TOPICALITY

RESOLVED:
1. Determined to act T1
2. Sealed, set T2

THAT:
1. Indicates an idea to follow T3-4
2. Pick one of a group T5
3. In a general sense T6

THE: modifies federal government
1. Refers to federal government as a general idea T7-9
2. Refers to the existing federal government, the one which exists now T10-13

FEDERAL
1. Government with a single central authority T14-17
2. Any time states make an agreement T18-19

FEDERAL GOVERNMENT: the agent of action in the resolution
1. Does not include the states T20-21
2. Means the government of the USA T22
3. Where central government is the ultimate sovereign T23
4. Federal government includes the states T24
5. States acting in unison is a federal government T25

GOVERNMENT:
1. A part of the state T26
2. Anything that controls the individual T27
3. Any authority representing the whole T28
4. Any authority making community wide decisions T29
5. Any organized action T30-32

SHOULD: ought to T33

GUARANTEE:
1. To try T34
2. Any promise T35
3. Take responsibility for T36-37
4. Must solve and fulfill T38-41
5. Must be high quality T42
6. A health insurance plan is a guarantee T43

COMPREHENSIVE: dictionary definitions
1. Including much T44-46
2. Including all T47-49
3. Does not mean all T50
4. Nearly complete T51
	Affirmative use:/Negative use:
5. Large T52
6. Full consideration of the problems T53
	Affirmative use:/Negative use:
7. Mandatory and uniform T54

COMPREHENSIVE: medical context definitions
1. Total T55
2. Complete T56
3. All health needs covered T57
4. Basic & major coverage, but not all T58
5. Comprehensive coverage vs. minimal coverage
	a. Comprehensive is T59
	b. Minimal is T60
	c. Minimal is not comprehensive T61
6. Hospitalization alone is not comprehensive T62

NATIONAL
1. Done by the national (federal) government T63
2. Whole nation T64-65
3. Nationwide in scope T66

HEALTH:
1. Body concerns T67-68
2. Includes mental, social T69-70
3. Subjective term, hard to define T71
4. Not just the absence of disease T72

INSURANCE:
1. Indemnify T73
2. Protect T74

HEALTH INSURANCE: Compensation for medical expenses T75

NATIONAL HEALTH INSURANCE: medical and policy context definitions
1. Can't define National Health Insurance T76-78
2. National Health Insurance is: Affirmative use:/Negative use:
	a. Prepaid, comprehensive, mandatory, payroll taxes fund it T79
	b. Social health insurance, for all, federal, funded by taxes T80
	c. Single program, unified, federal & private, not specifies who is covered and how it is paid for T81
	d. All have access, standardized care, various funding T82
	e. Access comprehensive, federal, funded by taxes T83
	f. Like medicare for all T84
3. Pay or play as different or distinguished from National Health Insurance T85-89
4. Pay or play and insurance reforms as distinguished from National Health Insurance T90-92
5. Pay or play, medicaid expansion, employer plans, as distinguished from National Health Insurance T93
6. Insurance reform is not National Health Insurance T94
7. National Health Insurance does not require federal funding T95
8. National Health Insurance must have access to all T96
9. National Health Insurance is not just Canada or Great Britain model T97
10. Access alone does not mean it is National Health Insurance T98
11. National Health Insurance can be done through private health insurance T99
12. A national health plan is not National Health Insurance T100
13. National Health Insurance is not the same thing as socialized medicine T101

TO:
1. Flexible term T102
2. Does not mean actually reach the goal T103
3. Toward, in the direction of T104-106
4. Means to have an effect T107

ALL:
1. Only those indicated (US citizens ONLY) T108-110
2. Whole T111-113
3. The most possible T114-115
4. Entire universe T116

UNITED STATES: T117

CITIZENS:
1. In the legal category of citizen T118-120
2. Any resident T121-123
3. Does not include military or the police T124-125

T1/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 1072., \\ VT94-PS
	 RESOLVED: FIXED OR SET IN PURPOSE; DETERMINED; ALSO, HAVING FORMED A RESOLVE. 

T2/ WEBSTER'S COLLEGIATE THESAURUS, 1976, P. 673., \\ VT94-PS
	 RESOLVED: BENT, DECISIVE, DETERMINED, INTENT, RESOLUTE, SET, SETTLED. 

T3/ OXFORD ENGLISH DICTIONARY, 1971: (COMPACT VERSION, VOL. II P.3277), \\ VT94-PS
	 THAT: "A SIMPLE DEMONSTRATIVE PRONOUN. 1. DENOTING A THING OR PERSON POINTED OUT" 

T4/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P.1221., \\ VT94-PS
	 THAT: THE PERSON, THING, OR IDEA INDICATED, MENTIONED, OR UNDERSTOOD FROM THE SITUATION. 

T5/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P.1221., \\ VT94-PS
	 THAT: ONE OR A GROUP OF THE INDICATED KIND. 

T6/ OXFORD ENGLISH DICTIONARY, 1971: (COMPACT VERSION, VOL. II P.3277, \\ VT94-PS
	 "THAT: 6. RELATIVE PRONOUN; A. OF A THING IN A GENERAL SENSE 

T7/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 1965., \\ VT94-PS
	 THE: ONE OF MANY OF A CLASS OR TYPE, AS OF A MANUFACTURED ITEM, AS OPPOSED TO AN INDIVIDUAL ONE. 

T8/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 1965., \\ VT94-PS
	 THE: USED BEFORE ADJECTIVES THAT ARE USED SUBSTANSIVELY, TO NOTE AN INDIVIDUAL, A CLASS OR NUMBER OF INDIVIDUALS, OR AN ABSTRACT IDEA. 

T9/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 1965., \\ VT94-PS
	 THE: USED TO MARK A NOUN AS BEING USED GENERICALLY. 

T10/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 1301., \\ VT94-PS
	 THE IS OPPOSED TO THE INDEFINITE ARTICLE A OR AN , AND IS USED, ESPECIALLY BEFORE NOUNS, TO RENDER THE MODIFIED WORD MORE PARTICULAR OR INDIVIDUAL. 

T11/ CORPUS JURIS SECUNDUM, VOL. 86, 1954, \\ VT94-PS
	 THE: THE. IT IS GENERALLY USED BEFORE NOUNS WITH A SPECIFYING OR PARTICULARIZING EFFECT, AND AS OPPOSED TO THE GENERALIZING EFFECT OF THE INDEFINITE ARTICLE "A" OR "AN" 

T12/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 1965., \\ VT94-PS
	 THE: USED, ESP. BEFORE A NOUN, WITH A SPECIFYING OR PARTICULARIZING EFFECT, AS OPPOSED TO THE INDEFINITE OR GENERALIZING FORCE OF THE INDEFINITE ARTICLE A OR AN.. 

T13/ OXFORD ENGLISH DICTIONARY 1973 P.2276, \\ VT94-PS
	 THE: *MARKING AN OBJECT AS BEFORE MENTIONED OR ALREADY KNOWN, OR CONTEXTUALLY PARTICULARIZED. 

T14/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 463., \\ VT94-PS
	 FEDERAL: OF OR PERTAINING TO A UNION OR CENTRAL AUTHORITY SO ESTABLISHED. 

T15/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 463., \\ VT94-PS
	 FEDERAL: OF OR PERTAINING TO A FORM OF GOVERNMENT IN WHICH CERTAIN STATES AGREE BY COMPACT TO GRANT CONTROL OF COMMON AFFAIRS TO A CENTRAL AUTHORITY BUT RETAIN INDIVIDUAL CONTROL OVER INTERNAL AFFAIRS. 

T16/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 1965., \\ VT94-PS
	 FEDERAL: OF, PERTAINING TO, OR NOTING SUCH A CENTRAL GOVERNMENT. 

T17/ AMERICAN HERITAGE, 1979, P. 481, \\ VT94-PS
	 FEDERAL: OF, PERTAINING TO, OR DESIGNATING A FORM OF GOVERNMENT IN WHICH A UNION OF STATES RECOGNIZES THE SOVEREIGNTY OF A CENTRAL AUTHORITY WHILE RETAINING CERTAIN RESIDUAL POWERS OF GOVERNMENT. 

T18/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 1965., \\ VT94-PS
	 FEDERAL: OF OR PERTAINING TO A COMPACT OR A LEAGUE, ESP. A LEAGUE BETWEEN NATIONS OR STATES. 

T19/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 463., \\ VT94-PS
	 FEDERAL: FAVORING OR SUPPORTING A GOVERNMENT FORMED BY A UNION OF SEVERAL STATES. 

T20/ THE AMERICAN COLLEGE DICTIONARY, 1960, P. 442. FEDERAL (2) GOVERNMENT (c), \\ VT94-PS
	 FEDERAL GOVERNMENT: PERTAINING TO OR OF THE NATURE OF A UNION OF STATES UNDER A CENTRAL GOVERNMENT DISTINCT FROM THE INDIVIDUAL GOVERNMENTS OF THE SEPARATE STATES: THE FEDERAL GOVERNMENT OF THE U.S.. 

T21/ AMERICAN HERITAGE DICTIONARY OF THE ENGLISH LANGUAGE 1969 (1ST EDITION, P. 481), \\ VT94-PS
	 FEDERAL GOVERNMENT: OF OR PERTAINING TO THE CENTRAL GOVERNMENT OF A FEDERATION, AS DISTINCT FROM THE GOVERNMENTS OF ITS MEMBER STATES: FEDERAL OFFICE 

T22/ BALLENTINES LAW DICTIONARY, P. 461, \\ VT94-PS
	 FEDERAL GOVERNMENT: THE GOVERNMENT OF THE U.S.; THE GOVERNMENT OF A COMMUNITY OF INDEPENDENT AND SOVEREIGN STATES, UNITED BY COMPACT. 

T23/ AMERICAN HERITAGE DICTIONARY OF THE ENGLISH LANGUAGE 1969 (1ST EDITION, P. 481), \\ VT94-PS
	 FEDERAL GOVERNMENT: OF, PERTAINING TO, OR DESIGNATING A FORM OF GOVERNMENT IN WHICH A UNION OF STATES RECOGNIZES THE SOVEREIGNTY OF A CENTRAL AUTHORITY WHILE RETAINING CERTAIN RESIDUAL POWERS OF GOVERNMENT. 

T24/ BLACK'S LAW DICTIONARY, 1968, P. 740, \\ VT94-PS
	 IN A FEDERAL GOVERNMENT, ON THE OTHER HAND, THE ALLIED STATES FORM A UNION,---NOT, INDEED, TO SUCH AN EXTENT AS TO DESTROY THEIR SEPARATE ORGANIZATION OR DEPRIVE THEM OF QUASI SOVEREIGNTY WITH RESPECT TO THE ADMINISTRATION OF THEIR PURELY LOCAL CONCERNS, BUT SO THAT THE CENTRAL POWER IS ERECTED INTO A TRULY NATIONAL GOVERNMENT, POSSESSING SOVEREIGNTY BOTH EXTERNAL AND INTERNAL,---WHILE THE ADMINISTRATION OF NATIONAL AFFAIRS IS DIRECTED, AND ITS EFFECTS FELT, NOT BY THE SEPARATE STATES DELIBERATING AS UNITS, BUT BY THE PEOPLE OF ALL, IN THEIR COLLECTIVE CAPACITY, AS CITIZENS OF THE NATION. 

T25/BLACK'S LAW DICTIONARY, ED. HENRY CAMPBELL BLACK, 1979, P. 550., \\ VT94-PS
	 FEDERAL GOVERNMENT: THE SYSTEM OF GOVERNMENT ADMINISTERED IN A NATION FORMED BY THE UNION OR CONFEDERATION OF SEVERAL INDEPENDENT STATES. 

T26/ BLACK'S LAW DICTIONARY, 5TH EDITION, 1979, P. 625., \\ VT94-PS
	 GOVERNMENT. THE WHOLE CLASS OR BODY OF OFFICEHOLDERS OR FUNCTIONARIES CONSIDERED IN THE AGGREGATE, UPON WHOM DEVOLVES THE EXECUTIVE, LEGISLATIVE, AND ADMINISTRATIVE BUSINESS OF THE STATE. 

T27/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 855., \\ VT94-PS
	 GOVERNMENT: THE POLITICAL DIRECTION AND CONTROL EXERCISED OVER THE ACTIONS OF THE MEMBERS, CITIZENS, OR INHABITANTS OF COMMUNITIES, SOCIETIES, AND STATES; DIRECTION OF THE AFFAIRS OF A STATE, COMMUNITY, ETC.; POLITICAL ADMINISTRATION. 

T28/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 855., \\ VT94-PS
	 GOVERNMENT: A BRANCH OR SERVICE OF THE SUPREME AUTHORITY OF A STATE OR NATION, TAKEN AS REPRESENTING THE WHOLE. 

T29/ HUGO READING, A DICTIONARY OF THE SOCIAL SCIENCES, 1977, P. 95, \\ VT94-PS
	 GOVERNMENT. 1. THE EXISTENCE OF THE PERSONS WITH THE AUTHORITY TO TAKE COMMUNAL DECISIONS. 2. THE MACHINERY BY WHICH VALUES ARE ALLOCATED IN A GROUP. 3. THE MANAGEMENT, DIRECTING, AND CONTROL OF THE PUBLIC AFFAIRS OF A POLITICAL UNIT. 

T30/ CORPUS JURIS SECUNDUM, 1943, VOLUME 38, P. 966, \\ VT94-PS
	 GOVERNMENT: . . . "GOVERNMENT" HAD BEEN DEFINED AS A BODY POLITIC, A STATE; A CORPORATE ENTITY THROUGH WHICH THE PEOPLE ACT; A FICTITIOUS ENTITY CREATED BY THE PEOPLE; THAT FORM OF FUNDAMENTAL RULES BY WHICH THE MEMBERS OF A BODY POLITIC REGULATE THEIR SOCIAL ACTION . . . 

T31/ CORPUS JURIS SECUNDUM, 1943, VOLUME 38, P. 965, \\ VT94-PS
	 GOVERNMENT: IN ITS ORDINARY SIGNIFICATION, THE ACT OR FACT OF GOVERNING; CONTROL, DIRECTION, THE EXERCISE OF AUTHORITY REGULATING THE ACTION OF SOMETHING; GUIDANCE, MANAGEMENT, REGULATION, RULE. 

T32/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 547., \\ VT94-PS
	 GOVERNMENT: THE FORM BY WHICH A COMMUNITY IS MANAGED. 

T33/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 1163., \\ VT94-PS
	 SHOULD: OBLIGATION OR PROPRIETY IN VARYING DEGREES, BUT MILDER THAN OUGHT . 

T34/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 847., \\ VT94-PS
	 GUARANTEE: TO UNDERTAKE TO ENSURE FOR ANOTHER, AS RIGHTS OR POSSESSIONS. 

T35/ DANIEL ORAN (J.D.), 1983 [ORAN'S DICTIONARY OF THE LAW, PG. 193], \\ VT94-PS
	 GUARANTEE: "3. ANY PROMISE" 

T36/ WEBSTER'S NEW DICTIONARY OF SYNONYMS, 1973, P.384-385., \\ VT94-PS
	 GUARANTEE AND GUARANTY GENERALLY IMPLY ACCEPTANCE AND ESPECIALLY CONTRACTUAL ACCEPTANCE OF THIS RESPONSIBILITY FOR ANOTHER IN CASE OF HIS DEFAULT. 

T37/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 560., \\ VT94-PS
	 GUARANTEE: TO MAKE (ONESELF) RESPONSIBLE FOR THE OBLIGATION OF ANOTHER. 

T38/ FUNK AND WAGNALL'S STANDARD DESK DICTIONARY, 1977, P. 285, \\ VT94-PS
	 GUARANTEE: 1. A PLEDGE OR FORMAL PROMISE THAT SOMETHING WILL MEET STATED SPECIFICATIONS OR THAT A SPECIFIED ACT WILL BE PERFORMED OR CONTINUED: ALSO CALLED WARRANTY. 2. TO ACCEPT RESPONSIBILITY FOR. 

T39/ RANDOM HOUSE DICTIONARY, 2ND ED., UN ABRIDGED, 1987, P. 847, \\ VT94-PS
	 GUARANTEE: SOMETHING THAT ASSURES A PARTICULAR OUTCOME OR CONDITION. 

T40/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 560., \\ VT94-PS
	 GUARANTEE: A PLEDGE OR FORMAL ASSURANCE THAT SOMETHING WILL MEET STATED SPECIFICATIONS OR THAT A SPECIFIED ACT WILL BE PERFORMED. 

T41/ AMERICAN HERITAGE DICTIONARY, 1982, \\ VT94-PS
	 GUARANTEE: 6. TO MAKE CERTAIN; ENSURE. 

T42/THOMAS TIMMRECK, Dictionary of Health Services Management, 1987, p.244 \\VT 93-94 
	Guarantee A promise (sometimes incorporated into a contract) that goods are of a certain high quality, will be fixed if broken, and will ] last for a certain time period. 

T43/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 THE SEVEN CRITICAL ISSUES 1. Should Everyone Be Guaranteed, by Federal Law, a Health Insurance Plan? For many years there has been a debate over whether or not access to health care is a right that should be guaranteed to every citizen. In the context of today's debate, this question has been more narrowly reframed as whether or not everyone should be guaranteed a health insurance plan by the federal government. 

T44/ THE OXFORD ENGLISH DICTIONARY, 1980 [COMPACT ED. PG. 743], \\ VT94-PS
	 "1. COMPREHENSIVE: CHARACTERIZED BY COMPREHENSION; HAVING THE ATTRIBUTE OF COMPRISING OR INCLUDING MUCH; OF LARGE CONTENT OR SCOPE." 

T45/ FUNK AND WAGNALLS STANDARD COMPREHENSIVE INTERNATIONAL DICTIONARY IN 1973 (PAGE 269), \\ VT94-PS
	 COMPREHENSIVE: 1. LARGE IN SCOPE OR CONTENT; INCLUDING MUCH; BROAD 

T46/ CORPUS JURIS SECUNDUM, VOL. 15A, 1967, P. 166, \\ VT94-PS
	 THE WORD "COMPREHENSIVE" IS DEFINED AS MEANING INCLUDING MUCH; COMPRISING MANY THINGS; HAVING A WIDE SCOPE; INCLUSIVE; HAVING THE POWER TO COMPREHEND MANY THINGS; OF WIDE MENTAL GRASP; INTENSIVE. THE TERM IS NOT SUPERLATIVE IN SIGNIFICANCE. 

T47/ WEBSTER'S NEW COLLEGIATE DICTIONARY, 1982, P. 170., \\ VT94-PS
	 "COMPREHENSIVE. 1: COVERING COMPLETELY." 

T48/ WILLIAM BARTON, LEGAL THESAURUS, 1980, PAGE 92, \\ VT94-PS
	 COMPREHENSIVE; ADJECTIVE; ALL-COVERING, ALL-EMBRACING, ALL-INCLUSIVE, ALL-PERVADING, BROAD, CAPACIOUS, COMPENDIOUS, COLMPLETE, COMPLETIVE, COMPRISING, CONSUMATE, CONTAINING, COPIOUS, DISCOURSIVE, ENCIRCLING, ENCYCLOPEDIC, EXHAUSTIVE, EXPANSIVE, EXTENDED, EXTENSIVE, FAR-REACHING, FULL, FULLY REALIZED, HAVING NO LIMIT, INCLUSIVE, INTENSIVE, LATE PATENS, OVERALL, PANORAMIC, SWEEPING, SYNOPTIC, THOROUGH, THOROUGHGOING, TOTAL, UNCONDITIONAL, UNEXCLUSIVE, UNIVERSAL, UNMITIGATED, UNQUALIFIED, UNRESERVED, UNRESTRICTED, WIDE, WIDE-REACHING, WIDESPREAD. 

T49/ WEBSTER'S 7TH NEW COLLEGIATE DICTIONARY, 1972, PP. 170-171, \\ VT94-PS
	 COMPREHENSIVE: ADJ. 1. COVERING COMPLETELY: INCLUSIVE 

T50/ WORDS AND PHRASES IN 1951 (VOL. 8, P. 443) \\ VT94-PS
	BEING COMPREHENSIVE IN THE SENSE OF INCLUDING MUCH, COMPRISING OF MANY THINGS, HAVING A WIDE SCOPE, INCLUSIVE, BUT NOT AS MEANING ALL-INCLUSIVE. 

T51/ WEBSTER'S 3RD NEW INTERNATIONAL IN 1964 (PAGE 467), \\ VT94-PS
	 COMPREHENSIVE: COVERING A MATTER UNDER CONSIDERATION COMPLETELY OR NEARLY COMPLETELY: ACCOUNTING FOR OR COMPREHENDING ALL OR VIRTUALLY ALL PERTINENT CONSIDERATIONS. 

T52/ AMERICAN HERITAGE DICTIONARY IN 1969 (1ST EDITION, P. 274), \\ VT94-PS
	 COMPREHENSIVE: 1. INCLUDING OR COMPREHENDING MUCH; LARGE IN SCOPE OR CONTENT. 

T53/ WORDS AND PHRASES (1984 CUMMULATIVE ANNUAL POCKET PART TO VOL. 8, PAGE 105), \\ VT94-PS
	 COMPREHENSIVE: COMPREHENSIVE PLAN CONNOTES FULL CONSIDERAITON OF PROBLEMS PRESENTED AND REASONABLE AND UNIFORM PROVISIONS TO DEAL WITH THEM. 

T54/ WORDS AND PHRASES (1984 CUMMULATIVE ANNUAL POCKET PART TO VOL. 8, PAGE 105), \\ VT94-PS
	 COMPREHENSIVE PLAN IS NOT MERELY A GUIDELINE WHICH MAY BE FOLLOWED OR DISREGARDED AT WILL. COMPREHENSIVE IS INTERPRETED TO MEAN MANDATORY AND UNIFORM. 

T55/THOMAS TIMMRECK, Dictionary of Health Services Management, 1987, p.119 \VT- ACS 
	Comprehensive care Total, complete care and services provided beyond those offered by usual health insurance plans. Comprehensive care usually includes dental care, eye care, and mental health services. This term is associated with pre paid group health plans, HMOs, Indian Health Services, and military health services. 

T56/VERGIL SLEE, HEALTH CARE TERMS, 1991 \\VT 93-94 
	Comprehensive Medical Care--A complete package of health care services and benefits, including prevention, early detection and early treatment of conditions 

T57/GLOSSARY OF HEALTH CARE TERMS, 1991 International Foundation Employee Benefit Plans, p. 91 \\VT 93-94 ' 
	Comprehensive health care: Services (1) that are intended to meet all the health care needs of a patient: outpatient, inpatient, home care, and other. 

T58/VERGIL SLEE, HEALTH CARE TERMS, 1991\\VT 93-94 	Comprehensive Medical PIan--A plan that combines basic and major medical coverages in a single plan. 

T59/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Comprehensive Benefits. -- At the other pole are those who advocate an expanded, more comprehensive benefit package that would increase coverage above most Americans' current benefit level. It would include more extensive coverage for outpatient drugs and many costly services, such as mental health care, alcohol and substance abuse treatment, and long-term care. It would also eliminate many copayments and deductibles that are now a standard part of most insurance policies. Those who favor this approach argue from the perspective of equity and access to needed services. Everyone gets access to services that, in the past, only wealthier people or those with extensive insurance coverage have been able to afford. The most comprehensive proposals recognize that, in an aging population, many will need improved insurance protection against long-term care costs, which are increasingly problematic for a growing segment of the population. 

T60/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Minimal Benefits. -- The minimal package generally provides protection against only very large medical expenses and a few routine services, such as preventive services for pregnant women and children. Such policies usually do not cover mental health care, drug or alcohol treatment, or long-term care and require patients to pay very high copayments and deductibles. As a result, the premium is much lower than for other policies. Proponents of this approach believe it is the only type of policy taxpayers and employers could afford to offer those now without insurance. It would provide adequate protection against most catastrophic costs -- the problem that is most economically threatening to uninsured families. In addition, its advocates believe that, if many of the routine costs of medical care are not insured, families will utilize less costly sources of health care and seek care less frequently for trivial medical problems. 

T61/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 In setting a minimum level of health benefits, proposals include one of three levels of coverage: (1) a stripped down, minimal benefit policy; (2) a plan comparable to the average health insurance policy currently purchased; or (3) a more comprehensive package that includes such coverage as mental health care, drug or alcohol treatment, long-term care, and few if any deductibles and co-payments for individuals. 

T62/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p.. 64 \\VT-JHH 
	Hospital insurance could hardly be defined as comprehensive health insurance. It certainly flew in the face of the reality of medical care: that there is a continuum of care and that, to a significant extent, hospital and outpatient care are substitutable. 

T63/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 845., \\ VT94-PS
	 NATIONAL: AUTHORIZED BY A NATIONAL GOVERNMENT. 

T65/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 845., \\ VT94-PS
	 NATIONAL: BELONGING TO A NATION AS A WHOLE. 

T66/ CORPUS JURIS SECUNDUM, VOL. 65, 1954, P. 52., \\ VT94-PS
	 NATIONAL: AS AN ADJECTIVE, THE WORD "NATIONAL" CONTEMPLATES AN ACTIVITY WITH A NATION-WIDE SCOPE. 

T67/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 558., \\ VT94-PS
	 HEALTH: THE GENERAL CONDITION OF THE BODY. 

T68/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 558., \\ VT94-PS
	 HEALTH: FREEDOM FROM PHYSICAL DISEASE OR PAIN. 

T69/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS TRUE CAUSES OF SICKNESS & WELL-BEING, P. 8 
	The World Health Organization (WHO) of the United Nations defines health as "a state of complete physical, mental and social well being and not simply the absence of disease or infirmity." 

T70/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 558., \\ VT94-PS
	 HEALTH: THE CONDITION OF BEING SOUND IN BODY, MIND, OR SPIRIT. 

T71/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELL-BEING, p. 9\\VT-MDS ....
	Clearly, the concept of health, just as the concept of disease, is value-laden and subjective. So if health is largely subjective in nature, how are we to identify and study healthy populations? The brilliant psychologist Abraham Maslow simply selected those whom he considered "healthy" without defining his selection criteria. They were healthy be cause he said they were healthy (Maslow 1950). 

T72/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELL-BEING, p. 8 \\VT-MDS 
	While the absence of disease may be necessary to good health, clearly health implies more than an absence of disease. Most would agree that an element critical to health is a sense of subjective well-being, happiness, joy, or exuberance--in other words, health is not an objective entity but a highly subjective one, reflecting the individual's cultural and personal values. Such entities are difficult to define and measure. 

T73/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 628., \\ VT94-PS
	 INSURANCE: COVERAGE BY CONTRACT WHEREBY ONE PARTY UNDERTAKES TO INDEMNIFY OR GUARANTEE ANOTHER AGAINST LOSS BY A SPECIFIC CONTINGENCY OR PERIL. 

T74/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 628., \\ VT94-PS
	 INSURANCE: A MEANS OF GUARANTEEING PROTECTION OR SAFETY. 

T75/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 559., \\ VT94-PS
	 HEALTH INSURANCE: INSURANCE AGAINST LOSS THROUGH ILLNESS OF THE INSURED; ESP. INSURANCE PROVIDING COMPENSATION FOR MEDICAL EXPENSES. 

T76/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 A Discursive Dictionary of Health Care, published in 1976 by Congress, hints at the ever changing perceptions of health care reform. The definition given for national health insurance is "a term not yet defined in the U.S." As the divergent bills now before Congress demonstrate, this term remains undefined. 

T77/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February  23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 Not only do many Americans frequently confuse the terms "managed competition" and "managed care," says Paul Starr, a Princeton sociologist and author of "The  Logic of Health Care Reform," but people are not always talking about the same   thing when they use the most basic term in this debate: " national health   insurance. "  

T78/Health Line, February  19, 1993, HEADLINE: HEALTH CARE REFORM: CAN YOU "TALK THE TALK" Nexis \\VT 93-94
  Questioning whether the public is "confused by the  terminology of health care reform," L.A. TIMES provides a brief   summary of commonly used terms.  TIMES:  "Not only do many  Americans frequently confuse the terms 'managed competition' and  'managed care,' says (WH health task force adviser and Princeton  Univ.'s) Paul Starr ... but people are not always talking about   the same thing when they use the most basic term in this debate:  ' national health insurance. '" 

T79/THOMAS TIMMRECK, Dictionary of Health Services Management, 1987, p. 379 \\VT- ACS 
	National health insurance (NHI): A proposed prepaid comprehensive , . .. insurance program that would be mandatory for all citizens and funded by payroll deductions. 

T80/VERGIL SLEE, HEALTH CARE TERMS, 1991\\VT 93-94 
	National Health Insurance--Any system of socialized heaIth insurance benefits, covering all or nearly all citizens, established by federal law, administered by the federal government and supported or subsidized by taxation. 

T81/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 National Health Insurance: A single, unified health and medical care payment system. Like Medicare, it would presumably be controlled by the federal government but administered by private concerns. The term itself does not indicate who would be covered and how it would be financed. 

T82/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * NATIONAL HEALTH INSURANCE: Any system that would provide all Americans access to an agreed-upon standard of health care. It can, but does not always mean a federally financed and regulated system, such as the one in Canada. 

T83/DEBORAH SHALOWITZ, Business Insurance, June 1, 1992, Pg. 36, HEADLINE: Health care dissatisfaction grows; But a national plan is no cure \\VT 93-94
	 National health insurance was defined as ''a comprehensive national health insurance program administered by the federal government and financed through either corporate or personal general tax revenues designed to give all citizens access to health care.'' 

T84/Richard B. Saltman, director of the Division of Health Policy at Emory University's School of Public Health, The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 3, HEADLINE: NATIONAL HEALTH INSURANCE: CAN IT WORK IN THE U.S.? \\VT 93-94
	 The current debate in the United States about reforming the health care system often turns on the likely characteristics of what proponents as well as detractors refer to as " national health insurance. " The concept immediately brings to mind a vast federal program like Medicare - only some eight times larger - that would encompass all 250 million Americans and determine the health care services each patient receives. 

T85/Business Insurance, January 18, 1993 Pg. 8, HEADLINE: Ending an unhealthy silence \\VT 93-94
 But by now, it should be clear that the winds of change are blowing in Washington. Bill Clinton won the presidency at least in part because of his promise to develop and win passage of universal health care. We expect Mr. Clinton and the Democratic-controlled Congress to deliver on that promise. If universal coverage is inevitable, an employer - mandate - which would preserve the employment-based health care system - is a much better way to help achieve it than a government takeover of the health insurance system or play or pay, an approach that likely would be an interim step to national health insurance. 

T86/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 Each change that is recommended under any reform plan will cause a similar cascade or rippling effect on costs throughout the medical care delivery economic sector. Reform plans with multiple effects are like throwing many rocks into a pond at the same time and watching the ripples interacting with each other. The precise results of multiple changes are very hard to predict. 

T87/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	President GEORGE BUSH: Strip away the rhetoric, strip it out of there, and play or pay just creates a back door route to nationalized health care and it encourages employers to stop offering benefits, throw the problem in the government's lap. 

T88/Paul G. Rogers, attorney, was a Democratic representative from Florida from 1955-79, The Washington Post, September 6, 1992, PAGE C7 HEADLINE: Playing Games With 'Play-or-Pay' \\VT 93-94
	 Against this background, the president's first concern -- that a play-or-pay mechanism would lead inexorably to national health insurance -- is both misplaced and ironic. It is misplaced because under plans that include such a mechanism, the insurance provided through a pay option could in fact be private insurance -- and because the proportion of the population whose employers received some public subsidy toward the cost of insurance could easily be limited by adjusting the level of the payroll tax. 

T89/Jerry Geisel, staffwriter, Business Insurance, December  28, 1992, Pg. 15, HEADLINE: The crisis of the uninsured spotlights health system ills; Partisan battles, special interests are obstacles to consensus \\VT 93-94
	 Secretary of Labor Lynn Martin, for example, described play or pay as   ''backdoor  national health insurance. '' 

T90/Lynn Wagner, Washington bureau chief, Modern Healthcare, February 24, 1992 Pg. 44 HEADLINE: Forces dig in on reform strategies, boosting likelihood of a stalemate \\VT 93-94
	 The plan behind door No. 1 would be national health insurance, a tax-financed government program providing a minimum package of benefits for everyone and setting annual limits on healthcare spending. Behind door No. 2 would be the "play-or-pay" plan that would force employers to offer insurance to their workers or pay a tax to bankroll a fund that would pay for care for the uninsured. Door No. 3 would reveal a market-oriented strategy that relies largely on tax credits and deductions to enhance access to healthcare and on competition to control costs. 

T91/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 2. How Do We Provide Universal Coverage? If the reader believes the answer to the first question is yes, universal insurance coverage should be guaranteed by federal law, there are three ways proposed to accomplish this goal: (1) Enact a single national health plan. (2) Require by law that all employers provide insurance to their employees, and enact an all-government program for all non-workers. (3) Require by law that all individuals purchase private insurance for themselves, subsidizing the purchases for low-income people. 

T92/Larry Lipman COX NEWS SERVICE , The Atlanta Journal and Constitution, February 24, 1992, Section A; Page 8 HEADLINE: Three major options \\VT 93-94
	 Although some two dozen health reform bills have been introduced, there are three major options. [1.] President Bush and Republican lawmakers are pushing for tax credits and deductions to help people purchase insurance. They also want medical malpractice reforms that would limit payments for pain and suffering and a rollback on state mandated insurance coverage. Critics say the tax benefits will do little to help people afford insurance and will fuel the inflation in health-care costs. [2.] Many House Democrats support a variety of bills calling for national health insurance, similar to the Canadian system. Critics warn that such a system would create a huge government bureaucracy and result in limited medical resources and long waiting lines for certain types of care. [3.] Other House Democrats and a group of senior Senate Democrats, support an employer-based system commonly called "play or pay." Under this plan, employers would either play by providing insurance coverage for employees and their dependents or pay higher payroll taxes toward a public insurance program for those not covered by employers. Critics, notably, President Bush, warn that it would result in higher taxes for businesses and lead to a national health-care system run by the federal government. 

T93/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. HIMMELSTEIN [Dr. DAVID HIMMELSTEIN, Harvard Medical School] : Really what you're saying, Carl, really is that you're going to put some insurance bureaucrat in charge of telling you who you can go to for your doctor and what kind of care you can get rather than saying you can go to any doctor in the hospital or hospital that you want; and what we could have in this country is what Canadians have and what in fact most Europeans have which is not some insurance bureaucrat telling us what we can and can't do but go anywhere you want we'll pay for it. 

T94/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * INSURANCE REFORM: A number of proposals designed to change the practices of insurance companies that prevent some people from obtaining health coverage. Among other things, they would prohibit insurers from seeking only the healthiest customers, and from charging high rates based on occupation or medical history. 

T95/Health Line, February  19, 1993, HEADLINE: HEALTH CARE REFORM: CAN YOU "TALK THE TALK" Nexis \\VT 93-94
  NAT'L HEALTH INSURANCE:  A system that would provide all  Americans with "access to an agreed-upon standard of health care," which would not necessarily be federally-funded.  

T96/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February  23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
  NATIONAL HEALTH INSURANCE:  Does not always mean a federally funded and   regulated system, such as the one in Canada, even though it is frequently used   to refer to such a program. Many experts, such as Starr, use this term to  describe any system that would provide all Americans access to an agreed-upon standard of health care.   

T97/Robert E. Moffit, Deputy Director of Domestic  Policy Studies at The Heritage Foundation, February  25, 1993,  Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through  Managed Competition \\VT 93-94
   While a sizeable congressional faction   still supports  national health insurance,  serious or comprehensive reform of   the health care system does not now automatically mean socialized medicine along the Canadian or British models.  

T98/Jody W. Zylke, MD, Jeanette M. Smith, MD, Helene M. Cole, MD., Journal of the American Medical Association: July 15, 1992 268: 329 TITLE: Contempo '92 \\VT 93-94
	 By far the most frequently mentioned wish was for equal access to health care for all Americans. The authors advocated different ways to provide this care, paralleling the proposals being debated nationally, from national health insurance to improvements in private insurance coverage. 

T99/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 The third option on the legislative menu is replacement of the current private insurance system with a government national health insurance system. Different models have been proposed, eg, a state-based system built on the Canadian model or an extension of Medicare for the elderly and disabled to all Americans. These proposals have in common the creation of government as the sole payor for medical care and, as in the pay-or-play proposals, cost containment through budgets and negotiated rates. 

T100/Herman A. Kohlman, FHFMA, is a retired healthcare executive, Healthcare Financial Management , October, 1992 , Pg. 89, HEADLINE: The American healthcare dilemma: is there a solution? \\VT 93-94
	 With regard to establishing a national health policy (not national health insurance, note the difference), the role of the Federal government should be confined to setting basic policy; implementation of the policy should be left to the appropriate individual sectors of the economy. 

T101/HARVARD HOLLENBERG, The New York Times, December  27, 1992, Section 4; Page 10; HEADLINE: Bringing the Doctors In \\VT 93-94
	  Avoiding socialized medicine may, as Dr. Koop suggests, deserve a high priority in development of a comprehensive and coordinated system of  national health insurance.   Nevertheless, if medical practitioners are reluctant to yield their fealty to the profit motive, the election of significant numbers of physicians to remain   beyond the ambit of "managed care" and limited co-payments could leave us with   no practical alternative.   

T102/ CORPUS JURIS SECUNDUM, VOL. 86, 1954, P. 909., \\ VT94-PS
	 TO. THE PREPOSITION "TO" IS A FLEXIBLE TERM, HAVING NO SPECIFIC AND NO SETTLED LEGAL MEANING, AND ITS SIGNIFICATION IS TO BE ASCERTAINED FROM REASON IN THE SENSE IN WHICH IT IS USED. 

T103/ THE CYCLOPEDIC LAW DICTIONARY, 1940, P1107., \\ VT94-PS
	 TO: "TO" OFTEN HAS A MEANING NEARLY SYNONYMOUS WITH "TOWARDS," ALTHOUGH ITS ORDINARY MEANING IS NOT SATISFIED UNLESS THE POINT OR OBJECT IS ACTUALLY ATTAINED. 

T104/ BOUVIER'S LAW DICTIONARY, 1946, P1180., \\ VT94-PS
	 TO: IN MANY CASES THE MEANING IS NEARLY SYNONYMOUS WITH "TOWARD." 

T105/ CORPUS JURIS SECUNDUM, VOL. 86, 1954, P. 909., \\ VT94-PS
	 TO: IN ITS ORDINARY MEANING, AND AS COMMONLY USED, THE WORD "TO" CONVEYS THE IDEA OF MOVEMENT TOWARD AND ACTUALLY REACHING A SPECIFIED POINT OR OBJECT, AND THE MEANING IS NOT SATISFIED UNLESS THE POINT OR OBJECT IS ACTUALLY ATTAINED. 

T106/ WORDS AND PHRASES, VOL. 41A, 1950, P419., \\ VT94-PS
	 TO: "TO," AS COMMONLY USED, CONVEYS THE IDEA OF MOVEMENT TOWARDS, AND ACTUALLY REACHING, A SPECIFIED POINT OR OBJECT, AND THE MEANING IS NOT SATISFIED UNTIL THE POINT OR OBJECT BE ACTUALLY ATTAINED. 

T107/ WORDS AND PHRASES, VOL. 41A, 1965, P419., \\ VT94-PS
	 ONE OF THE MEANINGS OF WORD "TO" IS THAT OF INDICATING EFFECT, CONSEQUENCE, OR RESULTANT CONDITION AND INDICATING WITH ATTAINMENT OF, SO AS TO BRING ABOUT OR INDUCE; RESULTING IN, BUT THE WORD ALSO MEANS INDICATING ATTENTION, PURPOSE, OR END AND IS DEFINED AS AIMING AT, WITH VIEW OF GAINING OR ENGAGING IN, FOR THE MAKING OF, AS MEANS TO AN END. 

T108/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: ONLY; EXCLUSIVELY. 

T109/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 37., \\ VT94-PS
	 ALL: EXCLUSIVELY; ONLY. 

T110/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: NOTHING BUT; ONLY. 

T111/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: THE WHOLE OF (USED IN REFERRING TO QUANTITY, EXTENT, OR DURATION). 

T112/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: EVERY. 

T113/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: WHOLLY; ENTIRELY; COMPLETELY. 

T114/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: THE GREATEST POSSIBLE (USED IN REFERING TO QUALITY OR DEGREE). 

T115/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 37., \\ VT94-PS
	 ALL: THE GREATEST POSSIBLE. 

T116/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 54., \\ VT94-PS
	 ALL: THE ENTIRE UNIVERSE. 

T117/ WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY, 1991, P. 1291., \\ VT94-PS
	 UNITED STATES: A FEDERATION OF STATES. 

T118/WORDS AND PHRASES, VOL. 7, 1952, P. 283., \\ VT94-PS
	 A CITIZEN OF THE U.S. IS A PERSON OF ANY RACE OR COLOR BORN WITHIN THE LIMITS OF, OR WHO HAS BEEN NATURALIZED UNDER THE LAWS OF THE U.S. 

T119/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 377., \\ VT94-PS
	 CITIZEN: A NATIVE OR NATURALIZED MEMBER OF A STATE OR NATION WHO OWES ALLEGIANCE TO ITS GOVERNMENT AND IS ENTITLED TO ITS PROTECTION. 

T120/ WEBSTER'S COLLEGIATE THESAURUS, 1976, P. 138., \\ VT94-PS
	 CITIZEN: A PERSON REGARDED AS A MEMBER OF A SOVEREIGN STATE, ENTITLED TO ITS PROTECTION, AND SUBJECT TO ITS LAWS. 

T121/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 242., \\ VT94-PS
	 CITIZEN: A RESIDENT OF A CITY OR TOWN. 

T122/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 377., \\ VT94-PS
	 CITIZEN: AN INHABITANT OF A CITY OR TOWN, ESP. ONE ENTITLED TO ITS PRIVLEDGES OR FRANCHISES. 

T123/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 377., \\ VT94-PS
	 CITIZEN: AN INHABITANT, OR DENIZEN. 

T124/ THE RANDOM HOUSE DICTIONARY OF THE ENGLISH LANGUAGE, FIRST EDITION, 1987, P. 377., \\ VT94-PS
	 CITIZEN: A CIVILIAN, AS DISTINGUISHED FROM A SOLDIER, POLICE OFFICER, ETC. 

T125/ FUNK & WAGNALLS NEW COMPREHENSIVE INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE, 1973, P. 242., \\ VT94-PS
	 CITIZEN: A PRIVATE PERSON; ONE WHO IS NOT A PUBLIC OFFICER NOR A SOLDIER; A CIVILIAN. 

AFFIRMATIVE

INHERENCY: Why we don't have national health insurance now
1. Causes of the problems in our health care system A1
2. NHI will not happen in the status quo A2-4, 72-73
3. Requires presidential leadership A5
4. No consensus exists on what we should do A6-12, 74
5. Voters won't force NHI A13-15
6. Value conflicts prevent NHI A16-27, 75-77
7. PACs and political contributions stop NHI A28-41, 78-79
8. Anti-socialist rhetoric has been effective A42
9. AMA resistance A43-47, 80-81
10. NHI is too complex for people to understand A48
11. Actions in the status quo will be incremental only A49-52
12. The system is too fragmented to work A53
13. Desire for profit stops NHI A54
14. People fear government involvement A55-57, 83
15. Legal profession pressures A58
16. Managed care won't be adopted, or HMOs A59, 84
17. Access is limited in the status quo (see significance section on coverage)
	a. Insurance is not comprehensive or universal A60-65, 94-100
	b. Free care is vanishing A66-68, 101-103
	c. Medicare is not comprehensive or universal A69-70
	d. Medicaid is not comprehensive or universal A71, 114
18. Vested interests stop NHI A85-88
19. The Clinton plan is flawed A89-90, 105
20. Americans do not trust foreign examples A91
21. NHI is at least 5 years away A92
22. Business is not pressuring for NHI A93
23. Racism causes inadequate medical coverage A106

NATIONAL HEALTH INSURANCE: HARMS TO BE AVOIDED AND ADVANTAGES TO BE GAINED

MEDICAL CARE SYSTEM IS OUR #1 PROBLEM A107

MEDICAL SYSTEM IS GOING TO MELT DOWN VERY SOON
1. Medical system is about to collapse A108-114
2. Meltdown within 5 years A115-117

COVERAGE CRISIS
1. Millions have no medical coverage A118-132
2. Business insurance is being cut A133-137
3. Millions are underinsured A138-139
4. The poor are denied coverage and care A140-143
5. Middle class is not being denied coverage as well A144-145
6. Number of people not covered is increasing A146-147
7. Losing your job may mean losing your coverage A148
8. Non financial barriers A149
9. Patient dumping A150
10. Retiree medical benefits being canceled A151-152
11. Millions of children are uncovered A682-683

LACK OF MEDICAL CARE KILLS AND MAIMS
1. People are denied needed care A153-154
2. 60,000 die each year because of denied care A155-157
3. Disease rates are higher in the uncovered A158-162
4. Infants and children suffer and die A163-175

COST CRISIS -- HIGH COSTS HURT
1. Costs are soaring out of control A176-182
2. Huge number of families are financially strained A183-186
3. We pay a lot and get little for it A187-189
4. Medical costs cause a huge number of bankruptcies A190-206
5. Family members get abandoned because of cost A207-209
6. Costs victimize women and drives them into poverty A210-213
7, Huge costs and comparisons A214

FEE FOR SERVICE SYSTEM CAUSES UNNECESSARY CARE
1. Fee for service system gives overcare incentives A215-217
2. Unnecessary care kills 80,000 A218-219
3. Unnecessary care wastes billions of dollars A220-223
4. Unnecessary surgery A224-227
5. Care is concentrated at the end of life A228-229
6. Unnecessary cancer care A230-231

NATIONAL HEALTH INSURANCE CAN SAVE ADMINISTRATIVE WASTE
1. Awash in wasteful bureaucracy A232
2. Huge amount of administrative waste now A233-238
3. NHI administrative savings are huge A239-242
4. Use this savings to cover the uninsured A243
5. Personnel featherbedding A24-245

LACK OF ACCESS STOPS NEEDED PREVENTIVE CARE
1. Status quo emphasis is on "sick care" A246-247
2. Delay in treatment increases costs and medical severity A248-251
3. This is true of moms, infants, and kids A252-254
4. NHI will improve referrals A255

MEDICAL SYSTEM DAMAGES USA INTERNATIONAL COMPETITIVE POSITION
1. Huge medical costs hurt USA business A256-258
2. This hurts USA competitive standing A259-261
3. Auto industry is devastated A262-275
4. Small businesses are hurt A276
5. Causes labor-management conflicts A277-279
6. Forces people to stay in jobs they hate, so it lowers productivity A280-283
7. NHI would solve A284

HIGH MEDICAL COSTS CREATE BUDGET DEFICIT CRISIS
1. Solving medical spending would solve the deficit A285-290
2. Economy is threatened A291
3. Medical spending trades off with other important programs the economy needs A292-293
4. Medical spending is a GNP hog A294

HEALTH CARE IS A RIGHT A295-301

USA & SOUTH AFRICA HAVE SOMETHING IN COMMON -- NO NHI A302-311

SOLVING THE PROBLEMS OF AMERICAN MEDICINE

GENERAL SOLVENCY EVIDENCE
1. NHI solves the problems of American medicine A312-319
2. Now is the time for NHI A320
3. NHI will increase health and decrease costs A321-322
4. Europe shows that NHI is an excellent solution A323-331
5. NHI will provide access A332, 371
6. NHI will not lead to too much care for some A333-334
7. Prioritization of care can provide what we have to those who will benefit the most A335-344, A684
8. Doctors can decide who gets care A345
9. Public opinion favors NHI A346-349
10. AMA opposition is not a threat A350-351
11. We have more than enough doctors, we can afford to lose some A352-356
12. Major corporations and business leaders support NHI A357-361
13. NHI will stop intergenerational conflict A362
14. Income limits for doctors are justified A363
15. Government administration will not be inefficient A364
16. NHI will stop patient dumping A365
17. Global budgets A366, A686-688
18. Don't believe anti-NHI propaganda A367-368
19. NHI will not lead to socialism A369-370

HOW WE PAY FOR NATIONAL HEALTH INSURANCE
1. Cost estimates (you choose)
	a. NHI will cost a lot A372-373
	b. NHI will cost a moderate amount A374
	c. NHI will cost zero A375-377
	d. NHI will save lots of money A378-380
2. We can afford it A381-383
3. We pay for medical care for all now, in many different ways, NHI will only centralize payment A384-391
4. American people are willing to pay more in taxes for NHI A392-401
5. Huge administrative savings A402-409
6. New taxes
	a. Sin taxes A410-417
	b. Value Added Tax [VAT] A418-426
7. Deferred savings are fine A685

CANADIAN SYSTEM FOR THE USA

1. In general, it is a good approach A427-429
2. The Canadian system is... A430-433
3. Choice remains for patients A434-435
4. USA would have a "deluxe" version of Canadian system A436-438
5. Canadian system guarantees access to all A439-446
6. Canadian system would have huge administrative savings A447-451
7. Canadian system saves money and avoid trade offs A452-459
8. Canadian system emphasizes primary and preventive care A460-461
9. Canadian system savings will finance access to the uninsured A462-463
10. Canadians are satisfied with their system A464-468
11. USA public opinion favors the Canadian system A469-473
12. Corporations support Canadian system A474
13. Canadian system prevents bankruptcies A475-476
14. Canadian system has efficient, comfortable hospitals A477-479
15. Canadian system will restore competitive edge lost by health costs A480
16. Canada-USA comparison
	a. Canada is as much like the USA as is possible A481-485
	b. Populations are not that different A486-488
	c. Governments are not that different A489
	d. Safety valve is not a factor A490
17. Anti-Canadian attacks are silly
	a. Torrent of lies and propaganda about the Canadian system A491-499
	b. Waiting lists are not a problem A500-514
	c. Technology will not be lost A511-512
	d. Charges of evil rationing are invalid A513-54
	e. Canadian system is not socialism A515

HEALTH USA -- THE KERREY PLAN

1. In general, it is a great approach A516-517
2. Health USA plan is...A518-525
3. Health USA plan won't be adopted now A526
4. Health USA plan will be comprehensive A527-529
5. Health USA plan makes care available to all A530-535
6. Health USA plan increases rural access A536
7. Health USA plan solves medical specialization problems A537
8. Health USA plan will use competitive forces A538-541
9. Health USA plan will use consumer choice forces A542-544
10. Health USA plan will reduce fragmentation A545
11. Health USA plan will save money for citizens A546-550
12. Health USA plan fights rising costs A551-556
13. Health USA plan lowers hospital costs A557-558
14. Health USA plan will decrease administrative costs A559-560
15. Health USA plan increases prevention and primary care A561-562
16. Health USA plan will foster no backlash A563-564
17. Health providers will love the Health USA plan A565-567
18. Health USA plan will be efficient A568-570
19. Health USA plan will help businesses A571
20. Health USA plan funding plans A572-574
21. Distinctions -- what Health USA plan is and is not
	a. Uses states A575
	b. Keeps insurance companies A576
	c. Does not focus on the workplace A577-579
	d. Health USA plan is not Canadian system A580-581

PLAY OR PAY SYSTEM

1. Play or pay is the best approach to solving medical care problems A582-583
2. Play or pay  and employer mandates are... A584-591
3. Play or pay produces big savings A592
4. Play or pay reduces the pain of financial costs A593
5. Play or pay uses the best facets of all approaches A594
6. Public opinion likes the Play or pay  approach A595-596
7. Play or pay keeps choice and privacy A597
8. Play or pay is the least disruptive NHI approach A598
9. Play or pay works in Germany A599
10. Play or pay limits new taxes A600

MANAGED CARE & HEALTH MAINTENANCE ORGANIZATION (HMO) APPROACH

1. Health maintenance organizations
	a. HMOs are... A601-602
	b. HMOs have high satisfaction A603-604
	c. HMOs emphasize prevention and primary care A605
	d. Capitation and end of fee for service system are the keys to cost control A606-607
	e. HMOs provide family coverage for $311 a month A608
	f. To decrease costs, must end fee for service system A609
	g. HMOs save 15% A610
	h. HMOs will be even cheaper when they stop shadow pricing the fee for service system A611
2. Managed care
	a. Managed care is...A612-618
	b. Managed care means HMOs A619-620
	c. Managed care saves money A621-622
	d. Managed care decreases unnecessary care A623

MANAGED COMPETITION, JACKSON HOLE, AND OTHER RELATED PLANS

1. Managed competition 
	a. Managed competition is... A624-629
	b. Managed competition uses market forces A630
	c. Managed competition is the best approach A631
	d. Managed competition decreases cost and increases quality A632
	e. Managed competition is liked by the public A633
2. Jackson Hole plan 
	a. Jackson Hole plan is... A634
	b. Jackson Hole plan increases coverage A635
	c. Jackson Hole plan decreases costs A636-637
	d. Jackson Hole plan changes the medical environment for the better A638
	e. Jackson Hole plan uses HIPCs A639-640
3. Starr model
	a. Starr model is... A641-642
	b. Starr model saves money A643

GARAMENDI PLAN, LIKE FRANCE, GERMANY, AND JAPAN

1. Garamendi plan 
	a. Garamendi plan is... A644
	b. Garamendi plan saves money and increases access A645
	c. Garamendi plan has huge savings A646-649
	d. Garamendi plan uses managed competition and spending limits A650
2. European models like the Garamendi plan 
	a. Described A651-653
	b. Decreases costs A654
	c. Price controls successful A655
	d. Controls hospital costs A656
	e. Good approach A657

MEDICARE EXPANSION PLAN A658-660

MARKET ORIENTED PLANS

1. Heritage Foundation plan A661-667
2. Tax credit proposals A668-676
3. Bush plan A677-681

A1/JOE CAPPO, staffwriter, Crain's Chicago Business, December 7, 1992, SECTION: ; Pg. 10, HEADLINE: Some painful truths about health care \\VT 93-94
	 Here are some of the factors that have led us to this predicament:  * A rapidly aging population. * A high level of poverty, violent crime, drug abuse and other social ills.  * Oversupply and duplication of high-tech medical equipment at hospitals. * An oversupply of doctors (one of those rare cases where too much supply has led to higher, now lower, costs).  * Increased demand by consumers for health care.  * Consumer ignorance of health care costs, plus a tendency for doctors and patients to not discuss the costs of medical procedures. * The introduction of Medicare and Medicaid in 1965, which greatly expanded  the number of Americans in federal entitlement programs and also led to numerous abuses by unscrupulous health care providers.  * The increase in medical malpractice lawsuits. 

