The MacNeil/Lehrer NewsHour

MR. LEHRER: Good evening. I'm Jim Lehrer in Washington.

MS. WARNER: And I'm Margaret Warner in New York. After our News Summary, we look at the health care tug of war between doctors and insurers. Then we take a second look at the cost of illegal immigration, and we close with a Roger Rosenblatt essay on Rwanda and the end of the world. NEWS SUMMARY

MS. WARNER: The United States offered a draft resolution today for a U.N. arms embargo and other sanctions against North Korea. The move was designed to force the North to allow full U.N. inspections of its nuclear facilities. If the resolutions passes, North Korea would have 30 days before sanctions take effect. Amb. Madeleine Albright outlined the proposal today at the United Nations.

MADELEINE ALBRIGHT, Ambassador to U.N.: Generally speaking, the sanctions fall into five categories: The first is stopping all technical and scientific cooperation that could contribute to North Korea's nuclear knowledge. The second, terminating all economic assistance through the United Nations or its subsidiaries. The third is reducing the size and scope of diplomatic activities with North Korea, both bilaterally and through international organizations. Four will be curtailing cultural, technical, scientific, commercial, and educational exchanges with North Korea, both in that country and elsewhere. And finally, prohibition North Korea from exporting or importing any weapons or components of weapons.

MS. WARNER: Amb. Albright warned that the U.S. would seek additional sanctions if North Korea doesn't change its stand. Today's action came as former President Jimmy Carter began a series of meetings in North Korea in an attempt to end the stand-off. Caroline Kerr of Independent Television News has that story.

CAROLINE KERR, ITN: Jimmy Carter's trip across the border today does not just provide a rare opportunity for a western statesman to meet the Pyongyang leadership. It could also represent the best chance of preventing conflict on the Korean Peninsula. With the pleasantries over on the South side, Mr. Carter and his wife were led across the heavily fortified border. But while he was rooting for peace, Seoul was preparing for war. The city's center was brought to a halt by a major civil defense exercise. Civil defense reservists scaled the walls of office blocks in simulated evacuations, and soldiers were put through their paces in dealing with a nuclear attack, while others dealt with the imagined effects of chemical warfare. Mock casualties were rushed to the university hospital in a chilling representation of the city under a barrage of North Korean missiles. The purpose of this exercise is to instill confidence in the population that Seoul is prepared in the event of war. The fear is that it might cause panic. In supermarkets across the country, people are beginning to stockpile food after government instructions they should have enough supplies in for a month. Officials here insist there is no panic in South Korea, but in spite of some skepticism, they're now hoping that diplomatic efforts across the border may prevent this scenario from becoming reality.

MS. WARNER: Late this afternoon, former President Carter began those diplomatic efforts by meeting with North Korea's leader, President Kim Il Sung. Earlier, Mr. Carter met with North Korea's foreign minister. He told the minister that progress can be made on other goals as soon as the nuclear issue is resolved clearly and the misunderstandings are removed. At the White House this morning, President Clinton was asked what he hoped the Carter trip would achieve.

PRESIDENT CLINTON: I think he will reaffirm our position. What I'm more hopeful of is that he will get a better sense from them about where they are, and they wil understand that we're very firm in our position but that there is an alternative path and a very good one for North Korea, that they don't have to become more isolated. They could become more engaged in the world in ways that would be much better for their own people.

MS. WARNER: The President also was asked if he thought the North Koreans were misreading U.S. resolve. He said he didn't think so but said the course they were following was a self-defeating one. Jim.

MR. LEHRER: The President also talked health care reform with the congressional leadership today. He was asked by reporters if he thought proposals to phase in universal health coverage would work.

PRESIDENT CLINTON: Well, I'm not convinced it would achieve universal coverage, but let me say that, you know, when I put my ideas out, I made it clear that I was very flexible on how to get there, how to solve this problem, which is a system that costs too much and does too little, and that we ought to find a way to cover the American people just the way every other advanced country has covered all their people.

MR. LEHRER: After the meeting, House Republican whip Newt Gingrich talked about health care negotiations.

REP. NEWT GINGRICH, Minority Whip: We've had a long period now for everybody to sort of position themselves. We're looking at this issue, and I thought the President opened the door to genuine bipartisan consultation to get to a passable bill that everybody could live with, and we'll see. I mean, there are obviously on health care more than most issues very broad differences, but I thought as part of the general tone of the meeting that it was workmanlike, rather than confrontational.

MR. LEHRER: We'll have more on the health care debate right after this News Summary. In economic news today, industrial production rose .2 of 1 percent last month according to the Federal Reserve Board. It was the 12th straight rise in output at the nation's mines, factories, and utilities.

MS. WARNER: The latest cease-fire in Rwanda has been shattered less than a day after it was announced. Late yesterday, government and rebel forces agreed to stop fighting and to free all hostages. But this morning, mortar fire broke out in the capital of Kigali, and there was an unconfirmed report that 60 teenage boys were massacred by troops loyal to the government. Israel and the Vatican announced full diplomatic relations today. They officially recognized each other last December, and they now will exchange ambassadors. An Israeli official said the agreement recognizes the Vatican's right to have a say on the status of Jerusalem.

