Transcripts For CSPAN3 Medicare For All Proposals Discussion 20240713

Thank you, everyone, for coming. Im tim carney. Im a visiting fellow here at the american enter Price Institute as being the commentary editor at the Washington Examiner. We are here talking about health care and we want to ask a specific question about health care and its a question of the Free Enterprise side and the free market consentive or libertarian side dont always ask in latin or who benefits . I think sometimes people on the right or right of enter are uncomfortable with that question because they say why should it matter who benefits because we see Elizabeth Warren will say a tax cut is bad because rich people benefit, but i think its actually a very important thing to talk about. One definitely influences our debates. If you remember in the 2008 campaign and the passage of obamacare, barack obama certainly thought it was very important to point out that he was battling, you know, the Health Care Sector. That he was battling the drugmakers or he was battling the insurers and very importantly and interestingly, he was not telling the truth when he said that, and it it shaped the way obamacare turned out that the hospitals and drugmakers were largely behind it or that they got to craft certain principles and it helped us understand yet bill became what it did. Its less surprising that weve seen hospital consolidation when you realize that the big hospitals were supporting lots of the provisions in this bill. So following who benefits from something tells us very important things. Today were largely going to talk about medicare for all, and the main way that that gets pitched is this is something that benefits all patients and the counter argument is that it will cost taxpayers. I think theres a lot more going on than that and thats what we will talk about, but not just medicare for all. Other free market conservative healthcare reforms and weve got some people up here who are experts in that, as well as talking about obamacare and who benefits from all of these, and maybe the answer is simply the patients, but maybe the answer is a special interest, so then the corolary, of course, is who suffers from these policies and we have an excellent panel up here to discuss it. First page, Winfield Cunningham is a Health Care Reporter who writes a newsletter for the washington post, a former colleague of mine from the Washington Examiner and michael canon, they received their full bios, and ill give the brief summary. Michael canon is the healthcare guy at cato and michael capreta is one of the leading health care guys at ai. I will start for medicare for all and just ask a page fr, pai what youve seen about your reporting in various medicare for all proposal, who do you think benefits and who thinks theyre going to benefit, et cetera. What do you see with that . Well, how much time do we have . It could be a really complex proposal and i think it could play out with a lot of different ways for different parties and when you look at the consumer it will be lower and middle income consumers that will benefit, because what were talking about is increasing taxes on businesses and employers on the wealthy to play for a more comprehensive set of benefits and i think particularly, people that could benefit from a more comprehensive medicare for all plan are the people that have been left behind by obama care which are the people that are, say, around 300, 400 federal Poverty Level and a little bit higher who may be eligible for limited subsidies in the marketplaces. Im sorry. Thats a 60,000 income for a couple. 60 to 75,000 Household Income for a family of four, i think, and those are folks, i think, that are recognized to really still be struggling to afford their Health Insurance and that the Affordable Care didnt really help because the cost of private Health Coverage keeps going up and the subsidies arent enough to blunt the costs for these consumers and of course, you can say the losers are the top 10 or so of incomeearning americans who would have to pay for this. Industry, you know, industry has really come out against medicare for all and theres this partnership that has been formed where pharma has come together with the hospitals, and the doctors actually were involved in this and they actually left over the summer, but theyve really been fighting the medicare for all proposals. I think it could be a mixed bag for doctors and hospitals depending on how this would be hash tagged because on one hand, you would obviously, they would bet more patients because you would reach universal coverage and they would have more people seeking their services and at the same time they would be paid less to med dare rates which is significantly lower than what they would get with private plans and drugmakers, this would be pretty bad for them because the government would have a much stronger role in determining how much they could be paid and Health Insurers are also really opposed to this because under bernies plan and basically envisioned no role for them going forward. So i think thats why youve seen an industry pushback, but ill leave it there. Thanks for having me, tim. I agree with much of what paige says, but i think that the losers will be much broader and if you could include from a medicare for all program and certainly if most of the increases are being borne by higher income people and there are subsidies for people not getting subsidies right now that those folks might see the little coming out of their pock tet an more health care coming their way and lets see some of the costs that they bear or what they lose. Theyre losing any ability to choose their own Health Insurance plan because according to Bernie Sanders, under his plan and the government will provide care for everything ask you have no insurance of Health Insurance plans, so youre losing your right to choose your own health plan. You are also people with lower incomes are also going to lose because the impact of the taxes will not only be felt by the people paying those taxes, and i do believe in order to pay for the medicare for all system you have to raise everyones taxes and no one will be immune to the tax increases, and even if the if your taxes go up by relatively little, the fact that Bernie Sanders would have to raise 16 trillion in something with taxes over ten years means that the economy will take a terrible hit. Collecting one dollar in taxes doesnt cost one dollar. It costs 1. 30 or even at the margin some estimates it costs up to 2. That additional increment has lost economic productivity so the president s counsel of economic advisers put out an estimate and they estimate that taxes would go up by 18,000 per household under a medicare for all plan by 2022. 18,000 in additional taxes per household, but the economy would experience so much Slower Growth as a result of the additional tax burden that the Household Income would be 17,000 lower than it was lower than it would otherwise be without the additional taxes. And even the lowincome households would suffer because there would be less Economic Activity and less job creation and less growth. So i dont think that its just the lowincome people would do well under this, under a medicare for all proposal because taxes dont just hurt the people who are paying those taxes. Beyond that, the i think the patients would also suffer because you enroll everyone in the medicare program. You dont get any of the benefits of competition that you get right now between and theres not much competition, but there is some competition between different ways of organizing and financing the delivery of health care. You do get some competition between totally fee for Service Payment and other Payment Systems for paying doctors and hospitals and we do see the fee for service that encourages unnecessary services, unnecessary admissions and so forth. We do see spill over effects whether there are other Payment Systems or insurances a more aggressive role in managing utilization. You