This is Democracy – Episode 18: Health Care Policy and American Democracy

♪ (music) ♪
Introduction with many voices: This is Democracy- a podcast that explores the interracial, intergenerational, and intersectional unheard voices living in the world’s most influential democracy.
♪ (music) ♪
Jeremi: Welcome to our new episode of ‘This is Democracy.’ Today we’re discussing one of the most vexing issues and most important issues in our society today, healthcare. How can we improve on healthcare policy, what is the role of health in the democracy and what does it mean to have a healthy society and a healthy democracy. We have with us a friend [00:00:42] and I think one of the most interesting people working on these issues that I know Dr. Stephen Sonnenberg. Steve is a professor at the University of Texas. He’s a professor in about 17 different parts of the University. He is most famous among young people on campus for teaching in the Plan II program, but he also have affiliation with the medical school and various other parts of campus. He’s also a practicing psychiatrist which is the area of medicine that he has his degree in and he’s played a major role also in writing and thinking about health policy issues. Steve, welcome.
Steve: Well, thank you. It’s good to be here.
Jeremi: It’s good to have you on. Before we turn to our interview with Steve, we have of course a scene setting poem from Zachary. Zachary what’s the title of your poem today?
Zachary: “Dear Doctor”.
Jeremi: Dear Doctor, well let’s hear it.
Zachary: “Dear doctor, Dear nurse, dear every kind healing soul that ever tried to give me a flu shot, crying half naked running down the hallway of a Wisconsin Clinic of my youth. And to the time I forgot to fill out the medical form for school but I was the only kid to know his health insurance provider. Felt in myself pride serving a purpose higher than every waiting room magazine to every doctor, nurse, physician to everyone who ever felt my forehead, put on a cast, pulled up my shirt to reveal a rash. To all the times I had to step on a scale, stare into the light, drop your drawers, turn, cough twice to the right. Don’t forget your calcium, drink warm milk to go to sleep at night. All the shots hysterical, wanting to see them come. To every time I haven’t gotten the flu, hadn’t succumbed to the Black Death and fallen on the floor of the classroom. To every day that passes without the Chicken Pox, Measles, lying dead on the bed. To the last words that have never been said. To all the [00:02:23] beatings and cold rooms, nutritional readings. Bye, I hope to never see you again. Hold still look into my eyes and count to ten. All the times that I’ve stolen the doctor’s stools, sat there surrounded by bleak wallpaper waiting to give them my stool in bathrooms of cold tile so clean. You know it’s got to be dirty. Stare into the eye piece, look at the birdie and have a good day. But hey as long as I’m alive it’s a good day. So I just wrote to you doctor, I wanted to say. Thanks for everything you did today.”
Jeremi: That’s terrific Zachary. I love the mix of humor and various experiences in one’s life with doctors. What experiences are you recounting?
Zachary: Well, I’m just recounting like a child’s early relationship with medical institutions and dealing with doctors and nurses and like everyday things in your life that are supposed to keep you healthy and everyone works really hard to keep you healthy as a kid.
Jeremi: Right, right. And it’s nice that you thank doctors. Well Steve, as a doctor and a scholar of these issues, why is it so hard for our society to get this right? Why is it that democracy do we seem to constantly be spending more and more money and yet not really getting healthier as a society, what’s going on?
Steve: You know I didn’t know I was going to hear Zachary’s poem. But actually, Zachary I think your poem really prompts me to respond in a certain kind of way because it’s clear that you’ve given a lot of thought to healthcare. You haven’t taken it for granted. You’ve been very aware of your own body, of your own mind, of your own healthcare needs and of the relationship that you have had with many healthcare providers. And actually you know, I don’t think this is the entire answer. And if I hadn’t heard your poem I might not be responding this way. But actually I think you really bring into focus one of the core problems that we have in our culture which is that we really don’t think collectively and seriously and self-consciously about healthcare.
