Abdul El-Sayed recently spoke with Nathan J. Robinson on an episode of the Current Affairs podcast. A transcript follows. It has been lightly edited for grammar, clarity, and concision.
Nathan J. Robinson: Good evening, Current Affairs listeners. This is Nathan Robinson, your editor in chief. I am here with a very special guest this evening, Dr. Abdul El-Sayed. He is the former director of the Detroit Health Department, where he rebuilt the health department from scratch. He is a former gubernatorial candidate for the state of Michigan, and he is the author of over 80 published papers on public health, and he is an expert on single payer healthcare and inequality in the American medical system, and I am so thrilled to have him with us.
Abdul El-Sayed: Thanks for having me, Nathan.
NJR: You have a fascinating career, but I want to start with what I think is one of the most interesting things that you’ve done. To me, the phase that fascinates me the most is your two years as the head of the Detroit Health Department, because you began as a public health scholar, writing about inequality in the healthcare system, but then you were plunged into actually trying to fix these problems. And that is a very different thing to try and do. It’s one thing to be a statistician and try to document things. But then, you sort of took over the department that, as I understand it, had very few resources when you entered.
AES: That’s right, I did an MD and a PhD, and for a long time, I thought my work was going to document health inequalities, to better understand them, and point to policies solutions. And I got somewhat disenchanted with the academic space, only because I found myself documenting more and more minute and theoretical kinds of issues, rather than actually pointing to the meat of the problem. You know, you can say the same thing multiple times, but you’re still saying the same thing, and you can say it in multiple ways. It’s still the same thing. And ultimately, I wanted to do something about it. I got this opportunity to come home to the city of Detroit, where I was born, just outside, in the suburbs, and raised there, and we’d spend a lot of time in the city, watching what it looked like to cross 10 years difference and life expectancy in a 20 minute car ride, which is the same 10 years difference that I would travel for 12 hours to see, when I’d go back to Egypt, where my father is from.
NJR: So, that’s like, downtown Detroit, versus the suburbs of Detroit.
AES: That’s more of the outskirts of the city of Detroit. The city is huge, it’s 138 square miles. And downtown, and midtown, are actually doing okay. The problem is actually what happens in the neighborhoods, where you have this complete lack of basic public resources, and public health was one of them. And I had the opportunity to come home. The city had gone through bankruptcy, and during the bankruptcy decision, they made the very fateful decision to shut down their 185 year old health department in a city with a higher infant mortality rate than my father’s native Egypt, where our children face three-fold the probability of being hospitalized for asthma, and four-fold the probability of being exposed to lead. I walked into a department that had five city employees, and 85 contractors, in the back of the building, where people pay parking tickets, in the city of Detroit. And my job was to provide basic public health goods and services alongside a team, and learned a lot about what it means to apply theory in a challenging bureaucratic context, and more importantly, to center what we often talk about in abstract, in the lives of real people that I got to meet and serve when I was health commissioner in the city.
NJR: Yeah, so, I want to talk about that, because when you were writing about health inequality, obviously you’re seeing it manifested in basically every domain. Healthcare in Detroit is obviously dysfunctional in 1,000 ways, and yet, when you enter that department, if you’ve got five employees, presumably, you have to triage, you have to pick things, so what do you do when you sit down and think about the question, “how do I pick something that will be useful?”
AES: Yeah, Nathan, I’ll answer that in two ways. First, oftentimes, when we talk about health, we mistake health for healthcare. Healthcare is all the things we can do when somebody gets to a clinic, or a hospital. The problem, though, is that the places where people get sick in the first place, are not those places. They’re in the communities where they live, learn, work, play, and pray. And that is the space where public health operates best. And when you don’t have that, you start to see deep inequities. Because the reality is that if you make above a certain amount in this country, the probability that you’ve engaged with your health department in any meaningful way, is pretty low. The fact is that you can afford a lot of the basic goods and services that protect you from having to get public service. And that’s a big problem with the way we think about public service in this country, in the first place, that it’s meant for low income people. But also, there’s a broader perspective in thinking not just about providing goods and services, like vaccinations, and lead test, but also, being able to build out, and plan an urban environment that protects people from getting sick. What does it mean to make sure that you can walk in the spaces that you live in? What does it mean to make sure that you are breathing quality air, and drinking quality water? You know, I struggled quite a bit. I remember for the first three weeks, I was completely lost, trying to, as you say, triage.
