 If all US citizens had access to Medicare, the government's medical insurance program for the elderly, would the US have been in a better position to handle the COVID-19 pandemic? Or would it have only made matters worse? That was the subject of an online SOA forum debate held on Wednesday, August 19, 2020. Arguing in favor of Medicare for All was University of Massachusetts at Amherst Economics Professor Gerald Friedman, author of the book The Case for Medicare for All. He went up against Sally Pipes, president of the Pacific Research Institute and author of False Premise, False Promise, the disastrous reality of Medicare for All. Here's Gerald Friedman and Sally Pipes in an online debate, moderated by SOHO Forum director Gene Epstein. The resolution reads, the COVID-19 pandemic makes it all the more urgent for the US to install a system of Medicare for All. Defending the resolution, University of Massachusetts Economics Professor Gerald Friedman opposing the resolution, Sally Pipes of the Pacific Research Institute. I'll be keeping track of the time and will be briefly interrupting each debater to say when he or she has five minutes left and one minute left. Jerry, you're first up to defend the resolution. The COVID-19 pandemic makes it all the more urgent for the US to install a system of Medicare for All. Jane, please close the initial vote and take it away, Jerry. Thank you. Thank you all so much for having me. I'm particularly honored to be discussing this topic with Sally Pipes. I've been reading her work, including criticisms of some of my work for years and come to respect her as an honest critic and a sophisticated analyst of health policy. So I think this should be fun. Like the best criticisms of Medicare for All, whether in the time of COVID or before, Pipes' critique comes in three parts. Economic theory, empirical analysis, and case studies. While her book integrates these three, I'm going to pull them apart here, discuss each separately, and then zero in on the implications of the COVID crisis. Case studies, first of all, make great rhetoric, but can be a bad guide to policy. Ms. Pipes gives us examples of people mistreated by Canadian or British health authorities. I give examples of people in the United States, denied care by insurance companies or due to the inability to pay for adequate insurance. Trading examples can make for fun, but by itself it's a fruitless practice. These are large countries. Case studies, anecdotes become useful only when they point to essential features of the health care system. What I get from Ms. Pipes' examples are hard decisions made by administrators responsible for the efficient use of taxpayer resources and perhaps mistakes. These examples can make for a good argument for reforming government process, or they can make for an argument for maintaining access to a private health care system, a point, by the way, where she and I are in agreement, notwithstanding the views of some of my friends in the single payer movement. The real question is whether these stories are representative, a question that can only be answered with statistics, like those that I'll be presenting in a minute. Indeed, I will demonstrate here that the examples I use, like the tragic story of Alex Smith and other diabetics unable to afford insulin, a story that I tell at the beginning of my book, are representative. The millions of Americans shut out of health care by lack of insurance or inadequate insurance is not an accident, not a mistake, but the consequence of a for-profit health care system, a market-driven system favored by Ms. Pipes. This leads me to economic theory, my favorite topic, and the core of Ms. Pipes' critique. Yes, as she says, economists live in a world of scarcity. Where she goes wrong is an assuming that a free market will minimize and allocate scarcity efficiently, subject only to the constraints of factor endowments, technology, and individual preferences. You have to throw those three in. Whatever the merits of this assumption in other markets, this is not the case in health care. Health economics is a relatively new field, dating back only to a 1963 article by the socialist single payer supporter and Nobel laureate, Kenneth Arrow. He was also my teacher. One of the most widely cited articles in economics, although I suspect this article is rarely read by the people who are citing it. It's a true classic in that way. Arrow demonstrates three crucial points coming from uncertainty and information asymmetries in health care. Providers exercise monopoly power, individuals seek insurance even at inflated prices, and for-profit insurance companies will use control of information to engage in adverse selection and obstructive practices restricting access and denying valued coverage. The result is a market with inflated prices and constrained supply. Does that sound familiar? If economic theory does not provide the support, Pipes assumes, neither does empirical experience. Far from exposing the failure of social insurance systems, such as the Canadian or the British systems, 50 years of practice demonstrates the abject failure of private health insurance in the United States to control costs or to provide adequate care. This can be demonstrated in a few simple graphs, which are coming up, comparing costs and health outcomes in the United States with other affluent members of the OECD, Organization of Economic Cooperation and Development, both in cross-section at the same time and longitudinally over time. U.S. health care spending is way above other countries, increasing faster and producing fewer gains in life expectancy than in other countries. These outcomes are a direct result of the failure of our for-profit market-driven health care. At this point, I'm going to shift into my graphs. Problems with U.S. health care. This graph should be pretty familiar to anybody who's looked into this at all. Life expectancy and health care spending in the OECD. Each diamond here represents a country. The vertical axis is life expectancy. The horizontal axis is the logarithm of per capita spending. The United States is notable. Not only are we spending 50% more than any other country, but we're getting health care outcomes everywhere else. You spend more, you live longer. The United States, this is true, by the way, within states of the United States, but it's not true for the United States compared to other countries. We spend more, we don't get the life expectancy. We're short six years in our life expectancy compared to what we should have, or we're spending $7,000 too much compared with countries with comparable life expectancy to what we have. What's more, this problem is getting worse. It wasn't so true in 1970, when we were like one and a half years behind Canada in life expectancy, but it's gotten more. We're falling behind while at the same time that we're falling behind in life expectancy, we're spending more and more. Another way to look at it is here. How much do we have to spend in the United States to get one more year of life expectancy? In other countries, it's around $400, Canada $380, the UK $409, Germany $398, Norway's not so good, the Netherlands a bit more, but the United States, well over $1,200. We are spending way more than other countries to get smaller gains in life expectancy. And some of this, you could argue, oh, life expectancy numbers are pulled down by high infant mortality, which maybe is due to the way we counted in the United States. I would argue about that, but that's not important. Whatever you look at, well, not anything. We actually have very good trauma survival rates. We have very good trauma centers in this country. We've had a lot of practice. We fight a lot of wars and we have a lot of internal violence. But for most other illnesses, we have worse outcomes. Look at maternal mortality. This is a clear cut issue. You don't want mothers to die in labor, but we have over twice the maternal mortality of Slovakia, almost twice Slovenia, where I think the president's wife came from. Compared to Canada, twice as high maternal mortality. This is a real failure of our healthcare system. Now, so why is it so expensive? And why are we doing so badly? We kind of all know the answers, administrative cost, and the high price of healthcare in the United States. We pay more for the same things. Part of this is the administrative burden. And it's not that we're bad at administering. We're good at that, actually. The share of spending within public insurance or private insurance spent on administration is less in the United States than in other countries. But the problem is we have so much more private insurance. And private insurance requires more administration than public insurance in the United States or in other countries. It's not that we go to the doctor too much. We don't. We go to the doctor less than do people in other countries. We go only a third as often as the Japanese, who have just about the longest life expectancy of anybody. They go once a month. We go four times a year. Our drug prices are high. This is not just my numbers for Medicare for all. You could go to the Trump administration's Council of Economic Advises. Generally, I would not recommend you do that. But they say drug prices are twice as high in the United States as elsewhere. And it's a problem that's getting worse as well as being increasing, almost recent. But with the consolidation of the hospital industry, something that's been exploding with the formation of these giant networks, they're driving up their prices. But not to everybody. They're not driving up their prices to Medicare. Medicare, unlike private health insurance, has been able to contain cost increases at just about the Canadian rate. In Canada since 1971, healthcare costs have risen pretty much with the cost of living. There's been really no increase in the medical cost index in Canada relative to other prices. The United States costs have risen over one and a half percent a year relative to other prices. That is entirely in the private health insurance sector. It is not true for Medicare. And it's not true for Medicaid. Medicaid's kind of another issue. They need to spend more on that. So how have we tried to contain cost, given that prices are going up and administrative burden is heavy? We do it by restricting access. A third of Americans reported that they could not do some medical procedure in the last year, almost three times the rate for other countries. Talk about weightless. The U.S. is where we have weightless. 