Why the Affordable Care Act Hasn’t Gone Far Enough (Audio and Transcript)
Listen to the full conversation above, and listen to past editions of “Scheer Intelligence” here.
Robert Scheer: Hi, this is Robert Scheer with another edition of Scheer Intelligence, where the intelligence comes from my guests, I hasten to add. In this case, it’s Dr. Paul Song, an oncologist of 20 years’ experience, radiation oncologist. But probably best known to listeners here as somebody who has been an advocate for a robust public option in health care, was a key adviser to Bernie Sanders, spoke often during his campaign on the need for a stronger system of control of prices and benefit for consumers, and what was developing under the Affordable Care Act.
But the reason I wanted to have you come in here is that everyone I know is saying it’s just horrible that the Affordable Care Act is actually being revisited and maybe wrecked, and so forth. And I, while I feel it’s an improvement–we took in people who had preexisting conditions, and more aid to poorer people who didn’t quite qualify for Medicaid, and so forth–but it seems to me that there’s also an exaggeration of the benefit of this plan. And so I read a piece that you wrote called “The Real Healthcare Debate Democrats Should Be Having.” And I thought it was the best single thing I’ve read on this whole issue.
And let me just say something, every once in a while in these interviews and in other things I do, I run into trouble; I say I would love to be on Medicare, all the doctors I know want me to be on Medicare, but unfortunately I still teach full time and I have the university health care. So I can use Medicare, I guess, when I go into the hospital, but the rest of the time I can’t. And I’m one of those people who’s paying the $800 for, you know, particular tests, of my portion, and hit with these big bills and everything. And so you know, I’m looking forward to when I can be.
So when I read your proposal, basically Medicare for all, but certainly they could have lowered the age of eligibility for Medicare as a start, if they wanted to be more pragmatic. I thought, this guy is right on target, and Bernie Sanders has now reissued some of that appeal. And so just to summarize for listeners what’s the objection of folks like myself and I guess Dr. Song, is that there is no cost control built into the Affordable Care Act, and that’s why it’s unpopular with so many people. You know, the Republicans would not be calling for repeal if the thing was wildly popular. They don’t touch Social Security and they don’t touch Medicare. So why don’t we begin there?
Paul Song: Well, thanks for having me on, and that’s a really great introduction to a large part of the dilemma in our health care and the Affordable Care Act. And as you mentioned, it did do a tremendous amount of good, but we need to take one step back to realize that there were 3,300 registered health care lobbyists for the 535 members of Congress, and more was spent in the run-up to the Affordable Care Act than what was spent on the Bush-Kerry election. And that’s why large parts of the Affordable Care Act look like it was written by the private insurance industry or the pharmaceutical industry.
Most notably, there’s no insurance rate regulation, so that’s where, as you mention, premiums have continued to climb. Here in the state of California just this last year, the exchange Covered California, premiums went up three times as much as they did the prior several years before that. There’s no prescription drug pricing controls. So in terms of how people who may have benefited by the Affordable Care Act still feel the pain on a daily basis, it’s when you go to fill your prescriptions.
You know, one out of 10 seniors can’t afford to buy the medications they’re prescribed, because they are so expensive. So there are a lot of real, inherent problems, and that was where the Republicans rightfully seized upon that. Unfortunately, the solutions that they had would have made things worse. But it doesn’t take away from the fact that the Affordable Care Act did fall short in many regards, despite the good that it did. The other thing I would say is, 29 million Americans still remain uninsured in the United States, even if the Republicans don’t touch the Affordable Care Act at all.
Here we have over 3 million in California, of which 250,000 are kids. The other thing that’s really important to recognize is that, you know, having insurance–so even though 20 million people gained insurance under the Affordable Care Act, doesn’t mean necessarily that that was having great access to care. Because one-third of all those people that got insurance under the Affordable Care Act have what we call underinsurance. Meaning that the copays or deductibles are so expensive that it sort of discourages them from seeking care. These Bronze Plans, which I think are kind of a scam, which are the cheapest plan that you can purchase under the Affordable Care Act–they have a $6,500 deductible before the insurance starts to kick in.
