« The Weeds

Sarah's Last Stand

2019-05-07

Dylan Scott joins Sarah and Matt to talk about single-payer's big day on Capitol Hill and some hot administrative data from Rhode Island.

Related reading:

CBO report

Dylan’s article on a Medicare-for-all hearing

Dylan’s other article on the Medicare-for-all hearing

Sarah and Dylan on the different Democratic health care plans

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This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
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The chair has allowed welcome for another, so did the weeds, I'm a box media podcast network I met in place, is here today with Don Scott and with Sarah clear, I am afraid to say this is a kind of us aside, sat up so that the means for me It is that it is perhaps an exciting time for sir, it's saddening, fighting dive. This is sadly, probably my last episode of the weeds, as you made it may have seen on the twitter website. It's my last week at Vaccinium, I'm going to a newspaper called the New York Times to join their investigator. Team- and I am broadly in queens with you- have heard of them. You know Donald Trump seems and I'll be a van bad. Maybe I can
Can you get him on board, but I'm going to be joining their investigations demon looking into all the wild and wacky things that happen in health care, but before I do that I got to choose what are what our last episode of minors. This will continue. Man will still because statistics Yes, the weeds moves, or even as I move on, but I got two I got to choose the topic from any of my last episode of the weeds and hardware stands, will know the very very first thing we talked about in the weeds with single pair and thought after the hearings last week after the c b overboard. What else should we should we talk about, but really bring it back to our weeds, the origins and talk about where we are some, the big events that have happened on single pair and the last week? I know it's hard to know, but did single pair healthcare has gone over the lifetime of the weeds as a show from like?
and I'm things some people talk about two something it now has a bill in Congress public as we talk about it so much hundreds of co sponsors, unlike an actual hearing in the world's committee as some kind of Serbia document, so it is now I mean I think you know people know about the Overton Window is now officially inside the window. That's that's that's what this all signifies, but then like White Del, yet you covered this like one, but what happened this committee hearing rights last week, the House Rules Committee held the first ever hearing. a medic care for all bill. Why did you go to the rose so this is sort of a very much like an insider in DC drama but like whatsoever on the backdrop of this the whole year since House Democrats took control. Is that, like house, democratic leadership needed to lake throw a bone to single pair supporters, and all these all the energy on the left around this medication
all idea and at the same time they don't want to be seen as like running whole hog and the direction of socialist single pair healthcare and so like what they what they had at what they said. The very beginning of the Congress was we're gonna, ask CEO for a bunch of information about single pair and we're gonna hold some hearings, and so I interpret it as we are going to have it in the House Rules Committee hearing, because that sort of a safe place to have it like if the house ways and Means Committee, the House, Energy and Commerce Committee, the Educational Labour committee. Those are like, though, the committees that are actually responsible for writing healthcare legislation in a flight. healthcare legislation we're going to move somewhere, it would start in those committees, so we're having it in rules. It is it's a small committee that had a handful of single Blair like ordinarily, the smallest in your room. I have ever, did they let you in the rumours two tiny fur. There were a handful of reporters in the room, but like their eye, there was no refinances video, but under the chairmen of rural
This is America is emitting, wherefore, oncogene, Mcgovern Roberto, I mean that's part of the the advocates wanted. A hearing, ringleader wonders able we're gonna, give you a hearing, then the leadership did not want to like do a bill, or have this be the party position, but the US it and want to have a hearing that consisted of leadership. Trashing single pay right so that they wanted to do something. That would count as that then at least the single payer people could say. was progress right so having a hearing in the committee that chaired by a single payer, proponent men that it was, it was like a positive here right and there was a tizzy last week about it. First, the panel of witnesses didn't have an explicit Medicare for all supporter. None of the people who can appear before the panel actually like advocated forceful. format of care for all, and so that became a story for a couple days, but then turned out that an activist with AOL
they. Mattie Barkin ended up, did end up appearing on the panel and give very moving testimony in favour of Medicare for also have this sort of like this was very much not like a legislative exercise was sort of like letting air out of but it also was, I think I mean we came away from it. It was much more or you can write x. Men said exceeding alkalies, it was a aiding, yet you turn it on what are the exceedingly polite Medicare for all hearing, which is not usually the way the Medicare for all debate goes on. I think let you know there was a sense going into it. Like. Oh yeah, it doesn't be like fireworks. Cuz Democrats are divided and we're going to see like these tensions come out and Republicans are going to trash it, but it wasn't not at all. You know. Donors really allows for major test secretary in new Member of Congress. She has given some quotes. The Washington post about you know busily we're not a bunch of dummies, we're not going crazy at this hearing it and they certainly delivered on that. I think part of that has to do. We had a conversation about this in the office Matt with actually who is
I and the committee, you know you don't like the highest profile members who are like going for the sound bite on rules of urine ways or means energy Commerce. Those are the people were closer to leadership, more high ranking in the party is that's part of the dynamic. It was a very timid hearing. in my view. You know it was not like poking at like ok like will what our like the holes. Care for all, even- and I think some of that was really set by having Addy testify there.
