The NewsHour with Jim Lehrer

MR. LEHRER: Good evening. I'm Jim Lehrer. On the NewsHour tonight, the veto of a late-term abortion ban, Margaret Warner runs a debate between two House members [Focus - Abortion Veto]; Part four of our series on the changing health care system, Lee Hochberg and Elizabeth Farnsworth look at regulations in Arizona [Series - Changing Times - Regulating Health Care], a conversation with the Pulitzer Prize winner for music, George Walker [Conversation - Pulitzer Winner]; and the bravery of those who fight fires as seen by essayist Roger Rosenblatt [Essay - Bravery Under Fire]. It all follows our summary of the news this Thursday. NEWS SUMMARY

MR. LEHRER: The U.S. military suspended daytime evacuations from Liberia today. An Air Force official said gunfire made the flights too dangerous. They will continue at night. More than 600 people, 150 of them Americans, have been taken out of Liberia by U.S. helicopters since Tuesday. There have been reports of widespread killing and looting since ethnic fighting broke out last weekend. A United Nations spokeswoman said today heavy looting in the capital of Monrovia had virtually paralyzed the UN food distribution system. Secretary of State Warren Christopher described the evacuation procedure.

WARREN CHRISTOPHER, Secretary of State: Initially, we were picking up people who wanted to leave only from our embassy. One of the changed procedures today is that we're picking up people at other places around the city. Our first goal, of course, our first responsibility is to evacuate the Americans. And I think we're probably, somewhat over a hundred of the Americans have been evacuated. Beyond that, we'll try to assist those whom ought to leave, who are perhaps representative of some of our allies or foreign countries, but I want to underscore it's a dangerous situation and it's far from tranquil there in Monrovia, just the opposite.

MR. LEHRER: The Defense Department has ordered three Navy ships and seven hundred Marines to the coast of Liberia. The ships are based in the Adriatic Sea. A spokesman in Sierra Leone next to Liberia said it could take seven or eight days for the ships to arrive. In the Middle East today, Israeli aircraft fired rockets at targets across neighboring Lebanon. This was the first time in 14 years Israel has attacked the capital city of Beirut. We have more in this report from Robert Moore of Independent Television News.

ROBERT MOORE, ITN: This was Israel's most daring air strike in Lebanon for many years: Helicopter gunships flying into Beirut and firing missiles at Hezbollah's main command center in the city. Amid the explosions, many residents fled in panic. For the people of Beirut, the air raid came as a complete shock, just as they're engaged in rebuilding this war-ravaged city. Israeli aircraft also hit out at suspected Hezbollah forces in Southern and Eastern Lebanon, including at a convoy traveling down the coastal road. Shiite guerrillas who have targeted Northern Israeli towns in recent days with rockets, used what weapons they could to fight back. But Israeli air supremacy over Lebanon is total. On the Israeli-Lebanese border, convoys of ammunition trucks were on the move, but the scale of the Israeli military action is unclear. So far, there is no suggestion of a ground offensive. Israel's most northerly towns are being evacuated by the military. Civilians, especially children, are taking refuge elsewhere, out of range of Hezbollah's rockets. The retaliation by the Shiite guerrillas is now expected.

MR. LEHRER: In U.S. economic news today, the Labor Department reported wholesale prices were up .5 percent in March. That's the largest increase in three months. It was blamed on higher energy and food prices. President Clinton offered a new pension reform plan today. It would give workers more access to their IRA's, Individual Retirement Accounts. They could use the money to purchase a home or pay for education. The President spoke of this plan in the White House Rose Garden.

PRESIDENT CLINTON: It expands coverage to help 51 million working Americans who are not now covered by an employer-provided retirement plan. Very importantly, it increases portability so workers can take their retirement savings with them and keep saging--keep saving if they change jobs or lose their job and have to wait a time to find a new job. With the Retirement Savings & Security Act, we can help to make retirement something Americans can look forward to, not dread.

MR. LEHRER: The plan would also make it easier for small businesses to establish 401-K accounts for their employees. Senate Majority Leader Dole and other Republicans said today they were first with many of the reforms proposed by the President. An attempt to win a place in a record book ended in tragedy today. Seven-year-old Jessica Dubroff took off on the second leg of a trip to set a world record as the youngest person to fly across America. But her four-speeder Cessna went down in bad weather near Cheyenne, Wyoming. Jessica, her father, and her flight instructor were killed. They started the trip yesterday from Northern California. Jessica was too young to be a licensed pilot. In Washington, the head of the Federal Aviation Administration described the rules that apply.

DAVID HINSON, Director, Federal Aviation Administration: There is a regulation that requires that the pilot in command have a license, be certified, and exercise safe control of the aircraft, and that a non-pilot may not manipulate the controls unless in the judgment of the pilot in command it's safe to do so.

MR. LEHRER: And that's it for the News Summary tonight. Now it's on to the abortion veto, health care in Arizona, the Pulitzer Prize winner for music, and a Roger Rosenblatt essay. FOCUS - ABORTION VETO

MR. LEHRER: President Clinton's veto of an abortion bill is first tonight. Margaret Warner has the story.

MS. WARNER: Abortion and politics is a volatile mixture. The debate over late term abortions, which opponents call partial birth abortions, is no exception. We begin with this backgrounder by Kwame Holman.

KWAME HOLMAN: The congressional debate over late term abortions was one of the most emotional and contentious in recent memory.

