Jon Wiener, host: From The Nation magazine, this is Start Making Sense–I’m Jon Wiener.  Later in the show: doctors these days are caught between caught between the Hippocratic oath–“first, do no harm” — and the realities of making a profit from people at their sickest and most vulnerable.  Eyal Press will report on that — and on the ways doctors are fighting back against profit-making health care.

But first: How can Democrats win back white working class swing voters?
we  have some striking new research about that.  Katie Rader will explain – in a minute.

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Jon Wiener, host: 60 per cent of American voters do not have a four-year college degree, and they live disproportionately in swing states. Some of them have abandoned the Democrats and have been voting for Trump, others haven’t been voting at all. How can the Democrats win them back?

There’s some important new research on that. For a report, we turned to Katie Rader. She teaches political science at Christopher Newport University in Newport News, Virginia, and she’s a board member of the Center for Working-Class Politics. She recently worked for Senator Ron Wyden in the Senate Finance Committee as a congressional fellow, and she’s the author of an important new article at thenation.com: How Democrats Can Win Workers, co-authored by Carissa Guadron.  We reached her today in Virginia. Katie Rader, welcome to the program.

Katie Rader, guest:  Thank you, Jon. It’s great to be here. Thanks for having me.

JW:  This study, done by Jacobin, YouGov, and the Center for Working-Class Politics, where you’re on the board, had a great method. Instead of asking people whether they preferred Biden or Trump, the poll described a pair of hypothetical candidates, each with a biography and a campaign platform and asked respondents which one they preferred. And the respondents were not eligible voters or registered voters, they were working-class swing voters and what the scientists called low-propensity voters, non-voters, we call them.

Democrats don’t need to win over all the working-class Trump supporters, if they just get some swing voters to swing back and get some non-voters to vote Democratic, that would be enough to win. And if Biden wins 50% of the non-college vote next year, he will almost certainly be reelected we are told. And if he wins only 45%, he will probably lose.

And there’s one more relevant thing here, Progressives have won a lot since Bernie’s 2016 campaign, but those victories have been concentrated in the well-educated, relatively high income and heavily Democratic districts. Even when Progressives have won primaries in working class areas, they’ve generally done so without increasing total turnout or winning over new working-class voters, which has been one of the Progressive goals going way back, especially with Bernie. So overall, Progressives have not yet made good on that one key goal to transform and expand the electorate significantly.

So this research project was one of yours. What did you focus on?

KR: What we’re trying to do in this research, and all of our research, is approximate real scenarios. And we’re also interested in congressional races, not to say presidential politics isn’t important, but for exacting a lot of things we want, things we want to see and win, that means winning Congress and getting particularly a majority in the Senate. But we were really interested in comparing more moderate positions and talking points to more progressive policies. And it gets reinforced by centrist members of the Democratic Coalition, that to win, especially in purple states, in swing states and working-class districts, you need to run to the middle. You need moderate policies, you need to moderate, they say, but we have not found that to be the case.

JW:  Let’s talk about the survey findings about messaging. What kind of issues did you find working-class voters prefer?

KR: The biggest takeaway, if we could have just one message to deliver to Democrats: it’s jobs. Running on jobs, running with populist rhetoric around jobs policies–those are really popular. So we had two different jobs policies. We looked at the more moderate position, which was incentivizing small businesses to create jobs or provide job training programs. And the other was a federal jobs guarantee. Now both of those, those jobs policies, across everything we looked at, we had another list of economic policies, we had some social policies, it was those jobs policies that were most popular. Both moderate and progressive position were popular across the board.

We saw some pretty fascinating class divisions as well: the jobs guarantee was really popular with working-class respondents, not just Democratic respondents, but also Republicans and Independents, which we think is really, really important and really fascinating.  It was not as popular among higher class respondents. Another thing we tried to do in the survey was really pick apart and look at the class profile of respondents and capture that in different ways.

JW:  So a federal jobs guarantee you found to be kind of the number one issue that appealed to working-class swing voters and working-class low-propensity voters. But don’t Democrats already know the power of jobs as an issue? Don’t most Democrats run on jobs?

