Volume 49, No. 9 September 1993

CONTROLLING MEDICINE THROUGH EDUCATION

The Clinton method for controlling the medical workforce is outlined in documents prepared by the President's Task Force on Health Care Reform, obtained by BNA's Health Care Policy Report on July 26, 1993.

The basic method is central planning by a small commission. The commission will dictate the number of various types of ``health care providers'' to be trained, enforcing its decrees through controls on accreditation.

The documents are marked ``Preliminary Staff Working Documents for Illustrative Purposes Only.'' They illustrate the basic assumptions and thought processes of the would-be designers of the Health Care Delivery System of the future.

An educational fund called the ``Health Care Workforce Investment Trust Fund'' would be financed by the method now being tried in Kentucky (see p. 3): a tax (``surcharge'') on all health insurance premiums, or alternately, on all health services billings. The $6 billion fund would support programs to train (or retrain) providers, to place them in underserved areas, and to extend National Service Corps opportunities.

A radical restructuring of medical education is envisioned, with the purpose of increasing ``primary care providers'' (general internists, family physicians, and primary pediatricians; primary-care nurse practitioners and physicians assistants; and nurse midwives) and drastically decreasing physician specialists.

Approved training programs would be those that are ``consistent with the national goals and directions set forth in the Trustees' annual report to Congress and the President.''

The report recognizes that physicians in residency do provide useful services and that their removal could have consequences:

Instead of permitting the continuation of programs that teach physicians to do craniotomies, perform coronary an- gioplasty, replace damaged hips, or repair aortic aneurysms, there will be new curricula in managed care, cost-effective practice management, prevention, mental health, geriatrics, and AIDS. Recruitment will be targeted to under-represented minorities, students from low-income families, and persons who will stay in an underserved area.

Graduate medical education would be funded through consortia of medical schools, community health centers, and Accountable Health Plans. States may elect to oversee the consortia, including the allocation of residency positions, perhaps through a board representing the governor's office, the health department, HIPCs, consumer groups, and others.

The Accreditation Council for Graduate Medical Education (ACGME) would only accredit the programs and positions that are allocated and funded.

In order to assure that at least 50% of residency graduates enter primary care practice, the federal government might limit by law the number of residency positions for specialty training. Alternately, federal funding might be limited to consortia meeting that goal. Additionally, the total number of positions would be restricted to no more than 110% of the size of the graduating class of US medical schools.

On the incentive side, compensation for generalist physi- cians would be increased relative to specialists [not necessarily in absolute terms--Ed.] by extending the Relative Value Scale fee schedule to all payers. ``Practice-site viability'' would be enhanced by supporting telecommunications, network development, ``community-appropriate'' CME, linkages with academic medical centers, and locum tenems programs for providing ``respite.'' State and local governments might become involved in ``provider placement'' to assure a good ``provider/community match.''

Trust funds would be used to develop ``certified retraining programs for specialist physicians desiring to practice as generalists'' and for demonstration projects which ``foster innovation in the education or deployment of the health work- force'' [emphasis added].

Emphasis would be placed on training providers in decen- tralized locations, close to rural areas where they are needed [away from population centers that offer the opportunity to see a large and diverse group of patients--Ed.] In case the number of training positions in a given specialty was too few to make it feasible to allocate them to every region, ``available positions would be allocated to selected region(s).''

An additional equalizing measure would be to ``remove reimbursement mechanisms that pay different rates for the same service when performed by qualified providers in different dis- ciplines'' (such as nurse midwifery).

Some physician reformers complain that their organizations (such as the Federated Council for Internal Medicine or FCIM) have heretofore been ``edentulous.'' Because the opposing ``forces are too strong and too entrenched to be overcome by logic or moral suasion,'' they advocate federal legislation to impose a ``comprehensive, enforceable approach to the physician work-force problem.'' Among other things, such legislation would establish a physician work-force commission to ``set limits on the number and mixture of training slots'' (J. Claude Bennett, ``The Affliction of Internal Medicine,'' N Engl J Med 329:212, 7/15/93).

Echoes

``Marxist studies of medical care emphasize political power and economic dominance in capitalist society....The health system mirrors the society's class structure through...stratification of health workers and limited occupational mobility into health professions....Medical ideology helps to maintain class structure and patterns of domination.''

