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today is composed of people who have never practiced, I think could have been a little better balanced.

Mr. ROSTENKOWSKI. As I said earlier, Mr. Duncan, it's primarily for an educational process and for the exploration of the experience that these gentlemen have. We expect certainly to have public witnesses and general practitioners at some time in the future.

Mr. DUNCAN. Thank you, Mr. Chairman.

Mr. PIKE. Thank you, Mr. Chairman. I am delighted that we are embarking on these hearings on a subject in which I have been very, very interested for a great many years. I think that I should say at the outset of these hearings, just so you may understand some votes that I cast in the future, that for 25 or 30 years now I have been either a director of a general hospital or a director of a proprietary hospital and an officer thereof. So I do have some frame of reference in regard to this matter.

We are going into this in a very broad sense. When we get to actual voting on an actual bill, which looks a long way down the road, I may feel compelled to vote present sometimes but it will not be for lack of interest on the subject matter.

Mr. ROSTENKOWSKI. I hope, Mr. Pike, that the opportunity for you to cast your vote will not be in the too long distant future.

Mr. Cotter?

Mr. COTTER. Thank you.

A PANEL CONSISTING OF E. L. WYNDER, M.D., PRESIDENT, AMERICAN HEALTH FOUNDATION; JOHN G. FREYMANN, M.D., PRESIDENT, NATIONAL FUND FOR MEDICAL EDUCATION; RASHI FEIN, PROFESSOR OF THE ECONOMICS OF MEDICINE, HARVARD UNIVERSITY; AND UWE REINHARDT, ASSOCIATE PROFESSOR OF ECONOMICS AND PUBLIC AFFAIRS, PRINCETON UNIVERSITY Mr. ROSTENKOWSKI. Gentlemen, we certainly welcome you. I am hoping this will be a refreshing beginning. I know that we on the panel here and you on the panel there are all certainly hopeful that we can develop some worthwhile legislation. I think we are in total agreement that the country is in need of some health insurance program.

It is at this time that I would like to welcome Dr. Wynder, president of the American Health Foundation; Dr. Freymann, president of the National Fund for Medical Education; Professor Fein, professor of the economics of medicine at Harvard University; and Professor Reinhardt, professor of economics, Princeton University. I am sorry to say that Dr. Kerr White, who was originally scheduled, is ill and will be unable to appear today, but we hope to have him sometime in the fu

ture.

Dr. Wynder, if you would like to begin the discussion, please do so.

STATEMENT OF E. L. WYNDER, M.D.

Dr. WYNDER. I would like to comment on the opening statement. I have and I do practice preventive medicine and if we in the medical profession would have succeeded in the practice of preventive medicine, it is unlikely that we would have to hold the hearings today.

It would seem from the history of medicine, as indeed from history in general, that while man has obviously enhanced his knowledge, he has not enlarged his wisdom. Forty-five hundred years have passed since Huang Ti declared in China:

Hence the sages did not treat those who were already ill; they instructed those who were not yet ill. . . . To administer medicines to diseases which have already developed and to suppress revolts which have already developed is comparable to the behavior of those persons who begin to dig a well after they have become thirsty, and of those who begin to cast weapons after they have already engaged in battle.

Several decades ago, William James Mayo was quoted as saying: The aim of medicine is to prevent disease and prolong life. The ideal of medicine is to eliminate the need of a physician.

We would concur that this is still the basic goal of medicine, as indeed is well reflected in an old Greek motto that has become the basic saying of our foundation-that it should be the function of medicine to help people die young as late in life as possible.

THE ISSUE

This being the case, we should ask how our current medical care delivery system is addressing itself to this issue, where the primary problems in achieving these goals lie, and how a program of national health insurance could contribute toward its attainment. With a decreasing birthrate, we are faced over the next few decades with the predictability of fewer wage earners as healthy as possible and reduce the need for unnecessary and increasingly expensive hospitalization among our older individuals.

If we fail in this, our Nation will be required to undertake a major shift of priorities in the national economy; one that would see an ever-increasing percentage of the gross national product tied up in health care delivery services. This would be a task of unprecedented dimensions, and one that might well be impossible within the present productive framework of our Nation, particularly in view of other formidable competing priorities.

