- Democrats and Republicans don't agree on much.

Generally speaking, they don't agree on healthcare policy.

Today's guests document those divisions in a new book and leave us with a richer understanding of what animates the two parties and their thinking on these important policies.

They are Robert Hackey and Todd Olszewski, this week on Story in the Public Square.

(upbeat music) Hello, and welcome to Story in the Public Square, where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller with the Providence Journal.

- This week, we're joined by Robert Hackey and Todd Olszewski, two professors of health policy at Providence College who are also co-authors of a new book, "Today's Health Care Issues Democrats and Republicans."

Gentlemen, thank you so much for being with us.

- Thanks for having us.

- Thank you.

- We want to get into the book and we were really fascinated by the approach because, unlike a lot of authors, you're sort of presenting both sides.

But Bob, tell us in your own words, what's the book about?

- So Jim, the book is about contested health policy issues.

We're trying to introduce the public, and our audience is really an informed reader, but not an expert.

So we're trying to make a resource available for folks who are taking this book out of public libraries or for students and faculty at college and university libraries to learn more about the health policy debates, and these were intentionally partisan.

And so what we're trying to do is to educate folks about where the two sides are coming from.

Our approach is to let the voices speak for themselves.

So we have democratic perspectives, Republican perspectives, but we don't endorse a particular position.

Our mission is to try to help folks understand where the two parties are coming from.

- So Todd, beyond the idea that the publisher came and asked you to do this, why this book, why now?

- I think the answer to that is why not?

Given that we are sort of in a time of political polarization, the book provides us an opportunity to examine partisan rhetoric and policy-making in the present day, to be able to capture what politicians and policymakers are saying and doing right now, at least with respect to healthcare and health policy, and then to put those actions into historical context.

- So Bob, we're gonna get into specific issues as we get a little further into the show, but just broadly speaking, can you outline the positions held now on health policy by Democrats and then also by Republicans?

Wayne, I think one of the fundamental questions that we explore in this book and which is really evident in each of the chapters, is what role government should play in the healthcare system.

That's really a fundamental divide here.

And the two parties come down on very different sides.

For Democrats, a larger, more involved approach to both regulation and focusing on issues such as equity is really important in pretty much all of these policy domains, and Democrats tend to view government as more of a benevolent problem-solver, and look to government for solving important health policy problems.

Republicans in contrast, tend to view government as a threat to liberty.

And we see that in most of these chapters as well.

And so we're seeing a real tension here, which really speaks to this particular moment we find ourselves in, where it's really difficult to forge consensus.

The parties are coming out of these very difficult issues, whether it's questions of reproductive healthcare, the Affordable Care Act, vaccination, from fundamentally different value positions.

And I think that's one of the things we're hoping to do is to educate readers about the foundations and the origins of those differences.

- So to Todd.

- Oh, sorry.

- No, go ahead Todd.

- I was gonna add to sort of Bob's point.

One of the key questions will be whether the government will occupy a more central role in addressing perceived shortcomings of our healthcare system and drive healthcare reform, or will the private sector occupy that position.

- So Republicans oppose the Affordable Care Act, AKA Obamacare, obviously, what else do they want?

Where else do they stand in terms of healthcare policy in the year 2021?

- So I think, if you look back at the Trump administration, you started to see some elements of this emerging.

President Trump never offered a comprehensive alternative to the Affordable Care Act.

In fact, Republicans were more united in opposition to the ACA than kind of in support of a common framework.

We saw that in their attempts to repeal the ACA in 2017, which failed, but certainly the emphasis on pricing transparency really underscores the point that Todd made.

A greater emphasis on markets, a greater emphasis on individual responsibility for health, as opposed to collective responsibility for health.

And so this notion is, government has a role but it's really limited to trying to ensure that there is a functioning level of competition in the marketplace.

And that healthcare is essentially like other goods and services.

Democrats view it fundamentally as a different thing, it's not like other goods.

And Democrats argue that in many cases, it should be removed from the market, that your individual ability to pay, your notion of shopping as a consumer, shouldn't drive your use of healthcare services.

- So that - Go ahead.

- No, that really drives to an issue of whether healthcare is a right, which is certainly the case in many other countries, or a commodity.

And you have an entire chapter on this.

So I guess maybe Todd, you can take this question.

Do you come down on one side of the other or not, in terms of your book?

