FOREWORD

The Senate Labor and Public Welfare Committee has broad legislative jurisdiction regarding the organization and delivery of health care. And in that regard the committee has continuing responsibility for legislative oversight with respect to the many health programs which are undertaken by the Federal Government under authorities which fall within the jurisdiction of the committee. Virtually all of these health programs are intended to improve the organization and delivery of health care in America.

In an attempt to compare and contrast the on-going effort here in the United States with similar efforts in several other major industrialized nations, I authorized the Senate Health Subcommittee to undertake a fact-finding mission to Great Britain, Israel, and Scandinavia. The findings contained herein reflect in considerable detail how these nations have grappled with many of the same problems that beset the American scene. I believe this report will be of great interest to the Members of Congress as well as the American people. HARRISON A. WILLIAMS, Jr., Chairman.

(V)

LETTER OF TRANSMITTAL

Hon. Harrison A. Williams, Chairman, U.S. Senate Committee on Labor and Public Welfare

Dear Mr. Chairman: The United States is the only industrialized nation in the world without a national health care system. That is difficult to believe, but it is true. How is it that every other advanced country has managed to do what we have yet to accomplish? And what have been their successes and their failures? In order to find some of the answers to these questions, I took the Senate Health Subcommittee on a two-week factfinding mission to Europe and the Middle East. During that mission we visited Great Britain, Denmark, Sweden, and Israel. In the course of our studies we talked at length with doctors, health officials, hospital administrators, insurance experts, academicians, students, government officials, and, of course, the man in the street. While there were many differences among the health systems of the countries we visited, there was one startling_similarity, which stood in stark contrast to our American dilemma. In each country there was a broad consensus that the top priority was to assure the provision of high quality health care to everyone in the society as a matter of right. The debate and discussion of how to organize the health delivery system and how to pay for the services provided always took place in the context of the assumption that decent health care had to be available to everyone without regard to income. How fundamentally different this is from America, where the overriding consideration is, unfortunately, money. In the foreign countries I visited, the words "deductible," "co-pay," "cost conscious," "cut-off," "cancellation," "ineligibility," "co-insurance" and "rip-off" are foreign words.

The basic point is that it is not impossible to assure high quality health care for an entire nation at reasonable cost. Those who continue to deceive the American public by propagating that myth are underselling the will and capacity of the American people in order to protect an outmoded cottage industry which has grown too costly and too inefficient to compete in the world market.

Most Americans are angry and frustrated about health care. Most Englishmen, Danes, Swedes, and Israelis are not. Most Americans do not have adequate health care; they get crisis care. Most Europeans and Israelis are not forced to wait until they are so sick they have no alternative but to seek care. In fact, their systems are specifically designed to encourage them to seek treatment before illness progresses to the point that it becomes serious and expensive.

Before describing some of the very interesting aspects of the four different health care systems I studied, I think it is very important to set aside some myths which many Americans believe about health care in other countries. In fact, prior to my visit, I believed some of them. Myth number one: The common man does not like the health care system and wishes it could be discarded. Nothing could be further from the truth. In point of fact, the vast majority of the citizens of

the countries we visited describe their health care system with great pride and satisfaction. And they react with disbelief when told of the differences between theirs and ours here in America.

Myth number two: National health care does not have broad-based political support. Again, this is false. In fact no major political party in any country we visited advocates the repeal of the legislation which legitimizes the health care system. To do so would amount to political suicide. It could be like a U.S. Senator advocating the repeal of Social Security.

Myth number three: If adequate health care is guaranteed as a matter of right to everyone, there will be no way to control costs. False. Each country we visited spends a smaller proportion of its GNP on health care than does the U.S. And, because of the rampant inflation of health care costs in America, the gap between us and them is widening.

Myth number four: In Europe and in Israel the Government tells the doctors what to do. In some ways, this is the most misleading myth of them all. What the government does do is to use its influence in respect to overall policy decisions such as how many hospital beds are needed; how much clinical research should be done; and what kinds of doctors will be required to meet the nation's needs. But the government does not involve itself in the clinical practice of medicine. If you think about it for a moment, you'll realize that no democratic government could do that and retain the confidence of its people or its health care professionals. And each country I visited has a democratic government and that government has the confidence of its citizens and its doctors. Do not forget that in our country the Government is also heavily involved in influencing health policy. Regrettably, that influence for the most part simply reinforces the status quo. The Federal Government is pouring billions of dollars into our worn-out, outmoded health system in order to purchase services for millions of Americans. As long as Government continues to be the silent partner of this country's provider monopoly, real reform will not be possible. Government-financed health care is alive and well in Europe and Israel. Before I describe each of the countries I visited in a little greater detail, I want to describe a concrete example of one of the ways in which their health system is really different from ours. A man and wife catch the flu. Shortly thereafter their two children do, too. Three days later the husband's flu is complicated by bronchitis. That precipitates a family visit to the doctor. The doctor examines all four members of the family in twelve minutes. And it takes him another two minutes to write a prescription and call the druggist. In America, the total cost of his services and the drugs is almost $60.00, all of which is paid out-of-pocket since the insurance coverage, which costs about $175.00 a year, was irrelevant since no member of the family had gone to the hospital. Had that same family lived in Great Britain. there would have been no charge for the visit to the doctor, and the drugs would have cost $2.40! In Sweden the doctor's bill would have been $1.40 for each person, or $5.60, and the drugs would have cost about one-half of their retail price, or $8.00 for a grand total of $14.00. Even in Yugoslavia, a country I had hoped to visit but did not because of the lack of time, there would have been no charge for the physician and the drugs would have cost about $1.20. In Israel and Denmark the story is essentially the same.