Dr. Steven Nissen: 'I want to replace the insurance industry'

The following is an unofficial transcript of parts of an interview that Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, gave to Ed “Flash” Ferenc, host of the labor-oriented, Cleveland-based America’s Work Force Radio, on Aug. 15, 2014. In addition to the points he makes below, Dr. Nissen also spoke about pharmaceutical drug safety and other issues. The audio of the entire program is available at The segments of the show that feature Dr. Nissen are noted at the end of the transcript.

HOST ED ‘FLASH’ FERENC: We’re going to start things off with Steve Nissen. Steve is the chairman of cardiovascular medicine at the Cleveland Clinic. He served nine years as vice-chairman, five years as medical director, of the cardiovascular center that directs multi-center clinical trials. He’s got some national leadership positions, too, which include a term as president of the American College of Cardiology. He also served the Food and Drug Administration as a member of the cardio-renal advisories panel. He spent about five years there and continued as an adviser to several FDA committees. He’s known for public policy discussions regarding drug safety; in fact he testified in the Senate and the House of Representatives on the need for FDA reform. Most recently, he’s been outspoken about the need for a single-payer health system, health insurance, or better known as “Medicare for All.” [Here the host talks at some length about the key features of a single-payer system.] …

Let’s talk about the [health] system as far as paying for it. What are your thoughts on the Affordable Care Act that is underway in America right now?

STEVEN NISSEN: Well, first of all, we had to do something. Having the richest country in human history having 50 million people without health coverage was a shame on our society, and is just not acceptable. And a lot of those 50 million people are working people. They’re people who work in jobs that are often low-paying, maybe the person who hands you your dry cleaning when you go up to the window, or in a fast food restaurant, and we have to be a civil society. We have to provide health care for everybody. Nearly every other developed country does that. They have universal health care systems, and we didn’t. The Affordable Care Act is a compromise that was forged through very difficult political discussions. And it’s far from perfect. I would have gone much further than it went, toward a simpler, universal health care system, but it did move us in the direction of making certain that everybody – or at least most people – have access to health care. To the extent that it did that, I support it, even though I recognize there are flaws in the way the law was designed. The flaws come out of political compromise. It wasn’t written by, necessarily, by a single party. It had to get some bipartisan support to get anywhere.

HOST: Yes. The single-payer system, it’s been, I guess, proven to work in a number of countries – you even referenced that a few minutes ago.

NISSEN: It does. I mean the Canadian system is excellent. They spend about half of what we spend, and a lot of what goes on in America is making us uncompetitive as a country is that we spend so much on health care and we aren’t any healthier than other people. A single-payer system is pretty simple. I mean if you want to think about a single-payer system, there’s one in place in the United States for people over 65. It’s called Medicare. Let me give you a fact about Medicare. The overhead for Medicare is about 3 percent. What that means is that 97 percent of what Medicare spends, it actually spends on for health care for people. The overhead for the private insurance industry is 29 percent, which means that almost one dollar out of every three is going for profit, for who knows what – I mean, trying to figure out who’s going to be covered and who’s not. Medicare is much more efficient, and so you can automatically reduce tens of billions of dollars in expenses just by making certain that you have a system like Medicare. There was a proposal during the health care reform debate to simply allow people to “buy-in” to Medicare, that is, use their own dollars to buy Medicare coverage beginning at age 55. I strongly supported that idea, but I supported it only because it was a bridge toward a true single-payer system. And what I hope would happen is that we’d get people to buy into Medicare at 55, then come back in a few years and say 50, and then we’d say 45, and the next thing we know, everybody could buy into Medicare and they would have had an efficient, high-quality system that worked. We don’t have that. Now what we have is the Affordable Care Act which really is trying to reform the insurance industry, not replace the insurance industry. I want to replace the insurance industry.

HOST: So they’d be out of it altogether.

NISSEN: Get them out of it. Their motives are profit, their motive is not making people healthier, their motive is making money. And the other part about the system that’s really challenging is that physicians, still many physicians, work on what’s called a fee-for-service basis, which means that the more they do to you, the more money they get paid. We work on a different model at the Cleveland Clinic. We’re all salaried. I get exactly the same salary every month, whether I order a cardiac catheterization or some other fancy test for you or not. There’s no incentive. There’s really no incentive to do things that aren’t really needed. Unfortunately, we are in a system where there is an incentive, and it is a perverse incentive. It’s one that says, the more stents you put in, the more money you make. And that is a problem, because it misaligns the needs of the patient and the interests of the patient, and the interests of the physician. In a single-payer system that works, we’d all be on salary. We would be [concerned about] quality care, but not on a fee-for-service basis.

