Melissa Harris-Perry: Welcome to The Takeaway. I'm Melissa Harris-Perry. We're doing something a little different for you all this week, we're revisiting some of our favorite Deep Dives, along with my partner in [unintelligible 00:00:09] information exploration, Dorian Warren. Today, Dorian and I are getting into all things health insurance. Don't worry, it's going to be fun and educational.

Now, heads up, we take this back in January when the Omicron variant was wreaking havoc and Dorian had just returned to the States from New Zealand. Well, I was just a little bit jealous. Anyway, enjoy.

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Melissa Harris-Perry: Welcome, everybody. This is The Takeaway. I'm Melissa Harris-Perry. For the first time in this new year, I'm joined by my friend Dorian Warren. Now, maybe you remember, Dorian is co-president of Community Change, co-chair of the Economic Security Project, and of course, Dorian is my co-host for The Takeaway Deep Dive. It is so good to have you back, man.

Dorian Warren: Hey, Melissa, it's great to be back on The Takeaway. I really really miss you all seriously.

Melissa Harris-Perry: I missed you too, but I didn't just miss you, I have been hating on you because I've been over here freezing, a particularly cold winter, and you flipped the script and have been enjoying sunshine and blue skies in New Zealand.

Dorian Warren: Yes. Let me say, the weather was fantastic, but Melissa, the biggest difference, honestly, was the pandemic. Omicron was ripping through communities, filling hospitals to capacity back home in the US at the same time that I was feeling what it was like to live in an almost COVID-free nation. Yes, New Zealand has held off COVID for nearly two years. Up until earlier this week, the country had suffered less than 16,000 cases and fewer than 60 deaths since the start of the pandemic. Now granted, that's in a population of 5 million, but still, it's literally a different world.

Melissa Harris-Perry: I was reading the news and that changed a bit this week, right?

Dorian Warren: Indeed. Omicron arrived just this week, and because we know that this variant is so contagious, the country is bracing for its highest infection rates of the entire pandemic, but with 76% of the population fully vaccinated and the government taking swift and strict measures, it's unlikely, Melissa, that Omicron will be as deadly in New Zealand as it's been here in the United States.

Melissa Harris-Perry: You're not kidding about those swift measures. I read that the prime minister actually canceled her wedding due to the rising cases. [unintelligible 00:02:30] at the same time and a pretty stark contrast, our former vice presidential candidate, Sarah Palin, she was unable to even proceed with a lawsuit where she was supposed to appear because she's still unvaccinated and COVID positive again.

Dorian Warren: Listen, the prime minister did indeed cancel her wedding, where famous Kiwi singer Lorde was set to perform. Since you mentioned her, Melissa, let me say definitively that the differences between Sarah Palin and Prime Minister Jacinda Ardern are too numerous too count. We don't have all morning here. This is not just about national leadership in this pandemic moment. The contrast between the US and New Zealand's experiences of COVID are rooted in history and different policy choices. New Zealand has publicly funded health insurance that achieved universal health coverage back in the 1940s.

Melissa Harris-Perry: Whoa.

Dorian Warren: This doesn't mean there are no inequalities in the system, but it does mean that every citizen can be treated in public hospitals and all citizens have insurance.

Melissa Harris-Perry: Okay, so I get it. When a global pandemic hits a nation with more than eight decades of universal health insurance coverage, then the outcome is pretty different than when it arrives in a nation like ours that has a patchwork of this insufficient and inequitable health insurance. I think that's exactly the reason why it is the right time for a deep dive of American health insurance.

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Julia Lynch: My name is Julia Lynch. I'm a professor of political science at the University of Pennsylvania.

Melissa Harris-Perry: We asked Professor Lynch to compare the US system of health insurance to others in the world. She pointed not down under to New Zealand, but across the pond to Denmark.

Professor Julia Lynch: Denmark has in place a whole range of policies that go from health care to a bunch of policies well outside the health care system, like paid sick leave, supports for businesses.

Melissa Harris-Perry: Now, of course, Denmark's population is just shy of 6 million people, and most of them are ethnic Danes, whereas the US population is more like 329 million. We are, of course, people from very diverse racial and ethnic backgrounds.

Professor Julia Lynch: One thing to keep in mind is that while the original social insurance and social safety nets and welfare states in places like the Scandinavian countries developed at a time when these countries were really racially homogeneous, unlike the United States, these societies have continued to develop and their welfare states have continued to develop. As they become more multiracial, they have in many cases held on to those original ideas of social solidarity and original policies that have been very solidaristic.

