WAL Dh bre

yee 4
DY

OLD GENERIC SPEECH

(leave as is, per CEK)
GREETINGS, ETC.
I'M FINALLY GETTING USED TO THESE CLOTHES.

IT'S BEEN ABOUT A YEAR, NOW, SINCE I HUNG IN MY CLOSET
THE UNIFORM OF THE SURGEON GENERAL, NEVER TO PUT IT ON
AGAIN.

BUT I DON'T INTEND TO HANG UP THE CAUSES I TRIED TO
CHAMPION AS YOUR SURGEON GENERAL.

AND I'VE TAKEN ON A FEW MORE.
I INTEND TO CONTINUE TO SPEAK OUT WHEN I CAN TO IMPROVE
THE HEALTH OF THE AMERICAN PEOPLE. AMERICANS ARE
INTERESTED IN HEALTH. SOMETIMES I THINK THEY MAY BE
EVEN OBSES SED BY HEALTH. MANY AMERICANS ARE CRITICAL
ABOUT HEALTHCARE;

BUT NOT NEARLY AS MANY ARE KNOWLEDGEABLE.
DURING MY TENURE AS SURGEON GENERAL, I TRIED TO MAKE
THE PEOPLE OF THE COUNTRY KNOWLEDGEABLE SO THAT THEY
MIGHT BE CONSTRUCTIVELY CRITICAL.

I AM ATTEMPTING TO CONTINUE THAT IN MY ROLE AS A PRIVATE

CITIZEN.
I DON'T HAVE THE POWER OF A PUBLIC OFFICE NOW, BUT I
DON'T HAVE ITS CONSTRAINTS EITHER.

EVEN AS SURGEON GENERAL I USED TO SAY SOMEWHAT
FACETIOUSLY THAT I HAD NO POWER AND NO BUDGET.

THAT IS CORRECT.

BUT I ACCOMPLISHED MUCH BY SPENDING OTHER PEOPLE'S
MONEY.

AND I HAD THE POWER OF MORAL SUASION TO CHANGE HEALTH

POLICY.
WITH THE HELP OF THE AMERICAN PEOPLE --AND THEIR
COMMON SENSE-- I FEEL I WAS ABLE TO HELP GET THIS

COUNTRY MOVING TOWARD BETTER HEALTH.

I'M SURE SOME OF YOU WERE MY ALLIES, AND I THANK YOU.
SHORTLY AFTER I LEFT GOVERNMENT SERVICE I WAS ASKED BY
N.B.C. TO DO FIVE PRIME TIME SHOWS ON THE STATE OF THE
ART OF AMERICAN MEDICINE.

ASA FORMER PIONEER IN THE FIELD OF PEDIATRIC SURGERY, I
THOUGHT IT WOULD BE FASCINATING TO BRING BEFORE THE
AMERICAN PEOPLE THE FULL RANGE OF THINGS THAT MODERN
MEDICINE COULD DO FOR THEM.

AND I'VE SEEN SOME BIG CHANGES SINCE I FIRST ENTERED

MEDICINE A HALF-CENTURY AGO.
BUT MORE RECENTLY, DURING MY YEARS AS SURGEON GENERAL,
I SAW ALL TOO CLEARLY THAT 37 MILLION AMERICANS COULD
NOT AVAIL THEMSELVES OF MODERN MEDICINE.

SO RATHER THAN FILM A SERIES ON GLITZY HIGH-TECH
MEDICINE, I SHIFTED MY FOCUS TO THE REAL ISSUE FACING

AMERICAN HEALTH:

THE STAGGERING PROBLEMS WITHIN OUR HEALTHCARE SYSTEM

AND OUR HEALTH POLICY.
SOMETIMES I WONDER IF THERE SHOULD NOT HAVE BEEN

ANOTHER SURGEON GENERAL'S WARNING:

"WARNING! THE AMERICAN HEALTH CARE SYSTEM CAN BE

HAZARDOUS TO YOUR HEALTH!

IN A WORD --WE HAVE BIG PROBLEMS.
TO BEGIN WITH, THIS IS A TIME IN WHICH WE HAVE VERY HIGH

EXPECTATIONS FOR MEDICINE AND HEALTH.

WE'VE PUT A GREAT DEAL OF FAITH INTO NEW TECHNOLOGIES,
NEW PHARMACEUTICALS, NEW SURGICAL PROCEDURES, AND SO
ON, AND WE CONTINUE TO HAVE FAITH IN WHAT I LIKE TO CALL

THE MAGIC OF MEDICINE.

10
WE ROUTINELY EXPECT MIRACLES TO HAPPEN -- EVEN THOUGH

THE REAL WORLD OF MEDICINE ISN'T ALWAYS ABLE TO DELIVER.

BUT I THINK IT'S ALSO BECOMING CLEAR THAT THOSE HIGH

EXPECTATIONS ARE FAST OUT-RUNNING OUR ABILITY TO PAY

FOR THEM.

11
OTHER WORDS, TODAY IN OUR SOCIETY WE HAVE A CLEAR GAP
BETWEEN WHAT WE WOULD LIKE TO SEE HAPPEN IN HEALTH
CARE ... AND WHAT CAN REALISTICALLY HAPPEN IN HEALTH

CARE.

AND SO THE AMERICAN PEOPLE ARE ENGAGED IN A DEBATE IN

ABOUT

ASPIRATIONS VERSUS RESOURCES.

12
WE HAVE A RISE IN THE NEW TECHNOLOGIES AVAILABLE TO
PHYSICIANS,
BUT, AT THE SAME TIME, A DECLINE IN THEIR SIGNIFICANCE FOR

A SUBSTANTIAL NUMBER OF PATIENTS.

OUR HEALTHCARE SYSTEM MAY FUNCTION WITH COMPASSION
AND COMPETENCE --EVEN EXCELLENCE-- FOR SOME
INDIVIDUALS.

BUT FOR TOO MANY AMERICANS OUR HEALTH CARE SYSTEM IS A

TYRANNY, MORE A CURSE THAN A BLESSING.

13
I THINK I SEE THE PROBLEMS CLEARLY.
I KNOW I CAN MAKE SOME SUGGESTIONS.

I HOPE I CAN MAKE A DIFFERENCE.

BUT THERE IS NO PANACEA, NO MAGIC BULLET.

THERE ARE NO EASY ANSWERS, ONLY HARD CHOICES.

14
er
MANY AMERICANS ENTER OUR HEALTHCARE NONSYSTEM, NOT
THROUGH A LOCAL DOCTOR, BUT THROUGH THE LOCAL
EMERGENCY ROOM.
YOU CAN SEE AMERICA'S HEALTHCARE CRISIS IN ALL-TOO-VIVID
DETAIL AT YOUR LOCAL HOSPITAL'S EMERGENCY ROOM.
BUT WHEN YOU WALK INTO THE EMERGENCY ROOM --OR GET
WHEELED IN ON A STRETCHER-- YOU MIGHT THINK THAT
INSTEAD YOU HAD ARRIVED AT AN OVERCROWDED BUS STATION

WAITING ROOM.

15
er

OUR BELEAGUERED EMERGENCY ROOMS COPE WITH AN ANNUAL
PATIENT LOAD OF 100 MILLION --THAT'S ONLY A LITTLE LESS
THAN HALF THE ENTIRE POPULATION!

AND THESE FRONT LINES OF AMERICAN MEDICINE REFLECT THE

CONFUSION AND TRAUMA OF A BATTLE ZONE.

16
er
EMERGENCY ROOM OVERCROWDING STEMS FROM TWO

GROWING PROBLEMS:

THE INSURANCE CRISIS AND THE DRUG CRISIS, IN THEIR MANY

FORMS.

WE CAN SEE THEM BEST IN URBAN AREAS WHERE ON ANY DAY
600 PATIENTS WAIT IN EMERGENCY ROOMS, WAIT TO BE

ADMITTED TO THE HOSPITAL.

17
er
FIRST, MORE AND MORE AMERICANS ARE UNINSURED, UNABLE
TO AFFORD PREVENTIVE CARE OR PRIMARY CARE FROM A
PERSONAL PHYSICIAN OR LOCAL CLINIC.
SO, WHEN THEY NEED MEDICAL CARE, THEY GO STRAIGHT TO
THE EMERGENCY ROOM.
BUT BY THE TIME THEY FINALLY TAKE THEMSELVES TO THE
EMERGENCY ROOM THEY ARE OFTEN SO SICK THAT THEY

REQUIRE HOSPITALIZATION.

18
er
HOWEVER, AS HOSPITALS GO BROKE,--AND DURING THE 1990S 2
OUT OF 5 HOSPITALS MAY CLOSE-- THE REMAINING BEDS
BECOME FILLED WITH VICTIMS OF DRUGS, AIDS, AND MENTAL
ILLNESS.
AND THESE NEW PATIENT OF THE 1980S AND 1990S STAY IN THOSE

HOSPITAL BEDS LONGER.

19
er
FOR EXAMPLE, IN NEW YORK CITY THE AVERAGE
HOSPITALIZATION HAS INCREASED FROM 13 DAYS TO 26 DAYS.
DRUG USE IN THAT CITY IN THE LAST TWO YEARS HAS LED TO A
35 PERCENT RISE IN MEDICAL COMPLICATIONS, AND A 60
PERCENT RISE IN PSYCHIATRIC COMPLICATIONS. IN THE SAME
TWO YEARS, THE NUMBER OF CRACK BABIES DSasremr HAs

DOUBLED.

20
AND THERE ARE NO ACCURATE FIGURES ON THE DRAMATIC
INCREASE IN TRAUMA DUE TO DRUG VIOLENCE. MEANWHILE,
CITY DRUG TREATMENT CENTERS CAN TREAT ONLY 12% OF
HEROIN AND COCAINE USERS.

THE PROBLEMS WORSEN EVERY DAY.

21

er
er
IN ADDITION TO THE DRUG USERS CROWDING NEW YORK
HOSPITALS ARE THE SOARING NUMBERS OF MENTALLY ILL
REQUIRING HOSPITAL TREATMENT. BETWEEN 1982 AND 1989 THE
NUMBER OF EMOTIONALLY DISTURBED PEOPLE BROUGHT BY

POLICE TO NEW YORK HOSPITALS INCREASED BY 60 PERCENT.

22
er
AND THEN THERE IS THE CRUSH OF AIDS. BY 1994 NEW YORK'S
AIDS PATIENTS WILL REQUIRE 2300 ADDITIONAL BEDS.
THAT'S THE EQUIVALENT OF 4 OR 5 NEW MEDIUM SIZE
HOSPITALS. |

BUT NO ONE IS BUILDING HOSPITALS THESE DAYS.

YES, NEW YORK CITY'S PROBLEMS ARE THE BIGGEST, BUT THESE
FIGURES NEED ONLY MINOR PROPORTIONAL READJUSTMENT TO

REFLECT A SIMILAR CRISIS IN MOST AMERICAN CITIES, LIKE

HERE

23
er
IN OAKLAND CALIFORNIA, FOR INSTANCE, IN THE LAST TWO
YEARS, THREE HOSPITALS AND A CLINIC THAT USED TO SERVE
THE CITY'S POOR HAVE CLOSED THEIR DOORS.
THAT LEAVES JUST ONE COUNTY HOSPITAL OPEN FOR THOSE
OAKLAND RESIDENTS WHO CANNOT PAY FOR HEALTH CARE.
ALTHOUGH THE HOSPITAL STAFF HAS NOT INCREASED, IN THE
LAST TWO YEARS THE NUMBER OF PEOPLE WHO USED THAT
EMERGENCY ROOM JUMPED FROM 55,000 TO 70,000. AND, TO
MAKE THINGS WORSE, MANY OF THE NEW ARRIVALS HAVE NO

INSURANCE AND NO MONEY.

24
er
SO, EMERGENCY ROOMS ARE OVERCROWDED AND
UNDERPAID....THINK ABOUT THAT FOR A MINUTE... THAT'S NOT

THE WAY IT USUALLY WORKS.

PLACES THAT ARE OVERCROWDED USUALLY AREN'T RUNNING

OUT OF MONEY.

MANY OF THE PEOPLE WHO FLOCK TO EMERGENCY ROOMS

SIMPLY HAVE NO MONEY AND NO INSURANCE.

