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A BlueCross To Die On · Politix

0:00
SPEAKER_00: So this is like a good topic for Democrats, right?
0:03
SPEAKER_00: Like healthcare, like, you know, steps along the kind of lines that you've outlined.
0:10
SPEAKER_00: But it's like a thing now where if you peek your head out,
0:14
SPEAKER_00: you know,
0:15
SPEAKER_00: above the trenches and storm into the no man's land,
0:19
SPEAKER_00: you're going to get shot at by some kind of industry stakeholders.
0:22
SPEAKER_01: Careful, careful.
0:29
SPEAKER_01: Hey, everyone, you're listening to a free preview of the Politics Podcast.
0:33
SPEAKER_01: This week,
0:33
SPEAKER_01: Matt and I will discuss the somewhat unexpected recent outbursts of online outrage
0:39
SPEAKER_01: at health insurance companies,
0:41
SPEAKER_01: the origins of this backlash,
0:43
SPEAKER_01: the policy and political implications of it,
0:46
SPEAKER_01: and the pros and cons of vigilante murder.
0:50
SPEAKER_01: I hope you enjoy the conversation.
0:51
SPEAKER_01: If you want to hear the whole thing, you can upgrade your subscription to paid at politics.fm.
1:00
SPEAKER_01: Hey everyone, welcome to the Politics Podcast.
1:02
SPEAKER_01: I'm Brian Boitler.
1:03
SPEAKER_01: I'm Matthew Iglesias.
1:04
SPEAKER_01: Okay, so difficult to know exactly where to start this conversation.
1:09
SPEAKER_01: I don't totally know how to introduce it, so I'm just gonna go chronologically.
1:13
SPEAKER_01: Okay.
1:14
SPEAKER_01: Last week,
1:16
SPEAKER_01: while we were recording about whatever we talked about last week,
1:19
SPEAKER_01: something else was happening that was like a throwback to aughts era progressivism.
1:28
SPEAKER_01: The initial culprits here were big progressive Twitter accounts,
1:33
SPEAKER_01: but they were basically passing along a press release from the American Society of Anesthesiologists.
1:41
SPEAKER_01: And the anesthesiologists were saying,
1:43
SPEAKER_01: Anthem,
1:44
SPEAKER_01: this big health insurance company,
1:45
SPEAKER_01: is going to stop paying for your anesthesia while you're still on the operating table.
1:52
SPEAKER_01: And so that managed to whip up a significant two-minute hate against Anthem, which I guess, whatever.
2:02
SPEAKER_01: I think the truth is a little more complicated, and we'll get into it.
2:05
SPEAKER_00: Yeah, we should discuss the specifics.
2:07
SPEAKER_01: We will.
2:09
SPEAKER_01: People were tweeting.
2:11
SPEAKER_01: People were tweeting.
2:11
SPEAKER_01: People were tweeting.
2:12
SPEAKER_01: And there are worse things in the world,
2:14
SPEAKER_01: I think,
2:14
SPEAKER_01: than progressives picking reasonable enemies like private health insurance companies.
2:20
SPEAKER_01: But then,
2:20
SPEAKER_01: like the next day,
2:22
SPEAKER_01: the CEO of a different giant insurance company,
2:27
SPEAKER_01: United Health Group,
2:28
SPEAKER_01: was gunned down by an assassin in the heart of New York City,
2:33
SPEAKER_01: which then put the same basic group of online progressives on the side of
2:38
SPEAKER_01: vigilante murder, which probably is less auspicious for all kinds of reasons.
2:45
SPEAKER_01: What do you think?
2:46
SPEAKER_00: Well, I mean, it was interesting.
2:47
SPEAKER_00: I mean, you know, so people tweet about all kinds of things.
2:51
SPEAKER_00: And when I first saw some people doing like pro-murder tweets,
2:54
SPEAKER_00: I was like,
2:55
SPEAKER_00: well,
2:55
SPEAKER_00: you know,
2:56
SPEAKER_00: weird things happen on the internet.
2:59
SPEAKER_00: What was interesting to me is that a number of significant people,
3:03
SPEAKER_00: of whom I would say Ryan Grimm is probably,
3:06
SPEAKER_00: you know,
3:06
SPEAKER_00: a colleague of ours,
3:08
SPEAKER_00: somebody who I know and,
3:09
SPEAKER_00: you know,
3:10
SPEAKER_00: agree with sometimes,
3:11
SPEAKER_00: disagree with sometimes,
3:12
SPEAKER_00: but I think it's like a serious person.
3:14
SPEAKER_00: He was insisting that there was a mass movement of this assassination is good,
3:22
SPEAKER_00: and the Democrats need to harness this pro-assassin fire that was sweeping America,
3:28
SPEAKER_00: which I'm deeply skeptical that that's true.
3:32
SPEAKER_00: I kept annoying various people to say that we should get some kind of poll or
3:38
SPEAKER_00: survey about this question,
3:39
SPEAKER_00: because in some ways it's hard to resolve.
3:44
SPEAKER_00: I think that's like a weird line to take.
3:47
SPEAKER_00: I think that,
3:48
SPEAKER_00: you know,
3:48
SPEAKER_00: most people object to murder,
3:53
SPEAKER_00: even of people who work in industries that they don't love.
3:56
SPEAKER_00: And I also think that it's easy to, you know, overrate the level of...
