Sarah Kliff and the Insane Saga of American Emergency Room Bills

in America a savings account. But all the major candidates have spoken with one voice about one thing, universal healthcare. Most have even endorsed Bernie Sanders Medicare for All bill, similar to Canada's National insurance system. Sounds simple, at least in theory, but as our President said, it's an unbelievably complex subject. Nobody knew that health care could be so complicate. Indeed, I needed someone to break it all down for me,

and the choice was obvious. Sarah Cliff of Vox is the clearest, liveliest, most knowledgeable health care reporter out there. Not only has she spent thousands of hours reading all the major universal coverage proposals, really all of them, but she studied foreign systems too, especially her native Canada, and finally Cliff started out as a politics reporter. She gets that even the best bill doesn't do sick, cash strapped Americans any good if it's not calculated to get through

Congress and onto the President's desk. As a savvy observer of politics, at one point, Sarah Cliff held out hope that the current president, understanding his base, might be the unlikely vehicle for reform. I remember the very start of right when he's coming it off, as he gave this inner view where he said he has a healthcare plan and it's going to cover everybody, and like it's going

to be cheap and great. I remember I was up on the Capitol and like all his healthcare reporters are like, oh, maybe there's a plan, Like maybe he has a Like there's never a plan. There just is not a plan. Now, this is a topic so broad and so essential in people's lives, and is uh, you know, always in the top three of people's concerns politically during election cycles. What are we going to do to revamp or to improve healthcare?

And in that conversation, and I want to keep this on very Layman's terms for the time being, because because because I'm a bit slow in this area, because people will point to the Canadian model and say, just to the north of US, Canada has this system. What does the Canadian system look like to you? What do they do and what don't they do? The Canadian system, I see it as one of the most equal health care

systems in the world. So what they do, which is unique, is they offer a government run healthcare plan to all their residents with no charge when you go to the doctor. And that is true for hospital visits, for doctor visits, for kind of the base level medical benefits. And what they do to kind of make that possible because it's kind of expensive, right to give everyone healthcare with no fees when you go to the doctor, they make it a pretty limited benefit package. So there is not vision care,

there is not dental care. Prescription drugs actually aren't covered in the Canadian system, which is now seen by Canadians is a pretty big gap and something some Canadian politicians are trying to fix. But what they really believe is that for this core set of benefits, everyone rich, poor, they should all have access to it. Nobody should be paying when they go to the doctor, and they do end up with slightly longer wait times as a result.

But most Canadians I've talked to about this, they're fine with us as long as the rich Canadians and the poor Canadians have to wait the same amount of time.

Right now. Now, when they were arguing about whether or not to have this in because you can talk a little bit from the history of it, how did it come about, What was the argument that won the day, How did they actually pull it off there that they convinced that the government and the people of the country that it was in their interest to pay for the lion's share of their medical care. Yeah, so it's kind of a wild story from Saskatchewan history, which most people

are not very versed. I'm dying it's the most exciting Saskatchewan history you'll probably learn all day. So what happened, and it really has some striking parallels to where we are in the US right now. In the nineteen sixties, there was a socialist running to be the premier, which essentially the Canadian version of governor of Saskatchewan. This guy named Tommy Douglas. Tommy Douglas was running on a healthcare platform. He was running on the idea that healthcare should be

a human right Canada. You know, kind of at a healthcare system, a more rudimentary version of what we have right now. Women were providing care at home to the best of their ability. There was kind of a makeshift system of doctors. What Tommy Douglas really argued in his campaign and the campaign that he won, was that health care should be a right for all Saskatchewan residents. And there's a lot of parallels with the Bernie Sanders campaign. I think, you know, this is a socialist running to

be the first socialist premier in Canada. He wins, and then he has to implement the thing. And in nineteen sixty two, July one, nineteen sixty two, Saskatchewan becomes the first universal health care system in North America provincially. So now we're just looking at one province Canada, eleven provinces.

It is so similar to where we are now. Conservatives making the argument that they don't want the government involved in medicine, that they know best, that they're worried, you know, that the government is going to choose what health care you get, and one health care you don't and all the doctors go on strike and Saskatchewan has to fly in British doctors from the National Health Care Service to staff their emergency rooms. It's pretty it's like a wild story.

And twenty three days so the doctor what end of the strike is. They also fly in this mediator between the Saskatchewan government and the Saskatchewan doctors and they get a few concessions and is known as the Saskatoon Agreement, settled on July twenty nine two. And what they agree to is that doctors are allowed to opt out of the system if they want that they don't have to participate in government health insurance. They can just work privately.