HOST: Aren’t you restricted now by the insurance companies? Don’t they say, “Well, you can’t do that because it’s not covered”?

NISSEN: Well, they have all kinds of rules, but the rules are about profits. The rules aren’t about health care. They put restrictions on because they have to receive X amount of dollars from people to cover them, and the less care they can provide, the more money they make. That’s a very different situation from a situation where your physician is saying to you, “This is what I need to do to keep you healthy.” I just don’t want those decisions that are made by physicians to be excessively influenced by profit, by money. I want them to be influenced by what people really need in order to stay healthy.

HOST: Doctor, how many people at the Clinic have the same view as you on this?

NISSEN: I think probably a minority. I think medicine in general has been on the conservative side politically. My views are much more progressive. I’ve always felt very strongly about these kinds of matters, going back 30 or 40 years, to when I was a college student. But I’m influencing people and there are increasing numbers of physicians in America that are beginning to say, “The system is broken. We need to fix the system. Here are some things we can do to fix the system,” and the first place to look is how we pay physicians. Honestly, I think if we could get physicians on a salary basis, that would go a long way, and if we could then get to a point where we didn’t have insurance companies figuring out how to squeeze every dime out of the system, but rather a system that says, “How we can take better care of patients?” then that would be a single-payer system where there would be a government insurance plan, everybody would get it. You know what’s amazing about Canada? If you were to go to Canada, and you were to be in a terrible car wreck, as an American, and go to a hospital there, you’d never receive a bill. You could be in the hospital there for weeks and basically it’s just assumed by the Canadian society that if something happens to you, and you get sick, you should be taken care of. There’s no system there for billing people. You just go in and you get taken care of.

HOST: Isn’t that amazing?

NISSEN: And not all these insurance forms and all this kind of pre-qualification, and basically it’s patient-oriented, it’s oriented toward the public need. And I believe that’s the right thing to do.

HOST: You know it’s a real shame that in some many states, so many governors, especially in conservative states, have opted-out of Medicaid.

NISSEN: That’s just terrible. I mean what they’re saying to the poorest people in the society is that “We don’t care about you. We’d rather make a political point than support your health.” It’s unconscionable, it’s unacceptable, and the public shouldn’t put up with it.

HOST: You know there’s an organization – you’re not part of Physicians for a National Health Program, are you?

NISSEN: I’m not.

HOST: You might want to check them out. We’ve had some of their members on this show. Just go to, or just google single-payer health care and it will take you right there. They report that more than 7,000 people died because of the governors in those states opting out of Medicaid. People just didn’t get their health care.

NISSEN: What a tragedy. I know.

HOST: That’s a story that should be on the front page.

NISSEN: I know. And the other thing is, what’s the mission of medicine? What’s the oath that we take when we become physicians? It’s to heal the sick. And I don’t care what the politicians think, what I care about is the person in that exam room with me is my patient and deserves whatever I can give them. And I don’t want the payment system to get in the way of people getting good health care, because it’s not a privilege, it’s a right. And in most modern, developed societies, it’s understood to be a right, not a privilege of wealth. It’s part of being a human being and living in a country that fortunately has the resources to do this. We have the resources to get everybody good health care. We just have to have the political will to make it happen.

HOST: What’s your mission here, are you going to become more active in order to push this?

NISSEN: Well, I spend a significant period of time talking to people on Capitol Hill and you noted earlier I’ve testified on these matters in Congress and I will stay engaged in the political process, as much as I find it difficult in many ways. It’s not a lot of fun. And I continue to talk to my fellow physicians about why I think we need to be advocates for change. And we’ll see. I’m hopeful that over a period of many years we will gain more support. If we can get more physicians behind this concept we will gain momentum. There are powerful economic forces aligned against what we want to do. I mean, talk to the Koch brothers. They have a different mission, and their mission is to figure out how to pollute the environment and get away with it. And I want to fight back and I’m doing it because I really care about the patients and I think that’s part of the role of a physician, to be an advocate for patients. We will continue to be advocates and there are a number of us in Cleveland, there’s an organization of physicians in Cleveland, that gets together periodically and talks about these things and we’re going to continue to do that.

Time markers for key audio segments of show, the full hour of which can be found here:

Ed "Flash" Ferenc’s introduction of Nissen and Ferenc’s explanation of single-payer national health insurance can be heard from the 1 minute mark to 4:42.

Dr. Nissen’s comments on drug safety, the FDA, and Big Pharma take place from 13:40 to 20:30.

Dr. Nissen’s comments on the hazards of using the Internet to get medical advice run from 20:30 to 22:50.

Dr. Nissen’s comments on single payer run from 24:30 to 38:00.