a 350 million miles per year faster than the rate that satellite's orbit the earth. so pitcher being smoked data rate faster you forget a scale of the problem. >> host: booktv on c-span2 talking to professor robert proctor from stanford university from history and science professor his book "golden holocaust" origins of the cigarette catastrophe and the case for abolition"

>> host: "in excellent health" setting the record straight on america's health care" the author dr. scott atlas but also a senior fellow here at the hoover institution at stanford what works about the american health care system when you looked at in the larger sense? >> that could take up the entire interview but what works rarely is what the book is about which is the actual medical care and availability or access as well as implementation or introduction of diagnostic and therapeutic treatment of

diseases. in fact,, a lot of the impetus was to clarify the background information that people don't really have despite what has been said about the u.s. health care system and the bottom line is with both access and quality of care. >> host: cost? >> it is an issue in well-documented and i concur with the documentation that the u.s. is the most expensive system for health care in the world whether per capita or any other metric. this is the major problem with the system that should be where the reforms are directed. >> some had been directed have they not worked? >> if you talk about the basic afford a better --

affordability care act that is now called obamacare if you look at the numbers the projected number that the cost will not come down. one of the reasons why reform was so essential but yet and all other agencies then of them project a decrease of expenditures so this is one of the ironies of the whole discussion about health care. >> host: but health care costs have never gone down? >> you make a good point* those have gone down historic the because it is not necessarily desirable to make them go down for a variety of reasons but technology and medical care has advanced so much over

the past 50 or 100 years that we would not want to dial back the clock like when i was born with the bedside diagnosis was the essence. we want that technology whether drugs or safer treatment that has been a boon for the quality of medical care. so there is a driver of cost you don't want to scale back that is it cost many but there are ways to increase the control of cost as a believer of free market controls and let people decide to of these competition and give the information as every other

good or service you may ask what is the fair price? it is that which people are willing to pay for something. not some arbitrary price fixing from central authority. >> host: are you practicing doctor right now? >> i was up until literally one year ago where i move from being head of radiology or was about 13 or 14 years the previous 15 years from clinical medicine and research and teaching. then i moved over to hoover to work on policy. >> host: when you were practicing did you except medicare and medicaid? >> yes.

i have always worked at the academic medical center such as stanford but yes we did. >> did the government reimburses at a fair rate? >> that is a difficult question to answer because it implies the subjective terms of fair. did they reimburse at a separate? yes. it was determined always significantly less than private insurance one way to assess is it fair to have doctors and general react to the reimbursement rate but the reaction is there is a decreasing number of doctors excepting patients specifically because of the

low reimbursement rate. such that they lose money for patients and rigo if you cannot make up for that in volume. >> host: dr. atlas you talk about the barriers to the fair market rate for health care. what are some of those barriers? >> one of the biggest is a third-party payers student system. people use this good or service it is the only one like this. so obviously there is no possibility to make a value based decision but second, in essentially all of medical care is covered

by the insurance itself. the way health insurance has is involved is the way it was intended to reduce risk of anticipated large expenses no health insurance is almost everything aside from the small copayment or small deductible is paid by the insurer so you don't really care what it cost because someone else pays but you pay in the end is say complicated route to. the biggest barrier is that there is no incentive to leave them with the cost. when something is free the tendency is let's consume as much as we want because i am not paying for it. that is the number one barrier. the second barrier is the government created health

insurance coverages with united states controlled but you are not allowed to buy insurance outside the state of which you live band that is nonsensical and does not happen with other goods or services with the paternalistic way you don't know what you are doing but in new jersey ad on a wide they couldn't shop in pennsylvania or vice versa. that is one problem. that is a barrier for competition and there are over 2000 mandates for all health insurance policies in the state.

many people obviously would never want to pay for. acupuncture, chiropractors come in in vitro, when i give a lecture the average age is 60 i would say we will not use in vitro fertilization but insurance is required to include that coverage. there is a lot of mandates estimated ramp up the cost of health insurance by as much as 50%. that is a barrier because there is in the opportunity for people to buy the insurance coverage they want to which would be cheaper. there is a whole host that has had an opportunity and a big one that i fail to mention is so lack of information. not just about price the quality if you get the mri

scan you dunno know not only what it costs but if they are board certified, training, you don't know if you get elective surgery if you go to a place where they do a lot with a good outcome. a huge amount of information that is necessary of value based decisions and then the question comes a people able how can you make a decision like that? my answer is there's no question to be in concert with doctors reid do this all the time with things you don't understand. i am not sure people can explain how a computer works

