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their faced and the legacies they have left behind. c-span's "the presidents" is now available as a hard cover or e book today at c-span.org/thepresidents. or wherever books are sold. >> this is chris pope. he's a senior fellow at the manhattan institute talking about issues related to health care. what positioning was the manhattan institute take? >> we're a center right think tank. the cost of health care is a big issue that people are concerned about. a big part of my job is to really try and figure out new policy solutions to reduce costs for people. >> one of the issues that have come up as of late is this idea of medicare for all. what do you think about it on its face? >> it's assumption that why don't we buy everything for

everybody. that's essentially what the claim amounts to. i think ultimately that fails to engage with the real essence of the issue which is health care is all about tradeoffs. >> you write it's not all it's cracked up to be. tell us why. >> in this recent piece it was medicare program traditionally. if you think about the real existing medicare benefit, there are real big gaps in the medicare benefit. medicare part b which covers physician services and outpatient drugs actually doesn't have an out-of-pocket cap that people are potentially exposed to tens of thousands of dhars dollars in out-of-pocket costs which is why lots of seniors buy medigap plans. >> so are you saying it's not billion built for a medicare for all type system if millions of

people are added onto the rolls? >> what's promised under the name medicare for all is essentially providing everything to everybody amount almost no cost out-of-pocket. there's a real big gap between the reality of medicare and the proposal of medicare for all. >> could there be a hybrid of the two to make it work? >> there could. again, you have to find the money from somewhere. i think the appeal of medicare for all as a rhetoric is really saying we have a medicare program that exists. when you ne the proposals for medicare for all actually don't look much like the medicare program as it was constructed. >> this idea of a single payer health care medicare for all, asking the congressional budget deputy director about a single payer health system. >> so mr. hadley, according to

the cbo report, how much did we spent on health care in 2017? >> 3.5 trillion. >> that's annually correct? >> that was -- >> that's 2017. so over ten years if we continue to spend 3.5 trillion it would be 35 trillion. how does that 3.5 trillion which takes up 18% of our gdp compare to other peer developed countries? >> it's significantly higher. >> significantly higher than what other countries are paying for their health systems. our current system costs 3.5 trillion. it is projected to cost $6 trillion by 2027, the most in the entire world by far. yet we have 29 million people without insurance which you opponented o pointed out and another 44 million which are underinsured. is a single payer system capable

of providing coverage for everyone in achieving universal health care. yes, a single payer system could achieve universal health care. >> a single payer system can achieve universal health care. >> what do you think? >> well, i mean if you're willing to spend an unlimited amount, you can certainly purchase whatever you want. the question is how much money does that achieve for other public priorities such as education, transport, defense. already if you look at budget projections at the existing medicare program commitments and other existing fiscal commitments out there, we're going to struggle to meet what we're already on the hook for without expanding the program potentially three or four times over. >> our guest with us until 8:30. 202- 748-8000.

what did you think of the representatives' comparisons with health care provided in this country with health care provided in other countries? >> countries have very different disease burdens. the united states has higher rates of obesity, higher rates of diabetes, heart disease, cancer. our health care system has to do more just by nature of more people are coming through the door in physician offices, more people are going to hospital. we also have more hospitals. i grew up in england. england has 200 hospitals. the united states has about 5,000. now the united states of course is a much bigger country than england but it's not that much bigger. on a per capita basis the united states has four times as many hospitals as england does. we have a much higher level of intensity of care, a much greater level of access to care. if you want the cutting edge treatments and you have insurance in the united states, you can get them and no one will

really put a barrier between you and that in many cases. so there are reasons we spend more than many other countries and ultimately there are ways in which we fall short. but in terms of filling the gaps that are there it's going to mean spending more money not saving money by doing more unfortunately. >> critics of single payer will often point to the national health service in england and talk about it in dire consequences. would you agree? >> like everything i think every country is dealing with tradeoffs in health care. there is no free lunch for anybody. in britain what you tend to have is you tend to have primary care be essentially free for people to go to. the emergency room is essentially free. so a lot of services have no immediate financial burden, but then there are some high end procedures that you're just not going to be able to have access

to. some of the cutting edge treatments are just not going to be available. even things like a hip replacement or a knee replacement, you might be waiting months, maybe four or five months for a major procedure if you're able to get it at all. >> how are preexisting conditions handled? >> the distinction between whether you purchase insurance before or after you get sick is not really a relevant distinction in england because people don't purchase insurance. they're automatically enrolled. >> what's the best approach? >> i actually think that the part of the affordable care act that's worked pretty well is the entitlement part of it. it's the subsidies for people who want to go on the exchange, it's the provision for financial assistance for people with preexisting conditions. i think that part of the affordable care act has worked fairly well. >> is that sustainable, though?