do see a reduction in unnecessary expenditures, not only among the patients that those efforts are targeted at, but even among the fee for service populations that have to compete with those other ways of paying. You get rid of that competition and the spillover effect that comes from competition and so patients would suffer, but i think the big winners under the medicare for all system would be first, the politicians that decide how much we pay in taxes, how much more we pay in taxes and how we spend all of that money of ours, and as a result, the lobbyists who are already health care has already for the past 20 years led all industries in terms of expenditures on lobbying, and the lobbyists would make a bonanza when we go for a Government Purchasing 50 of the healthcare and the United States and i think its much closer to 100 and there will be more opportunities and influencing how much money is spent and there will be big winners under medicare for all. Jim . . Thanks, tim, for having me on the panel and this doesnt make him change his mind, but i basically agree with everything michael just said, and i wont repeat all those points. Those are all very good points. I think the a couple of things to note about medicare for all and whats the point of the program . The point of the program is to bring the allocation of all of the resources and the Health System into government control, basically, and so the tax finance system and as michael indicated the big loser here really on the first order analysis is everybody who is a wage earner, basically because the incidence of financing will move more heavily toward incomebased taxation of some kind, either a payroll tax or income tax or some way of taxing the broad middle class and senator sanders admits that and that means theyll end up taxing wages to some degree than they are taxed now and by definition this will be a heavier burden on earned income which is not a good thing for the economy and for some reasons that michael articulated. I think the other point, though is who is the winner as people who will get health care more and maybe they have very low wages, no wages, you know, theyll end up in a more free, direct provisiontype system so on the first order analysis there might be some level of winning for that population as was indicated previously, but i think the big dynamic is something that occurs with five, ten or 20 years which is what happens when the government bes come the control of all of the resources and almost uniformly throughout the world when the system is run this way it leads to price setting by the government which, by definition, leads to supply restrictions and less competition. So sort of basic economics are if they set the price toward the level people will stop supplying it at least in the way it was previously. Thats just a reality and what happens when that occurs and people would have to wait longer and who loses under that situation. Its basically and this takes a long time to develop. So you can enact medicare for all and it wont be noticed for 15 or 20 years, but eventually will happen and people will wait longer for care and theres less innovation because theres less incentive to bring forward things that people are controlling the price for. So who loses under that . Its basically sick people, and so i think here you have to understand that why is there pushback against medicare for all, its mainly because people would worry about what it would do to the quality of health care over time, particularly for people who need a lot of intensity care and would benefit from innovation, having the best people go into medicine. All of the things that happen when its less controlled by the government and happen to a lesser degree when it is controlled by the government. So this is the hard reality for medicare for all which is one other point about this which is very important which is a lot of the cost of the nationalized government controlled system are off the books. So the way to measure whether something is done in financial terms and how do you measure when people have to wait longer and theres no innovation that would have occurred otherwise. Something that didnt get made that would help the patient if someone would invest in it 15 or 20 years ago and those are off the books costs that occur in the uk and canada and all of the National Systems that are not measured and theyre artificially lowering the costs, the supposed costs of those systems and they cost more because people would pay more if they can get the services faster, but they cant, so theres a whole dynamic here of lost opportunity with made care for all. Can i push back just to make this point . This is the point he makes in arguing for medicare for all. Its important to argue when youre looking at the proposal and you have to look at what the Current Health care system looks like. People are already paying lots of money out of pocket. You look at am employersponsored, and its been growing faster than inflation for a really long time, and if you look at the mercada center did an analysis and even they concluded that there would be a reduction in both National Health spending and personal Health Spending by 2 to 4 if you went to a medicare for all system and so part of the point that he often tries to make is yeah, youre talking about all these costs, but at the end of the day services are being paid for by somebody and theyre just costs that will be borne by the government versus directly by the consumers. In other words, i want to clarify this because for some reason bernie and hillary warren, who both make the argument never make it very clearly and just to reemphasize, if you take taxes paid that go to health care and you compare it to the premiums that i pay and the premium that the Washington Examiner pays, hes saying, why do i care whether its coming out of my wages, coming out of my paycheck, and its a redistribution and so the higher wage people will be paying more and the lower wage people will be getting more health care than they used to. Whats wrong with that argument . You might notice a difference if the if the taxes go up, but your brother might not have a job because the economy is not growing the way it would have if you were paying for premiums instead of taxes, but more broadly which brother . Well, you know. I know which one. Multiple. We all know which. We all have that brother, but more broadly than that, i think its a mistake to say that the mercada study says or the mercada center concluded that the centers proposal would save money that if you take all of the plans at face value and assume that they are plausible, then y that is how the numbers work out, but if it is politically infeasible for the sanders plan to or that congress would enact a medicare for all plan that it would reduce by what senator sanders envisions, then it is not plausible to say that a medicare for all plan would reduce would reduce the prices that Health Care Providers get paid and therefore would be a wash for most people in terms of taxes going up by no more than premiums go down and their taxes would go up by much more and this goes back to something jim mentioned. Yes, if the government sets the price too low then you get shortages or whatever and everyone assumes that medicare sets the prices too low and medicare sets the prices too high and the fact that the governmentset prices is not that theyre always too low is that they could be too low and the government has no idea and they dont selfcorrect. They are just as often too high and so and thats what all of that money, 500 million per year thats being plowed into lobbying and health care in washington, d. C. , it is going to do, its being invested in lobbying for usually higher payments to healthcare providers. This is my question when we say drugmakers will probably lose and hospitals are worried theyll lose, and we just think again about how obamacare happened and how we see the sausage get made in washington and i want to tell a plausible