The MacNeil/Lehrer Report; Health Care in America

ROBERT MacNEIL: Good evening. While we have had some of the same trouble you may have had in staying awake through this election campaign, you may have noticed that we have done a different kind of program periodically. About once a week on average, we have carried an extended report on a campaign speech on the theory that few people at home get to hear a real campaign speech anymore, just a few phrases in the nightly campaign round- up. Some of our viewers have misunderstood and thought we were pushing one candidate. Well, we weren`t, but we now have given extended coverage to two speeches by President Ford and one by Jimmy Carter. So tonight, to even things up, another Carter speech.

Yesterday, Carter appeared in Miami Beach to give more details on his proposals for national health care. We`re going to show you a substantial excerpt of that speech; then we`ll compare his health policies with the President`s and examine what kind of changes in health care we might expect in the next four years. Carter`s audience was the Convention of the American Public Health Association.

VIDEOTAPE

JIMMY CARTER: In recent years we`ve spent 40 cents, out of every health dollar on hospitalization. In effect, we`ve made the hospital the first line of defense in stead of the last. By contrast, we only spend three cents on disease prevention and control, less than half a cent on health education, and a quarter of a cent on environmental health research. Look at our record in recent years on immunization. In 1974, 37 percent of all our children of age one to four had not been immunized against polio; 44 percent had not been immunized against rubella; and 40 percent had not been immunized against measles. This year, as you may know, we have already had reported that there were 35,000 cases of measles, and that`s a national disgrace. This year also, as you probably know, President Ford proposed to- cut the federal spending on vaccine for immunizations against preventable diseases by 50 percent. This, of course, is no surprise to me, because for almost the last eight years the Nixon and the Ford Administrations have slashed one essential health program after another in the fields of maternal and child health, community mental treatment centers, health manpower, health maintenance organizations, occupational and environmental research, and health and biomedical, and many other fields. That kind of negativism about preventive health care is going to stop next January the 20th. (Applause)

Let me outline for you some of the goals of the next Administration in the area of health. First, we must return to the basic focus on the prevention of illness and disease onto the strong neighborhood and community organization. (Applause) Second, we must have a comprehensive program of national health insurance. (Applause) You know as well as any group the complexities of such a program. But certain, basic principles are clear. The coverage must be universal and mandatory. (Applause) We must lower the present barriers in insurance policy coverage and otherwise to preventive and primary care, and thus, reduce the need for hospitalization. (Applause) We must have strong cost and quality controls, and the rates for institutional care and position services should be set in advance, prospectively. (Applause) We should maintain the personal interrelationships between patients and their physicians, and we should give freedom of choice in the selection of physicians and of treatment centers to the patient to be cared for. (Applause) Along with catastrophic health insurance coverage, we must make the provisions of prenatal and infant care benefits one of our highest priorities. (Applause)

We must phase in the program as rapidly as revenues permit, helping first those who need help, and achieving a comprehensive program, well defined, in the end. Now, many questions remain to be answered on national health insurance as any member of Congress knows, as any professional health care specialist like yourselves know. And I ask for your advice and your help in obtaining the best possible program as quickly and as early as possible. The third thing we must stress is health and nutrition education. (Applause) Our public schools could do more to teach our young people the dangers of drinking, smoking, using drugs, over eating, and eating the wrong kinds of food. And also, we need to make sure that the young people have a habit formed of taking advantage of the public and private health facilities that we offer. Many times there`s never that closeness of feeling toward health care specialists engendered in a young person`s mind that I was fortunate enough to have because my mother was a registered nurse. Fourth, we must mount a renewed attack on cancer and other diseases caused by toxic chemicals in the environment, including strict enforcement of the new Toxic Substances Control Act which has just been passed.(Applause) Fifth, we must continue and expand biomedical research and be sure that it serves the health needs of all our people and we must have, and I intend to provide, government reorganization that will end the bureaucratic fragmentation that now frustrates any hope for rational and effective national health policy. This is crucial and must be done. (Applause) It would be almost impossible for you to name a single, federal agency that doesn`t have part of the responsibility for health care. We`ve got 302 different federal health programs. They are scattered throughout the federal government. There is no coordination, there`s no cooperation, there`s no careful planning, there`s no end of duplication and overlap and waste. Medicaid is in one agency. Medicare is in a different agency. Neither on of those is responsible for health care, the certification of the quality of care. That`s in a third and different agency altogether. So we need to consolidate and reorganize the federal government to make sure there is a clear delineation of responsibility, a clear cinema of authority, so that our professionals who work for the government at all levels can let your professional careers be spent in the most fruitful way for a change. That must come. It`s going to come next year. (Applause)

