Just this Monday, we celebrated Martin Luther King Day, a tribute to one of the great leaders of the movement for racial justice – but something that often gets forgotten in the flurry of MLK quotes that become memes this time of year is that equity in healthcare was a crucial part of King’s vision. Throughout his career in activism, he often stated his conviction that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman.” Sadly, over 50 years after his death, racial inequity in healthcare is even more shocking and inhuman. Today, we’re joined by public health expert Walter Tsou to do a deep dive into the horrifying world of racial health injustice, how we got here, and how we make real change.

https://www.youtube.com/live/yiq7TBVYc6g?si=QCbGU114cZviZe0G

Show Notes

The show is joined on MLK Day by Dr. Walter Tsou - past president of the American Public Health Association and former health commissioner of Philadelphia! Gillian asks how Walter dedicated his life to health access and health equity. When Walter graduated from med school he stumbled into a job at a public health clinic in West Philadelphia that treated patients lacking private insurance or the money to afford medications, which gave him his first window into the deep economic, racial, and health divides in the U.S. This launched his career in public health advocacy.

Walter served as the Health Commissioner of Philadelphia from 2000 - 2002, and to him the most stark racial inequity he had to deal with was the gap in infant mortality - black infants at that time were 2.5 to 3 times as likely to die before reaching age 1 than white infants. Walter looked up the most recent statistics in preparation for the podcast, and the number had barely changed. The traditional way that states are pretending to do something about infant mortality is to create an Office of Equity contained inside their Department of Health that has maybe two staff people. To make a real difference in infant mortality, Walter says, you have to tackle the largest social determinants of health - education, job opportunities, housing, transportation, and so on. Two or four people in an Equity Office aren't going to make a difference - it's window dressing.

On top of this, Walter says, the U.S. has abandoned most of its community health work, which was widespread under LBJ's Great Society programs after WWII, when community nurses would go into communities and address social determinants of health.

Gillian backs up to share some of the big-picture distressing findings from the Commonwealth Fund's scorecard on racial equity in U.S. healthcare:

Provisional life expectancy report released by the CDC in 2020 shows that Black and American Indian/Alaskan Native people live fewer years on average than white people (see data here)

Black/AIAN individuals more susceptible to chronic diseases like diabetes, hypertension

Higher rate of pregnancy related complications, higher infant mortality rate (see our episode on maternal health for more details)

Poor healthcare outcomes are driven by higher poverty rates, higher-risk environments, less access to healthcare among communities of color

Less likely to have health insurance, more likely to incur medical debt, more cost-related barriers to care, less preventative care

These unequal health outcomes persist across all states in the U.S.

Black women are more likely to be diagnosed with breast cancer at later stages and to die from breast cancer than white women

Uninsured rates are much higher in communities of color, particularly states that have not adopted Medicare expansion

Black Medicare beneficiaries are more likely than white beneficiaries to be admitted to a hospital or to seek care in an emergency department for conditions typically manageable through good primary care

Lower rates of vaccination - example - Black, AIAN,

It’s that time again folks… time for a Mailbag Episode! We reached out to our whole audience and all our supporters to find the pressing questions on everyone’s mind. Or at least we would have if Gillian hadn’t been too busy eating turkey to email our list. So instead, Gillian reached out personally to some of our superfans (anyone in her contact list who had previously admitted to listening to the show once) to find out what they wanted to hear from us. And here we are, with questions about everything from Ronald Reagan to elder care to dinner table conversation from some of our favorite stans!  

https://www.youtube.com/watch?v=pesLv7rekVY

Show Notes

Question from Liam Meyer in Massachusetts:

"Maybe discuss this on your podcast: Facing Financial Ruin as Costs Soar for Elder Care - The New York Times."

"You could also talk about elder care and how wildly fucked up it is. One especially galling bit is how Medicaid is basically built to just ignore cognitive stuff. Almost all metrics are about physical health so, like, if someone’s grandpa **could** theoretically cook and shower themselves (ie, “He can stand up and walk, he still has hands!”), Medicaid says it all good even if grandpa doesn’t know where the shower is, leaves the stove on all the time, and continually eats spoiled food."

