Medicare for All Podcast: The International Perspective

Click the green play button below to hear Episode 15: A Revelation, with our Director of Communications Stephanie Nakajima


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Joe: Welcome to Medicare For All Explained. This podcast will enlighten our listeners and dispel the distortions that surround Medicare for All. Medicare For All Explained is produced in collaboration with Physicians for a National Health Program, and [inaudible] produced by Joe Sparks. I’m your host, Joe Sparks.

This is episode 15, “A Revelation.” My guest, Stephanie Nakajima, discusses her personal experiences with health care systems in the United States, Japan, and Denmark.

Ms. Nakajima is the Director of Communications at Healthcare-NOW, which advocates for the United States to implement a single-payer health care system. She previously worked as a writer, editor, and journalist in Tokyo and covered the Fukushima nuclear disaster and organized crime. She has also worked for the Danish Institute for Human Rights and the Danish Refugee Council in Copenhagen.

Ms. Nakajima joins us today to speak as a health care consumer in how much easier it was for her to obtain quality medical care in Japan and Denmark. Stephanie Nakajima, welcome to Medicare For All Explained. 


S: Hi, Joe, happy to be here.


J: Good, so … what I’d like to start — I know you’ve spent some time in some other countries and experienced their health care system. Could you explain how you ended up in those countries and what your experience was with those health care systems and how they compared with the United States?


S: Yeah, sure. So I graduated from college, um, practically right into the recession, and for years worked in the service industry. Ah, mostly waiting tables, making minimum or sub-minimum wage, and of course not having health insurance. I probably couldn’t have afforded comprehensive health insurance anyway on my salary, but it wasn’t an option since I was rejected for everything except catastrophic coverage, because I had, uh, pre-existing asthma. And over those years, I lived in a crappy apartment with mold, and my asthma, especially without access to, a primary care physician, just got worse and worse. I did end up in the ER once, something that could easily have been avoided with medication; and sometimes people see that as sort of the climax of the story: Oh, another avoidable ER visit that would’ve been less costly if we’d just been treating these people with preventative care. The worst part of those years for me, uh, was the constant, like, chronic wheezing, which got worse when I tried to exercise; the coughing fits … living day-to-day with untreated asthma — psychologically, the strain of living my life like that; not having a fundamental need taken care of really decreased the level of control I felt like I had over my life, and it was very disempowering, actually. And the thing is: I thought it was normal, or it really decreased the quality of my life, but I didn’t realize it. And I didn’t realize that it didn’t have to be that way until I actually did get treatment. 

And that’s sort of where my international story begins. So around 2010, I moved to Japan, my dad’s country, and while I was registering my residency at City Hall, they asked,, Do you need health insurance? As if it were something they were just giving out. [Laughs] And it turns out that they were, and in fact, any resident of Japan can get on a public health insurance plan just by enrolling. There’s no application asking for your detailed medical history, or wondering if you’ve made a small mistake somewhere in your insurance application where it could be rescinded. There’s nothing like that; they don’t care what gender or age or whatever you are. And just like that, for the first time in my life, I had real, comprehensive health insurance, and it was so easy. And having that guarantee of being able to go to a doctor whenever, that was a revelation to me, and I realized then that I had been wronged in the United States, that I had a right to health care and that it was denied, it made me angry.


J: Just a quick comment: somebody said in other countries they’re not known as pre-existing conditions; they’re known as medical conditions.


S: [laughs] Exactly. Yeah, “pre-existing conditions” is something we created to keep people out of the health care system, basically.


J: So you were in Japan, and you experienced a good health care system. And then what happened from Japan?


S: Well, a year after that, the Fukushima Disaster happened, and anti-nuclear protests were springing up all over Japan, and in the midst of this national tragedy, uh, there was this huge anger about what had happened with the electrical power plants; and that sort of inspired me, and, a couple of months later, Occupy Wall Street made its debut, and that’s when I decided it was time to return to the States and really get in the game. But U.S. immigration laws were hard, I was just married to a Dane that I had met in Tokyo, and we were applying for his green card, but that ended up taking three years, and that can be a whole other podcast on immigrating into the United States. So most of that time we spent in Copenhagen, and during my time in Copenhagen, I got to experience a true single-payer health care system. 


J: And what was that like?


S: Yeah, so Denmark has a true single-payer health care system. There’s absolutely no co-pays — I think I paid a co-pay when I went to the dentist, um, so dental care is an area for improvement for Denmark — but otherwise, no co-pays for any general specialist hospital care; I never feared going to the doctor because I knew that when I left, the bill — no matter, what tests they did, or what additional visit they recommended — it would always be zero. And that was a huge thing that prevented me from going to the doctor while I was in the United States; you would have no idea, even while you were in the doctor’s office, even when you were asking the doctor, Okay, you’re recommending I do this but you can’t even tell me how much it’s gonna be? So there’s just this uncertainty that, really prevented me from accessing care when I was in the United States, and that was totally taken away when I was in Denmark.

