayed: And that is that is the important context here ,is that these decisions didn’t happen external to a push to do things a different way, right? I went to grad school in the U.K. and in the U.K. they have not just a single payer, Medicare For All-style government insurance system, they have a full-on government health care system. So every doctor, every hospital that you see is part of the government. And they made the decision to build their system up post-World War II in this critical moment in which we’re making decisions about how to build ours. And President Truman, who came just before President Eisenhower, had made it one of his fundamental goals, he saw it as almost a completion of FDR’s New Deal initiatives to cement national health care for Americans. And, you know, the story of the defeat there, which is something my coauthor, Micah Johnson and I write about in our book on Medicare for All is astounding because it created the entire campaign ecosystem as we know it. And you guys talk a little bit about Campaigns, Inc. and the development of the push against universal health care and government health care in the episode. Can you speak a bit more to that?

Ramtin Arablouei: Sure. Yeah. I think the fascinating thing for me in researching and learning about this is that, that really, like you said, kicked off a lot of the kind of the modern idea we have against like, the modern idea we have of campaigns being mounted by private organizations or kind of trade organizations against particular bills using kind of PR experts and other people who have a specialization on how to message. And it’s fascinating how much of that messaging has stuck. How much of this has been painted as either kind of a moral issue, at least against like the idea of socialism and collectivism. That just didn’t exist before that. And that’s a fac–for me that’s the thing that like sticks out very much for me today is that that same discussion, that same debate is what’s happening now when people are discussing whether we should move in this direction or not. And the other thing that that also points to for me is, you know, I don’t know if the Campaigns, Inc. kind of campaign is going to be as successful in a country that comes out of World War II differently. What I mean by that is, in Europe, they experienced extreme devastation. You brought up the U.K. I mean, they were, London was basically bombed to oblivion during the war. It’s the same case if you go to France. Of course, Germany. And so the situation they were coming out of was one that had a lot more desperation, so the terms of the debate were different. So in America, the U.S. actually experienced kind of an economic boom and ultimately kind of a rise of the superpowerdom out of that war. So that narrative that they painted in defeating kind of Truman’s bill, which is fascinating because you see this idea of the most powerful, at that time, the most powerful person on the planet, the American president is essentially defeated by very determined folks on the other side, insurance companies, the AMA, other folks. And so for me, that was the thing that I walked away thinking is, you know, the context matters so much. That without the security, the financial, economic, security of the U.S. at the time, perhaps those arguments would have worked differently.

Dr. Abdul El-Sayed, narrating: We’ll be back with more with Rund and Ramtin after this break.

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Dr. Abdul El-Sayed, narrating: And we’re back with more of my conversation with Rund Abdelfatah and Ramtin Arablouei.

Dr. Abdul El-Sayed: The role of the U.S. post war, I think , is a really, really important point, is that, you know, we see ourselves as the victors of the war, that our way is the right way, then by definition, and our way has been this sort of piecemeal approach to providing health insurance that’s got a whole bunch of gaps in it that Rund mentioned. The other part of this, right, is that the emerging threat post-World War II the threat of communism, right, and the USSR. That’s the beginning of the Cold War. And so it’s easy to lampoon a universal collectivist health insurance system as being of communism. And it’s striking that the same exact talking points, funded by the same exact corporate powers are what we hear today. I mean, in the 2019-2020 primary, when Medicare for All was being hotly contested, right, you had this Partnership for America’s Health Care Future, which is, in effect, a junta of a whole bunch of different health care corporations, including the AMA, that that existed specifically to fearmonger people about what might happen if we passed Medicare for All. And so, you know, you’re talking about, you know, the spread of 70 years and we still have not moved past these same talking points despite everything that we experienced. I also appreciated that, you know, you guys did this sort of in the post-script of that debate and in the height of the pandemic. And what’s striking to me is that we have had a pandemic now that has devastated people’s lives. It’s taken nearly a million of them. It’s destroyed millions more livelihoods. Many people, almost everyone has had a loved one who was affected, if not who died in this pandemic, and the conversation hasn’t really shifted. And that, to me, is just, it’s astounding. We’ve come through this unique moment in American history, and nobody has wanted to question like, Yo, why the hell we do it this way? Do you, based on your reporting and your experience having, you know, put this podcast out now, do you have any insights about why that might be?