story about how medicare could ask and when she tries to do this and she fails and she does what george w. Bush does and has a good midterm and she has a bigger democratic majority and just like industry reacted in 2008 right after obama won, the insurance lobby came out and says, hey, we will cover everybody and all preexisting conditions and limit our price discrimination as long as you cover everybody. They cut a deal and so you can see the hospital, the drugmaker, the doctors, enabout the insurers, but you can see the providers cutting a deal and saying, just give us, make sure you pay us enough and well go along with that. So then you get a medicare for all that industry signs up for. Is that a fantasy . The same thing would happen for medicare for all, but its hard to describe how much a heavy lift medicare for all would be because theres no way the insurers would get onboard for medicare for all. Unless they do a senator Kamala Harris. A Medicare Advantage for all thing in which case we would have to buy off the Insurance Companies, right . And you could buy off all of the hospitals and all of that, but youre still talking about removing 175 million americans from their private employersponsored health plans and you have to put something in there for employers who are worried about all of the workforce disruption that would come if people didnt have to stay with their jobs anymore. The number of people you would have to buy off and thats what youre talking about here. It could happen if government buys off enough people and that drives up the cost of a medicare for all plan. I think you make a good point of what the rates would be because thats what the doctors and hospital providers are worried about and it is a 40 reduction in payment under what theyre getting now which, youre right. Politically, you would have the industry just completely screaming in the ear of congress. And not all are 40 reduction of services. And this goes to the cost of whats medicare for all and if youre going to pay hospitals and doctors more, and it will cost more overall. I think i agree that were pretty far away from Congress Actually being able to pass anything like this, but you can tell that the industry is really worried because last summer is when they formed this partnership because they saw it being talked about more among the democrats running for president , and theyre really worried that this is kind of where the partys going, and i agree that if congress were going to do Something Like this it would have to involve higher rates to providers. There would have to be some kind of role for Health Insurers and i dont know how you get pharma onboard. A couple of things to say about this. We were talking about winners and losers if medicare for all got enacted and thats the initial question. I think one thing to think about is who are the winners and losers from the debate about medicare for all before it gets enacted. Besides the people on the stage, besides you having the event. I think far be it for me to offer advice to the Democratic Party because the they just ten years ago spent a lot of Political Capital enacting the Affordable Care act, and i mean, i maybe have a little amnesia here, but i do remember that president obama sold it to the country as being a gigantic step toward universal coverage, and if not the answer to universal coverage and now we turn on the democratic debates and theyre spending this time saying weve never achieved universal coverage and we have to do some kind of nationalized plan and there are probably a few americans scratching their heads saying didnt we already do this or werent we supposed to have done this . The answer to that is we kind of did already do it and why are they spending this enormous Political Capital saying the government has to take over the whole system when you look at the data and it says okay, there are 32 Million People without insurance in the United States and thats the first thing they want to solve for medicare for all, but twothirds of those folks are already covered by provisions in the Affordable Care act. They can get on medicaid or they can get in an employer plan or get in the aca exchanges. So of those, and this is an important thing. Theres more to this, and let me finish a couple of more points there and i wont filibuster. Then theres another group out there in the nonexpansion states and 2 million to 3 Million People who are low income and poor and cant get on medicaid. Theyre a highly sympathetic group that dont have an entry into the insurance system and they buy insurance on their own at least according to the Affordable Care act structure and then the last group that are the people that folks who wrote the aca including the Obama Administration specifically excluded which are the people in the country without proper do you meanation and couldnt get subsidized insurance for that reason. You know, it seems to me that it will be very difficult to square this circle and sort of say, yeah, now well cover them in a way that the Democratic Party didnt do ten years ago and secondly, extend more subsidies to people that are offering subsidies to get into Coverage Today and now we have to turn to people for the rest of the country thats insured and the sales pitch to them is a few parts. One, wouldnt you like to be able to switch jobs or, you know, one of the parents stay at home or something without losing the health care and this is the proenterprise argument to some extent for medicare for all and you can go off and start your own Small Business and youll be covered and theres a lot of people who might have insurance currently through goldman sachs, but they want to go and start their own little bank and if everyone was covered they could go off and do it and two, is people have a lot of really difficult dealings with Health Insurance companies that dont pay and maybe they believe that the government will be more fair. You might laugh at that second one, but at least address the general idea that people who currently have insurance think i would be better off or be more secure, at least. All of us have kids and if i lose my job, how am i going to pay my health care bills. To take away that fear, it might be valuable to patients. Well i yeah. I think politically it makes sense that thats what democrats are speaking to because people are discontent with their Health Insurance, and prices are going up and i think democrats have successfully also taken over this issue of preexisting conditions and trying to harness that against republicans because as we all know the Trump Administration is refusing to defend the Affordable Care act in this constitutionality challenge and were expectation ruling on that any day now, but yeah, thera still discontent with Health Insurance and the aca didnt fix a lot of that, and i think obama care has been so politicized that people think about it as a lot bigger than it is and for the most part it touched on part of the individual market and to jims point, we already have the mechanisms to ensure a lot of these people and the numbers ive seen show about half of the people who are uninsured are eligible to enroll in medicaid or get into the marketplace and they dont for whatever reason and so youre talking about a pretty small subset of people left and this is sort of the argument that the people are making which is why are we talking about this huge overhaul when we should be focusing on these 10 to 20 Million People that we do need to provide coverage for. I think the main way that the medicare for all proposal would reduce the problem of job lock is by toss being peep out of their jobs and eliminating jobs that would otherwise be created. You dont have to have the government take over the entire Health Care Sector in order to solve the problem of job lock. All you need to do is stop all of the other things the government was doing to create the problem of job lock and the reason there is a job lock is because somewhere along the line, congress and the irs