Factually! with Adam Conover - The Case for Medicare for All with Dr. Abdul El-Sayed

Episode Date: March 17, 2021

Why is America's health care system so effed up, and what can be done to fix it? Author, physician, and civil servant Dr. Abdul El-Sayed joins Adam to discuss how we got here, his belief in single-payer healthcare, and why he's hopeful for the road ahead. His book Medicare For All: A Citizen’s Guide is available wherever books are sold. Learn more about your ad choices. Visit megaphone.fm/adchoices See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

You know, I got to confess, I have always been a sucker for Japanese treats. I love going down a little Tokyo, heading to a convenience store, and grabbing all those brightly colored, fun-packaged boxes off of the shelf. But you know what? I don't get the chance to go down there as often as I would like to. And that is why I am so thrilled that Bokksu, a Japanese snack subscription box, chose to sponsor this episode. What's gotten me so excited about Bokksu is that these aren't just your run-of-the-mill grocery store finds. Each box comes packed with 20 unique snacks that you can only find in Japan itself.

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So if all of that sounds good, if you want a big box of delicious snacks like this for yourself, use the code factually for $15 off your first order at Bokksu.com. That's code factually for $15 off your first order on Bokksu.com. I don't know the way. I don't know what to think. I don't know what to say. Yeah, but that's alright. Yeah, that's okay. I don't know anything. Hello, welcome to Factually. I'm Adam Conover. Thank you so much for listening. You know, we hear so often that America is the richest country on earth. And, you know, it is. We have a very high standard of living and with it a somewhat stable government, a government that is pretty good at making sure that the things we need most to survive are plentiful, available and affordable for most of our citizens plentiful, available, and affordable for most of our citizens.

For instance, our society is very car-centric and people need to get around. And accordingly, we ensure that gasoline is cheap and plentiful, relatively speaking. Likewise, food is a necessity of life. And we have some of the lowest food prices in the developed world compared to our income. It is very, very cheap to get basic calories in America. Even if those calories are sometimes not so

healthy, at least you have access to them. And some recent events in Flint, Michigan, notwithstanding, the vast majority of people have access to clean running water. These are all basic needs that are often expensive in other countries, but we figured out how to provide cheaply to everyone in America because everyone needs them. But, you know, one thing that everyone needs just as much as transportation and food and water is health care. And oddly enough, in America, that need is very expensive to fulfill. Insanely expensive. We spend more money on health care than any country in the world. And it's not like we're getting better health care as a result.

In fact, Americans have shorter life expectancies than people in other rich countries. We pay more, yet we get less. It is fucked. Now, look, if you live in America, you know it's fucked. But I think it's important for the purposes of the conversation we're going to have today to review exactly how bad things are so we can finally start talking about, you know, some solutions. See, our health care system, to put it lightly, is, let's see, how do I want to express this? A Kafka-esque torture maze designed to extract the maximum financial toll from us at every single point? Yeah, I think that sounds right. See, in America, we get gouged by the pharmaceutical industry for prescription drugs and then by the medical device

industry for our hip implants. We get gouged by the ambulance that takes us to the hospital and we get gouged by the hospital that takes care of us. That's why hospital bills here cost more than anything, literally anything. Nothing in this country is more expensive than health care for the average person. And that's why over half a million families file for bankruptcy every year here due to medical bills. Even worse, it is literally our largest source of personal bankruptcy in the nation. Health care in the U.S. is mainly tied to employment. And this creates a drag on people who might otherwise want to move or change jobs or start their own businesses. Americans lose out on vital opportunities every day because they can't afford to perhaps put their insurance in jeopardy by changing jobs. And of course, even if you have insurance, it might not actually pay for the medical care you need.

For instance, if you need surgery, an out-of-network anesthesiologist you never asked for might show up while you were asleep and jack up the price and lead you to financial ruin. Costs in the medical industry are often hidden from us as patients, and then we're expected to negotiate with them after the fact. Kind of seems like a weird way to get chemotherapy, doesn't it? Now, this is the most important point. Here's what we need to hold in our minds. This bizarre extractive system is not natural or inevitable. It is, in fact, an accident of history. See, when I say other countries, I'm not doing that thing where I'm like every other country is smarter than Americans and they got it all figured out.

No, people are stupid everywhere and every place has their problems. But in some cases, the history of the medical industry happened a little bit differently and they ended up with a better outcome. In the UK, the National Health Service provides free health care for everyone at a very high standard of care. How did that happen? Well, it came together after World War Two. See, as Britain was rebuilding, there weren't enough businesses to supply health insurance and only the government. And there had also been decades of support for the idea of national health care in the United Kingdom that created the seed that grew to the NHS. And 75 years later, the UK loves the NHS maybe even more than they love the queen, especially after the events of the last week. That's a different podcast, you know.

Now, America's health care system also came about around World War Two, but it has a very different historical origin. See, during World War Two, there was a work shortage in America. So American businesses started offering health care to employees in order to attract them to work for their businesses. in order to attract them to work for their businesses. And as opposed to the ravaged UK and European economies after World War II, at that point, the US economy was roaring. So employer-based health care seemed like a good way to go. These businesses were flush.

They can provide the health care. As a result, efforts to create something like a national health service in this country were stomped out and the employer-based system grew to become the horrible system that we know today. And, you know, it's not working out so well, to say the least. But look, I want to emphasize again, this was an accident of history. This wasn't ordained by God or by George Washington. This is just the system that sprung up in our country. And that means that we actually could create a better system. We really, really could. So let's ask, what might such a system look like? Well, one of the most popular policy proposals goes by the name Medicare for all.

And here today to discuss it, we have Dr. Abdul El-Sayed. Dr. El-Sayed has been a professor at Columbia University's Department of Epidemiology, where he was the director of the System Science Program and Global Research Analytics for Population Health. And he is also the author, most recently, of a book called Medicare for All, A Citizen's Guide. Please welcome Dr. Abdul El-Sayed. Abdul, thank you so much for being here. Really excited to be here with you, Adam, and thank you so much for the time. So let's start by talking about what exactly is so fucked up about the American healthcare system.

