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These truths to be self-evident, that all men are created over the years as a member of Congress, I get to have a lot of really interesting people in the office, experts on what they're talking about. This is the podcast for insights into the issues. China, bioterrorism, Medicare for all in depth discussions, breaking it down into simple terms. We we hope we hold these truths. We hold these truths with Dan Crenshaw, Florida.

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Welcome back, everybody. We're back with Avik Roy. Now, if you remember the last time I called him Avik Roy, but that's not my fault because he spells his name Avi Ike. OK, but we just I was just corrected on that, which is also my Twitter handle.

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So, yeah, AFIK is what you should find if you want to follow me. Not Auvi-Q.

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Right. But it's pronounced Auvi-Q. Yep. So there you go. What is the origin of that name. Where's that from. Bangali.

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It's OK. It's the name of a hero from an ancient Bengali epic or something. At least that's what my parents told me.

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That's cool. I like that I might my name. Well, I guess it's from the Bible, Daniel. Other than that, yes.

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There's also a story to it. Yes, yes. Yes, I suppose. Yeah. And let's just remind everybody, you're the president and founder of the Foundation for Research on Equal Opportunity. And and your specialty is is is mostly health care. Is there any other subjects that you in particular dive into quite a bit? Are you still mostly in health care? Health care is the main one.

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I do a little bit of work on the broader issue of social mobility and lifting people out of the bottom. You know, the bottom parts of the economic ladder. I do a bunch of work on issues of pluralism. So how how America American tradition can be renewed by immigrants and by the diversification of America over time and to do some work on financial services reform. When I worked for Rick Perry back in the day, we did a lot of work on how to end Wall Street bailouts and make sure that we have a financial system that works for everybody.

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OK. I would love to get into all of those, but as I promised the listeners last time, we want to do health care centric conversation, obviously consistently among the number one issues for Americans. And the last time on the show we talked about, you know, what would be a more rational response to a pandemic, what would have been a more rational response to covid-19, where we at? How do we compare with the rest of the world?

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And so should we reopen schools? And if you didn't if you missed that episode, obviously you should download it right now and also give it five stars. Still haven't figured out what stars do for me on a podcast, but it seems like a good indication of whether your podcast is good or not. So give it five stars.

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But but you also you know, before the pandemic, you were you wrote a lot about health care policy, in particular Medicaid. You have a book called How Medicaid Fills the Poor. Another one called Affordable Health Care for Every Generation, a patient centered plan for universal coverage and and and permanent fiscal solvency. So, you know, this is really important. And it's as a Republican, this is something that it's important to me to help people understand. It's not about whether or not we want everybody to have some kind of access to health care.

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It's about how to do it. And, you know, we've sort of ceded that ground to the left like, oh, they're the ones who want health care for people and we're the ones who don't. Well, that's not really true. It's not true at all, actually, but we haven't done a good job of explaining that at all.

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So. Let's let's let's separate this conversation into two subjects here, Medicaid, how to make Medicaid better and and then then the conversation about what would be a better patient centered plan for universal coverage and how would that work while maintaining the foundations of our innovative health care system, all the good parts of it, while also making it more accessible to people. But starting with Medicaid, I mean, let me just let me just start the conversation with Texas, because the Texas gets a lot of heat for not expanding Medicaid under the ACA.

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Now, as we all know, Obamacare was basically fundamentally just an expansion of Medicaid.

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I don't know if you'd agree with that or not, but it kind of seems that way, you know, created these exchanges, of course. But but that that that accounts for a very small percentage of the increase in insurance. It's mostly Medicaid expansion in Texas refused to do it. So why would Texas, from a policy perspective, why would Texas refuse to do that? And is it a good idea or a bad idea? Well, I think you have to step back and first ask yourself what should be our policy goal, like what should we be actually be trying to achieve when it comes to health care policy and health care reform?

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And what I would say and here's here's a way to draw it that's different from the left and different from some voices on the right.

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You don't there's a conflation in people's minds between universal coverage and a government run single payer system. This is what you were alluding to a little bit earlier right here.

