WE'D FEEL GOOD ABOUT OURSELVES AND OUR HEALTH CARE

SYSTEM.

NO LONGER.

IN A WORD --WE HAVE BIG PROBLEMS.

SOMETIMES I USED TO WONDER IF THERE SHOULD NOT HAVF,

BEEN ANOTHER SURGEON GENERAL'S WARNING:

"-WARNING! THE AMERICAN HEALTH CARE SYSTEM CAN BE

HAZARDOUS TO YOUR HEALTH!

TO BEGIN WITH, THIS IS A TIM32 IN WHICH WE H&E VERY HIGH

EXPECTATIONS FOR MEDICINE AND HEALTH.


WE'VE PUT A GREi$T DEAL OF FAITH INTO NEW TECHNOLOGIES,

NEW PHARMACEUTICALS, NEW SURGICAL PROCEDURES, AND SO

ON, AND WE CONTINUE TO HAVE FAITH IN WHAT I LIKE TO CALL

THE MAGIC OF MEDICINE.

WE ROUTINELY EXPECT MIRACLES TO HAPPEN -- EVEN THOUGH

THE REAL WORLD OF MEDICINE ISN'T ALWAYS ABLE TO DELIVER.

WE HAVE THAT SITUATION RIGHT NOW WITH AIDS.


FOR THE PAST 8 YEARS, SCIENTISTS AND CLINICIANS HAVE BEEN

WORKING AROUND-THE-CLOCK TO UNDERSTAND AND CONQUER

THE DISEASE OF AIDS. BUT IT STILL REMAINS SOMEWHAT OF A

MYSTERY AND I DOUBT THAT WE'LL GET FULL CONTROL OVER

THE AIDS VIRUS BEPORE THE TURN OF THE CENTURY.

BUT, AS FAR AS THE GENERAL PUBLIC IS CONCERNED, THE AIDS

SITUATION IS THE EXCEPTION AND NOT THE RULE.


THE AMERICAN PEOPLE STILL MAINTAIN HIGH HOPES FOR WHAT

MEDICINE AND HEALTH CARE CAN DO FOR THEM.

BUT I THINK IT'S ALSO BECOMING CLEAR THAT THOSE HIGH

EXPECTATIONS ARE FAST OUT-RUNNING OUR ABILITY TO PAY

FOR THEM.

IN OTHER WORDS, WE HAVE A CLEAR GAP IN OUR SOCIETY

TODAY BETWEEN WHAT WE WOULD LIKE TO SEE HAPPEN IN

HEALTH CARE . . . AND WHAT CAN REALISTICALLY HAPPEN IN

HEALTH CARE.


AND SO THE AMERICAN PEOPLE ARE ENGAGED IN A DEBATE IN

RESPECT TO ASPIRATIONS VERSUS RESOURCES.

THIS IS A DEBATE THAT TOUCHES ON MANY ASPECTS OF

AMERICAN LIFE... BUT I'LL FOCUS JUST ON HEALTH CARE, WHICH

IS PROFOUNDLY AFFECTED BY THAT GROWING TENSION

BETWEEN ASPIRATIONS AND RESOURCES.


MANY OF OUR GREAT EXPECTATIONS COME FROM OUR ABIDING

FAITH IN EVER-IMPROVING MEDICAL TECHNOLOGY.

BUT NOW, I BELIEVE THE PUBLIC WONDERS IF MEDICAL

TECHNOLOGY MIGHT BE A MIXED BLESSING.

THANKS TO AN EXPLOSION OF NEW KNOWLEDGE IN SCIENCE

AND TECHNOLOGY OVER THE PAST SEVERAL DECADES, WE KNOW

HOW TO DO MANY NEW AND FASCINATING THINGS:


BUT KNOWING HOW TO DO SOMETHING HAS NEVER BEEN

ENOUGH.

PEOPLE ALSO WANT TO KNOW WHY . . . OR WHY NOT?

AND TODAY, AS THE COST OF OUR MAGIC TECHNOLOGY SOARS,

WE'RE ASKING "WHY?" MORE OFTEN AND MORE INSISTENTLY.

IN REGARDS TO PROLONGING LIFE, FOR EXAMPLE,    BOTH

THE LAY PUBLIC AND THE MEDICAL PROFESSION ARE EVEN NOW

DEBATING THE WISDOM OF USING SO-CALLED "EXTRAORDINARY"

MEASURES TO SAVE OR PROLONG THE LIVES OF PERSONS

PROFOUNDLY TRAUMATIZED OR TERMINALLY ILL.