Melissa Harris-Perry: In short, a nation's system of health insurance is what we call path-dependent, which basically means that where we are today is a result of where we began and each decision that we made along the way. To understand now, we're going to have to start with before.

Dorian Warren: Okay, let's begin in the US south at the close of the Civil War. Newly emancipated Black Americans are facing displacement, disease, and a devastating smallpox pandemic. In response, Congress established our nation's first federal health care program, the Medical Division of the Freedmen's Bureau was small and under-resourced, but these 120 doctors and 40 ramshackle hospitals across the south represented the very first time the federal government tried to provide health care to the American people. This was during a period we know as reconstruction.

Of course, it didn't last. The short reconstruction period of our experiment with multiracial democracy, of course, didn't last, but specifically, Melissa, lawmakers ended the Freedmen's medical division, arguing that this free medical care was breading dependency.

Melissa Harris-Perry: That origin story explains a lot about national attitudes towards a universal system of health care.

Dorian Warren: Yes, but wait because there's more. Fast forward to the turn of the 20th century, there's no health insurance or hospital system. If you called your doctor, you paid from your own pocket. By the 1920s, medical practitioners became more professional and their services became more expensive. Then in 1929, a group of school teachers in Dallas got together and contracted with Baylor University Hospital. The teachers paid 50 cents every month. Then if they got sick and needed to go to the hospital, they had access to inpatient hospital care.

Melissa Harris-Perry: Wait, isn't that basically how health insurance works?

Dorian Warren: Yes. This was the nation's first private health insurance. Within a decade, dozens of similar plans emerged. They then formed a single organization called, and wait for, Melissa, Blue Cross.

Melissa Harris-Perry: Stop it. I can thank some well-organized school teachers in 1929 Texas for this Blue Cross Blue Shield card in my wallet?

Dorian Warren: Well, actually, Blue Shield started out a bit differently. Primary care doctors didn't want to give all the control over to hospitals, so they created a separate network of insurance called the Blue Shield. For decades, people would buy Blue Cross for their hospital insurance and Blue Shield for their medical insurance. Back in 1982, the two merged. Melissa, that is why your hospital card has Blue Cross and Blue Shield on it.

Melissa Harris-Perry: Okay. I know I said path-dependent, but this is one long winding path.

Dorian Warren: It is, but stick with me for just one more curve in this historical road because I'm betting that you got that health insurance card from your employer.

Melissa Harris-Perry: Oh, yes, just two weeks ago, a shiny new one at the start of every January.

Dorian Warren: Exactly, because employer-provided health insurance also has a history, one rooted in World War II. With young men fighting overseas during the War, a labor shortage drove up wages and inflation. To cool down the economy, the federal government froze wages in 1942. Now to attract workers, businesses, and with the labor movement as a willing partner, started providing health insurance.

In 1943, the IRS made employer-based health insurance tax exempt. Suddenly, the cheapest way to get health insurance was at your job, and those policy decisions created are unusual in what some would say exceptional system of employment-based health insurance, another example, Melissa, of path-dependency that you just mentioned.

Melissa Harris-Perry: As you're walking through that, I'm realizing that you're getting us right there back to the 1940s. The same time 80 years ago when New Zealand established universal healthcare coverage through a single-payer system, that's the same moment when the US is instantiating this employer-dependent system of at least two different kinds of Blue private insurance. Professor Julia Lynch also explained that our current system is a patchwork of public and private insurance.

Professor Julia Lynch: Private insurance is a wonderful thing, if you have good private insurance, but I think it's really important to remember that a third of health insurance spending in the United States is actually by public insurance programs like Medicare, Medicaid and the veterans administration health system.

Melissa Harris-Perry: The patterns of that patchwork, well, they're predictable.

Professor Julia Lynch: About 60% of working-age whites have employer based coverage, so private health insurance, but that's only true for a little less than half of Blacks and around 40% of Latinos. When we think about what are the public insurance programs in the United States and who do they serve? Overall, about 20% of working-age adults have primarily public health insurance. That's going to be mostly Medicaid and insurance that they have as a result of their veteran status.

People over the age of 65 are more likely to have Medicare. About half of poor families have public insurance, and a quarter of near poor. Just to give you one more number that always surprises me, about 40% of babies who are born in the United States are, in fact, covered by Medicaid.

