The Future of American Health Care – Dr. Theodore Marmer

[Applause] good evening great to have you folks here what a glorious day it was and and so great to have you here it really is what pleasure that I welcome you to this first of our two-part series on the future of American healthcare we are really delighted at Concordia to bring this conversation that has dominated the national stage to a forum here at Concordia as you all know President Obama signed the Affordable Care Act in 2010 putting into place comprehensive health insurance reforms that began to roll out this past fall to some this has been the most significant legislative accomplishment since FDR and two others Obama care has become a new curse word our goal in this two-part series really is to bring some clarity to these divergent perspectives and perhaps help us navigate the impact of this legislation on both our personal and our collective lives tonight we are fortunate to have here with us dr. Ted marmar to help us to get this conversation started professor emeritus of public policy and management and professor emeritus of political science at Yale University dr. marmer Hurd earned his BA in American history and from Harvard and studied philosophy of language at Oxford before returning to Harvard for his PhD in political science and public policy he began his public career as a special assistant to Wilbur Cohn secretary of 80w in the mid-60s he was a senior social policy adviser to Walter Mondale in his presidential campaign of 1984 and worked briefly with the Clinton health care team before joining the Yale faculty in 1979 where he taught till 2009 a world-renowned scholar an award-winning author he has published over a hundred article in wide range of scholarly journals he contributes frequently to op-ed pages in both US and Canadian newspapers and commentary on national television and radio if you happen to watch his tie later on ask him about his tie with the Canadian and American flags are on them he has written 11 books including his most recent social insurance America's neglected heritage and contested future reviewers proclaim it balanced compact and informative written for the general reader as well as they experienced analysts and maybe one of the best volumes out of introduction to American welfare state ever written we are most fortunate to have him here with us this evening and please help me welcome him [Applause] well when you're to reduce that way what occurs to me is the thought that my mother would be very pleased if she were here thank you very much president George for that and I have to say I am just delighted to be with you tonight that's not true of every speech I give but it seems one of the first days of spring today and how could you avoid being a good mood with that coming that's one reason a second reason is that the topic the President George laid out turns out to be the topic I actually want to talk about if you looked at the title of my talk the future of American medical care you'd have no idea what I'm going to talk about notice about any title called the future of the major feature of such a title is that nobody can be shown to be wrong all right the future we don't know so I didn't want to talk a lot about the future I wanted to talk about really how to understand this episode in American public life called health care reform initially derisory the use of the word obamacare and now more descriptively the healthcare reform of 2010 but before I say a word about that whenever we're talking about health care or health it's important I think to loosen up a little bit and the following story actually two stories occur to me the one that I like the most is the problem of any speaker trying to reach an audience like you and it's a true story and the story is of the the election in 1960 the contest between Richard Nixon and John F Kennedy and this story was told to me about 20 years ago and allegedly is true it captures the problem of a speaker being able to reach an audience what happened apparently is that Adlai Stevenson who contended in both 52 and 56 lost to Kennedy in the primaries was quite angry at losing to this upstart from Boston and the Kennedy team was desperate to get this great orator to speak on on behalf of the candidate so finally they they encouraged him to come to Philadelphia and so he came gave a speech and at the end of the speech a woman of maturely years came up to and said rather worshipfully governor Stevenson that was the most wonderful superfluous speech I've ever heard Stevenson thought irony was the right response so he said to the lady My dear given your enthusiasm for my speech perhaps I should publish it posthumously to hitch the poor lady lady said without thinking Oh wonderful the sooner the better so that's one speech that captures it but but there's another one about health that's even more important to get through in order to get us into the talk about Obama's reform this is another story that was told to me when I was a young academic at the University of Chicago in the mid-1970s and it has to do with a Swedish doctor a GP by the name of Spence and dr. Svendsen comes in on Monday morning to his office and his nurse and office manager reports that he's there's an agitated 94 year old gentleman in his office in system that he see doctors fence and immediately dr. sense and says all right goes into the offices that sir could I can I help you and the 94 year old gentleman grabs up a magazine which in Swedish is prevention and says is it true what this article on prevention says Francis says I don't know what does it say well it says the following it says if I become a vegetarian at least most of the time if I give up at least half the consumption of red meat that I've had if I forgo sexual life entirely if I no longer drink and I give up cigars and in my pipe and I walk three miles a day is it true that I will live three point four years longer Vinson rubbed his chin and he says I don't know about the science