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Volume 51, No. 2 February 1995

DID THE WHITE HOUSE LIE ON PURPOSE?

The President's Task Force on Health Care Reform was permitted to operate in secret for one reason: a sworn affidavit by Ira Magaziner, which declared that all participants were federal employees (see AAPS News, Oct. 1994). Not even the White House is prepared to defend the truth of that statement.

But a false statement is not necessarily a lie, and a false statement made under oath is not necessarily perjury or contempt of court. The person making the statement has to have known that it was false, and must have intended to mislead the court.

On December 21, 1994, Judge Royce Lamberth dismissed the case of AAPS v. Clinton as moot on the grounds that the White House has released all documents covered by the Federal Advisory Committee Act (FACA). (Or promised to release them-as of this writing, AAPS is still unable to obtain copies of 250 floppy disks. They are said to be at the National Archives II, but a series of impediments has kept them out of our hands for weeks.) He referred the question of Magaziner's possible criminal contempt to the U.S. Attorney and stated that the Attorney General was responsible for deciding whether to seek appointment of an Independent Counsel.

Regarding Magaziner's declaration of March, 1993, the Judge wrote:

Plaintiffs allege that an examination of the Secret Service records of entries into the Old Executive Office Building-entries of people who were cleared in by Mr. Magaziner or his immediate staff-demonstrates that many of these individuals (who were not federal employees and who were active working group participants) were entering the White House complex well before Mr. Magaziner signed his March 3 declaration. Moreover, plaintiffs allege that members of Mr. Magaziner's own private consulting firm and its successor company were participants in the working groups whom he certainly should have known about....

The Judge also observes that while the White House ``now make[s] much of the `fluidity' of this process [of appointing members to the Working Group], none of that `fluidity' is included in Mr. Magaziner's March 3 declaration.''

Later, the White House took the position that ``membership'' on the Working Group was a meaningless term and was impossible to define. This ``simply demonstrates how misleading, at best, Mr. Magaziner's March 3 declaration actually was,'' stated the Judge.

In his sworn deposition, taken by AAPS on October 25, 1994, Magaziner stated that he did direct someone to prepare a list of participants in the Interdepartmental Working Group, probably sometime in February of 1993. However, he said ``I never looked at the list....I never checked all the names or screened the people myself.''

How, then, did he swear on March 3 that all of the working group participants were employed by the federal government without exception? He and the Department of Justice must have known that a single exception would have destroyed the claimed exemption from FACA.

One might also ask how Magaziner planned to do a competent job of reinventing one-seventh of the U.S. economy if he was not even aware of the important private-sector positions held by people he had appointed to leadership positions on his own Working Group.

Another question: who was responsible for correcting the error in the March, 1993, declaration, once it was discovered? Was it ultimately Hillary Rodham Clinton's job? And is the Department of Justice immune from accountability?

Magaziner certainly conferred with government attorneys, for example, before conducting ``informal'' (certifiably non-Working Group) meetings with the President, who wanted to be educated by ``some of the experts we had brought together and who were working on the health care proposal.'' Magaziner wanted to be sure the meetings were done properly ``because I knew there was a lawsuit pending.''

As we go to press, Attorney General Janet Reno has stated that it would be ``premature'' for her to comment about the case. ``The matter has been referred to the U.S. Attorney'' (Washington Times 12/23/94).

Many questions about the Task Force remain unanswered because they are outside the Court's jurisdiction. For example: How much money was spent on the process? Did the Administration lie to Congress about the budget? What were the undisclosed conflicts of interests of key members of the Task Force? Who was responsible for enforcing disclosure requirements? What contracts were let to private entities, circumventing the required oversight? Why did the subsidies proposed for academic medical centers increase by billions of dollars? Did it have anything to do with the meetings of a ``Saturday Morning Working Group'' of deans, who had discussions after the Task Force officially disbanded? What behind-the-scenes influence did tax- exempt corporations wield, and was it the functional equivalent of illegal lobbying, in violation of IRS rules? (See AAPS News, January 1995, for information about the involvement of the Robert Wood Johnson Foundation in state Clinton Look-alike reform plans.)

A conference regarding sanctions is to be held in Judge Lamberth's Court on January 9. After that, Phase I of this case may be over. But the repercussions will continue in Congress. Many provisions of the plan will surface, incrementally and without attribution, in both the national and state arena. Interested citizens need to ask questions like the above in their own States.


