February 3, 2026 • 43 mins
Maybe we shouldn't bring back polio? Question mark?
Liz talks with Rep. David Nagel (a physician! a Republican!) about vaccines, public health, and why he is no longer on a New Hampshire House standing committee. Spoiler alert: not his choice.
This episode was recorded on December 22, 2025. Pairs well with the Medicaid: It's Health Insurance! episode with Kristine Stoddard.
Become a monthly supporter of the show
Links:
- Nagel says choosing principles over party got him booted from health committee (The Laconia Daily Sun)
- GOP House member says party leaders tried to intimidate him before booting him off committee (NH Bulletin)
- House Health and Human Services Committee advances bill to repeal NH Vaccine Association (WMUR)
- Hearing scheduled for bill that would end mandatory school vaccinations in New Hampshire (Concord Monitor)
- Lawmaker wants to end hepatitis B vaccine requirement to align NH with Kennedy’s CDC (NH Bulletin)
- Reps. Sherman Packard & Alexis Simpson: Holocaust denialism has no place in the NH Legislature (Union Leader)
- Following leaked messages, House Republican education chair says she favors politically segregated schools (Concord Monitor)
- Op-Eds about the NH Vaccine Association
Have an idea for an upcoming episode? Email Liz: newhampshirehasissues@gmail.com
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rep. David Nagel (00:00):
So, uh, gentlemen I've known for a long
time.
Um, we were in a casualconversation earlier today.
In the midst of theconversation, he just suddenly
asked me, I I've been followingyour voting record.
And he goes, Are you sureyou're in the right party?
And the reason why the questionwas interesting was, I mean,
I've known him for a long time,but we've never ever talked
(00:21):
politically.
So I really didn't know whatside of the fence he was on.
So I wasn't sure where he wasgoing with that.
So I said, based on thelegislative options that I've
been given this year, I thought57% was about right, um, or
50-50 somewhere in that range.
Because I just think we weregiven some really bad choices
(00:41):
this year and some bad bills.
And, you know, then all of asudden I find out this gentleman
who all these years I thoughtwas a conservative Republican
was actually quite the opposite.
So yeah, it was kind of a funconversation.
And, you know, we left it offwith the discussion are you
changing parties?
That kind of thing.
Liz Canada (00:58):
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 NewHampshire has Issues, and I'm
your host, Liz Canada.
(01:20):
I'm recording this on GroundhogDay, February 2nd, about nine
o'clock at night.
Representative Nagel and Irecorded this episode a few days
before Christmas.
He references that a few timesin this episode.
Oh, a few things for context,because a lot has happened since
then.
One story you may have heard isof the leaked group chat by
Republican State Reps on theHouse Education Policy Committee
(01:42):
here in New Hampshire.
Oh, and there's a reference tosegregating schools in some way.
The story you may not haveheard was from two weeks ago.
Another Republican state reptestified uh in a public hearing
and uh used arguments that areof Holocaust denialism.
A few days ago, the Speaker ofthe House, Sherman Packard, who
(02:04):
is a Republican, and AlexisSimpson, the Democratic leader
of the House, co-authored anop-ed that talked about how
Holocaust denialism has no placein New Hampshire.
And I, for one, was very gladto see that op-ed published by
the two of them.
Here's what has not happened,however.
As far as I can tell, thatRepublican state representative
(02:24):
who spoke in that publichearing, he still serves on his
outstanding committee of theHouse.
The House Education Policymembers still serve on their
committee as well.
And I say all of this becausewhat you'll hear in this episode
was that last yearRepresentative David Nagel
disagreed with that same partyleadership on issues of public
(02:47):
health, and he was removed fromhis committee.
You'll hear more about it inthis episode.
I asked him to come on thepodcast because uh he is a
doctor, he is a staterepresentative, he is a
Republican.
And there are quite a few billsin the New Hampshire
legislature that would roll backuh vaccination requirements or
immunization requirements.
(03:08):
We talk about one of thosebills, House Bill 524, and we
mention that it did not passlast year because it was a bill
from last year.
But as a note, uh it's notgone.
It's still in the state houseworking its way through the
process.
But there are other bills, andsome of them are coming up this
week, actually.
There is a bill to remove allimmunization requirements for
schools and child care centersin New Hampshire.
(03:30):
There's a bill to uh prohibit alot of state agencies from
educating the public aboutvaccines.
This isn't hypothetical, butthese are pieces of legislation
happening here in New Hampshireright 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 youwould like to support the show,
(03:51):
you can become a monthlysupporter at patreon.com slash
NH has issues.
So thank you for listening.
Let me give your intro.
Rep. David Nagel (04:00):
All right.
Liz Canada (04:00):
Welcome to New Hampshire Has Issues, the
podcast that dares to ask, whatwill RFK Jr.
claim listening to this episodewill cause?
That's the best through linethat I could come up with.
That isn't too offensive.
It's the best I could do.
Rep. David Nagel (04:17):
Mine is why do we treat stigmatized
populations the way we do?
Because that's the whole basisfor who I am and what I do.
Liz Canada (04:26):
We'll get into those stigmatized populations, I
imagine, in our time together.
Sure.
All right, well.
Welcome to New Hampshire HasIssues.
I am your host, Liz Canada.
And my guest today is a NewHampshire state representative
and a physician, Dr.
David Nagel, RepresentativeDavid Nagel, and he represents
(04:47):
Gilminton, Guildford, andLaconia Ward 2.
Representative Nagel, welcometo the show.
Thank you for being here.
Rep. David Nagel (04:55):
Thank you.
Thanks for having me.
Liz Canada (04:57):
Listeners of the show know that I'm terrible at
geography.
How far am I in Exeter fromyour district that you
represent?
Rep. David Nagel (05:05):
It takes me 54 minutes to get to Exeter from
my house.
Gilminton is just a tad uhsouth of um the tip of Lake
Winnap, southern tip of LakeWinnipesaukee.
We're just west of Alton andjust about six miles south of
Laconia.
And Guilford and Gilminton areseparated by the Belknap
Mountains.
Liz Canada (05:26):
We're big fans of the Belknaps in our house.
Rep. David Nagel (05:28):
And his historically, uh Gilminton and
Guilford were actually one towngoing back to the 1700s.
Um they split up in the early1800s.
So I I don't know why they putGilminton and Guilford in the
same district.
Personally, Gilminton shouldhave its own legislator.
I really think that's kind ofsad that that they did what they
(05:48):
did, but um, I'm not involvedin those decisions.
Liz Canada (05:52):
And maps won't be redrawn until after the 2030
election.
So we have a little bit oftime, not a ton of time, but a
little bit of time until thathappens.
Rep. David Nagel (06:00):
Yeah, historically, when you walk into
the legislative officebuilding, to the right is a
picture that is George Roberts.
George is from Gilminton, hewas a former speaker of the
House in the 1970s.
And for probably back as longas there's been state
representatives, Gilminton hasalways had its state owns
representative up until aboutmaybe 15, 20 years ago.
Liz Canada (06:23):
Oh, interesting.
Rep. David Nagel (06:25):
Yeah.
Liz Canada (06:25):
Hmm.
I guess it always depends onwho draws the maps and what
their purpose is.
Um we'll leave a little mysterythere too, I guess.
We'll see.
Rep. David Nagel (06:33):
No mystery in that statement, believe me.
They're none.
Liz Canada (06:38):
Yeah, I bet I bet that's right.
I bet that's right.
Rep. David Nagel (06:41):
Nope.
Liz Canada (06:41):
So, representative, I'm gonna I like to start with a
simple question.
You're a physician and alegislator, and specifically,
spoiler alert, you are aRepublican New Hampshire state
representative.
When those two roles perhapsclash with one another, which I
think probably happens when itcomes to public health issues,
(07:03):
how do you handle it?
How do you handle when yourrole as a physician and your
role as a legislator sort ofbump up with one another?
Rep. David Nagel (07:10):
I mean, to me, it's not a difficult issue.
I, you know, I know for somepeople it is, and I think that
may be the problem with politicsin general.
You know, we were taught theday I showed up at the state
house, we took these classes andthey said your order of
responsibility is yourconstituents, then your
conscience, and then the party.
That has been said a milliontimes, and both parties say it.
(07:32):
I've given two unanimousconsent addresses on the House
floor, challenging people thatwe speak words all the time of
promising who we are, what we'regonna do.
The question then is do you doit or not?
And um, last I checked about 20uh 25 years ago, somebody was
born that we're gonna celebratehis birthday in a couple days.
(07:53):
And his sole purpose to be wasto challenge people.
This is what you say you'regonna do, this is what you do,
this is the gap in between, andhow do you fix the barrier in
between?
And to be honest, when I lookat things, I look first at what
the needs of the people Irepresent are, which is not just
my constituents, to be honest,it's my patients.
Um, I've advocated for therights of people with
(08:15):
disabilities for be well beforeI became a doctor.
So I didn't just begin when Ibecame a doctor, which is why I
became a doctor.
So to me, that all comes first.
And if I see party politicsendangering the people I
represent, then I it's not adifficult decision what
direction to go.
Liz Canada (08:33):
Uh near the beginning of the of the podcast
experience, I had the Democraticleader of the House, Alexis
Simpson, on the podcast.
