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Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
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Volume 51, No. 4 April 1995

HALTING THE MANAGED-CARE JUGGERNAUT

The prevailing wisdom is that the managed care juggernaut cannot be stopped. But when this view was presented at the March, 1995, meeting of the American Association of Clinical Urologists, a voice was heard from the audience: ``Wait a minute. Don't you remember that everybody was saying exactly the same thing about the Clinton Plan in early 1993?''

Kathryn Serkes, AAPS media consultant, had just given a talk on ``What Was in Those Secret Documents: an Update on AAPS v. Clinton.'' The documents were in large part drafted by experts in ``management,'' who have a huge vested interest in the managed-care takeover of American medicine.

The failure of the Clinton Plan was a setback, but the managed-care invasion continues across the country. What if all the criticisms of the Clinton Plan (loss of freedom, rationing, stagnation, and bureaucracy) came to pass without a single congressional vote (Texas Monthly 3/95)?

The strategy is quite straightforward: co-opt physicians by the age-old method of appealing to fear and greed.

The fear is obvious: if you don't sign up, your competitor will, and all the patients will go to him. (The plan doesn't have to appeal to the patients; their employer will sell them to the lowest bidder.) If your competitor won't sign up either, then they'll bring in somebody new, possibly somebody who couldn't make it independently and will thus be compliant.

Those who get in on the ground floor as part owners of the enterprise may profit handsomely. Physicians may also be attracted by generous offers to buy them out-an increasing likelihood as HMOs try to find a use for their spare cash. And underpaid primary care physicians may want those capitation contracts to cover their office overhead. In some situations, that $6 or $10 per month per patient can be very lucrative, depending on the gatekeeper's responsibility if patients get sick. (For example, one capitated gatekeeper in Arizona's managed-care Medicaid substitute said his indigent patients were quite profitable. Though the plan is far more generous than most insurance offered to working people, the patients seldom come in to take advantage of it.)

Those who take the bait may be in for a shock if they don't read the fine print in the contract. Many HMOs reserve the right to fire physicians without cause (S Calif Med 1/95), or because their patients cost the plan too much money (Forbes 2/13/95). Or the plan may return only a small fraction of the 20 percent holdback of discounted fees, claiming ``unexpected expenses.'' The plan does not explain the nature of the expenses, but the price of its stock goes up as does the compensation of top executives (Front Line, Spring, 1995).

Physicians who join up to achieve financial survival may instead face the unthinkable: personal bankruptcy. The threat is not well publicized; those who give warning may do so anonymously because an insurance company now has the power to stop their income completely.

Managed care claims to save money. Indeed, it does spend less on medical care, redistributing the cash into its bulging coffers. Nine of the biggest publicly traded HMOs are sitting on $9.5 billion in cash (Wall St J 12/21/94).

The savings do not result from efficiency. For-profit HMOs use as much as 30 percent of every health-care dollar for paperwork, advertising, multimillion-dollar executive salaries, and profits (Calif Physician 2/95). As with Medicare, the cost is understated if it does not include the added burden borne by the practitioner. One physician found his overhead doubled from 30 to 60 percent of his income (Texas Monthly). Some savings may come from cream-skimming; sick patients are willing to pay more for the right to see the physician of their choice. The primary mechanism is to deny care.

It's not just a matter of setting up barriers to ``unnecessary'' care. ``Managed care and managed death are blurring together'' (D.P. Sulmasy, Arch Intern Med 155:133-136, 1995).

Is the outcome inevitable? Is it true that ``the hydra has already displaced the solo medical provider''? Or that ``managed medical business aggregates are to country doctors what a space probe is to a rickshaw'' (Lauren Bain, Puget Sound Business J 2/3-9/95)?

The optimistic view is that the rickshaw can be replaced by an automobile, which will beat the space probe every time in providing ground transportation.

For the sake of their patients, it is the duty of physicians to be optimistic and therefore work to change the outcome.

