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rate of TB throughout the planet starting during the early 1800's when there were the early statistics available and to the early 1940's and 1950's.

There is a slope of that curve, the TB is declining each year and it continues to decline, and the first antibiotics against TB were only available in the 1940's. When streptomycin and PAS para-amino salicylic acid first appeared, the curve didn't change, the slope continued to go precisely the way it was going before. This tale is not meant to be therapeutically nihilistic.

What was taught to us was that many, many decades before there was the first antibiotic, because of better housing, because of better nutrition throughout the whole planet, TB was already declining, One, therefore, could identify TB not only as a bacterial disease, but also as a nutritional disease, and that this should not be forgotten.

Similarly, I remember at the Harvard School of Public Health at one time receiving a lecture about Syria where a decision was to be made. There was a disagreement in the Syrian Cabinet as to whether

build more roads for military roads or to build more prenatal clinics.

The argument was that you ought to build more prenatal clinics in order to lower the infant mortality rate. But they built more roads instead of more prenatal clinics, and do you know what happened? The infant mortality plummeted because with the roads their people could get to Damascus and get to medical care.

There are all kinds of public health byproducts of other governmental activities that are taking place. I am not at all certain even as a public health person that much more of the gross national product should be put into health services. I think there ought to be a redistribution of the percentage of the gross national product that we already are in health and that it ought to be more wisely spent.

I advocate national health insurance, but again incrementally. I think a piece of this national health insurance ought to pay for health education, which is an idea that should get started. We could save a lot of lives if we got people at the proper weight and exercise and cutting out smoking. I am not referring to anybody in this room, but that is far more important.

Mr. ROSTENKOWSKI. Mr. Vanik will inquire.

Mr. VANIK. I would just like to follow along on the discussion. I am so much concerned as to what we can really do about the problem in light of our costs of economic recovery and the cost of energy and all of these other things that are confounding our lives. When you talk about an incremental movement into health care, what are you talking about? How do you propose that we should legislatively to it?

I think it was you, Professor Butler, that talked about it. You all talked about it. Do you have a comment on it? Or are you like the House of Representatives on energy when we have 435 different plans?

Mr. BUTLER. At the risk of speaking before the others, it does seem to be on common thread and that is, the first increment would be to deal with the medicaid program. My view is that it needs to be federalized, and frankly States like mine ought to be talked about. California has made off with most of the money and you have to have a move in the other direction.

The rich don't need to get richer. That does not do New York City much good, but we ought to start with the medicaid program. In

starting with that we ought to take a look at what about people who are not categorically eligible for medicaid now.

You have a lot of working poor people who do not have health insurance and are we going to include them? That includes the bill this subcommittee has been considering about unemployment compensation.

Mr. VANIK. Do you concur in that, Mr. Heim?

Mr. Heim. I do not entirely disagree, but I had something a little different in mind when I was talking about developing a program incrementally. I think we ought to look at where the needs are the greatest right now which are not being met.

In my opinion I think this is in catastrophic coverage. My recommendation is that we should provide assistance to the citizens of this country where they are going to be hurt the most, and that is, you know, if a true medical catastrophe strikes that could take $10,000 or $50,000 or more, that it should begin there.

I was thinking more in terms of

Mr. VANIK. Does that meet Dr. Bellin's test of saving most of the lives, because catastrophic coverage doesn't mean you save most of the lives. It means you save most of the costs in a castastrophic situation?

Dr. BELLIN. If I could respond to that, it does to some extent meet one of my criteria, because I am concerned about the lives of the surviving members of the families, and I am not being facetious when I say that. I have seen families' lives ruined because of somebody living who it would have been better for the family, callous as it may sound, for the person to have died a week or two earlier.

There is the old moral delimma of who pulls out the plug. The plug is pulled out when the family faces the financial catastrophe.

Mr. VANIK. I did a little bit of research and there is an interesting correlation between the incidence of death and the termination of medicare coverage. This is just a statistic we can measure.

Regardless of the philosophical or moral issues involved, there seems to be a correlation that when they get near the end of coverage, that suddenly somehow the medical scientists exhaust their capacity to maintain life.