You know he is someone. I really recommend if you didn't see it going back and watching his opening statement, which he had to deliver through busily a computer generated and voices at advanced stage of ale ass to the point, we can no longer talk and uses a computer that computer that tracks, as I move, meant to be able to feed the computer what he wants to say his testimony, I think, really seem to sat the expectation of civility. I think it made it a lot harder for republicans who would have been aggressively trashing Medicare for all to to do it with after listening daddy talk about what it would mean for his life. So I think his presence in the fact those in Rome
the fact tat he was. There really seem to create the conditions for very, very civil and unfortunately, from our perspective, incredibly boring Medicare for his. Even the Republicans followed that leads. You know they, they sort of said worth sympathetic to the goals of de especially people like Addy. Everybody was very respectful of him, and while they, you know they took an opportunity. They did you ask their witnesses. Isn't this gonna cost a bunch of money and increase people's taxes and lead the rule hospice with closing. There was just sort of a very much more of a kind of one cash tone to the whole. All the preceding visit, I thought to me. This reflects exactly how far we are and how far the advocates for medical for all actually are to getting their plan because I too me essentially what happened here right is that, like when the sceptics chill out, Sometimes sceptics hit like very apt up in there like freedom right, I mean in the Medicare for all Baconians get to come back with. There
we made a moralistic arguments like isn't it sad when people get sick and they can get healthcare and, like every other, Can you know all our stuff, like this of Bernie Sanders, says on the campaign for a right, which is very fifty thousand feet up? But if you come down and you like, don't loudly oppose Medicare for all and it is kind of like. Let me turn the microphone over to you to have a policy discussion like like what would you like to do with the healthcare system the committee therefore and oftentimes, don't they don't have as much to say if they start filling out the details like their own position becomes more. Vulnerable right into in some ways, like Republicans, would most like to see, is like a fully fleshed out Medicare for all bill. That, like specifies exactly how much taxes are going to go up and whose taxes are going to go up exactly how much provider payments are going to be tied
and how much they gonna be kite like who is going to be in charge of deciding which services are eligible for reimbursement and which aren't you note that two dead dead did that data and then, like its others, are unanswerable questions right cause? If this is how it sometimes goes, I believe how you gonna pay for that and then provide while there's ways. Ripened is just just come like. How are you going to pay for that right and then, like you, could answer the question, but then the opponents could savage right and then the Medicare for all people, great, but they put up addy whose like a great advocate right, but is not a tax policy expert, and so it's kind of like our aid, guys like here, you go like. But what do you want to do in your restructuring of fifteen percent of the economy? This allotted timidity there actually write like there's. There's not just like these different nations of legislation came out right and went when JIVE pause Office sort of like modified the long standing single pair bill. It wasn't to fill in any of the bank
spaces, it was to say, like em, we're doing long term care to write. Yet, like Democrats at the hearing were not asking detailed questions about like what a fan financing plan might look like a couple of the witnesses were physicians, and so they ass, they would ask the doctors like if you didn't have to worry about navigating five different health. Insurers will be able to provide your patients with better care that kind of more red light weight. I guess policy discussion, rather than than looking like the more difficult questions that single pair poses and that in theory, what you do in a hearing. This is normal. It's it's a bad that the advocates of a given course of action don't have answers to all the detailed questions, but some theoretical sends like what you do in the hearings. As you like a hot, I would like to create a government finance system like I have heard that
haven't Canada, but I have some questions about how to do that, and now I'm going to bring up here. Some experts and I'm going to ask them questions right leg. What will the impact of this be unworkable hospitals and we're going to gather information and and and write about her bill, but they were really doing that rightly they were not. They were not asking questions that would move you closer to here's. What the plant will that's what made it. An odd exercises like the hearing was an end unto itself. The fact that the hearing was happening was what was in power, like even talked with some folks have been working on single pair bills for years, and they were like all the we. I really are the person I talk is said. All I really care about is that we have got no place on the stage now, and the fact that this hearing is happening is what's important to me. and so he I think than the question becomes. Where did they go from here? But clearly this was not the opportunity in their eyes to get in some of your time out. What do things that interested me was what
publicans decided to seize on in the hearing, and one of things I kept going back to was the fact that Vermont tried to, the single pairs, the sermon was unsuccessful, and this came up multiple times. I think in part, because the washing posted wrote an article about it and it just became the kind of thing that I saw them kept going back, you- and it was an interesting and kind of I mean it- was an attack on single pair that did and didn't make sense to me, but was so pricing that that was more of a focus than like the rationing staff, which did come for, I am being of some of the other. I think more valid critiques Medicare for all they kept coming back to the fact. Well, deep, blue Vermont to place a Bernie Sanders is from, they tried to do this and they were unable to do it and jam you do if they can't do it here. How are we possibly going to do in the United States, which, on the wonders, is actually pretty practical question that I think gum Democrats will need.
to grapple with guinea one. On the other hand, a kind of is it's a little bit of a false pretences. Having one of the reasons for my can do it is it's really really hard for a state to build single pair within a nation that is not single payer, but I was surprised to see that come up is kind of a frequent topic of discussion and it seemed like almost give thence to like the idea of Medicare of being like ok, fine, interesting system, but like look when they tried to do it, I wouldn't even even work a team to accede some ground and that being the area that they were turning on any immediately wonders airily? What is the point to other sprightly way, whether the the progressives on the hill trying to achieve exactly this is twenty? Ninety day have been talking about this for a couple years,
Bernie Sanders campaign. I mean the element I missing about for a long time by Bernie Sanders. His campaign was twenty fifteen twenty sixty and it was clear people were gonna. Sworder redouble their efforts on this twenty seventeen twenty eighty, and now it's twenty nineteen. This could mean election, They don't they don't seem to be zeroing in, unlike January twentieth, twenty twenty one. Now all these banks are gonna be filled, sure, but I think, you're getting. I think they are moving in that direction and they were going to talk about the z Your report that came out in a little bed, anything that is part of it too. I think there lay, I think, like dylan- was saying that their laying the groundwork we're single payer hearings are a thing that happens in Congress. be in your starting to get into some of that policy debate. How would you transition to their system? Bernie Sanders thinks you need for years, promote I've on things you need to. They both have like arguments with earlier
Yeah. You know, maybe nine months you now to give birth to your new health care to stop whose really to say, but I think The idea is especially when I think back to the affordable care activate. The idea is to make this part of conversation, and I think they have successfully done that, like it's pretty wild to me that most of the prominent two thousand and twenty candidates are running on this platform and now, like the the moderate option, is a Medicare buy it? the two one of things like this overturned window stuff. You run up at the very top of the episodes. I think that's a key thing, that's going on here. I think it just making it like part of the you, no water, that you swim in DC like making it part of the debate. That is happening, and you know doesn't surprise me to not see politicians getting it. The design issues of ok. Look. How much are we going to pay people? What is the actual? You know how we gonna pay back the list of benefits because, like why negotiate that away? That's what you are
C b, o over you know putting out their reports. That's what you have them to kind of Jew and spell out and universal Democrats kind of the best of both worlds. You can talk about your big Medicare for our plan, and then you can get some of this information starting to trickle out from CPU, also from like analysts, Rand, who are doing a bunch of modelling till it kind of figure out the like. Well, what does this look like great? I think they're really caught up in the idea of not negotiating with them, so looks like why not set out the sort of like Northstar go where everybody's covered under one plan and almost every medical services available at no cost and then like. Maybe eventually, you pair back from that but like. Why do that now, when we're just sort of an agenda setting what why am I anything to make this explicit right like, although twenty one are not out of them city were looking like more like twenty twenty five, maybe as what this is all leading?