Jamila Michener: My name is Jamila Michener. I'm an associate professor of government and public policy at Cornell University and co-director of the Cornell Center for Health Equity.

Melissa Harris-Perry: We asked professor Michener to tell us more about Medicaid.

Jamila Michener: Medicaid is our nation's health insurance program predominantly for low-income people, so people who are living in or near poverty. That's really the core of the program, is that it provides people who have a low income with health insurance. It serves pretty, pretty economically marginalized and vulnerable populations. It's supposed to be an avenue for ensuring those folks and giving them access to healthcare, and by virtue of that, the chance to live healthy lives.

Melissa Harris-Perry: Much like other parts of the health insurance system, Medicaid is fragmented.

Jamila Michener: It's a different program in different states. It's really not one program, it's 50 different programs and we've designed it to be that way, but that means that people have lots of different kinds of experiences with it, some dehumanizing and stigmatizing and some great and positive, and those experiences affect the way they think about and engage the government.

Melissa Harris-Perry: Because our private insurance system is tied to employment, I asked professor Michener, do these people work?

Jamila Michener: [chuckles] Yes. I laugh because I know you're asking the question with a bit of irony, but I couldn't tell you how many people, policymakers included, I talk to who are not asking that question with irony but really mean it. In many states, over 50% of beneficiaries are children. They're clearly not working. A sizable chunk of beneficiaries are people who have disabilities of a various sorts, and so they're not working because they cannot work.

Somewhere around 10% or 11% of beneficiaries are elderly. They're people who also we don't expect to be working because they've aged out of the workforce, but among the group of people who have Medicaid and also fit into the demographic life categories where we would expect them to be working, the vast majority of those people do, in fact, work.

Melissa Harris-Perry: This system might be complex, with private insurance for some, Medicare for the elderly, Medicaid for the poor, but in 2020, 91% of Americans had at least some form of health insurance. Even if it's not pretty, it seems like it works, but it turns out it's not that simple.

Jamila Michener: The federal government and state governments, unfortunately, reimburse the care for Medicaid patients at a much lower rate than for patients with other kinds of insurance. For example, if you have Medicare, our nation's program for elderly people who are 65 and over, doctors are going to get reimbursed at much higher rates for your care. If you have Medicare. If you have private insurance, they'll also get better reimbursement. If you have Medicaid, you're going to get those services from doctors or hospitals and those service providers are going to get reimbursed at much lower rates. That disincentivizes them accepting Medicaid patients because they're getting less money for those patients.

In a system like, unfortunately, the system we have, where part of what motivates the system is profit, by not reimbursing for Medicaid patients at as high as a rate as you do for other kinds of patients, what it means is that it makes it more difficult for Medicaid beneficiaries to access the system because there are fewer doctors that are willing to accept Medicaid patients. Many doctors will have a cap on how many Medicaid patients they accept.

Dorian Warren: Just think about that. As a nation, we abandoned a nascent system of public health delivery because the first beneficiaries were Black, formally enslaved new citizens. Instead, our system is forged in the fire of capital and competition. Even today, our system pits those with public and private insurance on an unequal footing in the competition to access healthcare.

Jamila Michener: I think the one thing that I would really want people to understand is that the inequalities in health that we see are really the product of history and they are baked into policies that really go far beyond healthcare. This means things like redlining and other forms of disinvestment from communities of color, practices of policing and incarceration that you've talked a lot about on this show, even things like environmental policy, poor communities have higher levels of particulate matter in the air from pollution and this leads to worse educational outcomes and greater vulnerability to COVID.

When we think about health equity in the United States and the role that health insurance plays, we can't ignore these other really longstanding policy choices that make certain communities just more vulnerable to illness to begin with.

Melissa Harris-Perry: Listen, I'm still reeling from how Professor Michener explained that medical reimbursement rates depend on the source of your insurance. I guess I vaguely understood this, but something about how she explained it blew my mind. Wait a minute, things cost what they cost. Are you telling me that what our health providers are paid and what our procedures cost is set by insurance companies? How long has this been happening?

Jamila Michener: Yes. If only it were as simple as it costs what it costs and then is just you get paid for what it costs, but many states, especially for programs like Medicaid, they pay for benefits on what's called a fee-for-service basis. Under this model, you pay directly for a covered service, and so based on what the service is, the amount that you're willing to pay, especially that the government is willing to pay is predetermined based on what the service is.

