Mr. THOMAS. It is difficult but without that it is also difficult to educate in terms of your complaining about costs here. This is at least a relatively potential savings. We need to do some of that as we move forward, because there are real savings. Dr. Wasserman, your examples were good and, obviously, civilization is a clearing in the jungle, and when we forget that, the clearing gets smaller. Dr. WASSERMAN. I just wanted to comment, earlier this week I made a presentation to our local board of health, and one of the concerns that they had was homicide, Prince George's had about 156 homicides last year. We talked about gunshot wounds because our commission on health also had some of our local surgeons. The night before the presentation, he had served in the ER and had two gunshots come in. We averaged the costs. For every gunshot wound, there were in direct medical care costs $16,000. That is not saying this is not just for people who die, this is just the treatment in intensive care and the subsequent regular hospital stay, anesthesia costs, and IV costs, et cetera. So when you talk about cost savings, and we also looked at the number of firearm deaths in males aged 15 to 19, it leaves you with very compelling arguments that if you got rid of the accessibility, say, of handguns or you did something on the front end, prevention, you would save countless thousands locally, which translates into millions and billions, as Dr. Fielding suggests. So when you talk about prevention, and we have multiple charts, you either pay now or you pay later. And when you pay now, you pay a fraction, either $1 on $10, or to give the example Mr. THOMAS. There is no question. The problem is when we put preventive care into a basic guaranteed benefit package, regardless of whoever's model it is, we pay now and we can't collect later, so it is pure cost for us to put those programs in. We are going to do them because we know clearly that they pay off, but from a budgetary point of view, it is very frustrating. And if we could have some corollary examples so we could talk about how if you passed other legislation, you do make savings as well, it makes it easier for us to defend the preventive that we put in, even though we don't get the cost savings in the bill. Dr. WASSERMAN. When Jonathan mentioned, if you prevent a teenage pregnancy in this year, 9 months later, if we put programs in our schools, and we just opened the Northwestern High School Health Center, if we prevent one pregnancy, then next year, we will save the costs and then we will save countless Mr. THOMAS. Some welfare savings, perhaps, on a corollary structure there as well so we can do that. But we need to have that, otherwise we are going to have to defend the total cost package, which I think is not fair, because we clearly will not spend as much as we are spending because the preventive will give us a return on our investment but we just can't score it. Dr. WASSERMAN. Let me just ask, then, because I think we can get you the information you need. If we put certain dollars up front this year, then we can show you that you can make savings in this year's budget. Mr. THOMAS. Did you do any look-backs, if you can say 5 years ago this was done, and therefore today, with hard savings, where you have some profiles that will allow us to extrapolate, that would be very, very helpful, because, frankly, it is frustrating as we move forward. Dr. WASSERMAN. And we have to keep it within the $900 billion health care budget both ways or can we give you some savings in other parts of your budget? Mr. THOMAS. As I said, I would like to have it narrowly within the health care area but then corollaries in others, so that clearly what you do in other areas will feed back into the health care system. My time is up. Mr. Carey, I can assure you that in your testimony, all your concerns about the difficulty of the local structures with the alliances and the rest, I feel fairly comfortable you won't have to worry about that. Mr. CAREY. I appreciate that, Mr. Thomas. Chairman STARK. Mr. Kleczka. Mr. KLECZKA. Thank you, Mr. Chairman. While I would not like to get Dr. Fielding or Dr. Wasserman in trouble with either Senator Moynihan or the NRA, I am sure you gentlemen wouldn't mind that conflict. One of the proposals floating out in thin air is a proposition to help fund the health care reform bill by increasing the tax on am munition. Now, clearly there would be additional dollars coming in, so I don't think that is in dispute. Do you see an effect on the current crisis of handgun violence and injuries that end up in the emergency room by an increase in the tax on ammunition? Dr. FIELDING. I am not sure how much information is available on that. I am not an expert in that area. I have looked a lot at the availability of handgun issues. Let me answer it in this Mr. KLECZKA. I would assume that the same would be true, if in fact we put on a heavy, heavy tax, the availability of ammunition might not be as great. Whether or not that is true, you and I don't know, naturally. Dr. FIELDING [continuing]. Let me answer, we have some good data from a couple of other areas that are being considered, revenue-raising opportunities from the smoking area. We do know that an increase in cigarette tax leads to reduction in teenagers who are starting and that is, by the way, where we stop making progress. We have a decline in teenage smoking, and it is pretty well stopped now, and one of the things that could contribute to much more savings is increasing that. There is comparable data in the area of alcohol. When you increase alcohol taxes, you do reduce consumption. So I think it is realistic to assume that at some level tax on ammunition would have some impact on the availability of ammunition in times of domestic crisis or other things, but what impact that has, I would not be able to speculate. Dr. WASSERMAN. I guess I don't think I would like to take on Senator Moynihan, but public health officials have no concern generally about the NRA. I think that Mr. KLECZKA. A bold statement. Dr. WASSERMAN. I think when we made our presentation to our local board of health and our local association of health officials in the State of Maryland, we would support Governor Schaefer's assault weapon ban in any kind of control of handguns. As my training, like Jonathan's, is in pediatrics, and kids get hold of a weapon in the home, there have been multiple studies that show most of the time those injuries on guns at