4:02
SPEAKER_00: dislike of the insurance industry that exists.
4:07
SPEAKER_00: As with many things,
4:08
SPEAKER_00: you know,
4:09
SPEAKER_00: people have complaints about insurance because the job of the insurance company is
4:13
SPEAKER_00: to not just approve every claim that comes their way.
4:16
SPEAKER_00: But
4:18
SPEAKER_00: you know, most people seem reasonably satisfied with the healthcare status quo.
4:25
SPEAKER_00: I mean,
4:25
SPEAKER_00: we know from all these policy debates that,
4:27
SPEAKER_00: you know,
4:27
SPEAKER_00: people want change,
4:29
SPEAKER_00: but they're also very risk averse.
4:31
SPEAKER_00: Um, so like beyond murder, um,
4:35
SPEAKER_00: You know, it's just like tricky, right?
4:37
SPEAKER_00: Like healthcare is always a potentially promising terrain for progressive gains,
4:43
SPEAKER_00: but it's also,
4:44
SPEAKER_00: you know,
4:45
SPEAKER_00: a little bit dicey.
4:46
SPEAKER_00: I definitely think that gutting down progressives
4:50
SPEAKER_00: I don't want to say random people,
4:51
SPEAKER_00: but just like gunning down insurance industry executives in the street is not a
4:55
SPEAKER_00: constructive form of change.
4:58
SPEAKER_00: I was also not,
4:59
SPEAKER_00: I mean,
5:00
SPEAKER_00: I was surprised when all the specifics about the killer came out,
5:04
SPEAKER_00: but I wasn't surprised by the fact that as specifics about who he was and what his
5:09
SPEAKER_00: background was came out,
5:10
SPEAKER_00: that the guy was not a left ideologue.
5:18
SPEAKER_00: This was a person who seems to have
5:22
SPEAKER_00: Started,
5:23
SPEAKER_00: spent most of his life as a kind of like centrist podcast dude who had a back pain
5:29
SPEAKER_00: problem that went badly awry,
5:32
SPEAKER_00: maybe some bad experiences with psychedelics,
5:36
SPEAKER_00: went off the grid,
5:37
SPEAKER_00: lost touch with his friends and family.
5:39
SPEAKER_00: Who knows, you know, exactly what happened during that six month kind of
5:45
SPEAKER_00: black period but you know i mean this is who shoots people right i mean there's
5:50
SPEAKER_00: like criminals involved in like ongoing violent disputes and then there's crazy
5:55
SPEAKER_00: people right like that's who shot at donald trump previously that's who shot um at
6:01
SPEAKER_00: this insurance executive like it's not you know revolutionary political action in
6:07
SPEAKER_01: any kind of constructive sense i feel like we should back into the the um
6:15
SPEAKER_01: assassin,
6:16
SPEAKER_01: assassination,
6:17
SPEAKER_01: political violence conversation by talking about the anthem anesthesia story first.
6:24
SPEAKER_01: Because that actually elucidates some of the tensions that you're referring to.
6:32
SPEAKER_01: Insurance companies being a good foil, but also not quite as...
6:39
SPEAKER_01: black and white evil as I think commonly understood on the left and the genuine
6:46
SPEAKER_01: difficulty of building a politics around healthcare even when healthcare is your
6:49
SPEAKER_01: good issue because I think you know
6:54
SPEAKER_01: People say stuff online that they might not,
6:56
SPEAKER_01: or that they should probably just maybe stay around friends.
6:59
SPEAKER_01: But I think most progressives,
7:00
SPEAKER_01: if you've got them in a quiet moment,
7:02
SPEAKER_01: would acknowledge that this person is unpopular for reasons.
7:07
SPEAKER_01: And so it's okay to kill him is actually a bad standard that would work out poorly
7:12
SPEAKER_01: for progressives,
7:13
SPEAKER_01: right?
7:14
SPEAKER_01: Right, yes.
7:16
SPEAKER_01: So when I saw...
7:21
SPEAKER_01: I almost got kind of taken in by it because I saw- To my shame,
7:24
SPEAKER_00: I hit RT on an outraged third degree,
7:30
SPEAKER_00: I can't believe what Anthem is doing here.
7:32
SPEAKER_01: I didn't,
7:32
SPEAKER_01: but basically I plead innocent because this was like,
7:35
SPEAKER_01: there were,
7:36
SPEAKER_01: I forget what it was,
7:37
SPEAKER_01: a more perfect union.
7:37
SPEAKER_01: I don't know, like a progressive site, but like one that kind of concerns itself with real facts.
7:44
SPEAKER_01: And so there was a link and I just assumed that they had written a story
7:47
SPEAKER_01: They had done some muckraking and found that Anthem was really trying to stick it
7:54
SPEAKER_01: to patients because,
7:56
SPEAKER_01: I don't know,
7:57
SPEAKER_01: they're paying too much for anesthesia.
8:01
SPEAKER_01: But it turned out that basically there was no reporting done.
8:05
SPEAKER_01: There was just this press release put out by this doctor's group,
8:12
SPEAKER_01: the American Society of Anesthesiologists.
8:17
SPEAKER_01: And if you read it closely,
8:21
SPEAKER_01: they were trying to wave the bloody shirt and really scare people about this,
8:24
SPEAKER_01: and it worked.
