Rep. David Nagel: 0:00

So, uh, gentlemen I've known for a long time. Um, we were in a casual conversation earlier today. In the midst of the conversation, he just suddenly asked me, I I've been following your voting record. And he goes, Are you sure you're in the right party? And the reason why the question was interesting was, I mean, I've known him for a long time, but we've never ever talked politically. So I really didn't know what side of the fence he was on. So I wasn't sure where he was going with that. So I said, based on the legislative options that I've been given this year, I thought 57% was about right, um, or 50-50 somewhere in that range. Because I just think we were given some really bad choices this year and some bad bills. And, you know, then all of a sudden I find out this gentleman who all these years I thought was a conservative Republican was actually quite the opposite. So yeah, it was kind of a fun conversation. And, you know, we left it off with the discussion are you changing parties? That kind of thing.

Liz Canada: 0:58

So we'll leave a little mystery because who knows what will happen in the future. Exactly. One can never be sure. You are listening to New Hampshire has Issues, and I'm your host, Liz Canada. I'm recording this on Groundhog Day, February 2nd, about nine o'clock at night. Representative Nagel and I recorded this episode a few days before Christmas. He references that a few times in this episode. Oh, a few things for context, because a lot has happened since then. One story you may have heard is of the leaked group chat by Republican State Reps on the House Education Policy Committee here in New Hampshire. Oh, and there's a reference to segregating schools in some way. The story you may not have heard was from two weeks ago. Another Republican state rep testified uh in a public hearing and uh used arguments that are of Holocaust denialism. A few days ago, the Speaker of the House, Sherman Packard, who is a Republican, and Alexis Simpson, the Democratic leader of the House, co-authored an op-ed that talked about how Holocaust denialism has no place in New Hampshire. And I, for one, was very glad to see that op-ed published by the two of them. Here's what has not happened, however. As far as I can tell, that Republican state representative who spoke in that public hearing, he still serves on his outstanding committee of the House. The House Education Policy members still serve on their committee as well. And I say all of this because what you'll hear in this episode was that last year Representative David Nagel disagreed with that same party leadership on issues of public health, and he was removed from his committee. You'll hear more about it in this episode. I asked him to come on the podcast because uh he is a doctor, he is a state representative, he is a Republican. And there are quite a few bills in the New Hampshire legislature that would roll back uh vaccination requirements or immunization requirements. We talk about one of those bills, House Bill 524, and we mention that it did not pass last year because it was a bill from last year. But as a note, uh it's not gone. It's still in the state house working its way through the process. But there are other bills, and some of them are coming up this week, actually. There is a bill to remove all immunization requirements for schools and child care centers in New Hampshire. There's a bill to uh prohibit a lot of state agencies from educating the public about vaccines. This isn't hypothetical, but these are pieces of legislation happening here in New Hampshire right now. So with all of that context, I'm going to pass it back over to Representative Nagel and me. But before I do that, if you would like to support the show, you can become a monthly supporter at patreon.com slash NH has issues. So thank you for listening. Let me give your intro.

Rep. David Nagel: 4:00

All right.

Liz Canada: 4:00

Welcome to New Hampshire Has Issues, the podcast that dares to ask, what will RFK Jr. claim listening to this episode will cause? That's the best through line that I could come up with. That isn't too offensive. It's the best I could do.

Rep. David Nagel: 4:17

Mine is why do we treat stigmatized populations the way we do? Because that's the whole basis for who I am and what I do.

Liz Canada: 4:26

We'll get into those stigmatized populations, I imagine, in our time together. Sure. All right, well. Welcome to New Hampshire Has Issues. I am your host, Liz Canada. And my guest today is a New Hampshire state representative and a physician, Dr. David Nagel, Representative David Nagel, and he represents Gilminton, Guildford, and Laconia Ward 2. Representative Nagel, welcome to the show. Thank you for being here.

Rep. David Nagel: 4:55

Thank you. Thanks for having me.

Liz Canada: 4:57

Listeners of the show know that I'm terrible at geography. How far am I in Exeter from your district that you represent?

Rep. David Nagel: 5:05

It takes me 54 minutes to get to Exeter from my house. Gilminton is just a tad uh south of um the tip of Lake Winnap, southern tip of Lake Winnipesaukee. We're just west of Alton and just about six miles south of Laconia. And Guilford and Gilminton are separated by the Belknap Mountains.

Liz Canada: 5:26

We're big fans of the Belknaps in our house.

Rep. David Nagel: 5:28

And his historically, uh Gilminton and Guilford were actually one town going back to the 1700s. Um they split up in the early 1800s. So I I don't know why they put Gilminton and Guilford in the same district. Personally, Gilminton should have its own legislator. I really think that's kind of sad that that they did what they did, but um, I'm not involved in those decisions.

