US Healthcare After Covid: What’s Next & How Could It Be Better?

The Medicare for All Act was reintroduced into the U.S. House in March with a record number of cosponsors and public support. But while the idea of a public single payer system has never been more popular, the relationship of Americans to their healthcare has never been more fraught. With over 500,000 Americans dead from Covid-19 and millions without access to coverage, it’s clear that we need change. But what sort of change? Laura speaks with health economist Dana Brown and two outspoken nurses in public hospitals, one in Veterans Affairs, who know intimately the pros and cons of the American healthcare system. We praised nurses loudly in the last year, but will we listen to them now on what needs to be done next to make US healthcare better for patients, caregivers, and everyone?

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Transcript

– Linda Ward-Smith: We as nurses are caretakers, we’re nurturers. We care about the whole body.

– Kelley Cabrera: So much of our healthcare right now is focused on metrics, and we have to eliminate that thought process from our healthcare.

We are here to demand more for our patients and demand more for our healthcare workers.

– Dana Brown: The idea is to invest in primary care and mental health services and community care.

– Kelley Cabrera: If we make our society healthier, we’re not going to need to depend on our hospitals to fix society’s problems.

– Laura Flanders: It’s all coming up on the Laura Flanders Show, the place where the people who say it can’t be done take a back seat to the people who are doing it. Welcome.

– Rep. Pramila Jayapal: Thank you so much for joining us as we officially introduce the Medicare For All Act of 2021. Our 125-page Medicare For All bill lays out a detailed blueprint on how we can transform the healthcare system into one that finally guarantees healthcare to everyone as a human right.

– Laura Flanders: The Medicare For All Act was re-introduced into the US House on March 17th with a record number of co-sponsors. But while the idea of a universal single-payer health system has never been more popular, the relationship of Americans to their healthcare has never been more fraught. The COVID-19 pandemic brought things to a head. With over half a million dead from the coronavirus alone in this country and healthcare workers pushed beyond the max, it is clear we need change and all sorts of people want it. But what kind of change? Today, we’re going to talk with an economist who argues that the US already has a public health care model that works. It may not be perfect but we don’t have to import a system from elsewhere. And we’ll hear from two nurses who know intimately the pros and cons of the systems we have now. We praised nurses loudly in the last year, but our question is, will we listen to them now on what needs to be done next to make US healthcare better for patients, caregivers, and everyone? Dana Brown comes to the show from the Democracy Collaborative where she directs the Next Systems Project. Kelley Cabrera is an emergency room nurse at Jacobi, a public hospital in the Bronx, New York. She’s also a member and lead bargainer for her unit of NYSNA, the New York State Nurses Association. Linda Ward-Smith is a Department of Veterans Affairs nurse and president of the American Federation of Government Employees, AFGE Local 1224, which represents 3,000 nurses in Las Vegas, Nevada.

So, this has been a rough year. I just want to hear from you. Kick things off. Kelley, your best moments of the last year, and perhaps, your least good moments. First, the last time we talked, you were still being told to, I think, protect yourself with a headscarf.

– Kelley Cabrera: Yeah, I think so. I think that’s where we were the last time we spoke. I think, you know, obviously healthcare workers and everybody has been through so much this past year, but I think for us as nurses, especially in New York, our best moments were when we, you know, we came out and advocated for our safety and for the safety of our communities and our coworkers, and you know, to see the outpouring of support from virtually everybody was really amazing. At that time, you know, I think the worst of it was being able to see ahead of time how we thought this would play out because of our broken healthcare system. Obviously we couldn’t have imagined it would have been as bad as it was, but just seeing how all of our systems failed at the time and how unfortunately they still continue to fail.

– Flanders: What about you, Linda?

– Linda Ward-Smith: Thank you for having me here as well. Pretty much the same across the globe. You know, we just began fighting for things that we felt we should have already had, PPE, protective gear. So it was very stressful in the beginning.

– Flanders: Was there a best moment?

– Ward-Smith: Best moment was coming together and just, you know, pulling together. I think we just needed to feel each other and know that we were in this together. And I think emotionally that’s what helped us through the whole thing.