8:25
SPEAKER_01: But what they were complaining about is that Anthem announced that it would adopt
8:32
SPEAKER_01: the Medicare fee schedule for anesthesia.
8:34
SPEAKER_01: So basically, everyone with Anthem health insurance would face the same financial...
8:44
SPEAKER_01: exposure as people who are on Medicare,
8:46
SPEAKER_01: the most popular insurance company in the country,
8:49
SPEAKER_01: the insurer in the country.
8:51
SPEAKER_01: Program, yeah.
8:53
SPEAKER_01: And so that really,
8:55
SPEAKER_01: I think,
8:56
SPEAKER_01: it makes tangible something that progressives and centrists fight about a lot,
9:05
SPEAKER_01: which is whether this health insurance system that we have,
9:10
SPEAKER_01: which is bad in all kinds of ways,
9:12
SPEAKER_01: would be easily,
9:14
SPEAKER_01: um,
9:16
SPEAKER_01: uh,
9:17
SPEAKER_01: um,
9:17
SPEAKER_01: amended or whatever,
9:19
SPEAKER_01: like,
9:19
SPEAKER_01: uh,
9:19
SPEAKER_01: reformed into,
9:20
SPEAKER_01: into Medicare for all like single payer.
9:23
SPEAKER_01: Um,
9:23
SPEAKER_01: and I,
9:24
SPEAKER_01: I,
9:24
SPEAKER_01: I really do think that like in good faith to,
9:29
SPEAKER_01: to people who are progressives like me,
9:32
SPEAKER_01: like they should think about how this went,
9:34
SPEAKER_01: went down and what the,
9:35
SPEAKER_01: what the ultimate resolution was,
9:37
SPEAKER_01: which was the insurance company backtracked,
9:39
SPEAKER_01: um,
9:41
SPEAKER_01: Just genuinely consider what that means about what would happen if Democrats in
9:48
SPEAKER_01: Congress really did try to end the private health insurance system and replace it
9:53
SPEAKER_01: with Medicare for everyone.
9:55
SPEAKER_00: So I think there's an organization called Physicians for a National Health Program,
10:00
SPEAKER_00: which is a major kind of single-payer advocacy group,
10:04
SPEAKER_00: which,
10:05
SPEAKER_00: as you can tell by the name,
10:07
SPEAKER_00: is organized by –
10:09
SPEAKER_00: medical doctors.
10:10
SPEAKER_00: And,
10:11
SPEAKER_00: you know,
10:11
SPEAKER_00: I think it's like a well-meaning organization that becomes a source of
10:15
SPEAKER_00: understanding for a lot of progressive people about this.
10:19
SPEAKER_00: And, you know, they kind of promote this vision of medical doctors as, you know,
10:27
SPEAKER_00: motivated health professionals who you get into medicine because you want to help
10:33
SPEAKER_00: people who are sick and because you want to help healthy people with preventative care,
10:38
SPEAKER_00: and it costs a certain amount of money to provide those services.
10:42
SPEAKER_00: You want to live, et cetera.
10:44
SPEAKER_00: You need
10:45
SPEAKER_00: medication, you need equipment, et cetera.
10:48
SPEAKER_00: And that if you had a government that was just willing to say,
10:52
SPEAKER_00: we are going to pay for the treatments that sick people need and for the
10:57
SPEAKER_00: preventative care that healthy people need,
10:59
SPEAKER_00: that like America's,
11:01
SPEAKER_00: you know,
11:02
SPEAKER_00: physicians,
11:02
SPEAKER_00: America's healthcare workforce would be so excited to be like done with all this billing,
11:07
SPEAKER_00: all this nonsense,
11:08
SPEAKER_00: all this screening,
11:09
SPEAKER_00: all these pre-approvals,
11:10
SPEAKER_00: and just like do medical care,
11:13
SPEAKER_00: um,
11:13
SPEAKER_00: you know, on the government dime and help everybody.
11:19
SPEAKER_00: And I think that that's like a really appealing vision.
11:22
SPEAKER_00: And also it's not fake, right?
11:24
SPEAKER_00: It isn't fake.
11:26
SPEAKER_00: I mean, what it is is it's idealistic.
11:29
SPEAKER_00: Yes, it's one half of the coin.
11:31
SPEAKER_00: It's extremely idealistic.
11:33
SPEAKER_00: And like,
11:34
SPEAKER_00: if you think about any public system that you have ever engaged with or that you
11:38
SPEAKER_00: have any kind of skepticism with,
11:40
SPEAKER_00: right?
11:41
SPEAKER_00: Like, there's a...
11:42
SPEAKER_00: version of America's police officers who, like, that's exactly their view, right?
11:48
SPEAKER_00: Like, we're just, like, here to stop crime and help people.
11:52
SPEAKER_00: There's a view of America's defense contractors that is just like that.
11:57
SPEAKER_00: Like, we are equipping the American war fighters with the material they need to keep the country safe.
12:03
SPEAKER_00: There's a vision of America's public school teachers that's like that, right?
12:08
SPEAKER_00: What you see in all these cases is that, like,
12:11
SPEAKER_00: This stuff is not fake.
12:13
SPEAKER_00: The people who get into teaching like teaching in schools and kids, and they want to help them.
12:19
SPEAKER_00: And the people who get into policing don't like criminals, and they want to keep people safe.
