100 Years of 100 Things: American Health Care

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Brian Lehrer: It's The Brian Lehrer Show, on WNYC. Good morning, everyone. Later in the show, Tiffany Cabán, New York City Council member. We invited council member Cabán yesterday, with a housing and mental health bill she hopes will keep New Yorkers from winding up in the shape that Jordan Neely was in before encountering Daniel Penny on that F train last year. Then we learn from Cabán's office that Elon Musk responded to a social media post Cabán made about the bill and the verdict.

Musk argues housing is not the answer to homelessness, though he may agree with Cabán a little bit about mental health. We'll see what the council member thinks when she joins us later in the show. Now we'll get a deep take on the insurance industry and the reaction to the public glee, among a surprising number of people, that has followed the murder of United Healthcare CEO Brian Thompson.

Here's a clip from Morning Edition today, where NPR's Odette Yousef, national security correspondent focusing on extremism, describes why the public reaction to this killing is different from the more common and smaller expressions of sympathy for acts of political violence she's seen, for what kind of extremist violence, and what it might say about the state of things in our country.

Odette Yousef: This killing seemed to tap into the feeling that seemingly most Americans have had, at one time or another, of frustration and helplessness with the healthcare industry. What really struck me, though, is that I have typically seen people who commit mass violence or political violence praised, even venerated as martyrs in really dark corners of the extremist world within online communities that emulate mass shooters, for instance, or in violent white supremacist spaces.

Seeing a much wider and mainstream public call this suspect a "hero" is troubling, and for extremist analysts that I spoke to, this really speaks to how Americans have, over time, become more open-minded toward political violence.

Brian Lehrer: NPR national security correspondent focusing on extremism, Odette Youssef. With us now, Dr. Elizabeth Rosenthal, former physician, former New York Times healthcare reporter, currently senior contributing editor to KFF Health News, and author of the book An American Sickness, How Healthcare Became Big Business and How You Can Take It Back. The book came out in 2017.

We'll do this in the context of our series 100 Years of 100 Things, but also with this relevance to the public response to the murder in the last week. She was last on the show in August of last year, to talk about the cost of weight loss, drugs, and how hospital mergers are pushing up medical bills. She's had multiple other appearances on healthcare costs here, dating back to 2013, and a long series on that with NPR, which some of you may remember.

Dr. Rosenthal, always good to have you, now under these intense circumstances. Welcome back to WNYC.

Dr. Elizabeth Rosenthal: Yes, [unintelligible 00:03:20] to be talking about some of these issues again.

Brian Lehrer: You told a CNN interviewer the other day that if this killing is related to the insurance industry, you think it was only a matter of time before something like this would happen, and that's the scary part, quoting you. By something like this, did you mean the killing, or the so-called rage and glee, as a New York Times headline put it, regarding the social media response and what we just heard from NPR's extremism correspondent?

Dr. Elizabeth Rosenthal: Well, I think a little bit of both. I should start off by saying I would never condone a murder. It's not right. It's tragic. What I was referring to, in terms of saying I'm not surprised, is that I think unlike other forms of extremism, people-- I've spent the last 10 years listening to patients, who are my constituency, being so frustrated, and so angry about the workings of our health insurance and hospital system.

It was interesting that your extremist correspondent called it an industry rather than a system, which it is now. That's really been bubbling up. We run a series called Bill of the Month with NPR, you're probably aware. We have nearly 10,000 submissions over six years. There is just so much frustration and anger with a healthcare system that just doesn't serve patients very well anymore. That's what I meant, that not everyone is rational.

Not everyone gets a denial of coverage or can't find a doctor and says, "I'm frustrated." It's really merged from frustration-- Sorry. It's evolved from frustration into real anger, so I wasn't surprised at the reaction. A murder, do I ever think that's right? No, but there's been this rise in behaviors, extreme behaviors that are acceptable in this country now, apparently, not to me, so it happened.