And I had asked her to come onbecause I had an episode about
the House and the Senate and theExecutive Council.
And I just asked her, tell meabout the New Hampshire House,
how does it all work?
And she shared that, you know,there's 400 of you all, and you
(08:53):
all serve on committees.
And so you are a physician, youare a legislator.
So uh loaded question.
What New Hampshire Housecommittee, Representative Nagel,
do you serve on?
Rep. David Nagel (09:05):
Um if you're talking in terms of standing
committees, the answer at thispoint is none.
Liz Canada (09:09):
None committees, zero committees.
None.
What happened?
Why?
Why are you on no nocommittees?
Rep. David Nagel (09:20):
So um basically
Liz Canada (09:22):
Did you choose to be on no committees?
Let's start there.
Rep. David Nagel (09:26):
I I will tell you how I got to run in the
first place because it's germaneto the question.
Liz Canada (09:30):
So that's such a legislator thing to say.
It's germane to the question.
Rep. David Nagel (09:35):
It is, yeah.
Liz Canada (09:36):
So it's perfect.
Rep. David Nagel (09:37):
So I I um, like I said, I've been
advocating for people withdisabilities for a long time.
I wrote a book on pain carepolicy in the United States
about seven years ago.
Um, totally unintentionally,that book sold all over the
world.
And I was kind of like reallyshocked.
It was kind of like a yeah duhbook, you know.
I was just saying what I sawevery day.
(09:58):
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 ofpeople to figure out like, how
do you make what I just wrotereal?
And so um, I remember one ofthe individuals in our group
just said, this book is yourplaybook.
Just take it and run.
So then I realized if I'm gonnabe dumb enough to say this
(10:21):
stuff, then I have to dosomething about it.
So we started looking at thepolitics of healthcare in New
Hampshire, particularlyinvolving the care of people
that are stigmatized.
And that's a broad thing thatwe could talk about as we go
along.
But, you know, well, how are wenot helping those people?
Why are they sufferingneedlessly?
Um, needless suffering is thename of the book.
(10:41):
So, anyways, um, I showed up alot in the state house to
testify for, and we we actuallycreated a number of pieces of
legislation.
You know, Gary Merchant, Garyand I became really good
friends.
We started a group on umlooking at alternatives to
opioids, how do we increaseaccess, things like that.
And then, you know, betweenthat and then showing up at
(11:01):
committees, all of a sudden Igot people on both sides of the
aisle saying, you should be uphere, not out there.
Meaning, and the committee nottestifying.
So they basically talked meinto running and I ran.
And I'll be honest, you know,in the current political
climate, I kind of didn't thinkI had a chance.
Because I mean, some people arereally strongly politically
associated with a part one partyor the other.
(11:22):
And, you know, I've been aRepublican for my whole life,
but you know, it's not like whoI am.
I don't like being limited to aword.
Uh so I ran and I won.
And um, these same people thatasked me to run wanted me to be
on Health and Human Services.
So I said, that's fine.
That's the only committee Iwant to be on.
Liz Canada (11:40):
And so the people who encourage you to run, I'm
assuming, are Republicansbecause 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 fullyaware that they were encouraging
me and that they wanted me tobe on this committee.
So my first term, I did serveon that.
And and I have to tell you, onething really interesting
happened while I was there isthat, you know, in the
beginning, there was all thispressure to vote with the party
and stuff like that.
But, you know, by the end ofthe session, all of a sudden,
(12:08):
especially the last two HHSmeetings, I was watching people
vote their conscience.
And you were getting to thepoint that when we were voting
on different bills and issuesand things like that, you
couldn't predict the outcomebased on party.
And I think in health and humanservices, that's important
because a lot of stuff that wetalk about is really not party
specific.
It's how do we care for peoplein need?
(12:30):
And I thought that was reallyspecial.
So, you know, when I ran againand 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 mebecause it that was what I was
trying to accomplish.
So, wow, this is going to beeven better.
So we show up, and you know,um, we had a series of what I
(12:51):
considered very dangerous piecesof legislation from a
healthcare point of view thatwould adversely affect the
people I care for.
And I said, There's no way inthis 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-calledmarket-based health care.
You know, there was one billthat had to do with direct care
facilities that would increasethe uh ability of a direct care
facility to come into NewHampshire without really
providing any improvement in ourhealth care other than
(13:27):
profiting themselves.
There was another bill onaccess uh where competitors to
critical access hospitals couldput their facilities.
The current law was 15 miles,you couldn't build within 15
miles.
They wanted to get rid of thattotally.
And to me, those are extremelydangerous bills because critical
access hospitals are extremelyimportant.
We cannot survive as acommunity, especially in rural
(13:50):
communities without them.
And to put them at risk toprofit somebody else just didn't
really make a lot of sense tome.
Um, the one you're gonna wantto talk about later was the
elimination of the New HampshireVaccine Association, which to
me is just purely legislativemalpractice.
Um, that's the kindest thingI'll say about that.
And then there was another onethat really bothered me a lot.
(14:12):
It was to eliminate the Officeof Healthcare Equity from Health
and Human Services.
And well, there were more, andyou're fully aware of these.
There were a number of bills ongender-affirming care for
adolescents, things like that.
Those were to come later, butit 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 ofthe 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 importantdistinction.
And so I, you know, that thatthey basically removed me from
the committee because I w Ithink this is to me
anti-intellectual, but like, youknow, they weren't willing to
listen to what I had to say.
They claimed I wasn't willingto listen to what they had to
say.
Um, they clearly weren'thearing what I had to say, and
(15:00):
they had clearly made up theirmind before there was even a
discussion.
And I think this is the partthat bothers me about politics
in this day and age, and I don'tthink either party can take the
high road on this, but youknow, when you have a bill that
comes before the legislaturethat the public um is opposed to
it by a vote of something like3,300 to 15, and the party still
(15:21):
insists on passing thelegislation or at least
supporting it, you're not doingyour job.
Your job is to re represent thepeople.
And if you're not going torepresent 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 haveto listen to, which you heard at
your orientation was numberone, constituents, number two,
conscience, number three, party.
Yep.
And so if 3,300 people arereaching out saying we oppose
this, it feels like thatsatisfies the number one
constituents what they'resaying.
Rep. David Nagel (15:54):
I mean, and I would argue your conscience fits
in there as well because yourconscience is like, well, you
know what?
If 3,300 people are sayingsomething other than what I'm
thinking, then maybe I shouldquestion what I'm thinking.
In the end, that's why theyremove me.
And this is what reallybothered me a lot is to remove
the New Hampshire VaccineAssociation was a this is an
(16:16):
incredible program that thisstate can be proud of.
I mean, we're celebrated allover the country for creating
this, and they want to get ridof it.
Liz Canada (16:24):
So let's let's talk about that.
Tell me what the New Hampshirevaccine registration is.
What what is it?
Rep. David Nagel (16:30):
So the the association was created
basically for a way of gettingnumber one is increasing access
to vaccination for, you know,mostly children, but also to buy
get the vaccines, you know, tobuy in bulk, you know, so you
could get a cost to cheat, youknow, which is what we're trying
to do with Canadian drugs, islike get our drugs cheaper, to
buy in bulk, get them cheaper,get them to the providers at no
(16:53):
cost so that they can administerthem to the kids that need them
and want them.
And the the thing that's reallyimportant to know about this is
that they don't make vaccinepolicy in the state.
All they do is provide accessto it.
The the money for it basicallyis an assessment of you know the
third party payers in thestate.
And they volunteer, you know,they were part of developing
(17:15):
this program.
It wasn't kind of like, youknow, they, you know, did went
along kicking and screaming.
They were part of thedevelopment of the program and
they do support it becausebasically it dramatically
decreases their costs andimproves the efficiency of
administration.
So the program was so popularthat 14 states have replicated
it.
And we're celebrated for doingthis.
(17:36):
There's roughly a 30%reduction, you know, in the
cost.
So, I mean, you're savingmoney, you're getting people
stuff that they want.
You know, the opting out ofgetting vaccination is not
removed.
If you want to do that based onreligious beliefs or whatever,
you can still do that.
It doesn't force anybody to getthe vaccination, it just
basically provides it for thoseat low cost.
(17:57):
It I hate to use the wordno-brainer because I hate it
when used people use the termno-brainer, simple or common
sense in politics.
But to me, this is kind of fitsin that regard.
And um, one of the things we'veheard very loudly, because I
actually was still on thecommittee for the testimony, but
we heard very loudly fromprimary care doctors is that,
(18:18):
especially in rural, uhfederally qualified health
centers, places where dollarsand cents are tough to come by,
that it would make thisdramatically harder for them to
access these meds because theydidn't have the ability up front
to buy them, to put them intheir offices to administer to
their patients.
So that would also dramaticallyincrease somebody's gotta pay
for it.
So it's gonna be either thepatient or it's gonna come from
(18:40):
insurance at a substantiallyhigher 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 toget rid of it.
But if it had passed, it soundslike 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, andefficiency.
It would have dramatically madeaccess to that form of care
harder.
It would have increased thecost of it, and it would have
dramatically decreased theefficiency of providing those
vaccinations.
So what we're in an O forthree.
