House of Representatives that I have never seen in 18 years. They vacated a quorum. I didn't know that they could do that. I don't know that anybody in Congress knew that they could do that until today, but it has been done. So when the bells ring, members of the panel leave.

If we leave, it is only because we have to answer either a rollcall or a quorum call.

Mr. Pike?

Mr. PIKE. If the gentleman will yield, I would like to say you talk about the monstrosities of the medical system, and I might just mention you are observing one of the monstrosities of the legislative system whereby 435 Members walk over to the House of Representatives, put a card in the slot, push a button marked present, and promptly leave.

I have long since made the determination that I had more important things to do, and, at the moment, this is one of them.

Mr. ROSTENKOWSKI. At this point, for the purposes of writing the record, I would like the panel to understand that any conversation that you have will be in the record, the interchange, plus the fact, that I am sure that we will join in questions in the not-too-distant future. So if there is any comment that any of the doctors would like to make with respect to the comments that another panelist has made, please feel free to make your observations.

Doctor Wynder?

Dr. WYNDER. I listened to the economist with great pleasure. I would like to ask myself what is the key thing I learned. Perhaps it might be the Sutton law applied to medical care; namely, we have that type of medical care where the money is.

In whatever we do we need to consider that in our kind of society the Sutton law is as likely to apply to medical care as to any other care or any other endeavor.

Second, Dr. Reinhardt mentioned the German system. Sometimes certain languages are perhaps more perceptive to a given issue than our own.

When Bismarck originated the system in Germany, they did not call it health insurance, they called it Krankenkassen. That means it is disease insurance. This is more or less what we have in this country. It was not until 1971 that, by parliamentary law, Germany created for the first time a cancer detection program for which this health insurance would pay.

Thus, historically we have to recall that one reason why the German system, in terms of preventive medicine, had not operated very successfully in the past, is because it dealt with disease insurance.

Let me give you a specific example that may relate to the maternal and to the infant mortality that Dr. Reinhardt referred to.

At one time the German system paid for prenatal care only, the gynecologists and obstetricians and at that time the GP, who did not want to lose a patient, said: "Well, I am not going to send them to an obstetrician-gynecologist, I will do the first examination and I will deliver the baby."

The German system had to change the system to also pay the German practitioner for prenatal care. All of a sudden all mothers were examined during pregnancy.

The final point I would like to make relates to the fact that most of the major diseases that we suffer from in our Nation today are manmade.

Let's take heart attack. Some time ago I had the pleasure to serve on a National Task Force for Arteriosclerosis. After meeting weekend after weekend here in Washington, in the final weekend we said to ourselves: "What's the most important finding we learned during our deliberation?"

The most important thing we learned was that heart attack and arteriosclerosis are not an inevitable consequence of being born or becoming aged. In other words, the leading cause of death in our country is manmade and is therefore man-preventable.

It seems to me that in a system where we are quite willing to pay for all kinds of coronary care units, but are unwilling to pay for preventive programs directed to the prevention of coronary disease, we put the cart in front of the horse.

Preventive services will never be better applied in this country as they are today or in any other country until we give economic incentives for such preventive services to be conducted properly.

Mr. ROSTENKOWSKI. Dr. Freymann?

Dr. FREYMANN. I would like to take issue with Professor Fein. Maybe we can bring some controversy into this discussion. I put this out for his reaction. He stated that producer behavior is the issue in health care costs. I agree superficially that it is. It is the doctor who sends the patients to the hospitals, who writes orders and writes the prescriptions.

There is no question that, at the operation level, producer behavior is a very important component of the cost of health care.

But I submit that there is a deeper level which is beyond the control of the physician. This is really a point of social decision.

Let me use a homely analogy to get across the point I am making. Let's say the health care system is like a dutiful housewife. The dutiful housewife is being told by her husband, which is society— and the Congress is representing society-"You have spent all you are going to spend on groceries. You had an open-ended grocery budget, and you have been spending more every year. This year we are going to crack down. We are going to have planning and be very rational about how you are spending the grocery money. I am not going to cut it back, but you are not going to get any more."