MR. LEHRER: And that's it for the News Summary tonight. Now it's on to doctors versus insurers, the cost of illegal immigration, and a Roger Rosenblatt essay. FOCUS - TUG-OF-WAR

MR. LEHRER: The big war over health care reform has spawned many battles, few more fierce than the one between the doctors and the insurers over who will be in charge of the medical system, the MDs, the MBAs, the doctors or the managers. We'll go to the front lines for a full debate after this backgrounder by our medical correspondent, Fred De Sam Lazaro of public station KTCA-St. Paul, Minneapolis.

MR. LAZARO: The loudest complaints about growing insurance company influence in medicine come from specialists like Dr. Thomas Lansen, a neurosurgeon in Westchester County, New York, whom we profiled in a story last year.

DR. THOMAS LANSEN, Neurosurgeon: I have to give all my efforts to trying to diagnose the problem, figure out what's wrong with the patient, come to the best therapeutic result for that patient, and I may have an insurance company call me and say, "What's taking so long? Speed up the work-up. Get the patient out of the hospital. Is that test really necessary?"

MR. LAZARO: Lansen cites the case of this patient who came in with a brain hemorrhage. Even though an angiogram test was negative, Lansen kept the patient on in the hospital until a second test could be performed.

DR. THOMAS LANSEN: About 10 percent of the time in these cases the blood vessel clamps down, the dye can't get through, and we can't see the site of the abnormality.

MR. LAZARO: This can result in another hemorhage, which would be fatal if medical care isn't available right away. Dr. Lansen says the insurance company was after him right away.

DR. THOMAS LANSEN: This non-physician person who talked to me said, you know, why is the patient in the hospital? I said, well, we had a negative angiogram. Precisely. You've got a negative angiogram. Send the patient home. And I said, no, you don't understand, we have to -- I explained the outline of our plan, and the response was, well, couldn't the patient be managed just as well at home with a visiting nurse coming in once or twice a day? It's clear that the patient's interest here is not the main concern of the insurer. The bottom line is the main concern.

MR. LAZARO: To many doctors, the trend toward more managed care has meant the industrialization of a revered profession, one that's part ministerial and part science. Westchester internist Jerry Edelman.

DR. JERRY EDELMAN, Internist: You're not even called a doctor anymore. You're either called a health provider or a vendor. Medicaid calls a doctor a vendor. And that's an insult. I mean, after spending 10 years of my life in training for this, I don't have to be called a vendor.

MR. LAZARO: But the growing dominance of managed care doesn't insult or worry Boston pediatrician Dena McFadden, who has spent her entire career in HMO's. She's an enthusiastic supporter of her employer, the Harvard Community Health Plan, which she says has cut out unnecessary costs and improved quality.

DR. DENA McFADDEN, Pediatrician: We have both clinician and non- clinician managers. As I say, I'm the physician in chief here at the health center. I work with a non-physician administratorwho is my managerial partner. I work as part of a team that includes nurse practitioners, medical assistants, my ancillaries. Itis a very large team of people. The doctor-patient relationship or clinician-patient relationship is still at the heart of everything that we do. But we see that not as a one-on-one relationship but, again, as a team of people who work together to make that relationship work.

MR. LAZARO: However, critics, including the American Medical Association, don't see widespread harmony in this relationship, and they fear the increasing dominance of non-physician managers to the detriment of patient care. The AMA managed to strike a response from an unlikely political bedfellow, Minnesota Democratic Sen. Paul Wellstone, a leading advocate for a Canadian-style government-financed system of health care.

SEN. PAUL WELLSTONE, [D] Minnesota: I am very worried that an insurance industry dominating these large plans will practice a bottom line medicine, and the bottom line is not the only line when it comes to health of people in this country.

MR. LAZARO: Wellstone has agreed to sponsor what the AMA calls the Patient Protection Act. It would limit what doctors see as second guessing by HMO's, and it would severely limit an HMO's ability to dismiss a doctor from the plan. The American Medical Association fears a cost-conscious HMO could dismiss doctors who don't meet the bottom line, and the AMA says that means patients wind up losing when a doctor can be fired for advocating in the patient's best interest.

MR. LEHRER: Now to our debate. Dr. Lonnie Bristow is the pesident-elect of the American Medical Association; Karen Ignani is president of the Group Health Association of America, a trade group representing most health maintenance organizations in the U.S.; Sarah Nichols is staff attorney for Public Citizens Congress Watch; and Dr. Steven Eberhy is vice president for medical services of the Prudential Health Care System and medical director for all Prudential Health Plans. Dr. Bristow, first of all, do you, doctors, consider yourselves in control of the health care system now?

DR. BRISTOW: No. I would say physicians are not in control of the health care system. But they are very much concerned about maintaining our role as advocates of the patient. The doctor- patient relationship, we believe, is what makes American medicine so special.

MR. LEHRER: So what is your concern about how health care reform might change that, and who might control the system under reform?

DR. BRISTOW: Well, managed care has been with Americans for over 50 years. Kaiser is a managed care approach, and we're very comfortable with that as one of the options that Americans may choose from, however, in recent years, there's been the advent of for-profit large insurance companies also entering the managed care field. And there's a concern that that may create divided loyalties, that it may, in fact, subvert some of the advocacy physicians that physicians traditionally have had. That's why the American Medical Association has proposed a Patient Protection Act as recently as two weeks ago to address those needs.

MR. LEHRER: And what in simplest terms is your concern about what might happen? Why -- in other words, why is a Patient Protection Act necessary?

