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8
The Legislative Perspective
John D. Rockefeller, IV
We on the Pepper Commission fU.S. Bipartisan Committee on Compre-
hensive Health Care] are charged with developing a public consensus on
long-term care. Catastrophic illness costs $5 or $6 billion a year, a mere
pinch. Long-term care costs $40 to $60 billion. And for the uninsured, one
must simply grab some figure in the tens of billions. The bill for our
nation's unmet health care needs is just extraordinary. The legislation on
catastrophic illness coverage has been a subject for many speeches. It is an
extraordinary thing, isn't it, that a program which is so directed, so progressive,
and so precisely right-a rare thing could be rejected by precisely those
people who have no business rejecting it, on behalf of all those people who
benefit from it. But that is what has happened.
UNMET HEALTH CARE NEEDS
I was recently in Chicago, where I attended a hearing of the National
Commission on Children. Much more important than that, perhaps, was a
visit of commission members into ghetto areas, into housing projects, to see
how it is there. First we started at Cook County hospital and saw prema-
ture, low-birthweight babies who weighed a pound and a half. Some got to
two pounds, some to two and a half. When they got to four pounds, they
looked like they were really healthy, and one rejoiced; but we did not see
many of them weighing four pounds. There were endless numbers of low-
birthweight babies. Should they emerge at a cost of some $50,000 to
$100,000 per child from the intensive care unit, most of them will have
permanent developmental disabilities.
We went into the housing projects to see what is happening there if it is
possible to get in, if the gangs are not already there, which they are in most
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45
of the housing projects. And there we saw how it is that teenagers who
discover they are pregnant at the age of 14 or 15 do not go looking for
something called prenatal care, especially since many of them do not even
know what it is. If they do know, and if they have applied for Medicaid (or
should be on Medicaid, which only reaches 42 percent of poor people any-
way) and Medicaid keeps sending the forms back, they will have already
had their babies by the time they get signed up. And so on and on and on.
We are in a crisis. The dimensions of it-not just the financial dimensions,
but the human dimensions as well are awesome.
I am a relative newcomer to health care. I asked somebody the other
day, whom I very much respect and who has been in this business for a long
time in Washington (not in Congress), how many people he thinks there are
in Congress who understand health care. He said, "Six." I was not one of
them, unfortunately. But give meia little time, and I will be, because I am
intensely determined about it. Since I am not one of those six, and since I
am a relative newcomer, it is probably not very good for me to presume to
make observations. Nonetheless, I will do so.
It strikes me that we are at a dangerous crossroads. We have literally
hundreds of billions of dollars' worth of health care needs that are as yet
unmet, some as yet unthought-of. I completely agree with Uwe Reinhardt
about the concept that a civilized nation simply will not tolerate having 37
million citizens who are uninsured, not to mention those who are underinsured.
How do we rectify this? America has apparently fastened onto the con-
cept of no new taxes, after having reduced taxes and having removed $150
billion from the revenue base of this economy every year since 1981. On
further reflection, however, some Americans have decided that lowering
taxes was not a good idea and that we should think about raising them. So
the two parties argue about whether we should lower them again and how-
capital gains or IRA? It is all sheer madness, if one cares about health care.
Health care costs are rising 14 to 15 percent annually. By 2003, Medi-
care costs will be larger than Social Security costs. Defense spending,
interest on the national debt, and Social Security and Medicare costs together
account for 85 percent of the entire federal budget.
Those who would cut costs, including Medicare payments, face the wrath
of the providers. Those who would add coverage, and thus the payment for
it, face the wrath of the taxpayer and, we now discover in the case of
catastrophic care, of the beneficiary.
We risk gridlock because everyone with a vested interest in our current
system providers, employers, patients, insurers, and taxpayers has something
to lose from the changes that must be made. On the other hand, I think that
all of these vested interests have a lot more to lose if the changes are not
made.
There is evidence of stress in the system. The budget reconciliation
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process was tied in a knot over catastrophic illness coverage. The coal
strike in West Virginia and the "baby Bell,' strikes this summer grew out of
arguments over who would pay health care costs. One-pound babies like
those I saw in the neonatal intensive care unit are still being born. The list
goes on and on. We have to find a consensus somehow, and we have to do
it very quickly.
We need, as never before, those persons who are most knowledgeable
about our health care system to help us reach that consensus. We need
people who know what is at stake and who stands to lose in the process of
trying to forge this consensus. That is where scientists fit in, at least in my
judgment.
GROWING AWARENESS OF EFFECTIVENESS RESEARCH
This conference is incredibly timely. The answer to the question "What
works in health care?" probably holds the key, or at least part of the key, to
the many conflicts that we will wade into.