And the health care system says dutifully, "Yes. We will do that." But when it is agreed that we are going to be rational and we are not going to spend any more money, the husband says, "By the way, Honey, don't stop serving steak."

Now I submit, as an example of "steak," the provisions in Public Law 92-603, which opened medicare benefits to anyone with end-stage renal disease.

I am not against people with end-stage renal disease, please understand. As a physician I can understand their need. But that was another billion dollars a year on our health care bill.

This was not a medical decision. There were respective physicians in the lobby which got that law through Congress, but this was Congress' decision.

Congress was, I think, reflecting the public, which was saying, "We know there are facilities for keeping people alive with renal disease, and we want them to be available to everybody."

But we can't have everything. We can have steak every night for dinner or we can have economy, but we can't have both.

The ultimate decision, I submit, is not up to the producer or the provider, the physician. The decision is ultimately a social one, and I think it lies in the hands of Congress how it is to be interpreted.

Mr. ROSTENKOWSKI. Professor Fein?

Mr. FEIN. I don't know that we disagree. In the first instance I said producer decisions, and in the second instance I said these are not in fact scientific decisions. They do require allocation of resources and those are heavily influenced by the way legislation is written. It is in that sense that I would differ somewhat, perhaps, with some of the language used by Professor Reinhardt, although I suspect that even here we will end up agreeing rather than disagreeing.

If I heard Uwe correctly, he indicated that there are many things we don't know about the direction that we would like the health care system to go in, and we ought to not only recognize that explicitly, but perhaps recognize it in our legislation.

It would seem to me that in the past, and it is likely to be the case in the future, we will find it virtually impossible to write what we would think, what we would term neutral legislation. The legislation that we write inevitably will direct resources and the more explicit we are about preventive care or early treatment or other areas where we want those resources to go, the better off we will be.

Your reference to the renal dialysis or renal care does prompt me to make one admissional remark on the question of equity. Earlier I said that I started with that perspective, and perhaps I can illustrate it with a story that appeared in the New York Times, December 28, 1970.

It was datelined, Richmond, California, a State that Mr. Corman comes from. It told about a young boy who on December 25th, Christmas Day, was very happy because, in fact, 800,000 coupons had been collected which had been transmitted to one of the cereal manufacturers in the United States as payment for a kidney machine, which would enable him to receive treatment at home instead of going to San Francisco three times a week at $200 per treatment.

It was a very warm story. It was a very marvelous Christmas Day, the child was happy, and the parents were pleased.

I suspect that many of us read that story and said, "It's a great country."

I would like to think that many of us stopped afterward and said, "What the hell kind of system is this that a little boy had to worry Christmas eve whether or not there are going to be enough people across the United States to provide the 800,000 coupons?"

What if they had not? So I think that my objective in National Health Insurance is to take care of that kind of a situation, not at the expense, however, of the situation which arises for many Americans every day, and for all Americans every year of primary care, the kind of things that most of us go to the physician about most of the time, the worry and the concern that arises. I agree with Professor Reinhardt on the importance of that psychic component.

Let me take that one step further. The argument is often made that preventive care is useful and primary care is useful because, among other benefits, it will save us money in the long run.

It is, I think, correct that a number of components of primary care will, in fact, pay for themselves by avoiding long-term treatment which is costly.

Having said that, I would hate to rest my case on that observation, because it seems to me that it is to use a false accounting system.

If there is a child who is sick with a high fever and you do nothing, the child may get better in 10 days, and let me assure you the gross national product will not be affected 16 years later when the child enters the labor force.

But if you do something and it only takes 5 days, you have saved a lot of pain and a lot of concern, and a lot of worry on the part of the child and certainly on the part of the parents, and the normal accounting system that puts everything in terms of GNP does not take account of pain and concern and worry.