25
er
AND THOSE THAT ARE POOR ENOUGH TO QUALIFY FOR
MEDICAID OR OLD ENOUGH TO QUALIFY FOR MEDICARE POSE A
FINANCIAL PROBLEM FOR THE HOSPITAL BECAUSE THE
MEDICARE/MEDICAID PROSPECTIVE PAYMENT SYSTEMS DO NOT
USUALLY COVER THE HIGH COST OF EMERGENCY ROOM
MEDICINE.
THIS TEMPTS HOSPITAL ADMINISTRATORS TO CLOSE DOWN
THEIR EMERGENCY ROOMS, FORCING AREA RESIDENTS TO TAKE
LONGER AMBULANCE RIDES, AND PERHAPS LEADING TO

UNWARRANTED DEATHS FOR RICH AND POOR ALIKE.

26
er
THERE IS A ROUGH AND UNFORTUNATE DEMOCRATIC EQUALITY
IN OVERCROWDED EMERGENCY ROOMS.
EVERYBODY GETS TREATED ALIKE.
IT DOESN'T MATTER IF YOU HAVE YOUR OWN INSURANCE,
MEDICARE, MEDICAID.... EVERY ONE GETS TREATED THE SAME IN

THE EMERGENCY ROOM: YOU WAIT YOUR TURN.

27
Tove A
pectot)

er
Many AMERICANS ON MEDICARE, ESPECIALLY MIDDLE CLASS
AMERICANS, MAYBE SOME OF YOU HERE-- THINK THAT THEY
HAVE THE SECURITY OF BEING ASSURED HOSPITAL CARE IF THEY
SUDDENLY NEED IT.
IN MANY PLACES THAT IS SIMPLY NOT TRUE.
IF THEY COME TO THE EMERGENCY ROOM, THEY WAIT ON
STRETCHERS OR CHAIRS, SOMETIMES FOR DAYS, JUST LIKE

EVERYONE ELSE, JUST LIKE THOSE WHO ARE UNINSURED.

28
er
SOMETIMES PEOPLE WAITING IN AN EMERGENCY ROOM FOR A
BED TO OPEN UP, EVEN PEOPLE WHO HAVE HAD HEART ATTACKS,
GET SO FRUSTRATED AND RESTLESS THAT THEY JUST LEAVE,
AFTER 24 OR EVEN 48 HOURS OF WAITING.
THEY'D RATHER GO HOME, RISKING SUDDEN DEATH, THAN

TOLERATE THE TERRIBLE ATMOSPHERE OF AN OVER-CROWDED

EMERGENCY ROOM.

29
er
EMERGENCY ROOM HEALTH PERSONNEL, THE WOMEN AND MEN
WHO ARE THE SOLDIERS ON THE FRONT LINES OF AMERICAN
HEALTHCARE, BECOME OVERWHELMED, NOT JUST WITH THEIR
ENDLESS WORK, BUT WITH FRUSTRATION AND DISILLUSION.
THEY KNOW THEY CAN'T DO FOR EACH PATIENT WHAT THEY
SHOULD DO, AND EACH DAY MANY OF THEM WONDER IF THEY
SHOULD GET OUT, CHANGE CAREERS BEFORE IT'S TOO LATE.
ALL OF US SUFFER WHEN THESE PEOPLE ARE DRIVEN TO

QUESTION THEIR CALLING.

30
er
LET'S FACE THE UNHAPPY FACTS.
RATIONING HAS COME TO AMERICAN HEALTHCARE IN
OVERCROWDED EMERGENCY ROOMS.
RATIONING HAS COME AS A MATTER OF COURSE, WITHOUT ANY
GREAT PHILOSOPHICAL DEBATE, WITHOUT ANYONE REALLY

WANTING IT.

JVFEF STE 7 Fu
My cet Trg -
BEtnv?°

aporic EV7TY
| Fi jt av WAws

31
OF COURSE, ONCE A PATIENT FINALLY MAKES IT FROM THE
EMERGENCY ROOM TO THE RELATIVE COMFORT OF A HOSPITAL
BED, THE PROBLEMS AREN'T OVER.

MANY PATIENTS SUDDENLY ADMITTED TO A HOSPITAL LIE IN
THEIR BEDS, FRIGHTENED BY TERRIBLE QUESTIONS..... NOT

ONLY "WILL I RECOVER?’,

32
ALSO
BUT “HOW WILL I PAY FOR THIS?" "WILL MY INSURANCE PAY FOR

THIS? WILL MY ILLNESS COST ME MY SAVINGS, MY HOUSE?"

THE AMERICAN PATCHWORK HEALTH INSURANCE SYSTEM
DEFIES EASY DESCRIPTION, AND EVEN MORE DEFIES EASY
CORRECTION OF ITS MANY PROBLEMS. BUT WE MUST

CONFRONT THESE PROBLEMS HEAD-ON, AND WE MUST DO IT

NOW.

33
OUR HIGH-TECH MEDICINE SAVES MANY LIVES, BUT HIGH TECH
MEDICINE IS ALSO HIGH-COST MEDICINE.

EVERYONE COMPLAINS ABOUT THE SOARING COST OF
HEALTHCARE IN THE UNITED STATES. YOU AND I HEAR A LOT
ABOUT THE FEDERAL DEFICIT. BUT LAST YEAR ALONE WE SPENT
MORE THAN FIVE TIMES THE FEDERAL DEFICIT ON HEALTH CARE
IN THIS COUNTRY...$661 BILLION... MORE THAN WE SPENT ON

EDUCATION AND DEFENSE COMBINED,

34
HEALTHCARE EXPENDITURES AMOUNTED TO OVER 11 PERCENT
OF THE GROSS NATIONAL PRODUCT. IN 1960 HEALTHCARE
SPENDING TOOK ONLY 5.3 PERCENT OF THE GNP.

NOW, I DON'T THINK THAT THERE IS ANY PERCENTAGE OF OUR
GNP THAT IS A MAGIC NUMBER.

MAYBE IT IS APPROPRIATE TO SPEND 14% ON HEALTH CARE.

 

BUT WHATEVER WE SPEND, WE WANT TO SPEND IT ON

HEALTHCARE, NOT ON RUNAWAY COSTS.

35
PART OF THE REASON FOR RUNAWAY COSTS IS INFLATION.
INFLATION IN THE COST OF HEALTH AND MEDICAL CARE
CONSISTENTLY RUNS AT TWICE THE RATE OF INFLATION FOR
THE ECONOMY IN GENERAL.

YET, THERE'S NOT A SHRED OF EVIDENCE TO PROVE THAT THE

QUALITY OF CARE IS IMPROVING AT THE SAME RATE.

36
(Patents

ty I fo Te

rey SP UDA x
rO A HOSPITAL OR A DOCTOR RECENTLY, YOU'LL

PROBABLY AGREE THAT HOSPITAL CARE AND PHYSICIAN CARE
AREN'T TWICE AS GOOD AS THEY WERE EIGHT OR NINE YEARS
AGO, EVEN THOUGH NOW THEY COST ABOUT TWICE AS MUCH.

I CAN TELL YOU THAT MANY OF MY FRIENDS AND COLLEAGUES
IN MEDICAL PRACTICE ARE TRYING TO DO WHAT THEY CAN TO
INCREASE THE QUALITY OF CARE THEY DELIVER WITHOUT

INCREASING THEIR COSTS.

37
BUT THEY ARGUE THAT THEY HAVE LITTLE OR NO CONTROL

OVER SOME OF THE INFLATIONARY THINGS THEY DO.

AND THAT'S TRUE.

I'VE BEEN THERE -- SO IT'S NOT JUST GIVING THEM THE BENEFIT

OF THE DOUBT.

38
BUT THE FACT STILL REMAINS THAT PHYSICIAN FEES ARE GOING
UP, AND THEY DO ADD TO A BURDEN ON THE PUBLIC THAT IS

BECOMING INSUPPORTABLE.

AND, AGAIN -- AS WITH HOSPITAL-BASED CARE -- THE AMERICAN
PEOPLE HAVE NOT BEEN ASSURED, IN ANY RATIONAL AND
MEASURABLE WAY,

THAT THE HIGHER COSTS OF A PHYSICIAN'S CARE WILL IN FACT
BUY THEM A PROPORTIONATELY HIGHER QUALITY OF SUCH

CARE.

39
WE SEEM TO HAVE, THEREFORE, A SYSTEM OF HEALTH CARE
THAT'S DISTINGUISHED BY A VIRTUAL ABSENCE OF SELF-
REGULATION ON THE PART OF THE PROVIDERS OF THAT HEALTH
CARE -- THAT IS, HOSPITALS AND PHYSICIANS -- AND
DISTINGUISHED AS WELL BY THE ABSENCE OF SUCH NATURAL
MARKETPLACE CONTROLS AS COMPETITION IN REGARD TO

PRICE, QUALITY, OR SERVICE.

40
I SAY THERE'S SOMETHING TERRIBLY WRONG WITH A SYSTEM OF

HEALTH CARE THAT SPENDS MORE AND MORE MONEY TO SERVE

FEWER AND FEWER PEOPLE.

IN THE PAST MOST AMERICANS TURNED CONFIDENTLY TO THEIR

INSURANCE TO PAY THE HEALTHCARE BILL. BUT THOSE DAYS

ARE OVER.

41
WE HAVE THREE GROUPS IN THIS COUNTRY:

THE INSURED, THE UNINSURED, AND THE UNINSURABLE.

THE LARGEST GROUP, FORTUNATELY, IS THE 160 MILLION
AMERICANS WHOSE HEALTH INSURANCE IS PROVIDED THROUGH
EMPLOYERS -THEIR OWN OR FAMILY MEMBERS--, AND THE

SMALL FRACTION WHO PURCHASE THEIR OWN INSURANCE.

42
THESE PEOPLE USUALLY ENJOY ACCESS TO THE BEST MEDICINE
IN THE WORLD, AS LONG AS THEIR INSURANCE HOLDS OUT, OR

THEIR PREMIUMS ARE NOT RAISED BEYOND REACH.

BUT EACH YEAR THESE PRIVATELY INSURED AMERICANS SEEM

TO BE PAYING MORE AND MORE FOR INSURANCE THAT BUYS

THEM LESS AND LESS IN HEALTHCARE.

43
EMPLOYERS NOW ASK EMPLOYEES TO ASSUME MORE OF THE
COST OF HEALTHCARE, THROUGH HIGHER DEDUCTIBLES AND

CO-PAYMENT, OR GIVE UP CERTAIN SERVICES.

THEN EMPLOYEES DIG IN THEIR HEELS AND SAY. "NO!"

44
HEALTH BENEFITS WERE THE MAJOR REASON FOR 78 PERCENT
OF THE WORKING MEN AND WOMEN WHO WENT OUT ON STRIKE
LAST YEAR...PRODUCTION WORKERS AND MINERS AND PUBLIC
EMPLOYEES AND TELEPHONE WORKERS AND SERVICE WORKERS
AND SO ON.

EVERY ONE OF THOSE STRIKERS FELT THE PRESSURE IN THEIR
FAMILIES AND IN THEIR HOMES. THEY ASKED FOR MORE —
MONEY IN HEALTH BENEFTTS...AND MANAGEMENT SAID IT
COULDN'T AFFORD TO PAY IT.

AND THEY CAN'T.

45
THE ISSUE THAT SENT PEOPLE TO THE PICKET LINES WAS NOT
WAGES. IT WASN'T JOB SECURITY. IT WASN'T JOB SAFETY. IT
WAS NOT ANY OF THOSE THINGS.

IT WAS THE COST OF HEALTH CARE.

AND FOR MOST OF THOSE WORKERS, IT WAS NOT FANCY HEALTH

CARE EITHER.

46
AND WHAT IS THE OUTCOME, WHEN THOSE STRIKES ARE
SETTLED AND OVER? I'LL TELL YOU WHAT HAPPENS.

MORE MONEY DOES GO INTO EMPLOYEE HEALTH BENEFITS, AND
THOSE INCREASED COSTS ARE EXPRESSED IN THE MARKETPLACE
AS HIGHER PRICES FOR THE GOODS WE PURCHASE AND OUR

UTILITIES.

