 Thanks for joining us for this talk on medical care. I have the task of being between you and lunch. And that's always a challenge. But this is one of my favorite topics to talk about. It's such a favorite that I've actually got 85 slides here. So I figure I have about, what, 30 seconds per slide. So we'll move through this as quickly as I can. There are a lot of topics that we could discuss here. But what I wanted to focus on are some of the reasons that we see higher costs in medical care in the United States and other countries too. But especially in the United States where the cost has become higher and higher, it seems, every year, and where there seems to be a pretty big gap between the United States and other countries. Also, I'd like to go over with you some of the current legislation, the Affordable Care Act, which has been a very controversial part of the efforts to deal with medical costs in the United States and then the proposals for something called Medicare for All, which you have probably heard about. So without further ado, let me just outline where we're going here in the next few minutes. First, we'll look at the rising medical care costs in the United States. And then in particular drug costs, we've seen some drugs that have become extraordinarily expensive. I'd like to offer some suggestions as to why that might be happening. There's been some proposals for price controls on drugs. I don't think that's the way to go, but I think there are some interventions from the government that have contributed to that problem. I'd like to talk a little bit about medical finance in the U.S. and there's where we'll discuss the Affordable Care Act and the Medicare for All. And then last, I'd like to do a brief comparison of the United States versus some other countries and their medical care systems, some of the problems that they've had. We've actually seen a kind of a convergence between the U.S. and European nations on how we deal with medical care. Seems that many of those countries are moving gradually toward a more private sector-oriented system and the U.S. has been moving apparently in the opposite direction, so we'll talk a little bit about that as well. So first, rising medical care costs. Vijay Boyapati in a Mises.org article pointed out four reasons for rising medical care costs in the United States. One is the employer-provided health insurance that began in the 1940s. A lot of this has to do with high marginal tax rates that we saw late in World War II. With very high marginal tax rates on income, employers were looking for ways to offer compensation to their employees that would not be heavily taxed. And so when the Supreme Court decided that the provision of health insurance to employees would not be a taxable benefit and this gave employers a way to offer employees a benefit without the heavy taxation that we were seeing at that time. Second, he mentions medical licensure. Medical licensure is a way of restricting entry into the medical profession and that can lead to less competition in higher prices. Third, he mentions the obesity epidemic. I won't spend any time on that here but that may be a contributor to numerous kinds of health problems. And then fourth, intellectual property patents, for example, on drugs that may have led to higher prices. The economic concept of moral hazard, sounds like moral hazard to be what you experience if you went to Las Vegas or something, but in economic terms, moral hazard is the risk or hazard that an insured party might participate in activities that are undesirable from the insurer's point of view because they make it more likely that claims will be larger. So in terms of say, automobile insurance, if I have car insurance and I'm covered for damage to my car, I might be more likely to park my car on the street where it's more likely to be side swipe by passing vehicle or I might be less likely to pull the car into the garage if there's a storm coming that might drop hail on my car. That's, there's a similar kind of problem in medical care. If I believe that my medical expenses will be covered by third party, then I'm much less likely to refuse those medical treatments even if the marginal benefit of those treatments is very, very small. So this diagram would show what we would see if we had a completely nationalized healthcare system. The moral hazard would suggest that individuals would not be very careful shoppers. They would not be paying the price of the medical care. That would be covered by taxpayers in general. So the individual is facing a pretty much zero marginal cost. Now there may be wait time, which is important and people may want to avoid waiting in line, but the monetary cost at least of their medical care would be so low that the quantity of medical care they demand may be enormous. If someone's going to cover, for example, you notice I'm wearing eyeglasses. I have some incentive to avoid very high cost methods of correcting my vision. I have not had laser eye surgery, but if my insurer said to me, well, we'll cover the full cost or if the government said, we'll cover the cost of laser eye surgery. Well, then at that point I'm $300 for glasses or $3,000 for laser eye surgery. Doesn't matter to me because I'm not paying the bill. So my consumption of those services would rise substantially. And even a small nod to these price incentives can make a big