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People say, well, every other country has single payer health care and universal coverage and we should be like that. Well, that's not actually true. Some countries have single payer. Canada has a single payer system where the only insurance company is the government. But there are a number of other of other countries that have achieved universal coverage through private insurers.

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That's what Switzerland has done. That's what the Netherlands has done. That's what Germany has done. For example, I could go on. But the point is there are a lot of countries out there that have achieved universal coverage through private insurance, not through government run insurance.

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And this is where, in a sense, the debate we have in America is wrong on both fronts. There are people on the right who say, well, if we if we try to achieve universal coverage, then we're conceding something that somehow this is a left wing idea. No, it's not. We would never say as conservatives that for every American to have a job, you need the government to take over the economy. We would never say for every American to have a smartphone, the government needs to take over the smartphone economy.

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Right. So we should also understand that for every American to have affordable health insurance, it's competition in an innovation and choice that's going to lead to affordable, high quality health insurance for every American.

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So that's the most important set of priors, I think, before you even dive into the Medicaid conversation, because then when you get to the Medicaid conversation, the point is, is that the only way to ensure that every American has affordable health insurance and health care?

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And if you've talked to people who are passionate partisans of Medicaid, that's what they argue, that it's either Medicaid or nothing, either people will die in the streets or you have to expand this broken program in which health outcomes are no better than people, those of people who actually have no insurance.

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Yeah, that's exactly right. And an even better analogy would be food.

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You know, like you're never going to get me to say, well, I can't get food, can't get food. Like, no, of course we don't say that.

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But but we also don't undermine the foundations of food production and choice and competition, like you said, have a government takeover just because we decided that food is a right. You know, I don't like it when they use the word rights. I think they're misusing that word. That's a very loaded word, means something. And it doesn't mean a service that's delivered by somebody else. But it also doesn't mean that just because we disagree on the use of the term right, as in health care is a right or our food is a right.

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It doesn't mean that we disagree that people should have it because obviously we think everybody should have food. And if people are starving, well, we're going to do something about that. Or, you know, and I think the same is true for health care. But we need we need to have that conversation, which is why Medicaid exists in the first place, because we do believe that if you're too poor to to have some kind of health insurance, we ought to have a safety net for you.

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But then again, the question is, OK, so what's the best kind of safety net? And so, OK, so we'll find out. I won't make you answer my my question about Texas yet, but we'll get to it. So then what is the better alternative to something like Medicaid that that is bloated? And I think you've noted in your research does not have the outcomes that we would wish it had either. Well, the solution is, is that everyone should have the same opportunity to buy private health insurance coverage of their choice, not coverage that's chosen for them by either the government or their employer.

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They should be able to choose their own health insurance, just like we all choose car insurance or we all choose other forms of insurance.

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And yes, we should subsidize the cost of that insurance for people who otherwise couldn't afford it. That's what Friedrich Hayek believed. That's what Ronald Reagan believed. And that's what conservatives should believe and many do believe.

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So very simple, like premium support plan, basically. Yeah, basically, it's basically a system in which and this is what Switzerland does.

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So in Switzerland, everyone shops for their own coverage. There are no public options. It's all private insurance. Private insurers compete in every district in town in Switzerland. And basically, if you're really poor, the government will subsidize either all or some of the cost of that premium and that the amount of financial assistance you get phases out as your income goes up. And that way you basically make sure that people who are really vulnerable, really poor, really disabled or sick get the coverage they need.

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But that healthy and upper income people are not subsidies. What we do today is that you and I pay income taxes so that Warren Buffett and Mitt Romney and Hillary Clinton can have government subsidized insurance, even though each of them is worth hundreds of billions and hundreds of millions, if not billions of dollars, which is totally insane. That is totally insane.

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So so, I mean, put simply, you'd probably I'm pretty sure you're in favor of health savings accounts. And so let's let's define what those are real quick.

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It's ideally it would mean just like everybody has a Social Security number, you'd also have a health savings account and you can put money into that account. And it's it's tax deductible and that account exists. And so if you're below a certain income level, you would just inject money into it and then let the person buy their health care and buy their insurance.

