 Good evening. Good evening. Go out for a while. Before we get started, I just want to do some quick introductions. And we have a very quick announcement as well. I am Brayden Vincent. I'm the Vice President of the University of Arizona Objectivist Club. Some of you may be wondering what is an objectivist and what does an objectivist club do? Thanks for asking. Objectivism is actually the philosophy of Ein Rand, the author of Alice Schrag and The Fountainhead and many other books that I don't have time to mention right now. But at its essence, objectivism is the belief that a man's sole moral purpose in life is to seek his own rational self-interest and his own happiness. I forgot what I was going to say. I'm going to pull out my notes for a second. Another central tenet of objectivism is Lazy and Fair Capitalism. That is the only way to preserve individual liberties. And that are necessary to live life according to your own values. Our club is committed to discussing relevant political issues as they apply to objectivist thought. And that's obviously what we're doing here tonight. But this would not have been possible without the help of many, many people. So tonight we would like to thank our co-hosts, the University of Arizona College Republicans and the young Americans for Freedom who have tables out front. They helped us prepare this, get the ball rolling up. We would also like to thank the Ein Rand Institute for their funding and for the resources that we have here tonight. We would also like to thank our debaters, Dr. Joyner, Dr. Brooks and our moderator, Dr. Stegman. And without further ado, I will turn over the mic to our moderator, Dr. Stegman. Thank you. It is my honor to serve as the neutral party here. I will keep the introductions very short. I'm a professor in the Eller College. Dr. Joyner, who will speak first by a coin flip that we had a few minutes ago, is a professor in the Eller College, in the School of Public Health and in the College of Medicine, of course, the most important one, and is the former dean of the College of Medicine. And Dr. Brooks is the president and executive director of the Ein Rand Institute. So the format will be, Dr. Joyner will have an opening statement, then Dr. Brooks. Then I will ask three questions which each person will have a chance to answer. They will alternate who answers first. They have not seen the questions. I have not discussed the questions with them. My goal here as the neutral party is to help everyone through these gentlemen become more informed about this highly complex piece of legislation about which there is great uncertainty about the ultimate outcomes. So after the moderator questions, they will each have a chance to ask the other person a question. Then we will have closing statements, and if brief closing statements, and if we're on schedule, there should be at least half an hour left for your questions. Are we going to, who's looking for my leader? Are the questions going to be collected by cards or are we going to do that by hands? Okay, very good. All right, so that without further ado, I will turn the floor over to Dr. Joyner. Thank you, Mark. Can you hear me? There's been a lot of interest in this debate, and I received a very interesting piece of advice yesterday from a colleague at Tucson Medical Center. I am on. Is that better? Or worse? Let's see how it goes. She was a drama major in college, and she advised me to stay largely away from logic and to focus on emotion. Now, unfortunately, as my ugly wife spoke about, and she's sitting over there, I don't really have an emotional bond going in my body. So I will start with logic and imagine that as the debate unfolds, my emotions will heat up. So I think there's a general consensus probably among almost everybody in this room, and certainly more broadly, that health care reform is needed in the U.S. But opinions vary widely on what should be done, and I think in the absence of clearly elucidating the problem we're trying to fix, it's nearly impossible to have a reasonable debate about the potential solutions. Here's the core problem. The U.S. has extremely poor value for the health care dollars when compared with other developed countries. And comparisons are the only meaningful way to judge the performance of our system. There is no absolute standard that we or any other country can use to judge performance. For example, should the U.S. have an infant mortality rate per 1,000 livers of 5 to 10 to 7.42? On average, in the U.S., we spend either per capita or as a percentage of GDP 2.3 times more than other developed countries on health care. If we've got what we were paying for, we should have by far the best health outcomes. But we don't, not even close, using a range of metrics from infant mortality to life expectancy to outcomes in diabetes, heart disease, and many more, they typically rank towards the bottom. I'm sure some of you are saying to yourselves, wait, we have the best health care system in the world. The simple fact is that we don't. We unquestionably can't provide the most technologically sophisticated care of any nation, but that is neither a direct measure of overall quality or of value within our system. Up until the Affordable Care Act, the U.S. was the only developed country without a mechanism for universal access to care. The 50 million uninsured in the U.S. who have demonstrably poor health and those without, those with insurance are major reason our health care quality lags behind other countries. They also contribute to higher costs. Up to one-seventh of health insurance premiums go to cover the costs for unreimbursed care. When individuals are forced to use the emergency room for their primary care, no one