47
IN OTHER WORDS, OUR VAST SYSTEM OF HEALTH INSURANCE
AND EMPLOYEE HEALTH BENEFIT PLANS HAS BECOME LITTLE
MORE THAN A "PASS-ALONG" MECHANISM BY WHICH
DOLLARS--TAKEN FROM THE AMERICAN PEOPLE IN THE OPEN
MARKETPLACE--ARE PASSED ALONG AND PUT INTO THE POCKETS

AND THE TREASURIES OF OUR RAVENOUS HEALTHCARE SYSTEM.

48
SINCE 1984 THE AVERAGE PREMIUMS FOR EMPLOYER-PROVIDED

HEALTH INSURANCE HAVE APPROXIMATELY DOUBLED... TO $3,117

IN 1989,

AND HAVE RISEN FROM 8 PERCENT OF BUSINESS PAYROLL COSTS

TO 13.6 PERCENT LAST YEAR.

BUSINESSES CAN'T ABSORB THESE COSTS AND ALSO EXPECT TO

BE COMPETITIVE.

49
AND TELL ME, WHAT'S THE POINT OF BEING TOUGH ON TRADE
WITH THE JAPANESE, FOR EXAMPLE, WHEN RIGHT HERE AT
HOME WE MEEKLY GIVE OUR HEALTH PLANS THE 10
PERCENT...THE 12 PERCENT...OR THE 15 PERCENT ANNUAL

INCREASE THEY DEMAND.

50
THE TWO THIRDS OF OUR POPULATION COVERED BY EMPLOYER-
PURCHASED HEALTH INSURANCE ARE THE PEOPLE WHO HAVE
THE MOST CLOUT TO CHANGE THINGS FOR THE BETTER.

MANY OF YOU MAY BE AMONG THEM.

YOU ARE PART OF THE INSURED GROUP WHO CAN FORCE THE

REFORMS WE NEED.

51
BUT FIRST THESE PEOPLE MUST IDENTIFY THE LEADERSHIP TO

BRING HEALTHCARE COST UNDER CONTROL.
IT IS NOT THE PRESENT LEADERSHIP.

THEY ARE THE ONES WHO GOT US INTO OUR CURRENT

PROBLEMS OF PROFLIGACY AND POOR CARE.

52
NOT LONG AGO A COALITION OF BIG BUSINESS AND LABOR

UNIONS FORMED TO ADDRESS THIS PROBLEM.

I THINK THAT THIS IS THE WRONG COALITION.

THE COALITION THAT NEEDS TO BE FORMED COMBINES

BUSINESS AND ORGANIZED HEALTH CARE.

53
TOGETHER THEY CAN FORGE THE ALLIANCE THAT REWARDS
HIGH QUALITY AND HIGH EFFICIENCY WITH MORE PATIENTS, ~
RATHER THAN REWARDING POOR QUALITY CARE WITH DOLLARS

AS WE DO NOW.

AND UNTIL THE PURCHASING PUBLIC "BUYS RIGHT" THE

SITUATION WILL NOT CHANGE.

54
THEN THERE ARE THE INSURED AMERICANS WHO RELY UPON
GOVERNMENT INSURANCE --MEDICARE FOR THE ELDERLY,

MEDICAID FOR THE POOR-- TO MEET THEIR HEALTHCARE BILLS.

BUT THESE INSURANCE PLANS NO LONGER FILL THE BILL.

55
THE GRAYING OF AMERICA CARRIES A PRICE TAG... AS MEDICARE
COSTS WILL DOUBLE BY 2020.

FIVE YEARS AGO AMERICA'S 1.3 MILLION NURSING HOME
RESIDENTS COST US $31 BILLION; BY 2040, AS THE BABY BOOMERS
REACH THEIR 70S AND 80S, 6 MILLION NURSING HOME
RESIDENTS WILL COST $139 BILLION. HIP FRACTURE COSTS --IF
UNCHECKED BY PREVENTION-- COULD GO FROM OUR CURRENT

$1.6 BILLION ANNUALLY TO $6 BILLION IN 2040.

56
THE DEMOGRAPHIC TRENDS ARE RUNNING AGAINST US AS WE

ATTEMPT TO MEET THESE COSTS.

TODAY, FOR EXAMPLE, FOR EACH PERSON WHO IS OVER THE AGE
OF 65, THERE ARE 5 YOUNGER, TAX-PAYING WAGE-EARNERS TO

PAY FOR THAT ONE PERSON'S MEDICARE COVERAGE.

DEMECHALAY

57
IN ANOTHER 20 YEARS, HOWEVER, FOR EACH PERSON OVER THE
AGE OF 65, THERE WILL BE ONLY 3 YOUNGER, TAX-PAYING WAGE-
EARNERS CONTRIBUTING TO MEDICARE.

THAT MEANS THAT IN A CLIMATE OF SCARCITY, AMERICANS WILL
HAVE TO WORK OUT AN EQUITABLE SHARING OF NEEDED
MEDICAL RESOURCES BETWEEN ONE POPULATION GROUP THAT
IS GROWING -- THAT IS, THE ELDERLY, PEOPLE OVER THE AGE OF
65 -- AND THE POPULATION GROUP THAT IS COMPARATIVELY

SHRINKING -- THAT IS, CHILDREN UNDER THE AGE OF 18.

58
OVER THE YEARS I'VE DEALT WITH ADVOCATES FOR CHILDREN
AND I'VE DEALT WITH ADVOCATES FOR THE ELDERLY. THEY ARE
BOTH VERY DEDICATED AND VERY PERSUASIVE GROUPS. AND
BOTH WILL BE QUITE RIGHTLY COMPETING FOR A LARGER PIECE

OF A SMALLER PIE.
THIS HAS CHILLING ETHICAL IMPLICATIONS, AND WE MAKE SURE

THAT OUR ECONOMICS BE DETERMINED BY OUR ETHICS, AND

NOT THE OTHER WAY AROUND.

59
MEDICARE IS NOT WHAT MOST PEOPLE THINK.

IT IS NOT A SYSTEM THAT PROVIDES FOR THE HEALTHCARE
COSTS OF THE ELDERLY.

THERE ARE MANY HOLES IN MEDICARE.

OLDER AMERICAN CITIZENS MUST FIRST MUST SPEND THEIR
OWN MONEY BEFORE MEDICARE KICKS IN.

MEDICARE USUALLY DOESN'T PROVIDE THE DRUGS MANY

ELDERLY NEED TO STAY ALIVE.

60
MOST CRITICAL, MEDICARE MAKES NO PROVISION FOR LONG-
TERM CARE IN HOSPITALS OR NURSING HOMES.

ELDERLY PEOPLE AND THEIR GROWN CHILDREN ARE OFTEN
SHOCKED WHEN THEY DISCOVER THAT WHEN THE AGING
PARENT NEEDS NURSING HOME CARE, IT IS NOT COVERED BY

MEDICARE.

61
FURTHERMORE, THERE IS NO PROVISION IN MEDICARE FOR THE
HOUSEHOLD HELPS THAT WOULD KEEP ELDERLY PEOPLE FROM
NEEDING A NURSING HOME,.LIKE SOMEONE STOPPING BY ONCE
A DAY TO SPEND AN HOUR ON THE HEALTH AND HOUSEHOLD
CHORES THAT NEED TO BE ACCOMPLISHED TO KEEP THAT

PERSON OUT OF AN INSTITUTION.

62
THEN THERE IS MEDICAID, THE FEDERAL INSURANCE PROGRAM

DESIGNED FOR THE POOR.
IF MEDICARE IS A DISAPPOINTMENT, MEDICAID IS A FRAUD.

MEDICAID IS A FRAUD BECAUSE MEDICAID EXCLUDES MOST OF

THE POOR.... BY CALLING THEM TOO RICH.

63
IT IS THE INDIVIDUAL STATES THAT ADMINISTER MEDICAID, AND
THE STATES CAN SET THE MAXIMUM INCOME LEVEL NEEDED TO
QUALIFY FOR MEDICAID.

THIS HAS LED TO SHAMEFUL STANDARDS.

IN TEXAS, FOR INSTANCE, A FAMILY OF THREE WITH AN INCOME

OF $3000 A YEAR IS TOO RICH TO QUALIFY FOR MEDICAID.

64
IN KENTUCKY THEY GO ALL THE WAY UP TO $3200 A YEAR FOR A

FAMILY OF THREE BEFORE YOU ARE TOO RICH FOR MEDICAID.

WHOM DO THEY THINK THEY ARE KIDDING?

65
MEDICAID ALSO ALLOWS TERRIBLE DISPARITIES BETWEEN STATE
SYSTEMS OF COVERAGE AND PAYMENT.

A PATIENT QUALIFYING FOR AN ORGAN TRANSPLANT IN ONE
STATE MIGHT NOT RECEIVE EVEN BASIC MEDICAL SERVICES AS

RESIDENT OF ADJOINING STATE.

MEDICAID NEEDS TO BE STANDARDIZED, EXPANDED AND
REFORMED.
MEDICAID NEEDS TO EMBRACE FAMILIES RATHER THAN

EXCLUDE THEM.

66
THEN THERE ARE THE UNINSURED, THE 12 TO 15 PERCENT OF
OUR POPULATION --THAT'S 33 TO 37 MILLION AMERICANS-- WHO
ARE UNINSURED, UNDER-INSURED, OR ONLY SEASONALLY

INSURED.

THEY'RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR

ENOUGH FOR MEDICAID.

67
THESE ARE NOT PEOPLE ON WELFARE.

CONTRARY TO THE WHINING OF SOME CONSERVATIVE
COLUMNISTS, THESE PEOPLE ARE NOT LOOKING FOR A
HANDOUT. |

90 PERCENT OF THE UNINSURED ARE WORKING PEOPLE, MANY
WORKING AT SEVERAL JOBS, NONE OF WHICH PROVIDES A

HEALTH PLAN.

68
RECENTLY RELEASED FIGURES INDICATE THAT ONE OUT OF
EVERY EIGHT AMERICANS FALLS INTO THIS CATEGORY OF THE
UNINSURED.

FOR BLACKS, THE FIGURES ARE WORSE, WITH ONE OUT OF FIVE
BLACKS UNINSURED. AND IN THE HISPANIC POPULATION, ONE
OUT OF EVERY FOUR PERSONS HAS NO HEALTH INSURANCE.
WHAT, THEN, DOES THIS "HEALTH CARE SYSTEM" OF OURS DO

FOR THE UNINSURED?

69
AS YOU KNOW, IN THE VAST MAJORITY OF CASES THE ANSWER IS
.. VERY LITTLE ... OR NOTHING. AND THEY ARE SUFFERING THE
CONSEQUENCES. STUDY AFTER STUDY INDICATES THE
CORRELATION BETWEEN NO MEDICAL INSURANCE AND SERIOUS

HEALTH PROBLEMS.
AND ALL OF US WILL SUFFER THE CONSEQUENCES TOO, BECAUSE

THE HEALTH PROBLEMS OF THE UNINSURED, IF IGNORED BY

SOCIETY NOW, WILL BE BORNE BY SOCIETY LATER.

70
FINALLY, AND TRAGICALLY, ARE THE UNINSURABLE: THE TWO
AND A HALF MILLION AMERICANS WITH SERIOUS MEDICAL
PROBLEMS WHO CAN'T EVEN BUY INSURANCE BECAUSE THEY ARE
CONSIDERED TO BE BAD RISKS.

AND NOW, WITH INCREASING FREQUENCY, SOME PATIENTS HAVE
THEIR INSURANCE PREMIUMS RAISED OUT OF SIGHT RIGHT IN

THE MIDDLE OF A SERIOUS ILLNESS.

71
IN JUST ONE OF MANY FAMILIES LIKE THIS THAT I KNOW, A BABY
WAS BORN WITH A HEART DEFECT REQUIRING FREQUENT
MEDICAL ATTENTION. BY THE TIME THE YOUNGSTER WAS TWO
YEARS OLD, THE FAMILY HEALTH INSURANCE PREMIUMS HAD
GONE FROM $198 A MONTH TO $1375 A MONTH, A SIX-FOLD

INCREASE.

HOW MANY OF YOU COULD AFFORD THAT KIND OF A JUMP?

72
THEY THOUGHT IT MUST BE A COMPUTER ERROR, BUT WERE
TOLD COLDLY BY THE INSURANCE COMPANY THAT IF THEY
DIDN'T LIKE IT, THEY COULD CANCEL THEIR INSURANCE.
HOWEVER, NO OTHER COMPANY WOULD INSURE THEM BECAUSE

THEIR YOUNGSTER HAD A "PRE-EXISTING CONDITION."

