Episode 41: The Moral Poverty of Capitalist Healthcare Framing

Citations Needed | June 20, 2018 | Transcript


Intro: This is Citations Needed with Nima Shirazi and Adam Johnson.

Nima Shirazi: Welcome to Citations Needed, a podcast on the media, power, PR and the history of bullshit. I am Nima Shirazi.

Adam Johnson: I’m Adam Johnson.

Nima: Thank you everyone for joining us this week, especially to any new listeners out there. Not that we don’t love listeners who have been with us for quite a while, but we’ve been doing this show since July of 2017 and come a long way I think.

Adam: They grow up fast.

Nima: I know. Can you believe it? Can you believe us? Thank you everyone for listening. Of course, you can follow the show on Twitter @CitationsPod, Facebook at Citations Needed and help us out, support the show, keep it going, keep it growing through Patreon.com/CitationsNeededPodcast with Adam Johnson and Nima Shirazi. You can help us out that way. That is much appreciated.

Adam: Yeah, any, any help on Patreon is very much appreciated. Helps keep it going. Um, so this week we are covering a topic that is of course of dear importance to a lot of people who are in the activist and progressive and even increasingly democratic space, which is healthcare marketplaces, private insurers competing for your business, insurance subsidies. For years, Democrats have bet big on a framing for healthcare that prioritizes technocratic and capitalist terms. They weren’t going to radically change the existing system of healthcare, they were going to simply accent the private insurance business model that we’re going to make things “smarter,” “easier,” “more tech-driven.”

Nima: Yeah, so as the Affordable Care Act or Obamacare, as it is sometimes known, but it is the Affordable Care Act, um, faces right-wing attacks democratic activists increasingly look to single-payer as the way forward. Efforts to shift the healthcare system require before they can really go anywhere a very radical shift in how we even talk about healthcare, the words we use.

Adam: So today we’re going to ask how can activists rewire the public’s brain when it comes to the topic of healthcare? How can they undo all the damage that’s been done by decades of propaganda? And what rhetorical ticks need to be retired to move the conversation about healthcare away from a technical achievement to a moral one.

Nima: We will be joined later in the show by Natalie Shure, a writer and researcher whose work focuses on history, health and politics.

[Begin Clip]

Natalie Shure: The idea that each of us has a body that it’s our job to take care of and that if you have a health issue that’s basically on you, that you failed somehow, that you haven’t been a perfect steward of your own body and health. I think that that’s very cooked into the idea of moral hazard in a healthcare context.

[End Clip]

Nima: To set the scene a little bit, here’s a little background on the landscape of what we’re really talking about. In 2016, America’s total medical costs hit a new record of $3.4 trillion. As The Atlantic magazine reported, “That’s about 18 percent of the country’s total GDP, meaning that one out of every $six dollars we spent in 2016 went to health care. The national doctor bill dwarfs anything else we spend money on, including food, clothing, housing, or even our mighty military.” And so this issue of, of healthcare is hugely important. It’s important not only to activists who want a single payer system, it is important to the lives and livelihoods of literally everybody who lives in this country.

Adam: So yeah, even the idea that healthcare is a patient’s rights issue from a consumer standpoint, and that the goal is to, sort of, “empower” healthcare consumers, is a sort of gross bastardization of a movement that was popularized in the seventies. Ralph Nader’s Public Citizen embraced the idea of the patient as an empowered consumer to wrest away, the autonomy away from the powerful medical establishment. You saw a similar kind of bastardization of what started as progressive language in a progressive movement in the charter school space, because as we talked about in Episode 1, the movement for charter schools actually did start off from teachers unions. It started off from actual progressive groups to give more choice. And then they took the concept and the language and morphed it into this far right-wing ideological and real estate investment tool. And so the efforts to kind of empower consumers just the same became a general framing device for what were ultimately reactionary capitalists systems of providing healthcare to people that, that these insurers were going to somehow empower, empower, generally that the word empower is typically a huge red flag for bullshit. When someone says “empower” you’re almost always getting, you’re either getting cynically bullshitted or its some kind of good faith progressive-y type who can’t come up with a better term. But the word “empower” is usually some, you should usually be very careful about what follows that. And so the movement to sort of empower the consumer into sort of talk about choice, that this obsession with choice is basically a way of saying we need to atomize everything and makes sure that everyone is off in the desert of the Mad Max capitalist system and fending for themselves.

Nima: Right. So what we see is this pretty well-intentioned short term messaging strategy emerge out of the sixties and seventies and just get then exploited and morphed into a very pernicious right-wing narrative over the long run. And so before the sixties and seventies, the term “consumer” was really not a part of the healthcare related patient first kind of notion about healthcare. It really did come up through grassroots and more progressive activism and then really exploded and was exploited in the 1980s, the, you know, very Reaganite ‘80s, very consumerist, very capitalist ,change in the healthcare system where privatization and individual responsibility was really fore grounded in terms of policy and certainly in terms of messaging. And in a country so rhetorically raised on the issue and importance of rights. “Rights” are in our national mythology always lifted up as the most important thing. We’re always fighting for our rights and yet healthcare, the thing that saves lives, the things that keeps people alive and healthy and productive and for a good economy, blah, blah, blah, all that shit. Healthcare has never seen as being a right to the citizenship of this, of this country. And that is actually, that’s not just a right-wing trope. That is across the political spectrum until you get very, very, very left. It is pretty much agreed upon that healthcare has never seen as a right to the citizenship. It’s just about making privatized healthcare more accessible, more affordable and what we see even in terms of the ACA, the Affordable Care Act, is a way to not have the government provide healthcare and those services to its citizenry. It’s a way to further insurance company’s ability to control that market and the marketplaces even term used when thinking about Obamacare health insurance marketplaces. the consumer exchange.

