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tv   After Words with Elisabeth Rosenthal  CSPAN  June 2, 2017 9:55pm-10:58pm EDT

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president's record on job creation so far. and editor-in-chief -- discusses the idea of universal basic income and what it could mean for us employment. be sure to ask he spends washington journal live at 7:00 a.m. eastern saturday morning. during the discussion. >> next on "after words" physician and analyst elisabeth rosenthal examines the business side of healthcare. in her book and american sickness healthcare became big business and how you can take it back. dr. rosenthal looks at the rising costs for medical services and offers guidance to consumers on how to better navigate the healthcare system. she is interviewed by doctor david blumenthal president of the commonwealth fund. >> hello. it is a pleasure to be here with you. i want to congratulate you on an incredible readable and thorough review of problems of
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our healthcare system and proposals for some solutions. i have questions for you based on my background as a physician and of course also as an occasional patient.first i would like to ask a couple of questions. the first one is what did you write this book? and why did you write it now? >> as you know i work for a couple of years on a series in "the new york times". my first in that series was the commonwealth fund to learn a bit more about the system and how it had gotten so - during that series we had a lot of patients stories through social media. and at the end of the series two years later had this wall of patients stories, people who
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are smart and for the most part insured patient. new york times readers are just hadn't been able to make the system work. and that was one aspect. another one was that we took little parts of the system and examined them one by one. and so often as newspaper reported by the time you're finished you realize that you just kind of scratched the surface. i really felt like i needed to know. in that series we showed how prices had gotten high. in fact his. they really wanted to understand the evolution of the process. because as a physician who trained in the 80s and is someone whose dad was a physician i knew healthcare hadn't always been this way. and i wanted to understand how to get to this system which literally nobody seems to like right now? and by understanding that, how can we get to a better place? we have seen so many efforts that reform.
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everyone agrees it needs to be reformed but yes we are still on the hill today, we are still arguing. >> as you mentioned you are a physician. i am a physician. we actually went to the same medical school. harvard medical school. both trained in internal medicine. he went on to be a journalist. how did that come about? >> i don't want to say by accident. i always loved both writing and medicine. my family has a lot of physicians in it. i had always done a lot of freelance writing on the side. the irony of this book in my career is really that in the early 90s i was working in an emergency room in new york. in an emergency room at that time, i felt the health system already was not working very well for people who were poor or uninsured. it was largely working pretty well for people like me who had good insurance.there was something in the early 90s, the
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clinton health reform plan. at the time they asked me if i would like to right about that. i thought i would come be a generalist for a few years, right about that and then that will pass. i will go back to being a physician and of course it did not. and i did not. and here i am. more than 20 years later talking about many of the same issues but kind of the same issues on steroids. the system has really to me, kind of spiral out of control. especially in terms of cost and prices. of course as we all know, without getting better results for patients. >> before we get into the substance.and there is a lot of substance to talk about. what are the things, one of the things that are very special about your book. and i've done a lot of books about the healthcare system, is the way that you ground it in stories. stories about doctors, stories about patients.
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>> >> i have also read those stories about the $1 million gold marrow transplants in the way most leaders see thoses they say that is
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really terrible or i don't understand the policy. that is heartbreaking but i hope i don't get that kind of cancer or don't insist on everything at the end of life the what i tried to do is make that connection between the acronyms from washington and how that affects you on the ground with an issue that plays out in our living rooms and kitchens so i was very fortunate most of those people came to me and said i want to share my stories. also with tremendous volunteers to help readers to understand so i often feel to have a dinner party
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with fun and interesting and thoughtful people they are compelling and absurd but i think day drive the narrative with that back and the policy of economics without suffering through the diagrams and charts because i of the health policy wonk but most people don't have the appetite for that. >> and doctors are about their patients' stories. >> what struck me as i was researching the book is like many of us with health reform by repeated the phrase 100 times with
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evidence based care. sold what other types of health care could there be? but then ended is terrible care. so those finances are on the front burner and that is the shifting would like to see. >> he organized this in a doctor leeway so what we call taking a history for perot and then went on to offer some therapies so i
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would like to take those three segments but maybe identify the problem what is the american sickness?. >> i was a new york doctors of the chief complaint was high prices. high prices and an affordable health care. i don't think anybody republican or democrat would disagree with that. >> how did we get to these high prices? this is where the history of present illness has to pull itself out so this is a classic case of the road to hell is
