John Donvan:

A while back, we held a debate in which the resolution was, “The U.S. Healthcare System is Terminally Broken.” And guess what, that resolution was actually defeated, and yet the idea that the system is broken is certainly the presumption of another idea that more Americans are telling pollsters that they are now in favor of and that democratic candidates for president are endorsing and promoting, and that is the idea of a single-payer system where the government picks up the bill for everyone’s healthcare coverage, and private insurance more or less goes away, at least, for most people. Once seen as an outlier concept, single payer is definitely getting a rhetorical tryout for this period in time, and it’s so controversial still that we think it has the makings of a debate. So, let’s have it, “Yes,” or, “No,” to this statement, “Replace Private Insurance with Medicare for All.”

I’m John Donvan. I stand between two teams of two who are experts in this topic who have thought about it long and hard. They will be arguing for this resolution and against the resolution, which again is, “Replace Private Insurance with Medicare for All.” As always, our debate will go in three rounds, and then our live audience here at the Cape Playhouse at Hunter College in New York City will choose the winner. And, as always, if all goes well, civil discourse will also win. One more reminder to the audience, if you haven’t done it yet or just arrived, please cast your pre-debate vote, “iq2us.org/vote,” is the URL.

You’ll be prompted to cast a vote for the motion, against the motion, or to declare yourself undecided. And we’ll keep that first vote open for a couple more minutes as the program unfolds. And it’s going to be the difference between the first and the second vote that determines our winner. Our resolution is, “Replace Private Insurance with Medicare for All.” Let’s meet our debaters. First, the team arguing for the resolution, please welcome Dr. Adam Gaffney.
[applause]

Adam, welcome to Intelligence Squared U.S. You are a pulmonary specialist — you’re the doctor on the stage — at Harvard’s Cambridge Health Alliance. You’re also president of Physicians for a National Health Program. Adam, it’s great to have you on the stage. Thanks so much.

Adam Gaffney:

Thank you for having me.

John Donvan:

And let’s meet your partner. Please, ladies and gentlemen, welcome Joe Sandberg.

[applause]

Hi, Joe. You are a progressive entrepreneur. You’re cofounder of Aspiration.com; you’re also cofounder of the advocacy group Working Hero Action. You are one of the nation’s top activists for the earned income tax credit, which helps low-income families. It’s great to have you on the stage. Thanks so much.

Joseph Sanberg:

Thanks for having me.

[applause]

John Donvan:

And we have two debaters arguing against the resolution, “Replace Private Insurance With Medicare For All.” Please first welcome Nick Gillespie.

[applause]

Hi, Nick. Welcome back. You have debated with us twice before. You’re undefeated, by the way, so a lot at stake here for tonight — for you tonight.

You’re editor at large of Reason magazine; you’re co-author of “The Declaration of Independents” — E-N-T-S — “How Libertarian Politics Can Fix What’s Wrong With America.” You’re going to extend that winning record tonight?

Nick Gillespie:

You know, it’s no secret that I have a glass jaw, John, so we’ll see. We’ll see.

John Donvan:

All right.

Nick Gillespie:

I’ll keep my guard up. Thanks for having me.

John Donvan:

Sure. It’s great to have you back. And let’s please welcome another returning debater. Ladies and gentlemen, Sally Pipes.

[applause]

As I said, Sally, you’re an IQ2US alum. You are president and CEO of the Pacific Research Institute. You’re a prolific writer on healthcare, including your column Piping Up for Forbes.com. That comes from your name, I’m guessing.

Sally Pipes:

Yeah.

John Donvan:

I figured that out. Your forthcoming book is called “False Premise, False Promise: The Disastrous Reality of Medicare for All.” Sally Pipes, welcome back to Intelligence Squared.

Sally Pipes:

Delighted to be here.

John Donvan:

So, ladies and gentlemen, our teams arguing for and against the resolution.

[applause]

So, let’s move on the debate proper. Our debate goes in three rounds. Round one, opening statements by each of the four debaters in turn. The first to speak in support of the resolution, “Replace Private Insurance With Medicare For All” is president of the Physicians for a National Health Program. Please, ladies and gentlemen, welcome for his opening statement: Adam Gaffney.

[applause]

Adam Gaffney:

Thank you. So, let’s be clear. On one issue, there is no debate. The United States has the costliest healthcare system in the world, and despite that, we leave nearly 30 million people uninsured and many more with insurance that is so skimpy it’s basically junk. As an intensive care unit physician, I have seen the harm that our system imposes on patients, care delayed, care forgone because of costs, with catastrophic results.

These are the facts, and we’re here to discuss tonight, how do we deal with them? Our side is going to argue that a single-payer improved Medicare for All system is not only the best way forward, it is actually the only way if we are going to solve three of the gravest problems of the American healthcare system. So, what are those problems, and how will single payer solve them? Number one, we have to cover everybody. As I mentioned, nearly 30 million people are uninsured in this country, and that problem is getting worse. Now, you may hear sometimes that it doesn’t matter very much because hospitals can’t turn you away if you show up, so what’s the big deal? Believe me, it is a giant deal. If you’re uninsured, and you go the hospital and are admitted, you may accrue tens of thousands of dollars of medical debt, bankrupting you.

But for the uninsured, the cost of physician care is often too high, the cost of prescription drugs are too high. So, what do the uninsured do? They go without the care they need. In the ICU, I have seen patients with common conditions like diabetes, like high blood pressure, not get the care they need for years because they were uninsured and wind up with life-threatening complications in the intensive care unit. I do not want to see that anymore, and we don’t have to. It’s a choice we make. Medicare for All would solve that problem by covering everyone the day it is implemented. Everyone in; no one out. Problem solved. Let’s move on to problem number two. We also have to improve coverage for everyone else.

Now, you’re going to hear from the other side tonight, I think, that Americans love their private health insurance. They don’t want to give it up. But the reality is, private health insurance is failing Americans from coast-to-coast, and they know it.

Insurance deductibles, the amount of money you pay out of pocket before insurance kicks in, are rising. Insurers’ greed keeps Americans from the healthcare they need. And what are the consequences of those high deductibles? People don’t get care. Children with asthma don’t get their inhalers filled. Seniors don’t go to the physician and wind up potentially in the hospital instead, with complications of chronic illnesses. A recent study found that women with high deductible healthcare plans, which are becoming the new normal, are very likely to put off diagnosis and treatment of their conditions. That means that people are using GoFundMe to raise money for their medical care, even though they have health insurance. So, Medicare for All would solve these problems very quickly and very simply. Everyone would get a public insurance plan that would cover your healthcare without copays or deductibles. Does that sound like fantasy? No. It’s how it works in many countries in Europe.

It’s how it works in Canada. We can do it here in the richest country in the world. All right. That brings me to the final goal: controlling costs. So, you may hear from the other side tonight that, “Well, that all sounds good. But how are we going to pay for it?” Well, I’ll tell you how we’re going to pay for it. We’re going to pay for it because our current system is far more costly than it needs to be. Let me give you one example. Private health insurance companies take 12 percent of every premium dollar you give them in their overhead, for their profits, for their administration, for their marketing, in order to fight with doctors, in order to fight with patients. That is sixfold higher than traditional Medicare, which only takes 2 percent for its overhead. That is enormous waste.

Meanwhile, on the other side, hospitals are employing armies of billers and coders to fight with the insurance companies. We spend $80,000 per physician in this country just to cover the cost of their interactions with insurers.

That’s fourfold higher than Canada. So, that wastes time that physicians should be spending with their patients — and it wastes time that patients should be spending recovering from their illnesses. We don’t need to do it this way. And the simple fact is that a Medicare for All system could save hundreds of billions of dollars in administrative waste, money that could cover everyone — we could use to cover everyone. So, in closing, the profound suffering imposed by our ailing healthcare system deserves strong medicine. There’s a reason why a majority of Americans support Medicare for All. There’s a reason why so many physicians think this is the best reform, both for themselves and for their patients. It is the only reform that can actually deliver universal healthcare while delivering the cost savings to pay for it.

For all of those reasons, I ask you tonight to vote yes on the motion that we replace private health insurance with an improved Medicare for All system for everyone in the country. Thank you.

[applause]

John Donvan:

Thank you. Adam Gaffney.

[applause]

The resolution, “Replace Private Insurance with Medicare for All.” Here’s our first speaker to argue against the resolution: editor-at-large at Reason Magazine, Nick Gillespie.

