Untenable. We should not be basing our Economic Growth strategy on fueling higher cross cost growth in the healthcare specter. I think we would be in trouble if we were doing anything other than to try to slow the growth of our Health Care Costs rather than trying to feel additional healthcare consumption. Host . And from new york is next on the independent line. Preston, you are on the air. Caller i think you are missing a huge part of the picture. We are talking so much about how to pay for medicare and medicaid, the old healthcare thing, what percentage will states pick up, no one is talking about why it is so expensive. We spend a larger part of our gdp than any other country in the world on healthcare. Im reminded of this conference of article recently in Time Magazine called bitter pill. You can get it online. It is about the cost of health. Can you address that . Guest i agree with the caller thats an incredibly important question is what do we do with the overall increase in healthcare costs because clearly they are growing. My paper was not designed to study that question. My paper was not designed to study the merits of healthcare reform at all. I was narrowly focused on trying to evaluating incentives facing the states, the position the states are in as a result of the law being passed eric past. Having said that, i think there is a lot that people miss with respect to the drivers of healthcare cost. I think part of this reflects the fact that our body politic is reluctant to accept certain realities of the academic literature. Finkelsteins research demonstrated that one of the big drivers of healthcare cost inflation was the rapid expansion of federally subsidized insurance in the 1960s to medicare and medicaid. The provision of federally subsidized insurance is a big driver of Health Service consumption and puts a lot of upward pressure on costs. There of another academic studies. One basically look at the factors throughout countries that drive health inflation. One of the big factors is the rate of growth of government provided health Care Services. If we are with ourselves, we have to recognize that one of the big drivers of healthcare cost inflation is the extent to which the federal government is subsidizing healthcare through various means. It will be difficult for us to get that under control and must we go back and take a realistic look at the growth of federal subsidization. Host a couple of questions have come up on twitter about the problem of Medicare Fraud. How big is the problem of Medicare Fraud . Guest there have been some recent stories of Medicare Fraud. It is definitely an ongoing problem, as it is with any federal program. I generally tend to say there is a continuum of fraud practices between the various federal programs. The lowest rates of fraud and abuse would be in a program like Social Security, which is comparatively quite efficient and few of the payments that go out the door do others in do anything other than what they are intended to do. When you bring in more third party processes like you do in medicare and medicaid, you have more of a potential for fraud. In medicaid or medicare, particularly medicaid, you will see more emphasis of fraud then you will see and Social Security. With Social Security, i think we should be very pleased by how well it runs. We could have arguments with the policy and whether we are making benefits to the right people, but i think the benefits are high. We need to do better with medicare and medicaid. Host i want to go out to california, one of the states that is participating in the Medicaid Expansion. On the democratic line. Caller good morning. A few minutes ago, your role as a trustee, you mentioned that it is your opinion is that Social Security is not quite as stable and sustainable as others. One of the others is a regular guest on here, senator sanders. Ive heard him and others say that Social Security is stable and is not a problem or a drag on our debt or deficit. Could you compare the two points of view . Guest i am happy to. I write a lot about this. Let me say before i begin speaking that if you line up 10 experts and ask them how severe is the Social Security financing problem, i will probably be among be one or two experts that believe it is more severe than the other eight or nine. Im not in the middle. Let me lay out why i believe i am right. First, the Social Security shortfall or is larger than it is for medicare. Medicare is a bigger problem for the general federal budget, but the size and changes we have to make in the Social Security in order to keep it a program it is much greater than it is. A lot of people do not realize that even though we consider and expect medicare to be the bigger driver of cost down the line, over the past few years, Social Security costs have grown more rapidly. They burn in the aggregate and in the first time for the obama administration. It grew faster than medicare. The current Social Security shortfall is larger than at any point it has been since before the major 1983 Social Security reforms. If you compare Social Security s current shortfall to the one we faced in 1983, it is about twice as large now i might even relative to the size of our tax base. What does that mean . If you like and look at the political high water marks of what our political system can achieve to keep Social Security going, we are now twice as far past that. In order to fix Social Security , the left would have to agree