Those rates are a product of negotiation and compromise over really what is a long period of time, in part by the government, but largely by the providers who are often setting the terms and often have a lot of pull and play in the political processes that determine what kinds of fees you get for what kinds of services.

Melissa Harris-Perry: Basically, our health insurance card is like our zip code, it's our neighborhood. If you have a three-bedroom, two-bath house in good neighborhood A, then you're going to get a lot more for it than in bad neighborhood B even if it's the exact same house. You're telling me that our current health insurance system is basically created residential segregation by insurance type?

Jamila Michener: Yes. This is why people call it a multi-tiered healthcare system. It's certainly a healthcare system where your care is rationed based on your income.

Melissa Harris-Perry: Who does this benefit?

Jamila Michener: The system, as it stands absolutely benefits the folks like Blue Cross Blue Shield. Even if they're in some ways paying higher rates, they also have a lot of the market share and they have the ability to negotiate with providers and with health systems to get rates and other kinds of structures that are favorable for them and for their bottom line. They can determine how much they're charging for their product in the market, how much they're charging for copays, how much they're charging for premiums. They have a lot more levers for making profit in a profit-based system like this. These are not the folks that are going to be rallying for a system that is more equitable and more universal and not profit-based. The profit-based system that we currently have is making them billions upon billions upon billions of dollars, even as healthcare costs are exploding. The government, on the other hand, has limited levers for getting more revenue and resources for a program like Medicaid or a program like Medicare. That's why they have limits in terms of how much they can pay and how much they can reimburse because they can't just up the prices because there are no prices.

The government programs are in a much more limited position and end up as a result having to make choices that aren't good for the beneficiaries of those programs, but the folks on the private side, it may sound like they're not benefiting from this scenario, but if you think about the system as a whole, they are absolutely benefiting from the healthcare system that is high cost, extremely high cost and profit-driven.

Melissa Harris-Perry: Who are the people who are not benefiting from the way our system is set up?

Jamila Michener: People who don't have a lot of income suffer and they end up having to just take whatever they can get, whether it's the lowest grade private health insurance or the health insurance that you get from the government. Now, of course, programs like Medicaid are really important and they're helping tones of people who otherwise would have no other options, but there are also ways that programs like that are just not providing people with the same level of access always that someone who has the best private insurance would have. It doesn't have to be that way.

Melissa Harris-Perry: Is this system fixable?

Jamila Michener: Absolutely. The system is fixable because we built the system, so we can change it. For a very long time, we have been making the wrong choices. Choices that prioritize profit and that emphasize the voice, perspectives, and preferences of corporations and of elite economic interest, and because we have chosen to give disproportionate political voice to those interests, we've ended up with a system that's profit-based and rationed based on your economic ability to pay.

We can very well design a different system, but we'd also have to have a different kind of politics that put priority on different things. For example, human dignity over profit or the market, and we'd also need to center and amplify the political voices of a different set of actors. If we were to make what would be some pretty transformative political changes, but entirely possible, especially if we think over the medium and long term, if we were to make those political changes, we could get a system that looked very different and that actually served the needs of everyone and that actually met the needs of the most vulnerable and the most marginalized. It's not what we have now, but that doesn't mean we can't have it.

Melissa Harris-Perry: Dorian, I'm struck that so much of what we've discussed points to the deep and persistent inequities in our system, but I appreciated that Professor Jamila Michener gave us reason to hope.

Jamila Michener: The system is fixable because we built the system, so we could change it.

Dorian Warren: Hope, change. Melissa, where have I heard those words before?

Melissa Harris-Perry: Well played, Mr. Warren, and you're right, in our very recent past, our nation made some big changes in our system of health insurance, but the path to that change was a stony road to trod, which is undoubtedly why then vice president Biden was irrepressibly enthusiastic about passage of the Affordable Care Act back in 2010.

Speaker 5: Mr. President, you've done what generations of not just ordinary, but great men and women have attempted to do. Everybody knows the story. Starting with Teddy Roosevelt. They tried. They were real bold leaders, but Mr. President, they fell short. You have turned, Mr. President, the right of every American to have access into decent healthcare into reality for the first time in American history.

Dorian Warren: In many ways, the ACA was transformative. It expanded health coverage to 20 million Americans, it created protections for people with preexisting conditions, it made sure that insurance covered preventive care and screenings, and it established competitive private health insurance exchanges that have helped to manage healthcare cost. It really was what Vice President Biden said about it at the time.

