schedule on your program guide or watch online at booktv.org. every saturday american history tv nonenfiction books and authors. funding for c-span 2 come from these television companies and more. >> it doesn't have to be. you connect it and not alone. >> they support c-span 2 as a public service. >> thank you very much ladies and gentlemen for coming. our topic today is medicare the

largest healthcare player in the american system a huge and growing federal entitlement. medicare will increase enrollment f from 65 million to nearly 80 million. total program spending will double. tough roughly it's $1 trillion within 10 years. nearly $2 trillion. t at the same time, medicare is rapidly changing. today roughly half of all seniors are enrolled in medicare advantage. the system of private coverage erwhich is the leading alternative. medicare advantage combined a contribution system. the government makes a contribution on behalf of the

beneficiary. given current trends medicare advantage is the dominant form ofth coverage. the question before the house and before the nation it's a big one. how do wehu provide high quality medical care with a rapidly growing population. the cost a that's afortable to seniors. in our new book modernizing medicare from john hopkins iuniversity press. colleagues provided specific answers to the question. bryan miller is a practicing physician and assistant professor of medicine at john hopkins university and fellow at thee american enterprise

institute. john goodman is president of the goodman institute. he'sde a prominent healthcare economist and father of health savings account. doug is president of the american action forum and a former director of the congressional budget office. now with the debt limit facing the country you can expect to see doug on the national television shows dealing with the debt limit and other problems that are connected with it. with that, ladies and gentlemen, i'd like our guests to come and join us. we will have a discussion about medicare i'm going to start us off with a question for you. right now, as you know.

millions of seniors are voting with their feet. they are enrolling in private medicare advantage plans. as opposed to traditional medicare. you deal with this in chapter 6 of the book. firstover all. thank you for having the conversation about the medicare program. medicare is two different programs. when you are in the employer market and pick your

benefits you sign-up for a health plan things are different theyu qualify for medicare. you also have to pick a prescription drug plan. traditional medicare program out of profit. there is coverage. this is for medicare advantage. traditional coverage and start supplemental coverage. 90% of plans are a prescription drug planle and supplemental benefits. they havean dental, vision, and hearing. if you enter medicare and have

three or five conditions you are on a fixed income you have a limited number of assets you can't spend all you want for the average consumer it's much easier financial instructions you don't have to make as many choses and the trade-off there is always a catch. they can't see every single doctor. are working through the years. you have health through the exchange. you could see every single doctor. it's not so scary. also,, there is usually utizatin

review we haveat controls that o with that. i will get more benefits and more protections. i will have limitations on how i use that. >> it's more convenient. benefits and morenient. convenient and easier to chose. >> it's administer affordable in many cases. >> it's more affordable from the beneficiary you have to pay prescription drug plan premiums you can't get it in the private market. you get it through the medicare advantage plan. >> john,in in 2003 republicans n

congressss enacted the medicare modernization act. a few years later congress with the support of president obama schedule act called obamacare. medicare advantage works better than the health insurance exchanges. can you tell us why that's true. p >> they are similar on paper. that's why 50% are in the

itexchanges. they makea a half million declaration per year. medicare advantage is the only place where a doctor discovers a change in medical condition and forward that to insurer where this is medicare and get a higher premium. that's why in medicare advantage you havee plans that specialize in diabetes and other illnesses. also what attracts people. this is the only place this happens. there is no plan inth the country. they had ethyl hell care costs. there is no commercial insurer. this was in the obamacare market. they are trying to run away from it. in regular medicare there are

10,000 things. not one of the 10,000 has it objective. the jobob is to make the patient healthier. over in the medicare advantage by contrast they make people healthier. the ceo of kaiser the plan 20% of die bettic patients get altered. they turnam into amtations. over in the medicare advantage plan by contress in the modernly successful one. aa third as many amputation. they do things that probably not

on the list regular medicare theyam prevent amputations they have dry feet and dry socks. i don't think that's on the list ofpa 10,000 things traditional medications pay for. blindness, again, we have much higher rate in regular medicare than the advantage plans. costing $100,000 per year. 20 to $30,000 per year for blindness. congestive heart failure we have a significant difference in outcomes and traditional medicare. so, these plans act differently. they are financial incentives are different.