Adam: Right, these marketplaces let liberals embrace, they still, they still accepted this choice narrative and the reason why choice narratives are popular is because (a) they’re almost always accompanied by a system that is a race to the bottom, but they fundamentally appeal to our arrogance and our solipsism. By way of analogy, when I used to wait tables in Midtown East, what they would do is they would have these sections, waiters would have sections and they wouldn’t let you pool or suggest you pool tips, which is always the more logical thing to do and there’s been some reforms around that, but when you waited tables, they’d always say, ‘Oh, the strong server goes here’ and you would get the better section where you’d make more money and then people would start to believe that they’re like actually a meaningfully stronger server, which isn’t really a thing if you ever wait tables as I did for four or five years. Like it’s a way of pitting people against each other so that you don’t do the logical thing, which is to pool your resources. And so these concepts that even again, even the ACA played into, that somehow we could all go and manipulate the marketplaces online and find a better deal. It’s appealing to our sense of everyone always thinks that they can do things better than everyone else, right? When the reality is that even if you can, it’s probably marginal. And then at the end of the day having solidarity and having a basically a pooled system or kind of proto-union is always in everyone’s best interest. So they, what they do is they do a similar kind of framing where were you appeal to people’s, uh, arrogance and sense that they can somehow choose and, and that’s why this language of choice so has so much currency in our system because it is so prevalent in everything we do.

Nima: What we also see is the notion not only of choice, but that citizens in need of healthcare, which is literally everyone, are referred to routinely as consumers and that only with more information and access to more accessible —

Adam: We need apps, Nima.

Nima: Right right right. Apps and websites —

Adam: We are going to app our way out of this fucking problem.

Nima: It’s that it really winds up being, like, an IT problem that needs to be hacked as opposed to an issue of what a society actually does for its members and certainly what a nation does for its citizens. So one example of this was in The Wall Street Journal, April 11, 2017, an article headlined, “Can Consumers Be Smart Health-Care Shoppers?” And the subheadline was, “Proponents of consumerism in health care say simple steps can save patients a lot of money. Skeptics say the system is too complex for shopping to pay off in most cases.” The entire framing is that Americans writ large are consumers of healthcare. This is not something everyone deserves, that something you have to earn it’s something you have to buy, and so this is how the article starts, quote, “Patients are told they need to take greater control over their care. But are laypeople capable of sifting through all their choices to make the right decisions — particularly when it comes to costs?” End quote. It keeps going. Quote, “A movement has been growing to give patients more information and choice.” End quote.

Adam: Yeah, very organic stuff there, a “movement.”

Nima: A “movement,” exactly.

Adam: Occupy Wall Street, Black Lives Matter, and Please, Please Privatize the Healthcare System More.

Nima: (Laughing) Right. And so the contrasting opinions on this all kind of follow the same logic. One is very pro-consumerism, the other nominally, not so much, but the first one comes from Dr. Devon M. Herrick, a health economist and senior fellow with The National Center for Policy Analysis, so that sounds extremely impressive and very serious, obviously, here’s the thing: The National Center for Policy Analysis is a free market think tank primarily funded by corporations and private foundations —

Adam: No way!

Nima: — established by wealthy conservative business families.

Adam: A super generic sounding benign think tank actually has sinister donors?

Nima: Yeah, can you believe it!?

Adam: I don’t believe it. Wow.

Nima: Can you believe it? NCBA, National Center for Policy Analysis, is actually funded by the Koch brothers.

Adam: The Center for Policy Analysis is not necessarily some neutral, balls and strikes think tank, but was in fact a deeply pernicious propaganda outfit? Tell me more!

Nima: Yeah. That’s right. Shocking. So obviously this is not said in the article, so people are left to just read this and be like, ‘Oh, well, you know, I guess that sounds interesting and impressive.’

Adam: Uh, Nima, it’s a growing movement.

Nima: It’s a growing movement, and so from the National Center for Policy Analysis website, it’s mission is to quote, “Unleash the power of ideas for positive change…”

Adam: (Laughing)

Nima: (Laughing) Sorry. (Laughing increases) I couldn’t even get through it!

Adam: Earlier, when I said that empowerment was their biggest red flag for bullshit, I’m going to say “unleashing the power of ideas” —

Nima: (Laughing)

Adam: — is definitely number one with a bullet.

Nima: I’m going to do this. (Laughing) I’m going to try and do this with a straight face.

Adam: Sorry.

Nima: (Laughs) “Unleash the power of ideas for positive change by identifying, encouraging and aggressively marketing the best scholarly research and innovative solutions. We work to educate the public, the media and policy makers about ways to create an opportunity economy for all Americans.”

Adam: Nonsense. It’s just words. Nonsense.

Nima: It goes on to say, “Our goal is to develop and promote private, free-market alternatives to government regulation and control, solving problems by relying on the strength of the competitive, entrepreneurial private sector.” End quote. So that’s the NCPA. That’s what one of these ‘just writing the ol’ opinion on consumer’s healthcare here.’ This organization, its executive director and the vice chairman of its board of directors was Allen West, who’s a maniac and it was founded and led until 2014 by this guy, John C. Goodman, who is credited by the conservative media watchdog group, Media Research Center, with playing a pivotal role in the defeat of the Bill Clinton administration’s plan to overhaul the US healthcare system. It was this guy, John C. Goodman, along with Senator Phil Graham, and our favorite Bill Kristol, neo-con nightmare. So that’s what’s behind what was published as reasonable ‘well, some think this, some think this’ piece in The Wall Street Journal, three months after Dr. Harrick’s arguments for more consumer wherewithal and a personal responsibility in the marketplace for healthcare, three months later, the NCPA itself announced that it was closing immediately due to financial problems.

