Eric Anderson "The Unhealthy and Uncaring American Health Care System" October 23 2016



okay at this time we're moving on to our main talk uh it's gonna be aa there Erik Anderson our workout president of Houston Oasis and also a member of the network of voices will be talking to us about the wonderfully caring and very healthy US healthcare system thank you brain up for that introduction looks like today I'm to be talking to you about selecting a location for your network oh that's right ok we're going to be talking about the unhealthy and uncaring American healthcare system I got to give you a full disclaimer I can see that some of our medical professionals in the group are actually sitting here in the front row I can't see any rotted fruit or anything so I'm probably safe there but this talk is not going to be critical anyone that works in medicine it's not really critical medicine at all action I'm a huge advocate Western medicine i think that medicine and healthcare are inherently good things what I'm gonna be talking about instead is the economics behind our exceptional healthcare system which is where my title comes from the unhealthy and uncaring American healthcare system it's a very good title you can tell us a great tell because I didn't come up with it I stole it the Walter Cronkite who 17 years ago in 1999 famously said America's health care system is neither healthy Karen Norris system he was right back then 17 years later he's still right today believe me so why did I get interested in health care it's not my profession i'm actually a financial analyst but I became interested in in 2012 when my first child was born precedent many of you know him and after his birth about a month and a half after his birth it was a relatively uncomplicated pregnancy everything was pretty routine I started getting bills as the man as I'm sure many of you are familiar with and it was a lot of those who was not just a built in the hospital the doctors was a bill for the surgeon with surgeons assistance in the anesthesiologist and everybody who waved and said hello to me to the hospital sending me a villa and I total of all these bills and it was six thousand dollars and I thought I'd a minute I've got good insurance I look at the back of my card it says maximum out-of-pocket per year two thousand dollars how do we end up with six thousand dollars so I called everyone and I explained to them must be some mistake I've got good insurance why am I paying six thousand dollars and all of them said oh no sir there's no mistake by the way if you don't pay us we're gonna send you to collections and destroy your credit so i made i paid the six thousand dollars it was worth it i would have paid more than that but still a lot of money to pay for something that humans have been doing since the beginning of time now i called my dad i asked him for advice you know my dad's done this whole pregnancy thing four times and I thought maybe he knew what I could do to better my situation here I said dad you know what and you had four kids what did you do right you got all these medical bills how did you plan for how do you save for it do you know what's what's right what's wrong usage beats me you were born in 1988 which was 24 years ago at the time jackin him i paid a ten-dollar copay and I've talked to other people okay it wasn't just my dad really good insurance all right other people around that time period we're paying about the same thing so something changed in the 24 years between 1988 and 2012 something has changed about our health care system what is it so I started looking turns out from roll you'll all be very surprised to hear the cost of health care has gone up wat that but it's gone up more than inflation right most things go up inflation is the is the kind of the normal rate at which things increasing costs usually wages increase to compensate for it so it's kind of an invisible effect let's look at a couple of different things and how they were affected by inflation between nineteen eighty-four 2015 all right first time I look at miss housing I've talked about housing before we're all very familiar with it housing in 2008 was in a bubble from the bubble burst it caused the global economy to fall to its knees right we're all familiar resistance called the financial crisis and something interesting about housing is when we look at wages housing and wages moving very close synchronous to each other by the way all these graphs are inflation adjusted so we've taken inflation how to be equation you're just looking at raw cost increase above inflation you'll notice that housing and wages move together in costs which makes sense right how are you how's the house going to go up in value it's consuming an increasing portion of our wages right until 2000 when it moves into a bubble hits 2008 and it all comes crashing down and well recently started going up more than wages again this talk is not about that but if you want a couple of reasons behind that interest rates a 1000 for about a decade now and there's been an influx of foreign investment dollars sponsoring anything but that's for discussion on another time also notice that wages since 1984 really haven't moved at all on an inflation adjusted basis that's also a discussion from there the time not very good thing but let's look at the cost of health care compared to these two no that's got a point more than the cost of housing eat the cost of housing when it was in a complete boat cost of healthcare is growing much much faster than inflation and it's growing much much faster than our wages are going which daves the question if it keeps growing faster than our wages are going how the hell are we supposed to pay for it it's consuming an ever-increasing portion of the American budget there's more than one way to look at the increasing cost of health care of course let's look at the cost of health care compared to the rest of the world is the amount of health care going up everywhere else perhaps well another way to measure this is to look at the health care sector as a proportion of our gdp what is GDP it is all the transactions of goods and services in the economy generally measured on a quarterly basis right every single