- This is a really good question.

And it's an important enough question that we actually have two chapters devoted to it in the book.

We have the sort of healthcare is a right or commodity chapter, which I authored.

And then Bob co-authored a single payer system chapter.

And I think the real question here as to whether or not healthcare is a basic human right or not drives many of the responses, many of the party responses to many of the chapter topics throughout the book.

And universal coverage as a policy goal or as a specter of government overreach is perhaps the perfect extension of this debate as to whether healthcare is a universal human right to be protected, and to be protected by the government, or if it's something else, if it's more of a commodity, a market good, and the government has a slightly different kind of role in moving that forward within our system.

- Todd, as a student of history, do you recognize other periods in American history where two parties, the two parties, Democrats, Republicans in the modern era have been so fundamentally at odds with the underlying values and principles that they bring to the healthcare debate?

Or is this, are we in completely untried territory today?

- It's neither old nor new.

The parties have disagreed on many fundamental issues for a significant period of time.

The single payer question has been debated since the 1920s and 1930s.

The gun rights question has been debated for perhaps just as long, maybe moreso the post-World war II America.

So I think we feel as if it is needed.

We are living this in real time and we are seeing the rhetoric become increasingly heated.

So we feel as if this is something that is new, but I think throughout the course of our book, throughout all the chapters, we see that many of these partisan tensions aren't quite as new as we think them to be.

- Bob, I remember your earlier research on "Cries of Crisis," and that's something that both parties have embraced is that the American healthcare is fundamentally broken.

Is there a brighter future where we might actually get something done or are the parties gonna hold onto these divisions as a way of turning out their voters in contested elections?

- I do think that's a key factor, Jim.

I would also say to kind of echo Todd's point, everything old is new again.

We've been talking about the need for healthcare reform for more than a century in this country.

We really go back to the progressive era with Teddy Roosevelt and the first decades of the 20th century here.

And partisan discord has been the norm, not the exception.

So I think that's an important thing.

And I did want to circle back to Wayne's question because I think much of the partisan discord really does focus on whether this is a right or not.

And if so, how much of a right to care we have.

And I think the challenging thing in the U.S., and this is one of the biggest issues we face, the answer is both to Wayne's question.

We view healthcare as both a right and a commodity.

And I think in the current U.S. context, it's really challenging because healthcare represents one out of every 6 dollars in our economy.

It's a multi-trillion dollar industry.

And there are huge stakes as we start to undertake reform.

This is a very crowded interscript space.

Everybody who is affected, whether it's pharmaceutical manufacturers, whether it's medical laboratories, hospitals, doctors, patients, insurers, everybody is worried about what reform means for them.

And so when we talk about healthcare as a right in this country, we have in principle endorsed that.

And we actually have legislation.

We have something called EMTALA, the Emergency Medical Treatment and Active Labor Act which passed back in the 1980s.

This is the law that says that hospitals can't turn you away if you present yourself at the emergency room, that you must be cared for and stabilized.

But we haven't extended that.

And then if you look at other countries, many of our EU competitors, the right to healthcare is enshrined in the Constitution as kind of a positive right.

And here in the U.S. we have not done that.

And I think that is a challenge for us as we start to struggle with this question here in 2021 of where do we go?

Can we do Medicare for all?

How expansive do we want the role of government to be?

Lurking in the background is this huge overlay of an industry that employs millions of Americans and it touches all of us.

And when you start to reform it, it can have significant consequences for all of us.

- And of course, that industry has many lobbyists in Washington and state capitals as well.

But Bob, I have another question here.

Obviously there's a significant political divide between Democrats and Republicans, and many residents belong to one party or the other, but what does polling or other research tell us about the American people looking past the partisan divide?

Is there any sense of what the American people want or what percentage of people would like a national plan or not?

Just elaborate on that If you can and then maybe Todd, you can, after Bob speaks, weigh in as well.

- Yeah, for sure Wayne.

As so on the one hand, and again, I think this is the divide we face.

When you ask the American public, and we've done so for decades, do you support the notion that healthcare should be available to all Americans?

In principle, people say yes.

And a solid majority of the country will come down in favor of that.

When you ask a more nuanced question, which is essentially, would you be willing to pay an extra a hundred dollars a month to ensure that all Americans have access to healthcare, or are you willing to limit your choice of providers, if necessary, to make sure that all Americans have access to healthcare.