Liz Canada: 5:52

And maps won't be redrawn until after the 2030 election. So we have a little bit of time, not a ton of time, but a little bit of time until that happens.

Rep. David Nagel: 6:00

Yeah, historically, when you walk into the legislative office building, to the right is a picture that is George Roberts. George is from Gilminton, he was a former speaker of the House in the 1970s. And for probably back as long as there's been state representatives, Gilminton has always had its state owns representative up until about maybe 15, 20 years ago.

Liz Canada: 6:23

Oh, interesting.

Rep. David Nagel: 6:25

Yeah.

Liz Canada: 6:25

Hmm. I guess it always depends on who draws the maps and what their purpose is. Um we'll leave a little mystery there too, I guess. We'll see.

Rep. David Nagel: 6:33

No mystery in that statement, believe me. They're none.

Liz Canada: 6:38

Yeah, I bet I bet that's right. I bet that's right.

Rep. David Nagel: 6:41

Nope.

Liz Canada: 6:41

So, representative, I'm gonna I like to start with a simple question. You're a physician and a legislator, and specifically, spoiler alert, you are a Republican New Hampshire state representative. When those two roles perhaps clash with one another, which I think probably happens when it comes to public health issues, how do you handle it? How do you handle when your role as a physician and your role as a legislator sort of bump up with one another?

Rep. David Nagel: 7:10

I mean, to me, it's not a difficult issue. I, you know, I know for some people it is, and I think that may be the problem with politics in general. You know, we were taught the day I showed up at the state house, we took these classes and they said your order of responsibility is your constituents, then your conscience, and then the party. That has been said a million times, and both parties say it. I've given two unanimous consent addresses on the House floor, challenging people that we speak words all the time of promising who we are, what we're gonna do. The question then is do you do it or not? And um, last I checked about 20 uh 25 years ago, somebody was born that we're gonna celebrate his birthday in a couple days. And his sole purpose to be was to challenge people. This is what you say you're gonna do, this is what you do, this is the gap in between, and how do you fix the barrier in between? And to be honest, when I look at things, I look first at what the needs of the people I represent are, which is not just my constituents, to be honest, it's my patients. Um, I've advocated for the rights of people with disabilities for be well before I became a doctor. So I didn't just begin when I became a doctor, which is why I became a doctor. So to me, that all comes first. And if I see party politics endangering the people I represent, then I it's not a difficult decision what direction to go.

Liz Canada: 8:33

Uh near the beginning of the of the podcast experience, I had the Democratic leader of the House, Alexis Simpson, on the podcast. And I had asked her to come on because I had an episode about the House and the Senate and the Executive Council. And I just asked her, tell me about the New Hampshire House, how does it all work? And she shared that, you know, there's 400 of you all, and you all serve on committees. And so you are a physician, you are a legislator. So uh loaded question. What New Hampshire House committee, Representative Nagel, do you serve on?

Rep. David Nagel: 9:05

Um if you're talking in terms of standing committees, the answer at this point is none.

Liz Canada: 9:09

None committees, zero committees. None. What happened? Why? Why are you on no no committees?

Rep. David Nagel: 9:20

So um basically

Liz Canada: 9:22

Did you choose to be on no committees? Let's start there.

Rep. David Nagel: 9:26

I I will tell you how I got to run in the first place because it's germane to the question.

Liz Canada: 9:30

So that's such a legislator thing to say. It's germane to the question.

Rep. David Nagel: 9:35

It is, yeah.

Liz Canada: 9:36

So it's perfect.

Rep. David Nagel: 9:37

So I I um, like I said, I've been advocating for people with disabilities for a long time. I wrote a book on pain care policy in the United States about seven years ago. Um, totally unintentionally, that book sold all over the world. And I was kind of like really shocked. It was kind of like a yeah duh book, you know. I was just saying what I saw every day. And I and it became aware that, you know, I I was just saying what people saw. And so that was kind of like, you know, a big deal to me. And so I met with a bunch of people to figure out like, how do you make what I just wrote real? And so um, I remember one of the individuals in our group just said, this book is your playbook. Just take it and run. So then I realized if I'm gonna be dumb enough to say this stuff, then I have to do something about it. So we started looking at the politics of healthcare in New Hampshire, particularly involving the care of people that are stigmatized. And that's a broad thing that we could talk about as we go along. But, you know, well, how are we not helping those people? Why are they suffering needlessly? Um, needless suffering is the name of the book. So, anyways, um, I showed up a lot in the state house to testify for, and we we actually created a number of pieces of legislation. You know, Gary Merchant, Gary and I became really good friends. We started a group on um looking at alternatives to opioids, how do we increase access, things like that. And then, you know, between that and then showing up at committees, all of a sudden I got people on both sides of the aisle saying, you should be up here, not out there. Meaning, and the committee not testifying. So they basically talked me into running and I ran. And I'll be honest, you know, in the current political climate, I kind of didn't think I had a chance. Because I mean, some people are really strongly politically associated with a part one party or the other. And, you know, I've been a Republican for my whole life, but you know, it's not like who I am. I don't like being limited to a word. Uh so I ran and I won. And um, these same people that asked me to run wanted me to be on Health and Human Services. So I said, that's fine. That's the only committee I want to be on.