DR. BRISTOW: Well, patients have always relied upon their physician to be their advocate, to provide them with the best possible advice that they can come up with for the clinical situation in front of them. Unfortunately, with a large for-profit corporation running the show, the bottom line of the corporation may assume greater importance than the health of the patients that are subscribers. And physicians who are connected with that large for-profit health insurance entity may become intimidated out of their traditional advocacy role for patients. And that's why a Patient Protection Act is essential.

MR. LEHRER: Ms. Ignani, you represent these companies that Dr. Bristow is talking about. Are his concerns legitimate?

MS. IGNANI: Well, I want to first of all thank Dr. Bristow for his kind words about one of his members. We do believe that the AMA position is really a smoke screen to turn back the clock on a lot of the progress that has been made with respect to HMO's, in particular. We have 50 million people who have made the HMO choice. As we look out to current projections, we see that probably somewhere in the neighborhood of 100 million will be in HMO's by the decade end. And I think this is really about not fairness, not patient proection, but concerns about balance of power, and where we come out on that question is that consumers should have the power to choose. This is an issue about choice of delivery system. And the kinds of recommendations that Dr. Bristow is putting forward and the AMA is putting forward would unfortunately add administrative burdens that would prevent us from doing the kind of quality selection of providers that we have been doing for a number of years, getting very good patient satisfaction ratings and working for patients essentially.

MR. LEHRER: You say consumers, but what you really mean are the insurance companies that run the HMO's, are you not? Aren't they the ones who would actually call the shots? Isn't that, isn't that the bottom line?

MS. IGNANI: Any HMO worth its salt, no matter what the status of ownership, is making clinical decisions in the hands of physicians. That's simply how it works. Our plans would not be comporting themselves in the delivery system so successfully if that were not the case. Our satisfaction ratings are very high. Our track record is very high. We stand on this. And I do think that this issue is about choice of delivery system. We can -- we have an alternative in the delivery system today, fee for service. This is about having multiple option delivery systems and ultimately leaving the consumer to make that choice, which would not be possible under the AMA proposal.

MR. LEHRER: Yeah. Dr. Bristow.

DR. BRISTOW: That's totally inaccurate, and you know that.

MR. LEHRER: In what way is it inaccurate?

DR. BRISTOW: Well, in the first place the Patient Protection Act insists that there be at least three options for patients to choose among, one including the pre-paid approach such as an HMO, another including the traditional fee for service approach with a sliding payment from an insurance company, and a third being a benefit payment schedule which -- in which an insurance company would make a fixed payment for a given service. So we insist that there do be -- that there will be choices for patients. More importantly, there should be a choice for patients to make an intelligent choice about their health insurance company. We want to insist that an insurance company define exactly what services will be covered for a patient and more importantly what services will not be covered for a patient. We want that insurance company to share with new subscribers what the satisfaction surveys show from subscribers who already belong or who have quit. More importantly, we also want to assure that physicians who work in that entity will continue as advocates for their patients by not being intimidated with the threat of being so-called "de-selected" from that entity if they simply provide that care that their best clinical judgment says is indicated for that patient.

MR. LEHRER: Now, what's wrong with that, Ms. Ignani?

MS. IGNANI: Well, the rhetoric that I think distracts from the real issue, which is providing no cut contracts here in HMO's, what we --

MR. LEHRER: For doctors.

MS. IGNANI: -- what we found -- yes, that's right. And there is no similar for nurses or health care professionals, as I know it, on the table. What we have found is our plans very rarely part company with particular physicians, and when they do, there are real issues of quality here. I think consumers care about that and want to have this kind of quality debate in the system as it now is being offered. We don't require any, or we wouldn't take the proposition or defend it that any individual should be required to join a delivery system. But this proposal is not about assuring choice across delivery systems but so constraining a particular delivery system that, in effect, it's not a live choice for consumers.

MR. LEHRER: Dr. Udvarhelyi, you are -- you are a physician. You are also involved in an HMO operation on a national scale. Do your doctors feel intimidated? What do you say to Dr. Bristow?

DR. UDVARHELYI: Our doctors don't feel initimidated at all. In fact, I'd like to point out that physicians that I work with do not necessarily share the views of the AMA. We recently did a survey of over 20,000 physicians that work with us, and 88 percent of them felt completely satisfied with the relationship they had with our health plans and felt that that relationship was a true partnership committed to improving the quality of care for our members. That indicates to me that we're doing an excellent job of working with our physicians, and the results are that 91 percent of our members are satisfied with the health care and their physicians.

MR. LEHRER: 91 percent of the -- we're talking consumers here, not doctors, right?

DR. UDVARHELYI: 91 percent of the consumers are satisfied.

MR. LEHRER: Yeah. The concern that Dr. Bristow and other doctors have raised is that when it comes down to the bottom line, in other words, the bottom medical line, when a doctor has to make a decision as to whether or not to give another test or do whatever, he or she is not going to make that decision. It's going to be somebody who is an MBA, to use the coin -- the main phrase there - - an MBA rather than an MD is going to make that decision. How have your doctors reacted to that?

DR. UDVARHELYI: Our doctors do not agree with that position. Our doctors feel that they make the decisions for patients, and they are able to deliver high quality care at a price that people can afford.

MR. LEHRER: How -- how aware are they of the price and the financial bottom line when they make their medical decisions under the system that your company operates.