A2/Jacqueline Frank, The Reuter Library Report, January 31, 1992, HEADLINE: U.S. AWED BY MEDICAL ADVANCES, LOST SIGHT OF COSTS, Nexis \\VT 93-94
	But health care analysts on all sides of the issue said they cannot see national health insurance coming in the United States in the near future. 

A3/The Economist, February 8, 1992, Pg. 14 HEADLINE: The healthy option \\VT 93-94
	IT HAS been called the issue from hell. A large majority of disgruntled Americans wants to see health care reformed. Yet every proposal is attacked by special interests or criticised for fomenting tax increases. Congress talks, to little effect. 

A4/Larry Lipman COX NEWS SERVICE, The Atlanta Journal and Constitution, February 24, 1992, Section A; Page 8 HEADLINE: CAMPAIGN '92: KEEPING YOU UP TO DATE HEALTH: MATTERS: The issues are coverage, costs Many fall through system's holes \\VT 93-94
	 But virtually all of that money is spent domestically, promoting a huge health-care industry of insurance companies, doctors, hospitals, and other health-care providers who have a vested interest in protecting their share of the system. 

A5/MICHAEL R. McGARVEY, health benefits planner, The San Francisco Chronicle , NOVEMBER 11, 1992, Pg. A21; HEADLINE: Solution to Health Care: Keep It Simple \\VT 93-94
	 Prediction: Unless our new president makes providing health-care insurance coverage for all U.S. residents a top priority of his first term, our nation's most basic health care problems won't get fixed. Proposal: Let's do it. 

A6/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 The most ambitious formula for universal access to health care and responsible cost containment appears to be a federal national health insurance program. It seems unlikely, however, that a national health insurance program will receive the broad support necessary to achieve a legislative mandate in this decade. A major factor supporting this viewpoint is the failure of health care payers, providers, and consumers to develop consensus on a national health care policy, or an agenda for health care reform. [n13] 

A7/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 If one looks forward to their early implementation, all proposals for largescale health care reform must be predicated on the foregoing pessimistic appraisal of the financing outlook. Nevertheless, it would be shortsighted to assume that the present frozen environment for health reform, as well as for other public social policy initiatives, will not ultimately thaw. The United States continues to have both the highest per capita standard of living and the lowest per capita tax rate of any advanced nation with the exception of Japan. However, it will take time before Americans reach a consensus that low taxes are not necessarily the best assurance of continuing national prosperity and progress. 

A8/United Press International, March 8, 1992, HEADLINE: F ormer Nobel Prize winner says national health care getting closer Nexis \\VT 93-94
	 A former Nobel Prize winner says the high cost of medical care and the large number of medically uninsured have Americans at least discussing a national health insurance program. Dr. Frederick Robbins, who won the 1954 Nobel prize in medicine, said Americans ''have not yet come to grips with the issue of a two-tier health-care system that is based on whether we can afford it. 

A9/United Press International, April 7, 1992, HEADLINE: Americans united on who should fix health care system, Nexis \\VT 93-94
	 While 61 percent of Americans are concerned that health insurance costs will outpace their ability to buy it and 50 percent are worried about medical bills they cannot pay, there is no consensus on a particular reform plan. 

A10/United Press International, April 7, 1992, HEADLINE: Americans united on who should fix health care system, Nexis \\VT 93-94
	 ''It [POLL DATA] clearly shows no party nor any plan has a lick of public support,'' said Sen. John Chafee, R-R.I., who has been one of the leaders of health care reform in the Senate. However, Chafee said the lack of support for any specific proposal gives leaders an opportunity to move forward without political concerns. 

A11/Herman A. Kohlman, FHFMA, is a retired healthcare executive, Healthcare Financial Management , October, 1992 , Pg. 89, HEADLINE: The American healthcare dilemma: is there a solution? \\VT 93-94
	 The subject of healthcare costs does not occupy the same position of prominence in either Canada or Western Europe that it does here. In these nations a consensus has been reached on national health policy. And while some may not approve of the level of benefits and the delivery systems provided in these nations, health care is not the highly charged, emotional issue that it is in the U.S. today. Because the U.S. has not developed a basic policy, health care is being driven primarily by economics rather than by logic as it aims to provide care for one and all. 

A12/Pension Reporter, November 16, 1992 ,Vol. 19, No. 45; Pg. 2058 TITLE: LACK OF PUBLIC CONSENSUS COULD SLOW NEW ADMINISTRATION'S REFORM EFFORTS. \\VT 93-94
	 One reason for lack of consensus is that most individuals do not trust the federal government, Blendon said. While interest in health care reform is at a 40-year high, confidence in government is at a 30-year low, he noted. 

A13/Robert J. Blendon, ScD, Drew E. Altman, PhD, John M. Benson, MA, Humphrey Taylor, Matt James, Mark Smith, MD, MBA, Journal of the American Medical Association December 16,1992; 268: 3371-3373, TITLE: The Implications of the 1992 Presidential Election for Health Care Reform\\VT 93-94
	 Our findings suggest that health care did not play the same decisive role in the 1992 presidential election as it had in the Wofford-Thornburgh race. As a voting issue, health care was not key in determining the outcome of the 1992 election -- no issue other than the economy was -- but it was an important secondary factor in influencing voter judgments. 

A14/Smith, MD, MBA, Journal of the American Medical Association December 16,1992; 268: 3371-3373, TITLE: The Implications of the 1992 Presidential Election for Health Care Reform\\VT 93-94
	 An analysis of our election night telephone survey and the VRS exit survey shows that health care was an important concern among American voters, but that the economy was the dominant issue that determined voting patterns and ultimately the election of Gov Bill Clinton. 

A15/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 In light of these priorities, the politicians have a problem. The voters' expectations and priorities do not match, and they are at odds with reality. 

A16/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Regrettably, the prejudice against establishing an NHCS prevents our society from assuring that all Americans have access to affordable health care and from controlling escalating health care costs. 

A17RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Currently, our government is so preoccupied with rising health care costs that it considers economic and business approaches to address the problem of access to health care and rising health care costs. A paradoxical question arises from this economic preoccupation: "Can the most affluent health care system in the world afford to provide health care to all of its people?" Even though more attention has recently been given to the plight of the uninsured and underinsured poor, our society overlooks the ethical dimensions of these problems. 

A18/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 In an analogous fashion, our society believes that health care is a human right but resists changes that would assure universal access to health care. 

A19/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 This libertarian attitude toward health care accounts for our inconsistent response in addressing the issue of access to health care. For example, prisoners are legally guaranteed health care, whereas the uninsured poor, imprisoned by their poverty, are not afforded equal treatment. The poor cannot afford to pay for doctors' visits and medications or for medical insurance. Thus, criminals have better access to health care than the uninsured poor. Our society responds more favorably to criminals whose illegal activities have resulted in the denial of their individual liberties than to the law-abiding poor whose liberties are curtailed by their poverty. 

A20/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Our society reflexively associates national health care systems with socialism. This mind-set accounts for predictably biased evaluations when we examine other national health care systems. The derogatory associations of totalitarian principles with socialism provide excuses for not seriously considering the advantages of other national health care systems. Furthermore, antisocialist rhetoric is used to discredit, for example, the advantages of the British and Canadian health care systems. 

A21/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 In a health care system with finite resources, the central conflict of values affecting health care policy is the right to individual liberty vs the right to equality. However, our society buys into the myth of unlimited resources. This myth helps our society to overlook our finite resources and to avoid this central conflict of values. This allows our society to place a higher value on a negative right over a positive right to health care. 

A22/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The concept of enculturation helps to explain why this moral idea is not currently the governing principle of our health care policy. Our society has predominantly internalized a system of values that makes us prejudiced against establishing an NHCS. A dialectic tension exists between the value systems that do and do not support having an NHCS (Table 1). At present, values that do not support an NHCS hold sway in public policies. 

A23/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 ANTISOCIALIST RHETORIC-HUMAN RIGHTS The overzealous use of antisocialist rhetoric is used to maximize the individual liberties of physicians and well-insured patients at the expense of the moral ideal of health care as a human right. Unfortunately, antisocialist rhetoric is used to work against our society trying to put this moral ideal into practice. "How can antisocialist rhetoric be appropriately used to maximize the liberty of all individuals and physicians? How can the moral rhetoric of 'health care as a human right' be used to appropriately regulate the practice of medicine so that all Americans have access to affordable health care?" 

A24RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 THE ANTIGOVERNMENT SENTIMENT-DEMOCRATIC PRINCIPLES The antigovernment sentiment is used to persuade society that the government is incompetent to organize an NHCS. This sentiment also works against the use of democratic principles in the provision of health care. "Can we trust our government to be responsible for the health of our nation, as we do our national defense? How can we use democratic principles to ensure that our government develops a highly effective NHCS that is accountable to the people?" 

A25/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 HEALTH CARE AS A BUSINESS-HEALTH CARE AS A HUMAN SERVICE Our society regards health care delivery more as a business than as a human service. "To what extent should financial viability of a hospital or the medical needs of a community determine whether a hospital remains open or not?" 

A26/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The purpose of generating ethical dissonance is to persuade the federal and state governments, the medical profession, employers, hospital associations, health insurance companies, and society-at-large that changing the value system of our health care policy is necessary to achieve universal access to health care. 

A27/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Without understanding the conflict of values affecting our health care ethic, the political, policy, and financial debates on these two problems will continue to polarize the various participants in health care into opposing factions. These opposing factions will doom health care policy changes to vacillating incrementalism or stagnation, as in the recent case of the Catastrophic Health Care Bill or in the current issue of who will pay for the health care of the uninsured. Unless we commit ourselves to the health care ethic of an NHCS, reform plans will not be implemented for a period of time sufficient to solve these two problems and will fall victim to uninformed political debate, stop-gap efforts, and haphazard changes. 

A28/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL-FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
  On Capitol Hill, the cash registers are ringing, racking up campaign contributions to lawmakers from groups eyeing the hottest policy debate in town: how to overhaul the nation's health care system.  

A29/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 From doctors to drug manufacturers, those with a vested interest in how  President Clinton and Congress streamline health care have dipped into their pockets more deeply than before, sending millions to key lawmakers in the last  election cycle. Twelve leading health, drug, and insurance political action committees alone gave candidates $ 10 million in 1991-1992, 20 percent more than in 1989-1990. These PACs also increased by 61 percent their direct and indirect contributions to Capitol Hill leaders and lawmakers who oversee health issues, for a total of $ 1.9 million, according to a Boston Globe analysis of Federal Election Commission records. 

A30/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 But PACs and their critics admit that last year's increase in health care money to Congress in large measure reflects the fact that health lobbies are jockeying for influence - if not for lawmakers' ears - in the forthcoming debate. PAC donations also increased because Congress had the largest number of open congressional seats in decades. 

A31/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 "The health industry PACs have been increasing their contributions to  establish the strongest possible position in this battle," said Fred Wertheimer, president of Common Cause, a group that advocates campaign finance reform. 

A32/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 "There were good bills, like a Canadian-style health care bill, that never  moved out of committee because a block of conservative Republicans and Democrats were seriously influenced by money from drug companies, doctors, and health  insurers," said Sara Nichols, a staff lawyer for Public Citizen's Congress Watch, which studies PAC giving. 

A33/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 Advocates are fearful that Congress, under pressure from the health industry, will fail to adopt a bold plan to cut or curb health care costs. 

A34/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 Indeed, some lawmakers who received large amounts of PAC money supported proposals that industry opposed, including national health insurance. 

A35/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 Lawmakers who signed on to bills advocating a "single payer" system, or a Canadian-style national health care system, received very little money. But  those who pushed for moderate change, in the form of free market insurance reforms, received lots of campaign support.  According to a July 1992 study by Citizen Action, a group critical of PACs, lawmakers who supported minimal or moderate health care changes received 60  percent more money from health care PACs in 1992 than in 1990. "What they are doing is beefing up the power of people who stand where they stand," Blendon, of the Harvard School of Public Health, said. "And they are sending the signal that if other people join that member in his views, they'll  get money in the future." 

A36/Elizabeth Neuffer, GLOBE STAFF, The Boston Globe, February 14, 1993, SECTION: NATIONAL/FOREIGN; Pg. 1, HEADLINE: Funds flowing to guide health reform's course; \\VT 93-94
 "It is money that will buy compromise," said Ellen Miller, executive  director of the Center for Responsive Politics, which tracks PAC donations.  "They will use this money to buy delay, inaction and, ultimately, compromise."  

A37/Pension Reporter, July 27, 1992, Pg. 1350, TITLE: PACS INCREASE CONGRESSIONAL DONATIONS TO PREVENT REFORM, CITIZEN ACTION CHARGES. \\VT 93-94
	 Health-related political action committees have increased their donations to House and Senate members in an attempt to prevent comprehensive reform of the nation's health care system, the consumer advocacy group Citizen Action charged July 22. 

A39/Pension Reporter, July 27, 1992, Pg. 1350, TITLE: PACS INCREASE CONGRESSIONAL DONATIONS TO PREVENT REFORM, CITIZEN ACTION CHARGES. \\VT 93-94
	 Forty-five percent of the money contributed to House incumbents went to members of the House Ways and Means and Energy and Commerce committees, which have jurisdiction over health care issues, Citizen Action said. "As part of their campaign to derail the public's demand for real change, slow down action and create political gridlock, the health and insurance industries have increased dramatically their PAC contributions to members of Congress," the report said. 

A40/Pension Reporter, July 27, 1992, Pg. 1350, TITLE: PACS INCREASE CONGRESSIONAL DONATIONS TO PREVENT REFORM, CITIZEN ACTION CHARGES. \\VT 93-94
	 "Health and insurance PACs are increasing the amount of money they spend on congressional campaigns because they want to blunt and undermine the groundswell of support for a single-payer national health insurance system," Citizen Action Political Director Robert M. Brandon said in a statement accompanying the report. 

A41/Pension Reporter, July 27, 1992, Pg. 1350, TITLE: PACS INCREASE CONGRESSIONAL DONATIONS TO PREVENT REFORM, CITIZEN ACTION CHARGES. \\VT 93-94
	 The largest PAC contributions during the 1992 election cycle included those from the American Medical Association ($677,969), the American Dental PAC ($531,644), the Independent Insurance Agents of America ($358,718), the American Family Corp. ($272,500), and the American Council of Life Insurance ($240,889), the report said. 

A43/ DENNIS L. BREO, Journal of the American Medical Association, August 28, 1991; 266: 1131-1133, TITLE: Sidney Wolfe, MD -- healing the system or just raising hell?\\VT 93-94
	 Today, Wolfe argues, "AMA, too, believes that health care is a right, but it has no idea how to solve the problems of the current system. It is too afraid that rights will turn into entitlements and endanger the privileges of doctors." 

A44/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 In the past, the American Medical Association (AMA) has done its utmost to keep government out of the picture with regard to the clinical practice of medicine. The AMA has successfully used this antigovernment sentiment to block many reform initiatives. The AMA did not conjure up this sentiment in a social vacuum. In fact, the AMA capitalized on a prevailing sentiment of society for use as effective propaganda. 

A45/Ian Dowbiggin, assistant professor of history at the University of Prince Edward Island, The Toronto Star, April 22, 1992, SECTION: INSIGHT; Pg. A17 HEADLINE: Why the U.S. has resisted medicare \\VT 93-94
	 One of the most consistent foes of national health insurance in the U.S. has been the American Medical Association (AMA), a lobby whose resources and prestige have proven hard to beat. 

A46/Ian Dowbiggin, assistant professor of history at the University of Prince Edward Island, The Toronto Star, April 22, 1992, SECTION: INSIGHT; Pg. A17 HEADLINE: Why the U.S. has resisted medicare \\VT 93-94
	 It is this situation that worries Americans today and history shows that much of the blame can be laid at the feet of organized medicine. Of course, the AMA has rarely acted alone. Insurance companies and organized labor - preferring to include medical benefits in negotiated settlements with management - have backed the AMA for years. 

A47/Ian Dowbiggin, assistant professor of history at the University of Prince Edward Island, The Toronto Star, April 22, 1992, SECTION: INSIGHT; Pg. A17 HEADLINE: Why the U.S. has resisted medicare \\VT 93-94
	 How will organized medicine react? With communism crumbling the world over, it can't rely on Cold War rhetoric any more. If history is any indication, it will attempt to postpone state health insurance through another dissatisfying compromise like that of 1965. 

A48/ Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical ASSOCIATION, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 However, many of these proposals are detailed and very complex. They contain relatively intricate legal, economic, actuarial, and regulatory concepts. Although these are obviously essential features for experts and legislators, their complexity makes it difficult for the informed citizen or health professional to make a reasoned choice among the proposals. As we know from earlier policy debates, without such understanding, it is difficult to find a basis for a consensus. 

A49/ John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 In this regard, a list of the health care priorities of the majority of our present government officials would include (1) a limitation on expenditures and (2) provision of access to care for all patients who need it, but (3) not changing things very drastically. The latter has its roots both in people's general resistance to drastic change unless they are in dire straits, and in the principle that radical change is better suited to revolutions than elections. 

A50/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 2. Simply patching the current system -- for example, with Medicaid expansions -- cannot achieve universal coverage. Even if government were to cover all the poor (rather than the current 40%) and subsidize private coverage for the near-poor, insurance coverage would remain too expensive for about half the currently uninsured. In addition, such an approach would have taxpayers bear the costs of low-income workers whom their employers (unlike most employers) fail to protect. 

A51/Erwin W. Fellows, St. Petersburg Times, November 11, 1992, Pg. 19A HEADLINE: Fundamental changes in health care unlikely \\VT 93-94
	 So we will probably see minor adjustments (hopefully, improvements) in the health-care system in the future; we are not likely to see fundamental change. That's what was depressing. Our stereotypes and prejudices get in the way of really dealing with a problem. 

A52/The Economist, February 8, 1992, Pg. 14 HEADLINE: The healthy option \\VT 93-94
	Past efforts to deal with this mess have been piecemeal. The list includes insurance regulation, tax reliefs and subsidies, price controls for hospitals and doctors, cuts in Medicare and Medicaid (the government's health programmes for the old and the poor respectively) and the establishment of health-maintenance organisations (HMOs). Some of these were sensible, some not; but none has cured the disease. 

A53/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 Victor Sidel, MD, a former president of the American Public Health Association, and his wife, Ruth Sidel, PhD, have written, "Although in one sense the United States medical-care system is highly structured --for the benefit of those who control it and some of those who work in it -- in another sense it is so fragmented, the responsibilities so diffuse, the levels of control so manifold, the communication and coordination between its parts so haphazard, that, except for euphemisms 'pluralistic' and 'pragmatic' -- the system almost defies brief description." [n9] However, this puzzle, when put together, is our system of health care in the United States. 

A54/Journal of the American Medical Association July 24, 1991; 266: 574 SECTION: BOOKS TITLE: The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals, by Bradford H. Gray\\VT 93-94
	 The Profit Motive and Patient Care tells how the profit motive has infiltrated the hospital industry and changed the nature of physician-patient relations. For-profit hospitals are now a prominent part of the hospital sector. Nonprofit hospitals, responding to cost-containment and competitive pressures, have come to resemble their for-profit counterparts. Physicians are challenged with a variety of entrepreneurial opportunities, incentives, and utilization programs that may intercede in their decision making. 

A55/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Other factors that militate against the formation of a national health insurance program include the widespread agreement that our system should remain pluralistic with substantial roles for both public and private payers, and a lack of confidence in comprehensive government social programs that is based on a record of inefficiency, rationing of services, and the perception of excessive regulation. 

A56/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 This antigovernment sentiment still exists and continues to undermine the role of government in organizing a national health care system. This sentiment persists in spite of the fact that all other western democratic governments have successfully adopted such systems and have insured that all of their citizens have equitable access to health care. And yet, we do not use this sentiment against the government organizing our national defense! We entrust our government rather than individuals to act in the public good of society. In spite of many shortcomings, our national defense is one of the best in the world and protects all American citizens against external threats. In contrast, our aggregate health care indexes lag behind most western democracies. 

A57/Erwin W. Fellows, St. Petersburg Times, November 11, 1992, Pg. 19A HEADLINE: Fundamental changes in health care unlikely \\VT 93-94
	 And why will the United States not adopt the best available system? First, because Americans have become so suspicious of government that they don't want it involved in dealing with the problem. Second, because Americans have such a negative attitude toward the mere mention of taxes that any proposal involving taxes gets immediately rejected. Even if a tax-supported system of health insurance would result in lower total costs for health care than the present arrangement, people would still be against it. 

A58/Theodore M. Pappas, President, The McLaughlin Co., Legal Times, March 23, 1992, Pg. 22, HEADLINE: Looking For Lawyers' Angle In Health Care \\VT 93-94
	 And while there is also the opportunity to complain about whose ox is being gored, the effort of the HIAS to influence national health insurance will be nothing compared with the effort of the trial lawyers lobbying against national health insurance. 

A59/The Economist, February 8, 1992, Pg. 14 HEADLINE: The healthy option \\VT 93-94
	This is the dream of "managed care", where services are subscribed to in advance and provided by HMOs. It could be encouraged by steering all public subsidies, whether direct (eg, Medicare) or indirect (eg, the tax exemptions for health insurance), to managed care. Yet is is unlikely to work, for two related reasons. The first is that fee-for-service medicine, with its inbuilt incentive to raise costs, is so entrenched in American health care that it prevents HMOs from affecting costs, even though one in seven Americans is enrolled in them. The second is that since consumers are largely insulated from on-the-spot costs by public or private insurance, producer power will always prove too strong for fragmented purchasers, even when they are HMOs. American doctors earn an average of $ 150,000 a year, or six times average earnings; the ratio is three to one in Canada, two to one in Britain. What is missing in America is a powerful buyer, to counter the weight of providers. 

A60/The Economist, February 8, 1992, Pg. 14 HEADLINE: The healthy option \\VT 93-94
	Soon genetic research will allow them to identify individuals prone to cancer and other costly diseases. If insurers can exclude such people, the whole notion of insurance -- spreading big risks among the many, not concentrating them on the few -- could collapse. 

A61/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Co-payments: A fixed amount paid by an individual for a specific service (for example, $5 for an office visit). 

A62//PR NEWSWIRE, May 20, 1993, HEADLINE: COOPERS & LYBRAND: CURRENT TREND OF SHIFTING HEALTHCARE COSTS WILL ACCELERATE NEW YORK Transmitted: 93-05-20 14:27:00 EDT, Online America\\VT 93-94
	Employers will continue to utilize an increasing array of cost shifting approaches for healthcare benefits and related responsibilities to employees, and indicate they will significantly accelerate this process, according to the findings of a newly released study of 541 companies across the nation conducted by Coopers & Lybrand, the international accounting and benefits consulting firm. 

A63/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Coinsurance: The amount of money paid directly by a patient for health services. This is in addition to the amount paid by their health insurance. This term may or may not include co-payments. Coinsurance is often a percentage of the total bill. 

A64/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Cost Sharing: The money paid by a patient for health services covered under his or her insurance plan. It includes coinsurance, co-payments and deductibles. Cost sharing is a strategy used by insurance companies and employers to decrease premiums. It is also used in an attempt to provide incentives for people not to buy unneeded medical services. 

A65/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Deductible: The amount (usually fixed for any one year) that a patient pays a provider before an insurance plan kicks in. Higher deductibles increase the monetary risk to the individual but also lowers premiums. 

A66/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 Every day, Quentin Young sees patients who aren't as fortunate as Somer: their health is poor. An internist in a large group practice in downtown Chicago, Young says under- insurance is a growing problem for his patients. A decade or so ago, he said, doctors were more willing to provide "charity" care, or to cut their fees for patients who couldn't afford expensive tests. These days, according to Young, escalating costs and declining reimbursement by insurance companies are forcing doctors to first perform "a wallet biopsy" -- screening patients for insurance coverage and their ability to pay. 

A67/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 "There used to be all kinds of ways to get people care that they couldn't afford," said Young, who for 10 years was chief of the department of internal medicine at Chicago's Cook County Hospital. "Not anymore." 

A68/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 Increasingly, hospitals and clinics are asking for cash deposits from patients before tests or procedures are performed. 

A69/Howard Dean, MD, Governor, State of Vermont, Journal of the American Medical Association, October 16, 1991; 266: 2080 TITLE: Caring for the Uninsured and Underinsured \\VT 93-94
	 There are two major faults with many of these plans. The first is that a number of them rely on continuation of the Medicare program. Any practicing physician will tell you that the Medicare program is a disaster. It underreimburses the physicians, it undercompensates the insured patients, and its bureaucracy and interference with medical practice are demoralizing. 

A70/Andrew Bates, NEW REPUBLIC, 02/03/92, TITLE: Middle-class Medicaid, Online America, Transmitted: 92-11-26 01:30:00 EST \\VT 93-94
Because Medicare covers only the cost of short-term, acute care, paying for long-term care has always been a problem for the elderly. 

A71/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 * Faced with steeply rising Medicaid costs, various states have arbitrarily limited the number of physician visits, days of hospitalization, and number of prescriptions for which they provide reimbursement. In many states, reimbursement rates for physician visits and payment for hospital care have been set so low that a large segment of the provider community has avoided accepting Medicaid patients or has severely limited the number of Medicaid recipients treated. 

A72/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Virginia Chaffin, Ribi ImmunoChem Research Inc.: Health care should be a private matter between care provider and patient, without the influence of politics and special interest groups. Laws impacting quality of life versus length of life, definitions of privacy, malpractice litigation and a host of other issues all need to be evaluated. The chances of any present system adequately addressing all of these issues and the many others involved are extremely remote. 

A73/JAMES M. BURCKE, staffwriter, Business Insurance, March 26, 1993, Pg. 16, HEADLINE: Timetable for change; Expect Congress to pass significant reform by 1994 \\VT 93-94
	 These experts [panel of (health reform) experts] say it is unlikely that Congress will ever enact a single-payer national health insurance system like Canada's. Only 6% said that the United States will eventually adopt such a plan. 

A74/Janet O'Keefe, policy analyst at the American Psychological Association, The Recorder, June 2, 1992, Pg. 11, HEADLINE: Risk Factors In the Failure Of Health Care Reform \\VT 93-94
	 The result is that too few national leaders are willing to support the major components of reform that are essential if we are to make the current system work: universal enrollment; equitable financing; effective systemwide cost containment; extensive regulation of the insurance industry; and the establishment of a uniform, comprehensive benefits package. 

A75/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	Fuchs [Victor Fuchs, Stanford University economics professor] noted that American society has been ideologically committed to individual freedom and, at least in the abstract, to equality. ''Tension,'' he said, ''has always existed between these forces, with the emphasis on individual opportunity and achievement prevailing most of the time, but with the egalitarian emphasis much in evidence in the 1930s and 1960s. 

A76RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Together with the influence of the other values described previously, the sovereignty of the biomedical paradigm has inverted the structure of the NHCS. 

A77/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 This inverted hierarchy reflects how the values of the biomedical paradigm have been enshrined in our health care system. These values have had a pervasive influence over the direction of medical education, health care policy, and law. For example, New York State law regulates how a physician writes a do not resuscitate order. Thus, the law mandates standard treatment as patients exit the health care system but not as patients enter the system. The death-and-dying issues of secondary and-or tertiary care take precedence over the issue of access to health care at the primary care level. 

A78/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Actually, Canada provides an attractive model for American reform. Canada (like most industrial democracies) combines universal health insurance with clear political accountability for raising and spending money for health services, and for the quality of the care the money buys. 

A79/Molly Ivins, Fort Worth Star-Telegram writer, The Atlanta Journal and Constitution, August 8, 1992, Section A; Page 13, HEADLINE: Special interests rig health-care debate \\VT 93-94
	 But that doesn't mean victory is in view. Just for starters, those opposed to national health insurance are putting $ 10 million a year into trying to convince Americans that the Canadian system is no damn good. 

A80/Los Angeles Times, January 17, 1993, Part E; Page 6; HEADLINE: DOCTOR PRESCRIBES SOME BIG CHANGES FOR AMA \\VT 93-94
 None of this puts the AMA -- or Scalettar -- on the political left. It, and he, oppose government fee-setting. They oppose a firm government lid on health spending. They oppose a health system like Canada's, where government uses tax money rather than private insurance to pay for everyone's care. 

A81/Los Angeles Times, January 17, 1993, Part E; Page 6; HEADLINE: DOCTOR PRESCRIBES SOME BIG CHANGES FOR AMA \\VT 93-94
Still, the American Medical Political Action Committee, its campaign arm, spent nearly $5 million on 1992 races, the kind of money that opens legislators' doors. 

A82/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 DICK DAVIDSON (PRESIDENT, AMERICAN HOSPITAL ASSOCIATION): If you look at the current health care delivery system -- that's an oxymoron -- we really don't have a system. The way health care is organized in this country is fragmented; it's not connected; one piece doesn't fit with another. When people come to health care institutions, we provide excellent institutional care. But they aren't necessarily connected to a continuum of care, and we think that most Americans end up having to fend for themselves in the absence of a coordinated care system. 

A83/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	Although far from dead, the prospects for national health insurance in the United States in the short run are poor because of the distrust in government, diversity of the population, and the lack of ''noblesse oblige.'' This is the view of Victor R. Fuchs, a noted Stanford University economics professor and researcher at the National Bureau of Economic Research at Stanford. 

A84/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 "We have the [bargaining] mechanism. It's called HMOs," says Kenneth Abramowitz, a health care analyst at Sanford C. Bernstein & Co. Abramowitz admits, though, that it could take 50 years for a critical mass of employers to join enough HMOs. Even if tax inducements speed up the process, as President Bush and Abramowitz advocate, the company-by-company approach won't work as long as providers can compensate for discounts by saddling others with higher charges. The bottom line: The system today is so expensive, uncontrolled and loophole-ridden that tinkering around the edges isn't enough. 

A85/Janet O'Keefe, policy analyst at the American Psychological Association, The Recorder, June 2, 1992, Pg. 11, HEADLINE: Risk Factors In the Failure Of Health Care Reform \\VT 93-94
	 Clearly, in comparison, many of the current proposals to improve the U.S. system are woefully inadequate, and few of their proponents want to face just how far away many of them are from real reform. A major reason underlying this is the strong opposition of those with a financial stake in the current system -- physicians and hospitals, the insurance industry, and some employers (primarily small businesses not currently providing health insurance for their employees). Together these groups spend millions of dollars in political contributions and media campaigns to oppose attempts at comprehensive reform. 

A86/Tom Hamburger; Staff Writer, Star Tribune, August 30, 1992, Pg. 14A, HEADLINE: Debate on health care suffers from serious ailment: politics \\VT 93-94
	 The range of reform plans is also restricted in American politics because of the enormous influence of money. Advocacy of a plan that takes on the interests of doctors, hospitals and insurers would pit a politician against the country's best-funded lobbies. 

A87/Tom Hamburger; Staff Writer, Star Tribune, August 30, 1992, Pg. 14A, HEADLINE: Debate on health care suffers from serious ailment: politics \\VT 93-94
	 Sen. Paul Wellstone, D-Minn., blames those groups directly for the limited debate on Capitol Hill and on the presidential campaign trail. "These powerful interests are almost able to determine what sort of issues even get on the agenda. The health industry and the pharmaceutical industry, they have tremendous influence," he said.. 

A88/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	Writing in the Winter 1991 issue of Health Affairs, Fuchs [Victor Fuchs, Stanford University economics professor] said ''the forces actively opposed to national health insurance in the United States are strong, well organized, and have a clear sense of what they do not want. The forces actively in favor are relatively weak, disorganized and frequently at odds regarding the reasons for wanting national health insurance or the best way to obtain it.'' 

A89/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 While the entire Clinton plan suffers from the oil-and-water problem of two strategies that will not mix, there are many other flaws. Among them: * For a fixed national budget to mean anything, it must incorporate explicit rationing, which is inefficient and rejected by the vast majority of Americans by margins of nearly four to one. n3 Otherwise it is nothing more than a spending target and will succeed only if other cost controls work. Unfortunately for Clinton, America's experience with health care price controls and entitlement programs suggests the "national budget" will be meaningless. 

A90/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 * By not significantly reforming the tax treatment of health care, the Clinton proposal locks in many of the perverse incentives and inequities of the current tax code. 

A91/Tom Hamburger; Staff Writer, Star Tribune, August 30, 1992, Pg. 14A, HEADLINE: Debate on health care suffers from serious ailment: politics \\VT 93-94
	 Ever since, national health insurance has been tagged by many as an alien idea - and one that could undermine any politician who advocated it. While Canada and Western Europe found ways to improve the delivery of health care, the United States remained stuck. Today, even as public anger roils over the cost and administration of health care, the debate is still truncated. 

A92/Capital District Business Review, January 4, 1993, Sec 1; pg 20, HEADLINE: This year gets health care off the back burner with a start of national health insurance reform \\VT 93-94
 Frank Walker, the AMA representative who visited the Capital Region in November, said he expects it will take up to five years for Congress to complete a national health plan. Others say that Congress probably will phase in health care reforms that will increase access to health care. 

A93/Business Insurance, January 18, 1993 Pg. 8, HEADLINE: Ending an unhealthy silence \\VT 93-94
 Despite such enormous stakes, employers have not been in the forefront of the reform debate. Typically, business groups have spoken in generalities about keeping health care plans voluntary. Or, they have supported non-controversial reforms, like federal pre-emption of state anti-managed care laws or increased electronic claims processing. That employer silence has come to an end. 

A94/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 The third group, a small but growing one, is that of the medically uninsurable. About 1 million people are unable to obtain insurance because of preexisting conditions. With the number of cases of the acquired immunodeficiency syndrome and those individuals who are positive for the human immunodeficiency virus increasing, private insurers are becoming more selective about whom they are willing to insure. A strategy that some states have established is an insurance pool through which insurance can be purchased at a subsidized rate. States are funding this program by requiring carriers writing insurance in their states to participate in the pool. [n12] 

A95/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 Both advocates and industry officials agree that the growing practice of excluding treatment of pre-existing conditions -- ranging in severity from acne to AIDS -- is swelling the ranks of the underinsured. One in three Americans, an estimated 81 million people, has at least one pre-existing condition, according to a 1991 Citizens Fund report based on data from a 1989 federal survey. 

A96/Health Line, July 23, 1992, HEADLINE: OPINION WRAP-UP: MORE COMMENTS, CRITICISMS ON HEALTH REFORM , Nexis \\VT 93-94
	 ST. PETERSBURG TIMES editorial notes that a Senate subcmte has found that as many as 20 of Blue Cross-Blue Shield's 73 plans across the country "are in financial distress" (see AMERICAN HEALTH LINE 7-20). TIMES: "Across the United States, the implications of insolvency are frightening. ... When Blue Cross and Blue Shield, which is the insurer of last resort, begins losing its grip, how much longer can this nation wait? How much longer can we allow health care to be strangled by a piecemeal network of non-profit and for-profit insurance companies?" (7-22). 

A97/Janet O'Keefe, policy analyst at the American Psychological Association, The Recorder, June 2, 1992, Pg. 11, HEADLINE: Risk Factors In the Failure Of Health Care Reform \\VT 93-94
	 A recent analysis by Citizen's Fund, a consumer advocacy organization, estimates that more than one in three Americans under age 65 -- more than 81 million people -- have a chronic condition serious enough that they could be subjected to denial or preexisting-condition exclusions. Any meaningful health care financing reform must address the problems of the uninsured and the underinsured, and must include effective cost-containment strategies for the system as a whole. 

A98/Health Line , November 17, 1992 , HEADLINE: AIDS AND INSURANCE: REAX CALL FOR NATIONAL HEALTH REFORM , Nexis \\VT 93-94
	 N.Y. DAILY NEWS: "True national health care reform would make the issue moot. John McGann's case makes another poignant plea for swift action" (11-12). JOURNAL OF COMMERCE: "The high cost of insurance and the volatility of group plans ... points up the failures of the health insurance system. Untangling the mess, though, is a job for lawmakers, not the high court" (11-12). 

A99/Health Line , November 17, 1992 , HEADLINE: RETIREE BENEFITS: EASY TARGET FOR COST-CONSCIOUS EMPLOYERS , Nexis \\VT 93-94
	 FACTS & FIGURES: An A. Foster Higgins survey of 2,409 employers nationwide found the number of employers offering health plans for retirees under age 65 dropped from 60% in '90 to 56% in '91. For retirees age 65 and over, the number dropped from 54% in '90 to 49% in '91 (see AHL, 8-18). The average cost of a retiree health plan increased to $2,486-retiree in '91 -- a 9.3% increase from '90. The average retirement age is 64 for companies not offering health benefits to employees under age 65, compared to age 62 among those providing coverage. 

A100/Health Line , November 17, 1992 , HEADLINE: RETIREE BENEFITS: EASY TARGET FOR COST-CONSCIOUS EMPLOYERS , Nexis \\VT 93-94
	 REAX: A. Foster Higgins' Pat Wilson on FAS No. 106: "This is the most difficult problem I've had to deal with in 20 years of consulting" (Cameron, 11-92 issue). BUS. WEEK: "Lots of ... corporations are axing or curtailing benefits hoping to minimize the financial broadside of the so-called 106 rule, as well as curb runaway costs in general. ... Certainly, retirees are the easiest target: They can't strike or quit for another job." AARP's Clare Hushbeck: "Employers are backpedalling like crazy from their commitments to workers." BUS. WEEK: "Saving the day, of course, would be some form of national health insurance to bridge the gaps left by Medicare" (Light-Kelley, 11-23 issue). 

A101Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Although many view this as "free care," the burden imposed on the working poor by the loss of a day's wages makes this anything but free. In addition, the long waits cause approximately one of every nine of these nonscheduled patients to leave prior to receiving care. These patients often return later in a more advanced stage of their illness, necessitating more intensive (and expensive) treatment, or hospitalization. Public hospitals across our nation serve a similar "safety net" function, straining their already limited resources. 

A102/Daniel Sisto, president of the Hospital Association of New York State, Newsday, February 27, 1992, Pg. 22 HEADLINE: Getting Our Health Care in Order; It's time to cut costs, not services or reimbursement for them. \\VT 93-94
	 There are other symptoms: overcrowded emergency rooms that divert ambulances to other overcrowded emergency rooms; burgeoning caseloads of AIDS, tuberculosis, measles, syphilis and the flu; an average of four hospital closures a year statewide. (Since 1982, three hospitals in Nassau and Suffolk and four in Queens have closed.) 

A103/Daniel Sisto, president of the Hospital Association of New York State, Newsday, February 27, 1992, Pg. 22 HEADLINE: Getting Our Health Care in Order; It's time to cut costs, not services or reimbursement for them. \\VT 93-94
	 So far, health-care institutions have done all they can to avoid eliminating services or cutting wards or closing completely by freezing wages, putting capital improvements on hold and, in the case of Brunswick and a hospital in northern New York, filing for bankruptcy protection. But ultimately, patient services are being, or will be, cut. 

A104/National Public Radio, SHOW: ALL THINGS CONSIDERED, March 26, 1992, HEADLINE: INFANT MORTALITY REMAINS HIGH IN USA, Nexis \\VT 93-94
	 Grad (Director, National Commission to Prevent Infant Mortality): So you have women who are eligible for Medicaid who never were in years past, but they can't get access to doctors who accept Medicaid or the clinics that accept Medicaid are very, very crowded and you have to wait hours to get an appointment or weeks to be seen. So financial access is only one piece of the pie. 

A105/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 The Clinton proposal undoubtedly served the purposes of an election campaign, for it contained elements from the major competing plans espoused by different factions of the Democratic coalition. But that is the central flaw in the proposal. It would mean a national health care system combining two contradictory strategies -- central planning with price controls, and consumer choice with competition. Rather than combining the best of each strategy, it would in reality mean the worst of each. If enacted, it is destined to collapse in chaos as competing health care providers seek to evade price controls and shift their costs to less regulated sectors, government bureaucracies expand to try to stop evasion, and consumers grumble at the red tape and rationing while exploiting every loophole in the regulations. 

A106/USA TODAY, May 13, 1992, Pg. 1A HEADLINE: Health care faces 'meltdown' over costs \\VT 93-94
	 A year ago, in the first Journal issue devoted to health-care reform, Lundberg said the problem of nearly 40 million people in the USA lacking health insurance is rooted mainly in racial prejudice. ''I re-assert that view today,'' he said at a news conference. 

A107/SAMIR N. BANOOB, professor of health policy at the University of South Florida's College of Public Health, St. Petersburg Times, February 7, 1993, Pg. 4D, HEADLINE: Health care: Painful remedies are needed \\VT 93-94
 The budget deficit, the recession, a weak economy and unemployment, to name a few. Among the problems, the health care crisis is the worst by far. 

A108/The Washington Times, May 18, 1992, Pg. A3 HEADLINE: 'Meltdown' looms in U.S. health care \\VT 93-94
	 Although many experts have described the nation's health care system as being in a state of crisis, Dr. Lundberg [Dr. George D. Lundberg, editor-in-chief of scientific publications for the American Medical Association] is one of the first to estimate how long it might last without major treatment - or to speculate on what might happen when the collapse comes. "In a worst-case scenario, the Congress would panic and nationalize the entire health care industry; they can do that," he writes in a JAMA editorial, adding: "The physicians, nurses, pharmacists and other health care workers would be conscripted as government employees; hospitals would be taken over and run by the government; health insurance companies would be abolished; the pharmaceutical and medical device industries would be nationalized." 

A109/USA TODAY, May 13, 1992, Pg. 1A HEADLINE: Health care faces 'meltdown' over costs \\VT 93-94
	 The U.S. health-care system faces ''meltdown'' in several years if costs continue exploding, medicine's sharpest in-house critic said Tuesday. Annual spending on health care is doubling every five years and could hit $ 1.4 trillion by 1996, ''which is impossible to tolerate economically,'' said Dr. George Lundberg, editor of The Journal of the American Medical Association. 

A110/USA TODAY, May 13, 1992, Pg. 1A HEADLINE: Health care faces 'meltdown' over costs \\VT 93-94
	 The consequence of that, he [Dr. George D. Lundberg, editor-in-chief of scientific publications for the American Medical Association] said, could be a Congress so panicked that it federalizes all health care. Health workers would be ''conscripted as government employees.'' 

A111/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 24, 1993, Part A; Page 14; HEADLINE: DEBATE FLARES ON WHO'S FIRST IN HEALTH PLAN\\VT 93-94
	 The reform bandwagon got an added boost Tuesday when an Institute of Medicine expert panel warned that the nation's employer-based health insurance system could soon "self-destruct without a major overhaul." The panel's chairman, Princeton President Harold T. Shapiro, added: "Some system of mandatory or compulsory coverage is required." 

A112/B. D. Colen, medical writer,Newsday, October 27, 1992, Pg. 61, HEADLINE: Health Care Reform's Price \\VT 93-94
	 Change is never easy. But by now it should be obvious to all that if our health care system is to survive in anything close to the form we now know it, radical change is desperately needed. 

A113/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 "We need to reform the health insurance market from the ground up . . . so it functions in the interests of the American people," said Tresnowski [Bernard R. Tresnowski, president of the Blue Cross and Blue Shield Association], who warned that the alternative is "medical meltdown." 

A114/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 The nation's health care system is headed for financial "meltdown" without a major overhaul, according to speakers at an Oct. 28 symposium. 

A115/The Washington Times, May 18, 1992, Pg. A3 HEADLINE: 'Meltdown' looms in U.S. health care \\VT 93-94
	 A "meltdown" of the nation's health care system and its replacement by full nationalization could occur by 1996 if costs continue out of control, a prominent medical editor predicts. Dr. George D. Lundberg, editor-in-chief of scientific publications for the American Medical Association, makes the forecast in this week's issue of the Journal of the American Medical Association. He bases it on data showing that the nation's annual health care expenses are doubling in less than five years. "We are looking at potential health care expenditures in 1992 dollars of $1.4 trillion in 1996," Dr. Lundberg wrote. "I do not believe our economy can tolerate these costs. If business continues as usual, without major change, I predict meltdown by 1996." 

A116/USA TODAY, May 13, 1992, Pg. 1A HEADLINE: Health care faces 'meltdown' over costs \\VT 93-94
	 But ''the crisis is in costs. If business continues as usual ... I predict meltdown by 1996.'' [Dr. George D. Lundberg, editor-in-chief of scientific publications for the American Medical Association] 
A117/Drug Topics, June 22, 1992, Pg. 64, HEADLINE: Our ailing health-care system, part 1 \\VT 93-94
	 But then, consider the views of George D. Lundberg, M.D., the American Medical Association's chief science editor. "If business continues as usual without major changes, I predict meltdown by 1996," Lundberg wrote last month in The Journal of the American Medical Association. Health-care costs, which now are doubling every five years, could hit an economy-toppling $ 1.4 trillion by 1996. 

A118/Paul W. Newacheck, DrPH, Lori N. Wicks, JD, Institute for Health Policy Studies, University of California School of Medicine, AMERICAN JOURNAL OF DISEASES OF CHILDREN, NOVEMBER, 1992; 146: 1376-1380 TITLE: How Will Children and Pregnant Women Fare Under Current National Health Insurance Proposals? \\VT 93-94
	 Today, some 12 million children and 9 million women of childbearing age have no health insurance protection. Millions more lack adequate coverage for basic health services, including prenatal care during pregnancy and routine supervisory care during childhood. 

A119/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 For example, look first at the problem of the uninsured and underinsured. Estimates of the number of uninsured range as high as 40 million, more than 15% of our population; and this number does not take into account those with inadequate insurance. In 1982, companies employing 100 or more people had 75% of them fully covered by health insurance; in 1989, it was only 48%. In the same period, the percentage of employees with family coverage fell from 50% to 31%. In addition, companies allowed the number of part-time employees to increase (to 55% in the case of Sears Roebuck) to avoid paying benefits, including health care. Finally, retirees are now seeing their health benefits challenged (Detroit Free Press. November 10, 1991). 

A120/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 This new urgency may reflect the fact that not only are a large and growing minority of Americans -- well over 30 million people -- without health insurance protection, but the majority now also see the system they count on in jeopardy. 

A121/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 Unfortunately, a large piece of the puzzle is missing, and this fact has drawn the attention of all those involved in health care planning. It is estimated there are 35 million Americans under 65 years of age who are uninsured. [n10] This largely medically indigent population is very much a heterogeneous population of Americans. About one third of this group are children under the age of 18 years. Of the 24 million uninsured adults, about two thirds, or 15 million, are in the labor force. The ratio of males to females is 1:1; however, nonwhites are 50% more likely to be uninsured than are whites. Uninsured Americans also tend to be less educated and to live in more rural areas. And regionally, the western and southern parts of the United States have about a 50% higher proportion of uninsured persons than do the north central and northeast. [n11] 

A122/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 The uninsured can be classified into three general groups: the employed uninsured, the nonworking uninsured, and the medically uninsurable. The first group, numbering 15 million, are the employed uninsured who work for at least some part of the year. When their dependents are taken into account, this group accounts for 70% of the uninsured population. The second group, the nonworking uninsured, represent about 9 million Americans. This group includes the homeless, some of the deinstitutionalized mentally ill patients, and people who are poor but do not qualify for Medicaid because they are not categorically eligible or their income is above the cutoff level for their state. The size of this group is highly dependent on the economy and the unemployment rate. 

A123/Jerry Geisel, staffwriter, Business Insurance, December 28, 1992, Pg. 15, HEADLINE: The crisis of the uninsured spotlights health system ills; Partisan battles, special interests are obstacles to consensus \\VT 93-94
	 The problem is enormous: 36 million people in the United States do not have  health insurance. 

A124/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University): In 1991, 35.4 million Americans had not health insurance whatsoever. This number, which represents about 14.1 percent of the population, in fact, in  fact masks a more dramatic deterioration in the health coverage  of Americans. 

A125/Dolores Kong, Globe Staff, The Boston Globe, July 24, 1992, Pg. 21, HEADLINE: Survey: Cost top health problem \\VT 93-94
	 The Census Bureau estimated last month that 32.1 million people, or 13 percent of the population, are uninsured at any one time. 

A126/Mary Holle Freeland, free-lance writer, Los Angeles Times, August 2, 1992, Part M; Page 3; Column 1; HEADLINE: PERSONAL PERSPECTIVE; AFTER WE HAD LOST EVERYTHING, WE QUALIFIED FOR HELP \\VT 93-94
	 Today, health insurance is a must in my household. However, approximately 37 million Americans are uninsured. A large portion are middle class who, like my mother, probably think they will be taken care of miraculously. They won't be. A national health-insurance plan would give the middle class a chance to control their destiny. Illness is never planned. Insurance can be. 

A127/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 24, 1993, Part A; Page 14; HEADLINE: DEBATE FLARES ON WHO'S FIRST IN HEALTH PLAN\\VT 93-94
	 Of the estimated 37 million uninsured Americans, 62% are full-time workers and their dependents, according to Ed Howard, executive director of the Alliance for Health Reform, a Washington-based nonprofit educational organization. 

A128/Robert Reno , Newsday, November 1, 1992, Pg. 101, HEADLINE: It's Health Care That's Making Us Very Sick \\VT 93-94
	 The Employee Benefit Research Institute reported last week that 36.3 million non-elderly Americans were medically uninsured, up from 33.6 million in 1988. The non-profit institute drew its figures from the Census Bureau's 1992 Current Population Survey. 

