Healthcare Debate: Should the U.S. adopt a single-payer healthcare system?

good evening my name is Jin Hwan dinya of the bridge School of Business Administration on behalf of the bridge school faculty staff and students I would like to welcome you to tonight's health insurance debate our event this evening is one of many that we have planned as a part of bridge Business Week an entire week devoted to helping our students network with members of the business community engaging career preparation activities and prepare to become ethical leaders in the global business community tonight's health insurance debate is made possible by a generous grant from the Chou's Koch foundation I want to take this opportunity to thank my colleague dr. Stephen Mullins for his leadership in organizing this event I also like to take this opportunity to thank dr. Dan ponder for agreeing to serve as tonight's moderate for tonight's debate dr. ponder is the early matter professor of political science and director of the matter center for pretty politics and citizenship he teaches courses on American politics the American presidency Congress and constitutional law if you think you have seen him somewhere before you are correct he's a frequent commentator American and Missouri politics for both local and national media outlets including NPR Morning Edition CBS Radio the Boston Globe Los Angeles Times and USA Today doctor ponder is widely published and is currently working on a large-scale project presidential leverage as well as one on the political economy of the Obama administration originally from San Luis dr. pounder grew up in Springfield and was a 1984 graduate of Springfield Catholic High School at the end of today's program you are invited to meet with dr. Weiss part and dr. Cort Goodman in the hallway area dr. Goodman's books are available for purchase and he will be there for book signing without further ado please join me in welcoming to the podium dr. Dan pounder [Applause] thank you for that introduction I'm really pleased that dr. Mullins and dr. Ted bagless who sort of spearheaded this asked me to moderate that actually kind of over blows what my actual job here tonight is it's to basically introduce our participants sit in the middle listen to them for each about 15 minutes after which each will have about five minutes of rebuttal and then I'm going to point to people who have questions that's that's pretty much my job tonight I am the director of the metter Center and Ellie Meador for those of you who grew up here will recognize the name as was noted in the introduction I grew up here and so I played on the baseball fields and swam in the swimming pool over at metter Park and I'll be honest I didn't know until I came back here 12 years ago that dr. Meador had professor mentor had been a professor of political science and economics here at Drury in 1968 there was an endowment established in his name and when that happened he said and this is a quote I had in mind my chief objective to impress upon my students the importance of solving the many perplexing problems and questions that they will meet in the society in which they live they should take a constructive and active part in trying to bring about a more democratic and more hopeful world in which future generations can live and so it is events like this that I think though I never met him that dr. Meador would be most pleased that this endowment was going to support all right now to the main event I'm gonna introduce each person who will speak and then after that I'll introduce the next person so the first person speaking in favor of a single-payer system is dr. ed Weiss part MD who chairs the Missouri chapter of physicians for a National Health Program which has more than 21,000 members nationwide dr. Weisberg is an assistant professor of clinical medicine at Washington University in st. Louis and he received his MD from the University of Illinois he's published several articles over the years the healthcare needs of the uninsured and volunteers in a variety of safety net clinics and other nonprofits in the st. Louis area he also recruits other physicians to practice of pre clinics across the nation please join me in welcoming to the stage dr. ed Weisberg and looking forward to this for a while so I'm delighted to see you all here I know I'm here to speak about Medicare for all but I've got to do a full disclosure which I probably should have told my hosts before this but I don't really care about Medicare for all I don't really care about single-payer that's when we'll talk about it but that's not what wakes me up in the morning that's not what lights a fire in my shoes and yet here I am but I'll explain what that means in a minute what really excites me what I'm really passionate about are two other things number one democracy which i think is actually on the brink these days and so I applaud drury for having pretty much opposite point of views with a surprising amount of common ground where we agree but I applaud you for having us here to have this conversation for all y'all come in here so number one democracy and number two that I care about that really I focus on is all these patients who I see I still see patients on a regular basis and I'm constantly running into someone who has something dire going on in their lives that I that they know is bothering them and I know what to do about it and we can't we can't get the funding to get this taken care of and disastrous things occur and I'll spare you the examples of that but so I happen to believe that this strategy Medicare for all is the most prudent solution to that my background is you started here is I'm a physician I practiced in Chicago at rush Medical Center for 20 years I moved to st. Louis in 2003 to be chief medical officer at Express Scripts which taught me a lot about the business community and made me realize the importance of having a business plan for changes and then I organized the Missouri chapter of this group nonprofit group as you heard we're open to all people through membership you don't need to be a physician despite our name so I believe sourcing is really important so here's a sample of kinds of sources that I'm using so every slide that I show you that has numbers will have a footnote at the bottom so I can tell you the exact source if you need to know that I believe I believe in the value of having you know good objective information so why build a system on Medicare well Medicare is pretty cool it's got a long track record of success at rescue seniors from poverty and I'll prove to you I think that it extends life expectancy so Harry Truman was the first member of a 52 years ago there's three things about Medicare that are not as widely recognized as I think they should be and we'll do it drill in on those firsts it expands freedom of choice we'll explain that in a moment secondly it eliminates an awful lot of waste and we'll explain that and then lastly I think I'll show you evidence that it it extends lives so let's talk about that for a minute freedom of choice and I need to introduce you to my mother-in-law where she is all 10 feet of her hi MA so she lives in Florida she has Medicare and a supplement and I have her permission to tell you she has a rare genetic disease in her heart rare and this disease is fatal it turns out it it's treatable it doesn't show up into your mid-70s she's in her mid 80s now and there's only three places in the country that actually focused on treating this one of them is in st. Louis so we flew her from Florida at the st. Louis got her this expert world-class care this was about six years ago and she went back to Florida and she's doing fine now she didn't have to pay a penny for that because it turns out that she has Medicare and a supplement and so they had covered she's prepaid for that basically so it didn't cost her a thing I on the other hand have a insurance product that I buy through the Affordable Care Act for my wife and my selves I spend $2,000 a month on premium with a six thousand dollar deductible if my wife my mother-in-law's daughter turns out to have the same condition and if we wanted to go from st. Louis to let's say Pittsburgh to treat that that wouldn't be in my network that would be out of pocket the hundred thousand dollars or so that we spent on my mother-in-law as a community I would have to pay that full retail and most folks can't afford to do that so my mother-in-law with Medicare and a supplement not the Medicare Advantage plan Medicare a supplement can go anywhere that she wants and in my wife and I cannot and y'all probably cannot so if you want to talk about messing with her Medicare she gets a different face so I said did you go anywhere that she wants well how is it really true we all know that there are doctors who won't take Medicare so how many turns out that there's nearly 700,000 physicians in practice the status from 2013 at that year in practice and of those 10,000 are 700,000 there were 10,000 who didn't take Medicare so it's true that there are thousands of doctors who won't take Medicare however there are hundreds of thousands who will more than 98 percent two practicing physicians and as a result people with Medicare particularly with a supplement these days can go anywhere they're in control of their own health care decisions it also means we stop wasting our money on bureaucracy so here's the SEC filings of actually Medicare a medical loss ratio from 100 percent if you're walking enough to want to know that I would call it overhead and that's SEC filings from the first quarter of 2016 and then you know 15 to 20 percent as you'd expect traditional Medicare according to the Medicare trust fund including the brick and mortar including the IRS staff that collects the taxes and all that is about two and a half percent for traditional Medicare it goes up higher if you look at Part D or Part C but traditional Medicare so it's hard to make up that remarkable overhead and then lastly and this is my wonky a slide I apologize but you all are up for that so it's it affects our life expectancy this is a chart of a mortality rate in the United States as compared to 17 other peer nations stratified by age so there's a 7 year old American compared to 7 year olds and 17 other peer nations there's a 45 year old there's an 80 year old so life is actually mortality rate by think of it as life expecting life expectancy stratified by age as compared to 17 other peer nations and no surprise there's the United States merrily cruisin along in the worst position despite paying roughly double what any other country spends on health care in total per person per year so there's us but well you knew