[applause]

Melissa Harris-Perry: Yes, a big bleeping deal.

Dorian Warren: To gain a little insight into the process of crafting the Affordable Care Act, we sat down with one of its architects, Dr. Ezekiel Emanuel, who is now Vice Provost of Global Initiatives at the University of Pennsylvania.

Ezekiel Emanuel: [unintelligible 00:25:29] is a big deal. There are 22 million Americans who got healthcare coverage. I will tell you many, many people stop me on the street when they recognized who I am and the fact that I worked on the Affordable Care Act, and thank me. Sometimes they tell me particular stories like, "I got a heart transplant because you passed the Affordable Care Act." That's obviously an exaggeration, but those are true stories, there are people who got medical services that they could not have gotten because of the Affordable Care Act.

We had about 45 to 50 million Americans without health insurance, and that was growing not declining, and it was getting more expensive. Second, we had growing costs that were growing about double the underlying rate of inflation, maybe even more in some years, just going up and up and up and with many consequences. Consequences for the federal government, consequences for states because they had to pay for Medicaid, and it was impinging on their ability to fund primary education, state colleges and other things.

Then we had inconsistent and uneven quality. I think people who worked on it, especially those of us in the White House and many of the people on the Hill, getting fairness, getting people who'd been excluded from the system without insurance, couldn't easily access a doctor or a hospital, that was very high on our minds. We wanted people to get coverage because we thought it was the right thing to do. People had a right to health insurance. It was integral to being a citizen.

It's important to make sure that people don't just have health insurance but they also have access to high-quality care. One of the things COVID has revealed is that while we might have made some progress on that through the Affordable Care Act, there's still a lot of differences between hospitals, say, in inner city and minority areas or hospitals in rural areas and maybe the best academic hospitals or the best private hospitals in the country.

I would also say that my colleagues were strongly dedicated to getting universal coverage, getting it as wide as possible, trying to control healthcare costs because they were very much weighing on people, and just trying to get people the care that they needed at the highest quality we could obtain for everyone.

Dorian Warren: As much fun as it is to travel back to March 2010 at that enthusiastic moment of passage, we can't stop there because signing the ACA into law was just the beginning. In January 2017, the Congressional Research Service published a report detailing 70 Republican-led attempts to repeal, modify, defund, or limit the Affordable Care Act.

Recording voice 1: They have to repeal the budget-busting bills like Obamacare.

Recording voice 2: Oppose the individual mandate, oppose Obamacare.

Recording voice 3: To repeal Obamacare.

Recording voice 4: I don't like the Obamacare plan.

Recording voice 5: Repeal whatever is left of Obamacare.

Recording voice 6: Repeal every single word of Obamacare

Melissa Harris-Perry: 70 congressional actions against the law? It makes [unintelligible 00:28:53] Harry and Louise ads against the Clinton Healthcare Reform attempt in 1994 seem mild by comparison.

Harry: The government may force us to pick from a few healthcare plans designed by government bureaucrats.

Louise: Having choices we don't like is no choice at all.

Harry: They choose.

Louise: We loose

Dorian Warren: It might seem mild by comparison, but those Harry and Louise ads were part of a successful effort to kill healthcare reform efforts during President Bill Clinton's first term, but after more than a decade of repeated attempts, and even the election of a Republican president who campaigned against Obamacare, the ACA is still the law of the land.

Melissa Harris-Perry: When you put it like that, I guess it is rather remarkable. In fact how has that the ACA survived a time of such intense polarization that has stalled, stopped, or killed basically all other reform efforts?

Dorian Warren: Well, Melissa, we might think of this as a lesson in policy stickiness, to use a very technical term. Big theoretical issues like the right to vote are, we know, important, but probably remote for most people because health insurance is personal and proximate.

When Harry and Louise are sitting at that kitchen table, they aren't assessing the health of democracy, they're calculating the health of their family. The ACA ensures that their 25-year-old daughter is fully covered on their plan, it ensures that Harry can get his prostate screening, and it protects Louise from being kicked off the family plan after she survived that breast cancer scare last year.

Melissa, we started with a comparison between New Zealand and the United States, but let's frame a different comparison. Think about the consequences of this pandemic. If Republicans can be successful in their appeal attempts. Since March 2020, 45 million Americans have had COVID-19 and survived. Without the ACA, would they all be denied coverage by health insurers because of a preexisting condition.