12:24
SPEAKER_00: And the people who get into...
12:27
SPEAKER_00: The business people who decide they want to run weapons manufacturing companies,
12:32
SPEAKER_00: I think,
12:32
SPEAKER_00: are quite sincere.
12:33
SPEAKER_00: Yeah.
12:34
SPEAKER_00: On some level in their motives and what it is they want,
12:37
SPEAKER_00: but also people have interests in life and those interests conflict and everybody
12:44
SPEAKER_00: wants more,
12:45
SPEAKER_00: more,
12:45
SPEAKER_00: more for the specific thing that they do.
12:49
SPEAKER_00: And there are resources and there are trade-offs and you have to think about how this works.
12:55
SPEAKER_00: will work in practice, right?
12:58
SPEAKER_00: Like the view of anesthesiologists is that anesthesiologists should be very highly
13:04
SPEAKER_00: paid for their work because it's important that they should have total discretion
13:09
SPEAKER_00: in terms of how much anesthesia people need.
13:12
SPEAKER_00: You know, they want life to be really good for anesthesiologists.
13:16
SPEAKER_00: And that's reasonable.
13:18
SPEAKER_00: That's what I would want to if I was an anesthesiologist.
13:22
SPEAKER_00: In any kind of professional society of anesthesiologists,
13:25
SPEAKER_00: of course,
13:26
SPEAKER_00: they're going to work to advance anesthesiologist's interests.
13:30
SPEAKER_00: But some, particularly if you had...
13:35
SPEAKER_00: a single payer system, right?
13:37
SPEAKER_00: If the government was cutting all of the checks for all of everybody's healthcare,
13:42
SPEAKER_00: you would face this question about like,
13:44
SPEAKER_00: how does it actually work?
13:47
SPEAKER_00: Like you can't just say yes to every service from every provider at whatever price they want to charge.
13:55
SPEAKER_00: That's like clearly going to be unworkable.
13:58
SPEAKER_00: Well,
13:58
SPEAKER_01: I mean I think that like you don't even – you can set – you can imagine a world
14:02
SPEAKER_01: where doctors didn't have professional associations and consumers didn't have advocates.
14:08
SPEAKER_01: Yeah.
14:08
SPEAKER_01: and then build a system that offers what both providers and patients would want in
14:17
SPEAKER_01: the abstract,
14:18
SPEAKER_01: which is providers,
14:21
SPEAKER_01: just honor their Hippocratic oaths and care for patients to the best of their
14:27
SPEAKER_01: ability without causing harm.
14:30
SPEAKER_01: And patients,
14:31
SPEAKER_01: whenever they are worried about something or feeling ill,
14:34
SPEAKER_01: they go to the doctor and they get whatever the doctor deems it necessary that they do.
14:41
SPEAKER_01: have or, uh, medicates them in a way that might make them feel better.
14:45
SPEAKER_01: Um,
14:46
SPEAKER_01: and that there was no impediment on the,
14:48
SPEAKER_01: on the,
14:48
SPEAKER_01: um,
14:49
SPEAKER_01: on the supply side that there was nothing that would happen.
14:53
SPEAKER_01: And then the doctors would get reimbursed at, um,
14:56
SPEAKER_01: at a healthy rate.
14:58
SPEAKER_01: That is a recipe for doctors swallowing the GDP of the country.
15:03
SPEAKER_01: And not even because they were doing anything cruel or greedy or anything like that,
15:11
SPEAKER_01: just because people would get older,
15:14
SPEAKER_01: they would go to the doctor more,
15:15
SPEAKER_01: the doctors would be confronted with a bunch of worried patients,
15:19
SPEAKER_01: they would offer them remedies to try to treat them and also to treat their
15:23
SPEAKER_01: their concerns, you know, beyond just like whatever was physically ailing them.
15:28
SPEAKER_01: And there would be like very little money left in people's pockets or the treasury
15:34
SPEAKER_01: to go around for anything else.
15:36
SPEAKER_01: And then people would start becoming upset about that.
15:39
SPEAKER_00: Well, and there's just always like questions around the side, right?
15:42
SPEAKER_00: So like I take my son to a dentist who keeps her office open on Saturdays, right?
15:53
SPEAKER_00: Which is very convenient, right?
15:55
SPEAKER_00: It means that we don't need to pull him out of school to get his like occasional dental care, right?
16:02
SPEAKER_00: Which is great,
16:03
SPEAKER_00: but also like most dentists don't work on Saturdays for reasons that I find
16:10
SPEAKER_00: completely understandable.
16:12
SPEAKER_00: And it's like,
16:12
SPEAKER_00: you know,
16:13
SPEAKER_00: if you want to make the medical treatment as convenient as possible for you,
16:18
SPEAKER_00: you might need to pay a premium for that,
16:22
SPEAKER_00: right?
16:22
SPEAKER_00: If you,
16:23
SPEAKER_00: in theory,
16:24
SPEAKER_00: it might be nice if you were able to get emergency medical treatment in the middle
16:28
SPEAKER_00: of the night or something,
16:29
SPEAKER_00: right?
16:29
SPEAKER_00: But like you probably can't, right?
16:32
SPEAKER_00: Like particularly in a public system,
16:34
SPEAKER_00: like paying for constant availability of everything would require premium.