DR. UDVARHELYI: There is no conflict of interest for the physicians in our plans. They make the best choices for patients. DR. BRISTOW: Jim, I hope that you realize that just in the month of March almost 300 physicians were fired by a large HMO in the city of Houston and replaced by several hundred other physicians in an IPA in that city.

MR. LEHRER: What's an IPA? I'm sorry.

DR. BRISTOW: An Independent Practice Association, and this was done by a very large insurance entity, and it was done in the twinkling of a month's time. Now that required almost 2,000 patients who inone month's time shift and find a new doctor, and believe me, those new doctors were well aware of the fact that the last set of doctors had been fired just like that. Now, you heard some disinformation before which I would like to correct. There's no cut approach to the Patient Protection Act. What we simply said is that, yes, a physician may be de-selected but it must be for cause. It should not be for no cause whatsoever, which is frequently the way the contracts run now. Now, it's interesting to me that many of the best HMO's in this nation like the Mayo Clinic, the Oxnard Clinic, as well as Kaiser, find that these rules are very comfortable for them. And the reason is because they are physician-directed, physician-oriented, and not directed by a large corporation. As you said, it's a question of whether or not you want your health insurance program to be designed and implemented by MBAs or MDs.

MR. LEHRER: Sara Nichols, is that how you see the argument here, whether you want -- whether the individual patient wants a doctor to make the medical decision, or an MBA to make this, is it that simple an argument?

MS. NICHOLS: Well, a lot of it does boil down to that, and, in fact, the case is that more and more hospitals and giant insurance companies are buying up physician groups and turning it into sort of a Mc-health care HMO setting, instead of these very high quality physician-driven managed care plans we've seen in the past that we really did think were good, unfortunately, but we definitely agree physicians should be in charge of the health care decision. We don't think that the Patient Protection Act goes far enough. So far it looks like a Physician Protection Act, and those protections are probably needed, but you're going to need to do a lot more to assure that consumers are protected.

MR. LEHRER: Why should the physicians -- the physicians have been run in -- some people -- here's -- I'll give you the argument at least. The argument has been well the physicians have been running the system pretty much up till now, and it's broken. Why shouldn't it be changed in some way if you're going to fix it?

MS. NICHOLS: Well, it's because the insurance companies are really who have broken the current system by siphoning off money that's earmarked for health care and putting it to their high administrative overhead and profiteering, and right now, the fastest growing line of business for the insurance industry is owning and operating HMO's, so it's going in exactly the wrong direction, exacerbating exactly that component of health care which is driving up costs and driving down care.

MR. LEHRER: So it's the profit motive, not the care motive that is driving people into the big companies that Ms. Ignani represents and to the health care business?

MS. NICHOLS: Absolutely, and HMO's by their very nature -- although there are some very good managed care plans -- and I don't need to say that there aren't -- HMO's by their very nature seek to make money by denying care, by cutting the amount of care that is provided and looking over physicians' shoulders and having some bureaucrat on the end of an 800 number second guessing it. That is a bad trend.

MR. LEHRER: Make money by denying care, Ms. Ignani?

MS. IGNANI: Not true. A very complicated set of issues though, you're quite right. There are different models in the health care delivery system, and perhaps some of the confusion arises from the fact that in a traditional fee for service system there is often just a pantheon of utilization review kinds of activities that sit on top of it. An HMO delivery system that we represent is a very different kind of delivery system that's offering more benefits to consumers, virtually no out of pocket costs to nickel and dime them, comprehensive coverage, emphasis on prevention, coordinated care environments, with an excellent quality track rec. [record]. The only delivery systems that have come forward with data come forward with quality assurance and have subjected themselves to public scrutiny. I'd like to really deal with this issue. I think that of profit motive here, because I think that this is somewhat disingenuous in the sense that we have to compare what we're talking about today to, in fact, the system that exists relative to managed care, which is the fee for service system, where -- excuse me -- individual physicians are organized in their private offices and professional corporations. Now, we have a system in the United States economy that works that way, and the literature in health care is replete with evidence that people have been concerned about the incentives in the fee for service system for unnecessary tests, unnecessary utilization, excessive hospital stays, and dangerous procedures.

MR. LEHRER: In other words, doctors are also making money as well as insurance companies is what you're saying?

MS. IGNANI: I think that there's --

MS. NICHOLS: I'll agree to that.

MR. LEHRER: To suggest otherwise is disingenuous is what you're saying?

MS. IGNANI: I think there is quite a lot beyond this smoke screen of political rhetoric, and we really ought to get down to the issues of what makes the system tick. How can we improve it, and how can we respond to the challenges that are on the public policy table?

MR. LEHRER: Dr. Bristow, but to the direct question, that's a fair statement. You all don't want to do this for nothing either, do you? DR. BRISTOW: No, of course not, and it's ridiculous to suggest that this is a competition between fee for service and the prepaid system. As I've said before, the Patient Protection Act calls for the availability of, of a prepaid system as one of the choices that must be available to the public. It has nothing to do with the competition between the two, although we think that competition is very healthy. What it has to do is protecting the patient's ability to have choices. And you can only make choices when you've got intelligent information provided to you. Patients need to know what is the profit margin in a given HMO so that they can make a judgment. Kaiser, a California study was done showing that Kaiser has an overhead of only 5 percent. That means 95 cents out of every premium dollar is spent on patient care. There are other large for profit health insurance entities in California, however, that spend only 70 cents of each premium dollar on patient care. The other 30 cents is spent in overhead, a large part of which goes as dividends to stockholders. And what the Patient Protection Act would say is make that information available to the public. They'll make their own judgment as to whether or not they think that the product they're getting is worth the dollars that they're spending, but until that information is made available. But until that information is made available, there's no way for them to judge. What I would say to the health insurance industry is: What is it that you have to be afraid of? On the issue of whether or not there should be cause shown to discharge a doctor, it's amazing to me that Ms. Ignani, who has a long history of involvement in the labor union movement, would take a position that physicians should be discharged without a show of cause when the labor union movement has always strongly said if you're going to discharge someone, you should at least provide the cause for that.