>> i think the amount of people on the individual market is actually relatively small. i think this gets lost in the discussion of the affordable care act. 90% of people of working age in the united states get health care through their employers. what the affordable care act did was it really revolutionized the individual market. that's less than 10% of people. so the individual market by itself is not the biggest fiscal burden. >> this is chris pope from the manhattan institute to talk about health care issues. our first call is from mike in baltimore, maryland. >> i'd like to ask your guest, i'm for single payer. i've always had insurance through the job. i had got laid off and once i had got laid off, i didn't have insurance so i called the maryland health connection.

the process was very easy. next thing i know i'm a diabetic. when i went to go pick up my medication, i took my $40 that i usually take and by me not having a job and in between jobs at the time, it was free. i couldn't believe it. i went and got my checkups. i'm back to work now. and now i pay a certain amount a month. it was a really good thing to know that when i was down that it came through and really helped me. that's all i got to say. i don't know too much about whether it's a good thing as far as medicare for all s, but i kn one thing, this health care really works for you when you fall. >> okay. that's mike in baltimore. >> yes. i mean, i think there are many ways to think about the impact that medicare for all would have. for people who actually already

get substantial assistance from government programs, they probably receive the least change or like they probably would have the least benefit or cost one way or another. the revolution would really be for people who are on employer plans who are on individual plans who are currently in different arrangements. so if you're on a state medicaid plan especially in a state like maryland, i think relatively little would change with single payer. >> from michigan this is john in dearborn heights. >> caller: if a consumer in the health care market they get sick and go to a hospital, they are forced to buy the health care. the supplier is holding all the h leverage. i was wondering how you can possibly bring health care cost down if the consumer is forced

to buy the product? >> i think that's a great question. congress is going to be talking about this issue of surprise out of network billing. it's the fact that when you buy a normal product in most markets, you know the price before you shop around. you know different options, what they are. when you have hospital care, even scheduled care, you really don't know what the price is. you don't know what services you're going to be billed for, you don't know what the anesthesiologist is going to charge. you don't know whether they're going to be in or out of your network. this is an enormous problem. last week the house energy and commerce committee had a bill on it led by senator cassidy who had a bill later last week. i think today we're going to see a bill again on this issue of surprise billing. >> from our republican line, tampa, florida, irene, hello.

>> caller: yes. 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 doesn't matter, you are going to pay a premium from your social security for medicare, which gives you as an older person no dental benefits. a lot of people get sick because they don't really have dental health and it creates a bigger issue. but i just 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've been paying in it all this time. i'm still paying in it and the part of it where i still have to

pay a co-pay for if i have to go to the primary care doctor, a co-pay if i have to go to a specialist. i just kind of wish that someone would fully explain it to people won't think people that get medicaid everything is covered. >> okay. >> thank you, caller. >> i think that caller did a great job, actually. that's exactly how it is. medicaid is actually in some ways more like what the proposals for medicare for all look like. medicaid covers most coverage. it really depends on the state but there is essentially no cost sharing, no out-of-pocket payments in the medicaid program. but for seniors there are substantial co-pays, substantial coinsurance, there's deductibles and premiums only associated with part b. i think the thing to bear in mind with medicaid is there is a

reason why medicaid can be so generous. that program is a very much targeted subset of the population. we need to target at the disabled, children, low income, elderly. if we tried to do the same thing for absolutely everybody in society, there's no way we could be as generous in terms of benefit coverage and in terms of access to care for the neediest sections of the population. >> they asked one question, did they support or oppose medicare for all in which a system where all americans got health insurance. 65% of those supporting it, 27% of those opposing it. asked when they oppose medicare for all, that dropped. only 555% of those supporting i. what do those numbers tell you? >> i think americans generally like having choice and being

able to be in control. there's certainly an aspect of medicare for all where the government would be in charge of all the money. the government would be in charge of choosing which doctors and which types of procedures you get covered and paid and if the government decides that certain procedures and certain types of care are not going to be covered, then people are just going to be out of luck. that's something that really is going to be challenging for selling a medicare for all proposal and i think people very much do value the access to care that they're currently able to get. >> from massachusetts on our line for democrats, mary you're on with our guest. hi. >> caller: yes. hello. i'm calling from massachusetts. am i still on. >> you're on. go ahead. >> caller: oh okay. i just want to say medicare has worked out great for me. i get a supplement so i don't

