In recent years, both through the findings of the TenState Nutrition Study and the work of the Senate Select Committee on Nutrition and Human Needs, we have become growingly aware of severe nutritional problems in this nation. These reports point out the relationship between poor diets and increased morbidity and disability among the low-income population. Nutritional problems, however, are not only confined to the poor, and a number of health problems, prevalent among the general population, can trace at least some of their origins to dietary causes. Hypertension, heart disease, diabetes and dental disease, for example, are believed to be related to dietary habits. We believe that, as part of any comprehensive set of health benefits, nutrition services and nutrition education should be included and covered. To diagnose and treat these conditions without provision of nutritional services can be futile and, without including coverage for these services, we would be depriving certain segments of the population of an important component of their health care, and would be omitting a key element of prevention.

The knowledge and ability to understand and preserve one's own health is also very important in the prevention of illness and in assuring the full benefits of a comprehensive health care system. The findings of the President's Committee on Health Education. convincingly point this out. To guarantee that our citizens gain this knowledge, we believe that health education services must be covered under a national health insurance system. Health education must intervene at many points in the system: to help the healthy individual to remain healthy, to assist the ill in gaining the necessary knowledge in caring for themselves, and to aid the recently ill in regaining health and in preventing further problems or recurrences. Also, health education must take place at all age levels, including the child in school, the parent, other adults, and the aged, because of the specific needs of each group which require different types of health education services. If we are to prevent illness and to assist people in taking care of themselves, as well as accruing savings both in regard to lower morbidity and less costly chronic care, we must assure the availability and financing of planned health education services as an integral part of a health insurance scheme.

We urge, as well, that national health insurance incorporate provisions for a comprehensive health care system for mothers and young children. Congress has amply demonstrated both the effectiveness and the cost-efficiency of such

an approach by means of the Maternal and Infant Care
and the Children and Youth projects, and through
community health centers and family planning programs.
The benefits of these demonstrations need now to be
extended to all Americans. Ample data confirm that
manpower are available, or could readily become available,
through expanded use of various health aides, midwives,
and physician extenders. Further evidence confirms
that such a program would check rising health care
costs, if not reduce them, by means of diminished
hospitalization, lower mortality and morbidity, and
reduced demand for expensive services to cope with
preventable catastrophic illness and life-long disability.
The services, which must be covered on a first dollar
basis, should include:

1. Prenatal care

2. Obstetric and midwifery services

3.
4.

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Homemaking assistance and mother-craft
Post-natal care for mother and infant

5. Family planning services

6.

7.

8.

9. 10.

Well-child and developmental check-ups

Routine immunizations and anticipatory guidance Preschool screening and school health services, services, including a mandate to treat and correct identified defects

Genetic counselling

Sickness care to treat children not reached

by private medical care programs even when

they are subsidized through insurance provisions

The total population, as well, must have included among the preventive service extended to them on a first dollar basis:

1.

2.

3.

4.

Home health services, including payment for homemakers nurses, podiatrists and other providers for the disabled, aged and chronically ill; expensive hospitalization is hereby diminished.

Periodic examination of all adult women for early
signs of cancer of the breast and cervix. Less
than half of adult women are now tested by Papanicolau
smears, even though the experience of more than
two decades suggests that the tragic consequences
of advanced cancer of the cervix could be nearly
eliminated by routine testing.

Periodic examination and early treatment for
hypertension

Preventive mental health services and family
counselling

Where these services are rendered either by private physicians or other types of providers, both professional and paraprofessional, the government will compensate them directly, or reimbursement will be handled prospectively for those programs that qualify as HMOs. However, where the lack of availability

of private manpower or facilities makes these services difficult to obtain, it is the government's responsibility, through direct public service programs, to assure that they are offered. The government must serve, then, as the provider of last resort to ascertain where and what programs are lacking and in guaranteeing, through public services (at all levels of government), that the people are receiving necessary care. A program of national health insurance should take steps to provide that guarantee, at the very least for preventive services.

We realize that the demands on the system with universal financing will be such that many services, including the above-mentioned, will not be available in sufficient quantity. Many of the preventive services that will be in great demand are presently being provided through tax-supported public health facilities and services, and we see a need for these programs, although they have existed in the past to primarily serve those who could not pay, to be strengthened in order to assure that the demands can be met for all segments of the population. We to not view National Health Insurance as a pretext for eliminating proven categorical programs. improved financing is implemented, certain groups that are most in need of services, such as rural populations, Indians, migrants, and the inner-city poor, will place greater demands on the system in order to raise their health status to that of the general population. So that we can meet those special needs, we would reiterate that categorical programs which presently address themselves to the special needs of these populations must be continued at least until they can be fully integrated into the general health care system.