MR. LEHRER: Ms. Ignani. Let's give her a chance to respond to that. Yes.

MS. IGNANI: I'd love to respond to that. Actually, I've spent a number of years actually advocating for employment kind of policies that Congress has refused to grant, and this would be an unprecedented series of rights, and if the AMA is prepared to embrace that for all employees in the economy, I think that that might be something that would be of real interest to members of Congress.

MR. LEHRER: You're saying they want special --

MS. IGNANI: That's right.

MR. LEHRER: Let me ask Dr. Udvarhelyi a question that goes to the base -- the basic fear that patients have, that a doctor in an HMO or in one of these large organizations may be confronted with a situation for medical reasons believes some additional thing, whatever it is, needs to be done, but his or her organization has some guideline, or to use the -- Ms. Nichols' term, you have to call some 800 number to get permission to do what a doctor believes is medically correct to do or is medically needed to do. How do you deal with that kind of problem in your organization?

DR. UDVARHELYI: We believe that HMO's actually do an excellent job at protecting patients. The physicians that work in our organization are those that have demonstrated a commitment to caring about quality.

MR. LEHRER: But how do you deal with the specific situation when it comes up where you're confronted -- one of your doctors is confronted with a situation that according to the rules of his -- his employers he or she cannot do -- cannot do what he or she wants --

DR. UDVARHELYI: There are --

MR. LEHRER: Is there a plance -- can he go and get permission to do it?

DR. UDVARHELYI: There are no rules that doctors can't do the best job to care for patients. The guidelines for care that are in this country are those that the medical profession, including physicians in HMO's. I think it's important to realize that there is a sizeable community of physicians that believe that HMO's are the best way for them to practice. And, in fact, that's the reason why 500 of my colleagues are here tomorrow to tell our story.

MR. LEHRER: All right, Ms. Nichols.

MS. NICHOLS: But many of the procedures that consumers most want from health care are routinely denied over the objections of their physicians. For example, in New York right now, the doctors are fighting for similar kinds of utilization review changes, in other words, allowing doctors to be more in charge of health care decisions, because a number of bone marrow transplants for women with breast cancer, in particular, had been denied routinely, but what happens is that the insurance company becomes sort of judge, jury, and prosecutor in these things, and makes the decisions and routinely overrides the doctor's decision. You need to have actually an independent review board in order to guarantee that consumers are going to be protected. It's not enough, unlike what Dr. Bristow might think, to put it simply of the hands of other physicians because increasingly physicians even in the same sub- specialty may be working for that insurance company, so it's got to be independent with physicians who are genuinely, genuinely represent consumers' interests.

MR. LEHRER: Well, we have -- yes, Dr. Bristow, quickly, we have to go.

DR. BRISTOW: The Patient Protection Act calls for the Secretary of Health and Human Services to license an appropriate prepaid health plan, and --

MR. LEHRER: Ms. Ignani, would you buy that?

MS. IGNANI: Well, I don't think we want the Secretary to micro manage the health care system, Dr. Bristow.

DR. BRISTOW: No, we're not asking that he micro manage it. What we're trying to get away from is exactly the situation that Mr. Lehrer described, and that was a patient I saw just a few weeks ago who's a judge, and that individual had very, very mild hypertension, belonged to a for-profit HMO, and he had a stroke. He went into the hospital and said to his doctor, "I think it would be nice if I saw a neurologist. Don't you?" The doctor said, "Yes, but in our HMO, for you to do that, you'll have to pay out of your pocket. I would be happy to do it, but you'll have to pay out of your pocket."

MS. IGNANI: I think we can't do this by anecdote, Dr. Bristow, because everyone has their own anecdote to make. Where you stand depends upon where you sit. But hopefully we can get beyond that.

DR. BRISTOW: I'd be happy to explain to you that he did not get that, that consultation at that time. Three weeks later, he had a second stroke, and this time he insisted on having one. He paid for it himself. The neurologist told him that his problem was due to having his blood pressure lowered too much. Had he seen the man - - the neurologist -- the first time, he very likely would have avoided the second stroke. The problem is that that kind of decision making should remain between patients and doctors.

MR. LEHRER: Dr. Udvarhelyi.

DR. UDVARHELYI: The issue of transplants that was just brought up is an important one. In our system and in many HMO systems, we work hard to identify the hospitals and physicians that do the best job. Recently, in the Journal of American Medical Association, there was an article pointing out that over half of the institutions that perform heart transplantation have patient outcomes that are really lower than what we'd like to see. We need to have the ability to identify those hospitals and physicians that are doing a better job and send our patients there. In the centers of excellence type programs, and including the one that we run, the results are outstanding. Patients live longer because we are sending them to the best places.

MR. LEHRER: All right. This argument could go on and on, but it isn't going to, at least not here tonight. Thank you all four very much.