Answer: "elder care" is a vague term that mooshes together lots of kinds of care for seniors. But "long-term care" is better defined, and has been a major focus of ours in recent years, needed not only by older folks but anyone with a physical or mental disability that means they need help with day-to-day living. Most of us will need long term care at some point in our lives.

What’s wrong with the U.S. long-term care system?

We don’t have one! 

Very few people are insured for long term care

Medicaid covers the vast majority of long term care services - you have to be or become poor to qualify (except in California, where Medicaid asset limits will be eliminated starting January 1, 2024!) We've heard many stories of people who have had to sell homes or farms, affecting their whole family, in order to become eligible for Medicaid.

Institutional bias: Medicaid will pay for long term care in a setting like a nursing home, but not home-based care which is cheaper and better for quality of life.

Check our our long term care episode for much more.

Questions from Geri Katz in Minnesota:

"Have you listened to the 1961 Ronald Reagan Speaks Out About Socialized Medicine LP? Why has the AMA historically opposed single payer?"

Answer: in 1961, before Medicare passed and before he was elected Governor of California, Reagan was a washed up actor talking about how "socialized medicine" would ruin our country. He sounds like a ghoul: “One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. Most people are a little reluctant to oppose anything that suggests medical care for people who possibly can’t afford it.”

Reagan was paid by the American Medical Association (AMA) to deliver this speech, which was printed on an LP so you could host a house party with your socialism-hating friends. The AMA has a long history of opposing healthcare reform, such as:

In 1948 when Truman proposed a national healthcare program - which was supported by an estimated ⅔ of americans - the AMA decried it as socialism and used member dues to fund a political campaign against Truman’s plan.

After passage of Civil Rights Act in 1964, the AMA continued to allow medical societies to discriminate against physicians of color.

The AMA has been involved in campaigns against Social Security, Medicare and Medicaid.

The AMA is a scam! According to Dr Linda Girgis, “Perhaps the biggest example of how doctors lost their trust in the AMA is the way they are funded.

Open enrollment. Deductible. Coinsurance. HMO. Indemnity plan. If you’re listening this far, you probably have a migraine already. Understanding the language of the health insurance industry, let alone selecting a health insurance plan, can be confusing, frustrating, and disheartening. But never fear - we are here to give you a crash course on everything you need to know about your insurance plan. No need to scroll through Healthcare.gov’s Health Insurance glossary and risk throwing yourself out the window…

We want to give you some tools here to understand what you’re choosing when you pick a healthcare plan, but no one but you really knows what’s best for your health, so (for better or worse) we aren’t going to give any actual advice here about what healthcare plan to pick. 

Also, all health insurance kind of sucks, so you will probably get screwed no matter what you pick. Basically, we’re going to try to decode all the mystifying language that the insurance companies use to disguise the ways they’re going to screw you so at least you’ll be able to anticipate how you’ll get screwed.

https://www.youtube.com/watch?v=32vw4LZpelA

Show Notes

Names

Whether you get health insurance offered by your employer, or you have to buy insurance on your own in an exchange or on healthcare.gov, or you have Medicare and you are looking at one of the privatized Medicare Advantage plans, you’re going to be choosing from a series of plans that have totally incomprehensible names and acronyms, so let’s start by breaking down the how the name of the plan itself will tell you something about how your insurer is going to screw you.

Generally the first part of an insurance plan’s name will be the name of the insurer (like “Blue Cross” or “United Health”), then you MIGHT get a word that says who is paying for the insurance plan (if it’s a “Group” plan that means an employer is paying for it, an “Advantage” plan is a privatized Medicare plan), and finally there will be an acronym that only 0.005% of people in America understand - and those are the generally people making money from the plans. These acronyms will be something like HMO, HSA, PPO, EPO, or my personal favorite “GTFO” - the “get the fuck out of here that can’t be a real plan” plan!

