From Faneuil Hall in Boston, The
Advocates. Tonight's question, "Should
The Federal Government Guarantee
Comprehensive Medical Care For All
Americans?" Arguing In favor is Patricia
Butler, attorney and specialist
in Health Law, and Health Facilities Policy.
Appearing as witnesses for
Ms. Butler are Max Fine, Executive Director of
the Committee for National
Health Insurance, and Bert Seidman, economist and
Director of the AFL-CIO Department of Social Security. Arguing against the
proposal is William
Rusher, Publisher, National Review. Appearing as
witnesses for Mr. Rusher
are Congressmen Philip Crane, Republican from
Illinois and Member, House Ways and Means Subcommittee on Health, and Walter
McClure, Health Policy
Good evening, and welcome to The Advocates. The
question of national health insurance invites that classic confrontation
between those who would have the federal government control the vital
industry and those who believe that private enterprise will always deliver a
better product at a better price. The product: health care, how we provide
it, and how we pay for it. Almost every industrialized country has health
care provided or at least paid for by the central government. In the United
States, we rely heavily on private insurance, and millions of Americans have
little or no insurance; Advocate Patricia Butler, a lawyer with the Colorado
Department of Health, says we should have a national comprehensive health
insurance plan in this country.
Our health care industry is not healthy. Only
national health insurance will give us the security, economy and the high
quality of medical care that we so obviously need. With me tonight to
present the case for national health insurance are Mr. Max Fine and Mr.,
Thank you. William Rusher, Publisher of the National
Review says, no.
The Kennedy-Corman Bill would turn over the control
of medical care in America to the same government that gave us the postal
service, Amtrak and the-. Swine Flu program, and make us pay for it the way
we pay for Social Security by an ever increasing payroll tax backed by a
general increase in the income taxes of everybody still healthy enough to
work. With me tonight to oppose this grotesque plan, and incidentally to
discuss some better ways of controlling medical costs are Mr. Walter McClure
and Congressman, Philip Crane.
Thank you, Mr. Rusher. We will be back to both
advocates in a moment for their cases. But first a word of background. The
basic problem in the United States seems to be that we Americans pay a
tremendous amount of money, more than anyone else in the world, for medical
services, which according to the statistics, are far from the best in the
world. Some people are disturbed by the statistics. For example, the World
Health Organization says that we rank tenth in life expectancy, fifteenth in
combating infant mortality. Thousands of American children die each year
from preventable disease. Health care services are unevenly distributed
around the country and the price of these services is skyrocketing. If you
have been in the hospital during the past few years, you will, have felt the
effect of costs which have risen thirteen fold since 1950, or twice the rate
of increase in the cost of living. In 1976, we spent $140 billion on medical
care, almost 9 percent of our Gross National Produce, more than half again
as much as we spent on national defense. For many years, there have been
proposals to reform the health care- system in this country. They range from
the proposal for national health service like Great Britain's, to one from
the usually conservative American Medical Association suggesting tax credits
to encourage people to buy private health insurance. President Carter is
expected to offer his ideas on how health care should be improved sometime
this spring. The proposal we are debating tonight is embodied in a bill
sponsored by Senator Edward Kennedy of Massachusetts, and Congressman James
Gorman of California. Here's what the bill would do. First, the federal
government would pay for almost all medical services and second, the
government would set rates of payments for these services, including
doctor's fees and hospitals. Proponents say that only through this kind of
dramatic federal intervention, can Americans be guaranteed reasonable access
to quality medical care at a price the country can afford. Opponents say it
would drive down the quality of medical care and drive up the costs. And so,
tonight's question, "Should The Federal Government Guarantee Comprehensive
Medical Care For All Americans?" Ms. Butler, the floor is yours.
Our doctors literally work miracles, but neither
they nor we have bothered to control the shocking costs of health care,
costs so high that some hospitals charge $300 a day, just for routine
services. Costs so high that they bankrupt the poor, the elderly, and even
the fully employed, who until serious illness strikes, think that because
they pay high premiums t hey have enough insurance. We pay hundred of
billions of dollars every year, this year over $800 for every man, woman,
and child in the country/ to a wasteful inefficient health care industry, an
industry that can not even guarantee us a doctor when we need one. This
folly must end. We must make our health care system more truly democratic,
more economical.. and certainly more humane. The Kennedy-Corman proposal
will do this. High quality, low-cost health care is a right. The
Kennedy-Corman proposal will guarantee that right to everyone. I call to the
stand my first witness, Mr. Max Fine.
Welcome to The Advocates, Mr. Fine.
Mr. Fine has served with the Social Security
Administration and the U.S. Public Health Service. He is currently the
Executive Director of the Committee for National Health Insurance. Mr. Fine,
for the past nine years you've worked for the adoption of national health
insurance. Why do you support such a program?
Because I believe that health care is a basic human
right. I believe that the working people of America and the poor and the
deprived are entitled to the adequate health care that they need. I also
believe that we have a system now which is overly costly, it's wasteful. We
have some of the finest physicians in the world, some of the finest
institutions but the services are disorganized, the system is run in a very
unbusiness-like way, costs are going right through the roof and I believe
that a properly constructed national health insurance program can implement
the principle of health care as a right, and can correct many of these
problems in the health care system.