The consideration of a national health insurance system is politically natural in the increasingly mutualistic atmosphere of our democracy. A health insurance system immediately brings to mind hospitalization needs and the coverage of disease costs, but if we are not to make of this system an economic monster, I urge you to consider how disease, life, and moneysaving measures can be built into such a system.

That is why I shall stress in my remarks areas involving preventive medicine. I would like to caution, however, that as has been experienced by national health insurance systems in other countries, and indeed from our own experience with medicaid and medicare-a cost-effective health insurance system requires, in order not to be economically overburdened, a disciplined population and a disciplined health care profession in order that its obvious advantages are not destroyed by an overzealous use of its opportunities.

It seems appropriate that, in discussing the health needs of the the United States, one begins by enumerating the major causes of death

and disability in our country, the opportunities for preventing or curing these conditions and the problems we face in combating these major foes of premature death and disability. It so happens that four conditions: Heart disease, cancer, stroke, and accidents, make up 70 percent of all deaths among Americans, while heart disease, arthritis and rheumatism, impairment of back, hips and lower extremities, mental and nervous disorders and hypertension represent 40 percent of the reasons for disability among our population. Therefore, it is in these areas that we need to concentrate if we are to make a significant impact on disease rates in the country.

The major factors contributing to death from heart disease, cancer, and stroke in the United States have been well established by epidemiological and laboratory studies. Factors for which the incidence is most consistent include, for cardiovascular disease-overnutrition (especially with regard to fat and cholesterol intake), hypertension, excessive cigarette smoking and physical inactivity; for cancer-excessive tobacco usage, nutritional deficiencies and excesses, and certain occupational exposures; and for highway accidents, alcoholism and drug abuse, poor highway, and automobile designs.

Thus, in a society where infectious diseases have been largely overcome through sanitary measures, immunization, and antibiotics, the major causes for today's death toll are chronic diseases. This death toll is largely due to unhealthy lifestyles, unhealthy working environments, and disease-inducing products. If we are to prevent these diseases, we need to concentrate on their causes.

PROBLEMS OF DISEASE PREVENTION

It may be asked why, if etiological factors of certain diseases have been established, there hasn't been more progress in the prevention of these diseases. Among the reasons for this failure are man's apparent apathy toward anything preventive-whether with regard to energy conservation, highway safety programs, or health. We tend to live for the present, believing that the future will take care of itself. We also seem to suffer from an illusion of immortality, apparently related to our inability to face death. The problem is further compounded because doctors are trained mainly in therapeutic medicine; and because reimbursement for medical care is nearly totally geared toward therapy. Given these facts, adding that preventive advice given to patients is not as dramatic in public or private terms as combating symptomatic diseases, it is little wonder that many of today's physicians do not stand in the vanguard for the cause of prevention.

The hospital system is another part of the problem. Our hospitals deal primarily with cure, not prevention. Since reimbursement is aimed mainly at inpatient, rather than ambulatory care, and since hospitals are reimbursed for therapeutic rather than preventive care, it is not surprising that the latter is being neglected.

These attitudes are reflected in current practices of the health insurance industry which, again, concentrates largely on reimbursement for therapy for specific disease symptoms and not on prevention. It is unrealistic to expect that the medical and allied professions, in an economic climate such as ours, will behave any differently than any other

segment of society. As long as our society provides economic incentives primarily for therapeutic care, it will be therapeutic care which receives the most attention.

Yet, we know from medical history that the world's major diseases did not succumb to therapy alone; instead the only time they were ever eradicated was when effective preventive measures were applied. This lesson from history also applies to chronic noncommunicable diseases such as cardiovascular disease, cancer, and chronic pulmonary diseasediseases which have a long latent period, which by and large are not likely to be cured in their later stages, but which are often preventable.

RECOMMENDED MEASURES

The following attempts to crystalize the major steps which can lower costs and contribute to a better health care program than the one we presently have.