Control vs. Coverage

Imagine an overnight change in U.S. medicine:

  • Medicare and Medicaid are gone.
  • Office visits to GPs, including a filled prescription for antibiotics, cost $20.
  • True catastrophic health insurance is available and so affordable that nearly everyone chooses it voluntarily.
  • Malpractice insurance costs are negligible because of the implicit understanding that physicians do the best they can for their patients.

Such a situation exists even now in Taiwan. AAPS student member Nancey Trevanian Tsai reports on her observations on a visit to her homeland, after an absence of 17 years. Over that period of time, many people had gone from tending rice paddies to wearing diamond Rolex watches, thanks to a free-enterprise economy. A visit to a physician now costs about 1.5 times as much as having one's hair washed and styled-a twice weekly ritual for many middle-class women.

And yet, there is a movement to socialize medicine in Taiwan. Some physicians are working more diligently, to save for the time when they lose their practices.

The debate is not about cost and coverage, Ms. Tsai states. ``It is about the power of a select few to control the society they claim to serve'' (Esteem, vol. II, #1, 600-K Fairfax Ave., Norfolk, VA 23507).

 

A Transition Phase

Managed care is not the wave of the future, in the view of Bob G. Lanier, M.D., President of the Medical Association of Georgia. Rather, it ``is a transition phase in the current ... reform process. Capitation and discounted fixed-fee plans will phase in, change, and phase out.''

Nor is managed care the key to ``cost containment.'' Lanier states, ``What we are doing now with managed care is increasing the cost, increasing paper work, excluding care, and controlling providers.'' In the long run, ``we can expect it to change.''

His recommendations: Protect medical freedom. Encourage and make it possible for patients to make independent decisions- for example, through medical savings accounts (JMAG, 83:658, Dec, 1994).

 

1994 Brought 1,625-Page List of Regulations

Publication of the government's annual inventory of regulatory actions was delayed until after the November elections. The purpose was concern that Republicans might seize on the 1,625-page document as evidence of a pro-regulatory bias. The official explanation: computer glitch.

According to a 1993 Executive Order (EO 12866), only ``significant'' regulations (those with an annual impact greater than $100,000,000) need to be cleared by the White House before they can go forward (BNA's Medicare Report 11/11/94).

The nation was launched by a 1,322-word document, The Declaration of Independence. Present regulations on the sale of cabbage total 26,911 words (National Review 10/24/94).

 

Anti-Progress Is Logarithmic

If this year the nation falls a year behind, and next year it falls behind again, it is not just two years behind, but three or four. The reason is failure to build on the progress of the first year. Every subsequent year it just gets worse. It's like compound interest in reverse.

Dr. Frank R. Di Fiore points out this principle in Private Physicians Newsletter, Nov., 1994 (1441 Avocado Ave. Suite 408, Newport Beach, CA 92660). By now, Canada is a century behind, in his view. Not only are women in labor deprived of epidural analgesia, in many places their babies are mandated to be delivered by midwives.

 

Bad Report Cards Have Their Uses

The Government Accounting Office (GAO) states that 10 or 15 years will be needed to develop ``highly'' reliable and valid performance measures for report cards on health plans. Administrative data bases are not designed for recovering clinical data, and the review of a single patient medical record costs about $16. There are no evaluative studies on the validity of report cards now used by health plans and government entities (BNA's Medicare Report 10/7/94).

Another pitfall, according to the GAO, is that some plans might intentionally decide to ``represent themselves unfavorably...to discourage enrollment of very sick and costly patients.'' For example, a plan might make no effort to improve a poor five-year survival rate for breast cancer patients. Or, if the plan wanted to look good, one strategy would be to focus resources on areas that are being measured (Health Care Reform Week 10/10/94).

 

Medicare Alert

With cuts in entitlements on the agenda of the new Congress, the AARP designated January 10 as ``Social Security and Medicare Defense Day.'' They asked their members to jam the Congressional switchboards, demanding opposition to proposed cuts. AAPS responded with Senior Citizens Freedom Day on January 9.

Senior citizens have good cause to be concerned. However, the threat comes not from Congress, but from demographics. Social Security and Medicare will soon be bankrupt, unless action is taken. Already, senior citizens, who relied on the government's false promises, are suffering. It is becoming increasingly difficult for them to receive the medical care they need. Physicians want to help them, but are less and less able to do so under increasingly oppressive Medicare constraints.