– Flanders: We are actually not here to have a debate about Medicare For All, because I suspect we would probably all be on the same page. But I am interested in what you make, Dana, of this discussion as it currently exists. Are we talking about the right things? Are we going far enough? In a moment like this, are there even bigger changes we could be thinking of, or starting to implement?

– Dana Brown: We’re asking some of the right questions, but we need to be asking a lot of other questions, right, in this moment of extraordinary crisis that was a long time coming, and it isn’t only the pandemic, but the crisis of systemic racism, which is in itself, a public health emergency. The massive inequalities in access not only to healthcare services because of insurance issues but geographic issues. There are places where there simply are no providers of certain services, or on the brink of something like 900 hospitals closing all over the country in both rural geographies and in urban areas. So I think we really have to ask questions about what are the healthcare and public health systems that we need to provide for everybody? I mean, we spent almost a fifth of our GDP on healthcare at this point in the richest country in the history of the world, and I guess my question is if we were to start with imagining how might we use a fifth of our GDP if we wanted to maximize health and wellbeing in our society, I think the answers we would get would be really different than just, you know, patching some holes here and there, putting a little bit more money into the existing non-system.

– Flanders: You’ve been upfront and center, Kelley, asking for a whole lot of change based on your experience in a public hospital in the Bronx. What stands out? What’s your number one, demand, need, desire, observation based on what you’ve been through?

– Cabrera: It is abundantly clear that we cannot remain on this trajectory. We can’t continue to try to patch a broken system. I honestly believe we have to start all over again. We have to break down all the barriers that our patients face to get care. Millions of people lost their employment, right, and now, because of that and because in America, your health insurance is oftentimes granted to you through your employment, I mean, we’re looking at a situation where more and more people are likely to lose their health insurance. You see what the disparities were during COVID and continue to be now, and I think the right way to approach that is just to change everything from the ground up.

– Flanders: Now it’s interesting, Dana, in her writing, in your writing, Dana, you often contrast the private system with the public system. But as people will see in this panel we have even more than one public system. We have public hospitals, like the one that Kelley works in, and then we have the VA system like the one that you work in Linda. You’ve actually worked in private hospitals before you came to the VA. What was the difference and why did you decide to stay where you are for as long as you have?

– Ward-Smith: The main difference I see is actually the way funding is done in the VA system, as opposed to private sector. The money is distributed different, priorities can be different, you know, because our population is different. We’re caring for veterans. So what are their priorities is what we mainly focus on. I do believe there’s changes that we all can make in each healthcare system. The disparities are still there regardless of what system you’re in. Lack of staffing, funding, equipment, all those things we still deal with here. Just re-shaping the focus on how those dollars are spent, I think, would be great start. We pay providers on how many people they see and how many patients they see and all the treatments that they can crank out as opposed to measuring that quality of care and giving them the time to actually improve on outcomes. I think that is something that we really need to start thinking about.

– Flanders: I mean, COVID, did it change things? Because this was not a surgery-solved disease. This was a care-treated disease. Did that change perhaps our thinking about who matters in hospitals?

– Cabrera: Absolutely. I often say when it comes to the issue of staffing, people don’t understand, unless you yourself are in healthcare, if you are a nurse, or if, unfortunately, you are a patient. I think that is the time when people come to realize that, oh my gosh, if we don’t have enough nurses, like I’m not getting my pain medicine on time. I’m not getting my treatment on time. And I think that became very, very apparent. And you know what Linda said, I agree with that wholeheartedly. So much of our healthcare right now is focused on metrics, metrics and reimbursements, and it is so easy to just see a person, when you get sucked into that thought process, to not see our patients as patients, you just start seeing them as numbers. How fast can we get them in and out? It doesn’t matter if they return and maybe they didn’t get the care that they needed, but they got out faster today, and we have to eliminate that thought process from our healthcare system.

– Flanders: Well, I think we have seen a bit of a shift in people’s attitude to government in the last few months, there’s still a chorus of voices from the Right saying, what COVID revealed was how our public system doesn’t work. Dana, as you think about the challenges, how do you advance an argument for the sort of even more radical change that you’re talking about?