``[F]orces of professionalism, elitism, and specializa- tion...divide health workers from each other....''

``The professional monopolists include physicians, special- ists, and health research workers....The main consequence of their activity is a `continuous proliferation of programs and projects' that `provide a symbolic screen of legitimacy while maintaining power relationships'....'' [emphasis in original]

``A group of professional tend to hold elite positions....The ideology of excellence helps justify these patterns.''

The solution (see p. 1)? ``Marxist analysts have worked with members of Congress in drafting proposals for a national health service.'' These proposals are described as ``pro- gressive,'' ``nonhierarchical, anticapitalist'' forms of practice that feature: 1. stringent limitations on private profit; 2. centralized health planning that limits professional dominance; 3. periods of required practice in underserved areas; 4. a national drug and medical equipment formulary.
H. Waitzkin, ``A Marxist View of Medical Care''
Annals of Internal Medicine 89:264-278, August 1978

``All bills appropriating money shall specify...the exact amount of each appropriation, and the purposes for which it is made....''

All legislation shall ``relate to but one subject,'' which had to be ``expressed in the title'' (see p. 3)
Constitution of the Confederate States of America
quoted in The Free Market, June, 1992

Correspondence with ``Carriers''

From Nino Camardese, MD, AAPS President, to George Stadlander, Director of Utilization Management, Blue Cross/ Blue Shield of Ohio:

I pray that this letter finds you in the best of health and good spirits and that God will bless you with both for many more years to come.

I must say that I am pleased hearing from you after slightly over a month. Certainly this is somewhat slow particularly when we observe the rapidity with which you informed the patient that his bill was not being paid-a matter of a few days.

Your letter has a number of errors...The burden of appeal rests upon the party who is in the wrong. You are wrong in several counts: i.e. 1. In not fulfilling your contractual obligations with Mr. S...2. In practicing Medicine without seeing the patient. 3. In making untrue statements: a. The (Doctor?) lady who called me (1) was not seeking information; (2) informed me that the hospitalization was unnecessary.

I courteously request: 1. Identification of your `consul- tants' who advised you on the alleged unnecessary hospitaliza- tion; 2. Their written statements, conclusions, and reasons for denying Mr. S.'s hospitalization; 3. A copy of their charges submitted to you for their professional services....

Thanking you in advance-warmest best wishes-God bless you.

P.S. Your total bill: $66.50.

From Allen Morrow, Deputy Insurance Commissioner, State of Washington, to Concerned Citizen, Care of AAPS, 8/2/93:

Commissioner Senn has referred to me your April 26, 1993, letter addressed to King County Medical Blue Shield...I would like to first apologize for taking so long to respond to you. I have no excuse for not responding sooner.

As you point out in your letter, cost control is a two-edged sword. One element certainly is to reduce the overall cost of claims, while the other is that the health coverage provider needs to examine its administrative expenses and reduce those where appropriate....

Although a health care service contractor such as King County Medical Blue Shield is not presently required to submit to the Insurance Commissioner specific salary information, they are required to submit this data in the aggregate period. We review the aggregate information to ensure that the overall amount is appropriate in today's environment....[sic.]

[No aggregate statistics and no criteria for ``appropri- ateness'' were supplied--Ed.]

Explanation of Benefits from Medicare to a Physician Re: a Patient he had never seen:

Total amount approved: $32.50

Total Medicare payment: 26.01

Total amount that was offset: 26.01

Total Medicare payment after offset applied: 0.00

Total interest due because of delayed payment: .01

A check from Medicare for $0.01 accompanied the EOB, along with a check from BC/BS of Connecticut for $0.22.

Attention: Office Managers and Staff

``There will be dislocation....Many people who work in billing departments at doctors offices...and in large hospitals will also be out of a job because the efficiencies in the new system will eliminate these positions,'' stated a Washington State legislator. He acknowledged the ``human cost'' of ``health care reform'' while urging people to support it anyway.

Legislators may say they are placing jobs at risk in order to create efficiency. But the actual result will be to give the jobs to bureaucrats in Olympia, stated correspondence from the Washington Chapter of AAPS.

``The legislature's callousness toward your job results from a lack of understanding that a physician's staff does more than push paper.''