Another amazing thing about my experience there is that I had totally free choice of GP or, whatever you call it, primary care provider and specialist. In fact, when I went to my GP to be referred to a specialist for an issue I was having, we didn’t talk about which one was a network or whatever, he just spoke candidly with me about which ones he’d recommend, which ones he wouldn’t, which ones were close to my house, and all this. I have a very restricted network here with my current insurance plan, and I feel like there’s a very big difference between a totally open network, and … what we have here, which is, a restricted network which actually impedes my ability to get care, because there are only so many specialists who, take my insurance. 


J: What you describe is actually a patient-centric system, and obviously, that’s much better and provides better service. Obviously I assume you were being treated for your asthma. If you are willing to share, were there other things that you went to the doctor for, other health problems that came up?


S: I did have other additional issues, although I think they were rather routine. I did actually, though, see my friend Anne, who was diagnosed with leukemia, she was just a couple [of] years older than I. And I got to see, sort of, the system in place around a very sick patient, and I got to see how a coordinated level of care that could only take place in a single-payer, that, revolves around what’s actually good for the patient, not how we can maximize profit from a customer. I got to see that experience, and I think that was one of the things that really solidified, for me, how valuable a single-payer is versus a profit-driven system.


J: Well, if the system’s so good, how come you came back to the U.S.?


S: [laughs] That’s a great question. I had decided that I wasn’t gonna come back to the U.S., unless I was, actively fighting the system, because it became very personal for me after I realized how much I had been deprived of during those years where I couldn’t go to a GP. And so I was offered a job at Healthcare NOW!, which is the patient advocacy organization for single-payer, and I kinda jumped at the opportunity, and fortunately with my insurance now I have a zero-deductible plan, which is great, but sneaky co-pays and the restricted network are... the decision, if I could make it, would be totally clear — I would absolutely have single-payer in Denmark over what I have right now. Any day.


J: I know women’s health issues are important to you. So how do you compare what’s happening with women’s health in Denmark as compared to what’s happening here?

S: So right now, we’re seeing this recent state of attacks on abortion happening on a state level right now, in Georgia, Alabama, Missouri. That’s really angered and terrified a lot of people who are rightly afraid of the future of Roe v. Wade, since that’s what these laws are really about. They’re trying to take down the Supreme Court ruling that made abortion legal. And there’s kind of good news and bad news about this moment; the good news is that, experts don’t believe that these extreme bans are going to actually challenge Roe, but the other — there are other challenges to the case and the pipeline that could chip away at Roe, by adding restrictions to the reasons that women can seek an abortion, for example, and worsen the existing abortion crisis, which I’m not sure is actually, getting enough attention. And I think that one of the things that we need to talk about when we talk about abortion is the fact that in other high-income countries, most of them, France, Denmark, England, Italy, most of these countries that we consider our peers, they fully fund abortion for their residents, as part of the national health insurance system. An additional number partially fund abortion, either require co-pay, like in Sweden or Switzerland, or they have some sort of, like, income limit where they’ll pay up to a certain income level. But at the end of the day, taxpayer-funded abortion is actually a very normal practice in other countries. And I think we need to be aware that globally, we’re kind of the regressive outlier. And that absolutely goes for abortion.

So I’ve had two abortions, uh … one was in the United States and one was in Copenhagen. At the patient level, the experiences, they weren’t that different. I would say that the biggest difference was that, of course, in the U.S., I was greeted by protestors with blown-up pictures of fetuses and mad security at this facility that was solely used to provide abortion services. It felt like a fringe event — and, of course, the fact that I paid $600 out of pocket for it, that was a huge difference. Whereas the Danish procedure was, of course, paid by me through my taxes, so free at the point of service, and it took place at a regular OB-GYN office as a normalized health care service. No one else knew why I was there, it was anonymous, and it felt routine. And that, I think, was as good as, an abortion experience can be. I think the biggest difference, though, for me, between those two experiences, was the context in which I had to make that decision. When I was in the U.S., the context was that I was uninsured. And I had just missed the window to apply on the exchange, I had basically just moved back to the United States from Tokyo. And so there was basically no choice, actually. I even called up a local hospital to see what it would cost out of pocket for me to deliver, and maternity care and all that, and let’s just say it was more than my annual salary is today. There was no way that — for me to see this as a responsible decision, even though my husband and I were solidly middle-class. And it didn’t really matter how I felt about whether I wanted to have a child or not. It wasn’t even really a decision. Whereas when I was in Denmark, and I found out that I was pregnant, it was a much more complicated decision, which is a good thing, because it meant that I had choices. The reason that it was a little bit complicated was that even though I had guaranteed health-care through single-payer there, and so would any children that I chose to have; would have that access to health care. And more broadly, it’s a society that thinks of child-rearing as a collective responsibility instead of [inaudible]. There’s more resources for parents. But, at the same time, I was dealing with [an] unrelated medical issue that would have made it very difficult for me to go through a pregnancy at that time. But instead of my choice being restricted by my class, or my insurance status, I was constrained by something that would have impeded anybody. And it allowed me to make a choice that felt dignified, and wouldn’t close off the future for me in a way that, being uninsured and not knowing what was going to happen in the future in terms of my insurance status would have. I think it really hit home for me at that time that that’s what reproductive justice means: it means having bodily autonomy, it means being able to have an abortion when that fits your life, it means being able to have children when that fits your life. And we can’t have full body autonomy without having a single-payer health care system that provides the whole range of reproductive services that people will need throughout their lives.