i will say, one thing if you read what george says and health affairs you would think we are describing two different worlds he calls medicare fee for service and medicare advantage capitated. some of the best plans pay fee for service. the difference is not how the doctors pay.r it's over here we have intergradedco coordinated care with the objective of keeping people healthy and it's not intergraded or coordinated. people makehe more money when ty get sick or require more treatment. >> thank youou very much, you do

cost stems referred to as premium support system. this would result in major savings the chapter focus is on taxpayer and beneficiary savings. i think the question if are a lot of americans would be the need or desire this is a comprehensive system the desire to reduce healthcare spending the only reason for moving in that direction. >> absolutely not. i focused on the budget cost and you told me too.

>> very good. >> i'll have to try it to take lessons we learn. medicare advantage is one of them. they have competing plans and decide which benefits. what things in addition to the care that will allow them to stay in better health and improve outcomes. look at the medicare part d program where we harnessed private negotiations. the planned sponsors deliver robust competition. let them pick among those plans to get the formularies the outcomesef they prefer and in tt

process we get extremely high satisfaction.em 80 to 90 percent are extremely happen we learned we can infuse into the healthcare programs of the federal government and respect for government and respect for theyrt decide what's important. i think respecting the values are the important things. way more important you know, fun fact youho shouldn't use it because you have no friends.

the medicare program is responsible foror one-third of data. this iss the program never been designined. we want that undercontrol and we want too serve the medicare beneficiaries and this is the way to do this. medicare aside from the fact it spends so much money as you point out from the national debt.ve medicare is governed by a very powerful regulatory regime. the bureaucracy for the center of medicare and medicaid services cms. for years. this bureaucracy set prices as john pointed out for 10,000 medical procedures it doesn't do a good job at that.

medicare advantage introduced a new dynamic into the system. that has an effect on the medicare bureaucracy. i was going to ask you bryan, as a med cat d professional dealing with seniors. how does medicare advantage, as a system, the competitive system of private plan change the role of cms. >> i'd like to respond to something dug h said. he had six doctors and pretty smart old lady the medicare advantageon plan helped get tmodifications in the bathroom. they got her the chair lift so she could go up-and-down. she had a two story row house.

you know a decent plan.to she was medicare/medicaid eligible. she would get here teeth pooled and h i asked her show she did that. iou picked the one plan that wod let me do that. i saidli what about your doctori picked the new cardiologist for this year after i get my teeth fixed when op enrollment happens i have a cardiologist in it. so, the beneficiaries can be pretty crafty and smart in a good way that was sort of fun for me to see. when you think about that, if we improve the plan finder and give

them better choses, like we show them how to shop with the health benefits package. ourr colleagues like lisa have written able we can empower them to make the choices and satisfaction. ems is focused on payment levels. the opps role. all of the roles happen. one was 1500 pages. the people sit their and read the rulee and analyze it for te appropriate stakeholder. you have the y usual cycle of medical especially those that pshow up around the time, of course, there is a stream of people going into the various buildings you have all of these payment levels. everyone from the former

secretary said we have tro transition from volume because of the benefits package. that allows the potential for cms to stop focusing on the role instead focus on the rates and plannedta regulation this is why i think both parties want. >> benefiting from the procedures. >> can i express a concern? >> sure.fu i don't think cmss it's a fundamentally different platform. youti provide the contribution. we talk about making them better. need that. making them better.

you try to microplan age the plan. this is to deregulate the system and get better outcomes. i worry about the future and more robust reform. >> good point. john goodman, in the private sector, you know, and you were largely responsible for this in many ways. assu a result of your work with congress.le prometing relent leslie the idea of a health saving account. to build-up an account and they can use the money for routine medical services and protect themselves against consequences.