Liz Canada (19:23):
So I mean, those are the big three of I'm no math of
admission, but that doesn'tsound great.
Rep. David Nagel (19:27):
No, I mean, whenever you look at health care
reform, that's what you'retrying to accomplish.
Improve access, improveefficiency, and the um either
decrease the cost or at leastslow down the rate of increase
of cost.
I mean, the reality is you'renot 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, ifyou don't vote to get rid of
this, which would make thingsmore 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 daythey kicked me off coincided
with the vote on that bill,which is HB 524.
Um, it was clearly one of thethings that I don't think that
was a a huge problem for them.
It was those two free marketbills that I referred to earlier
(20:20):
that they were very specificabout.
That they said these were partypriorities.
Um, and I was like, why?
You know, these are incrediblydestructive bills, and who and I
asked them very specificallywhose decision was it to make it
a priority?
I have uh a stack of papers ofall the bills that we have
coming up before us that I willtell you very specifically.
(20:43):
I have not looked through allof 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 thosebills, it's like, well, what do
you decide is going to be apriority and how do you make
your decision?
And and and to me, those thosebills were things that were
lines in the sand for me as adoctor taking care of patients
with a strong practice in therural, rural New Hampshire, and
(21:13):
having worked in settings likeAlaska, which is very rural, um,
I these bills are extremelydangerous.
And what they did notunderstand was that I've seen
how dangerous some of thesebills can become in in real
life, how they take advantage ofpeople, how they harm people,
but how they profit like venturecapitalists and whomever.
We people need to realize thathealthcare is a service
(21:36):
industry, it is not a profitindustry.
And this is very loud and clearin 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 bottomline, then we've got a problem.
And we know that's the problemwith our healthcare system now.
And I think when the politicalsystem 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 healthcareto be more expensive.
That's just something I'veheard uh a little chit-chat here
and there, that people actuallywant their health care costs to
go down, not to continue to goup.
Rep. David Nagel (22:17):
And I think there's a lot of good ways to do
that.
So the one committee I do chairis the State Health Assessment
and Improvement Plan, where webasically try to coordinate the
public health network of thestate with the Department of
Health and Human Services andcreate meaningful change and
things like that.
What we talk over and over andover again, it's all this
market-based health care has ledto what we call fragmentation
(22:39):
of care and siloization, meaningnobody wants to work with each
other.
Um they all want to work ontheir own, and we're gonna use
the most expensive, costly stuffthat profits somebody to do
that.
So, like, for example, we havea totally dysfunctional
electronic medical record thatcosts all of us a huge amount of
money and does not provide anyimprovement in communication,
(23:01):
and that creates a significantcost.
Insurers want to make sure thatwe're not wasting their money,
so they have a very expensiveprior authorization process,
which increases costs anddecreases access to care.
Because people don't work witheach other, you know, we're
leaving people out of thehealthcare network that can
provide valuable services forpeople.
There's also a monopolizationof healthcare in the sense that
(23:24):
we have certain types of doctorsthat seem to be able to control
the discussion of who getswhat's money and certain groups
persistently get left out.
Like, for example, mentalhealth, primary care, um,
substance use disorder, thingslike that.
Those people get shortchanged,which means their patients get
shortchanged.
And all of a sudden now thatbecomes an access problem
(23:45):
because we didn't have enough ofthose people to do.
Whereas if you're a sportsmedicine person and you have an
athletic injury, you haveabsolutely no trouble finding
somebody to take care of you.
And that creates access costand efficiency problems.
So we try to do to solve allthat.
Um, number one, I I had severalbills on prior authorization
(24:05):
reform, all of which have passedso far.
We I also tried to get rid ofthe electronic medical record as
a mandatory thing.
Um, I have several bills on itcreating integrative models of
care, not just for pain, whichis my primary focus, but for
other things as well, so that wecan learn how to work together
like we used to do before theadvent of the computer or the
(24:26):
cell phone, all that kind ofstuff.
Because believe it or not, atone point we as doctors used to
talk to each other face to faceand solve problems that way.
Liz Canada (24:33):
We all did at some point, once upon a time.
Everybody talked to one anotherface to face.
Rep. David Nagel (24:37):
And it's amazing.
Like I had this happen morethan one time.
Like, patient comes in to seeme, I do something for them.
There's a problem that happensafter.
Used to be they would call medirectly because they have my
phone number.
Now they go through a servicethat 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, theybring up a $10,000 bill when all
(24:59):
it took is one stupid littlephone call from me.
And I said, you know what?
I know what's going on withyou.
This is all you have to do.
Boom.
You know, problem solved, andwe just save the system $10,000.
And this happened, justmultiply that.
How often it happens.
The reason why this is gonnabecome a big problem is that
with corporate takeover ofhealthcare, which is definitely
happening.
(25:19):
Um, when I started, 80% ofdoctors are in private practice.
Now the number is about 15%.
So somebody owns you, they tellyou, you know, what you're
you're gonna do and what you'renot gonna do.
They create this silo.
We're also gonna have a hugeloss of health insured coming
up.
These people will not haveready access to care, but
doctors have a dissatisfactionwith their practice, they don't
(25:41):
stay anywhere very long.
So now you have a problem withcontinuity of care.
So your doctor doesn't knowyou.
And you may see a differentprovider every visit, which
means they don't know you.
Like I have patients I'vefollowed for 30 years.
Because of that, I know them.
I know, I know whatpsychologically motivates them,
I know how to interact withthem, but that doesn't happen.
And because of that, you'regonna see this flocking to the
(26:03):
ER for care because peoplearen't gonna have Medicaid
anymore.
They're not gonna have um foodsecurity, things like that.
And now you're gonna get thissignificant amplification of
unnecessary expenses because theER doctor doesn't know you at
all, nor are they gonna know youafter 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 accesshospital?
Rep. David Nagel (26:30):
I mean, it's a special the designated
hospital, and I'm not gonna beable to give you the formal
definition, but they'rerecognized because they provide
important services in an accesslimited environment for them to
function in in the black, so tospeak, financially, it's not
gonna happen.
So they're basically um given arelatively competitive
(26:50):
advantage so that so that theycan provide a service that
nobody else can provide.
So, for example, we talkedearlier about those market-based
approaches.
Well, I said you you suddenlyremove their competitive
advantage by putting somebody inthat's only gonna put take on a
specific service.
Those facilities will only dothat if they can generate a lot
(27:11):
of revenue doing it.
So, what they'll do is they'llcherry pick is the fancy word we
use.
Like, for example, let's say inthe North Country, orthopedics
generates a lot of revenue,which it does.
And, you know, for thefederally qualified health
center, they're not gonna have ahuge orthopedic practice, but
that's important for them fortheir bottom line.
These other people come inbecause now we've said that's
okay.
And all of a sudden they'regonna siphon all that off,
(27:33):
they're gonna create their ownsurgery center, they're gonna
create their own MRI, and all ofa sudden now you've taken all
this income away from thatcritical access hospital and
make it even more difficult forthem to survive.
So the difference is when I dothat, which I have done, I own
two of those places at one pointin my career.
That's money that we take awayfrom the hospital, but that goes
(27:54):
to us as profit.
The hospital uses that money tosubsidize other things that
don't make money.
So, like, for example, mentalhealth, primary care.
Primary care is not amoneymaker.
It also adversely affects yourability to take care of people
in need.
Like a lot of these for-profitplaces don't accept Medicaid.
Right.
I mean, Medicaid pays roughly10 cents on the dollar.
(28:16):
It's a money loser.
And if, you know, I believeit's everybody's responsibility
as a health care provider totake care of those people, you
know.
And you can limit yourpercentages, but you need to
take care of them.
And but they don't do itbecause they don't have to,
because they're for profit.
And so who gets the burden ofit?
The federally qualified healthcenter.
Or I'm sorry, the criticalaccess hospital and the
(28:37):
federally qualified healthcenters too, which is a similar
entity.
Liz Canada (28:42):
I had an episode um a bit ago about Medicaid
specifically, and I think werecorded it probably in the
summer, maybe the time meansnothing at this point.
Yeah.
But we weren't sure what itwould look like in terms of all
the impacts on Medicaid, right?
Like the federal budget thatjust went through.
(29:02):
I know changes are happening atthe state level too, but it
sounds like we should expect tosee a lot of people lose their
health insurance come January1st.
Rep. David Nagel (29:09):
I mean, the yes the estimate nationwide is
eight to ten million people willlose their health insurance.
You know, you can say what youwant about the Affordable Care
Act.
There were significant flaws init.
Um, and we could talk at lengthabout that.
A former Democrat governor andI had a discussion about this
real time when it was ongoing,and he just looked at me, he
said, this is gonna dramaticallydecrease access and increase
(29:32):
cost.
And um he, I think he just saidcost, but you you decrease
access by increasing costs.
So, like for example, mypremiums and my deductibles and
my co-pays all go up.
I'm not gonna go to the doctorif I don't have the money to go.
So, yeah, you might haveinsurance, but you don't have
greater access.
So that that was kind of whatwe predicted would happen, and
(29:53):
that is what happens.
So, but at the same point, itdid give people insurance.
So now you're gonna takeMedicaid and you're gonna make
significant cuts.