18% did not fill a prescription compared to 10% in Canada, where, as Ms. Pipes knows, many provinces don't have public insurance for pharmaceuticals. Compared to the U.K., 2% in the U.K. did not fill a prescription. Over 20% of Americans do not go to the doctor because, of course, and what happens when you don't go to the doctor? You know what? You die. Every circle here is a county in the United States, over 3,000 counties. The horizontal axis is the proportion in the county who could not see a doctor because, of course, vertical axis is the age-adjusted mortality rate. Counties where more people did not go to the doctor because, of course, have higher mortality. This accounts for 10% of mortality in the United States. The R-squared is good. The F-statistic is significant. This is a very powerful regression. You can fuss with it by adding a few other variables. I've played with it some, but that coefficient is pretty robust. Okay. How can we cover more people? I estimate that if we had Medicare for all, there'd be a 10% increase in medical utilization. Blackhouse has an 11% increase. We're kind of in, yeah, that's fine. Less billing and insurance-related activities, BIR. That accounts for 14% of total provider spending now. Much less for the public sector billing. The AMA reports that 8% of physician time is spent talking to insurance companies, virtually all having to do with private insurance. Move everybody to a common system. 5 minutes. Go ahead. Thank you. Move everybody to a public, a single public insurance system. They will free up enough time. They will free up nurse time. And it will draw doctors back into the medical profession who have been suffering burnout. An increasing problem in the American medical system. Reducing monopoly rents and administrative waste will save more money than the cost of expanding coverage. If we can afford the current system, we could certainly afford something cheaper. Now COVID has exposed all the problems in our healthcare system. And I'll highlight three points here. First, we have a Black Swan type event. The pandemic exposes the limits of the various insurance measures, the reserves that have been built up by hospitals, by provider organizations, and by insurance companies. All of whom have been going to the government as the insurer of, or the reinsurer of last resort. We are already having to bail out the private system because reasonably they didn't think this would happen and they didn't prepare for it. Second, the economic crisis that has come from COVID means more people have lost health insurance. Tens of millions of Americans have lost health insurance in the last four months. Just when they need it most. And why do we care that they need it? Because here's the third point. We have a communicable disease. I want my neighbors to get the healthcare that will allow them to not spread the virus to me. I'm totally selfish. I don't want to get sick. I don't want my neighbor to give me the virus. To avoid that, I want that person to have health insurance and to have access to healthcare. Medicare for all will make sure that they have that healthcare. Healthcare as a human right is economically efficient. And that is the case for Medicare for all. So thank you very much. Hey, thank you, Jerry. You came in under your lighted time, but that's a dead weight loss. Sally, you are arguing for the negative. Take it away, Sally. Well, first I'd like to thank Gene Epstein and the SOHO Forum for hosting this event and inviting me to be part of it. And I'd also like to thank Professor Jerry Friedman, who I've read a lot of his work over the years, too, for what I'm sure is going to be a productive, good faith exchange of ideas we're all professional in this debate. The question before us is whether COVID-19 makes it all the more urgent for the US to install a system of Medicare for all. That question assumes Medicare for all is something we should want in the first place. And I guess I reject that premise. To explain why, I'd like to address the most common justification. One here is for Medicare for all, one that Jerry just mentioned. The ideas proponents assert that healthcare is a universal right. As such, it should be provided by the government for free to everyone everywhere. On the surface, declaring healthcare a right seems reasonable. The idea is not new. You can find it as far back as the United Nations Universal Declaration of Human Rights. Over the years, many prominent leaders on the left, from Senator Ted Kennedy to current Vermont Senator Bernie Sanders, they've tried to formulate a right to healthcare. But this notion is based on a fundamental category error. Healthcare isn't a right. Healthcare is a good and a service. Just like every other good and service in a market economy, it is scarce. There is a finite amount of it. A portioning this finite amount inevitably requires trade-offs. Those who say that healthcare is a right ignore this reality. The view raises fraught, intractable questions that don't have easy or satisfactory answers. There's a right to healthcare entitled everyone to seek treatment from the very best doctors or at the very best hospitals. To ensure equal protection of a right to healthcare, would the government have the right to ban people from paying extra for better treatment? Perhaps top-notch facilities would be prevented from offering innovative procedures and instead compelled to offer a suite of government sanctioned services. This puts the government in a bind as well. If there's a million dollar pill that can cure a group of patients but the government can't afford to give it to them all, what do we do? In countries with single-payer systems, equality often picks precedent over health and therefore no one gets the pill. On the other hand, once we accept healthcare as a set of goods and services as opposed to an abstract right, the question before us becomes far more concrete. How do we make finite healthcare resources as widely available as possible without sacrificing quality or imposing unreasonable, potentially crippling costs on our government and on the economy? This is the question at the heart of healthcare policy. For proponents of Medicare for All, the answer to that question is clear. We must completely abolish private health coverage and replace it with a government-run insurance scheme. So let's evaluate that answer not as a moral proposition but as a matter of public policy. Once we do, it becomes clear that on almost every important measure, this radical approach would do a worse job than the market-based system we already have. A system, as I know, is far from perfect. I wanted to add. Let's start with Foxx. There is no denying, as Kerry said, that the United States pays more for healthcare per capita than any country in the world. US healthcare expenditures total 17.7% of gross domestic product. In Canada, healthcare spending is 11.6% of GDP. The government has a monopoly on covering everything deemed medically necessary, and they set a global budget tapping how much it will spend on healthcare. Out-of-pocket spending by Canadians accounts for about 14% of our healthcare tab. In the UK, health spending is a bit under 10% of GDP. People can purchase in the UK supplemental private insurance and about 10% due. Nearly 16% of health spending comes out of Britain's own pockets. It's tempting to look at this disparity and surmise that countries with single-payer systems have discovered some secret for lowering healthcare costs, one that America would be foolish not to copy. But for the most part, the only secret that they've discovered is that governments can dictate what they'll pay for healthcare, and there's little providers can do about that. And this helps explain why physicians in countries with government-run health systems earn less than their counterparts in the US. American doctors earn $313,000 on average last year. British doctors earn less than half that. According to research from the Commonwealth Fund, primary care doctors in the US made an average of $218,000 in 2016. Nearly 50% more than their Canadian counterparts, and nearly 63% more than British doctors. But is paying doctors less a practice America should emulate? After all, lower salaries have helped fuel chronic doctor shortages throughout the British system. In some practices, the care of 11,000 patients is left to just one general practitioner or what we call primary care doctor. These shortages are poised to get even worse once the COVID-19 pandemic subsides. A June survey of British doctors found that 14% plan to leave the profession, retire, or leave the National Health Service, Britain's version of Medicare for All when things return to normal. Canada faces a similar doctor shortage. Last year, an estimated 175,000 people in the country's four eastern most provinces were waiting to be matched with a family doctor. America's public insurance programs, Medicare and Medicaid, already underpay healthcare providers. Hospitals receive 87 cents for every dollar they spend, creating Medicare patients. Medicaid reimbursement rates for physicians are even less than Medicare's on average about 