This Pandemic Would’ve Looked So Much Different Under Medicare For All

Abdul El-Sayed’s new book ‘Healing Politics’ makes the case for a different approach to public health.

At a fraught time for both politics and public health, Dr. Abdul El-Sayed has a uniquely insightful view from the intersection of the two. His resume includes but is not limited to: epidemiologist, Detroit health commissioner, Michigan gubernatorial candidate with endorsements from Bernie Sanders and AOC, and podcast host. And now, author of the book Healing Politics: A Doctor’s Journey Into the Heart of Our Political Epidemic.

GEN caught up with El-Sayed about how our political system has failed to prepare us for the Covid-19 pandemic, and where we go from here.

GEN: To oversimplify, you got into politics and wrote this book because you had a professional view into how messed up the public health was in this country, and you wanted to fix it. How has the American response to Covid-19 confirmed or contested your understanding of those structural failings?

El-Sayed: The reality of public health is that it’s a lot more about preventing than it is about responding. So the fact that we’re even in a position of responding speaks to the foundational failure of our system. Not to take anything away from leaders on the front lines who are actively responding to the pandemic — they’re doing their best at the state and local level. I think the federal response has been less deft.

It speaks to the fact that as a country, we have disinvested in basic public infrastructure like public health departments. They’ve seen their funding drop by about 45% on average over the last 15 years. Disinvestment in the CDC and disinvestment in our global public health apparatus has left us vulnerable to this. Not just the pandemic itself but also the profound vulnerability of people to this pandemic. People are forced now between staying home from their $11.00/hour job to save lives or go out to work so that they can put a meal on the table for their family and save their livelihood.

What should we have done differently? What would better funding have paid for?

Number one, you can think about an epidemic kind of like a fire. You can put it out when it’s in the toaster, or you can put it out when it’s in the house, or you can put it out when it’s in the neighborhood — but then it’s an inferno and a lot harder to put out. Right now we’re fighting an inferno. [What we’ve done is] like taking all the batteries out of the fire alarm in your house and then laying off the entire fire department and then wondering why there was a fire.

We would have used that [funding] to actively engage with the Chinese government to help put out the pandemic when it was limited to just Wuhan. As soon as we had intel that there was the potential for a global pandemic, we would have started mass-manufacturing tests and gotten our hospitals ready for the challenge. We would have identified where we were going to put excess hospital space and where we’re going to find excess staff. We would have made sure that our supply lines for things like personal protective equipment and swabs and thermometers were accessible and protected. Then with the first case that hit the United States, we would have been able to contact trace that case in every major metro area.

Our response would have looked a lot more like South Korea’s response. A week ago, their kids went back to school. Our students had their school year canceled for the year, and we don’t even know if we’re going to be out of our houses by summer. So this is the difference when you invest in things long term and plan.

You’re a Medicare for All advocate. In your opinion, how specifically would having something like Medicare for All in place prior to this have helped?

I’ll give you four mechanisms. The first is that because our health system runs on a profit margin on both ends, both the payer end and the provider end, the hospital is, in effect, a business. So their highest profit margins are on elective surgeries. Without those, they don’t make money. Because they had to cancel all those elective surgeries [during the outbreak], they are literally battling bankruptcy and Covid-19 at the same time.

Two, because they’re businesses, they’re taught by their consultants that instead of stockpiling a bunch of supplies, which costs money and time and overhead, you engage in just-in-time supply chain. Just-in-time supply chain means that when the whole world is being hit by a pandemic, you don’t have the necessary PPE or ventilators or anything else to respond.

Three, people in our country have learned that if they have the nonspecific symptoms of a cough and a fever they probably should just power through because, especially at this point in the year where most people haven’t paid down their deductible, they’re going to get hit by a really expensive bill on the back end. So they just ignore it.

Lastly, as a society, we think of ourselves as consumers of health care. But in reality, in our health care system, we’re the reason a transaction happens between two companies: the insurance company and the provider of our health care. So there’s really no incentive in our health care system to prevent disease because disease is the reason that money changes hands.

With Medicare for All, it changes the entire concept of how we prioritize and incentivize our system. One, everybody gets care without a copay or deductible, which means that if you have those nonspecific symptoms you go to a doctor.

Two, instead of just-in-time and instead of having to make your way through elective surgeries, Medicare for All would allow a direct influx of resources at the hospitals in real time to take on a pandemic without having to worry about whether or not they’re going to go bankrupt because the payer is the government.