But on my third week of work, I actually got to meet a little boy, his name was Demarius. He was probably the most confident little kid I’ve ever met, right. Walked right up to me and gave me a handshake, and a big hug, and walked back to his mom. And the reality of it was that I couldn’t help but contrast his confidence to the circumstances in which he was growing up, the life that, statistically, was paved before him, and realized that the work that we need to do in the city to have the maximal kind of impact, was to break down the barriers that kids like Demarius have to being able to learn in Detroit, like we would want for any child, anywhere. So, it led us to thinking about what are those health outcomes that are a part of the intergenerational transmission of poverty? What are those health outcomes that we can really focus on that can not only protect somebody’s health, but also protect them from succumbing to the cycle of poverty that victimizes so many people in a place like Detroit? That helped us to focus on seven critical outcomes: 1) It was preterm birth and infant mortality, because we know that a child who is born preterm, their earning potential, 30 years on, tells the tale of their prematurity. 2) Teen pregnancy. We know that half the young women who get pregnant, have an unwanted pregnancy before they graduate high school, are going to drop out, and never get that degree. 3) We focused on the lead, because we know what lead does to a budding brain. 4) Asthma. People don’t realize this, but if you have a child with persistent asthma, even mild persistent asthma, they’re going to miss a day every two weeks of school, and try to tell a kid to learn when they’re not playing hooky, but can’t breathe one morning, and can’t go to school. We also focused on mis-nutrition, which we sort of think about as the amalgam between malnutrition and obesity. We’ve got to challenge that, because of the food swamps that people live in, and their access to certain kinds of foods, they’re not getting enough of the micronutrients that nourish a brain, and too much of the macronutrients that feed a belly, so kids are both malnourished, and obese at the same time. And we also focused on elderly isolation, making sure that our seniors had access to our young people, and could play a meaningful role in their lives, and really wanted to build out around environmental justice, and protection of the space, within which people live.
NJR: So once you pick seven areas where you think you can have a really strong impact for your money, what kinds of particular interventions do you pick, with limited resources, that can address those areas?
AES: I try to think about the way that we intervene along Ps. One is policy, the second is programs, and the third is partnerships. And, so, we wanted to create a portfolio of work across these three Ps. Think about lead, for a second. Lead is pernicious in the city of Detroit, not because of water, but because of housing. You know, because of the focus on the Flint water crisis, a lot of us sort of equate lead to water. But really, the reason that most kids who are exposed to lead are exposed is because they live in houses that have lead-based paint in them. Any home built before 1978 is likely to have this, and 93 percent of homes in Detroit are built before 1978. And, so, there’s a policy angle here, which is to say, how do we incentivize, properly, landlords to abate their homes from lead, and to do so in a way that protects the people who live there. And that’s about pushing forward on ordinances that really protect renters, and protect children living in rental homes. So, that’s a policy goal. And then there’s the programmatic goal, and the programmatic goal is to say, if a child is exposed to lead, how do we coordinate to make sure that every home gets access to all of the services that can be provided in the city of Detroit, rather than leaving it to sort of a hodgepodge that had been the case while the health department had been shut down. The third goal, is partnerships. How do we build meaningful partnerships across community organizations, so that the safety net that we want to provide is mended, and acts more like a safety trampoline, rather than a safety net. So, we thought about all of the potential policy program and partnership analogs across each of our critical outcomes, to think a little bit about where you would be investing, what were our limited resources, and then building out the organization so that we could expand the resource set that would go into investing into these three spaces across the seven outcomes.
NJR: And, so, what do you think was the best thing, or set of things that you were able to do during your time there? What worked?
AES: So, I’ll tell you, one of the programs that I’m proudest of, is a program that we created around vision deficits. We found that 30 percent of our kids who got tested for vision deficits would come back testing positive next year. That means that we knew that they needed glasses, and yet, between us, between the families, between the schools, nobody got them a pair of glasses. We knew we could solve this problem if we were willing to build a program around doing it. And, so, we built out a program to deliver every child a free pair of glasses, at school, within two weeks of a vision test. Today, that program has provided over 6,000 pairs of glasses. Now, I remember, the day we kicked this off, at an elementary school, in Detroit, a little boy, I got to put his first pair of glasses on him, and I remember him looking at his hand, and saying, “you know, I’ve got wrinkles in my hand.” And he’d never seen that before. And you think about what it means for a kid, going to a school that’s likely overcrowded, where the resources are minimal, and teachers are already being asked not to just provide basic educational services, but also, to be social workers, and parents and friends to these kids. If a kid is in the back of the class, and can’t see the blackboard, it doesn’t really matter what’s happening on the blackboard. And so, we knew that being able to give a kid a pair of glasses could mean the difference between allowing them to excel in the classroom, or a very different path. Now, I used to be a bit of a punk kid when I was in school, and that’s because I got bored real quick. And I remember when I’d get bored, I’d find ways to entertain myself, and sometimes, at the expense of the teacher. And you know, when you’re a brown kid, and you get in trouble, you’re now labeled. You become a problem child. And you think about the city of Detroit, where 85 percent of our kids are black, you start to see how a simple lack of access to glasses, where a kid who is looking at the board can’t even make sense of it, starts to entertain themselves, sometimes at the cost of the teacher, sometimes at the cost of the students around them, gets labeled a bad kid, and all of the sudden, you’re in a very different place, for a kid who was probably smart to begin with. That was a program for me that was really moving and exciting.
NJR: And what I like about it is that it’s just so straightforward. You just look at a problem, and you say, well, as you say, if the kids can’t see, they can’t learn, so why don’t we just give them glasses. It cuts to the solution in a way that, I feel like there’s this thing, even in democratic policy making, where we often overcomplicate things. I mean, you know, you understand the complexity of healthcare, obviously, and the way that everything affects every other thing. And this was one of the remarkable things, to me, about your campaign, was that your messaging was very, very simple, even though you’ve spent your life in the academy, which we often think about as a place that makes everything more complicated.
