 You know, the question is, why are we all here today? And I think there's really two reasons why we're here. Because first, of course, in a certain sense, I don't think it's hyperbole to say that medicine in the United States is broken. It's actually broken. Doctors and patients are very unhappy. The quality of care has been going down. The costs keep increasing. So even before COVID, by the way, life expectancy in the United States had dropped for three years running. And even before COVID, you know, Americans in general, where they were sick, they were depressed, they were fat, they were unhappy with their physical and mental health. So this is actually a quiet crisis in this country. So I don't know, but I wonder if we'll ever have accurate data about all the undiagnosed and untreated cancer and other serious illnesses as a result of the hospital and clinic lockdowns during COVID, I wonder if we'll ever get that. And strikes me as the kind of information we might want to have and know before we ever contemplate another lockdown for any reason. But at the same time, medicine is also, I think broadly speaking, fundamentally poised for an absolutely incredible entrepreneurial breakthrough. The kind of breakthroughs that will really revolutionize what we think of as medicine, not just the practice and the delivery of medicine, how we get care, but also how we think about health altogether and I don't want to use a trendy word, but how we think about things holistically. So today some of our topics are going to be on this idea of entrepreneurship and innovation in medicine, everything from cash practices, which are growing to Medicare programs, medical tourism, drug re-importation, the future promises, all kinds of huge innovations. And I think some of our speakers today will discuss how we can make some of this happen regardless of the depredations of government regulators. So it's something that's coming, but only if we have, I would argue, the good sense to allow it to happen. So like any good talk, like any good speaker, I like to use anecdotes, which just conveniently and helpfully support my own worldview. So I've got a couple of those. So just an anecdote, silly, but so I had a little bump on my scalp, had it for several years. So at some point I said, well, you know, maybe I should get this looked at. So I finally got around to it and this year I called a dermatologist in my town, a college town of about 75,000 people, a lot of retirees, so a lot of doctors. So I called the dermatologist's office. This is like calling for an appointment with the Pope in my town. Are you an existing customer, a patient? Have you seen the doctor before? No? I mean, I assume if I go to my local BMW dealership, they say, you know, if you ever bought a BMW from us before, I'm not sure. Maybe they would with the COVID back. So anyway, well, it looks like he can see you in some point several months ahead. Oh, okay, I don't know where I'll be that day, but I guess I'll be in your office. So several months go by, I go in, very nice young man, he takes a look at it and gives me really the only pertinent information. Nah, it's nothing to worry about, it's no big deal. It's not cancer or anything, but you know, we can take it off. Okay, great, take it off, because that's really simple. Great, take it off. It's no problem, I do this all the time. Great, take it off. Well, I only do that on Thursdays. Take it off now. Take it off, I'm here. No, I only do that on Thursdays. Okay, well, next Thursday, no, no, no. Not next Thursday, folks, Thursdays. In the abstract, so, okay. Few Thursdays go by, I go in. A very nice young man comes in, he's a very nice nurse. They do some stitches, take it out. Great, okay, so that's visit number two. Fine, I'm not unhappy with the quality of care I received. It should have been quicker, but I'm not unhappy. You gotta come back in a week and get the stitches out. Okay, when I come back in a week, I get the stitches out. What strikes me about the whole tiny little nothing experience is that not only were there three visits, but at no point in any of the three visits, at no point did anyone say a price, who would pay, how it would be paid for, how much it would, nothing. It was completely outside of anyone's consideration. So I assume, because he didn't say anything, that whatever goofy plastic card I gave them at the first visit somehow is coded with a bunch of numbers that says little things on your scalp are paid for. That's all I know. But if he had said to me in a world of cash medicine for basic services, if he had said to me, Jeff, this is nothing to worry about, but if you'd like to get it taken off, I can remove it. And I'd say, okay, how much? And if he had said $200, I'd say, you know what, I'm gonna do it. If he had said $2,000, I might have said, I don't, I kinda like it off, but I'll just live with it because you're telling me it's benign. And somewhere in between $200 and $2,000, I probably would have made a decision. You know what I mean? So what are we doing? And how much did it cost? I will never know. I will never know. I know how much my wife and I pay for our monthly premium. I know that. So here's a happier anecdote. Some of you may know the name of Congressman Ron Paul, who's a member of Congress for many, many years, and also a medical doctor before that, an obstetrician, delivered many thousands of babies. So in the 1960s, he was in medical school and was about to start his residency when he was unpleasantly interrupted by a request from the US military to join them to help prosecute the Korean War. But they gave him an option rather than being drafted of enlisting. And because he had already obtained his MD degree at that point, he would be an Air Force flight surgeon rather than whatever the equivalent is. I'm sorry, I don't know what the equivalent of a private is in the Air Force. So he said, okay. So he enlists, he's in the Air Force, he's doing all kinds of things, and he ends up at Kelly Air Force Base, which is now sort of defunct