I mean, I talked about a little bit in the intro, and I think that we hear about it a lot, but we hear about it so much it's often hard to take a step back and really appreciate like a new how weird it is and how strange it is. How do you put it? What is strange about the American health care system? Well, first, we're the only high income country in the world where 10 percent of our residents just don't have access to stable health insurance at all. That's number one. But number two, even for folks who do have health insurance, it is extremely expensive. We spend 18 cents on the dollar for every dollar spent in our entire economy on healthcare, as compared to, say, 30 miles from here in Canada,

where they spend about 11 cents and everybody's covered. On top of that, we pay more per unit healthcare than anywhere in the world for mediocre outcomes, right? Our infant mortality rate's 55th in the world compared to the world's best, which is in Japan. We live six years shorter than they do there. So it's ineffective, it's inequitable, and it's inefficient. And ultimately, it's because we have submitted to a system of healthcare in this country where we allow a profit motive to insinuate its way into every single interaction that we potentially have, whether it's with our providers, with the insurance companies, with the pharmaceuticals, with the medical device manufacturers, every single person,

every single party there gets their cut. And the last thing I'll say here, Adam, is that we're used to thinking of ourselves as customers, right? But let's say you were going to go to a local food mart and you decided you wanted to buy some broccoli rabe. And you go to the cashier with your broccoli rabe and you say, I want to buy this. They say it's going to cost you X number of dollars. You tender your money over. You get to take your broccoli rabe and eat it. If you think about yourself in the system, right? If you're lucky enough to be insured, lucky enough to be insured in our country, you go see a doctor or worse, go to the hospital. And then that hospital bills an insurance company that you've been paying and your employer have been paying every two

weeks to every month for the privilege of quote unquote being insured. And then they may or may not pay for your care. And even if they do pay for it, they're going to ask you to pay an extra amount of money into the kitty called a deductible. Yeah. So that you can get the care you already paid for. And in this case, you're not actually the customer buying the broccoli, Rob. You're the broccoli, Rob.

You're the reason that money changed hands between an insurer and a provider. And in that whole system, right? That morass, that swamp is why our healthcare is so inefficient and inequitable and ineffective. You've basically recapitulated like one of my favorite standup jokes that my friend, Brian Frangie, who used to write for our show and who's an incredible comic used to do. I used to see him doing this joke at open mics in New York city 10 years ago.

He'd say, you know, you, you break your arm. Oh, luckily my insurance covered it. You don't say that about anything else. You're not like, oh, I gave the guy five bucks for a sandwich. And luckily he made me a sandwich. And that stuck with me for a decade. Unfortunately, still true. I would love if that joke was out of date.

Yeah, that is weird. And it speaks to how the system doesn't seem to be serving anybody's interest, or at least the vast majority of people's interest. But I want to come back to the point that you made about the profit motive. Because, I mean, look, I believe that the profit motive is, you know, there's plenty of cases in which the profit motive is corrupting, right, in terms of incentives and the way it makes people act in our society our entire society also runs on it for the most part you know there's there's non-profit sectors here and there right but we provide most services via the profit motive why what makes medicine different that means we we shouldn't provide it via the profit motive in

your view i'll say two things that's true except for the things that we need most. Imagine every kid had to go to school bringing a check for that day's school. The majority of us go to public schools in this country. And frankly, the frustration happens when we either don't fund those public schools appropriately or when you get out of K-12 and now you're taking mounds and mounds of debt to get to go to school. That's where that fails. And so there's this concept called highway system, in which case there are tools, right? When you think about the provision of something as simple as the right to breathe clean air, we don't really think about that, but government is responsible for making sure that people aren't polluting the air around us or the water that we drink. And when it fails, it fails catastrophically. So there's a lot that we rely on government to do. And normally, those are those things that we know that are mission critical to people's lives. Now, I want to jump over to this to answer specifically for this healthcare question for a minute, right? Imagine, Adam, I told you, you know what? I can sell you a bundle of five MRIs for 5,000 bucks. And that's a good deal, Adam, right? You should take those MRIs.

The problem is I don't assume that you need an MRI anytime imminently. And the fact is that you don't know that you're going to need an MRI anytime imminently. So if I tell you you could buy these, but you can't give them to anybody else, you can't sell them for a profit, you're now in a situation where you're like,

you know what? I don't need this healthcare. What you really want is health. If you were to go play basketball, right, tomorrow, and you were to feel a pop in your knee, and I was to come back to you and like, you know what? I don't need this healthcare. What you really want is health. If you were to go play basketball, right, tomorrow, and you were to feel a pop in your knee, and I was to come back to you and say, Adam, you know, I've got those five MRIs for 5,000 bucks, but now I'm going to raise the price on you for 10,000 and I'm going to give you one, right? And it's the difference between having a functional knee or not having a functional knee. You probably would say, you know what? If I have the money, I'm going to pay it. And this is an illustration

of this concept in economics called inelastic demand, is that when we lose our health, we will pay almost anything for that. And what that illustrates is the fact that we don't actually want health care. What we want is health. And we see health care as a means to getting our health back after we lose our health. And the problem with this is that it creates this really broken profit incentive where there's no incentive to keep us healthy because only after we get sick are we willing to pay for health care. And we're willing to pay quite a bit for health care if and when we get sick. And so there's very little incentive in the system to keep us healthy. to keep us healthy. And that's the root of the problem here is that healthcare shouldn't be a consumer good simply because, you know, the vast majority of us, if we're privileged enough to be this way, we're born pretty healthy. And for folks who are not healthy, we have a moral responsibility

to make sure that they have access to every aspect of society. And so because it is mission critical for our lives and because there is a real responsibility that we have morally to uphold the well-being of people around us, I don't think it's fair to insert a profit motive into a system that really shouldn't be profited off in the first place. This should just be a human right, as we always say it is. And by the way, as it is in every other high-income country in the world, whether they are profound capitalists or more like social democracies in places like Finland or Sweden. So this is about whether or not we are willing to dignify our basic morals and we are willing to say that actually we should be invested in keeping people healthy rather than selling

them a product after they get sick. Yeah, you made two really good points there. I mean, one is that there are certain things that we as a society decide that should not be dependent on your ability to pay or that we should provide as a public good. You know, law enforcement, roads, firefighting, right? If your building burns down, you don't need to have a contract with a fire department. You used to have to pay fire departments. We used to have private fire departments that famously in the Tammany Hall era in New York would demand you pay before they put your fire out. They'd get into fights with each other because competing fire departments would be competing to who's going to put out a fire, stuff like that.