But I do think I think that a lot of words driving this action on the hill is an interpretation of what happened in two thousand and nine. That sort of the left was like throne, of both in the form of the public option concept, and I think the understanding that the public option was always going to be yanked away as, like the moderates like saved industry from the public option, I think that a lot of people on the laughed feel in retrospect not so much that they should have fought hard for the public option or whatever, but just that, they allowed the debate to be anchored to close to the centre right and that like, if what progressives believe is that every health care service should be free at point of service to every body, and it should all be financed by taxpayers
that like they should just say that, like over and over and over and over and over again, and that they should not attempt to answer any of the questions about how that specifically will work, because aware that they don't have the votes and that not not gonna get the votes and that they're not gonna check Jenny bodies mind, but that, like they are just going to say what they think, which is that all health care services should be free to every body and it should be paid for by taxpayers, and there should be no limits on it and, like they're gonna, try to make that the centre respond to them, but rather than moving Briac device. So it will be like just be like what. But what have you got Joe Biden Old and doesn't
you, like that's, worked like if you look at the center for american progress thinking this who lives like you, know the fulcrum of leg, democratic establishment, policymaking they put out this Medicare for extra for all. That's now become a Medicare for America Bill sponsored by Rosa De Loro, engender Cowskin, the house, that's lake, far to the left of where the Asia was like it would embrace. It seems like the impetus design cap to be like ok, here's Ours is because you get why, like free health care for everyone, could now the impetus is on cap to do the analysis of saint into no huge. Why why arises? Is just to guide it kind of creates a nice dynamic for single pairs supporters. Where you put that the more moderate people you do on the defence with their idea, I thought they'd as of a month ago. This was working really well for single pair people right. because, like you had Bernie still out there, then you had a number of other senators who got in the race early endorsing the medical, for
legislation, and then you had better work and be Buddha. Judge sort of anchoring would pass it for a ride flank of the debate by endorsing this Medicare for America legislation and that That was the dynamic that the single pair people want, like, I think, like they wanted Bernie and has to be the nominee bug, even if he wasn't like the centre, alternative had become so lax. in any, had created a situation and in which, like a moderate, democratic, senator right like eight a m oh Bennet, or whoever could be like yeah, I'm for this way to the left of the SBA plan, which is moderate now the extent to which Joe Biden has waded into the rays jumped out to a very large early lead, unlike not made any commitments at all along. These lines is like I'm not saying like this now me
the plan that seem to be working as a total failure, but like it, it calls into question re my, but it still I mean it says so earlier and like I think, we're gonna go through the debates that are gonna of God. Thoroughness like vomiting love, saying, there's gonna start in one word and start with the debates and Joe Biden who's going to have those moments. You know where he's ass. We do support health care for everyone. He's gonna like one of the things I was pretty interesting and we both wrote about this- is that Wall Street analysed some who said healthcare? Companies are pretty jazz. Virginia energy can be pretty good for the insurance companies if we had a bite and presidency, but I ain't Greer, you know he has been able, and I think it also like a nice reminder that, like the people, all of us follow on Twitter or not be alive, direct and like the one. We want to see what happens right leg. Maybe people are liking, Joe Biden, because they are assuming the Joe Biden they very mainstream establishment Democrat will endorse.
The new mainstream establishment consensus view, and maybe if you will do that right like if the upshot of all this is President Joe Biden and Medicare for America as outlined by cap, that would be a big success for the single pair movement, but also if what happens is Joe Biden just keeps being like. For it will correct. That was a big fucking deal like he wins with forty four percent of the vote is someone who you do. I went back and I read the story, but his views on health care, who am was actually a forest pushing against doing the afforded,
Kara actor that he you know it's not just. That is not a matter for all supporter, but when you look back reading through histories of the Obama administration, he there was this debate in two thousand nine. You were just sticking out of recession. Do we really want to throw our political capital behind Healthcare and President Obama was like? Yes, Joe Biden was like no, we should not do that and President Obama one because he is the president- and I think that is an important lesson about like a huge space between Biden, an Bernie. It's not just one is endorse healthcare and one hasn't, and one fervently believes we need to overall our health care system and one kind of things like
worth the political capital and I think that divide is going to come out more. I mean what we're on like week, two of the bite in candidacy. I think this divide will be like explored and come out more right as we get into the primary aim of this question for awhile about how like scalable health care. Politics really are because I think there's this perception, the like almost all Democrats for Medicare for all now and it's like a man, a break issue for them, and but I think that the polling is a little more nuanced and that, like yes, Democrats are generally sympathetic to the goals of national health. Insurance are universal care programme, but they're not really absolutist about it like in others. There is pulling that shows like at sixty percent of Democrats at its port Medicare for all, but more than half of them would rather prioritize fixing the affordable care act in the mirror. We should take a break. Yet, let's let alone we have talked a lot about her into the CBS video report.