of it but it will seem a lot longer so that's background foreground how to talk about this topic called health reform in the United States 2008 to 2014 and what I want to do about that is step back for a moment and instead acknowledge that for many of you and for every audience that I've spoken to this legislation the question about what needs and is being reformed in American medical care is a matter of deep interest and lots of strong feelings and strong values both positive and negative and so my the way I want to begin is to turn this around from a conventional description evaluation judgment call and instead say listen to me pose this as a puzzle first of all as a puzzle to be understood before we do any evaluation at all and the way I would put the puzzle to you that I think is accurate that is it's puzzling is as follows ask yourself the question why would a president a Democrat elected in 2008 buy of reasonable margin facing a Democratic House of Representatives and a Democratic Senate with 60 Democrats to deal with the question of a filibuster why would a Democratic president in those circumstances strategically choose to follow a course of reform that had been outlined by Republican economists at the Heritage Foundation in the 1980s now just give me credit for that being accurate if I'm accurate how could that be so why would that be so it is so it was designed by Stewart Butler one of those economists at the Heritage Foundation whom I debated a lot in the 1980s so that's the puzzle how do not how do you evaluate it first how do you understand it why would that be so and I'm going to now proceed to try to give you an answer to that question before I get to the question of where we are now and where are we likely to be fair enough II you with me for that okay I think the individual account of why Barack Obama decided to select that strategy has very much to do with the kind of accident of the US Senate in the in the early 2000s Barack Obama was a pretty inexperienced political political figure had only been one term elected he'd been a state senator in Illinois not doing very much actually with medical care and he came under the sway of Tom Daschle the former Senate majority of the year the South Dakota Democrat had been in for a long time in the house and a long time in the Senate who acted she was defeated in 2004 you know since I had worked with Daschle in the early 1990s I knew something about his views and I know two things about this one that he was very central in persuading Obama to run for the presidency in the first place that's one and two he expressed to Obama of view what had happened in the Clinton years that was hugely important to him and what that was was the bitter disappointment in 1993-94 that the Clinton reform which was preceded by all this enthusiasm nine months of gestation 500 people deciding what it was that was going to be in the managed competition within a budget which is the slogan for this and if you recall now for a moment some of you will recall actually but some of you will also recall from historic historical commentary the Clinton proposal took nine months from January to September was introduced a huge fanfare and a year later it died of political lack of oxygen without ever having a vote and – chelle's response to that was good God how had it been that we wasted this opportunity and didn't even have a vote and so I believe it's very important to know what was said to the president-elect and who recall as well that Daschle was supposed to be Secretary of HHS and also was going to be health care czar does that do you know enough about that historical said well that's true he was pushed out on a odd charts that he didn't get that quite the right calculation about some some auto gifts that he was given in the form of a driver and just before Tim Geithner was going to be in trouble for failing to pay his taxes for a nanny Daschle gave up and left but leave that aside for the moment up to 2009 when the president was getting ready to get his cabinet dasha was the most important person in Washington is in my view about what to do all right what did it mean for people like Daschle and Obama and why would they have picked the plan that they do I think two crucial parts of American public life are really important in understanding what they why they did what they did but before that let me just describe what they did what they did was a four part reform that's really important to be clear about what is that there was going to be an expansion of health insurance in the United States not in one new program not in an expansion of Medicare for all but rather in four different parts one there was going to be an expansion of Medicaid which has has never been the front and center issue of reform for American Democrats always social insurance has which is why I wrote the book I did but Medicaid was going to be part of it which has a more traditional connection to that part of American political thinking that believes the right role of government is not to provide a collective response for all of us facing a common risk but only to act when it is that people fall into income poverty and need help there's a that we could talk about that later but the difference between means-tested or asset tested programs and social insurance the crucial difference is that in social insurance where there's a common risk to income whether it's disability out living your savings injuries at work whether it's being born into a poor family or whether it's the sheer loss of wages from being sick all of those are risks everybody xampp t is subject to so social insurance is pooling around those risks and saying if we all put into the pot when and if we need it we can take it out but we don't have to prove anything about our poverty that's going to be an important idea and medicare for those of you who know about Medicare experiencer by family you know that party of Medicare is an absolutely classic social insurance idea right there's