[Congressional Record Volume 141, Number 2 (Thursday, January 5, 1995)]
[Senate]
[Pages S516-S518]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


                         ADDITIONAL STATEMENTS

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                   AN INTERVIEW WITH QUENTIN D. YOUNG

 Mr. SIMON. Mr. President, one of the people who has been 
calling for justice in the field of health care in this Nation for many 
years is Dr. Quentin Young.
  Recently, he was interviewed by the Christian Century, and that 
interview was published. It contains so much common sense that I hope 
some of my colleagues will read what he has to say.
  I ask to insert his comments at the end of my remarks.
  A person does not have to agree with everything that he mentions in 
his interview to recognize that we should be doing much better and that 
our friends in Canada are doing much better.
  My conversations with Canadian Members of Parliament suggest that 
there are some improvements that we could make on the Canadian system, 
if we were to adopt a similar system. To suggest, as have so many in 
our country, that the Canadian system is a failure, is an outright 
falsehood. It is of interest that not a single Canadian Member of 
Parliament has introduced legislation to repeal the Canadian system.
  The article follows:

  Health Reform and Civic Survival: An Interview With Quentin D. Young

       (Since his days as a medical student at Cook County 
     Hospital in Chicago, Dr. Quentin D. Young has been engaged 
     professionally and politically in issues of public health. 
     Currently clinical professor of preventive medicine at the 
     University of Illinois Medical Center in Chicago, Young is 
     also national president of Physicians for a National Health 
     Program. He has been a leading and tireless spokesman for 
     health care reform. We spoke with him recently about the fate 
     of the Clinton health care proposal and the alternative of a 
     single-payer insurance system like Canada's.)
       A year ago many people had high hopes for health care 
     reform. It was at the top of President Clinton's agenda and 
     it seemed to have widespread public support. Now the issue is 
     dead, and perhaps a crucial political opportunity has been 
     lost. What went wrong?
       President Clinton produced an enormously complicated 
     proposal, which left him vulnerable to attacks from across 
     the spectrum. Those of us who support a single-payer plan 
     thought that if the reform had been enacted the way he 
     proposed, it would have been a dreadful disappointment and a 
     step backward. By going the route he did, he was forced to 
     rely on the whole insurance infrastructure and a real 
     nightmare of managed competition. All these huge bureaus he 
     proposed--they invited ridicule and defeat. From his public 
     and private comments it is clear that he understands the 
     redundancy and the parasitic role of the insurance industry: 
     it adds nothing to the product and subtracts mightily. 
     (Basically insurance agencies and conglomerates are in the 
     business of finding reasons not to give care.) So in light of 
     that, his proposal showed a lack of courage. Another form of 
     cowardice was that he didn't come right out and call his 
     mandated premium--which had all the force of law--a tax. So 
     that's the President's contribution to the failure of reform.
       The decisive factor was the appalling undermining of the 
     democratic process that took place in Congress. At least $150 
     million were spent on lobbying, on polls, on onslaughts from 
     small business groups and others. In the face of this 
     pressure, Congress became impotent. I think that viewing this 
     activity intensified people's dislike of the political 
     process. And I also think that there's a little bit of 
     concern by those involved that perhaps the lobbyists engaged 
     in overkill--that they created a sense of futility among the 
     public. And power elites usually don't like to see a sense of 
     futility among the public. Nor is it wholesome from the point 
     of view of a reformer.
       The conventional wisdom was--probably still is--that a 
     single-payer plan is politically unfeasible.
       Well, the route Clinton tried was politically unfeasible. 
     His proposal couldn't have done any worse than it did. And 
     winning isn't the whole thing. The big changes that have 
     occurred in American politics--the abolition of slavery, the 
     adoption of unemployment insurance and social security--did 
     not happen in one swift action. There was a buildup of 
     popular pressure and finally a breakthrough.