SEN. ROBERT SMITH, [R] New Hampshire: [November 7, 1995] Can you imagine, could you possibly imagine the pain of this child, without any anesthetic, of having scissors put in the back of its neck and having its brains sucked out? Can you imagine the pain? This is the United States of America. Why are we doing this to our children? Could somebody please tell me why we're doing this. Why are we doing this? Give me a reason. I can't wait till I hear the other side. For what? Why are we doing this?

SEN. BARBARA BOXER, [D] California: Women in their late term pregnancies do not desire, do not anticipate, do not want, do not even think about abortion. Women in the late term of their pregnancies are anticipating the joys of childbirth, the fulfillment of motherhood and family. Doctors know late term abortions are dangerous and difficult. They're emergency medical procedures done in the most tragic and painful circumstances, and yet, this bill would outlaw an emergency medical procedure.

MR. HOLMAN: The bill banning so-called partial birth or late term abortions passed both the House and the Senate. But the Senate vote was well short of a veto-proof majority. And President Clinton did veto the bill. Yesterday, the President stood by as five women gave tearful testimonials of their late term abortions, necessary according to their doctors because of potential life threatening consequences. The President said he would have signed the bill, except for women in similar situations.

PRESIDENT CLINTON: I implored them, I said, if you want to pass something on this procedure, let's make an exception for life in serious, adverse health consequences, so that we don't put these women in a position and these families in a position where they lose all possibility of future child bearing, or where they, where the doctor can't say that they might die but they could clearly be substantially injured forever. And my pleas fell on deaf ears.

MR. HOLMAN: President Clinton also explained his decision in a letter to Catholic Cardinal Joseph Berneden of Chicago saying, "This is a difficult and disturbing issue, one which I have studied and prayed about for many months." But Cardinal Berneden released a statement of his own saying, "This incomprehensible decision underscores once again the importance of Catholics and all people of goodwill becoming an informed and involved electorate who are active in the political process. Today, White House Press Sec. Michael McCurry said he didn't know if the President had thought about the political consequences of his decision but understands he'll have to live with them, good or bad.

MS. WARNER: Action on the issue now returns to Capitol Hill, where the Republican-controlled Congress may try to override the veto. The issue also promises to figure in this year's election campaign. Here to talk about what lies ahead on both fronts are two key players in the debate, Republican Chris Smith of New Jersey, co-chairman of the House Pro Life Caucus, and Democrat Nita Lowey of New York. Welcome both of you--Let's get your perspective, that the President veto this bill.

REP. NITA LOWEY, New York: [New York] First of all, let's be very clear about who is being extreme. I've heard Bob Dole's statement today calling the President extreme. The President said very clearly that he would have signed this bill if it had an exception, in addition to life, for serious health risks. Bob Dole wants to outlaw all kinds of abortion. Bob Dole, in fact, supports a constitutional amendment, as does Chris Smith, to outlaw abortion. This is a particular medical procedure that women and their families face in the most tragic circumstances. I've met with these women. I've met with their families. They want to have children, and then they are faced in the last months of pregnancy with a decision by the doctor that this fetus can't live, that the brain may be outside the fetus, that the spine may be non-existent, so they are faced with this decision, uh, to end this pregnancy. And the President knows, as I know, that this is less than 1 percent of the number of abortions, and--

MS. WARNER: And how many--

REP. NITA LOWEY: --it's a real tragedy.

MS. WARNER: And how many, just tell us how many a year do you think are being done of this procedure?

REP. NITA LOWEY: There are just several hundred a year that are being done. There are just three or four doctors that perform this procedure, and they are done in the most tragic circumstances. As a mother of three grown children, healthy children, I pray that no one in my family ever has to face that decision and, if they do, they want this Congress telling them what to do. They want to face this decision with their loved ones, with their physician, not with this Congress.

MS. WARNER: All right. Congressman, given how relatively few of these are being done, as we've just heard, why was it so important to the Pro Life Caucus that this bill become law?

REP. CHRIS SMITH, [R] New Jersey: Well, first of all, the abortion industry admits to 500 or so per year. That's 500 children who are killed through a gruesome method, and we saw on the, on the pro--on the information leading up to this discussion the actual method involves the doctor delivering the child three quarters of the way and then the head, which is larger than the other parts of the body, is still inside the mother. He actually--

MS. WARNER: Excuse me, and at what stage in the pregnancy? Just explain.

REP. CHRIS SMITH: Anywhere from 20 weeks onward are these partial birth abortions performed, and then the doctor goes in with the Metzenbaum scissors, opens up a hole in the baby's back of the head, opens it up, and then puts in a suction catheter and the baby's brains are literally sucked out. Dr. Haskell, who--and this is one of the ways we found out about it at the National Abortion Federation's Conference in 1992--he talks about this in plain language about how the baby's brains are literally sucked out, and he has admitted on tape that 80 percent of the abortions that he does in this method are elected abortions. These are not life- saving abortions, and there is an exception in the language of the bill vetoed by the President that says very clearly that the life of the mother is one of those exceptions where this would be permitted, but, you know, the President also argues that he wants a health exception. Health was defined in the Doe Vs. Bolton, it was the companion--

MS. WARNER: Which is what?

REP. CHRIS SMITH: In 1973, Roe Vs. Wade, most people have heard about that, there was a companion decision handed down by the U.S. Supreme Court that explained that health means virtually everything, the well-being and the socioeconomic, the woman's age, any situation can be construed to be health. We know that if it's left to the abortionist to make the decision whether or not this is a health abortion, 100 percent of the time it'll be a health abortion. And we're also saying this is a method of child abuse. The child is 3/4 of the way delivered. Those tiny hands, the legs are kicking. Why not complete the delivery, rather than killing the baby? Dr. Haskell was asked about that. He said the object here isn't to manipulate the outcome--in other words--the live birth. It is to procure the death of the baby.