And once we get into the weeds, in other words, support drops precipitously.

And I think that we saw that before the Affordable Care Act.

We see that now.

Polling on Medicare for all suggest that certainly Americans are, in principle, are supportive of universal coverage, but they don't want any of the circumstances in which they access healthcare to change.

That's not terribly realistic.

- [Jim] Todd, do you want to add to that?

- I would move it in a slightly different direction in terms of thinking about our current experience with the pandemic and thinking about sort of the COVID-19 pandemic, because the degree to which sort of Bob's points really capture quite well, this political reality.

We also are experiencing this moment where we see the ways in which political polarization is having a direct impact on public health in the United States, and the ways in which Democrats and Republicans have disagreed at almost every juncture during the pandemic from the very beginning, whether about the origins of the disease, its severity, its name, and even the pandemic responses that we've all experienced over the last 18 months with respect to stay at home orders, masks mandates, vaccine mandates.

So it's almost as if with all of this taken together, the one's political identity defines sort of how you perceive the pandemic, and how you even conduct your life during the pandemic.

- This is something we chatted about yesterday when we did our little pre-interview, I find myself struggling.

You guys present such a wonderfully balanced approach to what the policy prescriptions of Democrats and Republicans are, that it's really a useful explanation of that terrain.

But what I find myself struggling with, and this may reveal my own bias, is that it feels to me, particularly around issues around the pandemic, that so much of the Republican party has bought into ideology over science, that I have a hard time taking them seriously when we're talking about mask policies and mask mandates and vaccines.

The amount of disinformation that has been pumped out of prominent Republican, either commentators or politicians, really sort of belies any seriousness in my mind on anything having to do with healthcare.

Am I completely out of bounds on that?

- Yeah, Jim, I don't think you're out of bounds on that.

But I do think that that underscores the divide we're seeing here in the U.S.

I mean, I think one of the things I look back at, before the election, the midterm elections in 2018, the Pew Research Foundation did some wonderful polling and they did the same thing again in 2020, asking people how they thought of the other party.

And one of the things I think is really telling for us at this particular moment.

The survey Pew did in 2020 asked Democratic and Republican supporters of president Trump and Joe Biden how they would feel if the other side won, and more than 90% of Democrats felt that the country would face real fundamental kind of dangers if the opposition party won.

And Republicans felt the same way.

And I think one of the biggest challenges here that we're facing is trying to reason together.

Now Lyndon Johnson had a wonderful phrase, Come, let us reason together, in terms of working out solutions to policy issues.

There's a lot of heat and not a lot of light happening in Washington.

So to your point, I don't think in many cases Republicans are interested in finding that middle ground.

I do think they perceive these policies, whether it's a mask mandate, a lockdown, social distancing requirements, they see them as a fundamental overreach of government.

What I think is so telling about this era is I often think back, when we're having these conversations about COVID, to the 1950s, when we were trying to defeat polio, and Jonas Salk and his colleagues introduced the polio vaccine.

The amount of rancor that we see with this vaccine is so different.

And it's infused with just partisanship.

Many people are willing to have other vaccines and don't question the validity of science that a polio vaccine works, that a MMR vaccine works.

But when you introduce the COVID vaccine, that's a bridge too far.

And I think that speaks to the moment we're in.

And science and politics are, for better or worse, at this juncture, fused.

I wish I had a solution for that.

I'm gonna have to beg off on that one because I don't.

I think one of our biggest challenges here is, frankly, the loss of confidence in science.

- So Bob, is there any way really to address that?

We've we recently had on the show, someone I'm sure you know, Dr. Ashish Jha.

He's the dean of Brown University School of Public Health, and he's one of the nation's and indeed the planet's top pandemic experts and researchers.

And so the question really is why, given even the political circumstances of today, why do not more people place their trust in science?

I mean, you gave great examples historically of where science quote unquote saved the day.

I mean, literally, for many people did.

Why has this happened?

Do you know the factors behind it?

A and B, do you have any hope it can be changed?

And how might it be changed?

A lot of questions there, I realize, but maybe you can take a crack at it, and then maybe Todd can.

- Yeah, I think Todd's gonna bring a more historical perspective.

As a historian of science, I think he will bring some things to the plate that I won't.

I think one of the things for me, it's not just confined to the U.S. We're seeing similar discussions in Europe, not to the same extent, but this challenging of scientific orthodoxy is happening.