Three, there’s no just-in-time supply chaining because it’s not just a business. You realize that you have a responsibility above and beyond your bottom line to care for people. So there’s more access to health care in rural hospitals and those hospitals don’t have to listen to all these directives that help them shave off an extra buck on their overhead.

Then lastly, there’s a real incentive to protect and prevent against infectious diseases and all disease by investing in our public health infrastructure, because the same payer that invests in prevention sees the benefit of the payout. So under Medicare for All, if the government is your insurer and the government is also your CDC, there’s a lot more incentive to invest in the CDC to prevent disease on the front end and save taxpayers money on the back end.

So we would have been so much better equipped for something like this. Everybody points to Italy, which is such a disingenuous point because when was the last time we ever compared ourselves to Italy? [Instead we should] look at South Korea or Taiwan, both of them best in class in terms of Covid containment, and both of them have a system that looks a lot more like Medicare for All than what we have.

Are you any more optimistic today than you were, say, two months ago that Americans will begin to understand why we need Medicare for All?

It’s hard to be optimistic about anything in the middle of a pandemic, but I am hopeful. I think reality has just made the argument for us.

The other sort of obvious point is that Americans actually do support this. It’s just that our politicians don’t. That’s a point that sometimes gets lost. You look at poll after poll after poll, people support government health insurance. That’s what Medicare for All is. Our politicians don’t because a lot of our politicians are too busy taking money from corporations that benefit off of the status quo.

I hate to say it, but by the end of this, everybody’s going to know somebody who either died or had a really bad [case] or went bankrupt. That reality — that forces us all to pay attention to the suffering we have as a society. I think that’s going to be moving our politics in a pretty tremendous way.

I live in the Chicago area, where Black residents are dying of Covid-19 at a disproportionate rate. I know that’s true in your home state of Michigan as well. Why is this happening and what do we do about it?

Disease has a very particular physics to it, in that it always finds its way to the most vulnerable people in our society. It doesn’t matter if it’s Covid-19 or infant mortality, Black folks suffer more. They suffer because of the system of insecurity to which they are the most vulnerable.

You look at who is most likely to work a low wage job on the front lines, driving a bus or working in a grocery store: folks who didn’t have a great public school system or access to university education tend to disproportionately be Black. Where are the communities where people’s lungs are getting pummeled by air pollution, even at baseline, so they have higher rates of asthma? We have a new infectious disease now that has a predilection for people with bad lungs. African American folks [have been] forced into that housing because of the Federal Housing Administration as a function of the New Deal actively discriminated against Black people.

All of those reasons and the ways that they interact with each other and bump up on each other and compound on each other, this structural racism in our society is why black people are suffering more.

What do we do about that right now? Obviously, in the long term there are huge structural changes that need to happen, but what do we do about this next week? Next month?

The big thing, frankly, is to buy people out of their responsibility to have to go out and work and put themselves in danger. If you’re choosing between working in the kitchen of a restaurant to save your livelihood or staying home to save your life, that’s a false choice nobody should have to face. We’ve made a one-time cash dispersal, which frankly does very little. We’ve got to do more. This is the moment where we’ve got to waive people’s health care costs. We’ve got to provide them a universal income. We’ve got to waive utilities and evictions. Then make sure to get the word out about what social distancing means, how to protect people, and then make sure that people are getting access to testing and getting access to hospital care when they need it.

A lot of people have made the point that politicians generally understand the need for preparedness for a war better than the need for preparedness for a pandemic. Obviously Trump is an egregious example, but why do politicians not seem to have the same level of deference for public health officials that they do for, say, generals?

Humans are not great at understanding cause and effect relationships when there’s not an obvious protagonist and antagonist, and when there’s a wide time differential between cause and effect. So this is why we’re so bad at preparing for things like pandemics or addressing climate change because these are long-range problems, the outcomes of which can’t be directly tied to a particular thing and that don’t have a clear antagonist.

In a war, there’s the bad guys that you’re fighting. They do a bad thing, you see the consequences of the bad thing immediately, and there’s an immediate ramp up and response. Whereas in public health, your enemy is literally unseen, it’s a tiny little virus that doesn’t have a name or face. It doesn’t scowl at you. You can’t stereotype it on the news.

Your book came out last week, but you wrote it before this pandemic began. What do you hope people take from it now?

I went back and forth as to whether or not we should actually publish the book in the timeframe we were planning on. The reason why we decided to publish [on schedule] is because I think the book matters right now. In so many respects, it tells the story of the preamble to what we’re dealing with right now. I wish that wasn’t the case, but I also think it’s important for folks to be thinking about how we got here, so that we can never get here again.

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