FOR MANY PEOPLE WHO MUST DECIDE THE FATE OF LOVED

ONES, HIGH-TECH MEDICINE SOMETIMES ACTS LIKE A FRIEND . . .

AND SOMETIMES IT ACTS LIKE AN ENEMY.

HENCE, SOME PEOPLE ARE TURNING TO LEGAL INSTRUMENTS

LIKE THE SO-CALLED "LIVING WILL" AND THE "DURABLE POWER

OF A'ITORNEY" TO PROTECT THEMSELVES FROM RUNAWAY

MEDICAL TECHNOLOGY, IN THE EVENT THEY ONE DAY HAVE A

TERMINAL ILLNESS OR INJURY.


HENCE, IN MANY REAL-LIFE SITUATIONS, TECHNOLOGY IS A

MIXED BLESSING . . . AT BEST . . . AND CAN BE A CURSE, AT THE

WORST.

IS OUR SOCIETY STILL READY AND WILLING TO DELIVER HIGH-

QUALITY, TECHNOLOGY-INTENSIVE MEDICAL CARE TO

EVERYONE, REGARDLESS OF COST?

I'D HAVE TO SAY THE ANSWER I GET AS I TRAVEL AROUND THE

COUNTRY IS, "PROBABLY NOT."

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WHAT WE HAVE, THEN, IS A RISE IN THE NEW TECHNOLOGIES

AVAILABLE TO PHYSICIANS . . .

BUT, AT THE SAME TIME, A DECLINE IN THEIR SIGNIFICANCE FOR

A SUBSTANTIAL NUMBER OF PATIENTS.

IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE

PAY DOCTORS TO TAKE A LEG OFF BUT WE DON'T PAY THEM TO

KEEP A LEG ON. NOW, ALMOST 80 YEARS HAVE PASSED AND WE

STILL HAVEN'T COME UP WITH A GOOD ANSWER.

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OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM --

WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- IS STILL

PREDICATED ON TAKING THE LEG OFF.

AND TO FURTHER COMPLICATE THE ISSUE, THE STRUGGLE

BETWEEN OUR ASPIRATIONS AND OUR RESOURCES HAS ALSO

COME AT THE WORST POSSIBLE TIME,

A TIME WHEN DEMOGRAPHIC TRENDS ARE RUNNING AGAINST US.

12


TODAY, FOR EXAMPLE, FOR EACH PERSON WHO IS OVER THE AGE

OF 65, THERE ARE 5 YOUNGER, TAX-PAYING WAGE-EARNERS TO

PAY FOR THAT ONE PERSON'S MEDICARE COVERAGE.

IN ANOTHER 20 YEARS, HOWEVER, FOR EACH PERSON OVER THE

AGE OF 65, THERE WILL BE ONLY 2 YOUNGER, TAX-PAYING WAGE-

EARNERS CONTRIBUTING TO MEDICARE.

13


THAT MEANS THAT IN A CLIMATE OF SCARCITY, AMERICANS WILL

HAVE TO WORK OUT AN EQUITABLE SHARING OF NEEDED

MEDICAL RESOURCES BETWEEN ONE POPULATION GROUP THAT

IS GROWING -- THAT IS, THE ELDERLY, PEOPLE OVER THE AGE OF

65 -- AND THE POPULATION GROUP THAT IS COMPARATIVELY

SHRINKING -- THAT IS, CHILDREN UNDER THE AGE OF 18.

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OVER THE PAST 8 YEARS I'VE DEALT WITH ADVOCATES FOR

CHILDREN AND I'VE DEALT WITH ADVOCATES FOR THE ELDERLY.

THEY ARE BOTH VERY DEDICATED AND VERY PERSUASIVE

GROUPS. AND BOTH WILL BE QUITE RIGHTLY COMPETING FOR A

LARGER PIECE OF A SMALLER PIE.

THIS HAS CHILLING ETHICAL IMPLICATIONS, AND WE MUST

GUARD AGAINST LETI'ING OUR ETHICS BE DETERMINED BY OUR

ECONOMICS,

AND NOT THE OTHER WAY AROUND.

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I'M SURE YOU PEOPLE WHO DEAL WITH THE EVERYDAY ISSUES

OF HEALTHCARE PROVISION LOOK DOWN THE ROAD AS I DO AND

SEE THE PROBLEMS ON THE HORIZON.