But don't many people in this country already have
Yes, but it is like a dog's breakfast. It's all over
the place. Some people have very good coverage, other people have buffalo
policies that only cover you when you're run over by a herd of buffalos on
Main Street, and in between there are all kinds of variations. Thousands and
thousands of different types of policies all for the same services. The
bottom line is that all of the health insurance, all of the private health
insurance that all of us have, covers only about one-third of the health
And are you suggesting that catastrophic illness
also bankrupts some individual families?
It certainly does. We know that every day in the
papers, wherever I go there seems to be a story that day in the paper about
another family being driven right over the hill by medical costs. A
catastrophic illness can be an ordinary illness because of the high cost of
And what's the cost of the average American for
Well, as you say, it's about $800 per person right
now. We pay it as tax payers, we pay it as premium payers, and we pay it
directly out of our own pockets for the services that the health insurance
we have does not cover.
How have medical costs risen in the last few years
and why have they risen so fast?
Well, they have gone right through the ceiling.
They've escalated much faster than other costs. Hospitals costs lead all
other costs in the Consumer Price Index. Health costs have escalated about
twice as fast as other costs. And the reason why is that it is a unique
industry. The hospitals are paid on a cost basis, that means that whatever
costs they run up, we pay them. Physicians negotiate only with themselves
how much they are going to be paid. You'd like to negotiate with yourself
and I would too, but if we did we might pay ourselves more than we should be
So we are spending hundreds of billions of dollars
on our medical care. Does this enormous expenditure give everyone the care
he or she needs?
No, the federal figures show that there are 30
million people who have no access to health care in this country. There are
many others who have limited access. They might have services when they get
very sick but, for example, 40 percent of the preschool children in this
country are not immunized against polio. There are many women who are not
seen in the first trimester of pregnancy. The result is that a great deal of
unnecessary mental and physical illness occurs.
And, is it difficult to get a family doctor when
you need one?
I'll say it is. We have far fewer family doctors
today than we had during the Depression. Doctors are all super
Alright, now we'll go to Mr. Rusher for some
questions for Mr. Fine.
Mr. Fine, let me see if we can understand a little
more precisely how the major provisions of the bill will work. As I
understand it, doctors and hospitals would be reimbursed for costs of
approved or common medical care, is that correct?
There would be negotiations with the hospitals and
with the doctors. Just as we have to have a family budget and live within
those means, they would have to live within those means of a budget.
But, the reimbursement would be for specific types
of approved care. Is that correct?
No. It would be for care that the doctor decides is
Well, that's what I'm getting…suppose we have a
type of therapy that a doctor wants to try out which has not been tried
before? How then, as I understand it now, having read the bill, the
reimbursement will not, cannot come to him or to the hospital for that
particular kind of therapy even though he and the patient both want it,
unless it is a medically approved therapy, approved by the Board in
The doctor determines what type of medical care he
wants to provide for the patient. If we are talking about a medicine, of
course we are talking about a medicine that would be an approved
Approved by whom?
By the same system that we have now for approving
The AMA, the medical profession, itself, or a board
They're involved in the approval of medicine.
Wouldn't the board in Washington under the plan,
the board established by the plan, have to approve the medicine too
In the same sense that the FDA...
Yes, in precisely the sense that the FDA
Now supposing, and that's precisely what I'm asking
you, sir. Suppose that this is a medicine or a treatment or a course of
treatments that the FDA or its equivalent, this new board, hasn't
Well, the FDA does not approve treatments, they
No, but this board would approve treatments and
No, this board would not.
Well, if you want to confine it to medicines, let's
confine it to that.
I don't want to confine it to medicines, I would like
to talk about treatments.
I would like to...if you don't mind, tell me what
would happen if a doctor and a patient agreed on a new medicine that was not
yet approved by the board that this bill would set up in Washington?
Well, we would hope that the doctor would not
prescribe that medicine to the patient.
Why? Why? Shouldn't, my heavens, there are new
drugs coming on the market all the time, are there not?
Well, a lot of people think that Laetrile is
efficacious, and most don't. I don't think that is the question.
But Laetrile is an example of one that had heavy
criticism. But, what about types of medicines that are widely used in other
parts of the world and that might save lives here? What I am getting at Mr.
Fine, is simply whether or not the decision of a doctor and a patient is
determinative in these cases, and the answer I take it is that no, it has to
be made and approved by a board in Washington.
In terms of medicine, yes, not in terms of the
physician's treatment of the patient.
And if the board in Washington hasn't been told by
enough Canadian mice that this particular drug is all right, then the drug
doesn't get used, even though both the doctor and the patient want the drug
for the treatment in question.
Well, that isn't exactly what this program is all
about, because this one would create innovations in treatment. We think that
there has been stifling under- the present system of innovation.
I think that you have just told me that innovation
would not be permitted. That is would only be approved.
I did not say that.
Let's try another question. Under the
Kennedy-Corman Bill, would a doctor with five years experience get the same
pay as one with twenty?
Not necessarily. The physicians themselves would
determine that on a local basis.
Surely, they would have to negotiate with you,
wouldn't they, with the board?
There would be a sum of money negotiated within a
community for physicians' payments, but within that community the physicians
would set relative value schedules.