Indemnity Plans (“Open Choice” or “Open Network” plans): are the opposite of managed care; you could use any doctor or hospital, there are no networks, no review of care or pre-approvals, no claims denials. These were the plans that virtually everyone had prior to the 1980s, and plans that virtually no one has today except maybe the extremely wealthy. In 1978, 95% of people had indemnity plans, then that dropped to 71% by 1988, and by 1998 it was down to 14%. Today, only 1% of workers have indemnity plans.

Indemnity plans are the opposite of managed care - you can see any doctor or hospital you want, there Today, you probably wouldn’t even want an indemnity plan, because the modern versions usually only pay a percentage of the cost of your care, leaving you with the rest and massive bills.

Health Maintenance Organizations (HMOs) represent only 12% of insurance plans today, so after taking over in the 1990s, old school HMOs are going the way of the dinosaurs. HMOs usually limit coverage to doctors/providers who work for or contract with the HMO (“in-network”). It generally won't cover out-of-network care except in an emergency. HMOs can also be limited by location, meaning you might have to live or work in a certain area to be eligible. 

Exclusive Provider Organizations (EPOs) are a new catch-phrase that are appearing more and more often, but they are VERY similar to an HMO, and you should think of them the same. In fact, that survey that only 12% of workers have HMO plans includes EPOs under the same category. EPOs often have larger networks than HMOs, and unlike HMOs, they don’t require referrals to see specialists - as long as the specialist is in their very limited net...

If you’ve ever had an experience with the American healthcare system, you’ve probably walked away thinking, “Why can’t we have nice things? Or even basic human things??” We get stuck on gurneys sitting in ER hallways, waiting hours for care; we skip other basic needs like food and housing to pay for the healthcare we can’t skip; or we wait for months for preauthorizations from our health insurance and referrals from our doctors. Of course, for the super rich you don’t have to endure any of these humiliating experiences, and they have developed some new, expensive ways to get the healthcare they need when they need it. So put up your pinkies and throw on a monocle – today we’re doing a deep dive into the lifestyles of the rich and famous to find out: just how fancy is concierge healthcare, and can the rest of us get some?

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

Show Notes

Let’s start with concierge primary care, the latest trend in fancy healthcare! What is concierge care?

Some concierge plans (also called Direct Primary Care) work with existing insurance – those are the cheaper ones ($600-1000/year, aka Hyatt Care). Some you actually pay a flat fee that covers all your services. Those are the really expensive ones, which can run from $2400 to $30k per year!

But what do you get for your money?

24/7 access to doctors (some promise your physicians direct phone number)

Coordination of care (referrals, preauthorizations if necessary)

Extra services like a health coach!

Some offer really crazy shit like home visits

Physicians have fewer patients and can spend at least 30 minutes with each of them.

Now there are more than 1,500 Direct Primary Care practices across the country, and 1 in 5 of the top 1% buy concierge physician care.

We're also seeing some hospitals, like Ben’s local mega-hospital Mass General, offering "Concierge Medicine." They have dedicated concierge physicians who see fewer patients and are more accessible, available by phone or email 24 hours a day, seven days a week. You also get your own health coach and a dietician.

Do you need to maintain insurance? Yes. At Mass General, your $10,000 membership fee covers a high level of "service" and "access" but not the cost of the medical care you need. Your insurance plan will cover the actual services provided by the concierge physician. That means $10,000 on top of your premiums, co-pays and deductibles.

Outside of the exorbitant cost, are there downsides to concierge care? You betcha.

It exacerbates the primary care provider shortage and creates two-tier system: direct primary care physicians have fewer patients, and also creates a two-tier system where rich people buy their way out of the physician shortage.

Despite all the marketing claims, concierge care may not lead to better health outcomes: there is a lack of peer-reviewed studies on care outcomes in concierge practices.