73
OTHER AFFLICTED AMERICANS WHO THOUGHT THEY WERE
COVERED BY INSURANCE SUDDENLY DISCOVERED THAT THEIR
INSURANCE COMPANIES WERE SIMPLY NOT PAYING THE BILLS.
IN CALIFORNIA ALONE, 100,000 PEOPLE LOST THEIR INSURANCE
IN 1989 BECAUSE THEIR INSURANCE COMPANIES HAVE GONE
UNDER.

SOME OF THESE PEOPLE HAD ALREADY PAID AS MUCH AS $200,000

IN PREMIUMS OVER THE YEARS.

74
YOU HEAR SOME PEOPLE TALKING ABOUT "CLOSING THE GAP"
BETWEEN THE HIGHLY INSURED AND THE UNINSURED. THAT
CONJURES UP AN IMAGE OF THE TWO MOVING TOGETHER.
THAT IS UNLIKELY.

THERE WILL ALWAYS BE SOME PEOPLE WHO CAN AFFORD A
CERTAIN DEGREE BEYOND THE NORMAL STANDARD. THEY

AREN'T ABOUT TO GIVE IT UP.

75
INSTEAD, WE NEED TO TALK ABOUT BASIC RIGHTS TO INSURANCE
FOR HEALTHCARE FOR ALL OUR CITIZENS, AND PROVIDE THAT
FOR THOSE UNCOVERED.

THESE PEOPLE ARE NOT LOOKING FOR A HANDOUT, BUT FOR AN
INSURANCE POLICY THEY CAN AFFORD, ONE THAT WILL NOT LET
THEM DOWN WHEN THEY NEED IT. Bare ioe

Te H tebe Fel

crt ¥
Mow 17 caw
BF er etle?

76
pov » 57
WE WILL NEVER REALLY SOLVE OUR HEALTHCARE PROBLEMS
AND OUR INSURANCE PROBLEMS UNTIL WE DEAL WITH A DEEPER

CAUSE.

AMERICAN HEALTH PROBLEMS STEM FROM DISEASE NOT ONLY
OF THE BODY, BUT ALSO OF SOCIETY, ESPECIALLY THE DISEASE

OF POVERTY.

Pov eATy

63 ps5?
si2 Mi

77
pov
POVERTY LIES AT THE ROOT OF MOST OF OUR PUBLIC HEALTH
PROBLEMS: DRUG ABUSE, AIDS, ALCOHOL ABUSE, MALNUTRITION,
SMOKING, COMMUNICABLE DISEASES.

THE EFFECTS OF POVERTY ON HEALTH CAN LINGER FOR A LONG

TIME.

78
pov
A RECENT STUDY FOUND THAT MIDDLE CLASS BLACKS WITH A
COLLEGE EDUCATION WERE TWICE AS LIKELY TO DELIVER LOW
BIRTHWEIGHT BABIES THAN WHITES OF SIMILAR EDUCATION
AND INCOME. THE RESEARCHERS CAME TO THE SOBERING
CONCLUSION THAT THE EFFECTS OF POVERTY AS

DEMONSTRATED IN LOW BIRTH WEIGHT CAN LAST FOR

GENERATIONS.

79
pov
ONE IN THREE URBAN KIDS LIVES IN POVERTY, AND EVERY DAY
IN AMERICA 100 CHILDREN DIE BEFORE THEIR FIRST BIRTHDAY.
IN HARLEM THE INFANT MORTALITY RATE IS WORSE THAN IN

PLACES IN THE THIRD WORLD.

80
pov
A STAGGERING 1 IN 5 BABIES HAS BEEN EXPOSED TO DRUGS IN
THE WOMB, AND 5% TEST POSITIVE FOR AIDS. 400,000 DRUG-
EXPOSED BABIES ARE BORN EACH YEAR, CROWDING NEONATAL
UNITS, COSTING US OVER $4 BILLION ANNUALLY.

OVERCROWDED PUBLIC CLINICS IN THE INNER CITY KEEP SICK
PEOPLE WAITING AN AVERAGE OF 68 DAYS FOR AN

APPOINTMENT.

AND OFTEN BY THE TIME THEY FINALLY SEE A DOCTOR, THEY

ARE SO SICK THEY REQUIRE COSTLY HOSPITALIZATION.

81
AS WELL AS URBAN AMERICA.

RURAL PATIENTS RECEIVE NO CARE; RURAL HOSPITALS RECEIVE

NO REVENUE.
IN RURAL AREAS FROM TENNESSEE TO TEXAS, HOSPITALS ARE
CLOSING THEIR DOORS AND DOCTORS ARE ABANDONING THEIR

PRACTICES.

82
pov
THE NATIONAL HEALTH SERVICE CORPS, A FEDERAL PROGRAM
TO PLACE DOCTORS IN RURAL AREAS UNDERSERVED BY
PHY. SICIANS, HAD ITS BUDGET SLASHED BY MORE THAN $72
MILLION, AND THE NUMBER OF PHYSICIANS IT SUPPORTED IN
RURAL AMERICA DROPPED FROM 1600 TO 120. THE FEW PUBLIC
CLINICS THAT REMAIN ARE OVERBURDENED AND OFTEN DISTANT

FROM THE PEOPLE WHO NEED THEM.

83
pov
SO, PREGNANT WOMEN GO WITHOUT SEEING A DOCTOR,
CHILDREN GO WITHOUT IMMUNIZATION, AND IN APPALACHIA
PREVENTABLE DISEASES LIKE MEASLES RUN RAMPANT BECAUSE
FAMILIES DON'T HAVE ACCESS TO IMMUNIZATION. THIS IS A

SCANDAL.

84
pov
IN & OUR STRANGE, SHAMEFUL SOCIETY --AN AFFLUENT SOCIETY
WITH TERRIBLE POVERTY-- THE PRACTICE OF MEDICINE HAS
BECOME COMPLICATED.
IT INVOLVES NOT ONLY DIAGNOSIS AND TREATMENT, BUT ALSO
THE RELATIONSHIP BETWEEN HEALTH AND SOCIO-ECONOMIC
FACTORS.
INCREASINGLY, PEOPLE LOOK TO MEDICINE TO SOLVE THESE
DEEPER PROBLEMS, PROBLEMS THAT ARE BEYOND THE ABILITY

OF MEDICINE OR DOCTORS TO SOLVE.

85
pov
DOCTORS CANNOT ELIMINATE THE POVERTY FROM WHICH

PATIENTS COME;

HEALTHCARE WORKERS CANNOT BRING BACK THE HUSBAND AND
FATHER WHO HAS DESERTED THE WIFE AND CHILDREN.
DOCTORS CANNOT KEEP THEIR PATIENTS OFF DRUGS ONCE THEY

LEAVE THE HOSPITAL.

86
pov
MANY PHYSICIANS HAVE TOLD ME OF THEIR FRUSTRATION WHEN
THEY RELEASE PATIENTS --WHOSE LIVES THEY HAVE JUST SAVED-
- WITH IMPORTANT IN STRUCTION S TO STOP USING DRUGS, TO
STOP USING ALCOHOL, KNOWING FULL WELL THAT IN A MATTER
OF HOURS THEIR PATIENTS WILL BE RIGHT BACK TO THE
BEHAVIOR THAT SENT THEM TO THE HOSPITAL IN THE FIRST

PLACE.

87
pov
TRAGICALLY, IT IS THE CHILDREN OF POVERTY WHOSE HEALTH

SUFFERS THE MOST.

OUR CHILDREN TODAY ARE A GENERATION AT RISK.
FOR THE FORGOTTEN CHILDREN OF THE INNER CITY AND RURAL
AMERICA, WE NEED TO GUARANTEE ACCESS TO HEALTH CARE

WITH ENOUGH HOSPITAL BEDS AND DOCTORS.

88
pov
WE NEED NEIGHBORHOOD CLINICS THAT PROVIDE PATIENTS
WITH THE KNOWLEDGE THEY NEED, AND TREAT THEM WITH

DIGNITY, SO PREVENTIVE AND PRENATAL CARE TAKE PLACE.

WE NEED TO FREE OUR SOCIETY OF POVERTY, SO THAT ALL
YOUNGSTERS, CAN LIVE TO BECOME THRIVING, HEALTHY,
PRODUCTIVE AMERICANS, A GENERATION NOT AT RISK, BUT OF

PROMISE.

89
THE DISRUPTION TO SOCIETY CAUSED BY THE ESCALATING COST
OF HEALTH CARE IS SIMPLY UNCONSCIONABLE.

THOUSANDS AND THOUSANDS OF AMERICAN FAMILIES EACH
YEAR ARE LITERALLY IMPOVERISHED BY THE AMERICAN HEALTH
CARE SYSTEM.

WE CANNOT LET THAT CONTINUE.

WE ARE FRUSTRATED BECAUSE OUR HEALTH DOLLARS DON'T
SEEM TO BE GOING FOR OUR HEALTH.

PEOPLE FUME WHEN THEY READ THAT HEALTHCARE
ADMINISTRATION NOW CONSUMES ABOUT 22% OF HEALTHCARE

SPENDING.

90
OUR CURRENT INSURANCE STRUCTURE OFTEN OPERATES LIKE A
SHELL GAME, A NATIONAL DISGRACE.

DOCTOR'S OFFICES OFTEN SPEND MORE TIME ON THE
INSURANCE FORMS THAN THE DOCTOR SPENT WITH THE

PATIENT.
EVEN THE INSURANCE INDUSTRY ITSELF HAS BEGUN TO CALL

FOR REGULATION AND REFORM.

91
eee SHOULD BE REQUIRED TO PROVIDE HEALTH

UT

IN SURANCE, WITH APPROPRIATE COST-SHARING, HEALTH
EDUCATION, AND FITNESS PROGRAMS. THE ECONOMIC IMPACT
ON SMALL BUSINESS CAN AND MUST BE LESSENED BY TAX
BREAKS AND RISK-POOLING.

OTHERWISE SMALL EMPLOYERS JUST DROP SOME EMPLOYEES

FROM THE PAYROLL.

92
SOME OF THE STATES ARE WAY AHEAD OF THE FEDERAL
GOVERNMENT IN DEALING WITH THE INSURANCE CRISIS.
MASSACHUSETTS HAS INITIATED A PLAN REQUIRING EMPLOYERS
TO CHOOSE BETWEEN PROVIDING EMPLOYEE INSURANCE

COVERAGE OR PAYING A TAX TO PROVIDE IT.

93
IN HAWAII, THE ONLY STATE REQUIRING EMPLOYERS TO
PROVIDE HEALTHCARE INSURANCE, 95 PERCENT OF THE STATE'S
POPULATION HAS INSURED ACCESS TO HEALTHCARE.
CONSEQUENTLY, PREVENTIVE MEDICINE AND TIMELY

TREATMENT HAVE BROUGHT HEALTH INSURANCE PREMIUMS TO

DewW FO

W etl BELOW NATIONAL AVERAGE.

CACAT EIT 477 E FHKE ECT HCL — PHOCHP Ly

TH EC HAVE
ie COvVCTIY OY

Pvt ZH EL
snewn 8 192, | M@sOea7 HAG 6.4-F-

C7 Mek A/D FCIME

TH EY

94
THOSE NOT INCLUDED IN EMPLOYER-PROVIDED INSURANCE
SHOULD BE ABLE TO HAVE ACCESS TO SIMILAR COVERAGE
ACCORDING TO SLIDING SCALE COST-SHARING AND RISK-
POOLING.

WE NEED TO EXPECT SOME FORMS OF TAX INCREASE IF WE ARE
TO ACT ACCORDING TO OUR ETHICS, AND PROVIDE HEALTH

INSURANCE FOR THOSE NOW UNINSURED.

95
WE CAN LOWER BOTH HEALTHCARE COST AND INSURANCE COST
BY LINKING INSURANCE COVERAGE TO BEHAVIOR.

IT MAKES SENSE TO VOID OR REDUCE INSURANCE COVERAGE
FOR PEOPLE WHO PRACTICE HIGH RISK BEHAVIOR: NOT
WEARING MOTORCYCLE HELMETS, NOT BUCKLING SEATBELTS,

DRIVING AFTER DRINKING, AND YES, CONTINUING TO SMOKE.

