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By Why Is This Happening?

What would it mean to have "Medicare for All?" The issue of healthcare emerged as a key campaign fight in the coming midterm elections, with ads and debate questions centered on coverage of pre-existing conditions. While Republicans dig deeper into a fear mongering campaign that "Medicare for All" means Medicare for none, a growing number of Democrats are throwing their support behind single payer healthcare.

Although "Medicare for All" is proving popular in polling, the left has a lot of work to do if they want to embrace it as a political project. Abdul El-Sayed has put a lot of thought into exactly that, having worked as the Health Director of Detroit and then ran on a universal healthcare platform in his recent bid for governor of Michigan.

ABDUL EL-SAYED: I push back on the socialism label simply because we've moved so far to the right in this country that when we talk about collective action on anything, right, people are like, "Well, that's socialism." No it's not. It's about providing people with basic access to things that they need to live a dignified life. Is it socialism to build roads? Is it socialism to make sure that the air is clean? I don't think it is. I just think that's good government because in the end, the whole point of government or people coming together is to act collectively in the best interest of all of us. That's what government is.

CHRIS HAYES: "Welcome to Why Is This Happening?" With me, your host, Chris Hayes.

So health care politics. Pretty crazy out there. I don't know if you've been paying much attention, but there's a lot of really fascinating things happening with health care politics in the country. One of them is that the Republicans are just lying about what their health care policy is. The president tweeting about how he wants to protect preexisting conditions, obviously, despite the fact that he literally personally approved the DOJ lawsuit that would destroy them. In fact, in the DOJ document about the lawsuit, the first sentence about the president personally approving it, the fact that the AHCA, that almost every Republican voted for, would have stripped away protections from people with preexisting conditions by allowing insurers to charge huge sums more if you, say, have diabetes. So they couldn't deny you insurance, but you can get a policy for $30,000 a month so you have insurance. Congratulations, diabetes sufferer.

And the nuttiest thing about this whole thing is it's widely politically unpopular. Massively, hugely politically unpopular. Protecting people with preexisting conditions is as close as you get to a consensus view in American politics. Everyone loves it. And Republicans everywhere from House races to Senate races are on the defense about this. And the way that they're dealing with it is to simply lie about what their own health care policy is. So that's one of the sort of axes of health care politics happening now.

The other one, which is fascinating, actually gets to two trends that are happening. One is a trend on the left, which is increasing support for single payer health care, which is often shorthanded as “Medicare for All.” There's increasing support in a number of different ways. One is polling on it. So Democrats are increasingly supportive of the idea. And two is candidates actively endorsing and running on it. Republicans think that this is a weakness, even though it actually polls quite well. And they think they can kind of jiu-jitsu it into a way of attacking democrats.

Alex Azar, who is the head of HHS said, "’Medicare for All’ is Medicare for none." And Trump is taking to going around saying, "The Democrats are gonna take your Medicare." And there's something intuitive about it. The idea is there's a fixed pie of care. Right, now you seniors are getting all of the slices of the Medicare pie. But if the Democrats get their way, they're gonna take a bunch of slices of the Medicare pie that you're getting all of and give it to these other people. Maybe people who don't look like you, and then they're gonna eat your Medicare pie. And then you're gonna be there with a little sad little slice of Medicare pie. That is the idea behind this. And it's not a crazy or ineffective political attack, it's almost certainly nonsense, but it speaks to a few things.

Image: Hundreds of activists and allies from the newly-formed anti-
Hundreds of activists and allies from the newly-formed anti-Trump group Rise & Resist staged a peaceful protest at Trump International Hotel and Tower in New York on January 15, 2017.Erik McGregor / Pacific Press/LightRocket via Getty Images file

One: the anxiety around health care. Two: the fact that the Republican party in saying “’Medicare for All’ is Medicare for none” is of course implicitly saying, "Medicare as it currently exists is good, we want to preserve it." And of course, Medicare as it currently exists is single payer health care for people at an age cut off. That's it. It is socialized medicine for people who have happened to be born at a certain time and lived a certain number of years. It's the thing that they say they hate but they're defending it. Because you know why? Socialized medicine, when people get it, is pretty popular.

But the other thing it speaks to is the fact that if Democrats are going to go down the path of “Medicare for All,” and I think there's a lot of political reasons and substantive reasons that that's gonna happen, they're going to have to wrestle with the devil in the details. They're going to have to be able to message to people like seniors currently on Medicare who vote like crazy, that their Medicare pie isn't being taken from them, right? They're gonna have to message to people that their taxes aren't gonna go up 300 percent. They're gonna have to make a political case in the face of tooth and nail opposition from the Republican party and the health care industry and others that this is actually not gonna do all these terrible things that Republicans say it will.

And they're also gonna have to figure out the substance of the policy. It is not a trivial thing to just say, "Okay, everyone get on Medicare." I have friends who have worked deep in the bowels of CMS, which is the agency that runs Medicare and Medicaid. It's very technical, complicated work, managing a health care system, a good health care system that gives people good options and good access to care and figuring out how to do all that. That's complicated, difficult, bureaucratic work that has to be done by really smart and qualified experts. And you have to build a really good and functioning bureaucracy to manage it. In the U.S., that is largely the case vis a vis Medicare particularly. But one of my frustrations with all the talk about “Medicare for All,” which, again, I think is a pretty persuasive political project, is just a lot of people talking about it don't seem to want to dig into the details. And the devil is all in the details. You can have good single payer or bad single payer. Good government services or bad government services.

So I wanted to talk to someone who is just uniquely situated to talk about precisely this because he is a person who has a stake both in the politics and the policy. He's a guy that ran for governor of Michigan on a platform of single payer for the state of Michigan. Statewide single payer. He is a believer in single payer for the country as well, “Medicare for All.” His name is Abdul El-Sayed. He is also a Rhodes scholar, a doctor — though whenever did his residency and became a clinician — and a doctorate in public health, and taught at Columbia School of Public Health. So he is an expert in public health and public health care systems. And he studied in England where they have the National Health Service. And he has taught about public health and public health care systems. And has thought extremely deeply about the actual construction of a “Medicare for All” system. He had a very detailed plan for Michigan State “Medicare for All.” And he's also a political believer in the potency of “Medicare for All” and single payer health care as a political project for the left and for the Democratic party.