denies it. A common retort is that health care in all other countries is socialized medicine. It supposedly leads to lack of considerable choice, long waits, an overbearing bureaucracy, and more. Put simply, these characterizations are inaccurate, misleading, and oversimplified, as pointed out by study after study. And they ignore the fact that some of the most highly regarded programs in the U.S. by consumers for value, for efficiency, for friendliness are Medicare and the Veterans Administration health care system. In fact, the latter is a classical socialized medicine delivery system. Our health care costs and overall quality are a tremendous drag on our economy. On a global level, they impact our competitiveness. On an individual level, two-thirds of all personal bankruptcies and the majority of home foreclosures are due to medical expenses. We are the only developed country in which either can happen. So what do we do? You will hear tonight an argument that capitalism in the market are the best approach, or at least I assume that's what you're going to hear. But it's not going to come from me. And the government regulation and intervention not only led to the current situation, but are to be opposed to every step. As you can imagine, from what I've said, I could not disagree with one. The market will not and cannot improve the situation in the absence of government intervention. Why is this? It's because health care violates more so than any other industry, basic features required for a market to function. In a well-functioning market, the buyers, in this case health care consumers, have full information about the value and the cost of what they're buying, and hence are able to compare products and services based on price and quality. This process drives meaningful competition, meaningful competition, and increases in efficiency. In health care, consumers can typically judge near the quality of the care they are receiving, nor do they know the total cost of those services. Prices are obvious to you, particularly for inpatient care. It is only when patients receive the bill that they learn of their out-of-pocket costs, which we pointed out are not the total cost of the system. Competition based on either price or quality is largely included. This is not in a functioning market, and it is why government regulations need it. Regulation leads to quality standards for providers, hospitals, and insurers. It helps to control costs. Government services are steward for the health care needs of the entire population. Where does the affordable care act come in? It provides a mechanism for the vast majority of uninsured Americans to obtain coverage and avoid the disastrous consequences of being uninsured. It allows children up to age 26 to stay on their parents' health insurance policy. It guarantees that individuals with pre-existing conditions, such as cancer or heart disease or being a woman, can purchase affordable insurance. Hope the individuals who develop an illness cannot be charged more or have their coverage dropped. Medicaid expansion and the health insurance marketplaces guarantee that individuals previously unable to afford coverage cannot do so. The list goes on and on, and when the public is surveyed, they are in favor of all of these individual changes by two to one margin or more. This is all done with transparency and pricing, and there is no competition among private insurers in the same clear descriptions of benefits and costs. In the absence of regulations, these have not and would not happen. Insurance companies would cherry pick the healthiest consumers and price discriminators without sufficient attention to the ability to pay or to need. They seek to maximize profits, which is exactly what their shareholders expect them to do. We don't have to guess about this. There is overwhelming evidence that it happens. I'm going to presuppose again that Dr. Rope may contend that over-regulation of the insurance industry has created the problem. My response, even the most conservative analysts, of analysts who have looked carefully at the data can do otherwise. More importantly, it doesn't pass the SNP test. The U.S. already spends more than other countries and has worse outcomes. The reasons are multiple, but further unleashing the profit model in the absence of a functioning market will only exacerbate the problem. I have 30 seconds left, and so I wanted to use it to butter up my opponent. I want to say that when I went on the Ayn Rand site and looked at the videos, the thing I was most struck with is they stick to principles. They don't get caught up in minor details. And it's very refreshing to be able to have a discussion about the philosophy and about the principles rather than some of the less helpful and less informative issues that come up in the policy of the politicians. It wouldn't be for me. I was going to compromise right off the bat. This is good because this agreement is pretty fundamental. Not only about Obamacare, but about the causes of the current crisis if there is one, and about what the nature of the crisis actually is. In other words, the efficacy of the American healthcare system as it is today. There are dramatic differences even when it comes to simple factual issues like that. So let me start by asking, you know, what is the problem? And we kind of agree the problem is the cost to seem to be too high. We've got a lot of people uninsured. We've got people with pre-existing conditions who can't get new insurance. We've got this problem of emergency rooms, people going to emergency rooms. That's not the ideal place to treat people for the flu. What wasn't mentioned is a crisis in the making, in my view, in Medicare. Medicare