Title: The cure that costs less, Prof. Sean Flynn (0:00) This guy said Singapore and he also said (0:02) they were delivering the best care in (0:03) the world at the lowest cost. And of (0:05) course, that's not a combination an (0:07) economist normally believes, right? You (0:08) don't get a Rolls-Royce at a Honda (0:10) price. We're spending about three times (0:12) as much as we should be on nearly (0:14) everything in the system. Just massive (0:16) waste, fraud, and abuse. Single player (0:18) is a disaster for quality of care, drug (0:21) development, innovation. Josh has the (0:24) time as a direct primary care physician. (0:25) and they only have patient pounds of (0:27) maybe 600 to um actually text the guy (0:29) every day till he's taking his metformin (0:31) and he's conforming and you know (0:33) actually doing what he should and then (0:35) in Josh's perspective just like the (0:37) Chinese doctor who got paid when (0:38) someone's healthy Josh gets 75 bucks a (0:41) month for doing nothing right because (0:43) that guy's healthy Josh gets paid when (0:46) and he makes his profit when that guy's (0:47) healthy and that's the kind of healthare (0:49) system we need to set up and we could (0:51) free up about $3 trillion a year every (0:53) year forever that could pay down the (0:55) federal debt that could fix the deficit (0:57) that could, you know, any public program (1:00) you want to spend money on, whether (1:01) you're on the left or the right (1:10) [music] (1:15) [music] (1:21) [music] (1:28) Welcome everybody. I'm honored today to (1:30) have Professor Shan Flynn. He is uh (1:32) economics professor at uh Scripps (1:35) College which is one of the Claremont (1:36) colleges um eastern part of LA County (1:39) and so forth. Um, and it's a beautiful (1:41) spot out there. And he's really talking (1:43) about a amazingly important issue. Our (1:46) our overpriced health care system, our (1:48) bloated healthcare system. And there's (1:50) probably, you know, it's arguable, but (1:52) there's probably no bigger domestic (1:53) strategic issue for the USA today than (1:55) the high cost of healthare. Now the fact (1:57) that the USA spends four times more than (1:59) Singapore which is uh something (2:00) professor Flynn has noticed uh on health (2:03) care is in comparative terms yet (2:04) achieves four to five years fewer of (2:06) life expectancy is a sign that something (2:08) is fundamentally wrong with our health (2:10) policies. I came across your work uh (2:12) yesterday excuse me recently through um (2:14) Sanjie Sopllock a friend of mine uh (2:17) health economist um in Australia and I'm (2:19) delighted to have you explain why the (2:20) USA performs so badly and how Singapore (2:22) has managed such an effective and (2:24) efficient system. We know that Lee Kwan (2:26) Yu uh I believe the late um uh Singapore (2:30) leader and president and frankly (2:32) interesting thinker consciously rejected (2:34) both the British and the American (2:35) system. Singapore thereafter designed (2:37) its own system from scratch. U clearly (2:40) they have the right incentives both for (2:41) consumers and market participants (2:43) enabling a stupendous performance. We (2:45) don't want to copy their system but (2:47) surely there are some useful principles (2:48) we can adopt and to it you have an (2:51) excellent book on this topic of which (2:52) I've read a good part but not in full. (2:55) Uh so that's a kind of a long intro. Uh (2:57) tell us a little about how you uh landed (2:59) on Singapore and what are your interests (3:01) both economically and in the healthare (3:03) system. (3:05) >> Well so thank you doctor. Um great to be (3:08) on uh just to jump right in. I (3:11) accidentally became maybe America's (3:12) biggest expert on Singapore's healthcare (3:14) system because a Rotary Club in (3:16) Claremont asked me to do a presentation. (3:18) It was about 6 months before Obamacare (3:20) got passed, the Affordable Care Act. (3:22) This would have been November of 2009 (3:26) and I needed a topic because I was asked (3:28) to do this on short notice. There (3:29) happened to be an op-ed in the Wall (3:31) Street Journal um the day before the (3:34) talk I was supposed to give and it (3:36) argued that both political parties both (3:38) the Democrats and the Republicans should (3:40) look at Singapore as the optimal foreign (3:44) you know guidepost um you know thing we (3:46) could learn from rather than the normal (3:48) suspects which are Canada and England (3:51) like even today if you go into a school (3:52) of public health um you know they're (3:54) teaching first year master students or (3:56) something or even the undergrads they'll (3:58) only usually usually talk about Canada (4:00) and um the UK maybe a few words here in (4:03) Germany or North Korea does or South (4:05) excuse me not North Korea South Korea (4:06) does something nice with billing but um (4:08) this guy said Singapore and he also said (4:10) they were delivering the best care in (4:12) the world at the lowest um costs um and (4:15) of course that's not a combination an (4:17) economist normally believes right you (4:19) don't get a uh a Rolls-Royce at a Honda (4:22) price right that's not what you're (4:23) expecting highest quality and lowest (4:25) prices but I went online the World (4:27) Health Organization has a huge huge (4:29) database of uh comparison statistics for (4:32) every country in the world and (4:33) everything I could get online said that (4:35) it was true. Singapore really was (4:37) running the most efficient, lowest cost (4:40) um and best outcome healthcare system in (4:42) the world usually and you know I' I've (4:44) now seen 20 years of decades of (4:46) statistics but usually in their top (4:48) three in life expectancy maternal (4:50) mortality infant mortality and they're (4:53) by far at the lowest cost. So whereas (4:55) I'm sure your audience is aware of this (4:56) since they keep up with health stuff. (4:58) We're spending about 18% of GDP of (5:00) national income on healthcare, Canada, (5:03) England, France now they're usually in (5:04) the 12 13% um sometimes 11 if they're (5:08) doing well. Singapore has been under 5% (5:10) throughout its history and I think it's (5:12) at maybe 4.6% right now. And what's even (5:15) more shocking about that, they have (5:17) mandatory health savings accounts which (5:19) means they've got so much money in their (5:21) health savings accounts. They're the (5:23) only country in the world that will not (5:24) have to unplug granny in 20 years (5:26) because their, you know, Medicare system (5:28) is going to run out of money like ours (5:29) is, right? And so they've got both a (5:32) secure system, a sustainable system, and (5:34) the most efficient in the world. And (5:37) over the subsequent five or six years, (5:39) um, Dr. Black, I ended up, you know, (5:41) even being a guest of the Singapore's (5:43) government and having a three-hour talk (5:44) with the Ministry of Health and seeing (5:46) all their different levels of health (5:47) care systems from the basic public (5:49) health up to the top. And it all checked (5:51) out. And what's really remarkable, let (5:53) me end here before um I just keep going (5:55) on and on. I love Singapore's healthcare (5:57) system, is um that they're very honest. (6:01) They send uh you know um experts out (6:04) every year um to go see best practice (6:06) around the world. And so everything (6:08) they've done there, they borrowed from (6:10) somewhere else. Um and they'll admit (6:12) that they just put it together properly. (6:14) And a lot of it was from the United (6:16) States, whether it's price tags because (6:17) they've got really competitive (6:18) healthcare. an American invented price (6:21) tags, you know, back in about 1850. Um, (6:23) health savings accounts. Um, you may (6:25) have had John Goodman on, the economist. (6:27) He invented health savings accounts. (6:28) He's still alive. He invented them in (6:29) the early '7s. Um, basically all the key (6:33) components of Singapore's system we have (6:35) here, we've never put them together (6:37) properly. Um, and so that that makes it (6:40) even more of a tragedy that we are (6:42) spending so much to so little effect. As (6:44) you pointed out, you know, our life (6:45) expectancy is five, six years less than (6:47) Singapore and Japan. Um, and we could do (6:50) so much better. And we could free up (6:51) about $3 trillion a year every year (6:54) forever. That could pay down the federal (6:56) debt, that could fix the deficit, that (6:58) could, you know, any public program you (7:00) want to spend money on, whether you're (7:02) on the left or the right or just lower (7:04) taxes. Some people on the right just (7:05) want to lower taxes. Um, yeah, there's (7:08) money for it if we fix the health care (7:10) system in ways that are known to (7:11) actually work and which we invented, (7:13) which is the really embarrassing part. (7:17) So in the green room we were like making (7:19) a reference to the Beatles and as you (7:21) were talking I was thinking not about (7:22) the Beatles but the Rolling Stones and (7:24) the great philosopher Mick Jagger in (7:26) satisfaction said you can't always get (7:28) what you want. You can try sometime you (7:29) just might find you get what you need. (7:31) Um it's not quite a apt but