MS. WARNER: Ahead on the NewsHour, paying the bill for illegal immigration, and essayist Roger Rosenblatt. SECOND LOOK - PRICE OF ENTRY

MS. WARNER: Next tonight, bearing the burden of illegal immigration. In many parts of the country, the cost of illegal immigration has become a major political issue. Several states have decided to do more than complain. They've gone to court, suing the federal government for the costs of educating, jailing, and providing health care to illegal immigrants. This spring, Correspondent Betty Ann Bowser reported from one such state, Florida. We have a second look now at that report.

MS. BOWSER: It has become a kind of everyday ritual at dawn, small groups of men gathering at this intersection in Miami. They say they come to this place called the canal to find work.

UNIDENTIFIED MAN: We will make money every day to try to survive. And the police don't leave us alone. They take us to jail, and they say don't stand around here, because they treat us like criminals. We're not criminals.

MS. BOWSER: Sometimes there are hundreds hanging out at the canal, and police officer Frank Fernandez, whose job is to patrol the neighborhood, says work is not what's on their minds.

OFFICER FRANK FERNANDEZ, Miami Police Department: From an outsider's point of view, you look out and say, what's so wrong about it, these people are just out here looking for work. But they drink beer in public, they urinate in public, they gamble out on the street. They have numerous fights. We've had several persons killed out here, stabbings. They're very violent.

MS. BOWSER: And these are mostly illegals?

OFFICER FRANK FERNANDEZ: I would say that 85 to 90 percent of them are illegal. And this is based on the fact that I've arrested probably most of them. And the information that I gather from the arrest form is that they're illegal.

MS. BOWSER: Every time Fernandez and his men arrest illegal aliens it costs taxpayers money because it ties up at least six cops, six cars, and a bus. The officers spend most of the morning doing paperwork. The City of Miami estimates it spends $100,000 a year just to police the canal intersection, and assistant city manager Ed Blanco says that is a burden taxpayers should not have to bear.

ED BLANCO, Assistant City Manager, Miami: These are illegal immigrants, and it's an immigration problem. And the attitude within Immigration is that it's a police problem, let the local authorities handle it.

MS. BOWSER: Dan Cadman is the district director for the U.S. Immigration & Naturalization Service. He says even if policing the canal was his responsibility, he doesn't have the personnel to do it.

DAN CADMAN, Immigration & Naturalization Service: I have 50 special agents for the entire state. That's the state, and that's everyone from supervisor down to trainee. Fifty special agents doesn't go that far, it just doesn't. I dare say that any police precinct in the City of Miami probably has two to three times that many people.

MS. BOWSER: But when it comes to illegal aliens and what they cost taxpayers, law enforcement is just the tip of the iceberg. Florida officials say their state is slowly going broke over what it spends to provide services for illegal aliens, services the federal courts have ruled are a constitutional right. In South Florida, the problem is acute. This is a gigantic international melting pot made up of Cubans, Central Americans, Haitians, Asians. Officials say for every immigrant who comes with documentation, there is another one who enters the country illegally. In Dade County, where tens of thousands of illegal aliens have settled, the cost of educating their children is $68 million a year. And at the county's big public hospital, Jackson Memorial, emergency health care for illegals is pounding the hospital's bottom line.

IRA CLARK, Jackson Memorial Hospital: We don't turn away anybody, and that really is the distinction.

MS. BOWSER: Jackson's chief administrator, Ira Clark, says when illegals get very sick, they often wind up in the emergency room, where they are treated at taxpayers' expense.

IRA CLARK: In this one institution, you're talking about a huge amount of money in a single year. You're talking about as much as $30 million in operating loss.

MS. BOWSER: Gov. Lawton Chiles says America is attracting a new type of immigrant who is coming here not to work but to get free services.

GOV. LAWTON CHILES, Florida: The word has gone back there, you know, you can get food stamps, you can get medical services, you can have these treatments.

MS. BOWSER: And in South Florida, the problem is getting worse as economic and political conditions deteriorate in the immigrants' home countries. More and more people are braving the shark-infested waters off Cuba and Haiti. Others are filtering in from Central America. When people come to the United States illegally, one of the ways they're allowed to stay is if they apply for political asylum, to claim they have a well-founded fear of persecution back in their homeland. So by the thousands, they come here to the INS, make application, are granted work authorization permits, and allowed to go. Right now, the INS has so many applications for asylum that it would take 100 years to process the backlog. And until a case is decided one way or the other, that person technically is an illegal alien.

DAN CADMAN: There is a tremendous amount of abuse of the system. The devil's dilemma is that if we don't grant work authorization, they either fall into the social safety net of the community around them, or they may turn to crime, or any one of a dozen less viable alternatives.

GOV. LAWTON CHILES: Very simply, federal bills are being charged to Florida's account, and we've had enough.

MS. BOWSER: Gov. Chiles recently testified before a federal commission formed to reappraise the whole patchwork of regulations that govern immigration. Chiles says the federal government should shoulder more of the financial burden for illegal aliens because it is national, not state, policy that allows them to be here in the first place.

GOV. LAWTON CHILES: When it's a federal policy that determines immigration or the absence of federal policy that allows it to happen because we have a law which is not being enforced, and yet, the burden for all of that -- Florida doesn't set any foreign policy -- I'm not allowed to be in the foreign policy business, I don't want to be.