And I was just in Washingtonand we got to meet with leaders
of the different departments andthe eight guy from HHS, we were
talking, and I asked himspecifically, what are you gonna
what's the plan to deal withthese eight to ten million
(30:14):
uninsured people and theramifications for our society?
And he he did not have a goodanswer, 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, thegoal 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 betterquestion is what amount of
fraud, waste, and abuse istolerable?
(30:48):
And and and the same point is,well, you're gonna have
collateral damage of eight toten million people without
insurance.
Me, myself, about 60% of mypatients right now are on
Medicaid.
I'm at fortunately at the pointin my career I can do what I
want.
So, you know, I don't needmoney anymore.
Um, but my whole career, I'veI've never discriminated based
(31:09):
on insurance.
And if a person has noinsurance, we try to make, I can
make their life miserable bynot providing the care that they
need.
And then you create a biggerproblem.
The other thing that we'veworked a lot on, the state
health assessment, I'm also on avice chair of the opioid
abatement commission, is likefor both of these things, we
have a lot of public money.
We have the rural accesstransformation funds, which is
(31:31):
gonna be over 100 million ayear.
We have $330 million of opioidmoney is like, well, what we
want to use it for is to preventthe problems that we end up
treating down the road.
So how do we use that money toprevent?
If you're not providing accessto care, you've now created a
prevention problem.
You know, you might feel goodfor a couple of months, but at
some point you're gonna have to,you the all this stuff's gonna
(31:52):
hit the fan, and we're gonnahave to deal with that.
The other thing we should alsoknow is that one federally
qualified health center in thestate are already closed.
Um, and another is I don't knowif they've closed yet, but
they're on their way to doingit.
That's an access problem forlower income people.
Trevor Burrus, Jr.
Liz Canada (32:08):
Because federally qualified health centers serve
patients regardless if they havehealth insurance.
Is that correct?
Like that's theirresponsibility.
That's what they are there todo is provide health services
for folks who literally cannotgo to another place because they
do not have the ability to payor the insurance to cover it.
(32:30):
And when I had that episodeabout Medicaid, we talked a bit
about federally qualified healthcenters and that that will lead
when those health centersclose, if they close or when
they close, it means more peoplego to emergency rooms.
And that is only going to makehealth care for everybody more
expensive and less accessible.
That was what I took away fromthat episode.
Rep. David Nagel (32:50):
No, and I think that that's totally
accurate.
And I I'm gonna throw in a plugfor federally qualified health
centers.
So shout out to the federallyqualified 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 payus and stuff like that.
The people that work in thosefacilities walk on water because
they can do better financiallyanywhere else than they can do
working for one of those places,but they still choose to do it,
kind of like our mental healthworkers, our correctional
workers, our childcare people.
(33:22):
They can all do bettersomewhere else.
Liz Canada (33:24):
And you say do better is made like financially,
they could make more moneysomewhere else.
Rep. David Nagel (33:28):
Yeah, but they choose to do that.
And and and and they shouldtheir actions should be
applauded and supported.
And what I'm seeing right now,like for example, a number of
towns and counties have have umdecreased their funding of the
behaviour mental health clinics.
So, well, what?
You know, you know, it's not alot of money that you're
spending to support a veryimportant service in our
(33:51):
community.
And what the thing thatbothered me at one of the
meetings was that one of thedelegates was criticizing the
people that work in theseplaces.
Like if they really care, theywouldn't leave.
I go, they have to pay bills,and what are you talking about?
You know, yeah.
Um, but these are like the bestpeople on the planet.
And again, since I brought upthe Jesus reference earlier, I
(34:12):
mean, they're very much livingthe message of you know, caring
for people in need, which iswhat the whole message is about.
I mean, that's all it's aboutis 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 wholemessage, is my understanding of
that too.
All right.
Well, shout out to theFederally Qualified Health
Centers.
They are doing incredible workand need more funding, is my
understanding too.
So you're a state rep,Representative Nagel, but you're
one of 400.
Yeah.
(34:45):
So how can you make change onthese things?
Like, how can you support thesupport the good and fight the
bad?
Like what's possible?
I mean, the what's possible forsomeone who is in the majority?
You are you are part of themajority 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 thesituation, look at it from all
sides, and try to figure outwell, what are the
ramifications, what's the goodand the bad, and then come to a
decision about what you want todo and feel comfortable with
that.
Your decision may be umcontrary to what the people in
power want, but you know, youneed to voice what your concerns
(35:27):
are, and then you draw yourlines in the sand and say this
is negotiable and this is notnegotiable.
And then you stick with that,but you plant your seed of your
message over and over and overagain.
The problem is if you stayquiet and just go along with the
crowd, that you're creating amuch bigger problem, and you
maybe just shouldn't even bethere.
(35:47):
There's 400 people with alldifferent kinds of expertise,
and some people are really goodengineers, some people are good
with this, that, the otherthing.
Well, this is what I do, thisis what I've lived, I wrote a
book on it.
So I must know something.
For me to stay quiet would becrazy, you know, it would be
wrong.
The challenge for me over thesummer was like, like, well,
(36:09):
where do I belong in this wholepolitical mess?
And I I will be honest, Italked to people on both sides
of the aisle about that.
Like, what do you think Ishould do?
No, I I don't know what theright 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 withlawmakers and I've spent a lot
of time talking to uh Republicanlawmakers who support
reproductive rights.
And quite a few of yourcolleagues have gotten primaried
out or pushed out of their ofthe caucus that you are also in.
(36:42):
And it feels like things haveshifted where, you know, there
used to be many more folks whowere similar to you, of you
know, thinking about yourconstituents, thinking about
your conscience and what isright in public health.
And those individuals werepushed 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 mylife.
I don't do I need this job.
No.
I mean, you know, we my friendsand 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 startedtwo nonprofits, we do a whole
lot of other things.
I really work with somewonderful 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 beegotistical for me to say what
that means for the state,because I'm not that important
(37:35):
in the scheme of things, butpeople that are willing to stand
up for that middle, they'rereally important.
And um, you know, my my bestfriend in the legislature didn't
get re-elected.
I I don't fully know why, butyou know, that was a huge loss
for the legislature, much morethan losing me.
I mean, we we always jokebecause he and I used to do
everything together, and he wasthe brains and I was the
(37:58):
passion.
So I I more than one peepperson said together we made a
really good team.
And I, you know, I I I reallymiss him a lot.
And I think it's not a goodthing he's not there.
You know, he was a Democrat,I'm a Republican, but we we
could always talk about stuffand you know, and then work
things together, and you know, Icould tell him, you know,
that's a bad idea, and he couldtell me that's a bad idea, and
(38:20):
then we could argue or talkabout it and come to some sort
of resolution.
And it's those people that weneed in the legislature.
And I don't know why they don'trun.
I I don't.
I can't speak for theprogressive left because I I I
don't know how things work inthat world, but I do know, you
know, in the libertarian right,they are incredibly motivated
people to get politicallyinvolved.
(38:41):
And I mean, they move to thisstate merely to get politically
involved, you know, which I findto be a really an odd thing to
do, but that's what they do.
And, you know, if if nobodyelse is gonna run and they are,
I mean it's not much you can doabout it.
So what we'd like to do isenergize 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 personwho thinks about things, you
could be perfect in thestatehouse.
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 thetable, 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 aboutvaccines, and that's okay.
The conversation went in adifferent 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 longdiscussion, I would think.
But I I do want to say that oneof the the reason why this is
important to me, early in mycareer, I created the first and
only um program for post-poliosyndrome in New Hampshire.
And I got to see people thathad suffered through polio.
(39:47):
And, you know, the t millionsof people we saved from that
horrible illness of the poliovaccination was incredible.
Um, when I lived in Alaska, um,there was, you know, one of the
problems with vaccination inAlaska was, you know, just some
people in rural environments,they don't have access.
So we had an outbreak of, youknow, protustas souping cough,
(40:08):
you know, that is totallypreventable, especially in
adults, it can lead to sort ofserious morbidity or mortality.
I've had the misunt privilegesseeing one patient with tetanus.
The fact that we can preventthat with tetanus vaccination is
incredible.
I just, it's really importantthat we realize how important
these vaccinations are.
(40:29):
And to decrease access to them,we're just asking to go
backwards in time.
When, you know, like one of theother diseases that I got to
see firsthand in Alaska wastuberculosis.
And granted, we don't havevaccination for that, but a lot
of these things through cleanair, clean water, uh clean food
supplies, and vaccination, wewere 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 continueto 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 reallymixed 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 animmunization because they're not
really quite the same.
But was that a good thing ornot?
But if you look at all theoutcome data on it so far, the
number of lives saved, uh, themorbidity avoided has been
(41:22):
pretty amazing.
And, you know, when you chooseto focus on the negative, um,
there's just so much hyperbolicthinking about the side effects
and all that.
There's never been a medicalintervention in human history
that did not have a side effect,which is why in the modern
Hippocratic Oath, we do not saydo no harm.
That those words do not existin the Hippocratic Oath.
(41:44):
And oh believe it or not, thegentleman I that wrote the
modern Hippocratic Oath was ateacher of mine.
Um, his name was Louis Lasagna,and that is why the modern
Hippocratic Oath is called theLasagna Hippocratic Oath.