But when rich people get to the hospital, don’t they get treated like the rest of us? Nope. Big hospital donors often get to skip the line in the ER and get VIP status. They get fancy luxury suites with fine gourmet dining, high thread count sheets, and suites with custom cabinetry. They also get the best nurse to patient ratios in town, with some luxury units assigning each patient their own nurse who has no other patients, 24/7.

These luxury units can be dangerous though. When the hospital is more concerned with pleasing the patient than providing the care they need, it can result in "VIP Syndrome." There's anecdotal evidence that because some patients want to stay in their luxury accomodations instead of being moved to a specialty or more intensive unit due to their condition, they don't get the kind of care they need, which can lead to worse outcomes or even death. At least one study suggests that higher patient satisfaction is correlated with worse outcomes.

VIP syndrome can lead caregivers to overtreat patients ...

Just over a month ago we lost Bob Barker, the man who taught us all about the brutal nature of capitalism one pricing game at a time. Now, thanks to the Inflation Reduction Act, the federal government is going to be playing a role in determining the prices for some of our favorite products. No, we’re not talking about cars or family vacations to the Bahamas – we’re talking about the prescription drugs that keep us alive! As the Biden Administration enters its own Showcase Showdown with Big Pharma, we’re taking a full episode to break down what that means and whether the result will be prices we can actually afford.

https://www.youtube.com/watch?v=cnxbIhEPhs0&t=1s

Show Notes

Our first (and only) contestant is Alex Lawson! He is the Executive Director of Social Security Works, the convening member of the Strengthen Social Security Coalition— a coalition made up of over 340 national and state organizations representing over 50 million Americans. Alex’s organization played a critical role in moving the Democratic Party (mostly!) away from efforts to cut Social Security, and has been shifting the momentum towards expanding Social Security. Social Security Works is also a key ally of ours in the national fight for Medicare for All!

Alex, come on down!

Alex starts by telling us about the time he took a camera to PhRMA's (the Pharmaceutical Research and Manufacturers of America) office the day of the Inflation Reduction Act signing ceremony. He conducted person-on-the-street interviews, asking if they knew PhRMA spent hundreds of millions of dollars to keep Medicare from being able to negotiate drug prices, and if they had any messages for the folks in the building? Most of the responses were of the "f-you PhRMA, we got you!" variety.

PhRMA has literally never lost until the Inflation Reduction Act was passed. Even though it's modest, Medicare went from having no authority over drug prices to the authority and mandate to find the fairest price for certain drugs is a huge loss to the industry.

Alex wants listeners to understand that this win is as simple as it sounds. Who buys the most drugs in the world? Medicare. Why doesn't Medicare tell the pharmaceutical companies what they're willing to pay? This is called the Maximum Fair Price. No other peer nation doesn't have some kind of negotiated standard for drug prices.

While our guest and hosts would prefer that Medicare be allowed to negotiate the prices of all drugs used by beneficiaries, PhRMA was successful in limiting the Inflation Reduction Act drug provisions to only apply to ten pharmaceuticals. (Still, pharmaceutical companies are suing to block the implementation of price negotiations.)

Negotiating the prices for only ten drugs may seem like a drop in the bucket, but the cost of those ten drugs alone make up a huge amount of Medicare's spending on Medicare Part D. And in coming years Medicare will be able to negotiate over ten more drugs, and so on. This will squish the most excessive profiteering of the pharmaceutical industry and deliver savings of $9 or $10 billion dollars a year.

We give President Biden credit for taking an aggressive stance against PhRMA to finally make good on an evergreen Democratic campaign promise to lower drug prices. But we also give ourselves some credit. First there was the debate in Congress in 2019 over HR3, the Lower Drug Costs Now Act. Advocacy by groups likes ours resulted in the House passing a robust bill that would have dramatically lowered drug costs. Then in 2021 both Healthcare-NOW and Social Security Works fought hard to win major expansions of Medicare in the Build Back Better bill (we were on track to win a lot more than prices for ten drugs). But Senators Joe Manchin and Kyrsten Sinema tanked the whole bill in the Senate.