Rund Abdelfatah: I do think, I will just say I think it’s striking that for the first time in a long time, and, you know, over the last seventy years, as you said, there has been very little kind of revival of the universal nationalized health care conversation. It’s interesting, though, in the last few years and in particular in the last election and the previous one, like that conversation was at least bubbling to the surface in a more robust way than it seems to have in the rest of that 70-year period since really, you know, again, that moment when the tax exempt status was codified and you start to just have the momentum shift. I think there’s, you know, after World War II, and with the like incredible economic boom that the U.S. experienced, I don’t think we should underestimate the power of that in propelling so much of the way that we do things in this country, and also the power of, again, having a shared common enemy, which was throughout the Cold War, which lasted a very long time, decades of feeling like communism and everything it represents, the idea of a communal good of all sort of being the kind of underpinning of the society, was the enemy. And I don’t think that we can kind of understate how those two forces of a rising kind of neoliberalism strain of capitalism and a very present threat of communism throughout much of the second half of the 20th century, how much that just kind of solidified a lot of the ideas that, yeah, up to that point were up for debate and were very much kind of like, you know, being questioned in American life up to World War II. So I see that as part of what has kind of allowed for a lot of the things that we take for granted as just fact about the way that our economy works, about the way that our politics works, about the way that our Supreme Court works–all of these things I think we take for granted. Often people have a short view of history, like, history is long, but our memory is short. I think that’s also part of it, right? It’s like when it’s the water you swim in and has been for, you know, 70 years, it’s hard to see beyond that. But I think I do get the sense that with the pandemic and even in the lead up to the before the pandemic, with the last couple of election cycles, I feel like the conversation is being had more openly, similarly to kind of the conversation around student loan forgiveness, things like that. Conversation that, you know, a decade or two ago would have been considered very, very far-fetched, they’re making their way into mainstream conversations. And that’s been interesting to see, right? It does make you wonder if is the momentum, uh, shifting?

Dr. Abdul El-Sayed: You know, what’s also fascinating is that that post-World War II period, while the economy was booming, was also one of the most relatively equal in American history, right? Between the Great Depression and the resolution of the Gilded Age through that experience and then the New Deal, you ended up having a relatively equal distribution as far as, you know, American history goes of wealth and prosperity. And, you know, that was at the height of the union movement. That was in a moment where there was an assumption that the capacity to share the wealth, the public wealth, was taken for granted. And I think, you know, as you spoke Rund, that it became really clear to me that those times, those conversations have shifted, because those times have shifted. Right? We are as unequal, if not more unequal than we have ever been as a society. And one of the things that’s really interesting to me is that the debate about health care, whether, you know, when you compare the last three debates we had–we’ll do the 2019 debate, and then you talk about the pre-ACA or Obamacare debate, and then you talk about the Clinton debate back in the 1990s–the conversation in those previous two debates was almost always about how do you provide health insurance for the poorest people, as if people who, you know, were middle income in this country could assume that they were going to get good employer-sponsored health insurance. I think this debate now is a very different one because we’ve watched as the nature of the insurance product has shifted so much with cost sharing, you have hugely rising deductibles and rising co-pays, and then beyond that, the premiums that people are paying are a substantial proportion of what they take in. If the median household in the United States earns about $69,000 a year, and the median deductible in the United States is $3,900, that means that people are going to lose literally a full-on paycheck just because they got sick despite the fact that they were insured, right? And if the operative term of insurance is “sure” then clearly nobody’s really sure about much. Which forces you to ask the question about whether or not this product is doing what it used to do? And that’s been a stepwise shift in the nature of the product itself and the nature of American inequality. I want to, you know, just stepping back as you all come out of this episode, you know, and you sort of engage with folks, you know, it strikes me that you’ve done a really in-depth look at the nature of our health care system, but neither of you come from a particularly health care background. What do you think is the number one misunderstanding that people have about the nature of our health care system?