What would be effective? Ask the Alliance for Managed Competition (Aetna, Prudential, CIGNA, and MetroHealth). They fear medical savings accounts would entice employees back into traditional fee-for-service arrangements, and are developing a position on MSAs now that the idea is gaining credence on Capitol Hill (BNA 1/30/95). Indeed, all patients may like to have savings accrue to them instead of augmenting the cash position of managed-care networks.

Another fearsome weapon is the one used against the Clinton Plan: sunshine. Many of the ideas in the AAPS pamphlet on questions to ask about managed-care plans are in a ``Truth-in- Packaging'' law, which has passed the Arizona Senate on a vote of 30 to 0 and is now pending in the House (copies available on request). The Arizona chapter of AAPS, led by President Joseph Scherzer, M.D., helped to promote the law, with advice from associate member Alan Immerman, D.C.

Managed care has had a privileged position under federal law since 1973, when many employers were forced to offer a federally qualified HMO. (This requirement expires in October, 1995.) Physicians should demand a level playing field.

The battle has not been lost-yet. But the surest road to defeat is preemptive surrender by physicians.


Texas Medical Association Supports AAPS Case

At its November, 1994, House of Delegates meeting, the Texas Medical Association passed the following Resolution: ``RESOLVED: That the Texas Delegation to the AMA encourage our AMA to commend the Association of American Physicians and Surgeons lawsuit challenging the secrecy of the Clinton Health Care Committee (sic.) and for the Board of Trustees of the AMA to consider financial support.''

 

``Dual Choice''

Under Title XIII, section 1310 of the Public Health Service Act (the HMO Act), ``dual choice'' requires employers to offer a federally qualified HMO as an alternative to indemnity health or service benefit insurance plans if they meet all of the following conditions: they have 25 or more employees, pay the minimum wage, provide health coverage to which the employer contributes, and receive a written request (``mandate'') from one or more federally qualified HMOs operating in a geographical area in which 25 or more of the employees live.

A private employer who fails to comply is subjected to a civil monetary penalty of up to $10,000, and may be assessed an additional $10,000 for each month of noncompliance. Noncompliance by a public employer, such as a local government, may cause public health funds to be withheld from the entire state. Public employers include states, cities, and school districts.

The dual choice provision will expire in October, 1995.

The HMO Act is administered by the Office of Prepaid Health Care Operations and Oversight (OPHCOO) within the Dept. of HHS, Room 4406, Cohen Bldg., 330 Independence Ave. SW, Washington, D.C. 20201, (202)619-0286.

AAPS member Holly Fritch Kirby, M.D., of Lee's Summit, MO, obtained this information.

 

No Choice about Choice

To receive accreditation, residency training programs in obstetrics and gynecology must, as of January, 1996, offer training in abortion.

According to John Gienapp, Ph.D., Executive Director of the Accreditation Council for Graduate Medical Education, residents with moral or religious objection to abortion are allowed to be excused from the training requirement. Training programs with such objections are not required to offer the training at their institution but ``must allow residents in their program access to training at another facility.''

Additional information may be obtained from the ACGME ``FAX on Demand'' service at (312)245-9174 or from Dr. Gienapp at (312)464-4920.

Between 1976 and 1991, the percentage of obstetrical residency programs that did not offer abortion training increased from 7.5 to 31 percent, and the percentage requiring such training fell from 26 to 12 percent (AP 2/15/95).

 

AAPS Documents on PolicyFax

Selected publications from AAPS are now available instantly by fax by calling (510)208-8000 from any touch-tone phone. Elected officials, reporters, and talk show hosts with accounts may use this PolicyFax service free of charge; for others, there is a $5 charge per document. PolicyFax is sponsored by the Heartland Institute and also offers documents from the Heritage Foundation, the Cato Institute, the Hoover Institution, the Independence Institute, and Doctors for Disaster Preparedness.