Liz Canada: 11:40

And so the people who encourage you to run, I'm assuming, are Republicans because you're a registered Republican.

Rep. David Nagel: 11:45

Both sides of the party, both sides of the aisle. And they they were both fully aware that they were encouraging me and that they wanted me to be on this committee. So my first term, I did serve on that. And and I have to tell you, one thing really interesting happened while I was there is that, you know, in the beginning, there was all this pressure to vote with the party and stuff like that. But, you know, by the end of the session, all of a sudden, especially the last two HHS meetings, I was watching people vote their conscience. And you were getting to the point that when we were voting on different bills and issues and things like that, you couldn't predict the outcome based on party. And I think in health and human services, that's important because a lot of stuff that we talk about is really not party specific. It's how do we care for people in need? And I thought that was really special. So, you know, when I ran again and I won even more handily, and and I was honored to say that, like at least in my town, I won both parties' votes. So that meant a lot to me because it that was what I was trying to accomplish. So, wow, this is going to be even better. So we show up, and you know, um, we had a series of what I considered very dangerous pieces of legislation from a healthcare point of view that would adversely affect the people I care for. And I said, There's no way in this world, these are not compromisable issues. I just can't do this.

Liz Canada: 13:03

And what were some of those issues?

Rep. David Nagel: 13:05

There were five, and I'm gonna remember four and probably forget one, but there were two bills that had to do with so pay so-called market-based health care. You know, there was one bill that had to do with direct care facilities that would increase the uh ability of a direct care facility to come into New Hampshire without really providing any improvement in our health care other than profiting themselves. There was another bill on access uh where competitors to critical access hospitals could put their facilities. The current law was 15 miles, you couldn't build within 15 miles. They wanted to get rid of that totally. And to me, those are extremely dangerous bills because critical access hospitals are extremely important. We cannot survive as a community, especially in rural communities without them. And to put them at risk to profit somebody else just didn't really make a lot of sense to me. Um, the one you're gonna want to talk about later was the elimination of the New Hampshire Vaccine Association, which to me is just purely legislative malpractice. Um, that's the kindest thing I'll say about that. And then there was another one that really bothered me a lot. It was to eliminate the Office of Healthcare Equity from Health and Human Services. And well, there were more, and you're fully aware of these. There were a number of bills on gender-affirming care for adolescents, things like that. Those were to come later, but it was becoming more and more clear that on all these issues, we weren't going to be on the same side. Trevor Burrus, Jr.

Liz Canada: 14:30

The we being you and the rest of your party.

Rep. David Nagel: 14:34

No, just party leadership. I would not call it the rest of the party.

Liz Canada: 14:37

Ah, okay.

Rep. David Nagel: 14:38

I I would make a distinction there, and I think it's an important distinction. And so I, you know, that that they basically removed me from the committee because I w I think this is to me anti-intellectual, but like, you know, they weren't willing to listen to what I had to say. They claimed I wasn't willing to listen to what they had to say. Um, they clearly weren't hearing what I had to say, and they had clearly made up their mind before there was even a discussion. And I think this is the part that bothers me about politics in this day and age, and I don't think either party can take the high road on this, but you know, when you have a bill that comes before the legislature that the public um is opposed to it by a vote of something like 3,300 to 15, and the party still insists on passing the legislation or at least supporting it, you're not doing your job. Your job is to re represent the people. And if you're not going to represent the people, you shouldn't be here.

Liz Canada: 15:33

Well, I mean, the thing that you said earlier, the top three things that you have to listen to, which you heard at your orientation was number one, constituents, number two, conscience, number three, party. Yep. And so if 3,300 people are reaching out saying we oppose this, it feels like that satisfies the number one constituents what they're saying.

Rep. David Nagel: 15:54

I mean, and I would argue your conscience fits in there as well because your conscience is like, well, you know what? If 3,300 people are saying something other than what I'm thinking, then maybe I should question what I'm thinking. In the end, that's why they remove me. And this is what really bothered me a lot is to remove the New Hampshire Vaccine Association was a this is an incredible program that this state can be proud of. I mean, we're celebrated all over the country for creating this, and they want to get rid of it.