Again, denial of coverage would never justify a murder. Nothing would, but there is this anger and frustration that, man, oh man, as I read these submissions, I am just lured by what patients go through.

Brian Lehrer: In your book from 2017, In American Sickness, you have chapters that trace the histories of costs related to various aspects of the healthcare industry. Hospitals, physicians, pharmaceuticals, medical devices, and more. Chapter one is called the Age of Insurance. You cite, as possibly the first example of something on a very small scale, that might be called employer-based health insurance. You trace it to a lumber company in Tacoma, Washington, in the 1890s. Would you describe what happened there?

Dr. Elizabeth Rosenthal: Well, I think the original idea of insurance was, companies were worried about employees losing time at work. There actually wasn't much you could do in a hospital. The idea was to pay for lost wages, basically. It was well and good, it served its purpose, but our insurance system has evolved into a kind of hydra. I was just trying to explain it to the Canadian broadcast company, to explain premiums, co-pays, co-insurance, deductibles, in-network out-of-pocket maximums, and out-of-network out-of-pocket maximums.

Pre-approvals, pre-authorizations, denials, and appeals. It's just head spinning. This is what our insurance system has become, and people are really frustrated with it. In studies, I think there's always the question of how many people like their insurance. I always say what a real survey question should, how many people like their insurance who've actually had to use it? Then the numbers nosedive.

Brian Lehrer: Let's trace some of this history. You say after that 1890s sort of invention of health insurance, on that small scale, early in the 20th century, the archetype for today's insurance plans was developed at Baylor University in Texas. What was that archetype, and the context for it?

Dr. Elizabeth Rosenthal: Again, hospital stays were long. I think they paid a day rate for time in the hospital, and it was for teachers, I believe, the original insurance of Baylor. It was a good idea.

Brian Lehrer: Yes. The early Baylor health insurance plan, I read in your book this morning, and a deal with the teachers union in the 1920s, I guess in that area of Texas, even included what we now call deductibles. The first X dollars paid out-of-pocket, before the insurance covers the rest. Did they call it a deductible 100 years ago?

Dr. Elizabeth Rosenthal: Brian, I think you'll remember better than I would. I'm not sure if they called it a deductible, maybe a patient contribution. We have words for things that don't exist in other countries now.

Brian Lehrer: Right, I know, and they sound so-- What's the word? Antiseptic, to use a slightly medical term. Euphemistic would be another term, for so many things in our society, and certainly some of these things in relation to medical billing. Right?

Dr. Elizabeth Rosenthal: Yes, of course. You describe this to a European or a Canadian, and they're shaking their head, they're like, "How do you deal with this?" The answer is, we don't deal with it. We, the patients, don't deal with it very well, and we don't get the care we need. We end up, as our KFF Health News diagnosis debt series discovered, 100 million Americans have medical debt, and about 15% of them feel they will never be able to pay it off in their lifetime. Is that how you want your healthcare system to work?

Brian Lehrer: Yes, I said euphemism. My producer says corporate speak. That's another way to frame co-pays, deductibles, all those terms, then. Well, we'll get back to the history in a minute. You just talked about Canada and their reaction. You talked about how, just before the show, you were doing an interview on the BBC. What do they think about our healthcare system in Canada, which has a form of single-payer?

Dr. Elizabeth Rosenthal: They can't quite believe it. It's unfathomable. I'm going to sound like a dinosaur here, but when I started as a healthcare reporter at The New York Times, I did a story about waits in Canada, compared to how quickly you could get things done in the US, and boy, now people wait, people wait, people wait to see a primary care doctor. The perverse incentives in this system, in our system, mean that if you need a hip replacement, you can probably get that tomorrow, because that's a moneymaker.

If you have a kid with type 1 diabetes, and you need to see an endocrinologist who's in network, good luck. You have to wait months, which can be fatal.

Brian Lehrer: That's the thing that we're supposed to associate with single-payer in countries like Canada. It covers the costs, but there's all this rationing, and you have to wait for a long time to get an appointment, or get surgery. I don't know if you've done cross-cultural comparisons, international comparisons, maybe it's true up there, you tell me, in the way that I framed it. I think we've all had the experience.