And so I thought this is the perfect person to talk about all this stuff because he... This is a guy who can go real deep. Real, real deep. This is not someone who's a politician who read a few briefing papers and has looked at the poll numbers or just has a genuine belief in it, which is also totally fine. This is someone who is himself a genuine — as you will see — a genuine and real expert in the actual details of what it would look like to actually do “Medicare for All.”

You're from Michigan. Where are you from in Michigan?

ABDUL EL-SAYED: Born and raised. I was born in Oakland County, I grew up in Oakland County. I went to college at the University of Michigan. I served the city of Detroit as Health Commissioner. And now I live in Lacombe County with my in-laws. I just recently came off of a political run and as you know, running for office doesn't pay very well. So we moved in, just had a baby, and it's been awesome watching her grow up with her grandparents.

CHRIS HAYES: Wait, you moved in with your in-laws as a kind of financial move while running for office?

ABDUL EL-SAYED: Yeah. Look, I mean, right now the cost of running for office makes it almost impossible for almost anybody who is not independently wealthy to be able to run. And for me—

CHRIS HAYES: Right, because you can't... Obviously, you can't work your day job. And if you're a person who works for a living, if you take a year off from work, that's gonna be tough.

ABDUL EL-SAYED: Yeah, that's exactly right. So 18 months, no work. Sarah, my wife, is a medical resident. So we had that income. And then we had my in-laws supporting us in a lot of ways.


ABDUL EL-SAYED: Yeah. But that's the reality of running for office if you are young and/or not independently wealthy.

CHRIS HAYES: Alright, so you're from Michigan, but then you become a doctor. Do you go med school next or you go to Oxford?

ABDUL EL-SAYED: So I did a combined MD/PhD program. So I did my first two years of medical school and then went off to Oxford. I had the opportunity to study on a Rhodes scholarship there. I did a PhD in public health while I was there. Focused on health disparities and understanding them and the policy approaches to addressing them and then came back and finished medical school.

While I was in medical school, I had done this PhD in public health. And so much of why I became a doctor was focused on trying to address why people got sick in the first place. And in my clinical years in medical school, all I realized was that doing so as a clinician was gonna be very limited. One patient at a time. And the most frustrating thing is you spend most of your time on patients who are gonna bounce back some time in the next year. And I realized that as a tool, medicine was gonna be really limited to address those big picture problems that are so thorny in our society and our health care system. And at that point, I decided not to apply to residency.

In fact, I had this one patient, she became a bit of a referendum for me on whether or not I was gonna do a residency. Her name was Miss G. And she was this indigent woman. She'd fallen and hit her head and she was drunk at the time. And then the emergency room, she didn't really get a full work up like she would've gotten if she'd fallen and hit her head in other circumstances. And I got really frustrated by this and so I purposely slow walked her situation. I didn't want to sign off on not admitting her. And then she started withdrawing, which I knew would happen. And so we admitted her and started treating her.

But in the course of that admission, we realized that she had full blown AIDS, which wasn't picked up on the history that they took in the emergency room. That she had had this actively bleeding pelvic mass, usually at baseline she had high blood pressure. But because of her active HIV, one of the things that HIV can do is infest the part of your body that regulates your blood pressure. So she actually had low blood pressure. Two weeks later, I diagnosed her with all of these issues, got her set up, got her set up with housing and to go to a rehab program. She ended up deciding to go home with a daughter that she'd lost contact with. And two weeks later, I was getting on the subway to go to dinner with a friend. And I walk onto the train and I see Miss G sleeping there on the train. And that was the moment I said, "Look, if we're gonna address the big picture challenges that put Miss G in situations like she was in, medicine's just not gonna be a sharp enough tool to do it.” And then that's why I decided to go into public health instead.

CHRIS HAYES: It's fascinating because when you think about it, my father was a community organizer and then he got a job in the New York City Department of Health and worked in public health for years.

ABDUL EL-SAYED: That's amazing.

CHRIS HAYES: And public health is... I mean, there's an argument to be made that it's the foundational enterprise of civilization. Literally the most important field and the most important innovations in the history of building a society are public health innovations.

ABDUL EL-SAYED: That's right.

CHRIS HAYES: Sanitation, clean water, that's basic... You can't have anything remotely like what we think of a civilization, industrial society, modern flourishing, in the absence of a whole bunch of public health innovations.

ABDUL EL-SAYED: So I'll tell you, I'm gonna say something that I opened all of my lectures with when I was a public health professor. I said, "Listen, humanity got a big boost the minute we realized how we could stop from doing our business in the same water that we were going to drink." That was one of the most important things that humanity did, right? Figured out how to keep one part of water “the dirty water” and the other part of the water “the clean water.” And right now, if you look at disease torn and ravaged communities, it's usually because of a failure of that basic sanitation. That is foundational public health. And the minute you can start doing that, people are gonna start to think about higher order questions. How do we water our crops and how do we make sure that we're teaching people big time skills that they need? How do we make sure that when people in the town next door who want to take our resources, how do we sit down and actually think about making peace and working together? I mean, these are all things that only happen in the context of making sure that people are not dying before the age of one at extremely high levels and having to fight disease a third of their life.

Image: Health Care Protest
A group of belly dancers in favor of "Medicare for All" perform outside the Supreme Court in Washington on June 28, 2012.Evan Vucci / AP file

CHRIS HAYES: There's another part of it too, which is that our experience of health is so individualized, but as a phenomenon, it's such a social phenomenon. So it's so intimate and so close to who we are. Like you feel sick or you feel freaked out because you have some rash that won't go away. It's private and it's a individual thing, it's an individual experience, but then a lot of times when you zoom all the way out, a lot of what's going on isn't about you the person, it's about you and where you live, or what class you're in, or what job you have.

ABDUL EL-SAYED: And that's a new phenomenon, right because—

CHRIS HAYES: You mean, figuring that out.