difference. So if you have people that have at least a little copay on their medical services, this can actually deter people from engaging in unnecessary medical expenses. This is a chart that I've shown in the past just because it's such a beautiful illustration of what's happened to costs in the medical care field as we've seen price inflation in other areas. We see massive price inflation in medical care. So here's medical care, 118% increase in prices over a 20 year period. And then if you look at general inflation, only about 64% over that same 20 year period. So what's going on here? Well, one clue is if you look at cosmetic services which are much less likely to be covered by third parties such as insurance companies or government, the increase in costs there has been only about 30% lower than the general rate of price inflation in the economy. So perhaps the fact that most Americans are receiving care that is provided by a third party may have something to do with the fact that people just aren't responding to higher prices by reducing the quantity they would like to consume. One study indicated that the moral hazard is, and this is a recent study, even though it's responding to literature from the 1980s, that medical care cost growth actually does have a strong relationship to the moral hazard problem. There's been some debate over this which I won't go into, but as Foy, Shyamana, Kozak and Filiponi pointed out, insurance drives the marginal price of medical care at the point of use to near zero. So consumers or physicians acting as their agents demand care until the marginal product of additional care is nearly zero. So we see the same thing in other kinds of markets. Tomorrow I've got to talk on higher education. We've seen a very similar kind of phenomenon going on there where third parties are paying for higher education with greater and greater frequency and that means that students are not responding as much to price signals as we might have seen in other markets. So empirical evidence exists in support of the conventional view, that is the moral hazard view. Studies have found that a fully insured population spends about 40 to 50% more than a population with a large deductible and their status is not measurably improved by the additional services. And this is called flat of the curve medicine where spending on medical care increases even though additional gains from such spending are very low or non-existent. Part of the argument for having third parties, insurance or government pay for medical care is that, well all medical care is going to make people better off and that's sort of the assumption that this is going to improve your life. So why should we put any limit on the amount of medical care people consume? But in fact we see that that's not the case. One famous or depending on your perspective infamous experiment that was conducted a few years ago in Oregon expanded Medicaid coverage randomly to additional applicants in the state of Oregon. And what they found was that the improvements in health outcomes for those who were, their names were drawn, they were part of this lottery. They found themselves having one additional Medicaid coverage and they found that their health outcomes didn't improve, they had additional medical services. In fact, as this study indicated, they used prescription drugs, office visits, preventive care services, mammograms. They had annual spending per individual in excess of $1,100 and yet they weren't measurably better off in terms of their health. So we can throw money at individuals to cover various medical care but it's not necessarily going to make people better off. We have seen rapid technological change in medical care. A family member of mine recently had surgery which just a few years ago would have entailed a long recovery period, probably more pain and more risk of complications and infection. And yet she was out of the hospital very quickly and has had a very good recovery. This kind of technique has been much more common as we develop new ways of doing surgeries and new ways of treating illnesses and injuries. So we have all this medical technology and yet we're using this in ways that increase costs and in some cases are not really improving the outcomes. The same study I've been referring to here says that medical insurance in its current state discourages individuals from economizing on healthcare decisions and incentivizes the adoption and over consumption of services with progressively diminishing returns on investment and they refer to this as the medical cost ratchet. So we're seeing people spending money on these services that probably there was a cheaper alternative that would have been 95% as good but that was not even considered because if somebody else is paying the bill, why bother? Some years ago I had some back trouble and I went to a chiropractor and the chiropractor said, well, I'd like for you to have an MRI. I said, well, okay, and I scheduled a MRI and I think I had it within a couple of days. Try that in some countries. And I didn't even ask about the cost. I had health insurance that would cover the MRI. Didn't ask the chiropractor if maybe an X-ray would have provided 95% of the benefit of an MRI without as much cost. An X-ray would have been dirt cheap compared to the MRI but I'm not a very good shopper because I'm not paying the bill. So I went to have