we don't have it for seniors. why can't they have any health savings account? >> okay, this is something people don't understand. the health saving account for nonseniors is the best account you can have. it's better than the i ra and 401k. during yourn working years you can save and by the time you reach i 65 and enroll in medical care you can use your health saving account deposits to pay your part b premiums. you can't do that with an 401k. if you were healthy, you will exhaust your accountnt paying te premiums during your senior

years and never pay taxes. when congress cree eighted this account. if we allow seniors to get a tax deductionit for deposits and thy turnnd around and pay the premim with it that's equivalent to letting them deduct premiums. they weren't in the mood to give another tax deduction to this group of people. that's why seniors were allowed to do this. that's why there is a solution. the idea is you don't get a tax deduction. you put after tax dollars in the account. it's not very expensive and allow the party payer to put money in the account for the chronically ill. you manage some of your care

we'llyo put money in an account for you. if you stay away from the veemergency room that money is r you. you go to the emergency room you wills. bare the cost. you get the good penal fits of your good decisions. seniors need an account. it's a roth not the traditional health savings account. >> so, the opponents of the contribution as a way to finance medicare. they often demonize the medicare. ioi heard it overand overagain. i heard it in the 90s how do i couldn't respond to that?

>> well, one, it doesn't matter. if it's good vouchers are fine. more on the point, i think. at the time of the discussion 15 to 20 years ago the dominant medicare program was the service program and defined contribution looked different in an unfamiliar and it was easy to scareit seniors. they privatetize and they work everywhere else. so, now with medicare advantage you have subsidy from the government and private come ticks plan.ck you pick the one you want. it's the most popular form of medicare. more than a half million beginning next year. it doesn't look that different. people have voucherized the

medicare voluntarily. we aree just trying to improve the quality of what they get. >> i know, the thing that's remarkable about this i was at the democratic national convention. it was a few convictions ago. basically they would give them the voucher and negotiate with a private healthce insurance. this was the source and the idea i got into s a rather spirited debate with someone in the media. i asked them, let me ask you this. the federal employees get a voucher.

>> get their first andir prioritize your ideas. there is a war over the ch characterization. cignafy it. the onenn john pointed out in te beginning. if youe need more care to get quality outcomes the system provides you with more resource. if i may, it's private medicare marketplace. the competition produces health benefits. that's not an oxymoron.

you don'tmm see it on a commercl or office space. it's a real thing. go back to the 1980s medicare have a drug benefit. helen ws. when we had the cell phone.or fast forward 2003 you get the prescription drug benefit. that's a 17 year delay. remember thehe resent debate we had they want to add hearing to ctraditional medicare. that's from private market competition where the ben bits are available. for thedi future of medicare private market competition is something that will benefit them. >> right, let me ask you this.

what is the source of the intense opposition to this movement the idea of transform ing med care what is the real guts of this opposition. what is motivation. youan heard bernie sanders say there should be no profit in healthcare. he believes that and he's not the only one. they don't like markets. they don't like for-profit businesses l or nonprofits that act like for-profits. that's it. >> breaks down payment styles.

one is notice ruptive. so. that's a big one. >> i'd say it's something different. fear and a lot oft control. hundredsos of pages of comments. they have financial stake in that and familiar with that. they can go argue with that if it's one of many options they losepo the power and the world s they know it has changed. >> veit's a rather traumatic change. the loss of control over -- basically what we are talking about is rat cal reduction in

the army of lobbies and consultants. >> my generation will finally be able to afford a house because of two recessions. iss will say, the loss of contrl isn't necessarily a bad thing this puts control in the hands of the beneficiaries. the point is to give health benefits for the beneficiaries. not for corporations or lobbyist it'ss. for the beneficiaries. if wee work on the changes slowy overtime it's good for the population. >> right, that's interesting you mention that. our colleague used to refer to medicare as the provider centric system. patient centric system. all of the activity in the house and senate is trying to figure

