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death in spite of the fact that our TV programs have heroic medicine in our living room twice a week every week.

That is what we are bombarded by and it does affect decisionmaking. If the student is trained with high drama in the hospital, he is likely to feel that primary care is less prestigious, less interesting and also less economically rewarding. He then, even if he is interested in going into primary care, is aware that if he goes into that field, perhaps his reward will be that 25 years later there will be a profile about him in the Sunday supplement to the Boston Globe. But that is not enough reward.

He is out there lonely because if the medical school isn't interested in him because he isn't in the hospital and he isn't doing the kind of research that has been supported in the past, his professional colleagues are not interested in him. He is out there in the frontlines working very, very hard in a rather difficult situation. Furthermore, there is a situation of which he is aware, that that what he does, sad to say, has less to do with the health of the population than the quality of their houses, the quality of their diet, nature of their jobs, and the opportunity to work.

Yet as a physician, though he knows that rat control is more important than treating the rat bite, he can't do anything about rat control, so he treats the rat bite in a very frustrated and very frustrating situation.

We pay a price for admitting very bright students to medical school. The price is that they are bright enough to see that the American population, Congress, society, have not placed any great emphasis on primary care and given that brightness and given that reading of society they drift voluntarily, but nonetheless into the high specialties, high technologies, highly institutionalized, highly prestigious areas of medicine and then we say, "Gee, there must be something wrong." Indeed there is.

Dr. WYNDER. Could I comment on that? I think Dr. Fein made a point of what is doable is not necessarily what is right and what is not doable is not necessarily wrong.

Many times I am sure you have been in favor of bills that you knew in your heart were right for your citizens in your district and yet you knew that the Congress would not vote for it. Such limitations also apply to medicine. Much of what we have said here we know to be right, but we know it not to be doable.

Some 512 years ago I gave a long and hard look at this and decided to learn from Einstein, who said, "It is not so much important what people say, it is what they do." So I asked myself what can I do in preventive medicine for this country?

I recognized for reasons stated I could not do it within the medical school. I could not do it within a hospital. So we set up our own organization that we called, and perhaps that is the first smart thing we did-we called it the American Health Foundation.

We just completed a $6 million research institute that specializes in disease prevention. Supported to a large extent by the National Cancer Institute we are looking at risk factors. We recognize that people like Mr. Cotter will continue to smoke because perhaps he is likely to think, as I said before, that he is immortal, so we recognize

[Laughter.]

Dr. WYNDER [continuing]. That for people like him we have to make smoking less harmful. We have a major program on how can we make smoking products less harmful. We recognize that most of us eat in excess in spite of the fact that we are physically not very active. Thus we have a major program on how can we modify the American diet so that we reduce its effects on coronary disease and several types of

cancers.

We call this managerial preventive medicine. It may be of interest to you that this new institute stands in Valhalla, New York

[Laughter.]

Dr. WYNDER [continuing]. And perhaps that was kind of a fortuitous choice, because Valhalla implies immortality. Second, we established a health maintainance institute. I would like to extend an invitation to all members of this committee to go through our health maintenance center, to be screened in 90 minutes and to have a nine-page printout on you on the physician's desk that has all your findings reported by the time with all abnormal findings on the first page.

We don't want the doctor necessarily to read all nine pages, so we have the abnormal findings on the first page. Many of these relate to asymptomatic conditions, your blood pressure, your cholesterol. It is a different medicine from the way we learned in medical school. When I was in school, the first question we learned is where does it hurt, what is your chief complaint? Somehow the doctor feels if the patient doesn't have a complaint, he can't be sick. Yet if you have hypertension or hypercholesterolemia, you are in fact potentially in worse health than if you have a cold.

Thus, smoke cessation programs, nutrition and hypertension program were started. We have such programs for adults and children. Clearly this is doable, and if you like to see how it works, I would like to invite all of you to come and see it.

Third, we have established a public health action center because we recognize that it is not just important what we do in our own institution, but how we can affect society. The public health action center has tried to influence the tobacco industry to lower their tar nicotine values with great success. The tar nicotine values are 30 percent less than 20 years ago and we are seeing a reduction in lung cancer among people smoking lower tar cigarettes.