but in a concert with doctors people are very good at walking through the patient's side if given the opportunity and incentive there are a variety of ways to do that. >> host: dr. atlas one of the major factors of the affordable care act is the so-called market place where people can shop for insurance. is that a step in the right direction? >> to talk about the health insurance exchange that is now the market place on the government web site. in general, i would say the ada, the concept is very good but the problem is the

implementation to have the execution that is key. if you look at the health insurance exchanges set up under the affordability care act some problems are so bad they cannot possibly function well. the three basic problems, the first is the minimum essential benefits coverage. okay. but the problem is when you look at those, there is such a nervous comprehensive list of medical benefits the price of the policies to cover those is necessarily high and eliminates the possibility for people to buy insurance policies as compared to what they want. the prices are jack debt beuscoverage is

required of all the policies eligible to be sold on the exchange. second, with the minimum loss ratio is it the edict by the affordable care act to quantify how much the insurance company can make profit wise to declare as the administrative cost to look at that ratio you have necessarily limited or excluded cheaper coverage under high deductible health care plans. for health savings accounts are not only cheaper but more desired and the more popular choice over the last five years the increase of that choice of employer sponsored health insurance because they're cheaper comment you could put it into a savings account that you get the money after words and it is associated

with the better wellness program and other screening tests that people what to and encourage healthy living. these are excluded by the minimum loss ratio or limited in the third and most important thing is the adl that health insurers cover the insurance policies must use guaranteed issue now matter what pre-existing condition and you had you must be able to get the insurance and it eliminates the waiting period. you'd be able to buy insurance if you just waited until the day you got sec so why would i bother to have insurance until the day i got sick? that would be the rational way to think. the third problem is there

is no difference in the premiums for the risk factors except cigarette smoking. you are not allowed to change the price everyone has the same price guaranteed issue no matter what risky behavior you engage gin and no delay to buy the insurance. it will make insurance companies the no-win situation it is a really possible to exist under that scenario. >> host: the arguments used set forth, is it too late do implement sincere already on the road to the pit -- affordable care act? >> a very good question. although he is

clear:something genetic happens obamacare is the law and to realistically i don't think it will be completely abolished. may be other people who disagree but given that scenario there are things that can be modified for instance by one house they are not implemented yet and i am not sure they will be to get rid of the negative edict like the tax on medical device companies that will necessarily cause job loss but also lack of access to new technology for patients. this is what congress and senate members can agree on but then california deal is

how to change the requirements on the health insurance policies for the exchanges. it is not too late to modify or change parts of the aca but i have a feeling it is unrealistic to say the entire block will be repealed. >> host: talk about good access to health care is some of that through emergency rooms? >>. >> the answer is probably no. but to clarify there is a huge difference of access to health care no matter how you define it access to general care, medication,

for americans are better than any of the country is held up as models and we can go through sedated in the book and secondly, do people get the care through emergency rooms? sometimes. that it is just as good to have no insurance as it is to have insurance. generally it is thought people go through emergency rooms to get the care. however, a lot of the care given to people is not but it is a misconception people without insurance don't get access to care. there is some of the issue that people who get access through emergency room don't need it. on the of the hand it is

marked the distorted. >> host: from "in excellent health" to the embarrassment of the government does centralize health care government officials themselves circumvent restrictions with their own personal care is at stake. the national health service in great britain spent more than 1.5 million pounds to pay for thousands of staff members to leapfrog their own waiting list and burlesque of any of italy elected to have his pacemaker surgery at the cleveland clinic and when president obama on the record supporter of single payer systems was asked pointedly to promise he would not seek out of plan held for his wife for daughters of they became sick the president refused saying if it is my family member my wife or children or grandmother i always want them to get the very best care. >> right. people ought to know that

even the most vocal proponents in the united states of the single payer health care themselves, for themselves when faced with the need for health care do everything they can to manipulate the system to access their own right to which is choice. they want the choice to pursue the health care options themselves because i have been one of those doctors sought out frequently including many you are not on the record the one who is was senator ted kennedy was a proponent of single payer health care and this was in the public record, i read the mri scan when he had his brain tumor not they he was my patient but he sought out with all of his power the best doctors in the country to help them even though in the political world he was pushing for single payer

