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Transcript by Rey Smith
Jini Palmer: Welcome to Town Hall Seattle civic series. On September 25th, 2019, writer and activist Timothy Faust came to our Forum stage to talk about his journey driving across the country to witness how the Affordable Care Act and Medicaid are affecting citizens firsthand and to bolster a healthcare model that he says can actually work for all American citizens. Faust explored the single-payer healthcare system, dispelled the myths that healthcare needs to be personally expensive and presented his new book: Health Justice Now: Single Payer and What Comes Next. If you’d like to hear an exclusive interview between Timothy Faust and correspondent Venice Buhain, check out our Town Hall original podcast, In The moment. And now, Timothy Faust and Health Justice Now.
Timothy Faust: Yeah. Hell yeah. How y’all doing? Thank you all very much for having me out. Thank you Third Place Books. Thank you Town hall. This is—apart from a couple of churches—the nicest place ever spoken in. I am shocked they let me inside. So, what a real treat. Before I get into my speech, which is just a roller coaster ride, I want to talk about something that I’ve seen recently in the news; not the normal news, but the health policy news, which is a lot like the normal news, but a little bit less bleak. The story takes place in Quebec. Quebec is a province in Canada—so far, y’all still with me—which I know personally for two things. One, it’s deeply punishing and very problematic black metal music, and two, it’s relatively low vaccination rates. Quebec has a 75% measles vaccination rate. And for context, you want a 95% vaccination rate to have herd immunity. They had a measles outbreak in 2011. They’re having one right now. Not a fantastic time to be non-vaccinated in Quebec. But there are 2 kinds of folks who don’t vaccinate their kids. On one hand, you’ve got the hard line anti-vaxxers, folks who know that vaccines are chemtrails for your body and only over their dead bodies will they vaccinate their families. And those are the folks you just can’t reach. But they’re the minority. Most folks fall somewhere in the squishy middle, the vaccine skeptical. They don’t want to hurt their kids—which is the correct impulse—so they Google, ‘Vaccines, good or bad,’ or, ‘Are vaccines safe’ and they look at the search results. They watched the news, they listened to the radio, they read the internet and get a lot of contradictory or misinformation about vaccines. So they defer making a choice. But like Rush says: ‘In choosing not to choose, you still have made a choice,’ and their kids go unvaccinated. And these are the folks Quebec thought they could reach. But doctors weren’t getting the job done. There are a couple of reasons for that. One: doctors have very limited amounts of time. Two: doctors perceive themselves as being very rational and hate dealing with the squishy or rationality of their patients. Three: doctors can be jerks, they can be pretty brusque, maybe brusque depending upon how that word is pronounced. And they just weren’t getting the job done. So Quebec tried something different, took a couple of hospitals and hired 53 social workers who they called vaccination counselors. These folks would go to the family just after delivery in the neonatal unit and say, ‘Ella, my name is John Claude,’—or some appropriately called [inaudible] name—‘and I’m your vaccination counselor. Are you thinking of vaccinating your child? What information do you need to make an informed choice? Here’s a binder, here’s some graphs, here’s some charts. Now, ultimately, whatever you choose is your choice alone, and I respect that, but how can I be useful in making this choice for your family?’ Now, what do you think happened? Of course you know, otherwise I wouldn’t open my speech with this anecdote, so let’s get it out of the way: vaccine rates in the observed hospitals went from 73% to 87%, which is pretty fucking unbelievable. That is an incredible improvement in health outcomes. I consider this to be the quad score of health policy initiatives. The quad kill. It is government-funded social workers doing compassionate labor that makes a meaningful difference in population health. This is the future of health policy towards which we all strive, and it is a future actively denied us by our American healthcare model. We live in a time of deep atomization and alienation and these kinds of self-harming conspiracy theories filled the void we feel between us and the world around us. And so it’s only this unprofitable, tedious, compassionate labor that makes a difference and it’s the kind of work that will never be funded by Aetna, never be considered by Cigna, never be boosted by Blue Cross Blue Shield. This is a future that is incomprehensible to the health finance model we have now because it’s not profitable for anybody to invest in. And so these considerations of things which actually make us healthy are totally divorced from our model of health finance. That is to say our health finance model is deeply unhealthy. It’s sick. That’s why I’m here to get down with the sickness; it’s for the millennials out there. I’m very disturbed. Let’s get into it. Let’s talk about healthcare.
Thank you everybody for coming out. Thank you so much for buying or being about to buy my book. Fingers crossed. This is my first book and frankly, I don’t think of myself as being much of a writer, but I’m very proud of it. It’s still a good book. Please still do buy it and I hope you find it useful. Instead of reading from the book for half an hour and giving you 30 minutes of how Medicaid works—which is compelling and fascinating, but perhaps not for this evening—I want to give you some of the themes within the book. It’s not all happy, but you probably already knew that. There’s a lot of bummers in American healthcare and there’s a lot of tears in this book, but I tried to line it with little glimmers of help, right? Because there is a vision in this book of a better world in which we can live free from the crippling fear of the betrayals of our own bodies, where we can live free and safe in our own flesh. And frankly, I believe in that future. I believe we have the tools and resources to build this freedom. We just have to demand it. We got to demand it in opposition to the world that we have now. A world that is not natural but created, created by people. And because it is created, it can be changed, but until it is changed, until we change it, ours is a birthright of continual exploitation. We are pumped for labor and drained of cash and we suffer. And we are then punished for that suffering. We are punished for being hungry. We are punished for being sick. We are punished for being disabled, punished for being poor, punished for being black or Brown, for being queer, for being pregnant, for being unlucky, for just being. And at the core of all that suffering and all that punishment sit 2 little truths: in this world, sickness makes you poor and poorness makes you sick. So if you permit me, for the next half an hour, I want to talk about that relationship and how it’s expressed through our healthcare and how finance models. I want to talk about three things: what we have, what we want and what lies beyond. I want to talk about the overwhelming brutality of our for-profit healthcare model. I want to talk about the relatively benign structural changes that we demand instead, and then I want to talk about something bigger: that broader vision of the better world, the moral compulsion of health justice. That sound good? Fantastic.