[applause]

Nick Gillespie:

Hi. Thank you, everyone. And, you know, what I want to start with is I want to start with the things I think that we agree on, all four of us on the stage. I won’t speak for John, but I suspect he’s in on this too — which is that we want a country where people can pursue life, liberty, and happiness, as they define it. And we want a country where people who want health insurance and who have medical care — that they get it, that it’s universal and accessible to all.

The question is, how best do we get there? And let me weigh out quickly the reasons why I’m against the idea of Medicare for All — particularly the way that it’s talked about by Bernie Sanders, who is really the impetus for this conversation. And he talks about it as Medicare for All means no premiums, no copays, no deductibles, and no more time wasted arguing with profit-driven insurance companies.

[cheers]

Does anybody — yeah. That all sounds great, doesn’t it? Okay. Now, how exactly do we get there? The — what — because we don’t want — we don’t just want a system that is available for everybody. We also want one that is constantly improving and innovating. And one of those things that’s interesting in Adam’s statements — he didn’t talk about improvements in healthcare. He didn’t talk about innovation. He didn’t talk about growing the ability of people to get more healthcare, even as, plainly, we would be increasing the demand.

And what I want to talk about — because Sally is the real expert on our side, in terms of the details and the nitty gritty of what the Canadian system is like — which is the only pure single-payer plan out there in the planet. And she’s going to talk about the deficits that that produces. But think about it in terms of general economics. In terms of general — a general economic system, markets deliver more stuff to more people in more ways than controlled systems, than a single-payer system is going to do. So, the question is, how do we deal with that? It is true, according to Gallop — the most recent Gallop polls — 80 percent of people in America say that the quality of their personal healthcare is excellent or good. 70 percent say their healthcare coverage is excellent or good. So, most of us are happy with the system as it is. So, that means, if you’re arguing for Medicare at all, you’re telling 80 percent of Americans, “You guys — you’re all wet. You’re wrong about things.”

One of the reasons for that is because, in order to do Medicare for All — and this is according to the proponents of the plan — the cost is going to be between $3 trillion to $4 trillion a year in new taxes that the government will be raising. That’s double what the federal government already is raising in taxes. So, we’re going to be doubling taxes. Some of that will be offset because, as private people, we — about 50 cents of every healthcare dollar is spent by the government, about 50 cents by insurance companies, employers, and people like that. So, we’re still looking at least $2 trillion a year in new taxes that you’re going to be paying. The cost of health — of Medicare for All is what had killed these plans in states like California, New York — which had seriously entertained it — or in Bernie Sanders’s own home state of Vermont, which actually passed a single-payer plan without talking about the cost that it was going to be.

The governor who was in favor of it, when it came to be, it turned out that they were going to have to increase, put in an 11.5 percent payroll tax on top of everything, and a 9 percent increase on the state income tax. They scotched the system. In a state that has fewer than a million people, they decided they could not afford Medicare for All. That’s an object lesson — Bernie Sanders’s home state. Now, Medicare for All, if you go back to this idea that, you know, supply and demand is not different when we’re talking about medical care than it is, say, when we’re talking about groceries, or about the production of books, or movies, or clothing. When you increase the demand for something and you do not increase the supply, you are going to get limited — you know, you’re going to get waits. You’re going to get waiting lists. You’re going to get rationing by a bureaucrat — not by what you can do. There’s no place outside of the system in order to get stuff because it’s all been public — it’s all been made public. Finally — and this is the other reason to be against Medicare for All — it’s going to kill innovation in the healthcare field.

And everything that is good about healthcare is better now than it was 50 years ago because of innovation. It’s going to stymie things in two ways. First off, do you really expect a centralized bureaucracy to decide, “Okay. This is a good, cutting-edge way of treating illness. We’re going to go ahead with that.” The government and bureaucrats in the government in particular, when they have — when you have no recourse outside of that system — which is the whole point of Medicare for All — there is no outside. They’re not going to be responsive. They’re not going to be forward-looking. They’re not going to be avant-garde when it comes to new types of healthcare. The other thing — and this goes to Bernie’s idea about profit-driven insurance companies. How many of you work for a living? And how many of you work for a wage? You know, talking about stuff that’s profit-driven is just mere ideological cant.

If you take away a drug company — if you take away a doctor’s incentive to make money and to come up with new ways of doing things — which is what will happen under Medicare for All because there will be strident price controls on all sorts of activities in the healthcare space — you’re going to hurt the ability to try new things and to make money from doing them. There’s nothing wrong with that. So, what can we do? And this — I’m going to have to give up my time here in a second. What we can do is do things to make markets function more clearly. Ask yourself, when is the last time — like, do you know how much your blood test costs you? Even out of pocket. It’s unclear. The healthcare system will be fixed if we bring more market signals in so that things are working better. And also, we can subsidize people — the 28 million people without insurance. We can give them money to help them buy insurance on the private market. And I’ll stop there. Thank you very much for your time.

[applause]

Please, vote against Medicare for All if you care about the cost of —

John Donvan:

Okay —

Nick Gillespie:

— if you care about convenience —

John Donvan:

— you’re stretching the time there.

Nick Gillespie:

— [unintelligible]

[applause]

John Donvan:

You’ve heard the first two opening statements, and now on to the third. Debating for the resolution — once again, “Replace Private Insurance with Medicare for All” — is Aspiration.com’s cofounder Joe Sandberg.

[applause]

Joseph Sanberg:

Thank you. I grew up in poverty. My mom raised me by herself, and when I was a teenager, we lost our home to foreclosure. I saw my mom wake up in the middle of the night in cold sweats, agonizing over how she was going to help her parents in their final years get healthcare, how she was going to make sure my brother and I were able to go to the doctor and get the care we needed.

I saw her struggle, working multiple jobs to pay for her private health insurance, because she often worked as a freelancer. The experience I had growing up and the experience my mom had raising me by herself doesn’t make me unique. In fact, it puts me in common with almost eight out of 10 Americans who live paycheck to paycheck.

This debate is much bigger than the question of single-payer health insurance. This debate is about the number-one reason that America has a poverty crisis. Poverty isn’t what the statisticians have told us, that if you live below some arbitrary mathematical line, you’re poor, and if you earn $5,000 above that line, you’re middle-class. Poverty is whether you have the peace of mind that when your kid is sick, you’ll be able to take her or him to the doctor. Poverty is that eight out of 10 Americans live paycheck to paycheck. When eight out of 10 Americans live paycheck to paycheck, we don’t have a middle class. We have a massive poverty crisis, and it’s a reflection of a changing economy where more and more people don’t work for an employer, but work in unstable, unpredictable freelancing jobs.

You know these jobs. They’re part of what’s called the gig economy. For an economy where people work for one employer, maybe employer-based health insurance was suitable. But a lot of the arguments you’re going to hear tonight against Medicare for All are arguments that are outdated 25 years. It’s true that people used to be reasonably happy with their employer-based health insurance when they had employers. But as we increasingly move into an economy where people are reliant on freelancing work, the idea of employer-based health insurance seems antiquated, and it is. The number-one way we can solve America’s poverty crisis is by ensuring that no one is of want or worry for healthcare, and the surest way we can do that is through a single-payer system that isn’t motivated by profit.

You’re going to hear a lot of statistics tonight about innovation and a profit motive and how it’ll stifle innovation if we don’t have private health insurance. But ultimately, your vote has to be a question of what kind of society we want to live in. Do we want a society where the god we worship is that of efficiency and productivity and the profitability of a particular industry, or do we want a society where we make sure that not everyone can pursue happiness, but that everyone is happy? Where not everyone has access to healthcare but has healthcare. Where people don’t have the right to live, they live instead of being too poor to die? Now, I bring a unique perspective as an entrepreneur and a businessperson. I operate in the private sector, and let me tell you, the current system is broken left, right, center, upside down, every which way to Sunday.

And it’s not just broken for the 40 million people who don’t have insurance and the 40 million people who are underinsured, who are disproportionally women and people of color. But it’s also broken for entrepreneurs, for employers, and for workers, and let me give you a couple of examples. The United States is the only developed economy in the world whose businesses have to compete globally without government health insurance. So, when our companies are operating in a global marketplace against companies from Germany or Japan or England, they’re competing against companies that aren’t responsible for health insurance, and therefore can direct more private sector dollars to real innovation that’s productive, inventing new products in research and development. Second of all, think about the effect on entrepreneurs. You know, at the top level, people think this is a golden era of entrepreneurship, but it’s actually untrue.