And what about a good doctor, with the same amount
of years experience as a bad one?
We think that most doctors are very good.
I know, but suppose we have a good doctor and a
less good doctor?
Would they get paid the same?
That's up to the local medical society.
Oh, it's up to the local medical society.
That's, for the medical foundation.
Do you really believe that the local medical
societies of this country should have the kind of power to decide that
I believe that the medical profession by and large in
this country measures up to very high standards. What we are interested in
is making the entire profession, giving them the opportunity to meet the
standards of the very best.
I suggest to you that what you have described is
putting immense new powers into the hands of the bureaucracy of the American
Medical Association, Mr. Fine. You are going to let local medical societies
determine the pay of doctors based upon whether or not in the opinion of
that society they are good or bad, and whether the patient thinks they are
bad or good or not.
Within a predetermined overall budget within that
community and nationally, there would be relative value fees set for
physicians, who might be boarded
I’ll have to interrupt Mr. Rusher, excuse me. Ms.
Butler, one more question.
Yes. Mr. Fine, you've described some shocking
problems to us tonight. What would be the principles of a national health
insurance program that would deal with these problems?
Well, in the first place, everybody would be covered,
automatically, if you lived in this country you would be covered. There
would be no conditions if you need medical care, you would get the medical
care. In the second place, the health security program and the national
health insurance principles that we support, would create basic reforms in
the health care system, relying very much through incentives on the
development of prepaid group practice plans and health maintenance
Excuse me. Before we go to Mr. Rusher, I would like
to get one thing clarified from your earlier statement. If a new medical
treatment were established, for example, a doctor wanted to try a new form
of X-ray treatment. Would there be a requirement that a board in Washington
approve it and set a fee for it before that could be done?
I was left a little confused by the former cross
And the confusion is partly in the law, which is
extremely obscure about some of these things. Do I have a question?
Yes, your question to that ask now.
Mr. Fine, is it important to you the consumers, in
this case, the patients, should have some choice in these matters?
Yes, I believe that...
And yet, they do not have, in this case, the choice
of what they are going to pay for a doctor that they want, do they? This is
left to a local medical society, I believe you said.
If you will permit me to answer the question..
We are interested in creating more choices. Today,
consumers do not have a choice of a family health care plan, and health
maintenance organization. Their choice, today, is pretty much limited to
fee-for-service, solo-practicing physicians.
Thank you. Mr. Fine, thank you for joining us on
The Advocates. Ms. Butler?
We all need protection against ruinous medical
bills. The health care industry needs a lid on inflation, and our democracy
needs to guarantee equitable services to all. To show us the intelligent way
that the Kennedy-Corman proposal will meet these needs, I call to the stand
my next witness, Mr. Bert Seidman.
Mr. Seidman, welcome to The Advocates.
Mr. Seidman is an economist, a member of the
President's Advisory Committee on National Health Insurance, and Director of
the Department of Social Security of the AFL-CIO. Mr. Seidman, under
Kennedy-Corman, what would we get now that most of us don't have or can't
Well, what we would get is a universal
comprehensive national health insurance which would make health care the
right of every American. Specifically, they would have available to them
physician services in the doctor's office, necessary in the home although
that is quite rare these days, or in the hospital, surgery or other types of
care in the hospital. And also coverage for the very expensive kinds
diseases which are sometimes called catastrophic.
Any other kinds of benefits?
Yes, as time goes on, there would be dental
benefits, probably starting with the children, mental health care, nursing
home care, and other kinds of long-term care. But these things might not be
in the program at the every beginning.
This sounds a lot like socialized medicine, like
they have in England.
No, no. It is not socialized medicine at all.
Socialized medicine as in England, for example, involves the government
owning the hospitals, and most of the doctors are employed by the
government. That's not the program we want at all. We want a program of
national health insurance, which is quite different from the National Health
Service that they have in England.
Under this proposal most funds would be channeled
through the federal government to administer the program. Why is this a
preferable way of financing medical care than what we have now?
It's a preferable way because the system we have
now, involves fragmented financing. We have hundreds of insurance companies
with many different kinds of policies and they're in no position to hold
down the cost of care, or assure the quality of care, and they have not done
so. The record proves this.
Then, how would the Kennedy-Corman plan help to
control medical costs?
It would do this because the financing of the
program would be from a single source, and in a democratic country the
single source would be the federal government, either financing the program
or controlling the financing of the program, and it would be in position, as
Mr. Fine said, to negotiate with the doctors and with the hospitals so as to
hold down the cost and to encourage the improvement of the quality of
Give us some examples of the types of controls that
would be imposed.
On the costs, themselves.
On the costs of care...in the first place, there
would be a national budget for health care expenditures and that would be
allocated among the various states and localities, and also among the
sectors of medical care, the physicians on the one hand, the hospitals and
other types of medical care. There would also be other ways in which the
costs would be controlled, chiefly, negotiation of the charges of hospitals
in the form of budgets in advance, and negotiation of fees with the doctors
as Mr. Fine has already indicated.
And some of these organized pre-paid group
practice programs of medical care?
I'll have to ask for a quick answer on that
Yes, there would also be those and they have
proved to be very cost-effective — by cutting down hospitalization, which is
the most expensive kind of care.