16:39
SPEAKER_00: And again, it's not to say you can't do some of these things, right?
16:44
SPEAKER_00: But on every margin,
16:46
SPEAKER_00: when you look at like real world single payer healthcare systems,
16:51
SPEAKER_00: they have things that they will pay for and things that they will not pay for.
16:55
SPEAKER_00: And that's the same as everything else, right?
17:00
SPEAKER_00: Like, I wish the bus that went by my house came more frequently.
17:05
SPEAKER_00: But for that to happen would cost more money.
17:08
SPEAKER_00: The city spends a certain amount of money on the bus system and there are limits to
17:12
SPEAKER_00: how much they spend,
17:13
SPEAKER_00: right?
17:14
SPEAKER_00: And so...
17:16
SPEAKER_00: There are problems in the healthcare system.
17:20
SPEAKER_00: And then there's features of human reality, right?
17:27
SPEAKER_00: And the fact that sometimes a person might want a healthcare service or a provider
17:33
SPEAKER_00: might want to sell a healthcare service to someone,
17:36
SPEAKER_00: but somebody else doesn't want to pay for it,
17:39
SPEAKER_00: that strikes me as a feature of the human condition that it's going to be hard to remedy.
17:47
SPEAKER_00: Ro Khanna had this idea.
17:48
SPEAKER_00: December 6th,
17:50
SPEAKER_00: he tweeted,
17:51
SPEAKER_00: who supports a simple law requiring insurance companies to pay for medicines or
17:55
SPEAKER_00: treatment prescribed by a doctor?
17:57
SPEAKER_00: Something we could do now while we fight for Medicare for all.
18:01
SPEAKER_00: Um, so that I think sounds good until you start thinking about it.
18:05
SPEAKER_00: Uh,
18:06
SPEAKER_00: but then he's been like,
18:08
SPEAKER_00: he'd like had to spend several days backtracking on that idea because once you
18:13
SPEAKER_00: think about it,
18:13
SPEAKER_00: he starts saying,
18:14
SPEAKER_00: of course there would need to be some check,
18:16
SPEAKER_00: like requiring anything.
18:17
SPEAKER_00: Medicare covers.
18:18
SPEAKER_01: And that'd simply end up in the same, same position, right?
18:21
SPEAKER_01: Like everything draws you back there.
18:24
SPEAKER_01: And like,
18:26
SPEAKER_01: You know,
18:27
SPEAKER_01: obviously,
18:28
SPEAKER_01: the process of creating the Affordable Care Act was not the same as the process for
18:32
SPEAKER_01: creating a single payer system.
18:35
SPEAKER_01: But it did include a lot of Medicare reforms designed to make both the system that
18:40
SPEAKER_01: Obama was building and Democrats at the time were building and also Medicare more
18:47
SPEAKER_01: efficient cost wise so that
18:51
SPEAKER_01: as all these newly insured people came into the system,
18:55
SPEAKER_01: it wouldn't just accelerate the rate at which healthcare costs were already
18:59
SPEAKER_01: swallowing the budget,
19:00
SPEAKER_01: right?
19:00
SPEAKER_01: And this is where the demagoguery around death panels came from, right?
19:06
SPEAKER_01: Like there was a...
19:10
SPEAKER_01: Two of the reforms, they were like pilot projects.
19:12
SPEAKER_01: One was to create a comparative effectiveness board,
19:17
SPEAKER_01: I think,
19:19
SPEAKER_01: in Medicare so that when a patient went to a doctor,
19:23
SPEAKER_01: the doctor would have information handy about what is like the lowest cost best
19:28
SPEAKER_01: treatment for patients.
19:30
SPEAKER_01: whatever condition that they had, stuff like that.
19:32
SPEAKER_01: Just like making sure you're not overtreating people,
19:34
SPEAKER_01: making sure that the care that patients are receiving is efficient,
19:41
SPEAKER_01: is like what they need.
19:42
SPEAKER_01: And then there was a separate thing where they were going to add a billing option
19:46
SPEAKER_01: for doctors who provide end of life counseling to their patients,
19:50
SPEAKER_01: which is just like,
19:51
SPEAKER_01: do you want an advanced directive?
19:52
SPEAKER_01: Do you have a living will?
19:53
SPEAKER_01: Like, have you thought about
19:56
SPEAKER_01: like how you want it to go when you die.
20:00
SPEAKER_01: And these are both really good ideas and actually very humane.
20:05
SPEAKER_01: But together,
20:06
SPEAKER_01: if you're an asshole or an idiot,
20:08
SPEAKER_01: you could be like,
20:10
SPEAKER_01: Barack Obama is trying to reduce the number of treatment options available to old
20:16
SPEAKER_01: people and replace it with a discussion with them about whether and how they want
20:20
SPEAKER_01: to die.
20:22
SPEAKER_01: And that's a death panel.
20:25
SPEAKER_01: And it doesn't matter whether you're reforming the system to be this sort of
20:31
SPEAKER_01: regulated public-private thing that we have now with different patches for
20:38
SPEAKER_01: different parts of the population or a single-payer system.
20:41
SPEAKER_01: You're going to have to have these kinds of debates or else none of it works.
20:47
SPEAKER_01: And there's no better system in the world that doesn't
20:52
SPEAKER_01: have to create some sort of rationing tools.