Melissa Harris-Perry: All right, that I get. Passage of the affordable care act and it's survival through more than a decade of significant and consistent attempts to dismantle it, that's a political and a policy win, clearly. We can look at the numbers and statistics about improved coverage or your point about what would America be right now without ACA in a pandemic. I got to say, I wonder if Americans experience it this way. Your point about the kitchen table. On a daily basis, for people living in this pandemic, I wonder if health insurance feels like a safety net. To try to figure that out, we asked the take away community and here's some of what we heard.

Speaker 12: For most of the last 20 years or so, I've worked in small nonprofit organizations with limited budgets. Having health insurance was hit or miss. Some of them provided some insurance. Often I had to find insurance on my own. I was working for a small organization when the ACA was passed and that was the way that I got insurance. I have to say, based on my salary at that organization, it was a bit pricey for me to try to have insurance, but I needed to have it and it was the first time I was able to see a doctor in years.

Now that I've been out of work, I get Medicaid through the ACA in New York state. That, at this time, it's free. I would like to have more robust insurance and have more choices if possible, and hopefully, my next employer will be able to provide the insurance rather than the burden being on me.

Deb: Hi, my name is Deb from Beaverton, Oregon. I have health insurance because I pay for it myself. I had to retire at the age of 63 because my back quit working out for me. Now I pay for my own insurance. It costs me $825 a month for my medical insurance, which is a good deal compared to what most people get. I am living on pensions and Social Security and I am eating through my meager savings to pay for my health insurance. Is it affordable? Yes, for now I can afford it. Is it rational for me to have to pay that kind of money? I don't think so.

Speaker 14: I think affordable is a little bit subjective because people wouldn't know that I couldn't afford very much. When I am faced with a medical emergency and my insurance doesn't cover all or much of what I'm being asked to pay for, I have to ask a family member for help.

Karen: Hi, this is Karen in Maple Grove, and my partner and I get our insurance through the Affordable Care Act and MinnesotaCare. We have a UCare plan, and honestly, without it, I don't know how we would've survived, period. I am a small business owner and insurance otherwise is completely unaffordable. As we are approaching our retirement age, that is one of our top priorities, obviously.

Melissa Harris-Perry: We have to say, we noticed a trend with one particular group, Medicare recipients.

Alan Tomko: Alan Tomko, Parma, Ohio. I've got Medicare A and B and Supplemental Plan N plus 250 a month. I go to the Cleveland clinic, where I get incredible care. I feel like I'm getting million-dollar care there. They're wonderful. Number two hospital in the United States. I wouldn't move because of that hospital. They take wonderful care of me.

Richard: Richard [unintelligible 00:34:35] Wimberley, Texas. Yes, I have health insurance. I've been on Medicare for about four years now and I couldn't be happier. I don't know what the problem is with Medicare For All, but I'm all for it.

Dorian Warren: The enthusiasm that we heard from Alan and Richard is shared by the overwhelming majority of Medicare recipients. A 2021 study from the Kaiser Family Foundation found that 94% of adults 65 and older with Medicare coverage report being very satisfied or satisfied with the quality of their medical care and the availability of specialists. To echo Richard, why not just implement Medicare For All?

Peter Suderman: My name is Peter Suderman, and I'm the features editor at Reason magazine.

Melissa Harris-Perry: Now, Peter things of health insurance reform quite differently.

Peter Suderman: I think too often people make the mistake of assuming that the government should be involved in the provision of health insurance simply because the government already does so much of that. We have Medicare, Medicaid, Obamacare, we have a tax incentive for employer-sponsored health insurance. What Republicans have mostly talked about doing for the last 20 years or so is tinkering around the edges.

What I would like to see politicians, especially on the right, do is think about peeling back layers and trying to have fewer of them rather than expanding the system that we already have and rather than trying to patch together create patches for the existing fractured system. Right now what we have is a very fractured healthcare system, and just about all of the reform proposals on the table that aren't single payer are designed to accept that fragmentation and then build from there.

Melissa Harris-Perry: Is there a way to really begin to peel back those layers without starting to step right on your constituents if you're a Republican or a Democratic lawmaker?

Peter Suderman: It's a great question. I think that if you are trying to start from scratch, the first thing you want to do is eliminate the tax preference for employer-sponsored health insurance. Then you want to think about what the government's role really should be in healthcare. To me, the government's role should be helping the people who need it most. Medicare, for example, which is the biggest program in the United States, doesn't do that. It's targeted at seniors and it's age-based and seniors are a relatively wealthy cohort.