Alright. Now we'll go to Mr. Rusher for some
question to Mr. Seidman.
Mr. Seidman, are you familiar in general with the
Veteran's Administration Medical Care Program?
I am not an expert on it. I know something about
Are you content with what you know, do you think
it successfully controls cost? You know that it is a totally federal
program, and totally cost controlled?
The Veteran's Administration Program, I think,
comes very close to the British system of a National Health Service.
Does it control costs.
It is not a program which I particularly
advocate. I don't happen to know the cost figures for the Veteran's
Let me help you on that.
...but it is not the program that I am
I think it is very close...
... it is a program which involves the government
owning the Veteran's Administration facilities, employing the doctors. It's
not the program that I'm advocating.
Yes, and just for the record the costs, under that
program, which are thoroughly controlled by the government of the United
States, according to a study of the National Academy of Sciences, are 20 to
50 percent higher than would be necessary for efficient operation of the
Efficient operation of the program? And I would
like to know whether the tremendous costs of other hospitals in this
country, the private hospitals, the community hospitals, and so on, are not
also very much greater than would be required for efficient operation.
Let's find out in the case of the New York City
public hospitals and compare them with some national figures. Would you care
to guess what in 1975, the per capita Medicare expenditure was for the New
York City public hospitals, which are...
The public hospitals are the hospitals in this
country which have to take the most difficult cases of the poorest people
with the worst medical conditions and if their costs were not higher than
the costs of other hospitals, I would be very much surprised.
Well, you are right on the money. Although just a
minute ago, you were casting aspersions upon the performance of the private
hospitals, so I thought that you would be interested to see.
I was not casting aspersions upon the performance
of the public hospitals, I was saying why their cost should be expected to
The figure for the New York City public hospitals,
for the record, was $1032 per capita, as against $590 per capita in the
nation at large.
And that's because the sickest people, the
poorest people with the worst condition go into the public hospitals.
Poor people don't get any sicker than the rich
Yes they do. The figures, all the statistics will
show, Mr. Rusher, that poor people do become very much sicker than rich
people. And it ought not to surprise you.
I think that the medical care...let's take some
very poor people indeed. The American-Indians on reservation, another
totally federally controlled program. Are you proud of that as an example of
Mr. Rusher, you are asking me about programs with
which I am not thoroughly familiar, but again if you are going to tell me
that-the costs are higher it's again because the Indians do have very very
low incomes, and they do have much worse health conditions than the rest of
I wasn't going to tell you the costs were higher.
I was going to tell you that the costs were totally government controlled,
and that the American-Indian medical program is one of the most notoriously
poor in the United States. You know...
I don't know that.
I should think that a person, as interested as you
I don't know that…
Just a minute, please...as interested as you are
in further medical care for the American people, would you inform yourself a
little better about Veteran's Administration program, which you don't know
about, and the Indian program, which you've only barely heard of. Why don't
you go out and find out what a mess the government you want to rely on has
made of the programs that are directly under this care?
In the first place, Mr. Rusher, I didn't say I
know nothing about these programs. I do know something about these
Well, tell us about these programs.
I know that the veterans would not be getting the
care that they do get, if there were no Veteran's Administration Hospitals.
And the Indians would not be getting the care that they do get if there were
no hospitals in the Indian reservations.
Well, I don't know about that. They might be
getting, I'll tell you this, they might be getting care that was much better
related to the costs of the care, and to what is delivered for that cost
they are getting, in the case of the American-Indian program.
Do you know any private hospitals that are
carrying on the kind of programs that the Veteran's Administration is, for
paraplegics and others, who have been badly injured in the Viet Nam, and
other wars? I don't, and the reason for that is because it's the most
expensive kind of care, and hospitals try to avoid that kind of care, so as
to improve their own incomes.
So that your bottom line is that you will, for the
only time in the history of the government of the United States when it
takes on what you would consider, apparently, a fairly easy problem, it is
going to solve it very expeditiously and very economical.
No, I say that when the government takes on the
problem of making sure that we're going to provide care for all the people
of the United States, that we are going to get better care for the country
as a whole, and a lower cost.
Thank you. Ms. Butler, one last question for Mr.
Mr. Seidman, isn't this national health insurance
plan going to result in a tremendous increase in cost?
No, it is not going to result in an increase in
cost. To the contrary, it is going to result in lower costs than any other
plan would or than continuing the present system. All we have to do is to
look to our neighbors in Canada. Ten years ago, they had a cost as a
percentage of the Gross National Product, approximately the same as ours, 7
percent. Ten years later, with National Health Insurance in Canada, it's
still 7 percent. In the United States, it is now 9 percent, and as others
have said, going through the roof.
Mr. Rusher, one last question for Mr.
Mr. Seidman, I understand that the elderly
populations are naturally much more expensive to care for. People over 65
have about 4 1/2 times as much medical care and hospital attention as people
under 65. What about the problem presented by two areas of the United
States, where the medical allegation under Kennedy-Corman, is going to be
different. Obviously, there would have to be more if one population was
substantially older say, Florida from the others, some state where it is
much younger. Do you see any problem there?
I do not see any problem. It is perfectly
possible to get the information which would make it clear that the area with
more elderly, would require a larger allocation.
All right. Thank you Mr. Seidman for joining us on
The Advocates. Ms. Butler?