But if they are going to work privately, they can't accept government insurance. So it makes a big trade off. The fees get raised a little bit, they get a bit of a pay raise, and the doctors agree to come back to work. And Tommy Douglas, the premier who started all this is actually a bit of an icon in Canada now. The CBC, the Canadian Broadcasting Corporation, in two thousand four hosted this kind of odd television event where they decided they would vote on like who was

the greatest Canadian and he was the winner. He was voted in this like primetime special player. But right do you think Wayne? Exactly? Um, So what happens after Saskatchewan does national healthcare? You quickly see other provinces building their own healthcare systems, to the point now that within a decade or so, Canada had national healthcare. And they pay

for all this with tax revenue. So Canada has significantly higher taxes than we do, and that money is federal income taxes is what they're financing the whole system with. When the agreement was made, when the mediator from the British healthcare system comes in and mediates the whole thing and they have what was that with the Saskatoon agree agreement? What do you what do you think was said to if you recall or what do you think finally convinced them to support this idea? I mean, I think there

was decent political support. So you know, you do have the doctor saying we don't want to involved in healthcare, but you also have this premier who has run this campaign promising universal healthcare. It's popular, you know, just in the out played politically. I think they got outplayed. I think they realized once they got three weeks into this strike,

you know, the government was not going to bend. They kept saying, we'll come back to work if you don't do this Medicare for All program, and the government just said no, you know, and eventually the doctors needed a job, right, like you can only go out of work for so long. They were like the air traffic controller exactly under. And you actually see similar things from when Medicare launched in

nineteen sixty five in the US. You saw some hospitals in the South, because of some of the rules around race that you had to treat patients of all race if you were going to participate in the Medicare program. You saw some hospitals in the South say, you know, well, we're not going to take Medicare, and eventually they caved because the government has a pretty powerful tool, right, They're going to pay you a lot of money to cover

healthcare bills. Usually we've seen historically healthcare providers come around and accept that money. Why do you think the same thing hasn't happened here. We've never actually seen a state try and do single payer in the United States. We've never seen a state get as far as Saskatchewan did, and I think part of that might be the lobbying that happens even before you get that far. So I think, you know, you haven't seen legislators be willing to go

far enough. You know, you did see Medicare and acted, and that was a big step in nineteen sixty five when the government created Medicare for the elderly Medicaid for the poor, and that was something the a m A, the American Medical Association, and they opposed both of those programs, which now are quite popular in the United States. So the popularity is what silence is the medical community. I think the popularity certainly makes it hard to lobby against them.

It's a lot I think would be very, very hard for the A m A to launch a campaign today is saying, you know, get rid of Medicare and go back to the way it was. When you have millions of Americans who are on Medicare, who like their Medicare plans, that's a pretty tough sell. How long after the creation of Medicare and Medicaid, both programs became the equivalent of like settled law. They're not under any threat. They're there to stay. I mean decades for Medicaid. I think medicaids

a pretty interesting example. So Medicaid covers low income Americans and it's a state program, so your state has to opt into it. In six five it's created. How many states opt into it? Now all of them? But that was not the case. Only about a dozen or so states signed on at first because one of the things the government said is, you know, we're going to pay part of the medical bills, usually most of the medical bills, but you're going to have to kick in some money too.

It wasn't until nine that all states participated in medicaid. So we're talking about twenty four years from the start of medicaid to universal medicaid in the US. We were joking before we started recording with you that you were given an assignment. You were like, oh God, not this, And now years later you're an expert in this field. Yes,

it was a little bit of happenstance. My first job was at Newsweek magazine here in New York, and I was an intern there um in right around when President Obama was making his first run for office, and I

was on the politics team. The election died down. There are too many people on politics and I got moved to healthcare and this healthcare debate was starting up in d C. So I kind of just raised my hand to cover it, you know, not knowing that what thirteen years later, I would still be writing about the same thing. But I think what I really love about this topic is that there's such an intersection between the policy decisions that are made and the personal stories. Like you said,

this is such like a human topic. There's so much at stake when people can or can't afford healthcare. A lot of the work I do right now is around healthcare pricing. You know, how much is charged for healthcare. And we've made this decision as the United States not to regulate our healthcare prices, and it's a very unusual

decision for a developed country to make. I talked to a family in California who have a daughter with a rare condition, and they were charged twenty dollars for an m r I. Like that is an astronomical because Stanford wanted to charge dollars for an m r I. Because you can make a lot of money charging twenty dollars for m r I. No one challenge them, nobody, no regulators, No, Well, there's no regulator to challenge them in the US, You're