that but you probably didn't know this according to the Institute of Medicine pretty reliable source once we turn 65 our mortality rate by age or I think of it as life expectancy plummets we sky are our life expectancy skyrockets in other words the most senior among us have the best health care predictions of anybody else in the world or rapidly get there and that to me means that we have to have the world's best doctors and hospitals and nurses and all that we have to or you couldn't possibly make that happen um we should be enormous ly proud of Medicare that's why I think we should build a system on Medicare because this is a darn good one in many ways so I think of it as a market solution and this is a ridiculously high level summary but on this end you can say that there's three ways to organize health care in the world one is this way and of course every country is different but let's look at this way of organising it this is national health service okay this is socialized medicine this is not what I'm here to talk about with you it's not the position I advocate but it does exist it actually works pretty well in some settings this is where you have publicly funded and publicly delivered right the government owns the means of production the government owns the hospitals and employs the physicians and everybody that is the definition of socialism that is how the VA does it and a variety of other countries and it is not what I'm here to talk about with you if the other extreme is how we do it today and y'all are familiar with the problems and the gaps and all of that I'm not going to be labor there these are both to my mind extreme ways to set up healthcare and I don't say that pejorative Lee you know but this is as far into medicine as a government can go therefore I consider this an extreme model again not what I'm here to talk about and that's extreme in the sense that we're the only country that actually uses this kind of an organizational system and maybe we've figured out the best solution but when you're the own it so maybe it's good but when you're the only place doing something a certain way that's by definition extreme and I frame it like that because in the middle there's what I think of as a pretty conservative model it's pretty conservative all this talking about is fixing the finance issues so it's publicly funded but it's privately delivered it is Medicare that's how Medicare works that's how Medicare in Canada works they call it Medicare so it's publicly funded but privately delivered this doesn't fundamentally change the delivery model although there are things we need to do there - I think of this as a market solution because today I'm competing against other physicians for the most lucrative insurance contract that I can get my hands on if I can get an insurance contract that's gonna pay me five dollars more per person for the 4000 people I'm gonna see this year that's twenty thousand dollars more a year for maybe two or three hours of time spent negotiating forever so so I spend my time and doctors all over the country and medical groups spend their time negotiating for the most lucrative insurance contract and that's how we've applied the free market to healthcare that's what it's doing to medical groups instead you should be able to pick the doctor you want to go see and you should go there and you should stop going there when you don't want to go there that to me is what a free-market should be doing - on the healthcare side that's a better use for it in my mind that's applying the free market to the delivery side although getting rid of these financial barriers we have there turns out that there are a built there's a bill on the house and a bill in the Senate that would do just that and they're similar with some important differences we'll talk about the one in the house HR 676 and you should read it HR 676 it's 30 pages so it says a number of things I'll call out two of the more bigger ones improve Medicare and expand it and improve Medicare what does that mean it means fix the gaps and benefits right Medicare doesn't cover things that everybody knows it should cover eyeglasses hearing aids dentistry for crying out loud so put those improvements into Medicare so that you don't have to buy it separately give that to everybody and get rid of the financial barriers right Medicare today has massive co-pays and deductibles and seniors who can afford to buy a supplement or or but an Advantage program or some other solution to fix that two-thirds of seniors do that so get rid of the financial barriers that really block health care that's what we mean when we say improve Medicare and then give it to everybody give it to Congress give it to teachers give it to students give it to coal miners give it to to everybody in the country not because it's a nice thing to do which you know you could argue it is but instead because that's the only way you get rid of the overhead of the enormous that those 18% overheads that I was showing you is compared to 2% you only would get to get the savings if you do this it also is the way that you can leverage the group purchasing power and let Medicare negotiate the prices of drugs we'll talk about that more that's the most powerful way to do that and lastly if you think about it businesses today that I have a hundred employees or 200 employees HAMP there they get one hemophiliac patient they get one cancer patient one hepatitis C patient and their costs can skyrocket the next year to make up for that so the variation is huge with a small risk pool the best way to have predictable costs if you have less risk is frankly to have the biggest risk pool you can and that's what insurance depends on and there's no bigger way to make a risk pool than this so it also makes economic sense if you just look at the numbers it turns out that there have been more than two dozen studies looking at the savings and cost and every one of them with two exceptions of two other studies that I'll talk about momentarily every one of them shows that we can at least break even if not save money by doing this so there's a large volume of evidence analysis done by literally dozens of economists independently showing the same conclusion so it's not just sort of a one-off thing here's one such analysis and it says this is from Professor Gerald Friedman who was the head of the Department of Economics at the University of Massachusetts in Amherst there I said it all when he wrote this trying to say it right and he said that guess what there are new costs but there are more new savings so what are the new costs he says first of all you'd have to pay more for Medicaid patients because they would then be in the Medicare for all program right so today I get about thirty dollars when I see a Medicaid patient I get about a hundred dollars for a Medicare patient and about a hundred and thirty dollars for a Cigna or a Blue Cross patient which means I have to assess what you're worth to me financially before I let you into my practice and that makes me sick I hate doing that plus it's expensive I don't want to do it so if every patient were worth the same because we were all in one system you wouldn't have to do that but there would be a cost and by this analysis it would be seventy four billion dollars you'd also have to pay something for the uninsured of course and everybody would start doing more you know we all start going to dentists and doing doing things more that frankly for the most part we want people to be able to do so there's new costs now there's one analysis that stops here got a lot of press in the USA Today and Wall Street Journal a couple years ago right before the election and it said we can't afford the new costs but it didn't look at the new savings and that's disingenuous so what are the new savings first there's one program to administer not dozens for the government so there's a small savings there I'm secondly health insurance administration would of course plummet the cost of doing that and we'll show you the impact of that on jobs and then of course the administrative costs to doctors and hospitals would plummet saving you this money which you could recoup by paying less for the service reduced the fees by that much and we break we stay whole but the country can save can save money so you can recline reclaim those costs the average doctor spends eighty five thousand dollars a year according to a Milliman study two years ago that is doing nothing but managing the insurance industry the average hospital has I don't know the number but hundreds of staff managing the insurance industry Toronto general has three people working in billing right and one of those three takes care of Americans who come over the border you know here we have literally buildings full of people we have more full-time equivalents working in billing and accounts receivable for hospitals according to national labor data we have more full-time people working in Billings and accounts receivable for hospitals then we have beds so the average hospital in the USA can put a full-time billing person at the foot of every bed and have a department larger than Toronto generals left over that's wasteful that's wasteful it's not helping anybody and lastly of course let Medicare negotiate the prices of drugs and devices so that's the other flaw that you see in the study sometimes I don't know what the right numbers are for this this is one study there are dozens as I said each economist makes different assumptions different models different buckets I'm not an economist I'm so I don't know what the right numbers all right just know that there's a number that belongs in the in the bucket of letting Medicare negotiate the prices of drugs and that number is not zero so the other study that I'm so critical of had no savings from letting Medicare negotiate the prices of drugs and devices and that's just that's just wrong we can talk more about that if you're interested but so one last piece on this you know I we're talking about a system that's somewhat similar to Canada's and whenever I bring up Canada the first answer I get from people is Canada it's different it's bigger or you know that's not as diverse you know it's got this it's got that it's not the same as us why would you think a system like Canada's could possibly work here and so let's look at this it turns out before 1971 the Canadian healthcare system was producing results almost identical to ours almost identical before 1971 our costs Americas and Canada's were following the same trend we were the same percentage of GDP we were the same and our life expectancies were just a few months apart and then we had a fork in the road