We have seen that the current medical industry
squeezes us for money and then doesn't deliver. Kennedy-Corman will change
all that. As you are listening to our opponents case, ask yourselves these
questions: Do they really care that people in this country can't get medical
care when they need it? Will relying on methods that haven't worked in the
past solve today's problems or tomorrow's? Are they really aware of how much
you and I are spending for medical care, and how little we are getting for
For those of you who may have joined us late, Ms.
Butler, and her two witnesses, have presented the case in favor of tonight's
question, "Should The Federal Government Guarantee Comprehensive Medical
Care For All Americans?" And now, for the case against. Mr. Rusher, the
floor is yours.
The problem of rising medical costs is a real
problem. Thanks to the wonderful advances in medical science in the recent
years, medical care is inevitably more expensive than it used to be. In
addition, unfortunately, the government by pumping enormous sums of money
into the system on terms that actually rewarded wastefulness, has made the
situation infinitely worse than it would otherwise be. And that is exactly
why the Kennedy-Corman Bill is not the solution to the problem. It's a relic
of the days when people thought that the quick and easy-solution to almost
any problem was to turn it over to the government. In recent years, we have
learned the hard way, that government intervention often just makes matters
worse, and practically always makes them more expensive. The solution, as I
am sure you already sense, is not more government intervention, not
government controls to try to clamp a lid on the cost the government's own
expenditures are forever driving up. There are far better ways, and to tell
you about them, I call first on Mr. Walter McClure.
Mr. McClure, welcome to The Advocates.
Mr. McClure is a health policy analyst with
Interstudy, which is a medical system's research group based in Minnesota.
Mr. McClure, what in your opinion is the basic problem in the field of
health care in America today?
Mr. Rusher, there are many problems, but I think
the overwhelming problem is cost. Costs are rising at such a savage rate
that it is really threatening our ability to assure adequate health care and
health insurance to all Americans, especially disadvantaged Americans. Now,
not only is it threatening our ability to provide adequate health care, it
is also threatening other social priorities - - assuring adequate food,
adequate housing, adequate education, welfare, jobs. The cruel thing about
this is that there is no evidence that we are getting more health for this
vast medical care expenditure. There is substantial evidence that we could
do as well spending less.
But doesn't the Kennedy-Corman Bill solve the
problem of rising medical costs?
I doubt that. It seems hardly to me a serious
proposition to take a badly behaving industry and propose to turn it into a
giant bureaucratic public utility entirely financed, regulated and control
by the federal government as the solution to cost containment. Now, the
government has no track record on such things, but they do say they are
going to set these regional lids, and so let's try it out. What happens when
the system is cluttered by the worried well coming in to collect their free
The worried well. This is the British experience?
Yes...who are coming in to collect their free
care. Now expenditures begin to rise above the ceiling. What can the
government do but slash doctors fees, begin to close hospitals, and start to
stand the patients in line? Now, these patients standing in line, and these
angry doctors, and these upset hospitals are not going to be sitting on
their thumbs. They are going to be applying heavy political pressure and
what will the government do against that kind of political pressure? It will
do what every wealthy country has done. It will cave. It will raise the
ceiling and it will then deficit spend, or add new taxes in order to support
this supposed cost-contained system.
Is there an example of government control that
might give us some guidance?
Well, I think your examples of the Veteran's
Administration and the New York City hospitals are excellent examples. I
would simply point out in the meantime that this system will be heavily
bureaucratized if the government tries to do whatever it does, and that
health care dollars will not be advocated by reasons of efficiency, or even
by reasons of health deed. They will be advocated by the most powerful
political lobby, and I suggest to you the abortion issue.
If medical costs can't be held down by something
like Kennedy-Corman, is there a solution?
Yes, I think the real solution is to begin to
introduce into this badly behaved system, affective competitive forces and
consumer choice. Wow, for example, the airline industry which for 30 years
was totally regulated and price-controlled by the federal government,
decided to introduce a little consumer choice and competition last year, and
suddenly discovered that we could reduce the price of airfare to Europe by
almost half. The same kind of medicine would be extremely good for our
health care system. In our present system, there is no reward for either
consumer or provider to be efficient. If care is totally free, it makes no
difference whether I go to the most expensive doctor or the most efficient
doctor. If I am an efficient doctor and I avoid unnecessary
hospitalizations, and I avoid unnecessary tests, I am penalized. Now the
answer to this problem, it seems to me, is for government to create some
competitive pressures so that efficient doctors can organize health care
plans which will compete against each other in conventional insurance, and
if a consumer goes to that efficient set of doctors, agrees to do that, then
he gets a lower premium and more coverage. That kind of incentive rewards
the consumer for seeking the efficient providers and it rewards the
efficient providers because they get the patients. There is a lot of
evidence that that might do a lot better than free care from the
Thank you. No, no. Come back please. Stay with us.
We will go to Ms. Butler...Ms. Butler, some questions for Mr. McClure.
Mr. McClure, you mentioned the V.A. system. I hope
that you are not suggesting that the Kennedy-Corman Bill is embodying that
kind of a system, because we know that Kennedy-Corman would use the same
private doctors and private hospitals that exist today.