I've seen it, I've been helping to take care of some people with ongoing medical conditions, and to get a first appointment with a new doctor, in many specialties, "Oh, they have an opening in March."

Dr. Elizabeth Rosenthal: Yes, 2025. I think people probably do wait longer for things like hip and knee replacements in Canada, and, I know, in Britain, because they are semi-urgent procedures. Usually, people can live with an aching hip. That would be done tomorrow here, because it makes money, but they would not wait in Canada, I don't think, to get a primary care doctor, which is the case here.

Everyone I know, in New York, lives in fear of their primary care doctor retiring, because you can't find another who has an appointment within six months. It's really hard.

Brian Lehrer: Listeners, we can take questions on the 100 year-- really, since she dates it to the 1890s, the 130-year history of health insurance in the United States. 212-433-WNYC 212-433-9692, with our guest, Dr. Elizabeth Rosenthal, former practicing physician, longtime journalist in the field, with The New York Times, KFF Health News, currently a lot of partnership with NPR, many appearances on this show, and her book that came out in 2017, called An American Sickness, How Healthcare Became Big Business and How You Can Take It Back.

Who has questions, especially about this 100-year history or about the situation today? 212-433-WNYC, 212-433-9692. Going back to the history, you write that the idea of health insurance, after being pioneered at Baylor in Texas, with that local teachers union in the 20s, caught on nationally, and by 1939, 3 million Americans had signed on, and the concept had been given a name, Blue Cross. Do you know where that name came from, or what Blue Cross actually was at its inception, in '39?

Dr. Elizabeth Rosenthal: Well, I know what it was. It was health insurance. The Blue Cross plans then were not for profit, not true today, for the most part. They were a perk that was offered for people coming back from the war. There was a labor shortage, and companies wanted to offer this perk of health insurance to attract people to jobs. Hence an industry grew up, as they are in Germany. Health insurers were all nonprofit. That changed in the 1990s, which was another stake in the road to what we have today.

Brian Lehrer: You also note, and I think this is underreported as a part of today's situation, that healthcare 100 years ago was cheap partly because there wasn't that much in the way of tests or treatments that existed, but over the last 100 years, beginning around the time of World War II, as you tell it, expensive medical technologies began to be developed. You cite the invention of ventilators as a turning point. When was that, and why ventilators?

Dr. Elizabeth Rosenthal: Well, ventilators and anesthesia, because then you can do surgery more easily. It's really probably better to say anesthesia, which uses ventilators. That opens up a whole field of surgical interventions.

Brian Lehrer: Then in the 1930s, the first injectable anesthesia. Right?

Dr. Elizabeth Rosenthal: Yes, yes. That's a stake in the road to where we are today. New medicines that are actually effective. Antibiotics, vaccines were all invented around that time, but they were all cheap. They were cheap until-- gosh, when I was in medical school, antibiotics were pennies, and now they're $250. You know what happened? I can tell you what happened, is people realized there was good money in this, and when people need an antibiotic, they need an antibiotic, so the laws of economic supply, and they'll pay a lot for it.

Te greed took over there. There are other points we can talk about. In 1963, when Medicare was passed, and then doctors could get paid rates, set rates for services, which they now say mostly are too stingy, but then a whole lot more people had insurance, so they could go to doctors more. I think the big changes came around the 90s and into the aughts, where the insurers, many of them, converted from not-for-profit to for-profit. Who's the primary client? It's not the patients, it's the shareholders.

Brian Lehrer: Well, why did that happen? That happened with Blue Cross, for example, which we talked about kind of debuting on the scene in the 1930s. Then in the 60s, they went from being a not-for-profit to being a for-profit. Why?