72% of Medicare, according to the Kaiser Family Foundation. Patients covered by these programs account for a huge share of the patient population. Medicare has nearly 60 million beneficiaries, about one sixth of our population. Medicaid has 65 million beneficiaries, one fifth of our population. It's no wonder that one out of every three primary care dots in this country is unwilling to accept Medicaid patients, according to a recent survey they can't afford to. If these underpayments become universal in the U.S., doctors would leave the profession or retire early, promising bright young people who never go to medical school in the first place. And patients would struggle to find timely care. A report from FTI Consulting estimates that pay cuts resulting from Medicare for All could shrink America's physician supply by more than 44,000 by 2050. One would think the cut rate prices paid in single-payer systems would benefit government finances, freeing up resources for other vital public sector priorities. In fact, despite having enormous power to underpay providers, single-payer systems have proven a fiscal nightmare the world over. Britain's National Health Service has been a near constant state of crisis for decades, even as it has consumed an increasing share of taxpayer funds. In the 50s, NHS spending accounted for just over 11% of the nations by 2018. Over 30% of all public sector spending went to the program. In Canada, more money is spent on healthcare than on any other budget item in every single province. In some provinces, well over 40% of all spending goes towards healthcare. Not even this is enough to keep up within your endless demand for medical care single-payer systems invariably generate. Nor is single-payer such a great deal for patients. Two of these systems might save citizens from having to pay for their healthcare at the point of service at least some of the time, but patients end up paying for care indirectly through higher taxes. Great Britain has broadly higher income tax rates than does the U.S. Each Canadian province forces at least some of its residents to pay double income tax rates. That, and that is of course on top of the federal rates. All told, the average Canadian family of four pays $13,311 in hidden taxes just for public health coverage, according to the Fraser Institute. So the idea that single-payer provides free healthcare is just fiction. But let's move beyond dollars and cents and discuss what it's like for patients in a single-payer system. As someone who was born in Canada, I can speak with some authority. In my homeland, government rationing of healthcare is a fact of life. In 2019, a typical Canadian seeking care from a specialist waited nearly 21 weeks, five months between seeing a primary care doc and getting treatment by a specialist. Patients in some provinces routinely wait more than 30 weeks for treatment. In 2018, Canadians were waiting for nearly 1.1 million procedures. If you assume one patient per procedure, that means three percent of the population of 35 million was on a waiting list. Extrapolate those numbers to the U.S., and that's the equivalent of more than 9.8 million Americans would be waiting for care. Britain's NHS is no better. A February report from the House of Commons Library revealed the share of emergency room patients waiting more than four hours for care has risen roughly five full since 2011. The number of patients waiting more than 12 hours for admission to the hospital get a record in January. That same report found that waiting times for cancer patients after referral by their GP were the worst on record. Waiting times for diagnostic tests were at their highest level in over a decade. And this was all before the pandemic. In the months since so many procedures have been delayed, England's waiting list for hospital care is on track to reach 10 million at the end of the year. That's more than one sixth of the country waiting for care. The number of people in England waiting longer than 18 weeks for routine care is at its highest level in history. And just yesterday, the National Health Service announced that they are going to provide over the next four years 10 billion pounds to private hospitals to try and help reduce the waiting times under the NHS. Meanwhile, Canada faces a backlog for surgeries that the government people have even said could take them years to get through. It is true America has its share of cancelled and rescheduled procedures since the pandemic began. But we didn't enter this crisis with record-long wait lists and overcrowded hospitals. In fact, the US has five times as many critical care beds per capita as the United Kingdom and more than twice as many as in Canada. Now, some might argue that longer waits are a reasonable price to pay for the security of single-payer system would provide. This argument seems especially resonant during this pandemic, an event that has resulted in mass joblessness as well as increased demand for care. But it is important to note that here in the US, the pandemic hasn't been as devastating for coverage levels as many tend to believe. While the pandemic has cost millions of workers their job at tragedy in its own right, many of these Americans still have access to affordable coverage. The Commonwealth Fund just came out and said that 2.97 million people who lost their job have lost their health coverage. The Urban Institute has given that number at 3.5 million. So not that, not very many. Cobra is one such option, albeit is a pricey one. Obamacare's exchanges are an option for the newly unemployed. People can sign up for Obamacare exchange coverage outside the normal open enrollment period if they lose their job. They may even qualify for taxpayer subsidies. Those without any savings and annual incomes below 138% of the federal poverty level, about 17,500, may opt for Medicaid. Others can avail themselves of the short-term limited duration insurance plans, which tend to cost far less than the full price coverage on the Obamacare marketplaces. Unfortunately, several states have severely restricted access to the short-term plans or they found them outright, such as in California and New York. This array of options is one reason coverage rates have remained relatively stable during the crisis. An analysis by the Galen Institute estimates that 98% of Americans who have lost their job-based insurance before the pandemic are still covered. Now if what I've said so far is true and America's current system is superior to the single-payer alternative, then you might wonder why 56% of the country favors Medicare for All according to the Kaiser Family Foundation. It's remarkable though how quickly opinion shifts once voters learn what single-payer actually means, i.e. only the government. That same Kaiser poll found that 58% of Americans opposed Medicare for All. If it would eliminate private insurance companies, 60% opposed it if it would raise taxes, and 70% would oppose Medicare for All if it led to delays for even some treatments. In other words, Medicare for All stops being popular and Americans learn the truth about it. I'd like to finish my remarks by laying that truth in human terms. I consider some of the stories of many victims of single-payer healthcare. 68-year-old Jack Webb, who died in one of Halifax Nova Scotia's largest hospitals a few years ago, under conditions no human being should have to endure. He arrived in the ER department two weeks after receiving a diagnosis of pancreatic cancer. He was having trouble breathing. His wife later recalled that when he was finally seen by a doctor, they were told he was the sickest man to arrive that evening. Yet Webb spent the next five days in agony because of hospital overcrowding. He was bumped from room to room, occasionally sharing space with several other patients. At one point, he spent six hours in a cold hallway. The night before he died, one staffer callously yelled to another. If he stops breathing, don't resuscitate. Webb and his family were in earshot the whole time. Think about Christina Walker of East Sussex, England, whose son Luis was diagnosed with cystic fibrosis when he was three weeks old. Imagine the hope that his family felt five years ago when a breakthrough drug or comedy earned FDA approval in the U.S. A drug that could have boosted Luis's lung function, slowed his disease, and improved his quality of life. Then imagine how they felt when Britain's cost-effectiveness body determined that the drug wasn't worth paying for. One of every 10 people with cystic fibrosis worldwide lives in the U.K. It took four years for the government to change its mind. Or consider one of the more recent victims of Canada's response to COVID, which led to the blanket of delays for elective surgeries. 50-year-old Chris Walcroft was diagnosed with failing kidneys last August. He was slated to have surgery mid-March to prepare him for dialysis. That elective surgery was canceled. A month later, Walcroft died on the day he was slated to finally see a specialist. There's one more victim, a single payer I'd like to highlight, my own mother. Several years ago, she thought she had colon cancer. She asked her GP for a colonoscopy and was told there were too many young people on the waiting list and she couldn't have one. She had an x-ray, which of course doesn't show colon cancer. After a few months on a waiting list, her condition deteriorated. She went to the hospital in an ambulance, spent two days in a transit lounge waiting for a bed and a ward. She did get her colonoscopy, but died two weeks later from metastasized colon cancer. These events didn't happen in a war-torn nation or under some corrupt authoritarian regime. They happened in some of the wealthiest, most advanced economies in the history of the world. This could easily happen here if we insist on following their example by adopting Medicare for All. Thank you. We now go to the rebuttal portion five minutes apiece. Jerry, you have the option of reblooding. Take it away, Jerry. Okay. Well, thank you. Thank you very much, Sally, if I may. That was really interesting. A few points about wait lists, first of all. Using OECD data, the share of Americans who are able to get an appointment with the doctor that day or the next day is 51%, it is lower in Canada, 43%. The UK is 57% with the NHS. So I'm not sure that the wait list issue really holds. And if you get down to wait lists, let's talk about the 33% of Americans who report that they were not able to do a medical procedure. This is pre-COVID. 