Melissa Harris-Perry: Right at this moment, I felt like I should stop Peter because he just dismantled employer based health insurance and Medicare in a single swipe.

Dorian Warren: Yes, but listen, you got to respect Reason magazine writers, Melissa. They are honey badgers.

?Reason magazine writer: Honey badger don't care just takes what it wants. Oh, my God. Watch it dig. Look at that digging.

Dorian Warren: Pitching ideas because they think they're right not because they are politically palatable.

Melissa Harris-Perry: That's the truth, Reason don't give a damn.

Peter Suderman: We are just a few years away from Medicare becoming insolvent in one of its biggest trust funds, and that means that come 2026, Medicare is not going to be able to pay all of its bills to hospitals and to many healthcare providers. That's going to create care issues for the seniors who rely on it. To me, that sounds like a program that is not working.

Melissa Harris-Perry: Why not just raise that ceiling, make Medicare solvent by putting more resources into the pot.

Peter Suderman: There's a limit to how much the government can simply spend money to fix these problems. At a certain point, these programs are going to become so expensive that simply spending more money is going to create issues like inflation that are both political and economic problems, pocketbook issues for middle class Americans. At some point, that spending is going to have to come under control.

Right now it's really remarkably not much of a political issue. This is not something that Joe Biden and Donald Trump, which admittedly was a strange presidential race, but it wasn't something where the presidents were arguing about this during the presidential debates in 2020. Yet, whoever is in the White House in 2026 is going to face this. I think Americans just aren't ready for the fact that Medicare is about to run out of the money that has been allocated for it by the federal governments in pretty short order.

Dorian Warren: It's surprising just how hard it is to imagine a robust policy debate on a substantive issue between the political parties, but Peter outlined what it could look like.

Peter Suderman: I think it really just starts with two things, one is that Democrats need to understand that resources, even for healthcare, are not unlimited. Those commitments eventually create problems when those programs become insolvent or are about to become insolvent, as is the case with Medicare. Now, Republicans have a different problem, which is that they don't care very much about healthcare policy at all. The last time a Republican administration actually tried to move forward or even really think deeply about a healthcare reform was the George W. Bush administration. There was some movement towards individual accounts and health savings accounts, but even there, it was really a second or third-order concern for Republicans because Republicans have largely given up on the idea of substantive healthcare policy being something that they run on, and what they do is they say democratic policies are bad.

In many cases, I would agree with that. I think that many democratic policies on healthcare are quite flawed. At the same time, it's not enough to simply say that democratic policies are bad because Republicans are also going to have to, if they win elections, face up to the problems that exist already in the healthcare system we have, again, taking us back to this issue of path-dependency that Republicans are just totally ignoring.

Dorian Warren: We knew that after cataloging many of the problems in our system, we wanted to discuss solutions. We called up a member of Congress who has been working diligently to find solutions.

Pramila Jayapal: My name is Pramila Jayapal. I am the Congresswoman for Washington's seventh congressional district.

Dorian Warren: Like all of our guests, Representative Jayapal pointed to the problem of fragmentation in our system. I asked her if that fragmentation maps onto political power.

Pramila Jayapal: Yes, it does. It also simultaneously is, obviously, mapping onto race and ethnicity, because the way the system works is Black Americans, Latinos, and Indigenous people are much more likely to be uninsured. They are also obviously much more likely to have their vote suppressed or to not be in the halls of power and to be seen as having political power, not being catered to by the current political system, let's put it that way.

Why couldn't we just ensure that the government provides the health insurance system? We still use our existing network of doctors and hospitals, but you never have to worry that if you're tossed out of a job that you're now going to be without health insurance, and if you happen to be amongst the category of people that are politically not seen to have power or not being catered to, or you happen to be a person of color or a low-income person, that you simply aren't going to be able to get any of your healthcare costs covered.

Melissa Harris-Perry: Now, the Congresswoman has been a leading Democrat on this issue and one of the authors of Medicare For All.

Pramila Jayapal: I think what we have to continue to do is, number one, help people to fight for the fact that they deserve healthcare. Number two, present a comprehensive vision, which is what my Medicare For All bill is. When I introduced it, it was the first time that we had had a comprehensive vision of what a Medicare For All system would look like, whatever you want to call it, and then also, how we would transition to it. I think that that detail, while it leaves open the possibility that people are going to strike at little things that they don't like, I think it is important because people need to feel secure that they're going to have healthcare.