       [[Page S517]] A battle over a single-payer plan would have 
     clearly defined the issues, as is happening in the debate 
     over the referendum on universal coverage in California. They 
     are having a huge David-and-Goliath fight against the same 
     forces that defeated the Clinton plan, because those forces 
     know that if California should miraculously pass such 
     legislation, then the game is over. In Canada in 1967 
     Saskatchewan passed health insurance legislation, and two 
     years later Alberta did. In '71 the Tory Parliament in Ottawa 
     voted unanimously for Medicare, which is what they call their 
     national single-payer system. And, of course, the rest is 
     history.
       It's clear that you regard Canadian experience as a success 
     story.
       Canada has a humane, fair, extremely popular system. It 
     does better than we do in longevity and infant mortality and 
     most other health indices. Its achievement in cost 
     containment is very simply summarized. Twenty-three years 
     ago, before Canada initiated its reform, the U.S. and Canada 
     were both spending 7.1 percent of their respective GDPs on 
     health care. Now Canada's spending has risen to 9.5 percent--
     not a tiny rise, but nothing like our rise to about 15 or 16 
     percent, with no end in sight.
       Whenever we talk about implementing a single-payer plan 
     like Canada's that aims both to offer universal coverage and 
     to cut costs, don't we have to talk also about putting limits 
     on services? And that's what scares people. We don't like the 
     thought of needing a heart bypass operation and being 315th 
     on the list.
       There has been an inordinate amount of Canada-bashing and 
     exploitation of fear on this topic. The short answer is that 
     that kind of denial of care can't possibly happen in the 
     short run. We're spending about a trillion dollars per year 
     now on health care, and the figure is rising. That's a per 
     capita expenditure that's 40 percent higher than Canada's--so 
     in terms of funding we would have 40 percent more available 
     if we were to adopt their system. If you suddenly were to 
     give the Canadian system a thousand dollars more per capita, 
     then any problems of rationing would be solved.
       In the U.S. under single-payer you'd immediately get a 
     minimum of $100 billion available for health care by 
     eliminating the waste in the insurance system. That's what 
     Canada experienced when it initiated its reform. Canadians 
     used to devote 11 percent of health costs to health insurance 
     administration--which is what we spend. Now Canada spends 
     less than 1 percent on insurance administration.
       Add to that the benefits of negotiated fees with doctors. 
     Many billions of dollars are truly squandered on excessive 
     fees, breathtaking fees--a half hour's work is rewarded with 
     $2,000 or $4,000. That's ridiculous.
       The problems of the Canadian system, compared to ours, are 
     trivial. More to the point, whatever problems it has involve 
     a relative shortage in the area of high technology. That's 
     precisely the area in which we have too much--literally too 
     much equipment and too many specialists. This is a burden on 
     the system. No reform will work until we rectify this 
     problem: 75 to 80 percent of our physicians are specialists, 
     only 20 to 25 percent are in primary care. The ratio should 
     be 50-50, possibly 60-40 primary care. Those are the kinds of 
     problems the marketplace gives us. Specialties offer the 
     higher rewards.
       A third source of savings with single-payer is that you 
     could really control the laissez-faire medicine that is 
     supposedly controlled by managed competition. I'm speaking, 
     for example, about unnecessary surgery. About a third of 
     hysterectomies performed in the U.S. were unneeded. There's 
     thousands of dollars and harm to patients that could be 
     saved. We're doing twice as many Caesareans as needed. At 
     least 20 percent of coronary bypasses shouldn't have been 
     done. So I don't think we have to ration yet if we eliminate 
     these problems.
       In the year 2010 it may be different. People are living 
     longer. There is no question about the correlation of age 
     with medical utilization. And scientists keep coming up with 
     more and more complicated things that we can do to help 
     people, which always adds big costs. But on the other end of 
     the spectrum, you wouldn't have to treat some people at all 
     because you've immunized all the kids and you will have early 
     detection of breast cancer, and so on.