out the payment formulas to get the right formula at the expense of your colleagues preforming different specialty of medicine. i'dlike to follow up with you bryan on something that preoccupied doug. that's the question of fiscal responsibility. you know, i mean, a number of us were watching the debate on debt limitdi and spending and so on. we look at what seems like, you know, crazy spending with the congressional madhouse. i know i'm showing my age. the idea of trillion dollars deficits is stunning. it's incredible. we are developing as doug pointed out. we look att a situation where we accumulate a large and dangerous

debt. your friends talk about the potential of a crisis. i don't think americans understand the gravity of this. in the case of medicare advantage, zeroing back to the medicare advantage program. bryan, kind of following up with what doug raised. that's the framework that medicare advantage is structured and programmed how do you see that contributing to the promotion of long-term fiscal sanity. >> yeah, the sanity in the healthcare policy is a nice change. we don't get it often. the medicare advantage program wee need benchmark reform. . . .t's risk adjusted remembe,

bird per beneficiary permonth , so that's a good framework for budgeting . we can debate about what the appropriate capitation or methodology is but we should have those debates . everyone is having those ll debates in medicare advantage .

there's article after article about medicare risk adjustment but the general principles of having a population-based budget for the medicare program is something that could allow us to potentially budget for medicare for the first time in office ãand ever >> doug, you have observations on that. >> that's the single most important thing we can do for medicare. at the moment everyone behaves accordingly and the providers, the device manufacturers, beneficiaries all realize there was a finite amount of money available to do good things so getting it on a budget by some mechanism, it's incredibly desirable from a physical point of view. there's agreement on this across the aisle. on the left you hear talk about how we have to create in the medicare program bundles, a bundle, a set of

services with the quality outcome. that's putting that set of services on a budget. on the right you havemedicare advantage .al it's got quality metrics and this valuation. there's an agreement about how to do this. this one is more comprehensive. neither is perfect. the change would come from better quality metrics and the first is the consumer willing to buy your service . we don't have that anywhere so that's the advantage of doing this but there's not much disagreement, it's just the scale. >> that's pretty remarkable. you think there's a y bipartisan ... >> i didn't say that. i think there's hope. at the level of policy design

there's an agreement about some of the incentive and that's what you see going on. at the level of stowing reforms and getting legislation through congress we got a lotof work to do . >> i will add that seniors start pusing for us because market penetration is the medicare program iwritten large has increased five one absolute percentage point every year for the past decade and he recently surpassed 50 percent. >> kaiser family foundation came up with their report, it's 50 percent which is quite remarkable. what's more remarkable is that our friends who write the medicare trustees report every year have always underestimated the growth of medicare advantage which i always thought was uninteresting . john, i have a question i wanted to ask you about your kind of provocative proposals in the book, modernizing

medicare. most people think that when you sign up for r insurance you should sign a once a year and that's it. basically the argument is of course youwant market stability . we want some secretly in the market and if you have a season people make their own decisions. they get their coverage that's it until the next season. we've been doing that private health insurance forever. we do it in a huge federal employee health benefits program and redoing it in medicare advantage but you however want to change that. you want to have a situation where people can make a decision to enroll they think they should enroll in plants. i imagine some of our friends from the insurance companies would be very nervous about this proposal. but poi would like to hear your

argument. i think anybody listening to this program especially you to around the country was like why think that there are to be a continuous open enrollment . >> not quite continuous but close to it. we have a strange asymmetry here. if you're chronically ill whether agyou're in the medicare advantage you're going to look at the networkshe of different plans . you canchoose from . and you're going to choose plans based on what doctors are in that plan but after you've made your choice you're stuck for the next 12 months. the insurance company on the other hand is not stuck and after you've made your choice , they can change their network and this has happened and there are tragic consequences of this happening where people have been denied access to cancer