A129/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Medical costs are rising rapidly, and millions of people have no health care coverage. The nation urgently needs a universal insurance program 

A130/SHERRY JACOBSON; Gannett News Service, March 20, 1992, HEADLINE: POLL:1 IN 3 KNOWS SOMEONE BANKRUPT OVER MEDICAL BILLS, Nexis \\VT 93-94
	 The government has estimated that 37 million Americans have no health insurance coverage and as many as 60 million have inadequate coverage. 

A131/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 The Census Bureau has estimated that in 1991, 14 percent (35 million) Americans were uninsured for the entire year. The Congressional Budget Office (CBO) has estimated that there will be over 37 million uninsured by the year 2000. In addition, the CBO has estimated that about 62 million people were without insurance for at least one month during 1991. 

A132/Los Angeles Times March 25, 1991, Part B; Page 5; HEADLINE: PLATFORM; A NATIONAL SHAME \\VT-MDS 
 This nation spends more money for health care than any other country -- 11.6 % of our gross national product, or more than $600 billion per year -- yet our barriers to access have become a national disgrace. 

A133/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 Increasingly, however, underinsurance is becoming a problem for those in large groups. Employers, stung by health care costs that are rising much faster than wages or inflation, are transferring the financial burden to workers. 

A134/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 "Companies are not doing away with insurance entirely, but what they are doing is shifting more and more costs to their employees," said Waxman, who served on the staff of the Pepper Commission. 

A135/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 Most Americans get insurance protection through the workplace. However, job-based coverage has become insecure, even for those who are currently well insured. [n2,n3] The reasons for insecurity differ for workers in small and large businesses. In small businesses, the threat to coverage comes from what can legitimately be described as the disintegration of the small group insurance market. 

A136/BNA PENSIONS & BENEFITS DAILY, Feb. 21, 1992, COUNTRIES WITH NATIONAL HEALTH INSURANCE HAD HIGHER PER CAPITA INCREASES OVER TIME Nexis \\VT 93-94
	 Two-thirds of the uninsured are in families of full-year, steadily employed workers, most of whom were employed full time...

A137/Jacqueline Frank, The Reuter Library Report, January 31, 1992, HEADLINE: U.S. AWED BY MEDICAL ADVANCES, LOST SIGHT OF COSTS, Nexis \\VT 93-94
	Small businesses are having trouble buying health insurance for employees. It is either too expensive, or the industry and workers are seen as a "bad risk" or employees have preexisting conditions that make them ineligible for coverage. The self-employed can rarely afford anything but coverage against catastrophic illness. 

A138/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] So that amongst the people who are actually insured are--as has been estimated recently in the New England Journal of Medicine, 50 to 60 million people under-insured. This man is  grossly under-insured to the point where he is terrified of the  idea of getting sick. What do we do about this? 

A139/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 The number of people with some insurance but with inadequate coverage for a significant illness or accident is also high. Lewin-ICF (a health-care consulting firm) has estimated that there are currently 15 million underinsured. The firm also predicts that this figure will grow to over 21 million by the year 2000. 

A140/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 In effect, our society discriminates against providing health care to the uninsured and underinsured poor. Discriminatory health care practices arise from both economic and organizational barriers. The uninsured and underinsured poor must overcome these barriers to obtain medical care. 

A141/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 While the options for care in rural America are diminishing for many, barriers to service for the poor have always been severe (particularly for the poor of color). Without a rural equivalent of public safety net hospitals and their house-staff providers, even those minority patients with Medicaid coverage often cannot find a private physician to provide their care. Recently, in Denton County, Texas (a wealthy county with 33 obstetrician-gynecologists), a patient who had Medicaid coverage was unable to find a physician willing to accept her for pregnancy care (Klein D. "Children at Risk." New York, NY: Public Television, WNET; aired on PBS, November 1, 1991). 

A142/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Our health care system has been very successful in providing the most technologically advanced medical care in the world to affluent and well-insured segments of society. Pride in this accomplishment has contributed to a success-induced blind spot. Our society overlooks and fails to adequately respond to the most significant shortcomings of our health care system, namely, social inequality in access to health care and escalating health care costs. [n1-n6] 

A143/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The economic barrier is the inability of patients to pay for needed medical care. This barrier has many consequences for patients and their families, which include the following: patients' inability to pay for medications, office visits, procedures, and hospitalizations; patient delays in seeking health care; the psychological effects on the family arising from these delays in seeking health care; and burdening families with severe financial problems when they do seek health care. 

A144/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University)] Lack of health insurance, which has long been a  problem for poor Americans is increasingly a problem with the middle class. 

A145/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 To the public, the health care crisis lies partly in the problem of affordability. But the core of the crisis is insecurity. People are afraid of losing their insurance coverage. It was no coincidence that health care emerged as a major issue during the current recession. When Americans, particularly white-collar Americans, are concerned about losing their jobs, they also become anxious about losing their health insurance. Middle-class Americans are terrified that health problems will drive them into poverty. That's why Americans support radical solutions, including national health insurance. In a 1992 survey by the Employee Benefit Research Institute (EBRI), for example, two-thirds supported a Canadian-style government-run system. Maybe that's socialized medicine, but it will give Americans what they want: a guarantee of basic health insurance for everyone, regardless of employment status or previous medical conditions. 

A146/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 15, 1991; 265: 2563 TITLE: Caring for the Uninsured; Choices for Reform \\VT 93-94
	 Government reports show a 24% increase in the last decade in the total number of uninsured people and a 40% increase in the number of uninsured children. [n14] Most uninsured children are part of a family with a working adult. (2) Recent studies have found that, despite considerable amounts of uncompensated care provided by hospitals and physicians, Americans without health insurance face major barriers to the receipt of needed health services. Although they suffer from higher rates of ill health than the insured population, the uninsured report fewer hospitalizations and fewer visits to a physician, shorter hospital stays, and fewer discretionary inpatient hospital treatments and tests, at higher cost. The uninsured also experience higher mortality rates when hospitalized than persons with health insurance coverage who have similar medical diagnoses. [n5-n11] (3) 

A147/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University)] Since 1980, the proportion of Americans who have any private insurance coverage has fallen dramatically. In 1980, 80 percent--83 percent of the population had private health insurance coverage, and by 1991, only 70 percent of the U.S.  population had any private health insurance. There was an absolute fall of more than 11 million  people; more than 11 million people lost private health insurance during the last decade, despite an increase in the  population of more than 21 million. 

A148/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 If they are privately insured, they surely realize that their families' coverage would be lost with the particular job to which that coverage is tied. If the family's breadwinner loses that job -- increasingly probable in our dynamic, recession-prone economy....

A149/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Financial and nonfinancial barriers to health care have been built into and reinforced in America's metropolitan areas. Long ago, medicine abandoned urban neighborhoods and completed a process of involution. Primary care and other medical services were pulled from the community, and coalesced at inaccessible "medical centers." These barriers have created and propagated growing segments of our populace that can be aptly described as Les Miserables -- people constantly searching for ways to get over, around, or through these very real barriers. 

A150/United Press International, May 19, 1993, HEADLINE: PUBLIC CITIZEN CLAIMS PATIENT DUMPING REMAINS WIDESPREAD WASHINGTON Transmitted: 93-05-19 19:46:00 EDT, Online America \\VT 93-94
	A public-interest group Wednesday accused hospitals of continuing to "dump" indigent patients even though a 1986 law makes doing so illegal. "The problem of 'patient dumping' will not go away so long as 37 million people remain uninsured and health care decisions are largely driven by concerns about who pays the bill," said Dr. Sidney Wolfe, director of the Public Citizen Health Research Group. Hospitals sometimes allegedly "dump" indigent patients by transferring them to other facilities - often to metropolitan-area hospitals that already have large numbers of poor patients anyway. 

A151/Pension Reporter, March 8, 1993, Pg. 548, TITLE: SPATE OF COVERAGE TERMINATIONS UNDERSCORES NEED FOR NATIONAL REFORM. \\VT 93-94
	 A spate of companies canceling retiree health coverage after years of offering "lifetime" benefits underscores the need for national health care reform, panelists agreed March 2 before a joint Senate subcommittee hearing. 

A152/Pension Reporter, March 8, 1993, Pg. 548, TITLE: SPATE OF COVERAGE TERMINATIONS UNDERSCORES NEED FOR NATIONAL REFORM. \\VT 93-94
	 "The high cost of retiree health benefits is having a devastating impact on retirees and businesses," Sen. Donald Riegle (D-Mich), chairman of the Senate Finance Subcommittee on Health for Families and the Uninsured, said in his opening statement before the joint meeting of his subcommittee and the Senate Labor and Human Resources Subcommittee on Labor. As the rising cost of health care has forced many companies to cut or eliminate health care coverage for retirees, many retirees are joining the ranks of the uninsured, Riegle said. 

A153/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Despite considerable amounts of uncompensated care provided by hospitals and physicians, Americans without health insurance face major barriers to the receipt of needed health services. Although they suffer from higher rates of ill health than the insured population, the uninsured report fewer hospitalizations and fewer visits to a physician, shorter hospital stays, and fewer discretionary inpatient hospital treatments and tests, at higher cost. The uninsured also experience higher mortality rates when hospitalized than persons with health insurance coverage who have similar medical diagnoses. [n13] 

A154/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  WOOLHANDLER [DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University)]: The actual numbers are that uninsured  people get about two-thirds as much care as people with insurance, and who would have comparable age and health status. Data from the national medical expenditure survey shows that at least 6.5 million Americans are turned away from care that they need every year, including more than half a million people are turned away from emergency care.  

A155/Mike Fairley, staffwriter, Black Enterprise, May, 1992, Pg. 20, HEADLINE: HEALTH DEBATE RAGES ON \\VT 93-94
	 Robinson [LeRoy Robinson Jr., executive director of the Minority Health Association] says no price is too high to pay because of the approximately 60,000 unnecessary deaths each year due to the lack of health care in this country. "It has to be the will of the people and the leadership of this country to do something about not only the cost, but the delivery, access and availability of health care." 

A156/Joe Murray, columnist, The Atlanta Journal and Constitution, February 5, 1992 EDITORIAL; Section A; Page 8 HEADLINE: We'd save on insurance if we just died quietly \\VT 93-94
	A lot of talk about national health insurance. Something's needed soon. If not national health insurance, there's a lot of us who are going to need national burial insurance. 

A157/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	FRED BARNES [TIME MAGAZINE]: I think we're all agreed that there is a health insurance problem with 35 million Americans who don't have health insurance, but is there really a health care crisis? In other words, these people who don't have insurance still get health care, they just don't get as much. They get about two-thirds of the health care that people with insurance have. 
	Dr. HIMMELSTEIN [Dr. DAVID HIMMELSTEIN, Harvard Medical School] : And a lot of them die because of it and not only that but there are a lot of people with insurance who can't get the care they need as well. Four million Americans each year can't get the care they need, are turned away and three million of them have insurance but can't pay. 

A158/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] Recent studies have shown that to be uninsured is to risk hospitalizations for avoidable problems such as pneumonia and asthma, and other problems, and ultimately to wind up  spending more, having the system spend more on you than if you got primary care outside the hospital. 

A159/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 A number of other parallels between the health care systems of South Africa and metropolitan areas in the United States are evident. These regions share strikingly high rates of black infant mortality, and a greater prevalence of diseases such as tuberculosis, pneumonia, and measles. These diseases have been all but eliminated among South Africa's white minority population through improved education, nutrition, sanitation, and immunization programs. Similarly, US blacks die at much higher rates than whites from preventable diseases. Blacks and Hispanics suffer disproportionately higher complications from diabetes and hypertension, and African-American men in Harlem have a shorter life span than men in many impoverished Third World nations. [n7-n9] 

A160/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Measles is yet another preventable disease that takes a heavy toll on the impoverished of both nations. Nonwhite children in South Africa continue to experience significant morbidity and mortality from this disease, while it has been largely eliminated among the white minority. [n21,n22] Poverty-related factors such as overcrowding, poor sanitation, and malnutrition are clearly related to the spread of this disease, but the failure to ensure immunization of infants and children is the primary reason for the persistence of this scourge. Along with Los Angeles, Calif, Dallas will long be remembered in our nation's conscience as the center of America's 1990 measles epidemic. Although the disease occurred primarily in ethnic minorities and the poor, the entire Dallas community was affected. The financial costs of more than 2500 cases of measles and the tragedy of young lives lost to this totally preventable disease will haunt us for years to come. The failure to provide a $3 immunization in some cases resulted in thousands of dollars in hospital expenses, while 12 young people paid the ultimate price -- death. 

A161/Daily Report For Executives, November 10, 1992, 1992 DER 218 d9 HEADLINE: Health Care, SOCIAL, TECHNOLOGICAL FACTORS DRIVING HEALTH CARE CRISIS, APHA SAYS Nexis \\VT 93-94
	 Poor Health Rankings Cited Despite possessing the best health care system in the world, the United States fares worse than many other developed countries on many health indicators, APHA said. [American Public Health Association] The nation ranks 19th in infant mortality; 28th in the rate of infants born at low birth weight; eighth in the percentage of children vaccinated against polio; 15th in the rate of maternal mortality; and ninth in life expectancy, according to the report. These rankings hold despite the fact that the nation has the highest hospital bills, the most advanced medical technology, the most refined prescription drugs, and the largest ratio of doctors to the population, the report said. 

A162/Pension Reporter, November 16, 1992 ,Vol. 19, No. 45; Pg. 2058 TITLE: LACK OF PUBLIC CONSENSUS COULD SLOW NEW ADMINISTRATION'S REFORM EFFORTS. \\VT 93-94
	 Despite possessing the best health care system in the world, the United States fares worse than many other developed countries on many health indicators, APHA [American Public Health Association] said. The United States ranks 19th in infant mortality; 28th in the rate of infants born at low birth weight; eighth in the percentage of children vaccinated against polio; 15th in the rate of maternal mortality; and ninth in life expectancy, according to the report. These rankings hold despite the fact that the United States has the highest hospital bills, the most advanced medical technology, the most refined prescription drugs, and the largest ratio of doctors to the population, the report said. 

A163/Los Angeles Times, March 27, 1993, Part A; Page 4; HEADLINE: CURRENT HEALTH SYSTEM 'KILLING OUR CHILDREN,' HHS CHIEF SAYS \\VT 93-94
	 Using some of the starkest language yet by any member of the Clinton Administration, Health and Human Services Secretary Donna E. Shalala said Friday that the nation's health care system must be revamped because it is not only "destroying" the economy but also "killing our children." "We actually don't have a choice (but to enact comprehensive reform)," Shalala said after sitting through a day of public hearings on the shortcomings of the current system, which consumes $800 billion a year but fails to provide adequate medical coverage for millions of Americans. 

A164/Los Angeles Times, March 27, 1993, Part A; Page 4; HEADLINE: CURRENT HEALTH SYSTEM 'KILLING OUR CHILDREN,' HHS CHIEF SAYS \\VT 93-94
	 Asked later to elaborate, she [Health and Human Services Secretary Donna E. Shalala ] said she had in mind the high infant mortality rate in the United States, which is widely blamed on a lack of prenatal care for pregnant women and newborns. "When we talk about prevention, we're talking very much about the way people start off in life," Shalala said. "So it's not just the economy. It's not just the impact of whether we're going to have jobs in this country," she continued. "From our point of view, it has a great deal to do with the kind of society we are, how we define ourselves and whether we care very much about how people grow up in this country." 

A165/National Public Radio, SHOW: ALL THINGS CONSIDERED, March 26, 1992, HEADLINE: INFANT MORTALITY REMAINS HIGH IN USA, Nexis \\VT 93-94
	 Linda Wertheimer, host: A report released today by the National Commission to Prevent Infant Mortality says that in its most recent study, conducted in 1989, the infant mortality rate in the United States dropped--the first improvement in a decade. But as NPR's Patricia Neighmond reports, the commission is not optimistic about future improvements. 

A166/National Public Radio, SHOW: ALL THINGS CONSIDERED, March 26, 1992, HEADLINE: INFANT MORTALITY REMAINS HIGH IN USA, Nexis \\VT 93-94
	 Patricia Neighmond reporting: Even though the infant mortality rate in this country is improving, the number of babies born extremely premature and at great risk of dying is on the rise, says Rae Grad, who directs the National Commission to Prevent Infant Mortality. In fact, Grad says the number of low birth-weight babies is at its highest level in over a decade. 

A167/National Public Radio, SHOW: ALL THINGS CONSIDERED, March 26, 1992, HEADLINE: INFANT MORTALITY REMAINS HIGH IN USA, Nexis \\VT 93-94
	 Rae Grad (Director, National Commission to Prevent Infant Mortality): The good news is the numbers are down; the bad news is the trends are still getting worse in infant mortality, which says to us that the reason the numbers are going down is through technology and better intervention rather than improved prevention. 

A168/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 Dr. DEBORAH DAVIS, Ottawa General Hospital: I think that all babies deserve - or all people deserve - equal access to care. And from what I saw in the States, that was not always the case. I felt it was cruel and unfair. 

A169/SHEILA RADFORD, The New York Times, June 11, 1992, Section A; Page 22; HEADLINE: Every Canadian Can Get Quality Health Care; They Put Us to Shame \\VT 93-94
	 Canada's national health insurance system may not be a medical model as you state (editorial, May 26), but it is so superior to what we have here that it is embarrassing. The United States has the highest infant-mortality rate of any Western nation, and that alone should shame the richest nation in the world. It also has one of the highest proportions of Caesarean-section births in the Western world. 

A170/Editorial by the St. Louis Post-Dispatch, in Chicago Tribune, February 16, 1992, Pg. 3; HEADLINE: Saving the babies \\VT 93-94
	 The latest figures on U.S. infant mortality show that this nation's rate has declined slightly. But there still is plenty of cause for alarm. Babies born to poor women continue to have less than a fighting chance of surviving their first year of life. 

A171/Editorial by the St. Louis Post-Dispatch, in Chicago Tribune, February 16, 1992, Pg. 3; HEADLINE: Saving the babies \\VT 93-94
	 In 1989, the latest year for which data are available, the Centers for Disease Control reported that for every 1,000 live births in the United States, 9.8 babies died by the age of 1, down from a rate of 10 in 1988. For black infants, the rate was 18.6. 

A172/Editorial by the St. Louis Post-Dispatch, in Chicago Tribune, February 16, 1992, Pg. 3; HEADLINE: Saving the babies \\VT 93-94
	 Conventional wisdom holds that minorities distort the U.S. infant-death rate. But even when minorities are excluded, this nation stacks up poorly against many other industrial nations. The infant mortality rate in Japan, for instance, stands at 5 and continues to decline. The rate among U.S. whites still hadn't dropped that low by 1989; it stood at 8.1. 

A173/THOMAS CLAVIN, The New York Times, February 9, 1992, Section 12LI; Page 12; HEADLINE: The Impact of No Health Insurance \\VT 93-94
	"Most definitely, there is a negative impact on the children," Mrs. Nixon said. [president of the P.T.A., Emily Nixon] "Without insurance, it's hard enough to keep up with the routine needs of a well child. But what if she gets sick? "Even a simple cold can develop into a full-blown chest illness. That child misses valuable school time, feels miserable and passes it on to her friends and family. Once a chain reaction starts, you just hope it doesn't get too bad." 

A174/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Infant mortality has been viewed as a sensitive indicator of the health status of a population, reflecting adequacy of medical care and social systems. Adverse social circumstances have been strongly associated with increased levels of infant mortality. [n11] Despite its position as one of the world's wealthiest nations, the infant mortality rate in the United States remains distressingly high compared with that of other industrialized nations. The US rate of 10 infants lost for each 100 000 births (20th in the world) [n12] is a national disgrace. 

A175/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Even in states such as Texas that have achieved infant mortality rates lower than the national average, there remain danger zones. Analogous to "drowning in a river only 3 feet deep," there are communities in the very shadow of America's finest medical institutions where infant mortality rates rival those of Third World nations. 

A177/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 We began by proposing that the answer to the question "How many physicians can we afford?" depends on how much society is willing to spend overall for physician services and how much each physician earns. As the Figure indicates, physician costs could remain stable at approximately 2.0% of the GNP despite an increase in the physician-to-population ratio to 176 per 100 000 if expenditures per physician rose at the rate of the CPI. On the other hand, overall costs as a percent of GNP could rise 50% (from 2.0% to 3.0%) even without an increase in the physician-to-population ratio if recent trends in expenditures per physician continue. 

A178Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 The combination, however, of physician supply expanding as projected and expenditures per physician continuing to rise at their recent pace is a particularly volatile mixture for those concerned with health care costs. Under this scenario, payers face the prospect of physician costs as a percent of GNP nearly doubling between 1986 and 2000. The rapid expansion of physician supply in this decade will intensify the conflict between payers attempting to hold down the ceiling on expenditures per physician and physicians attempting to maintain or elevate the floor of their incomes. 

A179Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 This open system of financing health care persists and contributes to escalating health care costs, [n26,n27] which amount to nearly 12% of our gross national product and result in a health care expenditure per capita that is the highest of any country in the world. Our concerns over rising health care costs will not affect this problem, as long as we refuse to say "no" in our "yes" society. Not surprisingly, in the absence of a national health care system, federal and state governments are severely handicapped in controlling health care expenditure. 

A180/The Economist, February 27, 1993, Pg. 30, HEADLINE: Health care; A dose of the HIPCs \VT 93-94
  BY 2000 American health-care spending could hit 18% of GDP and health might  absorb 30% of federal spending, says the Congressional Budget Office.  

A181/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 Without such a major reform of the system, warns Walter Maher, director of federal relations for Chrysler Corp., "there is nothingstanding in the way of the relentless absorption of this economy by the health system." 

A182/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 "Barring change, we believe health costs will exceed $ 2 trillion by the year 2000 and absorb over 20 percent of our nation's gross national product," Mr. Maher warned. 

A183/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 As shown in Table 2, nearly half of working families report that their contribution to the cost of health insurance premiums has increased as a result of rising costs, and one in five households see themselves as seriously hurt by medical bills. 

A184/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 6. How Should Health Care Costs Be Controlled? As shown in Table 1, costs are the number one concern of a majority of Americans. Between 1992 and 2000, personal health care costs are expected to increase from $ 2700 to $ 5100 per person. By the year 2000, an additional $ 300 per person will be spent for the direct administration of health plans. [n4] 

A185/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] So I think that the explanation is simply that the  middle class is being priced out of the health insurance market. 

A186/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 The American people have waited all that time to gain protection against disastrous medical bills and the benefits of regular health care. And the intervening decades have seen a needless and chaotic rise in health costs while coverage and the health status of younger Americans decline. 

A187Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  Americans are not getting value for their money. This, to a large extent, is what we mean when we say that health care costs are too high;  they are too high for what we are getting in return for our enormous expenditure of health care dollars. 

A188/The Reuter Transcript Report, February 24, 1993, FOX MORNING NEWS INTERVIEW, Guest: Rep. Henry Waxman (D-Calif.), Nexis \\VT 93-94
 REP. WAXMAN: The General Accounting Office did a study for us which showed that American consumers are paying a much higher price for prescription drugs than people in Canada,  buying the very same drug by the same manufacturer, or even in Mexico, where it's sold right near the border for a fraction of  the price of what people have to pay in this country. There's no question American consumers are paying more for drugs and  they are finding that not only they're paying more; the increases every year are far more than the growth of the economy, the rate of inflation and all of that. 

A189/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 VICE PRESIDENT GORE: We're going to ask you to address the following question: Why do some hospitals charge $5 for an aspirin and $35 for a towel, and what can we do about this problem. 

A190/SHERRY JACOBSON; Gannett News Service, March 20, 1992, HEADLINE: POLL:1 IN 3 KNOWS SOMEONE BANKRUPT OVER MEDICAL BILLS, Nexis \\VT 93-94
	 One out of three Americans knows someone who was forced to declare personal bankruptcy in the past five years due to unpaid medical bills, according to a survey by Louis Harris and Associates. That growing awareness is an indication that the nation's health-care crisis is becoming a personal struggle for more and more families, said Humphrey Taylor, president of the national polling company. 

A191/SHERRY JACOBSON; Gannett News Service, March 20, 1992, HEADLINE: POLL:1 IN 3 KNOWS SOMEONE BANKRUPT OVER MEDICAL BILLS, Nexis \\VT 93-94
	 The random survey of 1,254 adults found that 33 percent knew someone who had gone through personal bankruptcy due to medical costs. The survey, which was conducted Feb. 19 to 23, had a margin of error of plus or minus 3 percentage points. 

A192/SHERRY JACOBSON; Gannett News Service, March 20, 1992, HEADLINE: POLL:1 IN 3 KNOWS SOMEONE BANKRUPT OVER MEDICAL BILLS, Nexis \\VT 93-94
	 Of those who knew about the bankruptcies, 37 percent said they believed that medical bills had been a contributing cause of the legal action while 20 percent said it was a major cause. 

A193/SHERRY JACOBSON; Gannett News Service, March 20, 1992, HEADLINE: POLL:1 IN 3 KNOWS SOMEONE BANKRUPT OVER MEDICAL BILLS, Nexis \\VT 93-94
	 Previous studies have shown that many personal bankruptcies are caused by the high cost of long-term medical care. For example, nursing home care generally is not covered by private health insurance or Medicare, the government's insurance program for the elderly and disabled. 

A194/SHERRY JACOBSON; Gannett News Service, March 20, 1992, HEADLINE: POLL:1 IN 3 KNOWS SOMEONE BANKRUPT OVER MEDICAL BILLS, Nexis \\VT 93-94
	 Taylor noted that many Americans are forced to spend their savings and declare bankruptcy before they can become eligible for Medicaid, the health insurance plan that covers the poor. 

A196/SHEILA RADFORD, The New York Times, June 11, 1992, Section A; Page 22; HEADLINE: Every Canadian Can Get Quality Health Care; They Put Us to Shame \\VT 93-94
	 Many aging Americans and their families face financial ruin in attempting to pay for adequate health care. This does not occur in Canada. 

A197/Health Line, August 10, 1992, HEADLINE: MEDICAL BANKRUPTCY: HEALTH BILLS LEAVING A TRAIL OF RED, NX \\VT 93-94
	 GANNETT NEWS-HOUSTON POST reports, "Some experts have begun to refer to bankruptcy as the health insurer of last resort," as medical bills force "more and more American families into bankruptcy." According to the Consumer Bankruptcy Project, a study of nearly 24,000 debtors in TX, CA, PA, IL and TN, showed 12.4% of bankruptcies filed in '91 were due to medical bills, compared to 3% in '81. GANNETT-POST: "Recent bankruptcies show that it is possible to be middle-class, have health insurance coverage and still collapse under the financial weight of unpaid medical bills. ... And despite all the talk about health care reform in Congress, there is no specific bill that addresses the issue of medically caused bankruptcies." Charles Inlander, president of the People's Medical Society in PA: "This really underscores the failure of our system to respond to people who have health care needs. You should not be financially destroyed just because you get sick." 

A198/Health Line, August 10, 1992, HEADLINE: MEDICAL BANKRUPTCY: HEALTH BILLS LEAVING A TRAIL OF RED, NX \\VT 93-94
	 GANNETT-POST: "Some consumer advocates plan to use the growing number of medical bankruptcies to support the idea of a national health insurance in which the government would use taxes to cover all medical bills" (Sherry Jacobson, 8-8). 

A199/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 Medical bills and health problems are forcing more and more American families into bankruptcy. Some experts have begun to refer to bankruptcy as the health insurer of last resort. 

A200/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 As many as 112,000 personal bankruptcies filed in 1991 are believed to have been caused to some extent by illness, injury or accident, according to the Consumer Bankruptcy Project, an in-depth study of Americans who go bankrupt. 

A201/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 Recent bankruptcy filings show that it is possible to be middle-class, have health insurance coverage and still collapse under the financial weight of unpaid medical bills. ''A lot of people seem to be close to the edge after something as ordinary as a car accident,'' said Teresa Sullivan, co-author of the bankruptcy study. ''Even if you're insured, if you're so badly injured that you have to miss work, your medical bill may be paid but your other bills aren't.'' 

A202/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 It is not known how many Americans are struggling to stay out of bankruptcy because of medical problems. But it is clear that they are going bankrupt in record numbers. In 1991, there were 872,438 personal bankruptcies compared to 182,714 personal bankruptcies in 1980, a 377 percent increase. 

A203/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 The bankruptcy study of nearly 24,000 debtors pinpointed medical problems as a factor in 12.4 percent of the filings last year, based on a survey of Texas, California, Pennsylvania, Illinois and Tennessee. By comparison, fewer than 3 percent of those who filed for bankruptcy in 1981 listed medical bills among their major debts, said Sullivan, a demographer and sociology professor at the University of Texas at Austin. 

A204/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 The findings do not surprise credit counselors around the country, some of whom believe health problems account for an even greater portion of personal bankruptcies. ''A large percentage of our clients have experienced medical difficulties,'' said Joanne Kerstetter, president of the Consumer Credit Counseling and Education Service of Greater Washington, D.C., which assists 10,000 financially strapped clients a year, referring 10 percent to bankruptcy court. 

A205/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 Bruce French, a bankruptcy referee in northern Ohio, estimated that a third of his bankruptcy petitions resulted from substantial medical debt. ''These are people who are having trouble keeping their heads above water in general but the medical debts sunk them,'' said French, who also is a law professor at Ohio Northern University Law School in Ada. 

A206/SHERRY JACOBSON; Gannett News Service, August 5, 1992, HEADLINE: HEALTH CARE MESS DRIVES MORE PEOPLE TO BANKRUPTCY, NX \\VT 93-94
	 Some consumer advocates plan to use the growing number of medical bankruptcies to support the idea of a national health insurance in which the government would use taxes to cover all medical bills. ''This really underscores the failure of our system to respond to people who have health care needs. You should not be financially destroyed just because you get sick,'' said Charles Inlander, president of the People's Medical Society, an advocacy group in Allentown, Pa. 

A207/United Press International, May 10, 1992, HEADLINE: Sen. Simon issues Mother's Day call for long-term health care, Nexis \\VT 93-94
	 There have been increasing reported in recent months of cash-strapped family members dropping their aged mother or father at a hospital emergency room with no identification -- in essence, abandoning them to the health-care system. 

A208/United Press International, May 19, 1993, HEADLINE: PUBLIC CITIZEN CLAIMS PATIENT DUMPING REMAINS WIDESPREAD WASHINGTON Transmitted: 93-05-19 19:46:00 EDT, Online America \\VT 93-94
	Public Citizen issued a report Wednesday alleging that, based on Health and Human Services Department documents, at least 268 hospitals "dumped" patients between 1986 and 1992. But Wolfe and study co-author Joan Stieber claimed the 302 violations documented in the report represented just a small fraction of actual patient-dumping cases. 

A209/United Press International, May 19, 1993, HEADLINE: PUBLIC CITIZEN CLAIMS PATIENT DUMPING REMAINS WIDESPREAD WASHINGTON Transmitted: 93-05-19 19:46:00 EDT, Online America \\VT 93-94
	"There is the horrible spectre of dumping thousands of patients a year," Wolfe [Dr. Sidney Wolfe, director of the Public Citizen Health Research Group] told a news conference. "For many of these patients, dumping means death."

A210/United Press International, May 10, 1992, HEADLINE: Sen. Simon issues Mother's Day call for long-term health care, Nexis \\VT 93-94
	 Sen. Paul Simon, D-Ill., warned that millions of elderly women ''are living on the margin'' of poverty because they do not have long-term health insurance. Simon said women are more likely to need long-term health care than older men because women are more likely to live in poverty and are more at risk for physical limitations. 

A211/Carol Kleiman, Chicago Tribune April 6, 1992, BUSINESS; Pg. 5; HEADLINE: Lack of health-care benefits keeps low-wage workers on welfare's edge \\VT 93-94
	 Kathryn Edin, a sociologist and scholar with the Russell Sage Foundation in New York, , now doing research in Charleston, S.C., on the choices women make between work and welfare, said lack of health insurance is a major roadblock to employment. "It's the No. 1 thing women say they fear they'd lose out on if they left AFDC," said Edin, who did similar research in Chicago and will study women in San Antonio, Boston and rural Minnesota. 

A212/Carol Kleiman, Chicago Tribune April 6, 1992, BUSINESS; Pg. 5; HEADLINE: Lack of health-care benefits keeps low-wage workers on welfare's edge \\VT 93-94
	 "Studies show that the unavailability of health insurance tends to force women back into welfare," said Heidi Hartmann, director of the non-profit Institute for Women's Policy Research in Washington. Hartmann recently studied 500 AFDC women over a two-year period and found that 40 percent worked some of the time, that 20 percent rotated between work and welfare and that 20 percent combined work and welfare. 

A213/Carol Kleiman, Chicago Tribune April 6, 1992, BUSINESS; Pg. 5; HEADLINE: Lack of health-care benefits keeps low-wage workers on welfare's edge \\VT 93-94
	 National health care would be especially helpful to women "who get by on the salary of a low-paying job - until a child gets sick and that's it," said Ethel Long-Scott, executive director of the Women's Economic Agenda Project in Oakland, Calif. "Universal health care would be a big piece of the pie." 

A214/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 Public priorities are probably best judged by the way we spend our money. In 1987, we spent $500 billion for health care; but we made some other interesting purchases too: (1) $20.5 billion for pets, toys, and playground equipment; (2) $21.8 billion for tobacco products and smoking supplies; (3) $27.2 billion for beer, wine, and whiskey; and (4) $34.7 billion for cosmetics, jewelry, and personal care products. [n7] These expenditures, totaling $104.2 billion, were not quite as high as the $106.9 billion paid for health care "out of pocket" by consumers (including insurance); but it was somewhat less than the $112.3 billion spent for entertainment. Note that the latter does not include the amount spent on lotteries -- over 11 billion. Not surprisingly, we spent $433 billion for motor vehicles, parts, gas, oil, and auto insurance. These figures make me ask, "whose crisis is this, anyway?" Does it really belong to the patient if the average household spends about the same for entertainment as for health care, and four times as much for transportation? Does it belong to businesses which would like to use those funds for profits and a government searching for a new domestic platform? Both spend more on medical care than consumers; and their calls for change are definitely louder than those of our patients. 

A215/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 DICK DAVIDSON (PRESIDENT, AMERICAN HOSPITAL ASSOCIATION): We pay for care in a rather bizarre way in this country. We pay for care on the basis of every medical encounter. In other words, the only time a provider gets paid is if there's a medical encounter. And I think you can imagine what kinds of incentives that creates. In order to have more revenue flow through the system, you have to have more medical encounters. And what that does is to foster competition in the system, among and between hospitals and doctors, ultimately to treat more patients. It drives the whole competitive spirit toward capturing market share, and ultimately has the potential perverse incentive of wanting to order more tests and consume more units of service. We think we got to scrap that system -- and the sooner, the better. This system is broken, and we've got to come up with a new one. 

A216/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 What permits and even encourages such waste, analysts say, is the nation's medical payment system that now allows doctors and other health providers to prescribe almost any treatment they wish, and automatically pays the bills. 

A217/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 Studies in Florida show that doctors who invest in outside clinical laboratories and other testing services to which they refer patients order more tests than doctors who do not have such investments. 

A218/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. HIMMELSTEIN [Dr. DAVID HIMMELSTEIN, Harvard Medical School] : There's an enormous malpractice problem in this country. The biggest problem is that 80,000 people a year die from malpractice, and the president offers a malpractice reform which completely leaves out the fact that medical negligence kills 80,000 people and goes after this imaginary cost of defensive medicine which no one has ever shown with any reasonable piece of research is actually there. I think that's a bizarre concept of medical malpractice reform. 

A219/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Mr. SCHRAMM [CARL SCHRAMM, Health Insurance Association of America]: I think the American people don't even have a clue that 80,000 people died last year because of medical malpractice. Most of Americans think that their doctor was sent here from Sinai and he speaks truth. 

A220/ FAZLUR RAHMAN, practicing cancer specialist in San Angelo, Tex, April 18, 1993; The New York Times, “Viewpoints; Let's Hear It for Low-Tech Medicine,” Section 3; Page 11\\VT-AGL
	 * Billions of dollars are wasted yearly on defensive medicine, which is practiced mainly because of the fear of lawsuits. Doctors sometimes order expensive tests just because they may be faulted later for failing to do so. We must have malpractice reform, and restraint on abusive lawyers. 

A221/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 Although Brook gave no dollar estimate on potential savings, other analysts have estimated that wasteful spending on overutilization of treatments and diagnotic devices could be as much as $ 100 billion to $ 200 billion a year of the $ 600 billion spent a year on personal health care. 

A222/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)]The second component, also estimated about $ 100 billion, is the waste in terms of unnecessary tests, unnecessary prescriptions for drugs, unnecessary surgery--waste that is fostered by extraordinary conflicts of interest wherein doctors  refer patients to labs, and other facilities that they own stock in.  

A223/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 Defensive medicine adds somewhere between $20 billion and $100 billion to U.S. health costs, according to Robert E. McAfee, a trustee of the American Medical Association. "Suing physicians has become big business for lawyers," he said. McAfee, a physician in Portland, Maine, warned against a national health insurance system like Canada's, which he said had caused medical care rationing and "tragic" tax increases. 

A224/SHEILA RADFORD, The New York Times, June 11, 1992, Section A; Page 22; HEADLINE: Every Canadian Can Get Quality Health Care; They Put Us to Shame \\VT 93-94
	 I suggest there is also far too much unnecessary surgery in the United States; one might almost call it for-profit surgery. 

A225/United Press International, MAY 12, 1993, TITLE: REPORT DEEMS 16 PERCENT OF HYSTERECTOMIES "INAPPROPRIATE," Online America Transmitted: 93-05-12 10:54:00 EDT \\VT 93-94
 RAND said each year more than 500,000 patients undergo hysterectomies _ removal of the uterus _ at a cost of more than $2 billion. That number, however, has declined over the past decade as the procedure has been questioned. 

A226/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 Brook based his assertion on studies in the early 1980s that found that 14 percent of coronary artery bypass surgeries were medically inappropriate, as were 17 percent of coronary angiograms (dye-aided pictures of the coronary arteries) and 32 percent of carotid endarterectomies (widening a major artery that delivers blood to the brain). 

A227/United Press International, MAY 12, 1993, TITLE: REPORT DEEMS 16 PERCENT OF HYSTERECTOMIES "INAPPROPRIATE," Online America Transmitted: 93-05-12 10:54:00 EDT \\VT 93-94
 A report released by RAND researchers Tuesday concludes that 41 percent of hysterectomies performed at major health maintenance organizations are inappropriate or of uncertain benefit. 
The report, published in this week's Journal of the American Medical Association, says an average of 16 percent of the hysterectomies are inappropriate, and an additional 25 percent are of uncertain benefit. 
Researchers concluded that 28 percent of hysterectomies performed on women aged 21 to 40 were inappropriate, while just 5 percent of those performed on women older than 60 were inappropriate. 

A228/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 Senior citizens generally would prefer low-tech, low-cost care, experts say. But typically, no one bothers to ask or the patients are unable to speak. Too often, they haven't made their wishes known in advance. "In hospitals, we find ourselves over-treating patients without consulting them," said Dr. Howard Brody, chairman of the Michigan State Medical Society bioethics committee. "The hospital just seems to be a juggernaut, operating on its own without anyone in charge. The system is out of control." 

A229/Health Line, September 4, 1992, HEADLINE: COMMENTARY: VIEWS OF THE HEALTH CARE CRISIS Nexis \\VT 93-94
	 MAKING THE TOUGH CALL: Sam Brody, a NY physician, writes in the Long Beach PRESS-TELEGRAM, "I have seen this happen time and time again: A human being reaches the end of his or her life, but the family, or the nursing home, doesn't want the person to die there. ... So they ship the poor soul ... to the hospital. The hospital calls in a specialist (like me) to protect itself from any possible malpractice charges. ... The specialist in turn orders all sorts of expensive tests, procedures, maybe even surgery. All of which gets billed to Medicaid, i.e., the taxpayers. It's a horror for the patient, a horror for the family, and it's costing us all a fortune, money that could be better spent on lives that can be saved" (9-2). 

A230/Robert Bazell, science correspondent for NBC News, NEW REPUBLIC, March 15, 1993, TITLE: GROWTH INDUSTRY, Online America, Transmitted: 93-02-25 09:32:20 EST \\VT 93-94
 Doctors told each woman the treatments represented her only hope, but the treatments did little if anything to prolong either life. Such cases will quickly take center stage when the debate over health care reform in America becomes serious. Discussions of bureaucratic concepts such as managed competition and global budgets will matter little compared with the stark question of who gets what care and who does not. Cancer treatment offers some of the best examples of the obstacles facing any attempts to change American health care.

A231/Robert Bazell, science correspondent for NBC News, NEW REPUBLIC, March 15, 1993, TITLE: GROWTH INDUSTRY, Online America, Transmitted: 93-02-25 09:32:20 EST \\VT 93-94
 Questionable treatments clutter the entire landscape of American medicine. But in cancer therapy, the irrationality that drives much of our medical care reaches profound heights. There is no denying that cancer detection and treatment, especially surgery and radiation, save or prolong thousands of lives every year. But when it comes to patients who cannot be helped by surgery or radiation, many oncologists admit they are working in an era that will be recalled as the dark ages of their specialty, akin to the time when physicians applied leeches. Often they administer treatments when there is no objective reason to believe they will help the patient. This happens for many reasons, but most often because patients and their families demand hope and doctors believe it their duty to provide it, no matter how unrealistic and no matter what the cost.

A232/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 Contemporary American health care is awash in bureaucracy and paperwork. There are over 1500 third-party payers of health care in the United States -- most with their own forms to fill out -- and layers of administrative interference in the physician-patient relationship. Americans spend more for administration than any other nation. Modern hospitals are massive administrative bureaucracies; every physician's office must invest heavily in administrative personnel and equipment. Part of this problem is due to Americans' commitment to a plural system of finance. In Canada, by contrast, each province has only one insurance form for most health care services and far less overall administration. [n26] 

A233/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Jack A. Meyer, an analyst with New Directions for Policy, a Washington research group, said administrative costs soak up 22% of U.S. health-care spending. The American urban landscape, said Caplan of the University of  Minnesota, is dotted with insurance company towers (Prudential, John Hancock) and even an entire city (Hartford, Conn.).  "We have a huge administrative bureaucracy to keep the rich from having to share costs with the poor, the healthy from having to share costs with the sick and the able-bodied from having to share costs with the disabled," Caplan said. 

A234/B.D. Colen, medical correspondent, Newsday, December 8, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 79, HEADLINE: Health Care at Square One \\VT 93-94
	 It has been estimated that up to 25 percent of our health-care dollars now go for administration - read: "paying insurance company clerks, supervisors, managers and executives." We could easily find the money to pay for medical care for the uninsured by switching to a single-payer, nonprofit, national health "insurance" system.  

A235/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 According to material in the Bush administration's health-reform proposals unveiled in February, administrative expenses accounted for about 40 percent of claims for insurance policies sold to business establishments with fewer than five employees in 1987. The payout ratio was higher for bigger firms, although it was still as low as 77 percent for firms with fewer than 20 employees. 

A236/JOHN MACDONALD; Courant Senior Washington Correspondent, The Hartford Courant, April 25, 1992, Pg. A2 HEADLINE: In health care debate, numbers sometimes can mislead \\VT 93-94
	 The insurance industry likes to cite the lower 14.2 percent number, well aware that administrative costs have become a politically sensitive issue in the health care debate. The higher they go, the more explanations the industry has to supply and the more appealing the Canadian plan appears. 

A237/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 Others, such as Dr. David Himmelstein, a Harvard Medical School assistant professor and founder of a group backing national health insurance, say rationing would be immoral until waste is eliminated. Studies have estimated up to $ 200 billion a year is wasted on unnecessary care and inefficient paperwork. "Is it ethically defensible to ration care while doctors are averaging (income of) $ 170,000 a year?" Himmelstein asked. "We're at least 15 years from any need to consider rationing." 

A238/United Press International, January 16, 1992, HEADLINE: Group says Canadians getting low-cost health care, Nexis \\VT 93-94
	Citizen Action said an earlier study found that commercial health insurance companies in America spend 33.5 cents on paperwork for every dollar of health care benefits they provide. In Canada, the national health insurance system spent only three cents to administer each dollar of covered care. 

A239/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] The first component is the administrative waste. Compared with Canada, I think that almost everyone, except the insurance industry itself, will admit that we are wasting now, this year, over $ 100 billion in administrative waste. The industry itself and all of the administrative waste it foists on doctors and hospitals, and nursing homes. 

A240/Tom Hamburger; Staff Writer, Star Tribune, August 30, 1992, Pg. 14A, HEADLINE: Debate on health care suffers from serious ailment: politics \\VT 93-94
	 Since 1980, medical industry political action committees have contributed $ 60 million to congressional candidates. Those contributions influence what's considered feasible in Washington conversations, Wellstone said. 

A241/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Some $4 billion could be saved nationally in health care expenses if all medical providers moved to a paperless billing system, said Linda Jenckes, senior vice president of the Health Insurance Association of America. Another $30 billion to $50 billion nationally could be saved by curtailing provider fraud, Jenckes said. 

A242/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	[Dr. DAVID HIMMELSTEIN, Harvard Medical School] We can afford health care for everyone, what we can't afford is we can't afford to throw away $ 45 billion on insurance company profits and overheads that we could save under national health insurance and another 50 billion that they foist on doctors in hospitals in the paperwork for their ridiculous- 

A243/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	The proponents of the payment reductions approach say that, if growth in future expenditures could be slowed, these savings could be used to cover the uninsured with few new taxes or financial burdens. Proponents see these cost savings coming from the elimination of unnecessary administrative paperwork, duplication of facilities, inappropriate medical practices and tests, and unfair profit making found in the current system of health care. They believe the quality of care will not be reduced. They point to health plan administrative costs and physician incomes that are higher in this country than in any other as evidence that a less costly universal system is possible. 

A244JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 The United States has fewer doctors for its population than most European countries, with the notable exception of Britain, and its supply of registered  nurses falls at about the European average. Yet its health care system employs more people than Europe's -- especially those who sell health insurance and administer claims. "Behind every hospital bed in the United States is a clerk filling out forms," said Poullier of the OECD. 

A245/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. HIMMELSTEIN [Dr. DAVID HIMMELSTEIN, Harvard Medical School] : I'm offended that there are an enormous number of people making money off the health care system for not doing anything useful, and if you do good work, if you do work that needs to be done, you ought to be able to be paid for it and make money off of it. If you're doing useless work- we're paying $ 48 billion this year for insurance companies to push papers. 

A246/Herman A. Kohlman, FHFMA, is a retired healthcare executive, Healthcare Financial Management , October, 1992 , Pg. 89, HEADLINE: The American healthcare dilemma: is there a solution? \\VT 93-94
	 The current U.S. healthcare model can be described as "sick care," since approximately 90 percent of U.S. national healthcare expenditures are for making sick people well. In view of the demographic data available, continuation of the "sick care" model will increase the likelihood of: * Increased regulation, * Rationing of healthcare services, similar to that found in England and Canada, * Increased shortages of healthcare personnel due to chronic under-funding, * A slowdown in the infusion of new technology into the healthcare system, and * Growing healthcare expenditure resulting in lower percentages of the GNP being available to other sectors of the economy with an overall decline in the standard of living. 

A247/Daily Report For Executives, November 10, 1992, 1992 DER 218 d9 HEADLINE: Health Care, SOCIAL, TECHNOLOGICAL FACTORS DRIVING HEALTH CARE CRISIS, APHA SAYS Nexis \\VT 93-94
	 The health care system's reliance on treatment rather than prevention and its stress on high technology intervention instead of primary care have brought it to the verge of collapse, the American Public Health Association said Nov. 9 in a report calling for renewed emphasis on improving the social, economic, and environmental factors that affect health. 

A248/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  Q: What can you tell us about the level of health care received by the 35 million Americans who are uninsured? How many are turned away by hospitals, whether they're public or  private hospitals? How many are somehow being taken care of by the system? How many are getting no adequate health care at all?  WOLFE [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] : The best way of characterizing the health care  of the 35-plus million Americans who are uninsured is that it's  too little, and it's too late, and it's too expensive. As I mentioned a recent study shows that a number of hospitalizations, that people with health care avoid because  they are able to go to a doctor, wind up with people who don't have insurance going into the hospital for asthma, pneumonia, and things like that. So they often wind up in the emergency room because they don't have a primary care doctor to go to, and the emergency room is their primary care doctor, and they wait to go there until they're practically on death's door, as often as  not.  And they wind up engendering, in many instances, medical bills which they don't pay for, but which we pay for, that are much larger than they would be if they had primary care. 

A249/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  WOLFE [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] : Just one other thing is that prevention is also related to insurance status, and studies that Dr.  Woolhandler, and Dr. Himmelstein have done, show that many people who are poor and who are uninsured don't get to have their blood pressure taken, don't get to have pap smears, don't  get to have mammography, and wind up, again, with much later  stages of the disease being detected than would have otherwise been the case. 

A250/Bill Clinton, USA President, May 5, 1993 , President's Remarks at Ceremony for National Nurses Week, The Rose Garden 4:27 P.M. EDT Transmitted: 93-05-07 08:54:04 EDT, Online America\\VT 93-94
	 You know better than anyone else what is wrong with this system. You see all the people who show up at the emergency room to get the most expensive care too late because they didn't have a basic primary and preventive health care package. You see the enormous burden of paperwork squandering more and more hours of nurses and doctors, requiring more and more precious health care dollars to be diverted to clerical expenses instead of to investing in the health of our people. 

A251/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 However, lack of access to needed services can not only decrease a person's health it can also increase long-term costs. If an individual does not get prevention-related services (such as immunizations) or doesn't have his or her medical problems treated early enough, the long-term costs of medical care will increase. 

A252/National Public Radio, SHOW: ALL THINGS CONSIDERED, March 26, 1992, HEADLINE: INFANT MORTALITY REMAINS HIGH IN USA, Nexis \\VT 93-94
	 Neighmond: Prevention, including routine medical care and comprehensive prenatal care. In fact, the number of pregnant women receiving this quality of care is down. There are a number of things that explain these trends. One is drugs. The crack epidemic has taken its toll, producing more extremely sick and premature infants. Another is poverty. Today, one out of every five children lives in poverty and that's an all-time high. And while the federal government has made more of these poor mothers and children eligible for health services under Medicaid, Grad says it's failed to improve access to these services. 

A253/Editorial by the St. Louis Post-Dispatch, in Chicago Tribune, February 16, 1992, Pg. 3; HEADLINE: Saving the babies \\VT 93-94
	 The U.S. rate won't drop significantly, however, until this nation devotes more resources to prenatal care. Better still, it could adopt a national health insurance program that would address not only infant mortality but other health 

A254/Kathleen Troher, Staff Writer, October 25, 1992,Chicago Tribune; "Miracle Babies-High Tech Medicine Delivers Prenatal Carekey to Prevention" p. 3\\VT-AGL
	 Although many medical problems that force babies into neonatal nurseries cannot be avoided, doctors say that good prenatal care would certainly decrease these numbers. 

A255/LANIE JONES, TIMES STAFF WRITER Los Angeles Times October 1, 1991, : Part A; Page 1; HEADLINE: LEARNING BEDSIDE MANNERS;\\VT-MDS 
UC Irvine's Waitzkin, author of a recent book, "The Politics of Medical Encounters," argues that a system of national health insurance would make it easier for doctors to listen to patients -- and to refer them to social services. 

A256/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] American business is now spending as much on health insurance as is the size of its corporate profits. The health insurance expenditures for the last year, that it was studied, last year, were 108 percent of corporate profits. 

A257/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 The U.S. also spends more of its gross domestic product (GDP) - the value of items produced solely within U.S. borders - on health care than any of the 23 other members of the Organization for Economic Cooperation and Development (OECD). In 1989, for example, the U.S. spent 11.8 percent of its GDP on health. In contrast, Canada spent 8.7 percent; 16 other nations spent less than 8 percent. The private sector financed about 60 percent of the U.S. expenditures, as opposed to only 20 percent in all OECD countries combined. As a result, American companies have proportionately less capital to invest, thereby jeopardizing the country's international competitive position. 