strategically we into 1973 created the managed care movement and they in 1971 finished implementing their medicare-for-all Perley remember they call it Medicare so a fork in the road the same we went creating the managed care industry and they went with a medicare-for-all program so how does that look well first expenses here's percentage of GDP there we are relentlessly climbing up to about 19% today you've seen that chart here's the HMO Act passing ostensibly to reduce the cost of health care not really terribly impressive but being successful with that here's Canada's data there's Canada's data we were the same and then we were different and now they spend half of what we spend so it's not because it's such a different country it's because they had a different policy and our life expectancies are have changed too so this data only goes back to 1979 I apologize for that but in 1979 we were about a year apart with them living about a year longer than us at that point and now they live nearly three years longer than we do we were the same we made a policy decision and now they spend half and live and live three years longer I rest my case so the last thing that I want to tell you is that there's this movie that I that I have out back there for you for free sorry it's free I've kept DVDs of it and you're more than welcome to pick it up it's created by this guy Richard master he's the he's a small he's not a health care person he's a small businessperson he runs a factory in the East Coast and he got fed up with the high cost of health care of this past year his health insurance for his employees went up by four dollars per a per hour per employee and he's just fed up with that so you know how do you how do you do that so he started working on this issue and he came to the same conclusion I did and produced this film that's not about the touchy-feely life-extending part of Medicare for all it's about the business side of this and I recommend you watch it it's in the back and you have it for free and it's CEO to CEO but y'all are clever and I'm sure you can you'll get a lot out of it so so there's that and the last thing I would just say is you don't have to be a physician to join our group anybody can join you can follow us on Facebook we tweet do you know all this stuff so I'll have you know joining us online and I've got a sign-up sheets in the end the back to you over by the free DVDs yes I didn't even take the didn't even take my time [Applause] okay our next speaker is dr. John C Goodman he's the president CEO and Kelly Wright fellow at the National Center for Policy Analysis he received his PhD in economics from Columbia University and he's taught and done research at Columbia Stanford University Dartmouth College Southern Methodist University and the University of Dallas he writes regularly for such newspapers in the Wall Street Journal USA Today investors business daily in the Los Angeles Times and he's the author of nine books including patient power solving America's healthcare crisis and lives at risk single-payer national health insurance around the world please join me in welcoming dr. John Goodman Wow well thank you dr. ponder introduction like that makes me feel like I should run for office I'm John Goodman I approve that message I have a cell phone with me but not because I think I'm going to get an emergency call while I'm talking with you I just want to make a point there are more cell phones in the United States and there are people even the panhandler over here on the street corner probably has a cell phone but he probably doesn't have very good access to health care if something goes wrong with my cell phone in Dallas Texas or a dozen places I can drop into without any appointment and get high quality low cost repairs there are places that will send someone to my condone repair my iPhone right in my own home there's a national chains called I doctors the people who work for it a hospital and people who work for to call ty doctors but if something happens to me the average weight in the United States a day to see a new doctor is three weeks and in Boston where we're told they had universal coverage even before there was Obamacare the average way to see a new doctor is three and a half months amazingly one out of every ten Americans who enters an emergency room leaves without ever seeing a doctor just because they get tired of waiting in some California cos Patel's it's one in five which is about what it is in Canada now both on the right and the left we spent a lot of time through the years arguing about the differences between the United States and Canada and let me confess that I've been part of that in fact I held wrote a whole book about it and this book lives at risk goes through all the criticism of the American health care system and it compares to other countries and it says oh those other countries have the same kinds of problems in some cases the problems are much worse there's only one thing I didn't say in this book that I wish I had said and that is that for all the differences among these systems were really about 80% the same you know both the American system and the Canadian system are huge and bureaucracies that resemble the postal service or the Department of Motor Vehicles a lot more than the market for the repair of a cell phone now why is the market so kind to the cell phone and so mean to me and you I think it's because that cell phone is produced in a real market with real prices where entrepreneurs know if they solve our problems they can make millions of dollars whereas over in healthcare we have so suppress the market year after year decade after decade that none of us ever sees a real price for anything no patient no doctor no employer no employee what we have done is we've created a bureaucratic system which both in the United States and in Canada has many similar problems in Canada when you see a doctor it's free in the United States it's almost free every time you and I in this country see a doctor and spend a dollar only ten cents is coming out of our own pocket the other ninety cents is paid for by an employer insurance company or government in both countries the primary way we pay for care when we receive it is not with money it's with time if you look at look at the sorry what we forget so often when we suppress the market when we spread the price system is that we elevate the importance of non price barriers to care and non-market various care now what are those non-market barriers how long does it take you on the phone to make an appointment with a doctor how many weeks or months do you have to wait until you see the doctor how long does it take you to go from your office or your home to the doctor's office and back again and once there how long do you have to wait until you see the doctor those are non-market barriers to care and there's lots of evidence that we could talk about if you like if those non-market barriers are a greater deterrent to receiving care than the money price that patients have to pay and that's not just true for the middle class it's also true for the poor on Medicaid now in the United States there are about 43 million people on food stamps people on food stamps can go into any supermarket that you and I can go into they can buy almost any product that we buy they pay the same price that we pay when they go to the checkout counter in the old days they would put down cash and then their food stamps these days they have a credit card and you never hear it said that low-income people don't have access to supermarkets and the worst thing can happen is they get on a bus and go a couple miles but you never hear it said that supermarkets are not taking anymore food stamp customers now over in the Medicaid program we now have about 74 million people and they're the same people in many cases and what's the biggest problem they have finding a doctor who will see them I was in Boston not long ago and I talking to a female cab driver and I said how's the system working in Massachusetts and she said well I had to go down a list of 21 doctors before I found one that would see me and I said what kind of insurance do you have she was in MassHealth which is the Massachusetts program called Medicaid and I said well were you going down the yellow pages of this 21 doctors she says no no I was going down the list that MassHealth gave me that's what they call universal coverage in Massachusetts these days now when low-income people can't find a doctor what do they do they go to community health centers they go to the emergency rooms of hospitals safety net hospitals and my city it would be Parkland Hospital we're unless you're bleeding all over the floor you can wait four or five six hours for care depending on the time of day and the day of the week this is what what is happening across the country now at the same time there are 2,000 walk-in clinics in the CVS pharmacies which you have here many clinics all of you have access to the reason they call it Minute Clinic is because they're suggesting to you if they know that your time is valuable as well as your money and studies show that the care delivered in these minute clinics by these nurses follows best practices are well or better than traditional primary care so it's high quality low cost the problem is this then the city where I live the charge for sore throat or an earache would be about $75 but Medicaid only pays hatha so the many claims aren't seeing the Medicaid patients they're down at Parkland emergency room waiting hours if they get care at all we could enormous ly expand health care for low-income people throughout this country just overnight by letting them buy care the way they buy food it will be just that simple we want to solve our problems we need to let people buy health care the way they buy food we need to free the patient then we need to free the doctor doctors are there only professionals in our society who are not free to repackage and reprise their services when Martha market changes when demand changes what anything changes they are slaves to a third-party payer system and that's not just true here it's also true in Canada have you ever wondered why doctors don't want to talk to you on the telephone every other professional I know talks to me by phone talks to me my emails well it's because Medicare has seven thousand four hundred procedures that will pay doctors to do and this is absolute worst way to pay any professional because no matter how smart you are if you try to make a list of things you'll pay for and everything you leave off the list is something you won't pay for you're never going to have everything on the list that you want