Jeremi: Right
Steve: The people who have it take it for granted. The people who don’t have it throw up their hands in despair and kind of say well I can’t ever get it. They get very sick, they go to an emergency room. Maybe they get help, maybe it’s too late for them to get help. But they don’t then embark on a course of leading a healthy life, thinking about health. I want to take this unexpected opportunity not because of the poem but because you Jeremi, you asked me to participate on this. You know I have thought for decades that one way to frame the entire work of our democracy is through the lens of healthcare. That if we recognize that our concern with health is a pervasive concern, it can really frame the way we think about a wide variety of things. So in the courses I teach about healthcare, two undergraduates and these are courses designed to actually teach people Zachary not much older than you are, what year in school are you now?
Zachary: Uh 8th grade.
Steve: 8th grade, well so the students next fall in six months I will be teaching students four years older than you are now, in their first semester in college. I will be trying to teach them about the doctor-patient relationship. And that relationship really can be seen as a mechanism for viewing a wide variety of activities that our democracy considers essential including by the way we think about violence. The way we think about war. The way we think about agriculture. The way we think about raising food. The way we think about dealing with all sorts of water supplies including the oceans and what’s in them. Healthcare really is a way of thinking about life in its deepest and broadest ways.
Jeremi: And if I understand this really insightful perspective, you’re making the argument also that a democracy is ultimately about the health of its citizens.
Steve: A democracy is about the health of its citizens, yes. And the health of its citizens taken as a collective, actually as a way of describing health as a democracy.
Jeremi: Why is that so hard? It seems intuitive, but as a historian, I think it’s quite clear that it’s never been how we’ve thought about our democracy. That’s not to trash our democracy but generally we prioritize issues like economic growth or international strength. Why do we not talk about it this way?
Steve: Well I’m going to start responding to that by saying I’ve thought about this a lot.
Jeremi: I know you have.
Steve: And I don’t know.
(Jeremi laughs) I really don’t know. You know I think we humans have a very complex relationship to a range of issues that include our bodies and the way we think about our bodies to our relationships and the way we think about our relationships and by the way relationships are an absolutely critical dimension of healthcare. The way we think about our mortality. The way we think about matters of spirituality and faith. And by the way in the courses that I teach, and these are courses that are designed to teach pre-healthcare students to give them the values and the perspectives that they’re going to need to be successful as healthcare providers.
Jeremi: Outstanding.
Steve: And to go through graduate school, professional school and provide good care. It’s also by the way, these courses are designed to teach our future leaders who will not go into healthcare but who will be in a position to influence the culture, the society and these are the people who may occupy public office. And create healthcare policy. And some of these people are one in the same. Some of the healthcare providers will also be leaders and advocates. I really try to include in this course, the relationship of spirituality in healthcare. Now I don’t do this from a perspective of a particular spiritual position. And I don’t reveal to my students what my personal convictions are about spirituality, about a higher power, about a particular faith system. But I really don’t think you can think clearly about healthcare unless you think in a holistic way about yourself. That is a very demanding thing. So to shift gears a little bit, I’m very impressed with your poem. And of course I know you’re family and I know that you’re getting a very superior education 24/7 times 365.
Jeremi: Maybe more than he wants. (Jeremi laughs)
Steve: Well maybe he says that to you sometimes, I’m not going to go there. But I’ll tell you what, not more than what he’ll be grateful he got when he grows up. And I really think it’s a matter of education. You know we have to teach citizens in our society, in our culture how to think about themselves, how to think about themselves as members of a collective. How to think about themselves in terms of democratic broad based responsibilities. And healthcare should be a critical part of that and we don’t do that. Now let me tell you about a conversation I happened to have last night with four other psychiatrists and everybody in that group is on Medicare. And I am ten years older than the rest of them. And we got to talking about our childhoods and we got to talking about our experiences in the boy scouts. And we have been meeting together every other month for about eight years.
Jeremi: Wow.
Steve: And we never realized this before but we were talking about growing up and it turned out that four of ours were very involved in the boy scouts and we were all Eagle scouts and not only that but we were in the brotherhood of cheerful service, the Boy Scout honor society. And I can remember being a boy scout and taking a first aid merit badge.
Jeremi: Right.