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paved with good intentions. so to see a good idea that was a good idea but then somehow it was perverted as how we make money from this? people have often said that a lot of people got health insurance. that is not to say it is a bad day in and that was partly because health care was getting more expensive and there are historical reasons i don't want to get into but we end up with people on medicare or employer based insurance and for those of us who had health insurance for a long time we know that in those those-- the employer paid the premiums and you have very little out of pocket cost. what happens if you were
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business minded under that set up as an entrepreneur? so nobody pays so an office visit would cost dollars now maybe it is $100 or $200 then and some point around the '80s and '90s so what will the market bear? what could we church? so it was just a physician there thinking what does this mean for patients or health care? with this is people start to come in sometime as consultants for those being hired by hospitals they are not medical people. they don't know what is the best treatment for liver failure or pneumonia they
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are thinking how can we squeeze more money out of the system to make it more efficient? the answer they come up over and over is the easy answer you build differently to the same thing as to have been doing but charge a lot more so suddenly you see these charges come which was $200 now is $2,000 they receive the layers of the administrators from when we were in hospitals or former chief positions were medical people and of course, as a result hospitals were not very efficient but somehow we went over a boundary where business was primary
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and medicine became secondary. so then at that point many physicians would say here i am doing all this were cancer surgery and seeing patients so i looked at the layer of 20 administrators who were making $1 million per year i want more. not all physicians but many get into that spirit others get angry and resentful that they are being judged by how much money they are generating and then to be compared with a fellow physicians. so who is generating more
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revenue? maybe you get a bonus so once again you see those values that is efficiency your revenue generation or maximization with those old-time values so i with my patient can i understand the problem to assess their needs? hospital rates -- often note more about the billing cycles the of their infection rates. i was shocked this week when i saw centers of excellence for barry after surgery had widely varying rates in their complication rates. even though the certifying organization knows what they are, pete --- patients
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cannot know those. that seems crazy to me as to be a good consumer we deserve it information and it is our health. >> so let's move on to talk about what you're starting to do with witches the solicitor treatment to some of these problems some of them are valued based one thing is very special about your book is you spend time on describing things for the people in the system. oddly gore by reversing those problems?. >> i think if we wait for a solution to come from washington we will be waiting for a long time.
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and the affordable care active important things for health care that it covered people with pre-existing conditions, it covered 24 million people with an emphasis on value what is good for patients back into the bull's-eye and also changed the notion should government think of this as a responsibility? so i think now was a crucial time because many patients are at said tipping point they cannot afford this any more so those the spending 30 percent of their household income of one health care that is more than food or housing they're not going on summer
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vacations and having trouble sending their kids to college people are leaving the united states tragically because they have an illness like type one diabetes she is a grad student only looking for jobs outside of the united states because she is worried she cannot afford her diseased that is not "an american sickness" it is an american tragedy. so with a book i aim to help people to understand there are step-by-step solutions that the health care system got to be where it is and then we can start bringing back and part of that is what individuals can do so little things but they do
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work i became the bill troubleshooter for everyone at the new york times or have used these in have gotten a lot of bills reduced or reversed so one thing i tell people that it is uncomfortable for doctors but when i see my physician if he says we should get some blood test i feel okay to say i am a patient and it is my right to say why? because he both know when they order test there was a training why don't we just order the test? so you're just going down the list so now the question is how will
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that change might care? that requires a mineshaft like to see my mom goes to the doctor in says they saw my doctor alike curve and she did not even order blood test. as patients we have to say beebe the answer is to wait. but when it is time then i say to my physician the computer is programmed to send my blood order to the hospital lab. no. send it to one of the two commercial labs a network because one may charge $10 for the exact same test and the hospital would charge 500 per $1,000 in both know they just put a tube of blood into the machine has its outnumbers. so likewise okay if i need
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the x-ray dozens of centers within a mile radius we will do a good x-ray a reasonable price. we know that most doctors don't have the information but then we think the more they will and those who went into medicine they don't think about the bill's but that is the position to advocate for patients. that is the doctor's responsibility to say to the one that is charging $1,000 i don't want you riping off my patients.