AAPS does not ask for government subsidies. Rather, we need a long-term solution. We suggested that seniors consider the following changes: 1. Cut fraud, abuse, and overcharging by outlawing the assignment of benefits. All payments should be made directly to the patient. 2. Cut overhead costs by repealing useless or counterproductive laws and regulations (CLIA, OSHA, the ADA, coding and claims submission requirements). 3. Repeal all price controls. Pay patients a standard indemnity, and allow patients and physicians to negotiate a mutually acceptable fee. Physicians then need not fear that they will be accused of fraud if they give a needy patient a reduced rate. They will be better able to help the needy if not forced to work at below-market rates for all patients. 4. Permit and encourage private alternatives to Medicare.

If you'd like to be informed of developments by FAX and are not already on our network, please send us your FAX numbers. Ours is: (602)326-3529.


Legal Briefs

Another FACA Case-on Practice Guidelines. The US District Court for the District of Columbia rejected a request by a manufacturer of a device used in spinal surgery to prevent the issuance of guidelines for the treatment of low back pain (Sofamor Danek Group Inc. v. Clinton). These guidelines recommend exercise and over-the-counter medications for most episodes of pain. A 23-member panel, which included private- sector members, was convened by the Agency for Health Care Policy and Research. Plaintiffs contended that the Federal Advisory Committee Act (FACA) required open panel meetings and public availability of documents. AHCPR argued that FACA did not apply because the panel was not created by statute to give advice to the president or federal agencies. Rather, AHCPR set up the panel itself, exercising the discretion given to it by statute, which also allows the function to be contracted out to private parties.

AHCPR guidelines are meant to advise ``health care providers,'' not the government, ruled the court. Therefore, they may be formulated in secret by panels constructed in whatever manner AHCPR chooses, without regard to requirements such as openness or balance. (See BNA's Health Care Policy Report, 1/2/95.)

AMA Releases ``Final E&M Guidelines.'' On November 9, the AMA released documentation guidelines for ``evaluation and management'' services, which are published in BNA's Medicare Report 11/18/94. In the past, there were no guidelines on such questions as how many body systems must be examined to justify reimbursement for specific procedure codes. In fact, there were ``no guidelines to speak of'' at all, according to Bill Cox of the American College of Emergency Physicians (BNA's Health Care Policy Report 11/21/94).

Doug Henley, President-elect of the American Academy of Family Physicians, stated that physicians are ``encouraged'' to start using the guidelines as of June, 1995, for protection in the event of a chart audit. Also, he believes family physicians might be receiving less reimbursement for their work because they use less complex codes than they legally could.

They could also go to jail if they are using more complex codes than HCFA believes are warranted. Mr. Edgardo P‚rez- DeL‚on, former office manager for internist and AAPS member Wanda Velez-Ruiz, M.D., was just released after spending a year in the Ingham County Jail (see AAPS News, July 1994). In response to his Freedom of Information Act request for information on the definition of ``office exam,'' Esther Reagan, Assistant to the Director of the Michigan Medical Services Administration, stated that ``the answers to these questions are generally available/discernable from a review of the Medicaid Manual, MUPC Manual, and/or CPT Coding Books.'' She also told him that future FOIA requests would receive no response until he was released from prison. She advised him to have his attorney submit requests following ``appropriate rules for discovery.''

What Mr. P‚rez-DeL‚on is trying to discover is the policy under which he was jailed; his interpretation of ``office visit'' seems consistent with that in the recommended manuals.

Search Warrant Checklist. In today's threatening practice environment, you may want to brief all employees on what to do if confronted by a government agent with a search warrant. The November 24, 1994, issue of Medicare Compliance Alert (11300 Rockville Pike, Suite 1100, Rockville, MD 20852) offers a checklist. Some pointers include: (1) Ask to see the agent's identification. (2) Obtain a copy of the warrant and the affidavit supporting it. (3) Remember that everything you say can be used against you. (4) Check the expiration date on the warrant. (5) Contact your lawyer before leaving the office. (Agents' favorite time to appear is quitting time.) (6) Don't allow agents to use your copying machine as this makes it difficult to determine what has been taken. (7) Get a complete and very specific inventory of what is taken.