in San Antonio, Texas. So at the Air Force Base, which serves all the Air Force families both on and off base in the ER, he takes on ER shifts, was part of his duties. And occasionally he does extra shifts to make extra money, two bucks an hour to do extra shifts. All the ER doctors himself included did delivered babies. They would do tonsils, they would do appendectomies. There wasn't this heart, this bright line between a surgeon and another kind of that. I mean, this is the Air Force. Someone has to deliver a baby, somebody has an appendix burst, that's just what you did. So he gets out of the Air Force and him and his wife decided that they liked the Texas weather, the Texas climate and that they would stay. So they did a little bit of research, they looked around and they found an area in south Texas, south of Houston where there weren't too many OBs. They said, hey, this looks like a good place. You know, it's underserved. There was an older gentleman who was close to retirement who already had an OB practice. Ron Paul went and talked to him. He said, oh, great, we need more people down here. You know, it'd be great if you'd join me. So Ron joins this gentleman's OB practice. On the first day of Dr. Ron Paul's career as a private doctor, on the first day he had a waiting room full of patients he had no medical school debt and you know what else he didn't have? Malpractice insurance. As imagine today an OB-GYN, not having malpractice insurance. So the entire cost, cash cost of a woman's first appointment visit with him all the way through all the hospitalization treatment and actually delivering the baby. And back then, you know, sometimes women would spend a week in the hospital with a baby. The entire cost throughout that was about $200. Start to finish. And so, like every other OB in the country, he knew that a certain percentage of the women he would see just couldn't pay. They were poor. They didn't have the money. Every OB in the country had a certain percentage of his or her pregnancy, unless maybe they were in some ritzy area. And this was just part of it. You just took care of them anyway. You weren't considered noble or something. This was just sort of like, and then some women would make payments or some women would actually give him other things like that back in the 60s, no people would say like, they'd offer some chicken or something like that. So that's how far we've come. I mean, nobody ever considered this idea that like, well, you don't have insurance. So what are you gonna do when you pray it? I mean, well, you pay. So Ron Paul, unlike doctors today, had a happy medical career and a rewarding one. According to the 2018 Great Americans Physicians Survey, only half of doctors today would recommend the profession of young people, half. And less than half were happy with the direction of the profession. You know what their biggest complaint was? Their biggest complaint was their lack of autonomy, the interference by third parties, whether that's the government or whether that's a centralized insurance company and the corresponding lack of independence. It wasn't how much money they made. But doctors themselves, they think, and who am I to disagree, that they are working harder and harder for less money and also less prestige and respect. There are intangibles behind all this, there's human beings. So I'm sure, I assume most of us in this room, we'd like to live well into our 80s and 90s if we could. And we would prefer that those years be pretty robust and happy and healthy. So anybody with an elderly parent or grandparent though knows that the golden years are full of lots and lots of doctor visits. So who are these doctors going to be who are treating us in these coming decades if we're also fortunate to get into our golden years? Were they gonna be the best and brightest young people? We know already that, you know, the best and brightest young people are already going off to Silicon Valley or Wall Street or Tech. Are they gonna forego some lucrative profession to spend 14 hours a day looking at our, you know, clouded eyes and geriatric feet? Is that what they're gonna wanna do? So who's, especially, who's gonna wanna do this for $150,000 a year as some bossed around employee of some big HMO that's questioning what you do all day, what you prescribe with little autonomy or status? Who's gonna give up their whole 20s to go to medical school when this is what it means to be a doctor? When doctor loses what's left of its prestige, that's what keeps me up. So medicine, obviously, desperately needs to change, but what kinds of changes and decided by whom? That's really the question. And there are people in this room I think you can help drive those changes. So it really depends on which of a couple of competing visions we accept. And we all know that there's one version of medicine, we can call it fiat medicine. And this is the political version. It means fiat means commanded by government through legislative decree. It means that we pass laws and people get healthcare as a result. Just like we pass laws and people get welfare or they get housing and they get education or they get entitlements or any kind of government service. But in this vision, healthcare is somehow truly unique. It's not like any other good or service. It has to be provided by the state or at least mostly by the state with some sort of grudging overlay of nominally private but equally centralized insurance companies and HMOs, nominally private practitioners, nominally private medical schools. And this is basically the system we see in France, for example, where doctors are private but the state sort of determines, pays them and determines what they're paid. Versus the completely, you know, the DMV model of the National Health Service in Britain. And there's plenty of people in America who would love that, by the way. So what this vision says, this fiat version of medicine, it says, well, economics isn't real and incentives don't matter when it comes to medicine and healthcare is not