dollar and cents that is transacted for every single product or service measures into your total gdp in the entire world between 1995 and 2015 healthcare moved from consuming about nine percent of GDP to today consuming about ten percent of G so it has got a big cost but again you know also medical technology has improved so maybe we're getting a pretty good deal on that let's look at what has happened to us healthcare as a percentage of GDP a little bit more look at that our 1995 we were paying about thirteen percent of our gdp thirteen percent of every single trends action in the US was healthcare-related dollar for dollar to today we are paying close to eighteen percent our GDP finally are the largest economy on earth eighteen percent of our entire economy is going towards health care services now that number sounds have been more ridiculous when you realize that even with our spending of eighteen percent of our gdp we still have a significant portion of our population that doesn't have access to basic health care how pathetic is that alright here's my favorite by far here we have on the x access health expenditure inflation-adjusted and you'll notice that we have bullet pointed through time where we stand on these two axes per country right and then on the y axis we have life expectancy so what we're trying to measure here is approximate value how much are we paying for health care how much are we getting back in return compared to the rest of the world now there's a lot of different valuation metrics you can use besides life expectancy but this is a very simple bedrick that is easily tracked by countries all over the world I guarantee you this charge matches if we were to swap that out with other things like you can mortality rate and survivability of certain cancers the obvious outlier here is the United States who you can see is 10 more than anyone else in the industrialized world per capita for their health care and is receiving less than anyone else in the industrialized world for their health care in terms of life expectancy now I want you to make a mental note for me of where Japan Australia and New Zealand over about center of the pact your hands up right below them Australia rifle of them use if we're going to talk about them alright so let's talk about some of the reasons possible reasons why health care is going and why those reasons are invalid so the first one is there have been massive improvements in medicine and technology over the last three decades and that makes it more expensive right we're getting more out of it you have to put a little bit more into it well that reason doesn't really stand up because medical technology across the Western growth is relatively homogenous all right they got MRI machines in France too I promise you okay we may have certain innovations and expertise at others don't but others have certain terminations and expertise that we don't and generally everything in medicine is shared and publish right and then also maybe the ground we were just looking at tells the story the u.s. ranks poorly in comparative metrics of life expectancy infant mortality etc etc so it must not be true where we must not be getting our money's worth if the reason for the increase in health care costs isn't just in the US or because of emergency medical technology all right another possible reason health effects from changing lifestyles maybe we're eating too much money maybe we have an obesity epidemic right even with all her this America is a very obese on average patient maybe that's what's causing our healthcare costs to be so high well actually remember where I Australia New Zealand or both of them have similar obesity rates the United States and yet they have higher life expectancies and they are not paying nearly as much as we are for our health care so we can just miss that all right what about this it's got to be tobacco right all those filthy dirty smokers sucking their lungs full of tar they've got to be the ones putting all this extra strain under health care system causing it to be so expensive for us no sorry that's not it either in fact the u.s. ranks better than most nations in the world when it comes to tobacco consumption per capita we have really been a world leader in leading the fight against smoking so it can't be that oh I know it is it's going to be our aging population right we've heard this on the news the baby boomers one of the biggest generations they're getting over and older and as people get older they generally consumed or healthcare so wouldn't that increase the cost that's true as people age they consume a lot more health care but the US has a smaller proportion of elderly than most other industrialized nations especially countries like Japan which has a huge proportion of elderly citizens in their health care system and yet they all managed to have a higher life expectancy overcome so what is it well in brief it is our health care system itself many people refer to it has a free market system that's not right it's not actually a free market system it's a perversion of a free market system but let's just for the sake of argument assume that was a free market system now I need to disclaim as many of you know I am unapologetically capitalist I believe in the free market system and I believe in that certainty because I know that capitalism has created more value pull more people out of poverty and created more wealth than any other economic systems ride on earth I also admit that capitalism cannot be universally applied to any market and expect to get the same results capitalism remember is an indifferent system it is neither moral nor immoral it doesn't care it just asks one question and it does it very well what is the price alright so before i get into healthcare and capitalism let's talk about how capitalism works when it's supposed to be working let's talk about the market for ding-dang bicycles okay all right and the market for bicycles this is a very common graph you'll see when we're talking about economics a lot of people who use this this is the relationship between the price of a good in this case a bike bicycle and the quantity of goods that are produced in the marketplace all right so