Optimizing Our Healthcare System

Episode Summary

You don't need us to tell you there's something very wrong with the American healthcare system. The real question is: what can we actually do to fix it? Could Democratic candidates Elizabeth Warren and Bernie Sanders be right that Medicare for all would be better? Would a single-payer system fix all the frictions in the industry? On this episode, Kate and Luigi delve into the economics and capitalism of the healthcare debate.

Episode Transcription

Kate: You don’t need us to tell you that the US has a problem with its health-care system.

Speaker 2: Why does American medicine cost so much, and if we’re going to pay so much for it, why don’t we get better results?

Speaker 3: We have got a huge competitive disadvantage in American businesses, far more important than any tax change in terms of our health-care costs.

Luigi: And the dysfunction of the US health-care system has taken center stage in the Democratic primary, becoming, for many, the central issue of the election.

Bernie Sanders: Every family in America would receive comprehensive coverage as we move to a publicly funded program.

Elizabeth Warren: Health care is a basic human right, and I will fight for basic human rights.

Luigi: Everyone who has ever had to go to a hospital in the United States has felt the fear of getting stuck with an outrageous bill that your insurance won’t cover. Or, even worse, you don’t have insurance at all.

Kate: Have you ever gotten an outrageous bill, Luigi?

Luigi: Yes, actually, I remember when I was a graduate student, my wife had a tubal pregnancy, and we rushed to the hospital to get surgery, and after that I started to receive bills. There was one, there was a second, there was a third, and I never wanted to sum it all up, because it was too sort of shocking, but it was a lot of money, especially at the time, and especially given my finances at the time, it was a lot of money.

Kate: In terms of the actual numbers, here’s another way of thinking about how expensive things are in the United States. The U.S. spends about 17 percent of its GDP on health care, and that’s pretty high compared to most other rich countries. For example, in France, that number is 11 percent, and in Turkey it’s only 4 percent.

Luigi: On today’s episode, we’re going to take the Capitalisn’t view on health care in the United States. What’s the problem? Where does it come from? And, most importantly, how can we fix it? 

This is Luigi Zingales from the University of Chicago.

Kate: And this is Kate Waldock from Georgetown University. 

You’re listening to Capitalisn’t, a podcast about what’s working in capitalism today.

Luigi: And, most importantly, what isn’t.

The current system is not working. And if there is a thing that doesn’t seem to work that well, it is actually health outcomes. If you compare the United States to other countries, you are shocked by how poorly the United States does. Life expectancy is almost 83 years in Japan, 81 in Italy, and only 78 in the United States. Now, you might attribute that to the fact that in the United States people eat too many candies, and they eat butter and not good olive oil, and they don’t drink the good red wine, and they shoot each other. But I think that . . .

Kate: Sounds like you really have Italy in mind as the basis of comparison.

Luigi: No, Japan. But if you look at deaths that should not occur in the presence of timely and effective medical care, in France, you have roughly 50 of these preventable deaths per 100,000. In Italy, 65. In the United States, 103. And even in infant mortality, the United States doesn’t do that well, 6.2 per thousand versus 3.3 for France, 5.5 for Italy and 5.8 for Cuba. So, we are below Cuba in infant mortality. 

Let me leave you with one last scary statistic. The top 1 percent in the income distribution have a life expectancy 15 years longer than the bottom 1 percent.

Kate: Now, what’s so puzzling about health care in the United States is that its approach to health care is radically different than other countries in the rest of the developed world. In fact, it’s the only rich country that doesn’t have universal health care. Universal health care itself is a hard concept to define, but it refers broadly to some form of government action that’s aimed at making sure all citizens have access to health care that meets a minimum standard.

Luigi: No country has a pure health-care market or a free health-care market, it is always impacted by the government in one way or another. Now, the question is, why is the United States doing so much worse than all the other developed countries? 

Without scaring our listeners too much, I think that the problem is fairly simple. It is difficult to have a completely voluntary insurance system, because young people who are unlikely to have health problems prefer not to insure themselves, and sick people want to insure themselves a lot, so you don’t obtain a good sharing of risk if you don’t force people to get insurance. This is all the debate that we had about the mandate.

Speaker 4: Top Republicans like Finance Chairman Orrin Hatch now have woven a repeal of the individual mandate or the requirement to buy insurance into the Senate tax-cut bill.