Those two battles led us to the Inflation Reduction Act aiming high from the start, and resulting in a bill that will make a big impact on drug spending by Medicare.

With all the threats facing our country – climate change, a predatory economy, corporations buying our elections, and the overt move towards fascism among the far right – you would think that politicians would be laser-focused on the existential crises descending upon us. But instead, politicians in the US are devoting a considerable amount of their energy these days to an all-out assault on the rights of transgender people. Although the war on trans people has taken many forms, from bathroom bills to restricting school curricula, one of the most chilling is the denial of basic gender-affirming healthcare. Now, in places like Texas, elected officials have gone even further by targeting healthcare access for the most vulnerable trans folks – trans kids. In this episode, we’re joined by one El Paso family and a local gender-affirming care doctor who are fighting back!

https://www.youtube.com/live/KeSiTiiwjsk?si=Qi8XgotSntheNIHR

Show Notes

Our guest today is Lori Edwards. Lori is the Director of the Intergenerational Rainbow Link at Borderland Rainbow Center in El Paso, Texas, an organization that provides a number of services to queer people in their community. Lori is a mama bear to her two trans/gender fluid teens, as well as any person who finds themselves in need of a mama bear nearby. She has a BSNS from Purdue Global, is a certified Mental Health Peer Specialist and pulls from backgrounds in both emergency medicine and education to function as a Jane of all trades who's ready to tackle the unexpected. As an El Paso native, Lori returned to the borderland with her husband to raise their children close to family.

Liana, who is Lori’s daughter, is a 16-year-old trans girl who loves gaming, singing (rapping in particular) and is a student athletic trainer at her high school. She is also a Girl Scout and local advocate for LGBTQ rights in her city. Along with helping the family foster for a local pug rescue, she loves spending time with her 2 cats, 2 pugs, and 4 fish.

Dr. Toni Marie Ramírez is a family medicine physician with several years of experience in gender-affirming care. She received her undergraduate and medical school degree from Brown University and trained in family medicine at the Santa Rosa/UCSF family medicine residency in Northern California. She was born and raised in Socorro and moved back to El Paso in 2020 to be with family. Her work is strongly grounded in social justice and equity, valuing the power of community empowerment.

As a family medicine physician and gender-affirming care provider, Toni shares that those entering the medical field with the intention to provide and contribute to the health and well-being of a community, quickly realize that the healthcare system is not set up for this. We pathologize what is outside the norm in this colonized world and the medical community ignores the healthcare disparities of the trans community. Her 10-year experience in providing care has shown that it is astonishing how little medical providers know about gender-affirming care.

Gender-affirming care is not part of the curriculum in medical school, let alone residency. This allows medical providers to uphold this gender binary in medicine. Starting from the very beginning, our socialized aspects infiltrate the way medicine is practiced and taught. When it comes to the access aspect that comes from that, physicians are already not educated enough to provide such care. We live in a world that is very binary and the reason why there are so many disparities is not because of anything innate to trans or gender-diverse folks, but because of the transphobia that exists in the world and the transphobia that exists in medicine.

Sometimes people don’t access care because of a fear of discrimination or outright denial of care. Even in a progressive area of California, where Toni practiced, there are so many barriers to accessing care: (1) for feeling safe,

Almost every patient in America has had a frustrating experience in a hospital setting where we feel like we’re on a medical conveyor belt that moves WAY too slowly. We sit for too long in a waiting room; then our nurses or doctors speak with us very briefly; we might feel more like we’re filling out an online survey than we’re being listened to; then we might have more waiting; and then we’re pushed onto the next specialist or appointment too quickly. Of course some patients experience FAR worse disasters in hospitals. As patients, we know that something dysfunctional is going on, and it leads a lot of people to distrust their medical providers, and avoid healthcare altogether. But nurses, doctors, and other medical professionals themselves know that behind the scenes, they are being pushed to the brink by hospital corporations, and not really allowed to treat their patients to the best of their abilities. So today we’re going to focus on one of the most crucial behind-the-scenes hospital policies behind patients’ bad experiences: staff-to-patient ratios. 

https://www.youtube.com/watch?v=am1j0n0ZEfw

Show Notes

Our guest today is Gerard Brogan, RMN, RGN, RN. Director of Nursing Practice at California Nurses Association/National Nurses United. Gerard has over 40 years experience as an RN. He has practiced nursing in the USA since 1984, before joining the California Nurses Association in 1994 as a Nursing Practice Representative.  He is the Director of the Nursing Practice Department for the California Nurses Association/ National Nurses United.