obviously um (7:35) if if Singapore is paying a quarter of (7:37) what we are paying they're going to be (7:39) fewer things purchased I assume on some (7:42) level. um what what are the things you (7:44) know getting to you know satisfaction (7:46) lyrics um you might just you know can't (7:49) always get what you want but you just (7:51) might find you get what you need it (7:53) sounds to me as if that is kind of the (7:55) general economic proposition we have for (7:57) all kinds of other products um you know (8:00) I might want to have I don't know a (8:02) codery of five different cars sports car (8:05) um you know uh an SUV I don't know but I (8:07) have to pick up one because I only have (8:09) a certain amount of economic bandwidth (8:11) to do what I want to do um if Singapore (8:14) is paying a quarter, you know, what are (8:16) the things that they're not getting or (8:18) are they just getting everything at a (8:19) more efficient price? (8:21) >> Okay, so that's that's the latter more (8:24) more so the latter than any of the the (8:26) things you said earlier. Let me let me (8:27) try and unpack that a little. Um we (8:29) normally think and the following is true (8:32) in a competitive system where things are (8:34) competitive like the price of wheat. Um (8:36) if you're in a competitive system, then (8:38) price will be almost identical to cost. (8:41) And by cost, what you mean is how much (8:43) does it take to actually get something (8:45) done or to purchase something or to grow (8:47) something or to build it. Um, but (8:50) there's often big gaps between price and (8:52) cost. A monopoly is the closest thing, (8:54) right? Um, does it actually take $1,200 (8:56) to make an iPhone? No. Apple has 40% (8:59) margins, right? They can do this because (9:01) they've got a great public brand and (9:02) stuff, but the price of an iPhone is (9:05) well above the cost. Now, flip that (9:08) around to supermarkets. A typical (9:09) supermarket has a 1% margin, right? (9:12) Their prices are only about 1% higher (9:14) than their cost. So, there's certain (9:15) industries in which there are these big (9:17) gaps between price and cost. And there (9:19) are these other industries where um (9:21) there's almost no gap. If all of (9:24) healthcare were more like supermarkets (9:26) where there's these really thin margins, (9:29) then you'd have to say, well, if you're (9:31) spending less at a supermarket in one (9:34) supermarket than another or one country (9:36) than another, like say supermarkets in (9:37) Singapore, St. marks in the United (9:39) States, then yes, the only way to uh (9:42) spend less money if the, you know, price (9:44) equals cost and the costs are basically (9:46) the same everywhere, um is is to (9:49) actually buy less. You have fewer (9:50) apples, right? You you have fewer pounds (9:52) of beef um at a supermarket. But if (9:55) you're going from Whole Foods to (9:58) Walmart, (9:59) you can actually because the uh the (10:02) prices at Walmart are lower than the (10:04) prices at Whole Foods. And you know, the (10:07) quality is basically the same. nothing's (10:08) going to kill you. And you can get (10:09) organic stuff at Walmart, but the (10:11) markups are so much higher at Whole (10:13) Foods that um you could take your (10:15) hundred bucks at Whole Foods, go over to (10:17) Walmart, and actually come out with more (10:19) food. Another thing you could do is only (10:21) spend $50 instead of a hundred at (10:23) Walmart and still maybe come out with (10:25) almost as much food as you did at um at (10:28) the uh Whole Foods. So what Singapore (10:31) has done basically is is set up a highly (10:34) competitive health care system where (10:36) competition like with supermarkets, (10:38) right? The supermarkets, it's not (10:39) they're not being nice by, you know, (10:41) only having 1% markups. They're forced (10:43) to do that because there's such intense (10:45) competition between the supermarket (10:46) chains. Um that Singapore's basically (10:49) got that same level of intensity of (10:50) competition in its health care system. (10:53) So that the markups are very small. Um, (10:56) and so when you see the price lower over (10:58) there, you really could take a bunch of (11:00) money from the United States, go over to (11:01) Singapore, and buy more stuff than you (11:04) can in the United States. It's not that (11:05) the only way to get the lower (11:07) expenditures in Singapore is by cutting (11:09) back on the actual number of surgeries (11:11) and, you know, bottles of aspirin or (11:13) something like that because they've (11:15) eliminated these massive um, up (11:17) markings, these, you know, you I don't (11:19) want to say capitalist greed or anything (11:21) ridiculous like that, right? But they've (11:23) got a system where the price and the (11:25) cost are nearly identical, highly (11:27) competitive, the prices are low down (11:28) with the cost level rather than, you (11:31) know, the cost being low and the price (11:32) is high like going to Whole Foods Market (11:34) or something like that. And because of (11:35) that, you really aren't cutting back. (11:38) And so, you know, you can look at things (11:39) like um and now there are some places (11:41) where they are more efficient um in the (11:45) sense that they've got fewer doctors per (11:47) capita than the United States. They've (11:49) got fewer nurses per capita. They've got (11:52) slightly fewer dentists per capita. Um, (11:55) but it's not like they're, you know, (11:57) people there are can't find a doctor. (11:58) Actually, the wait times are shorter in (12:00) Singapore than they are in the United (12:02) States for all those things. There is no (12:03) nurse shortage or something. It's just (12:05) they've got a system that works really (12:07) efficiently. So, for instance, doctor, (12:09) um, my mother retired from Kaiser (12:11) Permanente as an eye surgeon. One of the (12:13) things that drove her out about I don't (12:15) know it's been 16 17 years but they got (12:17) Epic right which is this coding billing (12:20) system and when they first got it in (12:23) there were like 140 pull down menu so (12:25) anytime she saw a patient and you know (12:26) these are routine patients they're just (12:28) coming in nothing's actually wrong she (12:30) would have to fill out 140 different (12:32) things including for the men whether (12:33) they were pregnant or not right so (12:35) within six months Kaiser had to hire (12:37) what are called scribes which are people (12:39) with whose only job is to pull out the (12:42) do the pull down forms while the doctor (12:43) talks to the patient, right? Massively (12:46) inefficient. And yet when all these (12:48) electronic data systems were rolled out, (12:50) it was claimed by the advocates, oh, (12:53) with all this information science and (12:55) data informatics, the healthcare system (12:57) will save a huge amount of money, right? (13:00) That wasn't true because you had to hire (13:01) all these other people just to do the (13:02) pull down menus. Um, and so we've (13:05) managed to run, and here's the key part, (13:08) largely because we've created a system (13:10) where the prices are so far above the (13:13) cost, a system where nearly every (13:16) hospital administrator, government (13:18) public health person, um, you know, (13:20) someone running Indian medicine for the (13:24) Department of Interior, everyone can be (13:27) massively inefficient because they've (13:30) got don't have the pressure of actual (13:32) competition. and having to keep prices (13:34) down. And so I would argue the exact (13:37) flip of what you set up there, doctor, (13:38) which was a great setup, which is that (13:40) we have created a system where we are so (13:44) inefficient, right, in spending money (13:47) that it and we've so forgotten that the (13:49) price are way above the cost that we (13:52) think as a public policy thing whenever, (13:54) you know, say um it's usually the (13:56) Republicans, we're going to instead of (13:58) having 4% per year Medicare growth, (14:00) we're only going to have three. Everyone (14:02) starts screaming because they think, (14:04) well, the only way to reduce the (14:06) expenditure is to actually reduce the (14:08) number of surgeries and the number of (14:10) doctor visits and this and that, the (14:12) actual quantity of stuff purchased. But (14:14) that's not true when you have a vastly (14:16) inefficient system like like ours. And (14:18) and quite frankly, if you take Singapore (14:20) as the comparison point rather than (14:22) Canada or England, we're spending about (14:25) three times as much as we should be on (14:26) nearly everything in the system. just (14:28) massive waste, fraud, and abuse in (14:32) incredible like 10,000% markups on (14:34) generic drugs because there's these (14:36) we've set up a monopoly system for (14:38) distributing the drugs. Um, and so it is (14:41) not the case, and I want to be very (14:42) emphatic about this, it is not the case (14:44) that you would have to cut back on (14:47) services 75% if you cut back on (14:49) expenditures. If you cut out the three (14:52) 10,000% markups on certain drugs and all (14:54) these other things where we've gotten (14:55) really inefficient, you could have both (14:57) lower expenditures and just as much and (15:00) perhaps even