ABDUL EL-SAYED: Well, not only figuring that out, but also experiencing it individually. It used to be the case when we didn't understand exactly what communicable diseases were that most people died of communicable diseases. We forget sometimes that things like small pox and things like measles used to kill huge numbers of people. And so what would happen is you would have this huge mass contagion and then people would suffer together. You'd have hospitals where just rows and rows and rows of people who are suffering the same disease. So it was actually much more of a communal phenomenon.

CHRIS HAYES: And everyone understood it obviously because people are smart and it's life or death. And folks recognize right away what's coming their way.

ABDUL EL-SAYED: That's right. And you knew that you were at risk. So people would... If you had the means, you would up and leave the community where these things were happening. In fact, I'm reading, incidentally, a biography of John Adams. And one of the most scary moments actually in American history was that, back when congressional headquarters were in Philadelphia, there was this huge yellow fever outbreak. And several members of congress died. And John Adams had to leave because they were afraid it was gonna wipe out the entire U.S. government. And that was the experience of infectious diseases, which were the most common killers back in the day. But that communal experience is consistent today, it's just that we live much more atomized lives. We live independently and we don't normally recognize that the diseases that we experience, whether it's diabetes, or heart disease, or a stroke, that they really are epidemics because they're not communicable per se, but so many people in our society are hurting from them. And one of the downsides of that, actually from a public health perspective, is that because it's so individualized we lack the recognition of the responsibility for collective action around fighting these issues.

CHRIS HAYES: Absolutely.

ABDUL EL-SAYED: Back in the day when everybody you knew was suffering from yellow fever, the responsibility of addressing yellow fever was imminent. Everybody knew we had to do it, right? Now, 30 percent of our population is either pre-diabetic or diabetic and that's serious. But because most of us don't suffer that in public and we don't suffer that together, we're not willing to do the work of addressing it because it just seems like my problem or your problem rather than our problem.

CHRIS HAYES: Well, and that gets to what's so profound I think about health politics, right? Because at one level, it's the most intimate thing in the world. It freaks people out. When you think about, it's people that are most vulnerable. It's people that are most stressed. It's people at their most almost animalistic fight or flight. If you came to me and said… My daughter just had a little bug a week ago and I was out of my mind. She's fine, but I was out my mind. It was just a bug, but it went a little longer than we thought. I was in the ER with her one night. Watching your six-year-old get hooked up to an IV is like... You're just out of your mind. And someone came to me and was like: "Someone came to me with some sort of devil's bargain about we can screw over these thousand other people you've never seen, but your daughter would feel better." I'd be like, "Done. Done." I don't care what my politics are, I don't care about morals…

ABDUL EL-SAYED: Nobody let Chris in any position of power ever.

CHRIS HAYES: I'm just saying when you're thinking about sickness and health and family members, you get real mama bear. You get real animalistically survivalist about taking care of your own. And I think there's a connection between that place in your sternum and in your heart with the broader health care politics in the country.

ABDUL EL-SAYED: Exactly right.

CHRIS HAYES: If you come to me and say, "Dude, your kid... Something's gonna... Your care is gonna be limited." You go to seniors in Florida and say, "The lefties are coming for your Medicare." That is an effective thing because of how intimate and terrifying it is to be sick or have people that you love sick.

ABDUL EL-SAYED: Yeah, and that is the paradox of public health, is that our collective action could make health care and health so much better for so many people.


ABDUL EL-SAYED: And yet we use our profound individualism when it comes to the fear of losing access to actually prevent us from doing that thing. The lobbyists who have always lobbied for a money-based system in health, whether it was the AMA, the hospitals, the insurers, pharma, all of them have used that fear tactic of saying, "Well, your status quo, you know what it could be if it was different. And they're gonna shake the system. And you might lose something." And that loss aversion then becomes so much more profound for those folks. And the reality of it is that we pay too much, too few people have health care, and our health care is not actually that great. And the thing that we ought to be doing to actually improve health doesn’t have to do with health care at all. I mean, the reality of the thing is that health care is a really bad good because nobody actually wants health care. Nobody's like "Man, I want five MRIs." You don't actually wanna have any MRI, right, 'cause you wanna be healthy.

CHRIS HAYES: That's right. I went to this urgent care center, which was very good. They were great. But I'm thinking to myself, "Well, that's good to know." But it's also like, "Man, I hope I never go back there again."

ABDUL EL-SAYED: Right. I mean, that's the thing is that it's a really poor proxy for what you actually want, which is to be healthy. And you do these things that a doctor who has more knowledge than you about your own health tells you that you ought to do to be healthy. And so you see where the conflict of interest exists there.


ABDUL EL-SAYED: And then you have the insurance industry which says, "Well look, we really wanna sell insurance to the people who don't need it rather than the people who do."

And then when people are the sickest, that's when the American government kicks in. We wait until they get real sick after they're 65, and then we're kicking it in for everybody. And all of that time, before they turn 65, that we could have used to prevent disease in the first place after 65, we don't really do anything, because it's not in the best interest of the insurers.

The insurers are all, and this is the thing about it, right, the insurers in America know that they are underwritten by Medicare. Get them to 65 and you don’t have to pay a dime.

CHRIS HAYES: See, this is the thing I think that people don't actually understand about why the American system is so strange, expensive and perverse. Because, just take out all private spending in the U.S. health care field. I think as a percentage of GDP, public dollars spent on health care in the U.S. is roughly in the range of like France, that has universal health care. We're already spending the money as a percent of GDP that other countries that basically use all that money to do all the coverage are doing.

ABDUL EL-SAYED: That's exactly right.

CHRIS HAYES: It's crazy.

ABDUL EL-SAYED: That's exactly right. And that's what's so frustrating about the whole situation, is that it's almost impossible, like you said, to see it in the macro, to appreciate the system's failures because you're only really one cog in the system. And that's true, not just for patients, it's true for doctors. And so everybody's got this sort of, “well let me just keep my” mentality about it, which makes it so hard to actually think about what the system ought to be.

And a lot of people make a lot of money. That 19 cents on the dollar that we spend on health care in the United States, you just take that and compare it to any nationally subsidized system. We're spending 40 to 50 percent more. And that's almost entirely going into a profit margin for somebody.

CHRIS HAYES: Right. So that brings us to the big question about “Medicare for All,” and there's a bunch of questions. So I wanna sort of walk through them. And you were someone who, you recently ran for governor in the state of Michigan on a “Medicare for All” platform, I think both state “Medicare for All” and national, if I'm not mistaken?


