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After reviewing the debate in this country, and considering my experience both here and abroad, I have decided to discuss the subject under three headings:
I. Compulsory politicalized medicine-a description used in preference to the misleading and inaccurate term national health insurance;
II. Prepaid per capita group practice-instead of the misleading label health maintenance organizations (HMO's) used by its proponents;
III. Those devices for Government dictation and control-which are deceptively referred to by their proponents and apologists as utilization review, and professional standards review and professional standards review organizations (U/R and PSRO).
The latter two items are actually a part of the whole scheme to nationalize medicine. But since the HMO's and PSRO's have been the subjects of separate acts of Congress-even though the planners see them as a part of the whole drive to politicalize medicine, and defraud free citizens of their birthright--they should be dealt with separately.
I. Compulsory politicalized medicine.
Most so-called national health insurance proposals both here and abroad-in non-Communist countries at least-are based upon the following assumptions:
1. That ordinary law abiding citizens who are competent to vote and make choices among competing candidates for public office are considered incompetent to make proper choices for their own medical care in a free market and, therefore, should be denied the right to choose where, when, how, and by whom they should be treated.
2. That all citizens should have a part of their earnings forcibly taken from them by government and spent for medical care and that, as a consequence, government agents should directly interfere with the physician's judgment while he is treating the patient.
3. That government agents are more capable and competent, and I might say ethical, than ordinary citizens and even more capable and competent than the attending physician who supplies the service.
4. As a corollary, that where patients are at liberty to select the physician and hospital of their choice both the physician and hospital will unethically, inappropriately and unnecessarily provide medical care that the patient does not need.
5. That everyone has a definable need for medical care that government can identify and provide at reasonable cost and satisfaction to patients if only physicians and other suppliers of services will subordinate themselves to dictation and control through mechanisms devised and employed by a centralized bureaucracy.
6. That if government controls the provision of medical care, quality will rise, costs drop, and more satisfactory care will be available for everyone.
I not only challenge these assumptions as being false and unwise, but also challenge the bureaucracy and its supporters in the legislature to clearly delineate where the authority exists in the U.S. Constitution for such unreasonable and arbitrary dictation and control.
I mean by this that the proponents of such a program have the burden of proving that it was the intention of the framers of the Constitution to deny patients the freedom to choose their own doctor or hospital.
With respect to people's capabilities, obviously, if citizens are competent to vote in a society that presumably is based on self-government with emphasis on the self, then they should be considered competent to obtain their medical needs on their own initiative without governmental paternalism and interference.
The proponents of subsidy and control habitually accuse physicians of unethical practice, such as unnecessary surgery on a wholesale scale. The evidence does not support these charges. In fact, it has become an accepted tactic of the government interventionists to snatch figures ont of the air with no basis whatever in fact and to otherwise falsify the record simply to discredit doctors and create a false picture of a need for government action.
The assumption that government is capable of defining medical needs and satisfying them is contrary to the experience of people who have tried to make socialized medicine work only to find that it is inherently unworkable.
The cost of politicalized medicine to Government and the people is more than Congressmen should force their constituents to pay. And when their constituents find out the truth they are going to rebel.
Not only is the cost of politicalized medicine in money too high but its price in denial of individual liberties is unconscionable. Most people, in this country at least, treasure liberty as highly as they do anything else. Liberty is severely impaired by politicalized medicine and the record shows that to be true.
The Honorable J. Enoch Powell, British Minister of Health, 1960–63, who tried to make the British National Health Service work, said in his book, "A New Look at Medicine and Politics," that:
Under the National Health Service care is rendered free to the consumer at the point of consumption. Consequently supply and demand are not kept in balance by price. Since, therefore, resources are limited, both theoretically and in practice at any given time, or the demand is unlimited, supply has to be rationed by means other than price.
He goes on to say that:
Common thought and parlance tend to conceal or deny the fact that demand for all practical purposes is unlimited. The vulgar assumption is that there is a definable amount of medical care “needed," and that if that “need" was met, no more would be demanded. This is absurd.
