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