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7.

Universal coverage for all civilian residents of
the United States.

Comprehensive benefits including preventive,
diagnostic, therapeutic, health maintenance, and
rehabilitative services for all illnes categories
and health conditions provided through primary
care teams of physicians; dentists, nurses, and
allied health workers that are linked with specialty
consultative personnel, hospital, nursing home,
home care, and all other necessary services to
meet the patients' total health needs, and meeting
Federal quality standards.

Financing by a combination of Federal social
insurance and general tax revenues to insure
health care as a social right and to achieve
reasonable equity in paying for it.

Reform of the health care delivery system to
assure equal access to good health care for all;
to achieve efficiency and effectiveness in the
delivery of health care for all; and to facilitate
interaction between the private sector delivery
functions and governmental financing functions.

Organization and administration involving Federal,
state, and local governments, with the assistance
of regional organizations for planning and evaluation
with health-oriented direction at all levels.

Public accountability that assures maximum responsiveness of the health system to public needs, with adequate data systems for monitoring performance and comparative evaluation.

Economic leverage of governmental financing of the
delivery system, including payment to providers of
care for professional and institutional services
to defined population groups on a per capita
basis; annually negotiated rates for institutional
providers and choice of prepayment or fee-for-
service payment for professional providers; incentives
for providers to adopt patterns of organization
and payment aimed at achieving more effective and
efficient services, particularly those embracing
prevention of illness, accessibility, and continuity
of care.

8.

9.

Revamped state programs for licensure of health
facilities and health personnel to insure that
they meet a Federal minimum standard; encourage
the elevation of standards to the highest possible
level; provide for consumer participation in all
policy-making bodies; provide for reciprocity of
professional licensure of health workers moving
from one state to another; promote facility
development and franchising in proper relation to
social needs; include periodic inspection of
facilities and examination of personnel; provide
prompt disciplinary action against those failing
to comply with standards and other requirements.
Adequate manpower, service, and facility resources
with massive Federal support for reorientation and
expansion of basic and continuing education programs
in the field of health; recruitment and support of
students from segments of the population heretofore
largely excluded from the health professions by
economic, race, and sex discrimation; fostering
the education of more professional health personnel
who are interested in providing primary, personal,
family health care; retaining present health
workers and developing new types of health workers
on a career ladder who can assume many of the
tasks now performed by present types of health
workers. Further, such a program should allow for
redirection and enlargement of Federal support of
organized health services and facilities, emphasis
on support of regionalized health services;
development of organized health care delivery
systems with emphasis on primary care teams and
internal linkages among various providers of
services; expanding research in health services to
discover new and better. ways of providing quality
care most economically.

The nine points offered in this policy statement fall into four broad, interrelated categories relative to personal health services delivery. These are: 1) fiscal, 2) structural, 3) service components, and 4) an overriding concern for public accountability. We are confident that many of these items have already been, or will be, discussed at length by other witnesses. Thus, we will confine our comments to three basic issues which are of particular importance to the Association: public vs. private control, cost sharing and utilization, and prevention.

APHA believes that there is an underlying principle
which must govern any considerations in the development
of a national health insurance program: health care is
a basic human right- a right that not only implies
(equity in the securing of financial access) to services,
but the assurances that those services are of high
quality and responsive to the specific needs of the
individual. We are a nation that has had a long-
standing tradition of assuring that the education of
our children is a similar right. Few would argue that
the private gain of any individual or group should take
priority over the education of our children, or that
government, in financing or administering the educational
system, should favor any specific segment of the population
over another. If we are to extend the same principles
to health, and the APHA deeply believes we should, then
we must assure the same opportunities and guard against
the placing of private motives over the public good.
Historically, the provision of education has been
considered a public responsibility, both through the
financing of school systems and the strict regulation
of all educational systems, both public and private.
However, health services have been viewed to a large
extent as the responsibility of the private sector
with, until very recently, little public accountability,
and an attitude of laissez-faire towards their regulation.
It would be very interesting to conjecture about the
types of arguments and proposals that would be offered,
presently, if we had had a private educational system
in this nation and were now discussing proposals for
national education insurance. We are, fortunately, not
in the position to make such decisions regarding education,
but we are, very much, at that point in regard to
health care. It is important, then, that we examine
the validity of some of the arguments favoring the
continuation of private domination over health care
which have been advanced by organized medicine, the
private insurance industry, and other groups with
vested interests in preserving our present health care
system.