It has nothing to do with anItalian 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 notin there, because we have to
balance risk benefits.
And these are important things,and we the legislation that's
being proposed locally andnationally are really I
understand it from a libertarianpoint of view.
Um, you know, forcing people todo stuff that they might not
want to do.
(42:24):
But at the same point, theseare from a herd point of view,
from a public health point ofview, these are really important
interventions.
And I think it's I think theyneed 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'sit's as simple as that.
Rep. David Nagel (42:45):
And I will throw another plug for our uh
Department of Health and HumanServices because they're all
sold.
They walk on water, thosepeople.
We really ask our people to doa lot with very limited
resources, and you could arguewhether 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 dowhat 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.
So, uh, gentlemen I've known for a long
time.
Um, we were in a casualconversation earlier today.
In the midst of theconversation, he just suddenly
asked me, I I've been followingyour voting record.
And he goes, Are you sureyou're in the right party?
And the reason why the questionwas interesting was, I mean,
I've known him for a long time,but we've never ever talked
(00:21):
politically.
So I really didn't know whatside of the fence he was on.
So I wasn't sure where he wasgoing with that.
So I said, based on thelegislative options that I've
been given this year, I thought57% was about right, um, or
50-50 somewhere in that range.
Because I just think we weregiven some really bad choices
(00:41):
this year and some bad bills.
And, you know, then all of asudden I find out this gentleman
who all these years I thoughtwas a conservative Republican
was actually quite the opposite.
So yeah, it was kind of a funconversation.
And, you know, we left it offwith the discussion are you
changing parties?
That kind of thing.
Liz Canada (00:58):
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 NewHampshire has Issues, and I'm
your host, Liz Canada.
(01:20):
I'm recording this on GroundhogDay, February 2nd, about nine
o'clock at night.
Representative Nagel and Irecorded this episode a few days
before Christmas.
He references that a few timesin this episode.
Oh, a few things for context,because a lot has happened since
then.
One story you may have heard isof the leaked group chat by
Republican State Reps on theHouse Education Policy Committee
(01:42):
here in New Hampshire.
Oh, and there's a reference tosegregating schools in some way.
The story you may not haveheard was from two weeks ago.
Another Republican state reptestified uh in a public hearing
and uh used arguments that areof Holocaust denialism.
A few days ago, the Speaker ofthe House, Sherman Packard, who
(02:04):
is a Republican, and AlexisSimpson, the Democratic leader
of the House, co-authored anop-ed that talked about how
Holocaust denialism has no placein New Hampshire.
And I, for one, was very gladto see that op-ed published by
the two of them.
Here's what has not happened,however.
As far as I can tell, thatRepublican state representative
(02:24):
who spoke in that publichearing, he still serves on his
outstanding committee of theHouse.
The House Education Policymembers still serve on their
committee as well.
And I say all of this becausewhat you'll hear in this episode
was that last yearRepresentative David Nagel
disagreed with that same partyleadership on issues of public
(02:47):
health, and he was removed fromhis committee.
You'll hear more about it inthis episode.
I asked him to come on thepodcast because uh he is a
doctor, he is a staterepresentative, he is a
Republican.
And there are quite a few billsin the New Hampshire
legislature that would roll backuh vaccination requirements or
immunization requirements.
(03:08):
We talk about one of thosebills, House Bill 524, and we
mention that it did not passlast year because it was a bill
from last year.
But as a note, uh it's notgone.
It's still in the state houseworking its way through the
process.
But there are other bills, andsome of them are coming up this
week, actually.
There is a bill to remove allimmunization requirements for
schools and child care centersin New Hampshire.
(03:30):
There's a bill to uh prohibit alot of state agencies from
educating the public aboutvaccines.
This isn't hypothetical, butthese are pieces of legislation
happening here in New Hampshireright 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 youwould like to support the show,
(03:51):
you can become a monthlysupporter at patreon.com slash
NH has issues.
So thank you for listening.
Let me give your intro.
Rep. David Nagel (04:00):
All right.
Liz Canada (04:00):
Welcome to New Hampshire Has Issues, the
podcast that dares to ask, whatwill RFK Jr.
claim listening to this episodewill cause?
That's the best through linethat I could come up with.
That isn't too offensive.
It's the best I could do.
Rep. David Nagel (04:17):
Mine is why do we treat stigmatized
populations the way we do?
Because that's the whole basisfor who I am and what I do.
Liz Canada (04:26):
We'll get into those stigmatized populations, I
imagine, in our time together.
Sure.
All right, well.
Welcome to New Hampshire HasIssues.
I am your host, Liz Canada.
And my guest today is a NewHampshire state representative
and a physician, Dr.
David Nagel, RepresentativeDavid Nagel, and he represents
(04:47):
Gilminton, Guildford, andLaconia Ward 2.
Representative Nagel, welcometo the show.
Thank you for being here.
Rep. David Nagel (04:55):
Thank you.
Thanks for having me.
Liz Canada (04:57):
Listeners of the show know that I'm terrible at
geography.
How far am I in Exeter fromyour district that you
represent?
Rep. David Nagel (05:05):
It takes me 54 minutes to get to Exeter from
my house.
Gilminton is just a tad uhsouth of um the tip of Lake
Winnap, southern tip of LakeWinnipesaukee.
We're just west of Alton andjust about six miles south of
Laconia.
And Guilford and Gilminton areseparated by the Belknap
Mountains.
Liz Canada (05:26):
We're big fans of the Belknaps in our house.
Rep. David Nagel (05:28):
And his historically, uh Gilminton and
Guilford were actually one towngoing back to the 1700s.
Um they split up in the early1800s.
So I I don't know why they putGilminton and Guilford in the
same district.
Personally, Gilminton shouldhave its own legislator.
I really think that's kind ofsad that that they did what they
(05:48):
did, but um, I'm not involvedin those decisions.
Liz Canada (05:52):
And maps won't be redrawn until after the 2030
election.
So we have a little bit oftime, not a ton of time, but a
little bit of time until thathappens.
Rep. David Nagel (06:00):
Yeah, historically, when you walk into
the legislative officebuilding, to the right is a
picture that is George Roberts.
George is from Gilminton, hewas a former speaker of the
House in the 1970s.
And for probably back as longas there's been state
representatives, Gilminton hasalways had its state owns
representative up until aboutmaybe 15, 20 years ago.
Liz Canada (06:23):
Oh, interesting.
Rep. David Nagel (06:25):
Yeah.
Liz Canada (06:25):
Hmm.
I guess it always depends onwho draws the maps and what
their purpose is.
Um we'll leave a little mysterythere too, I guess.
We'll see.
Rep. David Nagel (06:33):
No mystery in that statement, believe me.
They're none.
Liz Canada (06:38):
Yeah, I bet I bet that's right.
I bet that's right.
Rep. David Nagel (06:41):
Nope.
Liz Canada (06:41):
So, representative, I'm gonna I like to start with a
simple question.
You're a physician and alegislator, and specifically,
spoiler alert, you are aRepublican New Hampshire state
representative.
When those two roles perhapsclash with one another, which I
think probably happens when itcomes to public health issues,
(07:03):
how do you handle it?
How do you handle when yourrole as a physician and your
role as a legislator sort ofbump up with one another?
Rep. David Nagel (07:10):
I mean, to me, it's not a difficult issue.
I, you know, I know for somepeople it is, and I think that
may be the problem with politicsin general.
You know, we were taught theday I showed up at the state
house, we took these classes andthey said your order of
responsibility is yourconstituents, then your
conscience, and then the party.
That has been said a milliontimes, and both parties say it.
(07:32):
I've given two unanimousconsent addresses on the House
floor, challenging people thatwe speak words all the time of
promising who we are, what we'regonna do.
The question then is do you doit or not?
And um, last I checked about 20uh 25 years ago, somebody was
born that we're gonna celebratehis birthday in a couple days.
(07:53):
And his sole purpose to be wasto challenge people.
This is what you say you'regonna do, this is what you do,
this is the gap in between, andhow do you fix the barrier in
between?
And to be honest, when I lookat things, I look first at what
the needs of the people Irepresent are, which is not just
my constituents, to be honest,it's my patients.
Um, I've advocated for therights of people with
(08:15):
disabilities for be well beforeI became a doctor.
So I didn't just begin when Ibecame a doctor, which is why I
became a doctor.
So to me, that all comes first.
And if I see party politicsendangering the people I
represent, then I it's not adifficult decision what
direction to go.
Liz Canada (08:33):
Uh near the beginning of the of the podcast
experience, I had the Democraticleader of the House, Alexis
Simpson, on the podcast.
And I had asked her to come onbecause I had an episode about
the House and the Senate and theExecutive Council.
And I just asked her, tell meabout the New Hampshire House,
how does it all work?
And she shared that, you know,there's 400 of you all, and you
(08:53):
all serve on committees.
And so you are a physician, youare a legislator.
So uh loaded question.
What New Hampshire Housecommittee, Representative Nagel,
do you serve on?
Rep. David Nagel (09:05):
Um if you're talking in terms of standing
committees, the answer at thispoint is none.
Liz Canada (09:09):
None committees, zero committees.
None.
What happened?
Why?
Why are you on no nocommittees?