CHRIS HAYES: But also you believe in it as a national program. And there's a bunch of different questions about what it means, et cetera, but before we even talk about what it means, I wanna talk a little bit about the politics of it and the way that the policy problems and the politics interact. Because one of the things I think that's true, the “Medicare for All” advocates will say, "Look, this polls really well. This is really popular."

I believe that. I think it is generally pretty popular. But, one of two things are gonna have to happen if you have something like “Medicare for All.” Either the government's gonna spend a lot more money, right? And to spend that money, probably taxes are gonna have to go up. Or, costs are gonna get squeezed, particularly out of the private sector, all that profit. And that means you don't have to spend as much more money. But in either cases, there's political road blocks.

If you're spending more money and you're taxing people more, you gotta sell a tax raise. And if you're squeezing the profit out of the system, every cent of profit you squeeze out of the system to save money for the system, someone's taking that home and making a buck off that, and not just like rich, fat cats. There's a lot of middle class people that work for health insurance companies. There's a lot of folks around that system that we've built up that aren't gonna be too happy to see that thing squeezed. How do you think about those two obstacles of political economy?

ABDUL EL-SAYED: So part of the problem with health care in the United States is that everybody's incentivized to make a buck out of it, whether you're a provider, doctors, hospitals, or you're a payer. That's the insurance industry. And right now, the way it works is that we have a ton of unnecessary care, because that's how doctors, providers make money. And we have a lot of money just spent on the provider side because we have duplicated overhead across all of these insurance companies, and because they all make 15 cents on the dollar for every dollar spent in health care. Both of those things are deep inefficiencies, and that has to have a structural fix.

What “Medicare for All" does is it basically squeezes out the payer side of profits. It says, look all of these insurers that we have, which by the way, nobody likes. I mean, nobody is like, "I love my insurer."

CHRIS HAYES: I love my insurance company. I love them.

ABDUL EL-SAYED: I really love fighting with them.

CHRIS HAYES: I have a tattoo. I've got a United Health care tattoo, it goes right across my chest.

ABDUL EL-SAYED: I've personally got a Blue Cross, Blue Shield.

CHRIS HAYES: Yeah, like on your forearm.

ABDUL EL-SAYED: But that's the thing, nobody enjoys their health care provider. They don't like the fact that they have to pay this premium, and then every time you try and use it, you've gotta fight them. You've gotta pay a co-pay at the point of care, and then you've got this deductible you have to... The whole thing is just broken.

And so what we're basically saying is, how about we do away with that side of it, and then because we've got one insurer, that that insurer who accepts everybody, that one insurer can then say, “Listen, here's what the price of this particular cost of service is going to be for everyone.”

It takes that profit motive off the top, and it holds a lot of the doctors accountable, because you've got a system now where you've at least taken the profit motive out of one side of the equation but not the other side.

CHRIS HAYES: I wanna make an important distinction here though, just so folks follow this, because this is pretty wonky but it's really important one. What you're describing, right, so you've got the providers and the payers, right? The payers are the insurance companies, the providers are your doctor. When you're talking about “Medicare for All,” when you're talking single payer, it means we get rid of all those insurance companies, we have one payer, one insurer, that's the government that insures everyone, but the providers remain private, right?


CHRIS HAYES: In Britain, you've got nationalized health care, which means in the national health service, the doctors themselves are public. They're working for a nationalized entity. “Medicare for All" is not that, right?

ABDUL EL-SAYED: That's right.

CHRIS HAYES: In “Medicare for All,” you would be a doctor working for the hospital or working for yourself or working for private practice, the ways that those doctors that provide Medicare do now. You would not be an employee of the government. I just think it's an important distinction.

ABDUL EL-SAYED: It's a really important distinction, Chris. And I'll tell you the example that a lot of people know of is the VA. The VA, if you were to say “VA for all,” that would be more similar to a single provider or the British system. Nobody's saying “VA for all.”


ABDUL EL-SAYED: What we're saying is “Medicare for All.” Anybody who has Medicare knows that they can go see any doctor and that that doctor will be able to be paid by Medicare, and that doctor is private, works for themselves, works for the hospital industry.

Now here's another important part of that distinction, Chris. A lot of people's experience of health care is that there are fewer and fewer companies that you can go to to get health care. You've watched a lot of rural hospitals and even urban hospitals close down, and you've seen them, if they don't close down, get taken over by a couple of very big behemoth health systems.

Part of the reason that happens is because there is a collusion that takes place with the providers, the hospital systems and the insurers. And what they basically do is they crowd out the little guy by changing the price that big insurers will pay to the big hospital providers. And it basically crowds out—

CHRIS HAYES: Wait, stop. I didn't understand that.

ABDUL EL-SAYED: Okay. So you've got a rate for, let's say we're talking about MRIs, right?


ABDUL EL-SAYED: If a small doctor, an individual guy who provides MRIs, if that doctor provides the MRI, they'll get a different reimbursement rate for that MRI than the big hospital system.


ABDUL EL-SAYED: Because they know that if they collude together, they just get a better deal. They basically buy in bulk. And so what's happened now is that small doctors have been pushed into having to be employees rather than being their own business owners, being employees for the big chains, for the big systems, and then they also just take over those smaller hospitals, too.

Image: Demonstrators protest changes to the Affordable Care Act on June 22, 2017 in Chicago, Illinois. Senate Republican's unveiled their revised health-care bill in Washington after fine tuning it in behind closed doors.
Demonstrators protest changes to the Affordable Care Act on June 22, 2017 in Chicago, Illinois. Senate Republican's unveiled their revised bill in Washington after fine-tuning it in behind closed doors.Scott Olson / Getty Images

CHRIS HAYES: As far as I can tell, everything's combining everywhere, and we just seem to be headed towards one company called Amazon that's gonna give us everything from like our streaming to our health care. That seems to be the natural endpoint of all this.

ABDUL EL-SAYED: I mean, you know Amazon just opened a full on... they're working with Berkshire Hathaway and Walmart.