doctors to do in this case they forgot the phone and they forgot email it's not just in this country the same thing is true in Canada so if we want to reform the system we have to free the patient and we have to free the doctor then people ask me can the free market work in healthcare and my quick response is the free market is the only thing that works in health care show me a health care market where there is no Blue Cross no Medicare no employer and I'll show you a market that probably works now looking around the room I'm gonna guess most of you and don't know very much about the market for cosmetic surgery but give it another 10 years and even you people will be interested this is a market where we've had huge increase in demand all kinds of technological change of the kind that we're told increases cost everywhere else in the system and yet the real price of cosmetic surgery keeps going down down down you get packaged prices you have price competition same thing with LASIK surgery the real price keeps going down down down despite all kinds of technological change you have price competition you have quality competition package prices are XCOM allows you to buy drugs online why because they're competing with a local pharmacy if Blue Cross paid all the bills there would be no rx comm it's there because of cash paying patients I've already mentioned the walk-in clinics the market for medical tourism is a real market where the third-party payers aren't 63,000 Canadians came to the United States last year to get medical care probably because I got tired of waiting in Canada 63,000 did you know that Canadian patients can come to the United States and get a hip or knee replacement for half half of what you would pay for the same operation they're paying even less than what Medicare pays these are free market prices and you can take advantage of that same technique and ask me in the question session I'll tell you how you do it so we need to free the doctors free the patients and free the entrepreneur to solve our problems the way they're solved in every other market now let's talk for a few minutes about Medicare and Obamacare the Democrats gave us Obamacare most Democrats in Congress would like to have a Medicare system for all of the country but they gave us Obamacare why because all kinds of problems that we can talk about but here's what the message I want to leave with you there's not a single problem in Obamacare today which by the live way leaves 30 million people without insurance it's not a single Obamacare problem that goes away by trying to put all those people in Medicare right you still have the question of what premium do they have to pay is this premium going to vary by age by income by health status what happens if they don't pay the premium as thirty million people are not right now and what is going to be the rolls employer right now most people get insurance the employer are they going to have to pay something and if so what is it going to be these problems are not going to be away and then there's the problem with the health insurance exchange I'm one of the few people that's been writing about the fact that we have a race to the bottom in the health insurance exchanges and by that I mean that the kind of insurance that's being offered in most Obamacare exchanges today looks like Medicaid you can't get to the best doctors and the best hospitals that had talked about on these Obamacare programs but now let's say we put all these people in Medicare he didn't mention it but a third of all the seniors in Medicare are in Medicare Advantage programs these are private insurance programs run by Humana and Aetna and Cigna and others and and how do you get into one of these you get it through an exchange so all the problems were the exchanges in Obamacare or potentially the same problems that we would face a Medicare potentially we could have the same race to the bottom now right now we're not having that race to the bottom because the Medicare Advantage program is done right just as the Obamacare exchanges done or wrong and by right I mean we have something much closer to a market for sick people and the brookings the liberal Brookings Institution has concluded that within Medicare the part of Medicare that works the best by that I mean has the highest quality in the lowest costs are these Medicare Advantage programs and within Medicare Advantage the ones that work the best are ones that are run by doctors and you should appreciate that Ed so so number one we don't solve problems by just saying okay now we're gonna call the whole thing Medicare all those problems don't go away and and by the way the reason the Democrats didn't put everybody in Medicare is because of the cost it cost about fifteen percent of your income that's that's basically the cost of Medicare for all so how many people are going to vote to give up their current insurance in order to pay fifteen percent of their income to the federal government for a system that they you you will say yes that's good but but but you were a minority most people didn't raise their hands alright so so no problems every one of those problems has to be solved there is a way to solve these problems there's a way to move from where we are now to to a market-based system and that is what I want to talk to you more about tonight but that would mean empowering individuals giving them control over the money stopping this idea that the third-party payers are going to tell the doctors what to do thank you very much [Applause] okay now what we have scheduled is five minutes of response rebuttal however you want to put it on each side we'll start I got a cell phone too and I'm really glad I got to pick my cell phone because we all want different things from a cell phone some of us want a good camera someone good this or good that so we get to pick our own cell phone and it's important that we do just like it's important that we get to pick our own doctors I get to pick my own Network I pick my own network and and I and I changed my network because all the networks are crummy they all have trapped calls depending on where you are so I think it's a really pretty apt metaphor we want control over our choice of the way the thing we interact with the cell phone or the doctor but the only reason we need choice over networks is because there aren't any good networks frankly in my experience so you mentioned that that we're the same is the same bureaucracy and all this is Canada that there's no advantages in Canada that I wouldn't wonder why it is they spent half as much and since starting this strategy they live three years longer according to internationally published data I'm not here at all to defend the ACA or Medicare Advantage or any of these of these options I think the ACA in many ways was a step forward I personally have insurance I was personally able to get some health care that I needed because of the ACA because of my pre-existing conditions but despite that I'm not here to defend it I think there's huge problems with it primarily that it preserves the egregious insurance industry but-but-but-but to but to make the claim that there's nothing that's wrong with the ACA that a medicare-for-all problem a medicare-for-all solution wouldn't solve is I mean that's just a really an incredibly empty statement look at the things that are wrong with with with the ACA the network's the fact that's that the that the insurance you buy through the ACA tells you which doctor to go to that wouldn't happen under Medicare for all the fact that the we haven't figured out exactly how we want to fund it in terms of how much employers to pay how much individuals should pay they because there are literally dozens of good ways you could work that out and if you want I can I can walk you through that or I can send you a white paper that was released by the same folks who released the Senate bill I can I can walk you through that there are dozens of ways and we need to have that we need to have the Edison National Stretton strategic discussion but the most important thing that I think would be different under Medicare for all that's not really the case under the AC because of the insurance industry is it with for the first time in our country establish a business case for a long term public health improvement when you look at Canada and see they're living longer than we are now and you look at every other modern nation and realize that a few years ago we used to be at least average in terms of life expectancy and now we're typically the worst most international measures of how our system is performing say that we have some of the worst health care outcomes in the in the world and and that's just not the way it needs to be and and you look at if the idea that if you capture everybody in the same system in the same program then something you did today to improve the populations health would benefit the system five and ten years from now because they would be healthier under today's system if an insurance company tries to do that they know that they have something like twenty percent annual turnover you change jobs your employer changes they know you have this turnover and so an insurance company today is punished if they do something that'll take five years to improve your health like a campaign for colonoscopies or a really good treatment of hypertension or diabetes it takes several years for that and at that point you won't be a member of that insurance company but under a medicare-for-all program you would be because it would be still yours by than ten years from now when you don't have that stroke so the investment in long-term benefits is huge I'm certainly not here to defend Medicare Advantage as a solution if you look at any Medicare Advantage plan in in New York City there is not a one that covers sloan-kettering so if you get the cancer in New York City and you've made the unfortunate choice to have a Medicare Advantage program instead of a supplement like my mother-in-law if you have a Medicare Advantage program and you have cancer in New York City you can't go to the premier hospital for cancer in New York City if my mother-in-law had an advantage program in Florida she couldn't have afforded to come here to st. Louis Medicare Advantage program Medicare has a 2.2 percent overhead Medicare Advantage is a for performing a percent profit in a nine point one percent overhead so they deliver something like 86 cents on the dollar towards towards health care so the answer is just a real simple solution we don't need to have some elaborate scheme of of you know how you refund people's health savings accounts and we don't need some elaborate scheme that