only something that we provide legislatively but we decree it a positive right. You have a right to healthcare services. So what this means is everything becomes political, right? It means how healthcare is provided, by whom, where, when, in what amounts. And even in some cases, whether it's provided at all is all determined politically. It becomes a political question. So in sum, this is what we call the single payer healthcare vision. It's not the reality in the US yet but it might be coming. There's a lot of sport from it. How many times have you heard over the years? You know, the United States is the only advanced Western country without a free healthcare system for its citizens. So the alternative and competing vision that those of us in this room hold is what we can just call market medicine, right? This vision says, hey, economics is real. So we rely on private capital and profit and loss and market discipline and market signals for how we allocate resources, including doctors. So if economics is real, that means incentives matter, the realities of supply and demand just can't be legislated away. So healthcare is not a right but it's something the marketplace delivers and actually delivers better than any centralized government can do it. And just as with private markets for all kinds of things in this world of ours, in this country of ours, it recognized, look, there's a robust role for private charity in helping to care for the poorest and most infirm among us. And that's always been the case in the United States. So where we are is of course, somewhat in between those two ideals, we have a sort of a third way system in the United States. What I guess what we could call it would be, we have a crony medicine in this country. So that's really the current reality. So this sort of combined state medicine but with an ostensibly private insurance systems and a vast overlay of course of Medicare and Medicaid services paid before by taxpayers but performed by private doctors. And of course, restrictive licensing of doctors, of drugs, of devices and all of this has proven hugely susceptible to regulatory capture by our lobbyist friends. So an observer, a Martian coming here might call this corporatism but a cynic might call it fascist. And we don't have any cynics in this room, I don't think. So the point here is this that under all three of these systems have their own touchstones, right? It's their own key aspects. Under a system of political medicine the touchstones become public money and public bureaucracy. That's how things are decided and determined. Under a crony system, the touchstones are lobbying and private bureaucracy. Like your HMO, like whoever paid my bill the other day at the dermatologist. But under a market system, those two touchstones are scarcity and choice. The same two touchstones we talk about all the time in economics. So America has to choose. We have to choose either expressly and consciously or by default, I'm afraid, which one of these three systems is going to prevail. But if we were building a system of aviation in this country we'd probably want to understand gravity and lift so that the plane doesn't crash. And scarcity and choice are sort of the gravity and lift of our healthcare system. So I want to talk about the future and I want to provide a little bit of optimism. What's the future of market medicine if we allow it? And even if we don't allow it, if it works its way through the cracks as it so often does. Well, reality asserts itself just like with airplanes. If the wing gets at a certain angle it loses lift and that fact of life known as gravity causes a very unpleasant situation for the people on the airplane. Well, the same thing is happening and has happened in medicine. So what would medicine look like in a free market? That's one of our questions there, at least a free or a freed market. One where almost all the doctors and nurses and other providers were actually indeed truly private market actors. One where health insurance wasn't mandated by law which of course takes it out of the marketplace instead and where any kind of insurance programs really a la carte plans from the bare bones to the Cadillac plans were actuarial risks and personal habits were actually allowed to influence premiums as they should. And where personal habits were important to know and most importantly where basic care was paid for with cash rather than insurance. Well, we can't know for sure. I mean these things are always changing and the marketplace oftentimes does things we can't predict but I suspect it would look and should look something like this. First, as I mentioned cash for basic services. When I went to the dermatologist the other day it should have been absolutely cash and high deductible catastrophic insurance for serious illness and accidents. That's the model folks. You pay cash and you have a high deductible catastrophic policy that's really cheap especially if you're a 20 something. Those policies used to be dirt cheap when they were allowed. A very healthy market and secondary insurance to cover those high deductibles I think would materialize. I think we would see cheaper and more ubiquitous long-term care policies for all those end of life costs which come up in our later years. And I think we would see as some of our speakers are gonna discuss today I think we would see an absolute bevy of really convenient frontline options for all of these common situations from your kid as a fever to a twisted ankle on the tennis court. Urgent care is the model but think all the convenience, the efficiency and low prices of a competitive cash market. And think about putting all those frontline providers all over in big box stores and pharmacies and strip malls in rural towns without ERs. I think you would see all that flourish. And I think that these frontline centers much like urgent care would actually expand. I think you'd see dental and eye care. I think you'd see expanded capacity for one-stop blood testing, the kind of thing that you now