specialists for example that they thought they were going to have access to some you're right, the insurance industry says if we had continuous enrollment that would be disruptive although i'll point out we used to have in the individual market continuous open and romans and that didn't lead to lots of disruption. what i propose is that you're going to be stuck with the plan you choose unless your health condition changes, you have a heart condition for example you should be able to go immediately to the special needs heart clinic . and several ages diabetic plan so change in the network that you had access to especially if there was a doctor treating you and that doctor is no longer in the network . that ought to be acondition for switching plans . so let's call it partial

continuous open enrollment and i think that wouldbenefit everybody . >> how do you respond to folks in the insurance industry and elsewhere who might say well, that sounds great but you're really promoting adverse selection in the system, that we will have more accessibility in the market as a result of that and that will jeopardize the viability. how would you respond to that ? >> the asymmetry is unfair e. the insurance company can take its network at the drop of a hat but the patient can't make switches. i think with senator right and his staff found that for several medicare advantage plans, for several of them the networks the doctors they claimed werein the network were really there . to me that would be grounds for a drop allowing enrollees

to switch to some other plan so we need to make it possible for people to switch plans especially when their healthis at stake , not because they just happened to change their minds on a whim but for some serious reason there ought to be a way to do this and the whole idea behind medicare advantage is risk adjusted premiums and when your health condition changes your plan is entitled to adifferent premium , probably a higher premium and that's the way the system w works and that's why it works well and that's why we have a special needs plan . >> let me follow up on this a little bit. >> it already exists an open enrollment. for medicare advantage you have your six-week period and a few more months when you can make a change but beyond that you can't change plans until the next open enrollment period . >> sounds like what you're

proposing is just for exactness things that happened to you, we have special enrollment period's to allow people to switch. >> yes but it needs to be ... it needs to be continuous or close to continuous open and romans. >> it's when the events happen and you then get four weeks to set up for a new plan n. >> you've got a health condition change, they lied to you about thenetwork, those kinds of things . >> but insurers, they have what you pay for.alit's exactness, i'm trying toagree with you . >> remember we are talking about somebody who used it to tell congress what to do .

>> in the exchanges it's a terrible example in n virginia of a couple had a daughter with a rare cancer and they had one health clinic in northern virginia that dealt with cancer and they chose the plan. after the open enrollment closed , that plan kicked out of their network and by the way, in that the obama exchanges to go out of network the plan pays almost everywhere. so this family was really mistreated. and i think that's wrong. >> let me ask you this though. we're talking about continuous and romans and it brings up another question, another whole area which is somewhat controversial with regard to medicare advantage and that is the way in which we have a risk adjustment operation, risk adjustment

system in medicare advantage. some of the arguments being made especially by some of our friends and healthcare is that the risk adjustment is so flawed it basically is such a fundamental flaw in the system that it basically is just an argument against the system. risk adjustment is a complicated area but it is an important area with regard to medicare advantage . going forward. doug, do you have any thoughts about how we should improve the riskadjustments ? >> i think the most important thing would be to stop developing the risk measures on fee for service relationin medicare advantage . you want to do risk adjustment on the ma population and risk adjustment is different than forecasting the particular

procedures. again, people start going down that road and the fee for service mindset, you have to characteristicindividual , have an identified pre-existing condition. whatever, take those characteristics and then you just do that and you don't pay attention evto what was on the care bubble and ask what's theoutcome in terms of care cost of care for a particular level of quality . you look at the before-and-after and do that math. and then stop tinkering with all this stuff in between. there's over tinkering. >> happening is there comparing the medicare advantage plans leto traditional medicare and the problem with those types of comparisons is medicare

advantage, doctors know or they should know that they're going to get moremoney if they find real medical problems . so there's pressure for them to be careful about documenting health conditions whereas over in traditional medicare there's no extra payment for a doctor being careful to get everything down on paperabout the patient's . the recent article in the new york times made in indian health affairs made a big deal about the fact that among the medicare advantage plans some find more heart disease than others and more diabetes or complications than others and the implication was these clients are making it up and i think it'sthe other way around . the plans are fighting them because it's in their in financial interest u. i don't think they'remaking up those numbers . the best plans keep people

healthy and theway to keep people healthy is esif you discover the prediabetic is prediabetic . you don't wait until his split needs to be amputated. these plans aren't equally e good. if i have one overall improvement in medicare advantage is that it needs to be more competitive. there are plans that ought to go out of business because they're not doing what they should do. the best plan is if you have diabetes make insulin free. that's free. and it's free because it pays . you keep the patient out mof the hospital and the sooner you make this market the better the quality of care. >> i can definitely say i agreewith you john . in traditional medicare you don't have incentive to code all these diagnoses.