And when you think about it, like, yeah, health, health care is one of those things that seems to fall into that category. Everybody needs it. It's a moral obligation to provide each other. And it's kind of the having access to health care is kind of the the basis for all other parts of life. Like if you if you don't have that, you can't do anything in similarly to a road. If we don't have roads, we can't get around. We can't have life at all. And, you know, in some cases, all right, we have a toll bridge. We have a toll road here and there. But in general, we decide let's have this be something that we all pool our money into collectively because everybody

needs it and we shouldn't make each other pay. And it does seem like health care is one of those things. But you also raise the point that, yeah, health care is structured such that there is this point at which it becomes really extractive if it is done with a profit motive. Because if the fire department comes to your house and they can set their prices whenever they want, you'll pay anything at the moment your house is burning down. And that's like a really perverse incentive for them to have. It means that it turns the entire medical industry into like profiteers of tragedy, right? Or the people who, you know, are going to sell you a bucket of water for $10,000 when your house is burning down. And I think, yeah, we have a certain moral revulsion to that when you put it that simply. And Adam, I'll even flip this on its head for a second. Imagine we had a set of laws that dictated the punishment for murder based on how much money the person who was murdered had.

Right. So if you murdered a pauper, right, that you would be charged maybe two or three days in jail versus if you murdered a billionaire. We might have a system like this, Abdul. I think we might. That's fair. You're making a great point. So we should fix that system, too also fix our healthcare system. Because in the end, right, it just does not serve any moral frame of justice to say that anybody's body is worth less, right, than someone else's body.

Because as you said, it is the sine qua non of life. You cannot function if you are imminently suffering some really grievous health challenge or even something small. I mean, you know, it's a fascinating thing that we're in the middle of a move and I nicked my finger and it was really hurting. And I was just thinking, I was like, I have this tiny little piece of skin that's been broken and now it's on my mind, right? Consistently. And it was a reminder of just how much of a blessing it is to have one's health. And it forces you to really think about what it's like for folks who have chronic illnesses, who have to suffer them every single day.

But even beyond that, who have to worry about what the potential life consequences and financial consequences are going to be because of the misfortune of their illness. That should not be the case in the richest, most powerful country in the world. It should not be the case anywhere. And yet we allow a norm in this country that puts the profits over huge corporations above and beyond that very basic moral frame. And the fact that we've done this in the past should not continue to pattern the future in the same type of moral failure. And herein is the fundamental basic argument for why we need to really take healthcare reform seriously and do so in a way that does not

continue to accommodate a morally flawed, broken system that allows major corporations to extract off of the illness of other people. Yeah. I mean, you make a great point about, you know, when someone is in poor health, the degree to which it takes over their lives in this country, not just because of whatever the health problem is, but because of the extreme difficulty of getting their care paid for. It's like a curse on people's lives. It becomes an immense burden of paperwork and phone calls and this and that. And, you know, anyone who's had a loved one go through it, you know, can, I think, relate to this. And I'm sure there's people listening to this who have gone through it themselves as well. But before we get on to, you know, imagining a better system here,

I just want to prod at this a little bit more because, you know, the story that we get told, that we tell ourselves about for-profit enterprise is that it's inherently efficient and that it causes prices to go down. And, you know, I'd have to say that I think that's true in many segments of the economy. There's often a race to the bottom effect, right? I mean, say what you will about Amazon and all the terrible things that company is doing, it does things very efficiently and very cheaply for the for the customer. And so why does why is that not the case? Right. When we're talking about the for profit health care system, when you look at the for profit health care system, I've covered it on Adam ruins everything we've talked about

hospital billing, about the charge master, for instance, about how there are these basically made up prices that get charged to people. There's a tremendous waste and inefficiency in care. There's, you know, shortages, as we saw during the coronavirus pandemic that's still going on. It doesn't look like the story that capitalism tells itself. It looks like something much worse. Why is that in healthcare specifically? Well, there are a number of reasons that the concept of a market fails when it comes

to healthcare. One of them is that usually when you enter a market, you know what you want. Let's say you're trying to buy a car. You have a sense of the kind of car you want, how much you want to pay for it, what the prices are going to look like. And you enter that market with knowledge of that thing. The problem in healthcare is that you're a consumer who doesn't actually know what you actually want. You're being told by the folks who are selling you the product, what it is that you need. So if I started clutching my chest right now, you'd say, Abdul, get yourself to an emergency department. I'm a physician, so I have a certain sense of what this could be and what my potential treatment options are. But if I didn't, right, I'd be at the mercy of the hospital and the

physicians who are going to give me care to tell me what care I need. An analogy to this is going to the mechanic, right? If you go to the mechanic and your car is making funny noises and they say, well, you know, you need a towel sprocket rod combiner. And you're like, oh, okay, how much is it going to cost? They're going to be like, well, you know, it's $2,000 for the product and another thousand for the repair. You don't know that that whole thing doesn't even exist. It's not a real part of an engine. And so you just say, okay, well, I want my car to be working again. And if this is what you, the expert, tell me I need, then then I guess I need that. That's called upselling. And that happens in health care all the time. This happened to me. This happened to me recently.

I went to my dentist who I've been going to for many years. Very good dentist. This dentist for my partner, Lisa, like fixed a major tooth problem that she had. So a good dental surgeon had a great time, kind of an upscale dentist. And, know, like West Hollywood kind of ritzy part of LA, but always felt it was worth it went. And they said, Oh, you've got some problems this last time. You've got some problems around your gums. We need to inject like, like an antibiotic gel in there. And I was like, okay, sure. Go ahead, go, go ahead and do it. That's fine. The last time I went, they said, you have a cavity. We need to fill it this time. They said we need to inject the antibiotic gel. They do this. And it's like a extra like two hundred dollars that my insurance doesn't pay for. I'm like, OK,

whatever they said to do it. But then at the end, they say, oh, and by the way, do you use an electric toothbrush? And I said, no, I use a regular toothbrush. I think I brush pretty well. They said, well, we should really get an electric toothbrush. We recommend this one. And then they put the electric toothbrush in my hands. It was a $300, uh, like Bluetooth electric toothbrush. And I'm like, I don't know. And the dentist says, no, this is the one that I really like. I really like this one. And they like put it in my hands. Like I had to physically, I was in the chair. I was like back in the chair with like the bib on and stuff. And I had to like, there was nowhere to put it. Like I had to just sort of like drop it on the floor next to me to like get it out of my hands when I went to the, and by the way, I'm sitting there looking up on