slightly more um actual (15:03) medical services being delivered, (15:05) especially to the the poor. That's, you (15:06) know, if we have time later, Singapore (15:08) has created the world's greatest social (15:10) safety net for health care. Um and uh no (15:13) wait times for the poor, same access, (15:15) same doctors. Um it's absolutely (15:18) amazing. But they could afford to do (15:20) that because they created a competitive (15:22) system where the price were driven down (15:24) the cost level. Here in the United (15:26) States, when Medicare or Medicaid goes (15:28) in to pay for something for an indigent (15:31) person, um they pay the almost identical (15:35) outrageous quote unquote market prices, (15:37) these chargemaster prices that we have (15:39) in our system, these bloated prices. (15:41) Singapore, since all prices, both public (15:43) and private are kept low by competition, (15:46) the government goes in and can buy stuff (15:48) for indigent people really, really cheap (15:50) without the 10,000% markup on the (15:52) generic drugs and things like that. And (15:54) so that's how you do it. You actually (15:56) need the intense competition. But and (15:59) the real trick here with Singapore, they (16:01) also built the world's greatest safety (16:02) net. They didn't create a two-tiered (16:04) system where the rich get stuff for (16:06) cheap and they can afford it and the (16:07) poor get nothing. It's not like that at (16:09) all. everyone gets the same level of (16:11) service. The government steps in. (16:13) There's actually um buds people hired by (16:15) the government with like sociology (16:17) degrees at every hospital um to actually (16:20) guide people through all their benefits (16:21) and make sure they get everything and (16:23) that the government will pick up the (16:24) bill. It's absolutely amazing. (16:26) >> So, there's a lot there. Um (16:29) [clears throat] I'm going to have to, (16:30) you know, relist to this uh video um (16:33) audio later because there's so much to (16:35) unpack. But obviously, the book is there (16:37) as well. we're going to get into the (16:38) book and how people can find it and find (16:40) you and so forth. Uh on a personal note, (16:42) I mean obviously I'm a physician and (16:44) I've had some thoughts about this stuff. (16:45) I, you know, I Substack away and I write (16:48) and I YouTube and all that kind of (16:49) stuff. And um there was a point about a (16:52) decade ago I was at a um healthc care (16:54) conference sponsored by a law firm in (16:56) town in Boston. And it's ironic and or (16:59) interesting maybe or coincidental that (17:00) Boston's sort of the medical mecca. (17:03) people come here, you know, there's a um (17:07) you know famous book by Samuel Samuel (17:09) Shem um that you know labels MGH as (17:14) man's greatest hospital and uh uh it's (17:17) it's you know tongue and cheek but they (17:18) they often feel that way here and so but (17:20) all those hospitals you know all the (17:22) Harvard hospitals are basically annealed (17:24) into one system and so you basically got (17:26) this huge thing it's mass general (17:28) bighgam da da da and so you know they (17:30) they have kind of a monopsiny (17:32) Um it's I don't know if they have a (17:34) monopoly. I mean they have a monopoly to (17:35) a certain extent for a lot of the the (17:37) the tertiary care that filters through (17:39) and they probably get some monopsy as (17:41) aspect where they can be a single big (17:43) purchaser of items and get some benefit (17:44) on the on the short end. But but the (17:46) prices keep marching up because I don't (17:48) think we have that much competition (17:49) within our own systems. We're not free (17:51) individual kind of atomized um um (17:54) purchasers as we are for shoes or (17:57) raincoats or pencils or whatever it (17:59) happens to be which can come in and out (18:01) of I'm not I I would probably short the (18:03) pencil market these days because people (18:04) don't I mean I have a pen in hand right (18:06) now but I don't really buy pens very (18:08) much anymore. I might get one here and (18:09) there at the bank but I used to buy (18:10) pens. I don't really do that anymore (18:12) because I got computers and dictation (18:13) all kind of stuff. So the markets (18:14) changed when I and we see some of that (18:16) in medicine. So anyway, getting back to (18:18) this conference I was at, uh I was (18:19) probably one of the few physicians (18:21) there, mostly lawyers and um and they (18:24) were talking kind of how to game the (18:25) system in a sense, not game it, but you (18:27) know, be aware of what are the (18:28) regulations, all the kind heavily (18:30) regulated place. We'll get to that (18:31) later. Um, but I got up and I said, you (18:33) know, what's really amazing and great (18:35) about the American health care system is (18:36) the way, you know, things have gotten so (18:38) much better this last decade and and (18:40) provided so much better care at so much (18:42) greater, you know, uh, excuse me, so (18:44) much lower cost, more efficient and all (18:46) that kind of stuff. And everybody just (18:47) kind of looked at me puzzled like what (18:49) plan is this guy from? You're saying, (18:51) you know, because I I led with that, you (18:53) know, everything got better and cheaper (18:55) and more efficient at the same time. I (18:56) said, "Oh, let me let me just I forgot (18:58) to mention. I'm talking about lasacic (19:00) surgery, dental implants, hair (19:02) transplants, and and veterinary (19:04) orthopedics." Okay, so if your dog needs (19:07) a new hip, I I swear I've looked in (19:09) these things. Somebody came brought a (19:10) startup to my angel group. You know, (19:12) they they've just gotten so enormously (19:14) better. They they're willing to (19:15) experiment. There's a huge market. (19:16) Everyone pays with cash for their dog (19:18) because there's not, you know, we don't (19:19) have doggy Medicare. We don't have doggy (19:21) Medicaid. All that kind of stuff. So, (19:23) people want something for their dog, (19:24) they have to go buy it. and they or or (19:26) they can conversely not buy it and let (19:28) you know you know Rover go around on one (19:30) bad hip or whatever. So you know in (19:32) ditto with all these other things which (19:34) are elective items lasic surgery and (19:36) dental implants whatever at some point (19:37) they might be incorporated in the (19:38) general um you know kind of medical (19:41) pharmacapia whatever but but at that (19:44) point so so everyone my point was that (19:46) things that are free marketed or freely (19:48) marketed either way wind up finding (19:50) their own equilibrium and people compete (19:52) and even you know with hair transplants (19:54) for instance um you know not just here (19:57) you're competing you know people are (19:58) going on these medical vacations to (20:00) Turkey and whatnot and they're getting (20:02) their hair transfer and they probably (20:04) can get certain things like you know uh (20:06) whatever certain surgeries in in uh you (20:08) know Mexico or wherever you know (20:10) cosmetic surgeries in the Caribbean, (20:12) Armenia blah blah blah so they can go (20:14) they can travel so winds up having a (20:16) marketplace for those elective things (20:18) anyway um you know there are certain (20:21) kind of innate inefficiency we have in (20:23) our system and I guess I would I do have (20:26) a scripted question here I'm going to (20:27) get to it u so what would it take to (20:30) redesign N Sean Flynn, Professor Flynn, (20:32) the American system in terms of time and (20:34) effort. Obviously, there would be (20:36) resistance from insurers, hospitals, (20:38) pharmaceutical companies, and medical (20:40) device manufacturers. Is there any way (20:42) by which stakeholders could also win (20:44) during the reform process? So, I don't (20:46) know if you want to tackle that one or (20:48) anything I mentioned earlier. (20:50) >> Okay. Now, is the stakeholders everyone? (20:53) Does that include like the big pharmacy (20:55) benefit managers and United Health and (20:57) things or do you mean the American (20:59) people sort of the primary stakeholders? (21:00) >> Well, we just had a barbecue the other (21:02) day. My my in-laws came over so we were (21:04) you know we were holding some steaks (21:06) ourselves. Um they were quite delicious. (21:09) [laughter] (21:12) >> I like that joke. (21:14) >> The American stakeholder could in that (21:17) you know somebody with high cholesterol (21:18) and winds up getting cardiac issues. No, (21:20) I I I mean that's just a you know I (21:23) would say you know this those those (21:26) stakeholders in that case would be the (21:27) ones listed the insurers the hospitals (21:29) so forth who have you know their their (21:31) you know gross their their GDP of their (21:34) own individual companies um are are at (21:37) stake by any kind of regulatory aspect (21:39) because so this big lobbying you you see (21:41) I mean I've been following the RFK Jr. (21:43) maha story uh in in DC and and it's been (21:47) hard to just kind of peel off a couple (21:49) of the you know less necessary vaccines (21:51) from that schedule. There's the NCVIA (21:54) which is kind of a nice rent seeeking um (21:57) you know blanket for companies to make (21:59) vaccines