MS. WARNER: Okay. Let's turn to this exception for the health of the mother. Congresswoman--

REP. NITA LOWEY: Yes.

MS. WARNER: --really two questions. First of all, you heard the Congressman say that that's been so broadly construed, as in many other kinds of decisions, as to cover everything. Umm, address that point.

REP. NITA LOWEY: I'd be pleased to. I'd like to make two points. First of all, I went to the Republican leadership with my colleagues and asked for a health exemption and offered to work with Chris Smith or any of the other Republicans to craft an exception that would be suitable. These abortions take place in the most tragic circumstances. Either the brain is outside of the body, the fetus cannot live. I think it's a distortion and it's demeaning to women to think that women who have planned to have an--a baby or people like Claudia Adis, who has worked hard, who has been a part of the American dream, who--

MS. WARNER: I'm sorry. Who is she?

REP. NITA LOWEY: --was planning with her husband, Richard--these are people that met with the President--

MS. WARNER: The President yesterday.

REP. NITA LOWEY: --met with me in my office, and told me how they were choosing names for the baby, and then were faced with this decision. They want to make that decision with the doctor and choose the method, have the doctor select a method that is the safest. This doctor, as a result of the bill, would have to go to jail and prove his innocence. You know, I think it's also important that our viewers know that Chris Smith supported a bill that didn't even have a life exception. Bob Dole voted against abortion a hundred times. He wants to eliminate all abortion.

MS. WARNER: All right. Let me turn back to this bill, if I could. Just very briefly, where does it go from here? Are you going to try to override the President's veto?

REP. CHRIS SMITH: There will be an attempt, I believe, in the House of Representatives to override the President. It's not likely in the Senate that the votes are there, but, again, my good friend and colleague from New York has misstated the facts. The bill that passed in the House had an affirmative defense for the life of the mother, and what happens--and one other thing--when I hear this Presidential spokesman suggesting that the President did not wear the political ramifications of this, this has been--President Clinton is the abortion President. Every aspect of his domestic and foreign policy from national health care to international population control has been to promote abortion on demand, birth control abortions around the world and here with taxpayer funding. This is just another manifestation of his unfortunately extreme position.

MS. WARNER: So what do you think--just a minute Congresswoman. What do you think, Congressman, are going to be--is going to be the political fallout from this decision this year?

REP. CHRIS SMITH: I think the President now has clearly demonstrated how extreme he is. He got away with it in Arkansas when he signed a health exception for late-term abortions which absolutely rendered that legislation meaningless, because we all know that health means anything. He now has tried this ploy again. It worked before. He thinks it might work again. But I think the electorate is much more informed. Abortion will be a front burner, not a back burner issue, and when people become aware, as, as Sen. Smith so well observed in his comments on the Senate floor, how can we do this to children, girls, boys, killed in such a hideous faction of actually sucking their brains out? It is child abuse. The President has locked arms with the abortion industry, a multimillion dollar industry that is making its money by killing babies in this fashion.

MS. WARNER: All right, Congresswoman, address, if you would, the political ramifications of this.

REP. NITA LOWEY: I would think that the American people are smart enough to know that President Clinton wants to see abortion safe, legal, and rare. Bob Dole wants to see abortion unsafe, illegal, and non-existent. Bob Dole supports a constitutional amendment to outlaw all kinds of abortion. He even supports outlawing abortion, as does Chris Smith, in the case of rape and incest for the most vulnerable. So this clearly was a political decision by Bob Dole and Chris Smith and the radical right of the Republican Party. They want to take women back to the back alleys. They don't want to see Roe V. Wade, the law of the land. The President was the reasonable one, offering to sign the bill if it had an exception in addition to life for serious, serious health risks. And I, myself, worked with the administration and wanted to work with Republicans to craft those kinds of exceptions. It's Bob Dole who is unreasonable and Chris Smith and the radical right of the Republican Party, and I think the majority of American women want the right to choose. They want to make these difficult decisions with their physician, with their loved ones. They don't want Chris Smith and Bob Dole and this Congress outlawing all kinds of abortion.

MS. WARNER: Just briefly--a brief, final word.

REP. CHRIS SMITH: When you try to protect unborn children from dismemberment, chemical poisoning, in this case partial birth abortions, it's called extreme. I happen to believe that Bob Dole is a very compassionate man. He believes in the sanctity of human life, and he's willing to say taxpayers shouldn't subsidize it and in many cases when we can protect those children, we should. Unfortunately, Bill Clinton has tried to force every taxpayer to pay for every abortion, and now we're talking about a method that is so cruel that it is nothing but child abuse. Children killed in this way--I wouldn't do this to a cat. I wouldn't do this to a dog, nor do I think anybody listening would do it. Yet, we do it every day to little baby boys and baby girls.

MS. WARNER: Congressman, we'll have to leave it there. Thank you both very much.

REP. CHRIS SMITH: Thank you. SERIES - CHANGING TIMES - REGULATING HEALTH CARE

MR. LEHRER: Now, Part four in our series on the changing American health care system. Elizabeth Farnsworth has tonight's installment from the Old State Capitol Museum in Phoenix.

MS. FARNSWORTH: In Arizona, as in other states around the country, a debate is underway on whether managed care organizations need more regulation. Here the legislature has gotten involved and several bills affecting the health care industry have been passed. For a look at the kind of problems that inspired the legislation, we have this report from correspondent Lee Hochberg.