HHS Policy: No Justice, No Mercy. In pursuant to a plea agreement, Doina M. Buzea, M.D., entered a guilty plea to the misdemeanor offense of making a false statement on a Medicare claim. She said she was ``manipulated'' by her superiors into signing a statement that she had personally supervised a treatment done before she was employed by the facility. She argued that a five year exclusion from Medicare amounted to depriving her of her profession, and such a severe and disproportionate sanction violated the ``spirit'' of the plea agreement. However, the statute requires a minimum five-year exclusion, and ``petitioner's equitable arguments cannot prevail against the plain words of the statute.''

Jacqueline A. Cordle-Boggs was the president of a corporation that supplied medical equipment to nursing homes. The company received $12,000 in Medicare payment for catheter irrigation kits, which are not reimbursable when used to administer fluids to patients unable to drink normally. She was sentenced to 24 months in prison (all but three months being suspended), five years of probation, restitution of $104,000, and five years exclusion. She argued that the billing practices were approved in advance by an official of the Medicare carrier. Further, she entered a guilty plea only because she did not wish to risk a trial, not because she had knowingly violated the law.

Lack of criminal intent, unfairness of trial, and mitigating circumstances are ``all arguments that cannot be address in the HHS forum.'' Neither the Inspector General nor the Administrative Law Judge is authorized to reduce the mandatory minimum exclusion (Civil Monetary Penalties Reporter, Nov. 1994).

No Moratorium on Stark II. HHS rejected a request from the AHA, the AMA, and ten other physician and hospital groups to delay enforcement of the Stark II self-referral ban scheduled to go into effect January 1, 1995. The law expands the Stark I ban on Medicare referrals to clinical laboratories in which physicians have a financial interest to many other services, including physical and occupational therapy, durable medical equipment, and inpatient and outpatient hospital services. Any misunderstanding of the law could lead to significant penalties. There are no proposed regulations for Stark II and no final regulations for Stark I. After thousands of hours of scrutiny of the law and the legislative history, many physicians have been unable to determine how or whether the law applies to them (BNA's Health Care Policy Report, 1/2/95). If you have a question, ask your Congressman. He probably doesn't know the answer (HCFA is trying to clarify unclear portions of the law), but he at least needs to learn the questions.

A Word of Advice from Wanda Velez-Ruiz, M.D. ``Don't take government money.''


Members' Page

Rights and Duties. Regarding the statement in last month's Legislative Alert that physicians have the right to follow their best judgment regardless of practice ``guidelines'': It is patients who have the right to the benefit of their physician's best judgment; physicians have the duty to use it.
Robert Carlen, M.D., Sayville, NY

 

British Priorities. My wife and I just returned from Britain. The failure of the National Health Service is evidenced by two articles from the London Daily Telegraph. While bloated with bureaucrats, the British system has a serious shortage of cardiologists; 30 health districts were without a single one. Most Western nations have six times as many cardiologists per capita, and the U.S. has eight times as many.
Willard J. Ambrose, D.V.M., Phoenix, AZ

 

Why I Will Not Participate in Medicare. To Mr. Preston Lowen, HCFA Representative, Syracuse, NY: As you know, I usually write to you every year to tell you why I will not voluntarily participate in Medicare. I have read that an increasing number of physicians have given up hope trying to fight the constant harassment and punishments applied to nonparticipating physicians....For Medicare to point to this increasing participation as evidence of its growing popularity is not much different from Hitler pointing to the growth of the Nazi party as proof if its popularity....

I am aware that participating physicians are paid more....I know that you are aware of my many adverse experiences, including the time the bureaucracy cheated me out of $13,000 in one year alone, through a mistake that a Medicare carrier admitted to making. Sovereign immunity, however, allows the rights of the government and its bungling Medicare program to supersede the rights and well-being of the individual. To sacrifice the individual for the good of the State is one of the main tenets of Socialism. I will not ever agree voluntarily to participate in Socialism...[I]t is evil and immoral....
Lawrence R. Huntoon, M.D., Ph.D.

 

Government Intrusion Spreads. I will not forget the support we received from AAPS and Dr. Camardese in 1992 when federal and state agencies tried to ruin our organization [see ``Nursing Home Invaded,'' AAPS News, Sept. 1992]....

When I heard on the news yesterday that Clinton is going to ``assess fines'' on all nursing facilities who fail to ``pass'' their totally subjective surveys, I just shuddered, and thought to myself, ``Is there no end to their arrogance?''