20:58
SPEAKER_00: It also starts to get very tricky because if you zoom really far out,
21:04
SPEAKER_00: something you'll hear people say is that there's a lot of waste in the American
21:09
SPEAKER_00: healthcare system.
21:11
SPEAKER_00: which I think is clearly true if you look at it in a certain respect, right?
21:15
SPEAKER_00: And so one study that I saw recently is looking at lumbar spinal stenosis surgery.
21:23
SPEAKER_00: Uh-oh.
21:24
SPEAKER_00: You know,
21:25
SPEAKER_00: this is some kind of,
21:26
SPEAKER_00: you know,
21:26
SPEAKER_00: back...
21:27
SPEAKER_00: People have a lot of...
21:28
SPEAKER_01: Something that might make you become a murderer if it goes bad.
21:31
SPEAKER_00: No, no, no.
21:31
SPEAKER_00: I mean, it's relevant.
21:32
SPEAKER_00: You know, so this is, you know, back pain is a problem that a lot of people have.
21:38
SPEAKER_00: It's very...
21:40
SPEAKER_00: Serious?
21:40
SPEAKER_00: It's very- It's debilitating.
21:42
SPEAKER_00: Yeah.
21:43
SPEAKER_00: And treatments for it are a little murky, like what should you actually do?
21:49
SPEAKER_00: So there's a particular kind of surgery that some doctors feel is appropriate for some patients.
21:56
SPEAKER_00: And this study looks at,
21:57
SPEAKER_00: they show that there's very large regional variation in how frequently this surgery
22:03
SPEAKER_00: is done.
22:05
SPEAKER_00: for different people,
22:07
SPEAKER_00: and that the regional variation is not explained by a difference in the quantity of
22:12
SPEAKER_00: people experiencing back pain,
22:14
SPEAKER_00: right?
22:14
SPEAKER_00: It's like the norms are different in different parts of the country.
22:19
SPEAKER_00: The outcomes are not better in the high surgery regions of the country, right?
22:25
SPEAKER_00: So when you're saying there's waste in the healthcare system,
22:30
SPEAKER_00: The waste is there are surgeries being performed in some parts of the country that
22:36
SPEAKER_00: appear to have no medical value,
22:39
SPEAKER_00: right?
22:39
SPEAKER_00: That's a lot of spending, and it's not helping people.
22:43
SPEAKER_00: And of course, having surgery is risky.
22:45
SPEAKER_00: There's lots of reasons to not have a surgery apart from the financial cost.
22:50
SPEAKER_00: So it's quite bad that we're performing unnecessary lumbar surgeries, right?
22:55
SPEAKER_00: At the same time,
22:56
SPEAKER_00: if you just like say to somebody the words,
22:59
SPEAKER_00: like there's waste in the healthcare system,
23:01
SPEAKER_00: or like we're going to pay for this by reducing waste in the healthcare system,
23:06
SPEAKER_00: You're not imagining a situation in which a medical doctor who has won your trust
23:12
SPEAKER_00: is telling you,
23:13
SPEAKER_00: Brian,
23:14
SPEAKER_00: you really need this lumbar surgery.
23:16
SPEAKER_00: And then you go to,
23:17
SPEAKER_00: it could be a faceless,
23:20
SPEAKER_00: evil UnitedHealth or Aetna,
23:23
SPEAKER_00: or it could be a faceless and evil government bureaucrat.
23:26
SPEAKER_00: And then they are telling you, no, Brian, your doctor is wrong.
23:30
SPEAKER_00: You do not need this surgery.
23:32
SPEAKER_00: We refuse to pay for it.
23:35
SPEAKER_00: Anyone who had that interaction,
23:37
SPEAKER_00: both with a doctor and then with a bureaucrat,
23:41
SPEAKER_00: would be infuriated at the bureaucrat.
23:44
SPEAKER_00: And you're going to be infuriated even if the bureaucrat is correct.
23:48
SPEAKER_00: Because the doctor, by definition, has won your trust.
23:51
SPEAKER_00: And the doctor might be a bad person doing a scam.
23:55
SPEAKER_00: That's an easy way to think about it.
23:57
SPEAKER_00: But again...
23:59
SPEAKER_00: The regional variation,
24:01
SPEAKER_00: it suggests that the doctors in the high surgery regions are sincere in their view
24:08
SPEAKER_00: about what patients need.
24:09
SPEAKER_00: They're not correct.
24:11
SPEAKER_00: Medical science is complicated.
24:14
SPEAKER_00: There are a lot of known unknowns.
24:15
SPEAKER_00: Always evolving.
24:17
SPEAKER_00: We saw during COVID,
24:19
SPEAKER_00: there was the thing that most of the experts thought we should do,
24:25
SPEAKER_00: but there's a lot of doctors in America.
24:28
SPEAKER_00: You can find doctors who have minority viewpoints on every topic because they're not...
24:35
SPEAKER_00: It's not like you...
24:36
SPEAKER_00: The whole reason you have doctors is that you can't just ask medical school wikis
24:44
SPEAKER_00: What should I do?
24:45
SPEAKER_00: It's not obvious or unequivocal how you should deal with patients.
24:50
SPEAKER_01: I mean,
24:50
SPEAKER_01: I think we can keep this on all fours by,
24:53
SPEAKER_01: A,
24:53
SPEAKER_01: sticking with this anesthesia example because it's so on point.