we've got two lines there the first one is the demand curve for bicycles this would be how a consumers react to a change in price for bicycles obviously the demand curve is going to look like this right as bikes get more expensive consumers are going to want less of them the fact that that line you slope means consumers have bargaining powers all right the bike gets too expensive and we go buy rollerblades all right the other curve is the supply curves the people producing bicycles and it's sloped the opposite would be this is the price of a bicycle increases producers want to produce more of it makes more resources available for the production bicycle so how do we solve this problem of consumers wanting bicycles and suppliers wins by bicycles tell me find the perfect price while we look at the equilibrium the intersection of where the supply and demand curves meet and we find our perfect price that makes our cyclists I'm glad to see Bradley is not here today what you're asking permission for this later but I the key to this chart that I want you to take away from this example is that when producers and consumers have bargaining power capitalism works all right now let's talk about health care right capitalism it's very good at answering one question what is the price the question we end up asking indirectly when we apply capitalism to health care is what is the price of your life ok the supply curve hasn't change healthcare producers and still produce and provide more health care or they can provide less stuff here and have a closer spot the demand curve has to change there's no more elasticity in it consumers don't have bargaining power if anybody in here has a heart attack are you going to shop hospitals all I want to get help all right you don't have bargaining power nobody can tell you otherwise which means that in a capitalistic free market health care system the suppliers of health care pull all the power to control price all they have to do is adjust the supply raise the prices as they want to all right I said earlier our health care system is not in perfect free market system it's a perversion of capitalism and there are several reasons why that is first of all there is almost no price transparency in our system you want to know what a hip replacement costs you want to know what it's going to cost to have a child you want to know what anything is going to cost good luck calling all the providers trying to figure this out like most of us we have insurance and we assume that the raid the insurance companies negotiated for us is fair and if it's not her on the book anyways also thanks to the nature of health care there is a lack of competition riders nobody's trying to undercut each other and he's trying to steal patients they all know that we all need health care we're going to comfort them no matter what and there's very little information to convey quality of healthcare it's very hard to find out who is the best hip replacement surgeon where is the best place to have to be these qualitative metrics they're not there but there are a little bit okay they're kind of hard to discover which impedes our abilities as consumers to be informed in to make informed decisions finally by the nature of medicine medicine is very complicated it requires many many years of study to understand it and all of us don't have that training like doctors do so in the end of the day we just don't know what we need we rely on the expertise of our medical professionals to tell us what we need which is consumers makes us unable to bargain unable to make sure we're getting with this rain forest alright the biggest perversion of medical system by far though is the intermediary that we have on insurance for most people in this country grab insurance your insurance is paid for by you in a pocket is paid for by your employer as a part of your total compensation so here's the relationship right consumers we receive services medical services from our medical providers hospitals doctors surgeons premiums are paid from the consumer or more likely from your employer to the insurer and the provider receives reimbursement from the insurer maybe a little piece from you ago babe duck or something but a majority of the money is transferring from the consumer to the insurer the provider we're separating consumers from the knowledge of what their healthcare consumption in what costs so what are everybody's incentives in this system consumers all they want is to get the best possible treatment and the maximum circles they're paid into their insurance and they want the best nobody got cancer and said I got the second best arm I one of the third best oncologists no we not the best we pay our insurance we're entitled to see ensure well their businesses to make money they're making money on the spread the spread between what they receive in premiums and what they panel to the provider so their incentive is to keep that spread as wide as possible and the providers we this is a bill for payment or this is a bill for service system right they are incentivized I'm not sending they're bad people one signed document aims to build for the maximum service and to receive the maximum reimbursement no one in this whole system is incentivized to control costs so what naturally happens but nobody's incentivize the Crosstown know what it just makes sense so as you can imagine understanding the relationship between the players in the health care system there is a lot of incentive for things to be placed orders a lot of wasteful spending in our health care system and a study done in 2012 by Price Waterhouse Cooper examined all the relationships between all the different chemical providers and they look at all the different statements and interviewed thousands of people and comprehensively put gather it report on the health care system where they found that more than fifty percent of all healthcare spending in this country is considered wasteful and for purposes of this presentation and for the purposes of this finding we will define wasteful spending and spending for a service or a good which provides no value to the patient think about that fifty percent of every single dollar transacted healthcare system is