an H I tax that comes out of wages on both the employer and employee side and when you're over 65 or have renal failure you are eligible for Medicare no matter what your circumstances are there's no tests of means there's no tests of assets fair enough clear enough about that all right that's not what the president chose to do in 2008 9 what did he choose to do on the expansion of insurance sorry the way I think one way to think about it is he was trying to move to universal health insurance by aggregating all the programs we now have not by having an expansion of one but by adding to all of them so there was going to be an expansion of Medicaid to involve people up to 138 percent of poverty there was going to be a maintenance of Medicare for those over 65 and those who are disabled in renal failure there was going to be a requirement that employers provide insurance or pay a penalty and that employees and others without insurance would be required to pay into a pool for insurance but with subsidies right you aggregate all that that's everybody if you require everybody to have insurance and all employers try to pay or pay into insurance and if you have Medicare and Medicaid that covers everybody now what they didn't think about is how difficult it is to make all of that happen but the idea was national health insurance by the aggregation of different programs that was one two there was a belief that because the diagnosis of American medical care had been that we were spending 18 percent of GDP at any one time in 2008 9 and we had 52 million Americans who are uninsured at any one time and about 90 million Americans who are uninsured over a two-year period at some time we were spending a lot and not getting what we need it for therefore the cost control argument was we needed to control the costs of American medical care we spend 40% more for example per capita than our neighbor to the north Canada and we are far and away the most expensive medical care system in the world and so the idea was that cost control was a second theme of the reform except that what was proposed for cost control by the Obama administration and would have been proposed by a Republican version – were four things none of which are going to do anything about cost control one by making prevention less expensive than care the thought there would be more prevent preventive services and I dare say there will be more preventive services but there's no reason to believe that more preventive services will mean less spent overall for reasons that I will answer if you're skeptical about it the second one is by the expansion of medical records electronic medical records was proposed as an avenue of cost control no reason to believe that may improve the quality of American medical care but it's not going to improve the costs of American medical care the third is an expansion of IT itself twenty billion dollars was set aside the IT which may possibly avoid some errors but the view that that will control the costs of medical care is based on no experience anywhere whatsoever and the fourth was a belief in comparative effectiveness research that is if we knew what worked better than some other medical revention we would be in good shape you've seen already that I'm pessimistic about the cost control side and I'm willing to take on any argument the other side this I've spent 45 years worrying this but let me give you a hint as to why I feel so strongly about this and let me do it in the form of principles that lead to an inference that you can't avoid principle number one a dollar of medical expenditure must equal a dollar of someone's income for you reflect on that for a moment if a dollar is expended in medical care for whatever it's going to be a dollar of someone's income in the medical care world are you with me so far anybody any one of want to attack that accounting identity if you know what the words mean you have to be it has to be true right so expenditure equals income of somebody now if you go from that axiom to the next proposition that that entails that the expenditure is for American medical care must equal the income z' of people in the medical care industry right if the first axiom is right the second one must be right correct I want some agitation here I need some eye eyes I have to say no or yes correct all right look at what follows from that though that pair of axiomatic reasoning points it means necessarily that the control of future costs of American medical care must be costly to somebody or it's not true there is no costless form of cost control right that's the point I mean unfortunately I mean this is like a fact about the world like the weather it's not a matter of my preference for it or my hostility for it it's indifferent to my views but it's crucial for your understanding why those four things don't necessarily mean if a dollar of expenditure is avoided because of preventive action and the doctor or the nurse or the hospital does something more that's not that's not the control of American cost it's an improvement in the circumstances of the person who's preventive illness was prevented let me hold hold that for a thought put it aside for the moment just say that's the proposition marmor says that cost control must be costly in the obama conception had nothing to do with making that plain all right thirdly and this is what's most interesting about this reform it is a set of new rules for American health insurance it's an effort to make private health insurance behave like social health insurance no private health insurer would take in somebody over the age of 65 and say let's see your expected expenditures as a matter of the group over 65 are ten times that of the aged person 20 so I'm gonna give you that insurance and a premium of three times the premium for the age of twenty nobody would do that if they did it they should be fired right because private health insurance has got to anticipate the aggregate cost of those people who pay the premiums as