I suppose also being from Missouri, originally, I have the right to quote Mark Twain, who in talking about these various experiences said: "He who swings a cat by the tail learns things that one can only learn by swinging a cat by the tail."

[Laughter.]

Mr. STARK. Now, health insurance is not a new concept for me. After the enactment of Public Law 89-97 in 1965 I was appointed to the first Health Insurance Benefits Advisory Council, along with my colleague to my right, Dr. Somers. There we wrestled with the myriad problems of implementing medicare.

Prior to that I had served as a member of the corporate board of our local Blue Cross plan. But now the Congress, and especially this committee, is faced with the awesome responsibility of deciding what this Nation wants or needs in the way of health insurance. Or indeed, even whether such a program is really wanted or needed.

Few people ever questioned the need for medicare. Health services for the elderly was such a towering need and one that could not be met by the limited financial abilities of the aged. Without adequate financing services could not be delivered by the health providers. Local and State governments were unable to cope with the problems short of the indignity of the means test and some highly inadequate welfare programs.

Kerr-Mills had helped, but it was obviously not the answer. So the health field and the public were ready to accept a Federal program of health insurance for the aged. In good part, through the wholehearted cooperation of hospitals, this new program moved fairly smoothly into

action.

There is an important lesson to be learned from medicare which bears close examination as far as health insurance for the total population is considered-the clash between expectations and reality, as was pointed out earlier. The public, and even the field of health, saw medicare as the answer to all the unmet needs of health care for the aged. Congress, of course, did not intend it to be a panacea, a total coverage insurance. But the public, unused to the fine print and stilted language of the legislative package, chose to believe it met all their expectations. The health providers made similar assumptions. They simply believed that they would deliver services and be reimbursed their costs. They never realized that the program would be hedged in with increasing limitations and an endless maze of regulations and controls that they now feel threaten their very existence.

Medicare reimbursement, as you know, is used to encourage compliance with accepted standards. I don't think there is anything wrong with using financial approaches of that sort in those ways. In fact, such uses are tangible acknowledgment of interlocking relationships between components of health care.

However, I do not subscribe to the viewpoint held by some that a national health insurance program should be seen primarily as a method of modifying the health care system. At the same time I do subscribe to the fact that while the primary objective is underwriting the cost of illness, that objective can only be effectively achieved through a modification of the present health care system. In other words, we must give close attention to determining that the financial

mechanisms support rather than determine desired steps toward an improved total health system.

From the private sector viewpoint any extension of Federal health insurance will be met with a closer and more sophisticated scrutiny than was ever given to medicare. This calls for complete honesty and a rational presentation of all the facts.

Pertinent questions are beginning to surface in the private sector. Is the push for NHI an emotional idea hedged about with slogans and clichés and impassioned utterances? Or are there some hard, solid facts on which to build a case?

It is clear that the health care field today is undergoing tremendous economic, political and technologic change. Although the forces pushing these changes have been around for a long time, there is a quickening of the pace resulting from increased expectations and a phenomenal rise in costs. Today many, if not most, of us find that we can no longer meet the cost of a major illness. I am reminded of Oscar Wilde's statement, "I am dying beyond my means."

Now access to quality health care is not readily available to many of our citizens. There are inequities caused by a geographic maldistribution of physicians. There is also a deficiency of primary care and family practice physicians, a maldistribution of specialists. Consumers want to be partners in decisionmaking and everybody agrees there must be increased accountability in the expenditure of funds.

Who supports the national health insurance program? Organized labor does, of course. But they support a program of total coverage. Some people are wondering whether the United Automobile Workers would yield its fine private health insurance program for a Federal program if it were anything less than total coverage paid. Or would Federal employees give up their excellent insurance coverage for national health insurance?

State governments would press for a national program in the expectation it would relieve them of the medicaid burden. Academicians can theorize with intellectual fervor on the practicability of national. health insurance and compare this country unfavorably with other nations. And yet almost all of these groups base their positions on a program of total coverage. Some even ask what the cost would be, or question what would happen if the Congress were to enact a less than total coverage program.