instead of medications and all (22:01) that kind of stuff. So I' I've you know (22:02) spoken and followed all that stuff but (22:04) obviously they're going to be (22:05) stakeholders who make it very difficult (22:07) and put the feet to the fire of anybody (22:09) who wants to think differently. So I've (22:11) had on Robert Malone on my show maybe (22:12) three or four times and um (22:15) you know physician and he was head of (22:17) the ACIP for temporarily and he got out (22:19) of it because just like you know it was (22:21) like too much uh you know ranker uh too (22:24) much pressure and whatnot. So anyway so (22:26) those are the stakeholders I'd say but (22:28) obviously the stakeholders are the (22:29) recipients as well. So the people who (22:31) would prefer to hold a stake than to (22:32) listen to any of these things. (22:35) Um okay so and thank you for that (22:38) clarification that makes it clear to me (22:39) how how I should should should approach (22:41) this. So let's start from top down and (22:44) get more micro. Okay, top down the (22:47) biggest problems are philosophical in (22:50) that um 30 40% of the country and maybe (22:55) 70 80 90% of academics of any (22:58) discipline, not just medicine related or (23:00) economics, they have a fondness in their (23:02) heart for the English and Canadian (23:04) systems. um they don't seem to read the (23:07) news and know just that the weight times (23:09) have been skyrocketing in both countries (23:11) that um they don't realize that there's (23:14) a private sector safe valve in both (23:16) countries. Yes, England has a national (23:17) health service but anyone can afford to (23:20) buys private health insurance and goes (23:21) to private hospitals. um they don't (23:24) realize that 80% of the Canadian (23:26) population lives within 50% of the US (23:28) border and so that the safety valve (23:30) there is people driving south to the US (23:32) to pay cash for things. Um and uh so you (23:37) know but but that being said though (23:39) their allegiance um to that system call (23:42) it national medicine, socialized (23:45) medicine, you give it whatever you name (23:46) you want. Um government controlled (23:48) medicine, government funded singlepayer. (23:50) Actually single pair is sort of the (23:51) neutral term which actually hides some (23:53) of the defects. But let's call it single (23:55) pair. Um single pair is a disaster um (23:59) for quality of care, drug development, (24:01) innovation. You could go on and on. I (24:04) remember back in the 1990s, I haven't (24:05) seen the new statistics, but at the time (24:07) the US had um 3,000 MR machines and (24:11) Canada had three. Um they should have at (24:13) least 300 because their population is (24:15) only a tenth the size. They had 1%. (24:17) Right? So these systems also massively (24:19) under capitalized by which I mean they (24:21) they make too few buildings. They have (24:23) too few operating theaters. You will (24:25) routinely, as a result, see articles in (24:27) the British tabloids about women at, you (24:29) know, public hospitals having to have (24:31) their babies in the hallway because (24:33) there weren't enough delivery wards. You (24:35) know, it's very predictable when a (24:37) baby's going to be born, right? There's (24:38) no excuse for a system not having enough (24:41) personnel and building space available (24:43) to deliver a baby after nine months of (24:45) waiting, right? Yet, they goof that up. (24:47) And so we have the biggest problem is (24:50) that there's probably 30 40% of (24:52) Americans who think that singlepayer is (24:55) the solution to all our current (24:57) problems, right? Um it wouldn't be for (25:00) two reasons. A the best it could (25:02) possibly be is to look like Canada, (25:04) England where these massive weight times (25:06) um and lower quality of care and you (25:08) could go on and on. Um, but the real (25:11) problem is if we tried to transition (25:13) politically through an act of Congress (25:15) signed by the president into such a (25:16) system, that legislation would be (25:19) completely gained by the current (25:20) powerful special interest. You'd (25:22) actually end up with something worse (25:24) than Canada and England. If you tried to (25:26) do it through our democratic processes (25:28) because the lobbyists would be in there (25:29) for big pharma, big medicine, big (25:32) insurance the whole way. You'd actually (25:34) get a less efficient and more more (25:36) expensive system. Right? So, but that's (25:39) that's a that's a big problem we have to (25:41) deal with. Um, on the other hand though, (25:43) political spectrum, (25:45) the Republicans um, and you know, (25:47) libertarians and anyone who's not of the (25:49) singlepayer mindset, they don't really (25:52) have any proposals that I I consider (25:55) publicly attractive, right? Um, they say (25:59) that we're going to wave um, what looks (26:01) to other people like this magic wand of (26:03) free markets and everything will just be (26:05) fixed. Um, and yes, it's true. And the (26:08) examples you gave are spoton. Anything (26:10) like LASIK that was not covered by (26:12) insurance, the cost has gone down, the (26:14) quality's gone up, um, just booming (26:17) business. And actually for those things, (26:18) no, very few people do medical tourism, (26:21) right? Relatively speaking, right? (26:23) Because they can get it for cheap right (26:24) here in the United States. Um, and there (26:27) have been other people like Keith Smith (26:29) at the Surgery Center of Oklahoma. I (26:30) don't know if you've had him on yet, but (26:32) they've been posting prices for um, (26:34) since 1998. um they do over 900 (26:37) surgeries now. Um and people do fly in (26:40) from Europe to go there. We have import (26:42) medical tourism in this part of the head (26:44) healthcare sector where they decided not (26:46) to take insurance because Keith Smith (26:48) and his crew there figured out how to do (26:50) everything really efficiently, high (26:51) cost, um excuse me, high quality and so (26:54) on. Um they get lots of Canadians, they (26:56) get lots of Europeans, they get people (26:57) flying up from the Caribbean and stuff (26:59) and Central and South America. So we can (27:02) do this stuff here. Um but politically (27:05) only one one side um the single pair (27:08) side has something that looks like uh an (27:11) easy quick obvious solution. And you're (27:13) probably aware of that old HL Mein quote (27:16) about um for every complicated problem (27:19) there's a situation that or a solution (27:21) that is what is it's like simple (27:24) intuitive and wrong right or something (27:26) like that right so single pair is that (27:28) HLIN solution that's like simple (27:31) intuitive and wrong um but the other (27:34) side doesn't have an attractive uh you (27:36) know opposing sort of thing to say uh (27:38) and there many of them I think are too (27:40) wedded to the you know they read um (27:42) Atlas shrugged at 19 and they just think (27:45) if everyone read this book too, they'd (27:47) fall in line, right? But that doesn't, (27:50) you know, deal with people really being (27:52) worried about where's my, you know, if I (27:55) get into an accident or if I get cancer, (27:57) if I roll my car, who's going to help (27:59) me? Am I just going to die or are they (28:01) going to help me and then I'm going to (28:02) go bankrupt? And I have a neighbor (28:03) across the street here. Um, he works in (28:07) warehouse distribution facilities. He (28:10) got a gash on a finger. It went to the (28:12) bone. He needed, you know, eight (28:14) stitches on his finger. Um, but, you (28:16) know, no permanent nerve damage, nothing (28:18) like that. So, not they didn't need like (28:19) massive surgery or anything. He got an (28:21) $18,000 bill from the local hospital, (28:23) right? Um, and I'm Catholic and, you (28:26) know, it's a local Catholic hospital. (28:27) Wow. How how charitable are these (28:28) people, right? Um, and and that's what, (28:31) you know, he's he's he's dealing with (28:33) now is how do I, as someone who makes (28:35) $20 an hour, um, figure out how to pay (28:38) for an $18,000 medical bill, right? And (28:41) so people are terrified. The political (28:43) right and the libertarians have no good (28:46) no attractive looking solution. And so (28:49) that and as I said, I really think if we (28:51) did get singlepayer, our version would (28:53) be worse than Canada and England because (28:54) the special interests here would make (28:56) sure they could still get to a a trough (28:58) filled with lots of cash that they could (29:00) feed at. Um, and so (29:03) the only way forward I really think that (29:06) could work here so that we don't end up (29:08) with single pair and we don't continue (29:10) just down the road we've been going on (29:11) here with giant corporate health and (29:13) stuff. Um, is the little guys like Keith (29:16) Smith. It's the direct primary care (29:18) doctors who just checked out. They don't (29:20) take insurance, but they'll charge you a (29:22) flat monthly fee for virtually (29:23) unlimited. Um, and I' I've got a direct (29:25) care doctor and so is my wife. Um, and (29:28) um, yeah. And then the fact that we are (29:31) getting more and more cash price (29:33) surgeries, um, cash