January 21, 1974
Page 59
HEALTH CARE IN AMERICA
Mr. RIBICOFF. Mr. President, on January 17, 1974, our distinguished colleague from Maine, Senator MUSKIE, delivered the keynote address to the Northeastern Pennsylvania Regional Governor's Health Conference and Hearings in Wilkes-Barre, Pa.
Senator MUSKIE's speech includes a broad and careful analysis of the problems – and some possible solutions – in our development of health resources, health delivery systems, and equitable health care financing.
Senator MUSKIE's speech serves as a thoughtful background for the important debate on health issues which we expect this year. I commend it to my colleagues and ask unanimous consent that it be printed in the RECORD.
There being no objection, the address was ordered to be printed in the RECORD, as follows:
KEYNOTE ADDRESS BY SENATOR EDMUND S. MUSKIE
JANUARY 17, 1974.
The core of our concern about health care has been well expressed by Governor Shapp: "To insure that every Pennsylvanian" – and, I might add, every American – "has access to high quality, comprehensive health care at a reasonable cost, regardless of geographic location or socioeconomic status."
We have a long way to go to achieve that goal. Our system is a success in many respects:
The dedicated men and women of the health professions have made great strides in the techniques of preventing and treating illness, injury, and disability.
Those who support and work with our health care system – those in research, health insurance, and government – have similarly labored to bring good health care to all Americans. Many Americans, as a result, receive excellent health care, at a cost they can afford to pay.
But too many Americans do not share that privilege, and the deficiencies of health care delivery and financing in America are grave enough that the system as a whole must be judged a national failure.
II
Let us take a look at it.
On the average, each American each year is disabled from some cause for about 15 days, and loses over five work days – and one out of ten spends time in a hospital.
Modern American living has created modern American health epidemics – like heart disease, which now is our number one killer, accounting for 750,000 deaths each year.
Increased awareness of our environment has brought with it awareness of environmental health hazards.
Inattention to health conditions in our places of work has led to the national disgrace of black lung, brown lung, grey lung.
And despite our rich resources, the traditional index of comparative national health – infant mortality – shows the U.S. lagging behind 14 other nations.
We have failed to provide adequate health manpower to serve our needs. Increasingly we have relied on graduates of foreign medical schools, who now make up almost 20 per cent of all physicians in America.
Although we may have made progress toward closing the manpower gap, we are still short some 50,000 physicians. And other health personnel are in short supply: overwork and under-staffing divert scarce nurses from lifesaving tasks, and inadequate numbers of emergency personnel literally may mean the difference between life and death in some areas.
More critical than the absolute supply of health personnel is their "maldistribution": Some rich communities have more doctors than they can reasonably use, while other areas – central cities and rural communities – are drastically "under-serviced."
In an increasing number of counties in the country – 140 in 1972 – there is no physician actively performing patient care. For the over one half million residents of these counties, a visit to the doctor – for a routine examination or for an emergency – requires a trip of perhaps hours to the next county.
Our programs to build health facilities have too often missed the real target. We have succeeded in building hospital beds to theoretically serve every American. But the fact is that they do not. Hospitals are over-concentrated in wealthy areas, with many communities shortchanged.
There is disproportionate construction of high cost facilities to service the patients of high-priced specialists, and too little support for serving community health needs through adequate outpatient and emergency care.
And when health care services are available in theory, they may not be available to the patient in fact. In many metropolitan areas, for instance, there may be no counterpart to the friendly care and advice of a competent local general practitioner, backed up by a well-equipped local hospital.
Instead, comprehensive health care requires a dizzying array of specialists, clinics, financial bureaucracies and social service agencies – each in a different location, each with their own forms to fill out, each able to deal with only a part of a patient's health needs. For some Americans this fragmentation of the health care delivery system makes it too inefficient and complicated to receive complete care. Indeed, the patient in effect must diagnose his or her own illness before calling the physician. The result is spotty care, or no care at all – when all the elements are potentially within reach.
And as dramatic as any other national failure is the scandal of the cost of health care in America. As a symptom of health cost inflation, our annual national health expenditures between 1950 and 1971 increased by $55 billion – but half of this increase went to pay rising costs, beyond the cost of providing for more services, and more patients.
These increasing health costs have created dramatic human tragedy. The pain of seeing a loved one paralyzed, or living out a terminal disease, compounded by the prospect of financial ruin and life long debt as hospital and medical bills mount to the tens of thousands of dollars.