just creates more overhead more complexity a nice simple solution we built it fifty-two years ago fix the couple of problems that I outlined to you and give that to everybody it's real simple I've showed you tons of data and can show you tons more that it's really prudent and it's builds on a system that Americans should be enormous ly proud of [Applause] let me start with that Sloan Kettering example because I want you all to understand what I think an ideal health care system would look like have you ever noticed on TV you see Cancer Treatment Centers of America saying if you have cancer come to us any of you seen those that's an example of of a center that thinks it's really good at something and their mark is really Medicare patients they're trying to get Medicare patients to come where they provide a lot of different services that you wouldn't ordinarily get under Medicare that's the kind of model I think is the right one now they're not in any Obama care exchange because the rates are too low and because the incentives are so bad so in my ideal health care system you would have really good centers of excellence specializing in diseases competing with each other and so if you had cancer or heart disease or some other problem you would get the kind of competition you see in a normal market let me go to a couple of other points that that Ed made do we really spend twice as much as all the other countries remember I told you nobody ever sees a real price for anything in our health care system that's true in England and France and all over the developed world we've suppressed the market everywhere well the way we do national income accounting the way we decide how much we're spending on health care is we add up all the expenses just the way we do it for every other good or service but if every healthcare price is a phony price you add them all up what you get is one big phony price so the truth of matter is no country notice what it's really spending on health care but if there any economics students here you know one of the first things you learn in economics is the real cost to a country you're providing something is not necessarily the price you pay it's the opportunity cost and the opportunity cost is the labor the doctors the the the nurses the hospital beds that you use to produce the outcomes because those people could have been doing something else that could have been producing something else and by that measure we're the United States is about in the middle of the pack we're about in the middle of the OECD world we're not the most expensive system when you look at real resources now as for administrative costs all these studies of administrative costs you know what they do they add up the cost of health insurance companies advertising collecting premiums all that gets included in in administrating but when they go to Medicare they don't add in the cost of collecting taxes well look folks that's not a fair comparison when you do the comparison the right way and consider all the costs Milliman who cited as an authority has concluded that Medicare costs more than private insurance savings on drugs he mentioned that there was one study that said there was no no savings guess who did that study was Congressional Budget Office and why does the Congressional Budget Office say there's no savings because they say if you did it the way the Veterans Administration does it and say there's certain drugs you know if we don't get the right price you can't have them then there are savings okay if you do that but we have under Medicare a rule that you have to cover every drug out there and what the CBO says if that's going to be the rule you're not gonna save any money by trying to negotiate it's like Donald Trump says if when you negotiate if you want to win you have to be able to walk away from the table VA can walk away from the table Medicare not life expectancy why is life expectancy for seniors so much better in this country then all across the developed world I I've not seen those statistics recently but for a long time I have had a theory about it and that is when seniors have to compete for health care resources for the younger population they lose out and one of the reasons they lose out is that all over the developed world politicians have discovered something very very important about the politics of medicine and that is most people aren't sick and if you end up spending all your money on sick people then you're not touching most voters and so this is why when we did the Medicare Modernization Act and expanded the prescription drugs this is why Congress went and covered a lot of little stuff that every senior could have afforded on their own and had this big doughnut hole where they have extra costs and and and and and and have cannot have catastrophic coverage that that could bankrupt any senior our politicians just like the politicians abroad have an incentive to spend more money on healthy people and less money on sick people than any of us would want if we were making that decision on our own and then comparing life expectancy in United States with Canada or any other country and I don't need to tell you all we're the most heterogeneous of all developed countries and we often get compared to populations that are more homogeneous than we are so in I guarantee you in Canada the Indian Inuits don't have the same life expectancy is there as the population the Cree Indians don't poor don't have the same life expectancy the rich in Canada but if you compare like with like you compare Americans of European this of Northern European descent like in Minnesota with Northern Europeans the statistics are about the same [Applause] okay now we get to the QA the the audience-participation we do have a couple of ground rules one is to stand and identify yourself raise your hand and I'll point to whoever I see first posed a question as opposed to making a speech and be sure to identify if your question is for dr. Goodman dr. west Bart or both yes [Music] just one correction I never said I wanted to go back to what we had we've had a hundred years of suppression of the market mainly caused by doctors by the way but but what would I do is I would liberate the employment law I mean what we have is the government telling employers that I have to operate under a certain system I would let every employee and every employer choose between wages and health insurance and so so I I what I think would be fair is you come to work so you have a package of benefits and it's a certain number and you could have as much in health care as you want as a bunch of wages as you want and right now we do not allow you or your employer to make those decisions we should and I think we need to recognize the older workers their health care does cost more and that's just a reality and and they may want more coverage for for various reasons but let let people ëthis issues be made by the choice of the employee and the employer and not by arbitrary tax law which really makes no sense so I want to go back to sort of the first second thing I said which is that my primary passion is about patients and so I'm imagining this system which is not hard to imagine because I've seen this way too often where somebody was struggling to make a decision between let's say wages and health and they've got four kids or two kids and they've got a kidnapped kid in school or something and frankly the the reality of making their budget work today versus the I'm not gonna get sick I'm indestructible in the future means that they choose not to buy healthcare or they buy a really crummy policy that exposes them to all kinds of problems so that's fine in your world where we then let them make that decision my question is so I'm the doctor in the emergency room and somebody rolls in with a heart attack and they're about to die and they don't have insurance because they decided that wasn't a priority because they thought they were indestructible what do I do do I walk away do I let him die do I put him off in the corner do I treat them not quite as well do I do I only do my good care for the people that are paying me good what what do you what do you do with these catastrophes and and if you if the answer is well you know that's where we'll have a safety in that we'll take care of them then my response to that is well I would find that much more prudent if I if for example we've done that with dialysis right we've decided as a nation that almost everybody in the country if they if their kidneys fail and they need dialysis that's one of the other ways to get Medicare so we as a country have decided that what is it seventy five thousand dollars a year if you need dialysis you get Medicare and that's good because they they all die otherwise all right well that's fine I personally thinks it's far more approve if you've made that decision if you're not willing to say let them die I think it's a lot more sensible to to treat their blood pressure to buy them the insulin to do the preventive stuff that maybe won't make them never get dialysis and ready but it might delay it by five years and that difference by itself is a huge savings so what do you do with these catastrophes and if you're gonna not let them die why not be prudent about it why waste the money may I may I just just one quick we're actually closer on a lot of things that some of you may realize I wrote the sessions guys the health care bill in the last session of Congress and under that bill we would have given every American who doesn't get insurance from an employer from the government a certain sum of money a refundable tax credit and and if they did nothing else it would by primary care for everyone and then some and it would get so no one would be kept out of the system no one would be denied primary care for preventative care and that would be free and be free for everybody so even if you didn't owe any taxes as refundable so so yes I believe that there should be that that should be there and then there should be a safety net now there is not a government in the world it isn't allowing people to die okay they all do this and Britain is especially bad at it and it was if you live in Britain and you need the latest cancer medicine the government decides whether you're going to get it and there are thousands of British cancer patients who have to choose between not getting the medicine are paying thousands and thousands of dollars out of their own pockets so so that's that Britain's maybe in one of the worst cases but they're all the countries are doing this so I would say let's have everybody have access to primary care let's have a safety net but let's recognize that that safety