An Incredible Hypothetical Flying Machine
The editorial ``Ira's Little Lie'' (Wall St J
6/8/94) describes the legal attempts of AAPS to [reveal] the
names of the participants of the Clinton Health Care Task Force.
They extracted only the names of some second stringers such as
the Robert Wood Johnson and the Henry J. Kaiser Foundations. The
only purpose of the Clinton Health Task Force was to provide a
birthing place for a socialist health plan, long conceived and
carried to term, just as Clark Kent's earthly parents gave him
earthly presence but had nothing to do with Superboy's conception
Mark Twain could have left behind a futuristic manuscript
about a mob of hundreds of people without any experience in
flying who called a meeting to develop a new airplane.
Eventually, Mark Twain would find a fool to board such a
contraption on its maiden flight, never to be heard from again.
The idea to develop a new health plan by a mob of one thousand is
The real antecedents of the ``Clinton'' Health Plan were
conceived in Europe over a century ago and have been fine-tuned
for decades. There is an uncanny resemblance to the Kombinates
and Kolchoses of the Soviet Union in the 1920s, which were all-
inclusive huge state farms and factories that smothered the
Soviet economy into oblivion....
Even Mark Twain would have conceded that a plane conceived
by people without hands-on experience must undergo testing before
Andre Minuth, M.D., Fresno, CA
The Elders Bully Pulpit
Many Democrats fear that Joycelyn Elders, MD, will hurt
their chances for reelection because of her relentless attacks on
Roman Catholics, Evangelical Protestants, and traditional family
values. Rep. Scotty Baesler (D-KY), former mayor of Lexington,
stated: ``My constituents aren't extremists...[but] when anyone
begins attacking their views and institutions as Elders has done,
they're going to react.''
Led by Rep. Cliff Stearns (R-FL), 86 Congressmen drafted a
letter to Bill Clinton, asking for Elders's resignation.
Nevertheless, Elders survived the recent shake-up in the White
House. One interpretation is that ``leftist cultural warrior
Elders'' really does represent the Clinton view (Human
7/8/94). Another is explained by Anne Sabloff of Americans
``Every time that Elders makes a fool of herself, she also
sends a subliminal message to the American people that all
physicians are idiots, not to be counted on or trusted. The
Clintons rely heavily on psychological methods to communicate and
sway opinion.'' As evidence for this analysis, Sabloff cites the
lack of complaints about Rush Limbaugh's heavy criticism of
``Roberge would be a good one to squash and set an
Jay Clement, US Army Corps of Engineers, 7/27/87
HCFA Issues Regulations To Implement ``Anti-Dumping''
On June 22, 1994, the Health Care Financing Administration
(HCFA) issued an interim final rule with comment period,
implementing the provisions of the Emergency Medical Treatment
and Active Labor Act, 43 U.S. C. Section 1395dd, also known as
the Patient Dumping Statute. The regulations, which were
initially proposed and published in 1988, were amended to reflect
statutory changes enacted by Congress in 1989 and 1990. The
regulations became effective July 22, 1994, with some small
exceptions. Physicians and hospitals will need to reexamine
their procedures for compliance.
The two most significant additions concern qualifications of
medical personnel performing initial screening examinations and
the required reporting of suspected violations.
The statute itself provides that hospitals must, within the
capabilities of its emergency department, provide an
``appropriate'' medical screening examination to any individual
who comes to the emergency department for examination or
treatment. Numerous questions have arisen concerning what type
of personnel are qualified to conduct the examination so that it
would be deemed ``appropriate'' within the meaning of the
The proposed regulations contain no specific requirements
concerning education or credentials for individuals conducting
emergency medical examinations. They state that the screening
examination should be done by individuals determined to be
qualified under the medical staff bylaws of the hospital.