Liz Canada: 16:24

So let's let's talk about that. Tell me what the New Hampshire vaccine registration is. What what is it?

Rep. David Nagel: 16:30

So the the association was created basically for a way of getting number one is increasing access to vaccination for, you know, mostly children, but also to buy get the vaccines, you know, to buy in bulk, you know, so you could get a cost to cheat, you know, which is what we're trying to do with Canadian drugs, is like get our drugs cheaper, to buy in bulk, get them cheaper, get them to the providers at no cost so that they can administer them to the kids that need them and want them. And the the thing that's really important to know about this is that they don't make vaccine policy in the state. All they do is provide access to it. The the money for it basically is an assessment of you know the third party payers in the state. And they volunteer, you know, they were part of developing this program. It wasn't kind of like, you know, they, you know, did went along kicking and screaming. They were part of the development of the program and they do support it because basically it dramatically decreases their costs and improves the efficiency of administration. So the program was so popular that 14 states have replicated it. And we're celebrated for doing this. There's roughly a 30% reduction, you know, in the cost. So, I mean, you're saving money, you're getting people stuff that they want. You know, the opting out of getting vaccination is not removed. If you want to do that based on religious beliefs or whatever, you can still do that. It doesn't force anybody to get the vaccination, it just basically provides it for those at low cost. It I hate to use the word no-brainer because I hate it when used people use the term no-brainer, simple or common sense in politics. But to me, this is kind of fits in that regard. And um, one of the things we've heard very loudly, because I actually was still on the committee for the testimony, but we heard very loudly from primary care doctors is that, especially in rural, uh federally qualified health centers, places where dollars and cents are tough to come by, that it would make this dramatically harder for them to access these meds because they didn't have the ability up front to buy them, to put them in their offices to administer to their patients. So that would also dramatically increase somebody's gotta pay for it. So it's gonna be either the patient or it's gonna come from insurance at a substantially higher price.

Liz Canada: 18:43

So last year there was a bill to eliminate that entirely.

Rep. David Nagel: 18:47

That's correct.

Liz Canada: 18:48

And if that had happened, because I don't think it did, right? Like that did not pass.

Rep. David Nagel: 18:52

It did not pass.

Liz Canada: 18:53

And you were pulled off committee for opposing that legislation for not wanting to get rid of it. But if it had passed, it sounds like it would make health care more expensive for people. Is that what I'm hearing?

Rep. David Nagel: 19:04

So when we look at maximizing health care, we look at cost, access, and efficiency. It would have dramatically made access to that form of care harder. It would have increased the cost of it, and it would have dramatically decreased the efficiency of providing those vaccinations. So what we're in an O for three.

Liz Canada: 19:23

So I mean, those are the big three of I'm no math of admission, but that doesn't sound great.

Rep. David Nagel: 19:27

No, I mean, whenever you look at health care reform, that's what you're trying to accomplish. Improve access, improve efficiency, and the um either decrease the cost or at least slow down the rate of increase of cost. I mean, the reality is you're not going to decrease cost, but you don't want it to accelerate. You want to control it.

Liz Canada: 19:43

So your caucus leadership apparently drew a line in the sand and said, if you don't vote to get rid of this, which would make things more expensive for people, we're kicking you off the committee. And you held the line, I'm not, I'm not changing my vote.

Rep. David Nagel: 19:58

Um, I would have to defer that to them specifically because you know, the only thing that was really weird about this is that the day they kicked me off coincided with the vote on that bill, which is HB 524. Um, it was clearly one of the things that I don't think that was a a huge problem for them. It was those two free market bills that I referred to earlier that they were very specific about. That they said these were party priorities. Um, and I was like, why? You know, these are incredibly destructive bills, and who and I asked them very specifically whose decision was it to make it a priority? I have uh a stack of papers of all the bills that we have coming up before us that I will tell you very specifically. I have not looked through all of them yet.

Liz Canada: 20:45

But um There's only 1,147 listed on the website.

Rep. David Nagel: 20:52

That's a bargain. That's right. So um, you know, of all those bills, it's like, well, what do you decide is going to be a priority and how do you make your decision? And and and to me, those those bills were things that were lines in the sand for me as a doctor taking care of patients with a strong practice in the rural, rural New Hampshire, and having worked in settings like Alaska, which is very rural, um, I these bills are extremely dangerous. And what they did not understand was that I've seen how dangerous some of these bills can become in in real life, how they take advantage of people, how they harm people, but how they profit like venture capitalists and whomever. We people need to realize that healthcare is a service industry, it is not a profit industry. And this is very loud and clear in the book I wrote that when we put aside our winter reading, yeah, Dr.