Ramtin Arablouei: In terms of the way–I won’t address sort of the way it functions, but more are sort of why we are where we are and something we’ve hit on here–so I think people often believe that this is a debate about the particulars of a kind of plan or the way that insurance is delivered to a person, etc., whether people are happy with their insurance or not, and I think it’s much more a kind of moral, philosophical debate about what the government ‘s role should be towards the people. And that is tied up with a very old narrative that Rund mentioned about communism and collectivism and what that means for the fundamentals of the American identity. So if you poll people individually about particular areas of health insurance–for example, Are you happy with your primary care physician or are you happy with the, you know, the care you get when you go to a hospital, what your views are on health care providers, etc., or how you’re happy with your particular kind of insurance–it’s a much more mixed bag in terms of the response. But if you poll people on a general sense of whether the government should be in charge of this, I think the attitude sometimes changes. What I mean by that is there’s this immediate kind of fear of a governmental takeover–whatever that means–of any sector of American society, that’s a kind of hangover from the Cold War period. And I think the thing that I took away from the episode is that every era, particularly after World War II, every debate has been colored or has been flavored with that hangover, with that taste of what happened during the Cold War. And that’s something I didn’t fully comprehend before going into this episode, that whether it’s the kind of AMA’s resistance to it, or the role that unions played in pushing for employee-based health insurance as a way of providing some kind of benefit to their workers–all of this is happening in this larger context of this great kind of two poles fighting over the, you know, the world. That was the view of the U.S. at the time, that there’s a Soviet Union over here and we’re over here and we represent two completely different ways of looking at the world. And the fact is, the Soviet Union wasn’t a very good poster person for the ideas of sort of collectivism. And people have never really looked to Europe for this. They’ve always kind of painted this in the terms of like “communism versus individualism” and that if we give in to this, it’s a slippery slope to living in the Soviet Union. And I think that’s something that we’re still, that’s why the terms of the debate have not changed in a lot of ways, because even though reality has changed, the philosophical moral implications of this have not. And I think that’s something that listeners should really take away that’s kind of a subtext of the entire episode that I that I take away from it.

Dr. Abdul El-Sayed: Yeah. I mean, it’s a lot of the industry that makes a tremendous amount of profit off of people getting sick has leveraged the example of the Soviet Union as the extreme example that they’re trying to protect us from. Where, you know, you go to almost any country in Western Europe and they have a better, more equitable, more sustainable, more affordable, system than we do. And, you know–

Ramtin Arablouei: And they have the market economies at the same time.

Dr. Abdul El-Sayed: That’s right. That’s exactly right. That’s exactly right. And so it’s, yeah, there’s a way of painting through extremes that benefits the status quo. I want to ask you, you know, moving forward, can you give us some sneak peeks at some episodes you guys are excited about coming forward?

Rund Abdelfatah: Well, we’ve been working on, you know, in light of the leaked potential decision from SCOTUS, a lot of folks are thinking about Roe v Wade and what’s going to happen there, and we’ve been thinking about that for a good while now and just working on a couple of episodes to give some context around kind of this deeper history. In the same way that we’re talking about health insurance, there’s some kind of actually interesting overlaps between some of the history of health insurance and the history of abortion in the US. So we’re again, we’re kind of working on those and we’ll have those out kind of around the time the actual decision is released. Because right now it’s been a lot of speculation. And Ramtin, you can share some of the others. But that’s sort of in the near future. I know that’s kind of top of mind for a lot of folks.

Dr. Abdul El-Sayed: Absolutely.

