Another reason which I indicated before which he stresses is that since we cannot face death realistically, we tend to ignore it. A third point that he makes is that we are egotistically in terms of our own immortality and thus believe it cannot happen to ourselves.

A fourth point he makes and he was rather apologetic on this is that the medical profession is so much known to be a healing art rather than a preventer that most of us don't want to go to a doctor when we are well simply because (a) he will not properly deal with us; and (b) if you play the word association game and you say day-night, table-chair-and, now you say doctor and answer healerin other words, you don't think of our profession as one that primarily prevents. All of these things together, make us shy away from prevention.

Mr. PIKE. Thank you.

Dr. FREYMANN. Čould I carry on, Mr. Pike? You are really getting to the heart of the problem.

Let me give you a figure on what would happen if we eliminated all cardiovascular-renal disease, which is our major cause of deaths. Life expectancy of a white male at age 10 would be increased by 12.2 years. The life expectancy of a white male aged 60 would be extended by 11.3 years. In other words if we made this enormous medical advance, the increase in life expectancy on the sunny side of 60 would be only 1.1 years.

We are extending life on into a time when most people are removed from productive existence. So that the problem goes far beyond medical care. If we achieve this Nirvana, if everyone lives out his full biblical "three score and ten," what do we do with them?

Congress is one of the few areas where you can keep on going. Everybody else has to retire at 65.

Mr. ROSTENKOWSKI. The committee will now refer to the question offered by Mr. Cotter.

Professor Fein, if you will continue to address yourself to that.
Mr. FEIN. Thank you.

I was commenting that one approach would be to start with children and pregnant women, one could go a long way for a modest sum in an area where resources are available, in an area where preventive care might most easily be organized and where capitation payment might most readily be accepted by physicians. While, as I indicated, I recognize that no Congress would bind any future Congress, one would like the legislative history of the debate to show that it is the intention of Congress that 1 year after the program is instituted for all persons up to, say, age 19 that the effective age would become age 24, and then 29 and then 34, and over a decade one covers the entire population.

If one wants to move more rapidly, increase the age in 10-year intervals per annum and one does the whole job over a 5-year span. The appropriate interval is easily selected so that the fiscal impact in any one year is about the same as the fiscal impact the year before. One can do it. One can play with the numbers. It would cost about $12 or $13 billion gross to cover everyone up to age 19 and pregnant women. The net figure would be significantly lower because of medicaid expenditures that are now already involved in that age group.

If the response that you made to such a suggestion were "But there are many Americans who are concerned about catastrophic expenditutres, who don't have children and who would feel uninvolved in this program and it would be insufficient to say to them that in a few years they would be covered," that you need something to address that problem, I would respond in the following fashion:

All Americans who are of an age where they don't have children that would be eligible for the program, but who are insured as a family unit, would find a significant reduction in their premiums for insurance by the simple act of covering children. Most insurance policies today have the same rate for a family of two as for a larger family, and if you removed the children, even the family of two would benefit in its insurance premium. But if that were not enough, I could see putting in place a program which said that we would cover children up to age 10, and which would also offer protection of a maximum liability much like CHIP or other proposals that have been made, a percentage of income, for others.

No one in the United States, for example, would face medical bills that will absorb more than 8 percent of his income. That, however, will phase out as we raise the age for total coverage. So that as the age of total coverage goes up from 10 to 20 to 30 to 40 to 50, the catastrophic impact becomes less and less significant because more of the population is fully covered; and eventually it becomes totally irrelevant.

That, I would submit, is a proposal that would not do violence to the structure of the medical care system in terms of placing high priority on expensive items, that would not put in place mandating that we would never get rid of, or coinsurance and deductibles that would cause inequities. It is a program that could be viewed as a way of going in a logical progression to an ultimate goal over a period of time consistent with one's feeling of administrative capability and capacity and so on.

I would make only one additional comment. You will note that I say it is a program that could be put in place over a period of time and in line with one's feeling about administrative capabilities. I did not say it is a program that one would need to put in place over a period of time to meet fiscal problems. I didn't say that for an important reasons.