Commenters had expressed concern that hospitals would have
to amend their medical staff bylaws to be in compliance with the
regulations. In the preamble to the new regulations, HCFA has
made it clear that formal amendments to either the medical staff
bylaws or the rules and regulations of hospitals must be
made to ensure compliance:
It is important to require the hospital to
determine formally what type of personnel is qualified
to perform the initial medical screening examinations
because such a formal determination will insure that
the hospital's governing body recognizes the
``capability of the hospital'' and is properly
accountable for this function. For this reason, we
believe that the delegation should be set forth in a
document that is approved by the governing body of the
hospital, rather than merely allowing the medical
director of the emergency department to make what may
be informal delegations that could frequently change.
If the rules and regulations are approved by the board
of trustees or other governing body, we agree that
these examinations may be set forth in the rules and
regulations, instead of placing this information in the
Because most hospitals provide for rules and regulations to
become effective without submission to the governing body, this
HCFA response illustrates the necessity for formal changes to the
bylaws. Physicians sitting on the bylaws committees of medical
staffs should take note of this requirement.
The second major provision of the new regulations requires
hospitals receiving transferred patients to report suspected
violations of the statute or regulations to HCFA regional offices
and state regulatory agencies within 72 hours of the patients'
arrival at the facility. A receiving hospital which violates
this requirement is, like the transferring hospital, subject to
termination of Medicare and Medicaid participation and civil
monetary penalties up to $50,000 for each violation.
One commenter stated that the term ``suspected'' is unduly
vague. HCFA agreed that the term is vague and then stated that
the requirement of reporting is imposed when a hospital ``has
reason to believe that a violation has occurred.''
As to the 72-hour requirement, HCFA has refused to recognize
that such time is insufficient to investigate a perceived
transfer problem to determine whether the complex web of
regulatory requirements are satisfied, despite HCFA's recognition
that particular cases are very fact-specific.
HCFA has also refused to specify when a hospital is deemed
to know about a potential violation through its personnel.
Therefore, it is important for hospitals and their medical staffs
to review their policies and have in place a ``chain of
command,'' whereby the records of transferred patients can be
reviewed if personnel have reservations regarding the transfer.
The existence of an in-house mechanism will enable the hospital
to demonstrate good faith attempts at compliance to state and
federal licensure and regulatory agencies at the time of survey
and in the event of an investigation.
If a hospital transfers a substantial number of patients to
another facility due to the facility's specialized capabilities
(e.g. a hospital without a burn unit transferring burn patients
to a hospital that has a burn unit), the hospitals should
strongly consider entering into cooperative agreements with one
another regarding transfer procedures to be followed in all such
cases. This will help to prevent HCFA from pitting one hospital
against another if questions arise.
The interim final rule with comment period can be found at
volume 59 of the Federal Register, pages 32086 to 32127,
which is available at any US Government Depository Library.
To be considered at the 51st annual meeting, October 13-15,
Resolutions must be received by September 13. Send to
Resolutions Committee Chairman Don Printz, 354 Arcado Rd Suite 4,
Lilburn, GA 30084.
Nominating Committee Report
Chairman James F. Coy, MD, presents the following slate of
officers for elections to be held at the 51st annual meeting:
President: Lois Copeland of Hillsdale, NJ
President-Elect: Don Printz of Lilburn, GA
Secretary: W. Daniel Jordan of Atlanta, GA
Treasurer: R. Lowell Campbell of Corsicana, TX
Board of Directors: John Boyles, Jr., of Centerville, OH;
Nino Camardese of Norwalk, OH; Donald Quinlan of Northbrook, IL;
and Joseph Scherzer of Scottsdale, AZ.
Watch your mail for registration materials. The annual
meeting will be held at the Ritz-Carlton Hotel in
If I were to describe government bureaucracy in one word, it
would be confiscation. All taxes combined confiscate
nearly half of my income. The bureaucracies that govern Medicare
and Medicaid confiscate about 40% of my professional time.