We are trying to affect the diet. Other people have added iodine to salt and reduced goiter in areas where goiter was very common, a typical example of managerial preventive medicine.

We are now newly funded by the NCI to establish sections in health economics. Here we study to what extent can preventive services reduce health care costs, as Mr. Martin asked today.

We are doing work in health motivation, though I believe this to be the weakest area. Only up to certain points can man be motivated toward better health because we always come to the point where man says, "Not me, certainly not now."

And we are involved in school programs. Thus, we have developed an organization that employs today some 200 people that is solely committed to preventive care, an effort that could be duplicated in other States. By so doing I hope that we can make an influence to change the current medical care delivery system.

We need change if we are going to have a better health care system.

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Mr. ROSTENKOWSKI. The gentleman from California's time has expired.

I think Mr. Cotter will inquire before he expires. [Laughter.]

Mr. COTTER. Thank you very much.

Frankly, Doctor, I don't want to die of senility. [Laughter.]
Mr. BURLESON. Or any other way.

Mr. COTTER. It has been a most provocative session. I know we have all benefited by the discussion back and forth.

We have had figures made available to us within the past 24 hours that some 80 percent of the population under 65 has basic hospital and medical care insurance and medicaid takes care of the indigent and medicare those over 65.

Now, how far do we go with the National Health Insurance program? Do we go cradle to grave, includes preventive medicine? Or do we take a piecemeal approach and expand the coverages offered by Blue Cross-Blue Shield, or insurance companies in general? Do we expand the care under medicare and medicaid?

This is the question. Would each of you care to comment on it? In other words, how far do we go? Do we do something in between? Do we do it piecemeal? How?

Mr. FEIN. This gets at the question in a different way, the question that Mr. Vanik asked.

Mr. COTTER. On another point, when you start directing doctors as they get out of medical school, we need some in OBG or whatever, I don't think this is right to dictate to doctors what fields they must pursue or where there is a need. But let me return to my basic question. How do each of you suggest we approach national health insurance?

Mr. FEIN. On the latter question, the latter comment, sir, let me just say that while it may be frightening to dictate to doctors where they shall be, under existing financing mechanisms you are, in fact, if not dictating, encouraging doctors to be in certain areas and in certain activities, and in certain kinds of medical care. So it is not as if the Federal Government and third parties have not already directed doctors through economic incentives.

Let me address it

Mr. COTTER. This should be correctable then?

Mr. FEIN. Yes; it should be and indeed I hope it will be corrected. According to the Social Security Administration, which annually offers us an article on national health expenditures and on private health insurance, I quote:

Despite the growth of private insurance in the health care field, an estimated 41 million Americans under age 65 have no economic protection through private insurance against hospital costs. 42 million have no insurance for surgical care.

The picture is not quite as bright as one would think when one looks at the number of people who have insurance, because in many cases that number is not 100 percent, of course, but in addition many of those who have insurance have very inadequate insurance. We do not count "Do you have an appropriate policy or adequate policy?"

How far should we go? Well, let me begin with a fundamental principle. It seems to me that there is one Federal program which has in a most adroit fashion intertwined the fate of middle class and upper income Americans with the fate of lower income Americans in such a manner that there is nothing the farmer can do to hurt the poor in that program without hurting themselves.

I refer, of course, to the social security system which encompasses all Americans. From that, and from one additional observation, namely, that it is not likely that we are going to have an adequate program for the poor and the near-poor people if we only address them. I conclude that it would be helpful to have a program like social security, which did encompass all Americans.

If the question is then asked, how would you move today if the Congress were unwilling to go all the way in one fell swoop? That is the question of Congressman Vanik.

Mr. COTTER. Which is a very practical consideration.

Mr. FEIN. It is a consideration. I am not sure it is a practical consideration because, in fact, we are already spending the money. But if that is a consideration, there are, I believe, three options, two of which ought to be rejected. Let me mention them all.