Most people are barely struggling to pay the premium to buy the Bronze Plan, but then when they have to realize that the first $6,500 of any care that they go to get has to come out of their own pocket, they can’t afford that. So we’ve seen, still, continued medical-related bankruptcies, which is the number one cause of bankruptcies here in the United States; we’ve seen people who, quote, got coverage, but they don’t go to see a doctor because they just can’t afford it. And now we’re seeing, even after the Affordable Care Act, more people having trouble paying their premiums each month than prior to the Affordable Care Act.
So as I say, it’s done some good, but I really look back on this and I think part of the reason the Republicans kind of punted on this–privately, they realize this was a Republican plan. Remember, this was instituted in Massachusetts by Governor [Mitt] Romney; before that, the individual mandate was initially proposed by Richard Nixon as sort of a foil to Ted Kennedy’s universal health care plan many, many years ago. This idea of tax credits and personal responsibility, quote, the individual mandate. But now what’s happened is because, again, it was proposed by a Democrat or even, I would even go as far to say, an African-American, they couldn’t get behind it.
RS: Well, and one of the points you’ve made is that when he was a state senator, before he was in Congress, Barack Obama said he was in favor of a public option. And it’s interesting, you mention Ted Kennedy; I knew Ted Kennedy quite well, and interviewed him frequently. And he was very much devoted to having something like the system you have in most advanced countries. And he knew you could not leave it up to the tender mercy of the insurance companies and the pharmaceutical companies; he understood the lobbying.
And the statement that got you into trouble when you were a key adviser to Bernie Sanders is when you were referring–they said you were referring to Hillary Clinton, but you really were referring, in the plural, to the Democratic Party, to many people in the Congress. And you said “whores for”–I forget the sentence–
PS: So, well first of all, I just want to point out that I was not a key adviser to Senator Sanders; I was a surrogate for the campaign, but not for, I was not actively advising him. But what I said was, I used the unfortunate term “corporate Democratic whores.”
RS: OK. So let me, I know, I’ve read your apology and so forth. So I think, you know, “corporate whores” is a very good description for Republicans and Democrats who’ve prevented us from having sensible health care. And to the degree that Hillary Clinton–not because she’s a woman, but because she’s one of those Democrats who played up to corporate power, whether it’s on banking deregulation or on the health care plan she devised–the whole emphasis was to have win-win. Get the big, rich companies, the big powerful interests to be on your side; get the lobbyists on your side. And you go to them and say, what can you live with.
Well, what they can live with is not necessarily what ordinary people can live with. And to my mind, the key thing in Trump being able to get away with denouncing this plan–if in fact it had been a better plan, they wouldn’t be able to get away with denouncing it. American people want sensible health care. And what Obamacare did, as far as I can see, is give it a bad name–for many people, not for everybody; it works out well for people who have preexisting conditions and so forth. But I think the key thing here is something you’ve written about and spoken about very eloquently; Democrats and Republicans both let the corporate lobbyists write these bills. And I want to get to one question that’s always raised–well, it was a start, it was a start. Well, if we had lowered Medicare eligibility, that would have been a big start.
Let’s say you lowered it by five years, OK, and see if it works. I think it would become like Medicare itself or like Social Security; people would say, hey, I want that, lower it even more. OK? Because you make a very important point that is often missed in the debate. You say, it’s not a question of the free market versus a government monopoly or something. There is no free market, because there’s concentration of ownership in the medical insurance industry, and you’re going to end up with very few players, so it’s going to be a tightly–it’s the old cartel model–tightly concentrated ownership. And then the consumers have to deal with that, and hopefully government is a bit on their side; but government just opted out of controlling price, controlling costs.
So the way you’ve posted it in speeches that I’ve heard by you, you say look, it’s concentrated power; the question is, is government preferable, where at least we get to throw them out of office and vote for them–isn’t that better, which is what we have with Medicare–or do you want to have the insurance companies have this concentrated power. Isn’t it–and so, I mean, Bernie Sanders seems to get that, right?