A258/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 Speaking for the Washington-based National Association of Manufacturers, Richard Dorazil, corporate director of benefits for Motorola, Inc., Schaumburg, Ill., testified that manufacturers paid an estimated $ 11.5 billion in additional health care payments as a result of cost shifting in 1991. 

A259/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 Shifts in the political climate and the need to remain competitive in a world economy created new constituencies for aggressive public and private efforts to contain costs. 

A260/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Government cost controls do work, and something along such lines must be implemented soon as competitive managed care will take too long to stem rising health care costs, said Henry Simmons, a physician who is president of the National Leadership Coalition for Health Care Reform. Something needs to be done soon on health care because its rising cost is affecting the nation's ability to compete internationally, he said. 

A261/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	''It is ironic that the competition revolution may prove a significant factor leading the country toward national health insurance, '' Fuchs said. [Victor Fuchs, Stanford University economics professor] 

A262/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 As the government has strengthened its priorities, however, business has become its welcome ally. The automakers, for example, complain that health care costs are a major factor in keeping profits down; even Lee Iacocca, a champion of capitalism, has called for consideration of national health insurance (Detroit Free Press. April 17, 1989). A list of the health care priorities of industry -- including private insurers -- might be: (1) to limit expenditures, but (2) to have medical care that keeps employees healthy and satisfied. 

A263/DONALD W. NAUSS, TIMES STAFF WRITER, Los Angeles Times, March 23, 1993, Part D; Page 2; HEADLINE: BIG THREE CALL FOR NATIONAL HEALTH CARE SYSTEM; \\VT 93-94
	 The Big Three auto makers Monday called for adoption of a universal health care system, saying that rising health care costs are threatening their global competitiveness. 

A264/DONALD W. NAUSS, TIMES STAFF WRITER, Los Angeles Times, March 23, 1993, Part D; Page 2; HEADLINE: BIG THREE CALL FOR NATIONAL HEALTH CARE SYSTEM; \\VT 93-94
	 At a five-hour hearing on health care reform, General Motors, Chrysler and Ford officials said employee medical benefits add nearly $1,100 to the cost of each car they produce, $500 more than what their Japanese competitors face. "We now spend more on health care than we do on steel," said Peter Pestillo, executive vice president for corporate relations and diversified business for Ford Motor Co. 

A265/DONALD W. NAUSS, TIMES STAFF WRITER, Los Angeles Times, March 23, 1993, Part D; Page 2; HEADLINE: BIG THREE CALL FOR NATIONAL HEALTH CARE SYSTEM; \\VT 93-94
	 "Our costs will continue to climb, which will hurt our competitiveness and our ability to create jobs in states like Michigan," Shalala said. The rising costs have been particularly burdensome for the auto makers, who have nearly as many retirees as employees. They complain that the Japanese competitors have lower costs because they have national health care coverage. They also argue that the Japanese plants in the United States have younger work forces with fewer retirees, giving them a competitive edge. 

A266/Pension Reporter, March 8, 1993, Pg. 548, TITLE: SPATE OF COVERAGE TERMINATIONS UNDERSCORES NEED FOR NATIONAL REFORM. \\VT 93-94
	 Nevertheless, simply requiring employers to continue to provide retiree health coverage does not address the problem of U.S. companies' growing competitive disadvantage because of the high cost of health care, including retiree medical care, Riegle said. For instance, Riegle provided data showing that there is a $600 per vehicle differential between Japanese-owned auto manufacturers operating in the United States and the big-three U.S. auto manufacturers due solely to health care costs. In 1990, U.S. health care costs per vehicle amounted to $1,086 ($383 of this amount was attributable to retiree health costs), compared to $475 per vehicle for the Japanese manufacturers operating in the United States. 

A267/Pension Reporter, March 8, 1993, Pg. 548, TITLE: SPATE OF COVERAGE TERMINATIONS UNDERSCORES NEED FOR NATIONAL REFORM. \\VT 93-94
	 Owen Bieber, president of the United Auto Workers, also noted the $600 health care cost differential between the Big Three automakers and the Japanese transplant facilities in the United States, due mainly to the cost of providing health care coverage to a workforce that is an average of 13 years older. "As long as employers have to compete on the basis of their health care costs, there will be substantial pressure on employers to seek ways to reduce these costs, and in particular, to cut back on health care benefits for retirees," Bieber said. 

A268/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 Health care costs are the major public policy impediment to the U.S. auto industry's competitiveness, according to new research by the University of Michigan. "New studies show that for the "big three" auto manufacturers health care costs are much higher than had previously been thought," according to Rep. Cardiss Collins, D-Ill., chairman of the House Energy and Commerce Subcommittee on Commerce, Consumer Protection and Competitiveness. 

A269/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 "Health costs now account for almost $ 1,100 of each vehicle Chrysler, Ford and General Motors manufacture, instead of between $ 500 and $ 700 as had been previously calculated," she [Rep. Cardiss Collins] said in opening a subcommittee hearing on the impact of rising health care costs on the competitiveness of U.S. firms. 

A270/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 "On this basis," she [Rep. Cardiss Collins] said, "health care is the biggest component of the total cost-of-production disadvantage America's big three auto companies face in competing with Japan's auto companies." 

A271/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 Testifying on research performed by the University of Michigan Transportation Research Institute, Ann Arbor, David J. Andrea, senior research associate, said the average health care component of a North American big three-produced vehicle is estimated to be $ 1,086. 

A272/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 Estimates are that if the United States were to adopt a national health insurance system, the big three American auto companies would save as much as General Motors hopes to save through its recently announced closing of 24 plants and the laying off of 74,000 workers, according to Rep. Collins. 

A273/MARY JANE FISHER, National Underwriter, Property & Casualty-Risk & Benefits Management Edition, February 24, 1992, Pg. 2 HEADLINE: U.S. Auto Makers Are Seen Taking Big Health Cost Hit \\VT 93-94
	 Speaking for the Chrysler Corp. of Detroit, Walter B. Maher, director of federal relations, Washington, told the subcommittee that health costs burden U.S. manufacturers with "enormous costs totally disproportionate to comparable costs borne by our foreign competitors." "In the case of autos, he said, "our costs are more than twice those of German manufacturers and three times those of Japanese." If health costs were evenly distributed throughout the economy, a U.S. business competing with a Japanese firm would start out with a 131 percent health cost penalty, according to Mr. Maher. 

A274/Automotive News, February 10, 1992, Pg. 2 HEADLINE: Health care: $ 1,086 per car \\VT 93-94
	President Bush's proposal for national health insurance tax credits was announced a day after auto industry analysts told Congress that health care costs are sapping the industry's ability to compete in international markets. Health care costs add $ 1,086 to the cost of the average Big 3 car, according to David Andrea, senior research associate at the University of Michigan. At Chrysler Corp., the cost is about $ 700 a car, according to Walter Maher, director of federal relations. 

A275/Jacqueline Frank, The Reuter Library Report, January 31, 1992, HEADLINE: U.S. AWED BY MEDICAL ADVANCES, LOST SIGHT OF COSTS, Nexis \\VT 93-94
	Chrysler chairman Lee Iaccocca said health care costs have eroded his company's ability to compete with Japanese products. Each new car includes 700 dollars worth of health insurance premiums for Chrysler employees, he says. 

A276/Robert Reno , Newsday, November 1, 1992, Pg. 101, HEADLINE: It's Health Care That's Making Us Very Sick \\VT 93-94
	 If you want to know what's driving the small business operators of this country nuts - more than taxes, more than government regulation, more than liability insurance costs, more than rents or cash flow or the availability of credit or the weakened economy - it's employee health insurance. This is no surprise. 

A277/DONALD W. NAUSS, TIMES STAFF WRITER, Los Angeles Times, March 23, 1993, Part D; Page 2; HEADLINE: BIG THREE CALL FOR NATIONAL HEALTH CARE SYSTEM; \\VT 93-94
	 William Hoffman, director of the UAW's Social Security department, said that unless a solution to the health care crisis is found soon, labor strife could hit the industry hard. "I am very concerned we will be forced into a prolonged strike, which would hurt the country's economy," he said. 

A278/Pension Reporter, March 8, 1993, Pg. 548, TITLE: SPATE OF COVERAGE TERMINATIONS UNDERSCORES NEED FOR NATIONAL REFORM. \\VT 93-94
	 "Unless prompt action is taken to address the problems associated with financing retiree health care benefits, I am concerned that the upcoming negotiations between the UAW and the Big Three automakers could lead to a strike over this issue in the fall of this year," Bieber [president of the United Auto Workers] said. General Motors already has cut retiree health coverage for its salaried retirees, he noted. "If we are forced into a prolonged strike over this issue, this could seriously undermine prospects for economic growth in the country," he said. 

A279/Jacqueline Frank, The Reuter Library Report, January 31, 1992, HEADLINE: U.S. AWED BY MEDICAL ADVANCES, LOST SIGHT OF COSTS, Nexis \\VT 93-94
	Rising costs of health insurance have become the biggest single source of strife between labour unions and management. Three fourths of all strikes in 1989 were over worker objections to paying a larger share of insurance premiums. 

A280/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 Warren Greenberg, professor of health economics at The George Washington University, said many individuals who want to change careers suffer "adverse job lock," fearful they could be denied health insurance at a new company because of family medical problems. Unhappy workers locked into their jobs hurt industrial productivity, he said. 

A281/Larry Lipman COX NEWS SERVICE, The Atlanta Journal and Constitution, February 24, 1992, Section A; Page 8 HEADLINE: CAMPAIGN '92: KEEPING YOU UP TO DATE HEALTH: MATTERS: The issues are coverage, costs Many fall through system's holes \\VT 93-94
	 Many people with insurance worry that if they leave their current job they won't be covered in their new job, so they stay. The U.S. Advisory Council on Social Security estimated recently that 28 percent of Americans were locked into an unwanted job because of fear of losing insurance coverage. 

A282/Paul Starr, professor of sociology at Princeton. The New York Times, February 4, 1992, Section A; Page 21; HEADLINE: The Ideological War Over Health Care; Conservatives Ignore History \\VT 93-94
	More ironically, many Americans find that the health system restricts their economic liberty in another way: they cannot exchange jobs, for fear of losing coverage of pre-existing medical conditions. 

A283/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	Another pressure for a national plan, according to the Stanford economist, comes from employers as their hiring decisions and employees' job choices become constrained by health insurance considerations. There will be more appreciation of the efficiency advantages of making health insurance independent of the labor market. [Victor Fuchs, Stanford University economics professor] 

A284/Paul Starr, professor of sociology at Princeton. The New York Times, February 4, 1992, Section A; Page 21; HEADLINE: The Ideological War Over Health Care; Conservatives Ignore History \\VT 93-94
	A U.S. national health plan that provided universal coverage, squeezed administrative overhead and contained health prices would help employers control costs and broadly benefit the economy. 

A285/PRESIDENT CLINTON, April 29, 1993, WHITE HOUSE PRESS RELEASE, REMARKS BY THE PRESIDENT AND THE FIRST LADY IN RECEPTION FOR THE HEALTH CARE TASK FORCE, Transmitted: 93-05-03 21:07:55 EDT, Online America//VT 93-94
	 The human dimension of this issue is utterly enormous. The economic dimension is also very great. We're here, struggling to really be serious about reducing the government's deficit, and under every scenario we can cut it quite a bit in the next five years, and then it starts to go right up again because of health care costs. So there has rarely been a time in the history of this country when an economic issue and a social issue, when an issue that affects all the big people and all the little people and all the people in between has been so tightly joined, as this health care issue.

A286/PRESIDENT CLINTON, April 29, 1993, WHITE HOUSE PRESS RELEASE, REMARKS BY THE PRESIDENT AND THE FIRST LADY IN RECEPTION FOR THE HEALTH CARE TASK FORCE, Transmitted: 93-05-03 21:07:55 EDT, Online America//VT 93-94
	 I think we can do more than one thing. And I think if people understand that you have to do both of these things -- have a new budget and a new direction and a new approach to health care to get control of our deficit and our financial future and to have something left to invest in our people, our economy and our own future, I think we can do it. 

A287/Peter Passell, staffwriter, The New York Times, February 25, 1993, Section D; Page 2; HEADLINE: Economic Scene; Clinton's plan pales before the 900-pound health-care gorilla. \\VT 93-94
  Health care is the 900-pound gorilla of deficit finance. And unless Washington curbs the animal's  appetite or sharply raises taxes to keep it supplied with bananas -- or both -- the deficit will break records by the end of the century.  

A288/Chicago Tribune, March 21, 1993, Pg. 18; HEADLINE: Diverse group urges Clinton to act quickly on health care for all \\VT 93-94
	 In a speech in Atlanta on Friday, Clinton said the country should move quickly on enacting a national health insurance program but gave no timetable: "If you want to bring the budget into balance, you must insist that . . . we move on to find a way to bring health costs in line with inflation and provide a basic package of health care to all of our people." 

A289/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 "It is the No. 1 public policy problem after the budget deficit itse and the two problems are "inseparable," Rep. Jim Cooper (D-Tenn) told some 300 business executives and health industry representatives. The rising cost of Medicare and Medicaid "is the engine that drives the deficit," added Bernard R. Tresnowski, president of the Blue Cross and Blue Shield Association. 

A290/Bill Clinton, USA President, May 5, 1993 , President's Remarks at Ceremony for National Nurses Week, The Rose Garden 4:27 P.M. EDT Transmitted: 93-05-07 08:54:04 EDT, Online America\\VT 93-94
	 And then the third thing we have to do is to attack the health care crisis, because if we don't we will never get the government deficit under control. We will never balance this budget, and we will never -- more importantly, we ill never provide the security that most families need . 

A291/PRESIDENT WILLIAM CLINTON, February 17, 1993, "A New Direction" Congress Address, WHITE HOUSE PRESS RELEASE, Transmitted: 93-03-01 15:42:58 EST//VT 93-94
	But all of our efforts to strengthen the economy will fail unless we take bold steps to reform our health care system. America's businesses will never be strong; America's families will never be secure; and America's government will never be solvent until we tackle our health care crisis. The rising costs and the lack of care are endangering both our economy and our lives. Reducing health care costs will liberate hundreds of billions of dollars for investment and growth and new jobs. Over the long run, reforming health care is essential to reducing our deficit and expanding investment.

A292/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 This is not simply a point about health care economics. Cost-consciousness and prudence in the use of resources are instrumental ethical values, since unrestrained spending makes it increasingly unlikely that the United States can create a system of universal basic coverage. There simply will not be sufficient resources. Careful use of health care resources and serious cost containment are also necessary because of the legitimate demands for resources in other important areas. As the percentage of GNP dedicated to health care grows, less money is available for education, job training, housing, transportation, welfare assistance, and the like. 

A293/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 The increasing proportion of the GNP spent on health is associated with a declining share of the GNP spent on other needs such as education and repair of the infrastructure, as well as on research and development. In 1990 businesses spent 61 percent of pre-tax profits and 108 percent of after-tax profits on health care benefits for employees (as opposed to 20 and 36 percent, respectively, in 1970). Health payments were 15.3 percent of total federal expenditures; 11.4 percent of state and local budgets went to health. These allocations reduce the funds available for meeting other government commitments and for investing in economic opportunities that contribute to long-term growth. 

A294/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 The second, newer problem involves the effect of rising health-related costs on the nation's long-run economic prospects. In 1940 health care absorbed $ 4 billion, a mere 4 percent of our gross national product (GNP). In 1990 such expenditures equaled $ 666 billion, or 12.2 percent of the GNP; projections suggest that in 1992 the country will spend more than $ 800 billion on medical care, or 13.4 percent of the GNP. 

A295/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Guaranteed Insurance. -- Supporters of federally guaranteed insurance coverage believe it is needed for four reasons. First, they see health care as an essential service, like public education, to which universal access must be guaranteed. They believe the most effective way to ensure this is by providing everyone with a health insurance policy. With such coverage, no American would be denied care for financial reasons. 

A296/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Our country spends the highest percentage of gross national product on health care and, yet, 37 million uninsured Americans have limited access to medical care [n7,n8]; 11 million of these Americans are children, 7 million of whom go without regular medical care. In contrast, all other western democracies implicitly or explicitly used the moral ideal, "health care as a human right," to establish different types of national health care systems (NHCS). These systems provide health care to all citizens regardless of their ability to pay and operate under a controlled budget. 

A297/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Health care is a human right. This moral ideal is the guiding principle of the health care ethic in national health care systems (Fig 1). This ideal carries an obligation for governments to assure universal access to health care. With the notable exception of our country, all other western democratic countries use this health care ethic to guide their health care politics, laws, and policies and to establish primary care as the foundation of the health care system. 

A298/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Our society needs to understand the reasons why we do not have an NHCS and why we cannot assure that all Americans have access to affordable health care. Comparing the Universal Declaration of Human Rights with the Declaration of Independence provides a way of understanding why health care as a human right is not part of our health care policy. The United States signed the Universal Declaration of Human Rights, which specifically includes medical care as a right. [n15,n16] 

A299/Matthew Menken, MD, Archives of Neurology May, 1991; 48: 472-475 TITLE: Caring for the Underserved; Health Insurance Coverage Is Not Enough \\VT 93-94
	 The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research stated in 1983 that "Society has a moral obligation to ensure that everyone has access to adequate care without being subjected to excessive burdens."[n1] By this measure, the health system of the United States is failing, since millions of citizens are unable to obtain necessary care each year. This is a paradox, given the large annual medical 

A300/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 In 1983 the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, formed under President Carter and continued under President Reagan, stated, "Society has a moral obligation to ensure that everyone has access to adequate [health] care without being subjected to excessive burdens." [n1] The commission's use of the idea of societal obligation implies a pluralistic approach that relies on joint efforts of the private and public sectors. A long-standing controversy is to what proportions do these two groups monetarily and administratively contribute. 

A301/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] The message, and the message is based on the Census Bureau's data tapes which form the basis of this report--the  message is, and it's being sent this year to over 35 million  people in this country--is that even though you are an American, you do not have the right to health care, an idea that is  foreign almost everywhere else in the world, certainly in the developed world. 

A302/Los Angeles Times March 25, 1991, Part B; Page 5; HEADLINE: PLATFORM; A NATIONAL SHAME \\VT-MDS 
All other economically developed countries in the world except South Africa have organized health programs that ensure universal entitlement to basic health services. 

A303/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 The suppressive policies and practices of apartheid in South Africa have directly contributed to preventable morbidity and mortality in black Africans. Due to socioeconomic segregation ("functional apartheid"), America's citizens of color also suffer excess death and disability. Health status measurements in the United States confirm the failure of the current fragmented health care system to recognize or respond to the unmet need or the barriers that exist. Predictably, the changes needed to improve the health status of black South Africans are similar to those that are necessary to remedy the situation in the United States. 

A304/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 THE Republic of South Africa has been the target of international protests, boycotts, and derision based on the treatment accorded their black majority population. Many of the most strident demands for change have come from the United States. While it is clear that the South African system must be dramatically restructured, it should also be noted that the plight of America's black and brown citizens is in dire need of attention. This is particularly evident in the area of health care. 

A305/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Most Western nations treat health care as a public good, similar to education for the young. The United States and the Republic of South Africa share the dubious distinction of being the only industrialized countries that continue to view health care as a privilege. This failure to ensure access to basic health care services for all citizens results in substantial economic and human losses for these countries. 

A306/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 The medical care system of presentday South Africa has been recently described by Nightingale et al. [n1] The segregated nature of this system is not surprising, but the similarities to health care provision in the United States are startling. The health care systems of both nations are characterized by inadequate (or totally absent) care for large segments of their population, gross inequities in the allocation of health care resources, and poorly coordinated and economically inefficient bureaucracies. 

A307/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 While apartheid in South Africa is strictly along racial lines, the segregation in our country occurs primarily as a function of socioeconomic status. However, since ethnic minorities comprise a disproportionate share of our country's poor, these groups remain the primary victims of oppression. African Americans and Americans of Hispanic descent are more likely to be uninsured and less likely to have access to health care than the non-Hispanic white population. [n2] Among hospitalized patients, lack of insurance has been correlated with significantly fewer expensive diagnostic studies and an increased risk of in-hospital death. [n3] 

A308/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Despite dissimilarity in the structure and process of apartheid between the United States and South Africa, the manifestations are the same. The wide disparity in socioeconomic status, preventable disease incidence, and life expectancy between white citizens and people of color in both nations bear witness to the myriad inequities of the current social and health care systems. 

A309/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
		 In many areas of the United States, public hospitals constitute the only health care alternative for the impoverished. Parkland Memorial Hospital in Dallas, Tex, is the primary provider of medical services for the economically disadvantaged of Dallas County. This 940-bed facility has been recognized as one of America's premier medical institutions. [n5] Despite this national reputation for excellence, Parkland fights a daily battle for continued economic viability. Like similar public institutions throughout the nation, our service population is overwhelmingly poor and minority. Many of the inequities described in the South African medical system are mirrored in the medical environment in Dallas and in the indigent health care arena across the United States. 

A310/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Precise quantitative comparisons of morbidity and mortality rates in the United States and the Republic of South Africa are difficult due to woeful inadequacies in South African data. This is particularly true for data regarding their black population. [n10] However, available information exemplifies the shared health care problems of the nonwhite populations of both nations. 

A311/Martin Dyckman, associate editor, St. Petersburg Times, January 21, 1993, Pg. 17A, HEADLINE: What if children could vote? \\VT 93-94
 It would be difficult to explain to a rational visitor from another planet why this nation guarantees health care to its elderly citizens but not to its children. It would be almost as hard to explain to a visitor from any other prosperous country on this planet, where South Africa and the United States are the only developed nations without universal care. 

A312/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 Democratic proponents of this [NHI] strategy perceive its advantages as simplicity, minimal administrative costs, and potential for cost containment. 

A313/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Second, they view it as a way of remedying the current inequity in our health insurance system. Universal coverage would eliminate current exclusions for preexisting medical conditions and would help to solve the problem of adverse selection -- an economic term describing the situation where the sickest members of our society purchase very expensive insurance (expensive because they are at high risk of using it), while the healthy remain uncovered or enroll in less costly plans and use less care. 

A314/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 Medicare, which has proved to be an effective and cost-efficient program administered at a cost of only 5 percent or so, many times less than that of private insurers. Much the same can be expected under national health insurance. Currently, nearly 2,000 health insurers offer a confounding and costly variety of coverage. Payments and rules vary. Whatever system is proposed, it will be uniform in coverage and payments will be equalized. Forms will be simplified. Overhead costs should drop. Payments will be prompt. Losses that result from free care will end. 

A315/Newsday, March 22, 1993, NEWS; Pg. 15 , HEADLINE: Multiple Voices for Single Payer; Growing demand for national health care \\VT 93-94
	 What these seniors want - along with almost every major, organized consumer group, numerous labor unions and scores of grassroots organizations, including many dominated by the elderly and religious activists - is a government-financed and administered health-care system. As simple as it is radical, the single-payer system would provide coverage for all Americans, virtually obliterate the insurance industry, and make the federal government responsible for all medical bills while giving people complete freedom to choose a doctor. The approach is a far cry from the market-based "managed competition" model. 

A316/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Clearly, the development of a novel health care system is ethically and economically imperative. Although building on the current foundation has a certain political appeal, that basis is severely flawed. The country needs to erect a new structure, one that provides universal, or national, health insurance and one that helps to contain health care expenditures. 

A317/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	''It is not difficult to achieve a national health insurance system,'' Fuchs [Victor Fuchs, Stanford University economics professor] wrote. ''All it requires is subsidizing those who are unable to afford insurance and requiring purchase by those who are unwilling to acquire it voluntarily.'' 

A318/Bill Clinton, USA President, May 5, 1993 , President's Remarks at Ceremony for National Nurses Week, The Rose Garden 4:27 P.M. EDT Transmitted: 93-05-07 08:54:04 EDT, Online America\\VT 93-94
	 People cannot say to us you must choose between having a healthy country, an employed country, a country 

A319/PRESIDENT CLINTON, April 29, 1993, WHITE HOUSE PRESS RELEASE, REMARKS BY THE PRESIDENT AND THE FIRST LADY IN RECEPTION FOR THE HEALTH CARE TASK FORCE, Transmitted: 93-05-03 21:07:55 EDT, Online America//VT 93-94
	 We're going to have enough insecurity as it is in America; and everybody is, with all the changes that are going on in this world. The least we can do is to join the mainstream of the world in taking care of our people better, providing a comprehensive, affordable, good, quality health care system. And it's good for the economy. If we can get that idea across we can prevail. 

A320/PRESIDENT CLINTON, April 29, 1993, WHITE HOUSE PRESS RELEASE, REMARKS BY THE PRESIDENT AND THE FIRST LADY IN RECEPTION FOR THE HEALTH CARE TASK FORCE, Transmitted: 93-05-03 21:07:55 EDT, Online America//VT 93-94
	 This is a magic moment in the history of this issue. People have been working for decades just to have the circumstances which exist now. And I hardly see anybody who doesn't admit that the time has come to do something, to do something bold and do something substantial, to do something we can live with from years to come that will really make our country better off, our people more secure, healthier and happier.

A321/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 For all the flaws, analysts on both sides of the Atlantic rank European health care far ahead of what the U.S. offers. Americans Spend More . . . (health expenditures per capita, 1990) United States: $2,566  France: $1,543 Germany: $1,487  Sweden: $1,479 Netherlands: $1,266 Italy: $1,234 Britain: $974 . . . but Are Less Satisfied . . . (share of persons who believe the health  care system works pretty well and only minor changes are needed) United States: 10%  Netherlands: 47% France: 41% Germany: 41%  Sweden: 32% Britain: 27%  Italy: 12% *  . . . and Achieve Poorer Results (infant mortality rates per 1,000 births, 1990) United States: 9.2% Italy: 8.5% Britain: 7.9% Germany: 7.5% France: 7.2%  Netherlands: 6.9% Sweden: 5.9%  Sources: Organization for Economic Cooperation and Development; Robert J. Blendon, Harvard School of Public Health 

A322/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Overall, these countries [with NHI] have equivalent or superior indexes of health, yet spend less on health care than does the United States. [n28] In spite of these documented advantages, certain disadvantages have become modern-day folklore, such as the unavailability of renal dialysis for patients over the age of 50 years or the long waiting lists for hip replacements in the British National Health System. These disadvantages have become effective propaganda against adopting a national health care system in the United States. However, such propaganda is effective only because it magnifies the disadvantages while minimizing the overall benefits of these national health care systems. 

A323/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 With finite health care budgets, these democracies have health care policy-making mechanisms that explicitly address conflicts of interest between the individual and society and conflicts over resource allocation between primary care and other levels of care. [n21,n22] Administrators of this policy-making process set priorities to allocate resources and to organize health care services that will meet policy goals. These western democratic governments provide patients ready access to family doctors and controlled access to high-cost technology and hospital care. Table 3 summarizes the common characteristics of these national health care systems. 

A324/ BILL BILLITER, TIMES STAFF WRITER, Los Angeles Times January 29, 1993, Part B; Page 12; Column 4; HEADLINE: GARAMENDI OUTLINES NATIONAL HEALTH CARE \\VT 93-94
 [Calif. Insurance Commissioner] Garamendi told the Irvine business people that the existing system of health care and health insurance is "inefficient and ineffective." "It's inefficient in that 25% of every dollar that enters the medical system is used for administrative expenses: paper pushers, computer systems, tracking claims, tracking forms," he said. By contrast, Garamendi said, Japan, Canada and most European nations only spend about 7% to 9% of health insurance money on administrative costs. "If we could be as efficient as those countries (in health insurance), we could save about $120 billion annually across the nation," Garamendi said. 

A325/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 The contrast with the United States is striking. Europeans have better access to health care than Americans, an estimated 35 million of whom are uninsured. By most objective measures, they are healthier. And what is most extraordinary, Europe actually spends less for health care  -- about one-third to one-half less in most countries -- than the United States. The U.S. health bill, growing far faster than overall inflation, will reach  something like $800 billion this year, or about 13.5% of the nation's entire economic output.  

A326/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Yet for all the flaws, analysts on both sides of the Atlantic rank European  health care miles ahead of America's. "What can Europeans learn from Americans  about the financing and organization of medical care?" asked Alain C. Enthoven, a health-care financing specialist at Stanford University. "The obvious answer  is, 'Not much.' " 

A327/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Health care in Europe, by contrast, is grounded in collective responsibility. European governments either directly provide most health care, as in Britain, or require that everyone be insured, while paying for most of their citizens' insurance, as in Germany. Either way, European countries operate on the same principle that governs public education in the United States: All of society benefits from a healthy citizenry, and all of society should shoulder the costs. 

A328/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 To Americans, the European approach might seem heavily centralized, bureaucratic and rigid. But Europeans are happier with their approach than Americans are with theirs. A 1990 study by the Harvard School of Public Health found that only 10% of Americans said their "health care system works pretty well." That put the U.S.  system squarely at the bottom of the 10 nations included in the survey. Of the six European countries surveyed, satisfaction levels ranged from 47%  in the Netherlands to 12% in Italy. Canadians, whose national health insurance system is much more European than American, were the most satisfied of all, with a 56% rating. 

A329/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 These ratings square with the few objective ways of measuring national health. Although America's diverse population, with its many minority groups, makes comparisons with more homogeneous Europe somewhat uncertain, it is  nevertheless true that the United States falls consistently below Western European nations in infant mortality rates and life expectancy.  Europe achieves these results even though it spends substantially less for health care than the United States -- typically 7% to 9% of national economic output, compared with America's 13.5%. Central to Europe's approach is a  technique that seems unthinkable in the United States: Governments set strict health-care budgets, and local health authorities must live within their  allowances. 

A330/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Technology aside, Europe is more willing to pay for preventive care than is  the United States, where the uninsured generally benefit from no such care at all and even those with insurance sometimes find reimbursement unavailable.  Americans, and especially the poor, must typically get sicker than Europeans before they can get the care they need, said Jean-Pierre Poullier, a health  policy analyst with the Paris-based Organization for Economic Cooperation and Development. That has the perverse effect, he said, of jacking up the cost of their treatment when they finally get it. 

A331/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 European nations avoid a substantial share of these administrative costs  because they do not make such distinctions. At least in this respect, their  decision to make health a collective rather than an individual responsibility actually saves money.  

A332/Ernie Freda, STAFF WRITER, The Atlanta Journal and Constitution, February 6, 1992, Section A; Page 9 HEADLINE: NATIONAL HEALTH INSURANCE \\VT 93-94
	How it improves access: Everyone is covered by a plan primarily paid for through the federal government and administered through the states. Benefits would be the same for virtually every American and would not depend on where you work or where you live. No restrictions on choice of doctors or hospitals. 

A333/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Opponents of an NHCS, when predicting the impact of a system predicated on a positive right to health care, portray a scenario in which the health care system encourages the individual to make inordinate demands for medical services and becomes institutionally responsible for the health of all individuals. [n52] This distorted prediction overlooks the fact that demands for medical care will always exceed supply and that society can work toward setting limits on the demands for health care. 

A334/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Some kind of national health insurance might also help, writes Payer [veteran medical journalist and author] : ''A uniform system of payment would make it as profitable to treat a truly sick patient as to convince a well one that he or she is sick . . . '' 

A335/B.D. Colen, medical correspondent, Newsday, December 29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	  But what about establishing care limitations based on carefully designed  outcome studies? That is, might we not determine in advance that medical work toward the "cure" of an individual's illness or injury will cease when the chances of leaving the hospital alive fall below a certain threshold?  We are now spending literally billions of dollars a year on futile attempts  to "save" dying individuals, when those dollars could be spent instead on people whose lives can be extended, or at least improved. 

A336/B.D. Colen, medical correspondent, Newsday, December 29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	  Why not say, for example, that when the chances of survival fall below 10 percent, efforts to extend life will cease? Why not say that if, based upon the state of medical knowledge at a given point in time, an individual has less than a 10 percent chance of emerging from a coma, all medical intervention will be discontinued? There is no question that these choices sound harsh, and are certainly hard, but they are far less harsh, and far easier, than refusing something as clearly life-saving as kidney dialysis to people over the age of 55. 

A337/B.D. Colen, medical correspondent, Newsday, December 8, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 79, HEADLINE: Health Care at Square One \\VT 93-94
	 No, the humane way to control health-care costs is not to make health care so expensive that people are forced to buy less of it.  Rather, the way to control health-care costs is to limit the amount of money that can be made by those individuals and corporations that provide health care. 

A338/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 Yet, as the nation struggles to contain the costs of keeping people healthy, some form of rationing is inevitable, experts say. Critical to the debate on rationing health care is the attention devoted to prolonging life. "Our view of death is the key to our whole health-care system," said George Annas, a Boston University law professor who specializes in health. "We have to stop treating death as if it's optional." 

A339/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 "The need for health-care rationing to make these decisions is inescapable," said Leonard Fleck, a Michigan State University medical ethicist. "And if there's any place where these choices get made, it's the intensive care unit." Intensive care is often considered futile for comatose and senile patients, and it can rob alert patients of comfort at the end. In surveys, doctors and nurses say they feel guilty for bombarding dying patients with heroic but hopeless treatments instead of giving them enough pain medication. 

A340/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 The idea of rationing really isn't new. For decades, health care has been served up through a system that ethicists call more unfair than anything Clinton could cook up: one based on the patient's ability to pay. The test is routinely failed by 37 million uninsured Americans; many hold jobs without health benefits and don't qualify for public insurance. Only in an emergency are they given unquestioned access. But after the rescue, the system typically casts them off again because they have no insurance. 

A341/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 "In this country, we've always rationed," said Dr. John "Kevin" Sullivan, medical director of Port Huron (Mich.) Hospital. "Now we're bringing it out of the closet." 

A342/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 Policies that won't be called rationing but would restrict care include: - "Global" health spending caps. Hospitals and doctors would have to keep total expenditures below a certain level, with choices made in advance about which services to provide. - Stringent limits on the number of high-tech machines and services in each region. Such rules would end the costly "arms race" in which hospitals buy expensive devices to keep up with competitors and end up steering patients to the facilities to cover their cost. - Weighing the costs and benefits of unrelated treatments. For example, federal officials estimate that $ 1 million will buy 11,100 life years if it is spent on flu vaccines for the elderly. But supplying $ 1 million worth of the cholesterol-reducing drug Lovastatin to high-risk men from 65 to 74 years old would buy only 41 life years. - Standardizing medical practices so providers could only collect fees for treatments certified as effective. A program that won't pay for ineffective treatments could save billions, said Peter Pratt, a health policy analyst for Public Sector Consultants in Lansing, Mich.: "All the excess garbage will fall out of the system." 

A343/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 American society must stop denying the inevitability of death, she said. "Greedily grasping for life, looking for that heart transplant even if you're 90 years old, is obscene. I mean, really, that's gross." 

A344/Martin Dyckman, associate editor, St. Petersburg Times, January 21, 1993, Pg. 17A, HEADLINE: What if children could vote? \\VT 93-94
 Here, we say we cannot afford it. In that case, cold logic should dictate spending what we have in the most cost-effective fashion - at the beginning of life rather than toward the end. Yet it is only our elderly who (for the most part) are entitled to subsidized health care regardless of their income or residence. Similarly, the vast majority of people over 65 - those who worked under the Social Security system - receive monthly government checks, regardless of need or where they live. Most recipients fancy that they are getting back only what they and their employers paid in. But only for the first seven years. After that, as one Capitol Hill expert puts it, "Social Security is a transfer from one generation to another." So is Medicare; of its total cost, only 9.6 percent is charged to the elderly as premiums. 

A345/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Consensus on these matters is not easily arrived at, but solutions exist. In other nations the government has often resolved these issues by delegating the decision-making process to physicians who allocate and control information and resources, determine priorities and perform rationing. 

A346/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Ironically, opinion polls show that most Americans favor a right to health care and an NHCS to provide health care for all. [n9-n12] In contrast, the Constitution of the United States does not address a right to health care nor provide the government with any guidance on how our society should address the health of the nation. [n13] 

A347/BNA PENSIONS & BENEFITS DAILY, Feb. 24, 1993, HEADLINE: MANUFACTURERS' GROUP TO BE FLEXIBLE ON ISSUES IT TRADITIONALLY HAS OPPOSED Nexis\\VT 93-94
	83 percent supported universal coverage. Of those, about 58 percent felt employers should continue as primary sponsors of health benefits for employees, while nearly 11 percent favored national health insurance and 10 percent favored employer-mandated benefits, and o 55 percent favored a play-or-pay system combined with other comprehensive system reforms. The survey randomly sampled 8,000 NAM members and was based on an 18-percent response rate, the report said.  

A348/Pension Reporter, March 22, 1993, Pg. 673, TITLE: SINGLE-PAYER SYSTEM MORE POPULAR THAN MANAGED COMPETITION, SURVEY FINDS. \\VT 93-94
	 The survey asked respondents about several different reform proposals. The first was described as national health insurance under which the government would pay all medical bills and set fees for hospital and doctors services, 70 percent said they would support such a system, 20 percent were opposed, 10 percent were not sure. 

A349/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 15, 1991; 265: 2563 TITLE: Caring for the Uninsured; Choices for Reform \\VT 93-94
	 On one hand, current opinion survey findings show that Americans are relatively well satisfied with the medical care they receive personally compared, for example, with citizens of Canada, Great Britain, or (West) Germany. However, growing public concern over access to care for the uninsured and sharply rising costs have led Americans to be much less satisfied with the overall workings of our health care system (Table 1). [n12,n13] 

A350/Dolores Kong, Globe Staff, The Boston Globe, July 24, 1992, Pg. 21, HEADLINE: Survey: Cost top health problem \\VT 93-94
	 He [Dr. William E. Callahan, president of the medical society] said the medical society and the American Medical Association support some form of national health insurance to expand access to care and to control costs. 

A351/Los Angeles Times, January 17, 1993, Part E; Page 6; HEADLINE: DOCTOR PRESCRIBES SOME BIG CHANGES FOR AMA \\VT 93-94
 With 292,000 members, the AMA represents 41% of physicians, drastically down from the early 1950s, when it represented 77%. Specialty societies -- for surgeons, internists and many others -- have grown at the AMA's expense. 

A352/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 We project physician costs for the year 2000 under several alternative scenarios, using different assumptions about the future supply of physicians and gross income (or expenditures) per physician. The supply of active, posttraining patient-care physicians is projected to increase from a ratio of 144 per 100 000 population in 1986 to 176 per 100 000 in 2000. Depending on whether expenditures per physician increase at the rate of the consumer price index, the gross national product, or the historical 1982 through 1987 expenditure trends, there will be an additional cost (in constant 1986 dollars) of $21 billion, $30 billion, or $40 billion, respectively, compared with projected physician costs under a scenario of a constant physician-to-population ratio. The disproportionate growth of costs for practice overhead will pose a particular problem for efforts to restrain inflation of expenditures per physician. 

A353/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 THE SUPPLY of physicians is rapidly expanding in the United States. Most studies of physician supply have focused on the issue of supply relative to a target calculated on the basis of anticipated "need" or "demand." [n1-n5] Vigorous debate continues about whether the increasing supply is appropriate for society's future health care needs [n6-n8] or is creating a physician surplus. [n9-n12] 

A354/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 In this report, we examine physician supply in the United States from a different perspective -- that of costs. Rather than addressing the question "How many physicians do we need?" we explore the question "How many physicians can we afford?" As health care costs as a percent of the US gross national product approach 12%, there is concern that our nation cannot continue to support such rapid growth in health care spending. [n13] 

A355/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 The number of physicians is anticipated to rise from a physician-to-population ratio of 144 per 100 000 in 1986 to 176 per 100 000 in 2000 (Table 1), an increase of 22%. The number of physicians actively practicing in the year 2000 will exceed by nearly 90 000 the number needed to maintain a constant physician-to-population ratio. 

A356/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 There is no "correct" number of physicians, any more than there is a correct amount of money to spend for health care. In this article, we have refrained from making judgments about exactly what level and quality of care we will be buying for the increasing resources that we estimate our nation will be investing in physician services in the year 2000. All costs, however, must ultimately be weighed against their benefit. Devoting more resources to physicians and physician services represents a choice, deliberate or otherwise, among alternatives for resource allocation. Well-informed choices will require careful examination of the anticipated costs and benefits of these alternatives. Physician payment policies in the 1990s will require greater attention to physician supply, specialty distribution, and practice expenses. 

A357/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Interestingly, the formation of a national health insurance program at present appears to have more support from the business community, which has become seriously concerned with the escalating costs of health benefits programs, than from the government or the public at large. 

A358/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 15, 1991; 265: 2563 TITLE: Caring for the Uninsured; Choices for Reform \\VT 93-94
	 In addition, as shown in the Figure, increased awareness of and experience with these problems have led the public, corporate executives, and labor union leaders to support some form of universal insurance coverage, even if it means an increase in taxes. [n14,n15] 

A359A/United Press International, January 5, 1993, HEADLINE: Midwest execs favor Canadian health-care plan, Nexis \\VT 93-94
 Among companies in favor of a national insurance plan were the Big Three automakers, Aeroquip, Ameritech, American Seating, Arvin Industries, Cargill, Central Soya, Dow Chemical, Eaton, Eli Lilly, Glidden, Inland Container, Motorola, Navistar, Pillsbury, Sparton, Timken and White Consolidated Industries. 

A359/United Press International, January 5, 1993, HEADLINE: Midwest execs favor Canadian health-care plan, Nexis \\VT 93-94
 While a national health care program was the first choice of nearly two-thirds of the respondents, the survey also found: --16 percent in favor of a pay-or-play option plan, under which employers would either purchase coverage for their employees from private insurance companies, or contribute 7 percent of their payroll to a federal fund that would cover employees and other uninsured Americans. --10 percent backed managed health-care programs to meet employee needs. These would include health maintenance organizations, preferred provider organizations and point-of-service plans. 

A360/BNA PENSIONS & BENEFITS DAILY, Feb. 24, 1993, HEADLINE: MANUFACTURERS' GROUP TO BE FLEXIBLE ON ISSUES IT TRADITIONALLY HAS OPPOSED Nexis\\VT 93-94
 "We recognize that health reform must be multi-faceted and proposals may  contain certain elements which we have traditionally opposed," NAM said. "Employers have neared a point of no-return on the cost issue. NAM  recognizes that any truly comprehensive reform of the U.S. health care system is almost certain to require changes in the way health care is financed." 

A361/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 Increasingly large companies have become more sanguine in their views about national health insurance because they realize that the present situation puts them at a major disadvantage in competition with their overseas counterparts. Automobile companies claim that their entire domestic manufacturing cost disadvantage is related to health-insurance costs. The failed efforts to contain costs and the adverse effect of those costs on U.S. industry have resulted in businesses, in the words of Lee Iacocca, "not just whispering, but talking out loud about making health-care financing a government responsibility." 

A362/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: That's not correct. Our society is mature and the elderly vote. And I don't see that we wish, or have any need, to set up contentions between the young and old or the male and the female or the rural and the urban, which is what we've got with our current separate programs - a separate Medicare for those over 65 and a separate Medicaid for those below a certain income level. When we are all in the same boat, all covered by the same health plan, then I think we can make decisions that will suit the maximum number of people. 

A363/B. D. Colen, medical writer,Newsday, October 27, 1992, Pg. 61, HEADLINE: Health Care Reform's Price \\VT 93-94
	 Given that physicians are now among the highest paid professionals in society, and given that the service they provide is a basic necessity, it is not unreasonable to put a ceiling on what they can charge if that is what is needed to see to it that the nation can make medical services available to all citizens, regardless of their income level. 

A364/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 But what about efficiency? Is it not axiomatic that private institutions, even if not always equitable, are at least more efficient than public ones? A fair answer would be: sometimes yes, sometimes no. 

A365/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 If all Americans had insurance, hospitals and doctors wouldn't off-load their unpaid charges onto paying customers, and SoCal could save 27 percent annually, argues Dr. Jacque Sokolov, the company's medical director. 

A366/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * GLOBAL BUDGETS: A technique in which the government sets an annual target or cap for all of the nation's health-care expenditures. Under the strictest type of budgeting, the government would set a national limit, as well as state-by-state limits, and each state would then apportion spending among doctors, hospitals and other providers. It differs from price regulation, which regulates individual fees, not total expenditures. 

A367/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 Fretful arguments are pouring out of the health care industry in opposition to President Clinton's drive for a national health insurance plan, whatever it may be. Astonishingly, they are the same concerns raised nearly 30 years ago when Medicare was created. They are as specious now as they were then. 

A368/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 The dire effects that were predicted for Medicare, the massive government program that pays a substantial portion of medical bills for Americans over 65 years of age, didn't come true. And it is just as likely they won't come true under a national health insurance plan for everyone else. 

A369/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The term "socialist" does not appropriately describe the health care systems in Canada and England, which are, respectively, referred to as National Health Insurance and the National Health Service. [n29-n33] The key word is national, used in the same way as in the phrase national education. If we applied antisocialist rhetoric against national education, one would expect that the right to basic education for our children would depend on the economic resources of the parents. 

A370/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 What are these false fears? - Government-mandated health insurance will lead to socialism, Communism or worse. It didn't. It won't. 

A371/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Eliminate Medicaid. -- Advocates say a single national insurance plan would eliminate the current two-tiered system under which Medicaid recipients and the uninsured are treated differently by physicians and hospitals, and it would eliminate the inequities in coverage between various state Medicaid programs. 

A372/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 The overall additional medical cost to society for providing the presently uninsured with insurance would be much less than $120 billion. 

A373/Ernie Freda, STAFF WRITER, The Atlanta Journal and Constitution, February 6, 1992, Section A; Page 9 HEADLINE: NATIONAL HEALTH INSURANCE \\VT 93-94
	How it would be paid for: New or increased federal taxes would finance the national system; estimates range from $ 250 billion to $ 400 billion. Most proposals call for it to come from income taxes, although some have suggested a federal sales tax or increased excise taxes on alcohol and tobacco. 

A374/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 Because of the many variables, interactions between the variables and many assumptions about the impact of changes, estimates of the increase in overall costs from fully covering the presently uninsured range widely. Estimates range from 2 percent to 6 percent of overall spending ($16 billion to $50 billion in 1992). 

A375/The Boston Globe, September 16, 1992, EDITORIAL PAGE; Pg. 16 HEADLINE: A formula for a national health plan \\VT 93-94
	 Taxes may - or may not - go up to pay for those who would come under the government organized coverage. Dr. John Ball, ACP executive vice president, expects the $ 800 billion now spent for health care in the US would be enough to cover everyone. 

A376/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Many academic health analysts believe a remodeled U.S. health care system would be able to deliver services to all Americans for the $ 800 billion now spent on care for only some Americans. These experts say the system could do so without denying anyone care that is medically necessary. They point to the large savings that would accrue if unneeded care were eliminated and patterns of administration streamlined. Indeed, some estimates suggest that as much as 25 percent of performed procedures are not required. 

A377/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	Opponents of national health insurance often claim that universal coverage would cause a substantial increase in total health care costs, Fuchs [Victor Fuchs, Stanford University economics professor] said. The logic of this argument suggests that those countries with universal coverage spend more on medical care than does the United States. ''In fact, the reverse is true,'' the economist said. ''Adjusting for differences in real income, the United States spends much more per person on medical care than does any other country. The average American spends about 40 percent more than the average Canadian, even though the difference in real income per capita is less than 10 percent, and Canada spends more per capita than any European country.'' 

A378/Lynn Wagner, Modern Healthcare, January 13, 1992, Pg. 6, HEADLINE: Reform may offer big saving or carry high costs -- CBO \\VT 93-94
	Under mid-range assumptions, national health insurance would save $ 26.3 billion, while an all-payer system would cost $ 5.6 billion. The greater savings under national health insurance would result primarily from lower overhead costs stemming from the elimination of private insurance and payment reductions because of lower costs. "The key finding is that a single-payer approach will extend Medicare-type benefits to every American and cost less than current spending," said a statement from Rep. Fortney "Pete" Stark (D-Calif.), chairman of the House Ways and Means health subcommittee, who requested the report. 

A379/Spencer Rich, Washington Post Staff Writer, The Washington Post, January 11, 1992, PAGE A11 HEADLINE: 2 Studies Differ Sharply On Health Care Overhaul \\VT 93-94
	The study released by Stark earlier this week was prepared by the Congressional Budget Office (CBO). The study's premise was a single federal insurance system patterned on Medicare, covering all Americans and using the Medicare payment system and cost-control mechanisms. Medicare generally pays doctors more than Medicaid does but 16 percent less than private insurers. It pays hospitals about 12 percent less than private insurers. Under those assumptions, the study found, a national system would cut costs $ 26.3 billion while covering everybody. 

A380/WALL STREET JOURNAL, February 3, 1993, Section A; Page 2, TITLE: HOUSE PANEL TOLD HEALTH-CARE SYSTEM RUN BY GOVERNMENT WOULD BE CHEAPEST \\VT 93-94
 Congressional Budget Office director Robert Reischauer, testifying before House Ways and Means health subcommittee, asserts that a national health-insurance system financed and operated by the federal government may have the best chance of controlling medical costs (M) 

A381/Marcel Frenkel, MD, MBA, University of Illinois at Chicago, College of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2483 TITLE: Caring for the Uninsured and Underinsured \\VT 93-94
	 The cost of universal coverage would be mitigated by (1) the savings derived from the elimination of the open-ended benefits of Medicare and Medicaid; (2) the fact that relatively little hospital care is needed by the uninsured, since two thirds are believed to be under 24 years; and (3) a tax on currently tax-free health care insurance premiums paid by employers that could yield $30 billion. 

A382/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Some would argue that the additional costs required to achieve universal access to health and long-term care are prohibitive. We disagree and believe that recent cost estimates and the proposed revenue sources for system reform are manageable. [n2,n4,n14] For example, Thorpe and Siegel [n14] have analyzed the new costs that would be incurred by enacting various combinations of expanded Medicaid and employer health insurance coverages. The public cost, as expressed in 1989 dollars, is estimated to range from $11.5 to $29.5 billion. Regardless of the approach selected to achieve universal access to health care, there is little doubt that reasonable control of the total expenditure level, as well as the annual growth in costs for a restructured system, will require implementation of cost containment mechanisms similar to, if not more comprehensive than, those we have proposed. 

A383/Mike Fairley, staffwriter, Black Enterprise, May, 1992, Pg. 20, HEADLINE: HEALTH DEBATE RAGES ON \\VT 93-94
	 LeRoy Robinson Jr., executive director of the Minority Health Association, doesn't accept the argument that national health care will cost too much. "Any time a society like ours spends over $ 600 billion a year on health care, there's certainly enough funds in the system to do whatever we want," he asserts. 

A384/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Third, they see it as a way of correcting our current unfair system for financing uncompensated care. Universal coverage would mean that those with health insurance will no longer be asked to pay for the care for those who do not have health insurance (often referred to as "free riders") through uncompensated care charges. Last, a single federal law would eliminate the wide disparities in insurance coverage among states. 

A385/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  WOLFE [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] : When you talk to a lot of the people who are supporting at least a number of these varieties that you speak of, they will say privately we know that we've got to go to a single-payer Canadian system, but the American public is not  ready to swallow the tax increases. Well, as can be seen here,  the public sector is already swallowing an enormous amount of the health care expenditure, and it isn't as though we're going  to go from no public expenditure, no tax base, to $ 800-plus  billion. 

A386/B.D. Colen, medical correspondent, Newsday, December 8, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 79, HEADLINE: Health Care at Square One \\VT 93-94
	 Yes, we need to raise the taxes paid by all Americans to assure adequate  health care for all Americans.  Raise taxes? Wait . . . Before you swear and stop reading this, consider what you now pay for private health insurance, insurance deductibles and co-payments. Suppose, for example, that you are employed by a generous corporation and pay only $ 25 each week toward the cost of your family health insurance coverage. Further, assume that you pay an annual deductible of $ 500, plus a 20 percent co-payment for all physician charges. That means you're paying at least $ 2,000 a year now for your health insurance, deductibles and co-payments.  