Or escalating health costs can force a choice between health and other necessities. One elderly woman, testifying before the Senate aging committee's subcommittee on health of the elderly, which I chair, told how she budgeted her annual income of $2,295.80: after rent of $1,104 per year, and telephone, medicare, transportation, washing, insurance, and $15 per week for food she had a total of $20.54 for all her needs for the entire year: social expenses, dry cleaning, clothes, furniture, household items, shoes – and also for drugs and the doctor's fee – and today – the increased cost of heating her home.
Her very human comment. "I am not a statistic. I am a senior citizen, and I want the same good health care that everybody else would like to have."
Another senior citizen on social security told the aging committee a similar story in more concise, graphic terms. "My medicine runs about $50 a month," he wrote. "I am afraid I will either stop eating or taking medicine prescribed for me. I can't make ends meet now. I am not living, just existing ... As they say, it is hell to be poor."
These stories tell us that our health system is a failure. With our resources, it is fundamentally wrong for good health care to be assured to the affluent, but denied to less fortunate Americans.
The advances of medical science, the pleasant new hospital, the well-planned regional health delivery system, and the actuarially sound financing system are failures if sound, reasonably priced health care is still beyond the reach of the isolated rural resident, the elderly and poor without direction, the middle income family facing the financial reality of serious health problems, and the American without funds to buy the services of America's health care system.
III
Much of the challenge of solving our health care problems must be met at the local, regional, and State levels.
But the basic causes of national health care failures transcend local and State boundaries. A national commitment – at the Federal level – is required.
Much of what we have done at the Federal level has been useful and has achieved important successes. But there have been gaps in those efforts – and disappointments.
IV
1. For example, our health research effort has always focused on "hard" medical science. We have been inattentive, however, to less glamorous but equally pressing research needs, such as the relationship of the environment and our health, and the value of public health education.
2. Our programs to develop health manpower have been disappointing. We have enacted legislation to expand medical schools and to subsidize medical students themselves – most of whom, soon after graduation, enter the highest paying profession in America, with an average per capita income over $40,000. One of our purposes in providing a subsidy was to encourage young doctors to locate in medically-underserved areas. The program has not served that purpose.
3. We have made little progress in promoting the development of medical paraprofessionals. One promising concept, at work in my home State of Maine, is the use of medics – Vietnam-trained medical professionals – to provide patient care.
Another is the utilization of nurses as physicians' assistants and mid-wives. But some physicians are jealous of their exclusive prerogative to administer even the most simple patient care, and some nurses fear the increased responsibility of an expanded role. Increased reliance on the non-physician professional is necessary to utilize doctors' skills efficiently. The physician, the nurse, and the public must begin to accept new concepts and a wider range of skills in the uses of medical manpower – and those concepts must receive Federal support which has so far been inadequate.
V
We need to reform our health delivery system. Not long ago, most Americans assumed that the "delivery system" had something to do with obstetrics. Now we are familiar with the charges that the way doctors and hospitals are paid is outmoded, and that they are inefficient. And we fear that our health care system will become as impersonalized as a mail order catalogue.
No one has proposed doing away with the family doctor – in fact, the general practitioner is in short supply, and as a newly recognized specialty is receiving new emphasis.
But it is also a fact that the traditional system of the doctor practicing alone – specialists as well as GP's – has failed to provide adequate health care to millions of "under-serviced" Americans. It has made health care uncoordinated and fragmented. And it is costly in manpower and money.
What we do need is an alternative to solo practice – such as the Health Maintenance Organization, or HMO. HMO's consist, simply, of a group of doctors, with their assistants, who provide patients – or "members" – all basic health services in return for a periodic enrollment fee. Because any single visit to the doctor does not involve a large fee, and because HMO physicians have an incentive to keep members healthy to keep costs down, HMO members generally receive better preventive health care, and require less hospitalization and less surgery, than the general population. And to the patient shuttled from one specialist to another under our current system, or unable to find comprehensive health care at all, an HMO can provide more personalized care.
Congress endorsed the HMO concept last month by enacting a program to give Federal financial help to approximately 100 new HMO's over the next five years.
This legislation will create a nucleus – on which I hope we can expand – of health delivery organizations which can serve some of our population with great success, and provide a competitive alternative to encourage other health providers to give increased attention to cost savings, preventive health, and comprehensive services.
Other selective improvements in health delivery are also needed. I have introduced legislation, for instance, to make available additional home health care for the elderly. My bill would allow home health agencies to be reimbursed by medicare when their elderly patients can not care for themselves, but do not require constant skilled care. It would double the number of days of home health benefits available under medicare. It would correct the current situation where home health coverage is so limited that some patients are given the "medicare cure" – a few expensive but unnecessary days in the hospital, merely to qualify for additional benefits.
HMOs and home health care are two examples of how our health delivery system could be improved. Essential to both is the concept of expanding the alternatives available to the consumer, encouraging in the health delivery system the same diversity and innovation that exists in the rest of our economy.