Steve: I can remember that high school of friends of mine and I was still active in boy scouts in high school. High school friends of mine were actually studying home economics which involved things like how to run a home they paid attention to nutrition. That paid attention to adequate sleep, to adequate exercise. So this was part of the culture and by the way it went along with another course that we used to get in my day in high school. Sometimes it was called civics. And sometimes it was called Problems in American Democracy.
Jeremi: Yes.
Steve: Well problems in American democracy went by the boards because some people thought were there are no problems in the democracy. (Jeremi laughs) We know this isn’t true.
Jeremi: Right.
Steve: And um, but these kinds of core values were taught when I was growing up and frankly I think by the time I got to college, I was prepared to be inspired by in particular three very very wonderful teachers in the humanities. One was an historian. One was a classicist. One was an English professor. Now I was doing pre-med, but I was encouraged to major in the humanities.
Jeremi: That’s wonderful.
Steve: Based on my earlier experience in the scouts I mean by the time I got to medical school I thought of myself as a purveyor of public health. I thought of myself as a public servant. I thought of myself as having a role to serve the democracy. And you didn’t know I was going to say this and you are probably not expecting this, and maybe it’s sounding too much like a sermon, but what I am saying is that this has to do ultimately with being able to provide good education, broad based for everybody. And I think everything in a democracy involves that. Now if we do that, and there is some emphasis on communal health, on broad based health, then I think people are going to be wiser in their political choices. They’re going to be wiser in demanding certain things from their public servants, from their elected officials, from the appointed officials. They’re going to be much more active. Now we did see that recently in the effort to appeal the Affordable Care Act. But it took a crisis to bring that out.
Jeremi: Right.
Steve: If in fact the polis, the people who make up our democracy and that’s what the democracy is. I mean it is the sum-total of all of us. If people were aware and were helped through their early education to be aware of how central health is to everything and how the healthcare providers role is very pervasive. We would have a much better healthcare system. Let me give you one more example. Right now the most, the largest purveyor of mental healthcare in the United States are jails and prisons. Jails and prisons are not equipped to do this. The healthcare providers there are not equipped to this. The facilities they have, not just the knowledge but the staff, the facilities I mean they can’t possibly meet these needs. You can’t possibly meet the needs of an addicted population that some people are beginning to think don’t belong in jail anyway. But an addicted population who come into jail who are involved in bringing drugs into the jails through a kind of secret black market. Who are not having the causes of their addiction treated. And by the way some of those causes are psycho-social and not just biological.
Jeremi: Right of course.
Steve: So this is, this is just a tragedy.
Jeremi: Sure.
Steve: And we could save money, provide better care, if we not only recognized the tragedy. Many people do, but actually actively try to do something about it. But then what happens well you know the advances could be made get hung up on for example political considerations and now I’m going to give another current example. And that’s Willie Horton.
Jeremi: Oh, George H.W. Bush fan?
Steve: Now I actually was very moved by what happened in the last couple of weeks and I think Bush was a good man. I also think he was co-opted by a political system that encouraged narrow minded thinking.
Jeremi: Right, so you’re referring to the political advertisements in 1988 that then candidate George H.W. Bush ran which basically highlighted this figure of Willie Horton who was an African American who had been released on Furlough from prison who then committed another crime. He blamed then governor Dukakis of Massachusetts for this. That was his opponent in the presidential race.
Steve: Yeah, now. Think about the ripple effect of the Willie Horton episode. It keeps people in jail. It leaves its mark on the culture. There’s a ripple effect, there’s a trickling effect outward and we really don’t have easy ways to measure this, but political diatribes like that actually prevent us from recognizing that we have healthcare tragedy in our jails and prisons, a mental health healthcare tragedy. It encourages people to be fearful and to advocate spending wasting huge amounts of money and basically not remedying what is not simply a penal system problem, but a healthcare problem.
Jeremi: But Steve, I agree but I’m not sure that it’s a problem that people don’t know about. And it’s also an old problem right. Decades ago we had mental–you know public run mental health hospitals that were sort of like prisons in many ways and before that we had the experience of slavery and convict labor. Is part of the problem that even those who were thought to think about healthy lifestyles and healthy communities are not taught to care about these groups?