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betting not only will that save money in individual cases but said the message to the centers that are overcharging we will act like this is the market now and price matters and we are paying for that with a $5,000 deductible plan it matters. >> so this is the important steve of your book with the burden of the cost of prices is also deciding what you will get and where you will get that with the consumer. i was struck by the recommendation that you made that people review the papers there asked to sign that many sign without looking to make sure they're not referred to doctors or hospitals that will not be paid by their insurance company because it is out of
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network. i have the picture of a patient on a stretcher clutching his chest and having to go to the paperwork or to run down the list of drug prices for the lab tests to say don't do these because they're not covered for you see the point i am making is that realistic?. >> this is a big unfair burden to put on patients for this is the situation refiner's solves. i don't think this is the old and a solution but the alternative right now is like someone in the book that is rolled then on the stretcher for the emergency appendectomy in the business manager says we need your credit card before we can
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proceed. she says a naked i don't have my wallet in the business manager says who can recall to get a credit card number to proceed? that is the alternative but they're a lot of parts of medical care that are not merchant -- emergencies it is not fair it is a burden but if we don't take these steps and then deal to the goal of course, is not to have to go through those forms i will take as long as it is in my network but to prod the of hospitals to respond to say if you go to the in network hospital and it is our job to ensure the
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radiologists the pathologist and anesthesiologists are all in your network because that is extra work for them. but the hospital and those which are in my network. i don't. so the goal is not to say this is the final answer but to say to push all of the providers who were not paying attention to do so and that this has fallen into the patient's slap -- lap and those who were thinking what is the right thing to do? but also physicians spend a lot of time with this out of control system.
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i have to fill out this paper work where the reauthorization for the paper work so that i think it will just get worse and worse. >> this relationship made it clear they're part of the system that we now have traditionally it is based on a level of trust it is an important part of the healing relationship and those of us who were trained in the midst of an illness. so what is left of trust in the health care system? is
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it lost irretrievably that used to be part of that relationship of clinicians than patients?. >> anybody who reads the book can see many of the best sources are physicians who were equally distressed and desperately want that connection with their patients some of that may we was needed and was so efficient it wasn't realistic to thank you could spend an hour with the patient with the notion that to be more efficient results in good care but one example that is minor but so much has been replaced with technology like telemedicine
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just give everybody and ipad and it will be better for electronic medical records that you were a part of is a useful tool but often they have been used as a substitute for the face-to-face interaction which is so crucial there was a program to give patients in hospice in my pad. -- the ipad that is great if used for certain kinds of things but if that is instead of a nurse to come by to hold their hand and talk to them which a lot of people need with home hospice that news is what is precious to me about health care and that is what
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patients and physicians want so health care could have done a lot more efficient and 30 years ago but it should not be the primary goal of health care. >> as we're speaking the house is deeply engaged in the future of the affordable care act with a government san policy at the national level and underline that discussion is whether health care is a market good that should be ruled by market forces or another mechanism for:the read your book sometimes i felt i was watching the market gone mad it was treated like a market but none of those forces that constrain, did they
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give you any thought whether health care is a free market?. >> what we have seen is probably not. somewhat tongue in cheek for the dysfunctional health care market if you think of health care as a business proposition, you get too crazy places like a lifetime of treatment is preferable to a cure. i'm not saying that anybody is really thinking that but that is for the market forces are that type 2 diabetes is a wonderful example they chronic example
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with palms and monitors people are much better than they were the sum they said we can cure diabetes what would happen? so there is an example laboring up in the book is working with the very old vaccine with type diabetes. but she cannot give it a form of funding because they look at this and say arabia the you kill the hour market so market forces it does not
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work so the market depends on a lot of forces that you have to make a choice when you lie on the stretcher with your appendix burst you're not in a great position to do that. or having our doctors choosing forcing you can work with your doctor but now sbc the choices are limited unless you fly to another city. some have had so much consolidation there is only one virtue of choices now colonoscopy is better cheaper in baltimore does not help me in the york so
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is not a market in that sense. also with hospital consolidation that leads to higher prices night better care. if a certain hospital has quarter of a cancer care in a certain part of florida then the answer is how will the market work? maybe an oncologist and say they're getting very high prices but again that is not so easy. that takes time for a doctor to move a practice and establish patients so what about those that have cancer in the meantime? and the biggest failure is looking
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at the price variation for medical procedures the same the cost $30,000 in one city like a knee replacement could cost 150 in another and 13,000 in france. how could this possibly function as a market? that is why a look at other countries health systems there is no place with the free-market there is only some degree have price regulation or somehow the more government based approach or socialized medicine or single payer with private doctors and hospitals like in japan and the rates are set at national negotiation but what is a more market-based approach but even in
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switzerland there is a degree of price regulation you cannot just let the market decide because it will decide what the market has decided that prices will rise to whenever anyone will pay. >> you do have a series of recommendations for the public sector as well you are recommending the public sector require prices be published in the health policy world. you are recommending insurance commissioners at the state level to be much more pressure it -- aggressive and to recommend the federal government's negotiate the drug prices something that congress has specifically forbidden for medicare.