my phone and it's saying, and like, I look on the wire cutter and stuff like that. And it says, don't get this toothbrush. This is exact cleans your teeth exactly as well as the $30 electric toothbrush. It just has Bluetooth and the Bluetooth features are useless. Just get the cheap. The cheap ones are worth it. You know, it is worth it to get an electric toothbrush. It just has Bluetooth and the Bluetooth features are useless. Just get the cheap. The cheap ones are worth it. You know, it is worth it to get an electric toothbrush, but get the, get the $30 one. So I like drop the thing off and I leave and I go to the front desk and they said, so you're getting the $300 electric toothbrush. And I say, no, I'm not getting it. And, and after that experience, I was like, well, hold on a second. The antibiotic gel that they put in there was that bullshit too because i don't trust them

anymore and now i can't go to that dentist like i i literally i i i left and i said to my girlfriend i can't go to that dentist anymore because i don't trust them anymore because they just tried to tell me to buy a 300 electric toothbrush that i 100 did not need i'm sorry there's a long story but i got mad all over again and this is just a normal checkup. But Adam, the thing you didn't understand is that they put the tooth in Bluetooth. Hey, I'm the comedian here,

all right? Abdul, stay in your lane. No, no. Give me more. Give me more. In my professional opinion, you really ought to have bought that toothbrush. Look, your story is exactly right, right? And, you know, they're a private practice dentist who's trying to maximize their bottom line. This is exactly the point though, is that once you introduce a profit motive into something as intimate as your health,

it starts to decimate the trust that you need and the kind of relationship that you want to have with the people who are providing you care. I'll give you my own story. I went to grad school in the UK and the one thing my wife told me, she was finishing college here and one thing she told me,

she said, look, I know you played football in high school, but no rugby, right? I'm scared to death that you're going to hurt yourself. And of course, I wanted to play rugby. So I show up to the rugby pitch after clearing it with my wife. And the first day I'm there, I asked the captain coach, so how do I hit in rugby Like how do I tackle? Cause in football, you're, you're taught to tackle behind the guy, like through the guy, cause you're all wearing pads. And he said, just like you do in football. I said, okay. So I lined up the guy in a drill and just nailed him. And when I fell, I felt a snap in my, in my ribs and I couldn't breathe, but I didn't, I didn't want, I mean, I felt like I had the entire pride of the United States on my

shoulder. So I just got right back up and I'm like, I'm good. I'm good. And, uh, and so I'm, I'm, I'm kind of running around catching my breath. And, um, and the next day I go to my national health service doctor and I said, you know, it hurts when I laugh, it hurts when I cough. And he just gives me this like wry British look. He said, so don't laugh and don't cough. I was like, all right. Um, that's not helpful. He's like, yeah, no, I know. He said, you're a medical student, right? I said, yes. He said, okay, well, do you think that your ribs are displaced? Meaning, do you think that the crack that might be there in between your ribs, the two

bones aren't touching each other? And that's a real emergency, right? Because then those broken bones can be rubbing against really sensitive tissue and really create some havoc. Yeah. But if they're not displaced, it'll just heal on its own, even if it's a bit painful. And I said, no, it's definitely not non-displaced. Like I just, it feels like either a bruised or a cracked rib.

He said, okay, so what do you want me to do for you? I said, I don't know. Don't you want to get an x-ray? Just make sure. He's like, he looks at me for a second. He's like, you know, this isn't your country. In your country, I'd send you to go to the x-ray. I'd send you to go to get a CT.

Why? Because I'd get some little extra money on the backend. Here, right? My job is to your health. I don't make any extra money by getting x-ray or a CT. And clearly you're fine, except for the fact that it hurts when you cough, it hurts when you laugh. And I gave you my best medical advice. Don't cough and don't laugh. And so the point that he was making is that I'm here to take care of you and your health, not to think about how I can make money off of you. And we've become so accustomed in our society for a system to try and ring us up for as much money as it can make off of us, that even as someone who knew clinically that there was going

to be no change in the management of my potential cracked rib based on whether or not we got an x-ray, because clinically, obviously, there was nothing all that wrong with me except for the potential bruise or the crack that I went to the doctor thinking, you know, he's probably going to want to run some tests. And it's the way that it's like built into our culture to assume that our providers are interested, right, in maximizing the level of care that we normalize it in a pretty profound way. And so much of what we need to be thinking about is, does that help us? Is that actually good for us? Because for me, an x-ray, you know, there's some risk to an x-ray. You're going to get a

little bit, some dose of radiation, but really it's minimally hazardous. But when you start thinking about added treatments where they're injecting you with something or they're giving you a treatment that may have side effects, this has real consequences for our health, let alone our pocketbooks. Yeah. I mean, the fact that it becomes normalized and that it's spread throughout the entire medical system in this subtle way, that's the more pernicious piece of it than the dentist putting the toothbrush in my hands. Right. Which is,

that's just the dentist. I don't even blame him that much. He's just trying to pay his rent, you know, and that's the system that he works in. But the fact that every single little decision is happening that way, that's what really makes it add up and makes our medical system so expensive. I mean,

there are entire, I've read different case studies of, you know, there'll be a treatment that a company or even a whole you know portion of uh the medical industry comes up with for a particular uh for a particular malady that isn't really that effective but becomes widespread simply because they can charge a lot for it i'm thinking of i mean i haven't read about this and what maybe there's new research on this but like spinal fusion for back pain is like this very complex procedure. That's like a, you know, a surgery that was being done for a long time for back pain that didn't even really seem to work. It just was expensive. That's why it was being done. There's so many examples like

that. I can only imagine how, how that, I don't know, it's just the high price of healthcare in this country seems to be every reason coalescing all the time. Just everything is coming together in every way, big and small, to make our healthcare this expensive. And Adam, I want to offer you just another example that's probably the most egregious one and one that really gets to this sort of space between our morals and our philosophy and our healthcare system is that we spend an obscene amount of money in the last three months of life. Something like a third of medical expenditures on Medicare are spent in the last three months of life. And in some respects, right, the question we have to be asking is, is death a disease? Right? Because every life ends and that's just a function of living. And obviously it's not something we all want to think about often, which is part of the

problem, right? But that every life ends. And so we've almost pathologized death itself and we're spending huge amounts of money, right, to try and allay death in the last three months of life, which means it's clearly not working. And so the big question that we have to ask is, how do you build a healthcare system where we dignify and actually move toward the kinds of outcomes that we really want, right? Because in the end, when I teach, I always tell my students, the first line I always say is, nobody saves lives, right? We can prolong a life. We can improve the quality of life. We can improve inequitable distribution across the population of a long, healthy life. But in the end, no saving

