Timothy Faust is the author of Health Justice Now: Single Payer and What Comes Next, available now from Melville House books. He recently visited Current Affairs Headquarters in New Orleans, Louisiana to speak to our staff on the Current Affairs podcast. were Editor in Chief Nathan J. Robinson, Podmaster and Contributing Editor Aisling McCrea, and Legal Editor Oren Nimni. A transcript of the conversation follows, lightly edited for grammar and clarity. Transcript by Ted Thomas.

NATHAN J. ROBINSON

Tim, we had an event last night, you were kind enough to come and give a talk co-sponsored by Current Affairs magazine and the New Orleans Democratic Socialists of America, a talk that went incredibly well, and you packed the house. You really roused the whole room. It’s rather incredible that on a Friday night in New Orleans with such a wealth of leisure for people to indulge in, so many of them chose to come to a talk on health care financing, so that’s a pretty strong credit to you.

TIMOTHY FAUST:

It’s humbling obviously, it’s cool. People come out, going toe to toe with Decadence and Decadence parties, which I believe is the big pride event in New Orleans. Yeah, I’m really grateful people came. I’ve kind of got it easy in that healthcare is the great unifier. Everybody understands that they have health and they have a body, and they are afraid of it. So it is not a big sell to come talk about healthcare, I’ve been benefiting from that.

NJR:

Just on the Lyft ride from the office to event we were talking to our Lyft driver and she was asking what we were on our way to an event for, my colleague Cate said “well, have you ever had to pay thousands of dollars for a surgery and spent years paying it off,” And she said “yes, I have spent years paying off a surgery that costs thousands of dollars.” Every single person in the United States I think has a healthcare horror story. You begin this book with a story of people you know, your friends and the way the completely fucked American healthcare system so damaged unnecessarily the lives of people you love. 

TF:

That’s my two friends Steve and Kyle who live in Jersey, who I actually met in the process of writing the book. Steve has muscular dystrophy. He weighs like 90 pounds—actually I think less than that, closer to 90 pounds if he’s sopping wet. He’s a wheelchair user. He needs a lot of help getting out of bed, eating, going to the bathroom, getting his meds changed, that kind of stuff.

But it’s not the kind of care that you need to get into a hospital. You can have someone come to your house and help you with it. It’s long term, it’s home health. You see, he has been fighting his entire life to get more home health hours from Jersey’s Medicaid program. Medicaid, because it has a limited budget, wants to really restrict how much home health it pays out, because it’s like pretty barbaric, it’s a pretty cruel program. Because it has a limited budget, and these are the kinds of things that don’t go away. If you need home health you might need home health for the rest of your life. It’s a big expenditure.

Steve’s mom had to take a decade off working to take care of Steve—that’s uncompensated labor. Steve’s family pitches in. They like pitching in because they like their brother, they like their son, they care about him. But that means they can’t work, and so their family suffers as a collective unit. So Steve finally got approved for 32 hours of home health, and so he was able to hire his best friend Kyle to be his home health aid. Kyle was working as a bartender in Astoria, New York with his wife who’s a Canadian immigrant, but he slipped a disc while putting his groceries away. He ended up going into massive medical debt because the same thing happened a couple of months later, and then he got Parvovirus in his knee. His wife wasn’t able to work. She didn’t have her visa to work for a long time. So the whole family went into massive medical debt. His wife ended up getting sick as well. So the whole family was medically bankrupt a couple of times over and they had to move back to Jersey to live with Kyle’s parents.

So Kyle is hanging out with Steve. Steve gave him his home health hours, Kyle became a home health aid, but Kyle was making at the time $11 an hour, maybe a little bit less, and wasn’t able to pay off his own medical debt bills with the salary he was making as a home health aid. So both my friends Steve and Kyle were being screwed over. Steve wanted to move out of the house and live with his girlfriend, but 60 hours of home health wasn’t getting approved and even though he qualified, and Kyle who wanted to help out his friend, he wasn’t getting paid enough to take care of his own bills. He had to actually quit his job in retail to get insurance to help with his own medical costs. But like both my friends are being screwed over for entirely arbitrary reasons. They are things that are entirely preventable and fixable, we have just chosen not to fix them.

OREN NIMNI:

I think that segues into a couple of themes you address in your book, and you addressed in the talk yesterday. One is all of this is a choice, a choice that the system has made to rob people of years of their life, and that is completely unnecessary, right? We could be spending our time and our money trying to figure out cures and treatments, social/psychological/medical therapies for a whole host of things, but instead people are spending their money and their time breaking their backs trying to get around medical debt, like when you are diagnosed with something or when you slip a disc putting away groceries it can really basically morph the next 20 to 30 years of your life because you are going to be trying to pay that off. The other thing that your stories brought up right now is you talk a little bit about the differences between hospital care and home care, and I wondered whether you could draw out a little bit more the inequities that home care workers face, but also under a Medicare for All system what would be done in a hospital, what would be done at home, and what the benefits are of each?