AES: I’ll tell you this, I think when it’s doing its best, the research enterprise, and the theoretical enterprise, should be about highlighting the obvious, even when it’s not obvious. We bend over backwards sometimes in our policy making, and even in our political discussion, to accommodate a worldview that itself is, I think, broken. You know, the thing about neoliberalism, it tells us that we have to bend our will to this notion that the free market can, and will, solve all problems, and that all policy making ought to be seen through that lens. And the problem with it is just like, well, look, there’s an obvious solution here. If you’re not trying to tell me that somehow, a four-year-old, or a five-year-old kid in a Detroit public school should have the wherewithal and the agency to provide themselves their own service, it’s BS. I think we have to be able to push against that and say, “your theoretical premise, here, is broken if and when it cannot solve basic problems for people who are suffering.” And that’s what it takes, I think, to cut through the garbage. And what we tried to do in our campaign was to say “there are many, many, problems inside and outside of healthcare that can be solved with some pretty obvious solutions that, in fact, are financeable,” right? To get past that problem, that the neoliberal framework tells us that there are only so many dollars and cents to go around, and how dare we ask corporations to pay their fair share, while giving handouts to poor people, who have been suffering the consequences of those corporations, for a very long time. We wanted to bypass all that theoretical garbage, and speak to real solutions, to real problems, in a real place.
NJR: I also get the impression that your approach to public health made you a somewhat more political—if that’s the right word—health director, than the mayor might have expected, when you took the position. And I know you got into some conflicts with the city for doing what was seen as going beyond your purview, by seeing things like the city demolishing houses and shutting off water as part of your mission as the health director.
AES: Yeah. Look, there’s a thing I always tell young people getting involved in public health, in particular: Anytime we’re talking about the access that different people have to a scarce resource, and how we provide that access, that is, in and of itself, a political question. You can’t get past that. Politics is fundamentally about how we divide scarce resources, and who gets access to them, and who doesn’t. And public health, unfortunately, is a scarce resource, when we have disparity gaps of 10 years, public health is a scarce resource. Now, we have to think about growing that pie, and we have to think about more equitably distributing that pie, and that meant standing up to political actors who believe in a system that has been disproportionately offering pieces of that pie to certain groups, for a very long time, and telling us that it’s all in our best interest. As the health director, my job was to make sure that people had access to their best, most dignified lives, and that meant being involved explicitly with some of these political decisions, even though politicians might not like it. And you know, I was the health director in a city that was shutting off water in 17,000 homes a year. I knew the remit of rebuilding the department, but at some point, believe that is fundamentally wrong. It is fundamentally wrong to tell people that they can’t have access to something that is 70 percent of our body’s makeup. So, that meant getting political, and bearing the costs of that political engagement. It’s also a big reason why I decided to run for governor. Every project we took on led us to the door of a politician where those doors were almost always closed, because we were advocating for kids like Demarius. And the funny thing is that those doors were always open for people like Chase Bank, or some corporation asking for some handout to come move 300 jobs to the city. That, to me, is just wrong. And we need political actors who are going to stand up and say, “you know what? Enough is enough.” This is about making sure we are doing what is right with our resources, and in particular, believing in a responsibility toward equity and evenness.
NJR: Yeah, if people aren’t familiar with Michigan, it’s really remarkable, actually, how obvious inequality is in Michigan. I haven’t seen it quite that stark in many other places. I mean, Detroit is a city that just has been hollowed out, and you talked a lot about the few miles you can drive and see a 10 year gap in life expectancy, but it’s not just that. People have been confined to two different worlds. You talk about corporate power, which really does, in the state, manifest itself in very clear ways. I remember, you made a big issue, in your speeches, of the way that Nestle had been given basically free access to the state’s abundant fresh water, to bottle and sell, while the price that poor people pay for water in Detroit— their water bills, and the auto insurance bills, are just crazy high.
AES: Yeah. And that’s the thing, right? It is part and parcel of deciding who gets access to what. If you are a corporation like Nestle, you can bottle unlimited amounts of our water for $40 a year, but if you are a poor, black family in the city of Detroit, or the city of Flint, or the city of Benton Harbor, you better pay your exorbitantly high water fees, which, by the way, are far more than $40 a month, or we’re going to shut off your water. How is that fair? How is that accessible? There is a clear answer to that question, which is to say, “Dear Nestle, if you’re going to bottle our water for $1 a bottle, you’re going to pay your fair share, and we’re going to use that money to make sure that poor people in our own communities get access to the water that they need.” It is a remark on our governance in our state that we are a state that has been blessed with more fresh water than any other state in the country— 21 percent of the world’s fresh water. And yet, we’re home to almost every water-related disaster you can think of, whether it’s the shutoffs in Detroit, or Benton Harbor, or Flint. The Flint water crisis, the PFAS that’s poisoning water all over the state of Michigan, we are that place that suffers more, when it comes to water, than anywhere else, despite having more water than anywhere else. It is a crying shame, and it speaks to the brokenness of our politics.