home injure the homeowners or their families and really don't help them and offer them certain safety and protection. I might go one step farther than Senator Moynihan. I don't know the legal issues here, so I get my own legal consultation as to what to do, and I probably need political consultation as well, but certainly if you licensed handguns, or if you eliminated handguns and I am not I don't think you have to worry about licensing rifles or anything to deal with people who legitimately hunt with those weapons, I support the second amendment-but I think that ammunition could be taxed, on the one hand, or you could license the ammunition for those people who already have the handguns. So if you are talking about handgun ammunition, I might want to know who is getting the handgun ammunition because the argument is always made that you can't-if you take away the handguns, you will only take them away from the right-acting citizen and they will always be in the wrong hands. So if we license the ammunition or find out who is buying the ammunition for handguns that we want to diminish, it might be another alternative. I guess, I see this purely as a public health issue. I often seeand in the conflict when there are individual rights against the public's rights, I think that we have to be looking at the denominator here: What is in the best interests of the American public? And often, again, with prevention, in the long run, and I think in the short run as well, we have adequate proof and documentation that prevention, up-front dollars will save over the long haul. Mr. KLECZKA. One quick question of commissioner Carey. In your testimony you indicate that the counties would like the option to be treated as corporate alliances availing themselves of the cap. My county and city have come to me with that same request. I think that is something we have to look at. Another portion of the bill requires the Federal Government to pay 80 percent of the health costs for early retirees age 55 to 64. Have the counties taken a stand on that? Mr. CAREY. Not to my knowledge, at this point. I can get you a specific answer to that question from the counties association. Mr. KLECZKA. Thank you, Mr. Chairman. [The following was subsequently received:] NATIONAL 440 First St. NW, Washington, DC 20001 The Honorable Gerald D. Kleczka February 8, 1994 United States House of Representatives 2301 Rayburn House Office Building Washington, D. C. 20515-4904 Dear Representative Kleczka: During the Ways and Means Health Subcommittee hearing on February 4, 1994, you asked Moses Carey, Orange County, NC Commissioner if the National Association of Counties had a position on President Clinton's proposal to fund the employer share of early retiree health benefits. NACO supports the early retiree provision. However, there are more counties affected by their inability to continue to self-insure and the lack of a guarantee that no more than 7.9 percent of their total payroll will go towards meeting their share of the health premium. Benefits afforded to the private sector should also be available to public employers. We hope to work with you to make the employer provisions equitable between the public and private sector. If you have additional questions on these issues or service delivery concerns, please have your staff call Tom Joseph, Associate Legislative Director, at 942-4230. Sincerely, Lany Manhe Larry E. Naake cc: Moses Carey Chairman STARK. I want to thank the panel for their contribution and call our next panel to which we will add Dr. William Richardson, president of the Johns Hopkins University; and including Merrill Matthews, Jr., the director of the Center for Health Policy Studies; James Stanton, president of the American Health Planning Association; Robert Gumbs, New York State Association of Health Planning Agencies; Arthur Stowe, president, Printing Industries of Maryland; and Marsha Radaj, vice president of operations of the Wisconsin Health Information Network, on behalf of Ameritech. Dr. Richardson. STATEMENT OF WILLIAM C. RICHARDSON, PH.D., PRESIDENT, THE JOHNS HOPKINS UNIVERSITY, AND CHAIRMAN, MARYLAND STATE HEALTH CARE ACCESS AND COST COMMISSION, ON BEHALF OF THE ASSOCIATION OF AMERICAN UNIVERSITIES, AND THE NATIONAL ASSOCIATION OF STATE UNIVERSITIES AND LAND-GRANT COLLEGES Dr. RICHARDSON. Thank you, Mr. Chairman. I am delighted to be here and I appreciate your courtesy in permitting me to join this panel. I am William Richardson, president of the Johns Hopkins University which, of course, includes the academic health center as well as many other parts of the university. I also serve as chairman of the Maryland Health Care Access and Cost Commission and so have a special interest in some of the issues you are discussing today. I appreciate the opportunity to represent as I do today the Association of American Universities and the National Association of State Universities and Land-Grant Colleges. Together these two university associations represent the great majority of the academic health centers in the United States. These associations have established a joint task force made up of the presidents of several universities and some vice presidents for health affairs, medical deans and others to address the questions that health care reform will raise with respect to the well-being of universities and their academic health centers. As we see it, members of the associations will be affected in four major areas. First, is universities as employers. Second, is our academic health centers as providers of care; third, our educational function; and fourth, the very important role we play with respect to university-based biomedical research. I don't think I will say much about universities as employers this morning because we are virtually all large employers and understand the implications of both the administration plan as well as others that have been proposed. We certainly will be alert to those impacts, but because of our size, I think we will not be affected differently than most large employers, with some differences between private and State institutions, of course. More important, I think, is for us to address the question of the overall impact of health care reform on academic health centers and therefore on universities as a whole. It is true that many institutions find that their academic health centers, their medical schools and their teaching hospitals comprise major parts of the academic enterprise. They are fiscally inter |