KR: You might think so, but if we are looking at candidates, what they said, particularly in the 2022 primaries, only about 18 per cent really talked about jobs in a concrete way. And candidate websites, those are open spaces, they can include the kitchen sink on there, when it actually gets to what kind of policies they’re going to put their weight behind and push forward, which, was another thing we looked at in the article, despite the sort of, I think in many ways, surprising popularity of a jobs guarantee, given that it’s not something we hear Democratic candidates talk about very often, yet it’s striking that it’s so popular. The closest you get in Congress are pilot programs trying to create possible job training for similar types of activities.

So yes, Democrats talk about jobs, but also they could be talking about them much, much more given, I think, what we know about the history of the party and the working class backbone and the popularity of these messages.

So we have another survey coming out, another report coming out soon, where we broke down, we looked at things like job training, more of a moderate-type program, ending bad trade deals. So thinking about manufacturing, deals like NAFTA, $15 minimum wage, looking at the package of policies included in the PRO Act, the right to unionize, increased protections for gig workers and also incentivizing job creation within manufacturing.

Now, all of those, basically, this is a little preview of what’s coming out, but all of those had basically majority support. You start to lose some Republicans as you raise the minimum wage. We looked at 15, we looked at 17, but basically all of those have majority support, including those more progressive. I picked out… What did I pick out? Providing more protections for gay workers, that was in the sixties, between 60 and 70% support among Democrats and Republicans. So Democrats don’t talk about it enough and they could talk about it more. And in very concrete terms that appealed to particularly working-class voters.

JW:  Your research found federal jobs guarantee had the number one, most positive response among working-class swing voters. Does this mean that Democrats need to stop talking about racism if they want to win back or mobilize working-class white voters?

KR: No. Talking about racism, talking about the importance of addressing inequality, does not hurt candidates.  But we did find, in that first survey, that if that is the lead and most prominent issue the candidates are focusing on, sometimes that can detract.  But including a commitment to racial justice on their platform–that does not hurt those candidates.

JW:  What you’re finding here is that the key issue is how politicians frame and discuss racial justice. If they make their number one goal ending systematic racism, they will not win new white working-class voters. If the centerpiece of their campaign is bread and butter economics and they also call for ending systematic racism, they do fine.  Have I got that right?

KR: Yes, that’s what our initial survey indicated.

JW:  And there were some other fascinating findings. Voters liked Democrats who criticize both political parties as out of touch, swing voters like tough populous messages like, “Americans who work for a living are being betrayed by super rich elites.” But there was one finding in your research that really disturbed me. The single most effective message in the poll was, “Protect the border,” and you found decriminalization of the border was very unpopular. So how do you explain the success of Republicans in making “Protect the Border” the number one message for these working-class swing voters we’d like to reach?

KR: Yeah, this is another tough issue where I think I could unpack what we see as the findings from this survey. I think one basic answer to your question is Republicans are talking about immigration much more actively and putting forward solutions more so than Democrats. So part of it is Democrats are, I think, much more divided within the coalition about the kinds of policies. Now, the other missing policy proposal from our survey, because we wanted to compare a more moderate centrist position to a more progressive, was looking at protecting our border, I think the language of our soundbite was something along the lines of “border infrastructure.”

So “revamping our border infrastructure system” versus “decriminalizing immigration and providing avenues for asylum.” We wanted to compare those moderate and progressive policies, but there’s sort of a middle ground also, “pathways to citizenship.”  There’s a similarly-oriented survey that came out by the Global Strategy Group. They’re similar in looking at swing-state voters and trying to understand this. 82% across their survey found Democrats and Republicans see the immigration system as broken, want some kind of policy fix. And among them, border of security, but also pathways to citizenship are both popular. So I don’t think it’s quite as grim finding, part of it is how we set this up in that comparison. But I think the other underscore is this is an issue Democrats need to figure out how they want to address because it is something that is really seen as a major issue facing the country.

JW:  Of course Bernie Sanders has been emphasizing bread and butter economic issues and attacking the billionaires for his entire career. Who else among the Democrats provides models of how to do this kind of politics, especially coming up in 2024?

KR: Two of my colleagues at the Center for Working-Class Politics just put out a great piece that I would highly recommend, talking about why we need more Matt Cartwright. So you may not know his name–

JW:  I do not.