Medicare has confiscated my ability to make professional judgment
about which treatment is best for a patient....and my right to
order certain appliances to help patients-like elevated toilet
seats (Medicare considers them to be a ``luxury item''). The
state even attempts to confiscate my thought processes by forcing
me to attend state-mandated ``health courses'' designed by
bureaucrats. In 1991, I had to spend three hours attending a
``child abuse'' course. Today, I had to forfeit another three
hours to attend a course on infection control pursuant to
``Chapter 786 of the Laws of 1992''....Much of the first hour was
spent telling us what the penalties and fines would be if we did
not attend the course ....The things taught in these courses were
so basic that I was embarrassed to be sitting and listening to
``medical school 101'' material, [but if I don't] the state can
take my license away....
The mere threat of a socialist-style health-care reform has
already caused 44% of cancer research to be delayed or curtailed,
according to a study released by the Biotechnology Industry
Organization. Moreover, 62% of biotech companies will make
further cuts if the Clinton Plan becomes law.
The White House responded in its usual fashion by trying to
tell industry that they could have made it still worse.
Lawrence R. Huntoon, MD, Jamestown, NY
Secure, Affordable Care with Choice Is Possible
The awesome power of tax incentives has stripped most
Americans of their medical care security, affordability, and
choice. Fifty years ago, to further the war effort, the govern-
ment allowed employees to exclude medical benefits from their
taxes. When the ``free ride'' was abused, employers moved to
``managed care'' (rationing and cost controls), instead of
recognizing the offending cause....
The ``hot potato'' in the managed care system is the risk-
choice link. Whoever has the financial risk will need to
restrict the choice of medical care and therefore will be
perceived as the villain. When physicians and hospitals take on
risk, they will be withholding the medical care. Then they will
be vilified instead of insurance companies.
If the tax incentive were broken-as by making all medical
care 100% deductible-many patients would choose to switch their
money from benefits to wages and buy high-deductible medical
insurance, which they (not their employers) would own. Medical
care would then be secure because it would not be tied to
employers. Prices would decrease because patients would value
shop. Patients who pay their own way could have their choice of
the best available care....
Bert A. Loftman, MD, Atlanta, GA
On Community Rating
[A family can be financially ruined by lack of automobile
insurance, and may be priced out of the market due to unfortunate
events, such as being rear-ended by a negligent driver.]
I would propose that a National Automobile Insurance Board
be created...Employers should be mandated to provide 80% of the
cost of automobile insurance....A community rating for automobile
insurance should be instituted, ensuring that older and safer
drivers pay more, so that the youth of this country can be given
some relief from the hardship the cost of this insurance imposes
Why should one sector of our society pay more for automobile
insurance than any other? Why should we expect our youth to
carry this burden? After all, their salaries and savings are
significantly lower than their elder fellow citizens, and they
graciously contribute to our Social Security fund, knowing it
won't be there for them when their time comes.
Automobile insurance should be a right, shouldn't it?
Robert T. Woodburn, MD, New Buffalo, MI
Resolutions Passed in South Carolina
The May AAPS newsletter reached me in a timely fashion. I
submitted Resolutions B and C as authored by Dr. Kenneth
Christman to the Horry County Medical Society. They passed
virtually unanimously and were submitted to the South Carolina
Medical Association, where they passed-again with a virtually
unanimous vote-on May 1, 1994.
Richard W. Young, MD, Myrtle Beach, SC
Are Physicians Responsible?
My practice is now 5% to 10% what it once was. I attribute
my predicament to the fact that I never have accepted third party
payment. I still believe it is detrimental to me and to my
patients to accept it.
I am convinced that the problems with medicine started with
the decision of physicians to accept third-party payments. In
1962, the AMA said it was unethical for physicians to accept
third-party payments. In 1963, the AMA said it was ethical for
physicians to accept third-party payments....
Medicine leads the way. If we socialize medicine, all of
America will follow. After that, Western civilization fails, and
dictatorship and slavery are the consequence. I hold physicians
responsible for the decline of America.