Dr. Elizabeth Rosenthal: It's the old Willie Sutton thing, that's where the money is. Why did Willie Sutton rob banks? That's where the money is. It was a financial decision, not a healthcare decision. Maybe someone thought, oh, well, not-for-profits are kind of fuzzy, and for-profits operate more efficiently. That's the first step in thinking of healthcare as a business, not as a caring endeavor.

Brian Lehrer: You write about hospitals in that context, too. The major hospitals in New York City, for example, are not-for-profits. On paper, New York Presbyterian Mount Sinai, others, but of course, people experience them as businesses. Why does it turn out that way, if they don't actually have shareholders? Which is the bottom line, usually, for why big corporations act the way they do, maximize profits, and minimize service, if that does maximize profits.

Dr. Elizabeth Rosenthal: Well, my first thing I say is to walk into the lobby of any of these places and tell me if it feels like a not-for-profit to you. There are marble lobbies, player pianos, and beautiful Zen gardens, and some. I think, "Where does the money go?" That's always the question. Yes, not-for-profits, by definition, can't have a profit, right? Instead, these hospitals have operating surpluses, and they have no shareholders to send them out to.

Instead, they buy things, pay executive salaries that are really high, and build stuff, there's endless ways to spend money in healthcare. They start venture capital firms to invent new things, which they get more money from. They're operated as businesses. One hospital that we looked at, the Cleveland Clinic, opens a for-profit hospital across from Buckingham Palace. I'm so upset about this whole thing, I can't speak.

When you ask, "How does this hospital, which caters to rich British people who don't want to wait for NHS procedures, help the people of Cleveland?" The answer is, "Oh, it helps us-- we learned how to share X-rays better." I'm like, "I could have told you that." We have not-for-profit hospitals engaging in nakedly for-profit endeavors now, they're businesses. Taking care of patients is kind of a side gig for many of them now.

Brian Lehrer: In the context of the invention of so many new medical technologies from the 1930s, as you trace it all the way to the present, when new things are being developed all the time. One of the things you cite in the timeline, in your book, is the first intensive care unit that opened in Copenhagen in the 1940s and then was adopted in the United States. The old cheap insurance policies, as you tell it, weren't charging enough to cover what they were then being asked to cover by the patients.

By the 1990s, as you were just discussing, Blue Cross Blue Shield, at the time that it went from being a not-for-profit to a for-profit, was hemorrhaging money. That telling shows some sympathy, seems to me, for insurance companies pushing up their rates and deductibles. Can you talk more about the industry's adjustment to that, where it was legit, as well as where it jumped the shark into greed and corruption?

Dr. Elizabeth Rosenthal: Well, I always say that the healthcare industry is a story of-- the path to hell is paved in good intentions, and of course, yes, with all these new things that could be done, they needed to charge higher rates, but did that necessitate a conversion to for-profit? There were other solutions to that. As I said, there are many health insurers in Germany, which does not have a national health system, but they are all not-for-profit, so yes, there's always a bit of sympathy.

The next era where there's some sympathy is-- the HMO era of the 90s really squeezed hospitals, because they were not prepared for that. It was about having patients have this kind of umbrella-covered care, and they paid hospitals not enough, so the hospital's answer, of course, is the business answer. They get consultants from McKinsey and Bain to come in, and you know what the consultants say? This is why we have the system we have today.

They say, "Look, you're leaving all this money on the table." Literally. That's a line from one of their reports. "You can charge for the recovery room. Why are you giving that away? You can charge for each liter of normal saline you put in. You can charge a facility fee for the time spent in that waiting room. You can charge an ER trauma fee if an ambulance brings a patient in." That's where the billing went haywire. Really went haywire, and I didn't even anticipate, in my book.

You mentioned it was first published in 2017. It stopped before this incursion, explosion of private equity in healthcare, which is now-- I don't even know where to start to talk about it, but I don't want private equity running my healthcare. That's all I can tell you.

Brian Lehrer: AI, this is one of the critiques that's emerged of United Healthcare in particular, the industry in general. Have you looked at that? I think a lot of people hear that, and there's a general, [gasps] "AI," but what's actually happening?