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And this is what Singapore does. So Singapore has a system in which there's actually single payer catastrophic coverage.

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But anything short of that really high deductible catastrophic coverage, you get hit by a bus, you have cancer, you have a stroke, anything below that is funded through a health savings account that you control.

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And for lower income people, that health savings account is topped up through their basically their equivalent of the Social Security system. Right.

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And and that system works incredibly well. And here's the key point. And this is something it's really important for people to understand.

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The US government, state, federal, local, combined, including Medicaid, we subsidize per capita.

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We spend more money subsidizing health care per capita in the US than any other country in the world.

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And yet we still have tens of millions of people who are uninsured. That shows you how profoundly inefficiently we're assisting the people who truly need the help and how much we're over subsidizing people who don't need the help.

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It's kind of infuriating. So I often talk about health care. I think we should fight it into three categories. And I didn't realize that Singapore's model was exactly like that. But that's sort of what I would suggest, which is primary care, regular insurance, and then the catastrophic insurance. Those seem like the right three categories to separated into.

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And then we and I guess Obamacare attempted to lump in all three. And that just doesn't seem to work because the catastrophic care and the catastrophic illness or injury, you know, that maybe requires years and years worth of care. It just makes the regular insurance way too expensive. And so, you know, you make that a single payer and then the question becomes, OK, how do you do that? Is it through a risk pool? Is it through a reinsurance program?

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I mean, kind of, you know, choose whatever works best, I suppose. Do you have a suggestion on that, by the way? Yeah, so, you know, one of the ways we sort of bumper sticker are our, as we call it, Medicare Advantage for all, because there are ways to basically either ways to take our existing system.

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The Singaporean system is really great. The problem is taking the system we have and turning it or migrating it into the Singaporean system. It's too hard. There are too many things that have to change.

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Too many special interests will block it. But something along the German or Swiss model is much more realistic. And what does that involve? That involves kind of like what you said, basically having a back end subsidy that protects people from those really, really catastrophic situations, especially if they're low income. It doesn't really it's not important, as I said, to subsidize higher income people. But if you subsidize really the vulnerable populations of lower income populations, even the middle class to some degree, but you unsubsidized the upper middle class, the wealthy, and you particularly emphasize that catastrophic type of insurance through that.

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And then you do the same. You maximize the ability of people to shop for care where it's appropriate to do so. You put all that together and you give people choice of insurance, too.

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That's really important because for the average person who gets insurance through their job, 80 cents out of every dollar of their health care consumption is paid for by the insurance. So if you have an HSA that covers the 20 cents but your instr insurance still covers the 80 cents, then you have only made incremental progress.

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So it's really, really important to make sure that people who get insurance through their jobs, people who get insurance from the government, that they have the same choices to choose their own plan and not just get the plan that's handed to them by their employer because their employers interests are different from theirs.

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Their employer is more about, well, this is all a tax break for me, so I'm just going to get the most generous plan I can, even if it's not what my workers actually want, because then I can try to keep them attached to my company, not leave to go somewhere else. So the employer is thinking about this in a completely different way than a wage earner who says, you know what, let me choose the plan that's best for me and let me take the savings and put that back in my paycheck.

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Yeah, you'd see wages increase to. Exactly naturally you would. The reason I bring up the three categories, two is one. One I like one because I love direct primary care. I think that's what that's what should be normalized in the U.S. And so we're talking about a seventy five bucks a month type of thing. Again, if you're poor, we could just inject that into an HSA and, you know, subsidize it that way. And then you can go to your direct primary care app and choose your direct primary care doctor.

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And I think it's the best system. And I want to see it expanded working on legislation to do just that.

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Then you get into insurance, OK, because that doesn't because that doesn't fix the broken leg. Your primary care doctor can't do that because because direct primary care is not insurance. It's a list of services. It's your basic checkups. It's maybe some blood work. You know, it's a great system, but it's not insurance. And so you break a leg, you need insurance, OK, but once your leg is healed, you know, you're good.