We must encourage, and you can help with this, alternative delivery systems such as health maintenance organizations and rural group practices. We must alto remember that it`s both more cost efficient and more health effective to use less expensive treatment methods where possible, to improve out patient services instead of over billing and over using hospitals. (Applause) We must clean up the disgraceful Medicaid scandals. That is important. That must be done and will be done. (Applause) We must encourage nursing home standards of safety, sanitation and care, and we must encourage programs. that will serve elderly people in their own homes whenever possible. (Applause) We must, by scholarships, by loans, and by other means, provide medical education for more students from minority and low income families and also for more women. (Applause) And we must encourage young health professionals to train and to practice in rural and inner city areas. We must remember, too, that a nation`s physical and mental health cannot be isolated from its economic health, and we must therefore end the present, Republican economic policies that have brought us, at the same time, both inflation and unemployment. And in the process, it made it impossible for millions of Americans to afford decent health care. Now, these are some of the goals that I will work toward if I am elected President, in the health field. I don`t claim to know all the answers. The answers are not easy. Our nation has struggled unsuccessfully for many generations, and we have failed where other nations have succeeded better. This does not require that the government run the entire health program in our country. I would not favor that. But there needs to be a close cooperation between public and private health care delivery and emphasis on prevention of the cripplers and killers of our people, and adequate financing of health care, a shift toward non-hospital treatment whenever possible, and a realization in our country that there`s a great saving to be derived economically if we can address this problem consistently and with forethought and a deep national commitment. These things must come. Now, I do know that good health ought to be a right and not just a luxury, and that good government has no more responsibility than of solemn and of deep concern to make possible good health for all its people. I think that our people are ready for giant steps forward toward a comprehensive and adequate national health policy. I think we stand on the threshold of an exciting new era in American health. We have the technology, we have the financial means; we are already spending the money; we have the professional knowledge; we have the deep concern. On every poll that we have run the American people put #1 when you ask a question, "What in your lives is important enough even to raise taxes if necessary" And the people`s response is always, "health care." It`s of great concern to those who need it most, and.it`s time for us to do it in this country.

MacNEIL: Jimmy Carter speaking in Miami Beach, yesterday. President Ford opposes national health insurance, believes that it hasn`t worked well in other countries, and that it would cost too much. On April 30th, 1976 President Ford said, "I see no national health insurance program that would protect the doctor-patient relationship. I see no national health insurance program that can be implemented without expanding the bureaucracy unbelievably." In October of this year, President Ford said, "The health area, in my judgment, where there is an immediate need for additional help is in catastrophic illness." Ford further emphasizes this area in a television commercial for his candidacy.

VIDEOTAPE

President FORD: In the field of health, taking major steps to protect older people from what I call catastrophic or prolonged illnesses. Under the proposals that I recommended, no person would have to pay more than $750 a year for both hospital care and medical care. With that kind of protection then, nobody really has to fear all of their resources being depleted. I`m sure everybody here has a friend or a relative - I certainly did in my family - individuals who were ill for a very long time, and that just eats up all the financial reserves that people have saved. I say frequently, and I mean it, there`s no reason why somebody should go broke just to get well.

MacNEIL: Mr. Ford`s catastrophic illness proposal would be integrated with Medicare and Medicaid. As he also said this month, "Under my proposal, persons covered by Medicare will pay no more than $250 for doctor`s bills and no more-.than $500 for hospital bills in any one year." Another part of the President`s health care program was first addressed last February. He sent a message to Congress saying. "I am asking Congress to enact the Financial Assistance for Health Care Act which will consolidate Medicaid and 15 categorical, federal health programs into a ten billion dollar block grant to the states. My proposal is designed to achieve a more equitable distribution of federal health dollars among states and to increase state control over health spending."

JIM LEHRER: Now we want to sort out the differences between the basic Ford and Carter approaches to health care, and with me are two men who make it their business to do just }hat: Max Fine, Executive Director of the Committee for National Health Insurance, a labor backed lobbying group here in Washington. Mr. Fine worked in the U.S. Public Health Service in the Social Security Administration before joining the Committee; and Jerome Brazda, Executive Editor of McGraw-Hill`s Washington Health Letter Group. Before coming to McGraw-Hill, he was a reporter for the United Press international.

First to you, Mr. Brazda. In simple terms, what are the differences between the two basic approaches?

JEROME BRAZDA: Well, about 180 degrees I guess. They are really quite different. President Ford talked in the beginning about a national health insurance program, but then changed his mind and never came forth with anything. And, in fact, the Medi care proposal that he just spoke about in the commercial was received by Congress with some horror because it was a political bomb. In fact, they had great difficulty getting anyone to introduce the bill. Finally, only a Republican from Tennessee, Mr. Duncan, put in the bill as specifying it was by request, meaning he didn`t want to associate himself with it or endorse it, because it was accompanied by, in addition, a catastrophic benefit which is what some people call "major medical," meaning it covers the costs above a certain level, but it also would help finance that cost by imposing increased cost sharing by the Medicare patients. And that`s the area in which Congress found it just politically ...