– Brown: You know, first and foremost, anything that you divest from will not work, right? Anything you take money away from enough and strangle enough won’t work. And we see that in public health. It’s not that we don’t have really smart people doing great work in the public health system in the United States. It’s that we’ve divested from it from decades and divorced it entirely from the provision of care that people like Kelley and Linda do. And the real argument for more public sector involvement in healthcare is just that the priorities can be different. In health and healthcare in general, we should be thinking about how to prevent people from needing to see Linda and Kelley, right? Be happy to see you when I have to, when I break something, right, but the idea is to invest in primary care and mental health services and community care in the public health stuff that, like good jobs and housing and sanitation that make conditions better so that fewer people, and so that systemically we’re more on equal footing and we end up in the hospital less. The logic of what you can monetize and what is, you know, you can pay for, what you can get a return on has seeped into so much of all of the bits of healthcare system that we have out there such that even nonprofit hospitals are saying, well, we’re doing fewer elective surgeries, so we have less money, so we’re going to cut nursing and we’re going to, you know, cut the hours of our ER staff and all these things that don’t make any sense to anyone who knows about health, but only about people who know about finance. We need to learn that we can divorce those two and that it might actually work out for the benefit of all of us.

– Flanders: I also have to point out that I do think things would be different if we weren’t dealing with a nursing corps that was primarily women of color and immigrants, we might see some more power in their hands. As it is, unions make a difference, and here’s a great clip of Kelley Cabrera preparing to address a rally for what nurses need in the public healthcare system in New York. This was shot in 2020, I believe, on her own iPhone for a special produced by the New York Times and FX, currently available, I think, on Hulu. Take a look.

– Cabrera: I have my mask from today. We’ve officially started doing the one mask a week. There’s going to be germs on the outside of a mask, no matter how often I wash my hands. By virtue of taking it off and putting it back on and taking it, like there will be some transmission where that is going to get on my face somewhere, and it just makes it that much more risky. Like, that’s just the truth. We need to make a statement collectively asking the powers that be that have the stuff, that have the supplies, that have the capabilities of providing us the stuff and the supplies and the resources to act quick. We want to get through this whole thing as safely as possible, and all of us just are out here asking the government for help.

– Man: That’s awesome. That’s super good. That’s a great statement.

– CBS Reporter: The nurses here at Jacobi Medical Center just held a press conference. They say the hospital is putting their lives at risk.

– Cabrera: The masks are supposed to be one-time use. The ventilators, the PPE, the IB pumps, we need them now, we needed them before, and it’s unacceptable. On Monday night, I spoke to my dad for a really long time. He said, When you know something, don’t doubt it. Don’t ever doubt in doing it. This feels like the right thing to do. Speaking out feels like the right thing to do.

– Flanders: So thank you for that, Kelley. I know it’s always challenging to watch yourself, but you did brilliantly and that whole video is worth watching. I encourage people to take a look. We’ll put a link on our website. Where are we in listening to nurses, and what would our healthcare system look like if we did? If we designed it according to your values, Kelley, what would be different?

– Cabrera: We would put an emphasis on actually improving our patients’ health. And that, unfortunately, the way our system is set up now, that is not where the emphasis is. Our priorities are completely backwards. To what Dana was saying before, that was brilliant, it’s this idea that, you know, if we make our society healthier, we’re not going to need to depend on our hospitals to fix society’s problems. And this is something that we see that is so prevalent, especially in the emergency room. We have such a shortage of primary care providers in this country. Why? The reimbursement rates for these doctors are so low. There’s no incentive for doctors who get into so much debt through medical school to go through that. So there’s so many less of them, there’s less access to care, so now patients end up using the emergency room as their primary care, which is unfortunately the way healthcare has been set up, that this narrative forms. It’s almost like we blame our patients, like why are you coming here for something so small? And it is truly and honestly not their fault. We’ve just created a system that is so broken. It doesn’t work for them.

– Flanders: Linda, you’ve been wanting to jump in here. Go for it.