The expenditures that are required are moneys that are going to be spent out of pocket anyway. They are in the health care system anyway. There is no reason for the Congress to be afraid of national health insurance on the ground that the United States can't afford it.

We are already affording $104 billion. The question is how will we distribute those $104 billion? There is no new money involved. We are not a little underdeveloped country saying "Shall we have a health care system?" We have got one. We have got an expensive one. So that it is not a fiscal problem, but it may be an administrative problem for any Congressman-I am sure it is-who though recognizing that the money is in the system already is not enamored of increasing taxes because he may feel he cannot explain adequately to his constituency that that increase merely substitutes for expenditures that are already made.

Mr. ROSTENKOWSKI. Mr. Crane will inquire.
Mr. CRANE. Thank you, Mr. Chairman.

I would like to congratulate the Chairman on these hearings; and add that while I share his appreciation of having academicians and people with research backgrounds present expert testimony. I look forward later on to having the opportunity for an exchange with some people actually on the firing line of American medicine. Based upon what has been presented here, none of you would be in disagreement with the idea that national health insurance is a desirable thing. Is that correct?

You are all in uanimous agreement on that point?

[Affirmative response.]

Mr. CRANE. The issue of spending the $104 billion that we are expending annually in behalf of national health care undoubtedly could be more intelligently spent if I were King. I think every one of us shares that assumption. But on the other hand, if to change your perspective ever so slightly, you were to contemplate trying to figure out how to deal in a positive way with some of the deficiencies that you perceive in the American health care system outside of an imposed solution from Washington, D.C.-and I place vastly less faith than you gentlemen apparently do in government's ability to solve problems what would you recommend within the private sector? We talk about the creation of incentives, but I think we have already created some incentives for a lot of physicians to get into teaching and research than private practice, which is demonstrable evidence to my satisfaction that we in government don't have omniscience. That has created some of the problems in our health care system.

Are there any of positive incentives within the framework of free institutions rather than imposed solutions: that you might suggest? Anyone on the panel at all I would appreciate hearing from.

Dr. FREYMANN. I would structure the payment system for physicians' services so that the physician who is capable of taking care of 85 percent of the patient care encounters-that is, the family physician, the general internist or the pediatrician-could receive sufficient payment for these services so that he could make a go of practice.

Solo practice or group practice there are all kinds of ways. I am not making a pitch for any type of practice or for any type of payment. But if we can put money into the system to pay for primary care there will be an incentive for medical students to go into these fields.

Dr. WYNDER. In line with what Dr. Fein said, the emphasis ought to be on the question which is a little bit for medicine as for what Martin Luther said for religion. He said, "If you give me your child until he is 5, he is mine for life." I would say, "If you give me a child until 16, the child would be a good health risk for the rest of his or her life."

The question is how do we do that? As Dr. Freymann says, "Pay the physician." I don't believe that the behavioral modification principles that are involved will suffice in terms of interest to the physician. The training in medical school today, independent of economic rewards, really has involves academic aspects that normally are not part of preventive medicine. Therefore, I don't think that even an adequate payment schedule can we get most physicians interested in that type of primary medical care. Therefore, in addition to economic incentives, we ought to realize that these types of primary preventive programs are best conducted by allied health professionals.

We clearly have to recognize as physicians what we can do best. We do well in therapy, but in terms of primary prevention unlikely to do as well as paramedical people. Therefore, let me repeat our emphasis ought to be on the early health care in prenatal, postnatal, school programs conducted largely by allied health professionals.

Mr. CRANE. Before we go further, can I elaborate on this point because I am intrigued by it? My recollection is that there was a study done on Mormons in this country that indicates that they were vastly healthier, live longer and so forth. The conclusion was made that it is in part because of their religious views on caffeine, cigarettes, liquor, what-have-you.

Are you saying that the development of the proper health habits from birth would probably be vastly more helpful and beneficial in terms of the total health of our national population than trying to repair deficiencies later on?

Dr. WYNDER. I think that is quite clear. In fact, Victor Fuchs, another economist of note, wrote a book, "Who Shall Live?"; and in one chapter he compares the mortality in the State of Utah with that of the State of Nevada.