This is a golden era of people starting companies, but they can’t survive more than a couple of years. And the biggest reason is those new companies are crippled by health insurance costs. And third of all is, let’s talk about the gender and racial wealth gap. The gender and racial wealth gap grows and grows with every passing decade, and the reason, primarily, is that women and people of color lack the collective bargaining power in our economy that they once had in an era of stronger unions. But there’s something else that suppresses the bargaining power of low-income workers. Imagine your hesitation to ask the person who controls whether your kid can go to the doctor for a raise. Aren’t you going to think twice about going to that person and asking for more money, knowing that, if you piss that person off, he or she can control whether you take your kid to the doctor?

In conclusion, as you hear us expound on the merits of single-payer health insurance and you hear statistics from this side and from our side, remember that this is fundamentally about a question of, “We want a country where people make money off of those who die and don’t have access, or a country that prioritizes, insuring that no one is too poor to live.”

[applause]

John Donvan:

Thank you, Joe Sanberg. Our resolution, again, “Replace Private Insurance with Medicare for All,” and here to make her opening statement against the resolution, CEO and president of the Pacific Research Institute, Sally Pipes.

Sally Pipes:

Thank you.

[applause]

Thank you. Medicare for All is more popular today than ever. Senator Bernie Sanders’ 2019 bill has 14 cosponsors. Congressman Pramila Jayapal’s single-payer bill has 118 cosponsors.

50 percent of Americans being polled today support the idea of Medicare for All. But, in spite of that, I am confident that I can make the case against Medicare for All and, by the end of the evening, that you will decide with Nick and myself that you should vote against the proposition. Support for Medicare for All resides on — rests on several misconceptions, the most important being that — the idea of Medicare for All. Medicare for All would simply enroll everyone in a government health insurance plan. Medicare, as we know it, along with Medicaid, would be eliminated. Private health insurance would be banned, and one million people in the insurance industry would lose their jobs. All Americans would be in a single-payer healthcare system. The only thing that this program would borrow from the Medicare program is the payment structure, and that’s a problem.

Doctors would be paid Medicare rates, which are 40 percent below what they get paid for treating private patients. Private patients subsidize doctors for treating Medicare and Medicaid patients. If we eliminate private insurance, doctors and hospitals will lose significant amounts of income. Many doctors will decide they want to reduce the size of their practice, they want to quit medicine, or they want to go into another profession. That will exacerbate our nation’s doctor shortage. Already, the American Association of Medical Colleges has predicted that, by 2030, America will have a doctor shortage of 120,000 doctors. Of course, these are all hypotheticals, so let’s look at two countries that have Medicare for All or aversion of Medicare for All systems. After more than 70 years in operation, the National Health Service, the U.K.’s socialized health system hasn’t found a way to treat an unlimited stream of patients and — with the limited resources they have.

In England today, more than four million Brits are waiting for medical treatment. Some are waiting for an appointment with the — with the — because of the dwindling numbers of doctors in the U.K. Others are the victims of rationing. They’ve been told they’re not sick enough to get treatment, they’re not skinny enough to be treated for anorexia, or they’re not blind enough to have their cataracts removed. Recently, the National Health Service said, in a way to reduce waiting times, they should conduct group appointments, where one general practitioner we call primary care see up to 15 patients with the same condition at the same time.

But even the U.K. allows private insurance. That’s not the case in Canada, the country where I grew up. In Canada today, there are over one million people on a waiting list waiting for a procedure or a treatment.

The cost of lost wages for these people who cannot work — according to the Fraser Institute — is $2.1 billion. Canadians are not facing short waits. In 2018, the median wait time from seeing a primary care doc, to getting treatment by a specialist, was just under 20 weeks. Canadian patients may face further waiting times. Doctors frequently prohibit patients, when they book an appointment, to discuss more than one — to discuss only one issue. If you need to talk a second or third issue, you have to book a second or third appointment. It’s no wonder that Canadians — 323,000 Canadians in 2017 left Canada and went abroad to seek treatment for conditions that they thought they needed care immediately. There are countless stories. My friend, Dr. Brian Day, who runs the illegal Cambie Clinic in Vancouver, Canada, he’s an orthopedic surgeon.

He does 60,000 surgeries a year at his clinic. And the government of B.C. has been challenging him, saying it’s illegal, and they want — the government wants to shut him down. In Great Britain, the stories are the same. Brett King and his wife, their son needed cancer treatment. He was age 6. They couldn’t get it in the U.K.; they said it wasn’t worth it. He went to Spain and had the treatment, but he — the couple — the parents were sent to jail for taking their son abroad. Mick Jagger, the Rolling Stones frontman. When he was diagnosed with needing a heart valve replacement, he came to New York’s Presbyterian Hospital and had the surgery. When he was in recovery, his younger brother in the U.K. said, “Thank goodness that Mick has not got to wait in line for the National Health Service.” Canadians and Brits pay a lot to — for the care that they wait. The average — it’s not free. Bernie Sanders will tell you single-payer healthcare is free. The average Canadian family, last year, paid $13,330 in hidden taxes for a healthcare system that rationed care and had long waits.

The taxes that Americans would face under Medicare for All would undoubtedly be higher, as Nick has said, since it would cover everything under the sun: dental, vision, long-term care, drugs. The Canadian system doesn’t even cover those things. Long waits, high costs, poor outcomes. This is the harsh reality for millions of people around the world who are living under versions of Medicare for All. America’s largely private health insurance system does merit reform. I grant you that. But Medicare for All is not the solution. I hope you will realize this and join me in voting against the motion. Thank you.

[applause]

John Donvan:

Thank you, Sally Pipes, and that concludes Round 1 of this Intelligence Squared U.S. debate, where our resolution is, “Replace Private Insurance with Medicare for All.” I want to move on to Round 2. Round 2 is where the debaters address one another directly, and they take questions from me — and also from you, our live audience here at the Kaye Playhouse in New York City.

Our resolution is, “Replace Private Insurance with Medicare for All.” The team arguing for that resolution — Adam Gaffney and Joe Sanberg — have said yes, Medicare for All, indeed, is strong medicine. But they say it’s the medicine that is needed now — that we’re in a country which is the richest in the world, but also produces the costliest healthcare costs in the world, yet with many millions of people still uncovered — that Medicare for All is a way to make a system that would be universal, that would eliminate the things that wear down people who are poor, of meager means, such as high deductibles — and also that it would be a system that because of — by unifying all of the operations under one payer would reduce a lot of the bureaucracy and the bloat, which they say is a major problem in working with multiple insurance companies.

Where administration, they say, goes into the hundreds of billions of dollars, with eight out of 10 Americans living paycheck to paycheck. They also point out that going to your — looking to your job for your insurance is an outmoded idea. We’re not in that world anymore because of the way that people work has also changed. The team arguing against the resolution — Sally Pipes and Nick Gillespie. First of all, as we just heard Sally say, they’re not saying the system doesn’t need reform; they are saying that Medicare for All is the wrong way to reform it. Nick Gillespie has argued that going to Medicare for All puts us in a controlled system, and that controlled systems never work as well as delivering what needs to be delivered as markets do; that going to Medicare for All would squash innovation, would squash improvements; that it would require $3 trillion to $4 trillion in new taxes; that it hasn’t worked — the team says it hasn’t worked in places like Vermont.

They very vividly describe problems in countries that have such systems as Canada and the United Kingdom. They basically don’t believe that bureaucrats will have the vision to make the kinds of decisions that lead to innovation and improvements in healthcare of the kind that we’ve all experienced over the last 50 years or so.

Basically, they’re saying that it’s too — it would have too radical an impact on our system, throwing a million people who work in the insurance industry out of work, causing doctors to give up the field because the way that they get paid will become very, very full of disincentives for them. So, those are — there’s a lot there. There’s — I also want to say that among all of our debates this is maybe the best set of opening — four opening arguments that I’ve ever heard, because you all took different cracks at this from different positions, and I’d like to try to dig into as many of them as we can as we move forward. But I notice that there’s a difference on understanding and interpretation of the facts. There’s also a basic philosophical difference, I think, between the two sides. I want to explore that very, very briefly just a little bit.