On the Status of Obstetricians in Canada

William Goodman, MD, of Toronto sent us a two-page, single- spaced list of ``requests'' (actually demands) that an obstetrician received from a patient's ``labour coach.'' The services of a labour coach, who is trained by a correspondence course of about 6 weeks' duration, are not paid for by Canada's national insurance scheme. The labour coach expects to be paid about $800, while an obstetrician receives $250 for the same delivery.

``My friend has always believed in fully informing his patients, as well as encouraging them to participate in decision- making. However, he was appalled by this attempt to load him with all the responsibility without really allowing him...to use his medical judgment. He refused to be a party to such an arrangement.''

The patient found another physician.

AAPS Physician Files Class Action Challenging Constitutionality of Kentucky Provider Tax

On July 23, 1993, AAPS member Stuart A. Yeoman, MD, and two other physicians filed a class action challenging the constitutionality of Kentucky House Bill No., 1, which was passed by the Kentucky General Assembly in a special session held in May, 1993. The lawsuit seeks the certification of a class of all members of the Warren County Medical Society and also seeks a temporary and permanent injunction against enforcement of the law.

The statute became effective on July 1, 1993, and the ``provider tax'' set forth in the statute becomes due and payable by physicians on August 20, 1993. A temporary injunction would restrain collection of the tax pending a final adjudication of the constitutionality of the statute.

House Bill No. 1 imposes taxes on hospitals; physicians; and pharmacies and others dispensing prescription drugs. Section 2 of the bill imposes a tax of 2.5% of the gross revenues of all hospitals for the provision of health-care items or services. Section 3 imposes a 2% tax on the gross revenues of ``health care providers other than hospitals,'' including nursing services for the mentally retarded, physicians' services, home health care, and HMO services. Section 4 taxes any entity dispensing prescription drugs at a rate of $0.25 per outpatient prescription.

Pharmacies are permitted to pass the tax onto other insurers or other health organizations with whom the pharmacy has entered a contract to provide health-care items. But the statute prohibits physicians from passing the tax on in any way.

Under the statute, physicians are required to file a tax return and pay the tax every month. Each physician must keep records, receipts, invoices, and other pertinent papers in the form which the Kentucky Revenue Cabinet may require. Further, any physician charged with the filing of returns and payment of taxes may be required to post a cash or corporate surety bond in an amount to be determined by the Kentucky Revenue Cabinet. If the physician fails to post the bond, the Kentucky Revenue Cabinet may bring an action to restrain or enjoin the operation of the physician's business until the bond is posted.

The Kentucky Cabinet for Human Resources is given the power to increase the class of health-care providers subject to the tax, and may decrease the amount of the tax ``proportionately.'' Additionally, the Kentucky Cabinet for Human Resources may increase the amount of provider taxes, providing that the General Assembly approves the tax. There is no provision in the statute for presenting the General Assembly's approval of the tax hike for his signature or veto.

Finally, the Kentucky Senate's amendments to House Bill No. 1 created the Kentucky Health Care Data Commission as an ``independent agency of state government.'' By these amendments, the Commission is authorized to gather a plethora of information, much of it very sensitive, from physicians and their patients. The statute provides no safeguards such as requiring a subpoena or other legal process before a search for information can occur or before agents of the Commission may enter a physician's office. Finally, the statute states that ``[e]very provider shall, as a condition of licensure, furnish to the commission any information'' requested by the Commission under the statute.

In his memorandum in support of the Motion for a Temporary Injunction, Dr. Yeoman forcefully contends that House Bill No. 1 is unconstitutional under the First, Fourth, Fifth, Ninth, and Fourteenth Amendments of the US Constitution and under no fewer than 13 specific provisions of the Kentucky Constitution. The statute singles out health-care providers for taxation in violation of the Due Process and Equal Protection provisions of the US and Kentucky Constitutions, and is also violative of Section 59 of the Kentucky Constitution, which prohibits special or class legislation. Dr. Yeoman contends that House Bill No. 1 amounts to a ``status tax'' which is blatantly designed by the legislature to avoid political accountability by targeting a specific group that is politically powerless to overturn the tax.