J: If we can put politics aside for a moment, why is it important for a woman’s health that they have access to abortion and other reproductive services such as contraception?


S: Sure. So I think that people shouldn't have to argue you know why they need or want an abortion. I don't think it should be contingent upon the circumstances in which pregnancy occurred. That's what I find a little bit problematic about some of the state level laws that are outlawing abortion even in the case of rape and incest. And some people are saying oh my gosh even in terms of rape and incest you know you're not going to allow people to have an abortion. Even then, I think if we start arguing about those sorts of conditions we're going down a path of normalizing restrictions around abortion of pregnancies that happen for other reasons.

And I think bodily autonomy requires that any person should be able to access an abortion for whatever reason they have for not wanting to be pregnant.


J: Well the other thing I've never understood, if life is so precious, I've never understood how anybody who says they want to protect the unborn but isn't also protecting the born and it seems one of the obvious ways to do that of course would be making sure everybody can get access to affordable health care along with making sure that other basic needs are met such as food, clothing, and shelter. Do you see a contradiction there also?


S: I see a huge contradiction there. I think that right wing arguments about pulling yourself up by your bootstraps when they sort of collide with these weird moral ideas about the rights of fetuses and versus the rights of the woman who is pregnant. I think that you get this very bizarre telopathy around what life really matters. What life does matter and what life doesn't matter. And it's just wholly inconsistent with a society that really takes care of people.


J: Well if you really wanted to reduce abortions you would give people access to forms of contraception and then it's been shown that doing that reduces unplanned pregnancies which of course reduces abortion.


S: Absolutely. And actually another thing that we can learn from the rest of the world here is that countries that have national health systems that are financed by tax payers progressively have lower rates of abortion than we do in the United States even though those countries do cover abortion as part of the normal catalog of services that are covered by the national health insurance system and I think that's because you know when you give people access to comprehensive health care they are better able to make choices and that includes reproductive health choices. 


J: Well from what I've also heard, and I'm not sure if I can put this delicately, but the rate of intercourse among these countries among the U.S. and European countries that we're talking about is relatively the same within one or two percent. So the question becomes if it's relatively the same how come we have a much higher unplanned pregnancy rate. And the only thing that I can figure out is just access to contraception is easier because you can get it without out-of-pocket expenses in their health care systems. 


S: Yeah absolutely. That's just part of healthcare. Having access to reproductive health services and that includes contraception and other countries also don't have restrictions like the ones that you see here around you know parental consent to be on certain forms of contraception. Then all of that I mean there's a lot of roadblocks for girls and women who are actually seeking these forms of contraception that don't even happen at the insurance level or almost like legislated at the state level.


J: One of the interesting things. So are you familiar with what happened in Colorado when they started offering teens free IUDs?


S: No, I'm not.


J: Well within eight years, teen pregnancies dropped about 54 percent and the teen abortion rate fell about 64 percent. Colorado gave the IUD to teens who wanted them even if they did not have parental consent.


S: That's fantastic.


J: Yeah. That also save them money and other things overall. You see that's what I don't understand if you're really interested in abortion and health care, it seems that you have to take these other considerations into account.


S: Absolutely. And this just actually reminded me of a friend I know who is a Brit. She had an abortion under the NHS before she went in for the procedure. They offered while they were doing the abortion if she wanted to have one of those IUDs implanted as part of the procedure so that if she wanted to not get pregnant in the future that they would be to do that at the same time. Sort of going back to the whole coordinated care thing. And I think that for me personally an IUD has actually kind of been out of the question because it's extremely expensive without insurance, whereas under the NHS, they can just offer that to everybody because it just comes again as part of the whole catalogue of health services.