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It's not cancer. But if you get cancer, you know, you could be talking about millions of dollars worth. And and this is and this is where it gets to a point where, OK, should we separate that out from regular insurance? Because if it's if that's if that catastrophic care is within regular insurance, it drives up everybody's premiums, as this is why healthy people won't even buy into it because they're like it's just not worth it, you know?

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And so so it doesn't matter even if Warren Buffett. You know, he's still paying those insurance premiums, even if it weren't subsidized, but he needs cancer treatment. It doesn't matter who is taking it, that's still millions of dollars at the insurance company is paying. And then they they they spread those costs amongst their premiums. And so the question is, is like at a certain point, can you just take them out of the out of the risk pool?

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And, you know, and then the question is, how do you do that? And it sounds like Singapore just says, hey, at a certain point of catastrophic coverage, when it gets too expensive, that becomes, you know, I guess single payer. And they're in there and their system. And in some states here in the US, they use reinsurance programs before Obamacare. States are moving to risk pools as a way to subsidize that. But is that the right sort of move?

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Is that the right kind of logic?

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Yeah, I actually like the reinsurance approach and in a health reform bill that's based on a lot of our ideas from one of your colleagues, Bruce Westerman, it's called the Fair Care Act.

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That's the idea that that that particular bill deployers, which is you use reinsurance to the way to explain reinsurance to to your listeners, is it's basically a lot like high risk pools, but it's integrated. So in a high risk pool, in the in the old way, what the way it worked was if you had a pre-existing condition, if you were really sick, you had diabetes or cancer or something, you were supposed to basically enroll in a completely separate health insurance program for people who had really serious pre-existing conditions.

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That's one way to do it.

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But I can see a lot of problems with that. But yeah. Yeah, because there are a lot of problems because like, first of all, you may not you may be eligible for that, not know it, or the funding may run out and you just basically get left locked out of the system and insurance companies have an incentive to push people into it.

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Exactly right.

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So the virtue of reinsurance or reinsurance is basically the sophisticated version of a high risk pool or high risk pool 2.0, you can call it, where it's integrated.

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So you enroll for insurance the same way you would. Regardless, you don't have to sign up for a different program. You sign up for insurance just like everybody else. And on the back end, in a sense, behind the user interface, the insurers and the government or whoever is funding the reinsurance program negotiate back and forth as to which patients are going to be in the reinsurance pool, the high risk pool, versus the normal insured population. And that ends up being economically a much more effective and efficient way to do it.

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That maximizes the utility of those taxpayer dollars to go to the people who need it but not wasting money. So the reinsurance approach is a much better way of doing what high risk pools were trying to do.

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And it's much more, in a sense, efficient than even the Singaporean system for for various reasons that that I can bore you with if you're really interested. Yeah, I think I am so, so, so, so the challenge of a single payer catastrophic system versus a reinsurance system is there's no market dynamic, right?

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So you have the government running the entire thing, which can have certain advantages from a fiscal standpoint because of the governments running the whole thing. And the government is the buyer. And the government says, well, you know, you can't gouge us on the price. We're going to decide what the price is. Right. That's a plus in a sense. The minuses, of course, if the government's dictating all the prices, there's there's potentially a lot less room for innovation because there's no dynamic price that an entrepreneur can come in and say, hey, I'm going to deliver this.

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I'm going to treat cancer more efficiently than my rivals and thereby capture a lot of incentives as a result of doing that. It's a lot harder to do that in a single payer system where people basically have no incentive to be more price efficient because you get paid the same from the government regardless.

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So you want to have some room for that innovation. And the reinsurance system, in my view, captures the best of of universal catastrophic coverage, but in a more market driven, dynamic approach where people can choose their coverage and there is room for entrepreneurs to make the system even better. Right.