In Britain, the Government is rationing medical care by making patients wait for the promised services. The bureaucrats here in the United States are trying to tell the patients that they can have whatever their hearts desire and that if they don't get it, it is the doctors who are keeping them from getting it. This is what all of the elaborate bureaucratic machinery with respect to utilization review and PSRO is all about.
2. Experience with medicare and medicaid since 1966 shows that political medicine is too costly. What is the evidence ?
First and foremost, the bureaucrats solemnly assured the Congressthe Ways and Means Committee, in fact--that hospitalization under medicare the first year would cost $900 million. Actually, the first year cost was $2.7 billion.
They pledged that it would cost no more than $1.4 billion the fifth year. Actually it cost $5 billion. They said after the 10th year it would
cost $1.7 billion and it is actually costing $10.9 billion. The first year cost was three times as much as bureaucrats said it would be and the 10th year cost has soared to over six times as much as they promised.
These expenditures are absolutely unconscionable and indefensible. But it is unconscionable, irresponsible and wrong to place the blame on the doctors. It is wrong to place the blame on the hospitals. The proper place to fasten the blame is on the Congress and the bureaucrats who were instrumental in the enactment of the medicare and medicaid laws. Medicare and medicaid have helped skyrocket HEW expenditures. HEW, in the fiscal year 1976, will spend over $118.4 billion. This is more than all of the spending for military defense. It is more than all the profits after taxes of all the corporations in the United States. It is more than all the personal savings of all the people in the country.
The fact that this has been hidden from the people causes them to wonder why the price at the grocery store and at every other place where people buy things have gone up through the roof. The answer is that a tax on a tax on a tax, from the raw material through every stage of processing, is gouging everyone. Certainly it is gouging the elderly, the widows who are living on fixed incomes and the poor who cannot vote themselves, as Congressmen have done, income which is protected from the escalation in inflation. The plunder through the Congress and bureaucracy is scandalous and must stop.
What I'm saying is this: Deficit spending is the main cause of inflation. Inflation increases prices by devaluing the currency. Those who are injured the most by increased prices are the poor and the middleincome groups, especially those on fixed incomes. These are the very groups that the planners of national health schemes claim they wish to help. In actual fact, therefore, these people are harmed and not helped by the deficit-spending schemes.
John Maynard Keynes, a Fabian-Socialist economist whose disciples have misled the free world into destructive deficit government spending that has caused inflation to rage in Great Britain, at over 30 percent now, threatens to destroy responsible self-government in the United States, recognized, however, that inflation was a deadly trap. In his book, written soon after World War I, “The Economic Consequences of the Peace," beginning at page 235, he said:
Lenin is said to have declared that the best way to destroy the capitalist system was to debauch the currency. By a continuing process of inflation, governments can confiscate, secretly and unobserved, an important part of the wealth of their citizens.
Then, he goes on to say:
Lenin was certainly right. There is no subtler, no surer means of overturning the existing basis of society than to debauch the currency. The process engages all the hidden forces of economic law on the side of destruction, and does it in a manner which not one man in a million is able to diagnose.
It is instructive in the light of Lenin's drive for state monopoly capitalism that the Department of Health, Education, and Welfare publishes from time to time charts showing the expansion of public spending and the complementary contraction of private spending for health care. They point out clearly the inexorable direction in which more government spending and control its leading us.
There are those who scoff at the possibility of the U.S. Government going bankrupt. Past apologists for the bureaucratic excesses of New York City scoffed at it going bankrupt, but it is.
Government after government is beginning to realize that government spending must be controlled. The budget deficit which this country now faces of $60 billion for this year alone is an outrage. Stoking the fires of inflation by bureaucrats and then passing laws to insulate the bureaucracy and the Congress from the direct effect of the inflation by an automatic cost-of-living escalator, could be the spark that burns the pants off all politicians disguised as Santa Clause and exposes them for what they are-thieves in the garb of benefactors. This great ripoff is not going unnoticed, and if the ripoff of denying patients the right to their own earnings and to willingly choose the doctor and hospital they desire is exposed to the electorate, it just may be that enough citizens will become so infuriated they will start spending more of their waking hours out in the precincts doing the kind of job that should be done to put in power a responsible set of legislators instead of a group dedicated to plunder without regard to its disastrous effect.
My second major point deals with prepaid per capita group practice.