have to make a separate trip to lab core for. You might see diagnostic, radiology and MRI, allergy stuff, metal health services, cosmetic treatments and with all this I hope that ER visits would fall because that's something that most especially government run hospitals would benefit from. And these stores, these store fronts, these market providers are gonna give you very fast or immediate appointments. You're gonna have an app that's gonna let you stay at home until it's time to drive over there rather than sitting around some dismal waiting room. And they're gonna involve telemedicine. I mean telemedicine has already grown exponentially because of COVID but now you know the truth of the matter is there's lots of things that can be done and prescribed just via a Zoom call with your doctor. I think physicians, assistants and nurse practitioners and other kind of non-MD practitioners are gonna play a huge role, a larger and larger role. I think we're gonna see both medically necessary and elective surgery undergo an absolute revolution and transparent pricing with an unbundling of those surgical services, the kind that you see at places like the Oklahoma Surgery Center. And I think furthermore the market is increasingly going to provide a range of surgery experiences from really bare bone clinics for people who are cost sensitive to what we might even think of as a luxury experience in a resort-like setting rather than a kind of an unpleasant experience in a hospital. I think the rehabilitation and sports medicine clinics are going to boom because we're gonna increase and understand that recovery and mobility are not something separate from our health but something part of it. And I'll tell you what, the Europeans especially with their Codex Alimentarius program have really tried to crack down on supplements but folks in America, one thing we really have going for us is that the baby boom generation takes a ton of supplements and the over 65 cohort in America is set to double over the next 30 years. So I think there's gonna be intense political pressure against the further regulation of supplements and alternative treatments. I think the cat is out of the bag with that. So as all of this private market expands, what's gonna reassert itself is elasticity of demand. We're gonna see conscious decision making with respect to the kind of decision making we see today with respect to things like cosmetic surgery and Lasik surgery. We're gonna see people being a lot more rational because they're gonna be using their own dollars and they're gonna actually think about healthcare and the cost rather than just running off to the ER for every last sniffle. And so finally, I think as things become more holistic and more market-based, diet, stress management, your own personal knowledge, your own personal habits are gonna play a much bigger role in the future of medicine because when we have price transparency through Marcus and when we have financial accountability because we gotta pay, it's gonna get people a lot more ownership over their own health and I think that's a good thing. And if anything, what COVID showed us over the last years, the last whatever, 18 months now almost, is that no one's coming to save us. We're on our own here, folks. Life expectancy, quality of life, that's in our own hands and we have to be taking responsibility for that. Doctors and other providers, they're here as our agents to help facilitate this. And so these days, and I see this in my own mom who's very deferential to MDs, but these days of quietly and passively sitting in the exam room and then just accepting whatever the doctor says and sort of dutifully going off when taking the pill they give you, I think those days are over and I think they need to come to an end. So none of this is a fantasy. All of this is happening in ways large and small already. It's not to say that government's not gonna be involved or government's not gonna try to restrain all of this. I don't want to, you know, the pre-market is not gonna create some sort of nirvana in medicine. But if anything, we've got all these insolvent governments at both the federal and state level which are gonna be forced to allow some degree of market discipline to deal with their own internal health care costs and the cost of entitlements. I mean, Social Security, Medicare, Medicaid, these programs aren't just gonna magically go on and on forever. And the FDA is gonna feel a lot of pressure, I think, from a world of, a global world of importable drugs and medical devices that you can go obtain in other countries. So even if we go the wrong way into an outright single payer system and we adopt it, I think we're gonna see a real bifurcation in this country. I mean, people aren't just going to accept this. So all kinds of things that used to be available only to the very rich through deflationary market pressures are gonna be available to all of us. You know, if you're Barbara Streisand, you don't wait three months to see your dermatologist. Right, you just don't do that. And so, you know, as deflation works, it's magic. I think more and more of us are going to be able to have our own concierge doctors and see our own cash clinics whenever we want to. And the beauty in all this, and I'll leave you with this, the beauty in all this is that as cash costs come down, insurance premiums, copays and deductibles are all rising. So the difference between the two narrows every year. And so I think that's a happy thing and a positive thing. And that's really why we're here today. We're here today to talk about that space, that opportunity, that Delta, that even the most rapacious government gives us between cash insurance cost between the state and the market, between the reality of scarcity and the wishful thinking of these bureaucrats who keep telling us we're gonna have free healthcare. And I think each of our speakers today has something very insightful to say about that. So that said, we'll welcome our host and our first speaker today, Joe Mattarisi.