the MRI and I've got the bill later in the mail and I saw where my insurance had indeed picked up almost all of the cost and the sticker price on this MRI was something like $5,000 or $6,000. And an X-ray would have been, I don't know, what, 50 or $60, I don't know, but it was the added advantage of having this super sophisticated MRI diagnostic test done worth the additional $5,000 that it entailed, maybe not. So one way that we've seen policy kind of adjust to help people become better shoppers is the advent of healthcare savings accounts or HSAs. And these are accounts which are tax favored. That is, you can put money into these and you don't have to pay taxes on any contributions to these accounts. And they're paired with a high deductible health insurance account for high costs. For high cost events. So if you get into an accident and it's a $10,000 medical bill or $50,000 medical bill, that is picked up by that high deductible medical insurance while routine kinds of expenses and deductible size expenses would be picked up by this HSA that you've contributed to tax free. So that's one way that we've seen people, we've seen people become better shoppers and they're confronted with that kind of policy. And that does seem to be a step in the right direction but not as common as I think I'd like it to be. So technology drives up costs but not always in proportion to the level of improvement in care that technology aims to deliver. Let's talk a little bit about drug costs. A matter of great concern, people have seen these kinds of stories coming out for some years about how some pharmaceutical company buys up a patent on a drug. They're essentially a monopoly provider of that drug and the price shoots up. The EpiPen was one of these cases where Myland, the patent holder on the EpiPen has exploited the fact that they've got this government protected market share. The EpiPen is vital for some kinds of, for people who have allergic reactions to some things. And so schools, for example, public schools anyway are required to keep these EpiPens on hand. So they've got a locked in market and there's with protection from the government against competition, there's no particular reason we would expect these firms like Myland to refrain from increasing the price. So in addition to the patent issue, we've also got the FDA standing in the way of innovation and competition. So if you want to get a drug that is similar to an EpiPen out into the market, you've got to pass the FDA's stringent requirements which are very expensive and it's not altogether clear that they're creating advantages in drug safety that are a correspondent to the added cost. So as this article points out, Michael Flex says, thus far the competing companies to Myland have been given excuse after excuse as to why their products can't see equal footing in the market. It's essentially a rigged game. Another pharmaceutical company named Gilead bought the patent for a hepatitis C cure called Suvaldi for $11 billion, took the drug through the last stages of the FDA approval process, which was completed in 2013 and then the very next year they made $12.4 billion from that drug. One course of treatment in the US costs $84,000 for this drug. Very effective, but if you want to compete with Gilead, you'll be facing all kinds of hurdles imposed by the government, FDA hurdles, perhaps patent hurdles and so forth. Jeffrey Sachs of course took the position that the company is morally culpable here and not the government that's creating these barriers to entry. So he said, Gilead should be held responsible morally and legally for all the HCV related illnesses and deaths that occur as a result of their unacceptable pricing policies. Despite record breaking profits, Gilead continues to keep the price of Sevaavir so far above its modest production cost that millions of HCV infected individuals are unable to access the treatment they require. What would he like to see happen? Perhaps price controls, it's clear that he wants the government to intervene more in this market, but I would argue that's government intervention in the first place that's created the problem that we're observing. Now what about patents? The argument's been made frequently that without the patent to protect a new drug innovation that we would see very few new drugs brought into the market because the innovator would not have that temporary monopoly to allow them to gain something from the expense they put into or the research and development of this drug. So a British Medical Journal survey of the most noteworthy medical and pharmaceutical discoveries of history, which you can see here, lists a lot of very significant life-saving advances in medical technology, but only two of these birth control pills and thorazine were patent protected. The rest of these came onto our market, saved countless lives without benefit of patent protection. So it's not at all clear that intellectual property is as essential as we've made it out to be, maybe not we in this room, but Americans often think that without patent protection that we would have less drug innovation. That's not necessarily the case. One CDC survey indicated that of the 10 most important medical discoveries of the 20th century, none of them had anything to do with patents. Nathan Nicolayson in Amisa's daily article a few years ago said that expanding the scope of research