is bankrupt, to put it mildly. If you project costs into the future, it is draining the funding of this country in dramatic fashion. It's probably underfunded by something like $60 trillion. That's not my number, that's the government's number, in terms of future expectations versus future revenues. And Medicaid, which produces very low quality healthcare and very low quality results and is incredibly expensive. And there's bankrupting in the process of bankrupting many states. This is a cost that is being pushed down to the state level. So we've got two massive government programs. Medicaid, no question, provides some of the best healthcare in the world. But at the same time, it's costing a fortune. My view is, all of these, without a doubt, all of these are caused by too much government. Too much government regulation, too much government involvement, too much government purchasing of healthcare. So let's start with this fact, and hopefully this is one fact we can agree on. We don't have free market healthcare in the United States today. The market in healthcare today is heavily regulated. It has elements that are free, but it has heavy, heavy involvement of government. Of every dollar spent on healthcare in the United States, government spends 51 cents. So this is not a market. This is a mix, a lot of government, some private healthcare. And even the private healthcare part of it, the insurance segment of it, is heavily, heavily regulated and controlled. Every one of these things, costs, uninsured, all of these are problems created by this structure. Why healthcare costs high? Well, the answer is pretty simple, right? When the government starts buying hammers, the price of hammers goes up. When people spend other people's money, they don't pay attention to costs. Now what government buys? Prices go up. Look at your tuition. It's not an accident that tuition is going through the roof, as government is intensifying its efforts to subsidize your tuition to give you more and more student loans. This has been growing. The more loans and the cheaper the loans are, guess what will happen? Tuition will go up. Costs always go up when the government starts buying stuff. Go back to kind of military spending and you can see this in spades. Why do we have uninsured? Because insurance policy is expensive. Why are they expensive? They're expensive because they're ridiculously regulated by the states, not the federal government. In this case, the states. In California, I'm 52. I've got two kids of my pure age. I'm done when I have any more kids. But when I buy health insurance today in California, I have to buy pregnancy coverage. I have to buy a whole bunch of coverages that I'm never going to use. Everybody knows I'm never going to use. Now what happens to prices when they cover more than you're going to use? They're going to be much higher because the insurance company doesn't know that we don't plan to have any more kids and they couldn't price that anyway. So prices is if I am. So the uninsured problem is caused by the fact that we have very expensive insurance coverage. We don't have competition insurance. The insurance companies, there are very few insurance companies because very few of them can work with the government. So we have very few of them. We don't have real competition. We don't have real innovation. We've never experienced real insurance markets. On top of that, and this relates to the pre-existing condition, but also the uninsured, the government in this country is getting our health insurance from our employer. Why? We don't get our home insurance from our employer. We don't get our auto insurance from our employer. We don't get our life insurance from our employer. We get them as individuals. If you lose your job, you lose your health care coverage. That's weird. What does your job got to do with your health care insurance? Nothing. Why do we get our health insurance from our employer, not private? Because government has given them a tax advantage. And as an individual, you don't get that tax advantage. This goes back to World War II. Ask me if you're interested in all this. And we can go on and on about how government basically completely regulates and distorts this market. What have we done with Obamacare? What we've done with Obamacare is doubled up. We've said, and this, by the way, is just a general principle in politics, whenever something doesn't work, try more of it. Stimulus doesn't work, it's a bigger one. Minimum wage causes unemployment to rates raises even higher. We can go on and on. It's exactly what we're doing here. We're going to regulate insurance companies even more. We're going to have them require coverage that I don't want, require even more coverage that I don't actually want. We're going to intensify all of this to make it more difficult to destroy more of the market, and ultimately the consequence is going to be exactly the same, raising costs. Now, I can say a lot about socialized medicine, which I have personal experience with. I'll just say this, I completely disagree. Outcomes in the United States are far, far, far better off, and I'll just give you two quick examples. My father's a physician in Israel. Israel has one of the best healthcare systems in the world. It's a Jewish country, so it has lots of doctors. But when my dad had a patient who was really, really sick, and who could afford it, he put him on a plane and he flew into the Mayo Clinic. When Bolasconi, the prime minister, the rich prime minister of Italy gets sick, he doesn't go to France, which according to the UN has the best healthcare system in the world, he comes to the US. There is no question that if you insure it, if you insure it, in that area