made a series of decisions that says . You get insurance through your employer its not taxed and if you take the 20,000 and so that creates effectively a huge penalty on anyone who wants to control it with that enormous chunk of that own income and portable Health Insurance that stays with them from job to job. So 90 of the people with private insurance in the United States have an awful form of Health Insurance that disappears when your job disappears. And so it is strained where the government gets involved in the Health Care Sector and the solution to the problem is what . More government. Obama care is another example. You mentioned theres a lot of dissatisfaction with companies and i share that dissatisfaction. Part of the reason is because most Health Insurance companies in the United States work with someone other than the consumer because the money is not coming from a consumer and its coming from an employer and they have to make the employer happy, and they dont have a longterm relationship with the enrollee because they know the enrollee will only be with them as long as theyre working for the one firm, but also look at the aca. The aca was supposed to have filled a lot of these gaps and the Health Insurance market that were created for the tax exclusion from the employersponsored insurance and it is dissatisfaction with Insurance Companies. Theres been research that shows that obamacares preexisting conditions and the supposedly most popular part of obamacare and theyre making insurance work for people with expensive medical conditions like multiple sclerosis and those provisions are making things worse. If you ask people whether they support the provisions theyll end the people with preexisting conditions and what if the coverage would get worse for you or your family, support flips consistently. These are not popular proversions and what theyre doing is making people more dissatisfied with private Insurance Companies which youre right, does prepare the ground for the government takeover of the entire thing, but you have to ask the question, is if these wellintentioned government provisions are making us less and less satisfied with health care, is that going to happen with single payer, as well . Heres the thing, republicans didnt have the guts to try to do what many would say is real reform of the Health Insurance system which is to decouple Health Insurance from your job, and this has been the system now that weve had for deed as and decades and theres not going to be the political will to do it and look back in 2017 when they came out with the repeal and replace big, sweeping reform bills and i think thats one of the reasons theyve fallen down over and over again in trying to come up with a viable replacement because they havent been willing to sort of take that if you want a true, free market wait a second. Theres history that needs to be explained here. My point is if you want a true free market you will not achieve that when the consumer isnt truly shopping for plans because its all provided by their employer. Senator mccain in 2008 against president obama and ran on a platform of providing every household in the country with a 5,000 tax credit toward Health Insurance and they would lose if they didnt buy Health Insurance and its beasically a universal Coverage Plan with households and everyone in the country would have had insurance and it would have made sure everyone was protected financially, and they had all kind of provisions and president obama and then senator obama ran hard against that, and famously purchased 100 million worth of ads in october 2008 just before the election attacking senator mccain for taxing Health Benefits for the first time in history and then a year later he ro posed taxing benefits for the first time in history and the level of cynicism that you can have is quite high. Mine is pretty high, but my point is that the notion that republicans have never or some, you know, theres never been offered a proposal to move in a more marketdriven direction and its completely wrong and they lost the nerve after that moment. He lost the election for a lot of reasons. They were serious about it and theyre never serious about that proposal. That was before my time. Im too young, so he had to have a Health Care Proposal and tax credit is functionally identical to an individual mandate and you also have to talk about cynicism on the part of republicans and theyre essentially an individual mandate and that was john mccains plan. Sure, i want to be harsher on republicans there will be a rebuttal to you in a minute. Republicans have never invested in health care. There is a joke i like to tell and its like this, what do republicans and christians have in common . They dont do health care and it really shows and so paige is right that theyve never invested the sort of of money and time and Human Capital and trying to advance a free market set of health care reforms, however, that doesnt mean theyve made any progress or that they havent made progress on the problem of job lock which weve been talking about. Im not a fan of this administration in general, but one thing they did that has made a difference in Health Policy is they change the federal governments interpretation of an exemption from federal Health Insurance regulations including the aca for called the short Term Duration insurance, and they changed the insurance in a free parallel Health Insurance that despite the name that can provide the secure longterm Health Insurance to people that is portable. And so, when they move from job to job, and so that happened, because of a few people in the administration who are committed to health care, and they are the Republican Party is able to exemplify that level of Critical Mass to change the regulatory chan change. Rebuttal. I am not a proponent of the republican plan, but the reason that more marketdriven health care has not happened and part of the system and though there are elements of it in the United States, it is not really that we would describe it this way now, and why hasnt that happened is the biggest opposition to sit the Democratic Party. The Democratic Party for many years has been incrementally pushing the policies to try to have, honest, just their point of view, and they would rather have the government control the resources than having a consumerdriven or marketdriven system. They have been able to sell that point of view to some degree of the public than the opposition has been to sell the other point of view. So we have gradually moved towards more and more regulation of the system, and more and more subs didizization of the system and if we dont want to continue down the road, there is a much more progressive progression of the marketdriven system. And isnt this the interest of the lobbyists the fact that the democrats and the left care a lot about health care or cant explain why the republicans dont care about it. Look at the lenses, and the Health Policy lenses across washington, d. C. , and across the country. And how many foundations are there on the left and sitting on huge piles of money, and dedicated to nothing but influence Health Policy, and you can think of a few off of the top of your head, and name one that is dedicated to premarkets. And think of all of the Health Policies that is kato institute. We dont have an endowment. And thinking the policy wonks how many are on the left and how many on the right on the free market side . There is a huge wonk gap, and i think that it shows up in the sorts of the proposals that we see in the republicans, and that asymmetry can explain the left drift, but we cant let the republicans off of the hook, because the democrats care more. And the portfolio for the republicans. And to return to the swamp factor that industry lobbyists benefit and that the congressional staffers who write the bill, et cetera, then they become the industry lobbyists and they benefit the more we have a network of subsidies and regulation, and the less relevant that guys