the reviews are in the presence but. recently topped the new york times new and noteworthy,. it is called a maia post in the ever-changing reputation. and from the new york journal of books, it makes it fast and engrossing read. and with father's day fast approaching, it makes a great gift. read about how historians rank the best and worst chief executives from george washington to barack obama. explore the life events that face our leaders and the legacies they have left behind. is now available as a hardcover today on c-span.org. or wherever books are sold. nion >> itthis is chris and he is a

senior fellow talking about issues related to healthcare. but thank you for inviting me. >> the manhattan to do, will positioning does it take a issues of healthcare? >> we are at think tank and the cost of healthcare is a big issue. and part of my job is to try to figure out new policy solutions. >> now to the issues that come up as of late not only in the presidential race, but the idea of medicare for all, what do you think about it on its face. >> it is an assumption of what we buy everything for everybody. that is with the claim amounts to i think ultimately fails to engage with the issue and that is all about trade-offs. >> tell us why? >> in this recent piece it was about the medicare program

traditionally. if you think about the real existing medicare benefits, there are big gaps in the medicare benefits. medicare part b, which covers outpatient drugs does not have an out-of-pocket cap. people are potentially exposed to tens of thousands of dollars of out-of-pocket costs, which is why seniors by medicare got plans. also in part b the cost sharing is quite substantial on prescription drugs and in many cases more than what people might be used to paying for plans that are available. >> so are you saying it is not billed if people were added on to the roles? >> medicare is a benefit and what is promised is providing everything to everybody at almost no costs. there is a real big gap between the two, the reality of medicare and the proposal of medicare for all. >> to be a hybrid of the two to make it work?

>> there could but you have to find the money from somewhere. i think the appeal of medicare for all as rhetoric is really saying we have medicare programs that exist, but it is finding a way we can do these things but when you leave from there to the proposals, the proposals don't look that much like the medicare program >> there was a hearing yesterday and one of the discussions came up with the idea of a single payer healthcare. it was pramila jayapal and she was asking about a single pair healthcare system and can respond to those? >> how much did we spend on healthcare in 2017? >> 3.5 trillion. >> and how does that $3.5 trillion, and that is annually, correct? >> that is 2017. so over 10 years. it would be 35 trillion and we

will talk about that in the second. how does that which takes of 18% of our gdp compare to other pure developed countries? >> significantly higher. >> so the current system cost 3.5 chilly and it is expected cost 6 trillion by 2027 and most in the entire world by far and we have 29 million people without insurance, which you pointed out in your report and another 84 million who are underinsured almost 1/4 of the country, the richest country in the world, is unable to access healthcare. is a single-payer system capable of providing coverage for everyone and achieving universal healthcare? >> yes. a single-payer system could achieve universal healthcare. >> that is a yes. a single-payer system can achieve universal healthcare. >> those of the questions. what do you think? >> if you are willing to spend

an unlimited amount, you can certainly purchase wherever you want. the question is how much money does it achieve for other public priorities such as self- education, transfer, defense, if you look at budget projections of the existing medicare amendments and other physical commitments, we will see struggling without expanding the program three or four times over. >> our guess is with us until a:30. if you have questions, you can call us what did you think of the representatives comparisons with healthcare providers in this country and other countries? >> they differ in some the different ways. they have very different diseases. the u.s. has twice the rate of obesity than many other countries do. we have high rates of diabetes

and heart disease and cancer. and so our healthcare system has to do more. by nature of more people coming through the door and more people going to hospitals, we also have more hospitals. i grew up in england and england has 200 hospitals. u.s. has about 5000. the u.s. is a much bigger country, but it is not that much bigger. the u.s. has four times as many hospitals as england does. we have a much higher level of intensity of care and a much greater level of access to care. if you want cutting edge treatments and you have insurance in the u.s., you can get them and no one will put a barrier between you and that many cases. so their reasons we spent more than other countries and ultimately their ways in which we fall short. in terms of going in the gaps, it means spending more money not saving money by doing more.

>> critics of the single-payer will point to the national health service in england and would you agree with the assessments? are there benefits and liabilities? >> like everything i think every country is dealing with trade-offs in healthcare. there is not a free lunch for anybody. in britain what you tend to have is primary care and it is essentially free for people to go to. emergency rooms are free and a lot of services have no immediate financial burdens, but then there some high-end procedures that you will not behave full to have access to. some of the cutting edge treatments are not available and even things like a hip replacement or knee replacement, there might be a very substantial weight and you could wait months for major procedure. if you are able to get it at all. >> how are pre-existing conditions handle? >> the distinction between

whether you purchase insurance before or after you get sick is not really a relevant. people don't purchase insurance. there automatically enrolled. >> although this is a major issue here, what is the best approach? >> i mean, i think that what works well is the entitlement part of it. subsidies for people who want to go on the exchange and the provision of financial assistant. people with pre-existing conditions can by plans i think that part has worked fairly well. and should be allowed to continue. >> is it sustainable? >> the amount people on the individual market is relatively small because it gets lost in the discussions, 90% people of working age in the u.s. get healthcare through their employers. but if portable care act revolutionized the individual market and that is less than