24:57
SPEAKER_01: But there are others.
25:00
SPEAKER_01: Do you remember also during the ACA?
25:04
SPEAKER_01: I'm going to screw this up because I'm operating from a 15-year-old memory.
25:06
SPEAKER_01: But it's something like, over here, Congress was debating the Affordable Care Act.
25:12
SPEAKER_01: And then a Medicare advisory board or something,
25:16
SPEAKER_01: I think that's what it was,
25:18
SPEAKER_01: issued a report or recommendation that was basically like,
25:23
SPEAKER_01: There's no health benefits statistically to annual mammograms and the health
25:28
SPEAKER_01: outcomes would be the same and are like just as good in Europe in places where-
25:34
SPEAKER_00: Within some,
25:35
SPEAKER_00: there was like some age bracket.
25:37
SPEAKER_00: I think there's always a recommendation.
25:38
SPEAKER_01: With an age bracket and it's like,
25:39
SPEAKER_01: if we go from one years to two years,
25:42
SPEAKER_01: the overall outcome situation would change.
25:44
SPEAKER_01: People freaked out, right?
25:46
SPEAKER_01: And they freaked out because breast cancer is scary.
25:50
SPEAKER_01: And they freaked out because-
25:52
SPEAKER_01: statistical realities don't necessarily apply to the person.
25:56
SPEAKER_01: And so every individual woman at risk of breast cancer isn't thinking like,
26:02
SPEAKER_01: oh,
26:02
SPEAKER_01: all I care about is whether the same number or percentage of women die each year
26:06
SPEAKER_01: from breast cancer.
26:07
SPEAKER_01: I want to make sure that if I get it, it's caught in a timely fashion, right?
26:10
SPEAKER_01: And so I don't support this change.
26:12
SPEAKER_01: And so the change was not implemented.
26:16
SPEAKER_01: And that's just like purely, that was just like the politics of healthcare confined to single payer.
26:24
SPEAKER_01: It was just within the single payer realm.
26:27
SPEAKER_01: And like even when you strip the profit motive out of the equation,
26:33
SPEAKER_01: which is like an important difference and we should like dwell on it,
26:38
SPEAKER_01: is that when Anthem says,
26:41
SPEAKER_01: we're only paying for this much anesthesia.
26:43
SPEAKER_01: And if you go over that allotment,
26:45
SPEAKER_01: then you're going to have to pay for it out of pocket,
26:47
SPEAKER_01: even if your surgery requires it.
26:49
SPEAKER_01: People are immediately like, are you making this change so that you guys can get richer?
26:54
SPEAKER_01: The government does not have that incentive.
26:58
SPEAKER_01: And that's one of the reasons why,
27:00
SPEAKER_01: despite all this,
27:01
SPEAKER_01: I think we'd be better off with a single payer system.
27:04
SPEAKER_01: But if we had it,
27:08
SPEAKER_01: The anesthesiologist would still complain and there would still be a big backlash,
27:12
SPEAKER_01: just like there was a backlash about mammograms.
27:15
SPEAKER_01: And then the government,
27:16
SPEAKER_01: people in Congress or people who work for HHS would have to decide what to do about
27:20
SPEAKER_01: that public anger.
27:22
SPEAKER_01: And if they did nothing,
27:23
SPEAKER_01: then in the next election,
27:25
SPEAKER_01: they might elect people who decide let's tear down Medicare for all.
27:28
SPEAKER_01: I mean, it's just like you really do have to think –
27:35
SPEAKER_01: Outside of the abstract to understand why the politics of single payer aren't as
27:41
SPEAKER_01: simple as they feel like they should be because you can just look to other
27:45
SPEAKER_01: countries and see it works out so much better where they have it.
27:47
SPEAKER_00: Well, I mean, I think even the profit thing can get a little overconfident.
27:54
SPEAKER_00: stated, right?
27:55
SPEAKER_00: Because if you've ever had job-based health insurance,
28:01
SPEAKER_00: as many of us have,
28:02
SPEAKER_00: sometimes your boss will come and say,
28:06
SPEAKER_00: uh-oh,
28:07
SPEAKER_00: the premiums are going up next year,
28:09
SPEAKER_00: right?
28:09
SPEAKER_00: And then you're like, oh man, that sucks.
28:13
SPEAKER_00: But the more robust the coverage is, the higher the premiums to pay for it are.
28:25
SPEAKER_00: In partial equilibrium, the insurer doesn't want to approve every claim because they want to save money.
28:33
SPEAKER_00: One thing we should say is that one of the,
28:35
SPEAKER_00: I think,
28:36
SPEAKER_00: under-heralded Affordable Care Act provisions was the medical loss ratio provision,
28:42
SPEAKER_00: which now establishes there's a minimum amount of
28:46
SPEAKER_00: of your premium that has to be paid out in the form of actual medical benefits to people.
28:51
SPEAKER_01: Yeah, I think it's 80% or 85%, right?
28:53
SPEAKER_01: And so only 15% can go to overhead.
28:54
SPEAKER_01: And that's not just bonuses for CEOs.
28:58
SPEAKER_01: It's like running the whole insurance company.
29:00
SPEAKER_00: Right.