about to charge whatever they can get away with. Yeah, so you know in this like in this particular case, they needed to see a certain specialist who is there, and the specially said, oh, let's take an m R I. And they figured, you know, how much can an m R I cost? Maybe a few thousand dollars. They weren't warned by the person how much the m R I was,

and honestly, the person probably didn't know. One of the things I hear a lot from doctors because I'm quite critical of pricing that well, we're just trying to provide the best care. We don't know the prices. And that might be the case, but you know, not knowing the

prices has a huge effect on the patients. I think sometimes when I talk to doctors, I feel like some of their views are a little bit myopic, that their focus is on, you know, we just need to provide the best care and the patient's going to deal with the bill later. Like the bill could be catastrophic for this family. They're not poor, but this bill is a quarter of their income for the entire year. And you know, the hospital just kind of said well, that's that's our price,

and now they're stuck with it. Um. So, you know, I really think it's such like an interesting, fascinating beat where you can see the policy decisions being made in d C, being made in state houses, of such personal effects on all of us. It's so universal, you know, no one gets stopped out of the healthcare system. Was it? There was some neo sporing his daughter. He has like a one year old, and she managed to tie a piece of her hair around her toe really tightly, to

the point it was turning blue. He takes her to the e R because it's the weekend. Everything else it's closed. Turns out it's totally fine. They put the news boring on it, head home. A few weeks later they get a bill for six for this interaction. You know, I

think price transparency would be a start. You know. I think who's opposed to that the hospitals, you know, because it's it's a great system right for hospitals right now where you can like take people who need care and then build them whatever and the alley on the way home, like that's a that's a system that really advantages hospitals. The American Hospital Association. So what does the medical profession itself say on the record of what kind of healthcare

they think the country should have. So I think they generally I see them as aligning with the Hospital Association. They are the people who are providing care pretty similar to hospitals, so they want to be you know, they generally support widespread access to care. They were supporters of the Affordable Care Act and the expansion of coverage. They also support, you know, pretty high they want to get, you know, and this is where you get into you

you can frame it different ways. They want to get what they say are reasonable rates for the services they provide. If you're opposing them, if you're an insurance company, you're going to say they want to get outrageous rates for the care that they provide. But they generally support access to care as long as they're getting paid the amount they would like to get paid. And you know, I will say it's hard to paint doctors with a broad

brush where you have an interesting split. There's been some interesting research if you look at the political affiliations of doctors, where you see primary care doctors, obstetricians generally lower paid fields in medicine. They tend to lean more liberal, align with the Democratic Party. Higher paid doctors and stusiologists. Radiologists tend to be a lot more conservative. So I will say,

you know, there are doctors who support single payer. There are doctor who oppose the Affordable Care Act, but generally if you look at their lobby, they're okay with expanding coverage as long as they're getting paid a decent amounts. Now, in Canada, where there's this core of services that are basic services that are covered by the government, you pay nothing. Does the majority of the population then go out and get a supplemental policy to cover the other side dental

and vision and so forth. They do about two thirds of Canadian care some kind of supplemental policy. Also for drugs too, is a major thing that people are buying their policies for that often works actually pretty similar to American insurance, where it's a benefit at work is that your employer will offer a supplemental plan. One of the things that's actually pretty unique about the Canadian healthcare system

is they won't let you buy duplicat of coverage. So if you live in Britain, you also get your basic plan. But let's say you want a private hospital room, or you want to jump to the front of the line for hip surgery, you can buy a private plan that will give you those benefits. In Canada, they and it's been the subject of Canadian court cases, they will not allow that kind of duplicat of coverage because they think

it cuts against the equality of their system. So they want to force you to standard line with everybody else, even if you don't, even if you have the means. So you have that description of the system in Canada. We're gonna get to the US in a moment, talk about the systems in in the UK. In the UK, so they you know, in some ways it's a much more public system. The hospitals, the doctors, many of them

are working for and owned by the government. So whereas in Canada you have a public health plan with private doctors and hospitals, in the UK you have a public health plan and public doctors in hospital the government. Everyone's on the payroll of the government. Pretty favorably. You know, Brits are pretty proud of their system. If you look at international rankings. The Commonwealth Fund, which is a really respected healthcare nonprofit, they rank the British one above the

Canadian one. But you know, I think what's interesting is even though Britain is such a public system, you also about ten percent of Brits who are buying this duplicate of coverage to you know, get to the frontal line, get their private room that they do allow insurance to compete with their plan. And they think of it as like a safety valve, like letting people out of the

system into the private system. That frees up some of the public doctors for lower income people, and it lets the people who want to buy their way duplicative are you know, I don't know if I would say a supporter, I think it's a more realistic system for the US.