and carry (29:35) specialists, imaging, lab stuff. Um, and (29:39) unfortunately most people don't know (29:40) this, right? And you know, obviously if (29:42) you're Tiger Woods and you just rolled (29:43) your car for the third time, you need (29:45) emergency care, you're going to get (29:46) medevac, but the vast majority of health (29:49) care spending, you actually have time to (29:51) think about it ahead. Even things for (29:53) like heart steps, right? Unless you're (29:54) really about to die, the cardiologist (29:56) said, "Oh, you can get it done next (29:58) month or in six weeks. will just (29:59) schedule you, right? There's emergency (30:01) surgeries and then there's basically (30:02) everything else. Um, and the vast (30:05) majority of stuff is everything else (30:07) where there's delay, where there's time (30:08) to shop around. And we're finally (30:10) getting an ecosystem in the United (30:12) States where there are, you know, I (30:15) could not just call Key Smith and ask (30:16) him for his price on a knee surgery. I (30:19) can call around to local hospitals. (30:21) There's websites like mdsave.com where (30:23) doctors already pre-arranged bundled (30:25) surgery prices and you know you can just (30:27) use their search bar and your zip code (30:29) and they'll find the ones near you. Um (30:31) give you the every doctors and sometimes (30:33) they're not the same, right? Because the (30:34) competition isn't that intense. Um so (30:37) you know sometimes some doctors are 10 (30:38) or $15,000 more or less. But you can (30:41) also look up they're all board (30:42) certified. You can see if anyone's been (30:44) sued, right? You can find out if the (30:46) quality is there as well. And so that to (30:49) me is how we can creep towards actual (30:52) authentic reform because entrepreneurs, (30:54) business people, if they know they're (30:56) operating in a competitive environment, (30:58) they just naturally figure out how to do (31:01) things more efficiency by and which in (31:03) medicine is the combination of higher (31:05) quality and lower costs. Um, which if (31:08) it's competitive also means lower (31:10) prices, right? Because there won't be (31:11) much of a gap between the price and the (31:12) cost if it's competitive. And so you've (31:15) seen that with these surgery centers. (31:17) But let me let me just say one more (31:18) anecdote here um as an example of the (31:21) push back in the system. And I don't (31:23) even mean malevolent intentional push (31:25) back. But I I talked to Keith once and (31:28) asked him, "Wow, how many other surgery (31:29) centers are in the country? Are you (31:31) going to stand up a bunch of (31:32) franchises?" He's like, "No, no, no. I (31:33) think they should all be locally owned (31:35) by local doctors." Um and he said he'd (31:37) advised on a whole bunch. And I'm like, (31:39) "Wow, why can't I find them on the (31:41) internet?" Right? Um he's like, "Oh, (31:43) they don't post their prices." I'm like, (31:44) "Why is that?" He said, "Well, a lot of (31:46) these surgeons. Um they also do (31:49) surgeries at like a local big hospital (31:51) and those local big hospitals have (31:53) non-compete agreements and and also um (31:56) these things where um they're they're (31:58) they shouldn't be undercutting anyone (32:00) else's prices, right? So they they've (32:01) got the hospitals negotiated a (32:03) reimbursement rate for, you know, I (32:05) don't know, um stent implant or (32:08) something. If anyone finds out that (32:10) doctor is doing the sten implants at a (32:12) lower price than the hospital charges, (32:14) then the insurance company can get mad (32:16) at the hospital because they're not (32:18) offering the lowest available price in (32:20) the area. So the hospitals actually (32:22) don't want the doctors out somewhere (32:23) else in a different facility doing them. (32:25) So we've actually created a system here (32:27) where it's illegal to tell people you're (32:29) doing it at well, excuse me, let me take (32:31) that. Not illegal. the incentives in the (32:34) system are such that everyone wants to (32:36) keep it quiet if they've actually got (32:37) lower price and higher quality, right? (32:39) You kind of have to do it clandestantly, (32:42) which is just completely ridiculous, (32:44) right? But there are doctors who know (32:46) they could make plenty of money um (32:48) setting up their own surgery centers (32:49) where they control the rent, they (32:51) control the cost, they don't have to (32:53) deal with the insane insurance company, (32:55) in network, out of network, higher cost, (32:57) lower cost. Um like Dr. Smith told me in (33:00) um oh sorry I'm for he's not in Kansas (33:03) City um what city in Oklahoma are they (33:05) in I'm forgetting it right now they're (33:06) not in Tulsa oh man but in his local (33:09) area in that county there are five (33:12) different Medicaid reimbursement rates (33:14) so depending on which hospital a (33:16) Medicaid patient goes to the government (33:18) will get charged more or less even (33:20) though it's identical service right (33:22) that's our crazy system here and (33:24) everyone to defend that has to keep all (33:26) the prices and the costs completely (33:29) opaque because someone would end up (33:31) asking, well, why is the government (33:33) spending twice as much at that hospital (33:35) as at this hospital? Isn't that unfair (33:38) to the hospital? Isn't that unfair to (33:39) the patients? Could that be dangerous (33:41) for private private care? And the (33:43) private insurance do the same thing. (33:44) Depending on what insurance you walk (33:46) into a hospital provider with, that (33:48) hospital provider will get paid more or (33:50) less for doing the exact same thing. And (33:52) that gets back to that gap between price (33:54) and cost. The cost is the same whether (33:56) they treat you or someone else at the (33:57) same facility, but the price they get (34:00) paid varies all over because we don't (34:02) have competition and everything's been (34:04) game. So, I'm sorry I went on for a long (34:06) time. (34:06) >> That's totally fine. So, I wrote down a (34:07) few things as you were talking. Uh, I'll (34:09) give you a couple of these words and (34:10) I'll try to string them together. I (34:12) wrote down NATO, uh, North Atlantic (34:14) Treaty Organization. I wrote down Detox. (34:17) I wrote Milton Freriedman. And I wrote (34:19) college. I wrote NBA. I'll see if I can (34:21) make sense of those, uh, scribblings. Um (34:24) basically Milton Friedman at one point (34:25) said look before you had Medicaid, (34:27) Medicare. Um uh I think he died in the (34:30) late 70s early 80s. Um but he said it's (34:33) not like people were were just sitting (34:34) on the streets like you know the image (34:36) of Kolkata whatever back in the day (34:38) starving and and and and roing you know (34:41) rolling around with tuberculosis or (34:42) leprosy or whatever they were charity (34:44) hospitals. greatest you know flowering (34:47) of of growth of of hospitals was in the (34:50) you know uh late 18th you know the (34:52) Bellipok the gu g guilded age and into (34:55) the early 20th century so right here we (34:57) have um the deaconist hospital that's (34:59) you know obviously catholic hospital you (35:02) can find any number of saint this and (35:03) saint that we have St. Elizabeth, which (35:05) recently closed. There's Beth Israel. (35:07) Anyway, there there's no shortage of (35:09) hospitals with, you know, some Catholic (35:12) um Jewish whatever name the Shriner's (35:14) Hospitals here. Um charitable impulse is (35:16) is a huge part of our society. Um I (35:19) recently saw Adysius uh excuse me the (35:22) Odyssey the movie and uh you know they (35:25) talk about Zeus's rule and it's also the (35:27) same thing as you know kind of the (35:28) golden rule we hear you know people have (35:30) had this kind of stipulation to care for (35:32) each other one way or another because (35:34) it's in our long-term best interest as a (35:36) society and what not maybe not individ (35:38) individually in any given moment. Uh and (35:40) so I only bring that up because you know (35:41) that's like you know sort of prehistory (35:43) bronze age or whatever. Anyway, uh so (35:46) for a long time we've had this idea of (35:47) looking out for each other. It's (35:48) probably in our best interest to take (35:50) care of each others to some extent. Um (35:52) so Milton Freriedman points out that (35:54) before we had these, you know, enforced (35:56) charities through Medicaid, Medicare, (35:58) whatever, disability insurance, we had (36:00) charities. It's not like people were (36:01) starving. Um so that's number one. I (36:03) brought up uh NATO because a lot of our (36:05) pricing and a lot of our model and the (36:07) reason that the UK and a lot of place in (36:09) Europe can get by with their uniayer (36:11) system is similar to the NATO. kind of (36:13) mapped on one to the other just the way (36:15) we provide defense for Europe and and (36:17) they get they pay far less of their own (36:19) personal budget towards defense. (36:21) Frankly, they can put a lot of that (36:22) towards med medic medical care and (36:24) socialize this and that. Um so we kind (36:26) of have an umbrella. We've had an (36:28) umbrella