33% of Americans who are not able to do a medical procedure much higher than in Canada or the UK or any other country, the 20% of Americans who were not able to fill a prescription. I mean, they went to the doctor and the doctor wrote the prescription and they still couldn't do it. We're not even counting all the people in the United States who did not go to the doctor because they couldn't afford it. And that's 300,000 by my estimate, 300,000 dead Americans. When you get to specific diseases like cystic fibrosis, people in Canada live longer than the United States. They live longer with most diseases, including cystic fibrosis. There are gunshot wounds. There are a few cases of a few cancers where we do better. But the United States is a fabulously wealthy country, the source of much of the medical innovation that's happened in the last seven years, most of which, by the way, has been financed by the federal government. Physicians, Canada and the United States and the UK all have somewhat fewer physicians than other countries in the OECD. The United States has 2.6 physicians per thousand persons. The UK has 2.8. So there's no evidence that, and Canada is 2.6, the same as the U.S., there's no evidence that people are leaving the medical profession in Canada or the UK unless you want to say they're also leaving in the United States, at which point we get to which is worse, the burnout of having to deal with the insulting insurance industry or lower reimbursement rates. Get to the reimbursement rates. Yes, the U.S. doctors have paid a lot, but they also have to pay for the medical training, including all those student loans that they picked up. They have to pay for the out-of-pocket course of dealing with the insurance company. Every medical office in the United States, if you turn your head around past the receptionists, you see these people who spend all day, some of them trained professionals, nurses, all day talking to the insurance industry. Those people are all coming out of the reimbursement that goes to the doctors. Take those courses away and American doctors are not terribly well paid, although they are very well paid in certain specialties. It does vary. Also, of course, in the United States, everybody's paid more than in the UK or even Canada, which is why we can recruit so many economists to come here. Finally, when you get to the course of $13,400 that Canadians pay out of the tax dollars for healthcare, well, let's compare apples and apples. Family insurance, which does not cover everything. A decent family insurance plan with an actuarial value of around 85% is going to cost you over $18,000 in the United States. Americans are paying more and they're getting worse coverage, as shown by the higher mortality and the longer wait times and the greater number of people who are being denied access to care. Our healthcare system in this country, the private healthcare system, is wasteful and too expensive. Thank you, Jerry. Five minutes rebuttal for you, Sally. Take it away, Sally. Thank you. And Jerry, I just want to say, in Canada, the UK, you can't call up a specialist. You can't call your dermatologist. You have to go through a GP and that's when you have that rate of five months between that and that. Anyway, what I wanted to say was, people such as yourself often begin your case by talking about how wasteful our system is and inefficient. We do spend more, as we've determined, than any other country we are, as you said, a very wealthy country. Yet we don't live as long as our peers, our infant mortality rate is higher. We don't fare as well in international rankings of systems made by the, points made up by the World Health Organization. But data points like these tell us less about the US healthcare system than people like yourself believe. Let's look at life expectancy. A baby born in 2017 could expect to live 80 years, according to the CIA's World Fact book. That's good enough for 43rd place worldwide, 1.9 years before going to Canada and 0.8 behind the UK. But many of the factors that influence life expectancy have nothing to do with healthcare. For example, the US murder rate as of 2016, quadruple great Britain's, and it's more than triple Canada's. Or if you look at car accidents, in 2013 the World Health Organization estimated that there were more than 34,000 traffic deaths in the US. On a per capita basis, there are nearly four times as many traffic deaths here in the US than in Great Britain, and nearly twice as many as in Canada. Many more Americans die of drug overdoses than New Brits and Canadians. It is a tragedy that we use so many Americans in the prime of their lives to drugs or violence, but Medicare for all is unlikely to affect those unfortunate realities. Then there is infant mortality. You talked about and written about the fact that we fare worse than 30 of 35 OECD nations on this metric. But that's in part because there is no consistent definition of a live birth across countries. Some classify babies who die within 24 hours as miscarriages, which are then excluded from infant mortality calculations. Some European countries require babies to meet certain height or weight requirements to be counted as a live birth. According to the NIH, the US reports as live births, more low birth weight babies who are at risk of dying on the first day and then register those as infant deaths. When a newborn is at risk, there are a few better places to be than in the US. Only Sweden and Norway have better mortality rates. Someone I knew in Calgary, Alberta was expecting quadruplets. There wasn't a single neonatal bed in Calgary and Edmonton or in Alberta that could deal with these quads. They were airlifted to Great Falls, Montana, a city of 55,000, where the quads were delivered and survived. The husband, these people were originally South African. They said the Canadian healthcare system is that of a third world country. Quad metrics like life expectancy and infant mortality inform the international rankings that critics of the US healthcare system like to cite. Indeed, the WHO, which places the United States at number 37 out of 191 countries worldwide, faces one fourth of its rankings on life expectancy. Another fourth derives from financial fairness. That practically stats the debt in favor of government-run systems, which prioritize equity over quality. If we now look at how people fare when they actually get sick and need care, America's system performs well. US cancer patients live longer than those in European countries, thanks in part to higher levels of spending on cancer care. US patients over the age of 45 who were admitted to the hospital with a heart attack or stroke have a lower 30-day mortality rate than there appears in other countries. But what about COVID-19? This pandemic has hit our country hard. Wouldn't Medicare for all have helped? This is by no means clear. Countries with government-run systems have struggled mightily as well. According to the latest stats from Johns Hopkins, the UK has had 18% more COVID deaths per 100,000 people than the US on a per capita basis. Britain has had the fifth most COVID deaths in the world. Canada has had roughly half as many deaths per 100,000 people as US, but our northern neighbor's case fatality rate is more than double ours. The US response to the COVID pandemic has left a lot to be desired, but the same can be said for other countries. Government-run health care systems are a bad idea. If anything, our extra health care capacity has helped us compensate for the shortcomings of our public health and elected officials. Thank you. Thank you, Sally. We now go to the Q&A portion of the evening. Be first offered to either of you, Jerry or Sally. Would you, at this point, like to put a question to the other person? Do you want to wave that right until later? Later, what do you want to do, Jerry? I want to wave the right question. No, I would like to throw a question. Just curious what Sally has to say. As she notes in her book, 92% of Canadians approve of the health care system. In the UK as well, I remember the opening of the London Olympics and mind you, I have nothing to do with the Olympics since Munich. I boycott them. But I did hear that the British put on this big display about the NHS because that's something that the country is very proud of. If people in Canada and Britain are so proud of their system, why do you think they're so proud of their health care system, given how bad it is in your eyes? Well, I think there are a couple of things. The NHS was a big part of that, of the opening of the British Olympics, which they won over France, which the French were very upset they didn't get. In Canada, the health care system started to be taken, the takeover started in the 1940s. And then in the 60s, it was pretty much taken over. And the Premier of Saskatchewan, a CCF or a socialist, was named the greatest Canadian, Tommy Douglas. So this was a slow process, completely taken over by 1984. Many people in Canada, they don't know anything but the government running their health care system. Canadians, my mum said to me after I'd been in the US for about 10 years, I hope