Speaker 5: By eliminating the individual mandate, 13 million people, mostly healthy, are expected to choose to go without insurance, driving up premiums by at least 10 percent for Obamacare customers who don’t get government subsidies.

Luigi: Many people feel that it’s very coercive to have a government mandate to have health insurance, but the reality is that the only way not to have a government mandate is to be very strict and let people die, if they get sick and they don’t have health insurance. Now, nobody’s willing to do that. This ex post problem makes it very difficult to have a system work without a mandate.

Kate: I think this question was well answered by two health-care economists, Garber and Skinner. This is from a paper that was 10 years old, but I think that its main lessons still apply today. I’m going to quote from this paper. They say that “the fundamental cause of health-care costs is a combination of high prices for inputs, poorly restrained incentives for overutilization, and a tendency to adopt expensive medical innovations rapidly even when evidence of effectiveness is weak or absent.”

Luigi: Translated, that means that people with health-care insurance tend to consume too much health care and are probably paying too much for what they’re getting. That adds up. And not only that, but there are perverse incentives in even the administration of health care, because there’s very intense lobbying to use more procedures, more drugs, even when these precision drugs are not necessarily demonstrated to be superior. 

Just to give you a sense, during the last decade, half a billion dollars was spent in lobbying every year by the health-care industry. In addition, during the 2018 election cycle, members of the industry gave roughly $225 million to federal candidates in outside money groups and parties. This is not to mention the problem of revolving doors. There are 267 former aides who worked for four congressional committees in reforming health care. They now work in the health-care industry. 

But the most insidious way, in my view, in which this lobbying takes place is in sponsoring research that, surprise, surprise, finds that the product is extremely useful and needs to be adopted. For example, there’s now a medical recommendation that after a C-section women should be treated with blood thinners to prevent fatal blood clots. Many doctors claim that there’s not really any evidence to support that such widespread blood-thinner use really improves health-care outcomes. Now, what is disturbing is that the recommendation was developed and espoused by a group of prominent physicians called the National Partnership for Maternal Safety, whose parent organization receives funding from makers of blood thinners, also known as anticoagulants.

Kate: Marketing of drugs in the United States is another area that I consider also insidious. Luigi, you quoted the statistic that about half a billion dollars is spent on health-care lobbying per year. Well, that number is on the order of about $4 billion when it comes to the money that’s spent on the marketing of pharmaceuticals as well as medical devices by their manufacturers. 

And what’s also disturbing, or more disturbing, is that, whereas in other countries—as well as the United States before the ’90s—marketing is OK, but it’s usually done to professionals, to doctors and health-care service providers, who have a good sense of what drugs are useful and what drugs aren’t, or which drugs are effective and which drugs aren’t. But now, in the United States, a huge amount of money is spent on direct-to-consumer marketing.

Speaker 6: Abilify . . .

Speaker 7: Crestor . . .

Speaker 8: Cymbalta . . .

Speaker 9: With Advair . . .

Speaker 10: Common side effects are dizziness, sleepiness, weight gain, and swelling of hands, legs, and feet.

Speaker 11: Serious, sometimes fatal events such as infections, lymphoma, or other types of cancer have happened.

Speaker 12: So I can join the fun at my family barbecue.

Kate: This started in the ’90s, and by 2002, 81 percent of consumers reported having seen a direct drug advertisement. Just anecdotally, whenever I talk to my friends who moved to the US from other countries, one of the things that shocks them the most is how many drug commercials they see when they’re watching TV as opposed to where they come from, where it’s almost unheard of.

Luigi: Plus, they tend to all be drugs for elderly people, both because elderly people need more drugs, but also because they are the only ones left watching TV, so I think that . . .

Kate: Are you sure those just aren’t the ones that are marketed to you, Luigi? Maybe those are just the ads that you’re seeing.

Luigi: No, it’s any TV. You go from CNN to whatever TV program I watch. I only watch news on TV.

Kate: Maybe that’s why.

Luigi: You get bombarded by medicines for old people. Now, you might say that I belong to that category, but that’s a different story.

Kate: Now, there are a bunch of economic issues that also arise in terms of the relationship between insurance companies and pharmaceutical providers. If you are an individual and you’re trying to bargain over the price of a drug, chances are you have no bargaining power whatsoever. But the more concentrated the insurance market becomes, and I guess the ultimate form of concentration is what we call single payer, where there’s just one government that’s negotiating with drug providers, the more power the insurance companies have to negotiate over the prices of those drugs. 