James H. Peoples, MD, Kinston, NC
Legislative AlertThe Political Equivalent of
If the national health-care debate is the Gettysburg of
domestic policy, then the Clinton Administration's options are
being reduced to the political equivalent of Pickett's Charge,
where the outcome is to be decided by a final, desperate
After months of internal gridlock, John Dingell, Chairman of
the House Energy and Commerce Committee has announced surrender.
He can't get a bill out of committee-certainly nothing that would
satisfy the White House. The incredible revelation that even Big
John can't deliver has been sinking in over at the Oval Office.
Just before the Fourth of July recess, the Administration
suffered an awesome humiliation in the full House Ways and Means
Committee when Congressman Bill Thomas (R-CA) offered the
original Clinton Plan as a substitute bill and called for a
recorded vote. Thomas had pulled this stunt before in the Stark
Subcommittee. Gibbons was infuriated. The vote was 17 to 0, with
all the Democrats on the Committee voting ``present.'' Not one
Democrat voted for the President's bill. Jim McDermott's ``single
payer'' option got 7 votes, and the Archer mild incremental
Republican substitute was defeated in a straight party-line vote.
With the indictment of Chairman Dan Rostenkowski, the
Chicago Powerhouse, the House Ways and Means Committee has a
slender majority, if that, for reporting out anything that
resembles the Clinton Plan. The slim 20-to-18 vote in favor of
the Gibbons version does not bode well for favorable floor
action. To make matters worse, the new chairman based his reform
on the Stark alternative that even Rostenkowski once repudiated
as ``too liberal.'' The key elements of the Gibbons Bill are as
- Universal coverage for all Americans and the establishment
of a guaranteed government standardized benefits package,
- An employer mandate, with employers paying 80 percent and
employees 20 percent of the cost of the standardized
benefits package. (Small business would get subsidies for up
to 50 percent of their costs.)
- The creation of a Medicare Part C program to enroll the
uninsured, the unemployed, welfare recipients, and all small
firms with less than 100 people if the firms opted to buy
into the government plan rather than private insurance.
- Voluntary purchasing cooperatives for the uninsured and
- New government subsidies for persons with incomes at or
below 240 percent of the official poverty level.
- Changes in the insurance rules to prevent any company from
cancelling or excluding individuals.
- Price controls. If spending in any state exceeded the
``target'' level (the annual increase in the gross domestic
product), and the state did not take appropriate steps, the
federal government would impose fee schedules (like the
Relative Value Scale) on doctors, hospitals and other
providers. Unless a special commission recommended
otherwise, this system would go into effect automatically in
- Financing through cuts (``savings'') in Medicare and
Medicaid, an increase in the cigarette tax from 24 to 69
cents a pack, an extension of Medicare taxes to state and
local employees, and a 2 percent tax on insurance premiums.
Already, the Gibbons Plan is being recognized as the
foundation of national health insurance. The Congressional
Budget Office (CBO) estimates that by the year 2002, the new Part
C program would grow to cover between 90 and 95 million people
under the age of 65. Altogether, that means that 130 million
people would be under the Medicare program.
In the Senate Finance Committee, the employer mandate lost a
key test vote on June 30th. Moynihan then proposed his own
hybrid, which ``aims'' at universal coverage; establishes
voluntary regional alliances; and establishes a less generous
standardized benefit package. But under the influence of the so-
called ``Rump Group'' on Senate Finance, the specifics of the
benefits package can be enhanced by the National Health Board.
Bradley added an amendment that would tax insurance premiums,
including the premiums of self-insured plans, at a level above
the standard health plan.
Moynihan's amended bill passed out of the Senate Finance
Committee on July 2, in the closing hours before the recess.