This notion that I think right now is certainly motivating the Democratic candidates, that healthcare is a human right. It’s one that we are increasingly hearing as part of the rhetoric. It’s not a new idea; the World Health Organization signed onto it back in 1946, and we signed those treaties, but it hasn’t really been part of the conversation until, I would say, the recent past. I want to start with — I’ll go to the side arguing against the resolution. This question — do you think healthcare is a right, and how does that inform the position you’re taking on the resolution? Sally Pipes?

Sally Pipes:

Right. Well, healthcare to me is neither a right or a privilege as it’s being talked about. It is a good — healthcare is a good and service, and like all goods and services, healthcare is necessarily scarce. Declaring a right to healthcare that is greenlighting essentially unlimited demand for healthcare will not miraculously engender unlimited supply in — to meet the demand for healthcare.

It’s also unclear what a right in healthcare really is. Does it mean the right to the very best doctors, the very best care, or simply a right to equal care? If the latter, would the government have to ban people from paying for better care, and does the right to healthcare come with any corresponding duties? If I have a right to healthcare, does the government have the right to tell me myself that I am not healthy and that I can’t have healthcare? Do I waive that right if I’m a smoker or if I’m obese, as in the U.K.? British people that are obese or smokers are having a hard time because doctors are told not to treat them. So, I believe healthcare is not a right.

John Donvan:

Let me bring the same question to Adam Gaffney.

Adam Gaffney:

Healthcare absolutely should be a right. It’s not a right in this country because we care more about the interests of the private insurance industry and their shareholders than we care about the rights of American patients. So, yes, it should be a right.

[applause]

It’s not some, you know, complicated philosophical question. We consider a lot of basic social services rights in this country. We think children have a right to an education. Are teachers a scarce resource in some sense of the word? I suppose. Does that mean we pay kids — we force kids to pay for their education, and the ones who don’t have enough money don’t get to go to school? What kind of a society treats these fundamental social services that we all require are as no different than luxury commodities? So, absolutely, yes, healthcare should be a right.

John Donvan:

Nicholas?

Nick Gillespie:

I think Adam’s, you know, response there shows the kind of paucity of this argument to call something a right or not. Let’s talk about food, for instance, because what I want to people to keep thinking about is the idea that medicine — the delivery of medicine is no different, say, than the delivery of food. We have — to say people have a right to food, what does that mean exactly? It doesn’t get us very far. But if we look at the food system in America, we create massive amounts of food.

Joe, you became a millionaire by creating Blue Apron, right? A new way of selling food to people.

Joseph Sanberg:

Yes.

John Donvan:

Just a millionaire?

Nick Gillespie:

Multimillionaire and your [unintelligible]. But what I’m getting at is that we don’t say because some people don’t have enough food, the government should then dictate the prices and the offerings throughout all of the food in the world. What we do as a society — and again, we don’t need to talk about rights. What we decide as a society is to say, “Look, we don’t want people to go starving, so we’re going to create subsidies. We’re going to create programs by which they can get the food that they need.” We can do that better or worse, but it’s the same thing with healthcare. I think to talk about it as a right or not a right doesn’t get us very far, and mostly what it does is it takes away from this idea, “If 80 percent of us are happy with our healthcare” — I’m not sure I’m in that 80 percent by the way, but, “if 80 percent of us are, what do we do to help the 28 million, not the 40 million?”

John Donvan:

Okay, before you move on to that, I want to stay on the right question for Joe Sanberg.

Joseph Sanberg:

Yeah, I want to make three points. First of all, if eight out of 10 Americans are living paycheck to paycheck, do you think eight out of 10 Americans are happy with their health insurance? Probably not.

Nick Gillespie:

Which one is lying then? Which 80 percent?

Joseph Sanberg:

Second of all — yeah, second of all, the question about whether healthcare is a right ultimately is your decision to make in this vote. If you believe healthcare is a right, and should be a right, and should be secured as a right by our government, then you should vote for this resolution. If you believe that healthcare is a scarce asset that’s monetized for profitability, then you should vote against this resolution. Third, health insurance and healthcare are different questions. One of the failings of this whole debate here and at large is the conflation of the question of insurance and healthcare. Medicare for All versus private insurance is simply a question of who pays the doctor.

In the present system, we’re all paying health insurance companies. They take 20 percent or so of what we pay them to spend on administrative costs and profitability for shareholders, and then use that other 80 percent to pay the doctors. In this program called, “Medicare,” which serves 60 million Americans — 60 million Americans who most need healthcare, the highest acuity of Americans, only two percent of dollars paid to Medicare go to administrative costs. Medicare is one of the greatest organizational triumphs in the history of humankind, and that’s no exaggeration.

John Donvan:

Joe, let me break in there to let — I want to take to your opponents one of the points that was made in the opening. I’ll take it to you, Nick Gillespie, is that Medicare for All has the virtue of, by definition, being universal, that — and I want to — I want you to respond to that, that that’s a worthy goal. It’s a necessary goal, I think they’re saying, and Medicare for All, by definition, addresses that issue.

Nick Gillespie:

I think that it is a fair point and a good question to say, “Why doesn’t everybody have access to healthcare?” And again, I take Joe’s point, you know, that healthcare and health insurance are two separate things. And what we really ultimately care about is, when you need to see a doctor, can you see a doctor? Are treatments being developed that really solve problems that we need to have solved? It’s not about insurance, per se, and things like that. Having said all of that, it’s one thing to say, you know, something like, “Medicaid,” which is a federal program that’s split with the states that deals with poor people — poor people have access to Medicaid and they get into the system, and then they can’t see doctors, because there aren’t any doctors who will take the payment schedule that Medicaid puts forward. Same thing with Medicare. Increasingly, doctors are saying, “You know what? I can — I — if I take a Medicare patient, I’ve got to take 40 percent less money than I’m going to get from a private company.”

That’s a problem. Again, the main thing to think about here is, “How do you deal, not with the mass of people who are doing okay in a system, how do you deal with the hard cases, the poor people, people with preexisting conditions?” That, we can deal with, not by destroying the system, and blowing it up, and turning it into Medicare for All, but rather by directly addressing people who need help.

John Donvan:

Okay, let’s let Adam respond to some of that.

Adam Gaffney:

Several things. I mean, first of all, many of the people you’re talking about who are doing okay are doing okay until they get sick. That’s a fact. Your insurance may seem fine until you are really sick, until you need chemotherapy, until you are diagnosed with cancer, until you are struck by a motor vehicle. The reality is, is that that’s when you real — when you see the flaws in the current system. That’s when you experience deductibles that are thousands of dollars. That’s when you realize that your networks keep you from going to certain doctors at certain hospitals.

So, I want to rewind briefly and respond to some of the comments that Sally made in her opening statement, because I think those are really critical. She painted a pretty scary picture of what healthcare is like in countries that have universal taxed finance systems, like U.K., France, Canada. Sounds like really scary stuff. In Canada, it’s funny, because the man who’s regarded as founding the Canadian universal system, Tommy Douglas, is regarded as a hero in that country. In the U.K., the NHS is commonly referred to as the national religion of that country. It’s funny that if these systems are so bad that people really actually seem to like them very much, not only that, they are petrified of taking the U.S. system on. That’s unquestionably true. You know, you heard a lot about waiting times in those nations. Pretty scary stuff. What about all of the people in the United States who are on waiting lines that are infinite in length because they have no health coverage at all?

How about all of them who never get to see a doctor or never get to take a medication they need? There is no waiting list. They just don’t get it. You know, the final point I want to make is this idea that there are cords of Canadian medical refugees heading south of the border for healthcare. That comment has been made for decades, and it’s easy to make it, but once you actually look at the facts, you realize it’s off. In the medical health policy journal Health Affairs, there was a scientific study of this issue that found no systematic evidence for Canadians fleeing south of the border to get healthcare.

John Donvan:

All right —

Adam Gaffney:

Yes, some do, but it is not a systematic problem.

John Donvan:

Sally Pipes?

Sally Pipes:

323,000 Canadians leave Canada and go abroad for getting an MRI, a CT scan, or a hip replacement, or whatever because the waiting lists are too long. Those numbers are not false. I am Canadian; I have doctors in my family. I know this. Tommy Douglas was named the greatest Canadian by the Canadian Broadcasting Corporation, the government monopoly radio and television station.

So, just — you have to think about where that came from.