I think, you know, we have a system where high income people are very used to being able to buy the care that they want to buy, and why shouldn't they you know, in Canada, they would argue, because your access to health care shouldn't depend on if you're rich and poor, and you know, if there's a baseline of healthcare that's paid for with the public dollar for them, why would you condemn other people who could have better healthcare because you'd worry about that private system of writing

the public system. So Let's say you know, in the private system, doctors are earning more, they like it better, they just stop seeing public patients and they create a practice where the well, you didn't allow that, you said

you have to do both. So I think it gets to like some core philosophical differences between like the UK and Canada, Whereas Canada, you know, at the core of their system, they just don't think money should buy you better health and where everyone to be in pain at the same time, want everyone poor and rich to be in pain and get better at the exact same time. Like, there's this great quote and um tr read he's a

fantastic journalist. He wrote this book, like he um. I think he's a freelance journalist now, but he used to write for the Washington Post. And he wrote a book in twenty comparing um It's called Getting Better, Comparing Different Healthcare Systems. And he's a fantastic quote in it that I've always loved. I feel like it summarizes the Canadian

healthcare system better than anything else. Someone told him Canadians don't mind waiting in line for healthcare as long as they know the rich Canadians and the poor Canadians are waiting the exact same amount of time. I think Australia has a fascinating healthcare system, so they, unlike Canada, they

really encourage people to buy a private plan. So I actually think, like the more I've learned about Australia system, that they're a promising model for the US where because they don't they they've run into challenges raising enough tax revenue. They've decided to deal with that not by shrinking the benefits or weights, but basically encouraging people to buy a private plan that is competing against their own plan, which feels like a much more American version of a healthcare system.

So this issue in this country obviously appears to be a very partisan issue. Are there any Republicans that you can name off the top of your head where you think are strong on good reforms in healthcare. I think a lot of Republican voters are interested in Medicare for all. That's one of the things that surprised me. I was actually doing some reporting and this area of Kentucky that went for Trump, but also it's a ton of Obamacare enrollment, you know, as reporting on why did all these Obamacare

rallies vote for Trump? And I wasn't there to talk about Medicare for all, but one of the things that came up multiple times from Republican voters was I wish we could have a system like Canada's, you know. And these are people who you know, supported President Trump, knew he wanted to repeal the Affordable Care Act, telling me they like Canada's healthcare system. And I think this is a place where you see a bit of a divide between legislators and like the Republican base and how they

think about healthcare. That was healthcare guru Sarah cliff a Vox. If you want to hear Bernie Sanders ideas straight from the horse's mouth. Here's the thing, as you covered, what is the function of an insurance company. It's not to provide quality care to of course the effect, the ways to make as much money as they possibly can. And um, you know what I think makes sense to me is we have right now a fairly popular successful program, cold Care.

It works pretty well for people sixty years of age old. Why not expand it to everybody? Here's the thing. Dot org is where you can find my whole interview with Bernie Sanders, now a declared candidate for the Democratic nomination to the presidency. In this is Alec Baldwin and you're listening to here's the thing. Sarah Cliff cut her Healthcare reporting Teeth covering the two thousand nine debate over Obamacare for Newsweek. I wanted to understand what Republican objections to

the policy had been back then. That is going to be, you know, government takeover of healthcare, that the government was going to dictate which doctors you saw. I only talk government takeover of health care to the idea that big government is always bad and always leads to something ineffective. And did they were there anybody who are taking any specific reasons why they thought it was better? I think.

I think the more thoughtful critique that I saw from Republican legislators is that one of the things Obamacare was going to do. It was going to require health insurance plans to cover a wide array of benefits, so something like maternity care, for example. Usually in the individual market before Obamacare, health insurance just would not cover pregnancy because pregnancy is expensive, so that would just be a benefit

that would not be included in your package. One of the things Obamacare would do, and this is along with like prescription drugs and mental health services. It told insurance companies, you have to cover this wide suite of benefits. I heard conservatives making the argument, you know, people should be free to choose. They should be free to choose a cheaper, skimpier health insurance plan and have that cheaper coverage, and

not everyone should be forced into these larger plans. So it's a bit of like a philosophical difference I think about healthcare right, like, whether we think, because we're all members of society and we all participate in healthcare, we should be required to purchase coverage for this wide suite of benefits, or if we should give people the option to buy these skimpier plans that often, you know, leave people a little flat footed when they actually do need

to go to the doctor. I think that was a key actual divide and how the two parties thought about policy. So do you think that there's some sense to that, which is that we should give people some choice. It's it's hard, right because if you leave out maternity care, you know, that puts the entire cost on anyone who's going to have a baby. The whole point of health insurance is to spread our healthcare costs out among a wide group of people, so that it's roughly affordable for

all of us. You know, even when you know, I had a baby last year, that's being spread out among my health insurance plans, and the years I don't have a baby, I'm kind of contributing to the other people having kids. It's really hard to let someone opt out and have a health insurance system still work, you know.