Economists call this monopsony power. Usually we think about monopsonies in the context of companies having control over wages, but in this case, monopsony can be a good thing for consumers, because it means that whoever’s providing them with insurance is negotiating with drug providers so that they get drugs or health-care services at the lowest cost.

Luigi: Actually, you said it can be good for consumers. It definitely could be good for government finances. Whether it’s good for consumers or not depends on your view of how much of that surplus is necessary to provide the research and development and how much is not. Because if you were able to extract 100 percent of the surplus out of the pharmaceutical industry—hard to imagine these days, but imagine you could—maybe they would stop investing and buy stock. If you stop investing, you will not get the improvement in medicines that we observe today.

We know, for example, that the price of insulin in Canada is one-third of the price of insulin in the United States. The reason is that the Canadian health-care service has bargained hard and reduced the price of insulin. So, at the very minimum, we can ask ourselves why, as Americans, we want to subsidize research and development for the rest of the world. And, if you think about it, with subsidizing research and development for Africa, we say that’s fine, because they’re poor and maybe it’s our duty to do so, but subsidizing R&D for Canada or Japan or Germany, that seems to be a bit crazy.

Kate: Yeah. And Luigi, you mentioned extracting surplus, and it also takes place directly whenever drug manufacturers or health-care service providers interact with consumers who don’t have insurance. So, if you’ve been in the sticky situation of not having insurance and having to go to the doctor or the hospital, you’ve probably been stuck with a crazy bill, I mean, on the order of tens of thousands of dollars. And sometimes you look at that bill and you’re like, wait, why is the bill for me higher than the total amount that would have been paid from myself as well as the health-insurance provider if I had health insurance? And this goes back to the idea that health-insurance companies have monopsony power, and so they’re able to bargain over the prices of the services that are provided, but individuals don’t, which is why individuals without insurance are, in some sort of perverse, contradictory way, stuck with an even higher total bill.

And what happens is that they usually don’t end up paying that full amount, right? So, if you don’t have insurance and you get a $100,000 bill, chances are you’re not going to have to pay that full $100,000. There are ways that you can negotiate with the hospital or the doctor. But what that effectively is, is a way for service providers to price discriminate against individuals who don’t have any health insurance. They can extract the full surplus from these individuals. And so, they start with the highest price possible, and then they cut that down to the maximum amount that each person can pay. 

One last thing has to do with taxes. There are perverse incentives that are created by the tax system as well. This might not necessarily lead to higher costs, but it does lead to a higher administrative burden. As Luigi mentioned in the beginning of the show, when he had to go to the doctor for his wife’s early pregnancy, he got hit with bill after bill after bill from different types of doctors.

And this is because, for very highly paid individuals, physicians and specialists included, the tax code incentivizes them to be independent contractors rather than hospital employees. So, of the best-paid doctors that you might come across in your lifetime, chances are they will all be individual independent contractors, sort of like they run their own little consulting businesses and provide consulting services to the hospital. This creates this administrative mess and makes things pretty stressful and complicated for the consumer, because you don’t really know how much you’re going to be charged, because you’re working with 12 different entities rather than one hospital.

Luigi: The bottom line is that the health-care market is filled with frictions and market failures and problems.

Kate: So, what can we do about this, to borrow from Bernie Sanders, huge quagmire of a situation?

Bernie Sanders: 500,000 Americans are going bankrupt. You know why they’re going bankrupt? Because they suffered a terrible disease, cancer or heart disease.

Kate: At least as of the time of this recording, there are a ton of Democratic candidates still in the running. Most far left, I would say, are Sanders and Warren. They’re pretty much on the same page when it comes to health care.

Bernie Sanders: Every study done shows that Medicare for All is the most cost-effective approach to providing health care to every man, woman, and child in this country. I wrote the damn bill, if I may say so.

Kate: They both believe in universal health care under a single, government-payer system.

Elizabeth Warren: There are a lot of politicians who say, oh, it’s just not possible. We just can’t do it. We have a lot of political reasons for this. What they’re really telling you is they just won’t fight for it.

Kate: And they want to do away, for the most part, with any opportunity for private health-insurance providers, because they think that that will distort the transition into a single-payer system. Now, assuming that that doesn’t get passed, they do support a public option, which means that if you can’t afford health care or if you don’t have insurance, then you should be able to buy into a state exchange that would normally only be available for low-income people. And on the price side, both Warren and Sanders support the idea that the government should produce generic drugs.