Additionally, plaintiffs contend that House Bill No. 1 is an unconstitutional delegation of power because it creates an ``independent agency of state government,'' and thus purports to create a fourth branch of government not authorized by the Kentucky Constitution. Additionally, the statute unlawfully delegates to the Kentucky Revenue Cabinet the power to increase the class of persons subject to the tax, even though the Kentucky Constitution requires that all revenue-raising measures must originate in the House of Representatives. Furthermore, the statute is an invalid delegation without adequate standards or safeguards to control the Revenue Cabinet's ability to require a physician to post a corporate or surety bond. Additionally, although increases in the provider tax must be approved by the General Assembly to be effective, this part of the statute is still unconstitutional under Section 88 of the Kentucky Constitution because the increase need not be presented to the governor.

The brief relies heavily on the Kentucky Supreme Court's decision in McGuffey v. Hall, 557 S.W.2 401 (Ky. 1977), the landmark case brought by AAPS members to challenge a statute requiring all Kentucky physicians to carry minimum amounts of medical malpractice insurance and granting immunity to Professional Standards Review Organizations (PSROs).

In McGuffey, the Kentucky Supreme Court held the statute to be unconstitutional omnibus legislation under Section 51 of the Kentucky Constitution, which provides that ``[n]o law enacted by the General Assembly shall relate to more than one subject, and that shall be expressed in the title...'' In McGuffey, the Court held that under Section 51, legislation may not be ``made up, sidetracked, taken apart, switched around and put together again like a freight train.''

Dr. Yeoman's brief argues that House Bill No. 1 relates to three distinct subjects: revenue, appropriations, and the creation of a powerful, independent agency. The brief maintains that: ``When one adds the creation of a new powerful, independent agency, it is obvious that the General Assembly rapidly assembled the `freight train' condemned in McGuffey, a freight train on which the general public will ride, but for which health-care providers must pay the fare.''

Dr. Yeoman will be a featured speaker at the 50th annual meeting of AAPS in San Antonio, October 6-9.

This lawsuit is being funded by the Warren County Medical Society Legal Defense Fund, P.O. Box 291, Bowling Green, KY 42102. Tax-deductible contributions are urgently needed.

New Members

AAPS welcomes Drs. Baltazar G. Anaya of Cincinnati, OH; Bob Apter of LaConner, WA; Ronald J. Aronoff of Dallas, TX; Louis A. Bernhard of Federal Way, WA; Henry L. Bethea of Houston, TX; Peter Birk of Virginia Beach, VA; Morris Brodkey of Toms River, NJ; John Buckwalter of Durham, NC; George A. Carty of Saginaw, MI; Vincent A. Cipollaro of New York, NY; Glenn C. Cook of Scottsdale, AZ; John T. Daniel of Durham, NC; Stuart H. Danovitch of Washington, D.C.; Lawrence C. Dempsey of Anchorage, AK; John P. DiCicco Jr. of Worcester, MA; Thomas A. Duc, Jr. of Charleston, SC; Maurice O. Edwards of Dallas, TX; Steven C. Elerding of Sunnyside, WA; David T. English of Auburn, WA; Robert Flores of San Fernando, CA; Cary D. Glastein of Tinton Falls, NJ; Stephen Goldman of Seattle, WA; J. Manuel Gonzalez of Van Nuys, CA; Michael Green of Seattle, WA; Mohsin Hakim of Shreveport, LA; Frederic T. Huffnagle of Milton, MA; Lewis A. Irvin of Grand Junction, CO; Harold Isaacson of Toms River, NJ; Daniel G. Jackson of Columbus, OH; Paul N. Joos of Renton, WA; Andrew K. Leake of Hampton, VA; H. Michael Lewis of Paris, TX; Alan H. Lieberman of Lakewood, NJ; William J. Mallon of Durham, NC; Randy Montgomery of Fort Worth, TX; Ronald J. Moser of Dayton, OH; Sam Moussa of Tucson, AZ; Robert Murdock of Salem, VA; Robert F. Nagan of Indianapolis, IN; Madras K. Padmanabhan of Mission Hills, CA; Thomas Palmeri of Bayside, NY; John Petraglia of Huntington Park, CA; Lindy Rachal of Houston, TX; Fran Rose of Irving, TX; Brij M. Saran of Gloversville, NY; Joseph D. Schulman of Fairfax, VA; William R. Seybold of Colorado Springs, CO; Lisa Strober of Tucson, AZ; Melissa Taliaferro of Leslie, AR; William S. Tunner of Richmond, VA; Lothaire D. Voegele of Charleston, SC; Jyotsana Walia of Auburn, WA; and Stephen Wilson of Honolulu, HI.