beyond pharmaceutical drugs, a survey of R&D labs and company managers revealed that between 23 and 35% believe a patent is an effective way of getting a return on investment. At the same time, 51% believe trade secrets to be an effective way of ensuring returns. Maybe patents aren't, again, as essential as we expect them to be. The FDA, taught in my classes about the FDA, I teach a course at Wofford College on regulation and I go through the medical regulation as well as other areas of regulation and there's a very common perception among students coming into the class that if we did not have an agency like the FDA that you'd have pharmaceutical companies selling poison to people or selling placebos to people that don't really have an effect, positive effect anyway, and that if we did not have the FDA, consumers would be helpless. They would just be the victims, routinely the victims of pharmaceutical companies that are engaging in some kind of fraud or negligence. And I say, well, now, so are you telling me that without the FDA, pharmaceutical companies wouldn't do any testing of their drugs? They wouldn't care if they had sold something to the public that created harm instead of good? Say, well, what happened to, what's the latest? Chipotle, I guess, when Chipotle had a couple of food poisoning cases among two or three of their numerous franchisees. What happened to their stock price? Was this good for Chipotle? That they were selling people food that evidently made them sick? I mean, Chipotle stock dropped their, they had, this is headline news that was not good for their business. Why would we expect it to be different for, I mean, I'm not going into the back of every restaurant that I go into and inspecting the food preparation process to see to it that they're preparing this in a sanitary fashion and so forth. And it's not because they've got some kind of plaque on the wall with a big blue letter A on there that I trust them. The inspection processes that I'm counting on are the ones that are carried out every day by the other consumers, the other customers. And if they have a bad reputation, I'm not going to patronize their restaurant. They know this. They have a very strong incentive to make sure that their product is of high quality and that pharmaceutical companies, at least those that might face some competition in a free market would also have the same kind of incentive. I'm gonna skip over some of this in the interest of time, but I will point out that the FDA does more than just impose hundreds of millions of dollars of costs on pharmaceutical companies. They also impose delays. We've seen some legislation in the last couple of years under the Trump administration to try to allow people more access to drugs that are in an experimental phase that have not completely passed the FDA, this right to try law that we've seen. And I think, again, that's a step in the right direction, but if there's a delay, and there always will be a delay, even in a completely free market, you see pharmaceutical companies that would test and that would take some time. They would test and make sure that the drug is okay before they would sell it to the public because they don't wanna be sued. They don't wanna see a decline in their reputation. But the FDA may extend that testing period out because the costs of doing so for the FDA are not as great. So for a pharmaceutical company, they've gotta think about the people that want to buy the drug and they want to buy it now if it's helpful because that will save their lives and they may be very desperate to have this drug on the market. The FDA doesn't have the same incentives and so they may have a longer period of delay before they allow the drug onto the market. And so we've seen that some of these delays have resulted in significant loss of human life. So Sceptra, which is an antibiotic, was delayed by about five years by the FDA. One estimate is that this costs 80,000 lives in the United States. Beta blockers, the lag in FDA approval may have cost a quarter million lives in the United States. And yet the FDA is regarded as being one of these essentials in the panoply of federal regulation that we just, well, can't imagine life without the FDA. What would we do? We'd all be just dying horrible deaths as a result of, and there are a few cases you can, of course, if you bring up the FDA's lags and so forth, you'll also read about thalidomide, which is a drug that the FDA was, that they had kept off the market while European countries had allowed that drug onto the market. It was a drug for morning sickness in pregnant women and it turned out to create very terrible birth defects. So the FDA says, well, you know, if it weren't for us, you'd have thalidomide on the market. And yet the costs of the FDA delays, the pharmaceutical companies that never bring a helpful drug onto the market because they can't afford the cost, those are not factored into most of those discussions. According to Mary Ruart, at least half of pharmaceutical innovations get shelved because the cost to take a drug through the regulatory testing process makes those drugs uneconomic for drug developers to pursue. She found that even with very conservative assumptions, the years of life lost due to FDA clinical demands is in the millions. Again, in the interest of time, I'll skip over some of this. If you're interested in more on this, I'll be happy to share the rest of the presentation, the file with you, but let me move along to medical finance. All right, so you've heard in the political debates recently some discussion of Medicare for All and of course the Affordable Care Act, which was passed under the Obama administration has been very controversial. This is how Americans tend to cover their health costs. This is health insurance enrollment as of this year in the United States. We have, as you can see here, the plurality of these plans are employment-based coverage. 