on on pharmaceutical prices (36:30) because we have more of an open market. (36:32) So we've been paying higher (36:33) pharmaceutical prices. We get more (36:35) innovation. the innovation, you know, is (36:36) all coming out of the United States as (36:38) being the generator of places where (36:39) people want to, you know, make the new (36:41) Viagra, make the new this and that (36:42) because we will pay for it at least top (36:44) dollar, at least under the patent, you (36:46) know, realm, whatever that is, 7, 15, (36:48) whatever, 11 years, whatever the number (36:49) is, we will pay that. Whereas Europe, (36:51) you know, has this monopsy monopsiny (36:53) aspect and they will, you know, (36:55) invariably get lower prices by, you (36:57) know, single payer and single purchaser (36:59) and all that kind of stuff. I brought up (37:00) detox um for a couple different reasons. (37:02) One is I used to do some narcotic detox (37:05) um as an ancillary part of my practice (37:07) with subox and outpatient whatnot and I (37:09) I ran into a lot of people who had been (37:11) through literally not even not joking 20 (37:14) detoxes within that calendar year and so (37:16) why did they do that? Well, they could (37:18) do it because you know it's like having (37:19) a free ticket at Disney or a year past (37:22) at Disney. They could go in and out as (37:23) many times they want and didn't matter (37:26) you know so they had no personal (37:27) repercussions. they're on some poor form (37:29) of public assistance um payment and the (37:32) the the detoxes are certainly happy to (37:34) see the person come by again. They they (37:36) collect money every time the guy shows (37:37) up and there's no ramifications, no rep (37:39) repercussions, no reformation. There's (37:41) no there's no re anything except rehab (37:44) over and over again. So the re rehab and (37:47) so I'm not I'm not even sure he gets hab (37:50) rehabituated (37:51) in any of those instances, you know. (37:53) Anyway, so so the but the other reason (37:55) reason I wrote down detox is because the (37:57) whole system in a sense is like a (37:59) narcotic addict. You know the the the (38:01) typical, you know, narcotic user needs (38:03) to get his fix. And so the system as is (38:06) has to have its fix. It's hard to get (38:08) something on a system off. And the (38:10) reason I wrote college down is because I (38:12) think the ancillary, you know, example (38:14) is college. You know, there's the I (38:16) think there has to be a college fix. (38:17) There's a lot of college being provided (38:19) that's unnecessary. People I think it's (38:22) bloated. everyone stays four years (38:23) whether you want to become a French (38:24) professor uh you know work on HVAC or (38:27) you know I don't know cure cancer what (38:29) everything needs the same kind of (38:31) touring machine answer of four years (38:33) because because college can get four (38:34) years of payment through the grants and (38:36) whatnot and whatever they they've (38:38) managed to get that rent seeeking (38:39) apparatus to get paid for four years so (38:41) every the answer to everything is four (38:42) years and so the only you know how would (38:44) you fix college well how would you fix (38:46) the health care system these are (38:47) probably similar things I mean YouTube (38:49) can can fix college Peter Teal you know (38:52) wants to get people away from college (38:53) and give them, you know, you know, a (38:55) certain amount of money to go get their (38:56) ideas right out of high school and go (38:58) pursue it rather than waste four years (38:59) in college. You know, we could probably (39:01) do something. I mean, I, you know, you (39:03) weren't that fond of the, you know, (39:04) electronic medical record and probably (39:06) in it initial, you know, permutations, (39:08) not so great. But I think that there's a (39:10) lot of stuff that can happen with AI (39:11) with medical records and portability of (39:13) our own so that we can source our (39:15) knowledge not necessarily through the (39:16) physician through the hospital whatever (39:18) through other means and leaving the (39:20) hospitals for those places that are kind (39:21) of the catastrophic aspect that has to (39:24) happen somewhere down the line. So when (39:25) you do have your massive stroke, you (39:27) don't necessarily go to Charles, you (39:28) know, you know, I don't know, Charles (39:30) surgery center on the corner, maybe you (39:32) need a hospital for some whatever. There (39:34) probably places where, you know, a (39:36) massive aortic aneurysm, whatever. You (39:37) go to the hospital because you're going (39:39) to need a lot of stuff going on, (39:40) transfusions, whatever, or transplant, (39:42) who knows? So there probably a place for (39:44) it, but probably, you know, it needs to (39:46) be paired down. probably colleges are (39:47) okay for certain things but not (39:49) necessarily for for everyone to live in (39:50) have a four-year keg party and absorb (39:53) you know the social meu while they're (39:54) getting a little bit of stuff that (39:55) they're not really paying attention to (39:56) they get the AI notes they passed in a (39:58) lot of people pretending to teach people (40:00) pretending to learn and people get these (40:02) pretension you know degrees after the (40:04) fact so you know if you want to get rid (40:06) of colleges I don't think you can like (40:08) tell the college to stop doing that (40:10) they're they're there for the long term (40:11) and Harvard you know with it (40:13) Harvardiness you know is able to sell (40:15) that as a as an actual credential and (40:17) the hospitals have that same kind of (40:18) thing in that people's mind at the very (40:20) least. So I think it's a kind of a slog. (40:22) Um anyway, so that's that's a diet (40:23) tribe, not a question, but you can (40:25) attack any of those things I've just (40:26) said or we can go to do either one. (40:29) >> Okay. Well, I like diet tribes. Um (40:32) there's Yes. Yes. People being frank is (40:36) uh something that we have a little bit (40:37) of a problem here in America unless (40:39) we're actually doing an attack at or (40:40) something. So um let's run with the (40:43) college example because I think that's (40:46) another great great place here um where (40:49) we need to point out that you know (40:52) prices are set by demand and supply. Um (40:55) the supply you at any moment in time you (40:58) can't control much of it's based on your (40:59) current technologies how many trained (41:01) people you have like in a hospital or a (41:03) college you could teach a physics class (41:05) or something. Um but you could have very (41:08) pernitious and very large effects on (41:10) demand. So if supply is fixed and demand (41:13) increases um if you're thinking of a (41:14) supply and demand graph that would be (41:16) supply curve not moving but the demand (41:18) curve being shifted to the right or you (41:20) could think of it being shifted up um (41:22) you get higher prices um and if the (41:25) supply curve is nearly vertical which it (41:27) is in the United States it's hard to get (41:29) a license to start a new college or (41:31) anything. it's it's nearly vertical at (41:33) least in a short period of time. Then (41:35) any rightward shift of the demand curve (41:36) or anything that increases the demand (41:39) and demand remember in economics is (41:40) defined as both willingness and ability (41:42) to pay for something. Right? Um I am (41:45) willing to pay for a Ferrari but I am (41:48) not able to pay Ferrari. So there's that (41:51) my my willingness just shows up as zero (41:53) movement in the Ferrari demand curve. (41:55) Right? But if someone gives me (41:57) subsidized student loans, oh now my (42:00) willingness to pay because now I can (42:02) spread it over the next 30 years, right? (42:04) Pay repaying the loan, my willingness (42:06) goes up. And so there have been two (42:09) major public policy goofs. Um which is (42:12) why college now is not just this dumb (42:14) ritual where no one gets educated, which (42:16) is largely true. There's tons of (42:17) evidence for this um objective evidence. (42:20) Um, a lot of students do not walk out (42:23) any more educated, better thinkers, or (42:25) even with technical knowledge in a field (42:28) after four years and they get their (42:29) bachelor's degree. The one they went in, (42:30) it's it's a travesty. Um, but the two (42:34) big things accidentally were a Supreme (42:36) Court case, and forgive me, I can't (42:39) think of the name of the case around (42:41) 1972 (42:42) where I think IBM got sued basically for (42:46) racial discrimination or some kind of (42:48) discrimination. might have been gender (42:50) because men or maybe [clears throat] it (42:53) was white men or whites were doing (42:55) better on the exams, the IQ test that (42:57) IBM gave to 18 year olds because IBM (43:00) used to be perfectly willing not to (43:01) insist on bachelor's degrees. They take (43:04) people out of high school. They'd test (43:06) them and the really smart ones would be (43:08) put on an electronic track where they (43:10) learn all these electronics first as a (43:12) workman, but then they'd actually be (43:14) sent to college by IBM. IBM would pay (43:16) for their college. they come back with (43:17) master's degrees, PhDs, and this and (43:19) that. And if you didn't test so well, (43:21) they might put you on a track to be a (43:22) janitor. Um, now part of testing well as (43:25) an 18-year-old, is did you get to go to (43:27) good schools? And so, yes, we have a (43:29) legacy of, you know, bad schools for (43:32) African-Americans in this country, (43:33) especially around 1970. Clearly, you're (43:36) going to get a few or smaller portion of (43:38) um African-Americans being able to do (43:39) well on those tests. Absolutely fine. (43:41) Disparent impact. I'm with you there. (43:44) But we ended up with a pernitious effect (43:46) of the Supreme Court ruling that tried (43:48) to um fix that because they basically (43:51) said it was illegal for any employer to (43:54) use IQ tests or even tests of technical (43:57) skill and ability to sort workers out (43:59) into different career trajectories. Now, (44:01) the US Army does this, right? They make (44:03) everyone take the ASVAB test, the Armed (44:05) Service was a vocational aptitude (44:07) battery test. And yeah, if you do really (44:10) well, even if you wanted to be a trigger (44:12) puller in a special forces, no, they (44:13) send you to intelligence. They just put (44:16) you someplace where there were they (44:17) you're an electronics guy, right? Um and (44:20) so, you know, jokingly within the (44:21) military, and my friends who were in the (44:23) military would joke about this. Yeah, I (44:24) ended up a grunt. I did bad on the test, (44:26) right? Um but they're happy with that (44:28) because they wanted to be a grunt. Um (44:30) but we switched to this system and (44:33) here's the weird thing. um businesses (44:36) could no longer do their own testing. So (44:39) they basically outsourced it to colleges (44:41) and universities. And this is when the (44:42) SAT took up. So the schools could sort (44:45) kids on ability. The schools could sort (44:47) on. And so basically you now in order to (44:50) get sorted into the career track at the (44:53) high end of IBM, you needed to go (44:55) through a bachelor's degree. you needed (44:57) to go to the big state school or MIT (45:00) because then as a 22y old someone had (45:03) done the sorting for IBM and all the (45:05) other corporations hiring. So that (45:07) massively increased the demand for a (45:09) bachelor's degree. it became the (45:11) official certification of elite success, (45:14) especially obviously if you've gone to a (45:16) highly ranked college and a lower ranked (45:17) college, right? Also, you create this (45:20) war among middle class parents to (45:22) suddenly make sure their kid goes to the (45:23) high ranked school rather than low (45:25) ranked school so they can get the job at (45:26) Goldman Sachs, right? Um Goldman back in (45:30) the 20s, they didn't they actually hated (45:32) people with bachelor's degrees. They (45:34) thought they were overeducated and would (45:35) be terrible traders on Wall Street. They (45:37) actually look for poor kids with very (45:40) bad formal training but who had street (45:42) smarts. That's who they wanted to train. (45:44) We got completely away from that. Um by (45:46) the end of the financial crisis 2008 60% (45:50) of Princeton's graduating class was (45:52) going to Wall Street. This is a complete (45:53) misallocation of resources in the (45:55) economy. Right? And also most of those (45:57) kids probably didn't even know you need (45:58) to go to Princeton for four years. They (45:59) would have been just as well at Goldman (46:01) Sachs as 18 year olds. Right? Total (46:02) waste of resources for society. The next (46:05) thing, Randy, was in 1978 or nine, Jimmy (46:09) Carter as payback for winning in 76, (46:12) right? He barely barely barely beat (46:14) Ford, right? Um, anyone my age or (46:17) younger can't even remember that (46:18) election. Um, but he just squeaked it by (46:21) despite Watergate and despite Ford, you (46:23) know, falling down the staircase and (46:24) being mocked on Saturday Night Live (46:26) every night, right? Um, this they they (46:28) he barely won. And the only reason he (46:30) won, I mean Jimmy Carter, was because (46:32) the teachers unions went out and knocked (46:34) on doors for him. So the payback was (46:36) creating the federal department of (46:38) education, which immediately massively (46:41) expanded the student loan program. We'd (46:43) had a teenytiny one only at engineers (46:46) since Splutnick because, you know, we (46:47) were freaked out by the Russians in the (46:49) 50s and wanted more engineers and the (46:51) only student loans we gave were for (46:52) technical things. the Carter (46:54) administration opened it up to every (46:56) major um every school in the country and (47:00) ever since then we've had this massive (47:02) increase in willingness and ability to (47:04) pay because you could take out the loans (47:05) for it, right? And so we screwed that up (47:08) and it's very similar to healthcare with (47:10) Medicare and Medicaid stepping in in (47:12) 1965 with the Great Society. Suddenly (47:15) there were all these billing codes and (47:17) anyone who could gain the billing code (47:19) or set themselves up as the highly (47:21) marked up middleman like United Health (47:23) or CVS Caremark could make a ton of (47:27) money because another way to put this (47:29) the user and the payer are different (47:31) people. Um I have a textbook with (47:34) McGraill. It's a good textbook but it is (47:36) marketed to the faculty because the (47:38) faculty choose the textbook and then the (47:41) students pay for it right the ch the (47:43) users are different um and healthcare's (47:46) got a lot of those aspects right what (47:48) gets purchased for whom is basically a (47:50) government money or a CVS care decision (47:53) or a committee at a state capital for (47:56) certificate of needs to build a new (47:57) hospital oh do we really need a new (47:59) hospital that might ruin the profits of (48:01) the existing hospitals couldn't allow (48:03) that we need them to keep their giant (48:04) monopoly hospitals. And so we've set up (48:07) all these dumb systems where we (48:08) massively increase the demand for (48:10) healthare because there's third party (48:12) payers that really don't care about the (48:14) cost, right? You know, any private (48:16) business if 20% of your money was going (48:18) to fraud like it is Medicare and (48:20) Medicaid, which is, you know, the (48:21) higherend figures. It's at least 5%, (48:23) right? It's probably 10. It might be as (48:24) high as 20. Any private sector company (48:27) would figure that out and they call the (48:29) police and get people arrested, fire (48:31) employees. Medicare, Medicaid, no. (48:33) everyone keeps their jobs. They're all (48:35) civil servants. It doesn't matter, (48:37) right? And so we have this system where (48:39) the demand is really, really excessive (48:42) because we've set up a bunch of bad (48:44) policies. And of course, the cost is (48:46) high. And of course, there's this giant (48:48) gap between the prices and the actual (48:49) cost of service. (48:51) >> No, it's incredible. I used to be a (48:53) disability exam uh doctor. And uh no, I (48:56) I for various parts of my life, I got (48:58) the nickname Dr. No uh for the James (49:01) Bond villain. Um, some people, you know, (49:04) called me Dr. Noit at all. That's (49:05) separate. That's with a K. And so the (49:08) Dr. No aspect was actually for a lot of (49:10) people in pursuit of narcotics before I (49:13) started the detox thing the decade (49:15) before that. They'd come to me, you (49:16) know, with a bunch of uh ailments, you (49:18) know, theoretically, and they were (49:20) explicitly allergic to every low-level (49:22) narcotic. They only wanted the highgrade (49:23) ones. [laughter] (49:26) I would sus that out. But I'd called a (49:28) fewarmacies and um you know and anyway (49:31) [snorts] (49:31) so I got this nickname epithet or (49:33) whatever compliment in my view um a (49:36) curse in theirs that I was Dr. No. Um (49:38) but that that kind of carried over (49:40) because I told them to get you know (49:42) detox or rehab or whatever. I didn't not (49:44) care about them or not care for them. I (49:46) cared for them a different way from what (49:47) they came for. They were actually there (49:49) again sort of to your point. They were (49:50) there on somebody else's dime to get (49:52) something that they wanted and you're (49:54) going to pay for it. But it's so (49:55) diffuse, you know, the million, you (49:57) know, hundreds of millions of taxpayers (49:58) have no idea that this one guy is going (49:59) to, you know, 13 doctors a day [snorts] (50:01) and getting prescriptions and selling (50:03) them having a whole separate business. (50:04) Kind of a fraud on on the run. Uh it's (50:07) like door dash uh you know, drug door (50:09) dash anyway. Um and it's dashing to his (50:11) own door for the most part. But um but (50:14) as a disability doctor, I worked both (50:16) for the Commonwealth of Massachusetts (50:18) and also for the VA and two separate, (50:20) you know, channels of people complaining (50:22) of disability. Frankly, the BA ones were (50:24) a lot easier and nicer because they had (50:25) been in the military and they, you know, (50:27) endeavored to serve the