LEHRER: They shot it down on that basis, didn`t they?

BRAZDA: They never did a thing with it, and none of those proposals had any hearing. Now, Carter, on the other hand, has from his first mention of health care, spoken out quite clearly for national health insurance. And he says national health insurance, that can mean different things to different people. In this case it means quite clearly a national health insurance program. He hasn`t flatly endorsed the labor backed Health Security Bill which is a real whoom-to-toom bill proposed by Max Fine, here, and the Committee For National Health Insurance, but he has come very close to it. And in this speech, he gave certain key words which indicated that he is rather strongly in line with that proposal. There were some interpretations of that speech that perhaps he really didn`t mean it because he said that we would not have a total national program, but by that, if you read it very carefully, he is saying that we are not going to take over the hospitals, and we are not going to make the doctors work for the government. But what the Health Security Bill has been is a national health insurance bill. So Carter is very strongly for the government involvement in health care. Mr. Ford, his entire policy since he has taken office has been to roll back on the government which already is quite heavy.

LEHRER: All right. Mr. Fine. How do these two, basic proposals differ in terms of cost?

MAX FINE: I think you have to recognize that health care is one of America`s great problems that we can solve without spending any more money. The question is, how much cost do you want to funnel through the federal budget. We already spent in this year $130,000,000 for health care; more than the entire defense establishment. So, no one is talking about spending more money. The question is, do we spend it through private insurance companies and continue to subsidize the present system, or do we try to get a handle on this system with cost controls and access to care through a national health insurance program.

LEHRER: Now, wait a minute. You said "No matter what happens it`s not going to cost any more money." The fact is that no matter what happens it`s going to cost an awful lot more money, isn`t it?

I mean, with or without a national health insurance program, the cost of medical care is going to continue to go up, and it`s going to continue to take a bigger hunk of everybody`s income, right?

FINE: That is correct. What I`m saying is that national health insurance will not necessarily cost more than to continue with the way we`re going- now.

LEHRER: I see.

FINE: There`s no proposal for national health insurance that would cost $130,000,000.

LEHRER: No matter whose proposal, they`re all in about 230 billion to 245, aren`t they? Everybody from the AMA`s program to your program.

FINE: That`s correct. I think it`s very important to recognize that everybody, including the AMA, everybody except President Ford agrees we ought to have a national health insurance plan. His position is beyond the pale. Everybody, from organized medicine to labor, and all groups in between, religious groups, the senior citizens, -- more than the majority of the Congress sponsors one bill or another.

LEHRER: And he has done that on the basis of finances, right? That he says we can`t afford it.

FINE: On the basis of finance and pejorative terms about interference in the doctor-patient relationship. As Jerry has just said, there is no bill that would take over the hospitals; there is no bill that would have the federal government have doctors as civil servants. Nobody is proposing to do that. The proposals are to deal with the financial thing, and through dealing with the financing to get a control on costs which are going out of sight.

LEHRER: Carter also, as you said a minute ago, Mr. Brazda, and as he indicated in his speech -- in fact, we just saw him say, "I`d like for you folks in the audience to help me come up with a way to do a national insurance program." He`s held out. He has not said he wants the federal government to do it all. He wants to involve the private sector. And in some of the material I was reading today, he made it very clear that he wanted to explore the possibility of the continued involvement of the private insurance companies, including Blue Cross, Blue Shield, the biggest one, and whatever.

BRAZDA: That`s correct. He`s keeping his options open on that, and wisely I think. He is coming out rather specifically for a national health insurance program even if he hasn`t laid out the comma and the clauses of it. And I have talked with some of his people who point out that why should they get any more specific than that at this point, because the opposition, the Republican Party Platform, is not for national health insurance, nor is President Ford, so they don`t have to get any more specific. The clear outlines of the bill remain to be seen once the election is held. The key to the whole thing, of course, is the fact that the President doesn`t write a national health insurance law. He can propose a bill. He can work for it as Lyndon Johnson worked for Medicare in 1965 with Congress. It writes the laws itself, and that`s where the really difficult going gets. Even Johnson had a tough time getting a Medicare bill through Congress despite the huge majority that he brought with him in his election. Let me finish saying this, that national health insurance has been rather of limited popularity in Congress.

LEHRER: Without the President`s negative feelings, yes.

