 All right, good afternoon. We've had a couple speakers here talking about the benefits of free markets. Better care, lower prices. So in the interest of balance, I want to talk about government. What can government do here? And so we're going to talk about Canada. Open minds, open markets. All right, so we're going to talk about Canada. Now, most Americans I have learned. I've been working on Canada for the past two years. Most Americans don't care about Canada. If you talk about Canada, it's like bragging about your kids' little league achievements. People sort of smile, and that's special. That's amazing. Nobody cares about Canada. But there is a group of Americans who deeply care about Canada, and that's progressives. So Bernie Sanders, AOC, the whole gang, for them, Canada is the promised land, just the land of Medicare for all. And so I'm going to be talking a little bit about what Medicare for all achieves in Canada. And in a nutshell, you get what you pay for, number one. Number two, when that is going through a bureaucrat, you are getting far less than you paid for. So those are the two lessons of the Canadian system. Now, I want to start out with sort of a couple of details on the Canadian system. It is indeed cheaper than the US system. This is true. Substantially cheaper. It's about a third cheaper than the US system as a percentage GDP. However, taxes are also about a third higher in Canada because it is paid for by government. So basically, as an American, think of what you pay in federal taxes. Now think of what you pay in state taxes. Now imagine if the state portion were the same as the federal. That's Canada. The provincial take is almost equal to the federal. And the reason is because the provincial authorities handle medical. They handle most of medical. So now there's a lot of research that says that if you take a dollar in taxes, it didn't cost a dollar. It cost $2 to $3. And the reason is because of incentives. So this is coming up with stimulus. Yeah, we're just moving money around. Don't worry about it. It's cool. Every dollar that runs through government, you suck up $3 and one comes out the other end. So you've got to keep in mind that the economic impact of that extra third in taxes may well chew up all of the benefits from the lower cost of health care. So that's point one. Now point two is the Canadian government is not very good at managing medicine. Governments in general are good at managing nothing. We have public schools. We have lots of evidence. And effectively, the Canadian system is cheaper because it cuts corners. It cuts corners everywhere. Everything is worse in that system. So we'll start with waiting times. Waiting times is they are epic in Canada. So average waiting time, this is from the referral from your primary to the treatment for a medically necessary condition. There's a condition that must be treated as soon as possible. So that's 20 weeks. That's nine weeks from practitioner to see the specialist. If the specialist approves your treatment, it's another 11 weeks for the actual treatment. In some provinces, it is epic. In Nova Scotia, it is 45 weeks. These are medically necessary treatments. These are not things that people are doing for fun. So in comparison, in the US, 77% of treatments are under four weeks. 6% run over eight weeks at the average in Canada is 20. Keep in mind, all of these numbers that I'm giving you here, these are all pre-pandemic. All of this is Canada in a normal state of affairs. This is not pandemic stuff. This is all beforehand. All right, that's waiting time. At any given moment, 1 million Canadians are on a waiting list for medically necessary treatment. Many of them, let's see, the average stay on that list is six months, longer in rural areas. One neurologist in Ontario, she gave a woman a referral for medically necessary neurological treatment four and a half years. All right, medically necessary. A boy in British Columbia, he waited three years for urgent surgery, during which he became a paraplegic because his condition deteriorated. Many Canadians fly to the US and they pay out of pocket cash, our prices out of pocket. So a woman in Alberta, she flew for a hip replacement, 20,000, 20,000 Canadian. She said it was worth it. She got a year of her life back. For a year of pain, a lot of people will pay 20 grand. So many Canadians fly to the US, they fly to the Caribbean. By the way, if they fly to the US, that shows up as our system being expensive. All right, next up, equipment, drugs. So you've got shortages in facilities, shortages in staff. 29th, Canada ranks 29th out of 33rd in the OECD for doctors per capita. Keep in mind the OECD includes Turkey, Mexico, Poland. It's got half as many specialists as the US. In rural areas, it gets down to 1 third of the OECD average. Doctors tend to cluster in the cities, which we'll get to. When budgets are set by politics, the doctors end up living in the places that are political clout. The average drug used is significantly older because it's cheaper. So why use the latest drug, which is expensive, when you can just put somebody on a generic? Now, there is tons of evidence that new drugs are better. Something called the offset effect, which is that new drugs end up, they're more expensive. But they save, I think it's well over 10 times their cost because a newer drug, you get better outcomes, you have fewer surgeries. Surgeries are astronomically more expensive than a pharmaceutical. So the system is not even being logical about it. It just cuts anywhere you can cut corner. Cut off a percent here, a percent there. There's a board in Canada, the PCBMP, pharmaceutical. Its task is to make pharmaceuticals cheaper every year. So they strong arm pharma companies. They push the prices down. They say, let the Americans pay the high prices. We all amortize the R&D costs here in the US. And then they want it basically at the cost of production, dollar appeal. They want to get as close to that as possible. So they squeeze the drug prices. The pharmaceuticals, therefore, they don't offer the newest drugs in Canada, partly because they're concerned that it will creep across the border. They'll cut out the profits in the one single market that they can actually make back their R&D. So the average drug is older. Let's see, you do have private employer plans. Those are doing older drugs because the newest drugs are not necessarily approved. But still, you have a wider take. You have about 10,000 to 12,000 drugs on the private employer plans. And then you've got the public plan. And those are offering 4,000. So in other words, everybody in Canada has to use older drugs because they're often not approved because of the price pressure. But in addition to that, the public plans is using even older, even cheaper drugs. Next up, equipment. So Canada has fewer MRIs than Turkey or Chile or Latvia. 