Liz Canada: 21:45

Nagel's books.

Rep. David Nagel: 21:46

There you go. When we put aside, you know, our service to our fellow human being for the sake of the bottom line, then we've got a problem. And we know that's the problem with our healthcare system now. And I think when the political system Amplifies that, now we're creating a bigger problem.

Liz Canada: 22:03

I feel like I have also heard from granite staters that they don't want healthcare to be more expensive. That's just something I've heard uh a little chit-chat here and there, that people actually want their health care costs to go down, not to continue to go up.

Rep. David Nagel: 22:17

And I think there's a lot of good ways to do that. So the one committee I do chair is the State Health Assessment and Improvement Plan, where we basically try to coordinate the public health network of the state with the Department of Health and Human Services and create meaningful change and things like that. What we talk over and over and over again, it's all this market-based health care has led to what we call fragmentation of care and siloization, meaning nobody wants to work with each other. Um they all want to work on their own, and we're gonna use the most expensive, costly stuff that profits somebody to do that. So, like, for example, we have a totally dysfunctional electronic medical record that costs all of us a huge amount of money and does not provide any improvement in communication, and that creates a significant cost. Insurers want to make sure that we're not wasting their money, so they have a very expensive prior authorization process, which increases costs and decreases access to care. Because people don't work with each other, you know, we're leaving people out of the healthcare network that can provide valuable services for people. There's also a monopolization of healthcare in the sense that we have certain types of doctors that seem to be able to control the discussion of who gets what's money and certain groups persistently get left out. Like, for example, mental health, primary care, um, substance use disorder, things like that. Those people get shortchanged, which means their patients get shortchanged. And all of a sudden now that becomes an access problem because we didn't have enough of those people to do. Whereas if you're a sports medicine person and you have an athletic injury, you have absolutely no trouble finding somebody to take care of you. And that creates access cost and efficiency problems. So we try to do to solve all that. Um, number one, I I had several bills on prior authorization reform, all of which have passed so far. We I also tried to get rid of the electronic medical record as a mandatory thing. Um, I have several bills on it creating integrative models of care, not just for pain, which is my primary focus, but for other things as well, so that we can learn how to work together like we used to do before the advent of the computer or the cell phone, all that kind of stuff. Because believe it or not, at one point we as doctors used to talk to each other face to face and solve problems that way.

Liz Canada: 24:33

We all did at some point, once upon a time. Everybody talked to one another face to face.

Rep. David Nagel: 24:37

And it's amazing. Like I had this happen more than one time. Like, patient comes in to see me, I do something for them. There's a problem that happens after. Used to be they would call me directly because they have my phone number. Now they go through a service that tells them to go to the emergency room. They go to the emergency room, the ER doctor never calls me. And now all of a sudden, they bring up a $10,000 bill when all it took is one stupid little phone call from me. And I said, you know what? I know what's going on with you. This is all you have to do. Boom. You know, problem solved, and we just save the system $10,000. And this happened, just multiply that. How often it happens. The reason why this is gonna become a big problem is that with corporate takeover of healthcare, which is definitely happening. Um, when I started, 80% of doctors are in private practice. Now the number is about 15%. So somebody owns you, they tell you, you know, what you're you're gonna do and what you're not gonna do. They create this silo. We're also gonna have a huge loss of health insured coming up. These people will not have ready access to care, but doctors have a dissatisfaction with their practice, they don't stay anywhere very long. So now you have a problem with continuity of care. So your doctor doesn't know you. And you may see a different provider every visit, which means they don't know you. Like I have patients I've followed for 30 years. Because of that, I know them. I know, I know what psychologically motivates them, I know how to interact with them, but that doesn't happen. And because of that, you're gonna see this flocking to the ER for care because people aren't gonna have Medicaid anymore. They're not gonna have um food security, things like that. And now you're gonna get this significant amplification of unnecessary expenses because the ER doctor doesn't know you at all, nor are they gonna know you after that day.

Liz Canada: 26:18

You mentioned much earlier critical access hospitals. What does that mean? Is that just any hospital? Or is it like a special, special, unique unicorn hospital? What's a critical access hospital?