Let’s start off having some fun with the fundamentals of health policy. Well, they’re fun for me; I wrote the book. First off, nobody can afford to pay their medical costs all by themselves. Medical care is extremely expensive and always has been, but generally speaking, not a lot of folks need it at the same time. In a given year, 50% of medical costs come from 5% of the population, a population which someday you will join, right? Eventually your day of tragedy comes and when it does, the medical costs will be enough to bury you. So we have the concept of insurance: insurers pool together money from a lot of people to pay off medical costs for those who need it. And so the larger this pool of people, the wider it can spread costs and the lower the per-person risk. In the U.S, we delegate the business of insurance to private insurance companies. Insurance companies charge us monthly premiums to build their risk pool and, like any company, their job is to make money. So if an insurer has too many people who use their insurance plans to seek medical care or too few healthy uneventful people or too many sick people—just one person with hemophilia for example, can cost up to a million dollars a year to ensure—it’s per person costs really increase. So to compensate it increases premiums. But when premiums go up, customers who can’t afford them drop out, but sick people—expensive people—can’t afford to drop out of their insurance plans because they need the insurance. So per-person costs go up even more. You have a customer base that is sicker and sicker and even more expensive per-person, leading once again to higher premiums through the sicker population. This big vicious cycle. This big ouroboros of misery. Thus an insurer wants as uneventful a risk pool as possible or wants to find ways to kick out sick customers or coerce them into leaving. Maybe it drops coverage for drugs sick people need, maybe it cuts off access to the doctors who treat the sickest patients. Maybe it does both. It does both. Insurance companies don’t lose money when you get sick, insurance companies lose money when you get sick and then use your insurance plan. And there’s nothing they can do about it, even if they wanted to, because if insurance companies were to offer the care people need where they need it, or if they were to offer it at rates so people could afford, sick people will then buy insurance plans and use the insurance plans and the insurer would lose money and that’s a real bad way to run a business.
You know what? Some point along the line, I wonder what’s even the point of blaming them in the first place, right? Blaming an insurance company for seeking profit, even though it hurts people, is like blaming a rabid dog for biting or lighting a scorpion or stinging. This is just what companies do. And that’s why healthcare doesn’t belong in the hands of companies, because they just can’t do the right thing. Instead, they’ve turned our bodies and our health into commodities and this commodification of healthcare reduces health to a financial transaction or an investment vehicle instead of a connection or relationship between a person and their body and their doctors and their community. That’s perverted. We’ve mistaken the profit motives of corporations for healthcare, and the people who profit from that gratification have decided to shackle the wellbeing of children to whether or not their parents are lucky enough to have a benevolent employer. And even if those parents are lucky enough to have a union instead of fighting for better wages and workplace safety, every year, they got to negotiate for more and more expensive insurance, insurance which can be stripped from them, as we’re seeing the UAW strikes. Our children, our families, the people we love are hostages to our employers, and if you ever tried to organize against those employers, if you dare demand your fair share of the fruits of your labor, their bodies are held ransom. Our employers demand total domination in mind, body and spirit, and they’ve used the tools of health finance to forge the manacles.
That sucks. That’s one side of the coin, but it gets worse—of course it gets worse, we’re way too early in the speech for things not to get worse—because the costs of healthcare keep increasing. Most of these cost increases occur because hospital CEOs, pharmaceutical executives, close personal friend Martin Shkreli, keep finding ways to charge more money for the same services or rack up fees for other services and no private insurer can stop them. Fundamentally in the U.S healthcare market, all prices are fake. They’re just totally fake. Here’s how that shakes out: in the U.S, the average inpatient procedure costs 40% more than the same procedure performed on the same patient when performed in France. Take MRIs; y’all know MRI machines? They’re just big fancy computers that print money, and in the U.S an MRI scan costs five times more than the same machine scanning the same scan when scanned in Australia. The costs are high because the prices are high, but it gets even dumber, way closer to home. Sometimes MRI scans from the literal same machine in the literal same hospital have a seven fold cost variance based upon entirely arbitrary factors like what time of day it is, what doctors are nearby or who’s paying for the bill. Prices are just totally fake. Over the past decade we’ve seen the price of insulin triple, not because of new costs to produce it, but simply because insulin manufacturers like making more money and nobody can stop them when they increase costs and charge as much as they can. Most frustratingly, think about the relationship between primary care and hospitals. Primary cares—things like checkups, basic medications, the kind of familiar, intimate healthcare you’ve got from your family doctor or GP—it’s high volume, it’s low margin and generally it’s not super profitable. But now, conversely, a hospital gets paid an average of $2,000 a night for an inpatient stay. So if you’re a hospital CEO, it just makes a hell of a lot more sense to push folks into inpatient care instead of wasting your time and minimizing your profit by letting them get cheap primary care outside the hospital. Or it makes sense to buy up those cheap primary care clinics and either close them down so folks go to the hospital or use those same facilities to charge hospital rates, which is what they do. 58 million Americans have no access whatsoever to primary care. So as you can see, these are the two fundamental but opposing truths to American healthcare. One: if you’re an insurance company, it’s just not profitable to insure people who are sick. Two: if you’re a big provider, like a hospital corporation, it is extremely profitable to charge sick people as much as you can, as late as you can.
And so we’ve built upon these jagged rocks, the loathsome church of American healthcare in which the question of who gets to receive health care and when, or who’s suffering matters, is rationed by profitability. Now, this whole scenario scares the bejesus out of everybody involved, particularly with the insurers; insurers are interested in finding ways to avoid paying rising costs. Often that means refusing to pay for claims they don’t want to pay. It’s probably happened to you. If not, it’s common; it happened to me on Monday. But this by itself is not enough to claw costs down. So we all got together—everybody in America back in the 1970’s—and invented the idea of consumer-driven healthcare. It’s the idea that you should make consumers—which is just a libertarian way of saying people—pay more for the costs of their own healthcare. We are told this’ll make us into smart shoppers, somehow, true actors in the free market who will make smarter and less expensive choices about our healthcare. We will Yelp our surgeons or something like that. That’s why your deductibles and copays increase every year; to make sure you put more of your own skin into the game. It’s a big load of horse shit. All this does is help insurance companies pay fewer claims, because people who are forced to pay for healthcare costs they can’t afford, just don’t seek health care. They don’t get primary care. They don’t get preventive care. Because we demand they bear the burden of expensive healthcare costs, they are left to watch their bodies turn into time bombs until they have a heart attack and leave their kids behind. We have decided to punish people with healthcare costs they cannot afford under the guise of making healthcare a matter of personal responsibility. Also let healthcare CEOs and their friends bring home millions and millions of dollars a year. But at the end of the day, costs keep increasing and quality of care stagnates for the most vulnerable among us.