UNIDENTIFIED HEALTH CARE WORKER SPEAKING TO DOCTOR: Headache, dizziness, high blood pressure, back and neck pain, CIGNA patient.

MR. HOCHBERG: Sunday night was a typical night at the Maryvale Samaritan Emergency Room in Phoenix. Patients streamed in steadily, but some had long waits, and it wasn't because the emergency room was overcrowded.

HEALTH CARE WORKER: Patient signed in at 9:55. It's 20 after 10:00. We're still waiting for permission.

MR. HOCHBERG: That patient was one of several who waited an hour or more just to get authorization from their health maintenance organizations to be seen in the ER. HMO's say it can take that long for their doctors to determine ER treatment is needed. Emergency rooms are expensive. One way HMO's cut costs is to authorize visits. Patients with traditional insurance don't have to await such authorization.

HEALTH CARE WORKER: Sholanda Warner.

HEALTH CARE WORKER ON PHONE: I'm trying to get an authorization for treatment on a Sholanda Warner.

MR. HOCHBERG: 85 percent of Maryvale's emergency patients belong to managed care plans. To control costs, those plans decide on a case-by-case basis whether they'll pay for ER care or tell their members to get less costly care in a doctor's office. ER treatment often is delayed while HMO gatekeepers consider the case. Sholanda Warner came in with a deep gash over her right eye and waited more than an hour with her father.

UNIDENTIFIED WOMAN: It's been an hour since the last time I spoke to them. We're still waiting for an authorization.

MR. HOCHBERG: The delays in treatment are confounding emergency room physicians like Dr. Patrick Connell.

DR. PATRICK CONNELL, Emergency Room Doctor: The authorization process and the bureaucracy and the waiting on phone lines to get authorization for long periods of time often results in tremendous delays in getting patients expeditious care.

MR. HOCHBERG: In the State of Arizona, 40 percent of residents are in managed care systems. That's slowed increases in health care spending, but along with lower costs have come some problems. Todd Girimillo and Aretha Victoria ran into problems recently when Victoria got the flu two months into her pregnancy. Her fever rose to 103.6, and when she began coughing up blood, she called Girimillo home from work to help her.

TODD GIRIMILLO: She looked absolutely terrible when I got there. She was burning up, and I knew that I needed to get her to an emergency room.

MR. HOCHBERG: At the Maryvale Emergency Room, Dr. Connell prepared to treat her for dehydration, but after 15 minutes, he got the word that the couple's HMO didn't consider Victoria's problem an emergency. Payment for emergency treatment would be unlikely; Victoria should go home and see her HMO primary care doctor in the morning.

TODD GIRIMILLO: I blew up! I was like what, what did they say? You know, I got upset. I was, I was--my initial feeling was panic, was, like I can't afford this man, no, no, what do I need to do to get this rectified?

DR. PATRICK CONNELL: Had we simply sent her out the door like the managed care plan wanted us to do, she could have jeopardized her pregnancy, she could have lost the pregnancy.

MR. HOCHBERG: Dr. Connell treated her. The bill came to more than $500. The HMO, Intergroup, one of Arizona's largest, refused payment. Intergroup's associate medical director, Dr. Naim Munir, says though the emergency room medical write-up clearly stated Victoria was coughing up blood, nobody had told the HMO gatekeeper, who decided not to authorize care.

DR. NAIM MUNIR, Associate Medical Director, Intergroup: Someone says you're coughing up blood. Is that an emergency, yes, there's no question that that's an emergency.

MR. HOCHBERG: Then why wasn't this immediately covered?

DR. NAIM MUNIR: Because, again, I go back to the same issue of I don't know what was communicated. If someone tells me that there is a 22-year-old patient coughing up blood, yeah, it sounds like an emergency. It sounds like as a caring, compassionate physician, you should care about that. I don't know what was communicated.

MR. HOCHBERG: After inquiries from the NewsHour, Intergroup paid the bill this week, but Dr. Munir says rejecting it at the time was prudent, and he says Dr. Connell should have called the HMO himself.

DR. NAIM MUNIR: I know it's difficult, and everyone's busy, but sometimes--if he had picked up the phone and talked to the physician on call and said, look, this is clearly an emergency, the patient's worried that the bill is not going to be paid by the insurance company, is there any disagreement in your part, the whole situation, including the patient's level of comfort with proceeding with further care could have been addressed right there and then.

DR. PATRICK CONNELL: You know, my training is to take care of sick people, and I'm, I'm often stuck as sort of the arbiter between the patient and their managed health care plan, and I don't think that's fair for me. I don't think that's fair for the patient.

MR. HOCHBERG: The Arizona legislature has passed a bill to try to avoid such confusion. Under terms of the Access to Emergency Health Care bill, HMO's must cover screening and initial stabilizing treatment for patients. That bill awaits the government's signature to become law. Another law awaiting the governor's approval would have helped Phoenix area resident Charles Riggs. Riggs says he's had to steer clear of his two active grandchildren as he's waited six months to have a bilateral hernia repaired. His HMO, CIGNA Health Care, offered to pay for traditional open surgery, which require six weeks of recovery. He asked for a less invasive but more expensive laparoscopic procedure.

CHARLES RIGGS: The open surgery is obviously not in the best interest of the patient. Not only that, it's barbaric. Why would you require somebody to have their abdomen cut open to do a procedure that is not necessary just because it's the cheapest way to do it?