1. First of all, we, as a nation, must resolve that health care ranks as one of our country's major goals. To accomplish this goal requires the cooperative efforts of various segments of society. It is obvious that the medical profession cannot, by itself, determine which type of a health system would be best for the country. Industry, labor, economists, health insurance experts, Congress, and the public at large need to coordinate their expertise with that of the health professionals in order to arrive at a health care delivery system which is best suited to the needs of the United States.

2. In order to improve the health care delivery system, both medically and economically, several measures should be included in whatever type of national health insurance system is contemplated.

The system must accentuate financial incentives for ambulatory care. Existing hospitals should be reorganized so that they can provide, in addition to therapeutic care, efficient ambulatory care for their communities. Appropriate incentives should also be given to physicians to provide preventive care. Included in this care should also be: Immunizations, maternal and child care, pre- and postnatal care, general health education and motivation, as well as therapeutic care. The ambulatory care unit thus includes both preventive-primary and secondary—and therapeutic programs. The preventive care programs should be of the short- and long-range type and should modify their services in line with the specific needs of various population groups. The ambulatory preventive care program should be extended into the schools where meaningful health programs are currently almost nonexistent. Effective preventive medicine-as is the case with education in general-has its greatest impact on the young.

3. Ambulatory care delivery programs can, to a large extent be carried out by allied health professionals, nurses, medical corps men, health educators, behaviorial psychologists and sociologists who, under the overall supervision of physicians, in many instances can undertake effective therapeutic programs and significantly help in modifying the lifestyles of our people and in detecting early disease.

4. A national health insurance program should not only provide effective ambulatory and preventive care programs but should also provide incentives for the public and the health care delivery system to see to it that such health services are effectively utilized.

5. Recognizing that individuals will always represent the weakest link in preventive procedures, in addition to providing meaningful incentives to utilize cost-effective preventive services, emphasis should be placed on "managerial" preventive measures. These include further development of less harmful smoking products-a measure especially recommended for a society which is likely to continue to condone smoking as socially acceptable-and the modification of American food products toward developing a "prudent" diet, one low in fat and cholesterol and thus more commensurate with today's reduced caloric expenditures, as well as a diet that leads to proper growth of our poor and underprivileged. Managerial preventive medicine also includes reducing workers' exposure to harmful elements through legislation and making certain that no new harmful components are introduced into the environment. It also includes the enforcement of speed limits which, in addition to saving lives, would also help in the conservation of energy. Existing laws with respect to drunken driving and automobile and highway safety should be vigorously enforced.

6. It is suggested that all preventive programs as currently conducted by various branches of HEW and other governmental agencies, be coordinated and supervised by an Office of Disease Prevention to be heated by a Deputy Assistant Secretary reporting directly to the Assistant Secretary.

Finally, I would like to bring the following recommendations to your immediate consideration, that:

7. In any authorization for national health insurance-even in the initial development stage-Specific allocation equal to one-tenth of 1 percent of the dollar authorization be directed toward preventive medicine, research, and evaluation of existing systems.

8. That the chairman with the advice of the committee direct the Secretary of HEW to appoint a task force on preventive medicine for the purposes of examining, on an across-the-board basis, the extent that preventive medicine is presently being practiced for the purpose of determining specific feasibility as to what is accomplishable through preventive medicine.

9. That the chairman with the consent of the committee direct the Secretary of HEW to report within 90 days on the extent of the taxpayer-supported research in the area of evaluating the cost benefit of preventive medicine.

10. That the chairman direct every witness to address themselves to the specific question of how the financial cost of disease care can be reduced through preventive medicine.

In summary, we have emphasized the roles which ambulatory care, preventive care, allied health professionals can, and should play in a national health insurance program. It should be emphasized that all such programs should be continuously scrutinized for their cost effectiveness and cost benefits.

Preventive medicine, if properly advanced, can make a major impact-both medically and economically-on the high rate of disease in this country. It requires a full-time coordinated effort for its goals and aspirations to be fulfilled. We have also set forth the obstacles-scientific, economic, and human-which face the proponents of preventive medicine. To overcome these obstacles requires the understanding and the support of the people and, consequently, the Congress. Congress,

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