[laughter]

[applause]

So, we do have long waits. I have many, many stories, but I just want people to know that when the government is fully in charge — my cousin is a doctor, my other cousin is a doctor — doctors are paid — they’re basically union members. They’re paid rates set by your provincial government. Nick may be the very best cardiac surgeon; I may be the very worst. We’re paid the same amount of money. There’s a global budget set. So, my cousin — in late November, his global budget for doing cataract surgery is used up, and he can’t do any more treatments unless he does them illegally or under Dr. Brian Day’s illegal Cambie Clinic. So, we have — the Canadian healthcare system is a disaster. It’s what Bernie Sanders and Pramila Jayapal want for our country, but it is going to be a disaster. My mom used to say before she died, “I hope you’re not becoming one of those impatient Americans.” Americans are impatient. They want to see the doctor right away; they want to get their treatment right away. And we’re a wealthy country, and that’s one of the reasons why healthcare is expensive here.

John Donvan:

Adam and Joe —

[applause]

I want to take two — I want you to talk for a bit about a point that your opponents made, which is that Medicare for All will ultimately start to lower costs for people in the healthcare profession, particularly doctors. There are a lot of numbers floating around, a lot of studies. Some say that they would be cut 40 percent. I know, Adam, you said you think that’s nonsense. But they do make a case that ultimately the way costs are going to be saved will be to reduce the amount of money that goes to hospitals and doctors, and then that will be a disincentive for innovation and actually for participation in the workforce, leading to a doctor shortage. It’s a coherent argument. I’d like to get your response to it, whichever of you would like to take it.

Adam Gaffney:

So, this is the fact of the matter. About 10 percent of our healthcare spending goes towards physician salaries. Now, a lot of people would like to see that lowered, but the reality is you can move to a Medicare for All system and keep that the same.

That’s not where the savings come from. The savings come from the fact, as I said earlier, that private insurance companies take 12 percent of their overhead — of their premium dollars for overhead versus 2 percent interest on Medicare. Our hospitals use 25 percent of their revenue just for billers and coders and administration, twice the portion of hospitals in Scotland, for instance. So, — and finally, there’s big savings to be made on pharmaceutical companies, which are getting away with murder by basically charging whatever price they want —

[applause]

— because they have a monopoly. Not a very free market-oriented system. So, that’s where the savings come from. You have hundreds of billions of dollars in savings on administration and drugs and drug prices, and you can transition to a Medicare for All system, and hospitals and doctors will be okay. We’re not going to suddenly get into boats and, you know, ship off to [inaudible].

John Donvan:

Okay, let’s point out that we don’t really actually know. Neither side really knows. We’re both working with hypotheticals. I think that’s okay, because we’re looking for the ideas behind hypotheticals. Nick, why don’t you take that on?

So, your opponents are saying it — the money doesn’t have to come from doctors. It will come from the bureaucracy of the private insurance companies, which now cover roughly 60 percent of the population.

Nick Gillespie:

Yeah, it’s actually higher than that. The number of people who are covered through private insurance is closer to 80 percent, I believe. But, in any case, this discussion of, “Medicare is great, because it only charges two percent,” or, “it only spends two percent on administrative costs.” That is because Medicare is geared towards retirees who are politically the most connected and, you know, powerful constituency in America. Any time the government goes to say, “You know what? We’re going to cut down on Medicare fraud, and billing abuse, or just mistakes,” people go bananas. Old people go bananas, they call their Congressmen, and it gets stopped immediately. In — Obama’s chief economic advisor, Christina Romer, did a study in — you know, during Obama’s years in office and found that 30 percent of Medicare’s budget could be cut without affecting medical care.

There is a huge amount of waste in Medicare right now as we know it, which is already bankrupting the country. There’s no incentive to look for fraud, and bad billing, and things like that.

John Donvan:

Joe Sanberg.

Joseph Sanberg:

[unintelligible]

Nick Gillespie:

For private insurance — for private insurance, yeah, they go after waste, fraud, and abuse, because they have to.

John Donvan:

Joe.

Joseph Sanberg:

Whether or not we cut 30 percent of Medicare’s budget without affecting medical benefits, I can tell you we can cut 100 percent of private health insurance and we can improve medical outcomes, because the essence of private insurance is about making profit for their shareholders. And the question that you have to ask is a philosophical one. It isn’t solely one about numbers and cents. It is a question of, “Do we want a society where the profit motive informs who lives and dies?” I’m a capitalist. I’m a business person. I’m an entrepreneur. I think many things are totally suitable to the profit motive, but some things aren’t.

We’ve tried this system of a profit-oriented health insurance industry, and it’s left 80 million people, disproportionately women and people of color, either uninsured or under insured.

John Donvan:

Joe, I mean, in terms of the profit that you’re talking about the insurance companies are making, in a recent year, or it was last year or the year before, they made something like $22 billion, which sounds like a lot of money —

Joseph Sanberg:

Correct.

John Donvan:

— but the proportion of money — the proportion of healthcare costs covered by private insurers was about a 1,000,000,000,000.1. That means their profit as a percentage of all of the money being spent by them on healthcare, it’s not even two percent. It’s .02 percent. It sounds like that’s not money that would move the needle in any significant way.

Joseph Sanberg:

Well, but let’s keep in — let’s keep in mind —

[applause]

— that 22 billion — that 22 billion is the profit for shareholders. That doesn’t count the tens of billions that go to executives, the tens of billions that go to unnecessary administrative work, all of which is ultimately a tax on low-income Americans who are disproportionately women and people of color.

So, it’s a much bigger pie than just the $22 billion of profitability.

Nick Gillespie:

You know, can I just quickly say insurance has been around as an economic instrument, you know, for centuries. It is not based on cheating people. It is based on figuring out how you can pull risks and make a profit off of it.

[applause]

There’s nothing wrong with that. And again, I want to stress this idea. We keep saying — I mean, I think you guys are claiming that medicine somehow is a totally different — it functions totally different than other parts of the economy, where it is a good that should be held in total advance of all laws of supply and demand. I mean, you — why isn’t food treated the same way as medicine by your light? And again, I would just argue we can deal with people who don’t have enough food. We can deal with people who don’t have enough healthcare without blowing up the entire system in a way that is going to create a place where we’re all waiting for old-style medical treatment.

John Donvan:

I have a sense, in the last 10 minutes we have not heard very much from Sally. I want to give you a shot to get into this conversation real quick.

Sally Pipes:

Oh, I thought I’d be talking too much, so —

John Donvan:

Nobody has ever said that on stage.

[laughter]

Sally Pipes:

Well, I mean, I have talked about the U.K., and about Canada, and about doctors and how they’re paid, the fact that my cousin graduated four years ago as an orthopedic surgeon. After two years, not one of her friends who are orthopedic surgeons was able to get a job in the province of Ontario, and —

John Donvan:

So, why do you think that would happen here?

Sally Pipes:

That has happened because the provincial government has a cap on how many orthopedic surgeons that they have. Meanwhile, you have all these people in Ontario on waiting lists to get hip replacements, shoulder replacements, knee replacements, and there are young docs waiting to do the work, and they can’t work, because they can’t get paid.

John Donvan:

Okay, let —

Sally Pipes:

— because the government is the sole payer.

John Donvan:

I want to ask Adam, “Take on that picture.” A picture that was just of — you know — caps on healthcare, people on waiting lists. It’s a very, very vivid picture. Rather than walk by it and say it’s right, et cetera, and it would be better because there are so many people unemployed, just deal with that problem.

Adam Gaffney:

So, first of all, it is true that there are some waiting times in Canada that exceed the United States. Other single-payer countries, including the most recent Commonwealth Fund data on international health system, finds that getting a same-day or next-day appointment is actually more likely in France and in the U.K. than in the U.S., even if the U.S. is better than Canada. So, this is — these are misleading statistics. But I want to just go back to one point that Nick just made, which is that the reason why these, you know, overhead costs are so low on Medicare is because they’re not clamping down on fraud. That’s a very unfortunate argument to make within one week of ProPublica releasing a detailed investigative report saying that private insurers are doing nothing, basically, to crack down on healthcare fraud.

That’s not the reason why traditional Medicare has such low administrative costs; it’s because they’re not spending all that time wrangling with providers over costs. And so, that’s simply not correct.

Nick Gillespie:

So, are you saying that there’s no fraud — waste, fraud, and abuse, or mispayments in Medicare?