MR. HOCHBERG: CIGNA rejected his request, arguing there was no medical necessary for the procedure. Riggs filed a grievance with the HMO, but it was rejected too.

CHARLES RIGGS: They wrote me back and said that their decision was final and that there was no review to that decision.

MR. HOCHBERG: Riggs persisted nonetheless, asking an independent surgeon to argue his case to the HMO, but CIGNA still would not approve the procedure. Late last month, after a five-month battle, CIGNA reversed its decision and authorized the laparoscopic surgery. The company spokesman was unavailable to be interviewed, but in a statement, CIGNA said it had changed its mind based on an opinion obtained from an independent surgeon. Riggs will get the procedure next week.

CHARLES RIGGS: The whole issue here, though, is, again, not the fact that they denied my procedure, my request, but that there was no appeal to that denial. You had to accept their edict or go out and get a lawyer.

MR. HOCHBERG: Cases like Riggs inspired the Arizona state legislature to pass a bill, giving the insurance commissioner the power to oversee health care and managed care organizations. The bill was heavily opposed by most HMO groups, and it is not yet known whether the governor will veto it.

MS. FARNSWORTH: Joining me tonight are State Senator Ann Day, who was instrumental in sponsoring those bills; Stuart Grabel, a consumer advocate with the PEMA Council on Aging; Marjorie Marks- Catz, a patient at a health maintenance organization; Dr. Naim Munir, who was just featured in our taped segment; Edna Wilson, who handles patient complaints for FHP Health Care; and Steve Barclay, counsel and lobbyist for the Arizona Association of HMO's. Thank you all for being with us. You heard the case--cases in the taped piece. Is that somewhat typical? Is that an overstatement? Are these anecdotes that don't prove anything? What do you think, Senator Day?

STATE SEN. ANN DAY, [R] Arizona: Well, clearly, I think in Arizona, where we have a significant portion of our population in managed care that as more people are in managed care, we will see more problems with the system, and I think the incentive is there in trying to keep costs down to reduce services at times. And the problems that mainly hear about are problems people have with referrals or problems with a prescription drug that they want, or getting appointments mainly.

MS. FARNSWORTH: What do you think, Steve Barclay? Do you think that looking at these anecdotes is misleading?

STEVE BARCLAY, HMO Advocate: I think it can be. I think you have to look at them. You can't ignore them but you have to look at other measurement tools. You have to look at satisfaction surveys, for example, the one the Hospital Association did here with the Gallup Poll that said 86 percent of Arizonans in managed care are very satisfied with their plans, and that was a higher rating, by the way, than the indemnity or PPO, which is preferred provider organizations got in their sampling, so I think you have to look at beyond just the anecdotes.

MS. FARNSWORTH: And what do you think, Mr. Grabel? You're hearing from elderly people. What do they say?

STEWART GRABEL, Patient Advocate: Well, I think we have to keep in mind what an anecdote is, and it's a story of a real life person, and there are a significant amount of them. We get calls in our office every day with similar stories, with similar situations in which people have been denied services. And it's very important that we pay attention to these because what's happening in Arizona is being repeated across the country. If the future is HMO's or managed care, then we have to correct the blemishes in order to make it work properly.

MS. FARNSWORTH: Now, Edna Wilson, you deal with these kinds of complaints. You deal with these calls within the HMO, within the organization you work for, so you do deal with the complaints and try to correct them, I assume, right?

EDNA WILSON, HMO Grievance Representative: Yes, I do. As a matter of fact, I don't see as many now as I have in the past, I have to admit. HMO's have been around for quite some time, and I have to admit that initially, yeah, there was some problems within the system, but I think we're making strives in correcting them, and I see less and less of that now, and I do deal directly with these things. The population of an HMO, how big is our population now as compared to the types of complaints or the numbers that you're hearing about?

MS. FARNSWORTH: Why? Why are there fewer complaints now--

EDNA WILSON: Well--

MS. FARNSWORTH: In your experience.

EDNA WILSON: In my experience?

MS. FARNSWORTH: What's changed in your company?

EDNA WILSON: We've--because we've listened to what the customer's needs were. We have--we have what we call a customer service department, in our organization it's called a member services department, and we listen to the complaints from the members, and we're doing something about those complaints. As a matter of fact, we were talking about emergency room denials. I don't see that many, and I deal with formal complaints from the members right now and claim denials, and we have new contracts in place to prevent those things from happening.

MARJORIE MARKS-CATZ, HMO Patient: Senator Day had mentioned two issues that she hears about,the issue of referrals and the issue of denial of prescription medications. And from a patient's point of view--

MS. FARNSWORTH: And you--you've had cancer, right?

MARJORIE MARKS-CATZ: Right. I'm a cancer survivor, and those are the two issues that I found the most difficult to deal with. For example, the issue of prescription drugs, prescription medication, I've had three different physicians within the HMO prescribe a medication for me and it's continually denied. And as a result, I have to pay $125 a month out of pocket for this medication. And it does not leave me with the feeling of security because if three different physicians who I respect and whose medical judgment I respect prescribe a very well-known medication and the HMO is denying it because they're telling me it's not in their formulary, then there's something not quite right.

MS. FARNSWORTH: Okay. Dr. Munir, do you think that the problems are a few anecdotes here and there? How do you judge the nature and the scope of the problem?