A387/B.D. Colen, medical correspondent, Newsday, December 8, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 79, HEADLINE: Health Care at Square One \\VT 93-94
	 Suppose the federal government paid all our medical bills. Your taxes could  be "increased" by $ 2,000 per year, or $ 38.46 per week, but your financial  situation wouldn't change at all. 

A388/The Economist, February 8, 1992, Pg. 14 HEADLINE: The healthy option \\VT 93-94
	"Tax increases", bellows a health-care industry eager to protect income against a powerful purchaser and to preserve the system's wasteful administrative apparatus. Technically, yes. But most people would barely notice the change. Contributions to state-controlled insurer would still be deducted from pay packets. Only the label would alter. And because such a national system would be cheaper, most people would, eventually, pay less than they do now. That should cheer many disgruntled Americans -- enough, perhaps, for a bold politician to face down the special interests. Even the ones from hell. 

A389/Ernie Freda, STAFF WRITER, The Atlanta Journal and Constitution, February 6, 1992, Section A; Page 9 HEADLINE: NATIONAL HEALTH INSURANCE \\VT 93-94
	Impact: Health care would no longer be dependent on insurance. While taxes would rise significantly, proponents point out that weekly deductions for the private health insurance that most Americans now pay would end. Moreover, a national health insurance plan could include no deductibles, no co-payments and total coverage for preventive health measures, so there would be little or no out-of-pocket expenses. 

A390/Bill Clinton, USA President, May 5, 1993 , President's Remarks at Ceremony for National Nurses Week, The Rose Garden 4:27 P.M. EDT Transmitted: 93-05-07 08:54:04 EDT, Online America\\VT 93-94
	 People say, well, it may cost somebody else some money. Let me tell you something, all those people who don't have health insurance today, they're being paid for by everybody else who's paying the bill. What about fairness to them? Who's thinking about them? I'll tell you something else. We've been reducing defense spending quite steeply and about all we can for the last five years. And all the savings we hope to have in the peace dividend have been exploded away by rising health care costs and interest payments on this deficit. 

A391/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Cost Shifting: Charging higher prices for health services to people with "richer" insurance plans to "make up" for being paid less from others. It results from large third party payers (both private and public) being able to negotiate discounts for people covered under their plans. This also results from the provision of services to the uninsured. Proponents for insurance coverage for everyone point out that society is already paying for much of the health costs of the uninsured through cost shifting. 

A392/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] I think that there is a misreading and a patronizing of the American public by those people in Congress who believe that the American public would not rather spend less totally, even though their taxes may be up. When the person who makes $ 30,000 a year pays the same premium as the person who makes $ 300,000 a year, it is incredibly inequitable. And for an administration, the up and coming Clinton administration, who claims that they are up for taxing the wealthy, it's interesting how that somehow doesn't fit in with a single payer system which would be essentially publicly financed. I think a lot of  learning has to happen, mainly by politicians, to learn that the public is ready for it; polls really show that, and I think they have to just stop patronizing the American public. 

A393/Sabin Russell, Chronicle Staff Writer, The San Francisco Chronicle, DECEMBER 16, 1992, Pg. A5, HEADLINE: Economy, Deficit Bigger Worries Than Health Care, Study Says \\VT 93-94
	 Significantly, voters showed a willingness to accept modest tax increases to support a national health-insurance program. Half the voters polled said they were willing to pay an additional $ 20 a month in taxes to provide coverage to  all Americans, but only 24 percent were willing to accept $ 50 a month. 

A394/Sabin Russell, Chronicle Staff Writer, The San Francisco Chronicle, DECEMBER 16, 1992, Pg. A5, HEADLINE: Economy, Deficit Bigger Worries Than Health Care, Study Says \\VT 93-94
	 Voters were willing to accept some, but not all, forms of taxation to support a national health program. The strongest support, 76 percent of voters polled, was for liquor and cigaret taxes, followed by 61 percent of voters favoring an income tax increase on those with incomes greater than $ 50,000. A tax on health insurance benefits that exceed the price of low-cost plans -- a key reform sought by backers of managed competition -- garnered support from 52 percent of voters. The least popular tax, on incomes greater than $ 25,000, was supported by only 29 percent of voters polled. 

A395/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 The irony is that the public is willing to pay higher taxes in exchange for assured coverage. In the NBC-Journal poll, two-thirds said it would not be possible to provide health care coverage for all without raising taxes. And two-thirds said they were willing to pay higher taxes so that everyone could be covered. 

A396/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 On the other hand, an astonishing 42 per cent said they would be willing to pay "a tax of up to 200 per month if the government could guarantee health care for you and your family with almost no other costs." The message is that Americans want health care security -- and are willing to pay a lot to get it. 

A397/Hospitals, Journal of the American Hospital Association, June 5, 1992, Pg. 10, HEADLINE: Survey shows voters willing to pay tax for health care plan \\VT 93-94
	 Three-fifths of U.S. voters say they would be willing to pay an extra nationwide tax of $ 50 per month to finance a national health insurance plan, according to a survey of 1,004 registered voters released recently by the Mildred and Claude Pepper Foundation, McLean, VA. Respondents were most receptive to increases in taxes on liquor and cigarettes and an increase in the personal income taxes for households earning more than $ 50,000. But increased taxes on Social Security benefits and gasoline were opposed. 

A398/The Houston Chronicle, January 9, 1992, SECTION: HOUSTON; Pg. 1 HEADLINE: SAVE THE CHILDREN; Surveys: Kids top priority list for tax dollars \\VT 93-94
	AMERICANS say they are tired of hearing about abandoned babies, abused toddlers and low school test scores. They want action on children's issues -- even if it means increasing taxes, according to two reports released Wednesday in simultaneous press conferences in Washington and Austin. Children topped the priority list for tax dollars, even when measured against hard choices such as fighting crime and drugs. 

A399/BUSINESS WIRE, March 23, 1993, HEADLINE: AMERICANS STRONGLY BACK CLINTON'S EFFORTS FOR HEALTH CARE REFORM, Online America, Transmitted: 93-03-23 15:55:00 EST \\VT 93-94
	 Americans strongly support most key elements the Clinton Administration is thought to be considering as part of its health reform plan, and a majority would be willing to pay more taxes -- including a 3 percent national sales tax -- to pay for it, according to a new survey by the Kaiser Family Foundation and Louis Harris and Associates. 

A400/BUSINESS WIRE, March 23, 1993, HEADLINE: AMERICANS STRONGLY BACK CLINTON'S EFFORTS FOR HEALTH CARE REFORM, Online America, Transmitted: 93-03-23 15:55:00 EST \\VT 93-94
	 When people were asked if they would still support the listed elements of reform if it meant some new taxes, 69 percent said yes. Fifty-five percent said they would rather see increased tax revenues dedicated to health reform rather than deficit redction (38%). Those polled prefer sin taxes to help finance health reform, however, a majority were also willing to 

A401/BUSINESS WIRE, March 23, 1993, HEADLINE: AMERICANS STRONGLY BACK CLINTON'S EFFORTS FOR HEALTH CARE REFORM, Online America, Transmitted: 93-03-23 15:55:00 EST \\VT 93-94
	 - 58 percent said they would support a 3 percent national sales tax, - 79 percent would support a $1 tax hike on a six-pack of beer, - 75 percent would support a 20 percent tax on guns and ammunition, - 74 percent would support a $1 tax hike on a pack of cigarettes. 

A402/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 The recent controversy over the costs associated with administering the current health care system has brought added visibility to the question of who should administer any national health plan. The role of the administrator is to collect the premiums and taxes, market the policies, set payment levels in conjunction with providers and payers, process claims, and monitor quality of care. Studies show that the direct costs associated with this process vary considerably. The Medicare program carries with it a 4% direct overhead cost, while overhead for private insurance ranges from 5% to 40% of costs, depending on the size of the employer group (Figure). [n12] Smaller groups cost more because of a combination of factors, including increased manpower needed to market to small firms and the small base over which the risk of high costs can be spread. 

A403/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 This suggests that any additional funding for medical care must be sought from individuals and households, out-of-pocket or through payment of additional "sin," income, or other taxes. The point could be made that an important source of potential funding has been overlooked: reform of the extant system of medical care provision to reduce its excessive administrative and malpractice costs and the elimination of many unnecessary and ineffective treatments. It has been estimated that the combined total savings from such reforms could amount to as much as $100 to $150 billion annually. In the present context it is essential to note that although substantial savings might be recoverable over time, they cannot be spent until they have been recovered, and the lead time for implementing practice guidelines is likely to be of the order of a decade of intensive outcomes research. [n8] 

A404/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 There is growing appreciation that the administrative costs of medical practice and health insurance in the United States are far in excess of those in other nations. [n31,n32] Himmelstein and Woolhandler [n31] have proposed that a large proportion of practice expenses in the United States are attributable to the cumbersome and complicated payment procedures accompanying our multipayer insurance system and could be ameliorated by a uniform, national health insurance program. Greater diffusion and duplication of office-based technology may also explain a portion of American physicians' high overhead and may require stricter regulation. Malpractice insurance, while not as dominant a factor in overhead as often believed, nonetheless accounted for 12% of expenses in 1986, up from 7% in 1982. [n16] 

A405/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 One area that has not been addressed well is administrative waste in the US health care system. Recent studies have shown that up to 20% of every dollar spent on the administrative aspects of health care is wasted. If the system were streamlined, then $ 15 billion of the $ 78 billion spent in administration could be saved. One cost analysis has shown that with the institution of a NHI plan, $ 30 billion in administrative costs could be saved. This money could then be potentially used to help offset the costs required for 

A406/Tony Connole, St. Petersburg Times, December 13, 1992, Pg. 3D, HEADLINE: Basics of Canada's health plan can work in the U.S. \\VT 93-94
	 Some of the cost of a national health plan should come from the profits of the health insurance industry and the elimination of the vast administrative costs imposed by that industry. The essence of their new policy asks that a national health insurance plan bear the unnecessary and high cost of continuing the administrative inefficiencies and confusing complexities of  the past. 

A407/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: It is precisely a consequence of having multiple private insurers simultaneously operating in the environment. In that situation, the government feels it must protect itself against the competing interest of other insurers [and try to find] an alternative way in which the patient could pay for this expense. A single payer [on the other hand] feels it is obligated by statute and public policy to pay for everything. Then there is no longer any need for hassles and paperwork to deny payment. 

A408/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 What are these false fears? - Hospitals and doctors will suffer serious consequences: lower fees for their services and mountainous red tape. The opposite happened. When Medicare announced it would pay only 80 percent of doctors' fees - a tradeoff against the guarantee that no bill for elderly patients would go unpaid - doctors immediately raised their fees, so they still collected 100 percent of their customary charge. Hospitals, long paid miserably lower rates by welfare departments for poor elderly patients, never had it so good. Medicare payments to hospitals were set at the full rate, and payment is prompt. The income of hospitals and doctors rose remarkably with the advent of 

A409/Ernie Freda, STAFF WRITER, The Atlanta Journal and Constitution, February 6, 1992, Section A; Page 9 HEADLINE: NATIONAL HEALTH INSURANCE \\VT 93-94
	How it controls costs: The biggest cost savings would be in the elimination of private health insurance, especially the administrative costs connected with the paperwork and review mechanisms imposed by the nation's 1,500 insurance companies. Secondly, states would be empowered to put hospitals on fixed budgets, a move that would cut down on the duplication of expensive services and equipment. Such a move also could result in longer waits for some non-emergency services. 

A410/Rudolph J. Mueller, MD, Rush Medical College, Journal of the American Medical Association, March 13,1991; 265: 1258-1259 TITLE: A National Health Insurance Tax on Tobacco and Alcohol: The Puritan HIT \\VT 93-94
	 To offset these medically related costs and reduce consumption while providing the financial backing of the underinsured, I propose the development of a national health insurance tax (HIT). The HIT would be directly applied to all tobacco and alcohol products sold in this country and would be recalculated annually. The product's annual HIT would equal the previous year's direct medically related costs divided by the quantity sold. With 34 billion packs of cigarettes sold in 1984, the 1985 tobacco HIT would have been 68 cents per pack ($ 23 billion in direct costs per 34 billion packs sold). [n4] In 1988, there were 27.7 billion gallons of alcohol sold for a 1989 alcohol HIT approximating $ 1.45 per six-pack of beer. A 1990 HIT estimate would probably be higher considering rising medical care costs. 

A411/Rudolph J. Mueller, MD, Rush Medical College, Journal of the American Medical Association, March 13,1991; 265: 1258-1259 TITLE: A National Health Insurance Tax on Tobacco and Alcohol: The Puritan HIT \\VT 93-94
	 Similar taxes have been proposed or are in effect. Recently, Rep Fortney Stark (D, Calif) introduced in Congress legislation to tax the tobacco companies directly for the Medicaid and Medicare costs secondary to tobacco-related illnesses, as reported by L. Jones in American Medical News (1990:3). A national HIT may be more effective, though, by directly taxing the patient-consumer at each purchase. While both would reduce consumption, the HIT would also provide a strong educational message, ie, smoking and alcohol consumption contribute to health care costs. 

A412/Rudolph J. Mueller, MD, Rush Medical College, Journal of the American Medical Association, March 13,1991; 265: 1258-1259 TITLE: A National Health Insurance Tax on Tobacco and Alcohol: The Puritan HIT \\VT 93-94
	 The HIT could then provide funds for a universal access program for the underinsured, estimated by the recent Pepper Commission at $ 24 to $ 70 billion annually. [n5] Additional HIT funds could provide the $ 2.2 billion needed to upgrade and expand the drug treatment system. [n6] The HIT could also support tobacco and alcohol disease -- related research, programs to stop smoking, and primary prevention educational programs. By providing for the financial support of the underinsured, all tobacco- and alcohol-consuming patients would have access to medical care for possible future illnesses, a "pay as you go" philosophy. 

A413/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 Another method to fatten the federal "wallet" had its chance in Congress in 1988 but was rejected. Presently, federal excise tax on cigarettes is 16 cents a pack. If the tax were increased to 32 cents a pack, as had been proposed, the 29 billion packs smoked yearly would provide additional revenue of $ 4.6 billion. 

A414/United Press International, May 10, 1993, TITLE: MAJORITY OF AMERICANS FAVOR SIN TAXES TO PAY FOR HEALTH CARE REFORM, POLL SAYS, Online America, Transmitted: 93-05-10 15:36:00 EDT \\VT 93-94
 Most Americans favor an increase in cigarette and alcohol taxes to help pay for health care reform, according to a Gallup poll taken for three health organizations and released Monday. 
The poll taken for the Coalition showed that 73 percent of those in a national sample support a higher cigarette tax. Of those, 67 percent support a $2 increase and 75 percent favor an alcohol tax increase. 

A415/United Press International, May 10, 1993, TITLE: MAJORITY OF AMERICANS FAVOR SIN TAXES TO PAY FOR HEALTH CARE REFORM, POLL SAYS, Online America, Transmitted: 93-05-10 15:36:00 EDT \\VT 93-94
Coalition [for Smoking or Health] lawyer Matt Myers said that a variety of economists in and out of government estimate that a $2 cigarette tax hike would yield at least $90 billion over five years, even accounting for the likelihood that higher taxes would make many people quit smoking. 

A416/United Press International, May 10, 1993, TITLE: MAJORITY OF AMERICANS FAVOR SIN TAXES TO PAY FOR HEALTH CARE REFORM, POLL SAYS, Online America, Transmitted: 93-05-10 15:36:00 EDT \\VT 93-94
American Cancer Society spokeswoman Patricia Sanderson, said that a $2 tax hike would not only provide money urgently needed for health care reform but spare the nation "burdensome health care costs and agonizing premature deaths for generations to come." 

A417/Ron Scherer, Staff writer, The Christian Science Monitor, November 3, 1992, SECTION: THE U.S.; CAMPAIGN '92; Pg. 2 HEADLINE: Smoking Is Another Tax Target \\VT 93-94
	 "We expect to be one of the revenue targets since deficit reduction and funding for some sort of national health insurance or health-care reform are going to be high up in the priorities in any new administration," says Walker Merryman, vice president for public affairs at the Tobacco Institute, the chief lobbying arm of the tobacco industry. 

A418/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 "Since its inception in the 1950s, the VAT has been widely adopted by both developed and developing countries," a February CBO report said. "More than 50 countries currently have VATs, including 20 of the 25 industrialized countries that make up the Organization for Economic Cooperation and Development. The United States remains one of the few Western industrialized countries without a VAT and the only one without a VAT or a national sales tax." 

A419/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 In Value Added Tax International Practice and Problems (International Monetary Fund, 1988), analyst Alan Tait called the VAT's rise "an unparalleled tax phenomenon"; it's now in use on every continent. 

A420/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 Japan adopted a VAT in late 1988 to offset budget deficits that had accumulated for over a decade. Two years later, Canada enacted a VAT to replace an existing sales tax that was thought to place an unfair burden on domestically produced goods. 

A421/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 Eight prominent economists and tax experts, spanning the ideological spectrum, expressed support for a VAT in a late-1989 letter sent to members of the Nashville (Tenn.)-based American Economic Association. The signers included Walker; Brookings Institution economist Henry J. Aaron; Harvard University economics professor Benjamin N. Friedman; Harvard economics professor Lawrence H. Summers, who is now chief economist of the World Bank; former Energy and Defense Secretary James R. Schlesinger; chairman of Nixon's Council of Economic Advisers Paul W. McCracken. 

A422/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 The World Bank's Summers has quipped, in an oft-cited line: "Liberals hate a VAT because it's regressive, and conservatives hate it because it's a money machine. When liberals see that it's a money machine and conservatives see that its regressive, it will be enacted." 

A423/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 Another argument for the VAT is that U.S. tax policy is out of sync with the rest of the global economy. Some experts say that America's federal tax system, with its relatively high dependence on income taxes, puts U.S. firms at a competitive disadvantage. "The increasingly international nature of business competition requires updating the American tax system to global realities," Murray L. Weidenbaum, who directs the Center for the Study of American Business, wrote in a recent paper. 

A424/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 VAT proponents note that under the General Agreement on Tariffs and Trade, nations can impose value-added taxes on imports and rebate them on exports. As a result, they argue, a U.S. VAT would be advantageous to firms engaged in international trade. 

A425/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 Even the most modest proposals to increase federal excise taxes, such as on gasoline and cigarettes, send state officials on the warpath. They reason that the more money Washington raises through such levies, the more the voters will resist hikes in comparable state taxes. 

A426/ANNE WILLETTE; Gannett News Service correspondent, GANNETT NEWS SERVICE, February 23, 1993, HEADLINE: NATIONAL SALES TAX YEARS AWAY BUT WOULD BE A MONEY GENERATOR, Nexis \\VT 93-94
 A value-added tax also has the advantage of being almost invisible to  consumers. Unlike traditional sales taxes, which are calculated at the cash  register, a value-added tax is assessed at each step of the production process. By the time the product reaches the store, the tax is included in its price. 

A427/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] So, in summary, as Steffie mentioned a few minutes  ago, we believe that an American modification of the Canadian health care system is essential; otherwise we will continue to be more and more embarrassed, as physicians, watching our  country deny health care to so many millions of Americans. 

A428/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University)] But our group does advocate what we think is the best  working model, the best model that has experience delivering  health care to all people, and that of course is a single payer  model, modeled after the system in Canada.  

A429/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 [JEFF LEVINE, Medical Correspondent] The Canadian health care system isn't likely to migrate into the U.S. any time soon. America is still a long way from deciding how to reform its health care system, but the Canadians have shown it is possible to provide medical care to everyone from the cradle to the grave. 

A430The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Single Payer. A system that has a single-payer -- the government -- for all health care. The government would impose a health tax of some sort to pay for it. Doctors, hospitals and other medical services would remain in private hands, although the government would impose various forms of price controls on them. This is also often referred to as the "Canadian model" or " national health insurance, " although many politicians have used the latter phrase simply to mean that all people should be able to buy health insurance. 

A431/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 SINGLE PAYER: A Canadian-style system under which the government would pay for all health care with specially earmarked tax dollars. Government would set  prices and impose regulations, but doctors, hospitals and other providers would remain in the private sector. 

A432/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent] : Except for dental care, virtually all of Canada's $ 62 billion health bill is paid through taxes. Even prescription drugs for the poor and elderly are covered. The system is run by each of Canada's 10 provinces with some help from the federal government. And unlike the U.S. where paper pushing consumes an estimated 24 cents of every health care dollar, it costs Canadians just 11 cents per dollar for their bureaucracy. 

A433/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * SINGLE PAYER: A Canadian-style system under which the government would pay for all health care with specially ear-marked tax dollars. Government would set prices and impose regulations, but doctors, hospitals and other providers would remain in the private sector. 

A434/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: While Canadian doctors are paid by the government, most are in private practice. Patients can choose any physician they wish. 

A435/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 "What we have," says Canada's Deber, "is managed care with free choice. . . . The Canadian system is the American system as it was 20 years ago, but with universal insurance." 

A436/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	 Q: One of the things that happens in Canada is there is a long wait for certain procedures. Canadians can come to the United States and deal with private medical care. How would you  modify the Canadian type single-payer approach here, so that  there was a way to get out of the bureaucracy, if you got caught in a resulting bureaucracy. WOOLHANDLER [DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University)]: Well, Canada currently spends about 40 percent less than the United States does on medical care, and what our group advocates is not cutting back U.S. spending by 40 percent. But taking our higher levels of spending, that we have here in the U.S., but spending on Canadian levels of efficiency. That means getting the money to actually care for people rather  than wasting a quarter of it on administration and bureaucracy.  

A437/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. STEFFIE WOOLHANDLER (Assistant professor of  medicine, Harvard University)] We think that with that kind of system we could really have Canada deluxe, that is, universal access, complete free  choice of physician, and no waits for any sort of surgery or any sort of diagnostic testing.  

A438/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. DAVID HIMMELSTEIN, Harvard Medical School: Well, we want Canada deluxe. We don't want just Canada. We spend $ 1000 more per person than Canada does and with that kind of extra spending we could have a far better system than Canada does. Canadians live longer that we do, they get more doctor visits than we do, they don't have any uninsured people in Canada. Canadians can go to any doctor, any hospital in the country and in fact there's no bureaucracy telling doctors and hospitals what to do. American doctors face more bureaucracy than any doctors anywhere else in the world and our quality of care is declining. 

A439/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 These countries have established different types of national health care systems to assure universal access to health care. For example, the Canadians value the principle of egalitarianism to such an extent that private insurance and private medical practice are not allowed. The public system provides equivalent health care benefits to all Canadians. In contrast, the British government has recently encouraged the expansion of private health insurance, so that increasing numbers of patients are obtaining their medical care independent of the National Health Service. Thus, having an NHCS does not preclude the possibility of private insurance and private medical practice. 

A440/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 If I were to get sick, with anything from a simple illness to something that was life threatening, there is no doubt in my mind that I would want to be treated in the United States. However, if I were poor, either covered by Medicaid or, especially, having no insurance, I would cross the border and wish I were in a system where there was universal coverage, perhaps offering me better care as well as dignity. I would not want to rely on what Uwe Reinhardt, a Princeton economist, has called a provider's "noblesse oblige." 

A441/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 With the Canadian system, every patient pays the same amount. A physician is barred from taking money from a patient -- even a tycoon -- to supplement the government-approved fee. Instead of competing for the best-insured patients, in other words, doctors would compete for patients, period. This could bring an exodus from the region's K Streets. Clinics could sprout east of Rock Creek Park and throughout Prince George's County. 

A442/DAVID U. HIMMELSTEIN,M.D., associate professor of medicine, Harvard Medical School, The New York Times, March 1, 1992, Section 4; Page 14; HEADLINE: In Health Care, Canada Beats U.S. and Britain; Drug Company Studies \\VT 93-94
	 As for availability of services, Canadians average 56 percent more doctor visits for evaluation and management, and 20 percent more surgical procedures than Americans (New England Journal of Medicine, Sept. 27, 1990, page 884). The figures Mr. Ridenour uses on waiting lists are the outlandish products of yet another drug company "study." 

A443/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: Shortcomings or not, many reformers insist the Canadian concept is the best cure for the U.S. health care emergency. Could the Canadian system be transplanted here? If so it would provide coverage for all the 35 million Americans who currently lack health insurance. 

A444/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Primary and emergency care, universally insured, are readily available. No financial or administrative barriers prevent patients from seeking the services of any family doctor. Canadians are not assigned doctors from approved lists, but rather choose them: It is that simple. 

A445/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Canadians visit physicians more often than Americans do and are highly satisfied with the service and the system. With a single insurer, the provincial government, there is far less paperwork for patients and doctors. More important is the widespread sense of security that comes from knowing that illness, however catastrophic, never results in financial disaster. 

A447/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Many studies have shown that a  "single-payer" system like Canada's would eliminate between $80 billion and $140 billion in administrative waste.  

A448/JOHN MACDONALD; Courant Senior Washington Correspondent, The Hartford Courant, April 25, 1992, Pg. A2 HEADLINE: In health care debate, numbers sometimes can mislead \\VT 93-94
	 It all sounded horrible, if true. The problem is that in the debate over health care reform, nearly every group has a favorite plan to fix the system. In Citizen Action's case it is national health insurance based on Canada's plan, where administrative costs are about 1 percent. Compare 1 percent administrative costs with 37 percent, says Citizen Action, and the choice is obvious. 

A449/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 There is a solution -- at least for our first two patients. Instead of adding a new layer, like a Band-Aid on a gangrenous wound, the aim should be to simplify: eliminate the 1,500 private insurers (they can always go back to auto and life) and replace them with a Canadian-style "single payer," which could be the Federal Government, a quasi-public agency or each of the 50 states. In one fell swoop, health-care costs would be reduced by much of the $80 billion that now goes for "administrative overhead," producing savings that, according to the General Accounting Office, would be sufficient to insure everyone, without deductibles, coinsurance or Oregon-style rationing. It would still be the job of the new single payer to crack down -- not on consumer overutilization but on rampant profiteering and plain old corruption (doctors referring patients to their own profitmaking CAT-scanning facilities, for example). 

A450/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	The most obvious source of savings under national health insurance, said Fuchs [Victor Fuchs, Stanford University economics professor], is in reduced administrative costs. Approximately 6 percent of U.S. health expenditures are in program administration and net cost of private health insurance. Several additional percentage points account for costs incurred by doctors and hospitals for billing and other administrative activities. By contrast, Canada's system of provincial insurance imposes minimal administrative and billing costs on health care providers because everyone must join, and premiums are collected through the tax system. 

A451/United Press International, January 5, 1993, HEADLINE: Midwest execs favor Canadian health-care plan, Nexis \\VT 93-94
 According to Imberman and DeForest, the major reason for choosing a national health care program on the Canadian model was elimination of health benefit paperwork by employers, and uniformity of care among employees of large and small companies. Another reason cited was the new accounting rule mandated by the Financial Accounting Standards Board that requires corporations to carry all future health care losses as accounting liabilities. The rule is expected to cause huge paper losses in companies with large numbers of retirees. 

A452/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Advocates [of Single- or All-Payer Systems, Budgets] also believe that direct governmental intervention is often required to resolve conflicts between the broader societal goals of controlling health care costs and improving the health of the community (which includes guaranteeing access to needed care) and the goals of physicians, hospitals, and nursing homes to provide the best care for individual patients while enhancing their own professional and financial positions. 

A453/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: The United States spends about $ 2,700 per person annually on medical care. Yearly medical costs run about $ 800 billion - nearly 13% of the gross domestic product. In contrast, Canada commits about $ 2,000 per citizen - that works out to 9.5% of its GDP. Still, Canadians live longer and have a lower infant mortality rate - proof, say proponents, their approach works better. 

A454/Reuters News Service, April 23, 1992, HEADLINE: U.S. GROUP SAYS PRIVATE HEALTH INSURANCE WASTEFUL, Nexis \\VT 93-94
	 Citizen Action vice president Bob Brandon said they found if U.S. companies had been as efficient as the Canadian national health care system the savings would have been $16.7 billion a year. "What this study demonstrates is the commercial health insurance industry is both wasteful and ineffecient," Brandon said at a news conference. 

A455/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Is Canadian care as expensive as ours? In 1991, Canada spent about 9.2 percent of its national income for medical care while the U.S. spent 12.3 percent; the proportions for 1971, the year Canadian Medicare became universal, were 7.3 percent and 7.4 percent, respectively. So, over two decades Canada learned how to insure everyone while spending less. 

A456/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Controlling costs means living within one's means. Canada, with a health budget, decides what to spend for care. Budgetless America learns about its health costs only after the fact; few celebrate the result. 

A457/Health Line, October 22, 1992 , HEADLINE: PRESCRIPTION DRUGS: THEIR DRUGS ARE CHEAPER, EH? Nexis \\VT-ACS
	 WHY?: According to the JOURNAL, the GAO study attributes much of the price differential to Canadian gov't regulation of health care costs, including prescription drug prices. JOURNAL: "But findings suggest that U.S. consumers may be subsidizing patients in countries with price controls at a time when U.S. health care costs are escalating out of control" (Stout, 10-22). N.Y. TIMES notes GAO found several ways Canada keeps prices down, including reimbursement for only the cost of the lowest-priced treatment; annual drug price reviews by a nat'l board; the alignment of price increases with inflation; and by encouraging competition by allowing generics to be sold after 7-10 years of exclusive rights, compared to 17+ years in the U.S. 

A458/United Press International, January 16, 1992, HEADLINE: Group says Canadians getting low-cost health care, Nexis \\VT 93-94
	Ohioans spent nearly twice per capita for health care in 1990 than their Canadian neighbors in Ontario, according to a report released Thursday by Citizen Action. Citizen Action, a national consumer and environmental organization which is pushing for creation of a Canadian-style national health insurance system, said health spending in Ohio during 1990 totaled $27.2 billion or $2,493 per resident. In Ontario, health spending for the same year was $13.08 billion or $1,377 a resident. 

A459/Lynn Wagner, Modern Healthcare, January 13, 1992, Pg. 6, HEADLINE: Reform may offer big saving or carry high costs -- CBO \\VT 93-94
	A single-payer national health insurance system could pare as much as $ 58 billion from national expenditures or add as much as $ 7 billion to the tab, said a new Congressional Budget Office report. 

A460/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 JEFF LEVINE, Medical Correspondent: One goal of the Canadian system is to keep people healthy enough so they don't need costly high-tech treatments. Preventive care is something of a passion in the Canadian system where there are many more family care physicians than specialists. In the U.S., it's just the reverse. 

A461/DAVID U. HIMMELSTEIN,M.D., associate professor of medicine, Harvard Medical School, The New York Times, March 1, 1992, Section 4; Page 14; HEADLINE: In Health Care, Canada Beats U.S. and Britain; Drug Company Studies \\VT 93-94
	 Finally, Mr. Ridenour's assertion that United States doctors are better trained than our Canadian colleagues confuses specialization and length of training. A far higher proportion of Canadian doctors are family physicians, but family practitioners on both sides of the border complete a full residency training after graduation from medical school comparable to that in the medical specialties. Canada's abundance of well-trained family doctors allows specialists to focus on their areas of expertise. In contrast, the United States suffers a shortage of primary care practitioners and a glut of underused specialists tempted to fill their calendars with unneeded procedures or patients outside their area of competence. 

A462/Tony Connole, St. Petersburg Times, December 13, 1992, Pg. 3D, HEADLINE: Basics of Canada's health plan can work in the U.S. \\VT 93-94
	 If a good and proven national health insurance plan is desired, one need only look to the study of the U.S. General Accounting Office dated June, 1991 which found that if the Canadian plan had been applied in our country, it would have provided coverage for all while preserving choice of medical provider. The study further found that the savings in administrative costs would be more than enough to finance coverage for the 37-million Americans currently uninsured.  

A463/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 For what we waste on insurance overhead and paperwork expenses that Canadians cheerfully forgo we could insure every American and have money left over. A study financed by the Robert Wood Johnson Foundation projected administrative savings of $ 113-billion a year from a Canadian-style system, and said overall spending would be $ 241-billion less. 

A464/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	 [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] Also recent surveys find that not only as we've known  for a long time are Canadian patients much more satisfied with their health care system, but in many ways, Canadian physicians  are also more satisfied with the health care system. Bob?  

A465/GEORGE P. STODDARD, The Atlanta Journal and Constitution, March 30, 1992, Section A; Page 8, HEADLINE: Canadian-style health system can work here \\VT 93-94
	 The Canadian system is obviously not problem free, but every report I have seen states that upwards of 90 percent of Canadians are satisfied. The growing pressure for reform in our nation clearly suggests that is not the case here. 

A466/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: Canadians have their share of gripes about the health care system here. But overall, it's extremely popular. So much so that any politician opposing Medicare would probably wind up very quickly unemployed. 

A467/DENNIS DUGGAN, Newsday, September 6, 1992, SECTION: FANFARE; Pg. 47 HEADLINE: Free Health Care? Could Happen \\VT 93-94
	 I recently returned from a trip to Canada, where I asked as many Canadians as I could ask whether their system of national health care was working. Not one said it wasn't. In fact, there would be a revolution there if the government tried to rescind the program. It is a measure of how badly we have been hoodwinked, misled and lied to by the American Medical Association (and its bought-and-paid-for, bootlicking politicians) that we now find ourselves struggling to get even with Canada when it comes to medical care. The AMA and its supporters have cynically kept decent care out of the reach of a great chunk of our population - so that we can't give our citizens the same level of care routinely provided by a neighboring country that we have often mocked for having "slow" ways. 

A468/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. HIMMELSTEIN [Dr. DAVID HIMMELSTEIN, Harvard Medical School] : Canadians don't describe it that way. In fact, 3 percent of Canadians said they prefer an American style system. That's the same number of Canadians as who are illiterate at this point. 

A469/DENNIS L. BREO, Journal of the American Medical Association, August 28, 1991; 266: 1131-1133, TITLE: Sidney Wolfe, MD -- healing the system or just raising hell?\\VT 93-94
	 Later, Wolfe says, "It's pretty well understood now that two thirds of all Americans support a single-payer health plan like Canada's, and our job now is to find congressional sponsors to translate this idea into legislation." [Sidney Wolfe, MD] 

A470/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Rather, polls show overwhelming support for a Canadian-style system of national health insurance. Sixty-nine percent of Americans say they favor such a system and are willing to pay higher taxes to get it.  

A471/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 24, 1993, Part A; Page 14; HEADLINE: DEBATE FLARES ON WHO'S FIRST IN HEALTH PLAN\\VT-ACS
	 Also on Tuesday, a coalition of citizens representatives met with Vice President Al Gore, presenting him with nearly a million letters and postcards that advocate the adoption of a health care system modeled after Canada's. 

A472/Lynn Wagner, staffwriter, Modern Healthcare, March 22, 1993, Pg. 28, HEADLINE: Reform may be tough sell -- polls \\VT 93-94
	 But as the task force presses forward, a poll released by Louis Harris & Associates found that two-thirds of Americans preferred a Canadian-style national insurance system, while nearly 60% opposed a managed competition approach. The poll, based on telephone surveys of 1,250 people, was released at a hearing of the House Select Committee on Aging. 

A473/Pension Reporter, March 22, 1993, Pg. 673, TITLE: SINGLE-PAYER SYSTEM MORE POPULAR THAN MANAGED COMPETITION, SURVEY FINDS. \\VT 93-94
	 Seventy percent of Americans would support health care reforms establishing a government-run, singlepayer system while only 29 percent would support reforms based on "managed competition," according to a survey released March 16 by Louis Harris, chairman of LH Research. 

A474/United Press International, January 5, 1993, HEADLINE: Midwest execs favor Canadian health-care plan, Nexis \\VT 93-94
 A national health care plan based on the Canadian model was the choice of a majority of Midwest executives in a survey released Tuesday. A comprehensive, single-payer national health insurance plan on the Canadian model was the first choice of 63 percent of executives in a survey of 143 companies in Michigan, Ohio, Indiana, Illinois, Minnesota and Wisconsin. The survey, conducted by Imberman and DeForest, a Chicago management consultant firm, cited money and paperwork savings and uniformity of care as reasons for choosing the Canadian model. 

A475/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 Dr. GUZMAN [Canadian Medical Association]: The most important thing we have is that neither the patients nor the physicians fear that an illness will bankrupt them or ruin their family. We don't think about that here. 

A476/Cable News Network, May 27, 1992, Transcript # 53 - 5, HEADLINE: News From Medicine - Canadians Defend Health Care Plan, Nexis \\VT 93-94
	 Dr. CAROLE GUZMAN, Canadian Medical Association: The most important thing we have is that neither the patients nor the physicians fear that an illness will bankrupt them or ruin their family- we don't think about that. 

A477/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 A smaller, leaner hospital industry. Ontario pays hospitals by means of a global budget, a single annual check that the hospitals split up among themselves. Costs are contained simply because the province never gives hospitals what they ask for. In 1992, the hospitals asked for an 8.6-percent increase in funding -- and got 1 percent. In response, Toronto hospitals have closed 3,700 of the area's 12,500 acute-care beds over the past three years. 

A478/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 A different kind of hospital. With universal insurance, hospitals buy new equipment, build new facilities and renovate old ones with a special government capital-improvements fund. Since 1987, Ontario has limited this to $ 485 million for the 51 Toronto-area hospitals. 

A479/SHEILA RADFORD, The New York Times, June 11, 1992, Section A; Page 22; HEADLINE: Every Canadian Can Get Quality Health Care; They Put Us to Shame \\VT-ACS
	 You state as a point against Canadian health care that hospital stays are 70 percent longer in Canada than here. I would venture that far too often in the United States patients are sent home before they ought to be simply because the individual's insurance company will not pay. Young mothers with their first babies are almost always sent home too soon. 

A480/ Los Angeles Times, March 25, 1991, Part B, p.5; HEADLINE: A NATIONAL SHAME \\VT-MDS
	For instance, because of Canada's national health program, Chrysler's health care costs for each of its Canadian workers are about one-third of those of its American employees.

A481/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: But I have confidence that our professions, our institutions are already capable of providing a very good quality of care. But given that most other things are equal between Canada and the U.S., I think it is fair to say that their medical care system has a lot to contribute. Since the 1970s [Canada has had] a higher life expectancy, lower infant mortality rates. And in most other - perhaps all other - major indices of health care outcomes, they are not only better than we are but are improving at a more rapid rate. 

A482/Health Line, July 23, 1992, HEADLINE: OPINION WRAP-UP: MORE COMMENTS, CRITICISMS ON HEALTH REFORM , Nexis \\VT 93-94
	 O' CANADA: In a N.Y. TIMES op-ed, Theodore Marmor and John Godfrey of the Canadian Institute for Advanced Research, seek to shatter the "myths" of the Canadian system: "Claims that Canada's program is less effective and no less costly than American's, and that it is beset by horrific waiting lists ad unhappy doctors, are caricatures." They said, "Canada has its problems and, no, its national health insurance program ... cannot be directly transplanted. But Canada balances access, cost and quality in ways the U.S. should find instructive" (7-23). 

A483/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT-ACS
	 Actually, Canada provides an attractive model for American reform. Canada (like most industrial democracies) combines universal health insurance with clear political accountability for raising and spending money for health services, and for the quality of the care the money buys. 

A484/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Yes, Canada has its problems and, no, its national health insurance program (known as Medicare) cannot be directly transplanted. But Canada balances access, cost and quality in ways the U.S. should find instructive. 

A485/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Canada is the country closest to ours in wealth, geography, ethnic diversity and patterns of medical practice. If we cannot learn from Canada, we cannot learn from any country. 

A486/DAVID U. HIMMELSTEIN,M.D., associate professor of medicine, Harvard Medical School, The New York Times, March 1, 1992, Section 4; Page 14; HEADLINE: In Health Care, Canada Beats U.S. and Britain; Drug Company Studies \\VT 93-94
	 He also cites a study arguing that correction for demographic differences erases Canada's cost advantage. This study, paid for by a drug company whose profits would surely suffer under a Canadian-style reform, drew the following comment from experts in the Bush Administration's Health Care Financing Administration: "The correction Krasny and Ferrier made to account for the differences in the demographic composition is mathematically incorrect and incomplete." The agency's analysts conclude that demographics account for about one-tenth of the United States-Canada difference. 

A487/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Those who attack Canadians' health insurance claim that their nation's social circumstances are so different from ours that nothing can be profitably learned by looking north. Such arguments are wildly exaggerated or simply inaccurate. We are told Canada has proportionately fewer costly patients -- the old and the poor. In fact, 11 percent of Canada's population and 12.2 percent of ours is over 65, a trivial difference, especially when contrasted with those of Germany and Sweden (where 16 and 17 percent of the citizenry, respectively, is old), which provide less costly medical care than we do. 

A488/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Yes, there are proportionately fewer poor Canadians. But the implication that our exploding medical costs are caused by treating the poor -- millions of whom are not insured and received little care -- is mistaken. 

A489/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 We read that the Canadian medical system works well because of the country's disciplined parliamentary democracy. Yes, it does work well, but not primarily for that reason. Canada's supposedly disciplined Government has a budget deficit comparable to ours, and its federal system is in danger of collapse from Quebec separatism. Most Canadians love their Medicare but view government no more favorably than we do. 

A490/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. HIMMELSTEIN [Dr. DAVID HIMMELSTEIN, Harvard Medical School] : Well, there's been a lot of propaganda about it, a lot of that financed by the drug industry that wants to keep things the way they are, but in fact when you look, the General Accounting Office looked, there aren't many Canadians coming to the U.S., probably more Americans going across the border to Canada for their care. 

A491/The Vancouver Sun, March 7, 1992, Saturday, Pg. A11, HEADLINE: U.S. candidates campaign on merits of Canadian system \\VT 93-94
	 American health-care specialists said criticisms of Canada's system have often been exaggerated. "It sometimes get painted as if Canadians are dying in the streets," said Judith Feder, co-director of the Centre for Health Policy Studies at Georgetown Medical School. "That's absurd." 

A492/DAVID U. HIMMELSTEIN,M.D., associate professor of medicine, Harvard Medical School, The New York Times, March 1, 1992, Section 4; Page 14; HEADLINE: In Health Care, Canada Beats U.S. and Britain; Drug Company Studies \\VT 93-94
	 Canada's health system provides better access to care, delivers better outcomes and costs much less than United States medicine. Most of the cost difference is due to the administrative complexity to keep private insurance companies involved in United States health care. Canada's experience, warts and all, is fair game for debate. But distortion and falsification do not assist understanding. 

A493/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 FRANCES LANKIN, Ontario Health Minister: Your President and some of your other politicians have made some outrageous statements with respect to the Canadian health care system that are incorrect. 

A494/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: The Bush Administration and the American medical establishment have trashed the Canadian approach as a pill too bitter to swallow. Dr. ROSANA PELLIZZARI, Canadian Family Physician: It's propaganda. It's lies, and I've seen some of the propaganda that the American Medical Association has prepared, and it's just not true. 

A495/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 BOB RAE, Ontario Premier: People have criticized our system. I mean, I would only say to them, 'Come here and look and see how it actually operates. Talk to people who've experienced it and who've benefited from it.' 

A496/The Washington Times, May 18, 1992, Pg. A3 HEADLINE: 'Meltdown' looms in U.S. health care \\VT 93-94
	 The AMA has strongly opposed congressional plans for a Canadian-type, government-run national health insurance system. 

A497/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 This myth-making is predictable. Because Canada has restrained its health care costs more successfully than we have, those who feed at America's $800 billion medical feast are frightened. Hence, Canada-bashing by special interests like the American Medical Association and Health Insurance Association of America, a trade association. After all, cost control means reducing the medical providers' income -- the one unassailable axiom of medical economics. 

A498/DENNIS DUGGAN, Newsday, September 6, 1992, SECTION: FANFARE; Pg. 47 HEADLINE: Free Health Care? Could Happen \\VT 93-94
	 Even so, some of them are fighting a rearguard action. Each day they deliver tales of horror, slandering the Canadian plan. The reason is that the Canadians live so close by. It is one thing to rail against the British, German, Franch or Swiss national health plans. But, gee whiz, the Canadians are just a hop and skip across the border from millions of Americans who have learned, to their shock, that those "hayseeds" are far better off than we. 

A499/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 "It's not like going to a hospital in Russia," said Roger Hunt, president of St. Michael's Hospital in Toronto. "We have curtains in the windows and carpeting on the floor. But there's no fluff here . . . . The norm here is that you have the same services accessible to everyone." 

A500/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  WOLFE [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] : The waits that do exist, and they really are not as much as the American Medical Association tried to convince people were there, are not for emergency services. There's really no evidence in Canada that people who need any kind of service at all on an emergency basis have to wait, and recently even some of the elective waits for certain procedures  have been taken care of.  

A501/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 What are the consequences of waiting lists and eliminating 1,500 bypasses a year? Perhaps none at all: Canadian cardiac mortality rates are the same as America's. But some people wouldn't be able to live as full a life. 

A502/The Vancouver Sun, March 7, 1992, Saturday, Pg. A11, HEADLINE: U.S. candidates campaign on merits of Canadian system \\VT 93-94
	 But Feder acknowledges legitimate concern over lack of availability of some medical technologies. David Jacobs, a business professor at the American University said, "Anybody who blindly says that one doesn't get immediate care in Canada and must wait for operations, obviously isn't seriously looking at the U.S. system. 

A503/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: But there are complaints the Canadian health system rations care that is readily available in the States. Although their officials say the situation has improved, waits for bypass surgery in some provinces were as long as six months. But Canadians insist that emergencies are handled on a priority 

A504/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 Ms. CATLEY-CARLSON: Where there is acute medical need, it's answered. Where there is a system where people can be put in line-ups, that does happen. 

A505/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: Doctor Wilbert Keon is founder of the Heart Institute, a Senator in the Canadian parliament, and a pragmatist. Dr. WILBERT KEON, Ottawa Heart Institute: There still is the occasional death on a waiting list and there always will be because no matter how much money you put in a system, it's not perfect from a scientific point of view at this point in time. 

A506/Cable News Network, May 27, 1992, Transcript # 53 - 5, HEADLINE: News From Medicine - Canadians Defend Health Care Plan, Nexis \\VT 93-94
	 MARGARET CATLEY-CARLSON, Canadian Deputy Health Minister: Where there is acute medical need, it's answered. Where there is a system where people can be put in line-ups, that does happen. 

A507/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Are there delays and waiting lists? Some, particularly for non-emergency heart surgery and hip replacement. The waiting is, however, hardly serious: Government statistics show that 96 percent of Canadians over the age of 15 get their care within seven days of requesting it. 

A508/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Nevertheless, critics in conservative American think-tanks such as the Heritage Foundation propagandistically tell stories of endless waiting in Canadian medicine. The reality is far less worrisome, but the media communicate the misinformation by repeating its anecdotes. 

A509/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 The United States spends some 37 percent more per person and still has some 37-million people with no health insurance. Canadians may have to wait for hip transplants, nonemergency coronary bypasses and other elective surgery, but as Dr. Jack Laidlaw, medical director of the Canadian Cancer Society, points out, "people who don't have any money in the United States wait forever." 

A510/Tom Hamburger; Staff Writer, Star Tribune, August 30, 1992, Pg. 14A, HEADLINE: Debate on health care suffers from serious ailment: politics \\VT 93-94
	 Bush has claimed that a Canadian-style system would add cost and delays. He cited six-month delays in British Columbia. In fact, there have been no such delays in British Columbia for years. 

A511/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] We should also note, though, that for a number of things such as organ transplants there's actually a higher rate  of organ transplants for certain parts of the body in Canada  than in the United States. 

A512/DAVID U. HIMMELSTEIN,M.D., associate professor of medicine, Harvard Medical School, The New York Times, March 1, 1992, Section 4; Page 14; HEADLINE: In Health Care, Canada Beats U.S. and Britain; Drug Company Studies \\VT 93-94
	 Canadians receive less of only a handful of elective high-technology services, like coronary bypass surgery, which is clearly overused in the United States. As our General Accounting Office has documented, there are virtually no waiting lists for emergency surgery in Canada. A fair evaluation would state that Americans are more likely to die from unneeded surgery than Canadians to die while on a waiting list. 

A513/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 MARGARET CATLEY-CARLSON, Canadian Deputy Health Minister: All systems ration. We ration by need and, to some extent, by time. You ration by money and the ability to pay for the services being rendered. 

A514/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 PRESIDENT BUSH: [Speaking during a campaign fund raiser.] Because central planners ration their health care, Canadians often must wait weeks or months for treatments readily available to Americans. LEVINE [JEFF LEVINE, Medical Correspondent]: Not so, say Canadian politicians like Bob Rae who point out that the U.S. has 35 million who have no health insurance at all. BOB RAE, Ontario Premier: You have the most rationed system in the world. Because basically you've rationed out of the system a whole group of people. 

A515/Tony Connole, St. Petersburg Times, December 13, 1992, Pg. 3D, HEADLINE: Basics of Canada's health plan can work in the U.S. \\VT 93-94
	 Good sense and reason dictate that we apply the basics of the Canadian plan to our country. Contrary to the falsehoods of those who oppose this direction,  the Canadian plan is not socialized medicine. Doctors do not work for the government.  We can get that insurance industry "monkey" off our backs! 

A940/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Health USA allows all parties in the health care industry to satisfy their interests in a way that provides coverage to all Americans and contains skyrocketing health care costs. 

A517/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Compared with our present system and compared with all "play or pay" proposals in the Congress, Health USA would improve access to primary and preventive care, control costs, reduce patients' out-of-pocket costs, finance health services more equitably, offer enrollees more choice of health plans, remove the burden of administering health benefits from employers, increase job mobility, and reduce administrative costs for physicians, hospitals, and most health plans. 

A518/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 The Health USA Act of 1991 addresses two fundamental health services financing problems: the more than 30 million uninsured persons and the rising costs for health care and for health insurance. Health USA would provide coverage of the entire resident population for comprehensive medical and preventive health and long-term care services through a universal tax-funded financing system. The federal government would contribute an average of 87% of program costs to each state, which would establish, under federal guidelines, a state health program. Each individual or family may enroll in any health plan approved by the state program, including many private plans, or a plan run by the state program. Through the approved plan of their choice, enrollees would receive covered services and obtain their care from participating physicians and other professional practitioners, hospitals, and other facilities. The state program would pay approved plans a capitation payment for every person enrolled. The plans would pay professional providers fees, as part of an all-payer system of fee schedules and expenditure targets, or capitation payments or salary. Hospitals would be financed through global budgets negotiated by the state program with each hospital. The plan run by the state program would pay the health care costs of any person who does not enroll in an approved plan, making the state plan the payer of last resort and eliminating uncompensated care and cost shifting by providers. Health USA would separate health care coverage from employment, ensuring uninterrupted coverage and eliminating employers' administrative role in providing coverage. Federal and state taxes would replace present methods of financing by private insurance premiums and large out-of-pocket expenditures. Building on the present system of health plans, Health USA would offer all persons a wide choice of competing plans in which to enroll and offer professional providers a wide choice of plans in which to practice. It would control costs by increasing financial accountability of providers and health plans, reducing present reliance on intrusive utilization review and on patient cost sharing. By controlling health care and administrative costs, Health USA would cover the entire population and, according to independent cost estimates, reduce national health expenditures by $ 11.5 billion in 1991. 

A519/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 THE Health USA Act of 1991, [n1] introduced by Sen Bob Kerrey (D, Neb), would reform the nation's health care financing system while strengthening the existing delivery system. It would establish a social insurance program to provide universal coverage through competing private and public health plans and to control health expenditures through a system of budgeting and all-payer reimbursement systems for physicians and hospitals. While building on American models of prepaid health plans and private physicians and hospitals, Health USA also would incorporate some features found advantageous in the national health programs of other countries. 