Our health finance model takes money from the poor and gives it to the wealthy. It is negatively redistributive. In 2014, it pushed 20 million people into poverty and 31 million people are still uninsured. The American model of health has failed and there are consequences for this failure. Because among so-called developed countries, it is America that is the most dangerous place to be sick. Among peer countries, America is the most dangerous place to be Black. Black infants die at twice the rate of white infants. America is the most dangerous place to be pregnant, with the highest maternal mortality rate of any first world country, of which 60% are entirely clinically preventable. It is the most dangerous place to be a child. The most dangerous place to be a woman, the most dangerous place to be gay, the most dangerous place to be old, and one of the most dangerous places to be disabled. Last year, life expectancy at birth fell by a 10th of a year and across the 4 million people born last year, that’s a theft of 400,000 years. But a funny thing happens when you look at all this data. When you examine all this data more closely, you realize all this danger only exists if you’re poor. Because rich people are exempt. They have exempted themselves from all these problems. Men born in the wealthiest fifth of Americans get to live 15 years longer than men born in the poorest fifth. Among women, that gap is 10 years. We have made a choice. We have explicitly made a choice: by sustaining our private insurance model, we have chosen to let poor people die from things which spare the rich. We have chosen to let poor children die from things which rich children do not die from. All because our health finance model genuflects towards the pitiless pursuit of profit. And this is war.
This is the terrible secret of American healthcare. This is the fundamental American illness. They are killing us and robbing our corpses to foot the bill. Now this big, stupid, multi-payer, profit-driven Rube Goldberg machine of American health is failing us today and, left unchecked, will collapse tomorrow. That is incontrovertible; it will collapse even further. So we demand something different: we demand a federal, universal, single-payer. Single-payer, pretty simple concept. I spent 15 minutes on private insurance. I can do single-payer in one sentence. We pull together all the money we’re currently spending on healthcare to cover, in full, all care for all people. See, one sentence, easy. It’s called single-payer because we create one publicly owned, publicly funded insurer. Now this phrase, ‘All care for all people’ is important, right? ‘Medicare for all’ is a fantastic phrase, but it’s a little bit different than that because we don’t want Medicare as it exists today. Medicare has cost sharing and private carve-outs. We demand an improvement at care that guarantees comprehensive coverage: medical, mental, dental, vision, and long-term care for all people in America—including non-citizens—that is free to use. Everybody benefits when accessing care is easy. Delivering care—being a doctor, being a nurse, being a home health worker—that’s complicated. The body is a huge bag of unknowable goo and it hurts all the time and relieving it’s misery is a complicated, difficult process. But paying for it isn’t; paying for it’s pretty simple. People ask, ‘Well, how can we pay for this?’ We’re already paying for it, we’re just spending our money really, really stupidly. America is already spending the money required to fund single-payer. We’ll spend $3.9 trillion this year on healthcare. Between half and two thirds of that is direct government spending. The rest is your premiums, deductibles and copays, a kind of private tax you pay to hospitals or your insurance company. Of that $3.9 trillion, one third—one fucking third—is spent on nothing more than waste. Half of that is payer-side waste like admin costs and high prices. The other half is provider-side waste like unnecessary or inefficient care. Now, take single-payer. One study claims that both single-payer plans in Congress will cost 10% less than what we’re spending right now. We could spend 10% less to cover all people in full. Large healthcare corporations jack up prices and jack up profits and the insurance industry is unable to do anything about it. It is incompetent, so it takes its cut and shovels the costs back upon you. And our swollen, furious American model of health bleeds and bloats and it leaves you to suffer.
Single-payer lets us liberate people from medical costs and reallocate this spending to take care of everybody longterm. Part of the reason costs are so high is because private insurers, with their small customer bases, just can’t negotiate with big hospitals. But once Medicare For All, once the single-payer represents 330 million people, it basically sets its own fair prices for care because it’s the most powerful negotiator around. So these wildly inflated costs got their balloons popped and are brought back down to earth and then we’re playing on an even field. But even before that happens, we free up all the money associated with the admin costs and profit in the private insurance market. This optimization opens up—in a conservative estimate—an additional $370 billion a year. 370 bundo, that’s a big chunk of change. What do you do with it? You use it to improve everyone’s standard of living? You build or reopen primary care clinics in rural areas. You fund community health centers in poor neighborhoods. And most importantly, you return the money to the people who do the work. Take for example, home health aides. Y’all know home health aides? Or have a sick parent, sick friend, sick kid? A person can receive care in the hospital, but again, that’s two thousand a night, which is really, really pricey. If you need a lower standard of care—need your meds changed, meds refreshed, help getting in and out of bed, going to the bathroom—you can receive care at home. And for a lot of folks, home is a nicer place to be. Home is where your dog lives. Home is where the internet lives. Home is where the TV’s programmed with the stations that you like. And home health costs only $120 for an average visit cost. If you’ve got a disability, home health and long term care mean you can have agency over your own life by being able to live at home instead of being cooped up in a loveless or even hostile nursing home. So everybody benefits, it’s more humane, and we save money.
Well, everyone benefits except for home health aides themselves, because for this humane and essential service, the 1.2 million home health aides in America are paid a nationwide average of only $11 an hour. So we can allocate this money to do what the private market refuses to do: pay fair wages for essential care that helps everyone. Think about it: what makes a real difference in health outcomes? Is that luxury hospital suites? Is it multimillionaire surgeons? Is it $40,000 data packages for nerds to look at? Is it apps? No, no, of course not. Those are just the folks that get to bill the most. The real difference is extra clinical care or compassionate labor. It’s social workers, patient advocates, vaccination counselors, nurses. These are the folks chronically unrecognized and undervalued and they’re the primary people who make a difference in long term population health. These are pretty basic ideas. These are pretty simple demands. We’ve long understood the social forces that make people healthy, and we understand the structural ones that make people sick, but in the multi-payer private model, nobody is investing in long term health. Nobody’s investing in population health. Nobody is investing in compassionate labor or paying these people fairly, and they never will. Right now, your private insurer only bears the cost of you receiving care while they’re insuring you. Because you’re gonna change insurers in a couple of years and eventually—God permitting—one day go on Medicare, they feel no pressure provided with care that keeps you healthy now or helps you become healthier in the future.