Rep. David Nagel (09:20):
So um basically
Liz Canada (09:22):
Did you choose to be on no committees?
Let's start there.
Rep. David Nagel (09:26):
I I will tell you how I got to run in the
first place because it's germaneto the question.
Liz Canada (09:30):
So that's such a legislator thing to say.
It's germane to the question.
Rep. David Nagel (09:35):
It is, yeah.
Liz Canada (09:36):
So it's perfect.
Rep. David Nagel (09:37):
So I I um, like I said, I've been
advocating for people withdisabilities for a long time.
I wrote a book on pain carepolicy in the United States
about seven years ago.
Um, totally unintentionally,that book sold all over the
world.
And I was kind of like reallyshocked.
It was kind of like a yeah duhbook, you know.
I was just saying what I sawevery day.
(09:58):
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 ofpeople to figure out like, how
do you make what I just wrotereal?
And so um, I remember one ofthe individuals in our group
just said, this book is yourplaybook.
Just take it and run.
So then I realized if I'm gonnabe dumb enough to say this
(10:21):
stuff, then I have to dosomething about it.
So we started looking at thepolitics of healthcare in New
Hampshire, particularlyinvolving the care of people
that are stigmatized.
And that's a broad thing thatwe could talk about as we go
along.
But, you know, well, how are wenot helping those people?
Why are they sufferingneedlessly?
Um, needless suffering is thename of the book.
(10:41):
So, anyways, um, I showed up alot in the state house to
testify for, and we we actuallycreated a number of pieces of
legislation.
You know, Gary Merchant, Garyand I became really good
friends.
We started a group on umlooking at alternatives to
opioids, how do we increaseaccess, things like that.
And then, you know, betweenthat and then showing up at
(11:01):
committees, all of a sudden Igot people on both sides of the
aisle saying, you should be uphere, not out there.
Meaning, and the committee nottestifying.
So they basically talked meinto running and I ran.
And I'll be honest, you know,in the current political
climate, I kind of didn't thinkI had a chance.
Because I mean, some people arereally strongly politically
associated with a part one partyor the other.
(11:22):
And, you know, I've been aRepublican for my whole life,
but you know, it's not like whoI am.
I don't like being limited to aword.
Uh so I ran and I won.
And um, these same people thatasked me to run wanted me to be
on Health and Human Services.
So I said, that's fine.
That's the only committee Iwant to be on.
Liz Canada (11:40):
And so the people who encourage you to run, I'm
assuming, are Republicansbecause 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 fullyaware that they were encouraging
me and that they wanted me tobe on this committee.
So my first term, I did serveon that.
And and I have to tell you, onething really interesting
happened while I was there isthat, you know, in the
beginning, there was all thispressure to vote with the party
and stuff like that.
But, you know, by the end ofthe session, all of a sudden,
(12:08):
especially the last two HHSmeetings, I was watching people
vote their conscience.
And you were getting to thepoint that when we were voting
on different bills and issuesand things like that, you
couldn't predict the outcomebased on party.
And I think in health and humanservices, that's important
because a lot of stuff that wetalk about is really not party
specific.
It's how do we care for peoplein need?
(12:30):
And I thought that was reallyspecial.
So, you know, when I ran againand 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 mebecause it that was what I was
trying to accomplish.
So, wow, this is going to beeven better.
So we show up, and you know,um, we had a series of what I
(12:51):
considered very dangerous piecesof legislation from a
healthcare point of view thatwould adversely affect the
people I care for.
And I said, There's no way inthis 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-calledmarket-based health care.
You know, there was one billthat had to do with direct care
facilities that would increasethe uh ability of a direct care
facility to come into NewHampshire without really
providing any improvement in ourhealth care other than
(13:27):
profiting themselves.
There was another bill onaccess uh where competitors to
critical access hospitals couldput their facilities.
The current law was 15 miles,you couldn't build within 15
miles.
They wanted to get rid of thattotally.
And to me, those are extremelydangerous bills because critical
access hospitals are extremelyimportant.
We cannot survive as acommunity, especially in rural
(13:50):
communities without them.
And to put them at risk toprofit somebody else just didn't
really make a lot of sense tome.
Um, the one you're gonna wantto talk about later was the
elimination of the New HampshireVaccine Association, which to
me is just purely legislativemalpractice.
Um, that's the kindest thingI'll say about that.
And then there was another onethat really bothered me a lot.
(14:12):
It was to eliminate the Officeof Healthcare Equity from Health
and Human Services.
And well, there were more, andyou're fully aware of these.
There were a number of bills ongender-affirming care for
adolescents, things like that.
Those were to come later, butit 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 ofthe 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 importantdistinction.
And so I, you know, that thatthey basically removed me from
the committee because I w Ithink this is to me
anti-intellectual, but like, youknow, they weren't willing to
listen to what I had to say.
They claimed I wasn't willingto listen to what they had to
say.
Um, they clearly weren'thearing what I had to say, and
(15:00):
they had clearly made up theirmind before there was even a
discussion.
And I think this is the partthat bothers me about politics
in this day and age, and I don'tthink either party can take the
high road on this, but youknow, when you have a bill that
comes before the legislaturethat the public um is opposed to
it by a vote of something like3,300 to 15, and the party still
(15:21):
insists on passing thelegislation or at least
supporting it, you're not doingyour job.
Your job is to re represent thepeople.
And if you're not going torepresent 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 haveto listen to, which you heard at
your orientation was numberone, constituents, number two,
conscience, number three, party.
Yep.
And so if 3,300 people arereaching out saying we oppose
this, it feels like thatsatisfies the number one
constituents what they'resaying.
Rep. David Nagel (15:54):
I mean, and I would argue your conscience fits
in there as well because yourconscience is like, well, you
know what?
If 3,300 people are sayingsomething other than what I'm
thinking, then maybe I shouldquestion what I'm thinking.
In the end, that's why theyremove me.
And this is what reallybothered me a lot is to remove
the New Hampshire VaccineAssociation was a this is an
(16:16):
incredible program that thisstate can be proud of.
I mean, we're celebrated allover the country for creating
this, and they want to get ridof it.
Liz Canada (16:24):
So let's let's talk about that.
Tell me what the New Hampshirevaccine registration is.
What what is it?
Rep. David Nagel (16:30):
So the the association was created
basically for a way of gettingnumber one is increasing access
to vaccination for, you know,mostly children, but also to buy
get the vaccines, you know, tobuy in bulk, you know, so you
could get a cost to cheat, youknow, which is what we're trying
to do with Canadian drugs, islike get our drugs cheaper, to
buy in bulk, get them cheaper,get them to the providers at no
(16:53):
cost so that they can administerthem to the kids that need them
and want them.
And the the thing that's reallyimportant to know about this is
that they don't make vaccinepolicy in the state.
All they do is provide accessto it.
The the money for it basicallyis an assessment of you know the
third party payers in thestate.
And they volunteer, you know,they were part of developing
(17:15):
this program.
It wasn't kind of like, youknow, they, you know, did went
along kicking and screaming.
They were part of thedevelopment of the program and
they do support it becausebasically it dramatically
decreases their costs andimproves the efficiency of
administration.
So the program was so popularthat 14 states have replicated
it.
And we're celebrated for doingthis.
(17:36):
There's roughly a 30%reduction, you know, in the
cost.
So, I mean, you're savingmoney, you're getting people
stuff that they want.
You know, the opting out ofgetting vaccination is not
removed.
If you want to do that based onreligious beliefs or whatever,
you can still do that.
It doesn't force anybody to getthe vaccination, it just
basically provides it for thoseat low cost.
(17:57):
It I hate to use the wordno-brainer because I hate it
when used people use the termno-brainer, simple or common
sense in politics.
But to me, this is kind of fitsin that regard.
And um, one of the things we'veheard very loudly, because I
actually was still on thecommittee for the testimony, but
we heard very loudly fromprimary care doctors is that,
(18:18):
especially in rural, uhfederally qualified health
centers, places where dollarsand cents are tough to come by,
that it would make thisdramatically harder for them to
access these meds because theydidn't have the ability up front
to buy them, to put them intheir offices to administer to
their patients.
So that would also dramaticallyincrease somebody's gotta pay
for it.
So it's gonna be either thepatient or it's gonna come from
(18:40):
insurance at a substantiallyhigher 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 toget rid of it.
But if it had passed, it soundslike 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, andefficiency.
It would have dramatically madeaccess to that form of care
harder.
It would have increased thecost of it, and it would have
dramatically decreased theefficiency of providing those
vaccinations.
So what we're in an O forthree.
Liz Canada (19:23):
So I mean, those are the big three of I'm no math of
admission, but that doesn'tsound great.
Rep. David Nagel (19:27):
No, I mean, whenever you look at health care
reform, that's what you'retrying to accomplish.
Improve access, improveefficiency, and the um either
decrease the cost or at leastslow down the rate of increase
of cost.
I mean, the reality is you'renot 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, ifyou don't vote to get rid of
this, which would make thingsmore 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 daythey kicked me off coincided
with the vote on that bill,which is HB 524.
Um, it was clearly one of thethings that I don't think that
was a a huge problem for them.
It was those two free marketbills that I referred to earlier
(20:20):
that they were very specificabout.
That they said these were partypriorities.