Two years ago, nobody on Capitol Hill was talking about medical outcomes
and effectiveness research. Nobody. Nobody was really talking about the
trade deficit until 1984, at which point we were already in the tank so
deeply but that's the way we are as a country. The crisis has to overwhelm
us before we recognize it and then sometimes we can get out of it. Now
outcomes and effectiveness research, if not quite the talk of the town, are
the tank of a good deal of it.
A recent survey of over a dozen studies on the appropriateness aspect of
medical care included these findings: "Research finds high incidence of
unwarranted pacemaker implantation." "Inappropriate coronary artery bypass
surgery is frequent." "Rate of inappropriate hospital use is high." "EThere
is] evidence of anti-psychotic drug misuse in nursing homes."
The potential benefits of outcomes and effectiveness research have jolted
many of us into what I hope is the realization that evaluation of health
services may not mean rationing in a pejorative sense. Some of us even
hope that the dual efforts of controlling health care costs and improving
quality are complementary.
In the Senate, George Mitchell, who is not an inconsequential figure as
Majority Leader, introduced a companion bill to the legislation authored by
Willis Gradison on the question of federal financing of a national research
effort on medical outcomes and effectiveness. Now Senator Mitchell has
requested, as have many physicians' groups, that his bill be included in a
much larger physician payment reform bill that David Durenburger and I
are working on.
The provision is integral to the success of our package. Our package
does not have integrity without that research in it. Physicians and policymakers
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47
understand that the process of rationalizing payments for services must
proceed apace, along with the process to understanding the value of the
services.
THE CHALLENGE TO SCIENTISTS
Today, the medical community and the political community are ready for
research. We hope it will improve the quality of care; we hope it will save
lives; and we hope it will make cost control more rational and more consistent
with good medicine. I encourage your scientific efforts enthusiastically,
pleadingly, but with two important caveats.
First, do not take political support of this concept for granted. To wit:
last week, the research community came within a hair's breadth of losing its
congressional backing. Senator Mitchell believed that a minimum of $35
million was necessary to get this national outcomes and effectiveness re-
search underway and he made a very strong pitch as Majority Leader to the
Appropriations Committee. But that committee did not vote out the hoped-
for funds. Only the personal appeals and efforts of Senator Mitchell won a
last-second restoration of funds. Without him, it would not have happened.
So understand, please, when I say that you cannot take support for granted,
because nobody understands it.
All of us will need to work diligently to protect those funds, because the
bill has yet to go to the House-Senate Conference Committee. Be aware of
that conference. Summon whatever influence you have and exercise it on
that House-Senate Conference to make sure that outcomes research money
stays.
That leads me to my second caveat, which is that, as scientists and as
experts, your advocacy is imperative. Last spring, Frank Press, President of
the National Academy of Sciences, called upon his colleagues to unite behind
specific scientific efforts. Do not throw them out Gatling-gun style; they
have to be given priorities you must set priorities. The work that you are
about here clearly must be one of those priorities. A nation that spends
over half a trillion dollars for health care can afford to spend-in fact,
certainly cannot afford not to spend $35 million to begin learning what
works.
Not only must your case be made to the public and to the Hill on the
need for this research, you must be persistent in your advice on the nature
of the research. The politics of where these studies should begin and what
they should seek will certainly overwhelm you unless you give us your best
advice on how to proceed.
Because of the budget crunch in Medicare, Congress will urge you in one
direction; that is, toward the effectiveness of the "big ticket" services. Pro-
viders of those same services will urge you in a different direction. You
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need to give Congress your objective advice on the best way to proceed.
We cannot do it ourselves.
David Durenburger is a Republican and I am a Democrat; we do everything
on the Pepper Commission together. That is our policy. I am chairman of
the commission, but he knows much more than I do-and I tell him that
frequently. We and our staffs do nothing without talking to each other. We
are trying to make our actions not only bipartisan, but bicameral. Most
people in Congress do not operate that way. We are determined to, and you
can help us.
CONCLUSION
Two years ago, health was not center stage; it was all a question of what
are we going to do with ASATs and Star Wars. But interestingly enough,
defense and all of the raging passions it inspires has receded in the last
year and a half, and other things have come to the fore. That has happened,
I suppose, because of the Gorbachev window, and I pray that that window
will stay open for a while.
People now are really onto the cost of health care, are really scared about
the annual increase in the cost of that health care, and really do understand
that there are very few people in Congress who understand health care. We
need you scientists; more importantly, we know that we need you and what
you are doing. You are called upon not only for the right answers, but also
for politically compelling evidence that those answers are right, evidence
that will help us forge a consensus and bring about needed actions. It is a
tall order, but I know that you will do it.
Representative terms from entire chapter:
care costs