That being said, you know, one thing the Affordable Care Act did is it did let younger people purchase catastrophic coverage, you know, coverage that paid for a smaller boundaryr benefits essentially like if you get hit by a bus, it kicks in, but you know, and that went up to age thirty under the Affordable Care Act. Republicans would have liked to let everyone by catastrophic coverage, but it's a big trade off. You really disadvantage when you let healthy

people just you know, buy these skimpy plans. You're really going to disadvantage the sicker people who need well. It becomes power, like you either in it or you're out right yeah, I mean, Democrats didn't like the individual mandate was an incredibly unpopular policy, but The whole reason they included it is because if you are going to make an insurance system work, you need a lot of people buying in. You need the sick people, you need the

healthy people. And when you have an array of options, when you have like the skimpy plan and the robust plan, the healthy people by the skimpy plans, they don't use much healthcare, the you know, sick people by the expensive plan with lots of benefits, and the insurance market, you know, essentially breaks down a little. You need the healthy people subsidizing the sick people in order to make things work.

But where, and just philosophically, when we'll government and society say, hey man, your forty pounds were more overweight, and you're over fifty, and your cardiac cat scans at the following metrics. To us, your your insurance gonna go way up. Maybe you can smoke right right now, they're saying, when you get a discount, if you don't smoke, you get a preferred rate. If you don't smoke. When are we gonna start to hand people the bill for their bad behavior?

Do you ever see any countries to do that? Well? In the Affordable Care Act actually under Obamacare. If you're buying an Obamacare plan, there is a question about whether you smoke, and if you do, you're going to be charged higher premiums. Um I don't know. I mean it's like a checkbox you could check no and get the cheaper premiums. I don't think anyone's really following up on that. I mean one of the things you actually see a lot doctors be obligated to report the fact that you

do that. They're your doctors and they know what you're I don't know many people who smoke and line to their doctor about that. Sure, yeah, I mean it gets into some kind of tricky patient privacy issues or you

don't want your doctor. But you know, you see a lot of corporate wellness programs and it's like kind of these ideas if you participate in the wellness program and like you meet certain wellness metrics, your company is going to give you a discount on your health insurance, like if you go to the gym or you know, sign up for some kind of program. And I mean it's

like a tricky ray area. I don't know. I don't know about how national healthcare systems are handling that right now, but I think it's an issue that becomes a bigger one, you know, as you see obesity rates going up, not just here in the US but abroad, like that's a difficult one to handle. But it seems to me now that the inequity of healthcare and the way it plays out now has broadened in the last twenty five years, is it safe to say that that an increasing number

of people don't have adequate healthcare now? So you did definitely see through the start of the Affordable Care Actor,

a rising number of people without health insurance. And I think that largely has to do with the fact just healthcare got really expensive that There's actually some great charts, I know, they're great for audio, where they show like our healthcare costs used to be in line with the rest of the world through like the nineties or so, and then in the nineties and these charts you just see the US skyrocketing up, whereas like Canada, Netherlands, UK are like growing at a reasonable rate of like three

or four percent a year, we start growing at seven or eight percent a year. And as healthcare costs rise, it's just harder for lower incompete boll to afford healthcare so you see this growing gap between rich and poor. You know, you don't see it for people over sixty five because they're on the Medicaid program. So everyone has access to healthcare once they get to sixty five. But Medicaid has always been like a pretty restrictive program. It's

difficult to get on. It's limited to certain groups of people. You have how many people just Medicaid service now? So right now Medicaid actually services about sixty million Americans. It's a really big chunk of the population. And it's actually you know, the people who have gained health coverage under Obamacare, most of them have gotten it through Medicaid. Before Obamacare. To get on Medicaid, you had to be poor and something, so like poor and a mom, or poor and disabled.