RS: And that’s what Ted Kennedy understood. Did you have any pushback from Senator Sanders on this stuff?
PS: No, Senator Sanders is actually championing, now, reintroducing a Medicare-for-all bill in the Senate. As you know, John Conyers has been introducing a bill in the House, HR-676, for probably the last 20-plus years. It’s encouraging to know that this year there are more sponsors in the House than there have ever been, which is a Medicare-for-all bill. As you mentioned, Medicare, despite the fact that it takes care of an older, aging population that has more preexisting conditions, most of the people are on numerous medications, still is much more cost effective than the private insurance market. Because, again, their interests are aligned with patients’.
The private insurance industry, you know, they only make money by denying care. So one of the things that I say about the Affordable Care Act, it wasn’t really welfare for people to buy health care; it was corporate welfare. It was basically using tax dollars to give to people to mandate that they buy a product for a for-profit entity that only makes money by denying care. Had we been able to eliminate the middleman or the insurers from this, that’s where the real cost savings of a universal health care system would have happened. By doing that, you know, the insurance industry spends so much money hiring people with the explicit mandate to deny care. That’s why we have this explosion of administrators and people on the phone who make your life, your physician’s life, your hospital’s life, miserable in terms of denying care; even the pharmacies that you go to fill your prescriptions, oh, they won’t cover this one. That is all designed to maximize their profits.
And in doing so, that takes about 25 to 30 cents of every health care dollar away from actual patient care, that is going to basically fight to just generate more profit for themselves. If we were able to take that element out and basically just have one universal payer that handled all the claims–but with the idea that they’re not here to make profit, they’re here to pay for correct treatment. And whatever treatment that is paid for, that money–or saved–that money left over is basically designed to take care of more people. That type of system would actually increase coverage for everyone. You mentioned Medicare; right now Medicare only covers 80 percent of outpatient services, but this would cover everyone, do away with copays and deductibles; it would help, allow us to take care of our undocumented brothers and sisters as well as everyone else. Because one way or another, we pay for that.
RS: You know, this whole show that I do here, this is to find American originals. And as I usually say, the crazy-quilt of immigration and different religions, ethnicities, produces interesting people. So to my mind, you’re one of the most interesting doctors we have in this country, not for your medical research because I don’t know anything about it, or your practice, but for [being] willing to stand up and challenge, you know, the profit model of the industry. So, take me through your own personal journey in this regard.
PS: So my mom actually came as a refugee to the Korean War. Her sister was a student here that was speaking out, because she was well-spoken in English and she was one of the few Koreans that was living here. And when she was speaking in New York to various women’s organizations and churches, people said well, what about your family? And [she] said oh, my sister is stuck in a refugee camp in Busan. And somehow some women got together and raised enough money to have her come to the United States. Fast forward, she graduated from Columbia Teachers College and during her last year, she was working as a student teacher in Harlem. And the parents in that community really took to my mom, and they went to the director, who at the time was Shirley Chisholm, before Shirley Chisholm ran for Congress. And they said, we would really like Grace Kim to become a teacher here after she graduates. So Ms. Chisholm went to my mom and said, the parents really love you; would you consider working in Harlem?
So here’s my mom, a Korean immigrant, about to lose her student visa to go back, and my mom said sure. So Ms. Chisholm wrote all the paperwork to get my mom her green card, and my mom became a teacher at this preschool in Harlem. When Ms. Chisholm decided to run for Congress, she asked my mom to consider a job in Newark; Newark, New Jersey, was looking for–Head Start was just really developing, and they were looking for their first educational director. And lo and behold, Ms. Chisholm said, I think you’re ready; I’ve been training you. And then my mom became the director. From that, my mom used to take my sister and I to the Newark preschool system during our breaks in summers, because she really wanted us to interact with all kids. And she also wanted us to see that, you know, the only difference between those kids and my sister and I were that we had, we were luckier to have more things, sometimes have two parents versus one, but that we were no different than those kids. And that’s really sort of what was embedded in us.