Steve: Well I think that one of the–this in a way what I’m going to say now is speculative on my part. I think it’s beyond my expertise. It’s not beyond my imagination. (Jeremi laughs) I don’t think we are living in a democracy where people are encouraged to think generously. I think people are encouraged to think really about their own concerns that they will not be enough for them.
Jeremi: Well the ways in which many people expound the work of Ayn Rand and others and Ayn Rand’s–one of her most famous books is called ‘The Virtue of Selfishness.’ And that would seem to make your point if people arguing for selfishness.
Steve: Yep, yep. And you know when Obama was president, and he was trying to enact the Affordable Care Act, there was kind of an interesting troupe that emerged the opponents of the act, parenthetically the opponents of the act who were republicans and represented at least traditionally people who were more economically advantaged than the base of the Democratic Party. These people were warning against a rationing of healthcare. They were creating fears that healthcare had to be rationed and the Affordable Care Act was going to usher that in that they were basically going to be death squads determining what all people could get what care. And I think that again, that speaks to something very fundamental in the warp and woof of our democracy. That we seem to have lost sight of the fact that at its core democracy promises to provide the most for the most.
Jeremi: Yes.
Steve: It’s the best system, it’s not perfect but it’s the best system that human beings have ever invented to create plenty for everybody. And potentially it could. That doesn’t mean that we don’t have to make difficult choices and when I say plenty I don’t mean everything that everybody wants. Now, I don’t want again to exceed my expertise here, but why does anybody have to make a billion dollars or accumulate billions of dollars?
Jeremi: Right, and it seems fully in line and in fact appropriate in a democracy that when we have unlimited needs, and limited resources that choices are made about allocating resources and it does seem to me that any functioning healthcare system in today’s day and age where healthcare is often so expensive surgeries, et cetera is going to have to make those choices. To some extent, there’s going to have to be rationing as there was rationing during World War II. As we rationed many other things in our society.
Steve: Well so now I’m going to reveal how radical a thinker I am about that.
Jeremi: Good.
Steve: I think we have to make wise decisions with the provision of care. I think we need to fundamentally reorder our priorities. Now if we recognize that you can view healthcare as a core theme that directs the activities of democracy as an in a sense something at the very core, at the heart of a democracy–then we begin to re prioritize the way we spend our money and parenthetically the way we tax our people. So I do no buy into the notion that we can’t do as much as is appropriate and necessary to promote the health of the entire population to eradicate bad nutrition, to encourage good exercise, to encourage a healthy life. You know only 20% of health is what goes on in a doctor’s office. 80% is structural. These are determinants that exist more broadly in the culture. I think if we really thought carefully about it, and if we thought ethically about it and I’m not just talking about medical ethics, now I’m talking about broad based ethics, Bill of Rights ethics, Constitution of the United States ethics. United Nations ethics concerning the healthcare as a human right. If we thought in a broad based way about that, I think we really could do it all.
Jeremi: Absolutely. Absolutely. So we always like to close Steve with an optimistic call to action because our listeners are the young leaders of tomorrow in many cases. So you spend a lot of time working with young people on these issues as you’ve referred to so eloquently. What really should young people be doing? How can they help make our society a healthier society?
Steve: Well you know it’s funny you should ask that because I think a lot about this. One of my few college classmates who isn’t retired, I graduated in college in 1961 and I was 21 years old. I mean wasn’t 12 years old or something.
(Jeremi laughs)
Jeremi: So you’ve certainly, you’re a model of health Steve.
Steve: I, well one might say that and my fingers are crossed but you know I’m going to be 79 in March and I have no plans to retire.
Jeremi: Good.