96
WHY SHOULD THE REST OF US SUBSIDIZE THE INSURANCE

COVERAGE OF PEOPLE WHO KNOWINGLY AND CONTINUALLY

PLACE THEMSELVES AT GREATER RISK FOR ILLNESS?

EVEN HIGHER TOBACCO AND ALCOHOL TAXES SHOULD BE

DEMANDED TO PAY FOR HEALTHCARE COSTS ATTRIBUTED TO

THOSE DEADLY SUBSTANCES.

97
ON THE POSITIVE SIDE, WE NEED INSURANCE PROGRAMS THAT
ENCOURAGE PREVENTIVE HEALTHCARE.

IT IS ABSURD FOR INSURANCE TO COUGH UP $150,000 TO REMOVE
A CANCEROUS LUNG, BUT NOT PAY $64 OR $200 FOR A SMOKING

CESSATION PROGRAM.

98
3rdp
NO ONE CAN DOUBT MY COMMITMENT TO CUTTING
HEALTHCARE COSTS, TO GETTING RID OF MISMANAGEMENT,
WASTE, AND FRAUD.
BUT I AM DEEPLY DISTURBED AND EVEN FRIGHTENED WHEN
THIS IS ATTEMPTED BY MISGUIDED INTERFERENCE IN THE

DOCTOR-PATIENT RELATIONSHIP.

Su fF pin t¥

“ ea
] petedesra rf

LOG)
S mia

99
3rdp
WHEN YOU GO TO SEE YOUR DOCTOR, YOU MAY THINK THAT
THERE ARE ONLY TWO OF YOU IN THE ROOM.
BUT YOU ARE MISTAKEN.
THERE ARE OTHER DOCTORS AND NURSES, UNSEEN, BUT SPYING

ON YOU, REALLY FUNCTIONING AS CLERKS FROM A DISTANCE.

100
3rdp

IN AN ATTEMPT TO CONTROL MEDICARE COSTS, THE FEDERAL

HAS DoNE WHAT PRIUNTE WOVITET LEAS Daye Lett Fe 4dNO Time |
GOVERNMENT Hees HIRED PRIVATE FIRMS WHOSE JOB IT IS TO
SECOND-GUESS PHYSICIAN DECISIONS IN ORDER TO CUT COST.
IF YOU NEED LIFE-SAVING BRAIN SURGERY, YOUR BRAIN
SURGEON MAY FIND HIMSELF OR HERSELF ON THE PHONE TO A
DOCTOR --NOT A BRAIN SURGEON-- IN FRONT OF A COMPUTER
HUNDREDS OF MILES AWAY TRYING TO PERSUADE YOUR
SURGEON TO SAVE A FEW BUCKS BY SCHEDULING 10 HOUR BRAIN

SURGERY IN THE AFTERNOON, JUST SO THE PATIENT DOESN'T

STAY IN THE HOSPITAL THE NIGHT BEFORE THE PROCEDURE.

101
3rdp
MOST PHYSICIANS ARE TRAINED TO ADVOCATE THEIR PATIENTS
INTERESTS, AND THEY ARE BETTER AT CLINICAL DECISIONS
THAN ECONOMIC DECISIONS.
ALL TOO OFTEN THESE INTERFERING REGULATORS FORCE
DOCTORS TO FIGHT FOR WHAT IS BEST FOR THEIR PATIENTS, TO
SPEND TIME ON THE PHONE OR WRITING LETTERS, TIME THAT

WOULD BE BETTER SPENT WITH THEIR PATIENTS.

102
3rdp
THE HEALTH CARE FINANCING ADMINISTRATION, THE AGENCY IN
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES THAT
ADMINISTERS MEDICARE AND MEDICAID, SET UP A PROGRAM IN
GEORGIA THAT FORCES DOCTORS TO DEAL EACH DAY WITH
REVIEW AGENCIES THAT SEEM TO ASSUME EACH DOCTOR IS A
CROOK, THAT EACH RELATIONSHIP WITH A PATIENT IS

FRAUDULENT UNLESS PROVEN OTHERWISE.

103
3rdp
THE GOVERNMENT AGENCY WAS SO PLEASED BY THE HARASSING
ATTACKS UPON DOCTORS THAT THEY AWARDED THE HARASSERS
YET ANOTHER CONTRACT, THIS TIME HARASSING CIVILIAN
PHYSICIANS WHO GIVE MILITARY PERSONNEL MEDICAL CARE
UNAVAILABLE ON MILITARY BASES UNDER THE CHAMPUS |
PROGRAM.
IN SOME STATES INSURANCE REGULATORS CAN ADVANCE THEIR
OWN CAREERS ONLY BY LODGING FRAUDULENT CHARGES

AGAINST DEDICATED PHYSICIANS.

104
3rdp
NO ONE IS MORE DETERMINED THAN I AM TO RID MEDICINE OF
OVERCHARGING AND INCOMPETENT PRACTITIONERS, BUT THIS
CANNOT BE DONE BY REGULATORS HARASSING PHYSICIANS,
DESTROYING THE ESSENTIAL TRUST IN THE DOCTOR-PATIENT

RELATIONSHIP.

105
3rdp
COST CONTROL SHOULD NOT MEAN REMOTE CONTROL
MEDICINE.
I DON'T LIKE THE IDEA OF A DOCTOR THOUSANDS OF MILES

AWAY MAKING DECISIONS FOR PATIENTS HE DOESN'T KNOW.

I DON'T WANT TO SEE MEDICINE TURNED INTO A PUBLIC
UTILITY, OVER-REGULATED AND UNDER-RESPONSIVE TO THE
NEEDS OF INDIVIDUAL PATIENTS. WE MUST RESTORE THE

HEALING BOND OF TRUST BETWEEN DOCTOR AND PATIENT.

106
rtn
SOME STATES ARE ATTEMPTING TO DEAL WITH THE CRISIS IN
THE COST OF HEALTHCARE AND HEALTH INSURANCE THROUGH
DELIBERATE RATIONING OF HEALTHCARE.
WHILE MOST OF US DETEST THE VERY NOTION OF RATIONED
HEALTHCARE, SOME ADVOCATES ARE DEMANDING IT AS THE

WAVE OF THE FUTURE.

107
rtn

PERHAPS THE OREGON PLAN HAS RECEIVED THE MOST

ATTENTION.
THE OREGON LEGISLATURE RELEASED A PROPOSAL CALLING
FOR A PRIORITY LISTING OF THE MEDICAL DIAGNOSES FOR

WHICH MEDICAID WOULD FOOT THE BILL.

108
rtn
THE IDEA BEHIND THE RATIONING WAS TO REFUSE MEDICAID
EXPENDITURES FOR EXPENSIVE PROCEDURES LIKE ORGAN
TRANSPLANTS IN ORDER TO PROVIDE THE 400,000 OREGONIANS
WITHOUT MEDICAL INSURANCE A BASIC LEVEL OF MEDICAL
CARE, ESPECIALLY PRENATAL CARE, AND CHILDHOOD

IMMUNIZATIONS.

109
rtn

SO, THE COMPUTER RANKED 1,600 MEDICAL PROCEDURES ON A
COST/BENEFIT BASIS. THOSE AT THE BOTTOM OF THE LIST, LIKE
LIVER TRANSPLANTS, NO LONGER QUALIFIED FOR MEDICAID

COVERAGE.

IT DIDN'T TAKE LONG FOR THE COLD LOGIC OF THE PROPOSAL

TO PROVOKE A WARM-HEARTED HUMAN OUTCRY.

110
rtn
NOT EVERYONE AGREED WITH THE RANKINGS, MUCH LESS THE
ENTIRE CONCEPT OF RATIONING.
THE OREGON RANKING OF DIAGNOSES PLACED MANY AIDS-
RELATED ILLNESS AT THE BOTTOM OF THE LIST. THAT
PROBABLY CAME FROM EARLY DETERMINATION OF HIV AS
SHORT-TERM TERMINAL DISEASE. BUT INCREASINGLY AIDS IS
VIEWED AS A LONG-TERM ILLNESS, AND HIV PATIENTS SHOULD
NOT AUTOMATICALLY BE VIEWED AS MORE EXPENDABLE THAN

OTHER PERSONS WITH LONGTERM CHRONIC DISEASES.

111
rtn
WHEN PROPONENTS OF THE RATIONING PLAN ARGUED THAT
"COMMUNITY VALUES" MIGHT HELP SORT OUT THE RANKINGS IT
MADE MANY PEOPLE SHUDDER.
AFTER ALL, "COMMUNITY VALUES" BURNED DOWN THE HOUSE OF
THE LITTLE HEMOPHILIAC BOYS WITH AIDS IN ARCADIA,
FLORIDA, AND "COMMUNITY VALUES" DROVE RYAN WHITE FROM

KOKOMO, INDIANA.

112
rtn
THE OREGON PLAN WOULD ALLOW BIZARRE INEQUITIES.
SINCE OREGON HAS THE ONLY CERTIFIED TRANSPLANT CENTER
IN THE NORTHWEST, OUT-OF-STATERS WITH OUT-OF-STATE
MEDICAID CAN GO THERE, BUT OREGONIANS ON MEDICAID ARE

DENIED ACCESS.

113
rtn
MORE THAN ONE POOR OREGON FAMILY WAS REDUCED TO
BEGGING WITH TIN CUPS AT GROCERY STORES AND MAKING
DESPERATE APPEALS ON TV TO GET MONEY FOR TRANSPLANTS
FOR THEIR CHILDREN.
WHEN THE MONEY DIDN'T COME IN THE CHILDREN WENT

WITHOUT TREATMENT, AND DIED....

114
rtn

AND THEY DIED IN A STATE THAT SPENDS MORE MONEY

ADMINISTERING ITS MEDICAID THAN ALMOST ANY OTHER IN THE

COUNTRY: $40 MILLION.

I'VE HEARD OF NO PLAN TO REDUCE THESE COSTS.

115
rtn
IN OREGON, MANY ARE ASKING HOW CAN YOU LOOK THE
PARENT OF A DYING CHILD IN THE EYE AND SAY, NO
TRANSPLANT FOR YOU, IT'S TOO EXPENSIVE.
CRITICS SAY ALL THIS IS REALLY A WAY OF FINDING A WAY TO

DO LESS FOR NEEDIEST.

THIS PLAN TAKES FROM THE POOR TO GIVE TO THE POOR.

116
rtn
IT TAKES FROM THE POOR TO GIVE TO THE POOR BECAUSE IT
APPLIES ONLY TO MEDICAID COVERAGE, THAT OFFERED THE
POOREST OREGONIANS. IF YOU HAVE MONEY OR PRIVATE

INSURANCE IN OREGON, YOUR HEALTH CARE IS NOT RATIONED.

117
rtn

OTHER STATES ARE TOYING WITH RATIONING.

PENNSYLVANIA DECIDED RECENTLY THAT IT COST TOO MUCH TO
PROVIDE 800 STATE MENTAL PATIENTS WITH A NEW DRUG
(CLORAZIL) THAT MIGHT ALLOW THEM TO RECOVER. SO ONLY
210 WOULD GET THE DRUG. HOW WOULD THEY DECIDE WHO
WOULD GET THE DRUG? OFFICIALS SAID THEY WOULD USE A
LOTTERY. NOT SURPRISINGLY, FAMILIES AND PSYCHIATRISTS

WERE OUTRAGED.

118
rtn

I KNOW WE HAVE HARD CHOICES TO MAKE.

I KNOW WE ARE TROUBLED BY RISING ASPIRATIONS AND

DECLINING RESOURCES.

BUT THESE STATE RATIONING PLANS GO AGAINST OUR GRAIN.

A SOCIETY THAT SPENDS MILLIONS ON LAWN CARE CAN FIND

THE RESOURCES TO PROVIDE LIFE-GIVING NECESSARY CARE TO

ITS POOREST MEMBERS.

119
TO MAKE SURE WE ALL GET MORE FOR OUR HEALTHCARE
DOLLAR, FOR OUR INSURANCE COVERAGE, WE NEED MORE OPEN
COMMUNICATION ABOUT THE QUALITY AND EFFICIENCY OF

HEALTHCARE.

WE NEED TO END THE CONSPIRACY OF SILENCE.