Let me put it another way. You know that if you’re at home and the window breaks, the weather gets in, and if the weather gets in, you get sick, right? Too hot, too cold, rainy, snow. And if you get sick or your kid gets sick, you got to go to the doctor. But if the local clinic was shut down or it’s booked solid, you got to go to the hospital. And if the hospital is far away or you don’t have a car, you’ve got to hitch a ride or you got to take the bus. And in most parts of the U.S, if you’ve got to take the bus, you’ve got to spend all fucking day dealing with the bus system. And if you’ve got to spend all day dealing with the bus, you can’t go to work. If you can’t go to work, you don’t make any money. If you can’t make any money, you can’t afford to fix the window that caused the problem in the first place. And so the answer isn’t to fork over a pile of cash every time you go to the hospital. The answer begins with giving people what they need to fix the goddamn windows, but there are no private actors in the American model who will bear responsibility for fixing these problems on their own. The only innovations of the private insurance industry are ones created to solve the problems created by the private insurance industry. They are incapable of addressing the real and foundational problems of healthcare. They are incapable of fixing the broken windows, of reopening the 18 rural hospitals that have closed in Texas because of a lack of Medicaid funds, of repairing the PVC septic tanks in South Carolina that have ruptured and brought hookworm back to the state. They cannot fix this injustice because they’ve been constructed by that injustice. They cannot solve these problems because they existentially cannot conceive of them as problems in the first place. But we can and we do. And so it makes perfect sense that the same actor who suffers when people don’t get care should be the actor who pays for that care in the first place. Because once that federal actor, once that single-payer, bears the costs of providing care and the costs of what happens when care is not provided—once we forced it to confront the rampant suffering of all its people—it can finally be used as a tool for realizing health justice. If your people are getting sick because they don’t have a place to live, or where they live is unsafe—it’s full of water, it’s full of mold, it’s flammable and so they’re going to the hospital— then housing is healthcare and you build safe social housing to bring healthcare costs down. If your people are getting sick because they don’t have healthy food to eat and so they’re getting diabetes or cardiac failure, then food is healthcare, and you provide them with affordable or free food options and the time, space and materials with which to prepare them to bring healthcare costs down. If your people are getting sick because they don’t have access to needle exchange programs, therapy, or counseling, then rehabilitation is healthcare and you build full-cycle addiction treatment programs to bring healthcare costs down. Because single-payer, while being fantastic, is not the goal; single-payer is only the tool. Health justice is the goal and when we fight for health justice, we all fight side by side because economic justice is health justice. Environmental justice is health justice. Reproductive justice for people who don’t want to reproduce, and for people who do, is health justice. Just wages and just working conditions are health justice. And justice for Black lives, justice for Brown lives, justice for trans lives, justice for the lives of immigrants, justice for people in prison, and the wellbeing of all people regardless of age, gender, race, or creed, that is health justice. Hell yeah.
We have inherited a world in which your permission to receive healthcare—your permission to be safe in your own goddamn body—is dependent upon how much a corporation can extract a profit from you. And thus we have permitted in our country utter desolation. And I want to talk about that desolation now. Over the course of researching this book, I took to the road. Every morning, I’d wake up, eat a banana, drive 6 hours in my 2002 Honda CRV, give a speech and then talk to folks. People would tell me the worst things that have ever happened to them over and over and over and over and over again. I kind of became a library of human misery. And so I want to share three stories with you. One long, one short, one medium, to contextualize the fight for healthcare and the movement for health justice.
First story takes place in Houston. One thing I haven’t discussed is mental health. And you can’t talk about mental health in Houston without talking about the Harris County jail and how it’s the largest quote unquote provider of mental health services in all of Texas. Which is a fine observation, but reality is a bit more complicated than that. In Houston, people who are arrested and suspected of having mental health issues are held in these dark, dank dungeon-esque cells in the Harris County courthouse. You would not know these cells existed unless you were explicitly looking for them. So if you’re a person with mental illness who’s been locked up for several days—for things like trespassing or disorderly conduct—what do you do? You haven’t had your meds while you’ve been locked up, so you’ve got two choices. One: plead guilty and you might get out on time served. Two: fight it, and you’re looking at more time locked up without your meds. And this is if you’re lucky enough to pass as functioning normally. If you’re in the middle of a serious episode, things get worse. Then you’re held for up to 30 days until the County gives you a session with a psychiatrist. People are held in the hospital wing of the prison or the prison wing of the hospital.
There’s this concept of the prison-to-hospital pipeline, which comes up when you discuss mental illness in jail, but it’s not a pipeline. Pipelines go in one direction. It’s more like a pinball machine. You’ve got these giant invisible flippers that bounce folks around from jail to hospital hospital, hospital to jail, jail to hospital, hospital to jail. And at some point there’s just no functional difference between the two. We refuse to care for people and so they become sick. We make them sick. And if you’re the wrong kind of sick or if you’re the wrong kind of person, we delegate your care to private prisons. It’s technically not a crime to be poor. It’s technically not a crime to be sick. It’s tactically not a crime to be black or Brown. But once you fall into the intersections, the rules change on you. If you’re a poor single mother of color, for example, you have virtually no right to privacy. If you’re in section 8 housing, an estate agent comes to your apartment twice a month and counts the shoes on your shoe rack. And if they find too many shoes, or if you’re a single mother and they find a man’s shoes, you can lose your benefits. If you are disabled and on Medicaid, every month a nurse comes to your house to check to see if you’re still disabled or if you’re faking it. And you only get to go through this deeply humiliating process if you’re poor enough to qualify for Medicaid long term care in the first place. In some states, you’ve got to make less than $2,000 a year. If you’re a Medicaid recipient in work requirements states, every month you’ve got to wait in line for hours in an understaffed office to prove that you’re employed. Time you can’t spend going to work. And so these processes drive people into the hospital, into the streets or into jail.
So long as we use prison to hide those who were made undesirable by their healthcare needs, healthcare and prison are inseparable. So while this idea that prisons are the largest providers of mental health care in the U.S is a well-intentioned and technically correct point, it’s wrong. Because no prisoner will ever receive the care, support or help they need to handle whatever’s fucking with them. And no prisoner will ever be saved from the return trip once they get out and remain sick and inevitably get arrested again. Because prisons are not hospitals. Jails are not doctors’ offices. They are warehouses for the mentally ill. They are storage units for the unwanted. That’s Houston.