TF:

Sure, in general when a person can receive home care you want to give them home care. Hospitals have a limited number of beds, home care is for a lower standard of care, like less intensive care needs, and I think whenever you can spend money on home health, you want to. The problem comes in when you realize nursing homes are the alternative. The alternative to home care is for a lot of folks a nursing home or a skilled nursing facility, a Skilled Nursing Facility (SNF). Those are, in Steve’s terms, where people with disabilities go to die.  Pretty loveless care, often there is a lot of abuse there, but it’s very profitable to run a nursing home. So you see in a lot of states—Arkansas is probably the most egregious but also Iowa has some pretty bad ones, where nursing home owners or nursing home funders will kind of stack the slate and prohibit state Medicaid programs from sponsoring home health and simply pushing people into nursing homes and taking that money and putting it there. In Arkansas a guy got busted for being employed by nursing homes while a direct employee serving in the state House of Representatives, and of course he was about to push through a bill limiting residents, a bill used to sue for medical malpractice in nursing homes.

You have this real pit of barbarism that is a nursing home, and it is entirely preventable. People there generally want to live at home; they want to have autonomy, basic autonomy over their own body. In order to qualify for home health in a lot of Medicaid states you have be totally indigent, Steve can’t make more than $2,000 a year. If he makes $2,001 he no longer qualifies for home health, he’ll have to endure a nursing home where the standards are even lower and other places. It’s real means testing; it’s a real squeezing out. Only the most deserving of the poor at home health. Under single payer we clearly would want to fund home health; it’s a long term net benefit, you want people to—like I don’t want to have to make economic arguments for single payer because I think the moral argument is more compelling. But there are economic incentives to invest in things like home health. It’s economically generative. You are hiring folks who are taking care of their loved ones. That’s good. You want to pay them well. They can afford to live off it. That’s a good thing to do, with their time, with their money. People get better care in a place where they feel safe. They have agency over their own lives. They can work if they want to.

Steve would love to work. He’s a good public speaker. He’s a good substitute teacher, but he can’t work more than two shifts a month or he loses eligibility. Like you create this world of agency, basic autonomy through things like home health, and through things like long term care. Hospitals still gotta do work. There’s this law, Roemer’s Law, which is a kind of tongue-in-cheek law. It observes that right now every hospital bed that is built is going to be filled, regardless actual need in the community, and that costs a lot of money. If you want to incentivize hospitals or compel hospitals to only treat people who need to be treated in the hospital, and push as much care as you can into outpatient facilities or even care at home.

Now a single payer system cannot solve that problem by itself. That’s more like where socialized medicine comes in from the direct relation of providers. But a single payer system can say things like we’re going to pay outpatient rates for this kind of care. Knee surgeries for example can almost always be done outpatient … A single payer system can say for example we’re only going to pay outpatient rights for knee surgeries, for complication x, y, z …and therefore a hospital is incentivized to push knee surgeries, knee replacements outside to outpatient facilities. Therefore a payer can do a lot to tilt by offering what it pays for or adjusting what it pays for, it can tilt a lot of these surgeries and procedures into more appropriate facilities, but fundamentally it’s not solving the problem by itself.

AISLING MCCREA:

When you talk about single payer you mentioned that you prefer to make the moral argument over the economic argument, and that’s extremely reasonable, but I do also—as someone who comes from the U.K. and the NHS, although it is not a perfect system it’s probably the most cost effective or certainly one of the most cost effective of all the single payer systems. I do really encourage people to go—if you Google “how much does the NHS cost me” I believe you can find sites that show the cost of the most popular or most common health treatments and surgeries, so you can look up what does a pacemaker cost under the NHS not to the person, because of course it’s free at the point of service, but how much does it cost to pay all the health workers, and to pay for the equipment, and so on, and it is really astonishing I think to compare the costs of what these things actually cost under a single payer compared to what they cost under the American system, so I would like to, before I forget, encourage everyone to go and see how insane the level of the markups is in the other system, and how not cost effective it is before we get into the moral argument of people shouldn’t have to die for no reason.

TF:

Oh, for sure, in the U.S. we are going to spend $3.9 trillion on national healthcare expenditures, and it has been estimated by some Nobel prize winner that a full third of that is fraudulent or wasteful, wasteful means either the hospital or the provider is delivering care that need not be provided or is marking up the rate, like $100 for a band aid. But also you have massive pricing variants which is more a payer site problem.