are going at it and competing on your own. And bringing the two threads together, they coopt the preopt side. So looking at the fees that physician pay for the National Pricing index proposal, and this is the proposal to reduce Government Spending by over 8 billion a year, according to aspi, and so what is happening is that you will have the conservative groups taking out full page ads at paiges publication the wall street journal saying it sim porting foreign price controls. And pitching the new opeds on the idea. It is nonsense, because medicare uses the governmentset prices in order to come up with how much they pay the makers of the drugs, but what is happening is pharma is going to conservative groups and saying, you know what, this is price controls and the conservative groups dont spend much time thinking about this, and we hate price controls, and so we will do these ads and then big pharma has conservative groups that are supposed to be dedicated to limited government and so for advocating for higher Government Spending in the name of reducing the size of government. I think that the republicans are up against two main things here, and one is that, you know, the party is just when you are going to be the party of less Government Spending and talking about an issue that is just expensive, it is going to be a lot harder for you, and Health Care Costs have just skyrocketed in the last decades with the new cures and medicines and procedures, and that is great in a way. But coming up with a way to pay for it, and that is hard to find out the example of another developed country where you would have what many consider the free market system. It is really hard thing to figure out. And then Health Insurance, and health care is a unique kind of good. I like to say it is the only good that you can purchase when you are unconscious. So, if you are going to value human life, and we are a country that says we value human lifeb and we require the Emergency Rooms to give you care when you walk through the doors the and you may or may not pay for it, that means a lot of Health Care Spending and Health Care Costs and how to cover it. That is why the democrats are much more readily turning to the government solution, but that is left with the question of how the pay for it. I once fell asleep and bought a taylor swift album on my iphone, and so you can also purchase that. Sure, sure. And so another policy analysis of who it benefits. Jim, you have been talking about the surprise billing regulation, and one of the counter regulations is that if you pass the rules, the prices may not come down, and when we are seeing that the hospitals are lobbying against the regulation, that is belying the argumenargu and that is what our colleague bennett beneato said. So what you are proposing in the ending the surprise billing. First thing to understand is the real failure of the insurance industry. There is nothing out that says they couldnt be doing whatever they need to do to corral the outlier providers who are doing the surprise bills and the anesthesiologists and radiologists and pathologists. So if you go in for the elective surgery, and you pick the surgeon and pick a hospital in network and they sent you a bill that says that the anesthesiologist is out of network, and how did the network let that happen . They should have said that you cant use a out of network anesthesiologist, and they do allow it to happen, because they dont want to deal with the fact that the anesthesiologists have a lot of leverage over them. So the first order thing has to be to push back on the insurers and the hospitals to say, you cant do this. We should not have to regulate this and congress problem, but because of your failure, you have to. So when you Say Something is in network, you have to make sure that the whole episode is in network, and that is going to get rid of 90 of the problem there. And they are saying, you cant deal with the poor anesthesiologists are going to beat us up, and pay them a lot of money, but that is your problem and get a lower rate. That is why we have you. If you cant do that, why do we have you . I would push back hard on the insurers to solve this problem. Now, having said all of that, and i think that senator alexanders bill is as good as you are going to get out of the congress, so dont ask for perfecti perfection, and they say, okay, get corral and you will binside of this innetwork system and we will back it up by saying that you cant charge more than the median market. I would prefer that they had not done that, and spotted it out between the insurers and the doctors, and that is the way that the political process is, and i can live with that if that is the solution. But the idea of going to the orbtration system to have an elaborate fee to pay for a 250,000 anesthesiologist fee, and it is a ledge hammer for a gnat that should have been kill and gotten rid of. So i think that, you know, that shows that this is an indication that when you are going to get medicare for all, there is going to be a lot of lobbying. This is a perfect example. It is going to be a mess. And so in the latest addition of the kato institutes regulation magazine, we have dueling arguments and one by bennett beneato and adjunct from kato advocating for the forced integration model that jim is talking about and the other article is arguing for arbitration on the new york model. But when surprise billing comes up as an issue, i always wonder why arent Insurance Companies marketing themselves to consumers on the basis of if you sign up with us, you will never see a surprise bill, and the answer is well, many folds. The fact that the consumers are not purchasing their own Health Insurance, because they cant control their own money, because if they do, the government penalizes them, and then the sort of the integration that jim and david were talking about and sort of forced through some targeted regulation. There has been 100 years of government interventions that have prevented the plans like kaiser perm manente from spreadg and forming, and that a Payment System like that can offer and including but not limited to the reducing the problems of the Surprise Medical Bills to zero or very close to zero. And so i dont have any confidence in either the approach that says that congress is going to solve this problem by setting a price, and whether it is set through an arbitration process and the median price in the market or congress deciding that we are going to write other terms of exchange between consumers and providers by forcing them to integrate. I think that this is a problem that the market developed a solution to more than 70 years ago and if we let that process unfold in more areas of the country and reduce the barriers to the plans we would not having conversations is of the surprise bills in the first place. This is a prime example of taking a problem that everybody acknowled acknowledges and the patient should be held harmless and not have to pay surprise medical bill, and yet, it is still devolving into the Patient Advocates in the hospitals on one side who want to do the benchmarking, and then the doctors on the other side, and it is actually they did not realize it is turning into this much of a fight, and it has shaped up this way this fall. Again, good for the lobbyists, because they seem to be the consistent winners here. And you mentioned doctors and a couple more questions and mics and then we will take questions from you. And isnt it possible that some of the losers to medicare for all for instance would be industries that are currently collecting rents and profiting above and beyond what they ought to be, and there they are talking about the social justice or the Free Enterprise, and isnt that possible that as doctors right now, they are overpaid, and that if you wanted to be in place a medicare for all, and there could be a medicare for all that just trims the massive profits, and maybe a fewer mansions in chevy chase would sell to doctors in d. C. , but