Luigi: On the one hand, Sanders and Warren want to obtain the benefits of a single-payer system, where everybody is covered and where you have the maximum amount of risk pooling. In order for this to take place, you need to ban not necessarily every form of private insurance, but certainly any form of basic private insurance. So, you might go to a country like France, where you can have private insurance, but its private insurance is for the stuff on top, not for the basic coverage. This move will generate a lot of turmoil, because on the one hand, you will have a lot of people who get deprived of the existing health-care system they have, which many people are happy with, and they will all be put in the same pool of insured, so treated in the same way.

The second big issue is, of course, how to pay for this. And the third is, how much does this impact the supply of health care? Because, if you simply subsidize everybody or provide insurance to everybody, but you don’t do anything to the supply, then the cost will skyrocket. And so, what you need to do is also do some intervention in the supply. 

Now, the idea of producing generic drugs is a little bit in that direction. But let’s remind the listeners that in the United States, the number of doctors is fixed by law. The number of seats in medical schools is fixed by law. So, the supply of doctors does not respond to the market. At the very minimum, if you expand demand, you have to expand supply at the same time. Otherwise, we know from economics 101, what you would observe is a huge surge in medical doctor prices. And we know by international comparison, the doctors are already much better paid in the United States than in other countries.

Kate: So, I personally am a fan of this proposal. I think that it hurts rich people. Certainly, the top 1 percent, maybe more than that, maybe let’s say the top 10 percent, and that’s because they don’t have or they won’t have the option for private insurance. 

Now, I have been on Romneycare. For a little while, I lived in Massachusetts and didn’t have any health insurance, and so I relied on the state-provided universal health insurance within Massachusetts, sometimes fondly termed Romneycare. And the few times that I had to see the doctor, I thought that the experience was completely satisfactory. You know, the waiting rooms were sort of dingy, and the lines were longer than when I had nice school-provided insurance. But for the most part, I was pretty thrilled by how efficiently it worked. I know that that’s just an anecdote, but it’s not like people are going to be waiting in lines around the corner and being deprived of key resources just because this goes to a system that would take care of everybody.

Luigi: But sorry, Romneycare was a public option. It was not Medicare for All, and it’s not that you eliminate the possibility of private insurance.

Kate: Oh, sure.

Luigi: Because I think that the controversial point is that one, and in particular it’s controversial, in my view, in the Warren proposal, because she went through how you pay for it. And one way she says she’s going to pay for it is that she’s going to basically take away all the money that your company’s paying for your health care and put it in the pool to finance everybody else. 

So, if I am paying less because I have very good care, in the Warren proposal, I find that the next day that I will be still paying less, but I will have the same insurance as everybody else. So, it is a form of, if you want, mild expropriation of the people who currently have chosen to have less compensation and more health care.

Kate: Yeah, to the extent that it is pegged to the current system of paying for health care, then I would call it redistributive rather than expropriation. But sure. People who are opting for better health care now will still be paying similar amounts but would be receiving the public option under this plan.

Luigi: No, but sorry, it is a bit of expropriation, because generally taxation is based on some principle of ability to pay. This is randomly chosen depending on who employs you. So, it’s not necessarily that you are redistributing from the rich to the poor. On average, you’re going to do that, I agree. 

But in practice, there is a lot of redistribution that takes place depending on who is your employer and what choices of health care this was done. And I think that that’s a bit crazy and will generate an enormous amount of bad will. I think people are subject to a status-quo bias. If you take away what they have today upfront, this will make their resistance enormous.

Kate: Well, yeah, I think that that’s the reason that the resistance is enormous and that it’s unlikely that this sort of health-care reform will be passed. But I think that it’s worth pointing out that there are a number of countries where this is the status quo already, and they seem to be perfectly fine with it. Countries where there’s an option for private insurance, but not that many people take it up, because the universal public health-care program works quite well. I think it’s just a matter of people in the US transitioning poorly. But that doesn’t mean that the system itself is a bad one.

Luigi: No, no. You need to distinguish between what is the optimal point at the end and how you get there. But how you get there, the transition phase, is not irrelevant. I might say that we shouldn’t have any coal miners in the world, because coal is polluting, but I cannot say F– you to all the coal miners and ignore their pain, because tough luck, it is a transition phase. Or I can say that free trade is better, but we do know that along the way it hurts a lot of people. So, the transition phase is very important and should not be ignored.

