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Supplementary Statements HARVEY I. SLOANE There is overwhelming evidence from this report, and from a myriad of studies, that the financial problems confronting the poor must be solved before we can have a significant impact on the other health issues confront- ing the American people. In describing the crisis of AIDS, teenage pregnancy and Alzheimer's disease, I cannot help but be greatly disturbed by the fact that these are minuscule in proportion to the numbers of people in this country who do not have adequate health care. More importantly, most of the other recommen- dations in the report to improve our public health system can never be completely implemented without addressing the indigent care problem. This most commendable report, in my estimation, is severely flawed if it does not come forth with a great sense of urgency to meet the health needs of the 43 million uninsured and underinsured people of this nation. I would ask for the first priority in the recommendations to be a call for the public and private sectors, at the initiative of the federal government, to implement a program that would provide a financing mechanism for the medically indi- gent in this country. Until we resolve this issue, general public health measures will be secondary. Most of the industrialized nations of the world have answered the call for insuring health care to the indigent. This report must issue a clarion call for that same action. 160

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SUPPLEMENTARY STATEMENTS 161 ROBERT J. RUBIN After examining a great deal of information and hearing from numerous witnesses, the committee concluded that the primary public sector respon- sibility for health rests with the states. I strongly support that belief. The genius of our federal system, however, is that the various states be free to carry out their responsibility in ways that they deem appropriate. I do not therefore believe that there is one correct structure of state government that will lead to the answer of the public health dilemma so forcefully articulated in this report. Indeed, our own case studies document that many approaches will yield an acceptable solution. Therefore I cannot support a prescriptive approach that seeks to impose a uniform structure on a diverse group of states. This is particularly true as several of the commit- tee's recommendations do not appear to be based on solid evidence, either empirical or practical. As regards the federal government's role, I believe that the committee did not heed its own words that "reorganizing is frequently the first re- sort . . . when in many cases the problem is not truly structural." The federal government is structured in a way that allows "a clearly defined national focal point for public health leadership." Whether that leadership is exercised appropriately is more frequently a political perception than an . ^. . empiric unc log. In conclusion, our report has much to commend it to all Americans concerned about the future of our nation's public health. I believe its operational recommendations, however, should have reflected the breadth and diversity that exist among our states as they strive to assure their public's health.

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