75%, in other words, four times fewer MRI machines than the US per capita. You end up waiting. Let's see, in Quebec, you wait five months for an MRI. You wait eight weeks for an ultrasound, which for an American, that's a trivial operation. And remember, all of that is on top of the standard 20-week delays. You have 35% fewer acute care beds. ER averages are out of the ballpark. Because if people are waiting 20 weeks for treatment, they go to ERs. So the ERs are packed. Average weight in Quebec is four hours. Many thousands just go home, hope for the best. And all of these are very well known in Canada. If a Canadian knows you're American, they'll defend the system because it's a point of national honour. It's like Americans with gun rights, right? If somebody says, nah, you guys don't really have a second. People get their back up. But anyway, all these problems are widely discussed in the Canadian press. They are all very well known. Hallway medicine, right? This is one of the concerns. It's where they don't have enough rooms. They don't have enough facilities. So patients are treated in hallways. There was a news article. Remember, all this is pre-COVID. There was a Tim Hortons, which is a Canadian Starbucks. Tim Hortons converted into an ER because they didn't have enough ER rooms. So I mean, it is endless. Now this is all in normal times. So what's the result? Doctors blow through patients, one and done. 15th out of 20th in the OECD for time with patients. This is for one of the richest countries in the OECD. They recently put in something called a one issue per visit rule. So this brings us to Peter Drucker, the management theorist, who said that what gets measured gets managed. So the doctors are being evaluated based on the number of patients they meet. So how do you quickly increase capacity? Well, you do one issue per patient. So a patient goes in. They've got a couple of different issues. They've got to choose which one they're going to go with. OK, the next one's going to have to wait for another however many weeks. So this is, of course, absurd, but that's how a bureaucratic system works. Now the sort of standard argument is that, yeah, OK, right. But Canadian life expectancy is quite high. It is. But keep in mind that Canada is a giant Vermont. It's clean living. You have much lower rates of obesity. They don't murder each other with the same enthusiasm we show in this country. There are little statistical quirks like how infant mortality is calculated. There's a bunch of outside reasons why Canada looks so fantastic in life expectancy. When you actually look at these survival rates, things like 30-day in-hospital mortality tends to be 10% to 20% higher than the US. So if you control for those external factors, or if you ignore them and you just ask once you go into hospital in Canada, what's your odds of surviving? It's about 10% to 20% higher mortality. With strokes, it's three times higher. Probably one might speculate because people are waiting longer to have it checked out. Overall satisfaction, significantly lower than in the US, despite the national pride in the system. One-third more Canadians rate their system low than Americans do. Now, so the system is a mess. It is held together with bubblegum and string. And this led to disaster during COVID because the system was massively overwhelmed. Now, we were concerned about that here. It turned out not to happen because the US has obscene amounts of capacity. We pay for it. There's other issues. But the point is we have an amazing amount of capacity. Americans have no idea how much capacity we have. It's outrageous. Canada does not. So the hospitals were genuinely packed in Canada. And this led to a couple of weird things. One of them was there was kind of a general sense of panic in society. So Canadians were much more open to strict lockdowns. The general attitude was do whatever you can. Oh my god, the hospitals are going to sink. The second was that politicians panicked. So Quebec, for example, had a super Cuomo event where they dumped everybody out of the hospitals into the senior homes. And so the mortality rates in Quebec are world beating. They're substantially higher than US levels. So it was a disaster during COVID. Even today, so the number of hospitalizations because of COVID are down 90% from the peak at this point in Canada. Still, hospitals are 148, 176% over capacity. In other words, the crisis has long passed. Now, this pattern doesn't just exist in the hospitals. It spreads across all of the social services in Canada. The other big one is long-term care. So long-term care in Canada is overwhelmingly provided by the government again, especially in the province of Quebec. And the same thing. It is understaffed. They don't have enough staff to feed hot meals to seniors. Seniors have to eat cold food. The system is, again, falling apart. So that interacted now. When you've got the hospitals being dumped, at least in New York, you had relatively functioning long-term care facilities. In Canada, you did not. So it was really a perfect storm. It was two teetering systems crashing into each other. Now, of course, as a consequence in all this, at this point, you have this enormous health deficit, which is the idea that all of these people now, they've delayed their cancer screenings. They've delayed their treatments. In a system that is already up against the wall, has always been up against the wall. And so now, there's concern that this is going to create a 5, 10, 10 year. It's just going to shift everything down. And there's going to be these enormous delays now. So that is one of the concerns at this point. Now, with the lockdown panic, just in terms of human costs, because of that sense of panic, we've seen a bunch of things that are shocking. A lot of people on our side, small government sympathetic Canadians, have felt like I don't recognize this country anymore. There have been pastors who've been pretty aggressively arrested for holding service. Let's see, a mother, she couldn't