wasteful spending tests that was wrong maybe didn't need to be run medication that was prescribed that perhaps didn't we would be prescribed all right there's another incentive to doctors are very liable to be suitable just wrong so they have an incentive right in there to make sure that they catch everything that they run every test they perform every procedure necessary to cover themselves from a lawsuit should think there's something what's more frustrating than wasteful spending is fraudulent spending and there's plenty of that to a health care system a survey also done by Price Waterhouse Cooper found that ninety percent of all medical bills issue contain errors ninety percent don't know what other industry on earth could get away with ninety percent mistakes things like pop coding up charging there's something called a cpt code those providers use them they're established by the American Medical Association and I believe they're required by HIPAA so anytime they built or something to get a band-aid or a surgery they have to use the appropriate cpt code but there's a lot of CPT codes out there up charging is when they use this the most expensive code in the category let me give an example perhaps see section all right there's a lot of different CPT codes for c-section to be a routine scheduled c-section without me complication there's a code for that and it could be a c-section that was done in an emergency where there's more attention required conductors or maybe a specialized surgeon needs to come in there's a cpt code for that too and that cpt code reimburses higher because of the extra risk it should what's happening here is the billing is not necessarily reflecting what should be charged on the bill in many many cases then there's double bill like I said get a lot of bills after you go to a housecoat and from a lot of different people more than one of those parties can we claim in the same safety teeth oh and you might not know it unless you specifically request from all your providers sent you cpt codes for that procedures you can check for this your insurance company isn't going to check for it they do some high-level jackson is a really expensive bill that might bring someone in to look at it but that responsibility is on you to find this kind of stuff they also might just flat-out charge for a service that wasn't performed right and charge it for 210 dates instead of one there's an extra six thousand dollars in correct time charges cpt codes build in 15 minutes increments alright so operating room time to time you spent in the operating room they have to build a cpt code for every single 15 minute implement the ER in the operating room and maybe they say was an hour instead of 45 minutes and then there's the most frustrating one the one that I had personally dealt with so much in my own experience over payment which is when your healthcare provider asks you to prepay in front of the procedure a certain amount based on what they believe your deductible and coinsurance or hard it's going to be and then after it all happens in its process through the insurance there's money left over that should be given to you but they never forget that statement so you never know about it unless you reconciled with yourself which is exactly what I did I got me a member of the family Alan I'm sure a lot of you would met him and not only like when Preston was born I got a bunch of bills mail about a month and a half after words from a bunch of different people and so this time instead of just landed paying them I called every single one of my wives I said send me the cpt pills and I created a spreadsheet where I reconciled my insurance benefits against what I was being charged to make sure that everything was on the up and up I found in almost every single case there was a mistake I you can see the the total here I was initially built for five thousand eight hundred sixty five dollars and eighty cents from a bunch of different providers and after I examine the bills and corrected mistakes I ended up owing 1560 dollars and eighty-seven cents there was forty five hundred dollars in out-of-pocket expenses there I'm not going to go to detail about all the mistakes I com just going to share a couple of my favorites the first favorite has to be for my insurance company my insurance has a five-hundred-dollar individual deductible which means that each member of my family has their own 500 adoptable that must first be met before the co insurance kicks in which is the insurance obligation on behalf of the building my case the insurance pays nine percent I pay ten percent for the coach it's actually pretty good plan but when I totaled up all the deductibles and reconciling bills I found that I was being charged $1,500 in deductible but I should have been only been charged a thousand right because there is my wife's deductible and there's Fallon's deductible 500 plus five hundred a thousand instead was 1500 I called and I asked and I demanded to be transferred to a supervisor and no one could answer my question where they wouldn't answer my question and so finally I went through all that big stack of paperwork on my own and I discovered that they were billing my wife c-section to me so they could use my deductible Eric Anderson was being billed for a cesarean section this is entirely the insurance company is doing because the hospital bills had it straight they had an oval to Jess I wasn't a part of the insurance company took those bills and change the patient to Eric Anderson so they could use an extra deductible it was unbelievable when i call them a love mr. Anderson we were so sorry what a mistake can you believe we did it's I do smell out the second one was a prepayment we have made to just as OBGYN it collected six hundred and fifty dollars in advance for the procedure and then interestingly enough i'm not going to half after it I didn't get any statement from so I called him and asked him to send me over hoops and they did and sure enough I found that there was three hundred and fifty dollars that belonged to me because the insurance had only build 398 of 650 and after calling and screaming and emailing and threatening to sue they finally reimbursed you three fifty