they would continue to be doctors and the price go down because they are negotiating to a lower price. So this is the commission that advices congress on how and the administration on how and how much medicare should pay for things. There is a wonderful report that they issued where they said that we have known for some time, and we have been aware for some time that there sis a problem and discrepancy of how much medicare pays them, and that is the primary care physicians are paid too low relative to the specialist, and the specialists are paid too much relative to the primary care physicians. And my favorite part of the quote is that we have known for some time, and they have known about this, and that the problem is here, and some people were overpaid, and the primary care physicians are being overpaid and if not in terms of p, but q, quantity. But the problem has existed for decades, and nobody does anything about it, and so why is because the lobbying power of the specialty provider groups. There is another quote in the same medpac report where they say that we are becoming aware, and maybe the fee for service was never a way to pay for it in the first place. And the government does not learn quickly, okay. The government makes mistakes, and keeps them in place whether it is pricing errors or the errors in how they structure the payments of primary care providers and apart from the price and so, there are overpayments in the medicare program, and i think that we move to the medicare for all system, and it is a mistake to think that the payments are going to stay first of all as low as they are, and that you will meet the Bernie Sanders targets or that system is going to correct those pricing errors over time. And we will end up with the same sort of pricing errors throughout the Health Sector that we have in the Health Sector right now. And the premise of the question is that maybe some new negotiator could come in and figure out the right price to come in to pay the physicians, but what would they use to figure that out, right . It is an arbitrary basis. In 1989, the congress created an arbitrary basis for paying physicians under medicare and it was developed and reformed over time, and that structure has been in place for all of the decades since, and that is the reason that when they created in the 1989, they thought that they were going to rejigger the formula and reward primary care. So if you go back to look at the studies and the analysis, and that this money is going to be moved out of the specialists and into primary care and the exact opposite happened. So this is one of the things that the government thought they solved and they didnt and made it worse. So if the government got involved and so we are going to set the prices for everybody, i have no doubt they could find a price that would be, and i know they do get things wrong on the upside here, but in this case, they will settle the low price, and say, we can only afford x because of reconciliation, and Congressional Budget Office scoring and whatever else is constraining the system. They are going to set a price, and it would lower it quite substantially, but nobody knows whether it is the right price. But it is not just sometimes they get the price too high. Look at part b drugs, the price is too high and the way they pay for the part b drugs is inherently inflationary, and you hear about the service differentials and practice is bought up, because they know they will be paid if they provide the services outside of the hospital than inside the hospital, and paying too much there. And when you hear about a physician opening up a specialty hospital, they know that medicare is paying too much for certain patients, and if they open up a hospital catering to those patients, they will make a lot of money. And i pulled the average payments of Knee Replacements and i have the drg number somewhere for you, but the amount of the Surgery Center of oklahoma charges for a Knee Replacement inclusive of the surgeon and the and theesthesiot fee is lower than medicare is paying in lots of states for the same procedure without counting the medicare payments for the surgeon and the anesthesiologist, and so they pay too much in lots of instance, and that is where you dont hear about the effectiveness of the lobbyists, because when have you ever heard, they are paying too much, and stop it. And so Billy Townsend said it in 2010 when they said they would make a contribution to the passage of the universal health care act, and he was the head of pharma and they were making out like bandits so even when they say it it is not true. The government overpays a lot more than people for health care than people realize. I think that is a key question that is not debated enough, and that is part of the reason that i had this, and we will see possibly how it plays out as this advances. So we have microphones in the back, and if you raise your hand, we will have a microphone brought to you, and identify yourself, and ask a question in a questionlike format would be appreciated. But the one more question that i am going to ask because you mentioned billy tozan and bobbyists, a bobby i lobbyist, and so, like lobbyists, they dont have a perfect vision, so was it a mistake for the drug makers and or hospitals to support the passage of obama care . Financially, morally . Well, financially. Do the shareholders lose out from that bill passing . Well, i dont think so. You have got how many more insured people as a result of the a krshgaca, and 14 million who dont care about the price of the drugs and the prices of hormones and oral contraceptives just happened to shoot up after the passage and not passage, but the full enactment of the acas coverage expansion to require everyone to buy 100 of the drugs oral contraceptives. Even the nuns. And the prices for those drugs skyrocketed and the Drug Companies know when they have a fully insured patient and Consumer Base they can get away with the higher prices, because if an Insurance Company tries to remove the drug from the fo formulary the patients scream bloody murder, and they are constrained and so on a cynical, sociallyirresponsible level, yes, it was a good move. I like the libertarians making a argument for maximizing the profits here. We are talking about the plunder here and not the profits. And from their perspective, a lot of the rural hospitals have been struggling in the underinsured areas and that is where the insured rate went up under the aca and they had more patient table to pay for the care. Questions from the audience, and there is a microphone coming from directly behind you there. Hi. Im bella. Could you speak a little bit to Health Care Plans in other developed nations, and to the universal Health Care Plans in other developed nations and how they compare to our system, and possible medicare for all system . Well, most of the other advanced economies have some kind of system that involves a lot more, well, not a lot more, but put it this way, the government gets involved in a degree to control the resource allocation in the system through either legislative process or the regulatory process or some combination, and there is a lot of variety in the economies of the notion ally notforprofit Insurance Companies to deliver care like switzerland and germany and others have direct provision across the board such as the u. K. They own the hospitals and they pay the physicians directly through the government. So there is a lot of differentiation across the countries, and i think that the big point to understand here is something that i tried to say at the outset. You know, what drives the Market Driven system is the resource allocation is outside of the control of the government to some degree, and in the hands of the consumers making decisions and the people that they interact with making decisions about what they are supplying them. In more nationalized systems in particularly canada and u. K. And australia the government is the final decisionmaker on