net may not always cover everything [Applause] I did you say innovation yeah okay no you're saying utilization morning okay in in the current system and in the system adds talking about everybody is incentive is reverse the patient in the pain for anything so it's your incentive to grab all you can get unless you just get tired of being around doctors and on the on the providers side the incentive is to charge everything you can to the third party because that's how you get your income and innovation 90% of all innovation in healthcare is designed to get more money out of the government or more money out of employers or BlueCross so unlike a normal market where innovation is focused on how do we lower costs and raise quality innovation Healthcare is responding to very perverse incentives if you want the system to work we've got to get rid of all those perverse incentives so he's right that we actually have more we have a lot that we agree about but it doesn't make for a fun debate so we're not going to talk about that so today I mean study after study today shows that an awful lot of the healthcare we do is not evidence-based and isn't the actually improving health outcomes there's very little variation around the country at who gets a hip fixed if they break their hip you know that doesn't matter if you break your hip you're gonna get it fixed pretty much anywhere in the country if you have arthritis in your hip the likelihood that you're going to get your hip replaced is related to the number of orthopedic surgeons so it's not based on the guidelines it's you know roughly a third of most procedures you can think of from hysterectomies to angioplasty x' to cardi about bypass roughly a third at very specific specific procedure roughly a third of what we physicians do today is based on the perverse incentives and and so we find those cases and we feel good about it because you know you people like having some of these things done but but what happened what's happened in what happened in Canada when they put in their program and frankly what happened here one in 1965 when we put in Medicare was that the percentage of people whom physicians see who are actually very seriously ill goes up and the percentage of people who physician see who really are not nearly that sick goes down so we find a way to stay busy and guess what we're actually a lot happier in our work when we're seeing the people who are really in need of our care so utilization you don't actually need a very big change in utilization which is good because we don't have an abundance access we have about middle-of-the-road number of doctors per person and in the country so utilization in both systems when they transitioned actually overall was largely flat and and shifted a little bit more towards the desperately sick who needed to care well you can't have it both ways you can't say we're going to give everybody choice of physician you can go to any physician you want to which means you can go to a physician who does lots of hips or you can go to one who doesn't or you how you've changed nothing so so I do believe in managed care I believe in a medical home I believe in integrated care and coordinated care but I believe people should be able to choose some uncoordinated care systems I believe those systems that work best are ones run by doctors not out of HHS not Medicare telling people not Medicare shouldn't be telling doctors how to practice medicine but doctors decide how to practice medicine but give them the good incentives and let let let them form a plans where they or they don't do the unnecessary things where they or they promise high quality necessary care and they don't waste your money and they don't waste your time [Music] so um when I go and talk to our state legislators the one that might my state senator back when I started doing this I walked up to her she was actually a sponsor of a single-payer bill in Missouri and I walked up to her and said hey I'm dr. red why spired I live in your district and she took her hand over her forehead and she went doctor I know malpractice malpractice get away from me she literally said that and then I said no no I like the build it you know we had we've become friends so physicians in the United States are incredibly focused on malpractice because the average internist in Missouri pays between ten and twenty thousand dollars in 2018 I had the reason to look this up recently between ten and nineteen thousand dollars per year for malpractice malpractice rates in Canada since we've been talking about that are more like three four or five thousand dollars for most specialties and the reason is why does someone sue someone Sue's because something bad has happened and so they don't know who's gonna pick you no longer work or what have you and they need someone to pay for the future cost of health care well in the model we're discussing there's that's not a concern the future cost of health care is something that it's not going to make them you have to go bankrupt and the biggest single piece of the judgment against a doctor when we are sued if if they prevail is to pay for the future cost of health care so if you're it's a less litigious society I get that it's not an apples to orange pear erson but in general the reason to sue goes away or largely goes away except I want to get back at them and the judgment is a fraction so it's a far less litigious society now is that I haven't seen that number that you're that you're citing but I've seen lots of analyses about the impact of malpractice on the economy and in healthcare and I can tell you the impact of malpractice on the mindset of physicians in this country is huge I've been sued once it's a it's a dreadful experience and it goes on for years and years and it's we hate it and so are the things that we do from time to time to try to just avoid that yes and those things are dangerous because they sometimes lead SCADA problems but the overall cost of it number one that from every analysis I've seen ah but the actual impact on the economics of health care is in the single digits of our expense I've seen the estimates and I'm sorry I don't have a source to quote you here but I've got eight but I can send you one if you need I've seen numbers that are more in the order of two percent of what we spend on health care and think about that because most of the cost of health care happens when you actually are desperately sick right most of the cost of health care happens when you've got cancer or when you've got an in stage heart disease or you've got some bad disease that's when the vast majority of what we spend on health care happens and most of it's just you really kind of like need that care so I maybe it's true for merchants departments I don't know that number it's interesting I find it kind of hard to believe but but maybe it's true but it's not it's not representative of the entire picture well on this subject I'm probably why no one but far the most radical person on the stage because I want to get the lawyers out of this completely I want to I want to see patients protected and I want to see the right incentives for doctors and let me just say that we're under estimating the cost of malpractice system if you take all the adverse medical events only about a fourth or are legitimately malpractice about half or negligent about half our accidents and maybe maybe a fourth or accidents and half our acts of God and you can't sue for any of that but what the doctors do is in order to avoid their slice of the pie they order more tests in each one of those tests creates risks in the rest of the pie so so in attempt to not be sued doctors are causing more adverse events in hospitals now what I would like to see us do is have something like workers comp that was when you enter the hospital you sign away your right to sue but you know that if anything bad happens you're going to be immediately paid and it doesn't matter where there's an act of God or whether it's an accident or well that could have been prevented or whether it's malpractice we're not going to argue about any of that you just pay and if you don't think it's enough you can pay a little bit more to have insurance and double and triple the the the payout so you get paid and and who's going to pay you an insurance company that covers the hospital the doctors but now that insurance company and the hospital administrators are going to be the monitors of safety and they're going to do something which you and the lawyers and juries and judges can never do so let's let's let the people who are competent to reduce errors have good financial incentives to do that and and get out of the courtroom well what I observe happening after so many decades is that people respond to perverse incentives by acting in perverse ways as long as you leave the perverse incentive there I'm very very confident that you'll continue to get reverse behavior so if you take the perverse incentives away that doesn't mean you get perfection it doesn't mean you get fairness but it means that anything bad that happens now it's not happening because you you made it financially attractive for it to happen so I just want to get rid of perverse incentives and let the market work and poor people I think are smarter than some of us give them credit for being but whether they're smart or not I think everybody is an ought I think if we are spending an enormous amount of money at the federal level on health care it is incredibly regressive the way we spend it we've the people in the top 20% of the income distribution are getting six times the help from the federal government at work for the health insurance at work as people on the bottom 20 percent so this it's terribly regressive I want to take all that money and divide it up and give everybody a certain number of dollars and I want to make sure that people who don't pay taxes get just as many dollars as everybody else and I believe that would be generous enough that it would certainly cover all primary care and a lot of secondary care and and that ought to be our our guarantee to the whole population that's better than having some people with these rich Pratt some people have insurance that will pay for premature babies will cost a million dollars right and these are families that never had the million dollars to begin with so so they didn't gain much of anything from that insurance at the other hand and we have 30 million people with no insurance at all that's a bad trade well I don't remember worrying exact that way I've also have also okay I've also advocated since then letting Medicaid be a public option in the exchange and letting anybody who wants to join