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It feels like you, don't even have hours in the day to get everything done. He might because you're missing out on three windows to me, I was up how he fell into a deep, dark abyss that opens up when we switch between working lives those three hours to all the productive time we miss out on thanks to at home, distractions, disorganization fatigue. It's no wonder the days future work should work with clear up. It does look up as a flexible productivity platform, the wings or you work at one. That's all you chats apps docks and ass. One centralized place like mission control companies like Goober Google. You click up to make. There is more productive, managed projects, people and goals more effectively, but for tee of all sizes industries cook up to pleasingly. features of one thousand plus integrations must have for anyone wanting to track manage intact,
They worked in one place, you're, always back with clear up trade free today, click up the dot com, slash weeds, so it makes me sad that there will not be with us, as Joe Biden needs to start as Amy's questions and the debates, because I think the commissioner wisdom around this has like swung so hard and in a few weeks- and we don't know, but what we have right now before us is the congressional budget office. Yes, good friends, you are sir, yes, yes, very good friends. They did. I guess this is not like us score of the single payer bell, because the singer pair Bill has written is a little vague, but they were kind of laying out what like like principles. Yes, I tell you the name of this report and House Democrats didn't want a score to be clear. Yank. Their request from Sepia was like Johnny
Eliza specific bill. Just answer some very broad general. We didn't get anything why I believe, as I really encourage you to pay attention to what it is that, like your guys, I'm Capitol Hill are actually doing an and ask yourself some questions of this this report. It is I'm tired of key design, components and considerations for establishing a single pair healthcare system, and it has a nice little graphic on the front about some of the components of single pair healthcare. Like role of current systems, covered serious services and caution, payment rates cost containment financing. It's like arrows and assert its items, not area aids like us Circle and they're all on the circle. It's I'm really get with the circles doing in the graphic, but that's neither here nor there. So even this city overboard I think it was also a little.
Dylan, and I let it I'll give you a sense of activity. Last week with a big single, their weak, we got the hearing, we got the severe report. The hearing was exceedingly polite. The c b o report, while I think very well written and informative, was essentially like international health systems, one a wide what they did. My favorite part of the report is a table and the fourth page that kind of outlines the different features of different international health care systems in a really clear and coherent way. I dont think it told.
People working on single pair anything different, I dont, get told them anything new about how such a bill would be scored that they didn't know already the things I thought I might see in there. That wouldn't were things I did like would deal with actual numbers like. If you set met reimbursement rates at Medicare levels, here's how much it would cost stir. You know. Here's that size of attacks you need generative financed, deserve that and it did not even get to that level of specificity. So instead it was a very thoughtful guide. You know, as a title says, to the key component. One right like you know what to expect renew expecting to write a single pair bill. I thought it was going to be oh, and maybe I misunderstood the request for an I thought I was going to be a tiny bit more specific than than what it ended up coming out, as I think it tells you a lot.
healthcare professors on Twitter, saying I'm going to assign this to one of my classes and the political press almost completely ignored it. There is that that that much lack of fireworks but yeah I mean I came away from this really interested like. I learn things about the taiwanese welfare system in that I didn't know and found kind of fascinating, like the fact that a really good I t system has been so inter girls to their success. I thought was interesting. The fact that they, like the way they do their global budgeting and pay providers. I thought was really fascinating, but, like yeah, there wasn't in terms of life what a medic care for all bill would look like here in the United States and how sepia would evaluate that. We really didn't learn. Anything like this report is completely devoid of numbers. I think
meaningful numbers. Sue me. This was like a brilliant way to undermine the push for single pair healthcare private. I just I feel like what like single pair proponents, like always want, is for like tough push back, and am I dig into a fight in which single parricide has this like ethics high ground and that whenever you can? Instead? This is like a little bit of like like a rope, a dope and realize hi, you are correct. Here- are a bunch of design. Consider there's a lot of good ways to make. This is tomorrow and it just like its tempting. You too, like ok, ok, pick one! You pick one right like like here: here's one thing to think about who's gonna only
but all right and then they go through some different ways- that you can do it right, and it is true right like it's, it's not that this question makes an unworkable. There are a lot of different models of this, but all countries that have a healthcare system like that they pick one of them right right, and so they just like they give you this new and like now is your problem as the author, the single Bayer. Basically, here all the difficult decisions you would have but he just who can say that every government has a clear hears that uses like yours. You select appetizer you slip out of her own right, but like now, it's no it's your problem, whereas the would be author of better care for all legislation like you have this, extensive you're, saying I dive in your problem. It's like your set of option. Do you do it our candidate, That is the way Taiwan does legged sets it up as like you. This is edited true. This is a problem that dozens of countries have solved before us at a basically says like we're not talking about an impossible thing, you noticed too