The other thing is, with my grandfather, so he fought the fight against the Japanese occupation, when Korea was under the Japanese occupation. And then, very much like we installed Hamid Karzai in Afghanistan, the U.S. government installed a very corrupt person in Korea, after Korea gained its independence, Syngman Rhee. And Syngman Rhee was very much like Karzai, very–consolidation of power, enrichment for his friends and family, but very corrupt. And ultimately there was a student uprising, and then they had the first democratic elections. And my grandfather became the first elected mayor of Seoul, popularly elected mayor of Seoul. Shortly after that, there was a military coup d’etat and he fought for democracy up until his death. So we were exiled; we were, the reason I was actually born in the United States was because my family wasn’t allowed to go back to Korea until 1992.
RS: [omission] Well, we’re back with my guest, Dr. Paul Song, a radiologist, oncologist and a leading advocate for health care reform who was a surrogate for Bernie Sanders during the campaign. Why were undocumented people left out of a major health care initiative, since the well-being of undocumented people living among us is a threat or a concern, right, to the rest of us? We’ve had periodic scandals–I remember at the L.A. Times that we had a headline, leprosy spreading because we have refugees bringing it in. I called Shirley Fannon here, who was the medical director, and I said, is this really true? And she said, no! And it turns out [laughs] you don’t spread leprosy that way; this is all phony. It was the banner headline in the L.A. Times.
But they made a good point: if undocumented people are cooking your food, taking your children to school, raising them, in your home cleaning and so forth, don’t you want them to have health care? And did it come up at all in the proposal for the Affordable–?
PS: So that’s what’s the most scandalous part, to me, about the Affordable Care Act, is that the Democrats–remember, when they started this they had a clear supermajority; Ted Kennedy was still alive. They only lost that when Ted Kennedy–Max Baucus dragged this on so long that Ted Kennedy succumbed to his brain tumor. But they–
RS: And Max Baucus is one of those people you would call a corporate whore, who really blocked any sensible health care and took a lot of money.
PS: Absolutely, he took the most money from pharma and the health insurance industry in the run-up to the Affordable Care Act; he was head of the Senate Finance Committee. But what people need to realize is, you know, Republicans are clear in terms of what they’re going to say and do, right? They were against the expansion of health care; they were against undocumented people gaining coverage; that was the whole [Rep.] Joe Wilson [yelling] “You lie” to President Obama in the State of the Union. But we didn’t need one Republican vote. If we had gone through this and said, we are going to cover our undocumented brothers and sisters, it could have been done. But that was the only part of the Affordable Care Act where Democrats and Republicans agreed, which was to exclude our undocumented brothers and sisters.
And here’s the insidious part to that: one way or another, we are paying for their health care. When you go to Cedars-Sinai or any of the hospitals, and they charge a ridiculous amount of money for an appendectomy, maybe twice as much as what it really costs, they justify it in terms of, well, we have to charge more so we can cover our uncompensated care. And that’s why all of us have this hidden tax, in terms of higher premiums, higher costs, because we’re excluding certain people from our health care system. So when an undocumented person does use our emergency rooms, obviously many times they can’t pay for that, and then we end up–meaning those of us who have insurance–subsidizing that in terms of higher premiums or higher hospital charges.
RS: And at the point when they’re most expensive, because if they’d had any of the preventive care, or any of the earlier treatment, it would be much less costly.
PS: Absolutely. And here’s the other part that I think has completely misled the public, is that the undocumented population are all takers–they actually, a lot of them pay taxes; they just don’t realize the benefits of that, right? They have to–wages–when they work for a company and they get their payments, Social Security tax is taken out of there; Medicare tax–even though they cannot qualify for those things, they’re taken out of it. So it’s estimated that, you know, the billions of dollars that the undocumented community pays in taxes here in the state of California, and then nationwide–they are entitled to health care as much as anyone else.