SOME CRITICS WILL SAY THAT THE CHIEF CAUSE FOR THE

CRUNCH IS THE BUDGET DEFICIT. ONCE WE GET RID OF THE

DEFICIT, SAY THESE CRITICS, WE WILL ALSO GET RID OF THAT

GAP BETWEEN ASPIRATIONS AND RESOURCES . . . BETWEEN

DREAMS AND REALITY.

MAYBE . . . BUT I DON'T THINK SO.

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WELL BEFORE WE TALKED ABOUT A BUDGET PROBLEM, WE

ALREADY HAD A HEALTH CARE ECONOMY THAT CONSISTENTLY

RAN AT AN ANNUAL INFLATION RATE THAT WAS 2 TO 3 TIMES THE

INFLATION RATE FOR THE REST OF THE AMERICAN ECONOMY.

BUT WE DIDN'T SEE IT . . . OR, IF WE DID SEE IT, WE PREFERRED

NOT TO WORRY ABOUT IT.

17


TODAY, WE STILL HAVE AN INFLATED HEALTH CARE ECONOMY . . .

BUT WE ALSO HAVE INFLATED HEALTH CARE ASPIRATIONS. AND

WE SIMPLY CAN'T AFFORD ANY INFLATION AT ALL.

WHEN I OR OTHER PEOPLE TALK LIKE THIS, OUR CRITICS COME

BACK AT US AND SAY THAT THINGS REALLY AREN'T THAT BAD . . .

THAT ALL WE NEED TO DO IS PUT A REIMBURSEMENT CAP ON

THIS . . . OR CHANGE THE ELIGIBILITY REGULATIONS FOR THAT . . .

OR CUT BACK A LITTLE HERE . . . OR PRUNE BACK A LI'ITLE THERE.

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NOW, I CAN ALREADY HEAR THE CRITICS SAYING, "WAIT A

MINUTE, DR. KOOP. THE SYSTEM AIN'T BROKE, SO DON'T FIX IT."

TO WHICH I WOULD REPLY, "YOU'RE WRONG. THE SYSTEM@

BROKEN . . . AND IT MUST BE FIXED." BAND-AIDS WON'T DO.

HOSPITAL COSTS ARE STILL CLIMBING . . . AND NO ONE CAN

PROVE TO THE AMERICAN PEOPLE THAT THE OUALITY OF

HOSPITAL-BASED CARE IS UNIFORMLY GOING UP AS WELL.

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ON THE CONTRARY, OUR PEOPLE COMPLAIN THAT THEY ARE

PAYING MORE AND MORE FOR MEDICAL CARE, AND ARE GETTING

LESS AND LESS.

WORSE STILL, AS THE COST OF HOSPITAL-BASED CARE

INCREASES, SOME HOSPITALS THEMSELVES ARE TRYING TO

NARROW THEIR PATIENT POOL . . . FOR EXAMPLE, ELIMINATING

THE NEED TO PROVIDE IN-PATIENT MEDICAL CARE FOR POOR

AND DISADVANTAGED AMERICANS.

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I SAY THERE'S SOMETHING TERRIBLY WRONG WITH A SYSTEM OF

HEALTH CARE THAT SPENDS MORE AND MORE MONEY TO SERVE

FEWER AND FEWER PEOPLE.

AND WE HAVE MUCH THE SAME PROBLEM IN RESPECT TO

PHYSICIAN SERVICES AND FEES.

22


I CAN TELL YOU THAT MANY OF MY FRIENDS AND COLLEAGUES

IN MEDICAL PRACTICE ARE TRYING TO DO WHAT THEY CAN TO

INCREASE THE QUALITY OF CARE THEY DELIVER WITHOUT

INCREASING THEIR COSTS.

BUT THEY ARGUE THAT THEY HAVE LI'ITLE OR NO CONTROL

OVER SOME OF HE INFLATIONARY THINGS THEY DO.

AND THAT'S TRUE.

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I'VE BEEN THERE -- SO IT'S NOT JUST GIVING THEM THE BENEFIT

OF THE DOUBT.

BUT THE FACT STILL REMAINS THAT PHYSICIAN FEES ARE GOING

UP, AND THEY JJQ ADD TO A BURDEN ON THE PUBLIC THAT IS

BECOMING INSUPPORTABLE.

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AND, AGAIN -- AS WITH HOSPITAL-BASED CARE -- THE AMERICAN

PEOPLE HAVE NOT BEEN ASSURED, IN ANY RATIONAL AND

MEASURABLE WAY,

THAT THE HIGHER COSTS OF A PHYSICIAN'S CARE WILL IN FACT

BUY THEM A PROPORTIONATELY HIGHER OUALITY OF SUCH

CARE.

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