 

Know the Enemy

``It has been said that families go `from overalls to overalls in three generations.' It has taken doctors a little longer than that. During the time of the Romans, doctors were of the slave class. At the time of the Industrial Revolution, as portrayed in George Eliot's novel Middlemarch, doctors took their orders from the bankers and town councils. How far are we from that today?...Are we going to allow the present slide to continue until we...are back to being slaves?''

In his Presidential address to the 29th annual meeting of the Priestley Society (Mayo Surgical Alumni), AAPS member John R. Hilsabeck, M.D., identifies seven major enemies of private medicine. Admitting the existence of real enemies is the first step in defending our profession. For a copy of this extensively researched address, write Dr. Hilsabeck, 11611 S.W. Skyline Dr., Santa Ana, CA 92705.

 

Medical Ethics Under Siege

In Belgium, one of the last European countries in which the patient is free to select his physician, the government has levied criminal charges against a crippled 70-year-old physician who installed privately funded MRI equipment without prior government approval. The Edith Cavell Institute in Brussels, of which Dr. André Wynen is retired director, is paying 10 percent per day of inpatient fees as a fine for making this apparatus available to patients. The original court threw out the charges against Dr. Wynen, on the ground that ethical standards could supersede the law, but they were upheld on appeal. Dr. Wynen hopes his case will reach the European Court of Human Rights (The Lancet 1/28/95).

 

A Tale of Two Two Tiers

Health Minister Marleau is determined to do something about one of two two-tiered systems. The one in Quebec is acceptable; it simply denies hip and knee replacements to more than half of the patients who would receive them elsewhere. The top tier jumps the queue, with the help of political connections, or goes to the U.S. However, the system in Alberta subverts the National Health Act by permitting patients who don't want to wait for cataract surgery to pay the facilities fee and have it done privately. This approach actually reduces the number of persons waiting for eye surgery, because each patient who opts for the private system creates a space in the public system for somebody who can't or won't pay the facilities fee.

Is it time to scrap the National Health Act, rather than to enforce it? (Michael Walker, Fraser Forum, January, 1995)

History is strewn with the wreckage of men and of nations lured to their destruction by the bait of something for nothing -lured by smoothly planned appeals to the criminal tendencies that lie dormant and unrecognized in almost everybody. And the lure succeeded only because its true nature was invariably hidden under a barrage of righteous propaganda.F.L. Maus


Legal Briefs

Reno Declines to Appoint Independent Counsel. Just before the deadline set by the House Judiciary Committee, and on a weekend when press coverage would be scant, Attorney General Janet Reno announced that Eric Holder, U.S. attorney for the District of Columbia, would be in charge of investigating Ira Magaziner's alleged perjury in the case of AAPS v. Clinton (see AAPS News, March 1995).

Magaziner was not in a high enough position to be covered automatically by the independent counsel law. However, Reno could have asked a special three-judge court to name such a prosecutor if she believed that the U.S. attorney had a significant conflict of interest.

Reno said she saw no reason to disqualify the Department of Justice even though it represented Magaziner and other administration officials in the litigation over the Task Force.

Charles Ruff, Magaziner's attorney, said he was pleased to hear of Reno's decision.

``We're confident that Mr. Magaziner did nothing wrong and he will be vindicated, and we're equally confident that the U.S. attorney will conduct a thorough and independent investigation,'' Ruff said.

Judge Lamberth concluded in December that Magaziner made some false statements about the working groups' members. But he said prosecutors must decide whether to charge that he knowingly and intentionally made false statements (Marcy Gordon, Associated Press).

Ms. Reno's opinion about independent counsels has apparently undergone a dramatic change now that the law can be targeted against Democratic administration officials. (Congress exempted itself.) Previously, she stated that such counsels were ``a crucial element of ensuring public confidence'' in government (Wall St J 3/7/95). While sharing Reno's aversion to independent counsels, the Journal noted that Eric Holder, who may be a candidate for judicial appointment, may have difficulty examining the Magaziner case with objectivity. Holder has gone out of his way in the past to praise Lauri Fitz-Pagado, another controversial Clinton appointee who was accused of concocting false testimony.