Steve: I really think what we have to do is educate young people. I mean you could say that the courses I teach at the University of Texas and the program I’m developing, with by the way the assistance of the National Endowment for the Humanities and the very strong support of the school of undergraduate studies as well as the College of Liberal Arts and Plan II and the Medical school. I mean these programs are really you know, they’re civics through a healthcare lens. And I really think again, I’m going to come back to education I think we need to do this. I think there should be courses on the doctor-patient relationship in high schools. I think there should be courses on health in elementary schools. I think along with natural childbirth classes, there should be courses on infant health. On maternal health and on parental health. Now let’s take internal health that is a subject that has gotten so caught up in a political debate. I have by the way great respect for all positions in the issue of abortion. I don’t dismiss any position about that. I think that again we really need to understand different faith systems. It’s all very important. But I think we get caught up in the small stuff. And I’m going to say in a sense the abortion debate is small stuff compared to maternal infantile.
Jeremi: Absolutely.
Steve: So I do think it’s about education and that’s why I hope I can continue to teach. By the way let me say, some of the students I’m teaching are going to become teachers themselves. And some of them are going to teach in high schools and some of them are going to teach in elementary schools.
Jeremi: Well and many of them will be community leaders and they can make this a priority. I think what I’m hearing you say is we need to stop taking health for granted or ignoring it and actually make it a number one issue. It is embarrassing that the United States as a whole and in particular in Texas, maternal health numbers are worse than they are in most other parts of the world. And that’s unacceptable and yet we don’t talk about that. This is terrific. Zachary, you actually had a health class in school right? Actually you guys have done some health. Are the things that Steve says, the excellent suggestions he makes–are they things happening? How can young people be better educated about these issues? What are your thoughts?
Zachary: I don’t know. I’ve never really taken a full health course like all year. But I’ve taken units on health. I think part of it is, it’s really not made to be that exciting as it’s often taught as history often is out of the textbook, on a screen. And I think to make it more meaningful to children it should be–you need to find teachers who are more passionate about the subject but also make it less about memorization and learning. But I think we do a good job about teaching kids about nutrition and health from a young age. So from the time I was like in Kindergarten and first grade we were learning about the body and nutrition in P.E. class. And so I do think we do a good job.
Jeremi: But do you think we need to do more of it?
Zachary: I think we need to do more of it in a better fashion that makes it more amenable to kids.
Steve: Can I say one more thing?
Jeremi: Please, Steve.
Steve: You know I talk to my students about scope of practice and I try to convince them that what I’m doing at the university is part of my scope of practice. It’s just as much a part of my scope of practice. If I were a surgeon, as doing an operation. I think one thing that would really be very useful is if actual healthcare providers, ones who were passionate came in and did some of that teaching. So I’m going to ask you a question. I don’t want to embarrass your father who invited me to do this, but when I was speaking did you experience the passion in what I was feeling and what I was saying?
Zachary: I think so, yeah.
Steve: Would–I’m putting you on the spot. I mean would that have been useful to you in the classroom.
Zachary: Yeah, I think hearing from–and hearing from professionals is always helpful and when it happens at school I think it creates more interest in the subject.
Jeremi: Well the worse thing in education is when something becomes routinized. Because something that’s routinized that sends a message that it’s not important. I think it’s the passion but also the connection to everyday life and that’s what you do so well Steve and that’s what we need to have more of. I think today’s episode has really made it clear that when we talk about health policy, we had to do much more than debate provisions of the Affordable Care Act. We have to have a more fundamental conversation about what a healthy society looks like, what health citizenship is. And I’m confident that young people think about that quite a lot. The choices that millennials make about where to go work now look different from their parents, about where to live. Many people live in cities like Austin because they like the healthy lifestyle that they perceive there. So maybe we’re moving in the right direction but I think today’s show should inspire us all. Not simply to educate, but also to talk about these issues on a daily basis. And that is why we’re here today and that is why this is “This is Democracy.”
♪ (music) ♪
Speaker 8: This podcast is produced by the Liberal Arts Development Studio and the College of Liberal Arts at the University of Texas at Austin.
Speaker 9: The music in this episode was written and recorded by Harrison Lunkey and you can find his music at HarrisonLunkey.com.
Speaker 10: Subscribe and stay tuned for a new episode every Thursday, featuring new perspectives on democracy.
♪ (music) ♪