those questions, and they have some level of total spending, and they say here is how much we are going to spend on physician salaries or services that the physicians provide, and we set some prices on the drugs, and so they are very much more involved in the resource allocation decision, and i think that is, you know, and in the end, that is what is really the crux of the matter, because in those countries, the development of the new products and the new innovative ways of taking care of patients is diminished because of that, and moreover, there is a resource allocation misallocation going on that is probably going to make it harder for particularly very sick patients to get the care they could have gotten otherwise. Walk through the type of the patients who benefit in a more socialized system whether it is england or canada type system, and the type who lose, and so it could be somebody who needs a drug that is not otherwise invented is the clearest example of somebody who would lose in a more socialized system possibly, but on the other hand, there is the poor person who just needs basic health care but is just a little bit, who currently benefits from medicaid or a little richer and doesnt. So if you were to walk through different classes of the patients and maybe it is older versus younger or chronic illness versus acute and what is the winners and the losers of the other systems versus a free market system . I have not studied other systems, but my understanding is that i guess that the losers in a more socialized systems could be, you know, people who are trying to get in to see a doctor or the hospital, and there tends to be more problems of shortage physicians there, because of problems of lower compensation. I was going to say earlier that there is a lot of talk in the Trump Administration about the fact that a lot of the funding for new drugs happens in the u. S. , because we dont put the same price controls on drugs, and so the administration is working on a proposal right now which would peg certain medicare payments for drugs that are administered directly by doctors the index of lower prices of other countries, and the idea has been that the president has talked about it a couple of times that they are basically freeriding off of us to be relying on to us allow high prices in the country which fund the r d for the pharmaceutical companies and then the other companies are benefiting from the drugs while keeping the price controls so that the people are not paying as much, and that is a proposal and obviously a lot of pushback from the pharma, but the latest is working on putting out a proposed rule on this. There is a fundamental misunderstanding that guides the comparison of international comparisons. The idea that the United States has a market system, and all of the other countries have a governmentdominated systems, and that is why the United States leads in terms of the medical innovations and other countries are not pulling their own weight in that regard. I think it is a mistake, and there is another way of looking at this that can explain the phenomena that we have a. So the United States does not have a free market in health care by any stretch. In fact, i like to say that the greatest trick that advocates of the social medicine has played is to convince the United States that we dont already have it. Here we have every form of socialized medicine and you want the british National Health service, and look at the British Health administration system, and if you want that system, our medicaid looks like that, and the german system employs that, and the swiss system is like obama care, and so we have it all right here. And the melting pot of the socialized medicine approaches. Yes. So if you are look agent whoc are looking at who is controlling the spending of the Health Care Spending, it is done by the market. I dont know what is free market about that. When the government takes away 1. 5 or 2 trillion from the taxpayers and spends it itself on the health care. But what people dont understand is to get the government out of my medicare. Yes, because socialized medicine is also the high cost of ignorance as well. It is beyond that. If you are looking at the broader measure omt of the government involvement which is Health Care Spending subject to coerci coercion, we can throw in the 30 or the whatever of Health Care Spending that is done by the employers or employersponsored insurers and the government says to let someone else, the employer to control 50,000 of your income and peck your health plan and we will tax you more. So the government is directing 80 or more of the market. So and so, we dont have a market system here. The u. S. Health sector is heavily influenced by government as much as the Health Sectors of any other advanced nation, and the difference of this is and explaining the differences of the innovations, our government makes different decisions with the power it has. And so in the u. K. , the British Government sets a limit on how much it is going to spend on the National Health service, and allocates the resources as best it can, and waits and all of that, but they set a limit. The u. S. Medicare program, and medicaid program, they dont spend a limit on the programs, and it is whatever the doctors and the hospitals order up, and the Drug Companies. In fact, the government does tend to push prices up, so if you are having no government limits on the quantity and the government is driving the prices skyward with such things as the payment formula of the medicaid part b drugs or the sponsored insurance that is encouraging people to buy more information, and the shift the curve and the price rises and this is what is generating all of the revenue that the Drug Companies are able to make, and sink into the rewards of r d and why i think it is an important part of the story of why we have so much more innovation, and i dont think, and i think it is a very serious mistake, analytical error to say that we have more innovation, because we have a free market. All right. Other questions . Yes. One microphone behind you. Hi. Im james, and earlier the Panel Discussed job blocking and Health Sponsored insurance, and how does the Health Savings account reduce the prevalence of job block, and do you think that incentivizing employers to more portability of the Health Saving accounts might further reduce the job blocking . You have a proposal on expanding. Well, right now, hsas dont do much in the job blockers, and that is the idea that you will stay with your job because you are afraid of losing your insurance, and hsas dont do a lot to make the insurance more portable. So whether you might be able to have an hsa through an individual market plan, but the hsa doesnt do much to make that plan that might be portable, but they dont do much to help you the afford that plan. Compared to a World Without hsas. However, if you expand the hsas in the right way, you could turn them into a vehicle for the worker to receive that 14,000 or 15,000 of their compensation that the employer is using to purchase their Health Benefits and to take it without adverse consequences. If you expand that hsas in a way that any employer who wants to stay in business is going to have to give the 14,000 to the worker who earned it, and then stay with the employer plan if she wants and use that money to pay for the employer plan, and she could also buy without penalty, a Health Insurance plan that does not disappear when her job change, and so if you are expanding the Health Savings accounts in a right way, you could prevent job loss so a larger portion of my presume into the hsa would exceed the federal limit, but i could expand that and use it for the premium of any high deductible i want . Yes, you have to understand, that is part of your earnings and compensation that you dont get to control because of the exclusion, and the tax preference from the employersponsored insurance. So if you are able to control that and workers across the country were