But improving mechanisms for delivering health care won't provide enough help unless we improve our programs for paying the bills.
To do so on a scale which will – in Governor Shapp's words – provide access, for every American, to high quality comprehensive, reasonably priced health care, will require that we establish goals beyond those we have been discussing.
VI
One goal should be to increase Federal responsibility for the health costs of the elderly, the poor, and low-income Americans, who are denied good health because they cannot pay its price; and of the catastrophic victim, whose tragedy may mean financial ruin and debt.
The cost of medical care is particularly a burden on the elderly, who now pay out-of-pocket health costs higher than before medicare was enacted. Inflation in health costs has also meant inflation in medicare: Eight years ago, the initial hospitalization deductible the elderly paid before medicare took over was $40; by last year, it had increased to $72. Last month, I proposed legislation to prevent still another increase in the deductible and coinsurance. My proposal was adopted by the Senate, but did not receive final approval by Congress.
As a consequence, medicare deductibles and coinsurance increased on January first by 17 percent.
The elderly on fixed incomes, already burdened by inflation, are hard hit by escalating medicare costs, and the high price of items like drugs not covered by medicare. Medicare now protects the elderly from health care costs about as well as a leaky umbrella. I am hopeful that in the coming session of Congress we can adopt measures – like the medicare deductible freeze provision I have proposed – to patch some of those leaks.
The coverage of government health insurance for the poor – medicaid – also must be expanded. Medicaid eligibility and benefits vary inequitably from state to state. To allow the "working poor" – who now have minimal private health insurance – access to health care, Federal responsibility and standards for the program must be strengthened.
Also among our goals must be a program to provide effective catastrophic health insurance – security for all Americans from the threat of multi-thousand-dollar costs of serious illness or disability.
VII
But our goals must go beyond simply increasing the amount of health care costs for these individuals assumed by the government.
We must alleviate the burden of health care costs for the majority of Americans – by providing them with an equitable health financing system, and by putting a lid on uncontrolled cost increases.
Attaining this goal will require wholesale reform: a national health insurance system which not only includes full health coverage for all Americans, but at the same time forces those who provide health care to be fully accountable for the cost and quality of the care they provide.
VIII
The American health care system is an addict. It has an ever increasing appetite for money. And as we satisfy that appetite by paying for rising health costs without forcing basic reform, we run the risk that health care costs will bleed dry the financial resources of the majority of Americans.
Our experience with medicare and medicaid demonstrates that federally guaranteed reimbursement of health costs not only allows more Americans to receive more health care, but also artificially raises the price of health. As more people seek health care, doctors and hospitals raise their fees.
There is no effective mechanism – through the free market, or through the financing system itself – to check health cost increases. Since price increases are paid by insurance, and not by the patient directly, there is no immediate decrease in demand. And so price increases become fixed at higher and higher levels.
Resulting inflation not only threatens the federal treasury with spiraling costs, but also aggravates the burden of health costs for the majority of Americans, since private health insurance pays only part of their bills.
Expanding insurance also encourages doctors and hospitals to provide the most expensive (and profitable) kinds of care, instead of the comprehensive, low cost preventive services most effective in protecting good health.
We have made some progress toward instituting cost controls under medicare and medicaid. And by establishing regional professional standards review organizations of physicians, we hope to improve the quality of care financed by these programs. But only by establishing cost and quality accountability for our health care system – through national health insurance – can we bring costs under control for the majority of Americans.
IX
Cost accountability under national health insurance should include advance budgeting – so doctors and hospitals will plan how to provide the most health care for the money available. It should encourage HMOs and other less expensive forms of care for all communities. It should include incentives to coordinate health delivery, encouraging hospitals and nursing homes to combine their services, giving more options to the public and to physicians.
And a basic element of national health insurance should be coverage of all Americans, for all health care. Removing the price tag from health, while improving the quality of care, through national health insurance, must remain our central goal.
X
The more limited reforms we consider in Congress this year should be evaluated against that the central goal.
We should continue to improve Federal support for research in the traditional medical sciences, and expand our effort into new areas of inquiry like environmental health.
We must give more encouragement to improving health manpower, where it is most needed.
We should continue to support health care delivery innovations, like HMOs.
And we should place a high priority on expanding financing coverage of health costsfor the poor, the low income, the elderly, and the catastrophic victim.
Progress will depend upon public awareness and public support. I hope that as we debate health legislation, we will hear from all of you about your concern for comprehensive reform.
We have created great health resources in our nation: dedicated professionals, concerned citizens, and committed political leaders. But we must aim high to attain our goal of assured, accessible, high quality health care – for all Americans.