Yet

After years of well-intentioned, but ultimately futile, attempts in this country to pass a national health insurance law, this Congress has the opportunity in its grasp to enact a system of financing health care for the American people, one that would affect not only special population groups but the entire nation. The APHA has considered this a high priority for the nation's health for over a generation. the passage of the national health insurance act for the first time in our history would have major short-run and long-run effects on the costs of health care, the control of health care decisions, the distribution of manpower and facilities, and would affect the health and welfare of our citizens for years to come.

Let us examine the choices and possibilities available to this Congress. One alternative is that no serious action would be taken. A number of witnesses before this Committee have expressed a preference that you wait until times are more auspicious for the passage of a bill, while others prefer the status quo for other reasons. This alternative will not be free of consequences, for the decision not to act is still a decision. The consequences to the consumer, the patient, will be to continue domination by providers of care and the financers of health, leaving the patient little control over his health care. This course would allow gaps in coverage and accessibility to remain unfilled. fair, it would also allow for the continuation of those aspects of our health care system that are good. However, despite our many enviable health programs and institutions, quality and comprehensiveness would still vary widely just as the quality and quantity of care available under existing Medicaid programs, private insurance, Blue Cross/Blue Shield and publicly funded programs do now. Likewise, the inequities and fragmentation of financing will continue and the diseconomies and inequities of present delivery systems will become entrenched. Accountability will be diffused while waiting for National Health Insurance, and this will put a damper on innovative programs because of the uncertainty of a universal. financing system. The costs of health care will be borne by the same people who must pay now -- the worker, the consumer, the employer, the taxpayer but the total cost of this care will continue to rise, for without adequate monitoring, incentives, or cost controls, health care prices will continue to exceed the consumer price index.

Another course of action is the expedient of passing a politically popular palliative such as a catastrophic type health insurance bill. This would appear to be a bargain to the taxpayers, but would, in fact, do more harm than good, for it would accelerate the maldistribution of resources: it would create the impetus to use more expensive hospital care, and it would favor overserved areas, unneeded services and the training of inappropriate manpower. This course of action would aggravate the inflation in health care costs. Some say that this approach can provide a flexible and incremental basis to which more comprehensive and equitable services could be added later. We disagree, for what we would be building on would be an inefficient and distorted health system which would squander our health resources with little gain in meeting health needs.

A third course open to this Congress is the passage of the Administration's bill. While uniformity would appear to be served, the consequences of committing this nation to a

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health financing system with built-in high deductibles, administration by private insurance companies, and cost control by state commissions with voluntary enrollment would undermine the fiscal viability of the system. Passage of the Nixon Bill would exert little leverage on reform of the health delivery system or on citizen participation in the expenditure of their health dollars. Moreover, this bill. will create new basic relationships in the flow of dollars and decisions in health care with less public accountability and, once enacted, these new relationships will become entrenched and difficult to change.

A fourth choice is the passage of a compromise bill such as the one proposed by Chairman Mills and Senator Kennedy. This choice too will lock government, health care providers, taxpayers and patients into new relationships. If this bill were passed it would result in more public financing control, probably leading to ease of administration and a basis for public accountability. Like the Adminstration's bill, it would eliminate some of the inequities of Medicaid. Also, it would promote some experimentation and some incentives to change the delivery of health care through the Health Resources Development Fund. It would, however, continue the inequities and inefficiencies of the present system through cost-sharing, fiscal intermediaries, and insufficient citizen involvement in decision-making. Inadequacies in cost control would continue, and aggravate inflationary trends resulting eventually in less care for the money expended.

It appears that all the alternatives outlined are less than satisfactory, including the alternative of procrastination. What course is left to the Congress? The APHA believes it is incumbent upon this Committee and the Congress as a whole to enact a law that combines public financing with more complete benefits, consumer input at all levels, incentives to redistribute health resources, and strong and unequivocal cost and quality controls. This course of action will not

be a bargain in the short run, nor will it be universally acclaimed. Yet it is a course that we believe would serve the best interests of the country now and in the years to

come.