Professor de Vise, how do you feel about this?

Mr. DE VISE. I realize the incremental approach has been the way the Federal role in health care has been. Every bit of past health legislation has been incremental. There has not been a single revolution in legislation. Perhaps national health insurance will be no exception, although I may imply in my remarks that I see nothing short of a revolution in cost control as a solution in national health insurance. There is a way to reconcile that approach with an incremental upproach and that would be to lay out what might be an ideal svstem that might be achieved after 10 years, that after 10 years of national health insurance this is what the delivery system ought to look like and begin incrementally by saying that the first year 10 percent of NHI money will go to this ideal system, the second year 20 percent, and 30 percent.

If we decide that capitation is the best way to go in the long run, we should incrementally reach that 90 percent or so in a space of so many years.

Mr. VANIK. It is awfully difficult to develop legislative language that would approach your suggestions. I think we have to deal with


more definitive points when we administer a service. But would you agree or is there some consensus that if we were able to combine the medicaid problems somehow with modifications of a catastrophic coverage plan, that we would take care of a tremendous problem in a manner in which it would be more universally accepted, or where we could make some reasonable estimate of costs based on the State experiences in which there is a measurable program?

Mr. DE VISE. I have a very uneasy feeling that if we are to reform medicaid not just from the point of view of costs, but from the point of view of access and quality of care, that we will actually result with a more expensive medicaid program. Many of the abuses that we have heard about have been because of the fact that the medicaid program in many jurisdictions invite such abuse, because of low and uncertain payments, redtape, and other obstacles. Typically physicians can only make about $6 per physician visit, which is about half what they can make in private practice.

So actually very few physicians are involved or participate in the program. So in a way the public gets a bargain because it discourages widespread participation by physicians in medicaid. We do have a few hundred individuals who make a mint, who have learned to provide mass production medicine where they see a patient every 3 minutes, but on the whole medicaid is cheaper today than it would be if there were comprehensive medicaid.

So if we just look at the cost containment on medicaid, we are not going to get it and also improve the program and have all States participate on the same basis.

Mr. VANIK. Here we have a political problem and it deals with the problem of those who contribute most to support the country. I am talking about the working people, the mature workers who are complaining, and perhaps rightfully so, that they are “locked out." They see the tremendous programs for the senior citizens. We have yet to talk about any really decent programs for the young people, the people whom we don't really do very much with from the standpoint of preventive medicine. But this group is one that is insisting, and rightfully so perhaps, for a really effective program because they are the ones who are supporting the entire existing system.

Medicaid doesn't really mean very much to them because this is a group of workers and self-sufficient people generally who are contributing through work and taxes during their working years. Do you think that catastrophic coverage, for example, would be enough of an inducement for them to contribute more money to support the medicaid system?

Dr. BELLIN. I would say yes to that question. I have been thinking myself the last number of months how do you translate the concept of incrementalism into real programs that can be legislated! I think one piece has to be catastrophic insurance. I can understand the growing irritation on the part of the working middle class with respect to what has been called the notch effect. If you are in the appropriate notch, you get the service and if you are above that, not much. The only way you can get to it is to spend down and make yourself broke.

If you make one buck more than that, you are out of the program completely. I don't know of any better kind of social policy to render

the country apart than that kind of policy. In order to give something to everybody, and appropriately certain catastrophic insurance ought to be one part of it. There is intrinsic merit to it anyway aside from the political utility.

The other aspect to this, and it gets back to the question of maldistribution, you cannot run any kind of program without physicians and whereas in New York City we have bombed out areas where there are no physicians accessible. There are other parts of the country, rural areas, and indeed cities, that don't have the proper number to a great extent because of maldistribution.

I think a responsible public policy cannot look at manpower separately from insurance. I think that error has been made and we have suffered grievously because of this error. I think part and parcel of the package must be the redistribution of physicians and there is no need for the Congress of the United States to feel defensive about studying this matter.