you're not becoming one of those impatient Americans. Americans are impatient. Canadians and Brits, if the doctor says you have to wait X months, then they say, well, thank you very much, we'll come back in five months or whatever. So that is something important. They don't know anything different. They're very nice. But if you look at the fact, if you look at the fact that people who need specialized care, the support for the system is not strong. There was just a poll that just came out this month in August, which shows that as a research company survey, that's the name of the company, that only 30% of Canadians think their system works well. And 31% said the problem, the reason they don't think it works well is because the long waiting list, 26%, the shortage of doctors, and 55% said many changes are needed to the Canadian health care system. We've talked about there's going to be 10 million people on waiting lists in the UK. The National Health Service, just today, they have a cap on the number of people who can train to be doctors. And they want to have that lifted. But the reason for not having that cap is always being the cost of training doctors and the NHS system of providing planning for these doctors. And people over 55 in Canada, the poll numbers have come up very high about their lack of support because they can't find specialists and can't get timely care. So those are the main issues that I would say about Canada and Britain. Sally, do you have a question for Jerry? Do you want to wave that right? You can exercise it later. Do you want to go to my questions, audience questions? Do you have a question? Either way, go ahead. Yes. I would say about, you know, he said millions of people have lost their, many, many millions of people have lost their coverage. Well, I've looked, you know, I looked at the numbers and the Commonwealth Fund said 2.97 million. The Urban Institute said 3.5 million. So what statistic, Jerry, are you using? Because we have about 27 million uninsured in this country. Seven million were eligible for Medicaid or CHIP and didn't sign up. Eight million were eligible for Obamacare subsidies and didn't enroll. So why are people not enrolling in the Affordable Care Act, which was in my mind always a precursor to single payer? And what about numbers? Okay. Well, first of all, the numbers that you're giving are outdated. I've been tracking weekly new unemployment claims. And about 40% of people who lose their jobs have had employer-based coverage. And there are 2.3 people associated with every person who has employer-based coverage, family members. So if you multiply 40% by the number of people who've lost their job by 2.3, then you get an upper bound number for the number who have lost their coverage. Now, not everybody loses their coverage right away. Some people have a month after. And some people are able to shift on to a spouse employment-based coverage. Some people have gone on to Medicaid, which has had expanded roles. But it's an ongoing process. Now, why don't more people than 8 million who have not taken up Medicaid includes those who would have been eligible if the states had expanded Medicaid? The number who have not taken up Medicaid is in states that have expanded Medicaid is much lower. One thing that happened with the Medicaid expansion under the ACA is the woodwork effect where people who had been eligible found realized, oh, my God, I could have had Medicaid. So that's always an issue. The take-up rate on Medicaid or other social programs is always an issue. The number of people who have not taken advantage of the ACA, well, a lot of these plans are still pretty expensive for people. Given the out-of-pocket course, if you have a silver plan on which your subsidy is based, that leaves you responsible for 30% of the course out-of-pocket, plus whatever premium you're going to be paying, which may be 3%, maybe 5%, maybe up to 8% of your adjusted gross income. And then there's states that have maintained the navigators and the advertising have maintained higher take-up rates on the ACA exchange plans than states would have. Is the ACA a step toward single payer? As my mother would have said, from your mouth to God's ear, I would hope so. You would hope not. You guys can return to asking each other questions. Shortly, we have a number of a lot of questions coming from the audience. Let me start with this one that's mainly, I guess, directed to Jerry. Having to do with your mention of the U.S. being a huge source of medical innovation, and the point that's being made is that the U.S. hugely subsidizes other healthcare systems through its medical innovation, innovation not only in drugs, but in procedures, and that it has something to do with the fact that the U.S. is more of a market-based system, more capitalist operating for profit than these other systems, or put another way, how do you account for the fact that the U.S. is more market-based and yet such a huge source of medical innovation versus the other medical systems? Half of research and development spending by drug companies comes from the federal government, the NSF, the NHS, and that includes a way more than half of the truly innovative research. Drug companies count as research and development, their marketing activities, their ever-greening activities, like adding Tylenol to an existing drug processes that are often destructive. All they do is extend the patents so that they can continue to charge exorbitant prices. The real research for virtually all of the major medical breakthroughs was financed through the public sector. That's the answer. I'm getting another question related to that. Are you fearful, are you concerned then that if the U.S. begins to imitate these other healthcare systems in other countries that produce far less medical innovation, that the U.S. will become less of a source of medical innovation in the future? Are you concerned about that in any way, given the low level of medical innovation in the systems that you sponsor? I would challenge the suggestion that Europeans are much less innovative. I mean, we spend a lot on medical innovation through the NSF, the NIH, through university research, through the activities of my colleagues in the north end of campus, the science end. A lot of that goes on elsewhere. I mean, if you look at the many of the most important innovations, and here we can go to Canada, pre-us Canadian single payer, Frederick Banting, and what's his name? Charles Best. And what did they get for their discovery of insulin? A dollar. They sold it to the University of Toronto to be given to the world for a dollar. The Salk vaccine in the United States, Jonas Salk gave it to the world for free. You know, you go on. I mean, people have lots of reasons, including Nobel Prizes, that for doing innovative research, much of what is done for profit is not productive. Adding an X or a Y to the name of some drug, I mean, companies spend millions on these types of things, and they market up as research and development course. So, I'm not particularly concerned. Sally, do you have a comment on the question on Jerry's comment? Yes, I do. So, you know, it's interesting that the United States is a country where all the big companies come to do the research and development. Companies like Laxos, Smith, Pline, Roche, Santa Fe, these companies do not do their R&D in those countries because those countries have price controls and they can't make it. So, they do it in the US. It costs about $2.6 billion from an idea and a drug to bringing it to market. Only 12% of drugs actually get through the FDA and all the clinical trials. So, you know, these other countries, we do sell our top drugs to these other countries like Canada at a reduced price, but these countries are free-riding off our research and development. And so, that is, you know, these countries need to get rid of their price control so that they're competing, we're competing on a level playing field. It's, you know, when you look at the vaccine, vaccines that are being, you know, researched now for COVID-19, most of them, whether it's Pfizer, whether it's J&J, Moderna, the vaccine trials that are going well are being, you know, done, developed by major companies. But Mr. Trump did sign an executive order to help private-public partnerships to make this go faster and Remdesivir, the drug from Gilead, which has proved use very effective in hospital situations. They're providing it for $3,000 for five treatments. You know, they're selling it at not that they're cost it all, but at $3,000 to help people get better. But we really need to, these other countries need to stop free-riding off our R&D. Canada has the Patented Medicines Crisis Review Board. A lot of the new drugs that are available here that are the pharmaceutical companies are willing to sell to candidate lower prices. The Patented Medicine Crisis Review Board doesn't even allow them in because they say the price is still too high. So, I want to keep the market open for innovation, research, and development because it'll keep us out of the hospital. And as Frank Lichtenberg at Columbia said, for every $1 spent on newer pharmaceuticals, we save $7.17 in hospital costs. So, let's keep that market open. I'm getting older. I want to be able to have access. I'm sure Jerry does, too. The latest, and I don't like hospitals. And actually, I don't like going to doctors either. I'm getting questions. It challenges you, Sally, to you, Sally, different related questions. I guess people are taking umbrage at your idea that the U.S. healthcare system is a market-based system because one of the questions is, to what extent would you reform the U.S. healthcare system to make it more market-based, in particular, the employer-based healthcare, which was an ironic result of World War II. Companies were giving this out. To what extent do you think it's really not a market-based system? To what extent would you make it more so in order to address some of Jerry's concerns? That's your question, Sally. Okay, good. Certainly, it is not a free market system, really, because 50% of our healthcare system is already in the hands of government in this country. I talked about $65 million on Medicaid, $60 million on Medicare. We have a lot of kids on the CHIP program for low-income children and, of course, the Veterans Administration. 