Um, and I was like, why?
You know, these are incrediblydestructive bills, and who and I
asked them very specificallywhose decision was it to make it
a priority?
I have uh a stack of papers ofall the bills that we have
coming up before us that I willtell you very specifically.
(20:43):
I have not looked through allof 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 thosebills, it's like, well, what do
you decide is going to be apriority and how do you make
your decision?
And and and to me, those thosebills were things that were
lines in the sand for me as adoctor taking care of patients
with a strong practice in therural, rural New Hampshire, and
(21:13):
having worked in settings likeAlaska, which is very rural, um,
I these bills are extremelydangerous.
And what they did notunderstand was that I've seen
how dangerous some of thesebills can become in in real
life, how they take advantage ofpeople, how they harm people,
but how they profit like venturecapitalists and whomever.
We people need to realize thathealthcare is a service
(21:36):
industry, it is not a profitindustry.
And this is very loud and clearin 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 bottomline, then we've got a problem.
And we know that's the problemwith our healthcare system now.
And I think when the politicalsystem 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 healthcareto be more expensive.
That's just something I'veheard uh a little chit-chat here
and there, that people actuallywant their health care costs to
go down, not to continue to goup.
Rep. David Nagel (22:17):
And I think there's a lot of good ways to do
that.
So the one committee I do chairis the State Health Assessment
and Improvement Plan, where webasically try to coordinate the
public health network of thestate with the Department of
Health and Human Services andcreate meaningful change and
things like that.
What we talk over and over andover again, it's all this
market-based health care has ledto what we call fragmentation
(22:39):
of care and siloization, meaningnobody wants to work with each
other.
Um they all want to work ontheir own, and we're gonna use
the most expensive, costly stuffthat profits somebody to do
that.
So, like, for example, we havea totally dysfunctional
electronic medical record thatcosts all of us a huge amount of
money and does not provide anyimprovement in communication,
(23:01):
and that creates a significantcost.
Insurers want to make sure thatwe're not wasting their money,
so they have a very expensiveprior authorization process,
which increases costs anddecreases access to care.
Because people don't work witheach other, you know, we're
leaving people out of thehealthcare network that can
provide valuable services forpeople.
There's also a monopolizationof healthcare in the sense that
(23:24):
we have certain types of doctorsthat seem to be able to control
the discussion of who getswhat's money and certain groups
persistently get left out.
Like, for example, mentalhealth, primary care, um,
substance use disorder, thingslike that.
Those people get shortchanged,which means their patients get
shortchanged.
And all of a sudden now thatbecomes an access problem
(23:45):
because we didn't have enough ofthose people to do.
Whereas if you're a sportsmedicine person and you have an
athletic injury, you haveabsolutely no trouble finding
somebody to take care of you.
And that creates access costand efficiency problems.
So we try to do to solve allthat.
Um, number one, I I had severalbills on prior authorization
(24:05):
reform, all of which have passedso far.
We I also tried to get rid ofthe electronic medical record as
a mandatory thing.
Um, I have several bills on itcreating integrative models of
care, not just for pain, whichis my primary focus, but for
other things as well, so that wecan learn how to work together
like we used to do before theadvent of the computer or the
(24:26):
cell phone, all that kind ofstuff.
Because believe it or not, atone point we as doctors used to
talk to each other face to faceand solve problems that way.
Liz Canada (24:33):
We all did at some point, once upon a time.
Everybody talked to one anotherface to face.
Rep. David Nagel (24:37):
And it's amazing.
Like I had this happen morethan one time.
Like, patient comes in to seeme, I do something for them.
There's a problem that happensafter.
Used to be they would call medirectly because they have my
phone number.
Now they go through a servicethat 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, theybring up a $10,000 bill when all
(24:59):
it took is one stupid littlephone call from me.
And I said, you know what?
I know what's going on withyou.
This is all you have to do.
Boom.
You know, problem solved, andwe just save the system $10,000.
And this happened, justmultiply that.
How often it happens.
The reason why this is gonnabecome a big problem is that
with corporate takeover ofhealthcare, which is definitely
happening.
(25:19):
Um, when I started, 80% ofdoctors are in private practice.
Now the number is about 15%.
So somebody owns you, they tellyou, you know, what you're
you're gonna do and what you'renot gonna do.
They create this silo.
We're also gonna have a hugeloss of health insured coming
up.
These people will not haveready access to care, but
doctors have a dissatisfactionwith their practice, they don't
(25:41):
stay anywhere very long.
So now you have a problem withcontinuity of care.
So your doctor doesn't knowyou.
And you may see a differentprovider every visit, which
means they don't know you.
Like I have patients I'vefollowed for 30 years.
Because of that, I know them.
I know, I know whatpsychologically motivates them,
I know how to interact withthem, but that doesn't happen.
And because of that, you'regonna see this flocking to the
(26:03):
ER for care because peoplearen't gonna have Medicaid
anymore.
They're not gonna have um foodsecurity, things like that.
And now you're gonna get thissignificant amplification of
unnecessary expenses because theER doctor doesn't know you at
all, nor are they gonna know youafter 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 accesshospital?
Rep. David Nagel (26:30):
I mean, it's a special the designated
hospital, and I'm not gonna beable to give you the formal
definition, but they'rerecognized because they provide
important services in an accesslimited environment for them to
function in in the black, so tospeak, financially, it's not
gonna happen.
So they're basically um given arelatively competitive
(26:50):
advantage so that so that theycan provide a service that
nobody else can provide.
So, for example, we talkedearlier about those market-based
approaches.
Well, I said you you suddenlyremove their competitive
advantage by putting somebody inthat's only gonna put take on a
specific service.
Those facilities will only dothat if they can generate a lot
(27:11):
of revenue doing it.
So, what they'll do is they'llcherry pick is the fancy word we
use.
Like, for example, let's say inthe North Country, orthopedics
generates a lot of revenue,which it does.
And, you know, for thefederally qualified health
center, they're not gonna have ahuge orthopedic practice, but
that's important for them fortheir bottom line.
These other people come inbecause now we've said that's
okay.
And all of a sudden they'regonna siphon all that off,
(27:33):
they're gonna create their ownsurgery center, they're gonna
create their own MRI, and all ofa sudden now you've taken all
this income away from thatcritical access hospital and
make it even more difficult forthem to survive.
So the difference is when I dothat, which I have done, I own
two of those places at one pointin my career.
That's money that we take awayfrom the hospital, but that goes
(27:54):
to us as profit.
The hospital uses that money tosubsidize other things that
don't make money.
So, like, for example, mentalhealth, primary care.
Primary care is not amoneymaker.
It also adversely affects yourability to take care of people
in need.
Like a lot of these for-profitplaces don't accept Medicaid.
Right.
I mean, Medicaid pays roughly10 cents on the dollar.
(28:16):
It's a money loser.
And if, you know, I believeit's everybody's responsibility
as a health care provider totake care of those people, you
know.
And you can limit yourpercentages, but you need to
take care of them.
And but they don't do itbecause they don't have to,
because they're for profit.
And so who gets the burden ofit?
The federally qualified healthcenter.
Or I'm sorry, the criticalaccess hospital and the
(28:37):
federally qualified healthcenters too, which is a similar
entity.
Liz Canada (28:42):
I had an episode um a bit ago about Medicaid
specifically, and I think werecorded it probably in the
summer, maybe the time meansnothing at this point.
Yeah.
But we weren't sure what itwould look like in terms of all
the impacts on Medicaid, right?
Like the federal budget thatjust went through.
(29:02):
I know changes are happening atthe state level too, but it
sounds like we should expect tosee a lot of people lose their
health insurance come January1st.
Rep. David Nagel (29:09):
I mean, the yes the estimate nationwide is
eight to ten million people willlose their health insurance.
You know, you can say what youwant about the Affordable Care
Act.
There were significant flaws init.
Um, and we could talk at lengthabout that.
A former Democrat governor andI had a discussion about this
real time when it was ongoing,and he just looked at me, he
said, this is gonna dramaticallydecrease access and increase
(29:32):
cost.
And um he, I think he just saidcost, but you you decrease
access by increasing costs.
So, like for example, mypremiums and my deductibles and
my co-pays all go up.
I'm not gonna go to the doctorif I don't have the money to go.
So, yeah, you might haveinsurance, but you don't have
greater access.
So that that was kind of whatwe predicted would happen, and
(29:53):
that is what happens.
So, but at the same point, itdid give people insurance.
So now you're gonna takeMedicaid and you're gonna make
significant cuts.
And I was just in Washingtonand we got to meet with leaders
of the different departments andthe eight guy from HHS, we were
talking, and I asked himspecifically, what are you gonna
what's the plan to deal withthese eight to ten million
(30:14):
uninsured people and theramifications for our society?
And he he did not have a goodanswer, 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, thegoal 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 betterquestion is what amount of
fraud, waste, and abuse istolerable?
(30:48):
And and and the same point is,well, you're gonna have
collateral damage of eight toten million people without
insurance.
Me, myself, about 60% of mypatients right now are on
Medicaid.
I'm at fortunately at the pointin my career I can do what I
want.
So, you know, I don't needmoney anymore.
Um, but my whole career, I'veI've never discriminated based
(31:09):
on insurance.