Kate: I don’t know, maybe you could argue that in this case the transition phase affects more people, or it would be longer, and so it’s more painful and deserves more consideration. I think the transition phase is important insofar it’s the reason that health-care legislation isn’t being passed, but I still think it’s important to think about the optimal.

Luigi: Yeah. But, for example, I think that the optimal is a system of universal, single-provider health care for the basics and some option of getting additional health insurance for more sophisticated things or better treatment. But I don’t think that going cold turkey from one to the other is a good idea, and there are a lot of other things that need to be done to make this transition, because in other systems you have some major form of rationing to avoid the overpayment of medical services, and you have a lot of restrictions in marketing and lobbying. Now, in the United States, if you do universal health care, with no restrictions, free lobbying and free marketing, you end up with 30 percent of GDP eaten up by health care and quality that is not much better. So, we need to be very careful with the transition.

Kate: I think we’re basically the same page in the sense that, yes, in this ideal world, universal single-payer is the right answer. The point being that if we move to this universal system, that doesn’t solve all the problems in the United States. In particular, it doesn’t bring prices down, to the extent that those prices are linked to administrative burdens or linked to high doctor salaries or linked to lobbying or linked to marketing. All of those things are problems that are particularly severe in the US that won’t be solved with a universal health-care, single-payer provision of insurance.

Luigi: So, how do you think that these can be solved?

Kate: Through a slew of regulations that are aimed at how much health-care companies, number one, can spend on marketing. Direct-to-consumer marketing of drugs should be, for the most part, banned. One of the policies that I support on the Warren and Sanders side is to have federal production of generic drugs. This is something, by the way, that Buttigieg and Biden don’t support.

Luigi: This provision is to fight cases like that of one of the most-hated men in America.

Kate: Shkreli. Yeah.

Speaker 13: You may remember the name Martin Shkreli. He’s the hedge-fund manager who jacked up the price of a lifesaving drug back in 2015.

Speaker 14: One tablet of Daraprim used to cost $13.50. The drug maker recently increased the price to $750.

Luigi: In a market where the buyer is the government or health insurance that has the mandate of the government to provide the service, demand is completely inelastic to prices, and so, there is a strong incentive for a producer to jack up the price to the highest number he can get away with. 

Shkreli became infamous only because he did it with gusto, but the pharmaceutical industry does that on a regular basis every year. The idea of at least threatening to enter into production of those drugs might be a useful way to try to reduce prices, but I think that it’s not going to solve the problem generally if the government is not willing to be a tougher bargainer.

Kate: Yeah, I think it’s worth mentioning that there are ridiculous regulations in the United States that prevent Medicare or the federal government from being able to negotiate and bargain with pharmaceutical companies over the price of drugs. And this is something that, across the board, all of the Democratic candidates want to do away with. I think it’s worth pointing out that there are similarities across the candidates on some measures.

Luigi: But I want to point out to the listeners that there is a reason why this legislation was introduced, because at some point, when you expand demand by the government massively, you are in a situation that we call in economics a bilateral monopoly. On the one hand, you have only one buyer. On the other hand, you have only one seller, especially for drugs that are under patent. And so, there’s only one producer, and we in economics have basically nothing to say about what the price is going to be in a bilateral monopoly. We only know that it’s in a range, but this range is huge. 

And so, on the one hand, people are concerned that the government is too aggressive, extracting all the surplus, and by extracting all the surplus, it will demotivate pharmaceutical companies from investing in new drugs. On the other hand, the opposite concern is that the government is completely captured and the pharmaceutical industry extracts too much surplus, and as a result, you have a distortion of all types, including the fact that we have a large deficit. 

But we need to realize that it does become an issue. As you expand the role of the government, like either the public option or Medicare for All will do, you are going to have this problem again in every sector, including in many cases for doctors, because the government will be the largest purchaser of medical services, the largest employer of doctors, and it will set the price of doctors, and as a result you might have a shortage of people who want to become doctors.

Kate: I don’t think it’s entirely ridiculous, because the situation that you just described, the one where markets break down or economics itself breaks down, right, this bilateral monopoly. That’s created by the government in the first place because of the patent protections that are granted by the government, and so I still think it’s ridiculous for the government to be like, OK, so we’re a big purchaser, that’s not fair, and then there’s only one provider, which we have created by keeping out all other providers. And so, because this doesn’t make sense from an economic perspective, we’re just going to tie our hands and eliminate our ability to bargain. That is just a silly system. It’s basically just giving a direct handout to these companies that are innovating, and yes, innovation is good, but if we want to be incentivizing R&D, we should be doing it in a better way.