lives, right? Everybody dies at some point. And once you think about it like that, the question becomes, well, what are the trade-offs in terms of what we could be doing in our healthcare system around investing in the longest, healthiest lives that don't imply medicalizing what we do in the last three months of those lives? And we make decisions around this profit motive all the time in seemingly unconnected ways. Let me just give you an example. In the 70s and 80s, we saw that obesity nearly tripled between then and now. And a lot of folks, right, have spent a lot of money and time and energy researching the cause of this obesity,

but they are always asking, what is the difference between obese and non-obese people, rather than asking what happened in the moment when obesity increased? Because I'll tell you what, we haven't evolved much in the last 30 years, but what has changed is our food environment. And it turns out that the big aspect of this is that there was a change in the way that we regulated crop production. We went from limiting the amount of crop production to protect the prices of crops for farmers to just fundamentally subsidizing things like corn and soy. And so once you start subsidizing corn, you now turn corn into more than just corn. You turn corn into sugar. You turn corn into gasoline. You turn corn into cows, right? And once you do that, you artificially

depress the price of those goods on the food market, which then make them a lot more plentiful. And that change in the food environment, right, as we were subsidizing through our public policy, the production of foodstuffs that ultimately made us obese, turned into, right, a number of patients on the back end because we know obesity predicts everything from diabetes to heart disease to stroke to cancer. And so we are spending money on the front end, right? In a way that is making us sicker and spending money on the back end to care for that illness, rather than asking if our goal is not the throughput of money through these systems, but rather the wellbeing of people who are the substrate of those systems, then what would we be doing differently?

We could actually just stop money, stop paying money to subsidize the production of agricultural products and also stop paying as much money on the back end to care for the obesity that results from it. Yeah. You know, I read, speaking of death, you know, I read Atul Gawande's book, Being Mortal, five or six years ago, and that was a revolutionary book for me. And it made the same point that that you did that so much of our care around death. And I'm sorry to go back to your first point rather than your second point, which is also an excellent one about the food system, but that we spend so much money. You know, people are about to die. Let's throw money at it. Let's just hook them up to everything. Let's, you know, hook them up to the beeping machines.

And not only does that not work because everybody dies eventually, people also have a terror of it. People are terrified of dying hooked up to a bunch of machines. And really what would make them happier and give them a better quality of life often at the end would be to be surrounded by their friends and families, to go home or to be in a, you know, an assisted living sort of environment that that is not so medicalized. But our system pushes in the opposite direction. And part of that has to be because of the profit motive. I mean, yeah, if a third a third of all health care spending is in the last three months of life, then, yeah, your your hospital is going to say, let's hook them up as much as we can. That's, that's, uh, that's the bar. You know, we lose money on the food. We make money on the bar.

That's where they, if that's where they make their money, that's where they're going to want to be, uh, spending the most on you. No, that is, um, that is, that is exactly right. And, and, and, and the frustration, right. I mean, I remember when I was in medical school, I was doing a rotation at a smaller hospital and there had been this extremely gifted end-of-life physician that had been hired that they were trying to move out of the hospital. And the reason why is because the hospital had also built an intensive care unit. And this physician was so effective at having end-of-life conversations that people were saying, you know, I really would rather have an end-of-life experience that puts me with my family, even if that means I may live a shorter time. Although the evidence suggests

that actually these folks live longer, rather than being hooked up to a bunch of tubes in beeping machines at that end of life. And so patients were choosing not to go to the ICU, which meant that that ICU was lying fallow, which meant that the hospital was losing money on the ICU. And so they actually were looking to move this physician out because she was so good at doing her job, because people were not going to the ICU, right? Because she was so good at doing her job because people were not going to the ICU, right? And those are the moments, those are the spaces where our system fundamentally fails to recognize that the substrate of that system are real people whose lives and experiences the system was intended to serve, but has been Frankensteined out of doing that.

It now is in a position where it's just how do we make more money and churn more through this system? Well, look, we got to take a really quick break when we get back. I want to talk about what we should do instead. But we got to take a quick break. We'll be right back with okay we're back uh abdul how did we end up with this incredibly fucked up health care system that we have in america while every other country as you say every other wealthy country has something that's much more efficient is it an accident of history or what? How did this happen? Yeah, frankly, it is an accident of history. What happened is that, you know, back in the day, we'll just go way back, medicine wasn't all that effective because we just hadn't yoked it to science yet. And at that time, you could see a doctor, you couldn't see a

doctor, it really wouldn't change the outcome for you. And then as we started to infuse more science into medicine, it actually got really effective, right? We were able to really treat people and nurse them back to good health. And once that happened, the cost of that training actually increased substantially, and it became unaffordable for the majority of Americans. And so actually Baylor Hospital devised the first real insurance program working with a local teachers union saying, look, as a hospital, you pay us the small fee of 50 cents a month and you can get care at our hospital, which by the way, would be $7 a month today, if you were calculating those premiums. And it was really care at our hospital, which, by the way, would be $7 a month today if you were calculating those premiums.

And it was really effective. Soon enough, this system of insurance spread and became the norm. And then during World War II, there was a cap put on how much you could pay employees and pay labor because, of course, there was a suck on labor because we needed to fill our factories. And also, unfortunately, we needed to send people out to wage war. And so what employers devised was this way of offering benefits rather than salary. And one of those benefits became health insurance. And then the IRS, in effect, infused our system this way by saying that benefits wouldn't be taxed. So health insurance became a benefit that people came to expect through work. And we then, the employer-sponsored health insurance system was born. Post-World War II, every other high-income country in the world recognized,

particularly in Europe, recognized that there needed to be a far more robust social welfare approach to health insurance, frankly, because the war had been so hard on them. Whereas for us, the war was in effect a major economic boon. And so we did not take that historical moment. And when we failed to do that, right, we allowed for the creation of these major monster industries in the form of health insurance, which subsists today. Health insurance spends, to put it in perspective, for the past 20 years, of health insurance, which subsists today. Health insurance spends, to put it in perspective, for the past 20 years, the health insurance industry has spent some $2.7 billion, with a B, lobbying. And that's just lobbying,

not to mention all of their advertising costs. In 2020 alone, they spent $151 million operating 845 lobbyists. Why? They made bumper profits on the pandemic. And for all of those 15 million people or so who lost their healthcare because they lost their jobs, the goal was, how do we make sure that the government subsidizes their COBRA coverage? So additional coverage for them. So more money in the coffers. And this is a moment for us, I think, that we have

to step back and ask, what is the consequence of the Frankenstein system that we've allowed to develop? Because right now, it used to be that conversations about health reform really focused on how do we provide healthcare for low-income Americans, which should be enough of a conversation to get us moving, but it hasn't. And now though, the median American who has health insurance, the average family of four, that median family of four, they're spending $3,500 on a deductible. And the insurance industry has realized that it can continue to increase the costs of premiums and then bolster their earnings with deductibles insofar as people actually get sick and need to use their insurance. And so it's become the cause of 67% of all personal bankruptcies in America.