Anyone who goes to medical school today and is paying his or her way is being subsidized to the tune of 70 and 80 percent and that is without exaggeration, and when they get out of school and internship and residency, they are going to make a nice bundle for the rest of their lives and there is no need for the Congress to feel defensive about saying, “All right, you have been supported this amount of time. You owe something to your country. During war we send you abroad, during peacetime you put in 2 years of service in an appropriate area.”

Mr. VANIK. I yield.

Mr. ROSTENKOWSKI. Yesterday we had testimony that even in Russia you can't direct the doctors where they are going to work. How would you do that in this country!

Dr. BELLIN. I am not so certain about the Russian experience. All the doctors want to practice in Moscow and Leningrad to be sure, but they do put in their time. In Turkey and in Israel people put in years in other undesirable areas. I think there is no reason for us to consider this is a hopeless problem. It is a problem that can be dealt with.

If we don't do it with the stick, we have to do it with the carrot. If we don't want to use the carrot, we have to use another method.

We have to adopt as a policy that we will flood the market with physicians. We could double the number of medical schools, have medical schools that operate at night as well, graduate twice the number.

Mr. VANIK. Now you have a little bit of that awareness in the Latin Imerican countries now. They say the quality of medicine isn't very good, but the shocking thing is you can go to Mexico and see doctors around in even the remotest areas. The costs are very low and they complain about not having a chance to make a good living.

In the Philippines, for example, and throughout the Spanish-speaking countries where they have created a lot of doctors, they seem to have been able to hold costs down. Doctors creating doctors is not quite as difficult as creating oil because it takes hundreds of generations to create oil, but it should not take that long to create doctors. But where there is a sufficient number of doctors, we at least find an availability of medical care.

Now I live in northern Virginia here and the only way I can get to a doctor is go into an ambulance and get to the hospital. Of course,

there are some clinics nearby that I can go visit, but they are just as tough to get into as the hospitals

. They audit me and get a report from Brinks or Dun & Bradstreet and decide what the fees should be. So much of the doctor's time is lost in shuttling between hospitals and in management of their own affairs.

I talked to some young doctors over in Sweden. This may not be a good example, but I said, "How do you like your system?" They said, “We love it.” I said, “Why?” “Principally because we work 53 hours a week."

They thought that was a great privilege to have that kind of a short workweek as a doctor. It was an accomplishment. They liked the easy access to consultation with colleagues, which was not always available in an individual practice. And they felt that they were really spending most of their time in medicine instead of other things that are a source of distraction.

I can just tell you that in my community when I visit the sick in hospitals, I sometimes walk in with a Wall Street Journal and they say, “Well, that is the new surgeon.” Other times I walk in with a Baron's, a Financial World, and they say, “He is the new neurosurgeon" or something else, but they judge my eligibility to enter the hospitals by what kind of financial paper I carry.

I thought at one point we might improve the efficiency of hospitals if along all the screens that monitor the heart we have the Dow Jones averages put right on the screen so they could with convenience look at my heart and also at their stock fluctuations, so that they could consolidate their time and not have to run out to call the broker so often.

But in any event I do feel that our system is wasteful of the doctors energies. Somehow we don't get all the efficiency we can out of the system. Even in comfortable areas it is very difficult to find a doctor to give you medical care-you know, you go to the hospital to get a tetanus shot and it costs you $12. You may want a prescription for a biotic and you just can't get it.

I think we lose more lives by denying standard medical care than the lives we save from complicated medical procedures. We should probably have a more open health care system.

In Mexico I had an accident some years ago and I remember buying some penicillin that was 50 cents a unit. When I got to the United States and had to continue my prescription the same medication was $7.50.

So these are some of the problems. I think Mexico ought to be studied. I don't know whether it is a good example, but I feel that in those communities even in remote parts of the country there is more medical help available. I don't know about the quality, but medical care certainly is available. Most of the time we don't need the sophisticated high-level judgment that is always important. Sometimes it is just a cut or a small illness that needs treatment. I feel that this kind of medical need is almost impossible to satisfy under the present system.

I thank you very much. We appreciate your tremendous contributions. We would be happy to hear from you. If you get any other ideas how we can develop an incremental plan which we can get through this Congress and get the President to sign--the latter point will be more significant than any other. We have this incredible burden of satisfy

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