The Affordable Care Act said, you know, if you are an individual, you earn less than fifteen thousand dollars a year, there's no end. You just get Medicaid, um and that's the law. Now that is the law, well, it's sort of the law now. So the idea was this program would exist in all fifty states, but we had a Supreme Court decision in twenty eleven that said states get to choose whether and not they want to participate in

Medicaid expansion. About two thirds of the states are participating, but some really big states Texas Florida have big populations of low income people who don't want to pay, and they only have to pay ten percent. I would say, you know, this is a really generous offer where they don't have income taxes in those state or other mechanisms to pay for and they want to keep it that way. There is no income tax in Texas and Florida's if

iinder stand correctly, I think that's right. And you know they don't want to raise in any case, they don't want to raise the revenue to pay for those programs. Um so. And that's really so. You see what the Affordable Care Act coming into place in the uninsured rate drops,

more people are gaining coverage. Can you see these trends of rising uninsured numbers reverse ever since Trump took office though, you've seen a bit of a reversal where some even though the Affordable Character is still standing law, some of the decisions they've made seem to have, you know, led to more people losing health insurance. So what are what are the most evil things you've seen hospitals and insurance

companies do when you've been reporting on healthcare. Yeah, so I'm gonna give you two from the emergency room space because this year I've been doing this project on emergency rooms where people have been sending me their e er bill. So I read all sorts of horrific stories all day. Yes, I've read about six d emergency or bills in the last year. UM, And so two of the things that jumped out of me. You you just click through the you feel a little better about yourself when you're only

dealing with a hundred fifty bucks. So one is Zuckerberg San Francisco General Hospital. So this is named for one Facebook founder who donated a lot of money to the public hospital. Um, they have made this really rare decision to be out of network with all private health insurance. They are also the only trauma center in San Francisco. So if you have a trauma, if you fall from a high height, if you are hit by a bus, an ambulance is going to take you to San Francisco

General Hospital. And if you have private insurance, they are not going to be in network with your health insurance. So let me tell you like what patient I wrote about there? Who know, this is just like a horrific story. This is a guy named Justin who was walking on the sidewalk and this pole hanging off the back of a public bus hits him in the face and knocks him unconscious. Next thing he knows, he wakes up at San Francisco General. He has you know, severe concussion. He

has a laceration to the face. He also ends up with a dollar bill. So this guy was hit by a public bus, taken to the public hospital, the public health bus. Yeah, like everything about this was so horrendous. Grand What kind of treatment did he receive when he was there? He got a CT scan, some pain meds, and some stitches. That was it. That was it. So it was very very basic. It was a pretty yeah. I mean it was not a complicated visit. And you know, this is a case where he had no choice. You know,

he was knocked unconscious. I think healthcare is the only good you purchase when you're not conscious. You know, someone else called an ambulance. The ambulance took him to place. You know, he's having this work done when he's not awake, And I think that is that is One of the reasons, you know, I find these er situations especially frustrating is because you know, you do do have people who aren't

able to shop. You can't decide if you want to go to the emergency room if you're having a true emergency, and that creates this monopoly like behavior where you see this billing at absurd rates because patients just can't say no. The presumption from when I was younger, what was explained to me once that they've got to charge everybody these big numbers to keep the place hot and ready for the serious catastrophic injury when you walk in the door and you've got poison ivy and they got to give

you a bill to help pay for the guy that had the steering wheel go through his neck. Yeah, I mean, I hear that a lot from emergency room. I am very skeptical of that argument one because I see the prices just very the price of being prepared seems to vary wildly from one hospital to another, so that it seems a little bit of a false justification. I do understand, you know, they need to keep the lights running, they need to keep it on, they need to be ready

for the gunshot. Wounds, but they also charged the guy with the gunshot wound a lot more than the poison poison ivy person. Like, they essentially have these things called facility fees where if you're you know, the poison ivy person, you get a level one facility fee, but if you're a gunshot person, you're going to get level five and

that's going to be quite expensive. So it's not like I do understand people have to It doesn't happen in Canada, right, Like, if you have a health care system where you decide that patients shouldn't be the ones bearing those costs, then you can avoid it if you want to create a policy situation that avoids it. Plus that more and more uninsured people are using emergency rooms for regular medical care.