Rep. David Nagel: 26:30

I mean, it's a special the designated hospital, and I'm not gonna be able to give you the formal definition, but they're recognized because they provide important services in an access limited environment for them to function in in the black, so to speak, financially, it's not gonna happen. So they're basically um given a relatively competitive advantage so that so that they can provide a service that nobody else can provide. So, for example, we talked earlier about those market-based approaches. Well, I said you you suddenly remove their competitive advantage by putting somebody in that's only gonna put take on a specific service. Those facilities will only do that if they can generate a lot of revenue doing it. So, what they'll do is they'll cherry pick is the fancy word we use. Like, for example, let's say in the North Country, orthopedics generates a lot of revenue, which it does. And, you know, for the federally qualified health center, they're not gonna have a huge orthopedic practice, but that's important for them for their bottom line. These other people come in because now we've said that's okay. And all of a sudden they're gonna siphon all that off, they're gonna create their own surgery center, they're gonna create their own MRI, and all of a sudden now you've taken all this income away from that critical access hospital and make it even more difficult for them to survive. So the difference is when I do that, which I have done, I own two of those places at one point in my career. That's money that we take away from the hospital, but that goes to us as profit. The hospital uses that money to subsidize other things that don't make money. So, like, for example, mental health, primary care. Primary care is not a moneymaker. It also adversely affects your ability to take care of people in need. Like a lot of these for-profit places don't accept Medicaid. Right. I mean, Medicaid pays roughly 10 cents on the dollar. It's a money loser. And if, you know, I believe it's everybody's responsibility as a health care provider to take care of those people, you know. And you can limit your percentages, but you need to take care of them. And but they don't do it because they don't have to, because they're for profit. And so who gets the burden of it? The federally qualified health center. Or I'm sorry, the critical access hospital and the federally qualified health centers too, which is a similar entity.

Liz Canada: 28:42

I had an episode um a bit ago about Medicaid specifically, and I think we recorded it probably in the summer, maybe the time means nothing at this point. Yeah. But we weren't sure what it would look like in terms of all the impacts on Medicaid, right? Like the federal budget that just went through. I know changes are happening at the state level too, but it sounds like we should expect to see a lot of people lose their health insurance come January 1st.

Rep. David Nagel: 29:09

I mean, the yes the estimate nationwide is eight to ten million people will lose their health insurance. You know, you can say what you want about the Affordable Care Act. There were significant flaws in it. Um, and we could talk at length about that. A former Democrat governor and I had a discussion about this real time when it was ongoing, and he just looked at me, he said, this is gonna dramatically decrease access and increase cost. And um he, I think he just said cost, but you you decrease access by increasing costs. So, like for example, my premiums and my deductibles and my co-pays all go up. I'm not gonna go to the doctor if I don't have the money to go. So, yeah, you might have insurance, but you don't have greater access. So that that was kind of what we predicted would happen, and that is what happens. So, but at the same point, it did give people insurance. So now you're gonna take Medicaid and you're gonna make significant cuts. And I was just in Washington and we got to meet with leaders of the different departments and the eight guy from HHS, we were talking, and I asked him specifically, what are you gonna what's the plan to deal with these eight to ten million uninsured people and the ramifications for our society? And he he did not have a good answer, which surprised me because by this point he should. Um, but then he said, Well, we're the clock is ticking.

Liz Canada: 30:26

Yeah, the clock is ticking on that.

Rep. David Nagel: 30:28

Well, it's beyond ticking, and so like um it already blew up, but well, it's half blown up. But he said that um, well, the goal was to decrease fraud, waste, and abuse. And I said, I understand that, but any system will have fraud, waste, and abuse. You can't prevent it. So the amount what a better question is what amount of fraud, waste, and abuse is tolerable? And and and the same point is, well, you're gonna have collateral damage of eight to ten million people without insurance. Me, myself, about 60% of my patients right now are on Medicaid. I'm at fortunately at the point in my career I can do what I want. So, you know, I don't need money anymore. Um, but my whole career, I've I've never discriminated based on insurance. And if a person has no insurance, we try to make, I can make their life miserable by not providing the care that they need. And then you create a bigger problem. The other thing that we've worked a lot on, the state health assessment, I'm also on a vice chair of the opioid abatement commission, is like for both of these things, we have a lot of public money. We have the rural access transformation funds, which is gonna be over 100 million a year. We have $330 million of opioid money is like, well, what we want to use it for is to prevent the problems that we end up treating down the road. So how do we use that money to prevent? If you're not providing access to care, you've now created a prevention problem. You know, you might feel good for a couple of months, but at some point you're gonna have to, you the all this stuff's gonna hit the fan, and we're gonna have to deal with that. The other thing we should also know is that one federally qualified health center in the state are already closed. Um, and another is I don't know if they've closed yet, but they're on their way to doing it. That's an access problem for lower income people. Trevor Burrus, Jr.

Liz Canada: 32:08

Because federally qualified health centers serve patients regardless if they have health insurance. Is that correct? Like that's their responsibility. That's what they are there to do is provide health services for folks who literally cannot go to another place because they do not have the ability to pay or the insurance to cover it. And when I had that episode about Medicaid, we talked a bit about federally qualified health centers and that that will lead when those health centers close, if they close or when they close, it means more people go to emergency rooms. And that is only going to make health care for everybody more expensive and less accessible. That was what I took away from that episode.