Liza Leal Barton of Houston is a new student member and the founder of the student chapter of AAPS at the University of Texas Medical School.

Bylaws Change Proposed

AAPS Directors approved the submission of the following change in the Bylaws for submission to the Assembly at the 50th annual meeting:

ASSOCIATE MEMBERSHIP

Associate membership shall be open to any business, association, or individual whose membership will benefit this Association, and the Association's goals and objectives.

DUES FOR ASSOCIATE MEMBERSHIP. The dues for associate membership shall be in accordance with a schedule of such dues, which schedule shall be adopted, and from time to time amended, by a majority vote of the Board of Directors. All dues shall be payable on an annual calendar year basis, and shall be due and payable within thirty (30) days of the due date. Any associate member failing to pay dues within ninety (90) days of the due date shall cease to be an associate member of the Association without further action on the part of the Association.

Letter to the Editor

...You can compare [the thought processes of the experienced clinician] with driving a car. When we learned, we had to work at coordinating the gas, clutch, wheel, turn signals, etc....But after decades of driving, it's all intuitive...If we were ever forced to account for each action, to drive ``by the book,'' the way we did when we learned, our driving would be terrible, truly degraded (May 3, 1993).

[What sort of medical education shall we have] in the stultifying atmosphere brought about by the peer review/audit - /guidelines movement, in which the only thing that counts is adherence to accepted medical practice?...When dissent is heresy, it appears thoughtless or dishonest to encourage eager, gifted, and curious medical students to think for themselves....

  part excerpted from The Lancet 340:1546, 1992

`` Please Do No Harm''

The story of Dr. Lois J. Copeland's landmark freedom-of- choice lawsuit, Stewart v. Sullivan, is highlighted in the Summer, 1993, issue of Policy Review, the quarterly magazine of the Heritage Foundation. Her article, ``Please Do No Harm,'' outlines her battle with Medicare bureaucrats and her victory in New Jersey federal court.

To obtain a copy of Policy Review, call toll-free, 800-544- 4843. (The article was excerpted in the July 28, 1993, issue of The Wall Street Journal.)

AAPS Calendar

Oct. 5. Board of Directors meeting

Oct. 6-9. 50th annual meeting, Menger Hotel, San Antonio, TX. For hotel reservations, call (800)345-9285. To register, call AAPS at (800)635-1196.

Oct. 12-15, 1994 (tentative), 51st annual meeting, Atlanta.

Legislative Alert

The Clinton Health Plan is undergoing final touches before the Great Unveiling and may be out as early as the week of September 20th. Nobody expects a comprehensive legislative package then, but Congressional sources are looking toward getting the broad outlines of the Clinton Plan. There may be some time for initial hearings in the fall before the Congressional debate begins in earnest in 1994.

Although David Gergen, Clinton's top media advisor, is said to be pressing the Clintons toward a more moderate proposal, the latest version has the following features:

• Universal Coverage, to be phased in by 1996. ``Universal'' means that all individuals will have to purchase health insurance coverage through a health insurance purchasing cooperative, except those individuals working for large firms, who will be exempted. Illegal aliens will not be included. Medicare is eventually to be folded into the regional health alliances; Medicaid would be incorporated more quickly, by means of vouchers. Federal employees and retirees would also be included, as the Federal Employee Health Benefits Program is abolished.

• A Standard Benefits Package. The package would be defined by a government health board or possibly by Congress. Long-term care, home health care, and prescrip- tion drugs (the latter with serious deductibles and copay- ments) are expected to be part of the package.

• Employer Mandates and Financing. Employers will be required to purchase health insurance for their employees, but there will be a phase-in of the burden on small employ- ers. In its most recent incarnation, the financing of the new system will be an employer-based ``premium'' system, instead of a payroll tax, but the impact on business is likely to be the same. The premium will be based upon the actuarial cost of the standard health-care benefits package embodied in all approved health-care plans, and will vary from state to state and from one geographical area to another. It is expected that small employers will be required to start paying about 3 percent of payroll and increase their contribution over several years, while high- cost, large employers are likely to phase down their medical premiums.