151 million people covered by employment-based health insurance. The orangey-yellow brown down here, that approximately third of the pie are single-payer plans, Medicare, Medicaid, and related kinds of coverage, but mainly Medicare, Medicaid. So these are single-payer government-run plans. And we have about 25 million legal residents who are uninsured, and then we have some who are in the individual market, 14 million people who went out on their own to buy health insurance, and then something called Medicare Advantage, which is a government program, but it's privately administered and is something we'll discuss in a few minutes. Subsidies that we have in the United States for both privately enrolled insurance plans and for, of course, Medicare and Medicaid and Medicare Advantage, which is, again, something we'll discuss in a minute, the subsidies to these are quite high. In the case of Switzerland, Switzerland's been able to offer something that is much more like a private market, it's not free market, don't hear me as saying that, but it has less public, less government subsidization of their system, and yet they have something very close to universal coverage by insurance in Switzerland. Maybe we'll come back to this in a minute, but the ACA, or Affordable Care Act, or Patient Protection and Affordable Care Act is what we call it, sometimes we call that Obamacare colloquially, but the main components of this legislation were to require insurers to cover all applicants without regard to medical history. Premiums would be set mainly on geographic location called a community rating and age, not on gender, not on any pre-existing conditions. We'll come back to the pre-existing condition thing in a minute. Everyone was required to obtain health insurance except those deemed unable to afford it and those religious groups that have obtained waivers. This was, the teeth were taken out of this recently, that there are no penalties now for not getting health insurance. The mandatory coverage isn't quite so mandatory anymore, but employers with 50 or more employees were required to provide coverage for employees working more than 30 hours a week and health insurance policies had to cover certain services and not have any cap on annual or lifetime benefits for an individual. The reason for requiring everyone to have some kind of coverage is to avoid adverse selection, which is where the people with the worst health are the first ones to line up for health insurance and therefore the most costly for the health insurance companies. And so this, if you required everyone healthy or unhealthy to get insurance, that means in effect, you can require the healthy individuals to subsidize the unhealthy individuals. That was the idea here. So those who are very expensive to cover will be covered as well as those who are cheap to cover. So subsidies were built in because of course this still means that you've got insurance companies covering individuals who have very high routine medical expenses. And so the subsidization here was part of the plan from the beginning. This is exacerbating a long-term problem with American medical care, which is that we have not just a patient paying a doctor or other medical provider in receiving a service, but we've got an insurance company and we've got the government all involved in the mix. And the patient's standards get lost because of the rules of the procedures of the insurance companies. The insurance companies themselves want doctors to reduce the cost of care. And so they'll put requirements on doctors and the patients themselves may not have a whole lot of control over the health insurance company because in order to change health insurance companies they might have to change their employer. And that's a difficult thing for most people to do. So the bulk of the cost currently is being paid by someone other than the patient, which leads to this moral hazard problem I mentioned earlier. Government pays around half, insurance companies pay a little less than half and the patient pays only a small fraction of the total cost of coverage. If you're the medical provider now, who are you going to listen to? Whoever's writing your check, right? So the patient may want one thing, but the insurance company says, no, you don't really need that or Medicaid says you don't really need that. And so you're stuck with much louder voices from the third party payer and the patient's own priorities may be lost in this mix. And so the Affordable Care Act complicated this significantly, and this is actually a far less complicated diagram than one I presented here in previous years, but basically this adds to the regulation on insurance companies. It adds to the regulation on employers. It again required patients to have insurance. The care providers themselves are faced with numerous new