Ramtin Arablouei: Yeah. We’re working on a lot of stuff that’s really exciting. We’re working one on the history of sugar and its role, so related to health care, sort of the business of sugar and how it became so ubiquitous and the interesting twists and turns between the actual product of sugar and high-fructose corn syrup, for example. And there are some really rich, fascinating stories. Like this story of health insurance, it points to the fact that things we take as inevitable or primordial are a result of individual decisions and individual interests of people that are working and living in a particular context. And so I think that’s one we’re really excited about. And we’re working on, yeah, bunch of interesting spicy things. We’re working on one on the history of slavery internationally, which, if it comes together, should be really interesting. So our show was always trying to push the edges of, and challenging, you know, our listeners and ourselves and trying to, you know, really surprise ourselves and challenge our assumptions and make ourselves uncomfortable. So we want to continue to try to do that in our future episodes.

Dr. Abdul El-Sayed: All right. Well, we really appreciate you doing that. We appreciate the show. And folks, I hope will go and check it out. You can get it wherever you are listening to this podcast. Our guests today are the hosts of NPR’s Throughline. They are Ramtin Arablouei and Rund Abdelfatah.  And we really, really appreciate you all taking the time to join us.

Rund Abdelfatah: Thank you so much for having us.

Ramtin Arablouei: Thank you, Abdul. And thank you for, ah it’s so nice to hear our names pronounced accurately.

Rund Abdelfatah: Yeah, my god. That pronunciation is beautiful.

Ramtin Arablouei: Uh, amazing.

Rund Abdelfatah: He said it better than we say our own names.

Ramtin Arablouei: Yeah, I know.

Dr. Abdul El-Sayed: I’m going to, I’m going to say, I’m going to go by the whole name so like: I’m your host, Dr. Abdulrahman Mohamed El-Sayed

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now: a recent report from the W.H.O. estimates that the true burden of deaths during the pandemic is up to 15 million, nearly three times higher than reported. The W.H.O. looked at excess deaths, how many more people died than what you would have expected extrapolating from deaths from before the pandemic. They found that excess deaths were at times substantially higher than reported. In my parent’s native Egypt, for example, they found that excess deaths were nearly 12 times as high as the reported number of COVID-19 deaths. I want to pause for a second and just put that number in perspective: 15 million people. That’s as if Minnesota, Wisconsin, and Colorado all just disappeared in the span of two years. As we reckon with the waning long tail of this pandemic, I hope we recognize that while some death was going to be inevitable, the scale of this puts it on par with some of the deadliest events in human history. Meanwhile, cases and hospitalizations do continue to tick upward, though slowly. What’s clear is that our BA-2 wave won’t be as large as the one they experienced several months back in Europe. That likely has a lot to do with what we learned last week, that nearly 60% of Americans had been infected with COVID-19 as of February, suggesting that there’s a substantial barrier of Omicron immunity, blunting the spread of these BA-2 sub-variants in the U.S.. That said, scientists have discovered several more Omicron sub-variants: BA4 and B5 in South Africa are particularly concerning as cases of COVID tripled there in just a week, an eerie reminder of the origin of the original Omicron surge back in late November. Both the variants appeared to evade the natural immunity produced by Omicron infection among unvaccinated people, though not among vaccinated people. They spread even faster than BA-2, which of course spread faster than Omicron. But there’s no indication regarding their severity. These new variants have been identified in the U.S. as well, though BA-2 remains dominant. All of this reminds us that while the pandemic era of COVID may be waning, it ain’t quite over yet. Stay safe out there.

One more thing before I go. I’ll be testifying before the Senate Budget Committee at a hearing about Medicare for All on Thursday at 11:00 Eastern Standard Time. We’ll put a link to our show notes if you’re interested in catching it live. That’s it for today. On your way out, I want to ask you to do me a favor, please do rate and review the show. It really does help. And if you love the show and want to rep us, as always, you can drop by the Crooked store for some America Dissected merch. 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, which are on sale for $10 off while supplies last.

Dr. Abdul El-Sayed: America Dissected as a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivia Martinez. Veronica Simonetti mixes and masters the show. Productions support from Tara Terpstra and Ari Schwartz. The theme song is about 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.