bucks all right what did I say I said wasteful spending value fraudulent spendings worse what's worse than fraudulent spending assholes I mean legal really really dishonest behavior collusive behavior from people who just flat-out you don't like all right so I've got an example here this is mr. Marcus Corelli winner of the 2015 most punchable face award most of you recognize him armscor Ali's not a doctor he's not he's not a scientist he doesn't know chemistry he's not adding anything of any value the medical system what he is is a capitalist all right yeah yeah what's funny about that yeah he's a 10-8 but not for this this was so illegal isn't aiming for stealing investor money in an unrelated thing all right so what he did is he bought the rights to a drop of active drug I think with daraprim is that right yeah it was given aids medication i think the drug was called Derek nervously whatever it was it was a life-saving drug he bought the rights to it he added nothing of value and increased the price four thousand percent four thousand percent for this truck right and all that happened as a result of this because all that could happen because it's perfectly legal we get these people legal Menominee's with patents all that happened is Congress all them in front so that a bunch of politicians could act like they were going to do something about it but really they couldn't what he's doing was perfectly legal even oh good they know but cats on prices for things like that yes and I may be missing for but I believe that we still don't have any caps on it is being pulled in front of Congress so far has done nothing for us but making a bunch of politicians look like they're tough on health care right all right so even when there isn't a patent drug companies can use techniques like evergreen ever greating is what a drug reaches the end of its useful time my beliefs 15 years maybe 14 yrs they change something about the chemical formulas something perhaps insignificant but enough that they can finally do have it and go for a number 15 years and evergreen is louder and keep selling it under the same day where same label also drug companies use something called drug coupons which on the surface sound like a very good thing but they're not actually a good thing for the health care system so if you are a consumer and you go to the pharmacy and you have a choice between a name brand drug in a generic truck you'll probably going to pick the generator because it's cheaper oh but wait sir pfizer has given you this coupon have the goodness of their parts which is going to pay your entire co-insurance on that game frame from oh great I'll take the name branded write the name brains always good at dura sells better than CVS and whatever right you get the name brand but your assurance fell but he still has to pay the price for the name brand so that savings that you've got just get skipped right back into the insurance system in the form of higher premiums and the price keeps going up and Pfizer keeps making money on their name brand drug well there's a generic out there and then there's also something which isn't legal but it's very very suspicious because a lot of it's been going on and that's collusive behavior between drug companies which I'm going to talk about in a bit all right to lose the behavior this is another star the healthcare system I'm sure everybody knows the CEO of Milan who purchased the rights to the EpiPen the shot of epinephrine and increase the price from a hundred dollars attack six hundred dollars in that because they had patented a new delivery method and got have happened on that and everybody else who wanted to sell evident pens which were not patented hit roadblocks when they reached the FDA because the FDA was concerned are not rightfully so that the generics could cause confusion among consumers when they're using epinephrine things since 2010 I want to talk about Vince late now that's enough about him I want to talk about instantly since 2010 2 2015 the price of insulin which does not have a patent on it has increased three hundred and twenty-five percent insulin was first synthesized in 1921 almost a hundred years ago there's no secret to how insulin is synthesized all right there's no there's no magical formula to creating it but it is a necessary life-saving drug the diabetics have to use on a daily perhaps many times a day basis so talking about collusive behavior how could something like that happen when there's no patent on there are three manufacturers of insulin of the United States all three of them at the same time raised their prices over the last five years how does that happen if two of them raised their prices and one of them doesn't everybody switches to the third one it keeps on the business if one of them raises their priceless they lose all their customers it takes all three in synchronous to raise their prices in order to make this plan work tell me there's not collusion going library tell me they're not working for their mutually beneficial interest yet the Federal Trade Commission has not brought a single case against there's something starting changes going on in health care right now traditional health insurance many people call it a lack health insurance that have health insurance we go to your doctor and you pay at end co-pay instead of paying them two hundred dollars and getting that applied your deductible it is going on a fav early as the cost of health insurance has been increasing as the cycle has grown to the point of what programs are so cost exclusive a cheaper alternative is being used called high deductible insurance plans no I don't know insurance can be fine but you as a consumer are on the hook until your deductible is met there's no co-pays you have to pay a hundred percent until you meet your deductible and the reason why that concerns me is because sixty percent of bankruptcies in this country are already related to health care debt sixty percent of bankruptcies and we push further costs of healthcare onto our citizens how do we expect them to go with it another big concerning factor the proliferation of high deductible insurance plans is that frankly the medical system has grown fat off of traditional