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obviously you're more sympathetic to government and the political consensus. >> i did not mean the last part to be recommendations by originalist so i wanted 2.0 there are a optioned of choosing men of the above does not work. so none of those is a solution. i am not saying that is an answer but to say we have to be consumers. we deserve that ann with
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austria it is considered elective surgery. i don't think that is a solution in and of itself and one of those areas the hospital that i had my a colonoscopy had $11,000 somewhere in the lobby but an element day are where they are they are because they happen in darkness so transparency will help in and of itself so whatever system we choose in the end i really didn't know much about this it is elected or appointed official and they
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do have a lot of control or power or the bully pulpit to make in -- your insurance works better for citizens but we although insurance directories are horribly inaccurate or in network but not taking new patients or provider that is listed with the network but the physical therapist is not to. surprise so the insurance commissioners can do a lot to be more consumer advocates and then the proponents. so do we pressure governors to appoint somebody to stand up for patients or that we pay attention to the issue on the ballot to get somebody who will promote
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patients' needs because we don't have the same rights of health care as shopping for groceries or a car and that is crazy because that is what we're fighting for now look at california that does have a very active insurance commissioner they have not solve the problem but he has made a better and he actually does not have a lot of legal tools but he can make a lot of noise and he has. >> we touched on the affordable care act a little bit earlier as this is a critical time with some of those issues better front and center in the debate like whether insurance should have to cover certain things called essential
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health benefits or if they have to charge everyone the same amount those issues are under debate right now and for what you learned with your study with those opinions of those ongoing debates?. >> i am not allowed to have an opinion but i can tell a couple the stories people should think about. i started before the hca came into effect so interviewed many people that year that were not insured because of a pre-existing condition so therefore could not afford insurance. so now that included people with pre-existing conditions or having the abnormal pap
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smear or the asthma inhaler if i did not have employer provided insurance i would have been in that pool even as a healthy person because we all have some kind of history. so likewise we will pull out the essential health benefits in those days they did not have to cover maternity care many policies did not i interviewed one young woman six months pregnant and her policy did not cover maternity care. people can say they have to be better shoppers but i'm sorry insurance policies are hard to read through it is not always obvious a she went shopping about for a maternity care to be rational to go to the
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hospital give me a ballpark we're willing to pay the city can't tell you. in the end they said it will be between 5,000 and $45,000 this is before the hca experience with no essentials benefits stuff happens that you cannot predict the rollout people to say i will not cover pregnancy because i don't want to get pregnant or i am a man so why pay for prostate cancer? that leaves people out in the call that a moment in their lives better on think anybody wants to say we will not treat your cancer or say you cannot come into the
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hospital to have her baby. that does not work. so health care is something we have to think about realistically but selfishly maybe help the today but not tomorrow. >> one of the aspects of the affordable care act is that you touched on in the book that you actually suggest that insurance companies could do more as it promoted the bundling of payment and a lot of people believe that part of the affordable care act is not under debate for right now. that is an important
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addition can you say more about those reforms?. >> so let greasy for airlines and the new pay for your bag and then you're drinking and then for your reporting is a with health care that has happened exponentially so if you are having a baby with maternity now is the heating pad or the delivery fee i had one wonderful patient who is a physician and said i will not buy this and then came to the hospital 10 minutes before delivery they gave her motrin she kept the
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newborn in the room then was given the new board feet and a lactation consultant that she did not need so the notion to be bundled and is our health care was done a long time ago and in other countries but now taken to the extreme for now all of a patient's care is taken in the bundling now medicare did some interesting pilot projects for knee and hip surgery even some employers in california who say the all these people involved we will give you a price is reasonable sum the price
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ranges between 20,000 and $35,000. for their bill for each component of the need for the anesthesiologist the three hours of recovery room time it is a sensible concept that has worked very well most of the found with a river doing for hip and knee replacements that did not add much for long
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periods of physical therapy. when they told they would not be paid separately that it doesn't change the outcome. in europe they did not do that because they knew it did not change the outcome so even some hmo does not do that. saw in a sensible experiment headed for policy under the affordable care act the secretary has expressed his dislike of this concept so i don't know where it will go but it is here dollars as physicians we should be enthusiastic that there is a narrative of a fixed price
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maybe somebody will skimp on our care but what we see in the but i have learned researching the book there is so much that is excessive that we could eliminate a lot of that's a hell think it will be france or germany health level of spending but we certainly can turn this sugar around and we need to or we will be bankrupt. >> host: i will turn back to another topic but hospitals as charities as nonprofits the affordable care act does increase the requirements for nonprofit hospitals through the community and charitable benefits they offer in