DR. NAIM MUNIR, HMO Administrator: I try to look at the problem objectively. When you look at the member satisfaction surveys, I think members have been very pleased with the care that they've been receiving with HMO's. I think it would be wrong to say that HMO's are perfect. There are these blemishes that we talk about. There are these blemishes; however, I think HMO's have brought physicians together, have brought hospitals together, and have allowed a forum for us to solve these problems. I think we're getting excellent at it, and I think for the first time at least being trained as a family physician, I've had the opportunity to see the health care system fully work as a system. I think in the past in the 1960's, it was an illness-based, non-system. I think HMO's allow all the active participants in health care to sit down, measure quality, which I don't think has ever really been measured before in the health care environment.

MS. FARNSWORTH: Okay, Senator Day, we may differ on how severe the problems are, but there have been problems, and that's why you have pushed some legislation, right? What is your legislation aimed at correcting? Go through just a little bit of it briefly.

STATE SEN. ANN DAY: Well, this year I dealt with quality of care, and I think that quality of care is starting to compete with the reduced cost. And clearly, people love having the $5 co-pay or a $10 co-pay, but I think that as managed care has evolved, practically in our backyard, and now employers are buying HMO's because it's cost-effective, that people found themselves restricted, and they couldn't make choices. And the problem is that when you're in a managed care environment or an HMO, the managed care, the HMO is making all your decisions for you. And when they get a license to operate in the state, they promise to deliver quality health care. And the question begs itself, what happens, where do you go, when they don't deliver quality care? And the answer is that you go to their grievance process, which is theirs, bought and paid for, and if you're denied, you're at the end of the road, and you have no place to go but to me, an elected official, or to file a lawsuit.

MARJORIE MARKS-CATZ: You mentioned the issue of control. And as a cancer survivor, one thing I learned as a cancer survivor is the importance of advocating for your own health care and the importance of listening to your body. And I had an incident, umm, last year when I had quite severe symptoms, went to my primary care physician and asked for a referral to a specialist becauseI felt, umm, that the symptoms that I had required the services of a specialist. Umm, he refused to give--he's the gatekeeper. He's now in control of my body and in control of my medical care. He refused to give me the referral, so what I went and did was, umm, changed primary care physicians. But from the time I had the symptoms until the time I finally changed the PCP, got the referral, made the appointment with the specialist, saw the specialist, had all the tests necessary, four months went by, and I was having severe pain.

MS. FARNSWORTH: Thinking generally, is legislation the way to go?

STEWART GRABEL: There has to be some kind of legislation. What we're dealing with, and what we were talking about just a moment ago, was someone who is articulate and capable of explaining what was happening to her and following through on dealing with the procedure. Among our sick people, among our people who require health services, there are a lot of people who are totally incapable of doing that. To not have an entity that can assist them through that process is to really deny them health care, to really deny them the ability to deal with it. And a managed care system is essentially in some ways an adversarial system, i.e., the checks and balances are set on the, on the premise of saving money, and in order to receive services, you have to advocate for yourself, you have to say to your primary care physician, I need to get additional services. If you're a senior citizen, if you're 75 years old and you've been taught that the doctor's word is law, you're not going to do that.

MS. FARNSWORTH: Dr. Munir, is this, is this the future, where, where--the stage where legislation, various medical associations, and HMO's will negotiate, work out, perhaps have legislation regulating the procedure, but basically this is the future, this is where medical care is going to be delivered?

DR. NAIM MUNIR: I believe so strongly that the future is going to be collaboration, but I don't believe it's going to be regulation. I think the focus of discussion back to the key issue, the majority of patients enrolled in HMO's are satisfied with their carrier. These are satisfaction surveys that are done by independent folks. Now, when there are these types of issues where the system breaks down, being trained as a family physician, the communication between patient and physician I think is ultimately important and for that physician to be the patient's advocate within the managed care system. If there is a patient who's having difficulty and having denials that they perceive to be unreasonable, that physician, the reason I'm employed and part of the HMO, the reason I work within that system is to allow opportunity for physician-to-physician contact. In the piece that we saw earlier tonight, I think that was where there was a breakdown also. There was a lack of physician-to-physician contact, and I don't think any amount of regulation is going to overcome those type of communication issues.

MS. FARNSWORTH: Sen. Day.

STATE SEN. ANN DAY: Elizabeth, I think the health care marketplace is different. We're not talking about commodities. We're talking about human lives. And I think for there to be fairness in the health care marketplace, there have to be checks and balances. We're not dealing with widgets. Health plans are not selling widgets. They're promising to deliver quality care, and I have to disagree that people are satisfied. I think there is a backlash against HMO's nationwide.

MS. FARNSWORTH: There is a lot of legislation. Thirty-three states have legislation.

STATE SEN. ANN DAY: In some states, it's a war. Now, do I think that you always need legislation? No. And, in fact, in Arizona, there are examples where outside of the legislation process there have been agreements on the maternity stay for newborns that was done without legislation. Then the Emergency Services Bill that was referred to earlier was negotiated and compromised in the legislature, and then we have the Quality of Care Bill that was never compromised because it's "regulatory." And here in Arizona, we don't like to regulate, but as I said, we're dealing with human lives, not commodities.

STEVE BARCLAY: I agree we're not talking about widgets here. We're talking about human lives. We're talking about patients. But there's an underlying premise here that I completely reject, and that is the premise that we don't care about our customers, our patients, our members, that we don't put their interests at heart, that all we care about is the process. We will not stay in business, it's as simple as that, we will not stay in business if we don't treat people well. We would not have grown from 700,000 members in HMO's in 1988 to almost 1.5 million if we hadn't been treating the vast majority of people well.

MS. FARNSWORTH: Now, explain how that works. That's because an employer, if their employees are really miserable with their health plan, simply will go to a different health plan, is that, is that the way that--is that why? You are self-reforming, is that what you're saying?