Adam: The question that this raises is, we dump on liberals a lot on this show for bad framing and being kind of feckless and being spineless. It is true. There’s so much money that goes into demagoguing healthcare and has been for decades from the right and then in an effort to sort of try to split the difference Obama really embraced a lot of the right-wing narrative on healthcare and basically said, ‘let’s keep the basic premise there, but the government needs to spend money to try to subsidize it.’ And by uh, creating a larger pool by creating a mandatory tax, which the supreme court later kind of litigated differently but that was the sort of general basic premise. And that ended up working in the sense that it helped people. ACA was definitely an improvement, but it really kind of set up both a legal and constitutional moral hazard moving forward and also took the wind out of the sails of an actual single payer movement. The assumption being is that, if you can’t get something that’s kind of mealy-mouth and centrist that, that this far left radical idea won’t happen at all.

Nima: Right.

Adam: And I think that if you look at recent polls over the last two years about support for single payer, that’s not true at all. That actually one of the major problems with the ACA was that it embraced these right-wing premises, this sort of mealy mouth, half ass way and people can sort of smell intellectual and political inconsistency.

Nima: So, are you saying Adam that incrementalism is not the way forward?

Adam: I’m trying to say that politics is not like a football field where there’s the right and the left and you have to make incremental yards. Like it did in 1910, 1920s football and you can never sort of make broad leaps.

Nima: What?!

Adam: No, that’s, that’s apparently not how it turns out.

Nima: Politics isn’t like wearing that, like, leather helmet and trying to, like, with your baggy pants try to jump over people, but only for small gains?

Adam: No, it turns out that this idea that if the quote unquote “moderate” voter, this sort of mysterious center voter, the kind of standing from Fairfax, Virginia —

Nima: The movable middle?

Adam: Yeah. That there’s, that you can actually win them over with broad moral arguments, which incidentally is the topic we’re going to discuss with our guest today.

Nima: Yes, absolutely. Good transition, Adam. So we are going to talk —

Adam: I’ll be here all week.

Nima: We are going to be joined by Natalie Shure, a Los Angeles based writer and researcher whose work focuses on history, health and politics. Stay with us.


Nima: We are joined now by Natalie Shure, a writer and researcher. Natalie, so great to have you today on Citations Needed.

Natalie Shure: Thank you so much for having me.

Adam: So your general thesis, among many other points you make, is that Democrats have kind of made a big rhetorical and ideological mistake. If you can call it a mistake, we’ll do the shtick where we act like they mean well for the purposes of this argument, by embracing the right-wing notion of healthcare as a commodity as opposed to the more rights based or moral framing. Um, over time, do you think this kind of language begins to rewire people’s brains and the way we think about healthcare and how does that kind of rewiring to the extent you think this commodity based language is popularized, to what extent do you think that kind of makes a reimagining of healthcare as a right and as something that maybe is single payer that much more difficult if not impossible?

Natalie Shure: Uh, yeah. I think that that’s absolutely the case and I think that that’s very much baked into the history of 20th century healthcare reform. During World War II and slightly after, there was a push for National Health Insurance, what we would think of today as single payer, was also very popular. The idea that the NHS, the National Health Service in the UK, was also founded around this time and Beveridge, the guy who comes up with this reform, was a very famous guy on the circuit here, he wrote a bestselling book. He spoke a lot. And so the idea of universal healthcare as a right, was actually a lot more popular and a lot more common than it is now. The AMA and some other moneyed interests pushed back that particular reform by the late forties, but you know, only fifteen years later they managed to pass Medicare and Medicaid, which doesn’t go as far as National Health Insurance does, but you know, it was still a major, major reform and extension of the public sector and the idea of healthcare as a right. And then since then we’ve really turned into a much more neoliberal direction and I think that that’s when you can start to pinpoint the rise of consumer rhetoric when it comes to healthcare in particular, uh, insurance. I think that this happened for a variety of reasons that are mostly trackable in terms of macro economic trends. You know, there’s a lot of inflation in the seventies. There sort of an abandonment eventually of any push toward universalizing a public sector program that kind of peters out a few years after the passage of Medicare and Medicaid. And you also start to get this rise of more reactionary economists who write about healthcare and health insurance as a moral hazard. The idea being that to keep costs down, we have to basically optimize individual behaviors and make sure that people aren’t using more healthcare than they actually need simply because it’s free. Uh, I think that these ideas are very silly on their face —

Adam: Those greedy, greedy healthcare takers.

Nima: Stop going to all those doctors!

Natalie Shure: Exactly. I mean, I don’t think that anyone enjoys doing these things.

Adam: Personally, I just had a kidney transplant for the hell of it.

Nima: Just for the hell of it. Yeah.

Natalie Shure: Well, it’s probably because you weren’t exposed to that cost because you have insurance. So why not?

Adam: It’s true. I have insurance now. It’s true.

Natalie Shure: Yeah. I mean, I think that, you know, as silly as it is, people still take this very seriously. I mean, that’s essentially the logic behind cost sharing, behind deductibles, co-pays, coinsurance as basically the idea that if you don’t have any skin in the game, you’re just going to force this poor insurance company to pay out the nose willy-nilly just because you’re bored, you know. So I think that trying to implement some consumer discipline, uh, and get people to use healthcare more responsibly is something that we start to see after that. I once typed in “healthcare consumers” into that Google Ngram one time and it’s, you know, just around here in the seventies that it just starts to skyrocket out of nowhere. And I think it’s because of this market logic that really gets injected by some of these AEI fellows who start writing about it. Ultimately, I think that the rhetoric serves to shift the conversation from, you know, a collective societal goal to a matter of individual prudence, it turns acquiring health insurance into an individual responsibility. And I that we still see that a lot today and the logic of the ACA, you know, the individual mandate is nothing else besides, you know, basically a stick to make sure that individual people act as the most perfect possible consumers of healthcare. Uh, and there hasn’t been, until now I think, over the past couple of years there hasn’t been a major reckoning with this logic and the political sphere for a long time.