The last question is worthy of careful study. If a program of modest proportions were enacted-less than all needs met and all costs paidis it not possible, or even probable, that labor and industry and the general public would find it necessary to carry supplemental private insurance to give them as good an insurance program as they already have?

Many health providers are asking this question, and visualizing the incredible chaos of having to deal with dual coverage on a large proportion of their patient load. They find it extremely difficult now to deal with the tie-in insurance with medicare and may well shudder to think what it would mean if the covered population jumped from 23 million to over 200 million.

While it is recognized that many special groups in this country are vocally advocating national health insurance, a question is raised

about the great "silent majority" who speak through no organized groups. What does John Q. Public think or what would he think if all the facts were logically presented? The architects of national health insurance should study this diligently.

The health delivery system is undergoing a health process of change and development at the present time. Some very real progress is being made. Would the massive demands of a national program impede or speed up this progress? Or would the demands exceed the capabilities of the system to produce services now? We should carefully analyze our priorities here.

I have saved to the last that all-engrossing factor of program cost, a cost in hard dollars that will be paid by the American taxpayer for any program enacted. As a businessman I must think in terms of return on investment, of yield versus expense. Will a national health insurance program, bringing health care within reach of those who may not have had it available before, bear tangible results in health outcome?

For example, how much improvement in the Nation's health status is likely to result from an insurance program? I won't attempt long comments on this, but a look back over the past 15 or 20 years shows little increase in life expectancy in the United States and there is presently no reason to believe that increased resources spent on health care will alter this appreciably. When one examines the major causes of morbidity and mortality in the United States for people over the age of 40, one finds the leading causes of death-heart disease, cancer, and stroke-are all affected by behavior characteristics-lack of exercise, smoking, weight control, and alcohol habits.

As a matter of fact, the highest return on additional investment in health services is really a subjective one-albeit very important—that it results in an improvement in the quality of life. This relief of severe pain and the alleviation of anxiety are two examples, but they are difficult to quantify in terms of value and magnitude.

Which then is more beneficial to our Nation? Dollars spent to teach nutrition to ghetto mothers, to buy more research into low-cost housing, to develop and operate a coronary care unit in a hospital, to spend more on research in new therapies affecting major causes of death? Should our priorities be aimed at modifying human behavior related to health in the broad realm of public education? What about biomedical research or research related to health care delivery systems? Obviously we do not choose between priorities. We arbitrate among them, we harmonize and balance them.

I was impressed with a statement made just a couple of weeks ago by Dr. Theodore Cooner, Assistant Secretary for Health, DHEW, in addressing the AMA. Dr. Cooper said:

Let us be frank with the American people, with their lawmakers, and with ourselves. When it comes to influencing health status, health outcomes-even probably the results of health care—there are a great many determining factors over which medicine has effectively no control.

It is one of the great and sobering truths of our profession that modern health care probably has less impact on the health of the population than economic status, education, housing, nutrition and sanitation, and the impact of changing technologies on working conditions and the environment. Yet knowing that. I think we have fostered the idea that abundant, readily available, high quality health care would be some kind of panacea for the ills of society and the individual. That is a fiction, a hoax

57-677 O 75--12

The question is: What will the billions of dollars of our public's money buy? Will it be a good return on our investment? I am not opposed to the idea of national health insurance. But I hope it can be studied with a clear, logical, analytical process that is not based on emotion, or long espoused theories, or bland assumptions or political expediency. It is too expensive and too important to be based on other than cold, hard facts.

Finally, about the health crisis. It has always been with us. Simplistically, we might say that polio vaccine was developed as a response crisis. Perhaps an NHI program will be developed as a response to a perceived crisis. Many of us are on diets as a personal reaction to a crisis. Perhaps an NHI program will be developed as a response to a crisis in health care. I hope that this committee, the Congress, the people of this Nation will not fear the word "crisis." Without crisis we will not have the slight edge that gives impetus to change, to growth, to development.