EDNA WILSON: They have the option to do that, right. We want to retain the membership, so obviously we want to keep them as satisfied as possible.

STEWART GRABEL: However, that equation works to a point. That equation works as long as it's economical to market to those groups, to those people. None of the doctors here, none of the individuals here would ever think of denying a patient care that was appropriate for them; however, the system does. And that's what we're seeing, and that's the effect. And what we're seeing is the effect of that.

DR. NAIM MUNIR: I'd like to step back and talk about accountability because I think that's what we're talking about. Are you going to hold HMO's accountable by anecdote? The anecdotes are important, and that's why there are people like me at HMO's who when there are issues that don't make sense to physicians hopefully that communication occurs at a per human being to human being level. But I--I think to have a discussion and not talk about the National Committee for Quality Assurance would be a mistake. I think that organization is a non-profit organization established in 1978 with the consumer representatives, including a senior investigative reporter from Consumer Reports--

MS. FARNSWORTH: This is the organization that does go around that you are accountable--

DR. NAIM MUNIR: It's a national organization, and hold HMO's accountable for measurably demonstrating that the HMO's have improved the quality of care and services rendered to their members. I think for us to somehow pretend that HMO's don't care about the members or don't want to deliver the best possible quality care is just to simplify things.

STATE SEN. ANN DAY: That's a trade organization. That's the HMO's trade organization. I call it a shell group. And that organization even states that they do not have the standards by which to measure outcomes, that by using their standards you can't compare one HMO against another--with another. And I do think that's where we need to head. We need to have standards for the different diseases, so that we can get good outcome measurement, so that we will have comparisons of one HMO against another.

MS. FARNSWORTH: And very, very briefly, the problem with that is- -

STEVE BARCLAY: These are very complex and difficult subjects. The only way we're going to be able to beat this, and we can't turn back, we got to look ahead, the only way we can beat this thing is if we work cooperatively together. And the example of the emergency room bill this year that we hammered out and the maternity length of stay issue which we got worked out without legislation are good examples. We're going to continue to work with Sen. Day and the rest of the legislature to try and solve these problems. Amazing things happen when we sit down at the table and talk to one another and, you know, address these issues. We can resolve them, but we've got to do it in more creative ways than legislating and regulating because those drive costs, and I don't think they drive quality.

MS. FARNSWORTH: Well, thank you all very much for being with us. CONVERSATION - PULITZER WINNER

MR. LEHRER: Now the first of a few conversations we're going to have over the next several days with those who won 1996 Pulitzer Prizes in the arts. The winners were announced Tuesday. Among them, George Walker for music, for his composition "Lilacs," which begins like this.

[MUSIC PLAYING]

WOMAN SINGING: Lilacs, lilacs--

MR. LEHRER: George Walker is with us now from New York. Mr. Walker, first, congratulations!

GEORGE WALKER, Composer: [New York] Thank you very much.

MR. LEHRER: How did you happen to write "Lilacs?" Tell us the story of "Lilacs."

GEORGE WALKER: I was commissioned by the Boston Symphony Orchestra to write a work for tenor and orchestra to commemorate the tribute that the Boston Symphony Orchestra was going to present in honor of Roland Hayes, the famous black tenor, whose career began in Boston with the Boston Symphony and who was a resident of Boston.

MR. LEHRER: Okay. And how long did it take you to write it?

GEORGE WALKER: I began the work late Spring of last year, and after finding the text which I decided upon the Walt Whitman text- -

MR. LEHRER: Now tell us about the Walt--it's from a poem by Walt Whitman, right?

GEORGE WALKER: Yeah. The poem is, "While Lilacs Last in the Door Yard Bloom." it's a poem that consists of 13 stanzas, and the poem is a reflection on the assassination of President Abraham Lincoln by Walt Whitman. It's a poem that consists of 13 stanzas. I was commissioned to write a work from eight to ten minutes, and I was not, of course, able to compose a work for--that would include the text for all 13 stanzas, so that did four of the thirteen stanzas. The first three and the--I believe the 13th stanza--to make a work that would have a unified whole primarily because of the fact that within the four stanzas the symbols that appear in the entire work were present--the symbols.

MR. LEHRER: The final piece was about 16 minutes long, is that right?

GEORGE WALKER: Yes, that's correct.

MR. LEHRER: First performed in February by the Boston Symphony.

GEORGE WALKER: Yes.

MR. LEHRER: And tell us a little bit about you. Now, that was what, your 70th piece of music that you have composed, is that correct?

GEORGE WALKER: No. I'm sure that I composed more music. I have over 70 published works, and most of the music that I have composed has been published. Quite a number of pieces, on the other hand, have been destroyed certainly after--

MR. LEHRER: Are most of these pieces--are they similar to "Lilacs" in they're for orchestra and for a solo vocalist as this one was?

GEORGE WALKER: No. This is a rather unusual category, and a category of writing a work for a solo vocal part and orchestra. I have written, however, a work that's called "Poem" for soprano and chamber ensembles that makes use of a small ensemble setting. But my works comprise orchestral works involving full orchestra, works that involve a smaller group, a chamber orchestra, and works for instrumental combinations, but this piece is rather unique for my output.

MR. LEHRER: Do you know, how did it come to the attention of the Pulitzer Prize Committee, do you know?

GEORGE WALKER: Well, the Pulitzer Prize depends on, on submissions and the work was submitted by my younger son, who's in California.

MR. LEHRER: Terrific.