you're an adventure single payers, but it's like, but it's like a long, annoying homework assignment, regular gear, saying like like professors we're like, I will assignments mazurkas like it's good right, it's a! U go back home representative so and so his who packet to read over, like you can do the problem sets. but it means that, like one of the first difficulties of pushing this forward, is it like that only do you need to like winsome elections and intimidates and people with primaries those up Ike inside the single payer camp. You need to reach some kind of consensus, robot these issues, and it's not that, like Canada system works, Taiwan system works, Sweden system works, but they're, not the say, yeah right, and so it's like you have to peck and it's easy as an individual like. I could look at this and delicate, this way. This way. This way this way in that way, but, like Sarah, might not agree right like now, we have you know it's. It's a kind of effective thing to be like, instead of you guys all teaming up to yell at me like what are you yell at each other? Yet
There is kind of an amazing circular logic and some pieces of the report's alike. On the question of private, and Parents they go into like whether or not you know you should get rid of it or not. or whether you should allow a private insurance plans, the basically compete with the National Medicare for all plan until they start off by saying. Well, if you get rid of private insurance, that's going to cut provider payments, and you know that could lead to these adverse effects: fewer doctors, hospital closings, whatever the light, then they say what, but if you allow private turns to remain. Maybe that allows for doctors and hospitals to make up some of the revenue that they lost in Europe offset some of those concerns that you
and then they bring it back around again like. But if you allow private insurance and private insurance pays a lot better than the public plan may be, doctors and hospitals give priority to those private insurance patients and that leads to people with the national health plan. The medical for all plan facing longer wait times. Are there not able to access the services that they feel like it? It prevented it presents you sort of like the problem from every side with no way to resolve it. right, which is sort of speaks well. I could this this great. Like anything, I care on page twenty wonder like they're talking about payment rates and then like at the end of that they saying other considerations are then one of the other considerations as, for example, teaching hospitals can have higher payment rates. It receive compensation for their future costs through direct payments outside the single payment system and, on the one hand, who fuckin care, on the other hand, people who have teaching us I was in their districts now that you mention it re, probably care. Actually a lot about does right needs this, like it's such a contrast
from like every other major countries carriage, he's healthcare as where everyday Sanders impression to this, like here a fucking annoying classical de unlike obviously, this is not an unsolvable problem right like either the teaching hospitals can get higher reimbursement rates inside the system or there can be an out of system. Supplemental payment either would work fine, there's no problem, which is that you would have to pick unlike who like who wants to do that? Then. This is like what pupils me and when they say like you're, talking about restructuring sixteen percent of the economy right? Is that, like you, cannot do that with like a four page high level and says of like what kind of outcomes you would like this like eighty but Gillian annoying details that are geared to sit down and there's a lot of stakeholders with them and people are,
we have all kinds of feelings, because it really matters right like if they teach in hospital as one of the major employers in your town, you're gonna, like what that in, on the other hand, it like a lot of towns and the hospital is a major employer, but it's not a teaching hospital. You don't want a system that, like loads, the dice against you, and some people way, unlike who knows and you're gonna get some of them wrong. Look inevitably lead The core things we learn from the affordable care act is sick. People tried their best slick right, a good health care Bell, and there were problems I can foresee some of it was drafted sloppily and had to go to the Supreme Court to figure out like a veto the law guaranteed M subsidies- everyone. I remember there is just one kind of Corky drafting error that really fucked up all the territory. It places like Puerto Rico and Guam fucked up their healthcare system because it created an individual mandate for those places or no, it did not.
If a dual mandate and do not have the subsidies but had guaranteed issue so office under the wreaking havoc on like territorial health This is why I now I M a good idea if the guy from Guam unease like we're lobbying on those we're not getting anywhere, it gives us a unique situation. Any kind of side is like now. This is just about anything. I can climb dry support statehood for although you know yeah, listen dear weeds on that x, Ray GAB. These tiny little Citizens aren't tiny for the districts of teaching hospitals and some of them are big. There is one that was brought up. in a really great article, a home in this dispute with New York Times by Margaret Singer, cats and renewables. In one thing, they pointed out- which I just never thought about- is the fact that a lot of our retirement accounts are invested in health insurance.
stocks? And I I don't know what you do about that and that's not really one where you can like look at Taiwan or Canada cause they never got to appoint rude such advanced healthcare systems that a nation's retirement savings were tied up in the future of your health insurance plans said there are a lot of annoying questions and some of them heating hospitals. You pick one but like the health insurance toxic. I don't really know. Unlike the really isn't like an international perspective to say, like Australia, did it this way or Canada did it this way, because none of them had to deal with that? I think one of things, a c b o report can't get out is the fact that we are a trend. If we transition to single pair, we be transitioning from a system that is such a developed health insurance infrastructure and that presents its kind of own unique challenges. Yeah to roll back to tourism. Before this sort of underscores the extent to which the these single pair push. I think mug works better as a bargaining chip.