Ms. Butler, what I am suggesting is you have an
example there, one of the few examples that we have of a medical care system
which is totally under federal control. Now, I agree with you there, the
doctors are employees of the government, but let's not kid ourselves.
Whoever pays the piper calls the tune. You can call it non-government
medicine if you like.
Thank you. You also expressed the concern that
under the Kennedy-Corman proposal people will consider their health care
free, because it is paid by the government, and that they will seek care
wastefully and unnecessarily. Now, I find it very difficult to understand
how anyone likes standing in line in the first place, and particularly how
someone is going to seek unnecessary care. It's not my experience that
people go to the doctor when they don't need to. However, Kennedy-Corman
Was that a question?
...by doctors and hospitals and other providers,
so won't they be obligated to educate patients about how to use the
My feeling is that when doctors find that they
are paid by the government, they will consider themselves working for the
government, not the patient. And there is a fair amount of evidence of
bureaucratic systems where that is what happens. As for patients using the
free care, 1 would just ask you, perhaps you have had an experience in your
family or perhaps some of the viewers have had experience, when you get in
the hospital when it is all covered by Blue Cross, do you really worry about
the expense? I don't think so. In other words, it's not that people are
rushing to get medical care. It's simply that there is a spare-no-expense
mentality created where nobody worries about the cost. When it's all covered
why worry about what it costs? You like carpet on the floor, TV?
So, you are really suggesting the elimination of
private health insurance, it sounds to me. Let's talk a little bit about the
problem of cost that you acknowledge. In order to control costs, wouldn't
you agree, that it is better to budget in advance, require doctors and
hospitals, group practices to determine their costs in advance, and then be
forced to stick to that budget.
I think that the best way we have of containing
cost that is proven in this country is an effective competitive system. We
do not have an effective competitive system in our present medical care
system. That is the reason we are having the problems. I entirely share with
the Kennedy-Corman people their objective of assuring all Americans adequate
health care, adequate health insurance at a reasonable cost, sensible and
relevant to our other priorities. It is the means that I disagree on. I
simply find it unbelievable that the solution to this problem is to turn the
whole thing over to the government. That sounds like we've learned nothing
in thirty years.
Fine. Let's talk about competition, Mr. McClure,
because I think that, that's the real problem in your proposed solution.
Isn't it true that because patients are not the real consumers of medical
care, that giving them any kind of purchasing power doesn't provide the kind
of competition you're talking about, and that's because it's the physician
who controls the use of medical services. In fact, doctors generate about
80% of the medical care costs. It's the physician that we have to be
controlling and not the patient.
The physician is the gatekeeper, but he does
things with the approval of the consumer, or the patient. The patient must
approve what is done.
Your suggesting that patients make those kinds of
decisions about what a physician tells them.
If I don't want what a physician recommends, I go
to a different doctor. What do you do?
I'm afraid that most people don't feel themselves
sufficiently sophisticated to one-up their physician and they
Are you saying that the government should second
May I answer your question?
I'd like to ask you one final question, and that
is that the Kennedy-Corman proposal will change the behavior of the
physician by imposing that kind of fixed budget, and it will be the
physician's responsibility to allocate medical resources according to that
fixed budget. Isn't that so?
I certainly agree that it will change his
behavior. He will now work for the government, instead of the patient.
Thank you. Mr. Rusher, another question
And if anything that Mr. Fine described about the
contents of the bill is correct, he is also going to have a weather eye
cocked on his local medical society, isn't he?
That sounds correct.
We are going to have, in other words, a medical
bureaucracy involved here.
I think that is what generally happens when
government try to take over or regulate an entire industry.
Thank you. Ms. Butler, one more question. Please
stay with us Mr. McClure. He's promised to stay with us for one more
I'd just like to know if you favor co-payments and
co-insurance upon the patient, and isn't that really once again, putting the
burden on someone who does not have the sophistication or the actual ability
to make these choices?
Ms. Butler, I may not be the best judge of
medical care, but I don't think that there is anybody I'd rather have make
that decision for me, and I give that right to all American people. I would
rather spend my own money for the medical care that I want. I do not want
the government to take my money away in taxes and say this is the medical
care you will get, regardless whether you want it or not.
Thank you. I am sorry Ms. Butler. All right Mr.
McClure, you can go now. Thank you for joining us on The Advocates. Mr.
I call my next witness, Congressman Philip
Welcome to The Advocates, Congressman Crane.
Mr. Crane is Congressman from the 12th district of
Illinois, the northern suburbs of Chicago, and is a member of the Health
Subcommittee for the House Ways and Means Committee. Congressman Crane, what
in your opinion is the worse single feature of the Kennedy-Corman
I think the worst feature of the Kennedy-Corman
Bill is the human suffering that will inevitably attend politicization of
medicine, and I think we have the examples to illustrate that point. When
you have politicians making the determination about how you will allocate
scarce resources, in this case public money, you are going to have decisions
that will be based on factors other than the immediate concern of the need
of patients who are ill. We have examples. A number of us visited the
British National Health Service, and while our friendly adversaries here
would endeavor to draw some fine distinctions between national health
insurance, and National Health Service, there are certain similarities. The
similarities involve the political judgments made. And in the British Health
Service, we had an example while we were there on the front pages of the
papers, of a woman who needed heart surgery, and they inevitably had to
ration the service to guarantee free service to one and all. The woman got
an appointment. They had limited bedspace and facilities. They rescheduled
her three months hence. She came in at that time; inadequate heart surgeons
available. They re-scheduled her a third time and they called her the day
before her third appointment to re-schedule her again, and she died at home.