50% of our healthcare is already in the hands of government. So Americans like competition, we have competition in all aspects of our life, except we're really in healthcare. So the things you mentioned, Jean, that during World War II when Wade and Price Controls were in, the government gave employers the ability to write off the cost of providing healthcare to their employees, and the employees get their healthcare tax-free. If you lose your job or you put your job, you go into the individual market, you have to buy your healthcare in the individual market, and you have to pay based on tax income. We need to change that so individuals can get their healthcare tax-free as well. We also need to open up things which is actually opening up now because of the pandemic, such as telehealth, where people can talk to their doctor over the Internet rather than having to find a car service or get on the bus, the train during the pandemic. So telehealth is a great idea. Scope of practice. We need to let more nurse practitioners and physicians assistants do things that they can do. Doctors don't need to. That will reduce, help reduce costs. I think medical school could be reduced from four years down to three. It would be cheaper, and it doesn't have to be four years. UNC Chapel Hill is doing that. Duke is trying that. And so there's a lot of things that need to be done. Medicare and Medicaid, you know, those programs came into being in 1965 under Lyndon Johnson and his great society. Well, you know, the average life expectancy in 65 was age 65. Today, the average Medicare recipient lives to age 79.5. And so Medicare needs to be reformed. They've already said that Medicare trustees, it'll be bankrupt by 2029 Medicare Part A. So let's, you know, do some means testing. Why should people like, you know, Warren Buffett even be eligible for Medicare? Medicare should be there for those seniors who really need it. So we need to raise the age of eligibility, means test it. And then on Medicaid, the program that, you know, for low-income Americans and people with disabilities, that program is very expensive. And as we've seen, you know, one in three new Medicaid eligible patients can't even find a doctor because the reimbursement rates are so low. So I'd like to see some opening up of the system in Medicaid so that there are like HMOs for people on Medicaid. We need to expand health savings accounts. That's a great way. 27 million people now have HSAs. People should be able to contribute to their HSA after age 65. Now you can't do that. And the amounts that you can put in your account should be, should be greater. And you should be able to use your HSA to help pay for your premium. There's all kinds of things. Got a lot, got a lot. I want to do this there. Thank you so much. Jerry, I want you to respond. But then I want to throw in a question that's sort of related to this just to spice it up. You seem to have suggested, maybe this is where you and Salad Converge, that you actually would provide some private option for people. So therefore, you've got a private sector affection sneaking into your viewpoint. And of course, how would you respond to Jerry? And how would you respond to the private option that you think is of some value? Take it away, Jerry. Oh, well, I absolutely think that it's essential that we preserve some private competition or a private option that as happens in the UK and as basically happens in every country with socialized health insurance. In Canada, that private option is sometimes the United States. And I think that it's really important that people have an escape valve. Now, obviously, this is a safe, an escape valve that only the privileged affluent will be able to get. I wish everybody could live in Amherst and I wish everybody could have the opportunities that somebody of my income could have. But I think that it's important that people be able to get out from under an insurance company or a government that is being overly restrictive. Now, competition, no, no, there is no competition to speak of. I mean, what's the competition to Mass General Hospital? There is none. And this is the point that Kenneth Arrow was making 50 years ago. God, I'm getting old, almost 60 years ago. That because of uncertainty and asymmetric information, people rush to brand names. And there are patent protections for the drugs. There are, there's word of mouth. That's why Mass General is able to charge four times as much as other hospitals in Massachusetts. And when I said this once to a meeting of the conference of the heads of research and teaching hospitals, the head of Mass General partners came to me very angry that we're not a monopoly, we don't overcharge. You got to compare us to Johns Hopkins. It's like, okay, yeah, Johns Hopkins is another of these grand names. So there isn't really competition. There is just monopoly rents. You own hospitals like Mass General or Johns Hopkins, there's kind of one in every state or two in every state if you're lucky. And those guys are raking in billions. The city of Boston is being bought up by the profits being generated by Mass General and it's getting worse. They can't do it to Medicare, but they do it to private health insurance and they are buying up hospitals throughout New England and closing them down to shift the patients to Boston where they can charge more at Mass General. Medicare and Medicaid already have, and I think this is a mistake, but they already have very large private elements. You can't say that half of American healthcare is public because of Medicare and Medicaid, et cetera. Medicare Advantage has about a third of the people on Medicare and almost every Medicaid system in the country has an HMO component and in many, everyone is immediately put into the HMOs. So there already is, we're already chipping away at the public sector. Finally, this is a small point, but as an economic historian, it's one that always bothers me and it bears on the competition thing. It wasn't the IRS that did it. Employer-based healthcare goes back to United States Steel, International Harvester, even before World War I. Employers pushed employer-provided health insurance so they could get control over their workers. And I think this is an area where Sally and I would agree that the employer-based system, it's not only wasteful, but it's intended to lock workers into uncompetitive situations, giving their employer a monopsynistic power, ability to drive down wages and exploit the workers. So that's one area where we would agree. And we would agree with the people in the Obama administration who are really hoping the exchanges would become a way to destroy employer-based insurance. We spend in tax subsidies close to $400 billion on employer- subsidizing employer-based coverage in this country. If we could, that's another area where she and I, I think, would agree. Do away with that subsidy. But anyway, I'll stop there. Yeah, a related question came in. Jerry, now back to you. The term apparently not being used by the questioner, but aren't there rules that require that if you're going to open up a hospital that the ability to do so has got to be reviewed by the other hospitals? And isn't that, that would be like if you can open up a delicatessen, then all the other delicatessants have to review your application and establish the need that some of that community need. Would you roll back that regulation in order to, to incur, to allow entry into the, into this market? Would you, which are the certificate of need that's called? Yes. Do you feel that's an, that's a government regulation that's an enemy of competition? Well, it would be if you thought that, you know, opening a new hospital is going to promote competition, which, you know, hospitals are very expensive to establish. I don't know how much we would want to rely on it, that element of competition. We're, we're getting fewer and fewer hospitals in this country. And I don't think it's because of the certificate of need. I think it's because of these hospital networks buying up the company, the other hospitals, and driving patients to the more expensive urban teaching settings. I don't, I haven't really looked into the certificate of need issue. So I'm going to punt on that one, whether we'd want to do it. I just want, I just want to just make a couple of points, because I think, you know, certificate of need for all the hospitals in that area to have to approve, if Jerry, if you wanted to set up a cardiology hospital, if they decide they don't, if they want to cardiology business in their hospital, they can direct, I think that is wrong. I think we need, we need all kinds of different hospitals. And under Obamacare, you know, new specialized hospitals were banned. We're also, we're seeing a huge reduction in rural hospitals. And you know, for people in rural areas who are older, you know, this is why telehealth is a good thing, because these people can't, can't get to the doctor, or maybe can't even get to the very best doctor. So certificate of need, I think laws should be in a lot of economists that agree with that. But I think, you know, in the ACA, we, you know, overturn the healthcare system with the Affordable Care Act. And there are only right now, 10 million people on the exchanges, 87% of the marketing subsidies, you've been earned up to 