So now the median American is asking a very basic question about how our healthcare works. And I think post-pandemic, we have an opportunity to really turn the tide here and say, you know what? We failed our opportunity after World War II. Let's not miss our opportunity after the pandemic. Yeah, it's so funny.

When I have read about this before, England has almost a different parallel story where my understanding is the National Health Care Service or National Health Service, which is beloved there as far as I know also sprang out of world war ii that it was a it was what it was just uh it was a wartime program that then stuck around um and that's the accident of history piece right this is just like what these two big countries did during this time of extreme war um but theirs seems to still be working pretty well. Ours is crumbling and is not providing health care for people. And it's I don't know. It never ceases to fascinate me how those little changes, those little decisions made 70, 80 years ago still reverberate today and have created sort of these edifices that have vastly different outcomes. But so let's talk about it. What should we be doing instead of the system that we have? Yeah, well, alongside my co-author, Micah Johnson, we wrote a book called Medicare

for All Citizens Guide. And we wrote this book as two physicians who believe that our health care system has forgotten the patients and the providers who are its heart and soul. And what Medicare for All is, taking it out of the politics for a second, is a single national health insurance program that covers everybody from the cradle to the grave. You keep it if you turn 26. You keep it when you get married. You keep it if you get divorced. You keep it if you change jobs. You keep it if you have no job.

You keep it when you turn 65. No keep it if you get divorced. You keep it if you change jobs. You keep it if you have no job. You keep it when you turn 65. No matter what happens, it's there for you. It would cover all of your basic health care needs. And it would fundamentally alter a lot of the broken incentives in our health care system in a couple of ways. Number one, we have over 900 health insurers in the United States and 7,000 different hospitals and clinics, right? To be able to crosstalk, to be able to bill each other, there is a huge overhead of billers who just

enable these institutions to talk. If you had one insurer, all of that overhead goes away because there is one insurer, right? You just need to know how to articulate with them. And they get to set the price. So rather than having this escalator of pricing that keeps driving the cost up because everybody's trying to make money off of the system, the insurance industry becomes what we call a monopsony. So everybody knows what a monopoly is. It's when you have a single seller of a good. I love talking about monopsonies. I'm so happy that you brought this up because it's one of my favorite ideas ever. Please explain a monopsony for us. Yes. So monopsony is the mirror image of a monopoly, right?

Rather than having a single seller who can set the price, you have a single buyer. And you just imagine it, right? And you go to a store and you're the only person who's ever going to buy a product. And if they're motivated to sell, you get to set the price. Why?

Because if you don't buy it, nobody actually sells. So they got nowhere else to go. Exactly. The government becomes a monopsony on healthcare. It gets to dictate the price of healthcare and holds the price stable and also brings the price down. And because it's a universal program, everyone is covered, no questions asked. And so this would increase our healthcare security. It would improve the efficiency of our healthcare system. It would make the system more affordable. And lastly, we talked about the misincentives in our system around keeping people healthy in the first place. We have an anemic

public health infrastructure in this country. We are obviously seeing that in the context of this pandemic. I mean, we pulled off a medical miracle to produce these vaccines, but it was like you designed a McLaren X1 engine and then dropped it in the body of a Ford Pinto, right? That's what we did. And so obviously it's not getting out to people because, well, our infrastructure is broken. Here's the thing. If you have one insurer and that insurer is the federal government, it has a real incentive to keeping you healthy through your life course because it's saving money on back end of that. And so all of the brokenness in our system that leaves us from actually preventing illness that we can actually take on via the system. So it is a one-stop shop solution, very elegant solution to all the problems that we face. I

sometimes use a metaphor of a small quilt, right? Imagine you had a quilt with a couple of holes in it and it's a little too small, right? So if you pull it up to cover your chest, your feet lose the coverage. If you pull it down to cover your feet, you lose the coverage on your chest. There's holes. So certain parts of your body are poking out

and your elbow doesn't get covered or your knee doesn't get covered because you're missing a hole. That's what our healthcare system is today. Instead, we're replacing it with a single very large felt blanket. It's what our healthcare system is today. Instead, we're replacing it with a single, very large felt blanket. It's the same coverage for everyone. It covers your whole body and you don't have to worry about how you're going to get covered and whether or not you're going to

fall through the crack. There's a degree to which it's also, it just makes more mathematical sense in terms of the math on how insurance works, right? That if you've got, the more people are under an insurance plan, the cheaper that it becomes for everyone, because the sort of cheap premiums that are being paid, in this case, in the form of taxes, for all the healthy people are paying for the unhealthy people. You want to get them all under the same tent, and that makes the whole system cheaper. Versus if you have a smaller insurer, if you have all this patchwork of smaller insurers, it's harder to make that math pencil out because one of them ends up with, oh, all the sick people are under this insurer. And then everybody in that insurer has to pay

higher prices. And am I getting that right? That's part of my understanding of why people advocate for single payer in the first place. Yeah, you are, you're speaking to a couple of different pieces of brokenness in our system, which I really appreciate. The first is that we've been seeing monster consolidation across the system, in large part because the bigger payers, the insurance companies, and the bigger providers almost always win. Why? Because they can negotiate prices that allow them to put their competition out of business and buy them up. Right. And so that is that is part of the problem. The other problem, right, is that exactly this point around where people go and in what system, because you have a single insurance program. Right. There isn't this game that the private insurance could play around one another to cherry pick the best patients. And then lastly, right, a lot of folks argue or they worry that Medicare for all would mean that Medicare as it stands today, right, would be cut over more, more slices. And so every piece of the pie would be smaller. But actually, right, when you include more people, particularly people under 65, those people tend to be putting more into the system than they tend to be taking out. Yeah. Which means that actually it makes the

Medicare system overall far more sustainable because you've got more coming in and less coming out as you spread it over more younger, generally healthier people. I mean, Medicare is already able to negotiate because it's so big. It's like one of the, it must be the biggest medical buyer currently in the country, I would imagine. It's able to negotiate for lower prices for prescription drugs, all these sorts of care. Now, if you imagine expanding that over the rest of the population and that's healthy people now who are, you know, don't need as much care. It's younger people. That is. You can see how it drives prices down even lower. So I understand it as a mathematical, hey, this works better, do the math yourself, it results in cheaper, better care.