NJR: I want to talk about the messaging of your campaign. I just had a remarkable conversation two weeks ago with Rhiana Gunn-Wright, who was your policy director.
AES: Ah, I love Rhiana. I’m sure it was a far better interview than this one is.
NJR: She’s brilliant, she’s a brilliant woman. And the interesting thing about her presence on your campaign, is that she was your policy director, for a sort of scrappy and insurgent campaign to even have a policy director is a little bit rare. I still find it remarkable. People can find these all on your website, but you have all of these policy documents that you have designed for the state of Michigan. You have a new auto insurance policy, you have your Michicare single payer healthcare plan, you had your MiFi internet for all, public broadband plan. And, so, I wanted to ask you about designing policies, where, on the left, we have to think, especially now that we’re in a position where political winds are blowing more in our direction, we have to think more about how to actually design policies that could actually solve problems. It’s very easy to rail against inequality and injustice, but you have to think a lot about, “how would we actually design a solution that would work to each of these individual things.”
AES: Yeah, that’s exactly right. And I knew that as a young, first-time candidate of color, that I was going to have to be that much more rigorous than anyone else in the race, so we decided we would set up a policy shop in our campaign, and invest in doing that. And obviously, Rhiana is brilliant, and we’re really thankful that she came along. She was working with me at the health department, prior to my run. And together, we asked ourselves, how do we put ourselves into the shoes of the people whom we want to serve? How do we see the world from their perspective and then build out from there? Asking very basic, first principles, experience-based questions, and building a policy of empathy, that empathizes with the needs of the people we want to serve, rather than empathizing with the current juxtaposition of the bureaucracy that tells us that we cannot. That’s the way we approached it at the health department, too, is put yourself in somebody else’s shoes, ask, what would I need from my surroundings to be able to be able to live the kind of life I want to live? And then, how do we work around them, rather than asking them to work around us? And that’s the way that we thought about it. And we did a ton of interviews, talked to people in all kinds of circumstances, to think about what the differences in experience might look like, and then working from there, and really checked our work with the community, to make sure we were trying to get it right. So I’m really proud of the policies that we put together, and the way we were able to talk about those policies, because it was authentic to the experiences that we really wanted to optimize around.
NJR: So, maybe you could give me an example of some problem that you designed a plan for, that you were really pleased with the way it came out?
AES: Yeah, so, MiFi is one of those plans. We didn’t actually go into our campaign and say, we’re going to make a really robust public internet infrastructure plan, but when we were talking to people, whether they were in urban communities and could not afford the WiFi that was available, or rural communities, who just didn’t have access to it at all, because the corporations that we rely on to provide it just haven’t laid the infrastructure down. We realized this was a real need. So, Rhiana and I sat down, and Rhiana actually pushed the idea. She said, “we really need to solve this problem for folks.” And so, we started talking about it, what this could look like, how the state should be involved, not to necessarily make public the internet infrastructure, but to be able to provide access to resources to build it out in places where corporations don’t feel like it’s their responsibility, despite the fact that we give them a monopoly on it, and to make sure that poor and working people whose children rely on internet to be able to learn in the 21st century, that they have access to high-quality internet. And that’s the plan that we created. We called it MiFi, a play on Michigan WiFi. We’re really proud of how it turned out, and I do hope that somebody picks it up, and turns it into policy, because I think it would help a lot of people in our state.
NJR: I wanted to talk to you about your campaign, because in many ways, I look back on it as a tremendous success. The events that you held around the state, there were people out the door. You’ve mobilized a lot of people. The people you had on your staff, I talked to them as I followed your campaign around, and there was a real excitement in the air, and you got people talking about a lot of good things. At one point, I think, was it the Guardian who compared you to Obama? It was a little unfair to you, to lump you in with a very different person. But, at the same time, the campaign did not succeed, and I think I sensed, when I was talking to you, on the campaign trail, a real frustration with the politics of the state, and the difficulty of running a campaign like that on a shoestring budget.
AES: Yeah. We all know that our politics needs fixing. And right now, we’ve got a politics that’s dominated by money, and a politics that allows corporations to leverage their money as speech, despite the fact that they don’t actually have to pay taxes, like the rest of us, but it’s fundamentally changed the hue of our politics. I ran against two opponents in the primary, one of whom spent $11.5 million of his own money to push a message that he copied from us, in a poorer sense, and another who worked with, what were found to be illegal dark money operations. That’s unfortunately the truth of politics right now. It is not as much about ideals and principles, as it has become about identities, and just sheer political machinations. But, you know, think where we did not succeed, and I don’t run away from the fact that I did not succeed— we didn’t win, and I’m not serving as governor of my state. And that, to me, is the outcome that any campaign is after. But we were able to move the conversation, and demonstrate a perspective on our politics that I hope does herald a future where our politics are just a little bit more accessible, and equitable, and ideal oriented. We showed how that can be done. You know, I didn’t win my first race. In that, I join a long line of politicians, most of whom we don’t know about, some of them we do, who lost their first race. But, I learned a lot, and I think we were able to demonstrate a way forward in the state, and you know, I hope that if there’s an opportunity to serve, and to serve for a purpose, I’ll be back at it someday. And if there’s not, then I’ll find other ways, hopefully, to continue to advance the ideas, and ideals that we ran on.