In the mid 1960s, when I tried to get support from local individuals and organizations to fight against Medicare, I was laughed out of town. I could see at that time the stranglehold that was being forced on unwilling participants....Anyone who spoke out was a ``crook'' opposed to ``quality health care.'' Now that those tentacles are penetrating all aspects of our lives, people are much more willing to listen....We always hear that ``you can't beat the system,'' but organizations like AAPS are proving this statement wrong.
William C. Dotson, Administrator-Owner Gaymont Nursing Center, Norwalk, OH

 

Priority or Disease? [Dr. Michael Johns, Dean of Johns Hopkins medical school stated in a JAMA editorial that] ``health care reform is now a national priority''....It is easy to conjure up a res publica with metaphoric legs and genitals beleagured by elephantiasis-the inevitable endpoint of burgeoning infestation by parasitic government and its prot‚g‚s. Our heavy- legged nation already drags, staggers, and stumbles....
William F. Sheeley, M.D., Phoenix, AZ
excerpted from letter to JAMA 270:2807

 

Statements of Fact. The following is excerpted from a letter that was mailed by the Idaho Medical Association to all its members: (a) The cost of medical care in Idaho is one of the lowest of any state in the nation, and the quality of care is as good or better here. (b) The Draconian cuts imposed by the fiat of managed care nationwide have had disastrous consequences for patients and physicians alike. (c) It has been estimated that if fewer than 20 to 30% of physicians capitulate and submit to managed-care contracts, managed care will probably be unable to take over a community. (d) Five or six attempts at managed care intrusion into the Boise medical community in the past 15 years have all failed. (e) Denying medical care for profit, which is a basic principle of managed care, is not in the best interest of patients or physicians. (f) Putting the patient in control of medical costs will solve price distortions. Medical savings accounts are currently the best way to achieve this goal. (g) The choice is ultimately OURS.
V.L. Goltry, M.D., AAPS Director, Boise, ID

 

Unity...How about Some Definitions First? In any conflict between two men (or two groups) who hold the same basic principles, it is the more consistent one who wins. In any collaboration between two men (or two groups) who hold different principles, it is the more evil or irrational one who wins. When opposite basic principles are clearly and openly defined, it works to the advantage of the rational side; when they are not clearly defined but are hidden or evaded, it works to the advantage of the irrational side.
V.L. Goltry, M.D., quoting Ayn Rand


Legislative Alert

Serious As a Heart Attack

If there is any doubt about the seriousness of the new Congressional leadership-Gingrich, Armey, and DeLay-put it to rest. These guys are about as serious as a heart attack. Look for major reforms of Congress, including cutbacks in committee staff and the elimination of proxy voting (the practice of having committee chairmen vote on behalf of absent Members of their Committee). There is talk of reductions in personal staff and limitations on the franking privilege. The legislative support agencies and the caucuses of the House, including the Black Caucus, the Republican Study Group, and the Democratic Study Group, are going to get the axe.

Look for fast action on unfunded federal mandates and a line item veto for the President, and expect House action on the Balanced Budget Amendment to the federal Constitution. Capitol Hill observers expect the Balanced Budget piece will also be accompanied by a supermajority (a two-thirds requirement) for raising taxes to comply with its provisions; in other words, this balanced budget amendment is going to fix a bias in favor of federal spending cuts.

Regardless of what happens on the Federal Budget, Gingrich appears ready to go after federal spending through the appropriations process of the House, cutting and literally killing or zeroing out unwanted federal programs. It is hard for a President to veto an Appropriations bill because it doesn't have enough spending in it; Gingrich appears to be ready to make Clinton face that politically unpleasant option.

Gingrich is taking nothing for granted. He met with Black Democrats Kweisi Mfume of Maryland and Charles Rangel of New York and told them that the welfare state has been an extravagant failure, especially so for black Americans, and that black political leaders should rethink their entire approach to liberal interest-group politics. Fat chance. But Gingrich is playing for big stakes, and he can't be called pessimistic.

Health Policy Slots

Congresswoman Nancy Johnson (R-CT) wants to take over the Chairmanship of the House Ways and Means Subcommittee on Oversight. A skillful debater, Johnson knows a lot about health policy and would use this position for more than Oversight over HCFA. Look for the subcommittee to become a major policy center. Incidentally, Johnson's role highlights another fact; women are showing a high profile in Congress. Their political coloration is very different, however. Eight Democratic women lost in November, seven of them very liberal members of the famous 1992 class heralded as the ``Year of the Woman'' in politically correct circles. Seven Republican women won in November, six of them very conservative.

