Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Response to Senator George J. Mitchell Rashi Fein Twenty years ago a few of us sat around a table in this building of the National Academy of Sciences and, as the Board on Medicine under the chairmanship of Walsh McDermott, talked about creating an Insti- tute of Medicine. I do not believe that any of us dared to dream that the Institute would so soon achieve such stature that it would be able to sponsor the series that we inaugurate tonight and that it could attract an individual as distinguished and as influential as Senator George Mitchell. Senator Mitchell has spoken about the problems we face and the need to solve them. He has stressed the need to set priorities and has suggested the need to expand and extend Medicaid, to strengthen our employment-based insurance system, and to forge new partnerships between government at both state and federal levels and the private sector. He has indicated his own concerns with two target population groups: those who would receive maternal and child health services and the chronically ill. I am certain that all of us share Senator Mitchell's concerns and agree that the needs are great and that it is time to once again begin to address them. We are indebted to him for his eloquent statement. Nevertheless, I would be less than frank if I did not indicate that
I was saddened by the senator's implicit reminder that the dreams we dare to dream in 1988 are more modest than those we dreamed in 1965 when Lyndon Johnson proclaimed the War on Poverty and dared to call on us to build a Great Society. The size and shape of the federal budget is such that Senator Mitchell would appear unrealistic had he set forth a program as comprehensive as those that were debated in 1974 when the House Ways and Means Committee considered President Nixon's Comprehensive Health Insurance Program and the alternative spon- sored by Senator Edward Kennedy and Representative Wilbur Mills. Let me begin by agreeing that it is important to begin work on Senator Mitchell's agenda. It would help significantly were we to accomplish all, or even a few, of the things he outlined. I mean no disrespect, therefore, if I nonetheless note that, useful as the agenda is as a summary of what we might do in 1988 and in the years that follow, it is an agenda that would have been considered "modest" by the standards of an earlier time, say, a mere 15 years ago. I want to spend a few minutes discussing what Senator Mitchell omitted, and more important, why, in my judgment, he omitted it. As you shall gather from my comments, I do not do so in a spirit of criticism, but rather as a commentary; not in anger, but in sadness. What has happened to our daring and our vision in the last 15 years? Time does not permit me to present a comprehensive set of remarks. I simply note that the answers are many: yes, there is a massive budget deficit; yes, an increasing share of our tax revenues goes and will continue to go to service our debt; yes, we wait anxiously to find out whether Japanese banks will buy U.S. government bonds, that is, whether they will lend us money; yes, we have chosen lower taxes and costly new weapons systems and the inevitable consequence is that it will be a long time before we dare to once again embark on new and comprehensive domestic ventures. And yes, in spite of the fact that the word "tax" is three letters and that "taxes" is five, we treat them both as if they were four letter words not to be used in polite society. But that is all economics and I believe that there is a much more important explanation for our current situation. We have lost faith: faith in our ability to undertake great ventures and succeed; faith in our national government, its honesty, concern, and competence. Who of us dares to believe that we can translate dreams into reality? Who of us
trusts our leaders so much that we would join them in a great adventure ? In my view, all that helps explain the nature of the 1988 health care and health financing agenda. We seek expansions, extensions, and improvements in existing programs and adjust our aspirations to what we see as limited fiscal and administrative resources. But we are richer than we think. Our states have administrative resources and capabilities that exceed those of the federal government. Many of them have wrestled with the problems of rate setting, cost- control, uncompensated care, regional planning, and the other micro- aspects of the health care system and have learned how to balance conflicting demands. Many of them have been what Justice Brandeis envisaged: laboratories in which we have experimented and from which we can learn. And we are richer than we think in terms of fiscal capabilities. We already have a health care system in place and are financing it. We spend 11 percent of our gross national product (GNP) on health. The issue, therefore, is not whether we can afford to finance health care in the United States, but how we will finance it. How shall we share the costs? Does the way we do so affect how much we spend? I believe that the way we finance care does affect the level of expenditures. 1 do not consider it irrelevant that in Canada, the prov- inces and Ottawa have entered into a partnership, a partnership that provides insurance for all and that embodies budgets, financing, and payment mechanisms that reduce administrative expenditures. Their health indices are equal to ours; their health care system is much like ours. But they cover all their population and do so at a smaller percentage of their GNP. I do not want to be misunderstood. We are not Canada and we cannot and should not adopt their system lock, stock, and barrel. But there is much that we can learn from others. I would hope that soon we would once again begin to dream dreams and to seek ways to fulfill them. I would hope that we would renew the dream that all Americans have the right to health care and that we would make the statements about those rights operational. I would hope that we would decide to finance that care in a manner that makes insurance available to all. I would hope that we discover that in a better organized system we can achieve both equity and efficiency. And I would hope that we would 8
seek to accomplish these goals with the involvement of the states, not only because some of them are able, but because they are closer to the people. That, I fear, is not an agenda for the immediate future. To address it will require a change in our perception of ourselves and that will not come overnight or in a hundred days. Until that occurs there will be much that we can do to better the human condition within the limits of existing capabilities. We are deeply indebted to Senator Mitchell for his statement about the things that we can do together.