MS. BOWSER: The impact of immigration in Florida has not all been negative. There are those who would argue that it is immigration that has defined the character of the state and made it an international tourist attraction. Miami is home to one of the largest Hispanic communities in the world, a blend of people from Spanish-speaking countries who help make a $220 billion annual contribution to the nation's economy. It comes through income and sales taxes paid and by the ripple effect, money Hispanics spend on housing, food, clothing, entertainment. And that does not include money spent by illegal aliens. Father Thomas Wenski has been ministering to the needs of the Haitian community for the past 15 years. He says there is no reason to think they won't make the same contribution Hispanics have. Wenski's parish, Notre Dame De Haiti, is one of the poorest in Miami, so he raises money by staging fairs, money he uses to help Haitians take care of themselves.

FATHER THOMAS WENSKI: The immigrants are going to always end up contributing more to the society than what they take from the society. That's been the experience of the immigration wave of the 1800's to the 1920's, and it's going to be the experience now and as this third wave -- this is the third great wave of immigration in the history of the United States.

MS. BOWSER: Dr. Lisandro Perez says his research backs up Wenski's belief. He says immigrants begin to make measurable contributions to the country about six years after they arrive.

LISANDRO PEREZ, Cuban Research Center: It is the case that they cost initially when they come in frequently in terms of health care, education, and so forth. It's also the cost that they pay taxes. It's also the case after a certain number of years in most communities, in most groups, they become established, they pay back a great deal of what in a sense they cost to a community.

MS. BOWSER: In Miami's Little Haiti, people are working hard to make those contributions come sooner rather than later.

UNIDENTIFIED MAN: [speaking to immigrant] So Florida has made a new contact?

IMMIGRANT: Yeah.

UNIDENTIFIED MAN: [speaking to immigrant] That's somewhere in your motto?

IMMIGRANT: Yeah.

MS. BOWSER: Father Wenski's church operates a job counseling service for the community. Roger Biamby is its director.

ROGER BIAMBY, Job Center Administration: We're not here to just accumulate and take and not give anything in return. We came here because we are industrious people. We are hard working. We are honest people, and we want the American people to know that, because given a chance, we can be the best worker an employer can have.

MS. BOWSER: Last year, Biamby's program placed 350 Haitians in jobs that paid an average of $4.71 an hour. Those are people who pay taxes, he says, not people who burden the government.

ROGER BIAMBY: If I get paid $150 a week, I come home with $150 a week, then I can rent a home in the Little Haiti community. I can go to shops owned by Haitians and buy items, goods that I need for my survival. I have to buy food, so, therefore, supermarkets in the area will see an increase in their sales as a result of only 350 people who were able to find employment.

MS. BOWSER: It's not easy finding jobs even for qualified Haitian applicants when the economy is sour, but one Haitian who's made it with help from Biamby's program is Mercidiev Andre. Andre came to the United States as an illegal alien 16 years ago. He got his first job washing dishes, then found work as a short order cook. Today he is a successful chef at one of the busiest seafood restaurants in North Miami. Andre is one of those who's giving something back to the country that took him in. Even though he's sympathetic to the plight of illegal aliens, he is uncomfortable with some of their expectations, and he worries that he and other taxpayers are paying too high a price.

MERCIDIEV ANDRE: For example, they want to be rewarded by hand, say do this --

MS. BOWSER: They want to be held by the hand.

MERCIDIEV ANDRE: Yeah. And like you tell them, you know --

MS. BOWSER: Do they want free medical care?

MERCIDIEV ANDRE: Care, they want free education.

MS. BOWSER: Education?

MERCIDIEV ANDRE: Free education, and everything free. Now I say you can't have that like that. You have to help. You have to work, pay tax, and you could get some kind of benefits. You help me, I help you. That's the way I think, what I feel. You know, you help me, I help you. You know, you can't just come in, you know, and all -- [Phrase in Creole] -- and they get up in the morning, they look, and nowhere to go.

MS. BOWSER: Do you see a lot of that?

MERCIDIEV ANDRE: Oh, yeah.

MS. BOWSER: When Andre came over in one of the early waves of Haitian immigration, he was seeking a better life, but many of the cubans who now make up South Florida's most powerful immigrant group first came over for political, not economic, reasons. They were fleeing Castro and Communism. So the tidal wave of illegal aliens, most of whom came here to work, is a touchy issue in the Cuban community, one that often divides families.

TERE ZUBIZARRETA: [looking at ad clip at her business] Let's run through this, please.

MS. BOWSER: Tere Zubizarreta is a powerful example. She runs one of the top Hispanic advertising agencies in the country. The agency has 28 employees and last year billed over $15 million. But 33 years ago, Zubizarreta was just another frightened refugee escaping Cuba with her infant son, Joe, in her arms. Today, Joe is vice president of her company and daughter Michelle is an account executive. Octavio Zubizarreta, Tere's husband, does accounting work for the Port of Miami.

OCTAVIO ZUBIZARRETA: I think that a lot of these people are right now economic refugees. I believe that these people are coming because they don't have anything to eat or they don't have anything to provide their families, and they're not looking freedom, they're looking for food.

JOE ZUBIZARRETA: I agree with him. I think that politically there have always been a steady stream of rafters or refugees trying to get into this country from Cuba and other, you know, Communist countries, but what we're seeing now is strictly due to economic reasons. And the influx of all immigrants, Haitians, Cubans, and Central and South Americans that get here, and they don't have green cards, there is a lot more crime in the state of Florida, and the prison system, and the judicial system is backed up, and that's what I say. A lot of these people have to be dispersed to Iowa and Minnesota and let them handle a few Haitians too.