KR: I know a little bit because I lived in Philly. He’s a member of the House of Representatives from Scranton, Pennsylvania, and he has now won a Democratic seat in a pretty heavily Trump district for the last two election cycles. He had a pretty tough challenger last time, and he is someone who’s basically doing the kinds of things our results are pointing to as being effective. He’s not shying away from progressive economic policies. He focuses on jobs, he focuses on bad trade deals and he puts things in really working-class terms. But he’s winning in a Trump district and a really working-class district. So he’s a person that we think is kind of doing this and he’s part of this battle within the Democratic Party. He was up for a leadership messaging position against Abigail Spanberger, a member from my state here in Virginia, around this very question, what is it going to take to win these districts? Spanberger ultimately prevailed. We think that the kinds of policies, positions and approaches someone like Cartwright is taking are really, really promising.

JW:  It seems like a federal jobs guarantee is not at the forefront of Democratic Party messaging this year.  But a $15 national minimum wage is something that our members in the House and Senate have been talking about. Is that a close enough approximation to make it for a potent issue in 2024?

KR: Yes, Democrats should be running on a $15 minimum wage. I do think it’s a very different policy than a jobs guarantee. And one of the questions I have for future research for us is federal jobs guarantee is such a popular position, but what do people think that that means? When they’re saying that, “I want this.” Is it, “Oh, I think this means I get a job, I get a better job.” This is not a new trend.  We look at A. Philip Randolph in the ’40s, one of my favorite civil rights and labor figures from the 20th century, and see that this has been a pretty popular policy for the last 80 years. But I don’t think we have a good idea of what people think that means. Basically, a guarantee of a job, a job that is with dignity, provides you with a living wage. So yeah, seeing the $15 minimum wage as a piece of that, absolutely.

JW:  There’s one other person on the political scene who has been talking the kind of talk you recommend, and that’s Joe Biden. He always emphasizes his working-class background in Scranton, and he spoke at the AFL-CIO convention in Philadelphia last week. Here’s a few quotes. “Wall Street didn’t build America, you did.” And he added, “If the investment bankers of this country went on strike tomorrow, no one would notice, but if you didn’t show up for work tomorrow, the whole country would come to a grinding halt. So tell me, who matters more in America?” And then he added, “Now Republicans are coming for your jobs, they’re coming for your future.” So it seems like Biden kind of understands what your group has been talking about.

KR: He definitely does. I think that’s some of the language that we should see, and I think there’s lots of ways that for us, Progressives, us on the left, Biden has been a surprise in some really good ways considering what we may have been expecting. Now I will say though, we have examples from the last six months too. He did sort of weigh in and strong-arm Congress into forcing a deal and basically breaking a strike among railway workers who were among many things, trying to have adequate protections and sick leave.

So yeah, I think there’s some ways that Biden has been refreshing on this front and putting forward that kind of messaging. But then we also have examples, and here’s maybe a limitation of our survey too, there’s messaging and then there’s what happens when candidates are elected to office and where they put their political muscle and their political weight.

JW:  Katie Rader’s article, “How Progressives Can Win Back the Working Class,” co-authored by Carissa Guadron, appears at thenation.com. Katie, thanks for talking with us today.

KR: Thanks so much, Jon.

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JON WIENER:  Doctors these days are caught between the Hippocratic Oath, which says, “First do no harm,” and the realities of making a profit from people at their sickest and most vulnerable. Eyal Press has been thinking about that. He’s a contributing editor at The Nation. His work has also appeared in The Atlantic and on The New York Times op-ed page. He’s a Puffin Foundation writing fellow at the Type Media Center and author of the unforgettable book, Dirty Work. We talked about it here. His new article, on The Moral Crisis of America’s Doctors, appears in The New York Times Magazine for June 18th. We reached him today at home in Brooklyn. Eyal, welcome back.

EYAL PRESS, Guest: Thank you so much, Jon. Great to be here.

JW:  The pandemic was hard on everybody, especially on nurses and other hospital staff. I understand why they have been quitting or thinking about quitting, but you say doctors are too, even though they are the privileged ones. They earn six figure salaries. They are doing prestigious jobs that spare them from the drudgery faced by nurses and other hospital workers. So why are doctors feeling like quitting?