The stat I like is that MRI scans — MRIs are easy because it’s one machine that does the same thing over and over again. There are no hard MRIs, there are no easy MRIs, it’s just that you push a button and the MRI happens, and in the U.S. MRIs costs five times more than MRIs cost in Australia, but it even gets dumber. Domestically, in Washington D.C. for example, Sarah Cliffe, now at the New York Times, found a sevenfold variance across the same MRI, the literal same machine in the literal same hospital, would have a sevenfold cost variance based upon what insurance the person has, when the insurance is being performed by which doctor, like some black magic, entirely arbitrary determinants of what things cost. Prices are fake, there is no costing that makes sense in the U.S. Prices are entirely arbitrary. You bill the most you think you can bill and then get away with it. Here’s an example. There was a new kind of device, basically an analytics package, that would be styled on the pacemaker that was being tested somewhere in the south. The hospital was owned by a parent company that also owned the manufacturer of the pacemaker analytics software, so they were incentivizing the hospital, pressuring the hospital, coercing the hospital to use this thing whenever possible.

But it was not quite determined how much Medicare would reimburse for it, because it was new technology. So the hospital literally went through the process of saying, “hey we installed this thing, we’re going to charge you $35,000” and Medicare said “no we’re not paying $35,000” and the hospital said “if we’re going to install this thing we’re going charge $34,000” and Medicare said “we’re not paying 34 grand for this thing.” The hospital tried it again: “we’re going to pay you $31,000” and Medicare says, “yeah that seems reasonable, $31,000” and the hospital then said, “this thing costs $31,000. It has been the cost the entire time.” It’s like asking your mum for something, and your Mom says “no,” and your Dad says “no,” and you go back and forth. That is the process of determining costs in the American healthcare model. You price off what you can get, not what the thing costs, and it leads to massive bloat in our prices because insurance can’t do shit about it. Hospitals don’t need insurance companies as much as insurance companies need hospitals, so hospitals price what they can get away with, and it has this massive pulling up effect of costs across the board, and the thing is pretty dumb.

NJR:

One of the things that people will get from reading Health Justice Now is an understanding of just why the “”how do you pay for it?” line is so absurd, because one of the main themes running through your book is what we are doing right now is having a giant pool of money being siphoned away from sick people and being handed to insurance company executives. And what we are trying to do is take that money and use it for actually treating people, and actually investing in finding ways to make people less sick. I mean I really don’t think the “how do you pay for it?” criticism goes beyond saying some big scary number like $32,000 trillion in federal spending, it really isn’t much deeper than that because if you start thinking about the current system and how a single payer system would work it’s very obvious that—you described it last night as basically a change in a spreadsheet, instead of the money going from you to an insurance company to a provider, it goes from you to the government to a provider. 

TF:

Right, and PERI, the Political Economy Research Institute, estimates that the Sanders and Jayapal plans would cost 10 percent less than what we spend now right out the gate. Another estimate predicts that right now healthcare costs go up faster in inflation every single year, we spend $3.5 trillion last year or two years ago, we’re gonna do $3.9 trillion this year, by ’27 it will be $4.7 trillion. It’s been estimated that single payer keeps costs flat over the next decade, so there’s a big delta of money that we’re saving. The joke answer is we can’t afford not to pay for it. We’re just hemorrhaging money right now as it is. Like the economic arguments are all very, very sound. It’s like one step beyond the economic argument. There exists this fear that if everybody can get healthcare everybody will begin getting healthcare. So there is the pent up demand for healthcare that has been tamped away and people can’t access it or whatever, and if we open the floodgates people will rush in and get healthcare, and we’ll go bankrupt from all this spending. That’s wrong, but also I don’t care. It’s wrong in the sense that if when you look at the NHS rolling out in the ‘40s, 60 percent had more insurance and overall utilization increased by only 30 percent. There wasn’t a rush on the banks in proportion with people getting insurance and two people aren’t going to be getting recreational surgery, like we’re not getting recreational heart transplants. People sometimes get care they do not need, but that’s not really their fault. They just know that they are sick and they want care, and it’s also a pretty small percent of the population. In general people want as little to do with the healthcare system as possible because they don’t want to be sick.