Rep. David Nagel: 32:50

No, and I think that that's totally accurate. And I I'm gonna throw in a plug for federally qualified health centers. So shout out to the federally qualified health centers.

Liz Canada: 33:00

We love them.

Rep. David Nagel: 33:00

We all have choices in life, what we're gonna do and how it's gonna pay us and stuff like that. The people that work in those facilities walk on water because they can do better financially anywhere else than they can do working for one of those places, but they still choose to do it, kind of like our mental health workers, our correctional workers, our childcare people. They can all do better somewhere else.

Liz Canada: 33:24

And you say do better is made like financially, they could make more money somewhere else.

Rep. David Nagel: 33:28

Yeah, but they choose to do that. And and and and they should their actions should be applauded and supported. And what I'm seeing right now, like for example, a number of towns and counties have have um decreased their funding of the behaviour mental health clinics. So, well, what? You know, you know, it's not a lot of money that you're spending to support a very important service in our community. And what the thing that bothered me at one of the meetings was that one of the delegates was criticizing the people that work in these places. Like if they really care, they wouldn't leave. I go, they have to pay bills, and what are you talking about? You know, yeah. Um, but these are like the best people on the planet. And again, since I brought up the Jesus reference earlier, I mean, they're very much living the message of you know, caring for people in need, which is what the whole message is about. I mean, that's all it's about is respect and love. It's not about anything else, and they're living it, and we're not supporting them.

Liz Canada: 34:24

That's the basic value of uh you take care of people who are in need. Yep. That's that's the whole message, is my understanding of that too. All right. Well, shout out to the Federally Qualified Health Centers. They are doing incredible work and need more funding, is my understanding too. So you're a state rep, Representative Nagel, but you're one of 400. Yeah. So how can you make change on these things? Like, how can you support the support the good and fight the bad? Like what's possible? I mean, the what's possible for someone who is in the majority? You are you are part of the majority party in the state house. What can what can happen?

Rep. David Nagel: 35:03

I start with this concept of number one is you know, like you analyze the situation, look at it from all sides, and try to figure out well, what are the ramifications, what's the good and the bad, and then come to a decision about what you want to do and feel comfortable with that. Your decision may be um contrary to what the people in power want, but you know, you need to voice what your concerns are, and then you draw your lines in the sand and say this is negotiable and this is not negotiable. And then you stick with that, but you plant your seed of your message over and over and over again. The problem is if you stay quiet and just go along with the crowd, that you're creating a much bigger problem, and you maybe just shouldn't even be there. There's 400 people with all different kinds of expertise, and some people are really good engineers, some people are good with this, that, the other thing. Well, this is what I do, this is what I've lived, I wrote a book on it. So I must know something. For me to stay quiet would be crazy, you know, it would be wrong. The challenge for me over the summer was like, like, well, where do I belong in this whole political mess? And I I will be honest, I talked to people on both sides of the aisle about that. Like, what do you think I should do? No, I I don't know what the right thing to do is.

Liz Canada: 36:21

I I Well, and I think, you know, in the in my full-time job, I work with lawmakers and I've spent a lot of time talking to uh Republican lawmakers who support reproductive rights. And quite a few of your colleagues have gotten primaried out or pushed out of their of the caucus that you are also in. And it feels like things have shifted where, you know, there used to be many more folks who were similar to you, of you know, thinking about your constituents, thinking about your conscience and what is right in public health. And those individuals were pushed out from the statehouse.

Rep. David Nagel: 36:59

And and I'll have to say, I'm the luckiest guy on the planet. Um, I wear a lot of hats in my life. I don't do I need this job. No. I mean, you know, we my friends and I um But it's a hundred dollars representative.

Liz Canada: 37:13

Why wouldn't you want a hundred?

Rep. David Nagel: 37:15

Exactly. But I mean, I I we we started two nonprofits, we do a whole lot of other things. I really work with some wonderful people in a lot of different settings in my life. If I left tomorrow, you know, I'm gonna still be busy. You know, it I it would be egotistical for me to say what that means for the state, because I'm not that important in the scheme of things, but people that are willing to stand up for that middle, they're really important. And um, you know, my my best friend in the legislature didn't get re-elected. I I don't fully know why, but you know, that was a huge loss for the legislature, much more than losing me. I mean, we we always joke because he and I used to do everything together, and he was the brains and I was the passion. So I I more than one peep person said together we made a really good team. And I, you know, I I I really miss him a lot. And I think it's not a good thing he's not there. You know, he was a Democrat, I'm a Republican, but we we could always talk about stuff and you know, and then work things together, and you know, I could tell him, you know, that's a bad idea, and he could tell me that's a bad idea, and then we could argue or talk about it and come to some sort of resolution. And it's those people that we need in the legislature. And I don't know why they don't run. I I don't. I can't speak for the progressive left because I I I don't know how things work in that world, but I do know, you know, in the libertarian right, they are incredibly motivated people to get politically involved. And I mean, they move to this state merely to get politically involved, you know, which I find to be a really an odd thing to do, but that's what they do. And, you know, if if nobody else is gonna run and they are, I mean it's not much you can do about it. So what we'd like to do is energize the middle.