That's right. I want to speak to one point that you made, Adam. In theory, Medicare should be able to negotiate for prescription drug prices, but by law, it can't. Why? Because the pharmaceutical industry lobbied tremendously, right, $4.4 billion over 20 years to make sure that it couldn't, which is absurd and complete bullshit. the whole, the point that you're making more broadly is true that the bigger the buyer, the higher the monopsony power, the better the ability to demand a better rate and achieve that rate. And that allows you then to buy in bulk. It's kind of like going to Costco for healthcare, right? Costco works because you get this membership and then they can buy in bulk on behalf of their members, right? And by doing so, they get a better price and then they deliver a better price for you, the consumer. It's exactly like that um uh really so we should be calling it is costco healthcare for all so well okay here's my next question though because look i'm very uh i'm very susceptible

to an argument about hey here's a much better system than the system that we have right if we do the math this works out better uh I love talking about it. I love thinking about those systems. But let's talk about how we get there from here. I mean, I remember in the run up to the Affordable Care Act, reading about this argument about, hey, here's how the UK got their health care system. Here's how we got our health care system. But the thing they have in common is you must build on the system that you have. You know, that's that is how we ended up where we are today. We had something before and we build it. We try to make it a little bit better.

It's not as though the UK had a mature health insurance, private insurance based system like we did and then said, you know what, let's wipe it out and let's institute the NHS. Right. It grew organically. We are now in the situation where that's what we would have to do. Right. It grew organically. We are now in the situation where that's what we would have to do. And it's what we know would be an immense disruption. Even if we were to say it's a good disruption, it would still be a disruption. Right. Where we'd have disruption to the insurance industry, to the health care industry itself, to the lives of doctors, to patients. And even again, if we were to say it would only be beneficial to patients, it would still cause a lot of confusion and a lot of disruption. It's just simply disruption. So why, in your view, is that the approach that we need to take rather than

making adjustments to the system that we already have to step by step by step get to a better world which is what the affordable care act tried to do and i have to say it's been 10 years i'm not looking around at america's health care system and saying wow the affordable care act fixed everything seems like seems still pretty fucked up to me um but why do you feel we need to to do the big disruption? I'll give you an analogy and then I'll speak to the facts. Imagine somebody who's a kid is playing and they fall and they break their hip, but they never actually go and get it fixed. And so their their leg is now two inches shorter than the other leg.

And they proceed to walk around with this two inch shorter leg for most of their lives, which then causes them tremendous amounts of knee pain, back maladjustment. Uh, and, um, they can't do the things that they would want to do.

Uh, if they were to go to an orthopedic surgeon, what that orthopedic surgeon would say is that, Hey, this healed, but it healed wrong. And the thing we have to do is actually break the bone again and then fix it so that it heals correctly.

They really do that? Address all the pathology. Absolutely. And so the point here is that we can continue to try and accommodate, right? We can get shoes with lifts, right? We can get crutches, which is kind of what the ACA was. But if we're serious about actually solving the accident of history that gave us a healthcare program that's more interested in the profits

of major corporations than the well-being of people, then at some point there is going to be a bit of disruption so that we can get to a point where all of the disruption that 10% of people, and frankly, most people feel in their lives because of this, goes away. And that's the analogy part. The other part is this. A lot of folks, where the rubber hits the road on this argument tends to be in a conversation about jobs. Here's the thing. We already have a shortage of actual healthcare providers, but we have a whole army of billers in the health insurance industry that exists to tell people why they can't get the care that they actually need, right? Imagine we were to all of a sudden include 10% of the population into the potential serious demand, an honest demand of healthcare, i.e. they have insurance that they can actually

use to get healthcare. You would all of a sudden have the opportunity to create millions, potentially, of jobs, right, for nurses and doctors and other healthcare providers, for the people who have been locked out of the healthcare system all along. And so on net, this is going to create a lot more jobs doing the thing that healthcare is actually supposed to do, which is provide you healthcare when you need it, rather than the kind of jobs that we often have right now, which are about telling people that they can't get healthcare. And I'll leave you with a story on this one. When I was campaigning, I ran for governor in Michigan in 2018. And

when I was campaigning across the state, I was talking about this sort of moral failure of our healthcare system. And a young woman stayed back afterwards and she said, I want to tell you something. I said, what's that? She said, you know, the thing that you said about, you know, the rot at the core of our healthcare system and the fact that there are people who actually are employed by the quote unquote healthcare system to tell people that they can't get care. I used to be one of those people. And I remember I had to tell a woman who had gotten necessary treatment for her breast cancer that she wasn't going to have that reimbursed and that because of that, she was going to fall into bankruptcy and that she was going to

lose her health insurance for that reason as well. And it gnawed at my soul to the point where I resigned my job. I went to nursing school and I now take care of people who have breast cancer because I want to address that moment that I failed that woman who needed us. And so there's a question about what we think our healthcare system ought to do. Do we think our health care system ought to deny people coverage so that a CEO of a health care corporation can make tens of millions of dollars every year? Or do we think that our health care system ought to be about providing people life saving and necessary treatment if and when they get sick? It's a fair point. It's a fair point. I mean, I do. I don't want to make I don't want to make a meal out of it. I do want to acknowledge that there's, you know, however many or tens of thousands, maybe hundreds of thousands of people working in a private health care uh, I'm not trying to put weight on that more than the immense misery that goes on in America over healthcare that we need to alleviate. Um, but it's, uh, yeah, it's, it's, it's a problem that needs to be solved. It's not, it's, you know, analogous somewhat to, Hey, we need to stop burning coal. Uh, we still need, or, you know, natural gas. We need to provide for folks who are

doing those jobs now um and and adam to your point you know we have to do this in a way that takes on a a real level and real concern with justice you know the notion of a just transition just like uh as we transition out of fossil fuels we need to justly transition our health care system so how is it that you potentially can pay that person who was working uh in one as we transition out of fossil fuels, we need to justly transition our healthcare system. So how is it that you potentially can pay that person who was working in one of these jobs as you also pay for their nursing school so that they can transition into a job doing the work that's going to be there for them? The other point of that is this, is that a lot of the infrastructure that currently exists in health insurers can actually be co-opted into the system, right? A lot of those people would go from working for a Blue Cross Blue