But if people were to get more healthcare, if there would to be a run on the banks so to speak or on the hospitals I think that is pretty good honestly. If we’re gonna spend our money on something, I’d rather it go to healthcare than to war crimes. One, that is an economically regenerative process. We get four bucks back for every $1 spent on healthcare, so it goes to people’s salaries; that is more indicative of making people more free in their own bodies. It’s a nice thing to happen, I think it’s good. I think the American people deserve to have their—by American people I include non-citizens—people in American deserve to be liberated within their bodies. If we had tamped down demand so there is an outpouring, that’s good. That’s a great relief to the miseries of the American people. 

NJR:

That’s also part of the argument against plans that include cost-sharing right? There are some economics that say, “oh you wanna include copays so that people are discouraged from seeking too much healthcare,” and one of the points you made is you shouldn’t be discouraging people from seeking healthcare because they’re not seeking an excess of healthcare, they are seeking as much as they require.

TF:

Right, and if you want to solve the problem of too much healthcare, we know how to do that. The answer is you hire a social worker to talk to that person, help them to figure out what they actually need, and go get it with me. It’s compassionate labor, which once again comes to the fucking rescue like it always does in every health policy initiative. There is always a social worker that actually does the thing that is meaningful, because there are folks up there who think that that they need a knee surgery or a lung surgery, that they’re dying, that their kid is sick or whatever, so having someone in the middle who helps them understand their problems and helps them advocate for the care they need is how you bring those costs down in a humane, and gentle, and cost effective way. That’s how you solve these problems, not by punishing folks. Now there are examples where cost-sharing maybe isn’t the worst thing in the world, but those are very limited and very small. My example is if you have a name brand drug that cost $100, and an equivalent generic that costs $1, or maybe putting a $1 or $10 cost-share on the $100 drug to push folks onto the cheaper free drug makes a lot more sense because drug pricing is so through the roof, and so many drugs are so similar to each other. So I can see some reasoning there for encouraging folks to get generic drugs whenever possible, but that is a much different example than asking folks to spend $10,000 to get heart surgery.

ON:

And that’s not the sort of example where you are asking — where you are trying to incentivize people to not actually get particular care that they might need. The moral argument seems very clear, that is people are actually making a run on the hospitals, then what the fuck have we been doing, up until now that everyone is not getting treatment that they need? I also think that you are right that most people who have interacted with doctors and with hospitals — it’s not the best experience, not just because of the cost, but it’s like doctors can be great, nurses can be great, but being in hospital is terrifying, and scary, and tiring and all these sorts of other things along with the cost. I can’t imagine wanting to get a bunch of recreational heart surgeries maybe under Medical for All I find a new fetish for myself, but I’m assuming that’s not going to happen. One thing I just wanted to ask you about which I found a really compelling piece in the way that you talk about single payer is about is where single payer sits in an overall fight for medical justice, and an overall fight for justice, for everyone in and of itself, because I think you are pretty clear that single payer is great but also not the Revolution. 

TF:

Right, single payer is like, it’s necessary but not sufficient is how I would frame it. It provides us a tool, a means of leverage. It provides us accountability. Right now, nobody is accountable for the long term problems plaguing Americans. Nobody is really accountable for unsafe housing or unsafe water or homelessness. Nobody is really accountable for unsafe food or lack of food. Nobody is really accountable for economic insecurity because all these problems are atomized and diffused across a whole bunch of actors, of which half are privatized. What a single payer system finally does is—and I say this in my book and my talk—single payer is forced to bear the costs of providing care/paying for care and the costs of what happens when care is not provided, and through that mechanism you build an accountable organization, because if people are in unsafe housing or are homeless you die of exposure much faster than if you die of cancer, than if they don’t have food to eat, if they don’t have a job, there’s no income, if they don’t have rehabilitation, if they don’t have transportation then they get sick, and if you want to bring down healthcare costs you gotta invest in the things that keep them from getting sick in the first place.

But right now nobody even considers these costs, and within the health finance model like ETNA, Cygnet, and Blue Cross are structurally incapable of considering these problems as being problems in the first place. Only a single payer system feels the burn, feels the pressure. But what that does is it gives us a tool towards agitating towards broader change. Right now we’ve got an accountable organization. We’ve got these movements that already exist and I think will exist in greater depth and greater force post-single payer. And we have the right place to begin putting our levers and pushing down. Right now I don’t think it exists in the same way and so the goal is long term emancipation for all people and single payer clearly doesn’t do that, but it gives us a way of articulating it or defining it in a way relative to something like national health expenditure.