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return for tax-deductible status but many people assume the united states volunteer or serve on hospital boards or donate as a charity you have some striking things to say about nonprofits. >> cry me make a few enemies but yes. having written this book and what really gets under my skin is i go to the hospital in new york i get the bill then the next thing in the milk -- and the mail we're so happy like to this service would you consider a donation? i don't need to charities but this powless
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many don't feel like charities at the moment not to say there are not hurting hospitals that don't have a good payor mix with that wealthy clientele willing to donate there really struggling now from a business perspective they're shutting down because they don't have a good business model. we're close the emergency room because not enough people come at night. that is not why we keep them open because people are sick for an emergency. the business is applied to hospitals and the structuring of care we end
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up with those decisions people say i get request asking for money and they say medicare or medicaid does not pay enough but then i say walked into the lobby of a local teaching hospital tell me that feels like a pour suffering place. we have been involved with wealthy teaching hospitals but today look like five-star hotels. i spoke to one trauma center this is a weird priority some hospitals now higher hotel executives to have a customer experience or
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advertise sheets and meals meals, i don't take it has to be like a prison but patients need to wise up to what is important most hospitals in europe look like i.c.e. schools and our basic so what are hospitals doing? do they feel like a charity you're serving the community? i recommend everybody looked at the 990 tax form of the hospital would get how much executives are paid the highest paid is the ceo of a local hospital. i don't want anybody to go broke or take a vow of poverty but don't think most
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need the top 20 administrators paid over $1 million per year than they say it is complicated my immediate answer is so is the foundation but that operates in 90 countries and did not make nearly as much money as those 50 illustrators at the local administrator in new jersey. that is a false negative and there is something important with the hca that i am afraid will go away were you doing to benefit the community or in the way of charity care? we never defined the level that we want and as communities we
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should take that next step that does not have to come from washington and then they take away there tax-exempt status maybe they need cheaper rates or molded infested housing maybe they could better use those tax dollars apple gives away a lot of computers but that does not make immaturity. what do we expect the these wealthy institutions? it is a long answer but i think every mayor and city council shall look at. >> on old your book takes a
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negative view on our health care system are there any good parts of health care in the united states that we should feel good about as taxpayers?. >> there are many many good people in the system there are parts of medicare that work very well for patients i run a facebook group there are 9,000 members who talk about arriving at the promised land of medicare so they don't have to deal with the unpredictable and crazy bills in the commercial world. it is true there are some kinds of treatments that fit
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that narrative over and over , yes drugs come to united states first often because it is more expensive and makes first two commercial them because they said the high bar for prices for the rest of the world but also their reliance on the profit motive to bring new drugs and treatment has bad results some great new machines some that were intended for small segment of patients now the think there is a a machine in canada but now there are dozens so now they're used on patients to do not need
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them said yes we get a first the people that need it is great but then there is a diffusion where it is not useful. the flip side treatments that are not useful purpose sometimes what we don't see because they are not a business model. my son was that president during that meningitis outbreak there were vaccines the market in all the other countries but never in the united states because it would be used in a limited way and wasn't worth going through the approval process so we get some types of treatment much quicker then
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there are others eventually it did arrive but only after the fda and the fcc jumper extraordinary hopes and then one year later finally arrived. and love my doctors i am proud that you find in this book you will not find anybody that is not happy with the results they are unhappy of the results and the cost and the burdens that put on them that is rarely have to focus our energy and research is more efficient to have a heart surgeon running to operating rooms but is that what you want? is the research to me
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that is not medical research but business efficiency research i am not sure there is a medical case to even try to do that. >> host: we are nearing the end of the our you have been terrific to listen to your description and i highly recommend the book as a highly personalizes these issues. and looking forward to see what you do with your reporting going forward to have comments on what you will do next?. >> i am now editor in chief with kaiser health and we're investigative health news service as a nonprofit so in that role i tried to continue to see why health
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care does not work on the ground so one thing we have not talked about is drug pricing widely do what everybody else does is to negotiate at the national level? there are bipartisan support or there is a crisis of the epi-pen or do reference pricing with canada if they don't go anywhere that is because of lobbying for how that affects the health care in united states today. >> host: it has been a pleasure i wish you luck with your book and kaiser health news and i will talk to in the future. >> good to talk to you
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again. . >> if you grow up looking at thousands of cases until one day you see that face was placed on earth just for you you fall in love in that moment, for me trump was like that except the opposite. [laughter] i saw him on the campaign trail i thought the person who was unique and deplorable characteristics
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were put on earth specifically for me to appreciate or and appreciate. [laughter] because i have rarely been spending the last tender to olivier's -- 10 or 12 years preparing for president trump to happen.
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>> host: governor kasich did say pleasure the last time i saw ipo fever during a fund-raiser in a barn. >> guest: governor

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