Shield to working for the federal government or the state government doing the same job that they were essentially doing, right? Obviously, there's going to be some loss, but let's not forget, right? You still have to provide health insurance and all that goes with it for the 350 million people in this country. And so those jobs are still going to be there. Obviously, the nature of them will change slightly, but a lot of that infrastructure will be required anyway and actually can be co-opted into the system. So let's talk about the politics of it. And I don't mean like, you know, the day-to-day cnn style politics i mean like how do we get something like this done um i mean i remember when 10 years ago single-payer health care was a policy idea um and it didn't have that much of a political valence

it was like hey this is something that we should do this is an objectively better system i still find myself extremely sympathetic to those arguments. Medicare for all is a much more recent political term popularized by the by the Bernie Sanders campaign. In your view, is there a difference when you say Medicare for all today in the title of your book versus single payer health care that we might have been saying 10 years ago? Is there is there a policy difference in that or is it simply branding? I think in a lot of ways, when we say Medicare for all, we are talking about single payer. The problem with single payer is that it's very jargony. People don't really know what a payer is. And we use payer and insurer interchangeably in the healthcare lexicon,

but that's not entirely obvious to most people. And so Medicare is a single payer healthcare program for people over the age of 65. People understand what that is. And so using the term Medicare for all is about translating the policy idea underneath single payer into something that people can grasp and understand without having to be a healthcare expert. And so whatever you call it, right, we need a single national health insurance program. And the politics, frankly, I'll be honest with you, we have a whole chapter in the book called organizing versus advertising, which is what this is going to come down to. The industry is going to spend millions, if not billions of dollars advertising to kill this. They're going to tell us that it's too expensive, that our country can't afford it, that it's going to force us to ration care, that it's going to eliminate our choice. And you've heard all of these talking points. In fact,

no matter when you talk about this issue in the public discourse, people are so primed with these talking points that you almost have to frame around them as you even engage the question. And the only way we're going to get past it is if we are able to build a movement of people organizing around this idea. And there's some historical precedent to this. Medicare was an idea that had been pushed for decades before it actually passed. And nobody saw it coming when it came, but when it came, it came. And it has fundamentally changed lives for seniors in this country and people with disabilities. And that's because you had a grassroots community of people who are pushing for dignity for our seniors in the form of health insurance if and when they got sick.

And so we're going to have to do the same thing. And I'll tell you, it's already happening. You see it happening all over the country. People like Lisa, who we talk about in her book, a woman who had a heart attack at 36 after her husband had a brain tumor just three years earlier, who was insured through her husband's employer, was in a situation where they could not pay their deductible and had their friends and family had to pitch a fundraiser for them and open up a GoFundMe. These are the folks who are now the foot soldiers of a push for Medicare for all. They're not the people who would have been involved in a conversation about health reform in the past

because in the past, it was almost always about low-income people. But now the median American is realizing that there is no surety in the insurance system and that there is a responsibility that we have to finally take it on. And they're getting wise to the fact that the reason we're stuck in the system we have is because there are major corporations that make a lot of money off of it. And that's just

not a good enough reason. And so you're seeing this movement really starting to take root. Yeah. Social security has a similar story behind it, too, that there was decades and decades of people just organizing around it and different ideas, you know, that weren't entirely that idea, but were demands for more government care of seniors and, you know, direct payments to Americans and et cetera, that eventually created a mass sentiment that made, you know, Roosevelt and the others in that era feel that they, okay, we need to do something or people are going to come at us with pitchforks, basically. What do you think that transition looks like though? I mean, Bernie Sanders rhetoric, for instance, is all about revolution, right? That we're all going to step up and demand it

and sort of sweep away the old in a tie to the new. Do you see that or do you see are there four or five intermediate steps along the way? Right. The ACA, there was so much talk about the public option, which would be the government health insurer that you could buy into. That would be maybe the first step on the road to single payer. Unfortunately, that was killed. So we never got to see whether that theory would have worked. But, you know, I can imagine those four or five steps. Do you favor one or the other of those approaches? I think there's probably going to be a combination of them, right? If you look at what the Biden platform was about, It was about a public option. In fact, I was on the task force

that helped to write it. And along with Representative Pramila Jayapal and Dr. Don Berwick, our whole goal was to take that public option and make sure that it was a step in the right direction, meaning that it was a truly public, public option, not just federal money available for private, to subsidize private insurance. That it was, truly public, public option, not just federal money available for private to subsidize private insurance, that it was it reduced the power of major corporations and that it included zero deductible and and was heavily subsidized, particularly for low income Americans. If we were able to pass that, I do think it is a real step in the right direction, but we have to keep going. And in the end, it's probably going to happen because we took some steps forward and then we finally pushed into it, right? I don't believe that real change, big change usually happens linearly. If you look at history, it normally

happens because folks pushed and pushed and pushed, took a couple of good steps and then took a leap. And I think that that's what's likely going to happen. I'll be honest with you. I'm going to go ahead and make a prediction. I think that into the future, the next Democratic nominee and into the future, every Democratic nominee will run on a platform of single payer or Medicare for all. I just think that that's where the country is right now. And the push has moved us in this direction. And so, you know, I think that for folks who believe that our healthcare ought to be more just, more equitable, more sustainable, that coming together to make sure that that is a reality is our prerogative. And the last thing I'll remind folks is that things don't happen just because, you know, the sway of history moves them.

It's because people pick up the mantle of change and they carry it forward. And, and that really is the charge here. Let's carry it forward. Let's do the thing that we should have done a long time ago. Let's correct the accident of history and build a system where we can truly be proud of and that dignifies all of us. Yeah. Well, thank you so much for being here, Abdul. I really appreciate you coming on to talk to us about it. Yeah, Adam, it was my privilege. Thank you so much. I hope folks will check out the book and also take a look at I write on these issues regularly at the incision, which is a newsletter. And folks can check that out at incision dot substack dot com. Amazing. Thank you so much for being here. for coming on the show.

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You can find me anywhere you get your social media at Adam Conover or sign up for my mailing list, which I almost never send out except when something very exciting is happening at Adam Conover dot net. Thank you so much for listening. We'll see you next week on Factually. that was a hate gun podcast