NJR: I remember watching you, and I got sort of sad at a certain point, because I’m sitting in your campaign office, watching it hum along, and you had a little bit of downtime, and you had to use it to do these donor calls, to just ask people, one by one, by one, who had already donated money, to donate more money, and they told me, a member of your staff told me, like, you spent basically 40 hours a week, like, a full-time job, just having to ask for money, which is all time that you can’t spend in advocacy, or out doing things, and out talking to people. I mean, it was just stunning to me, seeing, and realizing that the other candidates didn’t have that full-time job.
AES: You know, I think, unfortunately, it’s the reality of modern-day campaigning. It’s awful, and it shouldn’t be that way. I ran a campaign without taking corporate donations. That means where other candidates were taking $68,000 checks from big corporations, or having money funneled along these dark money operations, or were independently wealthy, and saw this as a vanity project, I had to do it the old fashioned way. And the reality is that though my campaign raised $5.5 million, all in individual contributions or state matching funds, we were outspent in the campaign 6-1. You know, that’s the facts of trying to run a progressive, issue-oriented kind of campaign. I’m also proud of the fact that though we were outspent 6-1, we earned 1/3 of the votes. So, in terms of performance-per-dollar, we did far better than anyone else, and we showed what it means to have a potent message that matters. But yeah, calling people up and asking them for money is just awful, and it shouldn’t have to be this way. Our politics shouldn’t be this way. They should really be about lining candidates up, asking what they believe, and how they intend to operationalize what they believe in their policies, and making a decision from there, rather than turning it into a big money game. One of the craziest things was most of that money was spent on television and advertising, and I remember seeing my first ad on TV, and in 30 seconds, $800 were burnt. I watched this thing, that is absurd, and yet, in the last week, we ended up spending less than any other candidate on TV. And so, our message, in the end, got overpowered by the baked-in polish of other candidates.
NJR: I guess I want to ask you directly, then, looking back on the amount of time you had to spend, the amount of money that you had to raise and then spend, was it worth it? There are lots of different ways that people can make a difference. One of them is running for office, one of them is serving as the director of the health department. One is serving as an intellectual, who puts ideas into the mainstream. You can be a community organizer, you can be a doctor. When you look back on it, does it feel like you should— no child got glasses during that campaign, right? You can talk about the issues, but you either win, or you don’t, and if you don’t win, is it still worth running?
AES: I’ve thought a lot about that, and I think it is. And here’s the reason why: There is a cynicism that has pervaded our politics, right now, that it cannot be better, that anyone with a good idea, and the ethic to try and take that idea public, is going to be beaten down by a system that’s dominated by a certain framework, a certain kind of candidate, and you cannot beat it. In just having the will and the courage that my team and I hoped we showed— we showed a different side of what politics can be, to people. And that’s breaking through. There’s also symbolism in what we did, that as an underdog candidate, who is openly, and devoutly Muslim, who is a millennial, who has never run for office in his life, that you can run the campaign that really forces people to take notice on the issues, and holds other candidates accountable to having to meet your message where it was, because it was true, and it was based in real principles. And, you know, for all of those young people who just never got to see themselves in politics, for whatever reason, they were too brown, too Muslim, too young, too immigrant, to be able to see somebody who looks a bit more like them, or who has been told you can’t do a thing, stand up and do it anyway. My hope is that will reverberate into the world. I’m thankful for the opportunity to have been a part of it.
NJR: Let me ask you why you reject the interpretation that was given after the election by Politico, and some others, that said, basically, that it was a test of your message, and what really happened, is you’re too radical for the state of Michigan— Michigan is a swing state. When you run on an anti-corporate message, it can’t resonate in a moderate state, and this is proof that you need to adopt the third way Democratic, neoliberal way of speaking to people.
AES: Yeah, I’ll give you five reasons why. 1) Bernie Sanders won Michigan in 2016, and he and I ran on very similar messages. Bernie had the benefit of being a sitting Senator, but he was still running an underdog race. 2) All politics is local, and to ignore the local circumstances, wherein I was running against one person who was a spoiler, who had $11.5 million dollars to spend, trying to compete on my message, who would split votes with me, and another who was a 14-year veteran of insider Michigan politics. As a 32 year old Muslim-American, to try to bake that out into one thing, which is the voracity of my message, seems a little bit intellectually dishonest. 3) It’s Politico. They always look for a particular vantage point, that they will leverage the events of the day to confirm or deny. 4) I ran against somebody who, the individual who ended up winning, Governor Gretchen Whitmer, who had a really strong base in Michigan politics as it stood, and her message was really consonant with the times in the state. 5) The dynamics in the race were such that we had to deal with a five month eligibility challenge that really dragged a lot of the momentum down. It probably cost us about $1.5 million to $2 million dollars. And that was in the circumstance where the other opponent, with $11.5 million dollars was starting to drop Super Bowl ads, and get a lot of name ID. And what people don’t appreciate is that in the end, a campaign is a momentum vector, and anything that hurts your momentum early will impact your vector later on. Those are five reasons why I think it’s sophomoric, probably intellectually dishonest, and not quite right to assume that Michigan is not ready for my message.