where we allow some private medicine, we have the best healthcare system in the world. If you take out the factors of lifestyle and other factors and you look at heart disease and cancer, if you have heart disease and cancer, this is the country you want to be in, nowhere else. And again, we can talk about infant mortality and why that happens and life expectancy and so on. But you do not want to be treated in any other healthcare system other than the United States if you have health issues. Now, there's a fundamental here, which we'll get to, I think it'll come up. What Obamacare does and what healthcare generally has become is a massive mechanism to redistribute wealth. Right now, the focus really is on sacrificing you, young and healthy, well, not you, because you get covered by your parents. But once you hit 27, you will be sacrificed for the sick and old. Generally, we don't have insurance anymore. We have a massive system of redistribution of wealth from young and healthy to sick and old. Now, I believe that is immoral. I believe that's wrong. I think you guys should be out in the streets demonstrating against it because it's going to screw your lives. And I'm out of it. We're going to ask that we hold applause until the end so that we don't get into an applause competition. And that will also... It's good. We're known about a market and applause here, so lacking a market will suppress it until the end. But the after-closing speeches might be a good time. So according to our preset plan, the first question will go first to Dr. Brooke. And my question is, the legislative process that created the Affordable Healthcare Act was messy with many powerful interest groups trying to affect the final legislation. Looking at the law that finally emerged from that process, who are the winners and the losers? Wow. I think almost everybody's a loser. I think there are very few winners. Insurance companies are winners in the short term. They get massive subsidies. They get supposedly... If everybody signs up, they get new entrants. So in the short term, they're winners. But in the long term, there will be no insurance companies in the U.S. I mean, Obamacare is just a stepping stone towards universal healthcare and towards the complete socialization of medicine. It was never meant to work. The idea that Obamacare was meant to work, in my view, is ridiculous. It's set up to fail, and the failure will then lead to universal healthcare. Patients, you guys who are young are particularly screwed. I think if you have pre-existing conditions and you're in your 50s, you're better off. You're worse off because you have less freedom, but you're better off because your healthcare is taking care of, I guess, because you guys are going to be paying for it. So I think it's primarily those who are with pre-existing conditions who are older, who are in the short term better off. But long term, nobody is. Because long term, what the system leads to what all socialized medicine leads to is rationing. It leads to government controls over procedures. It leads to a complete disappearance of innovation, of real competition, of trying new things. It's not an accident that over 75% of all medical innovation happens in the United States. And we're trying to kill that. And the whole world will suffer because they free right off of us all the time. They free right off of our drugs. They free right off of our medical devices. They free right off of our new procedures. We develop them. We pay the cost for them, and they get them basically for free. So long term, everybody loses. Short term, they are here and they're winners. But let me just say, this sausage process of creating legislation, this is the problem. This is why health care shouldn't be, government should have no involvement in health care. Because the whole issue gets decided by pressure groups, by who gets what. I mean, the discussions now about, this business lobby and that business lobby, lobbying for this, lobbying for that, extend this, give us this favor. It's not designed to be the best, because it can't be. Because it's designed by, because it's about redistribution, it's designed by all kinds of pressure groups who want to make sure that they get stuff and don't have to pay for stuff. So it becomes a battle of these forces that are fighting each other. And this is the nature of economic legislation out there. What it resulted is a disaster. It usually leads to more problems, not to solutions. And, again, in the marketplace, you don't get this. In the marketplace, you get real competition. What you get is a process by which innovation, coverage innovation is successful. And where people have an opportunity to ensure themselves, maybe to self-insure themselves, to make decisions about how to use their money for the furtherance of their lives to the best of their ability. Well, so, first of all, let me start off by saying that this debate is supposed to be about the Affordable Care Act. And a lot of what Yaron was talking about was not part of the Affordable Care Act. And specifically, that's cost control. So I think one of the ways that benefit will ultimately come about through the Affordable Care Act is through cost control, not only through some of the mechanisms that I didn't mention, but that are in the Act. Now, why wasn't there more cost control in the Act? Because everybody loses when there's cost control. The doctors lose, the insurance lose, the medical device manufacturers lose, the pharmaceutical companies lose, and the consumers lose if what it means is that you have to bear more of the cost. Here's the other reason why there wasn't more cost control. It has been very difficult, if not impossible, to control Medicare