They go there with the flu. They should be seeing a doctor and they shouldn't be cluttering up emergency room, but they got nowhere else to go because don't have

any insurance. Well, and I mean, one of the things I see a lot and all these bills I read, are people end up at the e er on nights and weekends because they know it's not an emergency, but it's the only thing that's open and you know, it's often like their young kid did something at a weird hour in the night, the urgent care said we can't we don't see pediatrics or the orient cares and open, so they go to the emergency room. So it just

it's it's a hard system for patients. There's like it really feels stacked against you in that sort of way. I mentioned who's a hero of the Republican side, and you didn't come up with a name. Is there one you think of that's a villain? Gosh, that's a good one. Um. I mean, one of the hard things here is that Republicans just they don't put a lot of their energy

into healthcare policy. I would say, you know, when I was covering the repeal debate in seventeen, it was very clear that, you know, Republicans are almost like the dog that caught the car they won on this campaign to repeal Obamacare, and I was like, oh crap, we actually have to come up with a replacement, and they were not able to do it. And I think, you know, it just speaks like a fundamental difference in the issues

that Democrats and Republicans are thinking about. Democrats are thinking about, um, you know, how can we cover more people? How can we you know, make health care access more equitable. Republicans wanted to repeal the Affordable Care Act, but I was kind of like I didn't know what came next and

then what and it wasn't clear. Like whenever I would interview people in about like, well, what are the goals of this health care effort you're working on that would become Obamacare and they say, you know, we want to increase access and reduce cost. Would be some version of that answer. When I would interview Republican legislators about this, it'd be like, well, we want to repeal Obamacare, and they think because they did not have and then what

it all fell apart? Who's the person that you think expresses the best possibility of where we go forward from here? So I think Sanders does have a very strong vision for where we go from here that he spent a lot of time thinking about. Gillibrand, Kamala, Harris Booker, all of them are signed on to the Sanders Medicare for All Bill. I think he really is. It is his issue,

you know, he spent a lot of time. I went with him on a reporting trip to Toronto about a year ago, you know, looking at the Canadian healthcare system. You know, I think he very much understands the goals of what he is doing, why he wants to do it. I don't know that his vision is the one that we end up with, but I think it's by far the clearest articulation I've seen of like here's the problem,

here's how I want to fix it. And I think Sanders end himself with the Canadian system, So he really abhors the idea of having insurance like Britons that lets you skip to the front of the line, and this is like a very core principle for him. I think it's also going to be a reason why his bill would struggle in Congress. Um. You know, if I saw us moving to a national system, I'd expect there'd be

some kind of private health insurance option. But I think, you know, it's I think he probably stands out as like the best articulator in the person who kind of best understands why he wants the system he wants, Like he has like a philosophical underpinning that kind of leads him to make certain policy decisions. And his vision of national health care and where are you calling that Medicare for all, Yes, Moose candidates in Vision calling this national

program medicare. Medicare is really popular. It pulls well. I think when you do polls of single payer versus Medicare for all, people like medicare. Actually in Canada it's also called medicare. So, um, it's a popular one. I mean, it's worth noting the program Democrats want to create is very different than Medicare care and Medicare you have to kick in something like of your healthcare costs. Most people buy private insurance to fill in the gaps in medicare.

So the program that they're suggesting is not giving the current version of Medicare to everybody. But since we all know what Medicare is, Medicare is popular, that's kind of become the terminology for a health insurance plan for everyone. Um. Why do you think what's the number one problem right now today? You think with the pharmacy business, I mean,

I think the prices are the obvious problem. Insulin. You know, this is something that was discovered in the ninete twenties hasn't really changed the prices of insulin are so, and insulin is something diabetics need to stay alive. This is another case where you know, you can't shop for insulin. You can't decide it's too expensive. So, you know, I interviewed one patient to you to say, if I don't take my insulin for a few days, I'm going to die.

Like I'm not, Like this is essentially like taking the price of water and tripling it. And they're going to get there and telling me and telling me as a patient, like, well, you come up with the money for it. You know, she's someone who she stays at these jobs she hates because she just cannot live her life without health insurance. So she her whole career. You know, she told me one thing, she went to law school because she felt like law was a stable profession because she'd always have

health insurance. Like that's a crazy way to live. That she is making every professional decision, every personal decision her life around access to insulin. And so I think, you know, when things with pharma, the prices are outrageous in the United States, and this comes back to the fact that the US is the only country that is not regulating

the prices. You know, when a pharma company wants to go sell a drug in the UK, they sit down with this agency called NICE, the National Institute for Clinical Excellence, and NICE basically decides, like pharma says, here's how much we want to charge. NICE looks at how effective your drug is and says, here's how much we're willing to pay, and you know, if they can come to an agreement,

it gets added into the national program. There are some drugs where you know, England says no, They're been a lot of controversies around certain really expensive cancer treatments that the national system in the UK won't cover because they

just don't think they're worth the money. So there certainly are some trade offs that after you made like there are some very outraged cancer patients in the UK, you say like I want the government to cover this, and they're not going to cover it, whereas in the US you probably could get coverage for it, but it's going to be incredibly expensive. So that's a big trade off between a system like ours in a system you know,

like the UK's. But I would say, at some point the drugs and we're at that point they're getting so expensive that it's like, yes, you have access to them, but if you can't afford them, what does that even option when when you when you use insulin as an example, when I'm wondering, what is it about their lobbying onto the extent that you can talk about that that makes them so powerful so affect Yeah, so there's just money.