RS: I want to talk about the medical profession. And you’ve spent your life as a good guy, OK, and trying to make sense. And all the doctors I know–I once spoke for Physicians for Social Responsibility; I went around the country, their international group won the Nobel Prize; marvelous people, the doctors who picked me up at the airport or introduced me, great people. And then I wondered, where–but they were so exceptional–I wondered, where were the other doctors? You know? And what’s going on here? You know, these people–and this includes the professionals in the insurance companies, and the pharmaceutical, and so on–they know the thing doesn’t work, the current system. Even with the Affordable Care Act, what is the percentage of our GDP which we pay for medical?
PS: About 18 percent.
RS: Yeah. That’s enormous. And we’re not getting this quality service that everybody agrees we need. And so where are your colleagues? OK, we understand you; you’re the oddball Korean who, you know, OK, had a history of human rights struggle, and you’re the exception. But what do they teach in medical school? Who are these people? Why do they go with the lobbyists? Why–I mean, what’s going on?
PS: So I will say this: that I am very encouraged now by the new wave of physicians that are going into medical school and coming out of medical school. A lot of them think far more than about themselves. I will say when I was in medical school some 30 years ago, it was a lot more, it was a time when Reagan was president and some people were going into medicine because they felt it was a lucrative field. Nowadays, the people that are going into medicine, you really have to want to go into medical school and into medicine for the right reasons. It’s $70,000 a year tuition; sometimes even more, and then the reimbursements are such, and the bureaucracy and all the headaches, so it’s something you really have to want to do. So I’m very encouraged.
When I go and speak to medical students throughout the state of California or elsewhere, a lot of them are all big, already, Medicare-for-all activists. Because they don’t, they’ve never practiced in a system when it was, quote, the good old days, when they could charge whatever they wanted, have nobody telling them what they could do. But that’s what’s changed, certainly, that I think, the people that are going into medical school now. The older population, a lot of them practiced at a time when the doctors were king. That they could do anything without any accountability. And that was really one of the reasons that led to the HMO movement here in California, is you had doctors, unfortunately, who were milking the system and, you know, extracting every bit of profit out of it.
So I think doctors have [had] as much of a blame in the health care woes as anyone else for a period of time. Now I think the insurance industry has become all too powerful, and really dominating any sort of discussion in the way patients are treated. But I would say in the run-up to the HMO movement, particularly here in California, you had a lot of doctors that were being quite excessive. I think that population is bitter and angry and really in it for themselves, but now you have this newer wave.
RS: When you say “in [it for] yourself”–I mean, you’re a radiation oncologist, and you’ve talked about cancer patients and so forth who go bankrupt trying to stay alive. And so don’t these people have a heart, I mean, these other doctors? I mean, don’t they see that, don’t they know that there are people suffering, and their patients? Who are these people?
PS: I wonder. Because I wonder how you can practice for a long period of time and become numb or blind to that, or just, you don’t care. Because what it came, what happened to me was, you know, over the years of taking care of patients, you get to know these patients really, really well. And particularly those patients that have long, year-long battles with cancer, and you see each time the emotional toll, the physical toll, but then you see the economic toll and you say, wait–you have insurance, why are you going bankrupt?
You can’t then go home and just get on with your life; it was too upsetting to me to see that. So I personally experienced it, and that was my epiphany, to see my own patients that I had been fighting and caring for. And I think it goes against our whole Hippocratic oath, which is to really look out for our patients, do no harm, but also not allow our patients to participate in a system that is mischievous or deleterious. And I think our system truly is all those things. So for those doctors who think the system is fine, or believe in more privatization and more free market–um, I think that’s political ideology that is blinding what’s really happening in the real world.
RS: So in terms of this real world, we don’t know what’s going to happen with–I mean, here’s a guy, Trump, who got elected saying he was going to get rid of this thing. However, cooler heads prevailed, even in Republican Party and maybe around Trump, and said, you’ve got to replace it with something. Is this an opportunity, in a way? I mean, you know, clearly there’s a message for the Democrats who think Obamacare has just been the greatest, and that’s if you can’t control costs, you’re not going to have the people with you. That–I don’t know why that was lost; maybe some people have a lot of income and they don’t worry about it. But I mean, I, you know, I’m an older guy, so I’m in a lot of these places getting health care. [Laughs] I’ve had a few operations and so forth.