CHRIS HAYES: Oh yeah. I mean Marx would say that that's a sort of natural progression of capitalism towards monopoly, and then it will make it very easy for the states to just nationalize the one company that's left standing. But basically they're incentives of scale, right?

ABDUL EL-SAYED: That's right.

CHRIS HAYES: The larger you are as an entity, the kind of more leverage you have with the payer, right?

ABDUL EL-SAYED: That's exactly right.

CHRIS HAYES: So the bigger you are as a provider, you've got big providers and big payers, you can cut yourself better deals and that's gonna squeeze smaller providers and individual providers.

ABDUL EL-SAYED: Exactly. That's exactly right. But you can see how this is bad for the rest of us.

CHRIS HAYES: Why though? Why is that not just creating more efficiency in terms of the cost?

ABDUL EL-SAYED: Because what tends to happen is that you move doctors out of places where they're needed the most.

CHRIS HAYES: I see. Right, so there's geographic cost there. So if you're in McAllen, Texas, if you're in down the Rio Grande Valley, you're more likely to be either individual or part of a small group set up than a big one, and so you're gonna concentrate your health care providers in smaller and smaller areas.

ABDUL EL-SAYED: And to talk about choice for a second — this is a very anti-choice thing. Basically what we're having is oligopolies, local oligopolies in health care. Republicans will always say, "Well, you have to be able to choose. Choice is so important in the system," as if somehow “Medicare for All” is gonna take away your choice.

It actually doesn't. It actually protects the fact that at the point of care, you actually do have a choice, because it allows the smaller doctors to be able to actually compete.

CHRIS HAYES: What you're saying is if you get away from the differential pricing that's happening right now, that is incentivizing concentration and larger chains, and you have one rate for everyone across the board, no matter who the provider is, you make it more possible for a flourishing of smaller providers.


CHRIS HAYES: So the government isn't doing this "Oh, you big hospital chain, we're gonna cut you a special deal on these MRIs that's gonna advantage you economically and you, the guy that's running the MRI in the Rio Grande Valley in the middle of nowhere, you're screwed."

ABDUL EL-SAYED: That's exactly right. And Americans like choice. And so the irony of the thing is that “Medicare for All” is actually a very pro-choice system. And I mean that in multiple ways.

CHRIS HAYES: But the other part of that though, is that when you look at other systems that do have some version of single payer — and again, these systems are super complicated. Like, there's lots of different ways to get universal health care, and the Swiss system is different than the French system, which is different than the Israeli system, which is different than the British system, and on, and on, and on — but when you look, the one thing that all these countries have in common is, doctors make less money. That's another big obstacle here.

I have friends of mine who are doctors who spend a lot of time and took out a lot of debt to be doctors, and they're doing pretty well now, but they don't feel super wealthy because they're hitting 40 and they're paying off their loans. And if you come at them and say, "Great news everybody, 40 percent salary cuts for everyone." They will riot.

ABDUL EL-SAYED: So I'll tell you a couple things. So number one, doctors are making less today as a proportion of the cost of the health care than they were in the past. And a lot of it is because of this consolidation and conglomeration in the system.

CHRIS HAYES: That’s interesting.

ABDUL EL-SAYED: That's number one. Number two, a lot of these countries make medical school free. And we're starting to see a movement in that direction. NYU just announced that they wanted to make medical school free for students there. And I think a lot of other schools are doing it as well.

CHRIS HAYES: That seems to me honestly like you can't have one without the other. You can't have the system now where you take out several hundred thousand dollars in loans and then make what you would make essentially in France. It's not gonna scan. You'll get rid of the incentive to be a doctor first of all.

ABDUL EL-SAYED: And part of what I think is important in terms of talking about medical salaries is that, so number one, right, the proportion of employees in health care who are doctors is actually quite low. Most of the employees in health care are going to be nursing staff or other staff. And our nursing staff and other staff make substantially less than they do in other countries. That's number one.

CHRIS HAYES: That's interesting.

ABDUL EL-SAYED: Even among doctors, there's a huge inequality in what doctors make. So you can look at a mean average of what doctors make in America and say, "Man, doctors make so much money."

But if you actually look at the median, it's not all that far off. And that's because there's a huge disparity between the specialties, things like orthopedics and dermatology and anesthesiology, versus the doctors that most of us who are healthy see most of the time.

CHRIS HAYES: Right. And that's where you get this perverse market incentive, which is to oversupply specialists as opposed to general practitioners. And of course, one of the things we know from a lot of studies is that actually supply affects demand in terms of specialization, right? So if you've got a lot of specialists, you get a lot more demand for the kind of care they have, and that tends to be more expensive.

ABDUL EL-SAYED: Exactly, because remember there's a huge inefficiency in our system because going to the doctor is like going to the mechanic. And every time you go to the mechanic, they tell you, "Hey look, you're gonna need a new..." and they name a word that you don't understand.

CHRIS HAYES: Right, “Johnson rod” is what George Costanza said in the Seinfeld episode, which I think you may be subliminally referencing.

ABDUL EL-SAYED: I love that you referenced Costanza.

CHRIS HAYES: "You need a new Johnson rod."

And I'm like, "Sure, I'll take a Johnson rod. I don't know."

ABDUL EL-SAYED: So that's exactly it. With doctors, they give you the medical version of a Johnson rod and here you've got more specialists who've got more different kinds of rods to sell you, and all the sudden, everybody's buying rods.

CHRIS HAYES: And we should say, I think it's not manifestly corrupt.

ABDUL EL-SAYED: No. It's on the margin.

CHRIS HAYES: When we talk about sales, it's on the margin. It's just like you — at some level, you understand that the provision of care is tied to your salary and the more care you provide, and the more stuff you do, the more money you make, and so there's just like this inescapable gravitational pull.

ABDUL EL-SAYED: And I'll give you an example. Think about back pain. We really don't know why it happens in a lot of cases.

CHRIS HAYES: And it terrorizes millions of Americans.

ABDUL EL-SAYED: It terrorizes millions of Americans. Everybody just wants it to go away. Now, you go see an orthopedist. And an orthopedist knows that in your 10-minute visit with that orthopedist, that they might make 50 bucks. But they know that if they go in and they perform surgery, they're gonna make $50,000. So what orthopedist on the margin says, "Hey look, you could go either way," and doesn't recommend surgery? Some really honest orthopedists do, but you can see why they might say, "You know what, maybe we'll do surgery." And medically, you can go either way. And most patients—

CHRIS HAYES: It's a defensible thing for them to say.