Nima: Something you’ve actually written about that I would love for you to talk about is both this idea of kind of where the idea of the deductible comes from and like what that actually serves to do. I think that, you know, everyone who has health insurance, uh, lucky enough to have health insurance, assumes that this is just a built in thing and that it’s normal. Um, so I’d love for you to talk about that as well as the idea of how this consumerist notion of choice has really kind of infused this debate so thoroughly. So I’d love for you to kind of talk about how that winds up also clouding this whole debate.

Natalie Shure: Sure. Um, yeah, I think that deductibles are a really important thing to talk about in relation to this topic because historically they are very tethered to this consumerist idea. Basically deductibles, which is for the non-Americans out there, that’s the amount that you have to pay for your own care before your insurance even kicks in. And over the past several years we’ve seen a rise of high deductible health plans. Uh, just this morning I actually had to re enroll in my plan that I get through work and found out that my deductible has risen. So if I want any healthcare coverage this year, I have to pay the first $5,900 of it. Um, which is a really staggering number, especially when you consider, you know, just how many Americans have fewer than a thousand dollars of liquid assets available at any given time. I mean, that’s a really prohibitive number for a lot of people. Uh, but the deductible came about in the 1920s. It was actually an Aetna invention, uh, back when they were offering automobile insurance for the first time. Uh, a deductible was basically a way to encourage people to modulate their behavior to dissuade super dangerous driving because people knew that they would have to pay a little bit if something happened. And also to basically dissuade people from getting any repair whether or not it was necessary. So I think that the example that they typically used was, you know, if you have dirty windows and no deductible, what’s to stop you from getting them replaced with super clean windows? Fairly silly logic. Most people don’t want to spend their time doing things like that, just like they don’t like to spend their time going to the doctor every time they have a sniffle. Uh, but I think that in the case of property insurance, there’s at least a little bit more of a logical justification. You know, the fact that our insurance models came directly out of that property insurance model, I think explains a lot of how it works today. You know, those property insurers happened to step into the market during World War II when there was an opportunity available to them. The logic of that system was never actually written for health coverage. And so I think that that’s very telling when thinking about how is it that we got so much consumerist rhetoric and consumerist logic tied up with healthcare coverage. Well, I mean it’s because that’s, it’s the history of its origin. That’s exactly how it came to be. So basically, I think that when we, when we think about choice and healthcare, and this is something that opponents of single payer and of universal systems love to bring up, you know, the idea that we deserve choice in healthcare, Americans deserve what works for them.

Nima: So, that idea of turning one’s own body into a product to either take care of or not, if it’s worth it enough, how does that also play into this idea of consumer choice?

Natalie Shure: Yeah. I think basically the idea that each of us has a body that it’s our job to take care of and that if you have a health issue that’s basically on you, that you failed somehow, that you haven’t been a perfect steward of your own body and health. Um, I think that that’s very cooked into the idea of moral hazard in a healthcare context. There are so many different dynamics, uh, some of which are lifestyle or choice based, some of which aren’t, not to get into a philosophical debate about what constitutes freewill and what constitutes choice or not, but, uh, yeah, I mean, the fact is that there are many, many factors that influence our health and our health outcomes and what sort of care we need and trying to adjudicate which ones constitute something that people should be dissuaded from needing which ones meaningfully can be. I think that, uh, those are very, very callous and antisocial questions that are really inherent in the idea of co-pays and deductibles.

Adam: I mean, it’s, it’s fundamentally an appeal to narcissism. You see this with the choice rhetoric around schools or whatever. People love the word “choice” because people assume that, ‘Oh, I know it’s in my best interest’ and despite the fact that I have a million things going on in my life and I don’t need to micromanage that, that there’s this image of this sort of authoritarian government. We saw this of course with a lot of the death panel rhetoric, um, which was very, very effective despite the best efforts from the Obama White House to push back on it. That there’s this oppressive regime that’s kind of going to force you to do things you don’t want to do. And you spend a lot of time going from place to place talking about single payer and trying to convince people. I assume that this is probably the number one objection you get. This is a very popular trope in American culture, especially right-wing media. They completely erased the fact that almost everyone loves their, their socialized medicine in other countries and that that its somehow uniquely un-American because it somehow undermines our choice. Can you talk about how you push back against that trope and, and how that trope became so popular? Is it ingrained in our sort of puritan ethic? What is the mechanism there other than just rank propaganda?

Natalie Shure: Yeah, I think that that is exactly right. That is an objection that single payer opponents bring up a lot of people ask about in good faith, uh, what I usually respond is the idea that, you know, yeah, I think that choice in some things is valuable to a lot of people. And in healthcare, when you think about choice, people want a choice of provider that is very important. What we have now, what those people tend to be referring to when they say, ‘But choice! But choice!’ they’re talking about insurance coverage and that’s a situation where, and I’d argue that choice isn’t something that we want or should aspire to. Basically, um, you know, the ACA markets, the ones that are functioning how they’re supposed to anyway, have a choice of several different plans that one can choose. And even people with employer-based coverage tend to have choice between at least a few different options. And those tend to be delineated either by company or by network. Each one has a certain network of providers or you know, certain things that they cover, a cost sharing scheme. So you can get a high deductible or a low deductible plan. High deductible plans tend to have lower premiums, low deductible plans have higher premiums. Uh, you might have a plan with coinsurance, with co-pays, things like that. And so choice when it comes to healthcare coverage is something that can actually be very oppressive for the consumer. I think that anyone who’s ever had the experience of shopping on the individual markets for a health insurance plan or of, you know, flipping through the manual, trying to figure out what the heck is covered once you actually have one, uh, that’s not exactly a great situation. And choice between coverage is basically how we get tiers of access, how we get people with really, really good plans, really, really skimpy ones and how now the conversation is being pushed even further toward the right. Uh, the Trump administration is trying to get shorter-term plans onto the market as opposed to, you know, ones that include the ten essential health benefits. Um, the idea being that now people will have the choice to have even more meager coverage, but you know, for even less money. And so I think that choice when it comes to coverage misses the fact that that’s not the choice that people want. People want the choice of provider, they want to be able to choose their doctors and stick with the providers that they have relationships with, not the actual coverage. You know, nobody has any emotional attachment to CIGNA or Aetna.