I hear a lot of talk, and most people I run into who, you know, are on private health plans or currently now on Affordable, they talk about those deductibles. And I keep getting back to that point: Obamacare would not be, or the Affordable Care Act would not be, in trouble if it had addressed cost. I think that’s the key thing. So why did someone like Paul Krugman, who people think is a well-intentioned, liberal guy and all that, why does he say–when Bernie Sanders came out for, you know, very into Medicare for all, why did he denounce it as unrealistic?
PS: Well, I think there are two arguments. Ah, you know, and I took exception to Krugman’s statements, too. There’s the political reality, which I get; you know, with a Republican Congress and Senate–
RS: Well, let me ask you, then; now, why is that true? Because, for instance, right now you have to be, you know, of a certain age to get Medicare. So you’re going to tell me that if they had lowered that by five years that that would be so difficult politically? You’d suddenly hear from a lot of people who said, that’s good–and everybody should remember, by the way–you know, again, I had a birthday yesterday. I’m now 81, full confession, I’m working like a dog at five different jobs including this one, teaching full time and everything else. But as I point out to my children and even my grandchildren, if I didn’t, you know, have health care, if I didn’t–I’d be a burden on you. Hopefully you’d still care about me, right?
So you know, my children would be–they wouldn’t have so much disposable income. They would be worried, how do you keep grandpa alive, OK? So Social Security–I remember this, because I took care of my mother and my father; they were working-class people. If they didn’t have Social Security, if they didn’t have some kind of medical coverage coming in, I remember in my father’s case, you know, I would think–well, where would I be? You know? I couldn’t have gone to graduate school, I couldn’t have done any–or I could have been heartless and said, OK, you know, go live in some, I don’t know where, skid row or something. So I just don’t get why Medicare for all is not a practical–how can they just dismiss it?
PS: What the facts show–and I think every one shows Medicare for all is much more efficient; in the countries that are doing it, there’s proof that it works–
RS: What countries are doing it?
PS: So, Canada has a Medicare-for-all system; Korea has a Medicare-for-all system; you know, more of the other countries like Denmark and the U.K. have socialized medicine, where it’s not just [that] the government runs the insurance aspect, but they own the hospitals and employ the doctors and such. But the idea is that in all of those countries, no one ever goes bankrupt because they get sick. Here, you know, the medical-related bankruptcies are the number one cause of bankruptcies, and two-thirds of the people that go bankrupt due to an illness actually have insurance. So how is that supposed to happen when you have–insurance is supposed to protect us, right, from catastrophic illnesses and issues and expenses. But that doesn’t, that doesn’t occur.
So getting back to the argument, I think that, so if you try to argue just the nuts and bolts of single-payer, there is no defense that you can say that it’s not better. That’s where I was saying with Krugman, I think if he has any legitimate argument, it may be that the political will is not there. And I will say, the political will is not there because it gets back to the whole corporatist agenda. You have people on both sides of the aisle that are beholden to the pharmaceutical industry, insurance industry. You know, when Senator Sanders recently introduced an amendment to allow reimportation of drugs from Canada, 12 Republicans actually voted in favor of that, but 13 Democrats voted no. And those 13 Democrats were the highest group of people that receive money from the pharmaceutical industry. So it gets back to the idea that you have Democrats and Republicans, and then you have corporatists that will block any meaningful legislation.
RS: Well, I want to thank you for being with us, Dr. Paul Song. And [he] brings great authority to the subject, but I think more important, brings great humanity; worry about the patient, worry about the people who don’t get coverage. Our producers have been Josh Scheer and Rebecca Mooney. Our technical staff engineers, brilliant engineers, are Mario Diaz and Kat Yore. This is another edition of Scheer Intelligence, back next week with another informative guest. Thank you.
—Posted by Emma NilesWait, before you go…
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