EP:  The traditional explanation for why doctors are stressed out emphasizes burnout. They just work too hard. They don’t do enough yoga and meditation. They need to slow down and spend more time with their kids. And this narrative has been around for years. And in my article, I suggest a very different answer. And I look at the work of Wendy Dean, a psychiatrist, who years ago read a story about a doctor who had committed suicide and was working at the time as a researcher at a US Army Medical Center and poked around and discovered that the suicide rate among doctors was actually comparable, if not higher, than that among military veterans.

JW:  Wow.

EP:  That this was actually a widespread problem. And she was not convinced by the burnout narrative. And what she kept hearing was that the medical system as constructed, our for-profit medical system, makes it increasingly difficult for doctors to care for their patients.

There are so many financial stakeholders that get in the way and tell doctors what you can and can’t do, which medications you can prescribe, which ones insurance will accept or pre-approve, how much time to spend with their patients. Really, it’s kind of micromanaging how they do their jobs.

And Dean’s conclusion was that the problem is not burnout. The problem is a moral crisis among physicians. And the term she used was moral injury, which is a term that has been used in the context of treating veterans. And I use it in Dirty Work, my book. And what it means is it’s a wound to the soul or to a person’s sense of self that occurs when they witness or do things that transgress their core values. And soldiers do this all the time, right. In the context of war, they see violence, they sanction or participate in violence that in civilian life would not be accepted. And then they have to live with the aftermath of that.

But moral injury’s actually much more widespread and capacious. I suggest in Dirty Work that anyone who really does a job that requires making ethical compromises on a regular basis. I look at prison guards in the book. I look at slaughterhouse workers who are susceptible as well to moral injury. And I think a case could be made actually that any employee in any job is susceptible to moral injury. If we look closely enough, and actually it was after Dirty Work appeared that I got a letter from a doctor saying, “Have you thought about doctors and how they increasingly find themselves in these compromising situations? Even though, as you said in your introduction, they are comparatively privileged, they’re well paid, they’re not thought of as people who would suffer at all on the job.”

JW:  One preliminary question. You talked about the for-profit medical system, but aren’t most of our hospitals run as nonprofits?

EP:  That is an illusion that a nonprofit hospital might lead you to think. But when many people go to the emergency room in this country, including at a nonprofit hospital, about a third of emergency departments in the United States at this point, roughly 30% are actually controlled by private equity firms that effectively determine everything from staffing, to rate of work, and reimbursement, and how many physicians assistants are used instead of doctors. So you have for-profit entities behind the scenes in a lot of these so-called nonprofit institutions.

I should also say that a nonprofit hospital is still part of a healthcare system in which healthcare is a commodity. And we are not a country that regards healthcare as a right that every citizen’s entitled to. So how you are treated when you come into a hospital, whether it’s a for-profit hospital like HCA owned or a nonprofit hospital, is still very much a function of whether you have insurance, what that insurance is, what they will reimburse, what they won’t reimburse, what they will cover. And doctors are very aware of those things. And if they’re not aware of it, they’re made aware of it by administrators. And by the way, the ranks of administrators have ballooned in recent decades in American healthcare. The number of doctors has not grown. So we have a system that increasingly is bureaucratic, administrative, and geared towards the bottom line.

JW:  You set out to interview doctors about their work, but it turned out many of them said they couldn’t speak with you. Why not?

EP:  Very few of them were willing to be named. And the fear and the reason they felt this is that they are in this increasingly corporatized medical system where they don’t have the freedom to speak out. Many doctors now sign contracts that actually include provisions saying, “You can be fired without cause. You will not have due process if you are let go.” And there are cases, I mentioned one of a doctor in Seattle who was fired for complaining about the safety protocols during the pandemic. It turned out, by the way, his employer was a private equity firm and they got rid of him. Doctors also signed non-disclosure agreements that forbid them from speaking to the press without permission. I can’t tell you the number of doctors I called and they said, “I really want to talk to you, but I’ve got a nondisclosure agreement. Can’t do it.”

JW:  You say emergency rooms are becoming a profit center for venture capital. Where else are the profit seekers taking over and putting the squeeze in hospitals?