this gentleman here is is vividly expressing as he nods to my remarks all right so all of you what you've been hearing a compression of the ratio of acceptable premium differences between the young and the old the barring of of cutting off insurance with a lifetime limit which is again trying to deal with the economic threat of illness in such a way that people could rely on it but individual firms again understandably are scared if you knew that 5% of the population getting medical care account for 50% of the expenditure jude's understand in a minimum why that's the case or if for example you were told that children over the age up to the age 26 could be on their parent's insurance well what insurance company would want a 24 year old who been hit by a car and was going to be one of the hikes the answers they wouldn't want that all of these rule changes are indirect ways to try to make American private insurance resemble the social insurance that Medicare illustrates and then finally the fourth part of this legislation is hundreds of special little programs that none of you know anything about in order to get through the congressional process it became like a Christmas tree where people put on one ornament or another particularly as it got closer to passage so what I want to say to you is this proposal selected by the president in 2007 and eight really in the course reflects an effort to combine many different things none of which he effectively explained to the country at large and so you've got a puzzle as to why that would be so why would this extraordinarily articulate president have not explained any of what I've explained to most of the country leaving 60% of Americans the polls say unsure whether they like this or don't like this and I think the answer lies in the distinctive understanding of American political institutions and the fate of the Clinton failure in 2003 2004 think of it this way American political institutions both at the national level and across space are structured in such a way to make it very hard to produce a coherent reform they make it very easy to stop things the veto points that are available are huge the implication of that for this group of reformers and their interpretation of the Clinton a phenomenon was that Clinton had erred by creating his own plan and sending it to the Congress instead of getting the Congress to participate in creating its plan where they had some ownership to it so what did what did the Obama administration do they gave it entirely to the five Committees of the US Congress on the aspiration secondly that they would get Republican support because they were doing what the Heritage Foundation said should be done in the 1980s did they get any Republican support no not one nothing so the strategic assumption that you needed to take a set of expansionary moves in order to get the approval of at least centrist Republicans failed completely and what would we left with a bargained out result that you had to be a Washington enthusiast to figure out what was going on at any one time okay so what do we have we have a piece of legislation with thousands of pages in it not understood by most people in the country being talked about in ways that don't even engage one another you if you go to Florida today if you listen to television and listen to the debate going on in Florida the Florida House seat that's going on the Republican is saying this is socialized medicine even though it's Republican socialized medicine and the Democrat is saying well we didn't get it right the first time we better go back and fix it in ways that nobody tells anybody else any compelling story so what is that leave me it leaves me with the present and this is this this talk was advertised as the future of American medical care as I said at the very beginning the impressive thing about the future is you can't be sure about it and if you think about where we are and think where we will be I would say the way to think about that is to say it depends on the context of political mobilization and political domination of the Congress and the White House and the economic circumstances looking forward you put that together you can have high growth or low growth you can have Republican domination or you can have Democratic domination you can actually also have split government which is to other conditions and under each of those cells if you go through that process very the economic circumstances vary the political domination and include the possibility of split government you will get six different projected outcomes so the lesson if I'm right today I think I'm within my time if I'm right today my guidance to you about the future of American medical care is the astounding proposition that it depends and I know how impressed you are by the fortitude of that prediction but I mean it seriously the this was let me put let me add one more point to it I'll stop and open it up for questions let me turn to at least two evaluations one that I've heard a lot and one that I've proposed of people who are saying positive things about the about the legislation and then people saying skeptical things about the legislation on the positive side and by the way this is completely separate from my own wishes I haven't told you about my own wishes yet but if you buy the book you'll learn that's hardly a celebration of the book but nonetheless there it is many people in debates have said to me Ted from the standpoint of the Democratic reformers they got the best outcome they could possibly have gotten there there was no more room for something wider and broader to happen in 2009-10 and I agree with that anybody who thinks there was a policy majority for medicare-for-all or some huge single plan I think is they they can believe that it was desirable but they can't believe that it was doable but now turn that turn that around for a moment the evidence that that was the most they could have done is that they did it and then the question is why did they