Dr. Elizabeth Rosenthal: Yes, and I'm sure AI does many things well. One thing it does not do well is review claims and customer service on bills. What we find is, automate the first round, and-- ProPublica did a wonderful series on this with United Healthcare, by the way, or for about United Healthcare. The first round of denials is often automated. We had a story, about five years ago, about a position at one insurer called the Denial Nurse.

I think that's old-fashioned now. Now it's just automated. In our Bill of the Month database, we have people who have a $500,000 bill, and they're offered, "Don't worry, we can offer you a payment plan of $40,000 a month." Would a human write that? No, we have another, my favorite, is one that's sent to a three-month-old, and it's denying his last night in the neonatal intensive care unit.

It says, "You were taking milk from a bottle and you were breathing on your own, so we deny your last night in intensive care." No human writes [unintelligible 00:26:29].

Brian Lehrer: I heard you talk about that on the CNN podcast, and you said the bill was actually addressed to the three-year-old.

Dr. Elizabeth Rosenthal: Oh, the three-month-old.

Brian Lehrer: Three-month-old. I'm sorry.

Dr. Elizabeth Rosenthal: Yes. Americans' first experience of life is often a healthcare bill, sadly.

Brian Lehrer: Laura in Warren, New Jersey, a retired physician, I understand. Laura, you're on WNYC. Thank you for calling in.

Laura: Thank you for having me. Yes. I'm a retired general internist and medical educator, so I'm very passionate about this, snd so many things that you said really ring true. I think our current-- we are supposed to teach our students about health systems. I always joke with them that if we had a system that worked, we wouldn't need to teach them health systems, we would just teach them about care they should be delivering. I'm so embarrassed by our health system.

Basically, longevity. Over the past 40 years, we haven't improved our longevity for the average-- Rich Americans are doing better, but the average American [inaudible 00:27:50], if anything, worse. Other rich countries are improving their longevity. Part of it is the difference in physician compensation over different specialties, [inaudible 00:28:05] point where-- really corrupt specialty choice by our medical students. They are attracted to things like your nose and throat, orthopedics, ophthalmology.

You get paid a lot of money for procedures-- things like diabetes and hypertension care that prevent people from having ophthalmologic problems in the first place. I've gotten so cynical about health systems over my 40 years of practice. It's just very discouraging.

Brian Lehrer: Laura, Doctor, thank you very much for calling in. We appreciate it. Dr. Rosenthal, the system, as we continue to talk about the history, that, as you describe it, grew up around employer-based insurance, because there was a labor shortage around the time of World War II, and then it got entrenched as the way we do medical insurance in this country.

Obviously, that left a lot of people without the right kinds of jobs, with competitive labor markets, who weren't in those competitive labor markets, uninsured, often unable to afford the increasingly expensive private insurance, or the care, directly. Democrats tried and failed to pass a new system in President Bill Clinton's first two years. People who were around then will remember that Hillary Clinton led that effort and it got defeated in Congress. They finally did, the Democrats did, with Obamacare, which is now almost 15 years old.

Progressives have argued that Obamacare became a guaranteed business plan for insurance companies, because it is private insurance companies who get to play in the playground of that insurance market, and it's subsidized by the government, by the taxpayers. Republicans argued that all the subsidies to help people afford policies were pushing the price of policies up, not down, because patients didn't have enough skin in the game, out of their own pockets, to avoid medical care, except when they needed it.

I think we know from this explosion of stories on this show right now, and all over the media in the last week, as well as in your reporting, for years and years, that people do feel like they have financial skin in the game, too much. How do you think Obamacare has worked?

Dr. Elizabeth Rosenthal: Well, we can't talk about Obamacare as the same thing that Obamacare was when it passed. I think it's amazing that we have Obamacare. It has done some hugely important things. First of all, it made sure that you couldn't deny people insurance, with preexisting conditions, or charge them outrageous rates. It made sure that preventive care, in theory, was out there for all of us.