Liz Canada: 38:57

So it sounds like you're making a pitch for a listener who's thinking, Run, maybe I should run for office. If you're a reasonable person who thinks about things, you could be perfect in the statehouse.

Rep. David Nagel: 39:11

There's a line with something like, I'm gonna get this wrong. If you don't have a seat at the table, your dinner or something like that.

Liz Canada: 39:17

Yeah.

Rep. David Nagel: 39:18

Did I say that right?

Liz Canada: 39:18

You're gonna find yourself on the menu somehow.

Rep. David Nagel: 39:21

That's it. That's it. Exactly.

Liz Canada: 39:22

Yeah. We didn't talk very much about vaccines, and that's okay. The conversation went in a different direction.

Rep. David Nagel: 39:26

Yeah, no, and we didn't really talk about that. And I kind of did want to. Um, but that would be a long discussion, I would think. But I I do want to say that one of the the reason why this is important to me, early in my career, I created the first and only um program for post-polio syndrome in New Hampshire. And I got to see people that had suffered through polio. And, you know, the t millions of people we saved from that horrible illness of the polio vaccination was incredible. Um, when I lived in Alaska, um, there was, you know, one of the problems with vaccination in Alaska was, you know, just some people in rural environments, they don't have access. So we had an outbreak of, you know, protustas souping cough, you know, that is totally preventable, especially in adults, it can lead to sort of serious morbidity or mortality. I've had the misunt privileges seeing one patient with tetanus. The fact that we can prevent that with tetanus vaccination is incredible. I just, it's really important that we realize how important these vaccinations are. And to decrease access to them, we're just asking to go backwards in time. When, you know, like one of the other diseases that I got to see firsthand in Alaska was tuberculosis. And granted, we don't have vaccination for that, but a lot of these things through clean air, clean water, uh clean food supplies, and vaccination, we were able to eliminate.

Liz Canada: 40:50

I don't think we should want to get polio to come back. No, I think we should continue to not have that. That's probably for the best.

Rep. David Nagel: 40:58

I get the issues with the COVID. That was I still have really mixed feelings about the way that we went about doing that. I mean, in a sense, you know, the mRNA, we can argue whether it's a vaccination or an immunization because they're not really quite the same. But was that a good thing or not? But if you look at all the outcome data on it so far, the number of lives saved, uh, the morbidity avoided has been pretty amazing. And, you know, when you choose to focus on the negative, um, there's just so much hyperbolic thinking about the side effects and all that. There's never been a medical intervention in human history that did not have a side effect, which is why in the modern Hippocratic Oath, we do not say do no harm. That those words do not exist in the Hippocratic Oath. And oh believe it or not, the gentleman I that wrote the modern Hippocratic Oath was a teacher of mine. Um, his name was Louis Lasagna, and that is why the modern Hippocratic Oath is called the Lasagna Hippocratic Oath. It has nothing to do with an Italian feast.

Liz Canada: 41:59

Lasagna is incredible.

Rep. David Nagel: 42:00

Yep.

Liz Canada: 42:01

Take that in whatever direction you'd like. So was Louis.

Rep. David Nagel: 42:04

He was an amazing man. And um, but that's why it's not in there, because we have to balance risk benefits. And these are important things, and we the legislation that's being proposed locally and nationally are really I understand it from a libertarian point of view. Um, you know, forcing people to do stuff that they might not want to do. But at the same point, these are from a herd point of view, from a public health point of view, these are really important interventions. And I think it's I think they need to be looked at that way. That's in a nutshell.

Liz Canada: 42:36

That's it. We don't want polio and that's it's as simple as that.

Rep. David Nagel: 42:45

And I will throw another plug for our uh Department of Health and Human Services because they're all sold. They walk on water, those people. We really ask our people to do a lot with very limited resources, and you could argue whether that's good or bad. I don't know.

Liz Canada: 42:59

Feels like it's bad.

Rep. David Nagel: 43:01

But it's amazing what they do do, and I just can't believe they would do what they do with what little they get.

Liz Canada: 43:06

Imagine how much more they could do.

Rep. David Nagel: 43:08

Yeah.

Liz Canada: 43:08

If they didn't have so little.