And I don't fully understand all of the reasons behind that, except that we have a really difficult political and media culture at this juncture.

I've been reading some interesting stuff about how we try to educate folks on social media.

And one of the remarkable things that seems to be occurring is that when public health officials post clarifications or comments on various sites, whether it's Facebook or Instagram or Twitter, to say, let me clarify this concern, what is really driving a lot of the misinformation is the comments sections in response to those posts.

So you essentially, you have one kind of evidence-based public health post, and then you have hundreds, if not thousands of people piling on in the comments section attacking, and offering alternative sources of evidence.

I think the availability of alternative sources of evidence, AKA quackery, for lack of a better phrase, is greater than ever before.

I think it's remarkable that folks are using medicines that were designed to treat horses in an effort to ward off COVID.

There's no scientific basis for that.

And yet we see not only millions of Americans kind of entertaining alternative perspectives, but people actually now organizing groups to try to figure out how to self dose.

Veterinary medicine as an approach to treating COVID.

That's a brave new world.

I'm not quite sure how we went down this rabbit hole.

And I think that, before I pass the Baton to Todd, I will say this.

Confidence in American institutions, in general, as you guys probably are well aware, has declined precipitously since the 1960s.

That includes government, it includes the media, it includes professional medicine, all sorts of groups, law, et cetera.

We've seen a steady decline in public trust and support for various institutions.

I think science is not immune to that.

- So Todd, you're take on this.

- I would second everything Bob said almost entirely.

Social media and the internet has given more Americans wider access to more information.

The question is, to what degree is that information veritable and verifiable?

The truth.

And I think that, taken alongside the fact that COVID denialism is part of sort of a longer historical trend.

If we think about the climate change debate.

If we think about sort of the history of tobacco and cigarettes, we see many of these same tensions between entrenched interests and sort of public health and public knowledge.

And I think we're seeing that sort of rise again, in the case of COVID, especially with respect to the vaccine, the trust or distrust in pharma and what that means for the public's perception to the vaccine.

- We've got about two minutes left here, and we could spend an entire episode talking about this, but let's talk a little bit about women's reproductive health.

A cynic would have you believe that the parties sort of adopted a stasis in the politics of abortion access as a way of mobilizing their bases.

And they never were gonna go much further to break that stale mate because that would be bad for their politics.

Texas, however, has taken that step.

Where do you come down on this?

Is there a middle ground to be had on women's reproductive health issues between the two parties?

Or is this a divide that will never be bridged?

Todd, why don't we start with you?

- I sense that this is a bridge that we will never be able to divide.

I think the notion of women's rights playing out alongside fetal rights is still deeply entrenched, has both religious and political underpinnings very much along the lines of much of the conversation we've already had.

We have two sides that have fundamentally different sets of values and principles and perceptions of what the government should or should not do in terms of regulating health behaviors or defining what constitutes health care right or not.

I believe we will always be on fundamentally different sides.

- Bob, in about the 45 seconds we've got left, we're about a year away from the 2022 midterm elections.

What role do you think healthcare plays in that debate next year?

- I think it plays a huge role, Jim.

I think, first of all, COVID is going to continue to loom large in the 2022 elections.

To the extent to which COVID remains a continually present factor for us if we don't substantially increase vaccination rates, if we continue to have high rates of transmission, that is gonna directly affect the American economy.

And one of the interesting things here is we're seeing kind of a divergence.

So for many democratic states where vaccination rates are high, and vaccination rates and party membership, party affiliation track very closely, COVID is a significant challenge, but it's not reaching the levels we're seeing in states, like for example, Alaska and Idaho, where you have, and certainly many states in the deep south where we have low vaccination rates, high rates of transmission among the unvaccinated, we're really kind of seeing two Americas on this front, kind of moving in very different directions.

But that's gonna have an impact on the election.

- That, I'm sorry to say, is where we've got to leave it, Bob.

Bob Hackey, Todd Olszewski.

This was a phenomenal conversation.

The book is important.

"Today's Health Care Issues, Democrats and Republicans."

Thank you for being with us.

That's all the time we have this week.

If you want to know more about Story in the Public Square, you can find us on Facebook and Twitter, or visit Pellcenter.org For Wayne, I'm Jim, asking you to join us again next time for more Story in the Public Square.

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