– Ward-Smith: You know, just thinking about what the healthcare system would look like if it was a nurse-ran, you know, we would focus more on prevention, right? Because we, as nurses, are caretakers. We’re nurturers. We care about the whole body, right? So in knowing that, we will focus on prevention instead of this disease-chasing kind of a mode and just worrying about the bottom dollar, where the bottom dollar would correct itself if we correct the issues that our population have. So definitely, I think we would be able to run it better.

– Flanders: I thought you might say that. Dana, what about you?

– Brown: Well, I love what Linda was saying. My question is what would our healthcare system look like if it were a system? And I know it’s not perfect, but one advantage that the VA has or that the British NHS has is that it is more of a system and it’s more integrated. As a patient, I have a chronic degenerative disease. I have nine specialists and neither, none of them have ever talked to one another and I cannot pay them to talk to one another. That’s an advantage that the VA has where, you know, a veteran can show up in Idaho one day and move to an island in Hawaii the next and all the records are there and all the specialists talk to one another. And I guess the question is like, can’t that be our starting point for what we ask for for everybody?

– Flanders: Talk a little bit more Linda about how the VA is perhaps worthy of a little more attention and another look. I mean, you’ve stayed there partly because of what Dana described, the security.

– Ward-Smith: Definitely. You know, we’re always on the cutting edge of new research, new innovation within the VA system, and I think it is a system that we should tap into to kind of model. Your patients show up and, you know, they’re going to all these different healthcare systems and nobody knows really what’s going on with them. And so that also can increase, you know, the negative outcomes that we have because we’re not keeping up with their whole body, whole healthcare like we should. That is one good thing that the VA does well, is we do communicate with other healthcare systems and we’re growing because we have new systems that we’re putting in place to make it even better. So definitely that would help.

– Flanders: And just remind me, Dana, the role that private insurance companies and their shareholders play in the VA.

– Ward-Smith: None.

– Flanders: Anybody want to underscore that?

– Brown: One other thing to point out real quickly is that, while the private sector and even many nonprofit hospitals and healthcare systems around the country have fired or furloughed staff or shut down facilities during the pandemic, the VA has been accepting non-veteran patients, they’ve been sending their staff all over the country to 49 states and territories, last I checked, to support public health programs, vaccination, delivering PPE. There’s just a real difference here in what the logic is, the defining logic of these systems.

– Flanders: I have here a very frightening list of all the states that are about to see cuts in hospitals, meaning closures of hospitals. In Alabama, 63% of hospitals, meaning 30 of them. In Colorado, 31%. Connecticut, they’re at risk of losing all of their rural hospitals. We have in our economy a super rich part of our economy and a super-everything else part of our economy, which is to say, not well-endowed. And as jobs go, as pretty much everything goes from broadband to hospitals, the money tends to go where the people and the assets are and get drained out of everywhere else. In the Bronx there, Kelley, you know, you were up against a huge patient load, not a well-resourced community. I’m imagining you might also be facing cuts now. What are you hearing and what do you fear about this continuing imbalance?

– Cabrera: It’s really disheartening. It’s such a stark contrast to what people were saying to us all last year, right? You’re heroes, you’re heroes, you guys are heroes, and clapping for us, and then to see the proposed budget in New York, for New York City, I think. From the way it’s written out now, we’re seeing about half a billion dollars to be cut from the public system. And this is the largest public hospital system in the country. It’s not hard to imagine what that means for our community. Does that mean that we’re not gonna open any more clinics? We were supposed to be opening these things called ExpressCare in New York City for all the public hospital systems. Do these cuts mean that they’re just, that will just not happen anymore? I would imagine there would be clinic hours would be reduced, a shortage of staff, all of these things which will always just harm our patients. And then later on down the line, it will be inevitable that we’ll be told, Oh, the public system is inefficient, because that’s always the way it plays out. They starve you of resources, and then they say that you’re inefficient for what, so we can privatize, and obviously, that is not the answer. The answer is, at this time where we’re depending so much on the public system, we should be investing in the public system.