i know you don't have incentive. in my iphone there's a app that tells me if my diagnosis coding, that the hospital is harassing me that has a practicing doctor with a diagnosis code and i can tell you it's huge business because doctors ignore that. they ignore the mentorship or minding or oversight and ignore the phone. i would say fee for service is definitely under coded. what we see is a confusion between coding and coding intensity. coding for something that is notusually there . coding intensity is what you're all talking about which is finding diagnosis that are there and have not been accounted for four pacifying more complications or just adding clinical specificity. adding clinical specificity is good for medication. there's also on the market regulators rkof program design

plans are finding more diseases or coding more diseases is more accurate d than coding complications thereof. it's incumbent upon in policymakers to get plans to do something with that information. i'm not really angry at health plans finding more diagnosis or finding more specificity and we should have debate about what degree that is accurate but if they are finding more specificity we should give them an incentive to use that information to help the beneficiaries. rather than eliminate the incentive to code appropriately. >> so it seems when we're going forward both on risk adjustment and payment we've got a lot of work to do in terms of crafting reforms for medicare advantage. i'm right about that. this is going to be areas of heavy lifting. is that right? >> i think that's right.

>> you think there's a bipartisan, could there be a bipartisan interest in reformingmedicare advantage ? or do you think there's hostility? >> that's an interesting question . you have to understand the democratic mine .th they don't like medicare advantage because those are for-profit first. they really like medicaid, i'm not sure they realize that most medicaid patients are being taken care of by for-profitmanaged-care companies . and what if they could get overthat , yes of course the two parties would come together because a lot of this is just common sense. >> there's a lot less disagreement if you look historically at the map a lot of their constituents are in the heavily concentrated

urban areas that are easier. >> more low income. >> so i think, i don't think it devises the authority. >> you're right in the medicaid market 80 percent of medicaid are in managed-care, open patients are hiring their not liking medicare being 14.2percent medicare advantage . and so it's like when we talk about premiums, competitive bidding,whatever we want to call it , the employee benefits program which we talked about in the past that's a premium subsidy program where 72 percent of the weighted average epa exchanges are also aubpremium subsidy . so what is wrong with thinking about how we can be more fiscally responsible for medicare and creating a better platform so that future generations or my

generation would have access to medicare benefits . >> generations i want to go back to doug for a moment. this is an important question . it's a simple question but i think we've already answered in a way i would like done to perhaps expand on this a little bit. the whole point of moving to a comprehensive contribution system premium support is to harness the power of consumer choice to basically enable people to make the choices that are best for them and at the same time that will drive efficiency in the healthcare system. but here's the issue. and you hear it over and over again. were talking about the population that is older, 65, 75, 80 and so on. is it a sensible strategy for older americans to make the these kinds of choices effectively? i raise this because if yyou look going all the way back to the new york times in the