costs because seniors push back against any notion that they're going to have a cut in benefits. So the legislature over and over and over overrides the recommendations of a group called MedPAC, which says that the cost should be controlled. I think that everybody is going to benefit in terms of the transparency and pricing. It will become more possible to have a true market. I don't agree, as you could tell, with the notion that we really have a market here, and I think I made that as clear as I could. And then I think the biggest winners are those who are uninsured or underinsured. That's a lot of people, and it is devastating to these people. The health insurance, the Affordable Care Act is fundamentally an insurance act. That's what it is. The Obama administration wanted to put more cost controls in. They were stymied at every point by the legislature, which I'm not saying is right or wrong. It's just that's not what the Affordable Care Act is about. I agree we spend too much, but there are other approaches that have to be brought to bear to control the cost. I think the Affordable Care Act is a first step. I didn't talk about what some of the mechanisms are, but we might get into that. I just have to respond to this comment about international comparison. That's not what the data says. It's just is not what the data says. Patients with heart disease, diabetes, respiratory disease do worse here than age-matched, gender-matched, income-matched individuals in other countries. They just do. That's what the data says. Anybody who wants to look at a report, I encourage you to look at the Institute of Medicine report that came out within the last year. Institute of Medicine is the most prestigious body of physicians in the United States. My wife happens to be a member of it. There's only about 500 members. They are basically acknowledging just what I said. The second question will be answered first by Dr. Joyner by prior agreement. All of the other industrialized countries have systems where everybody effectively has health insurance. That doesn't mean we should do that, but that's an observation of how those countries run their systems. In this country, there are certain markets, notably the car insurance market, where the government requires drivers to have car insurance. Again, that doesn't imply that we should do that with health insurance. There is, I think, a fundamental philosophical question underneath your different responses so far in your opening remarks. I'd like you to address this fundamental question rather than the details of the Affordable Care Act. The question is, in a well-designed healthcare system, should people have the option of whether or not to have health insurance? We first Dr. Joyner and then Dr. Joyner. Well, I would say, yes, they should have that option if they also take accountability for the costs associated with any illness that they acquire. That's the fundamental problem with not having insurance and needing care. Basically, what's happening is that the costs that are being borne by the system get passed on to other people. And that healthcare is something that we know everybody will need. That's one of the... Is there a... Is there something going on here? Unlike even car insurance, not everybody drives it, but everybody is going to need healthcare. And again, I don't think one should be forced to buy health insurance, but by the same token, to imagine that you don't need to buy health insurance and then the costs for that and the societal complications and economic consequences are going to be passed on to others, I think is a real problem. That's why, among other reasons, why every other developed country has a way to provide coverage for the entire population and there's multiple different ways to do it. One looks across the spectrum in other countries and it's not socialized medicine, even close to it, using the conventional definition. In fact, there's far less government involvement in many of the countries in Europe than there is in the United States, far less. Only 10% or so of the spending in Germany, France comes directly from the government. It comes from employees and employers. So I think that when I've traveled to Europe and I'm not suggesting this is necessarily the attitude that we have in the United States, in fact it's not the attitude. They just cannot understand how we could have a society where we don't provide healthcare coverage, just beyond imagination. I think it's because they view this as something that, if not a basic human right, is something that people will always need to access and that they can't predict what it's going to be. There's uncertainty associated with healthcare and the way to deal with that is insurance. This really goes to the heart of the philosophical difference, I think. I don't think society has obligations towards people. Society is not responsible for you. You are responsible for yourself. Society shouldn't dictate whether you have health insurance or not. Now, as a consequence, you should bear the cost if you get sick and you don't have those insurance. You should bear the cost. And there's only two ways in which if you can't bear those costs, you can get, if you will, health services. Let's say your neighbor is sick and he can't afford to get the treatment. He doesn't have the money and you live in my kind of world, right? Where if you don't have health insurance, you're not going to get treatment. He has two options. He can come to me or to anybody and ask for help. And I might help him. I think people generally are generous. There's lots of charity in the world. And I might not. It might be time to pay that tuition bill for my kids, right? And I don't have the money