hold her dying son. They told her absolutely not. He's dying. Just things that Canadians did not expect to see in their country. OK. So 60 years of trying, all of these problems, these budget problems, the consequences, the human costs, people living years in pain, all of these have been known for 60 years. It's been one of the biggest topics of discussion in Canadian politics, how to fix this, how to fix this. The constant solution is more budget. It's government. The problems get worse. The bureaucracy grows. You get these reforms that lay an additional layer on top over and over. What we saw, I was working at a free market think tank. And what we've been trying to do is to push more of a European system. You have to deal with the over 10 window. And if you say American health care in Canada, the ears close, you're done. So you've got to kind of ease people over. So we talk about Germany and Sweden and places that allow private care, which Canada does not. They're some places like Germany. We've tried to push these. There was a Supreme Court case that did actually agree that it is a violation of human rights for patients to be forced to live in pain under the government monopoly so they can see private treatment. And what our CEO at the time was told in a private conversation with health care bureaucrats, the bureaucrat was not aware which side of the political spectrum he was on. And the bureaucrat said, don't worry about it. Don't worry about it. We're going to limit it so much. It's going to be crazy. It's going to be hilarious. Watch this. And indeed, they said, no, no, no, the, you know, there was a Supreme Court case that said, I think it was a knee replacement surgery. All right. And so the government said, okay, got it knee replacement surgeries. Okay, good. So now in theory, you can open a private clinic in Quebec only that can do knee replacement surgeries. So good luck with the economies of scale on that one. There's a court case now that's been going on for about 10 years is doctor in British Columbia, Dr. Day wants to offer services. He has a giant sign in front of the clinic which says no BC residents. Okay, no British Columbian residents. If you're American, you can go to the clinic and get treated. If you're Albertan, you can go to the clinic and get treated. You cannot do it if you are from Vancouver. If you're from the actual province. Why? Because of provincial monopoly. So they are creative. They are nonstop. Every time, you know, these are Supreme Court cases. There was a lot of optimism of the times. And finally, Canadians are gonna get a choice. Biocracy's on it. So there are clearly problems in the US. I think we've heard through many of the speakers. Corporatism, corruption, you know, the patient doesn't pay the cost. These are all clearly problems. But the point that I do want to make here is that, you know, there are various solutions to these, things like price transparency, giving the patient some skin in the game, higher deductibles. All of these things would work to limit these. What would not work to limit these is handing it over to government. That is exactly, unfortunately, what the Medicare for all, it is very specifically looking at the Canadian system, right, in monopoly on government provision with no private. And so, you know, that brings just to recap quickly, right, that brings you get a system that cuts corners, lower quality equipment, older drugs, lack of staff, lack of facilities, hallway care, five minute drive-by consultations. The management becomes extremely bureaucratic. You know, hospital administrators in Canada, they have union rules or they have ministry rules about overtime, using repairmen to disinfect hospital. Everything's got to run up six levels of bureaucrat. By the time you're done, the managers don't bother. It takes a very, very rare manager to fight through that. And then, right, you have this enormous health lobby, right? This is something else that we can look forward to. Even the most right-wing governments in Canada are afraid of the health lobby. I'm speaking of Alberta specifically. I spoke with the Ministry of Health there, terrorized. The nurses union, they are a monster. They're very, very strong and they have a lot of media sympathy. If we introduce Medicare for All here, those bureaucracies are going to grow and whatever power they have today, times 10. And then the final point is just the global budgets, all right? So, you know, the way that government, the way that Canada system works is something called a global budget where essentially a given hospital is given a chunk of money and they have to make do with it, okay, rather than the money following the patient. So what, of course, ends up happening as we know from economics is the hospital has incentive to not treat people. In fact, it has an incentive to dissuade people from coming to the hospital. So it has leftover budget, possibly enough budget that they can take a vacation for training at the end of the year. So budgets are politically negotiated and this is necessarily what happens when you bring the government into the process, right? So no longer is it where a rural Alabama county, right, the hospitals there have enough money because, you know, the patient brings the money with them. Okay, no longer are you in that kind of a system. Now you're in a Alabama senators versus New York senators, right, Battle Royale. So to give an example, we studied one case in France, all right, where they did allow private competition with government clinics. And what was fun about this is that all of the new clinics located in the poorest areas of Paris. And this was surprising because everybody right and left expected the opposite. They figured, ah, well, the private sector is gonna come in, they're gonna skim off Scrooge McDuck, you know, and then people say, so that's gonna starve the public system of resources. Actually what happened was the opposite, which is that the political process in France does not put hospitals in black areas. They don't have any cloud, okay? It puts hospitals in white areas, rich white people who donate, who are politically active. So when the private sector came in, it did not skim Scrooge McDuck, it went where the need was. So the sort of moral of the story here is yes, our system is screwed up, we have a lot of corruption in it, we should be fighting that, but government solutions are going to make it much worse. Okay, thank you.