Adam Gaffney:

Of course not. There’s fraud and mispayments in every healthcare system on earth. The question is, how do we achieve the savings to cover everyone? And I think we’ve made a very strong case that you need a public insurance system to do that. One other point I just want to make —

John Donvan:

Actually, I want to let Nick or Sally respond to that, and then I want to go to audience questions.

Sally Pipes:

You want to —

Nick Gillespie:

Sure, go.

Sally Pipes:

Well —

John Donvan:

And if — I want to give you about 40 seconds, if you can do that.

Sally Pipes:

Well, first of all, there are only three countries in the whole world that have true single-payer systems — i.e. all private coverage is banned — Canada, Cuba, and North Korea. As I mentioned, the U.K. —

[laughter]

— has a private system, and about 10 percent of Brits actually have private care. And they — it’s used a lot, and companies do help to provide that. So, it’s an important point, that Canada is a true single-payer system.

In the new World Health Organization study that just came out on cancer survival rates five years out, Britain was the worst in five out of seven cancer survival rates. Pancreatic cancer, U.K. — in the U.K., it’s 7.9 percent. Lung cancer, U.K., 14.7 percent, 21.7 percent. All of these statistics are really scary. In the United States, we have all the new developments in cancer care, CAR T, stem cell treatments. These things are developed in the United States, not in these other countries that have price controls and have government taking a major part of our healthcare system.

John Donvan:

Okay. I want to let Joe — I —

Adam Gaffney:

What sort of [unintelligible] was invented by a insurance company? None.

Sally Pipes:

What’s that?

Adam Gaffney:

Which one of these innovations — which one of these discoveries, which one of these great new advances in medical science was achieved by AETNA, Blue Cross/Blue Shield —

Sally Pipes:

They’re not in the research business. They’re not.

Adam Gaffney:

[unintelligible] it’s irrelevant. It’s irrelevant.

Sally Pipes:

It costs $2.6 billion from the pharmaceutical biologic idea, to bring it to market. Most don’t make it. Only about 1 in 10 make it through the trial —

John Donvan:

I want to let —

Sally Pipes:

And we — they take place here. You don’t go to Canada to get stem cells. People come from Canada here.

John Donvan:

Joe.

Joseph Sanberg:

On the question of outcome, which is ultimately what most matters, longevity in the United States is declining. Did you know that the average lifespan of someone who is in the bottom 70 percent of income — 7 out of 10 Americans — their average lifespan is decreasing. I can’t think of a more damning statistic about the failure of our health insurance system. I want to add that there’s all these illusions the other side has made about quotas on the number of doctors who can be this, that, or the other.

These visions of government-run hospitals. None of that has anything to do with Medicare for All. Medicare for All is simply a question of, who pays the doctor? Medicare or private health insurance? Currently, private health insurance takes your money, keeps a lot of it for their executives, for their profitable — profit-oriented shareholders, and rations care to people who most need it.

John Donvan:

Okay. I’m going to step in because I think we’re — we’ve covered that ground a little bit and I’d like to get to some questions. So, right down in the front row.

Male Speaker:

I’m a physician. For the no team, does your argument against Medicare for All extend against Medicare for the elderly as we have it now? Are the philosophical arguments such that you would postulate, “Let’s disband Medicare?”

John Donvan:

I think that’s a valid question.

Nick Gillespie:

Sure, I’m happy to — you know, I am a very late baby boomer. I’m in the second-to-last year of the baby boom generation, which — and I’m not going to collect Medicare. Medicare will be bankrupt before I’m even there.

I don’t think that any entitlement should be based on age. I think all entitlements or all public assistance should be based on need. Seniors currently get a ton of money from the government, both in the form of Social Security and Medicare. I think that should go to poor people regardless of age.

John Donvan:

So, Nick, to the degree that Medicare represents a universal solution —

[applause]

— for a certain cohort, you would say no?

Nick Gillespie:

I think Medicare, as it is currently constituted, it covers less than 50 percent of its costs through various taxes and premiums and things that people pay into it. It is a big problem, particularly in an aging nation. I’m not in favor of Medicare for All. What I am in favor of is a free-market healthcare system that functions like food delivery, that functions like housing, that functions like buying books and TV and clothing and things like that, where we let the market work and do its wonders, and then we subsidize and help people who are not getting enough.

John Donvan:

Sally, I know you want in on this conversation. I just want to see if your opponent — one of your opponents would like to jump in on this question about whether Medicare, this program that’s been around since 1965 and is enormously popular with the people who benefit from it, was a good idea or not in the first place.

[laughter]

Would either of you — and if you don’t really have anything meaningful to say on it, if you’re just going to say it’s great, then I would go back to Sally.

Adam Gaffney:

I’ll make a 10-second comment. Before Medicare, most seniors had no health coverage. They went without care; many died as a result. That is no longer the case today. That is a huge progress. The idea that that should be turned back is unfathomable.

John Donvan:

I don’t think Nick was saying turn it back.

Adam Gaffney:

No.

John Donvan:

But, Sally, go ahead.

Sally Pipes:

I just want to say that Medicare and Medicaid under Bernie Sanders’ plan, and Pramila Jayapal, would be eliminated. There would be one single-payer government healthcare plan, the Indian Services plan, and the Veterans Administration, which is a single-payer healthcare system. And if you want to look at problems, look at the V.A.

John Donvan:

Okay, let’s go to another question.

[applause]

Sir?

Male Speaker:

I think this question is for the motion. In order to fulfill a healthcare utopia, you need to have accessibility; it has to be timely and affordable. Does Medicare for All simultaneously improve all three of those aspects, and if not, which two do you think are the most important?

John Donvan:

Run through this list again, the three things. Accessibility —

Male Speaker:

Affordability, timely, and quality.

John Donvan:

Thank you.

Joseph Sanberg:

One of the underestimated advantages of moving to a Medicare for All system is the tremendous increase in transparency that it would bring to our healthcare system and the improved research, knowledge, and treatments that would come with that transparency. Presently, and Adam can speak to this as a clinician, the medical community relies largely on information it’s gleaned from the Medicare system about treatment, outcome, quality of care, procedure. What would happen in a Medicare for All system is the amount of data that we would have would quadruple, quintuple, and likely increase the research and outcomes that are generated from a medical care system.

That’s an underestimated element. It also speaks to one of the weaknesses of the private insurance system, which is tremendous opaqueness. We don’t know, really, about outcomes. We don’t know about procedures. We don’t know about costs and contrasts to the Medicare system. It’s incredibly transparent. So, I think you definitely see an increase in quality over time from the increase in human knowledge that would be born of a Medicare for All system.

John Donvan:

Nick?

Nick Gillespie:

I want to second Joe’s request for less opaqueness or opacity in the system. Whether it’s Medicare or the private system, you know, I can remember a moment — this was some years ago — for the first time, I was on a high-deductible plan. A doctor — my doctor prescribed a brand-name prescription drug, and I said, you know, “How much is that going to cost?” And he was like, “I don’t have any idea.” And I was like — you know, in the way — in the examination room, it’s like, “Could you find out?”

And so, he had his nurse go, and they went to my insurance company, found out on the pharma copy, and they said it was like $30 a month or something. And he’s like, “No, that’s pretty high. I can give you a generic that’s $2 a month. Why not do that?” We need that kind of system — that kind of clarity in every aspect. That’s exactly what is lacking in today’s system. It’s lacking in Medicare —

John Donvan:

Sally.

Nick Gillespie:

— as well. And if — when Bernie Sanders say, “You will not have any premiums, no copays, no deductibles,” those price signals, which really matter, go totally out the window. So, I actually think Medicare for All means nobody’s going to know what anything costs anymore. That’s a recipe for disaster.

John Donvan:

Sally — I just want to ask —

Joseph Sanberg:

That’s not true. That’s not how the Medicare system works, and we’re not proposing, quote unquote, “single payer,” health insurance in the abstract. We’re proposing specifically Medicare for All, and the Medicare system is the most transparent health insurance system in the world, and we’re proposing that we extend it to all, that transparency extended to all.

John Donvan:

Sally, does Canada have the kind of transparency we’re talking about?