AAPS intends to urge Congress to undertake its own independent investigation of the Task Force, with particular attention to its funding.

After many months of inquiries, John Solomon of the Associated Press turned up evidence of more than $4 million in contracts awarded to develop the Clinton health-care plan, spread over several Cabinet departments. The Congressional Budget Office has turned up $6 million in contracts let by HHS and is still counting. While touting the exclusion of ``special interests'' such as physicians, the Task Force relied heavily upon highly paid consultants who shuttled between positions of influence in the private sector and highest levels of government, untroubled by the ethical proprieties required of full-time civil servants (Wash Post 2/22/95).

Payments of six figures were made despite a warning from White House lawyers to use full-time employees, not consultants. Memoranda documenting this warning were found on diskettes finally made available to AAPS just as the Judge was declaring the case of AAPS v. Clinton moot.

Fraud Dragnet Rakes in Cash. The Office of Inspector General of HHS recorded $8 billion in settlements, collections, and savings during FY 94. Civil monetary penalties reached a record level of $184.9 million. There were 1,169 successful prosecutions in FY 94, including 202 for health-care fraud and abuse. Providers should not rely on a Magaziner-style defense of saying that they weren't paying attention to each and every claim and didn't know that some were erroneous.

Many facilities are now developing a compliance plan (see Medicare Compliance Alert 1/30/95, (301)816-8950, ext. 223). If ``fraud'' is discovered, the government would like providers to turn themselves in. However, no amnesty is allowed, and ``rules of engagement'' have yet to be developed. Nonetheless, companies should feel pressure to confess due to the growing number of whistleblower qui tam lawsuits (BNA's Health Care Policy Report 2/26/95, (800)372- 1033).

Health-care fraud is now second only to violent crime on the Department of Justice's priority list. Beefed-up fraud units are focusing on ``unbundling,'' ``upcoding,'' and billing for ``unnecessary'' treatment. DOJ is also looking into the practice of waiving copayments. Certain HMO practices such as bonuses to physicians with the fewest referrals to specialists are also under scrutiny.

Expansions of fraud statutes may extend penalties to those who receive payment from private insurers. U.S. attorneys are seeking harsh prison terms with little or no chance for sentence reduction (BNA's Medicare Report, 11/4/94).

Recently, a New York internist-rheumatologist who signed on with a community clinic was sentenced to 46 months in jail, a repayment of $612,855, and Medicare/Medicaid exclusion for 10 years. He noticed that the lab was upcoding claims and billing for unordered tests. He asked his physician's assistant to tell the lab to stop and wrote a letter to the lab with similar instructions. Seven weeks later, he left the clinic ``after beginning to see that there was something wrong,'' but did not report problems to the authorities. Unfortunately, he didn't keep copies of his letters and was convicted of filing false Medicaid claims (Medicare Compliance Alert 1/30/95).

Physicians are responsible for all claims and forms that they sign. It appears that anyone who accepts government money (directly or indirectly) is at risk for being targeted by a vindictive prosecutor in the IG's office. Honest errors or oversights could be construed as fraud.

The AAPS Nonparticipation Policy, adopted in 1965, states the belief that the proper course for physicians is to decline to execute forms necessary for the implementation of government medicine. In 1990, Congress enacted a law requiring physicians to submit forms if their patients desired to obtain Medicare benefits. AAPS opposes that law. The AAPS position is that insurance benefits should be paid directly to the beneficiary (the patient) and that patients or their representatives should submit the claims for their benefits.

HCFA Enforcing Balance-Billing Limits. Some nonparticipating physicians have received letters demanding refunds to patients who paid more than the limiting charge for services rendered several years ago. One physician was ordered to refund various sums to more than 700 patients, under threat of sanctions. Note that the case of Stewart v. Sullivan offers no protection if a Medicare claim was submitted for a service.

