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Now, if we were representatives of the Defense Department, I am sure that long since you would have made us tell you how many tanks, how many aircraft carriers, and how many missiles we are talking about.

Even if we were representatives of another service industry such as education, I hope you would have been able to get us to tell you how many students we were going to produce. In other words, you would have insisted that we quantify the product.

Yet, in this entire discussion neither we on the panel nor anyone in the committee has tried to define what we are buying. I think this is why the economics of the health care are so peculiar. We talk about what we are going to spend, not what we are going to buy. Mr. Corman, but I agree that given the choice between that approach have access to the services of those who the States have licensed to take care of their health needs.

Is that sufficiently definitive?

Dr. FREYMANN. That does not answer the problem. As Dr. Fein pointed out earlier this morning, the provider is not always a physician. There are the other health care providers. But beyond all these is a social demand that certain health resources must be available.

I return to dialysis as an example. There is a social demand to make available to all people who have end-stage renal disease, unlimited resources to keep them alive. This social demand has actually been incorporated into Federal statute.

Mr. CORMAN. Do you know how that came about?
Mr. FREYMANN. Not in detail.

Mr. CORMAN. The detail is that 25 people would die if they didn't have it and they sat right where you are sitting,

If you could bring me 25 of anybody with anything and let us look at them, I can promise you that we will take care of their problem. It is the unseen ones that are difficult to take care of. Dr. FREYMANN. I am not surprised, and I sympathize with you

in facing that dilemma.

The point I am trying to make is that, if we are talking about national health insurance to free people from the fear of being wiped out financially, that is laudable and I am all for it. But we cannot say that and also say we are going to save money and hold down costs. There is no connection between the two.

The costs of keeping people alive are going to increase because our population is getting older and older, and our technology is getting better and more expensive.

We are going to be spending more and more money at the lifepreservation end of the health care spectrum unless we define (to use the title of Victor Fuchs' book) "Who Shall I Live.” When I say "we," I mean society, not the health professions nor the medical profession.

Who shall live? That, I believe, is the crucial question which will determine how much we spend for health care. Until we answer it we will be unable to control what we spend because we will not have defined what we are going to buy.

Mr. CORMAN. Dr. Wynder, did you have any comment ?

Dr. WYNDER. There is nothing that I can add which has not already been said. The bill that includes the basic premise to provide effective health care at a price we can afford should be the right of every citizen in our country.

The point just made in terms of kidney dialysis and the marketing problems we have had in preventive medicine prompt me to say cannot marshal here even four people who are so delighted they are healthy that they will come here before you, because if we are healthy we take it for granted. Once we become sick, we worry about the sickness that we then have.

Any bill has to make certain that physical restraint is being maintained by whatever health care system operates.

If you give upper limits, you can be certain that that upper level will be spent. Such fiscal restraint must certainly be contained in any bill.

Dr. Freymann stated that perhaps as we get older we will cost our society more in terms of some disease.

I am not that pessimistic. As I pointed out, I do not believe we have to die of ill health. There are, of course, other problems that we can deal with in terms of our aged. I would hate at this point to mention nursing homes but certainly nursing homes, if well run, are a far better and cheaper way of dealing with some of our problems relating to age than hospitals. Hospitals happen to be one of the most expensive ways in which we operate our medical care delivery system.

I do hope that as the weeks come, you will have witnesses from different branches of the health care system. I hope you can ask them how they can reduce the cost of their operations and how they could utilize perhaps some of the bed space now becoming empty for ambulatory and preventive care services.

Mr. CORMAN. Mr. Chairman, on that note I would just indicate for the record that panel 1 has opted for H.R. 21 and I won't ask anybody any more.

Mr. ROSTENKOWSKI. We have to get the votes and talk about the dollars budget.

Gentlemen, it has been most enlightening. The comments, as I said earlier in the back room were just fantastic. You have really begun our discussions and our investigation of the possibility of health insurance on a national scale on a real sweet note.

Professor Fein, did you want to say something?

Mr. Fein. On behalf of the panel, and I am sure my colleagues would agree with me, I would want to make a comment to you, Mr. Chairman, that if this is the way the Congress always works, then the image that some Americans have of the congressional process is faulty.

If this, on the other hand, is not the way the Congress always works, then, by golly, it should work this way.

Mr. ROSTENKOWSKI. Well, thank you.

Mr. FEIN. Because I am sure we do feel, all of us, that this was a most useful day to us as well as to you in the opportunity to leave feeling that we had an opportunity to share ideas with you and that these ideas then will be accepted or rejected but will be weighed as

you debate.

It is a nice feeling to have.

Mr. ROSTENKOWSKI. Professor Fein, this is a new concept. I would like to continue this approach of having the subcommittee really

geared to a dialog, conversational dialog, with our witnesses. I think the advisory panel that we put together, and you are members of it, are certainly going to help us frame legislation that will ultimately mean a great deal to this country.

I would like to say one thing to Dr. Fein. You talk about health education for the young, that it is not all bad.

Well, it is nice to note that you have made the observation that we are not all bad up here, Professor Fein, because we get that all the time, comments on how bad Government is run.

Dr. WYNDER. Mr. Chairman, may I add a final comment. Some time ago in Japan I was called upon to give a toast. I said, "May a country's greatness in the world not be measured by the height of the gross national product, but rather by a health care service that has in a most effective manner lead to the healthiest people in it.'

I hope some day that Congressmen and that Senators would be receiving the most votes from constituents who have successfully labored for a better health care system in America.

Mr. ROSTENKOWSKI. Thank you. This committee will stand in recess until 9 o'clock when we will take up the testimony of the Government's role in national health insurance.

[The subcommittee recessed, to reconvene at 9 a.m. of the following day, Friday, July 11, 1975.]


(The Role of Government in American Health)

FRIDAY, JULY 11, 1975



Washington, D.C. The subcommittee met at 9 a.m., pursuant to notice, in the committee hearing room, Longworth House Office Building, Hon. Dan Rostenkowski (chairman of the subcommittee) presiding,

Mr. ROSTENKOWSKI. The subcommittee will come to order.

We would like to welcome the professors and doctors this morning. I would like to express our gratitude for taking the time out of your busy schedules to participate with us in these discussions. The format of these meetings are an opening statement by each of you individually and then an opportunity for you to have an exchange and then the panel opens up to questions by the membership from this end.

It is quite informal. We would appreciate your trying to give us answers in as concise a manner as possible because, as you know, we are limited here to 5 minutes on questioning at least the first go-round.

We are looking forward to indepth conversation with respect to the Government's role in the national health insurance. We would like you to know that in yesterday's hearing the Members of Congress that participated in the discussions were quite impressed. I think these are very informative and educational sessions. It really is a two-way street, both for those of us who participate and those who give the knowledge you have to offer.

I would like to present this morning Prof. Lewis H. Butler, professor of health policy, University of California. It is nice to see you back in Washington, Professor.

I would like to present Lowell Bellin, New York City's commissioner of health.

Richard Heim, executive director of Health and Social Services Department, New Mexico; and Prof. Pierre R. de Vise, professor of urban science, University of Illinois, in Chicago. It is nice to see you.


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