ABDUL EL-SAYED: Exactly. It would be medically defensible for them to say it. They're going to make a thousand times more money.

CHRIS HAYES: But here's the—

ABDUL EL-SAYED: And then even patients, most patients are gonna be like, "Look, try something doc."

And so you can see how the system moves that way.

CHRIS HAYES: Of course. In that case, like at the margin, the provider, because it's this weird multi-prong system, the provider and the payers, the provider's got the incentive to say, "Yeah, get the surgery. It's $50,000."

But isn't the whole point that the payer is exercising the discipline there? And the payer, the insurance company, is like, "No."

And isn't that the thing the people hate about the system anyway?

ABDUL EL-SAYED: It's true.

CHRIS HAYES: Is that your doctor says, "Actually I can fix your back pain."

And then your insurer says no, even if it might be the case the insurer's actually right. Basically no one ends up happy there.

ABDUL EL-SAYED: No, you're right. And this is the problem. This is where we get back to the public health conversation. The best thing we could've done is figured out how to prevent the back pain in the first place.


ABDUL EL-SAYED: And we just don't have the kind of circumstances where that's the case. We are the most obese country in the world, which is probably the number one predictor of back pain.


ABDUL EL-SAYED: Most of us, if we're going to work or coming home from work, most of the energy that we exert is to put our car in drive and then move our right foot a couple of times. The amount of exercise that we do is quite limited. So you look at all of the ways that we are organized. It all drives in this hyper-medicalized system that costs us a lot of money and doesn't really leave us that much healthier.

Remember the thing that nobody wants to buy health care, everybody wants to buy health.

CHRIS HAYES: That's great, yeah.

ABDUL EL-SAYED: The thing about health is that it's something to be kept, not necessarily something to be created. Most of us are born healthy, thank God. And in those circumstances, the question is, how do you stay healthy rather than how do you make yourself healthy? We have all the tools, it's just the incentive and the investment has to be there to make that happen.

CHRIS HAYES: You've described all these sort of perverse incentives throughout the system that ratchet up the cost, that make customers less happy and that squeeze providers in terms of their choice and sort of push towards concentration, but you will admit that there is still gonna be a brute political economy problem, which is like transitioning to a “Medicare for All” system is gonna take dollars out of lots of people's pockets. That is gonna be hard, right?

ABDUL EL-SAYED: So let me share that just with a context that I know well. So we proposed, when I was running, we proposed a plan called “Michicare.” And in “Michicare” we would provide every Michigander health care. We would pay for it in two ways. One was going to be a payroll tax that started at .75 percent in the lowest quintile and went up as high as 3.75 percent in the highest quintile. And then also a gross receipts tax for after the first $2,000,000.00 in gross receipts. So basically on that alone exes out 75 percent of Michigan businesses, gross receipts tax for business. It's a 2 percent gross receipts tax, and then if you're over 50 employees, it's a 2.25 percent gross receipts tax.

So one of the ways we wanted to talk about this, the reason health care policy can be so mind bending is because we're talking in aggregate numbers that are very, very large, and very, very hard to understand. But we wanted to just look at, so how does the median family do if we were to think about this system?

CHRIS HAYES: Implement your... Just to be clear. So you've got a progressive payroll tax, and going to 3.75 percent, which is not nothing.

ABDUL EL-SAYED: No, it's not nothing.

CHRIS HAYES: You've got a 2.2 percent gross receipts tax on big businesses.


CHRIS HAYES: And then a 2.2 percent gross receipts tax on non-big businesses that have over more than 50 employees.

ABDUL EL-SAYED: Yeah, so let me just make that make it very simple, right—

CHRIS HAYES: That's not super simple.

ABDUL EL-SAYED: The first two million dollars are exempt, no matter who you are.


ABDUL EL-SAYED: So, that basically exempts 75 percent of businesses right there.

CHRIS HAYES: Okay I see.

ABDUL EL-SAYED: And then if you — let's just call it 2.25 percent for everyone, right — if you had a small business less than 50 be two percent, it's not a big difference. All of that would end up saving the median family, making $48,000 a year in Michigan, save them about $5,000 a year. Why? Because we already pay for it, right, we pay for it in so many ways. If you have private health insurance, the high likelihood is that not only does your employer have to pay for it, but then you have to pay for it every month, and it comes out off the top so you don't see it, but you're paying for it every single month.

And then on top of that, every time you want to go see your doctor there's a copay, and it doesn't even kick in in any real way until you hit your deductible, and then you've got to get on the phone and call somebody to make sure that they're actually gonna pay for the doctor who you went to go see. So you're already paying for it as it stands.

And then if you looked at businesses we actually looked at — let's say a 40,000 employee company. We estimated that a company like GM in Michigan for example would pay, say, 20 million bucks a year, because again they're already paying for it. In Michigan when you talk about these numbers, Michiganders know what it's like to be at risk for losing their health care because so many people lost jobs and therefore lost health care during the Great Recession.

And when you talk about these numbers saying, “Listen if we could return more than 10 percent of your money that you pay every single year, $48,000 salary, what would that mean to you? And know that you had health care?” And then beyond that you look at big businesses and say… Listen, you know one of the big issues in 2008, for example, when GM was going bankrupt, was that they were paying upwards of 15 cents on the dollar for every dollar that they took in, for not just employee health care but for retirees’ health care.

CHRIS HAYES: Retirees — which is the huge, huge cost center for all the big auto companies.

ABDUL EL-SAYED: Yeah, so what would it be like if you could just take that off the top? And the funny thing about it — I mean it's tragic — is that in 2008, when GM had to offload people, they offshored them to Canada. Right, so like I mean, this is the reality of the lived experience of having health care in America.

CHRIS HAYES: But what you've described again, I can't... I always feel like am I getting swindled here like you've described a win, win, win basically, like it's like everyone's doing better off, but it's, like, I don't know whether I believe that. Like someone's paying more, right?