Clinton is being handed a fait accompli; if he accepts it, it is
a humiliating retreat from the absolute, veto-based threat of
``universal coverage.'' If he doesn't, the Administration and
Congress are set for a titanic battle of wills. (What ``universal
coverage'' means, in the context of the current debate, is
Congress is running out of time. In the week before the
July 4th recess, the pace of legislative action picked up
furiously. Hour by hour, Senators met and caucused on new
versions of ``reform.'' Giving up on an earlier managed
competition plan, Chafee (R-RI), Durenberger (R-MN), and Danforth
(R-MO) (the Senate Finance ``Rump Group'') fostered yet another
option, ``the Mainstream Coalition'' package. It ``assures
universal coverage'' through a ``trigger mechanism.'' If 95
percent of all Americans do not have coverage by 2002 AD, then a
special commission (a mechanism beloved of the managed
competition folks) will send a recommendation to Congress, and
the Congress must act on the recommendations. The bill contains
all of the standard managed competition entities: ``Accountable
Health Plans,'' ``Health Care Coverage Areas,'' and a
comprehensive standardized government health package, developed
by the Commission and submitted to Congress for approval.
Senator Dole (R-KS), who has been at various places during
the debate, decided to get his team together and is asking them
to gird for battle. Dole's efforts now are to make sure, despite
the Rump Group's latest efforts, that Senate Republicans refrain
from handing the Clinton's increasingly desperate and frustrated
Congressional allies a victory by default or indecision. The
details of the Dole Bill are sketchy, but Senate conservatives,
led by Nickles of Oklahoma and Gramm of Texas, are signing off,
and conservatives still entertain reservations and suggestions to
fix various features of the hurriedly thrown together bill. By
July 1, some 40 Republicans Senators had signed on to the Dole
The old problems of cost may plague this measure too; for
the bill sets up a means-tested subsidy program for low-income
people and the cost estimates are sketchy. Moreover, the Dole
plan seems to set up some sort of standardized benefit for the
new subsidy plan, and there is no exclusion for abortion. That
has some conservatives and pro-life groups upset. Dole's staff,
namely Sheila Burke, will be working overtime trying to resolve
the drafting issues.
Senator Robert Bennett of Utah is the first Senator to
announce that if the Clinton Plan, or any version of it, should
come to the Senate floor he will launch a filibuster and try to
talk it to death. Bennett called the Clinton Plan ``poison'' for
the country and is asking his fellow Senators to address the
causes of the cost and access problems in the current system by
reforming the tax treatment of health insurance.
Some Senate Republicans fear that their opposition to the
Clinton Health Plan and variants will enable the Democrats to
blame them for ``gridlock'' and use this charge against them in
the 1994 elections. But Senator Paul Coverdell of Georgia, among
others, wants to make the 1994 elections a national referendum on
the Clinton Plan.
Coverdell's political reasoning is good. The polls indicate
that popular support for the specifics of the Clinton Plan
continues to decline, as people ask a lot of detailed questions.
A June CNN/USA Today survey shows that 50 percent of
those polled now oppose the Clinton Plan, while 42 percent say
they favor it. A US News and World Report poll shows
that only 17 percent strongly approve of Clinton's handling of
the health care issue, and 34 percent strongly disapprove. If
health care doesn't pass this year, 44 percent say that it will
be because the Congressional Democrats are trying to create
``another government bureaucracy'' that the American people do
not trust; only 28 percent say that the Republicans ``don't care
enough about guaranteeing health insurance to all Americans.''
An NBC ``Meet The Press'' poll says that 37 percent of
the people believe that Congress should pass a bill this year,
but 57 percent believe that they should further debate the issue.
Although 53 percent would vote against a Member of Congress
who opposed ``major health-care reform,'' according to a
Newsweek poll, the mood of Americans changes when
considering the legislative details. For example, 74 percent of
Americans now believe that the health reform will lead to
rationing. More Americans believe that the Clintons' Plan would
be bad for the country rather than good (37 percent vs 33
percent); 77 percent think that they would have to pay more for
health care; 76 percent think they would lose choices; and 58
percent think that quality would decline.