Limited Legal Consultation Service Available. AAPS may be able to help with questions about Medicare regulations, medical staff bylaws, contracts, and other practice issues (not medical liability). Call us at (800)635-1196. If the question is within the scope of our service, we will refer it to an attorney.


Members' Page

Private Contracting by an Anesthesiologist. I was unable to attend the annual meeting but have enjoyed the audiocassettes of many of the talks. One of the questions was asked by an anesthesiologist interested in the logistics of private contracting. I have contracted privately with several patients and plan to become more aggressive with contracting as the surgeons develop an understanding of the need for this. While I don't advise other physicians to privately contract, I would be happy to answer any questions directed to you or AAPS about my own practice. The basics are as follows:

1) Explain contracting to primary care physicians referring to the surgeons you work with. Their day-to-day paperwork game with Medicare dwarfs that of the anesthesiologist. They will privately contract just to avoid the paperwork demands. They will educate their patients, so the idea of private contracting won't come as a shock.

2) Explain to the patients that they would not want anesthesia service worth no more than Medicare pays (around $70 for anesthesia for a total knee replacement).

3) Tell the surgeons you work with that you have managed to keep your fees reasonable by not cost shifting. Refusing to give mandated discounts based on age will save their younger patients money. The Medicare beneficiaries have accepted this explanation rather well.

I have been referred patients by patients that I have contracted with. Their idea is that since they are going to pay for the service out of their own pocket, it must be worth having....Rather than lose patients because of contracting, surgeons are calling me asking when I can be available to provide contracted anesthesia care for certain patients.
G. Keith Smith, MD, Oklahoma City, OK

 

Oh No We Don't...Recently I experienced the final straw in a long series of unsettling events....The first came while I chaired our hospital transfusion review committee, which was instructed by the administration to develop a separate consent form for transfusions, even though they were already covered in our general surgical consent form. When I asked if the separate form would provide extra protection from litigation, I was told ``No, but we just need to do this.''

When my specialty board introduced a ``voluntary'' recertification examination, I asked if we had any evidence that such recertification improves quality of care or patient outcomes. The answer was a knowing nod and ``we just need to do this.'' When all the blood and body fluid precaution signs were removed, it was because ``we just need to do this.'' When a restraint policy requiring a full-page questionnaire to be completed daily was applied to intubated, ventilated, critically ill patients in the SICU, I asked why. The answer given at all administrative levels: ``We just need to do this.''

I suggest that we no longer accept this answer. If we physicians cannot understand the real reasons for all these changes, then we are not intellectually fit to practice our profession....If critical information continues to be withheld from us, we can only assume that there must exist some hidden agenda that would be unacceptable to us.
Philip S. Gibbs, M.D., Lebanon, IN

 

An Indicated Abortion. I hope we can abort socialized medicine for it is the result of incest (big government and big insurance companies) and rape (medical profession).
David H. Turner, M.D. Chattanooga, TN

 

Ethical Inversion. [Medical research, hospitals, doctors, nurses, etc. have but one reason for being]: the sick person.... But in today's ``health care system,'' the ``System'' is paramount. A sick person is a the expensive, bothersome, inferior, stupid, inanimate, subject, client - a pest to be tolerated, an obstructive intrusion. So his life and habits must be engineered, restricted, and controlled by his betters to make him compliant, cost- and resource-effective. Properly defined, this is veterinary medicine - the ``betters'' being the owners, and you and I are the farm animals.....The patient is only the necessary excuse for the wielding of power....[Current changes have the purpose of making] the ``System'' so expensive, cumbersome, and intolerable that the preconceived desired end (more government) can be proffered as the solution to the problem that big government created in the first place.
Curtis W. Caine, M.D., Jackson, MS

 

To Congressman Archer, on Managed Care.... Under managed care, especially under capitation, doctors and hospitals take on the insurance risk....Their goals and ethics will have to change to those of the insurance industry. Managed care sets up financial reward to those who withhold care. Is there any other segment of our economy in which the payment goes for goods or services not delivered? The financial and ethical foundations in medicine are deteriorating....such structures decay much more easily than they are rebuilt.
James Pendleton, MD, Abington, PA

 

AAPS Calendar

May 6 Regional meeting, Boise, ID: A Free-Market Solution to Health Care Price Distortion and the Corporate Socialized Medicine Managed Care Malignancy. Call 800-635-1196 for information.