A520/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 THE HEALTH USA PROGRAM: An Overview of Health USA. Health USA would provide comprehensive health and LTC coverage to the entire population through programs administered by the states under federal guidelines and with strong federal financial support. All people would be covered by their state health insurance program but would obtain benefits by enrolling in one of the private health plans available in their area or in a state-run plan. The state program would pay each plan a capitation payment for every enrollee, prepaying the costs of covered benefits. Plans would then pay physicians and other professional practitioners for care provided to their enrollees. Hospitals would be paid directly by the state program. (The flow of funds is depicted in the Figure.) Eligibility, Benefits, and Health Plans 

A521/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Paying the Health Plans Each approved plan [in Health USA] would receive a fixed capitation payment from the state program for every enrollee. The plan must accept the state's capitation fee as payment in full, except for limited cost sharing, for required benefits. Because plans could not compete by lowering their prices, they must compete by using savings from efficient operation to offer additional benefits, higher quality services, more amenities, more convenient service or hours, reduced cost sharing, or other features preferred by enrollees. Health plans also may sell additional coverage, but only for benefits not covered by the state program, such as private hospital rooms or dental care. Premiums for extra benefits may be paid either by individual enrollees or by employers, but they would not be tax deductible. 

A522/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 The State Plan as Payer of Last Resort. -- Anyone may enroll in the state-run plan, and any eligible person who has failed to enroll in an approved plan would be assumed to be covered by the state-run plan. This provision would make the state-run plan financially responsible for all eligible persons who do not enroll in a plan, eliminating uncompensated care and cost shifting. Non-enrolled patients would be encouraged to choose an approved plan as soon as possible following such service. As the payer of last resort, the state plan would receive capitation payments for all persons enrolled in it and for all eligible persons who have not enrolled in another plan. In order to prevent the state-run plan from gaining an unfair advantage from these extra capitation payments, it must keep separate accounting of these funds and, at the end of each fiscal year, return to the state program unspent moneys for nonenrollees. 

A523/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Paying Providers of Care [under Health USA] Physicians and other professional practitioners would be paid by approved plans under an all-payer reimbursement system. Hospitals would operate within a budgeted system, with flexibility to allow for changes in service volume and to encourage limited price competition. 

A524/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [Under Health USA] A common physicians' services claims form and reporting system would reduce physicians' administrative costs and provide data for profiling practice patterns and for tracking service volumes and expenditures. These data would be reported by each plan to the state program, which would aggregate data from all payers, yielding total expenditures for the state and for physicians' services for each local area. Each physician would receive his or her own practice profile and a comparison profile for the average of physicians in that expenditure-target grouping. The negotiating body representing physicians at each expenditure-target level also would receive practice profiles of member physicians. 

A525/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 I have introduced legislation that comprehensively reforms the way we finance health care in the United States. This legislation, the Health USA Act, controls soaring health care costs, extends coverage for health and long-term care services to every American, and de-links health insurance coverage from employment. 

A526/Tom Hamburger; Staff Writer, Star Tribune, August 30, 1992, Pg. 14A, HEADLINE: Debate on health care suffers from serious ailment: politics \\VT 93-94
	 Of the Democratic presidential candidates this year, only Nebraska Sen. Bob Kerrey advocated a single-payer, Canadian-style system. But he did not get very far. He was inundated by myths about what's going on in Canada by Republicans and members of his own party. 

A527/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA would cover all US residents for comprehensive medical and preventive health services and LTC. Benefits include inpatient and ambulatory hospital and physician care, preventive services, ancillary diagnostic and treatment services, home health services and skilled nursing facility care, prescription drugs, durable medical equipment, mental health services, and substance abuse treatment. All persons, regardless of age, also would be covered for LTC, including home and community-based care, institutional care, and respite services. 

A528/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA would provide comprehensive coverage to the entire population in one financing program, offer enrollees a wide choice of competing plans, regularize and control provider reimbursement, improve quality and control costs, more equitably finance health care, and reduce administrative waste for employers, health plans, and providers. It would fundamentally change how people obtain coverage and how the system controls health expenditures. 

A529/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] The state-operated plan would be required to control costs by using the all-payer fee schedules and expenditure targets and by limiting reimbursement for specialty services to designated types of providers. Only if these cost-control methods have proved inadequate may the state-run plan impose cost sharing on patients, with the same limits that apply to other plans and-or utilization controls directed at providers. Private plans may use any of these methods from the beginning. It is likely, however, that enrollees would switch to competing plans that do not require copayments and that practitioners would switch from plans that interfere with clinical decision making to other plans that use less intrusive methods. 

A530/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 The second problem is the growing uninsured population, now well over 30 million persons. [n3] Compared with people who have health insurance coverage, the uninsured have less access to necessary medical care. [n4] When they do obtain care, the uninsured generate costs that are shifted to other payers or are absorbed as losses by providers. Altogether, the completely uninsured and the inadequately insured are estimated to comprise about one fourth of the population, [n5] currently as many as 70 million people. 

A531/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Each state would [under Health USA] establish a program enabling residents to receive these benefits by enrolling in any approved health plan. (An approved plan is any private or public plan approved by the state program to offer required health and-or LTC benefits for the capitation payment from the state program.) The state program must establish criteria for participation by plans, all of which must provide the required package of benefits. Approved plans must allow any eligible person in the plan's service area to enroll during annual open-enrollment periods, up to a reasonable limit based on the plan's capacity. They may not exclude anyone due to a preexisting condition or deny coverage for that condition. 

A532/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 To discourage plans [under Health USA] from selectively marketing only to relatively healthy low-cost populations, capitation payments would be risk-adjusted. The state program would pay plans the average actuarially determined costs of caring for persons in each of several risk groups. The capitation payments also would be adjusted for local area-specific costs of providing care (primarily labor and land costs), enrolling a disproportionate number of low-income people, and other factors. Risk-adjusting capitation payments to health plans, banning discriminatory practices by plans, requiring open enrollment, and spreading risks across the entire population are likely to prevent the risk avoidance that now prevails among insurers. 

A533/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Assuring Equity and Cost Containment. -- Plans may not charge additional premiums for required benefits because that would give them an incentive to market mainly to more affluent areas or to offer a lower quality plan to low-income areas. Making all plans available to all people regardless of ability to pay would give real choices to every income group. Furthermore, allowing plans to charge extra premiums for basic benefits would lead to rapid increases in health expenditures if middle- and upper-income enrollees are induced to pay more for coverage. Banning extra charges by health plans for required benefits distinguishes the Kerrey bill from virtually all "play or pay" proposals. 

A534/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Finally, eliminating the link of employment and coverage would facilitate universal participation in one financing system. This is the best protection for low-income groups who otherwise would depend on separate public programs, as they do today and as they would in other reforms [n9,n11-n13] that create a public program only for those not fortunate enough to be covered by an employer who "plays." Only in a universal program, through which the middle and upper classes get their care, can lower-income workers and the poor avoid political isolation in a program that is vulnerable to the budgetary axe. 

A535/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 The HMOs and other insurers also should take some comfort from a national health insurance proposal [under Health USA] that gives them an important role, rather than, like a purely Canadian-style system, completely shutting them out. Health USA offers private insurers a central role in organizing care -- but within a public social insurance program that would provide universal coverage, control costs, and reduce administrative waste. Health plans would get their revenues from public programs, and they must be available to anyone in their areas. Risk-adjusted capitation payments would make it possible for them to operate in this environment because plans will get paid adequately for serving people whose health care needs tend, on average, to be more expensive. 

A536E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] Unneeded facilities are likely to be down sized or closed, while some rural facilities that serve important local medical needs would receive more secure support. State programs may provide capital to enable nonprofit and public agencies to organize plans. Health USA's national Resource Enhancement Fund would provide grants and loans to develop health resources in underserved rural and urban areas. 

A537/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 By gradually shifting demand for practitioners, Health USA would affect the number of medical residencies in various specialties. In addition, each state program would designate a portion of revenues for teaching hospitals and clinics to cover excess costs associated with teaching and research. Removing these functions from patient-care reimbursement will ensure adequate funds to meet these needs and help state programs control the supply of medical professionals in each specialty. It also will allow teaching hospitals to compete with non-teaching hospitals by separating teaching functions from their patient-care cost base. Financing 

A538/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Creating Fair Competition Among Health Plans. -- Competition among plans [in Health USA] can work to the advantage of both providers and enrollees. To the extent that any plan creates disadvantageous conditions for providers (eg, slow payment, intrusive oversight of clinical decisions) or enrollees (eg, poor care, inconvenient facilities or hours), they may switch to alternative plans. 

A539/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Creating Accountability.[under Health USA] -- Each plan must establish an advisory committee of enrollees and provide them adequate information, including financial records. State programs must develop grievance systems to hear and resolve complaints about plans. 

A540/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA's system of capitation payments to prepaid health plans would favor managed care, but it would foster a variety of models and plans that compete for enrollees on the basis of quality, convenience, and additional benefits, rather than price. The inclusion of private health plans offers some reassurance to those who might be concerned if they had only a large government program responsible for all aspects of their health care. 

A541/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Health plans would compete against one another for enrollees on a level playing field. They would be required to compete by using savings from an efficient operation to offer additional benefits to enrollees, more amenities, more convenient services or hours, reduced cost sharing, or other features preferred by enrollees. 

A542/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Individuals and families would choose among competing FFS plans, health maintenance organizations (HMOs) and other private plans, including, for example, Blue Cross and Blue Shield, commercial insurers, existing HMOs, local medical society plans, and consumer cooperatives. Alternatively, residents may enroll in a FFS plan run by the state program. Through their chosen plan, enrollees would obtain their care from participating physicians and other practitioners, hospitals and other facilities. 

A543/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Allowing people to join any approved plan, rather than contracting with just a few plans, would give enrollees greater choice of plans than present employment-based insurance. Requiring all plans to provide a uniform, broad minimum package of benefits would make the choice a manageable one, particularly because the state program would provide standardized information about all plans. 

A544/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Under Health USA, Americans choose to enroll in a private or public health plan operating in their area during an annual open enrollment period. These plans may be offered by an insurer, health maintenance organization (HMO), or any other entity meeting the basic requirements for participation. 

A545/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 As a universal financing program, Health USA would replace a multitude of separate federal and state programs, as well as privately purchased insurance for benefits covered by the program. Medicare and Medicaid would be folded into Health USA; federal employees and veterans also would be covered. All workers, retirees, and their families, as well as all those not connected to the workforce, would be covered. 

A546/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Even after tax increases, Health USA would cut the average household's annual health spending. Lewin-ICF estimates that it would cut $ 935 from the average family's expenditures for health insurance premiums and $ 627 from out-of-pocket medical expenses. Thus, although the average household's taxes would increase $1326 to pay for health and LTC benefits, its total spending for these services would decrease by $ 236. 

A547/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] Among families with incomes between $ 15000 and $ 20000, for example, 58% would find their total health spending reduced -- by $ 969 for the average family in this income group. 

A548/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] Finally, the tax-funded state programs would be the sole payers of health plans and would have monopsony power to negotiate effectively with health plans and providers of care to control costs. Health USA's estimated $ 11.5 billion reduction in total health expenditures contrasts with the added total health spending of "play or pay" and other proposals that focus on expanding coverage but fail to restructure provider reimbursement. 

A549/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] Despite allowed cost sharing, half of all families would pay less of their income on health care under Health USA, even taking account of added taxes, than they do today. Lower- and middle-income families would benefit even more. 

A550/The Hotline, February 7, 1992, HEADLINE: HEALTH CARE: "ISSUE OF THE DECADE" Nexis \\VT 93-94
	KERREY: Among the five, "none has made health care as central an issue as Kerrey" (Robert Dodge, DALLAS MORNING NEWS). His proposal, "the most detailed and comprehensive," would implement a national plan run by the federal and state governments. "It would be funded by new taxes on individuals and corporations, as well as new levies on Social Security benefits and excise taxes on cigarettes and distilled spirits. Although the new tax burden would be substantial, Kerrey argues that it would save $11 billion during its first year and $150 billion over five years." Kerrey adds 1-2 of U.S. families "would pay less for health care and the average family would save nearly $500 annually" (2-5). 

A551/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT-ACS
	 Health USA addresses two fundamental financing problems that are battering the US health system. One is the soaring cost for health care, now consuming 12% of the gross national product. [n2] These costs have struck hard at American workers and businesses. Between 1965 and 1989, business spending for health benefits rose from 2.2% to 8.3% of wages and salaries, and from 8.4% to 56.4% of pretax corporate profits (unpublished data from the Health Care Financing Administration). 

A552/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA would cost $ 479 billion in 1991, according to independent estimates by Lewin-ICF based on their Health Benefits Simulation Model. [n24] Despite its price tag, Health USA actually would decrease total national health spending by $ 11.5 billion in 1991 and by $ 158.5 billion over its first 5 years. The reductions in administrative and health services costs implemented in Health USA would provide enough savings, according to Lewin-ICF, to pay for extending coverage for comprehensive health and LTC benefits to the entire population and still reduce total national health expenditures. 

A553/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA would control costs through budgeting and financial incentives on health plans, providers, and patients. Putting health plans at financial risk for all required benefits for the specified capitation payment (plus allowed copayments) would provide incentives for them to control costs, while the provider reimbursement systems would give them effective methods to do so. The state-run plan and private plans that pay physicians on a FFS basis would control their practitioner costs through an all-payer system of fee schedules and expenditure targets, in which they share a common interest in preventing costs from escalating. To help physicians keep within expenditure targets, the state program would provide them with profiles of their own practice patterns and would send appropriate practitioner associations at each expenditure-target level the profiles for physicians within their grouping. 

A554/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] Health plans thus would be able to control costs and operate in the black because provider fees would be relatively predictable and because plans would be reimbursed the average costs of caring for their particular mix of enrollees. 

A555/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA thus emphasizes cost-containment methods that rely mainly on budgeting and financial incentives to influence provider behavior, a strategy that has proved generally successful in Europe, Canada, and prepaid health plans in the United States. Canada and Germany use fee schedules and expenditure targets effectively to limit growth in health expenditures relative to gross national product without compromising patient access or intruding on physicians' clinical decision making. [n16,n30,n31] The HMOs, particularly group-practice models, have lower hospitalization rates, and thus lower costs per enrollee, than indemnity plans, even controlling for possible patient-mix differences. [n32] 

A556/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Compared with present financing arrangements, Health USA would give greater power to third-party payers to control costs. One reason for the uncontrollable rise in health care costs has been fragmentation of payers, with 1500 separate private health plans and an estimated 175000 self-insured employer plans [n33] trying individually to obtain lower prices. Many employers are coming to the conclusion that, despite their best efforts, this strategy has failed. [n7,n8] Health USA would combine the relatively small market shares of all these payers in each state, plus the state-run health plan and the state financing program, into an effective all-payer system for paying physicians and hospitals, a change that is essential to gain control over health care expenditures. 

A557/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Hospitals [under Health USA]. -- The state program would negotiate with each hospital a global operating budget. Most states would pay hospitals per admission or per day, using the annual budget as a target, a method that is sensitive to changes in volume. Services above the target would be reimbursed at marginal cost. As with physicians, if negotiations between the program and a hospital reach an impasse, the issue would be referred to mediation or arbitration. Negotiating hospital-specific operating budgets would control hospitals' total costs while recognizing relevant cost differences among them. 

A558/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 [under Health USA] Hospital spending would be controlled by negotiating annual operating budgets and by restructuring financial incentives on health plans. Charging health plans for hospital services used by their enrollees would give plans an incentive to work with physicians to reduce unnecessary hospitalization and to use lower cost hospitals that provide equivalent services. Even states that treat each hospital's budget as a target would control total hospital costs. By paying hospitals their marginal costs for additional services above their budget targets, these programs would not penalize hospitals that serve larger-than-expected volumes of patients but also would not provide incentives for hospitals to aggressively market services. 

A559/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Replacing private health insurance premiums with a tax-funded public program would streamline administration of financing. Public medical financing programs, including Medicare and the Canadian national health system, have much lower administrative costs than the US private health insurance system. [n16,n17] Most costs of providing benefits to the currently uninsured would be paid for with Health USA's $ 11 billion estimated savings in such administrative costs. 

A560/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 In reforming our nation's health care system, we must strive for a system that is fair and equitable. Health USA illustrates an approach which would allow the United States to benefit from both a pluralistic, competitive health care system (unlike any in the world) and a system that is universal, administratively simple and better able to contain costs than our current system (like most other systems in the industrialized world). 

A561/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Primary Care and Prevention Health USA would enhance disease prevention and health promotion. Utilization of preventive services -- such as prenatal care, immunizations, well-child visits, Papanicolaou tests, and screening for hypertension and other diseases -- would increase because they would be provided without copayments as part of the required package of benefits. In addition, state programs must designate funds for a prevention account, to be used for community-based disease prevention and health promotion programs targeted to population groups with the greatest unmet needs. Traditional preventive medical and clinical services would remain the responsibility of health plans, while prevention account funds would address factors in the social and physical environment and behaviors of individuals that influence health status. These funds would enhance the work of state and local public health agencies, which no longer would have to divert resources to meet basic medical needs of the indigent population. Health USA would draw some revenues from increased taxes on tobacco and alcoholic beverages, both reducing consumption and making those who use them pay some of the associated medical costs. 

A562/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA also would place an increased emphasis on primary care. Prepaid health plans now rely more heavily on primary care physicians than does the indemnity-based FFS system. [n23] By capitating all approved plans, Health USA would create financial incentives for plans to emphasize primary care to control expenditures. These changes are consistent with the direction of recent changes enacted in the Medicare physician payment system. [n21] 

A563/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Compared with other proposals for universal tax-funded reforms, Health USA is likely to minimize political opposition because it is more adapted to the political conditions and structure of health care in this country. Consumers and providers now are covered through a variety of health plans that are similar to those on which Health USA relies. Even its tendency to favor managed-care arrangements follows the dominant trend in private insurance and, increasingly, in the Medicare program. In 1990, HMOs covered 36.5 million people, 14.6% of the US population. [n41] Among the employed insured population, 38% were covered by either an HMO or a preferred provider organization in 1990, up from 29% in 1988. Moreover, the unrestricted indemnity health plan is rapidly becoming merely a historical anachronism; these traditional plans covered only 5% of the employed insured population in 1990, down from 28% in 1988. [n42] 

A564/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 In the absence of major structural reforms in health care financing, both health care costs and the number of uninsured will continue to grow. But increasing public frustration with our health system is likely to strengthen the political will to enact far-reaching reforms. The Health USA Act would provide the depth of reforms that are needed, and it is within political reach. 

A565/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Physicians and hospitals may fear loss of market autonomy in an all-payer system. Health USA, however, would provide protection to both health facilities and practitioners. In negotiations between physicians' associations and the state program and FFS plans, the medical profession can influence both the conversion factor, which determines the monetary value of the fee schedule, and expenditure targets, which set total funds paid to physicians. Mediation and arbitration, rather than the imposed will of payers, must be used to resolve disputes. Physicians, both FFS and salaried, also would have market freedom to choose approved plans with which they contract. In addition, physicians may form approved plans through their state or local medical society, becoming their own collective payers. The state program and individual hospitals also must negotiate annual budgets, with disputes resolved by a mutually agreed upon arbitrator. 

A566/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA's cost-control structures and processes -- including capitated prepaid plans, negotiated global budgeting of hospitals, and self-regulation by local organizations of private-practice physicians who share a common set of financial incentives -- would create a system that balances professional autonomy with the need to restrain use of economic resources. Capitating health plans lets providers allocate resources according to their best professional and managerial judgment, a system that respects professional autonomy far more than looking over physicians' shoulders at each patient encounter or imposing financial incentives designed to make patients resist physicians' recommendations. [n36] 

A567/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Health USA does not change the way health care is delivered. It preserves the ability of Americans to choose among private physicians, hospitals, insurers, and health plans for their own care and coverage. It is not the Canadian, German, or any other health care system. It is a uniquely American system that builds upon the strengths of our current system and directly addresses its shortfalls. 

A568/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA, like the Enthoven-Kronick proposal, emphasizes prepaid health plans, but it differs in how it would control costs. Rather than relying mainly on increasing cost-consciousness among health services users and individual payers of plans, as Enthoven and Kronick propose, Health USA emphasizes changing financial incentives to health plans and providers through a unified all-payer reimbursement system. 

A569/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health plans [under Health USA] would be charged for the costs of hospital care for their enrollees, encouraging plans to limit use of expensive hospital resources, as HMOs have done, and to use more efficient facilities. Because the state-run plan would pay the costs of anyone not enrolled in an approved plan, providers would not bear uncompensated care losses or shift such costs to other payers. 

A570/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 The US health system now consumes a one-third greater share of the gross national product than any other industrialized nation's system. [n37] Health USA would use current resources more effectively and efficiently to improve the population's health and would make any increase in gross national product spent on medical care a deliberate policy decision. 

A571/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA's modest payroll tax would make employers' contributions proportional to labor costs, an advantage for many employers and especially those who pay lower wages or employ part-time or temporary workers. Employers also would get some relief from liabilities for retirees' health benefits, an estimated $ 402-billion burden on total corporate net worth. [n28] This liability falls especially heavily on older companies whose competitiveness is burdened by health-benefit obligations to their large numbers of retired workers, accounting for up to half their total health costs. 

A572/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA would be a federal-state program, in which the federal contribution would average 87% (ranging from 82% to 92%) of costs to each state, which would administer the program. Current federal health care spending -- including funds now spent on Medicare, Medicaid, federal employees, and Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) -- would provide 43% of the federal share. Another 39% would be raised from a 4% gross payroll tax paid by employers and a 1% tax on wages and salaries paid by employees (or by their employers). This tax also applies to self-employed persons. The remaining 18% of the federal contribution would be raised by increasing the top personal income marginal tax rate from 31% to 33%, increasing corporate income taxes by 10%, requiring employers to contribute half of what they now pay for retired workers' health benefits, expanding the social security earnings tax base to $ 125,000, making 85% of Old Age, Survivors' and Disability Insurance (OASDI) benefits taxable, imposing a 2% tax on adjusted gross non-wage income, and excise taxes on tobacco and alcohol products. All the states together would need to raise only $ 10 billion in new revenues to cover their 13% share of the cost of Health USA, after applying the $ 54 billion they now spend on Medicaid and 75% of what they now spend on indigent medical care. 

A573/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Tax funding is more progressive than health insurance premiums, which are set irrespective of income. Employment-based private insurance relies on regressive premiums and even more regressive cost sharing for services. [n25] Financing with tax revenues is more equitable because tax contributions are at least proportional to earnings. Health USA's payroll tax is about half the average share of payroll costs that employers and employees now spend on health benefits -- and would spend under the National Leadership Coalition proposal -- imposing a tolerable burden on most firms. To compensate for this low payroll tax, Health USA would draw other federal funding from taxes on health-damaging substances and from personal and corporate income taxes which provide a built-in subsidy (through the tax rates) for firms that have low profit margins and for low-income individuals. 

A574/The Hotline, February 7, 1992, HEADLINE: HEALTH CARE: "ISSUE OF THE DECADE" Nexis \\VT 93-94
	W. POST's Cooper, calling Kerrey's plan the "most extensive and most radical," notes the 5% hike in payroll tax would split 4% for employers, 1% for workers (2-6). 

A575/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Like the proposal of the Committee for National Health Insurance, [n20] Health USA relies on a state-federal partnership, but it places more binding requirements on states, health plans, and revenue sources to assure equitable access, effective control of costs, and progressive financing. 

A576/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Health USA establishes a changed, yet vibrant and competitive, health care marketplace. Unlike other comprehensive national health insurance proposals, Health USA does not eliminate the role of the private health insurance industry. It does, however, change that role. 

A577/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA separates coverage from employment, ensuring universal and uninterrupted coverage of the population and freeing employers from administrative burdens of providing health benefits. 

A578/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Unlike most other proposals, Health USA breaks the link between employment and health coverage. In doing so, Health USA provides Americans the security of knowing they won't face the disruptions in health care coverage that occur if their employment or marital status changes. 

A579/Sen. Bob Kerrey, Roll Call, May 4, 1992, SECTION: Insurance - Policy Briefing No. 40 HEADLINE: A Uniquely American System \\VT 93-94
	 Health USA also provides workers the confidence of knowing that they won't experience "job lock," but instead will benefit from greater labor market flexibility and mobility. Employers benefit as well. They will be freed from the administrative burdens of providing health benefits to employees, enabling them to focus on operating a competitive business. 

A580/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Health USA also differs from the Physicians for a National Health Program proposal, [n14] which is essentially the Canadian national health insurance system. The Canadian system has many advantages, including virtually universal coverage, excellent access to primary care, patients' freedom to choose their own physicians, a superior record of controlling expenditures for physicians and hospitals, [n15] lower administrative costs, [n16,n17] lower out-of-pocket costs for patients, and greater popular satisfaction. [n6] Despite these strengths, Canada's fee-for-service (FFS) reimbursement system insulates private-practice medicine from efforts to improve the cost-effectiveness of health expenditures. [n18] The variety of upward pressures on health expenditures has encouraged some Canadian provinces to develop US-style organized health systems as one method to control costs and promote preventive medical practice. [n19] 

A581/E. Richard Brown, PhD, School of Public Health, University of California, Los Angeles. Journal of the American Medical Association, January 22, 1992; 267: 552-558 TITLE: Health USA; A National Health Program for the United States \\VT 93-94
	 Like the Canadian system, Health USA would provide universal coverage, improve access to primary care, reduce administrative costs (although not as much as Canada does), control hospital and physician costs, ensure freedom of choice of providers, and reduce patients' out-of-pocket costs. But Health USA would accomplish these objectives within a framework of organized health plans that have incentives to control costs while competing for enrollees. These plans would be familiar to a majority of the insured population. 

A582/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 True reform will have to meet three basic criteria, all of which are in direct conflict: The reform must cover the 37 million Americans now without any insurance, it must tame the cost spiral, and it can't do the first two at the expense of quality. Of the mainstream approaches to reform -- play-or-pay, Bush's limited reform and Kerrey's single-payer national insurance -- play-or-pay does the best job of meeting all three needs. All Americans would have at least a minimum set of standard medical benefits provided by either their employers or the government; companies that didn't provide benefits would pay into the government plan, most likely through a payroll levy. To keep the expense down, doctors, hospitals, insurers, employers and the federal government would negotiate maximum spending targets and fees for specific procedures. 

A583/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 Both play-or-pay and single-payer plans solve the broader problems that the incremental plans ignore. For starters, both mandate quality, core health care programs. Better coverage for small-business employees, part-time workers, contract workers and others in the labor force with inadequate insurance now would undoubtedly cut down the high cost to employers of sick time and retraining. Business also gains when the entire population has health coverage because that reduces the national health care tab that gets parceled out. 

A584/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Play Or Pay: A type of employer mandate that requires an employer to either buy private insurance coverage for their employees (PLAY) or provide money to a governmentally sponsored insurance plan in which the employee would enroll. 

A585/Money, February, 1993, Pg. 15, HEADLINE: HOW WOULD YOU FIX THE HEALTH-CARE PROBLEMS IN AMERICA TODAY? \\VT 93-94
 Pay or play would require employers to provide coverage to all workers or to pay a federal payroll tax of 7% to 9% that would fund coverage of the uninsured. 

A586/The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Pay or Play. A way to finance health care for everyone, this proposal calls for employers to provide health insurance for their employees or pay a tax to help the government provide it. Most advocates of this approach also support some type of government-imposed cost controls. 

A587/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * PAY OR PLAY: A proposed that would require all employers either to provide health insurance for their workers or to pay a tax that would enable the government to provide it. 

A588/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 PAY OR PLAY: A proposal that would require all employers either to provide health insurance for their workers or to pay a tax that would enable the  government to provide it. 

A589/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Employer Mandate: A requirement by the government that some or all employers provide insurance coverage for their employees. 

A590/The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Employer Mandate. When the government requires that employers provide health insurance to their employees. Hawaii is the only state in the country with an employer mandate. Usually, advocates of mandates have proposed that employers pay a portion -- often 50 to 80 percent -- of the premium, depending on the size or profitability of the firm. 

A591/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Employment-Based Financing. -- The second approach, employer mandates, requires employers to make an insurance policy available to their full-time employees (and some would include part-time employees). Furthermore, most employer mandate proposals designate what percentage of the premium the employer and the employee must pay. Employers are often given the alternative of paying a payroll tax to buy their employees into a public plan if they do not want to take on the administrative burden of providing insurance themselves or think the public plan will cost less. These plans, known as play-or-pay proposals, often include an additional, much smaller payroll tax that is used to cover the nonworking uninsured. 

A592/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 On the cost side,the universal coverage in single-payer and play-or-pay would eliminate cost-shifting to pay for the uninsured by simply covering everyone. Not that it would be a straight savings: For one thing, Mercer's Beadle warns, people might take advantage of the "free" insurance to load up on medical care they don't need. More likely, business "players" under play-or-pay would have to cover part-time and seasonal workers they don't insure now. But that would be offset by their not paying for the working dependents of employ ees, since those dependents would be the responsibility of their own employers. The result: a 10 percent savings, Abramowitz figures. 

A593/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 What will finally push the politicians toward action -- probably in the next presidential term -- is that the system as it is just can't last. With the tab for health benefits already close to wiping out overall aftertax profits, by some estimates, how much longer can business keep paying? And as the AFL-CIO-s Ignagni says, on the employee side, "our people go to the bargaining tables, and our members are being besieged. Health care costs are crowding out increases in wages." Adds Chrysler's Maher, "The public has a low pain threshold." The best way to ease the pain is play-or-pay. 

A594/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 Play-or-pay takes the best of its rivals. Like the Republican programs, it would let companies shop the marketplace for the health plan that fits their particular needs. But like the single-pay-er plan, it would make sure everyone was covered by cost controls and insurance. And it would bring the forces of law as well as those of the market to bear on costs through fee bargaining. "The business community is helped only if you have a strategy that is assured to control costs," argues Chrysler's Maher. Play-or-pay "saves money by setting a limit for total spending and then forcing people to compete. And there's no question everyone in the country is covered." 

A595/BUSINESS WIRE, March 23, 1993, HEADLINE: AMERICANS STRONGLY BACK CLINTON'S EFFORTS FOR HEALTH CARE REFORM, Online America, Transmitted: 93-03-23 15:55:00 EST \\VT 93-94
	 The Kaiser/Harris survey asked Americans to respond to a plan with six key elements; an employer mandate, short-term price controls on medical and insurance fees, purchasing cooperatives to bargain for lower insurance rates, incentives to join managed care plans, and the ability to pay more for greater choice of doctors and hospitals. Eighty-one percent of those surveyed said they would support a plan with these elements, and 78 percent said the President will have fulfilled his campaign promise if he puts forth such a plan. 

A596/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Frank B. McArdle, Employee Benefit Research Institute: A single-payer plan would be too disruptive and too risky. It is better to preserve the best features of the American system by building upon the existing employer-based system. 

A597/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 Government insurance, however, would not mean government doctors. Under play-or-pay, private physicians, health maintenance organizations andeveryone else would be free to compete for patients, just as they do now. 

A598/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Play-or-Pay. -- Proponents argue that eight out of 10 people under the age of 65 years now get their health insurance through their place of employment, and it is least disruptive to extend coverage to the entire working population through employment-based private insurance. This system has been in place for over 40 years and, with minor changes, could insure most working people and their families. Such an approach permits individuals and employers to choose among a variety of private health plans and allows negotiation at each place of employment over the scope of benefits and cost-sharing arrangements. 

A599/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 Proponents [of pay or play] see the advantages of this proposal as retaining the employer-based private insurance system rather than replacing it with a government plan. Cost containment measures build on recently adopted Medicare payment policies, as well as the relatively successful experience of Germany and other nations with similar systems that control costs. 

A600/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 The main advantage of employment-based financing is that it does not require new taxes from the public or from employers now offering coverage. This approach only requires those employers who do not now provide coverage to do so. It also builds on a long history of employers and employees sharing the cost of coverage. Finally, it would end the practice of some firms gaining a competitive advantage by not providing insurance to their workers (or paying the additional burden of uncompensated care) and then charging lower prices for their products or services. 

A601/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HMOS, Online America, Better Health and Medical Forum, Transmitted: 93-03-16 17:36:56 EST \\VT 93-94
	 Individuals "belonging" to an HMO (or their employers) pay a fixed dollar amount monthly, regardless of whether or not health care services are used. When services are used, the fixed fee remains the same, regardless of the severity of one's illness or the amount or level of services that are provided. Often, however, members must pay an additional per-visit fee (such as $5 or $10). 

A602/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HMOS, Online America, Better Health and Medical Forum, Transmitted: 93-03-16 17:36:56 EST \\VT 93-94
	 While HMOs may represent savings to employers and individuals, they are not for everyone. Their advantages include: 1. A set monthly fee that covers all services. 2. An emphasis on diseases prevention achieved through periodic screening programs based on an individual's age, sex, and personal risk factors (including family history of disease). 3. An emphasis on disease prevention through health education and lifestyle modification programs for members. 4. Avoidance of medically inappropriate tests or procedures. 5. Emphasis on pre-natal services for pregnant women. 

A603/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 To find out how HMOs stacked up against traditional insurance and against each other, we asked readers who belonged to an HMO to rate their medical experiences from spring 1990 through spring 1991. We also asked readers with traditional coverage to rate similar medical experiences over the same period. (Our respondents in both surveys were relatively healthy.) Respondents in HMOs were just as satisfied as those with ordinary coverage. We found no meaningful differences in such factors as the number of office visits readers had, the length of the typical visit, the ability to get answers to questions by telephone, the number of specialists seen, or the waiting times to see a specialist. 

A604/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 When it came to satisfaction with out-of-pocket costs, HMO members were far happier than those with traditional insurance. That's the result of a trade-off, of course. When you join an HMO, you lose much of the freedom to go to any doctor you want. But the combination of lower out-of-pocket costs and coverage for preventive services may make it a good choice for many people. 

A605/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 The HMO's strategy is to use a primary-care doctor, rather than costlier specialists, to treat common problems. It will be this general practitioner, not an orthopedist, who will treat sprained ankles; the GP, not an otolaryngologist, will treat an earache; and the GP, not a urologist, will take care of urinary tract infections. (In some HMOs, gynecologists, pediatricians, and internists can act as primary-care doctors.) 

A606/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Capitation: A fixed amount that a health provider or a provider organization is paid for a given time period (usually a year) regardless of the amount of services provided. The amount and the types of services covered varies. HMO's do and AHP's would use this type of charging mechanism. 

A607/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 SISTER BERNICE COREIL (SENIOR VICE PRESIDENT, CATHOLIC HEALTH ASSOCIATION): Capitation is the best way to ensure true cost control under a global budget. Capitation re-aligns financial incentives and encourages providers to emphasize primary and preventive care, and a more rational use of technology, and reduce unnecessary care. 

A608/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 The Health Insurance Association of America found that monthly premiums for family coverage in 1990 averaged $ 311 for HMOs that provided care mainly through health centers and $ 316 for those that provided care in physicians' offices. Monthly premiums for health insurance with managed-care features averaged $ 319. 

A609/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 Said Erb [John C. Erb, a consultant with A. Foster Higgins], "The only way we can at least make a significant impact on cost is to change the system" to get away from the fee-for-service system. As long as the dominant form of managed care is still fee for service, we are going to have problems." 

A610/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 The Higgins survey, for example, showed that last year HMOs cost employers approximately 15 percent less per employee than traditional insurance plans. 

A611/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 Whatever method they use, most HMOs don't scrimp on payments to doctors and are mindful of what physicians can earn outside an HMO. If an HMO isn't competitive in what it pays, doctors will drop out. "We spend an awful lot of time finding out what the marketplace is paying," says William McCoy, director of market development for Humana. "We want to be fair." Because of those marketplace pressures, whatever increases doctors in traditional fee-for-service practices build into their fees each year eventually get cycled into what an HMO pays its doctors. That, obviously, undercuts the HMO's role as a controller of medical costs. 

A612/The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Managed Care. Refers to health care organizations -- such as Health Maintenance Organizations or Preferred Provider Organizations -- that "manage" or control the cost of health care by closely monitoring how doctors treat specific illnesses, by limiting referrals to costly specialists and requiring preauthorization for hospital care, among other measures. 

A613/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 MANAGED CARE: A type of health care organization -- such as a health maintenance organization (HMO) or a preferred provider organization (PPO) -- that seeks to control costs by monitoring how member doctors and hospitals treat patients and by limiting access to specialists and costly procedures. Managed care organizations would play a role in managed competition.  

A614/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 Managed care (is defined as) systems or techniques generally used by third-party payors expressly to provide what they consider an appropriate mix of medical and social services at the lowest cost to payors and patients. (American Medical Association) 

A615/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 A managed care program combines these essential elements: * Limited access to providers (physicians and hospitals). * Utilization controls. * Higher levels of benefits when using participating providers. * Quality of care controls. (Blue Cross of Virginia) 

A616/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 Broadly defined, managed care means any system in which whoever pays for medical care -- usually the employer -- takes a role in deciding what care is provided and who provides it. At its most elementary, this can mean simply requiring employees to obtain advance permission before entering the hospital or demanding second opinions for surgery, psychiatry or other services. At the other extreme, it can mean requiring employees to get care only through a health maintenance organization in which doctors, nurses and others are on salary, and a "gatekeeper" evaluates each case and determines which, if any, physician the employee can see and what treatment will be provided. 

A617/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * MANAGED CARE: A type of health-care organization--such as a health maintenance organization or a preferred provider organization--that seeks to control costs by monitoring how member doctors and hospitals treat patients and by limiting access to specialists and costly procedures. 

A618/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Managed Care: A system used by groups (including insurance carriers and corporations) to manage costs while maintaining quality of health and medical services. Specific approaches used by the payer of services include: pre-certification, utilization review, case management and medical necessity review. 

A619/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 Many different systems of medical care can be described under the term "managed competition." One of the most likely forms of managed competition is the Super-Health Maintenance Organization model. In this system, medical care is provided on an annual enrollment basis by private sector organizations which provide a full range of medical care from routine tests to brain surgery. Their services go beyond the physician services provided by traditional HMOs and include hospitalization, rehabilitation and preventive medicine -- hence the term Super-HMO. A critical element of the Super-HMO system is that payment is on an enrollment rather than fee-for-service basis. This means that the Super-HMO has an economic incentive to reduce unnecessary services, as opposed to the fee-for-service system, where the economic incentive is to increase services and tests. 

A620/CAROL GENTRY, staffwriter, St. Petersburg Times, March 13, 1993, Pg. 1A , HEADLINE: 'We will have to make some very hard decisions' \\VT 93-94
	 Managed care is the new phrase for prepaid health plans like HMOs that restrict patients to certain doctors and hospitals but cover all health services that are approved by the patient's doctor. 

A621/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 A number of companies that have switched to managed care are pleased with the results. Allied Signal Corp., a pioneer in the field, is estimated to have saved $ 90 million in the first three years of its plan. Southern California Edison Co. officials found they saved 20 percent in the first year of their plan, which it imposed over the vociferous opposition of its unions. 

A622/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * UTILIZATION REVIEW: A system now used by many health insurance companies, hospitals and doctors to monitor each physician's diagnosis, treatment and billing practices. The purpose is to lower costs by discouraging unnecessary treatment. 

A623/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 UTILIZATION REVIEW: A system now used by many health insurance companies, hospitals and doctors to monitor each physician's diagnosis, treatment and billing practices. The purpose of this system is to lower costs by discouraging unnecessary treatment. 

A624/The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Managed Competition. Not to be confused with managed care, this refers to the type of reform Clinton advocated during the campaign to overhaul the country's health care system. It requires the government to regulate insurers so that no individual can be denied coverage and everyone buying the same plan in the same region would pay nearly the same for it. Most employers and individuals would purchase insurance from a nonprofit agency (a Health Insurance Purchasing Cooperative or HIPC) that would negotiate the best price and service from competing health plans. Health plans would likely be organized by insurers or managed care companies (such as health maintenance organizations, or HMOs) that would own or contract with hospitals, doctors, clinics, etc., to provide care for the people who choose their plan. Experts agree most plans would likely evolve into "super-HMOs.' All health plans would have to offer a standard benefit package, the contents to be established by a government board. The government would collect information from health plans on their medical effectiveness and on customer satisfaction, which consumers could use during open enrollment periods to choose a plan. 

A625/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 MANAGED COMPETITION: Organized groups of doctors, hospitals, insurers and health maintenance organizations in each region would compete for customers by  offering a standardized benefit package. It is assumed consumers would favor the best plan offered at the lowest price, and thus the system would serve to control costs without price controls. 

A626/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 HEALTH INSURANCE PURCHASING COOPERATIVE: Often referred to by the acronym HIPC (pronounced hip-ick), these nonprofit agencies would act as the purchasing agent for consumers under a system of managed competition in negotiating to get the best plan at the lowest cost from networks of doctors and hospitals or health maintenance organizations.  

A627/Money, February, 1993, Pg. 15, HEADLINE: HOW WOULD YOU FIX THE HEALTH-CARE PROBLEMS IN AMERICA TODAY? \\VT 93-94
Managed competition, endorsed in principle by Bill Clinton, would mandate that all Americans should have federally prescribed standard coverage either through an employer or on their own. If companies provided more than the essential package, the value of the additional coverage would be taxable. The  money raised through that tax would pay private insurers to cover the uninsured. 

A628/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * MANAGED COMPETITION: Organized groups of doctors, hospitals, insurers and health maintenance organizations in each region would compete for customers by offering a standardized benefit package. It is assumed that consumers would favor the best plan offered at the lowest price, and thus the system would serve to control costs without price controls. 

A629/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Managed Competition: This approach to health policy reform sets up organizations to act as collective buyers of health and medical services from collective providers of services (similar to HMO's). In this model, the system for "managing care" is the responsibility of the provider groups. 

A630/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, MARCH 18.1993. TITLE: MANAGED COMPETITION, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:22 EST \\VT 93-94
	 Managed competition, one approach to health reform, is based on harnessing the free market model on which the rest of the economy is built. It recognizes the importance of an informed consumer in providing the efficient and cost effective delivery of products and services. 

A631/Health Line, October 21, 1992, HEADLINE: MANAGED CARE: DEBATING ITS EFFECTIVENESS Nexis \\VT 93-94
	 PBS' "MacNeil-Lehrer News Hour" discussed "what exactly is managed competition" and its role in the presidential candidates' health plans. PBS' Robert MacNeil introduced the segment by referring to a N.Y. TIMES article that declared: "The health care reform debate was over and managed competition had won." 

A632/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 In managed competition, health care consumers (including the previously uninsured) are organized into large purchasing cooperatives that can bargain down prices, and insurers, physicians and hospitals are eventually merged into health maintenance organizations and other facilities (hmos) that can achieve efficiency and economies of scale. Consumers will have choices, but of health plans rather than simply doctors. 

A633/Sabin Russell, Chronicle Staff Writer, The San Francisco Chronicle, DECEMBER 16, 1992, Pg. A5, HEADLINE: Economy, Deficit Bigger Worries Than Health Care, Study Says \\VT 93-94
	 Despite a lack of voter consensus on solutions, the study authors say there  is support for compromise along the lines of a proposal recently backed by Clinton. That plan would combine some form of government regulation with a restructuring of insurance markets known as ''managed competition.'' 

A634/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, MARCH 18.1993. TITLE: MANAGED COMPETITION, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:22 EST \\VT 93-94
	 The Jackson Hole Plan has a number of key points which include: 1. One or more non-profit organizations would be set up within a geographic community to act as collective buyers of health and medical services. These organizations would be called Health Insurance Purchasing Cooperatives (HIPCs). 2. All health coverage would be provided by private sector organizations called Accountable Health Partnerships (AHPs). They would be similar to present-day HMOs. 3. It would be the responsibility of the AHPs to "manage" the care of enrollees using activities such as medical necessity review, utilization review and pre-certification. Through this type of management they would be expected to provide quality services at reasonable costs. 4. An HIPC would buy services from AHPs based on getting "the best deal". If an AHP doesn't perform well, then an HIPC would move their business to another AHP. 5. States would designate an HIPC to serve as public sponsors for persons not connected to the workforce. 6. Employers could sponsor coverage directly or they could contribute to a local HIPC to sponsor their employees. 7. A national board would be set up to determine the minimum health benefits required under these plans, the information the HIPCs and AHPs would be required to collect and report, and the minimum standards for the performance of each of these two groups. This board would also develop practice guidelines that would be based on effectiveness and outcomes research. 

A635/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Enthoven also believed that such a system could remedy some of the injustices of the old health care system. Under the old system, insurance companies could pick and choose among clients and adjust their rates for the health experience of each consumer. But hipcs would have the leverage to force insurance companies and hmos to gear their premiums to the community average rather than to individual risks. 

A636/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, MARCH 18.1993. TITLE: MANAGED COMPETITION, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:22 EST \\VT 93-94
	 Proponents of this approach [The Jackson Hole Plan] indicate that cost saving from this approach are projected to come from a number of areas, including: 1. Economies of scale both for provider organizations and "consumer" organizations 2. Enough information would be available such that providers would have to genuinely compete on the basis of price, quality and customer satisfaction 3. Overall marketing and sales costs would be much lower as compared to the present system 4. Because providers would be following national practice guidelines, there would be fewer malpractice suits. This would encourage physicians to decrease unnecessary services and the cost of malpractice would go down. 

A637/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 1. The Enthoven Model: Enthoven, a former Pentagon official in the Johnson administration, believed the health care system could be restructured to reduce costs without imposing tight government control. Enthoven's secret weapon was the development of hmos. These organizations, which originated in the 1930s and began to spawn rapidly in the 1970s, combined the functions of provider, hospital and insurer. They were capable of saving money by reallocating resources within an integrated system. Their doctors, paid by salary, had an incentive to hold down expenditures. And as large institutions with thousands of subscribers, they could minimize the administrative overhead from which smaller companies with fewer clients suffered. According to a 1980 Rand study of the Health Cooperative of Puget Sound, the Seattle-based hmo averaged costs that were 28 percent below fee-for-service providers without any diminution in quality. 

A638/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Behind Enthoven and Cooper's approach lay a vision of a transformed health care system. Under managed competition, many of the 1,300 small insurance companies, which survive by "cherry- picking" their clients, would go under, and the larger companies would follow the lead of cigna and aetna and form insurer-hospital- physician networks that resemble hmos. Doctors--members of capitalism's last medieval guild--would become salaried professionals. And consumers, who once identified their medical needs with their personal doctor, would increasingly think of themselves as belonging to one of the plans offered by their hipc. 

A639/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * HEALTH INSURANCE PURCHASING COOPERATIVE: Often referred to by the acronym HIPC (pronounced hip-ick), these non-profit agencies would act as the purchasing agent for consumers under a system of managed competition in negotiating to get the best plan at the lowest cost from networks of doctors and hospitals or HMOs. 

A640/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Health Insurance Purchasing Cooperative/Corporation (HIPC): The name given in one of the most referenced (Jackson Hole) managed competition reform plans for non-profit organizations set up as collective buying agents of medical services. 

A641/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 2. The Starr Model: In devising a plan, Starr's strategy was to supplement managed competition with features borrowed from single-payer plans. He advocated imposing a global budget on the entire health care system. He and Zelman propose in the current Health Affairs that the government set a "maximum allowable rate of increase" on the low-cost premiums, while setting a discretionary target on out-of- pocket spending with the higher-cost premiums. By imposing a global budget, Starr would do nationally what the state of California did to Calpers. Starr would mandate insurance coverage for all citizens and fund it primarily through a payroll tax. He would also take steps to mitigate the creation of a two-tier health care system. While he would allow companies with more than 1,000 employees to opt out of the system, he would impose restrictions on their joining hipcs and on the kind of insurance they offer their employees. Companies, for instance, that tried to dump their older employees into the hipcs would find their own premiums risk-rated. But some of Starr's measures seem more cosmetic. He insists on calling the low-income plan the "benchmark premium." And he wants to require that all the plans, no matter how expensive, include a certain percentage of low-income consumers at the same rates as the benchmark plan--a kind of get-well fellowship for the deserving poor. 

A642/The Economist, February 27, 1993, Pg. 30, HEADLINE: Health care; A dose of the HIPCs \VT 93-94
  The Starr-Zelman [Paul Starr, a professor at Princeton University, and Walter Zelman, California's deputy insurance commissioner] scheme offers two ways of encouraging this approach. One is to restrict the tax break for employer-provided health insurance to the cost of a managed-care plan -- so anyone who wants the extravagance of fee-for-service  must pay for it in after-tax dollars. The second is state-run health insurance purchasing co-operatives (HIPCS). Expect to hear more of these animals, dreamt up last year by health-care reformers known as the Jackson Hole group. HIPCS would sponsor those not working for big companies, so they can exert monopsony  power when buying managed-care plans. They would stop the plans from turning away bad risks, as selectivity that is becoming easier thanks to advances in genetic medicine. And they could in time, and with public finance, be used to  cover the 36m Americans without health insurance, subsuming Medicaid, the federal-state programme for the poor. 

A643/The Economist, February 27, 1993, Pg. 30, HEADLINE: Health care; A dose of the HIPCs \VT 93-94
  Now comes the controversial bit. While Messrs Starr and Zelman reckon that  managed competition plus HIPC buying-power would improve health-care delivery,  they fear that it might not do enough to restrain costs. After all, nearly half of Americans with private insurance are already enrolled in managed-care plans  (see chart) -- and yet health spending has gone on rising fast. Experience  suggests that after a one-off initial saving of perhaps 10% (partly thanks to lower administrative costs), spending by managed-care plans goes by almost as fast as in fee-for-service medicine. So the Starr-Zelman scheme buttresses  managed competition with spending controls. 

A644/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	First introduced in February, 1992, The Garamendi [Calif. Insurance Commissioner] plan recommends integrating the medical coverages of all insurance, such as workers compensation and automobile, into a single 24-hour system guaranteeing comprehensive benefits. Under the plan, individuals could choose their own health care from competing HMOs and other private health plans. The plan proposes establishment of a fixed budget for all health care spending. Regional Health Insurance Purchasing Corporations (HIPCs) would collect a premium from employers based on an average of approximately 6.75% of payroll and from employees of 1% of income. The HIPCs (called Health Alliances by the Clinton task force) would be governed by employers, employees and consumers, and would certify the private health plans offering coverage and distribute the collected premiums to health plans according to the number of individuals enrolled. 

A645/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	The Kaiser report [Economic and Social Research Institute for the Kaiser Family Foundation ] states that by "combining market based incentives with strong regulatory features, the plan would lead to significant cost savings and expand access to health coverage." Additionally, it states that under "the Garamendi plan [Calif. Insurance Commissioner] , overall health spending could be lowered by $2.7 to $3.1 trillion over a decade." 

A646/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	Savings of as much as $3.1 trillion over 10 years would occur with adoption of Insurance Commissioner John Garamendi's plan for reforming the nation's health care system, a study by the Economic and Social Research Institute for the Kaiser Family Foundation has reported. 

A647/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	"The Kaiser report provides dramatic and clear evidence that enormous savings can be made through a comprehensive reform of our nation's health care system, " said Garamendi [Calif. Insurance Commissioner] . 

A648/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	The report [Economic and Social Research Institute for the Kaiser Family Foundation ] warns that "additional mechanisms (over and above a purely market-based managed competition approach) must be added to assure more substantial savings, particularly in the near term. A Garamendi-style [Calif. Insurance Commissioner] limit on funds that pay for health care is a potentially effective approach. This approach stand in stark contrast with such methods as 'voluntary' price controls or spending targets that lack effective enforcement mechanisms, which could exacerbate the cost crisis by delaying real action." 

A649/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	The Kaiser study [Economic and Social Research Institute for the Kaiser Family Foundation ] recommends an employee contribution of 1% and an employer contribution of 7.5%. This is still significantly lower than what most employers pay now for health care and workers' compensation medical coverage. Under the Garamendi [Calif. Insurance Commissioner] plan, there would be no yearly deductible and only modest co-payments for certain services, further lowering out-of-pocket costs to consumers over the current system. 

A650/BUSINESS WIRE, May 21, 1993, HEADLINE: CALIF. REPORT SAYS NATION COULD SAVE UP TO $3.1 TRILLION ON HEALTH CARE Transmitted: 93-05-21 15:29:00 EDT, Online America\\VT 93-94
	Dr. Jack Meyer, President of the institute [Economic and Social Research Institute for the Kaiser Family Foundation ] and an author of the report, said that it "demonstrates that a mixed approach to health policy reform combining managed competition with firm spending limits can achieve the twin goals of universal access and cost control, while improving the efficiency of the U.S. health care system." 