It created healthcare marketplaces so that people, in theory, and I'll talk about that in a second, could shop for plans on their own if they didn't have employer-based insurance. It subsidized and helped expand Medicaid. Unfortunately, the courts found that the Obama administration could not compel that. The original Obamacare had a lot of protections embedded in it, and many of them still exist. Many of them were eviscerated during the Trump years. There were subsidies that were cut by Trump.

The payments that were in there for navigators and public education were cut. The courts said states didn't have to expand Medicaid. There was a clause in Obamacare that said everyone had to buy insurance. That was found to be unconstitutional. The Obamacare we know, is important that it exists. I'm terribly glad it exists, but it does need some fixing, because as you said, the exchanges or marketplaces where people buy insurance are fabulously complicated.

The average person trying to shop on a marketplace is faced with over 100 plans. Someone said to me, there are some good ones in a tsunami of garbage. Many of those plans, if you buy them, you will find that if you get sick, you go broke, because the premium is low, but the out-of-pocket deductible is $9,000. That's really hard for a young person to sustain. You mentioned the subsidies.

President Biden reinstated some of those subsidies and some of the cash to allow for navigators and public education, so that's all good, but a lot was lost, the momentum was lost, in those years. PS, and this is the really important part, the current subsidies which make these plans affordable to people are set to expire at the end of 2025, and if that happens, if that is allowed to happen, which it likely will, under a fully Republican administration, that will mean premiums will go up by an estimated two to three times.

That will make insurance totally unaffordable to the people who do buy it on the marketplaces now, so we're in for a rough ride, and it's about to get rougher.

Brian Lehrer: My guest for another few minutes is Dr. Elizabeth Rosenthal, former physician, former New York Times healthcare reporter, currently senior contributing editor at KFF Health News. You may know her as partnering with NPR on the Healthcare Bill of the Month. It's of the month, right? You do that once a month?

Dr. Elizabeth Rosenthal: Yes, and we do it once a month.

Brian Lehrer: I'm going to ask you about one of those in particular in a minute, from earlier this year. She's also author of the book An American Sickness, How Healthcare Became Big Business and How You Can Take It Back. That book came out in 2017. We're getting so many horror stories in text messages and phone calls, let's just take one as representative, to some degree, of the group. Pat, in Park Slope, you're on WNYC. Hello, Pat.

Pat: Hey there, Brian, and Dr. Rosenthal. Thank you for taking my call. I'm a first-time caller, long time listener. With my story, about six years ago I found out that I had a severe case of colon cancer. I was fortunate enough to find a very good doctor. I had the surgery at the New York Presbyterian, which was excellent, by the way. Then I found out that there was an extra $15,000 that the insurance company was saying that I wasn't covered.

My insurance provider is Blue Cross, and I'm also a member of the World Trade Center Fund. While I'm going through chemo, I am going back and forth with the insurance company and the hospital, just trying to negotiate this $15,000. It was an awful experience, but again, my medical experience, my doctors were the absolute best, but the insurance part of this was a nightmare.

It was finally adjudicated where I didn't have to pay anything, but it was just really a horrible experience to go through. That's my story. The other thing that I had a question about was Medicare as you get older. I'm 60, and I'm going to need to start to think about what that's going to look like, and any advice.

Brian Lehrer: That's a big question, but on that horror story, he went for pre-approvals, he got a $50,000 bill anyway, he had to fight it. I can just see the heads nodding out there, right?

Dr. Elizabeth Rosenthal: Yes, absolutely. This story is absolutely emblematic of the problem. I think he said it was 15,000, but whatever--

Brian Lehrer: 15. Yes, maybe I misheard.

Dr. Elizabeth Rosenthal: Whatever it was. First of all, you probably can't figure out what on Earth that $15,000 is, what it was for, to even fight it. I'm sure you have to get an itemized bill and figure out what the $15,000 dispute is about. Then, as he did--

Brian Lehrer: Isn't that part of your reporting? That so many of these bills that are huge and that could be successfully disputed, like in Pat's case, people don't even try because they don't know that they have that option, or they just for whatever reason don't have the wherewithal.