We have an agency that has the heft and the money to begin tilting towards it, and you see that Medicaid — I shit talk Medicaid a little bit, but Medicaid is the most interesting and the best healthcare program in the U.S. I’m very proud to be a citizen of the country that has Medicaid. Medicaid invests in housing, Medicaid invests in transportation, Medicaid invests in needle exchange programs, and in long-term care because it has to, because Medicaid does bear those long-term costs of poor people not getting the care that they need. It does some really innovative things, some really interesting things. It also does some heinous, horrible things because it does have abusive people who are funding it, abusive state governments, it does have limited financial backing, so it has to make really difficult and heinous decisions, but it also does these really interesting, wonderful things and if we had a federal model that had unlimited backing to try out these new models of healthcare financing, we would see a lot of real cool shit going on. We would see models going on like the New York housing initiatives. We would see models like the transportation programs in parts of Indiana. We would see these kinds programs like the Strong Start program across the U.S. or Medicaid-funded social workers to talk to pregnant people in need and get them access to all the social work that they needed; safe housing, rehab, etc., and to bring up birth rates and bring down early deliveries, and it worked.

That’s the kind of program that a federal single payer can invest it. These things aren’t new, we don’t need to discover how to make people healthy. We know, we know the answer. It’s social workers usually, it’s housing, it’s food. But no one fucking other than Medicaid programs has the money to invest in it.

ON:

I have a question about how we get around some of the problems that might come up—I think we can talk about some of the other problems that people normally raise — but talking from a left perspective one of the things I worry about is allocating resources to communities, whether they’re rural communities or under-served communities, that don’t have hospitals right now, and it would be difficult for the government to figure out they need things because it seems the demand is so low, but actually it’s not and how to apportion funding. Or one of the other things I worry about with a like unified single payer system is — now the answer to this might be well that’s obviously why we need broader liberation, but one of the possible worries is well then the single payer sort of gets to decide things they are going to pay for and that they’re not and I can imagine a world in which — and this would not be a good world—but I can imagine a world in which we have a single payer that decides not to pay for gender reassignment surgeries, that we have a single payer that decides not to pay for certain things that — because of other racist or transphobic or other what you might call other liberal or conservative policy preferences, and I am wondering if there are — is anything built into the way we need to conceive of single payer so that it addresses both historically underserved communities that we might not understand what need is, or that gets around these other preferences that might get in the way, or if it’s just actually that’s a different fight, that is something that needs to go hand in hand with single payer but isn’t part of the medical financing model?

TF:

I think that’s a parallel fight to medical financing. Single payer under both the Jayapal and Sanders’ bills is required to fund all “medically necessary care,” which is really interesting with gender reassignment surgery and trans health because to what extent do you want to medicalize being trans? There is a movement to demedicalize it which I think is correct, but like now in order to qualify you could say under a medically necessary framework you’d need a diagnosis of some sort to authorize you to gender surgery or HRT which maybe isn’t the avenue we want to go down, so like how do you expand the scope of medical necessity to include things that are not traditionally recognized within medicine? That’s interesting, but I think that is parallel to but necessarily apart of how do we pay for it in the first place. If I understand you correctly you brought up role care as an example of a place where we might record a lower need for care, but that’s just a function because there are fewer hospitals, that’s a real one. Hospital consolidation is a problem single payer can’t solve that really scares me. Certainly what we have now is not helping at all, so it’s not like we are making any trade offs there. But you’ve got PE companies and you’ve got holding companies, you’ve got investor companies that buy up hospitals and then close down the rural ones because they’re not doing a good enough job, or they’re not profitable, so all of sudden you have a shortage of care.

One of the new horrors in our country is GoFundMe’s for rural hospitals. God that is so fucking bleak. I saw a GoFundMe for a hospital in Copper Basin Tennessee that wanted to raise I think half a mil, to keep its doors open and it raised $2,000, so it had to close, and folks had to drive an hour-and-a-half to get to Atlanta to get the care that they need. There are some ways a single payer can begin to tilt against that, but it’s not doing enough in and of itself. I think I said it yesterday, in Maryland they had this problem in which there was a big hospital in the middle of Appalachia area, a bunch of small rural clinics, and the big hospital shut down the rural clinics because they weren’t profitable, so people would have to drive to the big hospital and get their care, which is much more expensive to Medicaid, and so Medicaid said: Ok, here is what we’re gonna do, because we are the only insurer in the area, folks in Appalachia aren’t getting Blue Cross Blue Shield or Cigna. There’s not a lot of jobs there, right, no ones getting sponsored insurance — so Medicaid was the de facto single payer in that region. So Medicaid said: “Here’s what we’re gonna do. We are going to give you a set amount of money per year adjusted for inflation, costs of living, etc., and you can’t turn anybody away. We’ve modeled out how many folks go to the hospital we will leave. it will be consistent. We are giving you a fixed amount, so go forth and make your profit.”