I take that as a legislative go right. It's like if you're saying luck, man, if there is a new democratic regime like a democratic president, democratic Senate, Democratic House, I mean who knows if that will come about, but like we expect you, like the new president, the new pivot point legislators, the blue dog caucus to come to the table with a thing that will expand coverage to more people and cut down on the pricing power of private actors in the system round the more people you can get on. or for like something like sixty six leg, the more you have behind that, but the more you go the other way, and it's like. Oh, I am actually intrigued by your idea, single pair proponents. Can you just like tell me like legs: finally, what your ideas gonna look like then they ve made remarkably little progress. I would say again
something like, I think this sepia document is- is great. It's like a really good primmer on these use, but it isn't like break new conceptual ground. If you had been curious about this topic in twenty four June, you could have gotten people to write you up when exactly this document is theirs. like new discovery. Here, it's a great thirty pages on like how you would go about setting up a single pair system well in the option Anne and nobody has really done. It. Looked like the people on the hill right. There's no there's been no died, as were now in like year, five of Bernie Sanders, its quest for the White House toured light answering these kinds of questions, which everything necessary bad as What an alternative is there like again like with the political landscape being what it is all right? Look: what incentive is there? Look what I think it's like the perfect compromise of yours would advocate to leave this work to the ceo
to me. This is a different from some. What I've seen in the the green new deal community we're like. Yes, they are interested in Overton Window Games and they recognise that, like a ginger causing Cortez is not going to be like driving the legislative agenda personally, but they are in fact like scrambling to come out with regulatory agency proposals, narrow issues domain specific bills, because they feel like a real sense of urgency to like do as much as possible on climate change. as quickly as possible, and they are don't quite have their ducks in a row yet, but there like really trying to like come up with some stuff here right, whereas, like the healthcare people, have they been working at this much longer her right away, like still haven't gotten to like any of the nuts and bolts here, and I guess that comes to the question of lake. What do Democrats actually want to do if they get the chance and twenty twenty one and cause like, I think something they gets law
lost amid all this energy about Medicare. For all. Is that really the most slake effective political tactic of the last Gator, so has been running against the other person's healthcare plan. Like that's what Republicans deployed after a bomb, a care pass to brought them a lot of the house and then the Senate and then the way house and now, and then Democrats and twenty eighteen really what they were running on, was opposing the republican plans to roll back the affordable care act and so like it seems. It seems that sometimes I wonder like it for spending a lot of energy when Democrats would, if they had the opportunity in twenty twenty one to govern that like this would be more like a. We need to do something to finally get health care off the plate, but like this is not where they really want to spend their time and energy. Although what I think is interesting about this is that, if you go back to like old tedious
key conversations about healthcare from two thousand five, doesn't sixty thousand seven and write like one of things you remember it's just that, like systemic health care costs are like a big problem for America and the basic few is are not actually that different in the multiparty system or in the single persistent MIKE, as Sarah has has taught us all, and in five years had bogs like you, you could do the price regulation, sighed the context of the single pair system, or you can be America and and not, but like either way. That's why health care costs in the? U S, I'd like whether there on the government's bucks or your employers books are coming out in your pocket like their exorbitant like because the prices are high, you could make the prices be lower, but like
if the price were lower and even go, read the CPU report, and just like imagine it's not about single pair and, like all the same questions apply its like. If there wasn't so much money going into the doctors and hospitals like maybe some of the hospitals reclose, maybe the doctors remove, you know, like maybe quality would decline and On some level, I feel user inescapable leaves and nobody wants to answer these questions, but I bet it's a year in reserve. We run up into these problems all the time the prices I mean, I think, like ethic corner of it. If I've learned anything over my palace five years at vocs, including the sixteen hundred medical bills, I rather like the problem is the prices and night. We, I think it's allowed people don't like their health insurance companies are exciting to talk about getting rid of private insurance, but Edith I become pretty, can
it, but I think it's like I m. The promise of prices for the prices are also the hardest part to tackle cause. I know all that money that goes into healthcare from prices. They are jobs and they are new hospitals and there like building this healthcare infrastructure. So people are going to fight like hell to none, have the prices regulated, but the This is our at like, but if we do not want to take anything from what I said in the chauffeur five years like the prices are at the core of the problem, we have with healthcare. There are also the thing that our political system seems like to struggle. The most to deal with, but all of these intermediate options right. It's like you could do a buying. You could do Medicare four key You could do you know what everyone who say: ok, I'm gonna try to be less drastic Dominica for blink fine, but it'll implicates the same.
six issues like the reason we didn't get a public option back in two thousand and nine is that the strong, like a strong public option would have reduced the prices paid to providers and the providers didn't want prices downright like it's not right. I mean they're like this over him went like all that stuff is, is real, but, like the villa ground, troops right is not actually a void of all. It seems to me by scaling back to some of these, these other kinds of things, because, like either, we in some form or another are gonna pay like all this money to the hospitals or, or else were not right one. I think you seem. I think industry recognizes that, and you ve seen this.
the ship for America's healthcare future, which is basically a collection of every notable, the health industry lobby. England very high saying this cap plan is a makes they're not there there. They have perhaps wisely from politics perspective. What they have. Basically any kind of public plan is, is objectionable, Tibet, like re? They came out against the Debbie Stab now let people who are fifty years old by into Medicare they obviously come again spinnaker for all Medicare for America. like they're, not even willing to budge a little bit so David that this those stakes are, those battle lines have kind of undrawn already, and yet they don't even they have out there Overton Window has not shift where placing that's an interesting question and politics right. Is it when you have an idea that you know is gonna, be opposed by some powerful interests.
Does it make sense to like try to move closer to their position, even if they're gonna oppose you anyway right for the sake of seeming more reasonable Worry knowing that they're going to oppose you anyway. Does it make sense to go maximum in the other direction so that you can maximize the wines for other people right it's like if the hospital industry is gonna nuke you, adds one way or another. There is something to be said for like ok, but you can get free medicine right, so I think we should am. We should change gears and talk about a good use of healthcare, but I still spending. Let's do it. Take a break. Come back for a white paper This episode is brought to you by fender. Football is back and the best bet you can make is downloading the fan Dual Sports Bookshop. It doesn't matter if new to gambling or an old pro fan. Dual has something for everyone and as an offence. you'll sports betting partner of the NFL. You know your bet, you're, safe, there's, also
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island, administrative data and the thing they did that this really is a study that surprised me a little bit I'm so they looked at the impact of early life interventions for low birth weight. Newborns I'm if you are a baby who was born less than two. The threshold is fifteen hundred grams, which works out to about three point: three pounds: there? You are considered a very low birth weight. Infant and hospitals will typically do more things to me. The baby. The baby will near certainly end up in the
you it's going to get more intensive care, it's probably gonna come back for more neurological check up some after it leaves the hospital. The American Academy, a pediatric sis remain, recommends significantly more care for kids. You are under this fifteen hundred gram threshold, so what these researchers did, as they worked at the State of Rhode Island, to look at the kids who are just below the threshold in the kids or just above it. So looking at infants who way as little as thirteen hundred grams and as many as seventeen hundred grams a time of birth and they find that the threshold caught crossing is they describe. It means there's more intensive in hospital care and they show some pretty significant gains later in life. They show a point three for standard deviation, increase in test scores, parliamentary and medical smote middle school.