Adam: How dare you. I have much corporate loyalty to my, hold on, I got to check my card to see what it is. Cigna. Yes. I love Cigna.

Natalie Shure: Yeah, I love Cigna too.

Adam: I want to talk about that a little bit here because this idea of choice is a perverse one. Obviously you have to kind of Marxist argument that you don’t have a lot of choice when you’re starving to death. You don’t have a lot of choice when you know X million Americans have to go to GoFundMe to get a surgery done. That even the very notion of choice, you know, it’s the old cliché, choice without options doesn’t mean anything. And for many people they don’t have any options. So what, what good does the concept of choice mean?

Natalie Shure: Exactly. I think that’s absolutely the case and I think that when you have someone who is very, very strapped for cash, the idea that they can now spend less for way less coverage isn’t exactly an enticing offer. You’re basically saying that you want to usher in a situation wherein poor people can afford risk and little else, uh, that security, that genuine coverage costs more. I mean, that doesn’t mean that there’s actually a meaningful choice there at play.

Adam: Um, you, you mentioned the idea of complexity and one of the appealing things and the reason why I think that Bernie Sanders’ rhetoric took off is that it was, it was not complex. And I don’t mean complex as a sort of a compliment I think it’s actually mostly bullshit. Corey Robin wrote something in 2016 that I thought was super interesting when he was talking he was basically making the argument that neoliberalism was very exhausting, that it was very tiresome and that one of the reasons that the ACA failed is because it was very difficult to message because it was so complex. He said, quote, “Ezra Klein — teetering on about the nifty economics and cool visuals of Obama’s plan: how you could go to the web, check out your exchange, compare the little interstice of one plan with that little interstice of another plan, and how great it was because it was just so fucking complicate I thought to myself: you’re either very young or an academic. And since I’m an academic, and could only experience vertigo upon looking at those blasted graphs and charts, I decided whoever it was, was very young. Only someone in their twenties — whipsmart enough to master an inordinately complicated law without having to make any real use of it — would look up at that Everest of words and numbers and say: Yes! There’s freedom!”

Natalie Shure: Yeah.

Adam: Can you comment on complexity and what that means? Like for most people this, because I don’t even get it. Like I, I look up my insurance and my, my mind’s fucking boggled. Like the whole thing is so complex.

Nima: But that’s the whole thing. That’s, that’s how, you know, the idea that people who already are working three jobs just to get by now have to go into this quote unquote “marketplace” and they have all this choice and as if they’re going to, you know, read all these plans and understand them and that’s what the insurance companies are counting on. Which, I mean, there’s a reason why you like to scroll to the bottom and click “I agree” when you get an iTunes upgrade, like you’re not reading everything, you’re like, yeah, whatever, like I have, I’m doing other things. And so this winds up screwing the people who are already getting screwed.

Natalie Shure: That’s a really perfect thing to bring up and something that the mainstream media doesn’t seem to understand about these exchanges and about the fetishization of choice when it comes to healthcare coverage. Uh, last fall, if you’ll remember, when the Trump administration withheld the cost sharing reduction payments to companies on the ACA exchanges, which basically means part of the ACA is a subsidy paid directly to the insurers who have state level exchanges that allow them to offer a plan that will be affordable in terms of cost sharing. So lower deductibles and lower co-pays on the silver tier for people who get subsidies, which is already confusing. Uh, but when they started to withhold those, uh, people were terrified that the premiums would skyrocket. A lot of mainstream media folks really sounding the alarm about that. Uh, but then a lot of state level regulators came up with this work around. They basically loaded all of the increase in premiums onto silver plans, which are also how subsidies are calculated for people who qualify for them. All of that means that this created a situation where in people who qualified for subsidies on the ACA exchanges actually ended up doing better because the subsidies were calculated from a way higher number. And so you had this situation wherein, you know, it’s even more complicated because people who are making $40,000 a year who qualify for ACA subsidies found themselves with three bronze plans or very cheap gold plans, things like this. And so, you know, people on NPR, people on Vox’s podcast, people on Kaiser Health News podcasts were all saying, ‘Oh my gosh, shop around shop around. There are deals to be had.’ Uh, you know, as if this was great news. And I was just thinking like are you kidding?

Adam: (Laughs) Ah, love to introduce carnival barking to healthcare.

Nima: QVC of staying alive.

Adam: (Laughs)

Natalie Shure: Yeah. I was like, these aren’t like, this isn’t a fun process. This isn’t like looking for, you know, an antique lamp at a flea market where you’re digging through all these things. The thrill of the hunt. Fuck off. This is a really, really stressful anxiety inducing process for most people. It’s not fun. It’s not pleasant. It’s something that, you know, when you’re talking about healthcare, you’re talking about really intimate and difficult things in people’s lives, uh, that, you know, even looking through, trying to compare cost, sharing deductibles. They’re not just doing math problems, they’re thinking about things that their families have actually gone through. They’re thinking about things that they’re actually enduring, things happening to people that they love and it’s not a time that you want to think about, you know, what number is higher and how clever you can be about paying less premiums for whatever else you need. I mean, I think it’s a really absurd notion that this could possibly be a good idea.

Nima: Yeah, it’s really, really perverse. So the idea of healthcare obviously is, in the United States at least, linked directly employment and now with the ACA, it’s, it’s different. There’s a, again, this marketplace and the, and you know, whether there’s a mandate or not — can you kind of also talk about where uninsured people land in all of this and how their own agency is discussed as well as how they’re viewed as having some faults, some, some reason why, why now they don’t have insurance. Like, how does that all kind of work out in this discussion?