One way would be to phase in a benefits structure starting with certain kinds of benefits and not others. I don't think that is desirable for two reasons: The benefit structure you select will tilt the system in that direction; and, second, it is unlikely that you would select the benefit structure that emphasized primary care given that public would say to you, "Is this what National Health Insurance was about? You are leaving me dangling on hospital expenses and the stuff that frightens me. You haven't done anything." I would remind us all that medicare started talking about hospital care for a very important social, economic, and political reason.

So that if you go for benefits structure, I think you will do harm to the ambulatory care system. The same observation holds for going for catastrophic insurance.

You could phase in by starting with high coinsurance and high deductibles on the theory that that will reduce the impact on the Federal purse and over time you will fill in the gaps. The difficulty with that approach is that those who can afford to fill in the gaps immediately will do so, and you will have a two-class system. You will have the inequities. You will be back where you were.

In addition, you will have incurred in any system which attempts to be refined, high administrative costs associated with sorting pieces of paper.

There is a third mechanism and that would be to start with the benefit package that is comprehensive, that covers the care that one would like to see for all the population, but starts with a segment of the population. I do not suggest a segment defined by income because that is dangerous. We may never get rid of that. But start with a segment defined by age.

You can begin a fully comprehensive program without coinsurance and deductibles for children and pregnant women, perhaps more correctly "pregnant persons."

[Laughter.]

Mr. FEIN. You can start with that kind of a benefit package for a modest sum of money. One of the reasons that it is modest is kids don't use much hospital care. If you began with that package and though no Congress can bind any future Congress, and I am aware of that-if the legislative history

Mr. COTTER. May I interrupt you?
Mr. FEIN. Yes.

Mr. COTTER. Could we interrupt for a moment?

Mr. ROSTENKOWSKI. We will recess for 5 minutes for the vote. [Recess.]

Mr. CORMAN. Mr. Pike will inquire.

Mr. PIKE. Dr. Wynder, I have been thinking a great deal about your emphasis on preventive medicine and it leaves me with a small philosophical problem which I am sure you can resolve for me very easily. If we go your route in Valhalla, and people stop dying of these manmade diseases, what are they going to die of and what are the declining years of their lives going to be?

Dr. WYNDER. We shouldn't die of senility, but we should "die young" as late in life as possible.

Mr. PIKE. Does that really happen?

Dr. WYNDER. It should happen the way nature has intended it. A key question really is, and I would like to address this to my friends the economists, there was a paper from England suggesting that the ideal way to die in terms of health economics would be at age 65. In other words, when you are about to lose your productivity.

Mr. PIKE. You have suddenly begun to strike a nerve.

[Laughter.]

Dr. WYNDER. I thought I would say something provocative to my friends on the left here. I suppose you can say "on the left." [Laughter.]

Mr. FEIN. Thank you.

Dr. WYNDER. If we kept people well and really had a whole population that died at age 80, what would happen-not in this case to our health care system, because these people would die "healthy"— but what would happen in terms of social security cost and other costs? This is a key question that needs to be answered.

The ideal for a physician is, of course, to keep patients well throughout life. Our idea is not to prevent you from dying, but to prevent you from dying of disease. It can be accomplished that we die free of disease.

Now it is up to the health economists to tell us what would happen. indeed to other economic factors in our lives if a much larger segment in our population became very much older.

Mr. PIKE. Well, to me very frankly this is much more than an economic problem. While I recognize the validity of the economic aspects of it, is it perhaps not true that the reason people speed and the reason they smoke and the reason they live the kinds of lives they lead, giving them heart attacks, is because that perhaps subconsciously some of them decide that is not such a bad way to go?

Dr. WYNDER. The question you ask has been very central to our thinking and, indeed, on September 29 our organization is having a symposium in New York on "The Illusion of Immortality." We have asked these particular questions to Erich Fromm, Ashley Montague, and together with DeBakey, Robert Berg, and William Sloan Coffin will discuss these points.

In correspondence I had with Erich Fromm on this very point, he indicated that one reason why we take improper care of ourselves is because many of us are chronically depressed. Like you say, some of us may feel well, to go that way is not all that bad.

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