• Regional Health Alliances. Boards appointed by state governors would have ``extensive'' responsibilities for collecting premiums and shifting them back and forth across approved (``accountable'') health plans to make sure that low-risk and low-cost enrollees subsidize high-risk and high-cost enrollees. Each alliance will also have the authority to approve or withhold approval of government standardized health plans-the essence of ``managed competition''-and make sure that services are available to people in poor and ``medically underserved'' areas. Each of the accountable health plans will have to operate with a per-capita based budget, and will have to accept enrollees regardless of medical condition. Two percent of the revenue coming into the regional alliance system will be used to defray administrative expenses.

• Fee-for-Service Medicine. Although at least one ``fee-for-service'' plan will operate in each alliance and doctors would be free to join more than one health plan, fee-for-service medicine is expected to shrink significantly under the new regime.

• A Global Budget. Either Congress or a national health board or some other federal agency will set limits on ``health care'' spending. Compliance will be ``voluntary'' on the part of health insurance plans, doctors, hospitals, and pharmaceutical companies (unless voluntary compliance doesn't occur). It is likely that the Clinton Plan will contain ``back-up'' price controls to make sure that budget targets are met.

  The enforcement of this global budget will be left to the states. In effect, the Clinton Health Plan will establish latest in a line of approximately 174 federal laws that order the states to fulfill certain federal objectives.

  The federal government will step in if any state fails to enforce the global budget, but the details of how and under what circumstances the federal government will act is yet unclear. It is also unclear how the individual states are expected to enforce the national budget targets, though they expect to be given a variety of weapons by Congress. There will also be ``incentives.'' For example, if states exceed their allocated budget targets, they will be expected to pick up 100 percent of any additional costs to cover low income people within their boundaries. If states can assure the delivery of services below the specified target, they would be able to pocket the savings. Naturally, this incen- tive to control costs will encourage state officials to look high and low for any politically acceptable means to get under the allocated budget targets.

• Big Business; the Uninsured. In principle, the Clinton team has decided that big employers, who are self insured, should be exempted from the rules governing small insurers, but they will be asked to pay some sort of a surcharge in order to help offset the costs of the uninsured who will be enrolled in the system through the regional health alliances.

Congressional Jockeying

Despite the inclusion of terms used by advocates of managed competition, Alain Enthoven's ideas have been largely abandoned by the Clinton team. This disaffection of the original managed competition school is bound to have political repercussions on Capitol Hill. The group to watch: House Conservative Democrats, led by Congressman Charles Stenholm of Texas and Congressman Jim Cooper of Tennessee. Conservative Democrats are opposed to global budgets and price controls, and fear that what is coming out of the White House will be too heavy on regulation and too light on markets. In other words, the very same Capitol gang that has given the Clinton Administration so much trouble on the Budget is likely to be a serious problem on the health-care front.

On the left, the Clintons might also have a problem. While Hillary Rodham Clinton has been wooing the single payer advocates and winning some support here-no surprise given the broad outlines of the plan-the advocates of a Canadian- style system are still not sold. Harvard University's David Himmelstein says that the Clinton Plan will end up creating huge insurance company cartels, a criticism echoed by Congressional conservatives.

The Congressional Budget Office is weighing in with more headaches for the managed-competition crowd on Capitol Hill. According to its most recent report, a health-care reform plan based on a pure form of ``managed competition'' won't save any money, would still leave 25 million people uninsured, and would add $19 billion to ``health-care'' spending.

Managed competition advocates, in defense, point out that the CBO models are not configured to measure market-generated productivity and efficiency, and that the CBO model is inherently deficient in this regard. At the same time, as if to prove the point, the same CBO study says that a government-based, single- payer health plan would cover everybody and save $150 billion. It's easy to measure the savings generated by slapping a government cap on medical spending.

Meanwhile, Congressman Fortney ``Pete'' Stark (D-CA), the Chairman of the House Ways and Means Subcommittee on Health, is regularly attacking the Clinton Plan as unworkable and undesirable. Borrowing a potent weapon from the arsenal of Capitol Hill conservatives, the California liberal is proposing legislation to compel Members of Congress to enroll in the cheapest health-care plans, likely to be HMOs, in the proposed regional health alliances. Stark reasons that if Congress is going to set up these regional alliances and millions of Americans are going to be ``stuck'' in the lowest bidding or ``cheapest'' health-care plans in their region, with reductions in quality and service, then Members of Congress should get a taste of their own medicine.

As Stark told the Washington Post, ``The public is demanding that Congress include itself under all laws that it passes for others. After all, what's good for the goose is good for the gander.''