The response of the Clinton Plan's supporters to recent
developments in public opinion has been remarkable. Senator Jay
Rockefeller (D-WV) made the notorious statement in the April 19,
1994, edition of the Parkersburg (West Virginia)
News (carried by AP) that ``We 're going to push
through health care reform regardless of the views of the
It is increasingly apparent, despite White House propaganda
to the contrary, that the Clinton Plan's troubles are not with
Republicans. Senator Diane Feinstein (D-CA) (see July supplement)
is not alone in her misgivings. Senator Max Baucus of Montana,
second ranking Democrat on the Senate Finance Committee and an
original cosponsor of the Clinton Plan, has been telling
constituents (who are not buying Hillary's health recipe) that
even though he sponsored the Plan, he does not support it.
Congresswoman Louise Slaughter, a Liberal Democrat from New York
and an original cosponsor of the Clinton Plan in the House of
Representatives is asking Hillary Clinton and the Democratic
leadership in Congress to give her District (Rochester, New
York), an exemption from the Clinton Plan. And in the
deliberations on the House variant of the Clinton Plan in the
House Education and Labor Committee, Congresswoman Patsy Mink, a
liberal Democrat from Hawaii, actually won an exemption of the
State of Hawaii from that Committee's version of the Clinton
Plan. When Congressman Mike Castle (R-DE) offered an amendment
that would permit the other 49 states to get a waiver from the
terms of the Clinton Health Plan, it was defeated in Committee by
a vote of 16 to 27. Why special treatment for Hawaii? Hawaii
doesn't yet, even with an employer mandate, meet the stated
Clinton Gold Standard of universal coverage-about 95 percent of
the citizens are covered.
White House Offense Foiled
The Clinton Team has tried to take the initiative and to
define the terms of the national debate. But on the complex
subjects of financing, employer mandates, the structure of the
regional alliances and the role of the federal bureaucracy, the
Administration has found itself thrown back, defending its huge
plan against increasingly effective counterattacks. The problem
for the White House team is that the rhetoric and the reality are
always something different, or, at the very least, the rhetoric
is what some politely call a ``stretch.''
For example, the White House team insists that all Americans
are being ``asked to contribute,'' but Americans are not being
asked anything. They would be forced to take a pay cut. When
the White House says that businesses will be eligible for an
``insurance premium discount,'' it does not mean something
offered on the open market to stimulate demand, but rather a
taxpayer-financed federal subsidy.
The latest gambit is a White House media blitz that claims
that it wants to give Americans the same health care that Members
of Congress enjoy. The ploy is angering Members of Congress, who
see it as a cheap shot at Congress. It is also giving an opening
to conservatives to expose yet another Clinton Administration
propaganda effort. Unlike the Clinton Plan, the FEHBP is
voluntary; there are neither employer nor employee mandates.
Unlike the Clinton Plan, the FEHBP has no government standardized
benefits package, no National Health Board, and no premiums caps
or price controls.
Ira Magaziner still works like a super wonk into the wee
hours of the morning. The Clinton team may make a frontal
assault with a serious Clinton-style bill, maybe the Kennedy Bill
or the House Education and Labor bill-and just go for it-51
Senate votes or bust. But the clock's ticking.
Changes in Consumer Choice
Senator Don Nickles (R-OK) and 24 cosponsors have decided to
modify the original consumer choice bill (S 1743), deleting the
individual mandate to purchase insurance and the deductible
limits of $1000 for individuals and $2000 for families. The
consumer choice approach enjoys the editorial endorsement of over
130 newspapers around the nation.
Congressman Tom Petri (R-WI) has introduced yet another
variation on the increasingly popular tax credit approach, ``The
Multiple Choice Health Care Act of 1993'' (HR 4469). The heart
of the Petri bill is to end the federal tax exclusion for
employer based insurance, now estimated to reach $92 billion in
1995, and replace it with a national system of tax credits and