A seventeen percent point increase and probability of college enrollment and sixty six thousand less in spoke social programme expenditures by age fourteen and they train figure out what is going on here. What is different about these low birth weight babies and they find you know no the technical changes in the quality of schools. They go to no big changes in parental responses. They really think it is the additional medical care at that early stage of life that is leading to these larger gains and use paper essentially makes an argument that If you have this intervention very early in life, you can see some pretty big dividends, paid further on end, am I just as a pretty interesting paper that I had thought about? I surprised at the magnitude of the things that are finding across like college and roman social programme. Expenditure is like scores. It seems like a pretty ride wide array of things, and I think it also united. The last thing I take take away from it is: how am
how arbitrary a lot of things in medicine can be like. I think we set up this fifteen hundred Graham threshold because it seem like baby smaller than that, like they probably need a lot of help, but I don't think there's much less actor that different from like a baby that ways like a hundred grams, more we're talking about like an hour. There, too, don't I've read like it's a round number. He examined Frederick system yet, which is just based literally a block of iron sitting in a vote. Yes, I think that was also it's like. It seems like these babies, who are just above the threshold. You do actually Dylan's the newest parent on this path, gas. So we all know it you don't! Babies are too small and light. One ounce of different seems to actually make a big difference in the medical care they get in this paper, suggesting a big difference in their entire childhood outcomes. Yeah, I'm glad you so that, because my first thought, after it was. This was like. Do we need to change the threshold so that these kids, who fall just above it and are now getting like out performed by the
any my region is good regression discontinuity design. There is a bad, arbitrary cut off at work. What gives good for research ran to just be like If you're like here, you get something awesome and if you like lining of you, get nothing, that's like good for research purposes, but right, never again. Never when you stepped back and think about like that, never actually make sense bright will yet. But the magnitude of the changes is pretty remarkable and airy. I guess we do. We have any. This is way outside of my expertise
I think, you're rises to buy like, is just that? The opening period of your life is so essential that the more aggressive medical interventions can have these kind of lingering effects. I know they don't really going to like cause and effect, but I guess I wondered yes, I mean that's the argument they make in this year. By that essentially- and you know, I went through gazeta- they don't get super in depth and I wanted to understand better like what is actually different about being born. You know a fourteen hundred grand baby verses. Sixteen hundred, I was hoping there be more detail on this. There wasn't, but you today- and this isn't just about things- Rhode Island is doing differently. Rhode Island just happened to give them a lot of really great administrative data. They could use to do this study but the recommendations from the American Academy of Pediatrics is more intensive monitoring near. Certainly a Nick you admission more follow up appointments to check the baby's neurological status or you might be catching things, little bit earlier, but there is one place I was. I was hoping there be a little more
Detail in this study ended seem like you do in some places They were like it, I'm trying to track this down their citing well like one manual from Boston, says like yours: are you treat low eight baby? So one question I did have about this paper is: how am how standard are these protocols for low eight bees, and you know how clearly they being? followed in a rigorous ways that we could really say like. Yes, it's as additional medical care that is is leading to these better outcome I wonder how much the low birth weight is lit like what is the underlying issue exact. I guess I one thing I know from a lot of air pollution studies and wicked snap studies. Is it like a lot of that? There are a lot of things where the dependent variable wines as being very low birth weight. births right right. So, like socio economic role, you kind of wage, so I mean it. It could be that the
Children are very low birth weight because of some bad living conditions that the mother is experiencing and the extra intervene, chins in some ambient way like actually help alleviate right, the light glory, You're bad situation, right that, like it, you are in a just like a very stressful situation like having the extra medical attention might be helping you with something else. I mean it's, it's unfortunate. I wouldn't you know if it isn't they do in this paper. They do look at maternal stress, yet I find that to be. Two things are different under the Gatt which supplies makers, I would have also there may be other knock on things aren't studying, but that is one they thought to study and did not see a connection there. If there's anything, I have five years reads: I Thank you know it is this like a kind of interesting, like matter politics, about biology in the world? Why think a lot of people are permitted minded people
get a little yuri of this whole subject. But this I could turn of like really good evidence that, like biochemical circumstances of people's early life in terms of their exposure to particular pollution, their exposure to metal contamination, the nutritional environment that leg pregnant women and newborns receive the noise level to which children are exposed. That, like all of this type, makes a really big difference. and swamps. This sort of like economics class like everything, is about incentive. Kind of thing like like like be all you can be, unlike we don't want to deter people from from working hard type stuff that like People suffer, and we know it like intuitively right, like in an extreme case like some people can't see, right and it's not like what they need like better incentives.