EP:  Everywhere. We’ve always had a for-profit system in this country when it comes to medical care, but it’s accelerated. And I think we’re seeing that everywhere right now. Primary care practices that are being bought up by Walmart and CVS, because there’s money to be made in Medicaid and reimbursement. And I really don’t think there’s a corner of the medical system that hasn’t been touched by this. One of the key historical transformations that has happened is that in the past, doctors tended to work, the majority of them, in private practices where the hours and the terms of employment, the conditions of employment, were controlled by the physicians. They ran the practice. But 70% of physicians now work for these large hospital systems or corporate entities where they are told, this is how you will work, and where their productivity is tracked on an hourly basis, and where they have increasingly to fill out electronic medical records, EMRs, on every patient that comes through.

Now, EMRs initially, that changed, by the way, can be traced back to the Obama administration. The idea was, oh, let’s make the whole system much more easily interconnected. We’ll have these electronic records. One hospital can transfer them to another. It will be easier for the patient, better for the provider. What’s wrong with that? Right?

Well, what’s wrong with it is that increasingly when you talk to physicians, they feel the EMR has become a cash register. That it’s all about codes and billing and what you fill out, which determines how much you’re reimbursed. And here they are trying to provide care and instead hours and hours and hours of their time are spent at computers filling out these forms that get in the way of being able to care for people.

JW:  Some doctors are contemplating how to resist this system, especially young doctors. In the past year, there’ve been some striking developments on this front. Medical residents, for the first time, voted to form a union. I think Stanford was the first and now the Penn hospitals in Philadelphia have become the second. So tell us about unionization among residents and interns.

EP:  Residents have always been overworked and underpaid and felt exploited. This is not new, but in the past, I think they said to themselves, “Well, okay, we’ll eventually become attendings. We’ll go and work in private practices. Our lives will be easier. And so why do we need a union?”

Well, residents today are seeing things differently, and the ones I spoke to talked about how they see themselves as workers, as people who are going to not be controlling the terms of their employment and how are they going to fight back against conditions they feel get in the way of their ability to really provide humane care. And they’re taking a page from nurses who are more working class, have large unions like National Nurses United and saying they will stand in front of a hospital and form a picket line when staffing ratios are cut or when they don’t have time, they feel, to care for all the patients they’re supposed to be seeing. And here we are as residents and they are warming to the idea of collective representation, to basically wrest back power. And implicit in that is that they actually do see themselves as workers, not as people who are above working people.

JW:  The second front of this fight that you document is the fight underway in a few places against private equity, taking over doctors’ practices. Blurb from your piece that California has a law that prohibits nonmedical corporations from controlling the delivery of health services. And I understand that this is being tested in court. Right now there’s a lawsuit against something called Envision Healthcare. Envision Healthcare, I looked it up on the internet. They described themselves as a group of physicians delivering care to more than 29 million patients each year in diverse communities across the United States. What is Envision Healthcare and who is suing them in California?
EP:  The Association of Emergency Medical Doctors is suing them. And the suit alleges and argues that the idea that this is doctors who own and control Envision is really just a facade. That the people who really own and control Envision are investors–private equity.

JW:  Kravis Kohlberg & Roberts in particular.

EP:  Yes, KKR in particular. Blackstone, by the way, is also very heavily involved in the same corner of the healthcare industry through Team Health. It’s really insidious because what happens is the doctors are indeed, on paper, the owners of these practices, but they don’t actually control the terms under which the physicians are delivering the care. Right. That’s in Envision’s hands. That’s in the corporation’s hands. And it’s a very clever way to circumvent that law you mentioned that says, we should not have a nonmedical corporation interfering, getting in between, the patient and the medical provider. That would introduce the possibility of exploitation, profiteering abuse, false billing, all the other things that we know pervade our medical system. And so this suit is really important. If they win in California, it could have ramifications elsewhere.

JW:  The California lawsuit pits the American Academy of Emergency Medicine as the plaintiffs against Envision Healthcare. The latest on this is that a few weeks ago, Envision declared bankruptcy. They have 7.7 billion dollars in debt. How’s it possible for a bunch of doctors to owe 7.7 billion dollars?

EP:  It’s a perfect highlight of why this is so dangerous. This is not about providing better care to patients. This is business, for Envision, for KKR, for Blackstone. Why is private equity interested in emergency medicine? Why? Well, profits. Money. Robert McNamara of the AAEM who wrote a paper showing that they were getting 22% profits on average in the emergency medical practices where they were in control. Think about that: a 22% profit on emergency care.