400% of the federal poverty level. But, but you know what, really, you know, the average silver plan this year was $467 a month. A lot of people, you know, that are in that individual place, they can't afford $467 a month. And that's why, you know, the buy-in to it was not good. But I, as I say, I do see it, as we're hearing, I differ, I do see it as a stepping stone approach, just like I do with a public option that Joe Biden, you know, is talking about having a government insurance plan to compete against private insurers. My view is the government will lower, have a lower price for the healthcare and, you know, then it will crowd out private insurers. And it's just a more of a stepping stone approach to Medicare for all. Yeah, thanks. We have time for one more question to that. I'm getting a lot coming to you, Jerry, so I'm going to laugh at it. The question, a couple of questions relating to this, that the examples where institutions operate, medical institutions operate in a basically free market. Lasik surgery, of course, is a classic when you lower prices, high quality. Oklahoma Surgical Center doesn't accept insurance operates in a very free market. And the idea is that all of the ideas that were propounded about how this is not going to work because it's free market, the original research paper, seem to be belied by these examples, operating in a totally free market. Lasik surgery, for example, Oklahoma Surgical Center, for example. How do you explain that phenomenon in terms of your framework? Lasik surgery as a model for health care in the United States. I don't buy it. I mean, if you don't have the money for Lasik surgery, you don't get it. I don't care whether or not you have Lasik surgery or wear glasses or as long as you don't go driving with bad vision. There's not much of a public good aspect there. There is a public good in your ability to be healthy. Well, the Oklahoma Surgical Center, which is another, and perhaps you don't know that much lower prices that are transparent, that does surgery of all kinds. Anyway, go ahead. You can't take, you know, transparency in prices is something that is worth almost nothing because most people don't know what's going in. You don't know what you're going to need. And you don't know the quality of the service that you're going to be getting. I mean, that's where Arrow's making his case. It's the unknowns and the unknowns that you don't even know what they are. You go to the doctor. You know, I'm seeing these lights on the side of my eyes, side of my peripheral vision. And, you know, so I Googled it at night. I hope not. I hope not. I see that. So anyway, I don't really know what it is. I googled it. I'll be seeing the eye doctor. You don't know going into it. That's why people buy insurance. You buy insurance because you don't know. And it's something that you'll be needing. So, okay. Sally, you want to address that question briefly that Jerry just, I think direct primary care, you're talking about Oklahoma Surgery Center. There's a couple of thoughts. It's really great. Direct primary care. And that is a way to reduce costs and people to be able to get good primary care through this process. I think it's really interesting that 49% of young gods are now joining hospitals rather than going into private or a small group practice. But we want to support direct primary care and get doctors to, you know, see patients at a price. You know, they can do MRIs a lot cheaper than if you go to say you, the mass general and get the price that you get at mass general would be probably three times as much as you get at the, as you pay at the Oklahoma Surgery Center. We need to have all kinds of different ideas and systems because that's what makes America great. Not pushing people into one size fits all. Okay. We have only about 20 seconds left to the Q and A portion. So I think I better stop and then push you both an extra 10 seconds for your summary. So, Jerry, you go first. You have seven and a half minutes to summarize. Take it away, Jerry. Okay. Well, I'd like to think about children because children come into this world completely unable to pay for what they need. We hope that parents will help them. If you're smart and lucky, you'll be born to a parent who's able to afford the care you need. But what if you don't? Or what if you're born with some degenerative disease? What if you're born with some genetic condition? You know, who's going to take care of you? And are we ready to let those children die? Now, that's maybe I mean saying it strongly, but let's leave out death. Let's just talk about are we going to let those children grow in a society where they will be unproductive because they lacked the healthcare that they needed to grow up productive? If your parents don't have the money or if your parents are selfish, then what's going to happen to those children? At the beginning of life, you have the children. At the end of life, you have Medicare and you have the elderly. Now, why did we get Medicare for the elderly? It came in for the elderly because there was no functioning insurance market for the elderly. Health insurance was not being sold for the elderly because they were going to be too expensive to care for. And there's too much variation in the life situation and the health situation of the elderly. The insurance companies assumed that if you were looking for insurance, you were going to need it. You knew that you would need it. They couldn't tell or they would go in and assume that, well, maybe you're okay now, but there's a lot of variation of what's going to happen for the elderly. So they would have to price their health insurance at a high rate to cover the risk. So there was no functioning insurance market for the elderly. Children could not buy insurance for themselves. They could not buy healthcare for themselves. So there was no functioning healthcare market for the children, except those who were lucky enough. So what do we have? We have a healthcare system that is already a free market healthcare system that's already going to be restricted to say between late teens and fifties. And within that, people with pre-existing conditions, people who have degenerative discs, people who have cancers, people who have had cancers and may come back. So the free market for healthcare starts getting smaller and smaller and smaller. And then you get to the provider side. You've got the elite hospitals that are able to jack up their prices because of brand names. They're able to buy increasingly buying up other hospitals to drive away competition. We have monopolies on that side and we have a failure of the ability to buy insurance and buy healthcare on the other side. Altogether, you don't have a free market and you never have a free market in healthcare. What you have are varying degrees of imperfect competition or imperfect markets in healthcare. And then the question becomes, how do we want to handle that? Do we want to promote an impossible free market moving in that direction? What economists would call second best economics, which Kevin Lancaster and others showed, at least in theory, is not necessarily the best way to go. And Aaron is another one who worked in that area. What you want to do is choose the best option available while keeping in mind that governments make mistakes. God, we know that in the United States these days, governments make mistakes. And we want to have, you have to allow for that, as most countries do that have single payer type healthcare systems. So given that, you could subsidize people to go into the private sector, subsidize children, subsidize Medicare, and just let the market go, give every elderly person a chunk of money. Well, that's not going to work very well because that's not dealing with the monopoly on the other side, the monopoly of the hospitals, the monopoly of the drug companies, and the monopolies that would spring up because everybody does want insurance. So if you don't provide it through the public sector, they'll be buying it, they'll try to buy it from the private sector. Or you could do the cost effective thing, provide Medicare for everybody, where Medicare is able to use its monopsynistic power to beat down the rent seeking by monopolistic hospitals and monopolistic drug companies while providing the health insurance that all, or the healthcare that all Americans need. Now, of course, there are limits to what we can do. And government agencies like Nice and Britain will be deciding, will be making those decisions through the political process or democratic process. We hope to put constraints on that. We need to leave a safety valve for people, you know, people who have particular medical needs that are being neglected. You know, we need to be, you know, we need to admit that we may not be always be making the right decisions and government needs to be accommodated. But that said, the fundamental principle is there that we have that as a decent society, and as a society that's concerned about the productivity of its people, and as a society that wants to limit monopoly power. One minute, Joey. We need to have a strong government role in healthcare. And that's what Medicare for All is all about. I'll yield my time. Thank you. Okay. Thank you, Jerry. Sally, seven and a half minutes of your summary. Take it away, Sally. But some of the most powerful arguments against government-run healthcare are the stories of those who've been victimized by it. Take the case of Jamie Lee Ball, who in March of 2017 arrived at Ontario's Brampton Civic Hospital in excruciating pain. According to Canadian Broadcasting Corporation, she'd undergone abdominal surgery the previous month and knew her condition might be serious. Soon after she arrived, a doctor determined she was bleeding internally and might need a blood transfusion. She spent five days