to help. That's option one. His second option is to pull out a gun and take my money. Those are the only two options. There are no other options. What we are saying, losing my voice, what we are saying is that if you get the community together and they vote to take my money, then it's okay. Because when we say everybody has to have insurance, well, who's going to pay for that insurance? Well, we are. How are we going to pay? Well, it's going to be forced from us by the point of a gun. Try not paying your taxes. So, you can either ask for help through charity or you can steal their money. Democracy allows you to vote to steal some people's money and give it to others. That to me is morally wrong, morally offensive. My money is my money. You want my help, ask for it. I'm not obliged to help you morally. I'm not obliged to help you legally. But you certainly have no right to steal my money. It doesn't matter how sick you are. It doesn't give you a right to my stuff. It doesn't give you a right to my stuff. That's the fundamental moral question. Does any group, because they have a need, does that need give them a right to take from others? Does the fact that they are today, five-year-olds who are uninsured give them a right to your stuff? Because you're going to have to pay higher premiums under Obamacare so that they can pay lower premiums so that we can redistribute well from you to them. Why? Why shouldn't you have the right, the ability to make decisions about how to use your money? What kind of choices to make with how to spend the hard-earned dollars that you will make when you go out there and work? You guys love choice, right? You love choice when it comes to who to marry? You love choice? What, to smoke? Why don't you want choice about how to use your money? I did have some prepared questions, but given how the debate has gone, I'm going to go a little bit off agenda and the third question I'm actually going to ask two, I hope, shorter questions. So the first question, two-part question, the first question is very specific. Right now, federal legislation, federal law requires that an emergency room admit someone for care, regardless of their insurance status. Should that law be eliminated? No, I've got your problem. Should that law be eliminated? Should people continue to have the right to show up at an emergency room or should the emergency room be able to say no? The second question is, it will clearly take time to fully assess the effects of the Affordable Care Act. In the end, what measures should we use to determine, objectively, whether it is a success or failure, compared to the status quo that existed before the act? So, emergency rooms, what's interesting about this is by law, emergency rooms are required to treat anybody who walks in, but this is a relatively new law. In 1986, under the Reagan administration, I believe in repealing that law. Yes, I believe emergency rooms should have the option to turn people away. Certainly if you have the snivels, you should be allowed to be turned away. Or if you can't pay for something that's not urgent. But the fact is, pre-1986, it was unheard of that an emergency room would turn somebody away for a life-threatening disease. Every hospital had a charity fund in those cases where they had to treat them where it was life or death. But if it's not life or death, yeah, if you can't pay for it, you shouldn't get it. If I can't pay for food, you're up for charity to go get food. You don't ever wait to take mine. How do you measure success or failure? I mean, to me, the measures of success or failure at the end of the day measures of freedom, of individual liberty. I mean, how free are we at the end of the day? In terms of the choices we have, in terms of the options that are available to us. And I'm not just talking about freedom of the consumer, but freedom of the producers as well. A doctor's fear, a nurse's fear, medical device manufacturers, drug companies, freer once Obamacare is implemented or before Obamacare. I mean, we all know the answer to this. There are a lot less free under Obamacare. And therefore, I've already declared a failure by that standard. To me, the standard is individual liberty. It's not a consequentialist. It's not how many people are healthier over the cost or any of these other issues. Although I believe strongly, and I think there's plenty of strong evidence, that freedom leads to the good consequences. Prices go down when you have competition and when you have freedom and when you have liberty. You know, LASIK, which is not covered by any insurance policy, technology has improved dramatically over the years. Guess what's happened to costs? Gone down. Just because government is not involved in LASIK other than approving their technology, they leave it alone. They don't regulate it. They don't control insurance companies and so on. And you look at very similar phenomena in what do you call it? Pet medicine. Veterinary medicine. Very similar phenomena. Prices go down. Competition does that. So I believe strongly that when you allow for liberty of the individual, you get the right outcomes as well. Because Obamacare violates the principles of liberty, the principles of choice, the principles of freedom, it is already a failure and nothing that it can achieve will change that. So let's just say that unfortunately one of you on your way home tonight is hit by a drunk driver in your car and let's just say you don't have health insurance and you show up in the emergency room. By Euron's argument, he says if it's not life or death, then the emergency room shouldn't see it. Well, as a physician, I would like to say making that determination in some sort of clean way is impossible. It's