While Stark may be opposed to reductions in service and qualty in the managed competition model, he is no friend of ``excess'' spending, not on medical care. Stark told the National Health Council recently, as reported in the June 30th Congress Daily, ``We're a nation of `Let's keep grandma on the respirator until the final gurgle'.''

While the House Democrats seem to be split into two camps, managed competition and single payer, the House Republican leadership continues to fumble along, literally weeks before the Great Unveiling, like college sophomores trying to ``find them- selves.'' Senator John Chafee and Senate Minority Leader Robert Dole of the Senate Republican Health Care Task Force are still wedded to ``managed competition.'' whatever that may happen to mean at the moment. Chafee originally started work on the managed competition model, convinced that Clinton was going to adopt that approach. This was to be the basis for some serious ``bipartisan'' negotiation on health-care reform; Chafee wanted a plan that would ``jibe'' with the Clinton proposal. Now that Clinton has all but abandoned ``managed competition'' except in name, Chafee has nobody to jibe with, rather like an aircraft circling without a field to land. Moreover, Senate conservatives, especially those in rural states, generally don't want to have anything to do with managed competition. What will Senate Minority Leader Robert Dole (R-KS) do next?

There is still time for advocates of free-market reform to find themselves. Public expectations of Clinton's handling of the ``health-care issue'' have declined; more and more people think that whatever Clinton comes up with is not going to be much better for them. Clinton's proposal, whatever it will be finally, may end up on a level playing field with other propo- sals. That's not the way Presidential initiatives are supposed to work.

Clinton is expected to mount an enormous sales pitch. But any campaign is going to be conducted against a backdrop of continuing losses of political capital. The White House team celebrates on Friday nights if they can get by one week without some major political trauma, mistake, or misstep. Clinton's public approval ratings are the lowest at this point on record. According to the most recent Newsweek poll, only 44 percent approve of the President's handling of his job. On the crucial issue of the federal budget, only 34 percent approve of his handling of the budget, while 52 percent disapprove.

Abortion as a Standard Benefit

The surprising victory of the Hyde Amendment in the House of Representatives has set the stage for one of the toughest fights in the health-care debate: whether abortion coverage should be included in a standards benefits package in the Clinton health plan. The White House says yes, many moderate and conservative Democrats say no. A good test of how this item will play out was a floor fight in the Senate on retaining the Reagan Administration ban on taxpayer contributions for abortion coverage in the Federal Employees Health Benefits Program (FEHBP). Senator Barbara Mikulski (D-MD) led the pro-abortion forces to a 51:48 victory. Inclusion of abortion in the standard benefits package will trigger a filibuster.

Elders in Trouble?

While most Capitol Hill observers expect Joycelyn Elders to be confirmed as Surgeon General, it is likely to mean a tough floor fight and probably higher than normal political costs for Senate Democrats, who will have to take a deep breath and swallow the latest bitter pill from the White House. Democrats have been jolted by the statewide election of a Republican as Arkansas Lieutenant Governor. Mike Huckaby, a Baptist minister, won a narrow victory in the President's home state amidst a high turnout, carrying several heavily Democratic counties in the state. Capitol Hill observers are linking Huckaby's surprise victory to the on-going controversies surrounding Elders.

The Elders nomination is strongly supported by liberal groups, homosexual organizations, and certain prestigious medical societies, including the AMA. But Senators have received a barrage of telephone calls in opposition.

Because Senator Edward Kennedy refused to allow public testimony at an open hearing on the controversial nominee, a mock hearing was arranged on August 2 in the basement of the Capitol by the Ad Hoc Citizens Select Committee on Public Health Oversight. Mildred Jefferson, MD, Assistant Clinical Professor of Surgery, Boston University, chaired the meeting in Senator Kennedy's absence. Physicians voicing their concerns about the public-health consequences of Elders's policies- ``comprehensive'' sex education and school-based clinics- included Glen Griffin, MD, editor-in-chief of Postgraduate Medicine; William R. Archer, III, MD, former Deputy Assistant Secretary for Population Affairs; William F. Colliton, Jr., MD, of Bethesda, MD; William L. Bergman, MD, of Hahnemann Health Associates of New York; and Jane M. Orient, MD, Executive Director of AAPS.

A filibuster has delayed the vote until after the August recess.