A651/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Gerald L. Maatman Jr., attorney: In my view, a more appropriate and effective plan for the United States would be similar to various aspects of the national health insurance programs in France, Germany and Japan. These countries have adopted multipayer systems, which combine both private and public insurance. Such a health care system is politically more acceptable to Americans than a single-payer system like the one in Canada. 

A652/David J. Gross, staffwriter, Roll Call, February 1, 1993, HEADLINE: Health Care Lessons From Abroad France, Germany, Japan All Have Universal Access, Control Spending Growth Better,Nexis \\VT 93-94
 Workplace-based insurance is the foundation of universal health insurance coverage in France, Germany, and Japan. Employers in these countries are  required to offer insurance to employees and their dependents; employees  generally must enroll with the carrier selected by their employer; and insurers cannot deny coverage to any person on the basis of actual or expected health care costs. 

A653/David J. Gross, staffwriter, Roll Call, February 1, 1993, HEADLINE: Health Care Lessons From Abroad France, Germany, Japan All Have Universal Access, Control Spending Growth Better,Nexis \\VT 93-94
 Yet there are several notable differences stemming from these countries'  regulations for guaranteeing access and restraining spending. First, insurers - who are predominantly nonprofit - are required to provide  minimum coverage that includes a wide range of health care benefits. Second, insurance enrollment is compulsory (with minor exceptions) for all residents, and they have little or no choice of insurers. Third, workplace-based insurance is financed largely by employer and employee payroll contributions, rather than by actuarially-based premiums. And finally, each country has set payments to providers and limits on total health care spending.  

A654/David J. Gross, staffwriter, Roll Call, February 1, 1993, HEADLINE: Health Care Lessons From Abroad France, Germany, Japan All Have Universal Access, Control Spending Growth Better,Nexis \\VT 93-94
 The apparent success of the spending controls in France, Germany, and Japan  is evidenced by trends in health care spending over time. Between 1980 and 1990, health care spending in Japan stayed relatively stable, rising from 6.4 to 6.9  percent of Gross Domestic Product (GDP). In Germany, health spending fell from  8.4 percent of GDP in 1980 to 8.1 percent of GDP in 1990. In France, health  spending rose from 7.6 to 8.9 percent of GDP during the same period. By contrast, US health care spending rose from 9.3 percent of GDP in 1980 to 12.4  percent in 1990. 

A655/David J. Gross, staffwriter, Roll Call, February 1, 1993, HEADLINE: Health Care Lessons From Abroad France, Germany, Japan All Have Universal Access, Control Spending Growth Better,Nexis \\VT 93-94
 However, GAO was able to evaluate the effect of particular spending control  policies in Germany and France. GAO estimated that Germany's controls on  outpatient care - spending targets instituted in 1977, replaced by spending caps in 1985 - reduced inflation-adjusted spending growth by as much as 17 percent over a ten-year period. GAO also estimated that France's controls on hospital spending, instituted in 1984, reduced the growth  by as much as 9 percent in that sector over a three-year period. 

A656/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 "The strict planning systems for hospital care in Switzerland and the  Netherlands, the two European systems most similar to those of the United States, are the major reason why expenditures are constrained in these countries," said Bengt Jonsson, a health specialist at the Stockholm School of  Economics. 

A657/David J. Gross, staffwriter, Roll Call, February 1, 1993, HEADLINE: Health Care Lessons From Abroad France, Germany, Japan All Have Universal Access, Control Spending Growth Better,Nexis \\VT 93-94
 As the United States weighs reforms in the American health care system, a comparison of the health insurance plans in France, Germany, and Japan shows these three countries appear to control spending growth better than the US,  spend a smaller share of their national income on health care, and at the same  time provide universal access to health insurance. 

A658/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 It is possible to erect a universal insurance program that would avoid the gaps and adverse effects of the current system. The concept is straightforward: every person would be enrolled in the same financing program, one similar to the Medicare model. Under the Medicare program for the aged, disabled and people with end-stage renal disease, beneficiaries seek care from diverse sources even though the same insurance program covers them all. 

A659/SAMIR N. BANOOB, professor of health policy at the University of South Florida's College of Public Health, St. Petersburg Times, February 7, 1993, Pg. 4D, HEADLINE: Health care: Painful remedies are needed \\VT 93-94
 Third, duplication should be eliminated by instituting one state-based plan that offers the same services for all. Medicare, Medicaid, Veterans Health Services, Federal Civilians Insurance, Indian Health Services and all other  schemes except the Military Health System must go.  

A660/Reuters News Service, April 23, 1992, HEADLINE: U.S. GROUP SAYS PRIVATE HEALTH INSURANCE WASTEFUL, Nexis \\VT-ACS
	 Consumers could have saved $300 a year on an individual policy and $750 on a family plan if the commercial system were as efficient as the government run Medicare program, it said. 

A661/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 Like Maryland's H.B. 376, the Heritage Foundation Consumer Choice Health Plan seeks to: Assure access to at least a basic level of health care for all Americans; Create a system in which Americans keep their health plan from job to job, a feature known as "portability"; Introduce cost-conscious consumer choice, a feature now virtually absent from the system, as the driving force to keep costs in check; Empower consumers with tax credits or vouchers, through a change in the tax treatment of health benefits and health purchases, to afford care; and Reform the health insurance market to make it more sensitive to the needs of consumers. 

A662/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 The Heritage Foundation Consumer Choice Plan would phase out the tax breaks now available to Americans for their company-based health plan. The total federal revenue cost of this tax exclusion alone was $ 66.6 billion in 1991. n9 This same revenue would be used, dollar for dollar, to finance a system of tax credits for all families to offset part of the cost of their purchase of health insurance, or out-of-pocket medical costs, such as deductibles or copayments or direct payments to physicians. All families not enrolled in Medicaid or Medicare would be required by law to purchase at least a basic health plan. 

A663/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 By adding revenues from state and local tax and other changes, the total amount of revenues available for tax credits would be nearly $ 88 billion in 1991 dollars. [The Heritage Foundation Consumer Choice Plan] 

A664/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 The Maryland Consumer Choice Health Plan would make much-needed reforms in the tax code -- but only at the state level. To make state-sponsored consumer-choice plans more successful, Congress should amend the tax code to introduce individual tax credits for health insurance and the purchase of services, in place of the current tax break for only employer-sponsored plan. Such a proposal has been advanced by The Heritage Foundation. n18 

A665/National Review, March 2, 1992, Pg. 15, HEADLINE: Healthy competition; National health insurance Editorial \\VT 93-94
	 By ignoring the problem of company-sponsored plans, the Administration missed a crucial cost-control lever. A reform package, such as was recently outlined by the Heritage Foundation, would replace tax-exempt corporate plans with a universal system of tax credits similar to those the Administration has proposed for the uninsured. Employees would be required to purchase a basic health-insurance policy, but beyond that they could keep any part of the credit not spent on health care. Since insurance companies would then have an incentive to offer health plans costing less than the credit in order to gain customers, it would serve both to control costs and to spur efficiency. Best of all, this extension of the Bush plan wouldn't require additional taxes: the credit would be financed with revenues from now untaxed corporate health benefits. 

A667/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 Robert M. Moffitt, deputy director of domestic policy studies at the Heritage Foundation, said the $80 billion in employer tax deductions for health care plans could be better used by giving the money "right back to American families" in the form of vouchers, which they could use only to buy insurance for basic and catastrophic medical coverage. That would create a market demand for a whole new industry to provide information on the best plans as health care providers competed for the consumer dollar, he said. Employers could contribute part of the cost of whatever plans their employees choose, he said. 

A668/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 By reforming the federal tax code in this way, the Congress would make it easier for states to experiment with health care reform. In any case, there can and will be no complete reform of America's health care system, including the removal of the perverse incentives that are now relentlessly driving up costs in the system, without a reform of the perverse incentives in federal tax code. 

A669/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 The current federal tax breaks for employer-based health insurance are grossly inefficient, in that they favor employer-based insurance options to the exclusion of all other types of insurance. They are also grossly unfair, in that the larger family's personal income, the larger are the available tax breaks. The current federal tax system discriminates in favor of highly-paid executives in large companies with expensive, tax free health insurance packages, and discriminates against lower-paid workers and Americans who work for small companies with little or no health insurance benefits. 

A670/The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Tax Treatment. Refers to two separate proposals for changing the tax treatment of health benefits. Currently, employees do not pay taxes on the health insurance premiums their employers pay for them. Some health reform proposals call for taxing, like income, the amount of an employer-provided health premium that is over the amount needed to purchase the lowest-cost standard benefit package in a given region. The second type of tax proposal deals with changes in the deductibility of health premiums. Currently, employers can deduct from taxation the entire value of the health premiums they give their workers (self-employed individuals can deduct 25 percent). Some reform proposals include limiting the amount an employer can deduct to the cost of the least-expensive standard benefit package in a region. Both proposals aim to dampen the demand for high-priced -- reformers say excessive -- health benefit packages by making them relatively more costily. 

A671/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Tax Credit. -- Another alternative to Medicaid expansion is to forgo a public insurance program for low-income people and, instead, provide them with an equivalent tax credit for their own purchase of insurance from private insurers. It is suggested that this approach eliminates the stigma of a publicly run low-income insurance program and the overhead of government administration and offers individuals a choice of plans that would also enroll people who do not have low incomes (creating a single-tiered system). 

A672/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  The current tax treatment of health care services contributes directly to  this market failure, and that a change in the federal tax code is essential to  weed out the inefficiencies of the system and broaden access to affordable health insurance for millions of Americans through the private sector. While we agree on the need to change the tax code, we differ on the specifics of the  change. These structural differences, we believe, will have very different  results both for the health insurance market and for the character of our health care delivery system. 

A673/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 BENEFITS TAX: Depending on the proposal, it would either require workers to  pay taxes on the value of employer-provided health benefits exceeding a certain level, or limit the tax deduction employers may now take for providing benefits. Currently, employers spend an average of $3,000 a person to provide health coverage, which is not counted as income for workers. 

A674/National Review, March 2, 1992, Pg. 15, HEADLINE: Healthy competition; National health insurance Editorial \\VT 93-94
	 But the health crisis stems equally from those who have too much medical insurance, and pay little or nothing for it. A major reason for rising health-care costs is that employees of large corporations are compensated with generous, tax-exempt medical plans. With health care paid for by the employer, neither employees nor their doctors have reason to mind costs. The result: gold-plated corporate health plans that cover everything from Shiatsu massage to herbal remedies, and corporations that now devote an average of 56 per cent of their pre-tax profits to health care, as against 8 per cent in 1995. 

A675/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 * BENEFITS TAX: Depending on the proposal, it would either require workers to pay taxes on the value of employer-provided health benefits exceeding a certain level or limit the tax deduction employers may now take for providing benefits. 

A676/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Tax Preference/Treatment: Unlike wages, the cost of health benefits paid by an employer are considered a business deduction and not taxable as income to the employee. This encourages employers and employees to increase their health benefits in lieu of increases in wages. 

A677/Carol Kleiman, Chicago Tribune April 6, 1992, BUSINESS; Pg. 5; HEADLINE: Lack of health-care benefits keeps low-wage workers on welfare's edge \\VT 93-94
	 President Bush includes among his health-care proposals financial aid for families below the poverty level. He suggests offering vouchers of up to $3,750 to buy health insurance. But basic coverage costs at least $5,000 at a health maintenance organization, and equivalent coverage in other types of plans may cost even more, according to the non-profit Women's Research and Education Institute in Washington. The research group concludes that the voucher would "not meet the needs of financially strapped families for affordable access" to medical care. It adds that to buy the kind of coverage needed, a family "would have to supplement the voucher with at least $1,250 a year - a hefty percentage of average income for poor families." 

A678/Paul W. Newacheck, DrPH, Lori N. Wicks, JD, Institute for Health Policy Studies, University of California School of Medicine, AMERICAN JOURNAL OF DISEASES OF CHILDREN, NOVEMBER, 1992; 146: 1376-1380 TITLE: How Will Children and Pregnant Women Fare Under Current National Health Insurance Proposals? \\VT 93-94
	 In contrast, the Bush proposal is based on a market approach that offers businesses and individuals incentives to purchase health insurance but little in the way of coercion. The presidential plan would provide tax credits, equivalent to the cost of a basic "bare bones" private health insurance plan, for families with incomes below the poverty level. Additional tax deductions would be provided to middle-class families to encourage the purchase of private health insurance. 

A679/PR Newswire, February 6, 1992, HEADLINE: HEAL SAYS PRESIDENT'S HEALTH CARE REFORM PLAN BEST FOR AMERICANS Nexis \\VT 93-94
	Members of the Healthcare Equity Action League (HEAL) praised the health care reforms announced today by President Bush in Cleveland as a strong and positive market- oriented proposal in the health care debate. "The president's plan builds on the strengths of our current health care system and tackles the serious problems with common sense reforms that the majority of Americans support," said John Motley, vice president of federal government relations for the National Federation of Independent Business and a HEAL member. 

A680/PR Newswire, February 6, 1992, HEADLINE: HEAL SAYS PRESIDENT'S HEALTH CARE REFORM PLAN BEST FOR AMERICANS Nexis \\VT 93-94
	"A recent USA TODAY, CNN, Gallup poll found that 64 percent of Americans surveyed believe that reform of our private health care system is the best way to solve the health care crisis, not government-sponsored national health insurance. " 

A681/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Requiring Private Purchase of Insurance. -- The third way of guaranteeing universal coverage is for the federal government to require that all Americans purchase a policy for themselves and their families. Individuals would have to demonstrate they had purchased a policy through a national reporting form, such as the tax form. The cost of a policy might be subsidized by the government through tax credits and deductions based on income. This approach is similar to the requirement in most states that everyone who owns an automobile purchase an insurance policy. To facilitate purchases by people who might not be able to afford the price of a policy, tax credits and deductions could be made available through the federal income tax system. This plan is not linked to employment, recognizing that millions of people either change jobs or work part-time, and employment-based insurance does not provide them with continuous protection. Finally, it assumes that employers should not be required to contribute to the insurance policies of their employees, although most do and would continue to do so. 

A682/USA TODAY, January 8, 1992, Pg. 3A HEADLINE: Report: Health system fails kids - 25 million without insurance \\VT 93-94
	The nation's employer-based health insurance system failed to provide coverage for more than 25 million children in 1990, a report Tuesday says. And by 2000, half of the nation's children will be shut out of the major system providing health-care coverage in the USA, according to the Children's Defense Fund, a child advocacy group. 

A683/USA TODAY, January 8, 1992, Pg. 3A HEADLINE: Report: Health system fails kids-25 million without insurance \\VT 93-94
	''The picture today is even grimmer with more children losing coverage as their parents lose employment or see their earnings reduced,'' said study author Sara Rosenbaum. 

A684/Health Line, September 4, 1992, HEADLINE: COMMENTARY: VIEWS OF THE HEALTH CARE CRISIS Nexis \\VT 93-94
	 RATIONING: In a WASH. POST op-ed, State University of New York anesthesiologist James Cottrell writes, "Americans must accept the fact that we do not have the luxury of choosing whether to ration health care. Health care is already rationed and will continue to be rationed for the foreseeable future. The choice at hand is whether to ration health care inadvertently or haphazardly or to do so rationally and wisely" (9-3). 

A685/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 For example, a plan that is projected to save $40 billion the first year (and every year thereafter) may appear to be better than a plan that saves only $20 billion the first year. But if the second plan increases the amount saved by $10 billion a year for the next five years, it will provide an equal amount of total savings by the end of the fifth year and save $20 billion more every year thereafter. 

A686/The Washington Post January 26, 1993, PAGE Z17 HEADLINE: A Survival Guide to Health Care Terms \\VT 93-94
 Global Budgets. A vague term that refers to having the government monitor or control private and public health care spending. In its most modest form, global budgeting means having the government establish a national spending target that can be adjusted from year to year. In its strongest form, the government sets a national spending ceiling and apportions the national budget to the states. Each state divides the sum between hospitals, doctors and other health care providers and enforces the spending limit by setting prices and imposing penalties on facilities and physicians that do not comply. 

A687/SARA FRITZ, TIMES STAFF WRITER, Los Angeles Times, February 23, 1993, Part A; Page 5; HEADLINE: 'HMO, HIPC, PAY OR PLAY . . . ' LEARNING LINGO OF THE DEBATE \\VT 93-94
 GLOBAL BUDGETS: A technique in which the government sets an annual target or cap for all of the nation's health care expenditures. Under the strictest type  of budgeting, the government would set a national limit as well as  state-by-state limits, and each state would then apportion spending among doctors, hospitals and other health care providers. It differs from price regulation, which normally regulates individual fees, not total expenditures. 

A688/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Global Budget: The overall amount spent on specific health services by all buyers of services. In some health reform plans this amount would be set each year by a governmental body. If spending exceeds the amount in the global budget, sanctions (including price controls) may be applied. 

GENERAL NEGATIVE

INHERENCY ARGUMENTS

1. NHI is coming in the status quo
	a. Inevitable N1
	b. NHI will happen N2-4
	c. Consensus exists for major reform N5-6
	d. Crisis guarantees NHI N7
	e. Will cover all N11
2. Constituencies leading to NHI
	a. President Clinton N8-10
	b. Voters demand NHI N12-16
	c. Politically powerful middle class wants NHI N17-18
3. Traditional opponents of NHI are giving in
	a. Insurance industry N19
	b. The American Medical Association N21-24
4. Time frame for NHI in the status quo
	a. 1990's is the decade for medical change N25
	b. 90% of experts predict NHI in 10 years N26
	c. NHI coming in 1993 N27
	d. NHI coming in 1994 N28-29
	e. NHI coming in 1995 N30
5. Specific proposals coming in the status quo
	a. HMOs in the status quo N31-33
	b. Canadian system in the status quo N34
	c. Managed competition in the status quo

NEGATIVE HARM ARGUMENTS

USA MEDICAL CARE SYSTEM  IS WONDERFUL
1. USA medical care system is excellent N36
2. Highest quality in the world N37
3. No evidence supports comparative medical deficiency N38
4. USA quality exists even though gross mortality statistics do not show it N39-40
5. Americans are not dissatisfied with the way care is delivered N41
6. American health care system is the most cost beneficial in the world N42-43

INFANT MORTALITY STATISTICS DO NOT CONDEMN USA HEALTH CARE SYSTEM
1. Advocates of NHI use infant mortality statistics to justify their advocacy N44
2. No relationship between doctors and infant mortality N45
3. Access will not reduce infant mortality N46
4. Social and physical causes are dominant N47
5. Drug babies distort USA figures N48
6. Canada is no different in terms of access making a difference N49
7. USA saves babies others kill
	a. Other nations lower rates by not reporting low weight babies N50
	b. USA tries to save low weight babies N51

RIGHT TO HEALTH CARE IS AN INCORRECT ARGUMENT
1. Totally unrealistic N52-54
2. Not a legal right N55-56

LACK OF COVERAGE IS NOT A PROBLEM
1. People get care, but the cost of it is shifted N57, N477
2. Can't define it N58-59
3. Insurance is adapting N60
4. Same problems will exist with NHI benefit package N61-62

COST SPIRAL IS NOT A PROBLEM
1. USA cost increases are slower N63
2. Costs not huge in comparison N64
3. No villains in cost spiral
	a. Not the doctors N65-66
	b. Not the hospitals N67

MEDICAL COSTS DO NOT HURT US COMPETITIVE STANDING
1. Not empirically proven N68
2, NHI will not solve N69-70

PROGRAMS EXIST TO PROVIDE MEDICAL CARE
1. Medicaid for the poor N71-72
2. Medicare for the elderly N73-75
3. Programs for special groups N76

MEDICAL CARE DOES NOT INCREASE HEALTH
1. Increased medical access does not improve the health of populations N77
2. Less treatment improves health N78-79
3. Health care increase leads to health decrease N80
4. Medical care does not decrease mortality N81-84
5. Denial of access improves health N85-86
6. Modern medicine did not cause modern mortality decreases N87-88
7. Most medical treatments are not scientifically validated N89
8. Minimal medical intervention is best, should concentrate elsewhere N90
9. Doctors follow healthy populations, they don't create them N91
10. Modern medicine does not reduce disease N92-94
11. Modern medicine does not reduce infections N95-97
12. Modern medicine does not cure cancer or increase survival rates N98-101
13. People have been brainwashed to believe medical myths N102-103
14. High levels of medical skill are not needed to heal N105
15. Social class indicates health outcome, not medical care N106

BLOOD SUPPLY IS SAFE N107-123

SOLVENCY ARGUMENTS

GENERAL
1. USA does not need NHI N124
2. NHI is a terrible solution for USA health problems N125-126
3. It is an easy sounding solution, but it will fail N127
4. NYC examples proves NHI failure N128
5. Imperfect allocation of medical resources will always be with us N129

COVERAGE WILL NOT MEAN MEDICAL ACCESS
1. Still won't get medical care N130-134
2. Many non-financial barriers exist N135-136
3. Without non-financial medical reform, there will be no access N137-139
4. Medicaid and medicaid prove this N140-142
5. Geographic maldistributiion of doctors N1430145
6. Medical professionals refuse to serve some segments of society N146
7. Racism is a barrier N147
8. Language is a barrier N148
9. Patients lack knowledge N149

ALTERNATIVE CAUSES ARE NOT SOLVED BY AFFIRMATIVE
1. Education and health N150
2. Demography N151
3. Class differences N152-153
4. Family structure N154
5. Stress N155-156
6. Seek useless unconventional medicine N157-159

DOCTOR SUPPLY PRECLUDES SOLVENCY
1. Needed generalists are in short supply N160-161
2. Doctors won't go to the people who need them N162
3. Can't change doctor supply quickly N163

BENEFIT LEVELS WILL CREATE PROBLEMS
1. Benefit levels will be raised, driving up costs N164
2. Then, huge cuts will be made N165
3. Minimum package is bad N166
4. Must have long term care N167

PUBLIC OPINION WILL SABOTAGE AFFIRMATIVE
1. Public opposes NHI style controls N168
2. Opposition to NHI is part of our culture N169
3. Must change attitudes BEFORE NHI is adopted N170-173
4. Implementation is politically impossible N174
5. Polls showing public favors NHI are deceptive N175
6. Individualism causes opposition to NHI N176
7. Example: Medicare Catastrophe Act of 1988 N177

HUGE BUREAUCRACY WILL CRIPPLE SOLVENCY
1. NHI will create a huge new bureaucracy N178-179
2. It will have to be huge, it will control 1/7th of the economy N180
3. Will need a Supreme Court of Health N181
4. Example: government insurance programs N182
5. Example: military and British system N183

NO BIG ADMINISTRATIVE SAVINGS WILL TAKE PLACE
1. Administrative savings will evaporate N184
2. They are a pipe dream N185
3. Insurance only involves 10% of costs N186
4. Citizen Action study is wrong N187-188

AFFIRMATIVE COST ESTIMATES CANNOT BE TRUSTED
1. Skepticism is best N189
2. They use biased data N190
3. Politicians lie about their proposals N191
4. Estimates ignore implementation N192
5. NHI will increase costs N193-194
6. No hospital savings possible N195-196
7. Medical practice guidelines will fail N197
8. NHI will take five years to implement before any savings take place N198

RATIONING WILL BE A DISASTER
1. Costs can only be controlled through rationing N199
2. Government will ration who lives and who dies N200
3. Citizens will detest government as the rationing mechanism N201-203
4. Rationing will lead to underfunding N 204-205
5. People will be rationed to death N206-211
6. Citizens will not accept age based rationing N212
7. Citizens will tolerate price rationing, but not government rationing N213

VALUE OF PREVENTION IS LIMITED N214

MAMMOGRAPHY SCREENING IS OF LIMITED VALUE N215-223

PRICE CONTROLS FOR MEDICAL SERVICES WILL FAIL
1. Historical failure N224
2. Price controls are counterproductive N225
3. Price controls deal with symptoms of problems, not causes N226-227
4. Would freeze in current inequities N228
5. Lead to shortages of medical care N229-230
6. Leads to decreased quality of care N231-232
7. Leads to decreased investment in medical areas N233
8. Tends to benefit the rich N234-235
9. Leads to black market medicine N236-237
10. Leads to downward spiral of quality and availability N238
11. Leads to queuing and rationing N239
12. Leads to increased discrimination N240
13. Leads to cheating by participants in the system N241-242
14. It would be better to use a private based approach (like the market counterplan) N243

GLOBAL BUDGETS WILL FAIL
1. Spending categories cannot be properly defined N244
2. Price controls will not mean global budget success N245
3. Global budgets will be busted N246
4. Leas to denial of care to the sick N247-250
5. Will kill patients N251-252
6. Global budgets cause all the harms of price controls N253

INTERNATIONAL COMPARISONS SHOW NATIONAL HEALTH INSURANCE FAILURE
1. Foreign experience shows NHI does not guarantee a right to medical care N254
2. Foreign models are an outdated approach N255
3. France, Germany, Japan experience the same problems as the USA N256
4. Costs are rising out of control:
	a. Great Britain, France, Canada N257-258
	b. Germany N259
5. European systems are a bad model N260
6. Great Britain, New Zealand, Canada all inefficient N261
7. Netherlands:
	a. Moving away from NHI N262
	b. Use rationing N263
8. Use rationing and care denial:
	a. In general N264
	b. New Zealand, Canada, Great Britain N265
9. Great Britain's medical infrastructure is crumbling N266
10. They free ride off of USA technology N267

CANADIAN SYSTEM WOULD BE A MISTAKE FOR THE USA
1. General, not a good system for USA to copy N268-276
2. Canadian data and system cannot be applied to the USA
	a. Populations are too different N277-282
	b. USA system acts as a safety valve for Canada N283-287
	c. Culture is too different N288-289
	d. Form of government is too different N290-291
	e. Social factors too different  N292
	f. Health care industry is too different N293
	g. Definition of medical care is too different N294
	h. Abortion not counted N295
3. Canadian system still lacks access N296-302
4. Canadian system has decreased quality N303-310
5. Doctors fear the Canadian system N311
6. Public fears the Canadian system N312-313
7. Canadian system is inefficient N314-316
8. Canadian system has inefficient use of hospitals N317-320
9. Canadian system does not control costs N321-329
10. Adopting the Canadian system in the USA would cost too much N330-337
11. The Canadian system allows people to die while waiting for care N338-349
12. Canadian system advantages would be only temporary N350-351
13. Canadian system  would discourage new technology N352-355
14. Better to use a market solution (counterplan) N356
15. Canadian system is underfunded N357
16. Canadian system has the same problems as the USA N358
17. Canadian system worked because of an economic boom which is now over N359

MANAGED COMPETITION FAILS
1. It is counterproductive N360-361
2. Vague concept with no certain definition N362-365
3. Not substantially reduce costs N366-372
4. Does not provide coverage for all N373-377
5. Leads to increase bureaucracy N378-381
6. Only real beneficiaries are insurance companies N382-384
7. It is not NHI N385
8. Benefits are only short term N386
9. Leads to decrease quality N387
10. Leads to rationing N388
11. Can't serve rural areas N389-390
12. Hurts the doctor patient relationship N391-392
13. Will fail unless tax codes change N393-394
14. New York Times evidence is biased N395
15. Jackson Hole group evidence is biased N396

MANAGED CARE WILL FAIL
1. Does not guarantee access N397
2. Does not decrease costs N398-402
3. Advantages are short term only N403-408
4. Leads to decreased quality N409-410
5. Is not comprehensive N411-412
6. Biased in favor of insurance companies N413
7. Decreases appropriate care N414
8. Hurts the doctor patient relationship N415-416
9. Increases bureaucracy N417
10. Decreases innovation N418
11. Lack of patient compliance N419

HEALTH MAINTENANCE ORGANIZATIONS
1. In general, not a good system N420-422
2. No single definition -- lots of arrangements use the name HMO N423-424
3. Does not lead to decreased costs N425-426
4. Does not provide quality medical service N427-430
5. Does not utilize prevention N431
6. Leads to undercare N432-433
7. Patient satisfaction is no better N434

PLAY-OR-PAY PLANS FAIL
1. In general N435
2. Does not cover all N436-438
3. Will lead to NHI single payer system N438-440
4. Business will bow out, and workers will be pushed into the public system N441-445
5. It will hurt business N446
6. Medical-workplace link is outdated N447
7. Lead to a two-tiered system N448
8. Ignores the real problems of the medical sector N449
9. Leads to NHI or cherry-picking N450
10. Leads to a big government bureaucracy N451

PRIVATE INSURANCE BASED REFORMS WILL FAIL
1. Doomed to fail N452
2. Counterproductive N453
3. Does not cover all N454
4. Will lead to cheating N455
5. Is wasteful N456
6. Voucher system will be underfunded N457
7. Voucher system hard to administer N458

HERITAGE FOUNDATION PROPOSAL IS A MISTAKE
1. Will not give access to all N459, N478
2. Will lead to adverse selection N460
3. Will lead to increased inequalities in care N461
4. Will decrease benefit coverage N462
5. Impossible to administer N463-464
6. Federal Health Benefits Program is a failure and should not be a model N465-466

OTHER APPROACHES ARE INADVISABLE
1. Pepper Commission N467-468
2. American Medical Association N469
3. Enthoven-Cooper proposal N470
4. Fein N471
5. Starr N472

TRADE-OFFS INEVITABLE
Increasing coverage, lessening cost, and providing quality care, all trade off with one another N473-474

NATIONAL HEALTH INSURANCE IS ANTI-DEMOCRATIC N475-476

N1/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 A national health insurance system is inevitable regardless of which political party controls the White House because the middle class is afraid they can't afford care, Dean said. [Vermont Gov. Howard Dean (D)] 

N2/James J. Kilpatrick, syndicated columnist, The Buffalo News, December  23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	 In the matter of health care reform, an old threshold question can be  discarded. The question is no longer whether the United States will have some form of  national health insurance.  The question now is, what form will it   take?  

N3/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	But Fuchs [Victor Fuchs, Stanford University economics professor] said that eventually the need to curb cost while extending coverage will continue to push the country in the direction of national health insurance. The process will accelerate, he predicted, as nonprofit health care institutions lose their ability to provide some social insurance as an alternative to national health insurance. 

N4/Capital District Business Review, January 4, 1993, Sec 1; pg 20, HEADLINE: This year gets health care off the back burner with a start of national health insurance reform \\VT 93-94
 Health care experts used to talk about what care providers and consumers could expect "if" a national health plan were ever developed. Now they're talking about the shape it will take "when" a national health care plan is enacted. 

N5/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 15, 1991; 265: 2563 TITLE: Caring for the Uninsured; Choices for Reform \\VT 93-94
	 There is evidence of growing public dissatisfaction with our inability to resolve this serious problem, and there are signs of a broad consensus that some type of major reform is now required. 

N6/Charles Marwick, December 23, 1992-December 30, 1992, Journal of the American Medical Association; 268: 3415, 341, TITLE: Science Organization Sponsors Discussions About What Constitutes Health Care Reform \\VT 93-94
	 "It's no longer a question of whether there will be health care reforms, but what shape these reforms will take," says the association's Audrey Chapman, PhD, organizer of a series of these meetings. The American College of Physicians document represents another step in the health care reform debate that the college began in 1989 when it called for examination of financing (Ann Intern Med. 1990;112:641-661). 

N7/Capital District Business Review, January 4, 1993, Sec 1; pg 20, HEADLINE: This year gets health care off the back burner with a start of national health insurance reform \\VT 93-94
 With the national health insurance pot boiling and the state Medicaid reimbursement legislation brewing, it could be a contentious year in the health care field. While everybody supports health-care reform, arguments loom over the specifics. But some experts think that whatever finally is cooked up, consumers and health care providers already have benefitted from the 1992 presidential campaign getting the health care off the back burner. "Sometimes when you have a crisis, things get done quicker," said Stephen Lauko, chief executive officer at Child's Hospital in Albany. "I look at this as a time for hope and opportunity," he said. 

N8/MRS. CLINTON, Chair, Health Care Task Force, April 29, 1993, WHITE HOUSE PRESS RELEASE, REMARKS BY THE PRESIDENT AND THE FIRST LADY IN RECEPTION FOR THE HEALTH CARE TASK FORCE, Transmitted: 93-05-03 21:07:55 EDT, Online America//VT 93-94
	 None of this obviously would be possible -- none of the work that you have done, none of the work you are still doing, none of the work you will continue to do in the weeks and months ahead without a President who believes with all his heart that health care reform is the right thing for this country to do, both as a matter of human decency and dignity, and as an economic imperative. And he believes that the time for the changes that many of you have seen and talked about and worried about is now. 

N9/PRESIDENT CLINTON, April 29, 1993, WHITE HOUSE PRESS RELEASE, REMARKS BY THE PRESIDENT AND THE FIRST LADY IN RECEPTION FOR THE HEALTH CARE TASK FORCE, Transmitted: 93-05-03 21:07:55 EDT, Online America//VT 93-94
	 But the overwhelming focus of this administration has been on the economy, jobs, deficit reduction and investment in our people, and on health care. That's what we have focused on -- the things that will lift this country up again and bring this country together again, and give people some measure of security, even as they go out in the highly changed and charged world that we're moving toward.

N10/PRESIDENT WILLIAM CLINTON, February 17, 1993, "A New Direction" Congress Address, WHITE HOUSE PRESS RELEASE, Transmitted: 93-03-01 15:42:58 EST//VT 93-94
	We will provide security to all our families, so that no one will be denied the coverage they need. We will root out fraud and outrageous charges, and make sure that paperwork no longer chokes you or your doctor. And we will maintain American standards -- the highest quality medical care in the world and the choices we demand and deserve. The American people expect us to deal with health care.And we must deal with it now. Perhaps the most fundamental change our new direction offers is its focus on the future and the investments we seek in our children.

N11/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 In the future, numerous potential permutations exist as to which direction the private insurance industry and the federal and state governments will take. One thing is for sure -- Americans seem to want a system that will not allow 35 million of their fellow citizens to fall through the large holes in our safety net. 

N12/Robert J. Blendon, ScD, Drew E. Altman, PhD, John M. Benson, MA, Humphrey Taylor, Matt James, Mark Smith, MD, MBA, Journal of the American Medical Association December 16,1992; 268: 3371-3373, TITLE: The Implications of the 1992 Presidential Election for Health Care Reform\\VT 93-94
	 A postelection poll of Pennsylvania voters showed that 50% identified " national health insurance" as one of the two issues that mattered most in deciding how to vote; 21% said the issue was "the single most important factor" in their voting decision. The results of the Pennsylvania Senate race suggested that health care had arrived as a major political issue, one that could decide the outcome of key elections. [n2] Senator Wofford had demonstrated that talking about health care was an effective way to reach people about their economic fears and insecurities. National political candidates were quick to learn the lesson that this issue could attract voters, and not long after, President Bush outlined his health reform plan. 

N13/Robert J. Blendon, ScD, Drew E. Altman, PhD, John M. Benson, MA, Humphrey Taylor, Matt James, Mark Smith, MD, MBA, Journal of the American Medical Association December 16,1992; 268: 3371-3373, TITLE: The Implications of the 1992 Presidential Election for Health Care Reform\\VT 93-94
	 Our studies tracing the health care issue throughout 1992 indicate that it consistently ranked high on the list of public concerns, but that its salience declined from the lofty position the issue held in the 1991 Pennsylvania Senate race. In February 1992 health care was ranked as one of the two most important issues by 25% of the public, a figure half that found in the Pennsylvania election. The reemergence of the abortion issue around the time of the Supreme Court's Planned Parenthood of Southeastern Pennsylvania v Casey decision and Ross Perot's emphasis on the federal deficit drove down the salience of health care as an issue still further. [n5] In our election night survey 13% named health care as one of the top two issues (Fig 1). Even at this relatively low figure, however, health care was the second-ranking issue among those who voted for Governor Clinton, named by 18% of his voters, compared with 6% of President Bush's supporters. 

N14/Robert J. Blendon, ScD, Drew E. Altman, PhD, John M. Benson, MA, Humphrey Taylor, Matt James, Mark Smith, MD, MBA, Journal of the American Medical Association December 16,1992; 268: 3371-3373, TITLE: The Implications of the 1992 Presidential Election for Health Care Reform\\VT 93-94
	 In both 1992 election surveys, however, health care still outranked such traditionally important issues as abortion, crime, taxes, education, and foreign policy. [n3] 

N15/Robert J. Blendon, ScD, Drew E. Altman, PhD, John M. Benson, MA, Humphrey Taylor, Matt James, Mark Smith, MD, MBA, Journal of the American Medical Association December 16,1992; 268: 3371-3373, TITLE: The Implications of the 1992 Presidential Election for Health Care Reform\\VT 93-94
	 With the election over, what do the voters expect? We asked voters which two issues were most important for the newly elected President and Congress to deal with during the first 100 days of their term. Health care ranks third among voters' priorities for action during the first 100 days of the new administration. Once again, the economy and jobs are the overwhelming first choice for action. The federal deficit edges health care reform for second place on the voters' agenda (Table 2). 

N16/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 Harris Wofford's defeat of Richard Thornburgh in a Pennsylvania Senate race in which Wofford's support for national health insurance was a major issue. [n5] The results of the Pennsylvania election confirmed for members of Congress, as well as presidential candidates, that the voting public did indeed perceive a health care crisis and that electoral success required a proposal for a solution. 

N17/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 The change does not simply come from growth in the numbers of uninsured -- up to 36 million in 1991. [n6] More significant politically is the fear among insured Americans that their health insurance will not protect them against the rising costs of medical care. Employees of small businesses see insurance threatened by insurer practices that exclude coverage for preexisting conditions, hike rates when illness occurs, and deny coverage to individuals, occupations, and geographic areas deemed to pose excessive risk. Employees in large businesses see benefits threatened in wage negotiations as employers cut benefits in order to control costs. In essence, insecurity about health care has become part and parcel of economic security, and health care reform has become part and parcel of guaranteeing economic security to the voting middle class. 

N18/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 For medicine in the nineties, the news is good and bad. The good news is that the financing of medical care has finally become a recognized political issue. 

N19/Theodore M. Pappas, President, The McLaughlin Co., Legal Times, March 23, 1992, Pg. 22, HEADLINE: Looking For Lawyers' Angle In Health Care \\VT 93-94
	 I read, with interest, your article on the lobbying efforts of the Health Insurance Association of America in regard to national health insurance. ["National Health Insurance? Say It Isn't So," Legal Times Supplement, Feb. 17, 1992, Pag. 11. ] While the effort may be formidable, I know that Carl Schramm [president of the Health Insurance Association of America] has been going around town for the past several years saying something should be done about national health insurance and it may be time to experiment. 

N20/Sacramento Bee, March 5, 1993, Pg. A19, HEADLINE: A SPURNED ON HEALTH CARE PLAN \\VT 93-94
	 "We know that the status quo must go," said Dr. James Todd, executive director of the AMA, in appealing to the White House. His organization has helped block national health insurance for decades. 

N21/SAMIR N. BANOOB, professor of health policy at the University of South Florida's College of Public Health, St. Petersburg Times, February  7, 1993, Pg. 4D, HEADLINE: Health care: Painful remedies are needed  \\VT 93-94
  First, if a successful plan is to be achieved, painful remedies will have  to be administered. The lobbying power of large employers that are already  suffering enormously should be used to neutralize other special interests, such as the insurance industry, the American Medical Association and the   American Hospital Association.   

N22/Los Angeles Times, January 17, 1993, Part E; Page 6; HEADLINE: DOCTOR PRESCRIBES SOME BIG CHANGES FOR AMA \\VT 93-94
 "There has been great change in the AMA over the years," Scalettar maintained, "a greater concern for public needs, social values and ethics." 

N23/Los Angeles Times, January 17, 1993, Part E; Page 6; HEADLINE: DOCTOR PRESCRIBES SOME BIG CHANGES FOR AMA \\VT 93-94
 Another [change in the AMA] was the adoption of a 1990 plan called "Health Access America" saying that "the status quo is not acceptable," that all Americans should have adequate health coverage and that the government should make employers insure employees and dependents. This brought the AMA position close to one held by many liberals, including AMA arch-foe Sen. Edward M. Kennedy (D-Mass.). 

N24/Ian Dowbiggin, assistant professor of history at the University of Prince Edward Island, The Toronto Star, April 22, 1992, SECTION: INSIGHT; Pg. A17 HEADLINE: Why the U.S. has resisted medicare \\VT 93-94
	 But the growing and broad consensus in favor of universal health coverage may isolate the AMA. This is the kind of public relations disaster organized medicine - either north or south of the border - can ill afford. 

N25/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 THERE is every reason to believe that the 1990s will be a decade of significant change in American health care. The number of proposals for reform of the system and the rising chorus of voices demanding change suggest that some major alterations in the system are inevitable. 

N26/JAMES M. BURCKE, staffwriter, Business Insurance, March 26, 1993, Pg. 16, HEADLINE: Timetable for change; Expect Congress to pass significant reform by 1994 \\VT 93-94
	 No matter how it is finally implemented, access to health care coverage will be a reality for all Americans within 10 years, according to 90% of the respondents. [panel of (health reform) experts] 

N27/National Journal's CongressDaily January 26, 1993 HEADLINE: Kennedy: Health Reform This Year A 'Realistic Target', Nexis \\VT 93-94
 Senate Labor and Human Resources Chairman Kennedy said Monday that passage of major healthcare reform this year is a "realistic target." At a speech at Harvard University's School of Public Health, Kennedy declared: "The forces hostile to change no longer have a friendly ear in the White House. We have the president, Congress and the people on our side." However, according to a report today in The Boston Globe, Kennedy told a private luncheon afterward that he expects a "roar of advertising" against healthcare reform from "those who don't want it." He suggested opponents will try to frighten voters with predictions of healthcare rationing and limited choice of doctors and hospitals. 

N28/JAMES M. BURCKE, staffwriter, Business Insurance, March 26, 1993, Pg. 16, HEADLINE: Timetable for change; Expect Congress to pass significant reform by 1994 \\VT 93-94
	 Don't necessarily bet that Congress will enact meaningful health care reform legislation anytime this year. However, it's likely that meaningful reform will be a reality by next year at the latest, according to a panel of (health reform) experts. 

N29/JAMES M. BURCKE, staffwriter, Business Insurance, March 26, 1993, Pg. 16, HEADLINE: Timetable for change; Expect Congress to pass significant reform by 1994 \\VT 93-94
	 While only 41% of the experts [panel of (health reform) experts] that responded to the survey believed meaningful reform will be enacted this year, another 39% said meaningful reform would be passed in 1994. Fourteen percent said Congress will wait until 1995 to pass reforms, while 3% do not expect reforms until 1996. The other 3% said reform would be delayed until 1997 or later. But, none said Congress would ultimately fail to pass meaningful health care reforms. 

N30/JOE CAPPO, staffwriter, Crain's Chicago Business, December  7, 1992, SECTION: ; Pg. 10, HEADLINE: Some painful truths about health care \\VT 93-94
	  In writing the book "FutureScope" three years ago, I predicted we would have  some form of universal  national health insurance  by 1995. I don't see any reason to change that prediction.   

N31/PR NEWSWIRE, May 20, 1993, HEADLINE:  COOPERS & LYBRAND: CURRENT TREND OF SHIFTING HEALTHCARE COSTS WILL ACCELERATE NEW YORK Transmitted:  93-05-20 14:27:00 EDT, Online America\\VT 93-94
	The study found that 75 percent of employers provide more than one alternative to the traditional indemnity plan.  HMOs are offered by X69 percent of employers; however, only 42 percent indicate they have encouraged greater use of this alternative.  Of those companies surveyed, 35 percent expect to encourage greater use of HMOs and PPOs within the next 12 months. 

N32/PR NEWSWIRE, May 20, 1993, HEADLINE:  COOPERS & LYBRAND: CURRENT TREND OF SHIFTING HEALTHCARE COSTS WILL ACCELERATE NEW YORK Transmitted:  93-05-20 14:27:00 EDT, Online America\\VT 93-94
	Regarding managed care options, the study found 42 percent of employers have already taken action to encourage greater use of HMOs and PPOs among employees, while 35 percent of employers are planning to do so in the near future. 

N33/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 More and more workers, urged or even pushed by employers no longer able to pay the enormous increases in health-insurance premiums, are trading in their traditional insurance coverage for membership in a health maintenance organization. HMO enrollment has doubled since 1985. 

N34/Ernie Freda, STAFF WRITER, The Atlanta Journal and Constitution, February 6, 1992, Section A; Page 9 HEADLINE: NATIONAL HEALTH INSURANCE \\VT 93-94
	This proposal is gathering steam as the current system deteriorates. It would install government as the health insurer of every American. Such a system exists in Canada, which is the model most often cited by proponents of this plan. 

N35/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 Whatever its imperfections, managed care is spreading rapidly. Insurers see it as a device that can control costs while keeping most of the nation's medical care in the private sector. Many carriers also argue that it will actually improve quality, because as payers watch doctors, hospitals and others more closely, they will spot not only the high-cost providers but also inept doctors and ineffective treatments. 

N36/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 119 \\VT-JHH 
	In comparison with that wide range of problems, the healthcare system is in excellent, even superb general shape. The Longevity of Americans is the best in the entire history of the nation and, save for some special and minority groups, steadily improving. The average level of individual and societal health is already adequate to meet the general needs, and appropriate ends, of our society. "'

N37/Michael J. Dattoli, M.D., St. Petersburg Times, October 18, 1992, Pg. 3D, HEADLINE: Doctors are 'wrongly blamed' for increase in health costs \\VT 93-94
	 Do not be misled by the rhetoric of our politicians. The fact of the matter is that medical care in the United States is second to none. Students and physicians travel from around the world to train at U.S. medical centers. Unfortunately, doctors are wrongly blamed for the skyward move in health costs since they are at the very front line of our health-care system. In fact, physicians' services account for only 19 percent of national health-care expenditures, and this percentage is roughly the same as that of physicians who practice in countries having national health care. 

N38/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 I do not think evidence supports the notion that patients in the United States have deficient medical care, and the rise of conservatism tempers calls for nationalizing any system. 

N39/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 High health care costs in the United States may reflect superior quality of treatment that is not captured in gross mortality statistics, and these statistics reflect many factors other than medical care. 

N40/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992; CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p.3 \\VT-ADPL .
	With a different lens, Dr. Carl Weber, a surgeon in private practice, points out with pride that the United States cut the death rates for cardiovascular disease 10 percent and the rate for cerebrovascular disease
 19 percent from 1980 to 1985; England's improvement was 3 and 5 percent, respectively. He points also to the queuing (waiting lists) for operations in England--patients wait 18 months on average for a hip replacement--and his New York Times (May 30, 1990) commentary is titled "In Health Care, U.S. Is Best." 

N41/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Politicians should be wary, however, of assuming that this high-level of dissatisfaction means that Americans want big changes in the way that they themselves receive health care. A 1992 national survey, for instance, found only 26 percent were dissatisfied with the health care services their family received during the last few years. n5 What concerns Americans most is that their employer-provided benefits will be cut back, or that the cost of them of medical care will become prohibitive. n6 

N42/Committee FOR ECONOMIC DEVELOPMENT, Research
and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 3 \\VT-ADPL 
	Over the years; the growing amount of resources devoted to the health industry has produced substantial benefits. Industries supplying services responded to increased demand by rapidly developing new medical procedures to produce more successful patient outcomes. The higher level of demand encouraged manufacturers of medical devices and pharmaceuticals to develop new products that have provided benefits in excess of the cost to the patients receiving them.

N43/BNA PENSIONS & BENEFITS DAILY, Jan. 13, 1992, ADMINISTRATION OFFICIALS RELEASE STUDY CRITICIZING PLAY-OR-PAY REFORM PROPOSALS, Nexis \\VT 93-94
	"There is no silver bullet to address the health care needs of our citizens," Sullivan commented. He emphasized that there are many advantages to the nation's present health care system, illustrated by the fact that individuals from foreign countries travel to the United States to receive care. 

N44/Michael J. Dattoli, M.D., St. Petersburg Times, October 18, 1992, Pg. 3D, HEADLINE: Doctors are 'wrongly blamed' for increase in health costs \\VT 93-94
	 Every recent article that is critical of medicine includes the indictment that our health-care system has failed because the United States ranks 20th in infant mortality and 17th in life expectancy. These statistics have become the focus of the Clinton camp and are propagated by a communication industry which thrives on outrage and sensationalism rather than balanced judgment. Moreover, advocates of national health insurance will display these statistics as proof that our current system needs to be dismantled. 

N44A/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: I'm not proud that Georgia has the highest infant mortality rate in the United States. I think, how can this be? I think we have a prosperous state. How can it be? It is factors other than health insurance. It has to do with geographic problems, it has to do with educational problems.

N45/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 81\\VT-MDS 	Indeed, ..... . as shown in figure 4.5B, infant mortality rates appear to show an inverse relationship with the number of doctors per capita in the country. That is, the more doctors available, the higher the death rate among children in that country. This result occurs after adjusting for the per-capita income of the country's population. While no explanation for this curious finding is available, the association is highly significant statistically (St. Leger, Cochrane, and Moore 1978). 

N46/Harry Schwartz, writer who specializes in healthcare topics, USA TODAY, October 26, 1992, Pg. 14A , HEADLINE: Public health no cure-all \\VT 93-94
	 Or take the epidemic of low birth-weight babies and resulting infant mortality. True, if all pregnant women got prenatal care, that might be improved. But many of those who most need that care don't bother to take advantage of the available facilities. If you are a pregnant girl with a lust for cocaine and perhaps the first symptoms of AIDS, you may not want to consult a doctor. And many don't. 

N47/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p.17 \\VT-MDS 
	More than any other age group, the health of the infant is sensitive to its social and physical environment. For that reason, infant mortality rates often serve as the most sensitive index of socioeconomic conditions. In the United States, for example, infant mortality rates have fallen from just less than 200 per thousand live births in 1900 to 10.9 per thousand in 1983 (Metropolitan Life 1984), a fall of almost 2000 percent. Many premodern countries of the world today still have infant mortality rates that exceed those of the United States some eighty years ago.

N48/Michael J. Dattoli, M.D., St. Petersburg Times, October 18, 1992, Pg. 3D, HEADLINE: Doctors are 'wrongly blamed' for increase in health costs \\VT 93-94
	 With respect to the high infant mortality rate, it should be noted that 385,000 drug-exposed babies started life with enough medical problems to cost over $ 24-billion. This is a problem that is negligible in Canada, a country whose health-care system many would like to model. Somehow, this seems to be more a socioeconomic problem than a medical problem. How this can be favorably affected by passage of national health insurance is beyond my comprehension. 

N49/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 Infant mortality runs twice as high among the poor as the rich . . . rates of tuberculosis among tribe members run 40 times the national average . . . health care costs are rising faster than anywhere on the continent. Snapshots of the failing U.S. health care system? No. These findings describe Canada's vaunted national health insurance system, findings that demand notice from Americans who glibly advocate adopting the Canadian approach. 

N50/B.D. Colen, medical correspondent, Newsday, December  29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	   And have you ever wondered why Sweden has such low infant mortality rates, while the rates in the United States are so high? It's quite simple: Sweden's dirty little secret is that it makes no attempt to save those infants born weighing less than 1,000 grams - 2.2 pounds. In fact, no such birth is  classified as a "live birth." 

N51/B.D. Colen, medical correspondent, Newsday, December  29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	   In the United States, on the other hand, physicians routinely attempt - usually in vain and at a cost of hundreds of thousands of dollars per attempt -  to save infants weighing less than a pound. When those rescue efforts fail,   another infant death is figured into our infant mortality rates. Small wonder the Swedes have a lower rate than we do.  