Gerard has extensive experience in nurse-to-patient ratio legislation, having been a part of the successful campaign to establish nurse to patient ratios in California and subsequent experience in seeing the efficacy of the ratio law.  He serves as an educator for the organization, teaching classes to nurses on a variety of  topics relevant to health care in general and  the scope  of nursing  practice  and patient advocacy in particular.

Most of us will be patients at some point, so unsafe staffing practices in hospitals will have an impact on us or our loved ones. Studies show you have a lower risk of death, higher risk of poor outcomes, and a higher chance of re-admission if your hospital has adequate nurse staffing and your care is guided by providers' professional judgement. Sadly, in a for-profit healthcare system care decisions are made based on more on their budget impact.

You'll recognize unsafe staffing when you see it: things like long wait times, or feeling like a number instead of a whole person because your nurse doesn't have enough time with you. The nursing profession takes a holistic approach to care, looking at the entire person and the factors that contribute to their health; that takes time, which the healthcare industry doesn't want to give nurses.

Improving nurse staffing levels has been the #1 priority of nurses unions (and most unorganized nurses too) across the country for more than a decade. Gerard tells us that nurses are ethically and legally obligated to be a patient advocate and provide optimal care. When that can't happen due to the business interests of the employer, healthcare workers experience moral distress. (Rather than "burnout" which implies an individual, personal defect, Gerard uses "moral distress" to determine the suffering that happens when nurses are constrained by forced beyond their control from providing the care they should.)

There has been a sea change regarding nurse staffing over the last several decades. When Gerard began his career, staffing was "impeccable," he had professional autonomy and the institution's respect of his professionalism. In the 1990s when the Clinton's healthcare reform attempt failed, "let the market decide" became the dominant narrative in healthcare. Corporate interests descended on healthcare to make a buck and nurse staffing began to decline.

Today we bring you behind the scenes into our office at Healthcare NOW. Just like the TV show The Office, we have our hijinks and wacky characters, including some very smart interns! They have prepped some of their burning questions for this episode.

https://www.youtube.com/watch?v=YnG1C8DOZVY

First, from Intern Noah from Boston College:

In your opinion, what is the most effective way to organize/advocate for Medicare for All? 

Talk to one person, then another person, and then another! It doesn't start with money, marches, or celebrity endorsements (though if Oprah wants to support M4A, she should give us a call!) Those feel good, but without authentic relationships and networks, they don't make change. Unfortunately there are no shortcuts in organizing; we have to build the power ourselves.

Do you have any funny stories from an experience meeting a member of congress?

Gillian remembers meetings with former Republican U.S. Senator from Massachusetts, Scott Brown. Unfortunately all Senator Brown cared about was how the policy she was advocating for affected Dunkin Donuts.

Gillian fondly remembers the time former U.S. Congressman Barney Frank told her that her hometown in New Jersey smelled bad. He also told a room full of constituents "the only thing that marches on Washington put pressure on is the grass in Washington, DC." Epic one-liner that we don't necessarily disagree with. (He already supported M4A so it was all good.)

Intern Gulmeena, a public health student asks:

When we talk about Medicare for all - are we thinking of a system with government run hospitals and government employed medical professionals? Do you think such a concept garners resistance or are people open to that paradigm shift?