Sally Pipes:

No, because people don’t know — you have a — everyone has a care card. And as Madame Chief Justice Beverley McLachlin of the Canadian Supreme Court, who just retired — in the 2005 case, where the court ruled that Dr. Chaoui [spelled phonetically] should be able to provide healthcare to people not just in his office, but you know, at their — at his — at their home, or in their trailer, or whatever, she — in the deciding — in the decision, she said, “Medicare for All, the Canadian system, access to a waiting list is not access to healthcare.” Nobody knows what anything costs, but I do know that doctors are very frustrated, and a lot of the best doctors come to the United States because they can practice the kind of medicine they’ve been trained in. They don’t have to go to a small rural community when they’re a highly trained neurosurgeon to do surgery. This is something that Canada tried a few years ago. Fortunately, there was a huge backlash against it, but we need to keep the system open.

And I agree that price transparency is something that we need to promote.

John Donvan:

Okay, let’s go back to audience questions. Ma’am, on the aisle there.

Female Speaker:

You’re talking about market forces, and we’re not talking about market forces in healthcare, so to speak, but market forces in insurance and coverage. How do you think that we have real market forces now when we are not decoupled from employment, when you can’t go out of state, when you can’t have a little Geico gecko telling you to use their insurance? You can’t — when the users and payers are basically not one in the same, there are no market forces now in private insurance.

John Donvan:

You nailed it.

Nick Gillespie:

Yeah.

John Donvan:

All right.

Nick Gillespie:

Yeah, no, I —

John Donvan:

Take the question.

Nick Gillespie:

— disagree with you only in that there are no market forces. There are some market forces, but it’s all screwed up, because insurance companies act as cartels. And this is because of government regulation. You can’t sell insurance across state lines.

You know, certain people get carve outs. The whole idea that health insurance is treated differently as a form of compensation than cash is one of the original sins of this whole situation. We should not be treating health insurance, if your employer says, “You know what? Here’s $15,000 in health insurance,” it doesn’t get added to your tax bill, that’s a problem. We should all be paid what our employer wants to pay us, and then we should be free to buy healthcare or not with that money. I was saying, you know, again, this goes to the question of price transparency. As Sally was saying, nobody knows what anything costs. As a patient, I don’t know what it costs. I’ve gotten bills recently. I moved here a year ago. I went to a doctor and I ended up getting my insurance company, you know, said, you know, this seemed to be too much, and it was an office checkup, and it was like $600. I had no idea. I paid $35. Something is screwy here.

John Donvan:

Adam.

Adam Gaffney:

Well, one cost we do know is that the U.S. healthcare system is twice as expensive as the healthcare systems of other high-income nations.

So, despite that lack of transparency, we’re spending a lot more. The fact is is that healthcare cannot be treated as another market good. Why? Why is that? Because in a market system, those who can afford healthcare get it. Those who cannot afford it don’t and suffer. And that’s what we have in the United States. We already have the most market-driven system compared to these other systems. I think you agree. And as a consequence, you have tens of thousands of people dying a year because of lack of access to healthcare. One final point. The idea that — why can’t healthcare just be like, you know, beer, or cars, or luxury TVs? There’s one good reason why we can actually eliminate copays and deductibles to healthcare and not have this explosion in healthcare demand — it’s because people don’t want to take drugs they don’t need. They don’t want surgical procedures they don’t have to have. They don’t want brain biopsies. They don’t want to be in the hospital more than they have to. So, there is a self-limited demand. You can, in fact, eliminate copays and deductibles, and people will get the care that they need when they need it.

[applause]

John Donvan:

But Sally Pipes, you have argued — you have argued that when people really don’t have to pay anything, the demand is going to soar, rather than — and your opponent is saying that it will be self-limiting. So, take that on.

Sally Pipes:

Well, I believe it will soar because it — as I said, Canada spends about 11 percent of gross domestic product on healthcare, and we spend 18 percent — which is a lot. But Canada spends 11 percent because the government says that’s what the government can afford to spend. And that’s why you have rationed care and long waiting lists for care. That is just a fact. And so, we — universal choice will lead to universal coverage. You know, there are PPO plans, there are HMO plans. There are — there’s safer service. There’s Medicare. There’s Medicaid. There’s the CHIP program. There’s the V.A. But you know, things like short-term limited-duration plans for people who are between jobs — I mean, it is a disaster that during World War II, when wage and price controls were in, the government gave employers the right to write off the costs of health coverage. And we, as employees, would get it tax-free.

It was a way to attract people when you couldn’t pay people more. But that distorted the whole system, and we should all have our own individual coverage, and it should be private — and there should be many options. Universal choice would lead to lower costs and better coverage.

John Donvan:

Okay. We have time for one or two more questions. Ma’am in the white sweater, five rows in.

Female Speaker:

Hello. Under the Medicare for All program, how would you create — encourage patients to be responsible when they’re being given the services for free? And before — you already answered this once, sort of, but if you look at other systems, they have serious problems of abuse by people not showing up to their appointments, scheduling things that they want — and you have to have a system that would allow for —

John Donvan:

That’s a great question. That’s a great question. I’m very interested to hear the answer. Which of you would like to take that? Especially since it’s a point that your opponents made in the beginning, that people would just — would run everything they could out of the system.

I know that you just said that they would be self-correcting, but the audience member obviously needs more.

Adam Gaffney:

I mean, I fundamentally disagree with the premise of the question. I think people miss appointments sometimes because they have difficulties in life. They face other obligations: children, work. It happens. I’ve missed appointments. And it’s not a problem. I don’t think, as soon as you create a universal healthcare system, people are just going to book 12 appointments with four neurosurgeons and just not show up.

[laughter]

I just don’t think it’s going to happen.

John Donvan:

Okay.

Sally Pipes:

Let’s — can I add one thing?

John Donvan:

Yes.

Sally Pipes:

So, I just wanted to add one point. In Canada — so, many of my friends, as I said, and relatives are doctors. The average GP can see a patient for 15 minutes. That’s it. And they’re seeing 55 to 60 patients a day. A lot of the patients that are coming because they think it’s free — they are people who are lonely. They are old-age pensioners — they are actually booking appointments and taking up the doctor’s time, and there’s less time available for patients who really have a situation and they need care. And that’s why my friend retired at 40, couldn’t take it anymore.

John Donvan:

I think we have time for one more question.

Male Speaker:

You mention — you said that you wanted to make a free-market healthcare system, but you also mentioned that you want transparency within that system. So, my question for you is, how would market forces ensure transparency within a healthcare system?

[applause]

Nick Gillespie:

Okay. I suspect that they would ensure transparency in the same way that grocery stores ensure transparency.

[laughter]

What something costs is right there on the shelf. When you go the cash register, you’re asked to pay a certain amount, and that’s it. Free markets benefit from transparency. I think part of the problem we haven’t really talked about, and I have a lot of sympathy and empathy with the idea that insurers here are part of the problem. Not because they seek profit, but because they’re able to mask a lot of behavior and because they’re able to structure a lot of regulation that keeps competition out. Same with cartels in general.

With all due respect to Adam, you know, the medical cartel. Like, why don’t we have more medical schools than we used to, than we had, you know, 25 years ago or 30 years ago? Why don’t we have more doctors and nurses? Why haven’t we changed the way that we certify things and allow medical care to be delivered? It’s a big deal, you know, just to get urgent-care places put in and around New York, which are becoming a thing now. That took forever. Now, we don’t have a free market in healthcare, and that is not something that we should, you know, double and triple down on. That’s something we should get rid of and bring in more market force.

John Donvan:

That concludes Round Two of this Intelligence Squared U.S. debate —

[applause]

— where our resolution is “Replace Private Insurance with Medicare For All,” and here’s where we are. We are about to hear brief closing statements from each debater in turn. They will stand up again and address you. These statements will be two minutes each. It’s their last chance to try to persuade you to vote for their side, because immediately after they finish, you’ll be asked to vote again, and then we’ll choose the winner right after this. So, Round Three, closing statements.

Here, making his closing statement — I’m sorry — here, making his closing statement in support of the resolution, ‘Replace Private Insurance with Medicare For All,” here is Adam Gaffney, president of the Physicians for a National Health Program.

[applause]

Adam Gaffney:

Thank you, and thank all of you for hearing this debate. So, I want to close by saying this. Every day that I work in the intensive care units, I see some of the sickest patients in the hospital, people with kidneys or lungs or hearts that are failing often. The last thing I want is those patients to be thinking about is, “How am I going to afford this? How am I going to price-shop? How am I — how transparent are these costs?” I speak and counsel families at their darkest hours. The last thing I want them to be thinking is, “Will this make me go bankrupt?” But the reality is you don’t need to work in an ICU to know that illness is profoundly trying even in the best of circumstances.