The story I want to tell is about birth and death in Memphis, Tennessee. At the turn of the century, in Memphis, 20 black children died for every thousand live births. 20 black children died for every thousand live births. That is an incomparable, incomprehensible number found nowhere else in the first or second world. 20 black children died for every thousand live births. Why did they die? Because Memphis is home to 2 nuclear waste disposal sites pushed up against poor black neighborhoods. But it keeps going. These things always keep going. Where do poor babies go when they die? In Memphis, they go to baby land, a corner of the public cemetery. They are put to rest in cramped rows beneath the earth in unmarked graves a block and a half away from a Walmart. Or at least they were until recently, because in 2014, baby land filled up. Poor black children in Memphis die in such volume. America is killing the poor black children of Memphis by poisoning their mothers and poisoning their homes so effectively that we have run out of room to hide our shame and we have run out of room to bury the bodies.
And finally I want to talk about Scott County, Indiana. You might know Scott County as one of the few places in the U.S with a new population-wide epidemic of HIV AIDS. And we understand why. One: pharma companies invented tamper-resistant opioids, which can’t be crushed and snorted, which does nothing to stop misuse, but you got a new patent so it’s very profitable. If you’re a person battling addiction, not being able to snort doesn’t keep you from using; you just turn to heroin or turn to fentanyl. Two: then-governor Mike Pence shut down needle exchange programs in this state. Needle drugs are illegal. And so therefore they’re for criminals. And why should we spend money on criminal healthcare? Three: Indiana gutted, shut down or cut funding for local clinics and places like Planned Parenthood. And so here’s the breaks: if you’re a person in Indiana battling opioid use disorder, tamper-resistant pills mean you turn to needles, except now you can’t find a clean needle because the exchange is shut down and the clinicsyou would have gone to for help are unavailable as well. And so it’s predictable. More folks got needle-borne diseases like HIV AIDS and hepatitis C. But again, that’s not where the story ends. Most people have families, they have communities, and now they’ve got HIV AIDS or they’ve got Hep C and they’re in jail and their families miss them. These people who have been left behind. Now Indiana also has a very low property tax cap—which limits school funding—and it has a robust school voucher program. Better-off families who didn’t want their kids to attend school with the children of the left behind, sent their kids—and therefore their tax dollars—elsewhere. And so Scott County schools got less and less money and more and more kids per capita with families going through the shit. That means fewer teachers, less food and no mental health or guidance programs. I spoke with a guy who said you could spot a kid going through hell from a mile away, a kid with a parent in the system, a kid without support at home, a child unmoored in the world, but there was nothing he could do to help. There was no money, there was no funding, there was no funding for breakfast. There was no funding for therapy. There was no funding for daycare, there just weren’t any resources for the children of the left behind. And so Scott County saw an increase in child suicides.
All these things have causes and all these causes are cyclical. They have happened forever. They will continue to happen so long as we tolerate the idea that the body is a commodity, and if that commodity is not valuable—if there is no profit in the care of the sick or the homeless people or people battling addiction or people with disabilities or poor people, pregnant people, trans people, women, black people, Brown people—then there is always the private prison system ready to receive them for profit. And this servitude continues in death because it is the organs of the poor that are disproportionately transplanted, that are ripped and sold to the bodies of the wealthy. There is no end to the body horror of capitalism. There is no line too far for the commodification of the body. And I say these awful things not to pornograhize suffering, but because these are the stakes of the fight for health justice. And so I want to be explicit: insurance is not enough. Our goal is not simply insurance, but emancipation. We must put the people who have been most harmed at the front of the line. We must walk together every Goddamn step of the way. We must never compromise until we all have been liberated. Why is it that some have adequate healthcare and others do not? Why is it that some have adequate housing? Why is it that some have adequate food, adequate income, adequate safety, and dignity and humanity, while others do not? Why is it that some get to live freely while others are compelled to fear their own bodies? Our health is a portion to us along the lines of structural poverty and structural racism. Our American body has been poisoned by the wicked snakes of racial and economic and patriarchal domination. And so when we attack, we must attack the beating heart of capitalist exploitation itself. And these are the problems private insurance can not fix, will not fix, and in some cases, has cost. These are problems which can only be addressed with a full force of all America’s people, our bodies together forming the shape of our government, armed with a single-payer healthcare system.
Upon our throats are the boots of domination. And single-payer offers us a moment of relief which we might seize together and cast the whole thing off, to dismantle the hateful lottery which permits us basic human safety only to the extent that we are useful to the people who make money off our work and off our bodies. Freedom to organize, freedom to fight back, freedom to escape the strictures which bind you, freedom to be safe in your community, your home and your body. This is the future single-payer lets us march toward. Because single-payer is not the revolution; it is our first counter attack in a war that has already been waged against us, by which subsequent counter attacks are made possible.
Now, there is good news. We do know what works. We stand on the shoulders of the labor movement, which has shaped this fight since it first began. We stand on the shoulders of hundreds of thousands of nurses, of tens of thousands of doctors and the legacy of grassroots movements like ADAPT and ACT UP, who fought against impossible odds and won, and won, and won again. In San Antonio, the movement for paid sick leave turned out 144,000 people, the largest popular movement in years—if not decades—in that city. In Maine, the Maine People’s Alliance turned a minimum wage campaign around into a Medicaid expansion campaign and overwhelmingly won. In Idaho, 3 friends bought a Winnebago, painted it green and drove around the state to build a movement to expand Medicaid. And that movement won 61% at the ballot box, even when the Dem candidate for governor lost by 22 points. There was no blue wave; there was a popular movement. If we give people something material, they will fight to get it. They will fight to keep it. If we fight with people today, they will fight with us tomorrow. We build solidarity so we can build power. Nah, I can’t tell you what to do here in Seattle cause I live in Brooklyn, and nature abhors a carpetbagger. But I reckon our job is not to build a single popular movement. It is to stitch together a popular movement, a big messy quilt of fights for health justice in our factories, in our offices, in our churches and in our dive bars, which spans the country from coast to coast and plains to gulf. And through these kinds of popular massive mobilizations, and only through these kinds of massive mobilizations, this is a fight we will win. This is not a radical proposition among the people it affects; people like single-payer, people like Medicare For All; the more they hear about it, the more they like it. We are simply discussing a basic principle of fairness.
