[Congressional Record Volume 145, Number 65 (Thursday, May 6, 1999)]
[Extensions of Remarks]
[Pages E900-E901]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




               NEW DIRECTION FOR OUR NATION'S HEALTH CARE

                                 ______
                                 

                       HON. JANICE D. SCHAKOWSKY

                              of illinois

                    in the house of representatives

                         Thursday, May 6, 1999

  Ms. SCHAKOWSKY. Mr. Speaker, ``The crisis in American health care is 
real and getting worse.'' Those words appeared in an editorial today in 
The Washington Post, written by two distinguished scholars, former U.S. 
Surgeon General C. Everett Koop and John C. Baldwin, vice president for 
health affairs at Dartmouth College.
  I hope my colleagues will take a few minutes to read about the state 
of health care in our nation. Dr. Koop and Dr. Baldwin pointedly stress 
that universal access to health care must become a national commitment 
and will require a national investment. As important, they argue 
against the idea that health care should be treated as a commodity, 
saying that ``(w)e must rid ourselves of the delusion that it is a 
business, like any other business.''
  At a time when 16 percent of Americans have no health insurance, 
health care costs are skyrocketing, and medical decisions are made by 
HMO executives beholden to shareholders, bold solutions are needed. As 
Dr. Koop and Dr. Baldwin state, ``(o)ur problem is a failure of 
distribution, a failure to extend care to all of those who need it and 
a failure to recognize the importance of applying scientific rigor to 
the problems of broad-based health care delivery. If state-of-the-art 
American medicine were offered to our citizens in a comprehensive way, 
our levels of public health would be unexcelled.''
  They also recognize that we can not continue on our current path, to 
spend more than any industrialized nation in the world while providing 
less. Correctly, they conclude that ``the movement over the past few 
years to turn health care into a `business' through health maintenance 
organizations and other stratagems has not worked to the satisfaction 
of most Americans.'' Indeed, it is time for a new direction.
  The crisis in American health care is real and getting worse. A 
record 16 percent of Americans now have no health insurance--a grave 
situation that will not be solved by conventional business models. 
Indeed, the movement over the past few years to turn health care into a 
``business'' through health maintenance organizations and other 
stratagems has not worked to the satisfaction of most Americans.
  Frustrated, legislators across the political spectrum pursue the 
notion that legislative tinkering will solve the problems. But since 
the derailment of President Clinton's health reform plan in his first 
term--and particularly since the elections of 1994--the country has 
slipped or been lulled into a false sense of confidence that the real 
and worsening crisis in American health care can somehow be solved by 
implementation of ``reforms'' based on such euphemistic concepts as 
``gatekeepers,'' ``pathways,'' ``preexisting conditions,'' ``risk 
pools'' and other impediments to access--all disguised as tools of 
efficient management.
  To be sure, health care costs have risen too rapidly in the past 20 
years. Highly paid providers and administrators and exceedingly 
profitable health care corporations have played a role, though their 
contributions to rising costs have been less important than the effects 
of an aging population and the continual introduction of new 
technologies. But we must not abrogate our responsibility to make 
difficult choices in the vain hope that a ``free market,'' profit-based 
system somehow will solve the problem for us without our doing 
anything.
  If health care were a business, it would be a strange one indeed--one 
in which many sectors of the ``market'' could never be profitable. 
People with AIDS, most children with congenital, chronic or 
catastrophic illness, poor people, old people and most truly sick 
people could never pay enough to make caring for them profitable.
  Over the past few years, nevertheless, we have often heard that 
``health care is like any other product; you buy what you can afford.'' 
Most proponents of this idea quickly add that of course ``basic'' 
health care should be provided. But what does this mean? Suppose two 
children, one in an uninsured family and one in a well-insured one, 
both developed leukemia, a treatable and often curable illness. What is 
the basic level of care each child is entitled to?
  HMO executives properly emphasize that their responsibility is to 
shareholders. That responsibility is defined in terms of profit and 
stock price. The volume and market-share considerations in this 
``business'' require aggressive pricing. Sustained profits, in turn, 
require aggressive cost-cutting. This results, inevitably, in 
restriction of access and withholding of care.
  Both these things may well be necessary to improve efficiency and cut 
costs. But do we really want to relegate such decisions to analysts 
within the health care industry, or should we assert the public 
interest in these crucial ethical, societal and medical issues?
  We nod our heads when we are told that the percentage of our GNP 
spent on health care is ``too high'' and that inefficiency, the ``fat'' 
in the system, results in its providing less effective care than is 
available in other industrialized nations that spend a lesser 
percentage. But this argument is specious. The American biomedical 
research endeavor, supported in the main by the taxpayers, had led the 
world for more than 30 years and continues to do so. Attendance at any 
medical scientific meeting anywhere in the world confirms this hegemony 
and affirms the enormous respect the rest of the world has for American 
medicine.

[[Page E901]]

  Our system is not a failure. The dramatic decline in deaths from 
heart disease is salient evidence for the phenomenal success of 
technologically advanced American medical care for those who can afford 
it. Our problem is a failure of distribution, a failure to extend care 
to all of those who need it and a failure to recognize the importance 
of applying scientific rigor to the problems of broad-based health care 
delivery. If state-of-the-art American medicine were offered to our 
citizens in a comprehensive way, our levels of public health would be 
unexcelled.
  Like education (also, in important ways, not a business), the public 
health is a national investment and a crucial one. Could we justify a 
``privatized'' educational system that denied access to slower learners 
unable to pay--i.e., the children who need help the most? When you 
consider that we spend more on leisure than on health care (22 percent 
more just on recreation, restaurant meals, tobacco and foreign travel), 
is the percentage of the GNP we spend on health care really so 
inappropriate?
  The failure in distribution of health care is the product of our 
tacit acquiescence in the notion that health care access rightly 
depends on ability to pay. This idea has become, for many, a point of 
philosophical and ideological zeal.
  It is long past time we acknowledged that broad-based access to 
health care will be an exceedingly expensive proposition. We must rid 
ourselves of the delusion that it is a business, like any other 
business.
  The problem can be fixed. Forming a public consensus on this matter 
is a mighty and politically perilous challenge, requiring leadership 
and the courage to state that adequate health care is an appropriate 
goal for this country and a vital national investment. These are, 
indeed, treacherous waters. Can we get away from the cliches about 
``socialized medicine'' and the hackneyed references to overly 
bureaucratized, centralized, inefficient postwar European health 
systems?
  As world leaders in science, business and organizational management, 
we are capable of something new. We should maintain our commitment to 
the advancement of biomedical science for the public good and couple it 
with the management skills that have created our vibrant, competitive 
economy, and apply both in creating a national policy of investment in 
health.
  John C. Baldwin is vice president for health affairs at Dartmouth 
College and dean of its medical school. C. Everett Koop is senior 
scholar at the Koop Institute there and a former U.S. surgeon general.

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