impossible. There's a grazo. And I won't sort of give examples, but I could easily give examples. So I think to imagine that people shouldn't be able to get care in an emergency room if they don't have insurance because you can somehow discriminate people who need it from somehow those who don't is a fallacy. Of course, I completely agree that it doesn't make sense to use the emergency room for primary care. That's why the Affordable Care Act is such a good idea. It's exactly what happened in Massachusetts when they adopted Romney care, which as you understand, I suspect, was the template for the Affordable Care Act. Emergency department use has gone down. Quality has gone up. Costs are going through the growth and I, again, that's not the debate as far as I'm concerned here because that's not what the Affordable Care Act is about. Now, I have to comment on the LASIK example. I thought maybe this was coming. That's not what health insurance is supposed to be about, not for something like LASIK, which is a completely elected procedure where there's not uncertainty about whether you're going to get the procedure or not whether you're going to get sick or not. That's exactly the sort of circumstance that insurance shouldn't cover. It shouldn't cover cosmetic surgery. And it doesn't for the very reasons that that's not what insurance is for. Insurance is for uncertain events. Uncertain events like getting hit by a car. Uncertain events like, I'll bring this up now, it's just unimaginable to me that people should be held accountable for their health-related problems that are genetic in origin. If a woman has the BRCA-1 and BRCA-2 gene mutations, like Angelina Jolie has, she has a 90% chance of getting breast cancer. Well, is it reasonable to think that she shouldn't be able to, she should have to pay for it because she had a genetic predisposition that came from her parents? By the logic I'm hearing here, she should have chosen different parents. All right, we'll keep the audience in action for later. And you will have a chance to direct questions to the speakers. We're now in the phase where each can ask one question to the other and then we'll move to closing statements. So by the original plan, Dr. Brooke has a chance to ask Dr. Joyner a question with a two-minute response and then likewise. So I'm just, I'm curious about your view on the redistributive impact of all of these, of Obamacare and really all social issues and how morally, if we can shift to it, do you view that as justified? That's the question. I think it's completely wrong. I think it's completely justified for society to look out after the health of their citizens. I think that's what a society should do and government is the way that that's accomplished in conjunction hopefully with the private sector. One of the problems with the Affordable Care Act in terms of implementation is that it is an attempt to integrate government and private industry and that just doesn't work very well and we both agree upon that. So, you know, you can make the argument while you privatize it all and I clearly don't think that's a good idea but you could also make the argument that you have a single-payer system and I'm not going to say that's the right idea or the wrong idea but if you sit in the middle you are going to have problems. The Affordable Care Act was constructed based on the notion that we wanted to keep our employer-sponsored insurance process the same and I disagree about why we started down that path and I'm wandering a little off the topic but the reason why employer-sponsored insurance was adopted in the United States is that wage and price caps were put on place during World War II for industries and in order to attract employees they gave additional benefits and then we followed something called path dependence where we just kept modifying that system. I agree it doesn't make sense, it doesn't make sense but it is the system we've had and we tried to stay with it through the Affordable Care Act. You know, if we had to start all over again we wouldn't do it that way but we're not starting all over again in this country any more than any other country is because we're too far down the path. I'd like to hear another description of how insurance regulation is responsible for, let's just say, higher costs because I can't connect those dots and neither can the analysts that I've read including Chris Conover from the Cato Institute which is one of the most conservative sort of think tanks there is. I mean the data that I see and the data that I read about doesn't connect insurance regulation to higher costs. Well, I'd suggest reading Ken and again because I don't think that's the conclusion it comes to but I'd suggest reading John Cochran from University of Chicago who's done a lot of work on healthcare pricing and how a market would look like if it was truly privatized and I think he would agree. I think the number of ways in which any time you, so for example I gave the one example of mandates mandates clearly raise the cost if you added to a auto insurance that they will require to pay for oil changes if they will require to pay for every scratch whether you the consumer wanted that coverage or not then auto insurance prices would go up because they would have a much broader spectrum in which to cover. There's another sense in which and this goes back to the tax advantage because employers buy insurance there's less competition they're far more of these employer groups and therefore they're far fewer products the products that insurance companies devise are devised for these group policies rather than individual policies, individual needs which would generate a lot more competition and ultimately