did it did they do it because it was the most they could have done and unfortunately that gets you in a circular reasoning that's just not true I do agree that it was the most expansive thing to be done but you have to ask yourself as an evaluator what is a counterfactual what else could have been done then and the evaluative question is what would be the trajectory of option that was taken versus the option that was not taken both of which arguably were feasible in 2010 and just to give you an example of what I would have encouraged people to think about in 2010 that in my view was either doable then or arguably a politically advantageous argument to make for his goals for Obama's goals I would have said that lowering the age of eligibility for Medicare from 65 to 55 and at the same time turning the deduction for medical care expenses of 7at percent of adjusted gross income into a refundable tax credit would have turned that into a catastrophic protection plan for all Americans and involved none of the extraordinary upset that's followed in the wake of the four-part reform that I did I only say this to open your minds and to stimulate you to think differently about about counterfactuals which are an important part of evaluation now if I speak any further I'll go beyond the limit that I was given but I can't remember exactly what it is all stop right there thank you very much and and the rule here is if you've got any comment or question I'll repeat it to the crowd so it should not run around with putting you in the position of I don't know what Ted Koppel or something twenty years ago yes ma'am I'll do that at the end but not right now okay yes the question was if if she buys the book will I tell her my opinion of what should have happened I've sort of hinted at it already and I said I would do so at the end not at the beginning so as to keep some uncertainty yes sir the question here is could I fill out my claim that American government is counter majoritarian and that it's designed to stop rather than to do it's an 18th century Constitution and 21st century responsibilities what I mean by that is something simple when we have elections we don't elect a majority to do anything there's no policy that flows from our elections because one third of the Senate is elected not 2/3 or not they know no allegiance to any particular policy and although the Congress is elected every two years enhanced with a president it's so gerrymandered that whether they succeed or not has modest amount to do with what the president does and then as you will see if you look at what the books about an enormous amount of American government is decentralized even from federal programs so the disability program of the national government is administered at the state we do an enormous amount of education work at the state level so we decentralized areally as well as distribute or disperse at any one level and that's what I meant and so as soon as Senator Kennedy died the politics of this were changed dramatically and the the possibility of a filibuster was real and they had to get Congress senator from Philadelphia from from Pennsylvania to join to change parties to keep part of it going well that if you think about it's good imagine back to 1964-65 I was in the government I wrote a book about the politic Medicare what a different world that was the ratio of Democrats to Republicans was two to one there was no chance of stopping Medicare it was so overwhelming that the Conservatives added Medicaid and Part B to it that if anybody knows that in this group I'll give them my book but that's not not knowing very well so that's that yes ma'am good question let me state it to the group as a whole this is a forecasted a forecasting question what under circumstances where Republicans gain control of the presidency but certainly gain control the House and the Senate according to you what will happen then well that's a good question but the important thing would be to break up the Obama program into four parts and acknowledge that they're not all tightly bound to one another and so what you would expect is an attack on the mandate both of individuals and of firms you would expect loosening up of the loose requirements already about what you have to do if you have less than 50 workers unless even less in terms of the penalty I mean the problem of the Obama conception of universal coverage is that hinges on 52 million Americans getting signed up for insurance well at the rate we're going it's going to be a snowball's hill before that happens and there's all sorts of adjustments already made so the my my suggestion would be that there will I don't think there's any turning back on what I would call the adjustments to the rules of the game of health insurance not mandates but rather the pre-existing conditions all of those which are really meant to deal with the access to health insurance for people when they really need it and there's broad bipartisan understanding of that but the question of coercion of legislation that imposes penalties either on firms or on individuals it's either subject to bureaucratic unwillingness to do it that's part of it or levels of fines so little that they won't make any difference or it will be the subject of cutting back on the legal side and we'll see in terms of Medicaid we'll see a continuing split between those red states that want the money and those red states that want to be critical in those blue states that want the money and those blue states that have even biggest ambitions so that will be a world that will be completely uncertain but the idea that they will repeal at all well they can't repeal it as long as he's president so they can starve it they can starve it bureaucratically they can starve it temporally and we've seen a lot of that going on so under the circumstances of 2014 there's we're gonna have it if you want to have me back I'll be happy to come back in 2014 to review what we've said now but if it goes to the Republicans in