I don't want to draw any personal conclusions from this comparison excepting that the mortality is very much lower in Utah for a variety of reasons. Dr. Fuchs concludes if this were the health State of the country as a whole, our health economics would be in a very much. better shape.

Whether the lifestyle or whatever it is, these early formative years are not only important in terms of intellectual developments, but are clearly important in terms of health development as well. Mr. CRANE. Dr. Reinhardt?

Mr. REINHARDT. I agree very much with your point that we should perhaps not regulate the health care system too much from Washington, D.C. Of course, you realize that when you raise the question of what we can do, you are talking about intervention of some sort. I guess the issue is this: Are we going to intervene directly through regulatory edict, as we allow the CAB to do in the airline industry, or are we going to use the more subtle financial flows that are more congenial to the American temperament?

I think you are probably talking about the latter.

Mr. CRANE. If you will permit me to intercede for a moment, I think there are actions that we have taken already and I touch upon at least one where through Government assistance we put a disproportionate emphasis on recruiting medical researchers and faculty. So maybe it is a case of removing some of our previous handiwork. In another area, I read an article in a British medical journal that expressed apprehension over the fact that the British are moving in the direction of FDA with respect to drug approval. Here is an action that we took that has retarded introduction of modern lifesaving drugs into the United States so much so that British physicians consider us 20 years backward in that regard.

Mr. REINHARDT. Yes, as I said, you will see on page 20 of my prepared statement that I come out very strongly against regulation. Incidentally there was a conference last year-or perhaps 2 years ago at the Institute of Medicine, and the proceedings have been pub

lished in a book called "Control of Health," in which these issues are debated at length, and the participating economists come out much against direction regulation.

Now Dr. Freymann's suggestion to reimburse primary care physicians so that they can "make a go of it" requires added comment. Primary case physicians in this country are making an average of about $50,000 a year. By American standards I would call that making a go of it.

So the question really

Mr. CRANE. Do you know what the workweek is for the primary care physician on the average?

Mr. REINHARDT. Yes; we have rather good statistics on that. The average-depending on the specialty-is about 50 to 55 hours. However, these are self-reported hours and they seem to be substantially overstated. I think a more accurate statistic would be between 40 and 50 hours.

Mr. CRANE. OK.

Mr. REINHARDT. I think the proper policy is not one of raising the income of primary care physicians and holding everyone else's income constant. Relative changes in income may in fact have to go the other way. I refer to this point on page 17 of my statement: if we establish a national health insurance system under which physicians are paid on a fee-for-service basis, it is important that the third party gain at least partial control over the determination of the fee schedules. If so, it will be possible to change relative physician incomes through the fee schedule.

The system of customary local fees is exactly one of the evils that we have permitted which tends to motivate physicians to move into areas where they should not go, where they are not needed. We should take a hard look at the system of customary local fees. This will take courage. Ultimately we ought to use fiscal flows to foster an efficient nationwide distribution of health-care personnel. Such a method is quite different from direct regulation, whereby one would-for example-tell a physician he must have three nurses in his office. Mr. CRANE. Well, except if we can elaborate on this just a little bit— am I exceeding the time constraints?

Mr. ROSTENKOWSKI. Go ahead.

Mr. CRANE. Well, don't hesitate to interrupt me.

We had a discussion in here earlier in oversight hearings on utilization review and the AMA's suit against it. The basic objective of utilization review is cost control and prevention of alleged abuses by physicians in medicaid-medicare programs.

Do you not inevitably, when you get into reviewing fees, payments, conditions for payment and so forth, get a degree of lay judgment imposed upon the professional? It seems to me that that is an unavoidable consequence at least in the legislation drafted to date, the professional standards review organization. That ultimate authority, of course, rests with the Secretary of HEW.

When I put the question to Mr. Weinberger about specific prohibitions in the law against his attempting to provide guidelines or regulations that led to the suit, he simply cited other portions of the law that gave him burdens and responsibilities that highlighted the contradic