10% of people. so the individual market is not the is fiscal burden is most people on in it when where the other. >> this is chris paul to talk about healthcare issues. this call comes from mike in baltimore. your on with our guest.>> i am a single-payer and i have always had insurance through my job. i got laid off and once i was laid off i did not have insurance and i called the maryland health connection and the process was easy and the next thing i knew i am a diabetic and i went to get my medication i was in between jobs at the time and it was free. and i could not believe it.

i would get my checkups and i'm back to work now and now i pay a certain amount each month and it was really good thing to know that when i was down, it came through and it helped me. and that is all i wanted to say. i don't know too much about whether it is a good thing as far as medicare for all, but i know that this healthcare works for you when you fall. >> that is mike in baltimore. >> i mean, i think there are many ways to think about the impact that medicare for all would have. for people who already get substantial assistance from government programs, they would probably say the least change and they would have the least cost swimwear the other. the revolution would be for people who are on employer plans and individual plans were currently in different arrangements and so if you are

on the state medicaid plan, especially state like maryland, relatively little would change with single-payer. >> from michigan, this is john. >> yes, thank you. i had a quick question. if the consumer in healthcare market when they get sick and go to hospital, they are forced to get healthcare and they are going into the shoe store the restaurant and the supplier is basically holding the leverage. i was wondering how can you possibly cost down to consumers to buy the product?>> i think that is a great question, especially now that congress is to be talking about that today which is the issue of out-of- network billing. it is the fact that when you buy a normal product in most market, you know the price before you shop around and you know different options and what they are. we of hospital care, even scheduled care, you really

don't know what the prices and you don't know what services you will will for you don't know how much the anesthesiologist will charge and you don't know if they will be in or out of your network and this is an enormous problem that we will see.>> the administration made some efforts on the. >> and last week the house energy and commerce committee had a bill on that led by senator cassidy and i think later on today we will see the pensions committee have a bill on this issue of surprise billing. >> this is tampa florida and this is irene. >> good morning. i would like to say this. medicare for all sounds great, but i wish that you would have a program explaining that once you turn 65, it does not matter.

you're going to pay premium from your social security for medicare, which gives you the dental benefits. there are a lot of people like it sick because they don't have dental health and it creates a bigger issue. but i wish that someone would explain. i started working when i was 16 years old. when medicare first came on the market, when it was just put in place, i worked 40 some years, so i have been paying into it all this time. i'm still paying into it and the part where i still have to pay a co-pay first, i have to go to the primary care doctor, a co-pay if i have to go to a specialist, i wish that someone will fully explain that so people that get medicaid,

everything is covered.>> we will let our guest explain that. >> i think that color did a great job. that is exactly how it is. medicaid is more like what the proposal looks like. it covers most coverage and depends on the state. there are essentially no cost- sharing or out of pockets in the medicaid program. the for seniors, there are substantial co-pays and coinsurance and there is deductibles and premiums associated with medicare part b. the thing to bear in mind is that there is a reason why can be so generous and that program is very much targeted to population and we try to target to a subset of the population to children in low-income elderly. for people who if we tried to do the same thing for everybody in society, there's no way we

could be as generous in terms of adequate coverage and access to care for the needy are sections of the population. >> a poll asked if they supported or opposed medicare for all. 65% supported it and 27% opposed. when they oppose medicare for all in the system that would eliminate private health insurance companies through the medicare system, that dropped. 34% opposed. what do those numbers tell you? >> americans like having a choice in being able to be in control and there is certainly an aspect to medicare for all where the government would be in charge of all the money. the government would be in charge of choosing which types of procedures get covered and paid and if the government decides about a procedure is not going to be covered, then

people will be out of luck and that is the thing that will be challenging and i think people value the access to care that they are currently able to get.>> from massachusetts. mary is on. >> hello. i'm calling from massachusetts. >> you are on. go ahead. >> okay. i just want to say that medicare has worked out great for me. i don't have to pay anything and i have all kinds of procedures over the years. with cataracts specialized eye surgery for glaucoma and hip replacements.

and all the things that happen when you get older. and this is about $195 a month for me. it has been perfect and i have lived in the same area my whole life. everyone i know seems perfectly satisfied. when i was very young i've not heard any complaints at all that i can remember. so i think medicare has been fabulous. >> thank you for sharing your experience. >> i think that reveals something important about the program and it is has a very generous benefit provided to the elderly. we understand that those who are in the medicare program are unable to work and so taxpayers fund about 60% of the benefits.