restrictions. So this introduced a much more tangled web of regulation that patients and employers now have to navigate. That's actually one of the more serious problems with American medical care is the complexity is such that even the experts don't really understand it. And for someone trying to navigate this process, let's say you've got an elderly relative that needs to have care and can't make decisions for herself, trying to get through that process without bankrupting yourself can be very, very difficult. So the unintended consequences of the ACA were that premiums went up. Many people were choosing to simply pay the penalty rather than sign up for very expensive insurance plans. Insurers were pulling out of the government established healthcare exchanges. So options were limited and employers began limiting the number of workers who were working over 30 hours a week so that they, you had a lot of 49ers. You had a lot of employers that had 49 employees but not 50 because that subjects them to additional regulation under the ACA. So the ACA effectively subsidizes coverage for uninsured Americans who are sick by overcharging uninsured Americans who are healthy. So those high premiums are not accompanied by low deductibles. Indeed, the median deductible for a silver plan in 2019 was about $4,400. In 2010, the Congressional Budget Office estimated that 24 million Americans would enroll in the exchanges by this year. The actual figure was only about nine million. People were not signing on to this and the numbers that were expected. On average, premiums in the individual market have doubled since the ACA went into effect. The, this is actually a New York Times article that cited a paper that a student of mine and I wrote for the Journal of American Physicians and Surgeons a few years ago. The insurance premiums were supposed to fall. Obama had promised during his campaign that the average family would see health insurance premiums drop by $2,500 a year. Instead, they rose by around $3,700 a year as of 2014. Insurers have dropped out of the market, as I pointed out here, and this map is a county by county map and you can see the yellow counties on this map are the ones where there's only one carrier, insurance carrier in the exchange. The number of counties with only two carriers, even just not very much competition, it's about 1,200 counties or about 38% of the county. So we have a majority of the counties in the US who have only one or two insurance carriers in the exchange. Now that may not be a majority of the population but it's a majority of the counties in the US. Now the predictions that if you undermine the ACA, people are gonna be dying in the streets. I mean, you saw these kinds of predictions that we're gonna make America sick again and people are gonna be dying by the tens of thousands. But we actually, as Bob Murphy's pointed out in a Mises Wire article a couple of years ago, we don't have to make this choice between protecting property rights and preventing people from suffering and dying. We actually see a compatibility between these objectives. So Murphy, sorry, this is not Bob. This is, Orrin Cass pointed out that the best statistical estimate for the number of lives saved each year by the ACA is zero. Now, this is an updated chart from Bob Murphy's article. I've put some more recent data in here. The most recent I could find on this was 2017 but you can see this is the age adjusted mortality rate in the United States per 100,000. And 2014 is the year that the insurance coverage under the ACA fully expanded. And after that, we do not see very encouraging changes in mortality rates. In fact, they've gone up a bit. Mortality rates have slightly increased and you can see that in the years past there was a pretty encouraging downward trend in those mortality rates. Now, this is a very aggregative kind of statistic to show you but the problem I think is evident. Now, what about pre-existing conditions? How much would you have to be paid to ensure that house from loss by fire? We'll see, how much does the house cost? That's the premium, right? This is why coverage of pre-existing conditions, if insurance companies are gonna do this, then the ACA assumed that what we're gonna have to do is require the insurance companies to cover these pre-existing conditions, otherwise there's no way to handle this. But in fact, there are ways to handle this. You can ensure your insurability. So, David Henderson pointed out that under the individual insurance that existed before Obamacare, beneficiaries could buy guaranteed renewable health insurance. So if they had developed a condition while insured they could still buy health insurance at a premium that applied to the whole pool they were in when they originally bought insurance. We do this with life insurance all the time. So guaranteed renewability. Parents conceivably could even buy insurability insurance for their children. Even children they don't have yet. There's no reason why we couldn't have a contract written that says if I have children and they end up with a problem perhaps from birth, a medical problem, then you guarantee that you'll cover them for health medical expenses at a pre-set premium. No particular reason that could not happen. And then of course we shouldn't underestimate the importance of charity. This is often kind of blown off as unhelpful but it's significant. It has