The previously powerful Ways and Means Subcommittee on Health is expected to come under the chairmanship of Congressman Bill Thomas of California. Pete Stark (D-CA), who has ruled the Subcommittee for so many years, is expected to remain on the panel as ranking minority member.

The rumor is that Senator Bob Bennett of Utah is going to become the Chairman of the Senate Republican Task Force on Health Care Reform, the panel chaired previously by Senator John Chafee of Rhode Island. Bennett is a genuine free-marketeer who believes that tax reform is the key to health policy reform, and he has been influenced by the intellectual labors of the so- called ``Consensus Group,'' a coalition of Washington-based think tanks (the American Enterprise Institute, the Cato Institute, and the Heritage Foundation), chaired by Washington health policy guru Grace Marie Arnett.

Rewriting History.

What do you do about an unpleasant past? Simple. You do away with it. Recall that President Clinton on November 13th, in a rambling press conference on the 1994 election Meaning of It All, insisted that his health-care plan was ``mischaracterized'' as a ``government-run plan,'' and that this was not what he ``wanted to do.'' Make no mistake. This was not the blubberings of pummelled politician, too punch drunk to think of a credible alternative explanation (Such as: It was a government- run health-care system, and the American people didn't like it). No; this is the Official White House Line. It is in the same category as other precious gems of Little Rock rhetoric, e.g. ``There are no price controls in our health-care bill.'' Or, ``premium caps are not-repeat-not, price controls.'' One knows it's really super-official when the establishment's literary cognoscenti feel compelled to embellish and give some respectability to the Official Line in high-toned mags. So, James Fallows writes an apologia in the December Atlantic Monthly that says that we all got the whole Clinton health plan, the whole thing, all wrong.

Regardless of how often the President and his shrinking number of allies in the establishment press repeat the Official Line on health-care reform, it is not likely to change the public's original, and correct, perception of the Clinton Health Plan. In fact, by harping on it in this fashion, the President only risks even further damage to his already battered credibility. All folks have to do, if they are interested, is go back and check.

In speaking of the 1994 health-care debate and what it means for the future, Will Marshall of the ``moderate,'' Democratic- oriented Progressive Policy Institute remarked, in the November 5th edition of Congressional Quarterly, ``The health care debate did much more damage to this president than many realize. It defined the administration in conventional liberal terms....''

Perhaps even more interesting is the commentary of Jonathan Yardley, a genuine liberal, who is cultural critic at The Washington Post. In a January 2, 1995, article, Yardley suggests that the problems for Clinton and Co. go so deep as to be quite beyond conventional political fixes. The problem has to do with the evolution of liberalism itself: ``Liberalism isn't liberalism anymore; it's statism. However one may feel about the origins of contemporary American liberalism in the early New Deal, there can be no doubt that as it matured through the New Frontier and the Great Society into whatever it is that Bill Clinton calls the farce over which he presides, it's abandoned its commitment to the individual and placed all faith in government.'' The chief effect of modern liberalism, the thing that devolved into the monstrous thing it is today, is the grasping, groping attempt by liberals ``to exercise control over all areas of economic life.'' According to Yardley, ``This includes tax policy designed not merely to raise federal revenues for all those programs that don't work but to engage in deliberate social engineering, with the consequence that under present federal tax laws we are encouraged to purchase houses but not to get married. Go figure.''

As we have noted, it is also a tax policy designed to promote restriction on consumer choice in medical care, while nicely promoting uninsurance among those who can least afford it: employees in small firms.

And why all of this concentration of power: to crush individuality. Says Yardley, ``This it is doing-eagerly abetted by its handmaidens, the radical feminists and English department Marxists and multiculturalists-through a variety of efforts aimed at limiting individual free speech and action so as to avoid giving offense to persons whom it honors not as individuals but as members of victimized groups. Small wonder that `liberal' might as well now be a synonym for `fascist'.''

Remember, ladies in gentlemen, this comes straight from a premier columnist for The Washington Post!

The Next Stage of the Debate on American Medicine

Health-care reform remains high on the list of priorities for the general public, being listed as the voters' number one concern in a network exit poll. The new Congressional leadership cannot ignore this fact. However, Gingrich and his colleagues are not going to tackle this issue in the first hundred days of the new Congress, and it is not part of the Contract with America.