it is a 60% subsidy of the cost of the healthcare that you get when you become eligible for medicare. that is a very generous proposition for needy subsection of this population. we would not be able to provide as generous assistance to everyone across the board. >> made them. >> this is really relating to the affordable care act. the trump administration made available plans essentially restoring plans that existed prior to the affordable care act. they were essentially at half the cost of the plans you can get epthrough obamacare. the president said if you like your health care plan you can keep it and that was restoring the choice of plans people previously had. >> as far as the plans

themselves are you an advocate or are you opposed? >> i am very much an advocate, what the affordable care act did was it set that insurance has to be the same for people who sign up before they get sick as well as people that sign up after they get sick. that means premiums started spiraling upwards because the only people buying insurance were the ones with serious medical conditions. even though the subsidies that were -- plans protected these people who were involved from catastrophic expenses people who were willing to sign up really had no access to affordable coverage. think of the average cost of the plan, the benchmark premium is $5000 then you are affecting

another deductible on top of that, that is like $9000 before you are getting any real care. what these plans that the administration made available they restore health insurance price in proportion to the rest of what you pay and you can sign up before you get sick. we have premiums esthat are abo half the levels of obamacare becoming available but the benefit is essentially the same. >> what have been the legislative efforts to push back, it says the junk plans reduce access to quality care for billions including seniors and those with pre-existing conditions. the trump administration to expand these incomplete plans that don't even cover basic benefits -- >> some of these plans may not but the vast majority when you look at the coverage people are

able to get it makes it more affordable to get a more es comprehensive package, the junk insurance line is a political attack because it has become a partisan thing. these are the traditional insurance plans that we were used to before the affordable care act . >> good morning. i have a couple of questions i want to ask, a lot of the democratic candidates were talking about medicare for all and the idea of putting a plan out there and letting people by into it as a way to just as opposed to changing the system. if somebody wanted to buy the plan or even a company wanted -- coca-cola for all 20,000 employees what with the monthly premium be for medicare?

do you have an idea? >> that is a more complicated question than i think a lot of the candidates realized. currently for seniors who aren't entitled to medicare because they immigrated or they didn't contribute enough to social security are actually there already is a medicare buy- in option. it is actually twice as much as the average plan you will find. the actual buy-in already exists for the people who aren't directly eligible is not that great a deal. >> your second question color? >> people are under the perception that i am entitled to medicare because i paid into it as part of my payroll taxes while i've worked. is there a statistic that says when the average person has exhausted all of the money they have contributed, at what age have you exhausted all of your contributions and then after that you are being picked up by

the taxpayer? >> i think there is a sense in which yes people do quote contribute but the way in which they contribute is through paying taxes and it is fair enough to think about the medicare program which is essentially funded for taxes. that is especially true for medicare part b and part d the prescription drug benefit. if only for medicare part a that it is funded dedicated medicare tax which is really just a payroll tax. >> hello. -- you should do it more often. i am in california and -- california where it is services open to you.

many -- companies that offer insurance hospitals, doctors and pharmaceuticals. they want the highest profit on and thousands of percentage increasing drug prices and hospitals and then the government also planned there is lobbying in the billions but they don't want the status quo to change. there has to be a middle ground where you can have access to healthcare. in california if you have a good healthy lifestyle you definitely have the benefit of access to mental health, yoga and exercise and preventive care, prediabetic classes and

get yourself healthy with a very affordable instead of the thousands of dollars that we used to partnership between the government -- >> okay caller thank you. i think that raises some interesting questions. one point i think osit's lost i that the heart of the cost battle in healthcare is really the battle between the providers like hospitals and doctors on the one side and the insurers on the other side. the insurers make such a good bad guy. everyone knows the hospital -- no one feels affectionate to the insurer. i think through the decades the politicians have lined up very much and said especially and

that has made it very hard over decades for insurers to negotiate a good deal with hospitals for hospital care and the hospital practice has been soaring as a avresult of that. obviously the money the insurers have to pass on the cost to the people that want to purchase insurance. the fact that insurance had been weakened so long in negotiations with hospitals has essentially left the consumer without any direct protection from the cost or essentially paying the price for their weak negotiating power. >> we've seen efforts from the white house and democrats and republicans on lowering prescription drug costs, is that a good effort do you think? >> i think it is complicated in a sense that, yes prescription drugs are very expensive but the reason they are expensive is because they are very valuable. innovative prescription drugs

we could easily save ourselves money. i think the important thing to bear in mind is -- there is the generic drug market and the new branding drugs which have just been developed over recent years. 90% are drugs americans consume are generic drugs which price really isn't a problem. these are competitive and there is no -- expired and cost is pretty much at a stable rate. the price problem really is on the brand of drugs. these to develop and research and bring to market and get through the regular process. the question is how do you spread the cost of that $3 billion research and development and then end up in the price drugmakers have to challenge during that short window when clthey have some as

result --? >> he is the senior fellow talking about healthcare issues manhattan institute thank you for your time.