Natalie Shure: So many of these discussions, the way that liberals talk about the ACA, uh, you know, talks about how expensive things are and talks about ways to bring down premiums. But so many of these conversations leave out the uninsured and they certainly leave out the real reasons that people are uninsured. Uh, you know, I believe that some 30 million people are still uninsured under the ACA. A few of those people are people who fall into the Medicaid coverage gap. So those are states that didn’t expand Medicaid, people who would have been eligible for it, who, you know, don’t make enough money to qualify for the ACA exchanges. Uh, that’s around 10 percent of the overall uninsured. So not, not no one, but not a super significant portion. Uh, you know, I think that people who cheerlead for the ACA would like to believe that the other 27 million are people who consider themselves young and invincible, who just, you know, are too cocky to buy coverage. They feel like they don’t need it. Uh, and so they’re always talking about the individual mandate and how there should be an even higher penalty to really punish these young tech titans they imagine are the ones refusing to buy insurance. But when you look at the data, I think only around two percent of people say that they didn’t need or want insurance and that’s why they don’t have it. The vast majority, frankly, they just can’t afford it. And that makes a lot of sense. I don’t think that that’s hard to understand. Uh, and I also think that, you know, having those callous ideas about this population, about these people who lack meaningful access to healthcare, uh, if you think that they just didn’t buy it because they’re cocky, it’s very easy to blame them for this situation. I mean, I think that the primary advantage of taking healthcare out of the market and taking it out of the consumer realm is because I would love to create a situation where no one has to choose between healthcare coverage and diapers one month. You know, the idea that we’re forcing this to be a budget item for people who are really, really scraping to get by. The answer to that problem isn’t, oh, you know, slightly higher subsidies or even worse, oh, a higher penalty for not playing into this system. Uh, you know, you want to take that decision out of their hands and guarantee health care because that’s not a decision that anyone should have to make. If you make people make that decision, it’s of course not a surprise that poor people are the ones who lose out. I mean, risk is all they can afford.

Adam: Um, so single-payer as a, as a movement, I think we would all agree, obviously we’re all biased, but I think it has, I think it’s got the wind behind its back. That’s sort of the way the party is going. There’s now variations of single payer that are supported by what we would generally consider it to be center right or rather center left kind of right-wing Democrats now support single payer, it has become a conventional wisdom increasingly. Uh, there are efforts by different groups to sort of co-op that or to muddy the waters. There was the Center for American Progress that announced the Medicare Extra For All. It’s always important to have Extra For All in there. Then there was that somewhat dubious group that announced United States of Care that was, that had like Robert Fisk on, it was boosted by Jon Favreau, the former Obama speechwriter and, and a podcast kingpin. They both used qualifiers like “access to healthcare” or “affordable healthcare,” still kind of clinging onto the hyper qualified sort of neoliberal framing about, you know, we, we joke, the more qualifiers you use, the more neoliberal something becomes right?

Nima: Right.

Adam: So it’s not, you have a right to healthcare, it’s you have a right to access healthcare and then you say you have a right to access affordable healthcare, and then you sort of keep adding these qualifiers and even the Republican plan was called Universal Access.

Nima: And then you have a right to choose the most accessible and affordable healthcare.

Adam: Can we talk about what these terms mask and what the kind of point of this hyper qualified, uh, these seem to me and I’m editorializing a bit here and you don’t, you don’t have to agree, that they seem like kind of last ditch efforts by the corporate wing of the democratic establishment to kind of maintain a fundamentally capitalist or marketplaced healthcare system, uh, when the sentiment of the base and the party itself is moving towards just kind of fuck it, why are we even doing this lets just so a single payer like every other goddamn country on Earth?

Natalie Shure: Yeah. I think that the phraseology, “access to affordable healthcare,” which is like the ultimate hedge and it comes from a lot of the Democrats who have yet to fully sign on to the Sanders or Ellison single payer plans. Um, I basically think that, you know, that’s an extension of the idea. If you’ve decided that everyone has a right to “accessible” “affordable” healthcare then the people who don’t have it are just shitty at budgeting and it’s their fault, take it up with them. We built a system that they can access. They’ve just decided not to and you know, they should fix that.

Adam: Right. It’s a moral failing.

Natalie Shure: I think that when it comes to the Center for American Progress, the Medicare Extra plan, maybe this is overly optimistic, but I will say that seeing a mainstream standard bearer of the Democratic Party come up with a plan like this is heartening in that it does go further than anything that’s been on the table before this year. And so that seems to me, you know, a very obvious indication that if nothing else, the single payer movement has pushed the Democratic Party to the left in terms of what’s on the table from them. Medicare Extra For All would be better than the ACA, full stop. Uh, I think that falls short in a lot of ways, but I do want to concede that. The big flaw in the logic of the CAP plan is the fact that, uh, you know, once again it’s this fetishization of choice. It’s the idea that they will include all uninsured people and then, you know, depending on which employers want to opt into this Medicare Extra plan, so that instead of taking everyone’s plans away from them, only the people who want to. And then the people who, you know, this mythical group of people who love their employer based insurance plan, I have no fucking idea who these people are who like their insurance so much, but, uh, allegedly there are so many of them that it’s going to completely thwart the chances of single-payer ever succeeding. And so, you know, I think the idea there, the idea that, ‘oh, we can’t possibly take their choice of insurers away from them’ is really what’s animating a lot of this. Um, besides being based on a faulty notion, I think that, you know, that kind of plan forfeits a lot of the advantages that single payer offers. And that’s not only, you know, the idea of trying to entrench healthcare as a right and as a non-market commodity, which I think is important. Uh, but it also forfeits a lot of the efficiencies. One of the reasons that single payer tends to be more cost effective than other multi-payer systems is because, you know, having only one unified public insurance pool that pays providers a single rate you don’t have all of these negotiators, you don’t have all of these claims assessors, you don’t have obscene amounts of overhead costs just paying people to keep all of these bills straight. So if you have this system that maintains the private sector, uh, even beyond the profiteering, you basically keep a lot of that infrastructure in place, which precludes the system’s ability to efficiently lower costs the way that a well-designed system should. So I’m not sure, you know, I’m a little skeptical of the idea that this was an active plan to thwart single payers advance. Um, I mean, I think that that might be part of the logic for some people. I think that they are unable to think outside of the very narrow box that they’ve found themselves in to consider it a legitimate possibility. But I think that the fact that they’re even where they are now, I think speaks very highly for where the movement is. Um, the idea of choice versus not choice when it comes to coverage instead of providers is something that the single payer movement will have to work on because I think that for a lot of people listening in good faith intuitively the idea that ‘oh well if they want to they can switch into it and if they want to they don’t have to.’ I think that sounds very reasonable. So you know, we’re really going to, I think, have to work on explaining to people why that’s not as warm and fuzzy is that sounds.