Oct 12-14 52nd Annual Meeting, Falls Church, VA.


Legislative Alert

Voices of Moderation

Reflecting on the legal and tort reforms being pursued in the House of Representatives, Mr. George Bushnell of the American Bar Association (ABA)-an organization formally on record against reform inspired by Adam Smith or free-market thinking-has referred to the new Congressional leadership as ``Reptilian Bastards.'' (Newt, take note!)

Bushnell is a public-relations dream come true for proponents of tort reform. Just the kind of rhetoric that America's uproariously funny and overwhelmingly popular legal profession needs right now.

Medicare's Monster Budget

Medicare and Medicaid are among the federal government's fastest growing entitlement programs. Recent calculations of the costs and the threat of fiscal insolvency are adding to the urgency of Congressional reforms. Newsweek economist Robert Samuelson reports that between 1980 and 1995, Medicare rose from 5.8 percent of federal spending to 11.5 percent. Right now, Social Security at $334 billion and Medicare at $176 billion alone account for 39 percent of non-interest federal spending ($1.3 trillion). The Congressional Budget Office (CBO) projects that spending on Social Security and Medicare will grow from $510 billion to $719 billion, a rise of 41 percent, while the number of beneficiaries will increase by about 7 percent.

Medicare Part A is projected by government actuaries to go broke shortly after the turn of the century. These reports have been surfacing in Congress for years, and like water in the mailroom of the Titanic are considered unpleasant news, best ignored for the time being or largely dismissed by politicians traveling in First Class.

Likewise, the costs for Medicare Part B, which covers physicians' services, is continuing to grow at a rapid rate, in spite of all the ``cost-containment'' mechanisms (including the RBRVS nonsense) that Congress has imposed. The Medicare price control system has been an epic failure.

In a singularly powerful column, Robert J. Samuelson (Washington Post, 3/8/95) notes that the biggest problem facing Capitol Hill is an utter misunderstanding of the financial dynamics of the program, particularly among the elderly. This is borne out by public opinion analysts, who report that in general the public doesn't even know the difference between Medicare and Medicaid. Of all the federal programs that ought to be cut, cutting Medicare gets the least public support. It is the ultimate Sacred Cow.

Many of the elderly believe that they have paid for the benefits that they are receiving. Not so, says Samuelson:

``New retirees will receive an average of $5 in Medicare hospital benefits for every dollar they contributed, calculates Guy King, former actuary of the Health Care Financing Administration (HCFA)....We are a nation in denial. There's a sanctioned avoidance of problems that almost everyone knows will worsen with time. Spending on the elderly, though heavy now, is not crushing. As the baby boom nears retirement, though, it will become so....The real crusher is Medicare. Similar projections show it is growing from 2.5 percent to 7.1 percent of GDP by 2030... To cover the increases-and the existing deficit-would require that federal taxes be increased by about half. In today's terms, that's a $650 billion tax increase.''

The case for a serious restructuring of Medicare is building. Congressman Bill Thomas (R-CA), the new Chairman of the House Ways and Means Subcommittee on Health, says he favors a Medicare voucher option.

The President's position in the State of the Union address was that he would ``protect Medicare'' from congressional budget cutting. The Administration has recently gone farther than simply arguing against spending cuts or even spending restraint. Bruce Vladeck, administrator of HCFA, has made it plain that vouchers are not even on the table as a viable option, from the Administration's standpoint. AARP has vowed an all-out war on any serious Medicare spending cuts.