NJR: So it cost over a million dollars to deal with that eligibility thing?
AES: Not only was it in legal fees, but it was also in lost fundraising. It’s really hard to fundraise, when you’re making those one-on-one calls, with people who are saying, well, I’m reading in the news that you might not be eligible, so maybe I’m not going to make that donation right now.
NJR: News media is another thing that really stuck out to me, when I was over there reporting. I remember sitting out on the bus with you, and talking about what’s the local political media like? And you said there’s no local political media. You said, “look around you. Who is on this bus?” And it was me, from tiny little Current Affairs, it was Max Alvarez from the Baffler, John Nichols for the Nation. From town to town, when you went around, I really noticed the effects of the hollowing out of local media, the consolidation of corporate media in New York and D.C., to where, I think when your Michicare program came out, the only place I think it got coverage in Michigan, that I could find, was in the Mining Journal, in the upper peninsula.
AES: Unfortunately, journalism has come on hard times, and never has journalism been more important than it is right now. It’s particularly important in local circumstances, because they have to tell the story of what touches us locally. And the national politics of the day have been so abnormal that they have become so dominant in the forefront of our minds. But people don’t appreciate that. It’s local and state government that make most of the decisions that affect your day-to-day life. If you don’t have journalists holding politicians and officials accountable, telling the stories of real people, we’re going to miss the boat. And you see that in Michigan, I think you’re seeing that across the country, and it’s much to the detriment of our public discourse.
NJR: The last thing I want to talk to you about is Medicare For All. You have written a couple of articles for Current Affairs in which you take a firm stance in favor of Medicare For All. The most recent article you did was about what Medicare For All actually means, and you make the argument that there are going to be a lot of people trying to water it down, to treat it as a slogan. But we should see it as what Bernie Sanders, and Pramila Jayapal have said it should be, which is a national, single-payer, everyone-enrolled kind of program, and I want to ask you, why is single-payer so important? Conservatives would say, if we need anything, we just need what they call “universal catastrophic coverage,” that there will be a lot of people saying “well why can’t you just have a public option?” Why are you such a firm advocate for single payer as being what Medicare For All should be?
AES: So, look, I want to just step back, and just explain. Because sometimes we talk about single payer, and people don’t appreciate what “payer” means. If you think about the interaction in healthcare, there are three parties: There is the patient who needs the healthcare, there is the healthcare provider, be that the clinic or the hospital, then there’s the insurance company, or insurance provider, that pays for the care that the patient gets. And when we talk about single payer, we’re saying that in the system, there shouldn’t be all types of payers, there shouldn’t be many different insurance companies, there should be one single payer. And why single payer is so beneficial isn’t just that it would provide everybody healthcare. That’s really important, and it should be a primary goal, but it’s not the only goal. We also have to be thinking about what the dynamics of a multiple-payer system looks like. Now, we all know what the word “monopoly” means, right? In a monopoly, there is one seller of a thing, and because there’s one seller of a thing, they get to dictate the price. What we don’t often pay attention to is the contrapositive, which is the monopsony. And a monopsony is where you have one buyer of a thing, who also gets to set the price, because they’re the only one buying. And what single payer does is it creates a government monopsony on healthcare. And as a monopsony, that gets to bring the price down. The other part of that is that when you have multiple insurance companies, those insurance companies all have an overhead. They all have a C suite. They all pay their executives ridiculous amounts of money to keep you from having the healthcare that you bought already. And that’s all overhead. And we know that Medicare, and Medicaid, for example, run at a 3 percent overhead, meaning 97 percent of the dollars that are paid out are actually paid to provide people healthcare, rather than pay a CEO into their back pocket. We can eliminate a lot of that extra overhead. And then, probably most importantly, there is an effect on the way that the market operates, because right now, what you’re starting to see, is a massive consolidation around healthcare, both on the payer side, and on the provider side. So you’re seeing these massive health systems conglomerate, and then you’re seeing health insurers start to buy up smaller health insurers, which then creates the circumstances where you have an oligopoly in the providing and paying for healthcare, which drives up costs for everybody. What Medicare For All allows us to do is to stop this conglomeration and the oligopolization of the healthcare system, that then brings the price down. So what we’re talking about is eliminating the huge overhead, we’re talking about empowering health systems against health insurers, we’re talking about breaking the oligopolies in healthcare, and we’re talking about bringing down the overall cost, and providing everybody the care that they need and they deserve. Medicare For All does that. These other plans don’t, and we’ve got to be careful about how the term Medicare For All is going to be bent and re-bent by politicians who want to be for Medicare For All, a concept that polls at 60 to 70 percent, but don’t actually want to have to pay the cost. You can’t have your cake and eat it too.
NJR: You know, what are the human costs of having a private health insurance system? There is something that I take it that you believe is inherently dysfunctional about having health insurance be operated for a profit.