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And this is part of the dishonesty of the debate with Medicare for all, is they conveniently leave out the tradeoffs that you're making. You know, they make it seem like if Republicans were just nice people, they would be for Medicare for all. Well, that's not true. It's just that we we care about tradeoffs. And a single payer system automatically has tradeoffs, whether it's longer wait times or less innovation. Now, the countries around the world get to benefit from innovation in the United States, so they still have access to less of it.

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That's true. And they certainly have longer you know, Canada wait time, U.K. wait times versus the US or pretty dramatically different. They just have less doctors, too. I think it's overwhelmingly clear that single payer systems performed worse during covid. There's just less ICU beds, there's less of everything, because if you have price controls on any product, health care, anything, you're going to get less of it. That's just a fact is an inescapable fact.

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And and we see that borne out in the data when we were looking at, hey, who is who who is ventilator's like car on a per capita basis, like how many ventilators do we have versus other countries way more, way more ICU beds to you know, this is just this is just a fact.

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Our hospital system is by far the best. And so you don't want to undermine the foundations of innovations and research and quality that you only find in the US. I mean, for, you know, for the most the rarest of diseases, people people only come here. That's especially Houston. So undermining those foundations is is catastrophic, I think. And it because people are frustrated, because they see other for the same drug buy here in the US and buy the exact same one in Europe, it's dramatically cheaper and that's understandably frustrating.

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It's something we have to tackle. And I don't know if you guys done a lot of research on on just on how to figure out how to maintain innovation while also helping people get access to some of these cutting edge drugs.

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Well, you're kind of teeing it up for me here, because actually we just completed and launched a massive research effort called the World Index of Health Care Innovation, where we compared the 31 wealthiest countries on the world that had a population over five million on metrics like quality, patient choice, fiscal sustainability and science and technology.

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And the US ranked fourth out of the thirty one, not number one, but also not thirty one. The countries that ranked at the top five were Switzerland, Germany, the Netherlands, the US and Ireland. And last on the list was Japan. And I think four out of the five bottom ranked countries were single payer countries, the highest ranked single payer country in our rankings was Taiwan at number 10. So basically the nine countries that ranked above Taiwan at number 10 were all countries that have other universal private coverage or a significant role for private health insurance.

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And particular those countries at the top of the list do a really good job of innovation. The U.S. is by far the leader in terms of both scientific discoveries and also adoption and development of new technology. Most of the pharmaceutical companies, biotech companies, medical device companies are based here in the US, along with most of the Nobel laureates per capita. But there are other countries that do pretty well, not that to the UK actually, for for all of its socialized medicine actually has a really good scientific culture.

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And that led them to rank higher than you might otherwise expect given some of the problems and challenges they have with their health care system. But overall, absolutely, innovation is important and it needs to be part of the discussion.

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Yeah, and that's really interesting. And and again, it's that that's. Statistic turns into a dishonest debate because people are like, look, all these other countries has universal health care, but not the kind of universal health care that Medicare for all proponents are proposing. Like you said, it's it's private. So there's a profit. There's, you know, and that's what it gets to and how we can we can decry profit is evil. And in it, I get it because some companies certainly act in an immoral way.

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But the reality is, is is is profit is the only incentive for for a lot of this investment and innovation. And that that's that's just a fact that it's an inescapable fact. So that is that that is a pretty interesting study. So getting back to the question on Texas, though, so like what is the what is the policy reasoning then behind a state, you know, not wanting to expand Medicaid? Well, there's several elements to it, I would say, first of all, the biggest challenge with Medicaid is, is that it's impossible to reform.

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We've had Medicaid now for 55 years. It is basically never been reformed. It's the same program plus or minus that.

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It was in nineteen sixty five. It can't change. It can't evolve. It can't take on new developments, new innovations, new approaches to medicine. It's basically the same type of health insurance that it was supposed to be in nineteen sixty five.

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And what's the end result. The end result is that you have a system because it's, it's run by states and states can't borrow money from China when they go broke, unlike the US Treasury. What a states do if you're not allowed to change the benefit package because that's written micromanaged by Congress, if you're not allowed to change how much the individual Medicaid enrollee pays for their health insurance because that's micromanaged by Congress, then what can you do to control the rising cost of Medicaid?