120
WE NEED TO KNOW WERE PEOPLE CAN GET HIGH-QUALITY AND
EFFICIENT CARE.
THEN THE PATIENTS WILL DESERT THE POOR QUALITY,

INEFFICIENT SYSTEMS THAT WILL HAVE TO IMPROVE OR PERISH.

121
QUALITY, AND EFFICIENCY ARE DIFFICULT TO MEASURE. BUT

THEY ARE MORE IMPORTANT THAN MERE QUANTITY.

WE ARE DEVELOPING TOOLS TO MEASURE MEDICAL NECESSITY,

APPROPRIATENESS, EFFECTIVENESS AND OF COURSE OUTCOMES.

jw Five yYeaes i Dow7T WECLEVE A ewaHtEtl MOLE

, Pf bo Ss
Go sc&TIve fv Artes Pr

BAIN E AVERAMHE ES of Berd

PATIENT WIES

iC now swe THE
oe tL tIL HEL

ptosPrmHe Arn PAgBSICIaANW FoT MF

A iwlee v~ NOSES

aa ATS PAoGHE UC — - y 70k

122
WE CAN COMPARE, FOR EXAMPLE, THE CARDIAC SURGERY
OUTCOMES OF ALL THE HOSPITALS IN A STATE, AND SEE WHICH
HOSPITALS --AND WHICH PHYSICIANS-- HAVE MORTALITY RATES
ABOVE NORMAL, AFTER ALLOWING FOR VARIATION IN PATIENT
RISK FACTORS.

THIS INFORMATION IS THEN SHARED WITH THE PUBLIC, AND THE

APPROPRIATE STEPS TAKEN TO SOLVE THE PROBLEMS.

123
AT FIRST, HOSPITALS AND DOCTORS DON'T LIKE THIS INVASION
OF PRIVACY, BEING PLACED IN A FISH GLOBE.

BUT THIS SCRUTINY AND PUBLIC ACCOUNTABILITY IS HERE TO
STAY.

AND I'VE NOTICED THAT THE ONES WHO SQUAWK THE LOUDEST
AT FIRST ARE THE FIRST TO BRING THEIR OUTCOMES TO THE

NORMAL RANGE.

124
THERE ARE OTHER AREAS WHERE WE NEED CHANGES IN LAW

AND PUBLIC POLICY.

WE MUST REFORM THE MALPRACTICE MESS, THE TORTURED

TORT SYSTEM THAT FORCES DOCTORS AND PATIENTS TO VIEW

EACH OTHER AS LEGAL ADVERSARIES.

125
WE CAN'T HAVE DOCTORS WONDERING IF THEY'LL NEXT SEE

THEIR PATIENTS IN COURT, FLANKED BY THEIR LAWYERS.
IN A LEGAL CLIMATE WHERE ANYTHING SHORT OF PERFECTION

IS GROUNDS FOR A SUIT, SOME PATIENTS HAVE GONE TO THE

HOSPITAL WITH THEIR LAWYERS IN TOW.

126
MALPRACTICE SUITS CORRUPT BASIC EMOTIONAL CLIMATE OF
MEDICINE, MAKING THE DOCTOR AFRAID OF THE PERSON SHE

OR HE WANTS TO HELP.

BETWEEN 1981 AND 1986, NUMBER OF MALPRACTICE SUITS
TRIPLED, AND AVERAGE JURY AWARD QUADRUPLED (FROM
$400,000 TO $1.76 MILLION). NO WONDER COSTLY MALPRACTICE
INSURANCE FORCES DOCTORS TO MAKE INSURANCE PREMIUMS,
NOT THE COST OF MEDICAL CARE, THE BASIS FOR THEIR FEE

STRUCTURE.

127
MALPRACTICE DOES EXIST, AND WHERE THERE IS MALPRACTICE
--BAD, OR NEGLIGENT PRACTICE-- RESTITUTION AND
COMPENSATION ARE IN ORDER.

MEDICINE MUST RID ITSELF OF THE BAD APPLES THAT BRING

JUSTIFIED CRITICISM TO THE PROFESSION.

YET MANY MALPRACTICE SUITS ARE BROUGHT BECAUSE A

TRAGEDY HAS OCCURRED, IN SPITE OF THE DOCTOR'S BEST

EFFORTS.

128
OUR CURRENT SYSTEM DOES NOT SERVE THE PATIENT WELL.

EVERY INAPPROPRIATE MALPRACTICE SUIT DRIVES UP THE COST

OF MEDICINE FOR ALL PATIENTS AND DOCTORS ALIKE, WHILE

NEGLIGENT DOCTORS CONTINUE TO PRACTICE AND SOME VERY

GOOD DOCTORS LEAVE.

129
THE MALPRACTICE MESS IS WORST IN OBSTETRICS.

ALTHOUGH MODERN OBSTETRICS OFFERS BIRTH SAFER THAN
EVER FOR MOTHER AND BABY, THE CURRENT ASSUMPTION THAT
EVERY BABY WILL BE PERFECT HAS LED TO A MALPRACTICE
CRISIS.

PEOPLE ASSUME THAT WHEN THEY PAY AN OBSTETRICIAN, THEY

ARE BUYING A PERFECT BABY.

Mace bere
ar

3 J [

130
BUT LIFE --AND BIRTH-- DOES NOT WORK THAT WAY.
OBSTETRICIANS ARE SO OFTEN THREATENED WITH SUITS THAT
THEY ARE FORCED TO PRACTICE DEFENSIVE MEDICINE,
ORDERING FOR EACH PATIENT A BATTERY OF OFTEN
UNNECESSARY AND ALWAYS COSTLY TESTS.

AND THERE HAS BEEN A DRAMATIC INCREASE IN CAESARIAN
SECTIONS SIMPLY BECAUSE OBSTETRICIANS FEAR WAITING OUT

THE NATURAL BIRTH PROCESS.

131
THIS SITUATION, CAUGHT BETWEEN MALPRACTICE SUITS AND
UNNECESSARY CAESARIAN OPERATIONS HAS LED MANY
OBSTETRICIANS SIMPLY TO LEAVE THE SPECIALTY FOR WHICH

THEY WERE TRAINED.

AGAIN, THE AMERICAN PEOPLE ARE THE REAL LOSERS.

132
IN WEST VIRGINIA, FOR EXAMPLE, YOU CAN'T PRACTICE
MEDICINE WITHOUT MALPRACTICE IN SURANCE.

THE CHEAPEST POLICY AN OBSTETRICIAN CAN BUY IS $40,000,
AND THAT COVERS 50 BABIES --BUT NOT 51 BABIES-- DELIVERED
PER YEAR.

THAT AMOUNTS TO AN INSURANCE COST OF $800 PER BABY.....
AND NO ONE IN APPALACHIA CAN AFFORD TO PAY FOR AN $800

DELIVERY.

DO YOU WONDER WHY THERE ARE ALMOST NO OBSTETRICIANS

IN APPALACHIA?

133
MOST DOCTORS WHO ARE SUED FOR MALPRACTICE DON'T
"PRACTICE MAL".

MOST MALPRACTICE SUITS TODAY ARE FOR MALOCCURRENCE,

I'LL USE MYSELF AS AN EXAMPLE. I'M 73. IF I HAD MY GALL
BLADDER OPERATED ON TOMORROW, AND SUFFERED A HEART
ATTACK ON THE OPERATING TABLE AND DIED, IT WOULD BE

WHAT YOU USED TO CALL AN "ACT OF GOD."

134
YOU EXPECT IT TO HAPPEN TO A CERTAIN NUMBER OF 73 YEAR

OLDS UNDER THAT KIND OF STRESS.

BUT NOW THE TENDENCY IS TO BLAME SOMEONE.

WAS THE ANESTHESIA RIGHT?

DID THE SURGEON GO TOO SLOW? TOO FAST?

LET'S SUE; MAYBE WE CAN GET SOMETHING.

135
MALPRACTICE REFORM IS DIFFICULT TO GET BECAUSE
CONGRESS AND STATE LEGISLATURES INCLUDE SO MANY
LAWYERS, AND THEY AREN'T LIKELY TO ACT AGAINST THEIR
OWN.

BUT WE MUST DEMAND REFORM.

WE MUST ELIMINATE AWARDS FOR ALLEGED PAIN AND
SUFFERING, AND WE MUST DO AWAY WITH CONTINGENCY FEES
WHICH CLOG THE COURTS, BLACKMAIL PHYSICIANS, AND
PROMPT INSURANCE COMPANIES TO SPEND OUR MONEY OUT OF

COURT JUST TO GET IT OVER.

136
WE NEED TO GET PAST THE STAND-OFF BETWEEN DOCTORS AND

LAWYERS.

I'M SURE THAT BOTH THE DOCTOR AND THE PATIENT WOULD
PREFER TO HAVE THAT OLD RELATIONSHIP OF TRUST THEY USED

TO HAVE,
A RELATIONSHIP THAT IS UNFORTUNATELY BECOMING CHANGED

TO A PROVIDER-CONSUMER RELATIONSHIP.

pal

LMM"

137
I REALIZE THAT THERE ARE SOME BUILT-IN PROBLEMS.
PEOPLE AREN'T HAPPY ABOUT BEING ILL, NEEDING TO GO TO A
PHYSICIAN.

HAVING TO PAY A HIGH PRICE FOR IT MAKES IT EVEN MORE
UNPLEASANT. BUT WE NEED TO SUBORDINATE THE ECONOMIC
ASPECT OF THE RELATIONSHIP TO THE CLIMATE OF TRUST

BETWEEN THE DOCTOR AND THE PATIENT.

138
IF THE PATIENT THINKS OF HIMSELF PRIMARILY AS A
CONSUMER, GETTING THE MOST FOR HIS MONEY, SHOPPING
AROUND FOR A DOCTOR WHO CHARGES $5 LESS FOR AN OFFICE
VISIT, HE AUTOMATICALLY PUTS THE DOCTOR IN THE ROLE OF

THE SELLER, GETTING THE MOST FOR HIS SERVICES.

139
IF THE DOCTOR IS PRIMARILY CONCERNED ABOUT COLLECTING
HIS FEE, HE AUTOMATICALLY AROUSES THE CONSUMER
MENTALITY IN HIS PATIENT. WE CAN'T HAVE PATIENTS
WONDERING IF THEIR TREATMENT IS DETERMINED BY THE

DOCTORS FINANCES.

140
THE DOCTOR-PATIENT RELATIONSHIP CAN BE RESTORED.

BUT IT WILL TAKE COMMITMENT BY PEOPLE ON BOTH SIDES OF

THE STETHOSCOPE.

ALTHOUGH WE MUST HOLD OUR PHYSICIANS TO THE HIGHEST

STANDARDS, WE MUST REALIZE THAT HEALING AND RECOVERY

ARE NOT PERFECT.

141
THE HEALTH CARE SYSTEM IN AMERICA TODAY IS A TERRIBLE
MORAL BURDEN FOR SOCIETY TO BEAR, IN THAT THE SYSTEM
DOES NOT RESPOND AT ALL TO SOME 12 TO AS HIGH AS 15

PERCENT OF OUR POPULATION.

AND IT IS A TERRIBLE ECONOMIC BURDEN FOR SOCIETY TO
BEAR, IN THAT THE SYSTEM SATISFIES ITS OWN UNCONTROLLED
NEEDS AT THE EXPENSE OF EVERY OTHER SECTOR OF AMERICAN

SOCIETY.

142
WE NEED TO CHANGE THAT SYSTEM.

NOT JUST A LITTLE CHANGE HERE AND A LITTLE CHANGE THERE.

 

WE NEED TO BRING ABOUT A PROFOUND CHANGE, ACROSS-THE-
BOARD, IN THE WAY WE MAKE MEDICAL AND HEALTH CARE

AVAILABLE TO ALL OUR CITIZENS.

BUT CAN WE DO IT?

143
dbt
WE NEED TO TAKE SOME IMAGINATIVE STEPS.
FOR EXAMPLE, WE NEED TO SOLVE THE PROBLEM CAUSED BY
THE ENORMOUS EDUCATION DEBT THAT MOST YOUNG DOCTORS
HAVE TO SHOULDER AS SOON AS THEY BEGIN PRACTICING
MEDICINE.
MOST MEDICAL STUDENTS GRADUATE FROM MEDICAL SCHOOL
WITH A DEBT THAT SHAPES THEIR PRACTICE OF MEDICINE FOR

THE NEXT 20 YEARS.

fito STs am
ta ee

“y ier ay

144
dbt
GRADUATES OF LAND GRANT SCHOOLS, SUCH AS THE
UNIVERSITY OF IOWA, MIGHT BE OWE BETWEEN $45,000 AND
$65,000, WHILE GRADUATES FROM A SCHOOL LIKE BROWN,
DARTMOUTH, GEORGETOWN, OR GEORGE WASHINGTON OWE
OVER $150,000.