ABDUL EL-SAYED: So, the few people who are paying more are those folks in the top quintile — that's only if they spend almost nothing on health care as it stands in a year on their co-pays and deductibles.

CHRIS HAYES: So what you're saying is your contention about universal health care just in the state of Michigan with the structure that you guys put, is that basically you could create something that's squeezed the system or created the incentives in the system enough so that taxes would go up a little bit, but that the out-of-pocket costs for the vast majority of people would be less.

ABDUL EL-SAYED: That's exactly right. Now, who does lose? Insurance company CEOs.

CHRIS HAYES: Right, yeah.

ABDUL EL-SAYED: Right, Blue Cross Blue Shield in Michigan – their CEO makes 30 million bucks.

CHRIS HAYES: Wait a second, but not just CEOs. They employ a lot of people.

ABDUL EL-SAYED: So there would be…

CHRIS HAYES: You can't just hand-wave those people away.

ABDUL EL-SAYED: No, but there would be... I mean, so everybody still is gonna have to have health care, in fact. Everybody... There are going to be more people who have health care under this system than the old system, and they're still going to need to be those middle-income jobs of people who work in the bureaucracy of health insurance. They're just not going to be working for big corporations and instead they would be working for the entity…

CHRIS HAYES: The state.

ABDUL EL-SAYED: Exactly, the state. The reality of it is that you still have to pay for professionals what they're worth and I have no problem with that, but the other reality of it is that the person who administers whatever the state version of CMS would be, right, Centers for Medicare and Medicaid at the federal level, whatever, the state level that person would make substantially less than 13 million dollars a year.

CHRIS HAYES: Yes, I think that's fair to say. You know it's, like, not like he's the football coach you know.

ABDUL EL-SAYED: No, and then—

CHRIS HAYES: And that's who gets the 13 million dollar a year salary. The one state employee in every state to get them is the football coach.

ABDUL EL-SAYED: Jim Harbaugh’s worth it, okay?

CHRIS HAYES: Yeah, probably he is actually. So this sort of brings me into, like, the kind of most important point to me about this entire debate, because it's a bigger debate than just health care. I think you are part of a crop of Democratic politicians who are… sort of associate yourself with, you know, social democracy — maybe different visions of democratic socialism or kind of universal public goods provisioned universally, right?

And one of my frustrations in this moment, as someone who’s sympathetic to that, is that I feel like — and you are not doing this, I should be clear — there just is, like, there's an ideological or even a practical argument that's made on behalf of these things and then a lot of yada-yada-yading about the implementation. But, like, the implementation is everything. Like you could have really good socialism or really shitty socialism — and it's like the devil is in the details. But it turns out the details are everything.

Like Don Berwick is a friend of mine who ran CMS, and I have friends who are in this sort of health care bureaucracy, and it's complicated and hard and they make a lot of really difficult calls and they work really hard to sort of, like, set standards that get diffused through the system. And I'm living in New York City where we have one of the most incredible bits of socialism in America, which is the New York City subway system, and it's a goddamn smoking room right now because it's not being well-run. So it's like, I just sort of feel like, it's like you can't make the case for this sort of thing unless you've got: A) credible plans and B) investment in the blisteringly mind-numbing details of implementation.

ABDUL EL-SAYED: So I'll tell you, as a former health commissioner, I know that the devil is in the details. One of the programs that I'm really proud of and probably was the most fulfilling to me in my life was we built a program to guarantee every child a free pair of glasses. But the details on getting it right — you know, working to make sure we could bill it and working to make sure that all the parents in Detroit knew what this new form was going to be for, working with all the principals of all the public schools and the charter schools and the private schools, making sure that we could coordinate the testing for defect, vision defects and then testing for what kind of glasses you needed in the same day with a mobile clinic — like all of those details are critical.

But, you know, we need great leaders on the ground who are willing to do that kind of work. And I agree with you that whenever we lead on a set of values and are not willing to do the though work about how we operationalize those values into the details, then ultimately what we do is we do our values a big disservice. And as a progressive candidate for governor we put out some of the most detailed plans on what we wanted to do, not just on health care but on universal access to Wi-Fi, on our green energy plan, on issues like water affordability and access, because we knew that it's not enough to say “hey when we all get together we can make everything great.” Right?


ABDUL EL-SAYED: Because I've seen it go the wrong way. At the same time, I honestly I push back on the “socialism” label simply because, you know, we've moved so far to the right in this country that when we talk about collective action on anything, right, people are like, “Well that's socialism.” No it's — it's about providing people a basic access to things that they need to live a dignified life. Is it socialism to build roads? Is it socialism to make sure that the air is clean? I don't think it is, I just think that's good government. Because in the end the whole point of government was people coming together to act collectively in the best interest of all of us. That's what government is.

CHRIS HAYES: Yeah, I think it's a great point because it's become this weird definitional dispute about socialism, and some people say well public parks or socialism — it's like, well I don't know, at a certain point we're having a semantic argument. What public parks are are a public good collectively provided by a public entity, the government, that can be universally enjoyed. That's sort of the idea. I mean to me the thing I think about — you know, again, I'm obsessed with the subway, because I'm just obsessed with the subway generally but also I take it and I curse it — but to me it's just like the subway is an achievement on the level of the pyramids of Egypt. It's an incredible freaking thing and—

ABDUL EL-SAYED: As an Egyptian American, I take a little bit of offense, but not that much, not that much. The subways are pretty amazing.

CHRIS HAYES: They're amazing but you know there's a big difference between well-run and poorly run, you know and—

ABDUL EL-SAYED: Right, that's exactly right.

CHRIS HAYES: And it just, I do think we're entering a new era, and I just I guess my hope is just that there's people out there like yourself, and legions of them serious and clear-eyed and committed enough to the technical details of getting it right.

ABDUL EL-SAYED: Yeah, I'll tell you: I think, you know, one of the things that I would often talk about in conversations like these, is that we need a technical left, right? We need to make sure that we're investing in the scientists, and the technocrats who know how to get these things done, and at the same time know that we're thinking about what innovation in these spaces looks like. One of the biggest frustrations I have with the culture of government is that once we have gotten to a particular end we sort of wrap our arms and say well it's done let's move on. It's not done.