right is like in your eyes toward your eyes at work, but it is this, like whole spectrum of things were like the very low birth weight children just like, if you give the hell They wind up doing way better. Yet idea you see this tension and how kind of pregnant women and are true indeed, on the one hand, a lot of its very paternalistic and very like don't do this and don't do that and if you like, like I'm, still like a human while carrying this other human, but at the same time you also this developing body of research by the term. Interviews for an episode of us is the impact around people who are looking at the relationship between maternal stress and prematurely
and there's a growing consensus in the scientific community that one things that might be driving premature birth, which is a huge, huge predictor of her infant mortality. Fur ino complications late for that young baby is more stress that something about the bodies reaction to stress just makes it less hospitable place for the baby to hang out anything come out a little bit earlier as of air. He kind of basic interpretation of it. Science- and you know, on the one hand like when I was pregnant, like aged, hated, how like prescriptive everything was in a lot of it, wasn't based on evidence and, like you, end up feeling like this vessel for another, thing. On the other hand, you are a vessel for, like another human, like. There is more and more research suggesting the stress you experience is going to affect the baby that you're carrying, and I think there is often a case for balance like you need to
check the person carrying the baby, the baby being carried, but I think you're right Matt. It kind of gets it like this tension in, like liberal circles around like respecting parents, respecting you do pregnant women as like their own entity, but also like the decisions are making like they do affect the Bay you're carrying two and that's like a bit of a tension. That's going on. I thought it was interesting that the paper almost does that kind of cost benefit analysis, because not only is it clearly a kind of like third, this is evidence for aggressive intervention earlier in an infants life but like they. They then tease out lake and people, young people who ended up receiving these early intervention and receive what was it like? Sixty thousand dollars less enlightened, how about Alzheimer's and social spending public benefits, so I mean that seem to be. Hold subtext. Repaper was buddy
also as it as a redress for social inequities, right that, like it's, it's its correct and proper, to say that, like there should be less leg, overt and some conscious, like discrimination against doubts, but I think the clearest way to read a lot of this is that, like a lot of cumulative disadvantage actually occurs, the very very early in life and they like one of the most promising possible methods to like alleviate a lot of the big systematic inequities we see in America is too like really tackle the specifics around. You know I'm medical care and nutrition afflicting light small babies and small children and things like that, and not just in a kind of like. Sometimes you hear this in alike. Raw schools, sort of contact,
which obviously is important. People spend a fair amount of time in school, but, like you know, it's it's the whole. The whole thing right, like you got eighteen month odds, unlike some of them, are unlike nice, like halfway and middle class households where they have like a lot of resources to bear on this, and a lot of them are in trade and like the quality of medical care like infants are receiving. As like this debate is a big deal one. What did I be curious about is what the reaction would be like to trying to expand these programmes. Let's say, like you know the people around, they see, there's an essay awhile.
It is a bad threshold that we should really look. Let's try moving it up to eighteen hundred that probably can be pretty expensive for the Medicate programme because he knew about half of birth in the. U S are financed by Medicaid Nick you care is incredibly expensive because of the high prices we ve been talking about. It seems like this well, unlike the bigger global picture, it'll pay off in the long run, but you'd have to find the Medicaid dollars to em to finance expanding these services to another group of infants. I don't know how many babies vomit category, but I do know healthcare is very, very expense.
and you. This is like where you do get into lake in single parents. Often this discussion of rationing and then one of things were doing now, as it were rationing this medical intervention for the kids who seem to need it. The most in this paper suggests we're leaving out kids, who could also benefit from its because we're deciding ok. They should go to really the sick s stuff that not the second but the kind of the smallest of the you know what we're, how do you a baby whose, like three pounds, a nine ounces- that is a tiny davy- that babies out can be eligible for this their, and it really is one of the many many rationing says decisions that were made in the United States to say: ok, we're going to reserve this resource for the baby who ways you know three pounds: two ounces, but the baby ways three pounds nine ounces
not going to be eligible for the semi someday. We will do a proper, modern monetary theories of setting the we swelling. This is a good example of the sort of thing where I do feel that, like America is hurt by excessively budget focused. Think right because, like the real thing, the real question this pose is like a can. We like exe and the amount of nuclear facilities substantially to serve a substantially larger swath of that that the new NATO population, I don't know, you know something I know about, but what would be involved in doing that rank is its isn't just a monetary right. It's like, I think, You don't like straw into a big city Nick you and it's like just half empty all the time, and you could just like throw another nurse in their right. It's like you would have to build things. You have to train people are so what would be entailed in the hut, but then how much look. Would that actually be costly as a society, or would it be beneficial like rain?
we'd, be having a much healthier don't worry leisurely like wouldn't be Mozilla society not like. Would it be more costly for the Medicaid Rhode Island probably wasn't ready, but you have to think about it because I get a certain point like it probably isn't, where the cost ride like Putting every new born into this very intensive medical treatments would probably have very few marginal benefits made so that there is a point where it subs making sense, but looking at the cost, benefit narrowly in terms of like how does the budget framework specifically
work is gonna, lead you to under resource things that that pay off. Well, because, like the d, a decrease in Social says long term, such assistance bending is interesting right but, like that's just a small part of the like global social returns, presumably rattling. Whatever reason it is that that people getting treatment wind up having less poverty down the road like has more and more benefits dumb line. In any case, it's you. This is a call to re, evaluate the standard move it up. More states should consider releasing their administrative data about us so that we can get a clear picture what's happening every great while I think I got to the end geyser, so I'm I make my office is literally get me three blocks Amir, I'm glad I we have to go out on a minister to think at least single parent administrator. They have cares when dreams are made of it is it is I'm so
to everyone out therein weeds land. I hope you are your wish, sir. I find farewell from from the audio universe, but So you know we are going to have to return to show a little bit going forward and hopefully will have the you need take on perhaps a broader range of subjects of our. We will be missing absence from the expertise here, so You know please let me know my email address is mad at vocs dot com. If you ve got any thoughts on what you'd like to see, see the weeds go into in the future. This really is a bad thing. A right for listening ethics, Acerra for a lot of great pass over the years, Matt answering a good package and we
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Transcript generated on 2021-09-11.