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of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto
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
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
[A transition fund would] provide transitional support
to teaching hospitals substantially affected by
reductions in specialty residency positions, in order
to minimize possible disruption in services and to
facilitate replacement of services provided by
residents with services provided by nurse
practitioners, physician assistants, and other mid-
level personnel, as appropriate and consistent with
high-quality care. Such support would be phased out
over a five year period [emphasis added].
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).
``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
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
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
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
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
``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
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
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
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
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.
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
Bylaws Change Proposed
AAPS Directors approved the submission of the following
change in the Bylaws for submission to the Assembly at the 50th
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....
Henceforth let no man care to learn, or care to be
more than wordly-wise; for certainly in higher matters
to be ignorant and slothful, to be a common steadfast
dunce, will be the only pleasant life... (John Milton,
Robert Carlen, MD, Sayville, NY
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.)
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 AlertFinal Touches?
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
- 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
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
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