JW:  One other thing about this Envision lawsuit I wanted to ask you about. They claim the reason they are unable to service their debt is because the insurance companies have been denying their claims for emergency care. They blame, especially their largest health insurance payer, United Healthcare. And in their lawsuit they say United Healthcare “puts profits above all else.” How about that?

EP:  Wonderful. That’s a great quote. And it really captures the kind of Orwellian situation we’re in. By the way, they’re not wrong about the insurance companies, but the people who ultimately lose in this are the patients and the providers.

JW:  So we have doctors forming unions, we have doctors organizations suing to get private corporations out of medical staffing. And there’s one other front you talk about, direct care medical practice. Tell us about that.

EP:  It’s this model of care that has been growing in popularity among doctors who are fed up with having to deal with all these corporate middlemen. I wrote about a rheumatologist who just started practicing. This was in Ohio. And hearing her patients say, “Why did that cost $7,000? It was a blood infusion.” We’ve all gotten those bills. She went to some administrators, said she was shocked and really upset about the kinds of bills her patients were getting and complaining about. And they said to her, “Well, as long as the patient has insurance, it’s not our business.  don’t worry about it.” And she thought to herself, whose business is it, if not ours?

And she got so tired of it that she eventually left the practice and formed a direct primary specialty practice in rheumatology. And basically that means she deals directly with the patient ordering tests, ordering imagery, an MRI, for example, on a patient that I observed her treating and doing it directly rather than going through the corporations that take huge profits along the way.

Now I should say direct primary care is not a panacea. It is not going to cure all the problems of our healthcare system. You have to pay upfront, generally a monthly fee to get to see a doctor like this rheumatologist. For people without the means, and now it’s often a modest fee, but a modest fee for someone who doesn’t have a steady income is still a fee. And so it’s not going to solve everything. It doesn’t serve everyone. It’s also hard for these practices to attract patients, because I saw one such practice that really looked like basically an examination table in a tiny room, and it was a medical practice, one of these direct care practices. But it does tell you something that doctors are gravitating towards this because they’re so sick and tired of all of these headaches. And I think that’s an interesting kind of turning point as well.

We know that patients are not well served in our system. We know particularly if they’re poor, particularly if they’re in less privileged situations, we know that the patients suffer. I think it’s somewhat new to realize, wow, the providers are suffering as well. Because traditionally, and since World War II, the AMA and organized medicine has really adapted to the commercial ethos that pervades our medical system, fought against single payer health plans. Seemed perfectly happy with the system we had. But it’s really striking that the model is now forcing doctors to come to terms with the fact that there’s another group of people who are being exploited, and it’s them.

JW:  One last question about your article on The Moral Crisis of American Doctors. A lot of people told me, you’ve got to read this article. What kind of response have you gotten?

EP:  It’s really been pretty amazing. I didn’t know how folks would react. I thought, okay, some doctors are going to push back at this.  I’ve gotten letters from doctors across the country who basically just wrote to say, “This touched my soul. This is exactly what I’ve been struggling with.” I’ve gotten more correspondence on this piece than really any magazine story I’ve written. And really heart-wrenching letters just about people. So one person who wrote who left after finishing his residency, went to practice in New Zealand. Didn’t want to work in a for-profit system. Wrote a really moving letter to his fellow residents about why. Others who just told me they retired early. They just couldn’t take it anymore. So it’s really been just a response that suggests I kind of scraped the surface in this piece rather than really getting the whole story.

JW:  And how many comments were there at The New York Times?

EP:  There were over 2000 comments.

JW:  And I understand AOC has also responded to this piece.

EP:  I’m delighted to say that a colleague of mine follows AOC on Instagram, saw that she had posted the piece, and also, more importantly, beneath the image of the story, she said, “We have to renew the call for Medicare for all.”  I was really pleased to see that.

JW:  Eyal Press, his report on The Moral Crisis of American Doctors appears in The New York Times Magazine for June 18th. It’s online now. Eyal, thanks for all your work, and thanks for talking with us today.EP:  Thanks so much, Jon. Great to talk to you.