Gingrich's ``rethinking'' initiative got an added boost from Senator Robert Packwood (R-OR), chairman of the Senate Finance Committee. He recently stated that restraint in the growth of Medicare and Medicaid would have to yield approximately $400 billion over the next seven years if the budget is to be balanced.

Historically, Congress has addressed cost increases in Medicare by freezes in payments to physicians and hospitals. Less frequently, Congress has proposed changes in cost sharing requirements for beneficiaries. Currently, in Medicare Part B, the taxpayers, by law, fund up to 75 percent of the cost of the premium. The original understanding, when Medicare was enacted in 1965, was that the taxpayers would pay 50 percent of the premiums. At the same time that the taxpayer share has increased, Congress has imposed caps on deductibles, so that these are dramatically different from the higher level found in private health plans.

In other words, the Congressional ``cost-containment'' strategy equals cost shifting. The public is not likely to be in the mood for even more cost shifting, once they understand the price tag.

ERISA: Fawell's First Step

Representative Harris Fawell (R-IL), has introduced the ``ERISA Targeted Health Insurance Reform Act of 1995'' (H.R. 995). This is likely to be the first in a series of incremental reforms.

While liberals in Congress are calling for a restrictions on ERISA, Fawell is going in exactly the opposite direction. He believes that ERISA has enabled private companies to pursue cost- effective strategies.

The bill seeks to broaden medical insurance accessibility to uninsured families by removing state regulatory barriers and to improve the purchasing power of employers by creating ERISA Multiple Employers Health Plans.

The bill also includes provisions on portability, limitations on preexisting conditions exclusions, guaranteed renewability, utilization review, and fiscal solvency requirements.

As students of previous insurance reform proposals know, it will be critical to pay close attention to the details.

Serious Spending Cuts

The new guys-at least the ones in the House-are serious. One must appreciate the simple fact that for decades, the Congressional appropriations process has been largely a federal spending machine. Programs have been reauthorized by the House committees of jurisdiction, and the House Appropriations Committee routinely maintained or increased federal spending on these programs without so much as a by-your-leave. The rosters of public hearings were packed with advocates of higher spending. Every program was increased based on its presumed goodness in the perception of those who were served by it, including those who gained politically by its continued prosperity.

Moreover, there is a general rule, studiously observed in polite company, to use a special language for increases and decreases-language that has absolutely nothing in common with the ordinary meaning of language.

When little Johnny gets an increase in the allowance paid by his taxpaying Mommy and Daddy, and the increase is 25 cents rather than 50 cents, it is not likely that little Johnny will explode in moral outrage over a cut in his allowance. But official Washington is different. It is the only place in the universe where a spending increase can, with a straight and studiously anguished face, be called a decrease, and where a growth in a program can be called a cut if the growth is not as fast as somebody thinks it should be.

It's as if the entire process had been on automatic pilot. And for all practical purposes it has been.

But new members of the House seem determined to be impolite. The House Subcommittee on Labor and Health and Human Services, chaired by Ernest Istook (R-OK) cut 135 programs, amounting to $5.9 billion in spending reductions. The total appropriations rescissions amounted to $17.5 billion. This took nerve-although it is but a small fraction of what needs to be done.

The National Health Service Corps has been cut by 10%. According to the GAO, 7 percent of the students are in default and 13 percent have met their obligations through financial payment rather than service. GAO reports that HHS has no long- term retention data to judge the impact of the program.

The Subcommittee voted to freeze spending for Rural Health Research. The program ``provides no direct services to patients and serves only to support state bureaucracies. Similar research is also conducted at HCFA and AHCPR.''

The Subcommittee reduced by 25 percent the FY95 increase in the ``Ryan White AIDS Care'' program, a savings of $13 million. The Ryan White programs have already received $1.5 billion ($1500 million). The Public Health Service is spending $2.7 billion on AIDS research and treatment in FY95, and overall the federal government is spending $5.9 billion.