health care for the rest of us. and a broader point* is when you look at the other countries whether canada or england or all others in western europe, they not only individually seek out ways around in their own country they put into law to pay for medical care either in private care centers or outside their own country because they cannot handle the access problem. so while we are moving to a more nationalized system those that have that have made significant movement to privatization. >> host: scott atlas

people watched the interview and say he is a doctor and he makes x amount of dollars and he needs to make less and he makes too much. >> i think that has been said many times. it is not a surprise but unfortunately i don't make that much money but that is beside the point* but we have to look this is the tricky part of health care. this is the ethical moral dilemma of that gets into the discussion which is health care is different from everything else because health care is a right to. in the ideal world everybody would have everything for free maybe that is the ideal world but we don't have that attitude about having a

home, everyone should pay for it but it does not work that way the reality of life is things cost money. somebody has to pay for it. to doctors make too much money? i am in the camp that decides i don't think there is anyone that should say someone makes too much money. this is so broad that this is the land of opportunity as long it is equal opportunity you cannot guarantee equal outcome. i don't buy into the argument you shouldn't make that kind of money now if you apply it to doctors you get what you paid for in some sense and if you want a medical system where everyone works with

public-sector job with limits on what they earn and dictated by government you better be prepared to have medicare -- medical care to perform like the u.s. post office there's a reason why doctors flocked from all over the world to be taught by doctors in the united states. and i have been engaged in continuing medical education courses here and abroad and by far the leaders of innovation the leading educators of the world's doctors are american doctors. we don't go to other countries to learn new medical care. they all come here. thises generally true overwhelmingly so but if you want to make doctors forced into a public employee you will get what you pay for and we are already seeing of little bit of that if you look at the surveys of the

doctors and future plans, and many are getting out of the field and you will see if you want the best and brightest i am not arrogant enough to save those are in medicine but there are very good people in the medical field in the united states. if you want to clamp down to tell them what they will earn and all the other things with delayed return on investment because you don't make money until your mid-30s as i was in the bow and i know, you will get what you pay for. >> host: would you say doctors order to manney test to gain the system and everybody has to pay for that? certainly there is medical waste and redundancy. no question.

i think there has been a little bit of distortion of doctors scheming the system without saying it never happens that people think the radiologist order mri is and they make money. no. that is a legal. nobody can order a test like a diagnostic test where they received money. that does not happen in other countries that is common but not in the united states but the redundancy and waste of the u.s. can there are attempts with electronic medical records to streamline the system to get rid of the waste and redundancy of excess cost the that is not the biggest problem of the national

health expenditures are going. >> host: scott atlas why did go world health organization rate the u.s. health care system lower than what you say it is the? >> look at the actual studies of themselves which i did. instead of taking the bottom line. the impetus was writing after a dinner party of the michael moore party in the random numbers were thrown out with the report of 191 nations attended countries like croatia and cuba not by any common sense assessment and let me scrutinize the steady this has been done in the academic literature of public health.

reno the studies were seriously flawed almost two-thirds of the rankings was based upon the quality. said that was rewarding countries that have medical care that was deemed better that were those that got an a or c but that makes no sense it is better to be equal or worse in the eyes of the who report. there are other things that are set off such as when there was no data available they literally filled it in. it is literally so bad the head of health care organization of the economically advanced countries said the who report is one that we wish

would go away and was so poorly done but it got a lot of traction when you look to the government leaders they talk about how it has inferior health care and based on the rankings. if you look at life expectancy, infant mortality they are so flawed and actually defined in ways the u.s. would necessarily have a bad drinking and what i tried to do in the book you realize that. >> host: what about the male model where doctors are on salary? >> that works well for what it is. it is a unique place amongst all of the medical center's in the united states with health care delivery that it is a referral center. it has a reputation for

there is a guerrilla in the room with perceived quality and also an excellent place. they do things their own way. it works well for what it is that i am not sure it is reproducible. they have all kinds of things going on and right now to make it more attractive to the high end cash paying patients, they have their own challenges as well. >> host: we have been talking with dr. scott atlas here at the hoover institution. "in excellent health" setting the record straight on america's health care". dr. atlas thank you for being on the tv. >> is a pleasure to be here.

opposing slavery influences her husband to switch to the antislavery republican party and holds the first white house easter aid goal.

wife of rutherford -- rutherford b. hayes and we continue our series with comments and questions monday night live on c-span and c-span three and also c-span radio and c-span.

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