been and I think could be again. All right, before I run out of time let me say a few words about Medicare for All. So the idea here is we would have first dollar coverage, no co-pays, no deductibles. Everything would be covered, dental, vision, hearing, as well as the usual doctor visits and hospital expenses. Payments to providers would be cut by at least 40% relative to private insurance payments. So this is part of where they think they're gonna get the money from is by requiring that doctors and nurses and hospitals accept lower payments. Now hospitals today and other medical providers count on the relatively higher reimbursements from private insurance to offset the sometimes the losses that they take when receiving compensation for Medicare Medicaid. So this is a, if you take away that kind of transfer from reimbursements from privately covered patients to those covered by government, then you may have medical providers that simply close up shop. You may have doctors that decide that it's just not worth it anymore and they're gonna quit. We've already had a problem in some fields in that. Mercatus study indicated that Medicare for All would add approximately $33 trillion to federal budget commitments for the first 10 years that increases in federal medical expenses would be about 10.7% of GDP in 2022, 12.7% by 2031 and then rising thereafter. We would see in fact such a huge increase in costs that a doubling of all currently projected federal and corporate income tax collections would be insufficient to finance the federal cost of the plan, added federal cost of the plan. So let me just say something about Medicare Advantage. There are four parts to Medicare. For those of you that are not from the US or are not familiar with the way Medicare works, there's A and B which are the hospital and physician coverage portions that dates back to the very beginning of Medicare. Then we have part C which is this kind of an HMO type of medical plan where there's a monthly fee that you pay rather than fee for service. This dates back to about 1997. It has an out-of-pocket annual spend limit. Many of these plans which are privately run, privately administered under Medicare rules have drug coverage as well and there is competition among the different plans. There's 21 different plans. I'm not trying to project this image of this as a libertarian solution to medical insurance, but what I find interesting is that this is a lower cost method of providing medical care for many Americans and in fact the number of Americans who are signing onto this has increased. Out of all the different Medicare options, well, out of all, out of the Medicare options available, there aren't that many, but out of the Medicare options that are available, people are increasingly preferring this plan which allows more flexibility in which doctors they can choose. The orange here is the Medicare Advantage or part C enrollment which has increased significantly in the last decade and single payer Medicare, the traditional Medicare has been flat and even declining here in the last couple of years. So when someone says, well, we need Medicare for all, they're really talking about single payer Medicare which is more like old Medicare Part A and B not like this relatively market-oriented competition oriented kind of system. So under Medicare for all, insurance companies are not gonna go away, they're still gonna be around if you think Medicare for all is gonna get rid of these nasty insurance companies that don't do what you want them to do, they're still gonna be there, they're still gonna be managing the system as they do with Medicaid managed care contractors today. Doctors may exit, private insurance could be outlawed if it duplicates benefits provided by the government. And in fact, we see in Europe a shift toward private insurance as supplements to or replacements for the government provided services or care that's not what people really want. We see some major financial problems with Medicare and what we're interested in on this chart is the H.I. or health insurance, sorry, hospital insurance which is Medicare Part A and this to the left, these three columns are social security and disability insurance under social security. Last row here, the year the trust funds are depleted. Well, it looks bad enough for social security, 2035. For hospital insurance, 2026 is when the Medicare Part A trust fund is supposed to be depleted. It's already on a downward slope and yet we want to expand this and make this something that everybody has to sign up for. This doesn't seem like a very good idea. Marilyn Singleton writes and this is from the Journal of American Physicians and Surgeons. She says, currently hospitals make up the shortfall on Medicaid or Medicare reimbursements with payments from private insurance which would no longer exist under Medicare for All. You could slash CEO salaries, that's a drop in the bucket. Hospital workers are not gonna be very happy about taking pay cuts. So where's the money going to come from? And that's a real problem for Medicare for All proposals. I wish I had more time to go through what I mentioned earlier about comparing medical care, systems across nations, but as I said, I'll be happy to send the slides to anyone who's interested with all the charts and so forth and I'll be happy to talk to anyone afterwards if you're interested. Thank you.