And so in closing, I offer you my profession of faith. I believe beyond any doubt that single-payer is demonstrably sound and eminently feasible. I believe a properly ambitious and well-structured single-payer program will do more than any other American social program of this generation to soothe the burns, to resuscitate the spirit, and to nourish the moral will of the American people. I believe it will loosen the loathsome manacles of American health finance and it’s theft of our bodily autonomy. I believe this nation owes its people—whose labor has created its rich banquet—the safety and agency of healthcare. I believe this healthcare is greater in scope than that which happens upon an operating table. I believe that housing and food and income and more—the components of basic human dignity—are healthcare. And I believe that our work is that of striving towards justice for all people and I therefore believe—I have to believe—that single-payer healthcare is our moral imperative. Single-payer is our tool. Single-payer is our weapon. Single-payer is our first step, but single-payer on its own is not the goal. I’ve seen, as you have seen, such naked suffering inflicted in my American name. I’ve seen families ripped apart by the unrepentant, unyielding blood lust of capitalism. I’ve seen people I love torn limb from limb in the service of extracting profit, and this is intolerable to me. And so I say enough. Not in my name may this America persist. May we root ourselves not in fear, but in love for those who suffer around us, and from that love may we cultivate the fury by which this cruel machine can and will be destroyed. My friends, single-payer is moral, single-payer is necessary and single-payer is—I swear to you—single-payer is achievable. Solidarity now. Solidarity forever. Thank you very much.
That’s very sweet. Thank you very much. This is my hobby. This is fun, right? I think we’re doing Q&A. I will A any Q, preferably ones about health policy or a single-payer. But who knows, if you’ve got a wild Q, I’ll do it.
Audience Member 1: Very well done. And I should preface mine; I’m a retired healthcare provider and I am in favor of single-payer systems. But over the years I’ve encountered patients from Australia, Canada, Britain, and Finland, all of whom told me the same story, which was the routine daily office care was okay, but any kind of advanced therapy, specialty care didn’t work and was not as available as they needed and they wound up coming to this country for that kind of care. So unless you’ve got a magic answer for how to construct this, none of the other countries in this world had been terribly successful at it.
TF: Sure. I’ve got a couple of answers to that. First off, if they’re coming here for healthcare, they gotta be loaded, cause our American model for specialty care works great if you’re a millionaire and works pretty shittily if you make less than $40,000 a year. So there’s one point. Two: the countries you’ve mentioned have gone through pretty big austerity programs in the past 20 years. Australia, for example, embarked upon a wild campaign of privatizing orthopedic surgery and, like, hip replacements or whatever, which ended up doing nothing but driving up costs and creating a two-tier model with folks who had money and got private care, which then took money away from the public model, building a split risk pool. And in the UK, ever since Blair was in office, we’ve seen an austerity program privatizing parts of the NHS, making care worse. What I think the question neglects is that we’ve got awful, awful, awful care in the U.S if you can’t afford to get healthcare in the first place. Our wait times are longer than any other comparable OECD country. Once you take into account—well we don’t report a lot of our wait times, but the examinations that they have been done in Boston and LA report wait times on par with or worse than wait times in other OECD countries, and that doesn’t include folks who can’t afford to get care in the first place. They’re basically in line forever, and forever, as Prince tells us, is a mighty long time to wait for care. We have some hospitals that do amazing work, like the Cleveland clinic. But again, to go there, you gotta be a Saudi Prince or Bezos or whatever. They get fantastic health care. But I disagree with the idea that because other countries have difficulty in the provision of care and specialty care, that our American model is somehow better or doing a better job. I think that’s a little bit inaccurate. I’m sorry to rain on your parade. I should be more polite. But no, our model is fundamentally broken in all kinds of ways and simply because there is a supply-side issue in other countries—supply issue that’s been caused by the austerity measures in the past 20 years—is not to me an indication that we should not pursue a single-payer model.
Audience Member 2: So I think with any of these universal social programs that are proposed, I leave these talks just kind of feeling helpless; inspired but helpless. And so what would you say are some more practical, tactical things that every person can do now to get us closer to achieving single-payer?
TF: Good question. So I have two things to say on that because I always have two things to say and everything; that’s the theme of the night. One is a caveat, which is that I do not profess to be an experienced organizer. I’m a big fucking nerd who likes healthcare policy. But I can tell you the things that I’ve seen that I find interesting, right? Let me use the paid sick movement in San Antonio, for example. I guess my short answer is: find the movements that are available to you that you think you can win and go out and win them. Even if we elect a president, even a good president, who wants single-payer, he or she will not be able to win single-payer through executive fiat. It’s not how the U.S works. You need a mass movement to demand it. Actually every time there’s been a universal health movement in the past 80 years in the U.S, whenever it’s been led by politicians—even senators, even well-meaning ones who meant the entire thing, top union brass, folks on top of the pyramid—they’ve lost, because there is a massive and reactionary establishment that can outmaneuver, outgun, outspend them. And the things that have worked are mass movements that have organized very horizontally. I like to use ACT UP as an example. ACT UP was interesting because of the incredibly long odds they faced. It’s hard to recall because I wasn’t alive in the early 80’s, but we had sitting presidents who thought that HIV AIDS was God’s blessing to cleanse the earth of the gays, which is a pretty long fucking shot if your goal is to to demand HIV care for the free population, like you’re fighting against that, that’s massive. And they won. They organized a really broad coalition of folks: single mothers, people who are battling drug addiction, poor people, gay people, this big, big coalition. And they organized horizontally and made a mass movement that was able to demand things. This was back when stunt activism worked better, but they were able to demand things in ways that a politician by him or herself is not able. But this movement is not going to happen overnight. We’re not going to have a big mass, popular single-payer movement that’s unified in lockstep that happens and sweeps the U.S; if we do that would kick ass, but I don’t think we’re going to have it.
I think what I said before is how I feel: we want to build this big quilt. So I think find the thing you can win and win from there. Let’s use Idaho as an example. Idaho passed Medicaid expansion through this incredible campaign. I was there for the election; kicked ass. It started off like this: in Sandpoint, Idaho—which is a little ski town up in Northern Idaho on the east side—there was a shortage of funding for schools. And so 3 friends who live in Sandpoint thought, ‘Oh, this is horseshit. We want to fund our schools. Let’s put together a campaign to pass a lean to keep schools open.’ So they did. They organized their town of like 17,000 people and won the thing. And then they’re like, ‘Oh shit, we can win things if we organize. What a cool idea.’ They took the small momentum they had from winning things in Sandpoint and bought a camper van and painted a green so they could drive across the entire state and see what they could do. And so they threw town halls in every county in Idaho, dozens and dozens of town halls. They found folks who wanted to organize their towns or their counties, kind of gave them the keys to the Jeep and said, ‘Okay, please organize this thing. We’ll check in every now and again.’ And through this process, built a mass movement of hundreds of organizers who knocked on thousands and thousands of doors and won overwhelmingly at the election. And now they get to call their next shot. They’re gunning for statewide school funding and, I believe after that, repealing right to work in the state. You win a small thing—it’s like a snowball going downhill, that’s a metaphor we’re all familiar with so I’m not going to pursue that any further—but you win what you can and take it from there. In Texas, we’re seeing the movement for paid sick leave, which is—Texas is a hard place to live, I’m from there—but paid sick won overwhelmingly in Dallas, Austin and San Antonio, which is like: there has not been a lot of mass movement work in Dallas and San Antonio in a long time. Again, 144,000 folks turned out for it in San Antonio; that’s more than the number of folks that voted for mayor in the last election. That builds a movement. You can find the thing that you can win and win it. And it can be small. In Cincinnati, I think 8 people yelled at the sheriff over and over and over again, yelled at city hall over and over and over again, until they agreed to open and fund a needle exchange program, which is fucking massive for people that need it.
