you be

have some profiles that will allow us to extrapolate, that would 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 ammunition.

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:]

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 Nanhe

Larry E. Naake
Executive Director

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

woven and have a substantial impact on the university as a whole. It is more than an academic interest we have in the well-being of these health centers.

As to question of the continued successful operation of academic health centers under the legislation put forward and some of the other plans as well, one of the greatest concerns that we have is funding. Currently, there is a tremendous interweaving of revenues and sources of funds that support a very complex and interrelated set of missions, including the delivery of health care to low-income impacted populations in the areas around our health centers and special services that we provide on a regional basis and beyond.

We are concerned about the interrelated impact of changes in the sources of funding on both postgraduate and medical students' education. Also, as I noted earlier, there is a substantial cross subsidization of biomedical research. The impact that health care reform can have on our ability to conduct research is of special concern to us.

I should note that one of our concerns is the transition period that will take place almost without regard to what final form the action of the Congress may take. I say this because there is recognition within the Health Security Act of academic health centers, both in terms of the training of residents and other medical training and the training of other health professionals.

There is also recognition of the impact on academic health centers health care reform will bring. To whatever degree changes are phased in with recognition of possible shortfalls, pulling the financial rug out from under academic health centers is certainly a serious concern to the presidents of the universities within which these academic health centers are based.

If I could just say a word about medical education. I think there is wide acceptance-and indeed a movement towards-an emphasis on primary care. Whatever numbers are arrived at or whatever approach is taken, I think there is a strong commitment to move in the direction of training for primary care. We think it ought to be focused on the medical school where we can educate within the teaching hospital and in the community and physicians' offices and clinics.

We think second that it is important that different academic health centers be recognized as having different strengths and emphases and cultures. For example, in the preparation of primary care physicians of all sorts, we think that it is important to recognize that these will be done in different proportions and ways in our very diverse system of institutions.

Finally, I would note that it is increasingly important in our view that we look to other health professionals for the provision of primary care. Primary care providers in nursing and in a number of other health disciplines will be a key element of reform. Many of us have educational programs and research programs within our academic health centers to train and provide primary care services through other professional schools.

With respect to the issue of biomedical research, we are very concerned, I think it is fair to say, that the various sources of revenue the mix of income that comes in to support the very complex set of missions that I have described-does, in fact, cross subsidize