IT'S EASY TO SEE WHAT HAPPENS.

145
dbt
THE YOUNG DOCTOR WHO AT ONE TIME WANTED TO GO INTO
FAMILY PRACTICE, PERHAPS RETURNING TO SERVE THE PEOPLE
WHERE SHE OR HE GREW UP, INSTEAD IS TEMPTED INTO A
LUCRATIVE SPECIALTY THAT WILL ALLOW HIM TO EARN AN

INCOME HIGH ENOUGH TO PAY OFF THAT DEBT MORE QUICKLY.

146
dbt
SO WE GET STILL ANOTHER NEUROSURGEON OR ORTHOPEDIST
IN THE SUBURBS, AND WE DON'T GET THAT FAMILY
PRACTITIONER WE SO DESPERATELY NEED IN A SMALL TOWN OR

IN THE INNER CITY.

I HAVE A SUGGESTION ABOUT THIS.

147
dbt
WHEN A MEDICAL STUDENT GRADUATES, AN ACCOUNT COULD BE
ESTABLISHED BY THE FEDERAL GOVERNMENT, AND EVERY TIME
THE DOCTOR SEES AN UNINSURED PATIENT WITHOUT CHARGE,
THAT DEBT IS LOWERED BY THE AMOUNT EQUIVALENT TO A FAIR

COMPENSATION FOR THAT SERVICE.

148
dbt
THIS SOLUTION HAS SEVERAL ADVANTAGES: IT'S GRADUAL; IT
DOESN'T REQUIRE A BIG OUTLAY BEFOREHAND; IT OFFERS CARE
TO THE UNINSURED WHO NEED IT; IT PHYSICIANS TO OFFER
CARE WITHOUT FEE; AND IT LOWERS THE DOCTOR'S DEBT.

IT SEEMS TO ME THAT EVERYBODY GAINS.

WE NEED TO DO SOMETHING, TO DO MANY THINGS, BECAUSE

149
WE ARE AT A CROSSROADS. WE CANNOT AFFORD TO DO_
NOTHING,

TO CONTINUE BUSINESS AS USUAL.

THE PRESSURE FOR RADICAL CHANGE IS COMING FROM ALL
DIRECTIONS:

FROM MEMBERS OF CONGRESS, FROM BUSINESS, FROM LABOR,
AND FROM THE GENERAL PUBLIC.

INCREASINGLY WE HEAR THE DEMAND FOR RESTRUCTURING THE
FINANCING AND DELIVERY OF HEALTHCARE IN THE UNITED

STATES.

150
EVEN SOME BUSINESS LEADERS WHO NORMALLY CRINGE AT THE
THOUGHT OF GOVERNMENT INTERVENTION OR REGULATION
FIND THEMSELVES CALLING FOR A SYSTEM OF NATIONAL

HEALTH CARE AS A SOLUTION TO RISING INSURANCE COSTS.

151
MANY PEOPLE WERE SURPRISED WHEN LAST APRIL THE
AMERICAN COLLEGE OF PHYSICIANS, THE NATION'S SECOND
LARGEST MEDICAL SOCIETY, CALLED FOR A NATIONALLY-
FUNDED HEALTH PROGRAM, BREAKING A LONG TRADITION OF
OPPOSITION TO ANYTHING REMOTELY RESEMBLING "SOCIALIZED

MEDICINE".

152
FRUSTRATION WITH OUR SYSTEM LEADS SOME PEOPLE TO SEE

GREENER GRASS ON THE OTHER SIDE OF THE FENCE.

RECENTLY I'VE NOTICED A STRANGE INTEREST IN THE CANADIAN

SYSTEM.

EVERYWHERE I GO PEOPLE SAY TO ME, "WE NEED THE CANADIAN

SYSTEM." SOI SAY, "TELL ME, WHAT IS IT YOU LIKE ABOUT THE

CANADIAN SYSTEM.?"

153
THEY ALWAYS ANSWER, "I DON'T REALLY KNOW, BUT IT'S A GOOD

SYSTEM."

THE GROWING INFATUATION WITH FOREIGN NATIONAL HEALTH

SERVICES IS BASED MORE UPON DISSATISFACTION WITH OUR

SYSTEM THAN UPON UNDERSTANDING OF ANOTHER ONE.

154
MOST AMERICANS DO NOT REALIZE THAT ANY NATIONAL

HEALTH SERVICE, IS BASED UPON PLANNED SCARCITY.

EXPERIENCE THE WORLD OVER HAS SHOWN THAT WHEN
GOVERNMENT ECONOMIC CONTROLS ARE APPLIED TO HEALTH,
THEY PROVE --IN TIME-- TO BE DETRIMENTAL.

EVENTUALLY THERE IS AN EROSION OF QUALITY, PRODUCTIVITY,

INNOVATION, AND CREATIVITY.

155
THIS IS ESPECIALLY TRUE OF RESEARCH.

AMERICANS DESIRE, NOT ONLY AFFORDABLE HEALTH CARE, BUT
ALSO MEDICAL ADVANCES.

BUT MEDICAL RESEARCH IS NOT CHEAP, AND SOMEONE MUST
PAY FOR IT. AMERICANS ARE NOT LIKELY TO TOLERATE
HEALTHCARE SAVINGS IF IT MEANS SKIMPING ON AIDS OR

ALZHEIMER'S RESEARCH.

156
NATIONAL SYSTEMS OF HEALTHCARE EVENTUALLY BECOME
BUREAUCRATIC, UNRESPONSIVE TO PATIENTS, AND FINALLY THEY

BRING RATIONING AND WAITING IN LINES.

AMERICANS DO NOT PATIENTLY QUE UP FOR ANYTHING,

ESPECIALLY FOR MEDICAL CARE.

157
[EXTRA PAGEs ON CANADIAN SYSTEM]:

THE "PLAIN VANILLA" CANADIAN SYSTEM, ATTRACTIVE AT FIRST
TO AMERICANS, IS BECOMING LESS ATTRACTIVE TO MANY
CANADIANS. BECAUSE RESOURCES ARE LIMITED, ON PURPOSE,
THE AVAILABILITY OF SERVICES IS MUCH LOWER THAN IN THE
US, AND THE WAITING PERIOD MUCH LONGER. THE OTTAWA
CITIZEN (2/4/89) REPORTED THAT IN BRITISH COLUMBIA, IN 1988,
24 PEOPLE DIED WHILE THEY WAITED FOR HEART SURGERY,
BECAUSE THE WAITING TIME FOR BY-PASS OPERATIONS CAN BE 6
TO 8 MONTHS.

A FEW FIGURES DEMONSTRATE THE DIFFERENCE IN
AVAILABILITY OR SERVICES IN CANADA AND THE UNITED STATES:

AVAILABILITY OF SERVICE
CANADA (1988) US(1987)
# OF SITES POPPER SITE # NO OF SITES POP/SITE

OPEN HEART

SURGERY 11 2364 793 307
CARDIAC

CATH 31 839 1234 198
MRI 12 2167 900 271

IT WAS NOT UNCOMMON TO FIND THOSE CANADIANS WHO CAN
AFFORD AMERICAN MEDICINE SLIPPING ACROSS THE BORDER TO
PHYSICIANS IN BOSTON, BUFFALO, CHICAGO, AND SEATTLE. NOW
THE CANADIAN GOVERNMENT PAYS FOR CARDIAC SURGERY AT
70% OF WHAT THE HOSPITAL CHARGES.

158
I DO NOT FAVOR TOTALLY SCRAPPING THE SYSTEM WE HAVE
NOW;
BECAUSE OF ITS DIVERSITY, IT IS POTENTIALLY THE BEST IN THE

WORLD.

ONE WAY TO GET THINGS MOVING IN THE RIGHT DIRECTION IS
THROUGH A PRESIDENTIAL COMMISSION, A COMMISSION THAT
WOULD MAKE DECISIONS AND MAKE A DIFFERENCE, NOT JUST

ISSUE ONE MORE REPORT.

159
I URGED THIS IN A PRIVATE CONVERSATION WITH GEORGE BUSH
IN AUGUST 1988, SEVERAL MONTHS BEFORE HIS ELECTION TO

THE PRESIDENCY.

AND I'VE MADE THE SAME SUGGESTION IN EDITORIALS IN

NEWSWEEK AND FROM MANY PLATFORMS AROUND THE

COUNTRY.

160
WHEN I MET WITH THE PRESIDENT I TOLD HIM THAT A NUMBER
OF WEALTHY REPUBLICANS, CONCERNED ABOUT THE
HEALTHCARE CRISIS, HAD AGREED TO FOOT THE BILL FOR THE
COMMISSION, AS LONG AS IT INVOLVED BOTH DEMOCRATIC AND
REPUBLICAN CONGRESSMEN --NOT THEIR STAFFERS-- WHO
WOULD TAKE THE COMMISSIONS RECOMMENDATIONS BACK TO
CONGRESS FOR DISCUSSION, A VOTE, AND THEN

IMPLEMENTATION.

161
THEY ALSO WANTED THE COMMISSION TO AVOID SPINNING ITS
WHEELS, AND TO DEAL WITH A PROPOSED AGENDA OF NINE
POSSIBLE SOLUTIONS, TO MAKE DECISIONS, AND GET TO WORK

ON IMPLEMENTING THEM.

THE PRESIDENT GAVE ME NO ANSWER.

162
AND AS FAR ASI CAN TELL, NOTHING IS BEING DONE ON THE
FEDERAL LEVEL TO ADDRESS THE NATIONAL HEALTHCARE

CRISIS.

CHEERLEADING SPEECHES WON'T DO.
RECENTLY THE SECRETARY OF HEALTH AND HUMAN SERVICES
SAID WE NEED A CULTURE OF CHARACTER. THAT'S A NOBLE

ASPIRATION. BUT IT WON'T SOLVE OUR HEALTHCARE PROBLEMS.

163
WE CAN DELAY NO LONGER.
THE OPPORTUNITY IS NOW.
THE TIME IS SHORT.

THE STAKES ARE HIGH.

THE ALTERNATIVES UNDESIRABLE.

164
IT REMAINS TO BE SEEN WHETHER OR NOT THE PRIVATE SECTOR

SEIZES THIS ONE AND ONLY OPPORTUNITY.

WE'LL SEE.

WE ALL NEED TO BE A PART OF THE EFFORT.

BUT THERE IS NO QUICK FIX.

FROM HERE TO THERE COULD TAKE A DECADE, BUT WE'D

IMPROVE YEAR BY YEAR ALONG THE WAY.

165
[CONCLUSION]
FINALLY, AS MY GOOD FRIEND DR. TIMOTHY JOHNSON SAYS,
WHEN WE SAY HEALTHCARE, WE ALL TOO OFTEN MEAN
HEALTHCURE.

AND WE PUT TOO MUCH EMPHASIS ON CURING, TOO LITTLE ON

CARING.
WE NEED TO DO MORE ABOUT THE TIMES WE CAN'T PROVIDE

THE CURE, BUT STILL CAN PROVIDE THE CARE.

166
CURING CAN COST BILLIONS, CARING COMES FROM HEART AND

SOUL.

I'D LIKE TO THINK THAT WHETHER OR NOT WE HAVE FEWER

BILLIONS, WE'LL NEVER RUN OUT OF HEART AND SOUL.

THANK YOU.

HHEAEH

167
J ber

‘Gnet)
IN THE MEANTIME, YOU CAN DO YOUK rani 1J MAKE SURE
THAT YOU DON'T NEED TO USE THE HEALTHCARE SYSTEM, BY
PRACTICING PERSONAL DISEASE PREVENTION AND HEALTH

PROMOTION,

IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE
PAY DOCTORS TO TAKE A LEG OFF BUT WE DON'T PAY THEM TO
KEEP A LEG ON. NOW, ALMOST 80 YEARS HAVE PASSED AND WE

STILL HAVEN'T COME UP WITH A GOOD ANSWER.