have to pay anything. i've had all kinds of procedures over the years with cataracts and some specialized eye surgery for glaucoma and hip replacements and all the things that happen when you get older. with the supplement it's about $195 a month now. for me, it's been perfect. i've lived in the same area my whole life. everybody i know seems perfectly satisfied. i still know a lot of people i knew when i was very young and i haven't heard any complaints at all that i can remember. so i think medicare has been fabulous. >> okay. thanks for sharing your experience. >> i think that certainly

reveals something really important about the medicare program which is that it's a very, very generous benefit provided by taxpayers to the elderly. we understand that the elderly retirees and the disabled who are in the medicare program are unable to work. so taxpayers fund about 60% of the benefit. it's essentially a 60% subsidy of the costs of your health care that you get when you become eligible for medicare. that's obviously a very, very generous proposition for a subsection of the population. >> there was kaiser health news tells us that this week there was a hearing taking a look at something known as junk insurance plans. tell us about the nature of these hearings. >> this is relating to the affordable care act. the trump administration made available plans that were essentially restoring plans that existed prior to the affordable

care act. they're essentially about half the cost of the plans you can get through obamacare. president obama obviously famously said if you like your health care plan, you can keep it. so that rule was restoring the choice of plans that people previously had. >> as far as the plans themselves, are you an advocate for them? >> i'm very much an advocate of these plans. my view of what the affordable care act did at its core was it said insurance has to be priced the same for people who sign up before they get sick as sign up after they get sick. the first couple years after the aca went into effect was people started waiting to get sick before they purchased insurance. that means premiums started spiraling upwards. even though the subsidies attached to the affordable care act plans protected these people who were enrolled from

catastrophic expenses, people who were willing to sign up before they got sick really had in access to affordable coverage. if you think of the average obamacare plan, the benchmark premium is something like $5,000. and then you're facing another deductible on top of that of $4,000. so it's like $9,000 boyfrieefor you're getting any real services or care. wa these pl these plans of the trump administration basically restore essentially health insurance priced to the risk before you get sick. the insurance benefit is essentially the same. >> there's a legislative evident to push back against this plan. one of the signers says junk plans lead to higher premiums and reduce access to quality care for millions hurting seniors and those with

preexisting conditions the most. plans don't even cover basic benefits like prescription drugs or mental health services. >> that's not true. the vast majority of them in fact do. when you look at the coverage that people are able to get, it actually makes it more affordable to get a more comprehensive benefit package. the junk insurance line is really kind of a political attack. it's become a partisan thing. in terms of the quality of the benefits, these are the traditional insurance plans that americans were used to before the affordable care act. >> let's hear from tony, denver, colorado, independent line. >> caller: good morning. a lot of the democratic candidates are talking about medicare for all plan. buttigieg talks at the idea of putting the plan out there and letting people buy into it as a glide path as opposed to just changing the system.

my question is this, if somebody wanted to buy the plan or even a company wanted to buy it for coca-cola for all 20,000 employees, what would the monthly premium be for medicare? do you have any idea? >> that's actually a far more complicated question than i think a lot of the democratic candidates realize at the moment. for seniors who aren't entitled to medicare because they immigrated to the country or they didn't contribute enough to social security, there actually already is a medicare buy-in option. the premium for that is about $900 a month which is twice as much as the average plan you'll find through the affordable care act. so the actual buy-in setup already exists for the people who aren't directly eligible for medicare is actually not that great a deal. >> your second question, caller? >> caller: people are under the

perception that i'm entitled to medicare because i paid into it as part of my payroll taxes for all the time that i worked. is there a statistic that says when the average person has exhausted all the money they have contributed? at what age have you exhausted all your contributions and then after that you're being picked up by the taxpayer? >> so i mean, i think that's -- there is a sense in which, yes, people do quote contribute. but the way in which they contribute is essentially through paying taxes. it's fair enough to think about the medicare program as essentially funded through taxes. that's especially true for medicare part b and part d, the prescription drug benefit. that's entirely funded out of general revenues. it's only for medicare part a that it's funded through a sort of dedicated medicare tax and that's really just a payroll tax. >> this is deedee from oakland, california, republican