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Basically, all you can do is pay doctors and hospitals less. And that's what states do year in and year out in order to manage their budgets. Now, you're at a point now where in almost every state, Medicaid is either the largest or the second largest line item in their budget. The only way they can control that, by the way, that means that's crowding out funds for teachers, funds for roads, fund for public safety. That's all being crowded out by Medicaid.

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And so what do you do? The only way you can deal with that, if you're a state government because you're not going to kick people off Medicaid, you're not allowed to do is to pay doctors and hospitals less to provide the same care. And if you do that year in and year out, year in and year out, over time, what ends up happening? And it's true in Texas. It's true in New York. It's true in California.

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Doctors get paid a third or less on the dollar that they would get paid for a privately insured patient to care for that Medicaid patient. So what ends up happening? A lot of doctors say, you know what, I'm not going to take Medicaid patients because I get paid a third or a fifth. What I would get paid for that same service for a privately insured patient. So what ends up happening?

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If you have Medicaid, you have this piece of paper that says you have health insurance, but you can't actually get access to the care that you actually need when you need it.

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And in how Medicaid fails the poor. The book I wrote about this topic, I start the book with a story of a seventh grader named Amani Driver in Maryland who dies of a toothache because his mom can't get him a dentist appointment because nobody takes Medicaid. And this is the great tragedy of Medicaid.

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It's the great tragedy of Obamacare. As you said, that's what Obamacare does. It primarily expands Medicaid. And Medicaid is the program that will trap more people in a broken system in which you don't have access to care.

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In fact, Jonathan Gruber, of all people, the famous architect of Obamacare, has done research that shows that people who are uninsured but pay their doctor cash have better access to health care than people on Medicaid. So this is really important.

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And so if Texas expands Medicaid, not only will it be trapping itself in a fiscal trap because they'll have to pay for a big chunk of that Medicaid expansion. But more importantly, it'll be trapping millions of Texans in a system in which there won't be any alternatives. Because actually, if you try to say, OK, let's say you're a low income Texan and you're in Medicaid and you know that Medicaid doesn't pay your doctor enough, and you go to that doctor and say, you know what, I'll pay.

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I'll make up the difference because my kid really needs to get that care today. What if I make up the difference in terms of what Medicaid pays you versus what a private, privately insured patient pays you? That is a federal crime.

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You can go to prison if you try to do that.

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And this gets back to the thing we were talking about before when you mentioned the point about health care being a right. Health care absolutely is a right. And what is a fundamental right is your ability as a patient to get the care you need when you need it from the doctor you want paid in a way that's mutually convenient to you and that doctor. And that's the right that's being abridged by Medicaid and many other federal laws and regulations.

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Yeah, yeah. Know, I didn't even know that that it's illegal to even subsidize your own your own Medicaid and, you know, to get to the you know, Medicaid is inefficient because there's so many people that are right on the cusp of it.

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And so, you know, this is why what we talked about before, a simple subsidy into an HSA account where you can then choose your your insurance. You know, like you said, it's kind of a Medicare for a Medicare Advantage for all sort of scheme, much more efficient because, you know, it's it's it's it's a dollars worth of extra income that makes you ineligible for Medicaid. All right. And then and it's you know, not everybody has time to then go, OK, now I've got to get a different insurance plan or maybe it's my employers or whatever it is.

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It's annoying, to say the least. And a lot of people end up falling through the cracks and it just becomes a highly inefficient system. Totally. There's a lot of churn.

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That's an underappreciated element of this is like, you know, in our system, if your income is below X, you're on Medicaid. If it's above X, you're on Obamacare, or maybe you're on employer based insurance and you can go back and forth and you have to sign up for a different insurance plan and have a different network of doctors. And your care can fall through the cracks as a result. So that causes real harm.

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That's widely understood among academic researchers who might otherwise think of themselves as left of center. And that's one of the most important reasons why we have to move to a system which everybody has that choice of health insurance.