able to control that, it would be an effective tax cut on the order of 828 billion which is larger than the trump tax cuts or the reagan tax cuts, because it would be you getting to control part of your earnings that you dont currently get to control. And we have time for one more question, i guess. And if nobody else out there has it, i have it. Okay. One red jacket here. Thanks for take my question. I i im ariel cannon, and i would like to know as you are saying that overpaying the specialties, but on average 240 of the medicare rates are paid according to a rand study, so if we are worried about the medicare for all costing too much or overpaying the physicians, then how come private insurance is not doing any better . Good question. Great question. I think that first of all, the system that we have today is not a marketdriven system. So agree with michael on that point that we have only have an hour and 15 minutes here, and this is a complicated subject, and the idea of what we have in the United States operating with the market signals is not true, and so part of the reason that the private insurers are overpaying and i agree, a lot of overpayment on the private side is because the federal government subsidizes most of that payment. One thing that has been going from 1945 on basically is that on the margin when an employer plan has higher expenses, the federal government is subsidizing it on the order of about 35 through the federal tax break. So when you are spending an ax tra dollar through the employer plan, 35 cents of it is basically coming from the general taxpayers. When you have a system built on that kind of the structure, it is going to overpay. It is going to cost too much, because there is not enough discipline or money coming directly out of someones pocket that they dont want coming out of their pocket. So if you want a market to work, someone on the margin has to have the decision to say, id rather not spend that extra 100 if i dont have to and i would rather find another use, and getting my service elsewhere for 100 cheaper, but not enough of that is going on in the American Health care to put the pressure back on the private side. It is starting a lot with this employer system. Beyond that in the medicare system, it operates that way and that is why we have cost inflation, and utilization, and et cetera, and so when people want a marketdriven system which i advocate for strongly, it means in essence that someone has to pay more out of their own pocket when they buy higher cost health care. If you dont have that, you dont have a marketdriven system. We have it a little bit in the United States, but we dont have nearly enough of it to have a marketdriven system, and therefore the Pricing System is all messed up across the board. People are overpaid, and inflation, and overutilization and waste and all kinds of problems in the American Health care because we dont have the Market Driven system, but one other point, it is not easy to get there. There is one element of this that is hard to get around and has to be addressed which is that there is a massive information imbalance and people trust and want to trust and dont want to deal with it themselves, medical decision making. So when your physician says that you need to get this done, there are some people, and maybe the person to my left who would question it, and think about it, and look it up on the internet, and try to figure it out on his own, but a lot of people would say, i dont think that i can figure this out on my own, and i need to trust somebody to navigate me through the medical system, and because of that, the consumer is not in the same position they are when they go out the buy a car or house or lots of other complicated things. So this trust relationship kind of compromises the market a little bit, and it has to be addressed in some way, ways so that the market can function better. And a last word and paige. As i sit here, i am currently not undergoing a spinal fusion procedure that my orthopedist has recommended for me. You ask why it is so much higher in the private than in medicare or medicaid . If all we had a tax preference for health care is a shift of the demand curve and have the prices to rise. If we had on top of that a tax preference for Health Insurance, we would expect that to shift the demand curve more, and the prices to rise more, but on top of that, we have a tax preference for Health Insurance purchased by the employer with money that we never see and more insulated from the cost, and we expect it to shift the demand curve more and the prices rise more, and add to that the medicare and the Medicaid Programs and they have an effect on the private prices as well. It is not the costshifting effect that everyone seems to think it has and medicare is below the market rate, and the market rate is going to drive it up more, and the hypothesis suggests that if you reduce the medicare and the medicaid rates then the providers will charge private payers more. And the literal suggests that the more medicare and medicaid pay, the higher the private prices go, which is consistent, so that the high prices that we are seeing the private insurers pay is consistent with my hypothesis that medicare is often overpaying than underpaying. Paige, last word . Yes, i would add that the insurers loved the Affordable Care act, because to them it was the perfect solution of government saying we will give you money to cover all of the people, and require them to buy Health Coverage. Yeah, i think that you are going to continue to have the system that we are talking about and all of issues with the private coverage, and the employer system is so entrenched, and i dont see the movement of the republicans or the democrats to want to move away from that, and when you are looking at the democratic candidates, they came out of the gate rah, rah, medicaid for all and we vind on the bernies bill, and now they have backed away and said that we need a role for the private coverage, and we dont want to take peoples employersponsored coverage away from them, because the consumers have a weird relationship with the private coverage, and on one hand the premiums are up way too expensive and we dont like it, but we dont want the whole system to be upended and the democrats have seen it as politically difficult position, so you have seen senator Kamala Harris suggest this idea of the private plans continuing to be offering medicare and the plans that you have seen Pete Buttigieg suggest health care for all who want it, and they should have the option of staying in the employersponsored coverage or buying into the medicare, and they have made a good point about the cost of private coverage, but i dont see, you know, the system ultimately changing and in significant ways in at least the next couple of years. Thank you, paige, michael, jim, thank yuou all for coming. This week we are featuring American History Television Programs in prime time as a preview of what is available every weekend on cspan3. Tonight, historian dan albert and the book are we there yet the automobile, past, present and driverless and chronicles the history of the u. S. Autos and talks about driverless cars. That is tonight on cspan3. We are also showing you booktv in primetime and showing you what is available on cspan 2 this weekend, tonight, we will show you in depth guests including authors lee edwards and naomi kline and so watch those tonight on cspan 2. President trump will hold another Campaign Rally tonight, and this time in lake charles, louisiana, live at 8 00 p. M. Eastern and live on cspan, cspan. Org or listen free on the radio app. Campaign 2020. Watch the live coverage of the candidates on the campaign trail and make up your own mind. Cspans campaign 2020, the unfiltered view of politics. Four policy experts discuss china, russia, iran and syria, and this is part of a Broader Program of middle east strategy at the Atlantic Council in washington earlier in the week. This portion is just over 90 minutes