 

168
OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM --
WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- IS STILL

PREDICATED ON TAKING THE LEG OFF.

169

py
pv
SOME OF US ARE TRYING TO CHALLENGE THAT THINKING. WE
ARE ATTEMPTING A NEW AMERICAN REVOLUTION.
THIS REVOLUTION IS MORE IMPORTANT THAN THE NEEDED
REVOLUTION IN THE STRUCTURE OF HEALTH CARE OR IN THE

FINANCING OF HEALTH CARE.

THIS REVOLUTION CHANGES EVERYDAY INDIVIDUAL BEHAVIOR.

170
py
YOU ARE A PART OF THAT REVOLUTION, AND YOU'LL IMPROVE
THE HEALTH OF THE AMERICAN PEOPLE --AS WELL AS YOUR

OWN HEALTH-- IF YOU PLAY YOUR PART.

TWO CONCEPTS FORM THE BASIS FOR THIS REVOLUTION.

FIRST, YOUR HEALTH AND THE HEALTH OF THOSE WHO COME TO

YOU PROFESSIONALLY WILL DEPEND MOSTLY UPON THE

PREVENTION OF DISEASE AND DISABILITY AND THE PROMOTION

OF GOOD HEALTH.

171
pv
SOME ANALYSTS EVEN SAY THAT PREVENTION AND HEALTH
PROMOTION CAN POSTPONE UP TO 70 PERCENT OF ALL
PREMATURE DEATHS, WHEREAS THE TRADITIONAL CURATIVE
AND REPARATIVE APPROACH OF MEDICINE CAN POSTPONE NO
MORE THAN 10 TO 15 PERCENT OF SUCH DEATHS. EVEN IF
THEY'RE ONLY HALF RIGHT, THAT'S QUITE A DIFFERENCE IN

SOCIAL PAY-OFFS.

172
pv
SECOND WE HAVE COME TO REALIZE THAT THESE TWO
APPROACHES TO HEALTH -- THAT IS, DISEASE PREVENTION AND
HEALTH PROMOTION -- ARE THE PRIMARY RESPONSIBILITIES OF.
EACH INDIVIDUAL.

THAT MEANS YOU!

PHYSICIANS AND THERAPISTS AND PHARMACISTS AND NURSES
MUST PROVIDE AMERICANS WITH INFORMATION, SERVICE, AND
EXAMPLES. BUT THE CRITICAL CHOICES REST WITH EACH
INDIVIDUAL. AND THEY ARE FREE CHOICES IN NEARLY EVERY

CASE, NOT MANDATED BY LAW -- AT LEAST NOT YET.

173
pv
THIS TWO-FOLD CHANGE IN THE WAY WE LOOK AT HEALTH IN
AMERICA HAS NOT YET BEEN FULLY ABSORBED BY THE
AMERICAN PEOPLE, ALTHOUGH THEY SEEM WILLING ENOUGH TO

LEARN.

NOW, IT'S TRUE THAT AMERICAN PUBLIC HEALTH HAS ALWAYS
HAD A STRONG PREVENTIVE BASE:
WE WERE BROUGHT UP ON VACCINATION PROGRAMS AND WATER

FLUORIDATION AND BLOOD PRESSURE CHECK-UPS AND SO ON.

174
pv
NEVERTHELESS, I THINK THE OVERALL PERCEPTION AMONG THE
AMERICAN PEOPLE IS STILL AN OLD-FASHIONED ONE: THAT IS,
THAT PUBLIC HEALTH AND MEDICAL AND NURSING PERSONNEL
ARE REALLY ON THE JOB TO PATCH YOU UP IF YOU GET HURT OR
TO CURE YOU IF YOU GET SICK. IN OTHER WORDS, THE PATIENT
IS PASSIVE AND THE HEALTH SYSTEM IS THE ONLY ACTIVE

PARTY.

175
pv
I THINK THE PUBLIC STILL ADHERES TO THE IDEA THAT THE

PATIENT IS SUPPOSED TO "FOLLOW THE DOCTOR'S ORDERS."
OF COURSE, BY "FOLLOWING THE DOCTOR'S ORDERS," THE

PATIENT WILL DO THOSE THINGS THAT WILL HELP HIM OR HER

REGAIN THE LOST STATUS OF FULL HEALTH.

176
pv
WE IN THE PUBLIC HEALTH PROFESSIONS HAVE BEEN
DILIGENTLY TRYING TO TURN THAT CONVENTIONAL WISDOM

AROUND. AND I THINK WE ARE!

HEALTHCARE IS NOT SYNONYMOUS WITH DOCTORS AND
HOSPITALS. HEALTHCARE MEANS PREVENTION TOO. REMEMBER,
THE MOST FREQUENT CAUSES OF PREMATURE MORTALITY ARE:
SMOKING, DRINKING TOO MUCH, NOT WEARING A SEATBELTS.

YOU CAN TAKE CARE OF THESE PROBLEMS FOR YOURSELF.

177
pv
THIS MEANS WE HAVE TO MAKE A COMMITMENT TO HEALTH
EDUCATION THAT IS FAR GREATER THAN THE ROUTINE AND
ALMOST CEREMONIAL ATTENTION WE USUALLY GIVE IT.
THIS MEANS WE NEED TO TAKE VERY SERIOUSLY THE NEEDS OF
OUR SCHOOLS AND COLLEGES TO DELIVER TO THEIR STUDENTS
A COHERENT, CONSISTENT, AND UNDERSTANDABLE PUBLIC

HEALTH MESSAGE.

178
pv
AND I THINK THIS ALSO MEANS WE NEED TO UNDERSTAND AND
NURTURE THE PATCHWORK OF SELF-HELP AND GROUP-SUPPORT
MECHANISMS THAT HAVE POPPED UP SPONTANEOUSLY AND
PROFUSELY AMONG THE GENERAL PUBLIC OVER THE PAST

DECADE OR SO.

179
pv
SOMETHING --LIKE PREVENTIVE HEALTHCARE-- THAT MAKES YOU
FEEL BETTER AND SAVES YOU MONEY SHOULD CATCH ON.
AMERICANS, AS EMPLOYERS AND EMPLOYEES HAVE COME TO
REALIZE THAT HEALTHY WORKERS SAVE EVERYONE MONEY.
THEY SAVE EMPLOYERS MONEY IN HEALTH BENEFITS PAID, THEY

SAVE EMPLOYEES MONEY IN INSURANCE COSTS.

180
pv
THE JOHNSON & JOHNSON COMPANY, KNOWN FOR SELLING
HEALTH PRODUCTS, DECIDED TO SELL HEALTH TO ITS OWN
WORKERS, BY INSTITUTING A WELLNESS PROGRAM AIMED TO
DECREASE HEALTHCARE COSTS BY CHANGES IN EMPLOYEE
EATING HABIT AND EXERCISE. IN A CONTROLLED STUDY, THEY
FOUND THAT DURING THE FIRST YEAR, THE WELLNESS PROGRAM
COST MORE THAN IT SAVED, THE SECOND YEAR IT BROKE EVEN,
THE THIRD YEAR IT MADE ENOUGH TO PAY BACK THE FIRST
YEAR LOSSES.
THEIR GOALS WERE PRETTY SIMPLE, PRETTY BASIC: STOP
SMOKING, EAT LESS FAT, MORE FRUIT, BUCKLE UP, GET SOME

EXERCISE.

181
pv
I THINK WE'RE MAKING GREAT STRIDES IN THE ANTI-SMOKING
AREA.
THE PERCENTAGE OF THE ADULT POPULATION WHO SMOKES IS
STEADILY DECLINING AND THAT'S EXCELLENT.
THERE'S ALSO BEEN A DROP IN THE CONSUMPTION OF HARD
LIQUOR, WITH A SHIFT TO BEER AND WINE -- OR BETTER STILL,
FRUIT JUICE AND WATER. AS A RESULT, THERE'S BEEN A
DRAMATIC DROP IN CHRONIC LIVER DISEASE AND CIRRHOSIS

MORTALITY IN GENERAL.

182
pv

PEOPLE SEEM TO BE EATING LESS FAT, PARTICULARLY

SATURATED FAT AND CHOLESTEROL. THE DROP IN CIGARETTE

SMOKING AND THE REDUCTIONS IN FAT IN THE AVERAGE

PERSON'S DIET HAVE COMBINED TO CONTRIBUTE TO THE

DECLINE IN HEART DISEASE AND STROKE DEATHS OVER THE

PAST 10 TO 15 YEARS AS WELL. THERE'S NO DOUBT ABOUT THAT.

183
pv
WHEN WE CONVINCE OURSELVES TO EAT A PROPER DIET,
TO SAY "NO!" TO DRUGS LIKE ALCOHOL AND NICOTINE,

WE TAKE CHARGE OF OUR HEALTH.

DON'T RELY COMPLETELY ON HIGH-COST HIGH-TECH MEDICINE

TO SAVE YOUR LIFE.

184
OR AS SOME PEOPLE SAY:
"YOU CAN AFFORD PREVENTION ... YOU CANNOT AFFORD A
QUADRUPLE

BY-PASS."

TO BORROW A MOTTO FROM AN EARLIER AGE:

"LIVING WELL IS THE BEST REVENGE."

185

pv
pv
LIVING WELL ... LIVING SENSIBLY ... LIVING A HEALTHY
LIFESTYLE ... LIVING ACCORDING TO AN ETHIC OF PREVENTION ...
THIS IS YOUR "BEST REVENGE" AGAINST THE 3 D'S OF

DISCOMFORT, DISEASE, AND DISABILITY.

AND IT'S YOUR BEST HEDGE AGAINST THE 4TH AND FINAL D:

DEATH ITSELF.

186
pv
I CALL UPON THE AMERICAN PEOPLE TO DEMONSTRATE THEIR
COMMON SENSE BY TAKING UP THE CAUSE OF HEALTH
PROMOTION AND DISEASE PREVENTION THROUGH SENSIBLE

PERSONAL CHOICES.

WHEN I WAS SURGEON GENERAL I WAS INVOLVED IN A NUMBER
OF COMPLEX PUBLIC HEALTH ISSUES: SMOKING, OF
COURSE...AND THE "BABY DOE" ISSUE...AND THE RISE OF THE AIDS
EPIDEMIC...AND DRUNK DRIVING AND FETAL ALCOHOL
SYNDROME... INTERPERSONAL VIOLENCE. .. AND ORGAN

TRANSPLANTATION...AND SEVERAL MORE.

187
pv
BUT IN EACH CASE, TO A GREATER OR LESSER DEGREE, I
LOOKED TO THE AMERICAN PEOPLE FOR THEIR UNDERSTANDING
AND SUPPORT--THEIR EMOTIONAL, INTELLECTUAL, SOCIAL, AND
POLITICAL SUPPORT--BECAUSE I CAME TO KNOW THAT THEY
WOULD MAKE THE DIFFERENCE BETWEEN PROGRESS...AND

FAILURE.

CLOSE TO YOU TO DO THE SAME.

188
ag
NOW I'D LIKE TO SAY A FEW WORDS ABOUT A TOPIC THAT MAY

SEEM REMOTE TO MOST OF YOU, BUT WILL SEEM IMMEDIATE

SOONER THAN YOU THINK: AGING.

AS I LOOK ACROSS THIS AUDIENCE I DON'T SEE ANYONE WHO

LOOKS ELDERLY.

189
humorous lines: in section on aging; use elsewhere if not speaking on aging:

FORTUNATELY SOME OF US OLDER FOLKS MUST HAVE GOOD
GENES, BECAUSE WE'VE LIVED SO MANY YEARS BEFORE THESE
HELPFUL HEALTH WARNINGS. WE'VE EATEN FAR TOO MUCH
LARD, NEVER JOGGED UNLESS WE WERE LATE FOR A TRAIN,
THOUGHT FIBER WAS PART OF CLOTHING NOT DIET, AND WE'VE
MADE IT TO OLD-AGE. OF COURSE, IF WE'D KNOWN WE'D LIVE
SO LONG, WE'D HAVE TAKEN BETTER CARE OF OURSELVES.

she a

I'VE DECIDED THAT BIRTHDAYS ARE GOOD FOR YOU. THE
PEOPLE WHO HAVE THE MOST OF THEM LIVE LONGEST.

KKK AKA

[COUPLE WHO WENT TO HEAVEN......... OAT BRAN]

360