Nima: Mhmm.

Adam: Right. And instead we’re going to send a bunch of jackbooted Stalinist thugs to their house and force them. No.

Nima: Because that’s what the mandate is. That’s why Hillary was deemed the more progressive between Hillary and Obama when it came to healthcare because of the mandate. It just shows like how like this like bizarre incrementalism has just taken hold when there’s other thinking that should be, that should be supported.

Adam: Yeah. I want to be clear, I was not trying necessarily to conflate the Medicare Extra For All from CAP and the United States of Care, which I don’t for no other reason than the Center for American Progress plan had a lot of specifics whereas the United States of Care was kind of a vague PR launch. Um, and I don’t even know what happened to it. So, I want to be clear that we’re not painting with the same brush —

Nima: We all got care in the United States. That’s what happened. Clearly.

Natalie Shure: Yeah.

Adam: Yeah. That was a really bizarre and generic, like, like had a, it had a total “No Labels” vibe.

Natalie Shure: Yeah. I mean, my, my read on the United States of Care is this was, I think like from a very politically misguided point of view that, you know, the best way to defend and expand healthcare is to work across the aisle so that Republicans won’t try to push back against it. Which I think is the logic that Obama had initially, thinking that, you know, if he makes all of these pre-concessions to the right, then they’ll let the ACA stand. Of course, that’s not what happened. I think that that’s a very misguided line of logic, but right now it just seems to me to be a vanity project that people can call when they want a few quotes or when they want, you know, a semi visible speaker. Uh, I think it’s a branding exercise as of now. I’m glad that there was so much criticism of, uh, the political leanings and I’m glad that they were forced to address that afterwards. Uh, I do think that, you know, Andy Slavitt means well, maybe I’m being too trusting. Uh, but I don’t think that —

Adam: You are way too nice for this show.

Natalie Shure: (Laughs)

Adam: Um, I think a lot of people mean well, you know, sort of how everyone interprets that. I definitely think that the general issue is, is they’re operating with a very limited epistemological framework, right? Like they can’t envision a world where you do X, Y, and Z. So they have to figure out a way of convincing the, um, Lindsey Grahams of the world to sign on and that’s kind of where one typically takes the opposite track because again, Obama did try that. I mean this is, it seems like a lot of these people are still living in like 2004 and I don’t, I’m not sure on what, like we, we went through all this before. No matter what Democrats do they’re going to call it socialism.

Natalie Shure: Yeah.

Nima: Right, exactly. It’s like, no, no amount of aisle-reaching is, is going to actually speak to this.

Adam: Yeah. He literally rebranded Heritage Foundation’s policy initiative. Like, there was no —

Natalie Shure: Yeah, I mean I think I guess —

Adam: There’s no negotiating with terrorists.

Natalie Shure: I think that you’re right. And I think that, yeah, I don’t mean to soft pedal on how misguided this bipartisan consensus take-the-politics-out-of-healthcare rhetoric is. I think it’s absolutely bullshit. There is nothing that’s more inherently political than healthcare. Who gets to live and who dies and whose money and capital is going to pay for it is a very, very political question. You know, so I don’t, I don’t mean to give them, I guess I was just very heartened by the degree to which the United States of Care people appeared to take the leftist criticism of this seriously. I would have expected them to roll their eyes and just brush it off and I feel like there’s been a, a somewhat more earnest desire to grapple with it and you know, I, I really hope that that’s being done in good faith. I don’t know. Uh, it’s very easy to be cynical.

Nima: Do you think that that speaks to some of the success that maybe Bernie Sanders’ candidacy had that the broader single-payer movement is having, that they are demanding accountability for the kind of bullshit that is often rolled out? Like how do you see that actually as a positive, as an overall maybe moving toward something far more humane, far more kind of moral and right spaced? Like maybe that actually speaks well of what’s, of what’s happening.

Natalie Shure: Yeah, I mean I, I do think that it speaks well. I think that the fact that people feel compelled to address it, that it’s part of the discussion that the Overton Window has shifted. I do think that those things are important. Um, I mean that’s not going to be the sole mechanism by which we get single payer. That’s not how politics works. But I think that, uh, you know, while it’s important to be cynical and not kiss these people’s asses before they actually follow through on anything or have to put their money where their mouth is. But you know, when like centrists, when democratic vanguards are forced to address single payer or in some cases, you know, even if it’s for cynical political reasons, when they actually embrace it and sign onto it. I mean, I think that that’s a very good thing for anyone who supports these programs. What our goal is going to be in the coming years is to get more and more people talking about single payer, being cornered into supporting it. And you know, to make that as politically difficult as possible for them to back away from when they actually have a chance to. And certainly some people will try to, and I think that we have to make that just a political nonstarter for them.

Adam: Everyone else is venal and cynical but Adam Johnson. You didn’t know that? I, I, I want to end on one question, which is that moving forward, because this show is a show about language and about messaging. What is in your work that you’ve done, because again, I know you’ve had these conversations with dozens if not hundreds of people, what is the most common objection to single payer and what would you say is a good counter message to it that our listeners and those in their circle can kind of take home from that? Like what is the most common rejoinder when one proposes single-payer?