One of the most common attacks on M4A is to call it "socialized medicine." Very few countries actually have real socialized medicine, where insurance is public, all healthcare facilities are owned and operated publicly, and the healthcare professionals are public employees. In the United States, Medicare for All legislation does not socialize the facilities or professionals. By focusing on the payment mechanism, it would give the government a lot of power to reign in the worst parts of for-profit healthcare. Ben notes he has seen a poll showing a majority of Americans support socialized medicine, so who knows, maybe that's the future of the movement.

Would Medicare for All include long term care for the elderly such as nursing homes and hospice?

This has been a debate within our movement for a long time. Both M4A bills include long term care. The House version is more generous and comprehensive. The Senate bill would cover home-based long term care but not institutional. Currently most people get long term (which also includes care for people with disabilities) care through Medicaid, the healthcare program for the poorest Americans; this forces patients to spend down all their assets to qualify. Medicaid also has an institutional bias: it's much more likely to cover care in residential settings rather than homes, which is usually more expensive. If you're interested in advocacy around this issue, check out Caring Across Generations.

Intern Ioanna (who hails from Greece, a country with universal healthcare):

Considering that you have been a part of the movement since before Medicare for All was introduced by Sen. Sanders in 2017, how did you first hear about single payer healthcare, and what drove you into the movement at a time when it was not getting much or any (?) media attention?

Back in the day of phone books and print newspapers, Gillian learned about universal healthcare from Ben! When her own employer-provided healthcare left her underinsured, a friend in the finance field told Gillian "if your job doesn't give you good health insurance, that's capitalism's way of telling you that your job isn't important and maybe you should get a new one.

It’s summer, the sun is blazing, and we only have one thing on our minds - the upcoming thirtieth anniversary of the high-octane, expertly paced thriller The Fugitive, originally released August 6, 1993 starring Harrison Ford. Oh, and Medicare for All. We’re always thinking about Medicare for All. Now that we mention it, isn’t it funny how if we had a single-payer healthcare system, The Fugitive wouldn’t exist? In a single-payer system, there would have been no nefarious pharmaceutical executive to frame Harrison Ford for murder in order to cover up the side effects of Provasic. There would have been no need for Walter White to cook meth in order to pay for his cancer treatment. In fact, a lot of our favorite movies and TV shows would be entirely without conflict. In this episode, we take a look at a uniquely American subgenre: movies where our healthcare system is the villain! Plus, we dip into the Healthcare-NOW mailbag to hear from our listeners about your favorite movies where for-profit healthcare is the bad guy.

https://www.youtube.com/watch?v=nKat9vjm7tI

SPOILER ALERT. Some of these movies are masterpieces, and we'll be discussing spoilers. Seriously, we advise that you pause the podcast and watch Dog Day Afternoon now.

Let's discuss the uniquely American film genre that depicts the healthcare industry as the villain. One of the biggest healthcare villain blockbusters was, of course, The Fugitive (1993). Our hero Dr. Richard Kimball is falsely accused of murdering his wife. He escapes police custody and along the way uncovers the truth, that he was framed by an evil pharmaceutical executive who killed Mrs. Kimball to cover up the side effects of a profitable new drug. Fun fact: Tommy Lee Jones was the former college roommate of Vice President Al Gore.

The term “healthcare industry” dates back to the 1970s, and so does the reality of for-profit healthcare. Major transformations of our healthcare system have created real-life nightmares and impossible situations for patients, and that growing widespread experience of a healthcare dystopia then creates an audience for Hollywood script writers to build drama around healthcare situations. Two of the films submitted by our members come from the very beginning of the “healthcare industry,” in the early 1970s:

The Hospital (1971) stars George C. Scott and Diana Rigg. A serial killer targets doctors by making them patients in their own hospital, where they die due to hospital negligence. CW: weird sexual politics.

Dog Day Afternoon (1975) starring Al Pacino and John Cazale, dramatizes a true story of two Brooklyn bank robbers, motivated to steal to pay for gender reassignment surgery for Pacino's character's partner. In 2015, real life dad Bryan Randolph of Detroit robbed a bank to pay for his 1-year-old daughter’s cancer treatment after his health insurance canceled her plan.