       One often hears reports that wealthy Canadians come to the 
     U.S. for treatment--the implication being that care here is 
     quicker and better.
       I'm sure Canadians went to the Mayo Clinic and to Johns 
     Hopkins before there was mass health reform and they probably 
     do now. Many Americans are going to Canada for care. But the 
     crucial thing is that 99 percent of the health care the 
     Canadians receive is under the system, which maintains high 
     standards of research and training.
       One of the very important characteristics of single-payer 
     as it's played out in Canada, which I concede is due to its 
     parliamentary system of government, is the fact that every 
     week in each of the provinces and in Ottawa the minister of 
     health has to face questions and complaints--``Mrs. Jones 
     spent six hours in the emergency room'' and so on.
       Also, it is illegal in Canada, as it would need to be under 
     single-payer legislation here, for a private insurer to offer 
     a benefit that is covered under the plan. If you allow that, 
     you begin to undermine the system. You have to have everybody 
     in it--particularly the elites. They will guarantee the 
     product. They will see that by and large there's equity, 
     there's high quality, there's a way to correct incompetence.
       This point came home to me when I was on a radio show with 
     an Anglican archbishop from Canada. He talked about the 
     danger of Canada's being torn apart by the Anglophile-
     Francophile issue, and how a survey was conducted to see what 
     makes Canadians feel patriotic, what brings them together in 
     the midst of division. And way up at the top in the poll, for 
     Canadians of all stripes--including those in Quebec--was the 
     national health system. Here's a civic adventure that has 
     brought people together. Compare that to the U.S. system of 
     tooth and claw, of fear and bankruptcy and denial.
       One of the reasons physicians and patients in the U.S. are 
     wary about government-run health insurance is that they 
     suspect it will mean an unreasonable limit on physicians' 
     autonomy.
       One of the benefits of single-payer is that, with 
     everything going through the same computer, as it were, you 
     can easily create a physician profile, noting frequency and 
     interval of patient visits, number of ECGs prescribed, and so 
     on. With this profile you can easily begin to see the doctor 
     who is off the charts--who's doing three times the average 
     number of ECGs, for example. That's a place to look for 
     saving resources without oppressing physicians.
       U.S. doctors already face scrutiny, but of a different 
     kind: we doctors have an insurance person at the other end of 
     the line from whom we have to get permission to practice 
     medicine. Sometimes the line is busy, sometimes you're put on 
     hold, and finally when you talk to the person she needs to 
     have you spell the diagnosis that you're getting permission 
     to treat. Not a happy scene. Do that three or four times in 
     an afternoon and you wonder why you went into machine.
       The insurance system has transformed doctors into 
     technicians and given them some incredible restrictions. HMOs 
     sometimes forbid doctors from discussing treatment options 
     that aren't available under the plan. That violates the 
     principle of informed consent, central to any real patient-
     doctor relationship.
       I can give myself as an example of the need for appropriate 
     scrutiny. I was trained at Cook County Hospital in the late 
     1940s and '50s when one-third of the hospital beds were 
     dedicated to TB. We used to do X-rays on these patients every 
     week--it was the only guide to how someone was doing. And it 
     became an article of faith that one had to do a chest X-ray 
     of every new patient, certainly of every over-40 urban 
     dweller. About five years ago a younger colleague told me 
     that there's no medical justification for doing this. Routine 
     chest X-rays of people who have no symptoms are simply not an 
     effective diagnostic tool anymore. I was acting out of my 
     experience and training. But my old-fashioned approach had 
     ceased to be good medicine.
       You mentioned your own medical training. As you look back, 
     do you recall any particular experience that galvanized your 
     concern for reforming the way health care is delivered?
       Well, certainly training at Cook County was part of it. 
     It's a big public hospital that deals with an endless sea of 
     patients--1,500 a day come through the doors in every state 
     of malady: end-stage Alzheimer's, gunshot wounds, bad colds, 
     gallbladder problems, cancer. Whatever there was, County had. 