Natalie Shure: Sure. I think that the vast majority of people will say something along the lines of, ‘Gosh, it would be nice, but how are we going to pay for it?’ And so I think that what I would, you know, in terms of messaging and rhetoric, my answer to that is that, uh, you know, when people make those objections and how much it costs, they end up comparing what people pay in taxes now versus what they would pay in taxes with a single-payer system, which is indeed higher. But those aren’t the right numbers to compare. They should be comparing what we currently pay for healthcare now versus what you will be paying for healthcare under single payer. And that number ends up looking a lot more realistic. When people ask, how are you going to —

Adam: What is that number?

Natalie Shure: Well, I mean, I don’t know the exact funding mechanism, whether it would be a combination of payroll tax, progressive tax.

Adam: Right.

Natalie Shure: That would be something to be worked out later. That’s certainly not my field. Uh, but the average American spends several thousand dollars a year on healthcare overall in the United States. We spend, I want to say around $3 trillion per year. And so the idea of that being moved from the private sector, like all of that spending basically being placed into a public pool and being spent from there, which then allows costs to be kept down in the longer run, basically acts as some of the most, the most extraneous profiteers anyway. I mean, it doesn’t make public providers, those are still privatized. And so it doesn’t eliminate profiteering in healthcare in general, but it would certainly remake the health insurance system as we know it. And so it basically is a more, uh, efficient and more humane way of spending the money that we already spend, you know, redistributing it so that the sickest people aren’t paying the most for their care. People are paying into the system based on ability to pay as opposed to being unlucky or even, you know, being born women. I’ve, one thing I always tell people is that women end up paying a lot more out-of-pocket than men do in a commodified system because we tend to use more care because of our reproductive roles. You want to create a system that more fairly distributes those costs.

Adam: Right.

Nima: This has been amazing. Natalie Shure, writer and researcher calling us from the great state of California. Thank you so much for joining us today on Citations Needed.

Natalie Shure: Thank you guys so much. I really appreciate it.


Adam: Well, that was extremely informative.

Nima: Yeah, Natalie really knows what she’s talking about.

Adam: It’s always good to talk to people whose job is to talk to people all day and not just write hot takes, but to actually go to conferences and like try to like convert souls because you really do to like pick up on four or five major objections and you sort of have to develop how to talk against them and that’s one of the things I know that, Nima, when we first met to talk about this podcast, what we wanted to do was find ways in which to empower our guests, (chuckles) that’s called a callback kids, so they could sort of have the requisite —

Nima: Tools.

Adam: — tools to, like, frame it because it is I mean you’re talking about a movement that’s really picked up steam in the last two years, three years about single payer healthcare and there’s all these deeply ingrained and embedded misconceptions and clichés about what the downside of it is flying in the face, of course, of all this evidence that it’s cheaper, it’s better. All these other countries do it. That is always poopooed away. I think it’s great to sort of build up the kind of mental collateral to be able to combat that.

Nima: Yeah. Especially when so many reports are published and then reproduced, parroted in the press. I mean they, you know, there’s RAND reports and PriceWaterhouseCoopers reports that come out just always using the language that we hear repeated again and again to describe American healthcare insurance and public policy, framing it in really every debate, every article in terms that just consistently commodify, not only our laws and services, but our very citizenship and humanity. RAND has a study entitled “Consumer Decisionmaking in the Healthcare Marketplace” and it’s all about “jargon is bad,” which is true, and that all this stuff is too confusing for people to really understand and that and that you just need better tech to stop people from making suboptimal choices and to better frame what they’re actually getting, but it’s all really condescending and it’s all about treating this, what they call the “consumer,” who’s really in charge of their own healthcare and that it is incumbent on the “consumer” to engage with these health providers to have good experiences online.

Adam: Yeah, you’re not allowed to like question the fundamental axioms of capitalism. So if you accept the sort of epistemological straightjacket of capitalism or I guess in this case we’ll say neoliberalism, which is that you can’t really have the government do anything meaningful or meaningfully overhaul things because capitalism is a law of nature. It’s like gravity or the tides. It just sort of is and there’s nothing we can do about it. And this is the best you can come up with.

Nima: Right, and that all you need is like super, you know, user-friendly interfaces and big clear price points and a wide selection of products. Remember we’re talking about fucking health insurance, but a wide selection of products specifically designed to meet young consumers’ needs and like that’s really where the discourse is and has been for so long where patients are considered just a subset of the consumer where everyone is a consumer, it all just becomes fucking bullshit marketing for tech and for further keeping people without the actual services that they need and having them think that they are actually making wise choices because they are smart, savvy shoppers.

Adam: Because choices is necessarily a framing that implies that if someone dies, it’s because they made it, there was a moral failing or a bad choice. But of course, you know, you can’t make choices if you’re dead. So.

Nima: (Laughs) That’s a good way to end. Remember that kids, you can’t make choices if you’re fucking dead.

Adam: As Marx always said, you have no choices when you’re starving or when you’re dead.

Nima: Well, I think that’s an excellent and depressing way to end the show, as usual. Thank you everyone for listening. You can follow the show on Twitter @CitationsPod, share the show, like the show, send us messages through Facebook at Citations Needed and you can certainly help us out, keep it going through Patreon.com/CitationsNeededPodcast with Nima Shirazi and Adam Johnson. And thank you especially to our critic level supporters. I’m Nima Shirazi.

Adam: I’m Adam Johnson.

Nima: Citations Needed is produced by Florence Barrau-Adams. Our production consultant is Josh Kross. Research assistant is Sophia Steinert-Evoy. Transcriptions by Morgan McAslan. The music is by Granddaddy. Thanks again everyone. Have a great one.


This episode of Citations Needed was released on Wednesday, June 20, 2018.

Transcription by Morgan McAslan.