FINE: It`s clear from every survey -- Cambridge Survey, Harris, and all the others -- that a majority of the American people want a national health insurance policy, but we can`t get a plan without a leadership from the President.

LEHRER: But those same surveys also show that the overwhelming majority of the American people also feel that the health care that they get right now is excellent. So, you can read these things any way you want to. Let me throw this to Robin. Robin?

MacNEIL: Gentlemen, this may seem too simple a question, but what is national health insurance in the terms it is being talked about here. Mr. Fine, could you explain it to me?

FINE: Yes, Robin. There are different proposals. The major proposal, the Kennedy-Corman Bill which has the sponsorship of about 130 members of the Congress, would create a national health security program, tax financed, and use the leverage and support of that program to control cost, to level off the unevenness of quality, and to create basic reforms in the health care system, to create the types of health maintenance organizations that Governor Carter was talking about, and to put the emphasis on preventative medicine rather than over-hospitalization as we have been doing now for 20 years.

MacNEIL: And that would-be the equivalent for most people of the kinds of things that they and their employers now jointly buy from the private companies.

FINE: Yes. And under the Kennedy-Corman Bill they would continue to jointly buy it, because it would be a shift of the premiums they are now paying to Blue Cross and Blue Shield and the insurance companies into this Health Security Trust Fund.

MacNEIL: In other words, that would act as the insurance company.

FINE: Yes, it would.

MacNEIL: But you`re not sure whether Mr. Carter`s plan would keep this in the private sector, that is in these private insurance companies, or would shift it to that institution you have mentioned.

FINE: Governor Carter has called for a tax financed, national health insurance program, financed by payroll taxes and general revenue taxes. He is leaving his options open with respect to possibly using the insurance carriers, the Blue Cross or others, as intermediaries, as fiscal agents in the program.

MacNEIL: Yes. Can we, in conclusion here, ask each of you to say, given the political possibilities, Congressional wishes and the likelihood, as you mentioned, the difficulties with Congress, what kind of health care system are we likely to end up with -- I`d like to hear from both of you on-this - - if, first of all, Mr. Carter is elected President. What kind do you think it is going to turn out to be? Starting with you, Mr. Brazda.

BRAZDA: What kind of a health care system?

MacNEIL: Yes.

BRAZDA: Are you talking about the national health insurance in terms of the financing?

MacNEIL: The method of financing and the kind of delivery system we would have.

BRAZDA: You want my prediction?

MacNEIL: I would like your prediction, yes.

BRAZDA: (Laughs) I`ll venture one. Given the difficulties of enacting such a program -- I watched the Ways and Means Committee when Mr. Mills was still Chairman try desperately, and he was desperate to come up with something to show the voters. Two years ago, in 1974, he tried to write a national health insurance bill, and the interesting thing to me that day was who was against it, and it wasn`t so much what the organizations were for, it was what they were against, and it is being vigorously fought by most of the provider groups . . .

MacNEIL: Could you just tell me your prediction, briefly.

BRAZDA: So, therefore, I doubt that anything as sweeping as Max proposes will be enacted. I think something more limited, maybe on terms of maybe a catastrophic program for all people and an expanded Medicaid program for the poor, and then following it incrementally after that.

MacNEIL: And that would end up with something like you were saying is something like what President Ford is now proposing. Is that what you mean?

BRAZDA: Well, he is really not proposing it, no. What he was proposing was simply a catastrophic program for the aged. Senator Long and Senator Ribicoff on the Finance Committee have proposed a bill for the catastrophic coverage of all Americans.

MacNEIL: I see. Mr. Fine, what do you predict would we have with Mr. Carter and Mr. Ford a couple of year down the line?

FINE: I believe with President Carter, that we will have, at the end of his first term as he says we will have, a comprehensive, universal, national health insurance plan covering everyone, phased in over the period of the four years. I believe that under President Ford we will have no change in the present system. I believe that in the years ensuing it will become so costly, it will collapse.

MacNEIL: Thank you. We have to leave it there. Thank you both, gentlemen, and thank you Jim. That`s all for tonight. I`d just like to add a little footnote. tonight. This broadcast happens to mark the first anniversary of this program. We began a year ago tonight in New York to experiment a little with the traditional television, news format. We are now carried by Public Television Stations into more than 200 cities. We are grateful to all those cities and to their viewers. Our aim is still to slow down and take a really penetrating look at one story a night. By attempting this, we hope to help you understand both the great and the simply fascinating issues of the day. We don`t pretend to be exhaustive or definitive in one night. Our basic aim is not just to arouse your curiosity, but to satisfy it a little more. That`s what we said a year ago tonight. It is still my aim; it`s still Jim`s and that of the team behind us. For all of us, I`m Robert MacNeil. Good night.