the Senate and continues in the house we're gonna have incredible stalemate and a fight over every aspect that they can control and I should tell you as well that the United States is not the only place in the world that is experimented with having competition among insurance companies for the uninsured that's happened in in Switzerland in 2019 96 and it happened in the Netherlands in 2006 and you should know that the consequences of those policy changes everybody in the country is insured but is required to be insured and there are punishing fines for people who don't pay their amount and intrusive regulatory interventions in people's lives and going into their bank accounts to create liens and interestingly enough in the Netherlands 700 new tax authorities were hired in order to adjust the subsidies for those being subsidized from month-to-month so I haven't said much about it but what should be what you should keep in mind let me put it to you it's slightly differently let's imagine that the America before the Obama reform was a patchwork of different Americas there were socialized medicine in the VA there was European social insurance in Part A and Medicare there's European poor law with Medicaid or means-tested programs 175 million Americans had the health insurance that their bosses or their Union bought for them and there was a national a national emergency room law which said you can't throw people dump people out of the that because we don't want to be in a society where that happens those are the five Americas so call those the patchwork of American medical care each of those five with radically different explanations about what our obligations were to one another no common understanding of why it is we should help our neighbors or not okay now think about the Obama reforms the four parts I talked about as a series of patches on a patchwork that metaphor makes sense now follow that and think about sowing the patches onto the patchwork to make a quilt well if you have any experience with quilts you know there's lots of boundary problems there's lots of edges there's lots of ways in which you can go wrong that will give you a handle on the extraordinary number of complexities that have arisen because they decided in I intend to pursue a strategy which was a complicated aggregation of programs that was not a simplification but that made more complex what was already complex okay yes sir last 30 years and looking at that health care system and push your name is very famous one of the things I observed there is they have a system called the culture okay which is a german word and that's between a physician and a nurse and i was wondering when we would begin to see that Affeldt run this country I think we've seen it in terms of the nurse practitioners who really in many respects enjoying that you know the hard work physicians were involved in that's just a common question New York State now they have mandatory testing after taken for a lot of the professions they have this law of the place that's right especially big series on infectious disease and one of the things that's in there is if you go into the hospital you have open-heart surgery if you have a coronary artery bypass graft and you've developed a infection in the sternum or you know your chest wall CMS the Centers for medicare/medicaid you have the option of not paying for that treatment Rebecca and they can't charge the patient okay it always is interesting maybe you're talking about a very costly hospitalization and treatment somebody's paying for it someone well first my second question is an observation it seems like the hospitals are marketing away from certain specialties for instance cancer treatment in part is very much in while mental illness addiction those things are out okay and so there are testing money into certain fields and selecting other fields and I want to support my opinion well my opinion is that you're accurate about the last point you made I don't know what else you're looking for except to say that when when we pay for medical care the way we do which is on diagnostic related groups for hospitalization and for fee schedules for free for service medicine and never debate what it is that we're paying for it's not surprising that highly technical interventions get more rewarded than less technical interventions I didn't know where you were going with the Russian case I've not been to Russia but it may well be that filters are our useful model but but Soviet medicine is not a useful model in my view because most of the allocation of medical care is determined has been determined by payments under the table not above the table and I don't think any Americans whatever our vices is we don't like the idea of people getting access to medical care that way but let what I do think but what your question has prompted me to think about is something I haven't mentioned yet but I should it's an extension of the debate I say we haven't had it's proceeding basically the debate we had before 2010 was American medical care was very expensive we had a lot of uninsured there are quality problems we should do something about that and that diagnosis however widely believed is not a is not a guide to remedies and the key question that we never had a serious debate in this country was how do we think about the principles that should guide access to medical care do we think for example can you hear me if I move away a little bit oh you want me you want to imprison me to you we haven't agreed on this imprisonment but I'll submit to your gentle Authority up there this is serious this is a serious topic there are at least two radically different justifications for why somebody should get a good or service one is the market test which is your ability and willingness to pay to a willing supplier should be the determination of who gets what that's how we allocate cars that we allocate houses that's the way we allocate clothes in a market economy that's the dominant willingness and