I think that it is regrettable that on occasion those programs are favored which can "pay for themselves."

That is a humanitarian component to health care, an awful lot of it is about that, and it seems to me, again to use the phrase of civilized society that in an accounting we ought to pay attention to those components as well so that the thrust for equity is not only for the little boy on the renal side and not only for the people on the preventive side who will, in fact, as a result of the preventive treatment, save the economy's resources, but also for the people, all of us on occasion, who need care and supportive mechanisms and it won't make a bit of difference to GNP, but it will make an awful lot of difference to the quality of life of the Nation.

Mr. ROSTENKOWSKI. Thank you, gentlemen.

Congressman Pike will inquire.

Mr. PIKE. Professor Fein, I am very impressed with your statement about the complexities of deciding who gets what unless we essentially give everybody everything and the cost of doing it, and the choice of making these decisions.

Obviously you feel that any system should provide a kidney machine at home for anyone who needs it. Would you put any limitations whatsoever on the kind of care which should be provided under a national health system?

Mr. FEIN. Let me try and answer that with more than a sentence. Mr. PIKE. Heart surgery for everyone?

Mr. FEIN. I believe that in fact in this economy with a GNP of over $1 trillion, we can do an awful lot more than we are doing. I believe also that we can do an awful lot more than we are doing within existing budget resources if we had a system which was more rational in its allocation.

I do believe that we would at various levels save money out of the waste that we now have.

Some 2 years ago there was an influenza epidemic in Boston, and the question was asked, as patients were in beds in the halls of the hospitals, "Does this not demonstrate that there is a shortage of beds?"

One of the keen observers, a hospital director faced with that question, found it rather difficult to answer, but when pressed he said, "No. There is no shortage of beds, because 25 percent of the people who are not in the halls, who are in beds, don't need to be there."

We have designed a financing system that encourages their being there, and that is the costly part of medical care, which is to say, I think we could do an awful lot better for the $104 billion we are now doing if we did not have a preference for high cost, technological, institutional care.

A lot of people can be treated in other forms for the same $104 billion.

Two. Other societies, in fact, have demonstrated that you can force and bring a more rational allocation by not having an openended budget system, as is the case in the United States.

One of the interesting observations is that in the United States, if you want to know what we spend on medical care, you ask the people at the Social Security Administration, Office of Research and Statistics, approximately 6 months after the end of a fiscal year. "What did we spend in the year beginning a year and a half ago?" but in Britain you know what you are spending, because you have decided what to spend. This does force very hard decisions.

In Britain it forces the hard decisions because Britain is a poor country. I don't think the decisions would be quite as difficult in the United States.

Three. If we come to a point where, in fact, medical science is able to do things for people that are beyond our budget abilities. even with whatever reallocations we might make from other spending sources, I would like to see a societal decision. Shall there be open heart surgery financed or shall there not? That is a tough one. It is a tough one, because the next question has to be-if society says that in terms of its priorities it can't do primary care and open heart surgery and that it opts for primary care-will you deny open heart surgery to those who can afford to pay for it of their own pocket? That is a tough one.

I know where I stand on it, but I can respect the fact that others would have a different point of view.

Mr. PIKE. You know where you stand on it, but I don't know where you stand on it.

Mr. FEIN. I don't believe that I feel comfortable in a society in which-remember, when we talk about open heart surgery and the expensive things we are talking about life and death situationsin which life becomes a matter of a marketplace where some can purchase it, life, because they are rich and others can't because they are poor.

Mr. PIKE. So as a doctor you will say to the rich man, "You will not get it?" You are not a doctor. You are a professor.

You would say to the rich man, "You would not have it?" Mr. FEIN. I would. Rationing life through a lottery is one thing. but rationing through income and wealth is quite another. Mr. PIKE. It is a tough question and I thank you.

I want to let other people in here, but I would like to ask one tion of all of the members of the panel. Taking the totality of