So I would posit that if you feel alone and confused in the world—me too—find the folks who are winning things that you want to help win and join them and from that build a broader lattice. I also would posit that Seattle DSA is here and, as a DSA member, they’re a good place to start.
Audience Member 3: Hi, I’m Jen. I’m with Whole Washington and we’re trying to get a universal healthcare system for Washington State on the ballot, so starting smaller, people-powered. So if anybody wants to be involved, this is an entirely volunteer organization and we’re trying. My question is: how do we get elected officials to reframe this whole conversation away from plans and coverage and money and commodity and look at us as like our health is the wealth.
TF: Scare the shit out of them. That’s it. I mean, I think that’s my answer.
Audience Member 4: I had a question over here. So my name is John and thank you for coming out for tonight. I’m a community organizer here in Western Washington as well as nationally with medical students and physicians. And I have two questions. One: what is your take and your gut feeling about the current climate around Medicare For All? So we see Hakeem Jeffries comes out, cosponsors Medicare for all, but at the same time we see Elizabeth Warren come out with her own plan, Kamala Harris pulls her support from Bernie’s plan, et cetera. And then the second part of my question is: what gets you through the day? Like what makes you optimistic or not so optimistic for the future?
TF: Sure. Cool. Good questions. So in re: your first question of like, we’ve got these nominally pro-single-payer folks that get cold toes and pull out: I think they understand that there is blood in the water—it’s our blood, we are bleeding into the water—and they want to catch the flavor, catch the spirit, and so they offer nominal things and then once they actually have to put their feet to the fire—I’m mixing metaphors left and right, like a big soup, I guess that’s a simile but whatever, I wasn’t good at school—they pull out. And they’re lost causes, right? Kamala Harris is a lost cause, was born as a lost cause on healthcare. All these folks are not going to come back to our side unless, again, we scare the shit out of them, which maybe will happen, maybe won’t. So I’m kind of inclined to not worry about them as much. I think people generally like single-payer; it’s polling between 50 and 70 right now in the U.S. All the fuzziness happens in the liberal or the moderate democratic side. Republicans are pretty consistent in how they view it. But the movement is now growing in ways that it hasn’t grown in any prior attempt in the past 80 years. Everyone is afraid of their own—we’d get two things happening. One: the healthcare model in the U.S is collapsing, costs skyrocket and there’s no containment measure. So therefore insurance companies have now like $6,000 premiums, which nobody can afford unless you’ve got a lot of money. And two: there’s that stat that I don’t like, but it’s very convenient, which is that most folks can’t afford a $400 expense, and medical care at this point is—even with insurance—is way beyond that $400 range. There was a tipping point that we are sitting right on top of, and it’s gotten to a point where even the moderately well-off are also feeling the fear. And it’s also gotten to a point where we have a wonderful tool that’s been given to us to organize for single-payer, which is that nobody likes their insurance company. People love being insured. I love being insured, but I could give a fuck less about my specific insurance company. I want to have as little to do with them as possible. I want them to pay for my meds and that’s really about it. And that is a great commiseration point for building your own movement and it is working. I’ve seen—I won’t even go into all the anecdotes—but I’ve seen people who normally would not be in the same boat getting in together to talk about healthcare and take it from there.
Two, what keeps me going is a Monster White, the sugar-free version of Monster, cause that’s the healthy Monster. I’m a health policy person, so I gotta be health conscious. I try to—it’s hard to do in the book tour cause my publisher has to sell books—but when I’m on tour for fun—it is fun, it’s a hobby, my girlfriend hates that I have this hobby, but it is a hobby—I get to go to places that maybe don’t get healthcare speakers very often, like rural Arkansas, Idaho or whatever. There you don’t have like the—and God bless all of you—the usual bookshop event-going-to people coming to hear me talk, it’s folks that have questions or are uncertain or unsure and want to talk about their job or their kid or their friend or whatever. And those folks are getting on board too. I believe the things that I say; the more folks learn about this program, the more they like it. There are some portion of folks who are always going to be against this, or think that this is creeping communism; that this is going to ruin America and they’re going to have to live in hell forever and with that kind of shit, and like God bless them, they deserve healthcare too, but I’m not worried about them. I really believe that the folks who need to learn about single-payer and can benefit from single-payer are hearing about it, learning about it in ways that are good. I think my job, at least, is to go and keep talking about it always as much as I can and give folks the tools to talk about it like Health Justice Now: Single Payer and What Comes Next, a book you can buy here at Third Place Books. That answer your question? Cool.
Audience Member 5: Currently a lot of the innovation that happens with the new medical devices and digital therapeutics—all the types of things that just advance healthcare—are done by entrepreneurs. And they do that a lot with risk reward and if you take some of that profit motive out, where does the innovation come from?