ability to pay is the determinant of the allocation of access to goods and services we make transfer some income as in in kind with food stamps to make an adjustment but we leave it to people to work out with suppliers what it is they're willing to sell and what they're willing to buy with the income that's available we call that a market good radically different is what one could call the South the only term you could use a merit good that is a good or service only D be supplied because of evidence about the capacity to benefit and the degree of need of the person in charge the person under whose status is being you could have someone in great need but not able to benefit for example someone an alcoholic who has kidney failure would be an example of that you could have people who had an ability to to benefit but not but not all that much need certain forms of cosmetic surgery might well satisfy that but the judgment of what the seriousness of the need and the ability to benefit in medical care is a central principle of the allocation of medical care according to non-market criteria that's when can Canadians say that there's no deductibles and coinsurance when they get universal health insurance or when a British NHS person says this care is free at the point of service of course it's not free but it's free at the point of service what's going on well what's going on is the knowledge that if you put financial barriers between anxiety and care between injury and care with it between worry and care you will produce a distribution of access to care that reflects the income distribution and not reflects medical need as judged by medical personnel now I've just said this in two minutes Dave you did you hear this between 2007 and 2014 not once it's unbelievable unbelievable it's like having a conversation well leave it aside what it's like having a conversation the thoughts come to mind which I can't repeat so yes sir it seems to me that wanted summarize the Affordable Care Act as the increase in insurance to the uninsured Plus enhancements to other and what he said earlier your talk is that well that's the question is really well won't the ACA the Affordable Care Act be criticized as long as medical care expenses continue to rise more rapidly than for example national income or per capita income that's tricky and I feel as if on giving you the FBI files on the truth about health care costs the American public has been led to a false judgment in the last year by a lot of people with with a lot of economic interest in fooling us about the costs of medical care if you read headlines in The New York Times or The Wall Street Journal that medical care inflation is falling haven't you read that it's true I mean medical care inflation fell to about 4% last year in the 1970s it was 10 and 12 percent and they're accurate as far as it goes but what counts about inflation is what's happening to your income at the same time that inflation takes place what was inflation generally last year it was about 2% last year on average that means the ratio is 2 to 1 of medical care to non-medical care inflation anything rising at twice the rate of general inflation is going to command more of our income over time it must follow as day follows night soda pit that's one thing to take into account the other of course is the difference between the rate of inflation the rate of increase in overall expenditures which is about 4% last year in the rate of increase in premiums which was 7% because that cycle forms another one so people experiencing premium increases are not experiencing the other phenomenon and that if you I don't know anybody who has pointed that out except one the president of the Kaiser Foundation who wrote a piece last week saying is inflation rising faster than it used to well it depends on whom you talk to well that's not true that it depends I think it's true that you'll get a different story but it's not true but it depends on whom you're talking to it it depends on what the truth of the claim is now I don't know what one more question you're about you you've been a very patient man with experience and I just appreciate any expression you may have or anybody else here this audience about the medical licensing system being dysfunctional and unconstitutional because now of course the Supreme Court of the site or at least decided that would be imposed tax to see physicians that States cannot legitimately certifies being perfectly qualified to practice medicine let me explain what's happened here nearly past decade and raise this issue of my legislators and so I would not address this issue so senator Bruno called in the head of state medical board Walter Ramos who's also a registered nurse and he's also an attorney and he said quote all state medical boards have no authority over the national board of medical examiners and as I mentioned in John Ashcroft and a personal meeting his comment was I didn't know of course system is beat both dysfunctional and unconstitutional so the question is here for everybody is how can States really perform their jobs for providing protection and public safety when they have no authority over testing agency to give licensing exams and how can physicians who are applying for license verify that their exam to being graded properly as afforded other regulated professions such as attorneys well I hate to end on this note but this is a very technical and special area of American medical care policymaking I doubt that the constitutionality question will be settled and I think state authority to set standards for professionals will find a way to be recovered but it's not an area where I have any special expertise so although you came and set up there patiently I'm sorry I can't answer that question for you well and you're gonna have Betsy McCoy here next and let me just alert you that you won't hear the same story from her that you served for me thank you very much [Applause]

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