I think a lot of its money. I think there are these ads that ran during Clinton Care, these um Harry and Louise ads that are kind of like burned into the memory of anyone who worked in a campaign dollars, Yes, campaign dollars, and they really launched like an all out of salt on Clinton Care. That really was one of the reasons why that was not able to go forward. I think eval one on an Obamacare so they didn't And this is you know, a theory of government that

the Obama administration had. The abministration felt like they could not survive a pharma on slot. So one of the things they did, and they felt the same way about the A m A the hospitals. They felt like, if these guys line up against us, this won't survive. So they got them all to endorse the bill. And that was a big trade off because there's sort of you know, pharma was not going to endorse the bill that regulated drug prices. So they said, Okay, with Obamacare, we are

not going to regulate drug prices. We'll put a small tax on the farm industry. Basically, they created taxes on all these industries but didn't regulate their prices, and that got them all to sign on. You know, I I don't know if the current Democrats operate under that theory

of governance anymore. I was, you know, just meeting with Promilla Jayapaul, who runs the House Progressive Caucus and rolled out of Medicare for All bill recently, and she basically feels like, you know what, like that, like we are beyond that, we are not having farm and where's their bill? Like we are doing a bill you know, in goal is to piste off farm us, spend as much money

as you want, like we are ready for it. They see a lot of bad outcomes of bringing industry on board with your healthcare bill, and kind of a different view than Obama did going into the Affordable Care Act. Let's assume that everything stays as it is right now, and we have at least in Congress, we have a Republican Senate in a Democratic House, and the White House changes hands. Sanders or whoever, Kamela Harris, whoever in the

White House. What kind of plan do you think there's a chance we can end up with or I think you see a lot of like the assault in the Affordable Care Act, they probably redo some of the stuff you can do through the executive branch. Try and shore that up. It's going to be hard to do these sort of things through executive action, you know, it is going to be hard without having the Senate. It is hard to do a half ast version a weird idea I've heard floated, which like seems to engender a lot

of lawsuits. It is much easier to just lower the eligibility age of Medicare from six to zero, which is like very odd way to do this, Like a lot of benefits would be missing that It's like not the Sanders plan, But I guess that would be like a version of this um that could be done without as much legislating. But I think it's going to be hard and divided government to move forward on this um. I think it's it's a big idea that gets a little

bit stuck in the wheels of Congress. Are you someone who you think it's essential that we have to have a tax increase in order to afford that we do. I mean, we need to get the money from somewhere. And you know, if you've talked to Bertie Sanders about this, he'll say, yes, there'd be a tax increase, but also nobody would be paying their health insurance premiums anymore. So you know, the things is getting changed out of your paycheck. You're taking out of your paycheck, just get changed a

little bit. But I think that is where these programs run into a lot of challenges. There's this guy at Harvard. His name is Williams. Show, and he's kind of like if you're a country who wants to build single payer, he's like the health economist you call. And when I've interviewed him, he's worked without a dozen countries and he says about half of them fail. And the reason they fail is always the step of how do you pay

for the thing? Like you can come up with a really cool system, but the place where it always gets hard is like figuring out, Okay, how do we pay for that system. Do you think that healthcare is at a crisis in this country right now? Yes, I think, And what qualifies I think what qualifies it as a crisis as you have people still going into really significant crippling debt to afford healthcare that they can't say no to.

Like I look at the example of insulin, like that seems like a crisis to me, that people that there are reported stories of people dying because they cannot afford their insulin, Like that feels like it's something fair to call a crisis. Um, what's next for you? What are you working on now? I just know I need to stop reading emergency room bills? Which country has the worst health care system as far as you're concerned, Oh god,

I mean, I think we developed countries. It's got to be the US, right, Like we if you look at any rankings were always incredible, just incredible. The United States healthcare system or Hodgepodge of systems, ranks the worst in the developed world. We spend the most for the worst outcomes. The United Kingdom spends literally half the amount per person as the United States and fares better on hospital safety, on many disease outcomes, on infant mortality, preventative care, and more.

Brits even live two years longer than Americans. You can find Sarah Cliffs reporting, including her fabulous frustrating emergency room billing project at vox dot com. Her podcast, telling the human stories behind healthcare policy is called The Impact. This is Alec Baldwin and you're listening to hear is the Thing four for