And I think that's the kind of phenomenon that inevitably is the result of
allocating those dollars based on political judgments rather than precede
needs by individuals.
Her lack of a doctor was more of a problem to her
than her lack of sophistication, to use by opponent's term.
What other costs are there? You've spoken of the
cost of human suffering?
Well.. I think from a realistic point of view, and
I'm speaking now from the political perspective, you're talking about dollar
costs that are astronomical. In fact, the additional dollar cost of
Kennedy-Corman, on top of what the government is already spending on health
care in this country, is approximately $130 billion. Now, that would
represent an immediate 25% increase in every American's taxes, and you saw
what the Congress did in response to the 5% proposed tax increase under
Social Security. I didn't vote for that but my colleagues on the other side
of the aisle did, and they have been scrambling ever since, to go back and
repeal that action in the face of voter antagonism.
Rushing ahead just a bit, since time is short. We
heard from both, of the witnesses on the other side, particularly Mr. Fine,
the great problem of the lack of coverage for whole large categories of
Americans who only had insurance if they were run over by buffalos, and
things like that. Would you tell me please how serious is the problem
presently, of lack of coverage, and how best could it be solved?
Well, I think any humane person would say any
single individual who is not covered constitutes a problem. On the other
hand, what you're realistically talking about it 6% of the American
population that has no coverage at all. And that is about 12.2 million
people by a recent survey. And I would only argue that you don't throw out
the baby with the bath water. There are ways of addressing that problem,
realistic ways, ways that can be supported financially, and without imposing
the incredible kind of taxation that's contemplated under this
And without charging $130 billion.
Lastly and briefly, is there any other defect of
the Kennedy-Corman Bill or problem that you see with it?
Well, there's one that British physicians told us
about when we were in Great Britain, and that is once you sever the
connection between doctor and his patient and as was mentioned in early
testimony, that physician is then working for a different provided of his
income, you've lost something infinitely precious in our current health care
system. And so- there is a disposition for a rather calloused and
indifferent approach to treating that patient. And I think anyone who served
in the army, particularly, has had some experience with the kind of
solicitous treatment you are going to get from a physician or dentist in the
You don't take very seriously the supposed
distinction between the man, who is on the outside, but working for
Ms. Butler, some questions for Congressman
Yes. Mr. Crane you've made quite a point of the
experience in Great Britain. As we know, the British Health Service has been
in existence since just after World War II, and a health insurance program
in that country since 1912, and there are no moves whatsoever to repeal that
system or to alter it. And, as I understand it, the British people have
overwhelmingly indicated their strong support of that system.
Is that why one-third of every graduating class in
Britain's medical school immediately leaves the country, and the brain drain
is now up to 45 years olds.
Well, as I understand it, as a matter of fact, the
British system has developed a number of extraordinary medical technologies,
and it is very innovated.
Oh yes, in fact, that's a very good point you
raised. They invented the CAT scanner the device that detects brain tumors
and brain cancers. When we were there three, years ago, the British National
Health Service had purchased only one, and had none on order for 50 million
people. There were roughly 90 that had already been purchased in this
country, and 100 on order at that time. At the present time, there are more
CAT scanners in the city of San Francisco than in the entire British
National Health Service today, which is another one of the faults of the
And of course, I am sure, that you would be the
first to point out that the
CAT scanners proliferating in this country have
increased tremendously the
problem of medical care inflation. Let's talk a
little about the tax
increased problem that you assert. You claim that we
will be adding
$130 or $140 billion to the federal budget for medical care.
this true, that this money is not new money, but money that we
currently spending on insurance premiums; out of the pocket for
care and we'll just be shifting the money we already spend to a
payer, in this case the federal government, and spend the money
equitably and more economically.
That is the theory behind it. I think that has to
be demonstrated in practice because even in the British National Health
Service, there are people who are paying confiscatory levels of taxation who
will not go to the British National Health Service and stand in line waiting
for years to get a hernia operation. But I think in addition to that, there
are many Americans, millions of Americans today whose insurance premiums are
being paid by their employers. Now those workers are going to get the
immediate impact, instead of having it paid by their employer, of a 25% hike
in their personal taxes.. It's an insupportable tax increase.
What is your answer to cutting the cost of medical
care? We've heard that Mr. McClure favors some sort of a program of changing
organization of medical care, but we haven't heard anything that you would
Well, how much time do we have?
You know we ideally should devote a whole program
to alternatives, and sensible and intelligent alternatives to the program we
are suggesting tonight. I think that the inherent deficiency of the program
that we are discussing tonight is enough to reject it. There are problems
that can be addressed in intelligent ways. Tax credits have been thrown out
I think, in earlier testimony, as one way of dealing with it, an extension
of the coverage for those limited individuals who are in the categories that
will sustain potential catastrophic coverage. There are rifle shots, in
other words, that can be directed at specific problems. That's what we
should be jointly working on.
Sounds to me like a shotgun approach alright, and
I don't understand how that is going to solve the problem...