The next explosion of healthcare plots comes in the 1990s and early 2000s, when “managed care” plans and HMOs spread like wildfire, replacing traditional insurance. Intended to bring down rising healthcare costs, managed care brought us such classics as prior authorization, widespread claim denials and limited networks. This kicked off a new wave of films in the 1990s that start using health insurance villains become key plot points. The failed Clinton health reform efforts also happened in 1994, which created probably a sense of hopelessness around Congress fixing these problems.

As Good As It Gets (1997): This cringefest features Jack Nicholson as a cranky, bigoted and obsessive compulsive writer. Nicholson's character can only eat at one restaurant, where he meets waitress Helen Hunt, and pays for her child's cancer treatment so she can continue to work and serve him. All kinds of toxicity, sexism, and structural inequities on display in this one.

Patch Adams (1998): features Robin Williams in a real life story about a doctor whose unorthodox ways bump up agai...

As Tom Petty taught us all in the 1980s, Waiting is the Hardest Part. That’s even more true when you’re waiting to see a doctor for a problem that needs attention. Anyone who has ever tried to secure a doctor’s appointment in this country knows that a) it’s going to be harder than scoring Taylor Swift tickets and b) you are going to face serious delays before you get your care. In this episode, we’re getting into the nitty gritty of wait times in the U.S. – how bad are they, how do we compare to the rest of the developed world, and why are wait times the right’s favorite scare tactic when it comes to Medicare for All?

https://www.youtube.com/watch?v=Y3QJH4eFXY4

The narrative attacking Medicare for All - you’ll NEVER get to see a doctor and everything will be like communist Russia… or, god forbid, CANADA! This is one of the top scare tactics used by opponents of Medicare for All, but their claims about wait times aren't always based on the truth.

What our opponents seem to forget is that we have wait times in the US too. Ben, Gillian and our members all have stories about wait times, including Gillian's story of being told "call back next year," and Ben's condition that worsened and turned permanent because he couldn't get an appointment for for months for an urgent matter. We heard from members with horrific conditions that prevented them from working or even do normal day to day activities, but had to wait months or even over a year for care.

In our broken system, getting a wait time is actually a privilege; if you don't have insurance or can't afford the copay, you won't even get to make that far-off appointment you need.

This is another reason we often end up in the emergency department. In some cases there is no other way to get medical attention for an urgent or emergent condition.

The reality of how our wait times compare to other countries' is challenging to capture because the U.S. is one of the only developed countries that DOES NOT TRACK WAIT TIMES. Reporting is not required. In other countries, they track wait times for every service, and in some cases you can look up average wait times online for visits, procedures and hospitals. Research on countries with national healthcare plans shows that wait times vary dramatically, from country to country.

We often don’t even talk about the most critical wait times, which are ambulance response times and processing patients in emergency departments. It's hard to find good comparative data on this, but these are major weaknesses of the U.S. healthcare system.

Finally, there is evidence of a major equity component here.

Poor people and BIPOC have longer wait times for all services (including health services).

Hispanic children have longer ED waits.

Patients in poor neighborhoods have longer ambulance response times for cardiac arrest.

What actually drives wait-times? Unlike the scare tactics from the right, it's not about the payment system. It’s mostly about adequate supply (of providers, specialists, scanning equipment, labs, etc) and accessibility - which is different from our payment/insurance systems. In general we do pretty well at wait times for very profitable services - like MRIs and CT scans. We do very poorly at unprofitable (or low-reimbursement services) like primary care, mental health care, and substance use care. There is an exception to this, because…

When it comes to wait times for particular physician specialties, including primary care, a major source of the problem is that physicians control how many medical school slots AND how many medical residency slots are available across the country, in every specialty. Economist Dean Baker calls this a “cartel.” 

How would Medicare for All impact wait times in the U.S.? M4A might not directly impact wait times, but it would put into place tools that would allow us to control wait times. For starters, we could track wait time data.