to twice as much a benefit restraints, the right would have to agree to twice as much in tax increases. The problem is getting worse very rapidly. We are in uncharted waters. There is no precedent for fixing a Social Security shortfall the size we now face. While it is possible on paper to draw up a solution to Social Securitys problems, whether our lyrical system is willing to political system is willing to face it is very much an open question. Each fasting passing year will be less likely that we can a cop with that. Host dan in New Hampshire on the republican line. Caller good morning. I have been on Insurance Agent for over 20 years. I have looked at this from all angles. I am a Firm Believer in Health Saving accounts. I have been doing hsas four years. The incentive of making people spend their own money and having interest in how healthcare dollars are spent we have a thirdparty system in this country. Employers, medicare, medicaid. There is no incentive for the individual if they are not spending their own dollars, they will not be as conscientious when they are spending somebody elses. We live in a society with huge numbers of lawsuits. There are some money lawsuits, defensive medicine and spending billions of dollars per we are living longer, we have the best technology. Medicaid and medicare, medicaid in particular, what incentives do we have to move people off medicaid . What incentives are these folks going to have to not over utilize the system . What approach can we have where people have incentive to make smarter decisions on how they seek services, seek their healthcare . We need more transparency in the system. We do not have enough. You cannot walk into a Doctors Office and find out what things cost. Nobody can tell you. We need to more incentivize the whole system for everybody so people know what these things are, what it is costing us. I would like him to address these questions. Thank you. Host New Hampshire is one of those states that has said it will be designating in this Medicaid Expansion. Guest my sentiments are much like the callers and some respect. A deep problem is that there is not enough conscious is on the part of the. So you do not have the normal Market Forces that rein in the growth of cost. In response to the question as to what are we doing to increase the incentive i am pessimistic. We are not moving in the right direction. The bigger effect of third Party Provided insurance is to a greater extent to shield people from the financial consequences of their healthcare purchasing decisions. By expanding Health Coverage as much as we will be doing under the hca, it may have humanitarian benefits, but whether it leads to a cost conscious system where the individual consumers become more costconscious, i do not think we are moving in that direction. One final point, it is important to keep in mind the separation between the question of services which people are likely to be costconscious and services where people are not likely to be costconscious. If you have an emergency or you have some catastrophic illness, invents, and you have to have it dealt with, it is probably asking too much to expect that individual to say that through an hsa. If you look at the way many hsa plans are constructed, it is a basic plan to handle the could start catastrophic events. I think the potential for cost consciousness is greater with respect to the other, routine healthcare rather than with these catastrophic events. It is a way to create Greater Consumer accountability. I would be in favor of it. Host sheri from clearwater, florida. Caller am i on now you g . Am i on now . Acupuncture, has been around since india, herbs, which have been in the bible. Doctors do not have all the answers. There are too many misdiagnosing and under diagnosing. There is too much reliance on Expensive Technology and prescriptions for pharmaceuticals that cost so much money and have so many side effects, and they may only be 26 effective. Plus i have often heard medical suppliers laugh at how much the how much money they are making overcharging. We have so much waste and corruption am a and the quality of our healthcare is so poor. Guest first, the caller is right. Technology is a big driver of cost growth. We have tended to adopt a new technology that costs twice as much, even if it is only 5 more effective. That has been a driver of cost growth in the system overall. I think the academic literature one place there is broad agreement is the historical role in Technology Advancement and driving the overall cost. On the second point about what thirds of what sorts of Care Services we allow for, this is one of the things that the inevitable byproducts of having the government involved to such a large extent with providing insurance through programs like medicaid and medicare because once you do that, the government has to make a decision as to what it is going to cover and not cover. It is inevitable that there is going to be places where the government says, if you are on your own, you could buy such and such service, but the federal government wont choose to separate subsidize that through a federal program. Host florida is a place where governor rick scott, a republican, is trying to get expansion of medicaid to happen. I want to get you to respond to a same and he made in his state of the state address this week, according to a politico story. He said our options are either having from floridians pay to fund these programs