By putting everyone in one public tax-financed healthcare system, we can do two things. We can control costs and reduce waste the same way every other high-income nation has done over the previous decades. But at the same time, we can expand coverage to everyone in the country and improve coverage for everyone else. We’re not talking about lowering medical bills; we’re talking about abolishing medical bills. We’re talking about ending medical debt, ending medical bankruptcies. These will be relics of the past. So, I want to end by — not by talking about what’s wrong with our system, but talking about a better future, a future where everyone can get the healthcare they need when they need it, whether they’re rich or poor, old or young.

A healthcare system where you can go to bed every night knowing that you and your loved ones will always have access to healthcare no matter what obstacles you face in life. If you share that vision of the future, I ask you to vote yes on the motion “Medicare for All,” and thank you so much.

[applause]

John Donvan:

Thank you, Adam Gaffney. And that is the resolution, “Replace Private Insurance with Medicare for All.” And here to make his closing statement against that resolution, Nick Gillespie, editor at large of “Reason” magazine.

Nick Gillespie:

Thanks, and I want to thank Adam and Joe. I learned a lot this evening, and I think we all — whatever side we end up on, we can agree that we learned things, and that’s it’s beneficial to talk about this. I’m going to talk real briefly about my experience with an HMO. This was in the late ’80s. I was in grad school, and I was buying my first healthcare plan. My parents were children of the Depression, and they said, you know, “Get as much healthcare as you can no matter what’s going to happen.” So, I bought an HMO plan that costs $2,000.

I was making $9,000 a year at the time. It was great. It covered everything. The first day that I was eligible, I went there. I booked an appointment, and I got about 30 tests done. And, as I was walking out, I saw a machine in the hallway, and I said to the doctor, you know, “What’s that do?”

And he’s like, “Well, it does this. Do you want to — let’s hook you up and give you a test.” It was great. Everything was free. There was no price other than what I had paid already, and — which would take me over a decade to pay off $2,000 that I put on a credit card check. Kids, never do that, okay?

[laughter]

It compounds. The next time — so, you know, that’s great. That’s Medicare for All. You know, the bill is paid and then it’s free. The next time I went to the HMO in order to get treatment, because I had a rash or something, they were like, “Is it life threatening? Is it dangerous? Do you need to go to the emergency room?” No. “We’ll see you in six months,” because everything was maxed out. That’s what happens when you increase demand and you don’t do anything about supply.

That is what will happen with Medicare for All. And the problem with it is also that it won’t be developing new treatments. The better thing to do is allow markets to function much better and more clearly than they do, helping to delink health insurance and healthcare from employers — that would be awesome — in ways we kind of discussed –and then subsidize people who cannot afford insurance on the open market. That’s the way that it works in housing. It’s the way that it works in food and all sorts of other things. It’ll work great in healthcare. So, vote against Medicare for All and vote for a future of better care and new innovative practices. Thank you very much.

John Donvan:

Thank you.

[applause]

And here to make his closing statement in support of the resolution, here is Joe Sanberg, cofounder of, “Aspiration.com.”

Joseph Sanberg:

Two cents. That’s what this debate comes out to, two cents.

We have a choice between a system that currently serves 60 million senior citizen Americans, the Americans who are most likely to need healthcare, serves these Americans in a way that only takes two cents of every one dollar for administrative costs. It’s the system preferred, frankly, by the most powerful group of American politically, which are senior citizens. Or we can have a system where 20 cents out of every one dollar goes to administrative costs, a system that is leaving 80 million people uninsured or under insured. That’s it. That’s what this debate is about. It’s not about what’s happening in Canada, or in Britain. It’s not about quotas on how many people can become orthopedic surgeons. It’s not about any of that. It’s about the proposition that Medicare for All should replace private health insurance.

Medicare, a program that takes just two cents of every one dollar for administrative expenses, a program that serves the 60 million Americans who most need healthcare, that we should make that program two cents. That program two cents available to everyone instead of the program that takes 20 cents, leaves 80 million people uninsured or underinsured, and leaves us with a nation where seven out of 10 Americans are experiencing a decrease in expected lifespan. In closing, the question is, “Two cents or 20 cents?” If you prefer a system where only two cents of your dollar goes to administrative expenses, a system that has expanded the longevity of senior citizens, an organizational triumph frankly unmatched in the history of our country, then I urge you to vote for Medicare for All as a replacement of private health insurance. Thank you.

John Donvan:

Thank you, Joe Sanberg.

[applause]

And our final speaker of the evening to make her case against the resolution, as a closing statement, here is Sally Pipes, CEO and president of Pacific Research Institute.

Sally Pipes:

As we have heard tonight, healthcare is tricky. It’s one of the few public policy issues that affect every one of us and often does so when we are at our most vulnerable. Perhaps tonight’s debate convinced you that the American healthcare system is in need of change. I agree with you. Private insurance is not perfect. But I hope that you will vote against the proposition because I believe Medicare for All would leave us all much worse off. It may sound morally right to have Medicare for All. It may be worth the trade-offs: higher taxes, rationed care, long waits, whatever. In exchange for a program that is supposedly going to give you security through a government-run program. Medicare for All cannot repeal the law of supply and demand. Good intentions can’t fund hospitals, pay doctors, eliminate waiting times, and ration care.

Just ask Canadian crooner Michael Bublé, who is from Vancouver, as I am, and you’ll find out. When his son Noah, age 3, was diagnosed with liver cancer, Michael Bublé did not stick around in Vancouver. He went to UCLA and took his son, where he says he had the best doctors there. His son today, Noah, is cancer-free. Most Canadian patients aren’t so lucky. Several years ago, my own mother died of colon cancer after doctors ordered her, as a senior, to wait for a colonoscopy because there were too many younger people on the line who were going to have longer lives. And so, she was denied that. She died two weeks later from metastasized colon cancer. My family’s experience with single-payer is not unique. Countless families in Canada and the United Kingdom have stories like mine. We can’t bring our loved ones back, but we can take action to save others from similar fates.

We can stop single-payer from taking root in this country. We can say no to the false promises offered by politicians about Medicare for All. And you can do your part right here, right now, by joining me in voting against the resolution. Thank you.

[applause]

John Donvan:

Thank you, Sally Pipes. And that concludes our closing statements, where our resolution is, “Replace Private Insurance with Medicare for All.” And now it’s time to find out which side you found most persuasive. I want to ask you again to go to your mobile devices and go to the URL IQ2US.org/vote. You’ll be prompted with the same choices you were before: Yes, No, or Undecided — meaning you became undecided or remain undecided. Okay, let me say something that I really feel compelled to say after this debate. I said your opening statements were among the four best I’ve ever seen. I’ve got to say the same thing about your closing statements.

They were all different, all came from different perspectives, were full of passion. Really, really well-constructed, you know? When we have future debates, I’m going to refer people to your closing statements as four in a row that were really great. And on top of that, it’s so clear that there’s a very, very profound philosophical divide — maybe some very serious disagreements on core values. And yet, I felt that you all four of you treated each other with respect, and civility, and dignity. You listened — you truly listened to each other, and that’s the goal of the thing that we do here. So, I want to thank all four of you for the way that you did this.

[applause]

And you know, Nick and Sally, I think you demonstrated today why we’ve had you back. I want to say to the For team, we’ve got to have you back. You were spectacularly good debaters, and I want to thank you. All right, it’s only now I’ve been given the final results. Remember, it’s the difference between the first and the second votes that determines who is our winner.

On the resolution, “Replace Private Insurance with Medicare For All,” on the first vote, 36 percent of you agreed with the resolution; 35 percent were against; 29 percent were undecided.

Again, that’s the first vote. It’s going to be the difference between the first and second that determines it. On the second vote, resolution, “Replace Private Insurance with Medicare For All,” the team arguing for the resolution — their first vote was 36 percent; their second vote was 40 percent. They pulled up four percentage points, so that is the number to beat. The team against the resolution; their first vote was 35 percent. Their second vote was 51 percent; they pulled up 16 percentage points.

[applause]

That is enough. The team arguing against the resolution “Replace Private Insurance with Medicare For All” declared our winner. I want to thank our debaters, thank our audience. Thank you from me, John Donvan, and Intelligence Squared U.S. We’ll see you next time.

[end of transcript]

This is a rough transcript. Please excuse any errors