TF: The innovation comes from where it always comes from, which is public universities. Right now, public universities—like right now, let’s see you as a farmer, as an example, we as farmers often there are too many innovations—Oh Jesus. Where do I start? Here’s where drugs come from. A guy named Big Dave who we text once every Friday. No, drugs come from underpaid or unpaid grad students who do work with public universities that are sponsored by pharmaceutical companies. Their work is then bundled up and sold to Pfizer or whatever and. But they spend their entire life making a molecule, Pfizer buys that molecule, makes 10 iterations of, throws it at a wall, sees what they can do, and it turns that into a drug it gets a patent for it. That’s where all drugs come from. All meaningful drug research is done in public universities. It’s not profitable to explore curing cancer, cause that’s really, really hard and the years you spend researching it, you don’t get any profit. So pharma companies opt out of it; they only choose to mitigate things that they can sell that they have a market for off the bat that make a lot of money happen. They just buy the rest from universities. Two: the primary innovation in pharma in the past 20 years has been marketing waste. It’s the opioid epidemic. Pharma companies spend, I think, 3 times on marketing what they spend on R&D. And so the MS Contin to Oxycontin jump was a triumph of marketing. ‘Oh, we can take this drug and lie about it and market it really, really, really heavily to doctors who don’t know any better—the patient doesn’t know better—and do it over and over and over again. And when they catch us, we’ll pay a fine.’ And that model worked extremely well. I don’t mean to be glib, but that is the primary innovation of pharma. On the DME side—equipment manufacturing—you’ve got a whole cantankerous endeavor going on there. One of the primary innovations in equipment is the 510(k) program. The 510(k) program was an FDA approval process by which—normally if you put out a new thing, like a brand new thing, like an elbow extended, like a thing that is brand brand new, you’ve got to go through—I don’t know why you’d need that, help you a basketball I guess—you go through a pretty rigorous examination process, which makes sense. But if you’re an equipment manufacturer, you can put out a thing, like a bandage or a pacemaker or whatever, and say, ‘This thing is materially equivalent to things that already exist, therefore it doesn’t warrant any further investigation, so please don’t investigate it.’ And FDA says, ‘Okay,’ and you get fast tracked. And unsurprisingly, 80% of device recalls come through the 510(k) program. So the DME have also innovated things like paying doctors to become their brand ambassadors for life, basically. DMEs have invented things like proprietary screws, so you can own their proprietary operating tables, so you can only use their gear when doing operations that your hospital has contracted out with them. DMEs have innovated things like sending DME employees to work in the hospital with you to make sure you only use their devices. These are the innovations; they’re all marketing-centered. The actual R&D is done, once again, by underpaid grads or unpaid grad students and doctoral students. So if this is the kind of innovation we risk not having by going to single-payer, I say, fuck yeah, that’s cool as hell. That’s like a benefit, not a consequence.
Audience Member 6: Okay. So I just have a quick story. So I’m a retired nurse. I worked at the University of Washington. Early in my career we had one of the University of Washington board of trustees members as a patient. And back then—this was over 30 years ago—they would asterisk people on the admin sheet who did not have health insurance, and this guy’s got an asterisk next to his name. And everyone was freaked out when you don’t have insurance; that’s one of the reasons I liked my job is because it had really good health insurance. But what that showed me was that the really wealthy don’t need insurance. This guy had like—I don’t know what it was—$25,000 or $50,000 health bill from being in the hospital, but he could write a check and it was no problem. And so the people who are running things, like at the board of trustees level, have no concept of what it is to be worried about healthcare. And since they run so much of society that’s really a problem. So I really appreciate the idea of single-payer.
TF: That is buckwild to me. Thank you so much. Wow. Well, I had been saying that I have a question nobody asked that I want to ask myself and then answer, if you bear with me for a second—we’re not done yet, what’s your clapping for, that story was incredible, in which case I’m sorry for cutting you off—what happens to providers? What happens to provider pay? Let’s go through it. So there’s this fear that doctors will make less under single-payer, that right now America is a heaven for doctors because they get paid so much. And if we go to single-payer, they’ll get their salaries cut and then nobody will want to be a doctor and we’ll have a doctor shortage. We already have a doctor shortage. A couple of things on that. One—this is a little glib, but it’s true—if America were such a wonderful place to be a doctor, we’d see a mass rush to the border of Canadian doctors coming here to work in our model. And they don’t for a lot of reasons. Two: doctors right now have got to spend 60% of their time dealing with insurance. Nurses, it’s 40% of their time dealing with insurance. You gotta see your patient and then run into the back and see if they have Cigna plan AZ, Blue Cross plan Alpha, Aetna 10123; you gotta figure out what form to fill out and then argue with the insurance company about what care you give and what care you don’t give, over and over and again. You spend more of your time doing this than actually doing the work of seeing patients. Under single-payer this process becomes much simpler because there is one insurer and there’s one fee schedule, plus a couple of modifiers. So you say ‘I saw patient ABC, they have conditioned Z, I did 123,’—or however you would have paid it, there’s different payment models—you push the button and you get your reimbursement so you can spend more time seeing more patients. Chase that Skrilla. Three: I think there is a parallel fight to single-payer that needs to be—a couple of parallel flights, things like relieving medical debt has a parallel fight that I think is required to build a more equitable health state—but here’s another one. Right now one third of people in med school come from the top income quintile in the U.S. Only the children of doctors can afford to become doctors. That’s because med school costs three hundo thundo, $300,000.
So you’ve got that in the back of your mind. ‘Oh, I’ve got this massive debt and also it gets interest, so I’m looking at paying this thing off in 20 years.’ And you look at the chart of doctor salaries and it goes like this. Down here you’ve got primary care providers, pediatricians, folks that do the tedious, nice work of being nice to people. Over here you’ve got your hand surgeons, your brain surgeons, your hand and brain surgeons, your Ben Carsons who are making the multi-mundos (multi-millions). So you look at this graph and you go, ‘Oh shit, I should be a brain surgeon.’ So folks get pushed into the specialty care. And this is part and parcel with how the AMA influences Medicare and setting efficient prices in a given year; it’s overrepresented by specialists who push higher specialist fee structures. It’s in the book. But it also means that, at the same time, most doctors do fall into the lowly paid side: primary care providers, pediatricians, et cetera. But we’re at an inflection point. I met a doctor in, I think, Paducah, Kentucky; she’s a 67-year-old primary care provider and she can’t retire because no one can afford to move to Kentucky and be a primary care provider. So you’ve got these massive holes across the U.S where no one can afford to go and do basic healthcare. So we import doctors under the J1 visa program, but then we’re just taking doctors away from their countries and causing more problems where they come from. And then also those folks don’t get paid very well and it’s a short-term program sometimes. We built a pretty stupid model; it was entirely self-inflicted. Back in the early 90’s we were afraid that there’d be too many doctors. There was a New Yorker cartoon of doctors in a bread line. And so through Clintonian-era policy—our friends, the Clintons—we cut down residency programs and put in place a couple other measures to reduce the number of people who could go to med school. So all of these problems are self-owns; we’ve done this to ourselves and therefore we can get ourselves out of this, it’ll just take a little bit of work. So I think a parallel fight, the fight for single-payer, is that of making all medical training—doctors, nurses, home health workers, et cetera—fully subsidized or free. Yeah, hell yeah. Because this is a civil service. This is a fundamental component of the American health model. We need these folks. Why do we limit them to needing to be wealthy in the first place? Thank you very much.
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