– Flanders: Is it as simple as not letting the market do what markets do, Dana, because that’s kind of what we’ve been doing up to now, even inside the public system.

– Brown: If we think of healthcare as a public utility or a right rather than, you know, a service that you can buy then the calculus changes, because the positive externalities of having a healthy population, right, people can stay in the workforce, they can go to school, they can participate in their community, right? But we’re cutting everybody off at the knees by saying, Well, it’s your responsibility as an individual, it’s your responsibility as an underfunded hospital and staff to like fix things once everybody’s sick, right? But if we think of this as a public utility, as a service, right, that it’s just something that’s part of life, you subsidize it like you subsidize public transportation, because it has positive benefits for the economy, for local businesses, for people.

– Flanders: Well, I’m going to start a new practice in this season of the show by asking people what it is that gives them the faith or the belief or the experience, perhaps, that things actually can change for the better. Has there been a moment in your life, a person or an experience or a place or something you glimpsed that has given you this faith?

– Ward-Smith: Through COVID, it brought out the person and people, you know, we connected in a way that I don’t think we’ve ever connected before. Even in all of the myths of the bad, it brought out some good. So I’m hopeful, you know, we’ve been exposed, right, our weakness, and I’m just hoping and praying that with that, we will get that change that we want to see in our healthcare system.

– Flanders: Kelley, clearly something put a fire in your belly.

– Cabrera: It gives me hope when I see other people start making that connection and when I hear people finally start saying, you know, the bad things out loud. I have hope that we can move forward from this. It’s just going to take a lot of work and a lot of organizing. But I hope that we’ll be able to get there.

– Flanders: What’s next for you, Dana, as you think about a next system for healthcare?

– Brown: To keep working with people like you and Kelley and Linda and learning, but more than anything, I think, to continue to encourage all of us to make our demands as big and bold as the needs that are out there. I mean, I think, you know, the multiple crises that we’re continuing to live through, both in terms of health and the economy and structural racism show us that there’s a lot of work to be done, but therefore, I think our collective demands and our collective imagination about what could be just needs to go really beyond like, you know, filling in this year’s budget or, you know, getting us the PPE we need. Yeah, all of those things are necessary, but I think we have to demand the structural change that would kind of naturally deliver better outcomes. If we asked for more, we could get it. It’s eminently doable to have a more coherent and more people-centered healthcare system. So we’ve just got to keep asking.

– Flanders: I appreciate you all. Thanks for being with us. Dana Brown from the Democracy Collaborative’s Next Systems Project, Kelley Cabrera from the Bronx Jacobi Hospital and NYSNA, the New York State Nurses Association, and from Las Vegas, Nevada, Linda Ward-Smith, we really appreciate all of the work that you’ve all been doing. We’ll be back with more in just a bit.

We’ve been exposed. I love that line from Linda Ward-Smith on today’s program. We have been exposed. While 2020 may go down in history as the year of the great shutdown, in many ways, it was a year that opened us up, opened our eyes to our strengths and weaknesses as a society. It’s been a year we’ve been exposed to the importance of our essential workers, especially nurses, which is why when it comes to rolling out the vaccine, governors across this country brought in nurses to receive those vaccine shots first. In New York, it was Sandra Lindsay, a Queens, New York nurse, who said she volunteered to get the first shot in the state and in the nation because she wanted to instill in the public a sense of confidence. And that’s what nurses do. When it comes to public trust and confidence, nurses rank number one. So I’m concerned that since December, I’ve barely seen a nurse in the mainstream news. I’ve barely heard what they have to say on this subject of what happens next. Now our news around COVID is all about pharmaceuticals and pharmaceutical corporations and statistics, who’s gotten the shot and who is left. We need to be listening to nurses now more than ever. What have they learned in the last year of the pandemic about what we need to change as a society and in our systems of public health. So mask up, but mask your mouth, not your ears. Let’s listen to nurses. Let’s get healthy.

For the Laura Flanders Show, I’m Laura. Thanks for joining us. For more on this episode and other forward-thinking content and to tune into our podcast, visit our website at lauraflanders.org and follow us on social media @TheLFshow.

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