Medicaid let Bill Gates join Medicaid let it compete on a level playing field with with private insurance but people who qualify for Medicaid need to get as much money as the average Medicaid patient now get now it's being spent on so that's not $2,000 that's maybe twice that but in any event but other people should be able to to join Medicaid now now for Bill Gates he would have to if he wanted to join Medicaid I would require him to pay the actuary fare premium whatever that happens to be but I wouldn't I don't have a problem Medicaid competing but the main reason I want Medicaid to compete is not because I think Bill Gates is going to want to join it I think people are trapped in Medicaid and I think they can get better care outside of it well yes I mean we I can't remember if this was in the Cession caste bill but I mean I think both sessions and caste we're open to the idea of of letting Medicaid I think it's in the bill that Medicaid patients can leave Medicaid and join a private plan and get a get tax relief and that's something that is outlawed under Obamacare okay but let me just respond to that very common because that's that's very good because a lot of people don't understand that Medicaid is not run by the government and Norah's Medicare in this country we farm this out to private entities and in in Medicaid all of Medicaid is administered by private entities blue cross and so forth at risk entities are giving care to two-thirds of the Medicaid population these are these are health plans like Centene which is also in the exchanges they're at risk that can make profits they can make losses and that's how we're running Medicaid this isn't government this is private sector competing for patients now in Medicare it's almost all administered privately and one-third are in the same kind of health plans that the young people here today are in managed by by Humana and Cigna and so forth so this idea of government versus probably we get we get wrapped up in a distinction that's not worth making the federal government doesn't know how to run these things so it's going to contract with private contractors the issue is what kind of incentives to they have if they have perverse incentives you're gonna get first outcomes so one of the areas that we actually probably agree about is that we both mourn the loss of who've a Rinehart who was a recently passed away and he was a health care thought leader futurist and he said here's how you go about picking how care for and plan and health insurance plan he said there's four steps to picking a health insurance plan step number one decide what diseases you and your family are going to have in the coming year step two find the best doctors and hospitals to treat those diseases step three find the insurance company that covers those doctors and hospitals and step four if there is no such plan go back to step one and pick some new diseases so I happened about four years ago when Missouri was looking at at whether what to do with Medicaid whether to expand it and such I had the the honor I guess of being appointed as a member of the Medicaid expansion task force that Tim Jones at the time the Speaker of the House put together and we traveled around the state hearing from people about Medicaid and and we learned some interesting things in particular this was when Medicaid was unlike what you just said was entirely administered by the state of Missouri they may have outsourced some of the claims managing you know mechanisms but it was entirely managed by the state of Missouri and the overhead for Medicaid for the state of Missouri mo health met at the time which was internally run including anything that they paid on a contractual basis outside their published reports were that mo health nets overhead at the time before managed care had much penetration here in Missouri to Medicaid was 2.2 percent almost the same as as the Medicare trust fund report which by the way does include the cost of IRS staff them but almost the same 2.2 percent and we were looking at having private and private insurers start to take this over in a managed medicaid strategy and I asked every one of them what their overhead was because we just heard it was 22.1% I think was what the none from the number we just heard that and they all said one said 7.5 one said 9 1 said 12 I think overhead so that was interesting it was hard for me to imagine how adding that much extra overhead could actually ratchet down the care when we already knew Medicaid was paying a unit cost that was pennies on the dollar and that utilization in Medicaid for anything that was elective was was really kind of poor because people couldn't get to a doctor so he knew utilization and unit price were already low so it was hard for me to imagine how how how outsourcing this to a Medicaid managed medicaid company was going to save us anything and indeed I read in the newspaper just this this past week I guess it was that Medicaid in Missouri guess what is going to be costing the state dramatically more than the state budgeted for because of those problems so you know I'm not convinced that that's that that's the right solution and Medicare it's true that if you have a Part C plan that's a privatized program thing that's run by commercial insurance it's true that if you have a supplement but true that that's also run by commercial insurance but traditional Medicare Parts A and B and indeed the model that we're looking at know I think some of the claims processing there are some a few outsourced services but but no that's this is a public program publicly funded and privately delivered okay small a small correction you you you can't put up on the screen something that says look at all this these costs that are being imposed on doctors by the private insurers all these administrative costs and then turn around say but when we count the cost of tax collection we're going to ignore the costs that are being posed on on tax payers so if you're going to a fair comparison if you look at the social cost of both now ubi Reinhardt's idea he thought was a silly idea but I have a serious version of that idea I don't think that open season should be once a year I think there should be continuous open season so you choose a you you have a hard problem you choose a plan with you know good good heart doctors now sudden you got cancer you want to move over to a different plan I think you should be able to do that now you can't I wouldn't allow you to game the system that as I wouldn't allow you to buy a real skimpy plan and then you get sick and then buy rich plan and and not pay the cost of that upgrade so but as long as it's a set like let's say as long as you're moving from silver to silver I would have continuous open enrollment but to do that you have to have the kind of risk adjustment that we don't have right now with good risk adjustment you'd have a market for sick people you'd have advertisements on TV saying we're here to solve your problem let me just make a comparison have you ever noticed that on TV all the casualty insurers are saying the same thing you know whether it's the Allstate saying you know you're in good hands or whether it's the who's the little bunny running around I mean every every insurance ad you see has the same message when the really bad thing happens we're going to be there to take care of you you don't ever see health insurance saying that but if we had a good market a real market for health insurance they'd be saying the same thing too if you get cancer we're gonna take care of you get diabetes we're gonna take care of that's when you know when you see ads like that that's when you know the market is working so we have ads like that right they're a little bit more covert but I don't know if you've ever seen these but there are actually free echocardiogram devices traveling around the state that are offering free screening for conductive heart failure hooray why is that going on it's going on because if you have if you have a Medicare Advantage program or even traditional Medicare if you have traditional Medicare and you and you go to the hot and you and you go to a system Medicare will pay more for a for a CHF patient to congestive heart failure patients for somebody without that so so the system so the insurance companies Medicare Advantage in particular wants to find people that have congestive heart failure but who aren't really sick so you run those ads on the TV machine and guess what the real sick people are already usually in a healthcare system someplace the people you'll attract are the healthy ones who might be able to get the diagnosis you meet the echocardiographic criteria for congestive heart failure you can get the knock-up in the in the reimbursement but it doesn't really make make a difference but all the insurance is that we're all in this together no no but all you're saying is that people will exploit a real faulty reimbursement system and it's just the same in Canada or a Medicare is it anywhere else so under a model where you can move around from insurance to insurance the question is who pays for the burn unit the week before you need it because stuff happens that's really expensive and if I don't have to buy insurance that covers a burn unit until I get that horrible burn that I'm probably never gonna get so none of us are gonna buy burn insurance unless we're in an industry that's likely we start these four that we start with the premise that the burn insurance has to get paid and what's happening under Obamacare is we're expecting these plans to take people who are sick and cost a lot and not get paid anything and that's why all the insurers are left the big ensures our left Obamacare and only thing left is Medicaid there's almost no conversation in public policy today about how to get risk adjustment right but if you want the system to work we ought to be talking about this very issue a lot so come back in 20 years when we figured it out because today we don't have anything like that doesn't what you were describing doesn't exist today yes but I'm a visionary or hallucinate er sorry sorry didn't insult you there yeah I did so if I could elaborate on your point a little bit the question is what would people have to pay and the particular study you're deciding is Professor Gerald Friedman's and he has an analysis that's based on assumptions which I think are probably reasonable there are many other economists that have made assumptions pretty similar and I'll give you the specific answer to what your Twitter us into what dr. Friedman has proposed but understand that these are based on assumptions and and they're modeling and so every one of these is a little