J: Yes. And of course as I mentioned that would probably save money in the long run for a variety of reasons. Although I don't want to make necessarily the saving money argument to providing health care, I think the single payer system would substantially reduce our national health expenditures.

Getting back to a single payer system is there anything else you'd like to add about the benefits of having a single payer system.


S: I think that for people who get really sick which many of us will at some point in their lives, there is no doubt in my mind that you would want to be focused entirely on getting better and getting the best treatment that you can versus trying to figure out how to pay your bills. So one of the experiences that I had when I was in Denmark was watching my friend Anne who was diagnosed with leukemia go through her treatment under the Danish system and also at the same time watching a friend back home you know through Facebook and social media, her husband also had cancer and seeing their experience of course through the lens of you know social media versus what I was seeing with my friend.

So I'll just call her Susan. Her husband, he was diagnosed with some form of cancer I think bone cancer or something and they had to actually do what you would expect a typical Go Fund Me to keep up with all the costs for his treatment. And that was on top of what I saw and was going through actually firsthand. She actually had a two year old child. She had to get help with the child because she couldn't pick her up anymore as she was going through chemotherapy. But what I did see with Anne’s treatment was that there was such a coordinated level of care for her from the moment that she was diagnosed. You know, she was at her General Practitioners office and she was complaining that she had some bruises on her legs and this weird fatigue. And they did some tests and then when they came back they told her, look you have leukemia and you have an appointment with a doctor at Rigshospitalet which is like the big research hospital in Copenhagen in one hour. And not only was all of her treatment paid for fully, but the way that they coordinated it was amazing. For example, she immediately met with a therapist who would be helping her deal with sort of the mental and emotional strain of having cancer and then going through all the chemo and then additionally for a year after that she continued to have follow up therapy to deal with like the trauma of having cancer. And then another thing they did for her was that they put her in a group of people with a similar diagnosis and a similar age range and set up times for them to have like a coping group where they shared experiences and sort of helped each other get through the experience of chemotherapy and all of her care with her GP and then with the doctors at the hospital was all just you know fully coordinated and they were all in contact with each other and there was never any question about whether or not you know when she had complications, which she had many, if they would be covered as she was just admitted to the hospital. I never saw anybody pull out a paper and trying to find out if this was covered by her insurance at all. And so I thought that that was just absolutely the way I would want to be taken care of if I ever got sick like that.


J: So you think that's a better system than saying it's going to cost you this amount of money and you better use Go Fund Me and good luck? 


S: Yeah. I'm not really sure what the appeal of that kind of system is.


J: On a more serious note, I've talked to several doctors and one nurse and the stories you hear about people trying to afford their chemotherapy are just heart wrenching and it just makes me sick and I find it disgusting. Before we end is there anything that you'd like to add?


S: Well one thing I would like to add although I'm not sure if it really segways perfectly with what we were just talking about but I did want to talk about the fact that I believe that federal funding for abortion in the United States is a really important issue and I think that the single payer movement needs to come out for it explicitly and lead the way on this conversation because the reproductive rights movement and the single payer movement are intertwined in ways I think that we don't always appreciate. They depend on each other for their success. For example right now something like half of women pay for their abortion with private insurance. And of course this is not great. Every woman should have access to abortion fully covered by their insurance. And of course it's for women and women of color. Those who are most likely to need an abortion are also the ones who face the greatest financial burdens of getting one. But if we were to pair a single payer without fully repealing the Hyde Amendment you know the Hyde Amendment of course prevents federal funds from being used for abortion treatment would mean that effectively all women in the country would lose access to insurance coverage for abortion services which is of course not acceptable. So if we tried to pass a bill without explicitly covering abortion of course not only would it be politically impossible, it would just be -- we would be going backwards actually. And so like all things single payer, a national health plan is an exercise in solidarity. We're not going to get single payer without including abortion rights and we won't fulfill abortion rights without a single payer. So it's really got to be everybody in nobody out 


J: Well along those lines, Representative Jaya Paul's bill does include abortion coverage and it specifically says that its coverage and overrides the Hyde Amendment and I believe that Senator Sanders bill does also. So that's a good sign.


S: Yes. Representative Dion Paul and Senator Sanders bill are both really strong on abortion. They do repeal the Hyde amendment and they do say that comprehensive reproductive health care is covered. They don't explicitly mention the word abortion which I think is one area we can improve on but overall, I think that this is like a huge step in the right direction for us, yes.


J: Well Stephanie, thank you so much for being on Medicare for All Explained.


S: Thanks so much for having me. 


J: You have been listening to Medicare for all Explained. Information about this podcast can be found at our website, The music for this show is Super Bubbly by Jessie Spelaine. The logo was created by Lily Sparks. Thank you for listening.