lower prices. But regulations generally you go industry after industry after industry, whenever you have regulations and if you go to places like California or New York where you have heavy regulations prices are higher. So for example in New York where you've got imposed guarantees costs are through the roof in New York and indeed Obamacare is actually reducing the costs for New Yorkers. In New York you're actually under Obamacare to get cheaper health insurance because it was so heavily regulated before there's actually a reduction in a sense of regulation. Regulation always raises the cost of doing business because it constrains competition it constrains, it allows the insurance companies to control the markets. This happens in every single industry. Now each speaker has a chance to make a three minute closing statement and according to the original plan the first opportunity goes to Dr. Joyner then Dr. Brook will make the final statement and after these closing statements I think applause would be appropriate if you wish to do so and then after that we will go to audience questions. Well I'm going to return to the basic point I made in my introductory statements and that is that healthcare doesn't operate like a market and I'm just going to reiterate that there's too much uncertainty there's a no understanding at any sort of appropriate level at any meaningful level of what quality of care means you know whether you get better or worse that may or may not be related to the care you get because in general consumers it's information asymmetry but worse the costs are obscured and the costs are obscured in part if not in large part because of the profit motive the costs are not obscured with Medicare but the costs are absolutely obscured frequently with private insurance and one of the things that that has done is to drive prices through the roof the prices of our services in the United States are three to four times those what they are in other developed countries our costs are not higher because we utilize more services in fact we utilize less people go to the doctor less they have fewer hospitalizations they have shorter hospital stays we have fewer physicians so in terms of utilization we are lower than most other developed countries but our prices are three to four times as high why is that? because there's no price transparency if there's price transparency then you have competition and the absence of price transparency you can't possibly have competition because nobody knows what the price is nobody knows what the cost is I just want to come back to this issue of insurance and the problem that one gets into with insurance if you don't price it appropriately with redistribution and that is a well known concept called adverse selection and this is crystal clear that this happens in healthcare and in the health insurance part do you have a group of individuals who have insurance and they're paying approximately the same amount of premiums but some of them are healthier some of them are sicker the ones that are healthier are going to drop out of the insurance pool that raises the cost for those who are insured and are sicker this leads to what's called the death spiral and it unravels very quickly there's all sorts of evidence for this and you just can't have a situation that functions where insurance companies are setting prices where they can charge people who are sicker more and have a functioning system so let me try to make two quick points of course healthcare can operate as a market yes there are massive asymmetries of information that's what markets afford to solve those problems and the problem is a lack of imagination I can think of ten different ways in which the profit motive could lead to closing those asymmetries of information we don't see it today because we have no market the adverse selection problem exists absolutely but it is solved by markets when they are free to function properly you don't get death spirals you actually get healthy markets that produce products that consumers actually desire price visibility is a consequence of consumers demanding that if you create a system like we have today where consumers have no incentive to demand that of course there's no price transparency markets are the way to get all of these things but I want to step back a moment and I'll get caught up in economics and make this one point we have a fundamentally different vision of what society should be like and its function should be I believe that government is there to do one thing and one thing only the role of government is to eliminate coercion from human life it's to allow us to be free it's to allow us to pursue our happiness to allow us to pursue our lives to make choices that we see fit make mistaken choices make good choices, all kinds of choices but government is there to protect us from the crooks, the fars, the gangsters the terrorists, the found invaders but other than that to leave us alone to let us pursue our lives to let us make choices to let us use our minds to engage with reality to find the best path for each one of us and there are going to be different paths to achieve our happiness by pursuit of rational values government is not there to be unannied government is not there to protect us from ourselves it's not there to protect us from the marketplace that's our responsibility to live the best lives that we can live when government tries to do all those things the only way it can do those things is by limiting our liberty limiting our options reduce our ability to pursue our life, liberty and happiness and that is the tragedy of America today and the tragedy of our healthcare and the rest of the country are hitting thank you