     And you see the most disenfranchised, the most impoverished, 
     the wretched of the earth. I was just a middle-class, kind of 
     liberal person, but it became clear that a doctor at County 
     could adopt one of two philosophies--and the staff was about 
     evenly divided along these lines. About half the doctors felt 
     that they were witnessing divine justice, a heavenly--or 
     Darwinian--retribution for evil ways, for excesses in drugs, 
     in booze and everything else. Patients came to the hospital 
     with their breath laden with alcohol, with needle marks on 
     their arms, their babies illegitimate and all the rest. The 
     other half decided that here was the congealed oppression of 
     our society--people whose skin color, economic position, 
     place of birth, family size, you name it--operated to give 
     them a very short stick. When you saw them medically and 
     psychologically in that broken, oppressed state, it was clear 
     that you had to address issues of justice, not just medical 
     treatment.
       I had to decide which of these value systems was fair and 
     just, and which one I could live with. It seemed to me the 
     first approach is judgmental and harsh and simplistic. Taking 
     the alternative view gave me a shot at being a part of the 
     human race. And taking that view also accounts for my 
     optimism. While we are not a noble species, I've seen 
     evidence that when people are given the opportunity they can 
     be very noble. People get bigger than themselves, take risks, 
     are altruistic. I've been privileged to be in a few of those 
     moments, like the civil rights movement. That little kernel 
     of altruism, which may account for .002 percent of everyday 
     behavior, at times expands to be 100 percent for that day, or 
     that week. My notion, both as a doctor and as a citizen, is 
     that you have to expand that altruistic fraction.
       When we interviewed former Surgeon General C. Everett Koop 
     about health reform, he said at one point that a central 
     issue is the simple question, ``Am I my brother's keeper?'' 
     Is it fair to say the American public, or a large section of 
     it, has basically said no to that question?
       [[Page S518]] It's not fair to say that. The polls keep 
     saying that Americans want universal care. They even say 
     health care is a human right, which of course it isn't. It 
     is, at best, an implied right the way privacy is.
       There's a dialectic to being one's brother's keeper. It 
     isn't simply, ``Christ asserted it and therefore it's 
     right.'' It's a living thing. I don't have the credentials to 
     be theological, but I do think that the act of taking care of 
     everybody in our health care system will make us our 
     brother's keeper. It will emancipate us to attack the other 
     enormous problems that we must solve. We can't have people 
     hungry every night. We can't have children uneducated. But we 
     do. We have to stop that. We won't survive otherwise. And 
     nowhere is it written that every society survives. It's 
     written somewhere that they all perish. And we've got all the 
     credentials to go down the road to oblivion--not tomorrow or 
     the next day, but not necessarily very much later. Time is 
     running out.
       You are putting health care reform in the context of a much 
     larger moral crisis.
       I do see health care reform as crucial to national civic 
     survival. Consider some of the huge problems we have: air 
     pollution, waste disposal, failed schools, homelessness, 
     crime in the streets, hunger. The common denominator is that 
     there are no resources available to solve these problems 
     beyond what's already out there. Then consider health care, 
     which is the biggest problem, and one that affects everybody. 
     Homelessness affects those who have to live around the 
     homeless, and it affects some sensitive people, but otherwise 
     the problem belongs to the people who are homeless--and so on 
     with all the problems I mentioned. But when you get to 
     health, it's everybody's problem--if not today, then 
     tomorrow. And it's the only social problem that we can fix 
     using the resources--manpower, facilities, expenditures--we 
     already have in place.
       I don't want to be apocalyptic, but I think the case can be 
     made in terms of the national mood--the polarization, the 
     hate, the despair, the dissatisfaction with the political 
     process--that health care reform offers us our last best 
     chance to restore a sense of civic life and civic 
     responsibility.
     

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