AES: Let me tell you this: I don’t practice clinical medicine. And the reason I don’t practice clinical medicine is ultimately because when I was in medical school, I saw how the system not only does not operate for those who need the system most, but actively discriminates against them. I was a fourth year medical school student, there was a woman who had came in. She had fallen and hit her head. She had been drinking that day, and slipped on the subway, hit her head, and she was in the E.D., and when I went to be the liaison between the hospital floor and the emergency department, I asked the emergency room doctor what the CT showed. Now, anybody who hits their head and goes to the emergency room gets a CT. That’s just, like, basic clinical medicine in the United States. The reason why, in part, is because it’s cover-your-ass medicine, part of it is also that when you hit your head, you have head trauma, and there could be something that a CT would catch. Now, she didn’t get a CT. And I asked why, and he said, well, you know, she didn’t hit her head that bad. I could see the abrasion on her head. It turns out that the quality of the care that she got was so bad, that when I forced the admission, we ended up taking care of her for two weeks for everything from full blown AIDS, that had basically broken down the hormonal command center in the body that controls blood pressure, out of control diabetes, to an actively bleeding pelvic mass, all of which were not picked up, because there was no real history or physical done. Why? Because this woman was homeless, she was black, she could have been enrolled on Medicaid, but because of the circumstances of her life, was not. And she would have been a patient that the E.D. doctor literally told me would be called a “social admit,” meaning, we’re not going to be able to solve her problems here, so why would we even bother? And to me, that’s the kind of patient I wanted to be able to take care of when I went to medical school in the first place. The kind of patient that our health system should be taking care of in the first place. And under a Medicare For All system, that woman has the same healthcare that you or I do. She gets the same quality of care that you or I do. And because we have this for profit system, we are, in fact, rationing care away from the people who need it the most. And that’s just not right. It is a moral question for us right now.
NJR: Let me lay out for you, here, what I know to be the strong conservative criticism. They would say, well, even if your Medicare For All system improves health outcomes for that particular subset of people, for most people, the majority of people, who have employer sponsored plans, they are relatively happy with their plans. Under a Medicare For All system, they are going to lose their plans. They are going to have their healthcare taken away, they are going to have their healthcare rationed, they are going to have wait times, they are going to have doctors who are going to be unwilling to extend the same quality of care because the reimbursement rates are going to be much lower, and that as soon as people find out about this, the majority of people are going to turn on a Medicare For All plan, they are going to say, “this is why it failed in Vermont, California, Colorado, and other places that have considered state level single payer plans.”
AES: So, the only thing I’ll say in response to that, is that people will do anything to avoid loss more than they will to achieve a gain. And whenever you say to somebody for whom the status quo is actually quite bad, but it is the status quo, that the status quo may change, and worse, that there are fear mongers in the system trying to point to that change and say “you will lose something that you currently have,” especially something as important as healthcare, that tactic can be relatively powerful. That’s exactly what they did with the health insurers, and the AMA, and the hospital systems, and pharma, did during the Clinton-era health reform discussion with the Harry and Louise ads: “When they choose, we lose.”
Here’s the facts: Americans pay more per capita on healthcare than any other country in the world, by far. We pay 19 cents on the dollar for every dollar spent in our economy, on healthcare. And we’re paying it in ways that we see, and in ways that we don’t. If you have employer-provided healthcare, the high likelihood is that you have some amount of money deducted from your paycheck, every two weeks, that goes to pay for healthcare, and if you actually wanted to use that healthcare, not only do you have to pay at the point of service, in the form of a co-pay, beyond the deductible you have to pay if you have some kind of catastrophe that happens to you. But the likelihood is that you’re probably going to find yourself on the phone with some Blue Cross representative, advocating why you needed the care that you already paid for. The user experience of American healthcare is actually awful, and we pay so much for it. The fact is that under Medicare For All, we end up paying a whole lot less. You can see doctors, because the reality is that we can actually change the reimbursement system so that they’re actually well paid for what they do, and because it covers everybody. There’s not this circumstance where do you take my healthcare, do you not take my healthcare, it is my healthcare. It is the healthcare plan for everybody. So your access to a doctor, in fact, your actual point of care choice, is better under Medicare For All than it is under your employer-provided health insurance system. And you’re in a circumstance where you never have to worry what might happen if you lose your job. In Michigan, Michicare was really popular, because so many Michiganders actually know the experience of losing healthcare, because the recession was so damn hurtful for so many of us. And one of the worst things that happened was that people not just worried about losing income, but what happens if I don’t have the healthcare that that job provides me? Not only that, but we have so many young people in our country, right now, who are forced into working gigs that don’t offer high quality healthcare, as it stands, so the experience for most Americans, and for Americans as we move down the generational level, is that actually that employer-provided healthcare thing isn’t working for us. We spend too much, it is conspicuously absent when we need it, of questionable reliability, based on what we do in our professional life, and I can’t even see the doctor I want to see. So, it’s not working for people.