in other states while denying healthcare to our citizens or using federal funding to help some of the poorest in our state. I conclude that the federal government is committed to paying 100 of the cost for new people on medicaid. I cannot in good conscience deny the uninsured access to care. Guest he has deftly articulated one of the benefits the states are facing. You have the potential to have additional Healthcare Benefits financed by other people. We are all federal taxpayers, so we will all be paying for the larger Medicaid Expansion whether or not our state dissipates. The other side to that argument is what is the condition of the state budget . That is a matter for the Florida Legislature to deal with. But there will be costs for the state involved with the expansion. They have to decide, and apparently they have, whether the Health Benefits justify the cost. Host thank you for coming in today. Guest thank you. Host up next, our america by the numbers segment in which we will focus on your daily commute to work. We will be right back. Abigail letters have been in print and she has been ready since the 18 40s when her grandson first publish an edition of her letters, which went through four, in the 1840s. She was a bestseller through the 19th century. She has always been famous. Our conversation with historians about Abigail Adams is now available on our website, cspan. Org firstladies. The United States patent and Trademark Office is one of the few federal agencies that actually is designated to exist in the constitution. Patents and trademarks are a fairly modern invention. The first patents were actually royal grants given to inventors for monopolies on of their inventions. They were popular in england and continental europe. But because edition takes it one step further. This is for useful inventions, and from the beginning of a novelty was a key aspect of the patent offices role. You will notice that every one of the models have a little tag with it. Each of the tags is tight on by a piece of red ribbon. This little piece of red ribbon is one of the supposedly originations of the phrase red tape. Government red tape. So it is hard to tell that this is originally red ribbon that each one of these was tight on. It was not until the was tight on and the patent was approved that you would cut through all the red tape. Originally, patent models were required to show the operation of an item. So each one of these models works in the way that a full scale version would work. This week and on American History tv, tour the National Inventors and museum on american artifacts, sunday at seven at 7 00 eastern on cspan 3. The washington journal continues. Host we look at a new report from the Census Bureau on American Workers commute. We are joined by dr. Robert mckenzie of the Census Bureau and Robert Puentes, a senior fellow at the brooke Brookings Institute. Dr. Mckenzie, how long is it taking the average worker to get to work these days, and how has that changed . Guest the u. S. Census bureau asked abel how we get to work here it we asked how long it takes them to get there, how they get there and where they work. This is all collected in the American Communities survey. It highlights more than a quarter of all workers working in a county that is different from where they live. The average travel time is about 25 minutes, and this has not changed as much over the last decade. If youre highlights here a few more highlights here more than 75 of workers get to work by automobile. But this has changed very slightly over the last decade. It has gone down by about 2 . Host folks at home can follow along with these numbers and charts on our Facebook Page. You can see on our Facebook Page at facebook. Com cspan. We want to take your questions in this phase segment. We want to hear about your commute and how long it takes you to get to work. Urban commuters can call 202 5853880. Suburban, 2025853881. Rural, 2025853882. If you work from home, 202585 3883. Those numbers are on the screen. Mr. Puentes, take us through these numbers that are collected by the Census Bureau. How are they used to influence policy or talk about policy on transportation and infrastructure . Guest these numbers really matter. When you look at the u. S. Economy, we do not just have one national economy. We have 360 something metropolitan economies. These places matter. These metropolitans are made up largely of commuting paths. That shows economic connections between a u. S. County. There is a cohesiveness that exists. The numbers really matter for looking at metro areas. But when you think about what we are trying to do now as a nation, trying to recover the economy, trying to create more jobs, we know we need more jobs, we need better jobs. We also need to make sure that those jobs are accessible to people. It is no good to have jobs all over the place that people arent able to get to. These numbers directly tie in to the conversations about where we are creating jobs, what kind are creating and who they are for. Those things matter. With commuting, there are trans rotation policy communications. 4 5 of the trip are Something Else, but because theyre highly concentrated in the morning and evening commutes, that is a lot of trans the restaurant he transportation network. It really matters for transportation policy and planning. Host dr. Brian mckenzie, talk about how people are getting to work these days. Are we still a car bound country . Guest abs