country, blah, (50:28) blah, blah. Um, and their stuff was very (50:30) kind of fixed. Uh, the state one was for (50:33) people who wanted to get on, you know, (50:35) kind of long-term disability and (50:37) payments so forth. So, they were (50:38) grandized. If they had a bad pinky, it (50:40) meant they couldn't work at all. You (50:42) know, they something whatever. So, so (50:44) their view of what disability was and (50:46) mine, the patients of mine differed (50:48) because I I tried to look everything (50:50) objectively and I would um you know (50:52) write things up. I couldn't out and out (50:54) deny people, but I'd say uh you know, (50:56) Professor Flynn just you know, he has (50:58) certainly has a bad pinky, has horrible (51:00) gouty arthritis. We should fix that, (51:02) whatever. But that's not going to really (51:03) interfere with his his job, which is (51:05) economics professor. So, he's going to (51:06) use either left or the right side of his (51:08) brain or either one. And nothing to do (51:09) with his pinky. I I don't think he's (51:10) disabled. He doesn't need to be on our (51:12) money for now. blah blah blah. And so he (51:14) can probably go back to work tomorrow (51:16) anyway. Um but but I I found that I (51:19) would write stuff. I didn't write it as (51:20) explicitly as that, but I wrote things (51:22) that were, you know, if you could read (51:23) through it, you'd say, "Oh, this guy's (51:24) pretty much okay." And I' um and people (51:27) would come back to me and I thought (51:28) they'd come back angry, but every now (51:30) and then, you know, repeatedly people (51:32) came back to me though, "Thank you, Dr. (51:33) Bach. I really appreciate you gave me (51:35) that disability." [snorts] And it's like (51:37) I'd be like, "What happened?" You know, (51:38) I look back and and the disability team (51:42) at at at it was actually through UMass (51:45) uh university, whatever. They they would (51:47) approve everything. They But their (51:50) business model working for the (51:52) disability unit was to keep themselves (51:55) employed. And how do they do that? By (51:56) handing out more disabilities. So (51:58) they're they're they're just, you know, (52:01) their model is not the same as yours. (52:03) you know, college administrators don't (52:05) have the same interest in keeping costs (52:06) down as you and I might. Anyway, we're (52:09) kind of rounding out our hour. Um, (52:11) >> okay. So, one one quick anecdote to (52:13) follow up on that. (52:15) >> Yeah. So, so in ancient China allegedly, (52:18) I've never been able to verify this, it (52:20) used to be the case that rich gentlemen (52:21) of means would pay their medical doctor, (52:24) but only um when they were healthy. If (52:27) they ever got sick, they cut off the (52:29) money because that way the doctor would (52:31) have an incentive to keep them healthy. (52:33) And let me bring this to something (52:34) modern in America. Um, there are these (52:36) direct primary care doctors. They get (52:38) paid a fixed amount per month. I think (52:40) the national average is about $75 a (52:42) month. Um, and you know, talking to one (52:45) of them, who maybe you should have him (52:46) on your show, Dr. uh, um, Josh Umber, (52:49) Witchah, Kansas, runs an outfit called (52:51) Atlas MD there. Um he likes to joke that (52:55) he loves getting you know some older fat (52:58) guy and uh and just you know as one of (53:01) his patients because Josh has the time (53:02) as a direct primary care physician. they (53:04) only have patient panels of maybe 600 to (53:07) um actually text the guy every day till (53:09) he's taking his metformin and he's (53:10) conforming and you know actually doing (53:12) what he should and then in Josh's (53:14) perspective just like the Chinese doctor (53:16) who got paid when someone's healthy Josh (53:19) gets 75 bucks a month for doing nothing (53:22) right because that guy is healthy Josh (53:24) gets paid when he makes his profit when (53:26) that guy's healthy and that's the kind (53:28) of healthare system we need to set up (53:30) >> yeah that's a business model thing so uh (53:32) last couple questions how would consumer (53:34) consmers be involved and engaged in (53:35) demanding reform. If you were Trump's (53:37) health secretary, what would your (53:38) elevator pitch be to the people of the (53:40) USA to get them on board and or to to (53:42) Donald Trump, etc. to get him on board (53:44) and wanting to do what you want to do? (53:47) Well, one thing you know that the idea (53:49) of Trump RX um not not the cheap drugs, (53:51) but the government website with trusted (53:53) information where you could find the (53:54) lowest cost providers, that would be (53:56) great. Singapore's government does a (53:58) similar thing with the uh hospitals and (54:00) surgeons. you could look up which (54:01) hospital has the most, you know, um, uh, (54:04) you know, the lowest rate of (54:06) complications on surgeries and stuff (54:07) like that. And so there's all this (54:08) quality and price information out there. (54:10) If there were a trusted national source, (54:13) um, of course, everyone's going to try (54:14) and game this trusted national source, (54:16) Randy, so I'm not naive here. But if (54:18) there were something where consumers (54:20) could actually just type in their own (54:21) zip code, um, and just ask, hey, where's (54:24) the lowest cost provided for for X or Y (54:26) or Z, that would be amazing. Um (54:29) similarly letting doctors, you know, (54:31) continue to practice across state (54:32) borders. Um there's there's like a lot (54:34) that could be done to lower the cost of (54:36) care because very often, you know, um (54:39) someone just needs to see you for two (54:40) minutes because you're such an expert. (54:42) Doctors are such experts that they can (54:44) figure out what's wrong with you, make (54:46) the right diagnosis. The treatment plan (54:47) is usually very standard. And if there's (54:50) a standard treatment plan for millions (54:52) of people, right, with the same (54:53) diagnosis, this is the country that (54:55) invented the assembly line and the Model (54:58) T Ford, right? That's something we can (55:00) do. Um, but most people think of it as a (55:03) bespoke thing. They got to go talk to a (55:04) doctor. It's things individual. The (55:06) treatment's going to be different. But I (55:08) think the starting point is the um the (55:11) uh price comparisons um price tags on (55:14) everything and quality metrics that can (55:15) be trusted. (55:17) >> Well, I like that. So, if you could if (55:19) you could uh implement one change um you (55:23) know get Congress to do one reform (55:25) during this term of government, what (55:26) would it be? (55:28) >> Um you'd switch all the ACA subsidies um (55:33) and not just the the the tax subsidies (55:35) to the individuals, but the whole darn (55:36) system is subsidized. You just give (55:38) people the money. It would look like (55:40) what Milton Freeman wanted with school (55:42) vouchers, which have turned out to work (55:43) really well. Give people the money, put (55:45) it into their health savings accounts. (55:47) most people most and then the government (55:48) would just create a catastrophic backs (55:50) stop um have it administered in the (55:53) private sector there's a bunch of stuff (55:54) sorry we running out of time here but um (55:57) yes when people are given the money (55:59) themselves and this is true in Singapore (56:01) we didn't talk a lot about Singapore but (56:02) they've got health savings accounts and (56:04) the government gives like every baby (56:05) gets $3,000 just for being born into a (56:08) health savings account people spend that (56:10) money very carefully due to something (56:11) called loss aversion which got a couple (56:13) guys the Nobel Prize um Daniel Conorman (56:16) and Um, yeah. So, make that speed bump (56:19) there. Give the people the money and (56:21) then let them decide when and where to (56:23) spend it rather than some bureaucrat (56:25) who, as you said, thinks they need to (56:26) shovel money out the door in order to (56:28) keep their job. (56:30) >> Well, thank you so much, Sean Flynn. So, (56:32) g give us the name of the book and how (56:34) people can buy it and find you. (56:36) >> Okay, so the name of the book is The (56:37) Cure That Works, and the subtitle is uh (56:40) how how we can have the world's best (56:42) healthcare for a quarter of the cost. (56:43) Um, it's on Amazon. That'd be the (56:45) easiest way. Just go on Amazon, The Cure (56:47) That Works, and um if you you need to (56:50) remember my name. Um I also wrote (56:52) Economics for Dummies, one of those (56:53) yellow and black things. So, first look (56:55) up Economics for Dummies, get my name (56:57) and then get the Simport Healthcare (56:59) book, which is called The Cure That (57:00) Works. (57:00) >> I got to say I I like the Dummies (57:02) series. And um I uh have not seen yours, (57:06) but I I probably will go buy a copy if (57:08) you uh will venture to autograph it for (57:11) me. I um I've been called worse myself (57:13) and uh you know uh so I very much (57:16) appreciate your your being here on the (57:18) show. Thank you so much, Professor (57:19) Flynn. (57:20) >> Okay, doctor. Thank you so much. A true (57:22) pleasure. Thank you.