Argument

The system, with its tradition of the private financing and practice of medicine, is essentially good and we have the best health system in the world. In addition, as President Nixon recently pointed out in his. State of the Union address, public systems, as they exist in other countries, have been unsuccessful.

Comment

This argument is specious. There is a widely acknowledged health crisis in this nation--the various indices, such as infant mortality (see Table I), life expectancy (see Table II), and incidence of specific diseases, that determine a nation's health status all reflect serious deficiencies in our system and place us far behind other developed countries-despite the fact that this is the richest and most technologically advanced nation in the world. Although the United States has made great advances in the science of medicine, advances of which we should be justly proud, much of this work was financed directly by the government, or indirectly through tax credits. We cannot ignore that the delivery problems are greatly in evidence, particularly when viewed in terms of the wide disparity in morbidity and mortality rates between the general population and specific groups including the poor, minorities, the aged, etc., (see Tables III-VIII). Other nations, particularly those in Europe, contrary to the President's assertion, have shown much better records of success both in terms of the health of their general populations and in levelling the disparities among the various segments of their populations. Although problems still exist in countries such as Sweden, Denmark, England or France, the breaking down of economić barriers to health care has been an important factor in allowing health care to be available to all their citizens and in improving the health status of all income groups.

Argument

The profit motive and the free market concept are needed to assure quality of care and, the preservation of the patient's right to choose where that care is received. Also, private insurance has proved to be an equitable and cost-efficient means of financing health care.

Comment

The underlying fallacy in this argument is the assumption that the medical care market is governed by the same rules as are other segments of the economic system. Costs, consumer choice, and availability of services do not have the same significance when one is talking about health services as they do in reference to other consumer products and services. The limited supply of physicians, health facilities and other medical services in many parts of the, country preclude a free market system. Individuals, by virtue of where they live, or their lack of mobility (due to illness or poor modes of transportation), may have very little free choice in selecting their physician or health facility and must choose

whatever is available or nearest to them. In addition, as a result of their economic status, their choice of providers might be limited to those who will accept payment through Medicaid or Medicare, or to receiving care in a public clinic. Competition certainly may lead to lower cost and to improved quality of care, but this would assume real competition exists and, in many parts of this nation, this is not the case in regard to health care. Instead we have developed a system that is an oligopoly, which, nevertheless assumes the rules of the free market place and there have not developed the necessary means to control excesses of that non-competitive system. Also, in regard to other services and products, the consumer exercises his or her power through selecting one service or product over another. In health care, if the same wide variety of choices does not exist, the consumer cannot have the same control. This is of serious concern, given that the commodity involved has direct impact on health or, even, life. A free market also assumes informed consumer choice, yet the work of doctors and other health professionals is highly technical and the patient is all too often ignorant of the adequacy of his care. Lastly, a free market assumes responsiveness of supply to changes in demand; yet the time involved to train a physician or build a hospital, and the even greater difficulties involved in shifting resources to where they are most needed, make the system unresponsive to consumer demand. In order to rectify this lack of consumer influence over the quality of the service provided, any national health legislation must include provisions which vest such mechanisms for greater responsiveness of the system in the hands of the consumer or his representative. In other words, at all levels of the system, within planning agencies, regulatory bodies, and in health facilities, consumers must be directly involved in making. decisions that will affect how, when, where and by whom their health services will be delivered, and must be given adequate training to render them fully capable of making such decisions.

Although the profit motive has certainly led to some improvements in health services, it has also worked to the detriment of the consumer, for private gain has often taken precedent over the public good. There is much evidence in the literature, and in testimony before Congress to support this fact. Hearings presently being held by the Senate Subcommittee on Antitrust and Monopolies have brought out many examples of such abuses. Also, many studies have documented cases of unnecessary surgery (see Table IX), the overuse of injections, and physicians whose patient loads far exceed levels where quality services are possible. Although such examples are not totally attributable to the profit motive, there is ample cause to believe such excesses are certainly encouraged by the possibility of increased income for providers.