2 $1500 maximum liability maintained.

PRIVATE

TAB C

32%

25%

29

3%

36%

33%

4%

26%

29%.

9%

7%

$103.0

$109.5

$112.3

$114.0

$111.0

$107.0

$116.0

$112.8

$107.4

(IN BILLIONS)

Mr. ROGERS. Thank you, Mr. Altman. I think that would be helpful and as soon as we can get those the committee would be appreciative. I believe you already have the basic plans and they have not been changed too much from last year's proposals.

Mr. ALTMAN. Yes.

Mr. ROGERS. How soon do you think you could get them to us?

Mr. ALTMAN. Well, I keep checking daily. We are trying to do it in two different ways: One, we have developed a rather complicated computer model which hopefully will be useful not only to the Department, but for the Congress as well, and for many years to come.

To put that computer model into place it has taken about 3 years of fairly intensive work. It is beginning to work. Some of the estimates need to be refined and we are beginning to get the first runs, and I would suspect within a couple of weeks we will have one or two plans completed.

We would like to get them all completed before we make any of them available. Not because we don't want to share the results with everyone as soon as possible, but because if you present one plan, that becomes the focal point of the discussion and you don't have any comparison. So that is why I mentioned several months.

We are also trying to get our actuary to do some estimates in an independent way and he indicates that we will be getting estimates from him within the next few months.

Mr. ROGERS. That would be helpful.

Mr. SCHEUER. What you meant specifically when you said it would be helpful not only to the Department but to the Congress, tooMr. ALTMAN. Well, I meant the results of the estimating model. We are trying to make each of the congressional staffs knowledgeable about how that computer runs so that they can have access to it.

Mr. SCHEUER. We would have access to it-if we have a legislative proposal of our own, could we give it to you to put through the computer to help cost it so we have a sophisticated idea?

Mr. ALTMAN. We would try. I would say quite honestly, it depends on the workload and that kind of information you want. Sometimes in the past a flood of demands has come in from all over the place and we have had to say, no, we can't do it not out of an unwillingness but really due to lack of time.

Mr. SCHEUER. This is off the record.

[Discussion off the record.]

Mr. ROGERS. Could we ask Dr. Rivlin and Dr. Mitchell a few questions? I think that would be helpful.

Let the record show Dr. Altman has removed himself from the table. That is very good.

All right, now, Mr. Scheuer.

Mr. SCHEUER. Well, a couple of questions as starters, Mr. Chairman. This is a sort of philosophical question for everybody to have some fun with.

On the bottom of page 9, you have the following sentence: "Virtually all patients with end-stage renal disease" does that mean terminal?

Mr. ALTMAN. It is a medical-maybe Dr. Hyde would like to explain. In the past it has been

Mr. SCHEUER. Does that mean a terminal disease?

Mr. ALTMAN. Yes, sir.

Mr. CARTER. Not necessarily. They may have a renal transplant. Mr. ALTMAN. Unless there is some intervention to change that. Mr. SCHEUER. "Virtually all patients with end-stage renal disease now given such therapy, rather than only those with the expectation of long-term survival and rehabilitation as originally intended."

Now, sooner or later, as we develop more and more sophisticated and extraordinarily expensive systems of extending life for patients with all kinds of cancer, heart, stroke, everything, let's say, at a $1,000 a day, sooner or later society has to begin to make some hard choices. Do we spend money for people in their 70's and 80's, at these enormous costs for extending life a short period of time? When we make the decision to do that aren't we making the decision not to do something else perhaps in the area of preventive health care or opening up new maternal child clinics, of doing something about the situation where today over a fourth of the kids-1 out of 4-haven't had polio immunization.

Life is full of tradeoffs, and I just wondered how society is going to make this choice of extending life for elderly people who are terminally ill but who, at the cost of enormous investment by society, can have their lives extended somewhat, as against doing other things in the health care system or other things in education, housing, or law enforcement, or other public service systems? How do we make decisions on these investments while maintaining our sense of humanity and compassion?

Mr. ALTMAN. Well, here, I am personally at a loss to come up with answers. I have grappled with that particular problem for several years now, because I think it really is a critical question.

When you recognize that as you go down the list and look at the enormous expenditures that we put into individuals in the process of dying, not in the process of living

Mr. SCHEUER. That is what I am talking about.

Take, for example, Mrs. Roosevelt. When Mrs. Roosevelt realized she was at the end of a terminal illness, she requested her doctors not to give her any further technology, not to give her any further life-extending systems. She wanted to die with grace and dignity, and she did.

Now, that was her choice. Well, what do we do about the person who opts for all of the extraordinarily expensive technologies when life to all intents and purposes has terminated? When does society intervene and make some kind of decision?

Mr. ALTMAN. Mr. Scheuer, I think you are asking me a question that I can't answer.

I think, collectively, some day we will have to answer it, and I think mainly it will rest, if I might say so, on your shoulders and the publicly elected bodies to begin to make some of these calls with the help of the professional. But ultimately, in my view, it is a societal decision.

You cannot ask the provider to make that decision. I think they can advise you. They can advise us, and we have put them in that position.

LONG-RIBIO BILL

The bill would establish a (1) catastrophic protection plan for the general population and a (2) medical assistance program for the poor.

Catastrophic Plan.--The catastrophic plan, which would cover persons of all ages insured under social security, would provide unlimited hospital care beginning with the 61st day of care, and 100 SNF days for persons who have received covered hospital services under the program. It would also pay for medical services (physicians, laboratory and X-ray, home health services and medical supplies and appliances) after the family has incurred $2,000 in these medical expenses. All services would be subject to costsharing similar to that under Medicare, but with a limit of $1,000 annually per person. The plan would be financed by a special tax, similar to the Medicare tax, of 0.3 percent rising ultimately to 0.4 percent.

Medical Assistance Plan. --The medical assistance plan would cover families with income under specified levels. It also includes a "spend-down" provision which takes account of both family income and medical expenses. Present Medicaid eligibles would be automatically covered.

The program would cover the same types of services as the catastrophic plan, and, in addition, intermediate care facilities. Hospital care would be limited to 60 days, but the plan would pay for all benefits