90s, the basic argument against moving in this direction was that the complexity of healthcare was so overwhelming that ordinary people could not actually make these decisions and that experts only make these decisions. so you talk about this. tell us what you think about that. >> we are not asking for a senior to sit on a desert island and decide for themselves about everything in their lives. we are asking them to make important choices with trusted advisors, family members and they can talk to providers and doctors so the idea that somehow in healthcare and healthcare alone you're by yourself and your making these dcomplicated decisions it's a red herring. that's notthe reality . we make complicated decisions a lot and we don't understand the technicalaspects . we all buy these, how do they

work? so you've got advisor networks, you've got no need to be a technical expert on the thing to consume. in financial markets, we do that in product markets. we do this everywhere in the economy and those seniorsare out there making those decisions . i'm still not sure why my 90-year-old mother needs cooper many but she's got one . they're participating in other places. >> there's that glossary of respecting their ability and getting them that help they need but everyone said they will never be able to do this , it's too hard for seniors. and it has worked very well. perfectly, no very well and that's a solution to take seriously . >> you're the most natural

person for a senior to turn to for advice about y healthcare is that seniors primary physician and we muzzle these guys. during the obama years, the physician could not tell the patient if the patient was an accountable care organization as the medicare advantage plan. even under trump the doctor cannot encourages patient to join a medicare advantage plan these a member of so we need to on muzzle the doctors , who have by the way the most information about plans and how they work, what would be good for thepatient they're treating . >> you have booking.com, kayak.com, airfare, hotels. you can't even use anair b&b to reserve a house e.

we make complex decisions all the time with help from others providing appropriate information. we can and should do thatfor medicare . the thought about laying down a premium, part of premium support is treating fee-for-service, bringing them on an equal playing field. people are upset about risk adjustment, why don't we think about bringing risk adjustment to all market participants? why don't we apply star ratings to traditional medicare? none of this should be a subsidy, we need to treat that private option and preserve it for the future but that's the conversation i don't think the policy community has had. >> it's a vitally important point because we all are participating in any complex sectors of the economy for example like retirement and financial planning which most of us had limited expertise in these areas and we rely upon.

we rely upon advocates, rely upon family and friends and so on in order to make these decisions and i am told by the economists that is you guys that there are market leaders in many cases where in other words you get maybe 10 or 12 percent of the entire demand side of the equation will determine the direction of which things go and it iseems in this case, medicare advantage should be doing pretty well with regard to the rather massive increase in an romans over the last several years. >> ladies and gentlemen, i think we are coming to theend of our program . i would say this , that over the next 10 years, we're going to spend a lot more on medicare than you do today complete because of the sheer size of the senior population . and with rapid medical technology , the cost of delivering medical care ona

per capita basis will increase . so the issue is really not so much how much we spend but the ultimate issue is are we getting the best value for our medicare dollars? higher quality care at an affordable cost. higher quality care is and i think our view would be higher quality of care is not a product of better chronic central planning. our colleagues who have contributed to this wonderful effort have made the point that choice and competition, it is demonstrable. if you're interested in the details of how choice and pe competition can work improving the medicare program, check out our new book, modernizing medicare, harnessing the power of personal choice and market competition from john's hopkins university press. all good things come to an end and so is our program at

its end. please give our panelists a hand. and thank you all very much or joining us. thank you all for coming to the heritage foundation . >> let me take the liberty on behalf of the panel to thank u you . thank you very much. >> book tv every sunday features leading authors discsi their latest nonfiction books. at seven bullet: 30 p.m. from freedom fest former aclu president and new york law school professor damien strasser shares her book 8 where she argues we should combat a speech withfree speech instead of censorship . then at 8:40 5 pm investigative journalist david knight worth looks at the rise of extremist groups in the us and their impact on

democracy with his book the age of insurrection. watch book tv every sunday on c-span2 and find a full schedule on your program or watch online anytime at booktv.org. >> sunday night on two and day in her book generation san diego state university psychology professor james wyatt talks about the differences between the six generationiving in the united states . babyboomers, gen x , millennial'sgey and the pullers. she argues technological advances she generations more than anything else and explores what impacts itwill have in the future . >> we can see real divisions showing up with more people identifying at the extremes of ideology or polarization between democrats and

republicans on variousissues around race . i think it's good to know well, what does this look like overtime not just some old at one time where wecan't tell what age and what's generation and what'schanged . but look at this across decades . >> her book generation sunday night at 8 pm eastern on you and day. you can listen to q&a and all our podcastson our free app . >>