NJR: When you were at the Detroit health department, and when you were designing the Michicare program, you thought a lot about how to make government actually work well, and I wonder, when you’re thinking about a national single payer program, what do you do, or what are the considerations that need to be taken into account, to make sure that it actually functions well. Because, again, I think people’s fear is, and this is going to be the main part of the messaging, is, well, look at the V.A. scandals, look at the way Healthcare.gov— they couldn’t even run a website. Look at the DMV. How do you have a functional government program that people are actually satisfied with, and gives them a good user experience?
AES: Yeah, we need to make the investment. The conservative game has always been rob government of the resources that they need to succeed, and then point at that for not succeeding, and say, “it’s impossible for them to succeed.” This is the conservative ploy, all the time. This program needs to be well-funded. It needs to run at the scale that American healthcare runs at. I think the hidden question here is how do we engage providers? Because there’s a lot of fear among American doctors, and providers, generally, about what the system would look like. And we need to empower their voices in the conversation. The two most important groups in American healthcare are 1) patients, and then 2) providers. And if we put them up and say, again, like we did at the health department, “how do we get in your shoes?” and ask “how does this system work for you, to get all of the garbage out of the way, so that you can do your job, and so that you can be rewarded for the job that you do?” I think that we can design the kind of system that really empower providers in that system above, and along with, patients that we want to empower in the first place. And so, there’s a lot of optimizing that can be done, but we have to get through the political conversation to actually have that basic and deep policy conversation. And so, if we’re always thinking about patients, first, and then thinking about providers, we can be in a circumstance where we optimize the system to where the user experience is great, and then we have to fund the system appropriately.
NJR: Last question I want to ask you is, I see this argument a lot, which is where people love the phrase Medicare For All, and then the moment you say “it’ll raise your taxes, and you’ll lose your health insurance,” the polling drops. What do you think is crucial to crafting the messaging in a way that is going to get people over their jitters, and how are we going to have an effective pro-single payer message that really gets people past the worries that they’re going to feel when they see those ads on television, saying “this is about to destroy the country, it’s about to explode the deficit. This is the most radical plan in history, and your healthcare will never be the same.”
AES: Yeah, I think there is a political law of big numbers, where I know the difference between 35 billion, and 35 trillion. But it’s hard for me to wrap my mind around numbers that big. Providing everybody access to healthcare is going to cost a big number. But the reality of the matter is that people don’t appreciate what that big number actually means for them, and we’ve got to do a better job of translating what the costs and benefits look like for an everyday family. When we wrote Michicare, we didn’t push out this is what the system is going to cost, because it’s a meaningless number. Most people don’t appreciate what the actual budget of a state, or even the budget of the federal government, actually is. It’s just a really, really big number. So, instead, we said, for the average family, how much is this system going to cost them, and how much is it going to save them. And what we found was, for the average family of four, earning 48,000 in the state of Michigan, this plan is going to save them $5,000 a year, $5,000 that they’re not paying in employer-provided healthcare, or co-pays, $5,000 that they can go invest in whatever it is that they want to invest in, potentially a new car, potentially a tutor for their kids, potentially save up for college. But that’s 1/10 of your earnings, if you’re an average family of four in Michigan. That’s a big deal. So, by being able to frame it in numbers that everyday folks are used to dealing with, because they’re the numbers that you think about every time you look at your personal budget, that’s a much more user-empathic approach to thinking about what the costs and benefits of everything is. Now, if we were able to, as progressives, sit down and say, “hey, dear American tax payer, I want you to understand what the cost of the war in Iraq is going to cost you every year.” If we were willing to actually make that argument, and that kind of advocacy, it would really change the way most folks think about their government, and how it spends their tax dollars. I think it’s incumbent upon us to say yes, taxes are going to increase to pay for this, but what you’re not paying is co-pays, deductibles, and a monthly insurance fee, and in the end, because of the cost of the insurance system, and healthcare goes does, you’re going to save $5,000 for the average family of four, earning $48,000.
NJR: I just wrote an article, actually, called “Looking At The Bottom Line,” where I cited the way your Michicare plan presented the numbers, which I liked, because you didn’t tell them you weren’t going to raise their taxes, you said “look at the bottom line: Here’s your finances, and you come out ahead.” I feel as if that’s absolutely critical, because then people understand that when you say “your tax bill is going to go up,” that’s meaningless if you’re getting far more back in benefits than you’re giving up.
AES: You know, the funny thing is, when you get a paycheck, it always comes with that deduction statement. Usually your healthcare and taxes are just lines in that deduction statement, and the reality of it is that most of us don’t really pay attention, because we just look at the number the paycheck is. So, the key thing to realize is, yes, my taxes might go up, but the deductions for healthcare go down, so that number in your paycheck goes up, because of Medicare For All. That’s what people are looking at. So, we have to speak in the language that folks are actually speaking, rather than these billions and trillions of dollars that really, for most of us, are meaningless, because we’re not looking at the state’s budget every year.
NJR: Abdul, thank you so, so much for spending the hour with me. I truly appreciate it. This was really fun.
AES: Let’s do it again. I appreciate you taking the time.
NJR: All right, best to you.
AES: Yeah, talk soon.
Transcribed by Addison Kane
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