There should be a constant push to innovate in public service, just like there is in private enterprise. And private enterprise is because people want to make money on the next greatest good, but in public service it's because we want to continue to become more efficient and more effective at being able to provide that public good, because it matters to people's lives, and for the same reasons that we believe in these social policies in these collective goods we ought to also believe in innovation in those goods and trying new things, and there is a sort of spirited conversation about how we actually build that out.

You know, one of the nice things is we're starting to see a lot of folks who would have gone into more lucrative careers in the tech space starting to ask, “Well what is my public responsibility?” and bringing that same approach to innovation into the public goods space and into government.

CHRIS HAYES: So you, this was the first time you ran for office, right?

ABDUL EL-SAYED: That's right.

CHRIS HAYES: Because Detroit Health Commissioner is an appointed position, right?


CHRIS HAYES: What surprised you most?

ABDUL EL-SAYED: You know, I decided to run in the aftermath of the 11/9 election and one of the big questions that we were asking, I think implicitly in the moment is, if we are a country of good people, how did we just elect that man president? And the people of the state of Michigan over the past year and a half, I think, have given me the greatest gift I ever could have had in that moment, which is reassurance that people are good people.

And it's the nature of the conversations that we have — the fact that we are taught to communicate in tweets and sound bytes that are meant to be more extreme or made more extreme than they really are that — has driven the kind of polarity that we see in our politics right now. And when you actually break that down and you start seeing people in their own community spaces, their VFW halls and their community centers and their town pubs, and you look them in the eye and you share a conversation about the two central questions I think are core to our democracy, who are we, and who do we want to be, you start to realize that people are a lot more nuanced than the public conversation would have you think.

And people are good. They're generally good, they wish well for other people. It doesn't matter what side of the political spectrum they're on, but a lot of the confusion in our public conversation I think is driven by this sort of brokenness of our public conversation, and when we are able to move beyond that I think it matters a lot and that to me was very surprising. I mean I'm an Egyptian American, devoutly Muslim. I was 32 when I kicked off my campaign. I was the unlikeliest of candidates for governor and I would have expected a lot of people to treat me far less respectfully and respectably than they did because of how I had been trained on our social media and public conversation.

But when you have the courage to just walk in all of us me or them and just share a moment in time and space a real moment together where you can see each other's eyes, you realize that people are just far better. And that, to me, was a realization I needed at that time and I'm thankful that I got.

CHRIS HAYES: Final question. I've been asking people this and it's a hard one. It stumps a lot of people so if it's dumps you it's okay. What is something that you've changed your mind about?

ABDUL EL-SAYED: A lot of things. You know I used to believe that the policy mattered more than the politics. It's a reason I pursued a career in the technical space. I was coming of age in the moment of Barack Obama, right, and I graduated college ‘07, he won in 08. I was a grad student—

CHRIS HAYES: Good God, you are young.

ABDUL EL-SAYED: Throughout his time I thought, you know, if we got it right and we got the policy right that the world would see that it was correct. And I think so many of my frustrations with that era in our politics have to do with recognizing that, actually, the politics matter just as much. And when I say politics it's not the gamesmanship of the politics but it's the willingness to be patient with how we communicate about it.

I mean if you believe in your own truth, right, then you should believe in the patience that you have to communicate that truth, rather than what I think we do on the Left too often is to look at people and be like, “Well if you don't understand what I'm saying then you must be stupid.” And that's just — it's just a terrible way of thinking about the world. It's because we're not explaining it well and because we're not talking about it in language that people understand.

I mean so often we’ll point back to the data: well the data says this and the data say that. Most people don't communicate in data, right? Your mom, when you were young, didn't sit down with you and say, “Well listen there is a significant association between the likelihood of you sticking your finger in that socket and you being electrocuted.” She said, "Listen, if you touch that thing it's gonna hurt you."


ABDUL EL-SAYED: We communicate in parables and stories and we're not very good at having that conversation, and I think our politics on the left have to be a lot more thoughtful about how we tell the story of who we are and who we want to be and how our policy then rigorously undergirds that politics.

I think that learning for me has been profound and sometimes painful and sometimes frustrating, but if we're willing to have that conversation, it's not that other people are not just as smart as people on the Left on the Right, it's that we're not having the right conversation and we need to start having that conversation.

CHRIS HAYES: Abdul El-Sayed is a professor of public health. He's the former health commissioner for the city of Detroit, former Democratic gubernatorial candidate in the state of Michigan and, as you can tell, a pretty exceptional guy. I really appreciate it.

ABDUL EL-SAYED: Hey, I really appreciate you having… making the space. It was a great conversation and I really appreciate the moment.

CHRIS HAYES: Great, thanks again to Abdul El-Sayed who's, as you can tell from that interview, a fascinating guy. We have a website for “Why Is This Happening?” that you should know about, it's at, and there's lots of stuff up there. There's links to things we mentioned in the interviews and that are often THINK pieces, which are sort of op-eds that are related to our interviews.

In fact, there's a new one by Shireen Al-Adeimi, and she was a guest a number of weeks back. She's a Yemeni woman who has been tracking the war in Yemen. She talked about the war in Yemen — the Saudi-led war in Yemen — and she's got a piece about the Saudi complicity, particularly Mohammed bin Salman, his complicity in waging that war in Yemen and about the sort of world waking up to the moral horror of the regime in the wake of the apparent murder of Jamal Khashoggi.

So that's a great piece. You should check that out. You can check out a lot of stuff at We also always love to hear from you at Why Is This Happening? There's two main ways you can get in touch with us. One is you can tweet it to us using the #withpod — W-I-T-H-P-O-D with a little pound symbol, that's the hashtag, is in the front. No one knows a pound symbol means anymore.

You can also email us at We read all those emails, we see all your tweets, we often get ideas for things that we can do. People have sent in guest suggestions that we've done. For instance, Abdul El-Sayed was a guest suggestion from a listener, so thank you for that, well done. But we'd love to hear from you. We'd love to hear your feedback, we'd love to hear suggestions or topics or anything for the show. “Why Is This Happening?” is presented by MSNBC and NBC News, produced by the “All In” team, and features music by Eddie Cooper. You can see more of our work, as I said, including links to things we mentioned here, by going to