All $2 million of the FY95 funds to the HHS ``organ transplantation'' program have been cut. This program does not finance organ transplants. It supports a registry, a network, and outreach activities.

All the remaining FY95 funds ($4 million) were cut from the HHS ``trauma care'' program. This programs provides no direct care to patients, but just funds state bureaucracies.

About $1.4 million will be saved by cutting the HHS ``health data analysis'' program, which provided data directly linked to the development of the Clinton health-care plan.

Botching Dr. Foster's Nomination

Please follow this carefully, using a Number 2 pencil: First, the President's position on abortion is that it should be ``safe, legal, and rare.'' The First Lady's position, stated shortly before the November election (possibly in another attempt to reinvent the Administration's image) is that abortion is morally wrong. As she remarked in an interview in the October 31st issue of Newsweek, abortion is ``wrong,'' but it should not be ``criminalized.''

Next, the President announces his intention to appoint Dr. Henry Foster to succeed Dr. Joycelyn Elders, who said that ``pro- lifers should get over their love affair with the fetus.''

Then the White House Staff (the team that keeps repeating that the Clinton health-care plan was ``mischaracterized'' as a government-run system) tells Senator Nancy Kassebaum that Dr. Foster performed one, and only one abortion. That might have fit the pristine Clintonian ``safe, legal, and rare'' standard.

Then, well, it's not one, but maybe a dozen. Well, no, it's not a dozen but maybe as many as 39. Meanwhile, reports surface that it could be many more. (This kind of stuff dogged Senator Joseph R. McCarthy in the 1950s: How many Communists did you say were really in the State Department?)

Senator Barbara Mikulski (D-MD), staunch ``abortion rights supporter,'' says that the kids on the White House staff ``botched'' the Foster nomination. Senator Joseph Biden (D-DE) said ditto, and he won't vote for it. Later, he changes his position. Senator Arlen Specter (R-PA), also an ``abortion rights supporter,'' says that truthfulness is the issue. Ditto Senator Dan Coats (R-IN), manifestly not an abortion rights supporter. Ditto Senate Majority Leader Bob Dole.

In the meantime, White House Chief of Staff Leon Panetta, whose visage these days seems to register a perpetual case of indigestion, is forced to defend the White House on national television. Dr. Foster did nothing wrong, and abortion is a ``legal procedure.'' This type of argument has remarkably low political octane, probably not enough to power up the Foster nomination. It is rather like saying that the sun is ``remarka- bly hot.''

The Washington Post reports that the ``pro-choice community'' is outraged that the debate has been framed in a way that suggests that abortion is ``somehow wrong'' (which is the Hillary position, right?) Questioned by the national media, Dr. Foster also says that he ``abhors'' abortion (also the Hillary position).

Realizing that this debate over the number or circumstances of Dr. Foster's abortions is not productive, the White House repositions itself for counterattack: Foster's opponents are ``extremists.'' In other words, focus attention on the opposition, not on the subject of the controversy. Opposition to abortion (the Hillary position on the moral but not the legal plane) is not sufficient for characterizing one's opposition as morally suspect. The real underlying opposition to Dr. Foster is-of course-based on race.

Dr. Foster contributes immensely to the civility of the debate by telling a Washington audience that ``white right-wing extremists'' are opposing his nomination, meanwhile stating that the reference to ``whites'' was a mere slip of the tongue (like Dick Armey's?).

Meanwhile, new issues surface, including Dr. Foster's sterilization practices and the extent of his knowledge about a particularly unpleasant affair involving the nontreatment of men with syphilis.

Fascinating Senate hearing are slated for April. It may be good competition for O.J. and his lawyers, all doing their best to restore America's confidence in the legal profession.

(AAPS favors abolishing the position of Surgeon General, a post now used primarily to lend medical credibility to Admini- stration social policy.)