Dr. Elizabeth Rosenthal: Yes, KFF polling, I believe, or KFF policy, found that-- I think it was about 1 to 2% of denials are actually appealed, because PS, guess what, as Pat said, you're sick while you're doing this, you are not feeling well. It's just so unfair to patients, to expect people to do this, and as he said, many people like their care. I would say that's changing less and less.

They like their care, but they don't like their insurance, and they don't like dealing, being the go-between, between the hospital and the insurer who, in fact, should take this out on their own, this should not be the patient's problem.

Brian Leharer: He asked about Medicare. It was a very broad question. Let me frame it like this, because in one of your Healthcare Bill of the Month segments on NPR, you did one called Her Air Ambulance Wasn't Covered by Medicare. Her air ambulance wasn't covered by Medicare. It will cost her family $81,739. That wasn't about private insurance, it was about Medicare. How different do you see them as being, in terms of all these dynamics we've been discussing?

Dr. Elizabeth Rosenthal: Well, Medicare on the whole is much simpler. I speak to many patients who say they can't wait to get to the promised land of Medicare. Hospitals have to accept certain rates from Medicare, so there's much less negotiating that goes on. There's much less in the way of pre-approval. It's not perfect, but-- part of the problem people run into, which the Biden administration is starting to address, is-- there are different parts of Medicare, so it becomes very confusing.

Again, you have Medicare A, B, C, and D. Medicare A and B is standard Medicare. Then you have to choose Medicare Part D, which is a drug plan, which, again, is run by the private companies. If you're on expensive drugs, which almost all older Americans are, you can have a lot of out-of-pocket expenses through Medicare Part D, although President Biden is trying to limit those, has limited those.

Brian Lehrer: One more call. Reid, in Brooklyn. You're on WNYC. Hi, Reid, thank you for calling in.

Reid: Hi, Brian. Long time. Long time. One thing that I've seen going around, that I think is missing from these larger conversations about ethics and morality, is that we have so many different definitions when one person kills another person. There's three degrees of murder. There's manslaughter, negligent homicide. What do we call it when a corporation enacts policies that kill people en masse? Friedrich Engels called this concept social murder.

I'm not going to read off the whole definition, but these events happening in a boardroom, be it a health insurance company, be it DuPont factory in Hoosick Falls, where they poisoned the groundwater and gave thousands of people lethal blood cancers, we don't have a word that, accurately, in my opinion, describes the moral culpability that corporations have for when they enact policies that kill people.

Now, we can debate the specific morality of what Luigi did, but I think that he raises a very valid point about, first, what the definition of murder is, and second, that when people live in a system in which they feel that these things can happen with barely even a slap on their wrist due to lobbying, many other things, that people will take other action when they feel that they're not being heard in a system that kills them en masse.

Brian Lehrer: [crosstalk] Thank you for raising that question, Reid. I don't know that there's really much debate, or should be, about the morality of what Luigi Mangioni did. The whole other part of that, Dr. Rosenthal, that Reid raises, and I know there's an article about this in New York Magazine right now, by Sarah Jones. There was one that touched on this by Jia Tolentino in The New Yorker.

One expression of the rage today, and the support, however much that is, as we've seen all these laugh emojis, clapping emojis, and stuff online. When we did a segment with a detective about the investigation, some people wrote in, saying, "You shouldn't be talking about this one death as the real outrage. You should be talking about the countless number of deaths resulting from health insurance denials." My response is, "We can be talking about both."

And that's put that way, it's too dehumanizing of Mr. Thompson, when it's an either/or like that, especially since, at least on this show, we do segments all the time about healthcare costs and political alternatives. With all the reporting that you have done in this field, can you estimate, to Reid's central point, how much premature death there has been in this country because of health insurance denials of coverage, even for the insured? We're talking about the insured, right?