GEORGE WALKER: And, uh, this was the, the initial process of filing the application, the fee and the photograph--

MR. LEHRER: Sure.

GEORGE WALKER: --and that sort of thing.

MR. LEHRER: You started playing the piano when you were five years old, is that right?

GEORGE WALKER: That's correct. That's when my, my interest and involvement in music began.

MR. LEHRER: And you started--and you trained at the Curtis School of Music, correct?

GEORGE WALKER: I went from high school to Oberlin College and then from Oberlin College to the Curtis Institute, where I studied piano under Rudolph Serkin and composition with Rosario Scalero.

MR. LEHRER: So--did you, did you compose music from the beginning as well? Was that what you--

GEORGE WALKER: I--I didn't begin to compose until I was 18. I didn't even attempt to compose. I was primarily interested in pursuing a concert career as a pianist.

MR. LEHRER: And when did the compos--the composing thing happened because of what?

GEORGE WALKER: I became ill in the course of my first European tour, which took me to Sweden, Denmark, Holland, Italy, and England, and I came back to the United States, realizing that I would be severely handicapped in attempting to pursue to appear when I wasn't physically at my best, and I--after doing some teaching, pursued a doctorate degree at the Eastman School of Music. I went to Paris to study with Nadia Bulenje, where I began to work full-time as a composer.

MR. LEHRER: Did you ever think that you might some day be sitting here or anywhere talking about having won the Pulitzer Prize?

GEORGE WALKER: Well, that's an aspiration that comes after one certainly becomes familiar with the processes involved in getting performances and opportunities and, and the results that can come from winning competitions.

MR. LEHRER: Sure. Does it have a special meaning to you to be the first black to win the Pulitzer Prize in Music?

GEORGE WALKER: Well, the meaning for me is essentially a kind of culmination of the aspiration of--of--success in this particular area, a major prize, and of course it does mean something to me to know that I, I have been selected to win it, and because I am black, and because no other blacks have won the competition, that I'm therefore the first.

MR. LEHRER: Certainly, certainly. Well, again, Mr. Walker, congratulations to you, sir, and happy--

GEORGE WALKER: Thank you so much.

MR. LEHRER: Thank you, sir.

GEORGE WALKER: Thank you so much. ESSAY - BRAVERY UNDER FIRE

MR. LEHRER: And finally tonight, essayist Roger Rosenblatt on those brave people who fight fires.

ROGER ROSENBLATT: In a period of less than six weeks this past winter, three New York City firefighters died doing what firefighters do--put out the fires. The roof of a burning building collapsed on Louis Valentino in the Flatland section of Brooklyn. Not long before his death, Valentino had attended the funeral of James Brian Williams, another firefighter who was killed in a Rockaway, Queens fire. And both Valentino and Williams had paid their respects at the funeral of Lt. John M. Clancy, who died in a Jamaica, Queens fire less than a month before that. [bagpipe music in background] The deaths of the three men make a total of eleven firefighters killed on duty since March 1994, when a fire in the Soho section of Manhattan killed three in one blow. New Yorkers take in these deaths in news stories with antipodal tones. There is the scene of the fire with its terrible hypnotic frenzy, and there is the scene of the funeral, heavy and darkly ceremonial, like an ancient rite for an ancient hero. [bagpipe music in background] Between the scenes of the battle and the consequence lies the question: Why do they do it? After the most New York deaths, people began to suggest that firefighters are getting unnecessarily aggressive. To risk one's life to rescue a baby from a burning building is one thing, but why risk your life for a pile of bricks? The Brooklyn structure that fell in was used as a chop shop for stolen cars. It was in violation of the building codes and the fire codes too. But the firefighters respond that there is no way not to do their jobs aggressively. Society asks them to put out its fires, so they do. The risk involved is the same size as the task. Think of it. There is no other job which by its nature automatically entails the risk of one's life. Even police and soldiers can have quiet patrols and still be said to do policing and soldiering. But a firefighter, to be a firefighter goes into fires. Until last summer, people in the Northeast knew little of forest fires, other than pictures shown of professionals and volunteers in places like California. Then a forest fire that began the parched woods of Eastern Long Island brought the enormity of the event home. Breathtaking, literally, the fire devours the oxygen and rolls like a deadly sea where the wind takes it. Firefighters rush to one location; the fire lurches to another. The scorched trees, like scorched buildings, are black beyond black. There comes a moment when watching the fire's relentless, capricious progress that one thinks they'll never stop it; the fire will eat the world. And then it is stopped. The fighters stand around in their oversized outfits, sweating, red in the face. The heat is off. The enemy, the beast, as in a story of ancient heroes, lies in a heap and smolders. I think it is the cognizance of fear that drives firefighters to put their lives on the line, not their fear, ours. They protect life. They keep the fires away. That is what they do. That is all they do. Until one of them dies, people may forget how exceptional they are. But when the worst comes, we know who these people are and when one of them is killed, we remember who they were in the world. "When I grow up, I want to be a fireman." Do kids still say that? If they do and if they mean it, they will grow taller, stronger, and more impressive than any building or any tree. I'm Roger Rosenblatt. RECAP

MR. LEHRER: Again, the major stories of this Thursday, the U.S. military suspended daytime evacuations from Liberia. Gunfire made the flights too dangerous. They will continue at night. Israeli aircraft fired rockets at targets across Lebanon, including some in the capital city of Beirut, and the Labor Department reported U.S. wholesale prices here were up .5 percent in March. We'll see you tomorrow night with Shields and Gigot, among other things. I'm Jim Lehrer. Thank you and good night.