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inclined to participate in the Medicare program as they were at one time, and this is causing a great deal of concern on the part of patients.

Access to care is also affected by the cost of the care. Medicare is not a totally free program. There are some people for whom copayments and deductibles are a real hardship. If they are not eligible, if they are not at that specified income level where they become eligible for Medicaid to pay for their deductible and copayment, then they are somewhere in that gray area of never-never land, and they have trouble getting their copayment and deductible together. Just as you keep hearing that some 30 million Americans do not have any health insurance at all, when you talk about quality of care, you have to talk about the people who are eligible for care before they get sick and the concerns that they have.

A COMPREHENSIVE STRATEGY

I want to commend the Institute of Medicine (IOM) for the excellent study the committee and staff have done. Two very ambitious and challenging objectives have been laid out. The first is to establish a comprehensive theoretical framework for the development of quality assurance; the second is to implement an integrated strategy for improving the quality of care in the Medicare program.

I am optimistic that Congress is going to work with this and is going to do the very best that it can to make some of these recommendations come true. Members of Congress will give a great deal of thought to it, because they are very concerned about a long-range strategy in health care, too. Nevertheless, a word of caution is needed. I think that Congress is afraid right now to be doing anything with our health care delivery programs after the catastrophic health insurance legislation (the Medicare Catastrophic Coverage Act of 1988) that we passed and then repealed under a barrage of objections. So, the members of Congress are somewhat wary right now about doing almost anything.

CONCERN ABOUT COST CONTAINMENT AND MEDICARE

I have been deeply concerned for some time about the Medicare program and our health care system in general, and in particular about the way that Medicare is influencing the practice of medicine and having mixed effects on our patients and our physicians. The constant budget cuts in Medicare over the last 10 years, which now total about $40 billion, have a considerable impact on the program. This has produced an undesirable context and frame of mind for the administration of this program. Efforts to assure quality of care and to maximize the value of enormous investments in our health care are most welcome. However, crude efforts to control utilization



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