TERE ZUBIZARETTA: I would like to know who gave you the authority to become a judge on human beings. Who gave you and your father the authority to determine that the ones that are coming now are not coming for political freedom but for economic reasons, and who --

JOE ZUBIZARRETA: The same person that gave you the authority to decide that all the Cubans should come in here and have lives of their own, and everybody else needs to go back to their country.

TERE ZUBIZARETTA: Well, no, I don't think that everybody else should go back to their country. I think the beauty and the greatness of the United States of America is that it is a country that is formed by immigrants of all nations, and that's why we are such a perfect society, because we have the best of every culture. Then if the people come here to offer their wares and to practice their profession or their trade, to even help the country grow bigger, why not? Who are we to say no?

MS. BOWSER: While public officials argue whether to answer yes or no, in Miami alone, some 4,000 people become United States citizens every month. Never before in the nation's history have so many people wanted to come to America.

MS. WARNER: Earlier this month, Florida took another step to reduce the costs associated with illegal immigration. It began the process of deporting illegal immigrants who are imprisoned for non- violent crimes. Florida estimates the deportations could save it as much as $30 million a year. ESSAY - END OF THE WORLD

MR. LEHRER: Finally tonight, the end of the world as seen by essayist Roger Rosenblatt. He warned that it includes some graphic pictures.

ROGER ROSENBLATT: People who study such things have always assumed that the world will come to an end in one spectacular shot, not unlike the world is said to have begun in a big bang. The great flood of Genesis was a big bang of sort, the sacking Rome, the Inquisition, all those vast, extended European wars, the plagues, the Nazi Holocaust, and Hiroshima, and Nagasaki, two literal big bangs that strongly suggested to all who suffered and buy them that this is the way the world ends. That was T.S. Elliott's incantory prediction. This is the way the world ends, the assumption being that there will be one way, one singular way by which we will wind up our business here, and when that happens, by Big Bang or by whimper, the Earth will be as empty as the air. But, in fact, the world may end the way the little country of Rwanda has been ending itself these past few weeks, in a small place, hardly the size of the world, closer to the dimensions of Vermont, and individual, person by person, rather than by the cataclysmic noise of fissionable materials. In its own quiet, methodical way, Rwanda has asked, who needs the big, bad bomb, when one has at hand a much lighter, less expensive, and more manageable weapon, like a club or a machete. Where there's a will, there's a way for the will to end, and it doesn't have to end all at once either. It can end and end again, a series to be continued. If the end of the world may be thought of in these ongoing terms sort of like a serial killer, it makes it easier to contemplate and visualize. The historian, Otto Friedrich, wrote a permanently important book in 1982 called The End of the World in which he made the point that the world ends every so often. Mr. Friedrich did not include Rwanda in his assessment but he could have guessed at it. I did happen to see Rwanda. A few weeks ago, I stood by the Kagora River that flows between Rwanda and Tanzania and looked down into the water crammed with bodies that appeared and disappeared like swimmers in a public pool. Then I looked up into the still green hills of the country from which those bodies came. Everybody there wondered what would be discovered when the last weapon has been swung and one could finally enter Rwanda to see what has happened there. Technically, of course, we know what has happened there. The Hutu government, aided by the military, decided to eradicate by genocide all the Tutsi tribes people and Hutu moderates on whom they could lay their clubs and machetes. One hundred thousand, two hundred thousand, the numbers of the dead are merely guessed at. Reports are issued periodically from the murder house of hacked off arms, legs, heads, men, women, and children. For now, the carnage must be imagined since all of it cannot yet be seen. But Auschwitz could be seen and Dresden and Cambodia. Bosnia can still be seen, if anyone cares to look. So the imagination does not have to strain itself to envisage Rwanda. Picture the emptiness. Hear the silence. Once people enter the new Rwanda, they will know it at once by the silence. But as for what really happened in that country, well, everybody knows that too. There was politics naturally and tribalism naturally. But on the deepest level, there were people naturally who from time to time set aside what they have called their souls and recalled their under-developed evolutionary state and murder one another in great numbers for the hell of it. On the plains of the American West, in China, in Indochina, in Japan, and Western Europe, and Eastern Europe, in Latin America, and Sudan, and now Rwanda. This is the way the world ends, little by little, place by place, as far as the river takes it. I'm Roger Rosenblatt. RECAP

MS. WARNER: Again, the major stories of this Wednesday, the U.S. announced it would seek a U.N. arms embargo and other curbs on North Korea over its refusal to permit nuclear inspections. The action could be followed by other U.N. sanctions. At the same time, former President Jimmy Carter held talks with North Korean officials in an attempt to de-fuse the stand-off. Mr. Carter told them that progress can be made on other goals as soon as the nuclear issue is resolved clearly and the misunderstandings are removed. And in Rwanda, yesterday's cease-fire was shattered by a new round of mortar attacks in the capital, Kigali. Late today, France said it was ready to send troops to the Central African nation if the killing continues. Good night, Jim.

MR. LEHRER: Good night, Margaret. We'll be talking about Rwanda and North Korea tomorrow night when Sec. of State Warren Christopher is here for a Newsmaker interview. Until then, I'm Jim Lehrer. Thank you, and good night.