bit different under the tax structure that Professor Friedman was was was promoting he was saying that anybody who makes up to about four hundred thousand dollars a year would which is what 98% of us I don't know and we up to that level of income would of course see a tax increase but people who make but they would see that tax increase as dramatically smaller than what they would save by eliminating premiums you know my my $2,000 a month you know that the average premium I think is twelve thousand dollars for a family of four in 2016 employers fare so that the premiums would would disappear the co-pays would would disappear or we could maybe say a little bit coinsurance would disappear no risk of leaking you know if you decide to go to mail instead of two BJC or what have you there would be no economic risk to that so under the study that that you're referencing he says up to the taxpayer he said which i think is about a six percent payroll tax I don't really remember exactly shouldn't even quarter number but he his assumption was that was that it would be up to four hundred thousand dollars a year of income and we would everybody on that income level would break even or stay or do better now the Senate bill is very similar and the Senate bill has a white paper that came out of the same timed it's got literally dozens of proposed funding mechanisms and under every one of those they almost every American would be spending less because of getting rid of the bureaucracy and all these other things you have to pay fifteen percent of income and you either pay it through taxes or you pay some of it through taxes and the rest of it through premium it's hard for me to believe there wouldn't be any premium even in Medicare we have premiums but but but this is a lot of money and you're asking people to give up their private insurance which they know and often like for a system which may not go well and having seen how poorly Obamacare has gone I don't see how you'll ever get public support for this so 15 percent doesn't cut well if you look at it we're currently spending nineteen percent of our income on health care Canada is currently spending half of that most other countries are spending half of that so you know I'm not sure where that number is coming from but you can look what I've seen some people do and I don't know if here you've done this some people have you actually taken the average cost of a Medicare patient and said that's what the average cost of a thirty year old would be - and guess what when you're 70 you're more expensive because you're sicker and you've got other stuff happening so you can't just take the average cost of Medicare and roll that out and say that's the cost of of giving Medicare to everybody I didn't do that [Music] correctly that's exactly what dr. Friedman said he said ninety-five percent of Americans would pay less under this model [Music] [Applause] [Music] well let me just tell you okay [Music] well just real quickly what happens in Canada is the main way they try to save money is by limiting the resources are devoted to healthcare so Canada has one of the lowest rates of MRI scanners and cat scanners among the developed world it has a very low rate of acute care beds and that's why the waiting is so long time at ten months to get a knee replacement which is why so many folks are coming down here and paying out of pocket for a knee replacement but most important I think that the reason I think people get misled is going all the way back to Anthony beavin and Britain they kept saying we want health care to be the same for everybody and that's what I thought you were implying we're on this together that your access to care your income shouldn't matter your age shouldn't matter your social class shouldn't matter they said that over and over again it has never happened there is just as numerous numerous studies in Britain have concluded there's just as much inequality and access to care today is there was way back 60 years ago and I can tell you in Canada if you look you'll see the Inuits increase they don't have the same life expectancy as other Canadians low income Canadians don't have the same life it's connecting this high income Canadians and I have I'll just tell you that whatever you have non-price right here's a principle this Goodman's principle of how health care politics works whenever you have non-price rationing wherever you have demand exceeds supply high-income well-educated people will find their way to the head of the line the same skills which allow people to do well in the private marketplace also allow them to do well in bureaucracies that ration by weight so I to answer more of what you brought up what do we learn from around the world the probably the most important strategy for reducing costs on the hospital scientist to establish global budgets so for hospitals so that they don't have to justify to the insurance company every every band-aid that they've used they need to do cost accounting internally so they can order intelligently but the the huge savings by having one global budget from one payer instead of having to negotiate and having to track every every single thing global budgets is a critical strategy for reducing health care costs the other things we've learned is eliminating bureaucracy I kind of described that during my talk another important thing we've learned is well for crying out loud that the government negotiate the prices and things that were that were that we're buying so median wait times in Canada actually published data I think from the OECD it is says that the that 80 emergent things are taken care of immediately in Canada like they are in most other countries but elective surgery the 80 percent of Canadians wait less than four months for elective surgery some wait much longer but 80 percent wait less than four months for elective surgery and in British Columbia they're they're pioneering this thing because they have one payer in the in the province you can actually go online in British Columbia and get a picture of a human body point to the part of the body that's bothering you it'll then tell you five different types of specialists they could take care of that you pick the one and then it shows you the waiting time within whatever geography you want around your house the waiting time for the next appointment for the orthopedist within five miles of your house and if it turns out that's longer than you want you can you can then say send me 10 miles send me 20 miles so you can make rational decisions based on the waiting time for every doctor in your in the country you can't do that in the United States because we don't have any way of beginning to collect that kind of data the last piece I'd like to make about disparities in health care is how incredible Medicare is at solving that we know that African Americans lived shorter lifetimes than than white Americans but it turns out that when you go on to dialysis and you get Medicare it turns out that African Americans live longer on dialysis than white Americans do it turns out that if you're in the VA african-americans remaining life is longer its age adjusted is longer than is white Americans it turns out that the best strategy for dealing with disparities in health care is to just give everybody access to how get for crying out loud okay one more final I think we should stop there no no I haven't told you any horror stories about Canada tonight what I've told you is it bureaucracies is 80% just like us you know doctors are paid fee-for-service they don't talk to you by telephone they don't email you it's like it's like the post office and both systems could be much much better they are now [Music] by the way in Canada it's easier to see a doctor than the United States I want to get that out it's easier to get primary care in Canada but but if you want tests if you want blood tests and other kinds of tests that's harder to get in Canada so anything costs money is harder anything that's that that doesn't cost money is easier so it turns out we profoundly over-utilized tests so that's not necessarily such a terrible thing but why is it that primary care is more available in Canada because about 20-25 years ago they were having the same problem we were starting to hit we were having of too many specialists and not enough primary care doctors and they recognized that as a nation and instructed the medical schools if you want to keep getting well funded by the federal government you have to shift the balance here's a schedule here's how many more primary care doctors we want you to recruit you can't just make somebody be you have to recruit the kinds of people that want to do it and train them with a positive experience to it but you can make a national strategy that changes that here we have two specialists for every primary care doctor in most of the world we have two primary care Doc's for doctors for every specialist we can fix this yeah but what that means is the healthy guy just like you said doesn't have much trouble getting to see a physician he's in and out but the elderly person that needs a new knee waits 10 months in pain it's just not what the statistics show this is what they show no it is it's weight and pain for ten months they're not dying so therefore it doesn't matter we're moving the same direction we're getting more and more like Canada every day so every Canadian complains about the waiting list I don't want to make light of it it's a real fact every Canadian has a story about waiting for their whatever longer than they wanted to end it's they hate that that's they hate that and in the next breath though they say but you know how you guys put up with having to have a bake sale when you get leukemia which a friend of mine had to do I literally I you know that they call our system they see the injustice on our system they could fix that problem by spending more but they've made a decision that you know there are these egregious anecdotes but we have them too on our side and they've made the decision that this is the how much they want to spend and we can make these decisions as well or past time clearly there's a plenty more to say our presenters will be in the back and for book signing to talk with you a little bit more I want to thank you for coming out tonight I want to give our presenters one more round of applause [Applause]

Channel: Drury University

Views: 1,862

Rating: 5 out of 5

Keywords: healthcare, debate, single payer insurance, insurance, single payer healthcare, healthcare debate, Ed Weisbart, John C. Goodman, single payer, health insurance

Id: SGEwJ275QnU

Length: 96min 16sec (5776 seconds)

Published: Tue Apr 10 2018