No, that's rifle shot.
...of access to care for people who need it.
Well, certainly, because we define who the people
are. And that, in fact, we have worked on in committee. We had a specific
case in point, when we had the higher unemployment rates and the extended
periods of unemployment of some of those people who before they found new
employment after they were laid off, their insurance coverage expired. They
were people who fell between the cracks. We identified those people,
endeavored the draft legislation to deal with their specific problem.
But that won't provide any kind of medical
services in areas of the country such as rural areas and ghettos, where
there are no physicians that refuse to practice there.
Well, let me put that problem in perspective. We
have 3084 counties in the United States. One hundred thirty-two are
doctorless, and two tenths of one percent of our population live in those
doctorless counties. Now to be sure that's a problem, but even Great
Britain has a maldistribution problem with thirty years of socialized
medicine. The Soviet Union has a maldistribution problem, not withstanding
the fact they can persuade a physician to go practice in Siberia, at bayonet
All right. Mr. Rusher, one more question
Congressman Crane, is the matter of crossover or
just the change of money from one pocket to another really the truth? Isn't
it a fact that they are going to be enormous increases administrative and
otherwise with respect to any such programs, put into effect?
Well, in the preliminary remarks by our lovely
moderator here, the reference was made to the astronomical increases in the
cost of health care in this country. I would only remind you that about
twenty years ago, we were paying 3 cents for two-day delivery, first-class mail,
and now we are contemplating 16 cants first-class mail and in addition to that
the possibility of three-day-a-week delivery. I think there are some very
distinct parallels that can be drawn between what has happened there, and
what one can reasonably expect from government medicine.
Thank you. Ms. Butler, one last question from
Mr. Crane, do you believe that health care is a
right and should be afforded to all Americans, regardless of whether they
have the ability to pay?
I think every physician who goes through medical
school takes the Hippocratic Oath that recognizes that he has an obligation
to treat people in need. Now we have created problems in providing or
fulfilling that need. The old phrase, "Is there a doctor in the house?", for
example, was a call that went unheeded after physicians started to get
penalized in the courts for giving immediate care and not following up on
I don't understand how that has any relationship
to the problem of people who can't pay for care?
Well, in response to your question, I would say
that if you have the ideal situation and that's Mark Hopkins' ideal teaching
situation, that's a patient on one end of the log and the doctor on the
other. And so in terms of fulfilling that right you've defined, it's a
question of whether you have the adequate personnel and the adequate
facilities, and I would argue Kennedy-Corman is guaranteed not to enable us
to provide those facilities.
That's all we have time for. Thank you, Ms.
Butler. Congressman Crane, thank you for joining us on The Advocates. And
now, let's go to our closing statements. Ms. Butler?
If we pretend that old-fashioned competition will
lower the costs of medical care, we're just fooling ourselves. Moreover,
old-fashioned competition can never bring medical care to everyone, and cur
opponents know it. Timid, half-hearted measures will never curb a bloated
industry's appetite for dollars. Not when it's the doctors and the hospitals
who alone decide what they can charge. Our national health insurance
proposal has the strength, the imagination and the courage to make our
health care system truly service all, and save us money. It will minister to
our sick economy by controlling costs through a national budget for health
care, and through incentives that will reward doctors and hospitals not for
extravagance, but for good service and economy. When our proposal goes to
work, no one will ever again awake from needed, surgery, to the nightmare of
being handed a bill he hasn't the means to pay.
Thank you. Mr. Rusher?
The choice before you tonight is not a choice
between health care and the lack of it, it is a choice of, between health
care agreed on between doctor and patient and financed in a way that makes
both of them conscientious of the costs. And health care supply, under a
rigid guideline, laid down by a board in Washington and financed in a way
that will make everyone concerned completely indifferent to the costs. So
indifferent, in fact, that a special system of controls has been specially
added, to the bill in a desperate attempt to keep them from going through
the roof. Such controls have been tried in this country repeatedly, as you
heard. They have never worked and they won't work now. The Kennedy-Corman
Bill is dying on the slopes of Capital Hill tonight, because it has been
recognized by just about everybody for what it really is. A sweeping
bureaucratic bid to bring all of American medicine under central government
control at a cost vastly higher than the American public either needs or can
afford to pay. Don't sit this one out, ladies and gentlemen. Vote no.
Thank you. And now we turn to you, the audience,
and ask what you think about the questions raised in tonight's debate.
"Should The Federal Government Guarantee Comprehensive Medical Care For All
Americans?" Send us you vote, yes or no, on a postcard to: The Advocates,
Box 1978, Boston, 02134.
In February, The Advocates debated the question, "Should
The United States Support Self-Determination For The Palestinians In A
Middle-East Peace Settlement?" The Advocates' audience responded in this
way: 1782 in support of self-determination for the Palestinians, 5977
If you would like a transcript of tonight's debate, or
transcripts of our previous debates, please mail a check or money order for
$2 to that same address: The Advocates, Box 1978, Boston, 02134.
Two weeks from tonight, The Advocates will return to
debate a question of super power diplomacy and global strategy, "Should The
United States Reject Detente As Its Strategy In Dealing With The Soviet
And now, with thanks to our advocates and their
distinguished witnesses, and our audience, we conclude tonight's