insurance it is not as efficient as it needs to be I've examined the profit margins of the largest publicly-traded Hospital companies and I tell you they're luckily break even on many quarters if they suddenly lose this benefit we could be talking about recession a medical recession now I'm not saying that's going to happen but these trends continue there's absolutely a possibility alright some brief conclusions obviously America needs is sustainable healthcare system that has a mechanism or cost control built into it we don't have that right now there is no cost control nobody's incentivize to control costs be that regulation that mandates maximum caps on things be that a entirely socialistic healthcare system where the costs are mandated where everyone in this system is paid a flat price or maybe a Medicare style system where the cost of reimbursement for things are paid for but the hospitals and doctors are still private workers I don't know but whatever the system is it absolutely needs to have the price control mechanism built into it we're just going to give you the costs rising and rising rising also I think medicine needs to be for the regulator and I'm not talking about the practice of medicine i'm not talking about the certification of doctors or health care professionals I'm talking about medical billing needs to be regulated as a consumer when I spot something wrong in my medical bill my only recourse right now is with the provider all right there's nobody else I can go to there's nobody else I complain to believe me I tried i sent complaints the attorney general's office through every one of those fraudulent bills I heard nothing back I sent in place to the health and human services department I heard nothing back I said complaints to the Texas insurance department I heard nothing back as a consumer we have no recourse except to resolve this with our survivors directly and you know what I was lucky my provider said oh sorry our mistake here will print be the difference what have they had said down sue me they could very well do that I don't have the money to find it's a lawsuit against them over three hundred and fifty dollars certain thing about where the bosses can take years there needs to be easier recourse I think a great example of this is the Consumer Financial Protection Bureau which has jurisdiction over the banking center if you catch any mistake on any statement anywhere you can submit a complaint to the CFPB and I tell you I've done it before it's like calling SEAL Team six all right they are all over that I thought there was a mistake on my American Express statement the other day well nothing there was actually years ago and I submitted a complaint to the CFPB man they were on the phone with me within an hour we're talking of it was sued and amounts of 20 something dollars and I was followed up with phone calls from American Express burgers try to clear it up and then they sent me a letter of apology and of course credit of the difference and why don't we have some kind of system like that for medical bills where 90% of them apparently containers also the FTC needs to wake up and start pursuing collusive behavior claims against drug companies and we need to re-examine our patent system we are giving people an incentive to innovate I agree with that I agree with the patent system alright we are incentivizing people to come up with new ideas potentially life-saving ideas and their compensation for that is if you come with this idea you get 15 years of monopoly but maybe if we give away this free 15 years of monopoly we should have some kind of control in place to make sure that it's not used if what is being patented is a life-saving medication right now we don't have that all right that's the end of my talk thank when you were going over all the bills everything you got me put it in spreadsheet would you be able to provide a template free to detailed summary of like we called by one and how they or crime mystery absolutely you know what why don't I just post my spreadsheet on the private Facebook group as i said i'll delete all the perfect medical information they give me a template people can use um yeah that's it talking about the fraudulent billing you gonna try this report into the postal inspector box because if I didn't think of that you know I have never been impressed with the postal service right the cpt codes that on the Internet is it standardized ah yes actually so my ensure is blue cross blue shield and blue cross blue shield on their website has a reference I can use the book of CPT codes with the description that says exactly what each of code should be applied to Vista the coast are from the American Medical Association you can also sign up for a count on their website and they let you and I don't know why they want you to buy a book but you can look up up to five codes a day with their free accounts I just use the blue cross the desert toolset couple more questions one drop one more question all right ah I'm going to take you in the back yeah I'm the spray priest presentation I've been a long firm advocate of a single-payer better care for all but whenever I talk to some of my I guess more conservative friends or people who are on the other side about how we can help train where if ever studied in Canada was here and one thing I always bring up his wait times and how you know how you know you have an astronomical wait time and say Britain and France Sweden and you would have as much of a wait time I think in I've my response at all it's always been you know no system is perfect and pretty sure canada japan in west years are not without their problems but that's something i always have a hard time yeah you saying yourself no system is perfect right in the zone yeah they're uh they're a bunch of your health care systems every country seems to do it a little bit differently when some mix between private public restricted public you know how the reimbursements work how they solve the issues of wait times and whatnot there's a lot of things to play with their but the bottom line is the way we're doing is wrong it used to be fixed thanks thank you so much for me you

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