Evidence abounds that the frenetic campaign to sell HMO's to the American people is doomed to failure. Why? Because it's a concept that doesn't fit the average American's idea of how he wants to obtain medical care.
In the first place, there is not a shred of provable evidence that prepaid group practice costs less than fee-for-service, private practice medical care for the same service or that patients of these groups are healthier and live longer than the rest of the comparable population.
There is sobering evidence, on the other hand, that elimination of fee-for-service, in fact, disrupts medical care to the detriment of the truly sick. Dr. 'Sidney R. Garfield, considered the father of the KaiserPermanete program, explained it this way in a 1970 article in Scientific American:
Only after years of costly experience did we discover that elimination of the fee is practically as much a barrier to early sick care as the fee itself. The reason is that when we remove the fee we remove the regulator of flow into the system. ... The result is an uncontrolled flood of well, worried-well, early-sick and sick people into our point of entry--the doctor's appointment-on a first-come, firstserved basis that has little relation to the priority of need ... The impact of this dtmand overloads the system and, since the well and worried-well are a considerable proportion (of patients), the usurping of available doctors' time by healthy people actually interferes with the care of the sick.
I might add just a sentence from Enoch Powell's book. He says: That in a medical service free at the point of consumption, the waiting lists, like the poor in the Gospel, are always with us.
Care will have to be rationed for those patients unfortunate enough to have abandoned freedom of choice for the false lure of the HMO's in the belief that all their medical needs and demands would be satisfied for a fixed fee paid in advance.
What I and a lot of other people would like to know is why Members of Congress, the elected representatives of the people, continue to insist on picking the taxpayers' pockets to pour more money into a program that the people have convincingly demonstrated they don't
want. Is the motive a passion to give Government another weapon in the continuing campaign to control doctors and obliterate the practice of private medicine in America?
This unconscionable disposition on the part of some Congressmen to try to buy votes by promising free medical care to everyone on the pretext of helping improve medical care while reducing its cost is patently a political fraud. If you want to debase the quality of medical care and drive up its cost, and degrade the people in the process, turn the Nation's health care over to Government bureaucrats.
I might add, sir, Enoch Powell said something else to me personally. It is not in his book. He said it is strange that people continue to be amazed at the suggestion that when a politician says something that he could be politically motivated.
The third major point, namely controls through so-called utilization review and subsidization through PSRO, is particularly objectionable and unacceptable to any person who believes in individual liberty, particularly, if he is sufficiently wise to know that Government controls to justify subsidies is the baited trap of tyrants. An old con man once told me that the first step in taking a sucker is to put thievery in his heart. The bureaucracy and its partners are doing just that in utilization review and PSRŐ as well as HMO's.
Politicians justify the interference on the premise that the Federal Government is subsidizing health care and Government can properly control anything it subsidizes [Wickard v. Filburn in 1942, 317 U.S.,
The excuse for imposing controls is that: The costs of the medicare and medicaid programs have skyrocketed far beyond the early estimates-Government estimates. In this fiscal year alone, medicare and medicaid will cost the Federal and State governments some $19 billion.
The legislative and executive branches of the Federal Government are blaming physicians for these skyrocketing costs, e.g., the Senate committee report on this legislation said:
The rapidly increased costs of these programs (medicare and medicaid) are attributable to two factors. One of these is an increase in the unit cost of seryices, such as physicians' visit, surgical procedures and hospital days. The second factor ... is an increase in the number of services provided to beneficiaries. Witnesses (not identified) testified that a significant proportion of the health services provided . are probably not medically necessary. Unnecessary hospitalization and unnecessary surgery are not consistent with proper health care.
Through the PSRO sections of this law, politicians are making it appear that "practicing physicians” are being given “full responsibility and authority” to keep costs from skyrocketing.
This is a double-barrelled deception.
First-political promises and excessive Government spending are the primary causes of increasing costs, not the actions of physicians. Physicians are caught in the upward spiral of inflation along with everyone else.
Second-physicians are not being given responsibility and authority to control costs through PSRO's because such authority as this law provides is strictly in the iron-handed control of the Secretary of HEW and his employees. But, even more important, neither he nor his employees have power to control costs effectively.