And if a person has noinsurance, we try to make, I can
make their life miserable bynot providing the care that they
need.
And then you create a biggerproblem.
The other thing that we'veworked a lot on, the state
health assessment, I'm also on avice chair of the opioid
abatement commission, is likefor both of these things, we
have a lot of public money.
We have the rural accesstransformation funds, which is
(31:31):
gonna be over 100 million ayear.
We have $330 million of opioidmoney is like, well, what we
want to use it for is to preventthe problems that we end up
treating down the road.
So how do we use that money toprevent?
If you're not providing accessto care, you've now created a
prevention problem.
You know, you might feel goodfor a couple of months, but at
some point you're gonna have to,you the all this stuff's gonna
(31:52):
hit the fan, and we're gonnahave to deal with that.
The other thing we should alsoknow is that one federally
qualified health center in thestate are already closed.
Um, and another is I don't knowif they've closed yet, but
they're on their way to doingit.
That's an access problem forlower income people.
Trevor Burrus, Jr.
Liz Canada (32:08):
Because federally qualified health centers serve
patients regardless if they havehealth insurance.
Is that correct?
Like that's theirresponsibility.
That's what they are there todo is provide health services
for folks who literally cannotgo to another place because they
do not have the ability to payor the insurance to cover it.
(32:30):
And when I had that episodeabout Medicaid, we talked a bit
about federally qualified healthcenters and that that will lead
when those health centersclose, if they close or when
they close, it means more peoplego to emergency rooms.
And that is only going to makehealth care for everybody more
expensive and less accessible.
That was what I took away fromthat episode.
Rep. David Nagel (32:50):
No, and I think that that's totally
accurate.
And I I'm gonna throw in a plugfor federally qualified health
centers.
So shout out to the federallyqualified 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 payus and stuff like that.
The people that work in thosefacilities walk on water because
they can do better financiallyanywhere else than they can do
working for one of those places,but they still choose to do it,
kind of like our mental healthworkers, our correctional
workers, our childcare people.
(33:22):
They can all do bettersomewhere else.
Liz Canada (33:24):
And you say do better is made like financially,
they could make more moneysomewhere else.
Rep. David Nagel (33:28):
Yeah, but they choose to do that.
And and and and they shouldtheir actions should be
applauded and supported.
And what I'm seeing right now,like for example, a number of
towns and counties have have umdecreased their funding of the
behaviour mental health clinics.
So, well, what?
You know, you know, it's not alot of money that you're
spending to support a veryimportant service in our
(33:51):
community.
And what the thing thatbothered me at one of the
meetings was that one of thedelegates was criticizing the
people that work in theseplaces.
Like if they really care, theywouldn't leave.
I go, they have to pay bills,and what are you talking about?
You know, yeah.
Um, but these are like the bestpeople on the planet.
And again, since I brought upthe Jesus reference earlier, I
(34:12):
mean, they're very much livingthe message of you know, caring
for people in need, which iswhat the whole message is about.
I mean, that's all it's aboutis 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 wholemessage, is my understanding of
that too.
All right.
Well, shout out to theFederally Qualified Health
Centers.
They are doing incredible workand need more funding, is my
understanding too.
So you're a state rep,Representative Nagel, but you're
one of 400.
Yeah.
(34:45):
So how can you make change onthese things?
Like, how can you support thesupport the good and fight the
bad?
Like what's possible?
I mean, the what's possible forsomeone who is in the majority?
You are you are part of themajority 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 thesituation, look at it from all
sides, and try to figure outwell, what are the
ramifications, what's the goodand the bad, and then come to a
decision about what you want todo and feel comfortable with
that.
Your decision may be umcontrary to what the people in
power want, but you know, youneed to voice what your concerns
(35:27):
are, and then you draw yourlines in the sand and say this
is negotiable and this is notnegotiable.
And then you stick with that,but you plant your seed of your
message over and over and overagain.
The problem is if you stayquiet and just go along with the
crowd, that you're creating amuch bigger problem, and you
maybe just shouldn't even bethere.
(35:47):
There's 400 people with alldifferent kinds of expertise,
and some people are really goodengineers, some people are good
with this, that, the otherthing.
Well, this is what I do, thisis what I've lived, I wrote a
book on it.
So I must know something.
For me to stay quiet would becrazy, you know, it would be
wrong.
The challenge for me over thesummer was like, like, well,
(36:09):
where do I belong in this wholepolitical mess?
And I I will be honest, Italked to people on both sides
of the aisle about that.
Like, what do you think Ishould do?
No, I I don't know what theright 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 withlawmakers and I've spent a lot
of time talking to uh Republicanlawmakers who support
reproductive rights.
And quite a few of yourcolleagues have gotten primaried
out or pushed out of their ofthe caucus that you are also in.
(36:42):
And it feels like things haveshifted where, you know, there
used to be many more folks whowere similar to you, of you
know, thinking about yourconstituents, thinking about
your conscience and what isright in public health.
And those individuals werepushed 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 mylife.
I don't do I need this job.
No.
I mean, you know, we my friendsand 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 startedtwo nonprofits, we do a whole
lot of other things.
I really work with somewonderful 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 beegotistical for me to say what
that means for the state,because I'm not that important
(37:35):
in the scheme of things, butpeople that are willing to stand
up for that middle, they'rereally important.
And um, you know, my my bestfriend in the legislature didn't
get re-elected.
I I don't fully know why, butyou know, that was a huge loss
for the legislature, much morethan losing me.
I mean, we we always jokebecause he and I used to do
everything together, and he wasthe brains and I was the
(37:58):
passion.
So I I more than one peepperson said together we made a
really good team.
And I, you know, I I I reallymiss him a lot.
And I think it's not a goodthing he's not there.
You know, he was a Democrat,I'm a Republican, but we we
could always talk about stuffand you know, and then work
things together, and you know, Icould tell him, you know,
that's a bad idea, and he couldtell me that's a bad idea, and
(38:20):
then we could argue or talkabout it and come to some sort
of resolution.
And it's those people that weneed in the legislature.
And I don't know why they don'trun.
I I don't.
I can't speak for theprogressive left because I I I
don't know how things work inthat world, but I do know, you
know, in the libertarian right,they are incredibly motivated
people to get politicallyinvolved.
(38:41):
And I mean, they move to thisstate merely to get politically
involved, you know, which I findto be a really an odd thing to
do, but that's what they do.
And, you know, if if nobodyelse is gonna run and they are,
I mean it's not much you can doabout it.
So what we'd like to do isenergize 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 personwho thinks about things, you
could be perfect in thestatehouse.
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 thetable, 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 aboutvaccines, and that's okay.
The conversation went in adifferent 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 longdiscussion, I would think.
But I I do want to say that oneof the the reason why this is
important to me, early in mycareer, I created the first and
only um program for post-poliosyndrome in New Hampshire.
And I got to see people thathad suffered through polio.
(39:47):
And, you know, the t millionsof people we saved from that
horrible illness of the poliovaccination was incredible.
Um, when I lived in Alaska, um,there was, you know, one of the
problems with vaccination inAlaska was, you know, just some
people in rural environments,they don't have access.
So we had an outbreak of, youknow, protustas souping cough,
(40:08):
you know, that is totallypreventable, especially in
adults, it can lead to sort ofserious morbidity or mortality.
I've had the misunt privilegesseeing one patient with tetanus.
The fact that we can preventthat with tetanus vaccination is
incredible.
I just, it's really importantthat we realize how important
these vaccinations are.
(40:29):
And to decrease access to them,we're just asking to go
backwards in time.
When, you know, like one of theother diseases that I got to
see firsthand in Alaska wastuberculosis.
And granted, we don't havevaccination for that, but a lot
of these things through cleanair, clean water, uh clean food
supplies, and vaccination, wewere 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 continueto 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 reallymixed 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 animmunization because they're not
really quite the same.
But was that a good thing ornot?
But if you look at all theoutcome data on it so far, the
number of lives saved, uh, themorbidity avoided has been
(41:22):
pretty amazing.
And, you know, when you chooseto focus on the negative, um,
there's just so much hyperbolicthinking about the side effects
and all that.
There's never been a medicalintervention in human history
that did not have a side effect,which is why in the modern
Hippocratic Oath, we do not saydo no harm.
That those words do not existin the Hippocratic Oath.
(41:44):
And oh believe it or not, thegentleman I that wrote the
modern Hippocratic Oath was ateacher of mine.
Um, his name was Louis Lasagna,and that is why the modern
Hippocratic Oath is called theLasagna Hippocratic Oath.
It has nothing to do with anItalian 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 notin there, because we have to
balance risk benefits.
And these are important things,and we the legislation that's
being proposed locally andnationally are really I
understand it from a libertarianpoint of view.
Um, you know, forcing people todo stuff that they might not
want to do.
(42:24):
But at the same point, theseare from a herd point of view,
from a public health point ofview, these are really important
interventions.
And I think it's I think theyneed 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'sit's as simple as that.
Rep. David Nagel (42:45):
And I will throw another plug for our uh
Department of Health and HumanServices because they're all
sold.
They walk on water, thosepeople.
We really ask our people to doa lot with very limited
resources, and you could arguewhether 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 dowhat 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.
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