29:00
SPEAKER_00: So I think there's sometimes a perception,
29:02
SPEAKER_00: an underrating of how much actually changed with the Affordable Care Act,
29:07
SPEAKER_00: in part because some of these changes didn't have the impact that more left-winged
29:11
SPEAKER_00: people wanted them to have.
29:14
SPEAKER_00: The idea of this medical loss ratio regulation was to reduce the kind of financial
29:21
SPEAKER_00: incentive that insurance companies have to deny claims because you wouldn't be able
29:26
SPEAKER_00: to just reap some windfall profit from it.
29:30
SPEAKER_00: It just turns out that, like, that's nice.
29:32
SPEAKER_00: I mean,
29:32
SPEAKER_00: there were a couple years back when I had job-based insurance when I got a rebate
29:37
SPEAKER_00: check due to,
29:39
SPEAKER_00: you know,
29:39
SPEAKER_00: medical loss ratio underage.
29:41
SPEAKER_00: But it didn't.
29:42
SPEAKER_00: Like,
29:42
SPEAKER_00: the reason we were having these conversations about the anesthesiologists,
29:46
SPEAKER_00: about the UnitedHealthcare CEO,
29:48
SPEAKER_00: is that,
29:49
SPEAKER_00: you know,
29:50
SPEAKER_00: capping overhead.
29:52
SPEAKER_00: Insurance company is a lower profit margin than average industry.
29:56
SPEAKER_00: Their administrative overhead is now capping.
29:59
SPEAKER_00: by a regulatory nature.
30:00
SPEAKER_00: It doesn't end the fact that people have complaints about coverage denials because
30:06
SPEAKER_00: it's just in the nature of life,
30:10
SPEAKER_00: right?
30:10
SPEAKER_00: That if like a qualified doctor is telling you
30:14
SPEAKER_00: I could help you with this.
30:15
SPEAKER_00: And somebody else is like, no, you can't have it.
30:17
SPEAKER_00: Like, that sucks.
30:20
SPEAKER_00: Nobody wants that.
30:22
SPEAKER_00: I mean,
30:22
SPEAKER_00: I remember one time I had a friend of mine who's a doctor,
30:27
SPEAKER_00: but not,
30:29
SPEAKER_00: you know,
30:30
SPEAKER_00: she worked for the Army,
30:31
SPEAKER_00: told me I should get something checked out,
30:34
SPEAKER_00: a tooth thing that was bothering me.
30:36
SPEAKER_00: The dentist told me, uh-oh, you got to get that addressed as quickly as possible.
30:42
SPEAKER_01: Oh, yeah, the abscess or whatever is going to infect your brain and kill you.
30:45
SPEAKER_00: And then the quickest as possible that I could get in network was like five days away.
30:52
SPEAKER_00: But there was an out of network guy who was like,
30:54
SPEAKER_00: I can address this acute pain and possible brain cancer tomorrow.
31:00
SPEAKER_01: Brain, brain cancer, brain infection.
31:02
SPEAKER_00: Yeah, whatever it was.
31:04
SPEAKER_00: But so I chose to get this addressed quickly rather than slowly because it was really painful.
31:10
SPEAKER_00: But it turned out like everything was fine.
31:12
SPEAKER_00: All this alarmism was like, I mean, it hurt.
31:15
SPEAKER_00: But so like this is wasteful care.
31:17
SPEAKER_00: But also I was glad to have
31:19
SPEAKER_00: my jaw fixed in one day rather than five days.
31:24
SPEAKER_00: And it's like,
31:25
SPEAKER_00: there's no,
31:26
SPEAKER_00: there's no cosmically correct answer,
31:30
SPEAKER_00: I think,
31:30
SPEAKER_00: as to like,
31:31
SPEAKER_00: how much should the government prioritize very rapidly addressing potentially,
31:37
SPEAKER_00: but probably not that hazard.
31:40
SPEAKER_00: You know, it's like...
31:42
SPEAKER_00: It would be nice.
31:43
SPEAKER_00: I wish the playground closer to my house was more luxurious than it is.
31:49
SPEAKER_01: Why didn't you go to urgent care?
31:52
SPEAKER_00: Why didn't I go to urgent care?
31:55
SPEAKER_00: Because it was surgical.
31:56
SPEAKER_00: The urgent care couldn't handle it.
31:58
SPEAKER_01: Well, okay.
31:59
SPEAKER_01: I wasn't there.
32:01
SPEAKER_00: Maybe these army doctors don't know what they're talking about.
32:04
SPEAKER_01: I have personally and within my family private insurance company experiences that
32:12
SPEAKER_01: were genuinely infuriating.
32:14
SPEAKER_01: Nobody in my family, I swear, committed any murders as a result.
32:19
SPEAKER_01: But I'll talk about them on the other side because I do think that they elucidate.
32:25
SPEAKER_01: They help underscore why...
32:29
SPEAKER_01: There is like a valid reason for,
32:34
SPEAKER_01: you know,
32:35
SPEAKER_01: progressives or populists or whatever to be suspicious of health insurance
32:40
SPEAKER_01: companies and like question their actual purpose.
32:44
SPEAKER_01: We'll talk about that.
32:45
SPEAKER_01: And Luigi Mangione on the other side of the paywall,
32:50
SPEAKER_01: if you want to hear that part of the conversation,
32:52
SPEAKER_01: go to politics.fm and upgrade your subscriptions.