In these cases, either per year, these days, over time or in any way, or if United Healthcare has had a special place in this story, if there was a way to charge companies with social murder, as that phrase that he cites is called. How many would there be?

Dr. Elizabeth Rosenthal: I guess the kind of 30,000 foot answer is, our life expectancy in this country is declining. Is that because of healthcare, people not getting healthcare, or because of guns? Maybe a little bit of both. I think that's the larger issue. I mean, some people do sue hospitals, they're all very aware of this, for what they consider unnecessary deaths and injuries, but that is a long course, and one that grieving families tend not to take, because they're grieving, and nothing brings their loved one back.

I think there is an issue of moral culpability, largely writ in a health system that is not taking good care of patients. I think the physician who called brought up something of the problem. Physicians who work within an industry are not allowed to do what physicians do, and they're not paid adequately to do what physicians do, and by that, I don't mean the orthopedists and the heart surgeons who are paid plenty, but the primary care doctors, what should be the base of our healthcare pyramid, gets short shrift.

Primary care doctors, neurologists, anyone who can't do a procedure, because we reimburse for procedures, they get really short shrift, and they're the doctors who should be the front line, the doctors who we really need. The physician mentioned that young doctors go into these lucrative specialties, which is true. It's often said because they pay so much for medical school, which is probably partly true too, but some medical schools are going tuition-free, so I think there are a multitude of problems, and there is moral culpability.

Hey, that's why I'm doing the job I've done for the last 30 years, because I'd like to see change. What kind of change, I think, is up to voters and politicians, and people should be voting health care as much as the price of gas. That's my takeaway.

Brian Lehrer: Yes, well, that's really what my last question was going to be anyway. I'll give you a little more platform on that. Donald Trump on Meet the Press, on Sunday, basically said health insurance is so complicated, he doesn't know if he'll come up with any plan to make it better. You've now informed us that Congress is going to be confronted with this anyway because the Obamacare subsidies will expire at the end of next year, and they'll have to renew them or not.

How do you want to see the system reformed? Are there any biggest pieces, if you had your way?

Dr. Elizabeth Rosenthal: Well, as a journalist, I can't say like, "Oh, this is the answer." I'm not sure if I do know the answer, though I have preferences. What I will say is, when we look around to different countries, there are some who have national health systems. There are some, like Germany and Switzerland, that don't have national health systems. They have insurers, but they do have some kind of price control, which we don't. We get to let the healthcare industry charge whatever the market will bear.

I look at bills for things like MRIs, which, when they were new, were amazing, and you could maybe justify a higher price, but now they're old, and the range of what's charged is from $300 to $10,000. We need a way to control-- what the great Uwe Reinhardt said, "It's the prices, stupid." Whether we do that globally, the way some states are trying to introduce a public option, so everyone can be insured, or state health care plan, or we do it by, in some way, controlling prices, I'm not sure.

What I think we've seen in the outpouring of rage this week is that something needs to give. As I would end with our listeners/voters, is-- We said in this last election that people were angry about the price of gas and eggs. I'm like, "It's not just gas and eggs. It's your health care. If you feel poor, it's your health care. You don't deal with it every day like you deal with gas and eggs, but boy, look at how much we spend on that, and how much comes out of your paychecks and your taxes to fund that."

Brian Lehrer: Yes, well, I agree with you about that. That's why, when we did a three-part national election series in October, on the cost of living and comparing the candidates on that, the three topics we chose were healthcare, housing, and the care economy, taking care of your kids and your elders, as the real drivers of inflation in the United States. Thank you so much for putting additional meat on those bones for us.

Dr. Elizabeth Rosenthal, former physician, former New York Times healthcare reporter, currently senior contributing editor to KFF Health News, partner with NPR on their Healthcare Bill of the Month, and author of the book An American Sickness, from 2017. Thanks for tracing this 100-year history in addition to talking about current conditions.

Dr. Elizabeth Rosenthal: Thanks for having me, Brian.

 

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