in a stretcher, on a stretcher, in a hallway, screaming in pain and crying. The hospital had declared a code gridlock, meaning in Canada that it had no, the hospital was at capacity and no longer able to put patients in beds. At one point, she was booted from her prime spot in the hallway to accommodate a cancer patient. She told the CBC that everyone shared a single public bathroom. Virtually every Canadian knows someone who has a story like Jamie Lee's. But it's no wonder, and Jerry even mentioned this, that as many as 323,000 Canadians out of a population of 36 million go abroad to obtain medical care because they find the waiting list is too long and they are in pain. They want to get good care in a reasonable time. And Canada's leaders know their health care system is failing. Claude Castongue, the so-called father of Quebec's Medicare system said, we thought we could resolve the system's problems by rationing services or injecting massive amounts of public funding into it. 40 years after installing single payer, he proposed to give a greater role to the private sector so that people can exercise freedom of choice. Yet the progressive wing of the Democratic Party seems uninterested in learning from Canada and Great Britain's mistake. Senator Sanders' two Medicare for All bills contemplate a level of public spending that goes far beyond massive. Both the Libertarian Leaning Mercatus Center and the Left Leaning Urban Institute estimate that the increase in federal spending under Medicare for All would be between $32 and $40 trillion over 10 years. And that estimate is the best case scenario. In all likelihood, Medicare for All would cost far more. And that's because if health care became free at the point of service, Americans would demand more of it. We heard economists at MIT, Amy Finkelstein has pointed that out. Remember, Medicare came into being along with Medicaid in 1965. The president, Lyndon Johnson, said it would cost about $1 billion in the first year, $12 billion in 1990. Medicare in 1990 cost $110 billion. These government programs will cost so much more. But let's accept the case scenario. And assume a cost of $32 trillion over 10 years. It's far from clear where that money would come from. It would have to come from new taxes. Because as we've heard from economists like Charles Wayhouse, even if you doubled all the personal income taxes and corporate income taxes, it wouldn't be, it wouldn't cover the cost of this single payer. And a recent proposal by Senator Sanders, Markey, and Kirsten Gilligrand, they introduced the make billionaires pay act. The bill would impose a one-time 60% tax on money made by billionaires during the pandemic. This wouldn't raise enough money to cover Medicare for all. There just aren't enough millionaires and billionaires to cover in wealth taxes, new payroll taxes, new income taxes, taxes on financial institutions. They would come up short. What this means is that the middle class Americans, not just the wealthy, would have to see their taxes rise substantially under Medicare for all. And Senator Sanders has admitted that. We saw in the poll numbers I gave that support goes way down for Medicare for all to about 37%. If it means increased taxes, and it means losing your employer-based coverage. Now, massive tax increases might put a damper on the economy during good times. Just imagine how much damage they do during a period of historic joblessness, such as we're facing today. Now, some might suggest that Americans would no longer pay insurance premiums. These new taxes would be a wash. But according to Ken Thorpe from Emory University, more than seven in 10 households with private insurance would pay more under a single payer system than they do under the current system. And let's not discount another kind of cost of Medicare for all that it would impose on Americans. If the experience of Canada and the UK are any indication, patients would lose access to many of the new medicines that we have access to in this country. Of the 243 new medicines launched between 2011 and 2018, just two thirds were available in the UK. Even fewer were available in Canada. 88% were on offer here in the US. This disparity in access to cutting edge treatment helps explain why the US has better five-year survival rates for the most common forms of cancer, breast, stomach, prostate, rectal, and ovarian than in Canada and in the UK. Stats like that back up one of my favorite quips about Britain's National Health Service from a writer at The Guardian. The only serious black mark against the NHS was its poor record on keeping people alive. Medicare for all would not just reduce access to cutting edge treatments here at home. It would have global implications and ramifications for medical innovation. The United States is an indispensable source of funding for research into new drugs, therapies, and vaccines. If Americans began underpaying for drugs, the whole enterprise of drug development would become economically infeasible. The result would be fewer new drugs for treating cancer, Alzheimer's, heart disease, and even COVID-19. This brings me back to the resolution at hand because COVID-19 is the clearest example of the dangers of underfunding medical innovation. Much of the promising work towards curing this disease is happening right here in the US. I talked about Pfizer, J&J, Moderna, AstraZeneca, and the UK working with University of Oxford. That's because our somewhat market-based healthcare system has given rise to a vibrant, well-resourced research ecosystem. The ecosystem could not survive under a single payer system like in Europe and in Canada. Medicare for all would make it harder or not easier to meet the challenges of this pandemic. It would leave us tragically unprepared for future public health crises. It would impose crippling costs on our government and the economy, and it would make the pain and indignities suffered by Canadians and everyday occurrence. Michael Buble, a great Canadian singer from Vancouver where I'm from, and his son at age three in Vancouver was diagnosed with liver cancer. He didn't wait to see how he could have it treated in Canada. He went to Children's Hospital at LA, had it treated, and five years later, he is cancer-free. He said we had the best doctors, the best specialists, and this is what we want to keep America open for. Thank you. Okay. Thank you, Sally. You came in a few seconds under as well. Jane, please open the final vote and interrupt me once the final vote is in. Meanwhile, a couple of announcements. Our next online debate will take place on Wednesday, September 9th. The debate resolution will be to combat inequality. Greater investments must be made in public schools so as not to accommodate the formation of pandemic pods by affluent parents. Defending that resolution will be the University of South Carolina professor John Dale opposing the resolution Corey Dangelis of the Reason Foundation. But don't try to buy tickets yet. It will take us a few days to have this event posted. In addition, instead of watching Kamala Harris this evening, you might prefer to catch last month's three-way soul form debate on the coming presidential election in which three different libertarians advocated for Biden, Trump, or Joe Jorgensen. So far, that debate has had more than 36,000 views on YouTube. And I'm sure Jerry and Sally, your debate is going to have a huge audience. So tonight we just get the crowd that's around us. But of course, the larger audience is to come. And that's just YouTube views. That doesn't include our podcast. I had a debate with Gerald's, Jerry's former colleague, Richard Wolff, that set the record of 1.2 million views. Jerry, see if you can do better than your colleague Richard Wolff did. But Sally is going to push you over the top, Jerry. And so that's going to be the 1.2 million that you'll both have. And so in addition, I should mention, I was on the Tom Woods Show podcast debating David Stockman last week, former budget director under Ronald Reagan on the economic outlook. One might say I played optimist to David's pessimist. You can access this debate by googling the Tom Woods Show. In addition, I also appeared on the Free Man Beyond the Wall podcast and gave host Pete Crononis a granular account of how things are going at the epicenter, otherwise known as New York City. Pete calls the episode New York City has reached herd immunity, according to Gene Epstein. You can access that by googling Free Man Beyond the Wall. We're also grateful for the generous support. These people are being paid big bucks, $500 apiece, to do what they just did. And that's a pretty big wage, $250 an hour. We assume you didn't come in at all prepared. So therefore, it's just basically paying for you for your time on air. And that's 500 bucks. That comes from the Smith Family Foundation, to which we're very grateful. And for administrative and technical support, we get the Reason Foundation. Jane, is the voting closed? Jane, are you there? Hello? Did you email me the results? Jane, where is it? One on the side? Oh, there we are. Okay. Let's see now. All right. Now, voting, all right. Voting yes on the resolution, pre was 20% in favor. As you know, it's who moves the needle. And Jerry, you picked up 6.6 and three quarters points. You went to 26.7%. So then the marks of that was the number to beat 6.67%. Sally went from 60% to 73.2%. So she picked up 13.3 points. Sally, you get the touchy roll. But it was beautifully done by all of you, both of you. I should thank you to you both. And good night to all. And we hope to see you at the next debate. Indeed, we hope to see you at the subculture theater in downtown New York for a physical debate, an old 20th century debate, once we can return to our physical space at the subculture theater. Thanks, Jerry and Sally. And good night.