A lot of the counter to changing our healthcare system comes from the fact that people, the opposition, the lobbyists, the big pharmaceutical companies, the big private health insurance companies, they prey on people's fear, that you're actually going to lose healthcare. Then we just point to the VA, we point to the Medicare system and we say, "No, actually, we're enrolling millions of new people into Medicare every day."

We could easily turn that into the system that we're talking about because it is already in operation and it is working very well except that we need to even expand the Medicare system to cover more things. That is also contained within Medicare For All. Just adding dental, vision, and hearing to our current Medicare would be the part of the Medicare For All Bill that is about improving current Medicare as we know it.

Dorian Warren: Dental, vision, and hearing. Representative Jayapal is definitely taking these dives deeper, and we asked her to say more about this crucial point.

Pramila Jayapal: This is something we hear about all the time from seniors. Imagine the irony of the fact that as you get older, we know that with aging comes a decrease in vision, a decrease in hearing, the need for hearing aids, and increased issues with dental care. Right now Medicare, and many health insurance programs actually, but certainly Medicare does not cover hearing aids, it does not cover most of dental, it does not cover eyeglasses. It makes no sense at all because these are also-- If you look at dental as an example, it is very much tied to diabetes and other serious illnesses that cost a lot of money.

If we just covered comprehensive dental and vision and hearing for our elders, it would make an enormous difference to the quality of life to decreasing incidents of things like dementia. The researchers found that if you can't hear, you move into a state of dementia much more quickly. It makes sense. These are the things that we could do right now. Frankly, they don't cost very much money at all because you pay much more into the system if you allow these conditions to continue to escalate.

Most importantly, it's about human dignity. As you get old, you should be able to see, you should be able to hear, you should be able to have your teeth and eat and enjoy these last years. That is what we were pushing in the Build Back Better Act. Unfortunately, there is still resistance even to those ideas.

Dorian Warren: Basic human dignity. I know that's right, Melissa. It's also about what families deserve.

Pramila Jayapal: If we had the system that we're talking about, like with a Medicare For All system or a government health insurance system, whatever you want to call it, it would save 98% of families money on their healthcare costs, thousands in savings for some. That cannot be underestimated, how much the lack of money just in your pocket affects people's ability to live.

I think what we want is families who feel like they can prioritize their health and who feel like they're not going to be pitting a healthcare cost, whether it's a cancer treatment or diabetes treatment, against a housing cost or against the cost of food on the table, that you wouldn't have grandma cutting her prescription drugs in half at the kitchen table because she can't possibly afford the entire prescription as it has been assigned. I just think that is a really important point, is how this affects the pocketbooks and the mental health and happiness of families across our country.

Melissa Harris-Perry: Dorian, thanks so much for joining me on this deep dive. I am glad to have you back, even if it means you had to leave the land of sunshine and single-payer system.

Dorian Warren: Melissa, our dives are always an adventure. Before we go, I think we should highlight one more call from The Takeaway community, Javon called from Tampa, Florida with a message that resonated for me.

Javon: Yes, I do have healthcare. I actually [inaudible 00:48:10] myself as being exceptionally fortunate because a hundred percent of the cost of my healthcare, for me and my family, the premiums are covered by my employer. I happen to work for a labor union that takes seriously its values about the idea that everybody should have healthcare. We've seen recently that all over the country, organized workers have been able to make major gains in the benefits in their treatment in the workplace at John Deere, Kellogg's, or more recently, Starbucks. I would encourage every working person to start organizing. Unions are built by regular everyday people and they secure the rights that regular everyday people need, like healthcare.

Dorian Warren: How I feel about organizing? If the system doesn't work, there's always something we can do about it, organize, organize, organize.

Melissa Harris-Perry: Okay. Can you all tell that my friend Dorian is a labor union scholar and a third-generation community organizer?

[laughter]

Melissa Harris-Perry: Well, that's our show for today. We hope that you learned as much as we did. Thank you to all of our guests, Professor Julia Lynch, Professor Jamila Michener, Dr. Ezekiel Emanuel, Peter Suderman, and Representative Pramila Jayapal. A big thanks to the team here at The Takeaway who grind day and night to make this show. Thanks so much for listening. I'm Melissa Harris-Perry, and this is The Takeaway.

 

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