It is paradoxical that when the Chinese write the word "crisis" they do so in two characters, one meaning "danger" and the other "opportunity."

Thank you.

Mr. ROSTENKOWSKI. Thank you, Mr. Stark.
Dr. England?

STATEMENT OF ROBERT G. ENGLAND, M.D.

Dr. ENGLAND. Mr. Chairman, members of the committee, I thank you for the opportunity to be a member of this third panel session on national health insurance. I have to apologize for my delivery because the climate in Washington doesn't seem to be satisfactory with my sinus and my upper respiratory tract is in bad shape.

Further, I reorganized my statement last night, some of it is pasted together with Maclean's toothpaste and although it is fragrant, it may make the going a little bit rough.

I am Robert G. England of Carlinville, Ill., and I am engaged in the practice of private medicine. My time is devoted to and my income is derived from the practice of private medicine. These are the only credentials I claim. I am not employed by any organization whose existence is dependent upon Government grants or subsidies and, therefore, of course, neither is my existence dependent upon subsidies. I am not part of any insurance interest whose profits or nonprofit. income depends upon the legislative process. Nor do I represent any lobby appealing for Government subsidy.

Legislation and regulations emanating from the Federal Government create such obstacles to the provision of quality medical care that it is apparent that opinions of physicians in the private practice of medicine have been largely ignored by the Congress. Surely only by failure to consider what the private practitioners know would Congress have promoted the existing situation.

Glancing at the list of members on other panels, I am not sure that one of me from the private practice of medicine is enough to provide a balance against the others who are outside the private sector.

I am singularly impressed with the fact that there seems to be a tremendous amount of academic personnel on these panels, many of

whom have been ardent advocates of compulsory politicalized medicine for many years; whereas, there seems to be a dearth of private physicians who are not committed to Government intervention and control.

Mr. Chairman, in your letter to me of June 30, 1975, you made two statements that I think are pertinent to this discussion. The first item I refer to is your statement that "My intent in conducting these panel sessions is to launch that vital educational and exploratory process that must precede the construction of a legislative proposal by this subcommittee."

The philosophy underlying this statement troubles me. Does every complaint, every alleged social need constitute a demand for legislative remedy?

I submit such is not the case in a country of free men. To the exten legislation is used to provide such remedies, the liberty of free men is diminished. Once one accepts the legitimacy of such legislation as the answer to all human problems, the information fed into the legis lative process is easily organized to impel further legislation, and, consequently, further diminished liberty.

Unwittingly some who as short as 13 days ago hailed the free enterprise system as the bulwark of the Nation's liberty can now be found participating in an attack upon it. There is a mountain of unexplored evidence on the case of national health insurance which, if reviewed in the light of the historical development of freedom and the history of this country, will cause any group of legislators to pause before going ahead.

For example, the situation of the Indians in this country should be thoroughly explored. What role has the private sector had in caring for their health and what role has the Federal Government had?

The record appears to be that this group of citizens was more paternalistically cared for by Government as far as medicine was concerned than any other sector of this economy. Yet the morbidity and mortality rates of Indians is one of the most unfavorable of any in the country.

The second point I wish to comment on is your statement that: Consequently, the aim of these first sessions is to undertake a broad assessment of such fundamental matters as the historical development and current status of our health care system. The respective roles of Government and the private sector as they have evolved over time and the critical and economic organizational issues involved in the delivery and financing of health care.

With respect to this point, we should take a good hard look at medicare and medicaid from the standpoint of patients and the doctors who take care of them. Also we should evaluate the result of similar socialized medicine programs in other countries.

It is my hope that this committee will rise above partisan politics and look at what is good for patients in general and not what is good for labor union leaders or what would divert tax money to insurance companies, medical societies, the bureaucracy, or whatever.

In this connection the historical development of freedom in the United States did not come about by Government interfering in the minutest detail of everyone's life. As a matter of fact, everyone here knows that this country was founded by people who were trying to get away from Government dictation and control. It doesn't make