Luigi: No, I agree. But you know, as we are going to expand the role of the government, this is going to become a bigger and bigger problem. For example, for doctors, I have witnessed in Italy basically a generation of doctors being expropriated, because all of a sudden, the government decided to lower the prices. And for a while, this was great, because the government was able to buy doctors’ services at a cheap price. And you know, if you have gone through medical school, it is unlikely that all of a sudden you are going to leave the profession and do something else. But fewer and fewer people actively enter medicine. In my generation, very few people became doctors, because the return to being a doctor was very low. And now, in the future, as the older generation is retiring, Italy is facing a problem of doctors, because too few people chose to become a medical professional.

Kate: I think that that’s a fair point. But once again, in the US, the government is intervening, it’s requiring people to have medical licenses in order to be doctors. The number of people who are getting these medical licenses just isn’t keeping pace with the number of people who demand medical services. And so, that’s part of the reason why the salaries for physicians have been going way up. And so, as long as this barrier to entry exists, and the government isn’t explicitly price-fixing, we would expect that there should be some rents to be earned by doctors.

Luigi: And there are. But what I’m saying is, be prepared that if you go into Medicare for All, then you also have to start subsidizing medical school or start to massively import doctors from Cuba, which is a great solution for the United States but is not a great solution for the world. But it is an issue that you need to think about. The system is very complex. There are so many frictions that once you move one part, a lot of other things need to be changed.

Let’s have a discussion about cost. Bernie Sanders has not even tried to provide a cost estimate. Elizabeth Warren has tried, but I think it is a bit put together with a lot of hope. First of all, she decided overnight to double the wealth tax. When we had our episode about a wealth tax, I said the danger of introducing it is that it is going to go up, and it’s not been introduced yet, and the demand has already gone up. So . . .

Kate: And I said that there should be caps, by the way, but caps that are like 10 percent. I agree that we also need to be realistic about this transition period and that costs are a huge component of that. I don’t think that we can just switch to single-payer, universal health care without a private option overnight. Not only is this fantastical from a political perspective, but it would mean that the government would be paying for all of the rents, as you said, that the pharmaceuticals and the health-care service providers are already extracting.

I think that we need an interim period in which there’s a public option for people who don’t already have health insurance, where they can buy into Medicaid programs that are pretty low-price. And in the meantime, the real focus of the government should be bringing these prices down, before we switch over to any single-payer system. So that means, you know, restrictions on marketing. It means limitations on lobbying. It means training more doctors and essentially removing all of the administrative burdens and frictions that give rise to all of these rents that can be expropriated along the way.

Luigi: I will add to your series of proposals that should be implemented along the way a more rigid system of authorization of new procedures, where proving that it is marginally better from a medical point of view is not enough. There should also be a cost-benefit analysis, in the sense that if I am an epsilon better but enormously more expensive, it is not obvious that my medicine or my procedure is better, because you’re not factoring in the cost. 

In addition, I would be very aggressive against the cosmetic changes of medicines designed only to charge higher prices. We know that basically there is no difference between Nexium and Prilosec. Those are two medicines for reflux, and Nexium was introduced only because Prilosec was running out of patent protection. Nexium was aggressively marketed to all the doctors and to all the health-care organizations to try to get into the prescriptions and be able to charge higher prices. I think that this practice should be eliminated, because it’s pure dissipative rent-seeking.

Kate: I agree. One final point that I’d like to make is I think one of the hardest issues to address is how to incentivize meaningful innovation in the pharmaceutical industry and the fact that this burden in large part rests on the US right now. That means that US citizens are subsidizing global innovation and health-care services. I’m not an international policymaker, and so this is sort of pie in the sky, but I think that there should be some sort of international coordination when it comes to the funding of scientific research. And I think that the US should send a message that it needs global participation. We can’t just keep bearing this burden on our own, because it’s ruining our politics.

Luigi: But what is interesting is to see how much the debate has changed in nine years, because when Obamacare was under discussion, only the most radical Democrats were supporting the public option. That was actually taken out of the proposal, precisely because there wasn’t really very strong Democratic support. And now, the most conservative Democrats are supporting a public option, and what I understand is the majority, or at least the plurality, of the Democrats are already way past that. And I think that that’s a sign of the discontent that is spreading in America about the health-care system.