One of the most striking features of the debate, cited by Daniel Yankelovich, chairman of DYG Inc., is the persistent support for ``universal coverage.'' But the support is superficial. What people really mean when they say they support ``universal coverage'' can be paraphrased this way: ``We don't believe anybody should be deprived of care because of money. We support the President's goal of insurance for all that can never be taken away. But only if the nation can afford it and it doesn't limit choice of doctors or raise taxes significantly or cause employers to cut jobs.''

Yankelovich goes on to say that the policy alternatives have been framed by professional policy analysts and experts, whose ideas may be quite different from those of the public. When people are confronted with the tradeoff in a clear and consistent fashion, they go beyond ``raw opinion'' to ``responsible public judgment.'' One issue on which there doesn't seem to be much debate is the portability of insurance.

A poll released in December by the Health Care Leadership Council found that 90 percent of Americans were satisfied with the quality of their care, 89 percent were satisfied with the choices they had, and 74 percent were satisfied with the cost of their coverage. The survey also found that 56 percent of the respondents support inclusion of medical savings accounts in a reform package, and 57 percent they would use them if they became available.

While not inclined to favor another stab at ``com- prehensive'' reform, the American public is likely to support incremental steps, if those steps are clear and do not threaten their choices, especially of doctors and specialists. One reform that is likely to garner broad support in the House and the Senate is the application of 100 percent tax deductibility to the self-employed, giving tax relief to individuals who purchase their insurance through pools other than those organized by their employer.

Interestingly, among the many new faces on Capitol Hill are a small group of doctors, most notably Bill Frist of Tennessee, a heart surgeon-a good professional balance to Congressman Jim McDermott of Washington State, a psychiatrist, who is the leading Congressional champion of the single-payer, Canadian-style system. McDermott, by the way, will offer the single-payer bill again this year.

Who's In, Who's Out

The ``health care policy community,'' many of who have been rocked out of their trees by the November elections, are trying to figure out a way to position themselves. It is pretty easy to figure out who will have the ear of the new Congressional leadership. Those with easy entry include the Health Insurance Association of America, led by Bill Gradison, former Congressman from Ohio and a former member of the Ways and Means Committee; Gail Wilensky, former HCFA administrator, now of Project Hope; John Moteley and the National Federation of Independent Businesses (NFIB), whose small business message was well received by conservatives when they were in the minority. Big insurance companies, who were pushing the Cooper bill and various managed competition schemes, are not the favorite of the conservative leadership.

Who's out? Besides the obvious (e.g. Families USA), count the lawyers out. The Trial Lawyers Association has been a leading opponent of tort reform; and the American Bar Association (ABA) has gone on record against market-oriented insurance reform. Last August 9th, even as the Clinton Plan and its various incarnations on Capitol Hill were going down to defeat, the American Bar Association's House of Delegates defeated a resolution that would have favored consumer choice and market competition. In defeating the pro-free market resolution, lawyer John Pickering from Washington D.C. called it an ``Adam Smith approach to health care reform which has not worked in the past and will not work in the future to control spiraling health care costs.'' Pickering and Company have perfect timing, right? Mr. Pickering meet Mr. Gingrich, Mr. Armey and, uh, Mr. Smith.

A War on Regulations?

Congressman Tom DeLay of Texas has asked the Administration to put a moratorium on federal regulations. The White House has refused. But oversight on government regulation has only just begun. Look for a tough review of DRG's and the RBRVS and the CLIA and OSHA regs in this session of Congress. The HCFA is entering a brave new world of Congressional hostility to regulation. Nobody in living memory has ever been there before.

Regulation breeds corruption, falsification, and black markets, especially price regulation. According to the Bureau of National Affairs report on Medicare (12/22/94), close to 4600 hospitals face civil prosecution for violations of the False Claims Act for wrongful billing for non-physician outpatient services in hospitals.

The Future of Medicare

There will probably be no major reorganization of HCFA this session of Congress. But because of the massive budget problems of Medicare and Medicaid, look for a serious discussion on how to bring these monsters under control. One idea that is making the rounds is free choice. What if new retirees could opt out of Medicare, keeping their private sector plan, perhaps receiving a Medicare voucher to offset the cost? What a radical idea.