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And just for people that don't understand the difference between Medicare and Medicare Advantage, Medicare Advantage is the market based private sector program within Medicare, where private insurers basically cover the benefits that you would get from the traditional Medicare program.

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But it's all private insurance that you choose.

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And that's one of the ironies of when Bernie Sanders says he supports Medicare for all. He actually doesn't support Medicare for all because he wants to abolish Medicare for Advantage. The market based program within Medicare Advantage that now enrolls about 40 percent of all seniors wants to remove the best parts of Medicare and get everybody.

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Yeah, and give everybody the worst Medicare.

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Every year, more and more people enroll in Medicare Advantage. We're within a decade. We're probably going to get a point where a majority of all seniors in the Medicare program are not enrolled in traditional single payer, government run Medicare. They're actually enrolled in this market based version of it.

[00:30:29]

In a few minutes, we have left speaking about Medicare. You know, when I as a millennial and I look to the drivers of our debt, which is astronomical at this point, it's Social Security and Medicare, Medicaid being a part of this also, but mostly Medicare, Social Security. And so what would be the reforms? To protect our seniors who need it while also making the program more solvent, would it be somehow an expansion of the Medicare Advantage model or how would we do that?

[00:30:59]

Yeah, it's a couple of things.

[00:31:01]

One, it's an expansion of the Medicare Advantage model because Medicare Advantage delivers the Medicare package of benefits and coverage at basically 10 percent lower cost than the traditional Medicare programs, because all that competition and innovation leads not only to lower costs, but higher quality health outcomes for people in Medicare Advantage are better than those in Medicare. So that's number one. Let's eliminate some of the artificial obstacles to more people enrolling in Medicare Advantage because basically low income people should be in Medicare Advantage.

[00:31:31]

It delivers better a better premium for them, lower premiums. They would save a lot of money and lower cost to the taxpayer and higher outcomes. So that's all very important. The other thing we have to do with Medicare is means tested more. Again, it's ridiculous that you and I pay taxes so that Warren Buffett and Mitt Romney and Hillary Clinton can have government subsidized health insurance through the Medicare program. That makes no sense. We should have a system where the truly vulnerable, the truly needy, and that includes people who are retired on a fixed income and don't have a lot of networth saved up.

[00:32:00]

Let's make sure that we've we have that program fully funded for them, but for the very wealthy types. Let's let's let's kick them off Medicare in the Fair Care Act. The bill I was mentioning before from Bruce Westerman, that bill has a provision in which if you have and forgive me if I'm not recalling this exactly correctly, if you have a lifetime earnings above 10 million dollars, you're ineligible for for taxpayer funded Medicare benefits. The assumption being that you've earned 10 million dollars over the course of your life.

[00:32:32]

You've earned enough that you should have put some away to save for your own health care instead of depending on the taxpayer to bail you out. That's the least we can ask, given that the vast majority of Americans have nothing like that saved up when they reach retirement.

[00:32:47]

And that's a simple, simple thing that the money that you actually could save from that would make an enormous difference to our federal debt. And by the way, on that that world index of health care innovation that I was mentioning before, the thirty one countries, the US ranked second to last on fiscal sustainability, second to last.

[00:33:04]

Well, it was last Japan. Japan just sucks at this, huh?

[00:33:12]

Well, I mean, the big problem is, is their debt, their debt to GDP ratio is is like double R, so they have a 200 percent debt to GDP ratio overall, leaving health care aside. And then on top of that, they have a heavily subsidized system that where the costs are growing and they have a very old population, they're not having having enough kids. So their population is getting is growing in terms of the elderly and overall, their net population is actually declining.

[00:33:38]

So young people are basically not coming in like yourself to to finance the tax revenue needed to to pay for all that elder care.

[00:33:47]

Right. That makes a lot of sense. OK, fascinating discussion with Avik Roy. Thanks so much for for your research and everything you do to help Americans get health care. I think this is such an important conversation. Really appreciate it.

[00:34:03]

Hey, thanks for all you're doing to get the message out and all the good work you're doing in Congress. Appreciate it very much.

[00:34:09]

Like a lot of fun.