N52/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Viewed in the context of this value system, it becomes clearer why our society cannot put the moral ideal, health care as a human right, into practice. Health as a right can be viewed from different ethical perspectives. According to one perspective, rights can be categorized as negative or positive. [n51] A negative right can be regarded as a libertarian value; the individual's liberty is protected against infringements from society or the government. Individuals are responsible for their own health care. They can use their economic resources to buy whatever health care they choose. In contrast, a positive right can be regarded as an egalitarian value; the individual receives health care entitlements from the government. Then, government is responsible for ensuring that all Americans have equitable access to quality health care. 

N53/Health Line, October 20, 1992, HEADLINE: COMMENTARY: READY (AND WAITING) FOR REFORM, Nexis \\VT 93-94
	 NEED FOR STRAIGHT TALK: Robert Samuelson writes in NEWSWEEK that the problem with reforming the health care system is that the public wants costs to be contained but also believes health care is a right. Samuelson: "The trouble is that if health care is a right -- everyone deserves the best, whenever it's needed -- costs will soar." Samuelson observes, "All other societies use government to balance these mutually exclusive expectations. ... Only government can force us to see and confront these choices. The task of the next president is to change the terms of public discussion. It is to make us face our contradictory expectations. It is to compel us to compare drawbacks and to construct a better imperfect system" (10-26 issue). 

N54/Health Line, September 4, 1992, HEADLINE: COMMENTARY: VIEWS OF THE HEALTH CARE CRISIS Nexis \\VT 93-94
	 RICHMOND TIMES-DISPATCH editorial reads, "'Health care is a right, not a privilege.' That's what the bumper stickers say. The slogan sounds as cozy as a hot-water bottle, but is it correct?" TIMES-DISPATCH: "The unpleasant truth is that medicine is a commodity. It, too, is subject to supply (doctors, nurses, dentists, druggists, etc.) and demand (patients). When vote-hungry pols redefine health care as a right, they create insatiable demands for products and services" (9-2). 

N55/Charles Dougherty, Prof- at Creighton U., AMERICAN HEALTH CARE, 1988, p.29. 
	If the question of the existence of a right to health care is interpreted legally, the answer in general in the United States is negative. A right to health care is not guaranteed in the Constitution, nor does it appear to follow legally from any of the substantive rights set out in that document.

N56/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Not surprisingly, a recent court case denied that health care is a human right. [n14] This legal decision is consonant with the Constitution, but it certainly is not consonant with the Universal Declaration of Human Rights (1948), [n15,n16] signed by US representatives, that specifies medical care as a right. Since all US citizens do not have access to basic health care, we remain in violation of article 25, section 1, of the Universal Declaration. Thus, on the issue of universal access to health care, public opinion and the Declaration of Human Rights stand in contradiction to current public policy and the Constitution. 

N57/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 However, most of the uninsured are already being provided a significant amount of services. Much of the cost for those services is being shifted (through price increases) to those with health insurance or the tab is being picked up by tax payers through public health service programs. 

N58/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 "It's not like pornography -- you know it when you see it," said Cathy Hurwitt, legislative director of Citizen Action, a Washington-based consumer advocacy group. "It really depends on how you define underinsurance." 

N59/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 The definition varies considerably, notes Judith Waxman, a lawyer with Families USA, a nonprofit Washington-based foundation that lobbies for health care reform. "That's why the debate about what constitutes an acceptable benefits package is raging and will continue to rage." 

N60/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE , MEDICAL COSTS, p. 5 \\VT-JHH
	Blue Cross, Blue Shield, commercial health insurance, Medicare, and Medicaid have changed and will continue to do so. They were designed to respond to the organization of medical care, the medical knowledge base, and the economic relationships that prevailed when they were conceived and built. 

N61/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February  14, 1993, Part A; Page 1; HEADLINE: HEALTH PACKAGE DILEMMA: WHAT SHOULD IT COVER? \\VT 93-94
   In designing a core package of benefits, the Administration must not only  strike a balance among high-powered, competing interest groups, but also guard   against offering too much -- or too little.  

N62/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February  14, 1993, Part A; Page 1; HEADLINE: HEALTH PACKAGE DILEMMA: WHAT SHOULD IT COVER? \\VT 93-94
   Too rich an array of benefits could bankrupt a system already teetering on the brink of collapse. Too skimpy a package invites a Faustian bargain: If people lack certain medical coverages, they are likely to delay seeking care  until their illnesses require far more expensive treatments. 

N63/PR Newswire, January 17, 1992, HEADLINE: REPORT BLASTS NATIONAL HEALTH INSURANCE Nexis \\VT 93-94
	Following close on the heels of a national push by the Democratic Party for national health insurance, a Midwest-based policy research group has published a report it says undermines the entire rationale for the idea. According to Joseph L. Bast, president of The Heartland Institute and a co-author of the report, "U.S. spending on health care is actually growing significantly more slowly than in Japan, Italy, and France, and at nearly the same rate as spending by West Germany and Canada. This despite the fact that these countries have national health insurance. Moreover, the U.S. health care system has dealt with rates of AIDS, teenage pregnancy, homicide, and drug abuse without parallel in other countries." 

N64/BNA PENSIONS & BENEFITS DAILY, Feb. 21, 1992, COUNTRIES WITH NATIONAL HEALTH INSURANCE HAD HIGHER PER CAPITA INCREASES OVER TIME Nexis \\VT 93-94
	 In 1990, medical care accounted for 14 percent of total personal consumption, compared to 27 percent for housing and household costs and 19 percent for food and tobacco. 

N65/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 Doctors are wary of limits on their income, saying that their high salaries are not a major cause of rising costs. "Overall, physicians contribute maybe 14, 15 percent to the cost of medical care," says Crowley, of the medical society. 

N66/James J. Kilpatrick, syndicated columnist, The Buffalo News, December  23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	   The doctors protest that their fees have not   risen inordinately; their expenses for rent, nursing staff and malpractice insurance have been steadily rising. But somebody has to pay the doctors.  

N67/James J. Kilpatrick, syndicated columnist, The Buffalo News, December  23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	   Hospitals plead not guilty; doctors and patients demand the most modern diagnostic equipment, and the equipment costs a fortune. Hospitals are labor  intensive. Maintaining a staff of nurses, orderlies and record-keepers strains   every hospital's budget. Somebody has to pay for hospital care.   

N68/DAVID KINDIG, Prof. Medicine Univ. of Wisconsin, 1992, UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 30 \\VT-MDS 
	Finally, we have omitted, but commend, the article by Uwe Reinhardt entitled "Does Spending by American ', Business on Health Care for Employees Erode this Nation's .Competitive Position?" where he argues that the high health insurance premiums paid voluntarily by American businesses do not necessarily inhibit their competition in international markets since it is a part of total compensation and that health expenditures do not necessarily displace investment in other areas of productive capital.

N69/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 The study [The Mackinac Center for Public Policy] concluded that countries which offer national health insurance eventually develop problems normally associated with government-controlled or "socialist" systems, namely: rationing, long waiting lists, special favors, bureaucratic inefficiency, and unavailable or outdated technology. The report cited the following examples: -- The British system denies treatment to 9,000 kidney patients, and as many as 15,000 cancer and 17,000 heart patients each year. -- A Canadian patient died after his heart operation had been postponed 11 times. Now, about 100 Canadian heart patients go to the Cleveland clinic each year to receive timely treatment. [The Mackinac Center for Public Policy] 

N70/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 The Mackinac report also found that national health insurance would not benefit organized labor or the auto industry. To finance a health insurance program similar to Canada's would require $339 billion in new taxes financed by an additional 15-percent payroll tax, a 16-percentage- point increase in the income tax, or a 10-percent value-added or sales tax. High-wage industries would suffer the most. For example, the auto industry would pay an average of $2,586 more per assembly-line employee under a national health insurance payroll tax. [The Mackinac Center for Public Policy] 

N71/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 MEDICAID Medicaid was established as a joint program of state and federal governments, with the latter covering 50% to 83% of program costs according to a state's per capita income. The total cost of this program is about $ 45 billion, with a $ 25 billion federal contribution and a $ 20 billion state contribution. To be eligible, one must meet three tests (income, categorical, and resource); each of these is set by the individual states themselves. Those eligible for Aid to Families With Dependent Children and Supplemental Security Income are automatically eligible for Medicaid. The former program has levels set by states; the latter program has levels set by the federal government such that in 1985 an elderly couple must have had a combined income of less than $ 472 a month to be eligible. Categorical requirements must be met as well. One must be a member of a family with dependent children or be aged, blind, or disabled. 

N72/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Medicaid: A medical insurance and assistance plan that covers many health services for qualifying low-income people. It is a state run program with at least 50 percent funding from the federal government. Coverage and benefits vary widely from state to state. 

N73/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Medicare: A federally run and financed health insurance plan for everyone over the age of 65 and certain severely disabled individuals. 

N74/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 MEDICARE Medicare is primarily a program of health insurance for the aged. A Federal Hospital Insurance Trust Fund is financed by an earnings tax paid by employees, employers, and the self-employed. Medicare began as a $ 4 billion program. In 1988 Medicare will cost the federal government approximately $ 90 billion, and it is growing at approximately 8.5% annually. It has two parts; part A provides hospital insurance benefits that include up to 90 inpatient days annually with a 20% coinsurance fee for hospital charges. Reimbursement of inpatient hospital charges are based on a prospective payment system known as diagnosis related groups. The annual deductible continues to increase and in 1989 will be $ 560. Since 1983, the federal government has been shifting a larger portion of health care costs to Medicare beneficiaries through larger deductibles, greater use of services with coinsurance, and use of services not covered by Medicare. 

N75/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 Part B [Medicare], which provides supplementary medical insurance benefits, is a voluntary insurance program financed from premium payments by enrollees and contributions from federal funds. There is a Federal Supplementary Insurance Trust Fund for payments under part B. Benefits include physician services, diagnostic roentgenograms, and laboratory and other tests with payments of 80% of reasonable charges. Charges under part B have an annual $ 75 deductible. Prescription drugs are not covered at all under the Medicare program. Beneficiaries often purchase Medicare supplemental policies from private insurance companies to help pay the deductible, the coinsurance fee, and costs for prescription drugs and sometimes to extend coverage of inpatient duration. Unfortunately, many of these policies have poor coverage, and the elderly who purchase these policies receive much less than they expected. 

N76/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 Our pluralistic health care puzzle includes at least seven pieces: private insurance, Medicare, Medicaid, the Veterans Administration medical care system, the Department of Defense hospitals and clinics, the Indian Health Service, the Department of Justice's Federal Bureau of Prisons, and at least $ 10 billion of uncompensated health care provided by hospitals and physicians. With all this we are left with a system in the United States that some have described as a scrambled jigsaw puzzle and a complementary complex pattern of health care financing. 

N77/Dr. Fritjof Capra, Prof Physics, U Calif Berkeley, THE TURNING POINT, 1982, p138-9 
The confusion to be drawn from these studies of the relation between medicine and health seems to be that biomedical interventions, although extremely helpful in individual emergencies. have very little effect on the health of the entire population. The health of human beings is predominantly determined not by medical intervention but by their behavior, their food, and the nature of their environment.

N78/Ivan Illich, MEDICAL NEMESIS. THE EXPROPRIATION OF HEALTH, 1976, pp.79-80 
	Most of man's ailments consist of illnesses that are acute and benign-either self-limiting or subject to control through a few dozen routine interventions, For a wide range of conditions, those who are treated probably make the best progress. 'For the sick,' Hippocrates said, 'the least is best,' More often than not, the best a learned and conscientious physician can do is convince his patient that he can live with his impairment, reassure him of an eventual recovery. or of the availability of morphine at the time when he will need it, do. for him what grandmother could have done, and otherwise defer to nature,

N79/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 117-118 \\VT-JHH
	These data suggest that we should give a relatively less .important place' to health expenditures in the future. Health should not continue to have the privileged place it has gradually gained over the years. The recent growth of expenditures does not reflect corresponding health gains (suggesting that we have not invested the money all that well in any case) and, no less importantly, has occurred while the index of other societal goods has declined. Measured by the standard suggested earlier--the adequate functioning of our major social institutions--we al ready have a sufficient level of overall societal health, more than enough. Most of the growth in healthcare expenditures has come about because of the growth of public demand, a demand insulated for the most part by third-party payments, allowing individuals to pursue their individual health needs with little ' .. worry about the-personal financial cost to themselves or the collective cost to society. It has also more fundamentally come about because we have let ourselves be seduced by the idea that, in healthcare, there is no such thing as enough.

N80/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p.5.\\VT-MDS
	These recent decades of apparent health decline are the very years during which our health, expenditures have been growing most rapidly. 

N81/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 58 \\VT-MDS 
	Most 'medical care is not primarily intended to be life saving. The vast majority of patients consult physicians because of the appearance of symptoms from which they seek relief, generally of pain or discomfort; physicians do not confront truly life-threatening emergencies all that often. Life prolongation is not the objective of most treatment; it is the quality of life for which most patients seek help, not the quantity of life.

N82/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p14-l5 
	After a century of pursuit of medical utopia, and contrary to current conventional wisdom, medical services have not been Important in producing the changes In life expectancy that have occurred.' A vast amount of contemporary clinical care is Incidental the curing of disease, but the damage done by to the health of individuals and populations is very significant. These facts are obvious, well documented, and well repressed. 

N83/Dr. Fritjof Capra, Prof. Physics U-Calif Berkeley, THE TURNING POINT, 1982, p136-7 
	Almost everyone knows somebody whose life has been saved, or whose pain and discomfort have been dramatically reduced, by medical Intervention. Indeed, our modern medical technologies are superb in dealing with these emergencies. But although such medical care can be decisive In individual cases, it does not seem to make a significant difference for the health of populations as a whole. The great publicity given to such spectacular medical procedures as open heart surgery and organ transplants tends to make us forget that many of these patients would not have been hospitalized in the first place if preventive measures had not been severely neglected. 

N84/Dr. Fritjof Capra, Prof Physics. U Calif-Berkeley, THE TURNING POINT, 1982, p.35
	The increase in life expectancy has resulted primarily from a decline in infant mortality,' turn is related to the level of poverty,. the availability of proper nutrition, and many other social. economic, and cultural factors. Jut how these multiple forces combine to affect infant mortality is poorly understood, but it has become apparent that medical care has played almost no role In Its decline.

N85/LEONARD SAGAN, M.D., 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS WELL-BEING, p 172\\VT-MDS
3. Although the relative or proportional health advantage of the upper classes has persisted undiminished for several decades, the decline in absolute death rates of the lower classes has been more rapid. It is hardly plausible that those people with the least access to medical care, and presumably that of the lowest quality, would reap the greatest benefits if that care were effective in reducing death rates.

N86/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 84\\VT-MDS 
	An important reason for this failure of medical care availability to affect mortality rates is that, while some remedies and procedures are clearly effective, physicians instinctively expand the indications for these remedies to many more persons than those for whom they are effective.

N87/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 84 \\VT-MDS
Evidence reviewed strongly suggests that the availability of medical care in general has played little role in reducing death rates from their historically high levels to those. found in modern societies.

N88/Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS, 1983, P. 28
	Critical epidemiologists have questioned medicine's effectiveness by examining trends 1n general mortality and life expectancy as well as mortality from specific diseases. Major historical improvements in both general and specific mortality patterns antedate rather than followed medicine's technical advances. Despite the undeniable usefulness of certain diagnostic and therapeutic techniques with individual patients. such techniques have exerted little historical impact on health of large populations.

N89/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 59 \\VT-MDS
Contrary to the common wisdom, the efficacy of most therapy has not been subjected to rigorous scientific validation; on the contrary, most medical therapy today is based on authority and tradition and has not been evaluated for efficacy in the sense of life prolongation. Until recently there simply has not been a great deal of interest in conducting studies directed to this point; generally physicians have been more concerned with comparing one treatment with another rather than with whether a treatment actually results in life prolongation." 

N90/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 138 \\VT-JHH
A healthcare system that provided nothing other than sanitation, good food, a decently clean environment, childhood immunization, antibiotics, and trauma care would already have done enough to assure that the majority of its citizens could carry out their societal roles. The more the system attends to individual needs not met by basic public health measures and primary healthcare, the more it guarantees an ever-larger agenda and costs, as and ever-higher especially the curative research agenda gravitates, to has, conditions affecting the individual lives of the elderly. A society may move on beyond that point, but there is no compelling reason to think it must do so. A society cannot be said to owe its citizens the pursuit of every medical possibility to meet every curative need, much less when the possibilities of doing so are endless.	

N91/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976, p21-2
The fact that the doctor population is higher where certain diseases have become rare has little to do with the doctor's ability to control or eliminate them. It simply means doctors deploy themselves as they like, more so than other professionals. and that they tend to gather where the climate is healthy. where the water is clean. and where people are employed and can pay for their services.

N92/Dr. Fritjof Capra, Prof Physics, U Calif. Berkeley, THE TURNING POINT. l982. p137 
	The fact that this dramatic change has taken place more or less simultaneously with the rise of modern scientific medicine has led to the widespread belief that it was brought: about by the achievements of medical science. This belief, although shared by most doctors, Is quite erroneous. Studies of the history of disease patterns have shown conclusively that the contribution of medical intervention to the decline of the infectious diseases has been much smaller than is generally believed. 

N93/Dr. Frltjof Capra, Prof Physics. U Calif. Berkeley, THE TURNING POINT, 1982. p138 
	This lack of correlation between the change of disease patterns and medical intervention has also found striking confirmation In several experiments in which modern medical technologies were used unsuccessfully to improve the health of various 'underdeveloped' populations in the United States and elsewhere. These experiments seem to indicate that medical technology alone is unable to bring about significant changes 1n basic disease patterns.

N94/Ivan Illich, 1976, MEDICAL NEMESIS-THE EXPROPRIATION OF HEALTH. p.15 .
	The study of the evolution of disease patterns provides evidence that during the last century doctors have affected epidemics no more profoundly than did priests during earlier times. Epidemics came and went, imprecated by both but touched by neither. They are not modified any more decisively by the rituals performed medical clinics than by those customary at religious shrines.

N95/Howard Waitzkln. Medical Scholar. THE SECOND SICKNESS. 5983. p28-9
• In a paper written as president of the Infectious Disease Society of America, Kass searched for evidence that modern medicine had been effective in reducing the impact of infection. He traced death rates back over a century for several diseases thought responsive to antibiotics. (tuberculosis, diphtheria. and scarlet fever) or immunization (whooping cough and measles). For each disease studied, Kass found that the major declines in mortality preceded the diagnostic tests and specific treatments developed by modern medicine. This observation held true for diseases caused by bacteria. for which antibiotics had been discovered. and by viruses, for which immunization had been introduced. Kass concluded that, contrary to popular belief. improvements in the incidence of infectious diseases generally did not result from advances of medicine but rather from broad social changes that were difficult to pinpoint.

N96/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 66 \\VT-MDS
	Thus the evidence is clear that medical therapy probably had little to do with the major decline in mortality from infectious disease. Although antibiotics were indeed "miracle drugs" for certain limited classes of infectious disease for a short period after their discovery, their widespread abuse both as a result of their common use in animal foods and their medical abuse has caused them to lose much of their effectiveness. While there are undoubtedly individual exceptions, for the population as a whole it appears unlikely that antibiotics contribute beneficially to our life expectancy.

N97/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 65 \\VT-MDS
	 Bacterial resistance has progressed to such a point that many infections which thirty years ago were easily controlled with antibiotics are no longer easily treatable (Finland 1979). For example, the gonococcus, cause of the commonest venereal disease, is often no longer sensitive to penicillin. Most recently pneumococcus, frequently associated with lobar pneumonia, has shown resistance to antibiotics .

N98/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 82 \\VT-MDS 
This observation has been replicated in many communities, and with a great variety of cancer types; cancer consistently advances more rapidly in the poor than in the affluent and is less responsive to therapy. Differences in outcome are clearly not the result of differences in medical care (Savage et al. 1985).

N99/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p.75-6 \\VT-MDS 
	What this means is that, at any given age, the risk of dying of cancer is no different today than it was fifty years ago. True, the mortality rates 'of cancer at specific organ sites have changed--lung cancer, for example, has increased, stomach cancer has decreased--many, however, have remained unchanged. Other than for the role of cigarettes as a cause of lung cancer, the factors responsible for change in either direction or the frequency of cancer of other groups is unknown.

N100/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 76 \\VT-MDS
	Many people will be surprised to find that there is really very little evidence whether cancer treatment prolongs life, shortens life, or has no effect at all. If that is the case, then why do patients undergo treatment? The answer is that desperate patients seek therapy and doctors provide it, with neither party demanding rigorous proof of effectiveness.

N101/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 74 \\VT-MDS
There is no debate regarding the observation that survival from first detection of cancer to the ultimate conclusion of the disease has gradually increased over the past three decades. But some dispute does arise from the interpretation of this observation. improvement in survival has been widely attributed, both by physicians and the public, to improvements in therapy, yet some experts disagree. They believe that increased survival : following diagnosis could well be the result of more intense medical surveillance, better diagnostic technology, and earlier detection rather than the result of more effective treatment (Boffey 1984).

N102/Ivan Illich, MEDICAL NEMESIS.-THE EXPROPRIATION OF HEALTH. 1976, p22 
	Awe-inspiring technology has combined with egalitariian rhetoric to create the impression that contemporary medicine is highly effective.

N103/Arabella Melville, CURED TO DEATH. THE EFFECTS OF PRESCRIPTION DRUGS, 1982, p230 
	Expectations of medicine have been subject to a long process of over-inflation by the media and the medical profession, as well as by the pharmaceutical industry. It is a process with potentially dangerous consequences.

N105/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p172-3 
The skills needed for the application of the most generally used diagnostic and therapeutic aids are so elementary that the careful following of instructions by people who are personally concerned would probably guarantee more effective and responsible use than medical practice ever could. Most of what remains could probably be handled better by 'barefoot' nonprofessional amateurs with deep personal commitment than by professional physicians. psychiatrists, dentists, midwives. physiotherapists or occultists.

N106/LEONARD SAGAN, M.D. and Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, P. 82 \\VI-MDS 
This failure of increased access to medical care to reduce differences in health among the social classes is consistent with the experience of those health that wide of social classes; ' prepaid plans serve a spectrum the differences in outcomes remain, even within the same medical facilities. ' 

N107/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Widespread concerns have developed about the safety of the blood supply since the advent of the AIDS epidemic. But a close look reveals that enormous progress has been made in preventing the transmission of infectious agents though blood products. 

N108/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 In fact, FDA and the blood industry have implemented safeguards in recent years that have made the blood supply much safer than ever before. Blood is vital to the American health-care system, and FDA plays a crucial role in ensuring the safety of the nation's supply. 

N109/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 FDA establishes regulations and guidelines designed to protect the blood supply from dangerous contaminants and unsafe practices and uses its ongoing inspection program to insure the blood industry's full compliance with good manufacturing practices. 

N110/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Blood safety begins with the donation. Only healthy individuals are allowed to give blood. All potential donors undergo extensive screening designed to reveal any medical condition or behavioral pattern that may put them at greater risk of carrying a blood-borne infectious agent. 

N111/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 If information from the screening procedures indicates that a donor has a high risk of having been exposed to the AIDS virus or to other dangerous viruses or bacteria (such as those that cause hepatitis or syphilis), that person is not permitted to donate blood. 

N112/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Contrary to popular belief, the practice of paying people to donate blood for transfusion rarely, if ever, occurs in the United States. This practice virtually ended nearly 20 years ago. Today collection for whole blood transfusion use is voluntary, and donors have no financial incentive to give their blood. The situation with the collection of plasma for use in manufacture is somewhat different. 

N113/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Moreover, unlike blood for transfusion, plasma products must be processed to refine them for therapeutic use. This processing includes treatments that kill or eliminate viruses. 

N114/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Through a vigorous battery of tests, lab technicians analyze all blood collected for transfusion for signs of contamination with serious blood-borne agents. These tests include: 1. Hepatitis B Surface Antigen Test -- for evidence of infection with the hepatitis B virus. Hepatitis B can become chronic and cause severe liver damage, cancer and death. 2. Hepatitis B Core Antibody Test -- additional screening test for hepatitis B 3. Hepatitis C Antibody Test -- for evidence of infection with hepatitis C (the form of the disease most frequently transmitted through blood), which can cause chronic hepatitis 4. Human Immunodeficiency Virus Type-1 (HIV-1) Antibody Tests -- for evidence of infection with the AIDS virus 5. HTLV-I -- for evidence of a rare leukemia virus found mainly outside the United States 6. Syphilis -- for evidence of this sexually transmitted disease, which, if left untreated, can cause severe neurological damage. 

N115/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 In addition, many blood centers test for antibody to HIV-2, another form of the AIDS virus, which is extraordinarily rare in the United States. Although no test is perfect, these tests are very sensitive. 

N116/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Tests for antibodies to the HIV type-1 virus, for example, can detect more than 99.9 percent of infected blood units that contain the antibody. 

N117/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 The tests are particularly effective when used with the pre-donation screening measures, which also help to eliminate units donated by recently infected individuals who may not have developed antibodies to the virus that would be detected by laboratory tests. Blood units that test positive for evidence of any of these agents are not used for transfusion. 

N118/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 FDA carefully monitors the record-keeping and other essential elements of safe blood preparation, such as screening, testing, labeling, storage, and handling. Each year the agency inspects all blood establishments and examines significant aspects of their performance. If FDA finds any problems or deficiencies, it requires the firm to take prompt corrective action. The agency checks to make sure that these difficulties are fully and quickly resolved. 

N119/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 As a result of these cooperative efforts to improve the safety of the blood supply, the rate of transfusion-related cases of hepatitis has dropped significantly. Less than 30 years ago, nearly 1 in 3 patients receiving blood transfusions contracted some form of hepatitis. 

N120/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Reforms in the collection process, as well as modern donor screening and testing methods, have lowered the risk of contracting hepatitis through transfusion to less than 3 in 100 patients. This represents a greater than 90 percent decrease in the rate of blood transfusion-related hepatitis infections. 

N121/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 Great progress has also been made in stemming the spread of HIV infection through the blood supply. As knowledge grew about the threat the AIDS virus posed to the blood supply, FDA immediately began steps to decrease this risk. The agency established screening procedures in the early 1980s specifically designed to prevent donations from those at higher risk of infection. Within months after the HIV type-1 virus was identified as the cause of the disease, a screening test was developed at the National Institutes of Health in Bethesda, Md., and use of the technology was licensed to several private companies. 

N122/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 As a result of these and subsequent actions, the risk of contracting AIDS from a blood transfusion is estimated to have dropped by more than 99 percent from 1983 to 1991. In fact, the chances of contracting the AIDS virus from a blood transfusion are now estimated to be rarer than dying from an adverse reaction to penicillin. 

N123/FDA Consumer, March 11, 1993, TITLE: BLOOD SUPPLY SAFETY, Better Health and Medical Forum, Online America, Transmitted: 93-03-11 15:15:12 EST \\VT 93-94
	 FDA's Blood Product Advisory Committee, composed of leading outside experts in the fields of hematology and transfusion medicine, also meets regularly to review crucial issues affecting the blood supply and to advise the agency on these matters. 

N124/Charles Dougherty, Prof. Creighton Univ., AMERICAN HEALTH CARE, 1988, p.3. 
	There are many positive things to be said about health care in the United States as the twentieth century draws to a close. In general, the quality of care is high, and access to it is widespread. The nation s health-related statistics are good and generally improving. Life expectancy continues to rise. Infant mortality continues to decline. Government programs and policies, especially Medicare, have met with considerable success and remain highly popular. 

N125/VICTORIA A. WANZER, The Atlanta Journal and Constitution, September 29, 1992, Section A; Page 7, HEADLINE: Nationalized health care will bankrupt nation \\VT 93-94
	 National health care (socialized medicine) will promote inequality in care, limit education and research, provide shoddy, limited care, promote disincentives to work, and bankrupt this country! 

N126/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Gerald L. Maatman Jr., attorney: It is my opinion that a single-payer, government-administered national health insurance program is not a panacea for the situation we face in the United States. 

N127/JACK D. DAVIS, The Atlanta Journal and Constitution, April 28, 1992, Section A; Page 13 HEADLINE: 'Easy' answer is the wrong one \\VT 93-94
	 Health-care reform is one of the most important issues facing the nation. There is an easy-sounding solution currently being proposed, however, that I believe would not be the best option for our country, for business owners, for this community, or for patients. That proposed system is national health insurance. 

N128/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 For many decades New York City has operated a major health and hospital system with a current budget of about $2.5 billion that has been committed to providing care to everyone, regardless of ability to pay. Accordingly, New Yorkers may be said to have had "universal coverage" for almost a century. Consider, however, the following quotation from a recent report of the state comptroller: HHC [the Health and Hospitals Corporation of New York] is faced with severely overcrowded conditions stemming from significant increases in AIDS, psychiatric, and drug-abuse patients; a lack of available discharge options for patients occupying acute care beds unnecessarily; and bed closings due to shortages of key staff such as nurses and social workers. [n2] 

N129/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 32\\VT-JHH 
 We will always have to live with unfinished medical progress, an always rough line dividing past success and present failure. Yet because of the persistence of an emphasis upon individual need, we have been left with an impossible task, that of solving the social problem of allocation -- how we should distribute our collective resources -- with ingredients that are private and individual. The evidence that if cannot be done is all around us and grows day by day.

N130/Eli GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p. xi-xii \\VT-JHH
	But the thrust of the analysis is to suggest that more money alone would help only a little, not ~ lot, to resolve the serious problems facing patients with catastrophic illness, cancer, those suffering the infirmities of old age, the mentally ill, and those who are chronically poor.

N131/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 NO ONE, least of all an economist, needs to be persuaded that people who lack money or health insurance are likely to encounter difficulties in obtaining essential health care services. On the other hand, the economist has an obligation to explain that the adoption of a system of universal coverage will not, ipso facto, translate into assured access for essential, much less optimal, health care for those who are currently disadvantaged. The reasons that universal coverage will not necessarily guarantee effective services to all are embedded in the nature and characteristics of the health care system. 

N132/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 On the positive side, successive surveys conducted by The Robert Wood Johnson Foundation (Princeton, NJ) in the years 1976, 1982, and 1986 found that the new financing efforts contributed a great deal to increasing the number and range of health services available to the poor and the uninsured. [n3] However, there are important negatives that should be identified in the context of the resurgent belief that financial reform by itself, possibly at last in the form of universal coverage, will result in access to effective health care for all. 

N133/Paul W. Newacheck, DrPH, Lori N. Wicks, JD, Institute for Health Policy Studies, University of California School of Medicine, AMERICAN JOURNAL OF DISEASES OF CHILDREN, NOVEMBER, 1992; 146: 1376-1380 TITLE: How Will Children and Pregnant Women Fare Under Current National Health Insurance Proposals? \\VT 93-94
	 The future role of Medicaid under national health insurance proposals must be closely evaluated to assess changes in mandatory and optional benefits, particularly the preventive care or early and periodic screening, diagnosis, and treatment benefits. In summary, improved financing of health care is a necessary, but not sufficient, step toward improving access to high-quality health services for all children and pregnant women. To ensure access, explicit attention must also be devoted to the public health infrastructure to complement health care financing reforms. 

N134/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 These barriers, separate and distinct from the issue of financing, are among those that need to be addressed if the implicit promise that universal coverage will provide effective access is to be realized. 

N135/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 NONFINANCIAL BARRIERS TO ACCESS This section illuminates a number of cultural, demographic, geographic, and institutional factors that adversely affect access, even in the case of individuals who have reasonable coverage or the means to purchase it. 

N136/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 There are three primary factors that may influence access to medical services: 1. An individual's ability to pay for services with or without insurance coverage. 2. Lack of knowledge by an individual about when to seek medical services. 3. Geographic or physical barriers that prohibit an individual from obtaining medical services. 

N137/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 15, 1991; 265: 2563 TITLE: Caring for the Uninsured; Choices for Reform \\VT 93-94
	 When considering the various proposals, it is important to keep in mind the caveat raised by Ginzberg and Ostow [n25] in their article in this issue. Even if we do enact a universal health care plan, we will need additional solutions to "the range of [nonfinancial] factors that will continue to impede access to effective care for a significant segment of the population." 

N138/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 A large proportion of the urban poor and the uninsured obtain all, or the bulk, of their medical care from emergency departments, clinics, and inpatient services of public hospitals, the vast majority of which are seriously strained with respect to capacity, staff, and equipment. Even with the introduction of universal coverage, it is likely that most of these low-income individuals will continue to seek and obtain care from these neighborhood institutions. At the same time, it is not likely that enhanced coverage would enable most of the public hospitals to remedy the pressures and inefficiencies under which they have long been operating in the near or middle term. 

N139/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	Other things, however, have changed; the emergency department, with a cost of $140 or more per visit, is not a desirable site for the poor to receive ambulatory care. Some acute care hospitals are forced to retain patients, usually at a high per diem cost, because there is neither an available nursing home bed nor a suitable home to which they can be discharged. It is hard to see how universal coverage would resolve these institutional "non-fits." 

N140/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 The analysis thus far has emphasized the powerful barriers that impair access to basic medical care for various individuals and groups, even in the presence of private or public insurance. The barriers are that much greater for the approximately 32 million persons who are uninsured. In sum, our pluralistic health care system is failing in greater or lesser degree to meet the basic needs for effective medical care of about one third of the American people -- the uninsured, the underinsured, and the underserved Medicaid population. 

N141/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 Although it was widely believed that Medicaid would be a first step for the poor to gain access to mainstream medicine, that expectation has not been borne out. 

N142/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 82 \\VT-MDS
The failure of Medicare and Medicaid to reduce the disadvantages in health outcomes among the elderly and the poor has also been observed in the United States (Benham and Benham 1975).

N143/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HEALTH POLICY GLOSSARY, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:18 EST \\VT 93-94
	 Access: The ability to get health services. It is determined by the availability of services and the ability to pay. Having health insurance increases a person's access but doesn't guarantee it. The services may not be covered under the insurance plan, the amount the person has to pay out of their own pocket may be too high and/or services may not be located within the geographic area. 

N144/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 DICK DAVIDSON (PRESIDENT, AMERICAN HOSPITAL ASSOCIATION): We can give all Americans a health security card in terms of insurance, but that doesn't necessarily provide access. That health insurance card doesn't get you access in the Mississippi Delta. It may not get you access in parts of Montana, Wyoming, or any other place. And that means that we've got to move to the development not only of providing people health security, but a health delivery system that has them have a place to go. And that doesn't exist in all parts of the United States today. 

N145/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The organizational barriers that impede our society from assuring universal access to health care arises from structural deficiencies in our health care system; the most notable deficiencies are the poor distribution and insufficient numbers of primary care physicians and the lack of a governing body to control rising health care costs. 

N146//Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 "The ability to get a full range of health care services means more than just having an insurance card," says Barbara Colt, executive director of the Rhode Island Health Center Association, which represents community health centers. "There are just certain populations that the so-called establishment provider network doesn't care for, and doesn't want to care for. They don't want to take care of the other problems these people have." 

N147/Durado D. Brooks, MD; Journal of the American Medical Association, November 20, 1991; 266: 2746-2749 TITLE: Medical Apartheid; An American Perspective \\VT 93-94
	 Conversely, in the United States, most legal obstacles to nonwhite progress have been dismantled over the past 40 years, and legislation has been advanced to ensure equal protection under the law for all citizens. This has allowed significant gains in many aspects of life for America's ethnic minorities. Unfortunately, the removal of legal barriers alone is not sufficient to reverse the devastating effects that centuries of discriminatory policies have had on income and educational attainment. Due to these historical inequities, the majority of American's black and brown populations continue to lag far behind the white majority with regard to economic achievement and stability. Though legally sanctioned discrimination based on race has declined, educational and economic realities have imposed and maintained de facto apartheid for a substantial portion of America's minority citizenry. 

N148/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 Immigrant Status and Language Barriers Medical care characteristically requires an interaction between the patient seeking care and the physician or other care giver. The United States has been admitting approximately a million legal immigrants, refugees, and illegal aliens every year for the last decade and the inflow will increase in the years ahead. A high proportion of these new-comers take up residence in coastal cities in the West, the South, and the East, although increasing numbers are also relocating to cities in the interior, such as Chicago, Ill. Most of the immigrants do not, at least initially, understand, speak, or read English; others have entered the country illegally and generally avoid contact with institutions such as hospitals and clinics for fear that routine record keeping may result in their detection. Although universal coverage would make it easier for many members of these groups to seek and obtain effective health services, language handicaps and the threat of deportation will continue to inhibit their use of the health care system. [n6] 

N149/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 Not knowing when, where or how to seek health care services also influences access. Unlike other access problems, lack of knowledge about when it's appropriate to seek medical consultation cuts across all socioeconomic boundaries. 

N150/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING. p. 176. \\VT-MDS .
Death rates are clearly associated with educational achievement, but what of morbidity, disability, and the subjective quality of life? In the National Health Interview Survey, conducted by the National Center for Health Statistics (1983), people were asked to evaluate their health. Well-educated people reported themselves in excellent health far more often than those who were poorly educated (see table 9.2). To some extent, the greater income associated with higher education may account for this effect; at any given level of education, about 10 percent more people report themselves in excellent health than those in the lowest income group. That effect is small, however, compared with the effect of education; holding income level constant, about 30 percent more people with college educations report excellent health when compared with those without education.

N151/Michael J. Dattoli, M.D., St. Petersburg Times, October 18, 1992, Pg. 3D, HEADLINE: Doctors are 'wrongly blamed' for increase in health costs \\VT 93-94
	 What voters are not being told is that the escalating cost of meeting health-care needs is largely driven by the growth of the U.S. population, aging of our citizens, domestic violence and lifestyle abuses among ordinary Americans. We are among the world leaders in every category of crime and are considered to be the homicide capital of the world. Trauma is now the leading cause of death for people under 44 years of age, killing more than 140,000 in the United States each year. Violent assaults left more than 50,000 men, women and children quadriplegic in the past year, requiring a lifetime of care that comes with a price tag of greater than $ 6-million per victim. These facts alone should help to explain the slightly decreased life expectancy in the United States today. Furthermore, in the past 12 months, more than 400,000 smokers died from cardiac and lung problems. Even more disturbing, caring for those smokers who did not die cost the health-care system $ 52-billion. 

N152/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 172 \\VT-MDS 
	When barriers to medical care are removed by governmental subsidies, social class differences in morbidity and mortality persist unabated in both the United States and the United Kingdom.

N153/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 173 \\VT-MDS 
	Social class is strongly associated with the morbidity and mortality rates of a broad range of diseases and accidents. These differences in health have been persistent throughout this century. They affect children as well as adults and are almost certainly not the result of differences in access to medical availability. 

N154/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 110 \\VT-MDS 
	Just as the growth of the affectionate nuclear family was associated with improvements in health, deteriorating family relationships of the past several decades may well be associated with a relative decline in health, particularly among children and teenagers. As the modern nuclear family has come unglued, crime, suicide, and drug use have soared, just as have divorce and teenage pregnancy while scholastic achievement has declined. These associations and causal relationships have yet to be widely appreciated.

N155/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 40 \\VT-MDS Could stress be an unrecognized factor in explaining the decreased resistance of premodern populations to infection and death? We greatly underestimate the stress associated with the poverty and uncertainty of premodern society--the reduced coping ability of the illiterate and hopeless, the acquiescence and fatalism that mark members of traditional societies.

N156/LEONARD SAGAN, M.D. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS 7 WELL-BEING, p. 111 \\VT-MDS 
In this chapter we shall review the literature on stress, disease, and death. I conclude, with Wolfe, that there is incontrovertible evidence that stress can kill. The other assertion, that ours is a highly stressful society, is one that I shall challenge. On the contrary, I believe that one of the important reasons for the lower mortality rates in modern society is that we have largely learned how to manage and control stress, both on a personal and on a societal basis.

N157/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: UNCONVENTIONAL MEDICINE, RESEARCH, Online America, Better Health and Medical Forum, Transmitted: 93-03-16 18:26:54 EST \\VT 93-94
	 The recent survey represents the largest effort yet to assess the use and cost of unconventional and alternative medicine in the United States. According to the report, Americans spent $13.7 billion ($10.3 billion out-of-pocket) for alternative medical care in 1990. 

N158/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: UNCONVENTIONAL MEDICINE, RESEARCH, Online America, Better Health and Medical Forum, Transmitted: 93-03-16 18:26:54 EST \\VT 93-94
	 About 10 percent of Americans obtained health care services in 1990 from unconventional medical practitioners, according to a survey reported in the January 27, 1993 New England Journal of Medicine. The practitioners included chiropractors, herbal healers, and massage therapists. 

N159/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: UNCONVENTIONAL MEDICINE, RESEARCH, Online America, Better Health and Medical Forum, Transmitted: 93-03-16 18:26:54 EST \\VT 93-94
	 According to the researchers, about 55 percent of the treatments were covered at all by health insurance, and 90 percent were undertaken without the recommendation of a physician. 

N160/FAZLUR RAHMAN, practicing cancer specialist in San Angelo, Tex, April 18, 1993; The New York Times, "Viewpoints;! Let's Hear It for Low-Tech Medicine," Section 3; Page 11\\VT-AGL 
	General internists have been particularly unappreciated by the reimbursement system, though they are a vital .link between family physicians and specialists. Unfortunately, there is a shortage of doctors practicing general internal medicine. The number of medical school graduates pursuing such a career fell from 36 percent in 1982 to less than 15 percent in 1992.

N161/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 In the United States, approximately 36% of practicing physicians in 1986 were generalists. [n15] This specialty distribution differs considerably from that in Canada and most western European nations, where well over 50% of physicians are generalists. [n21,n22] Using the income data in Table 3 and assuming that overall physician supply rises as projected to 176 per 100 000 poplation, we calculated the financial impact of redistributing 14% of the physician supply from specialists to generalists to achieve a 50:50 mix in the year 2000. A 14% redistribution would lower overall physician costs by $5 billion in the year 2000. Compared with the potential savings achieved by reducing overall physician supply, this $5 billion "redistributive" saving is the equivalent of reducing the overall projected physician supply for the year 2000 by approximately 12 000 physicians under conditions of no change in specialty distribution. 

N162/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 Physician Practice Preferences Access to medical care implies access to physicians. However, it has long been evident that most physicians are reluctant to practice among the poor, the geographically isolated, and minorities. Recent studies of the health care system in the nation's four largest metropolitan centers have revealed a 10-fold or greater differential in the proportion of physicians to population between more affluent areas and low-income, minority neighborhoods. [n5] Within such a professional culture, there is little reason for confidence that universal coverage by itself would effect an appreciable redistribution of the physician supply that would significantly improve access for underserved populations. 

N163/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 As one commentator has observed, health planning is like steering a tanker ship: you have to turn the rudder well in advance to change directions downstream. [n30] Most of the additional physicians who will be in practice in the year 2000 are already in medical school or residency training. While some proposals have concentrated on restricting the entry of foreign medical school graduates into US residency programs, the projected physician supply for the year 2000 already incorporates substantial reductions of foreign medical school graduates under existing admission policies. [n4] 

N164/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 * Establishing a standard benefits package for Americans will encourage heavy lobbying by medical specialties to be included, much as they have lobbied successfully at the state level to be included in "mandated benefits" laws. The likely result: a steady increase in the cost of the basic package. 

N165/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 The burden of this review underscores that even large-scale financing reforms aimed at increasing coverage do not automatically translate into broadened access and improved services. After some years, federal and state governments often encounter budgetary stringencies that impel them to retrench in covering costs, to decertify persons who had previously been enrolled, and to place limitations on eligibility and benefits. The lessons extracted from the experience of earlier health care reforms should not be overlooked in the debate over the new agenda item known as universal coverage. 

N166/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Opponents of a minimal benefit policy believe this type of insurance coverage will be inferior to other insurance policies, will prolong the existence of a two-tiered system of coverage, and will lead to underuse of preventive, primary, and chronic care services by those most in need. 

N167/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 30, 1993, Part A; Page 1; HEADLINE: LID ON HEALTH COSTS NEEDED, GORE SAYS \\VT 93-94
	 Among those who urged the Administration to incorporate long-term care was Daniel Schulder, legislative director of the National Council of Senior Citizens. "Comprehensive reform without long-term care is like a transportation system without roads," he said. 

N168/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 What the public is not willing to do is accept limitations in service. In the 1992 EBRI poll, only 20 per cent said that Americans will have to "accept limits on what care is available to the average person." In a mid-March Gallup Organization Inc. poll for CNN-USA Today, people opposed by almost 2-1 the idea of reducing costs by "limiting the number of hospitals that can have expensive high-tech medical equipment." 

N169/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Enculturation is a key concept to the understanding of the discrepancy between our professed belief in health care as a human right and our discriminatory health care practices. Enculturation is the process whereby members of society unconsciously internalize cultural values. This process occurs in the absence of interpersonal and social conflict; the individual is simply not exposed to or encouraged to consider alternative values. In addressing health care issues, this concept can clarify how our internalized cultural values implicitly conflict with alternative values, which would assure universal access to health care 

N170/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Our government and society must be educated about the value system that supports the establishment of an NHCS (Table 1). Advocates for an NHCS must gain widespread media coverage of this educational activity to triumph over our national equivocation on these health care issues. [n54] First, our society must sufficiently understand and overcome its prejudice against having an NHCS. Second, the government must outlaw discrimination against the uninsured and underinsured poor. 

N171/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Until our society substantively changes and stabilizes the value system of our health care ethic, millions of Americans will go without adequate medical care, and the health care system will remain unjust. 

N172/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 To achieve such a change, society must undergo a moral conversion to a new blend of ethical priorities. In this way, we will avoid patchwork reforms that incrementally change our fragmented health care system. [n53] Such incremental changes will never solve the problems of inequitable access to health care and rising health care costs. Addressing this conflict of value systems will determine whether our society can solve these two problems. 

N173/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The argument for an NHCS often provokes a defensive counterargument that renders our society resistant to establishing an NHCS. This defensiveness arises from the perception that these arguments are attacks on highly cherished values that are an integral part of our health care policy. These values prevent our society from putting the moral ideal, health care as a human right, into practice. By understanding the reasons for this defensive reaction, our society may reconsider the priorities of the values affecting our health care policy. 

N174/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 3. Replacing the current system with government-run national health insurance is simply not practical. Shifting so many people and so many dollars from the private sector to the public sector is too disruptive to be politically feasible in the near future. 

N175/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	While public opinion polls indicate a readiness for national health insurance, Fuchs [Victor Fuchs, Stanford University economics professor] believes they are not credible indicators of political behavior. ''The great majority of Americans are not actively involved in the debate, but tend to be opposed,'' he wrote. 

N176/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 American individualism has emphasized self-reliance in health care matters. The doctor and patient negotiated an arrangement for the provision of medical care. Then, insurance companies became intermediaries in this process to act in the best interest of the individual patient. Even with the involvement of third parties, the individual still has the responsibility to arrange for health care coverage. 

N177/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Members of Congress should recall the firestorm of protest that followed the imposition of higher taxes on the elderly in the Medicare Catastrophic Act of 1988 to gauge the likely public reaction to a policy that would explicitly deny medical services to Americans, or reduce the quantity or quality of those services. For that would be the result of imposing government-dictated national budgets, known as "global budgets," and price controls on the United States health system, moves now being contemplated by the Clinton Administration and many in Congress. 

N178/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Those who do not favor an all-government plan are concerned about increasing the government bureaucracy and the potential for influence on the choice of insurance benefits available and the treatment decisions of physicians and hospitals. 

N179/Mike Fairley, staffwriter, Black Enterprise, May, 1992, Pg. 20, HEADLINE: HEALTH DEBATE RAGES ON \\VT 93-94
	 However, Health and Human Services Secretary Dr. Louis W. Sullivan believes that the high level of bureaucracy in a national health care system would make it unmanageable (see "The CEO Of Health," September 1991). "We should keep our health care system primarily in the private sectors -- with insurance, hospitals, physicians and other health professionals -- but work harder at streamlining the system and controlling costs," says Sullivan. 

N180/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 LAWRENCE MCANDREWS (PRESIDENT, NATIONAL ASSOCIATION OF CHILDREN'S HOSPITALS): The one area I am concerned about is that the government should not become a massive rate regulator and planner and try to take over one- seventh of the economy and control it. That would be the worst of the Canadian system without the best parts of it. 

N181/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 At the other extreme, other advocates of rationing -- including, it appears, President-elect Clinton -- would entrust detailed guidelines over what health care Americans will or will not receive to some independent national board, a kind of "Supreme Court of Health." Such a board supposedly would be immune from public pressure, much like the Federal Reserve Board or the U.S. Supreme Court, and its edicts would carrythe force of law. Not surprisingly, rationing by an independent board is among the least preferred options of an American public which is in any case overwhelmingly opposed to rationing. And even if such a board were beyond the political reach of patients angry at its decisions, the creators of the board -- Members of Congress -- would not be. 

N182/Thomas Sowell, senior fellow at the Hoover Institution at Stanford, Forbes, September 28, 1992, Pg. 83 , HEADLINE: Mispricing the risks \\VT 93-94
	 Such incentives and results are often missing in government-provided services that call themselves "insurance," as well as in other government activities that take on some aspects of insurance, such as disaster relief. Before looking forward to government-provided or government-controlled " national health insurance, " it may be well worthwhile to look back at some other government "insurance." 

N183/VICTORIA A. WANZER, The Atlanta Journal and Constitution, September 29, 1992, Section A; Page 7, HEADLINE: Nationalized health care will bankrupt nation \\VT 93-94
	 When the federal government controls health care, will the equipment be purchased a la the military procurement system, with contracts going to repay political favors, at costs escalated 1,000 percent? Great Britain has as many as 11 different and competing channels for ordering hospital equipment; delays of as long as nine months occur in filling orders for something as simple as 1 1-2-inch screws to fasten broken bones. 

N184/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	Eliminate administrative inefficiencies. A recent study suggested that $ 100 billion dollars could be saved if administrative costs could be reduced by emulating the Canadian government-run system. Most analysts believe that the potential saving is far smaller. But even if such an enormous reduction could be achieved -- a highly unlikely prospect -- it would offset the annual growth in expenditures for only a year and a half. 

N185/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, "Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL 
	Schwartz and Henry Aaron, an economist at the Brookings Institution, say that relying on the elimination of waste and useless procedures to offset technology is a pipe dream and that savings to be realized are not at all close to the $ 100 billion to $ 200 billion that some analysts estimate.

N186/Reuters News Service, April 23, 1992, HEADLINE: U.S. GROUP SAYS PRIVATE HEALTH INSURANCE WASTEFUL, Nexis \\VT 93-94
	 Commercial health insurance companies account for about ten pct of the $585.3 billion spent on health care in the United States each year and cover mainly employees of small to medium sized companies. 

N187/Reuters News Service, April 23, 1992, HEADLINE: U.S. GROUP SAYS PRIVATE HEALTH INSURANCE WASTEFUL, Nexis \\VT 93-94
	 The Citizen Action study was based on claims and premium information provided by the insurance companies to federal and state regulatory agencies. It did not include Blue Cross-Blue Shield insurance, self-insurance programs or health maintenance organizations. 

N188/Reuters News Service, April 23, 1992, HEADLINE: U.S. GROUP SAYS PRIVATE HEALTH INSURANCE WASTEFUL, Nexis \\VT 93-94
	 The Health Insurance Association of America disagreed with the report because it did not include the self-insurance plans funded directly by large employers and administered by commercial insurers. "Citizen Action attempts to convey the impression that eliminating the private health insurance industry-- or at least, eliminating administrative expenses -- is the 'silver bullet solution' to health care financing reform," the association. The association said a switch to a single-payer, government run health plan would lead to health care cost inflation that would wipe out any savings. The HIAA said administrative expenses are only 14.2 pct for each dollar of benefits paid when all private insurers are included. 

N189/JOHN MACDONALD; Courant Senior Washington Correspondent, The Hartford Courant, April 25, 1992, Pg. A2 HEADLINE: In health care debate, numbers sometimes can mislead \\VT 93-94
	 But clever analysts can make numbers add up a lot of different ways, so it's wise to treat these studies skeptically. 

N190/Molly Ivins, Fort Worth Star-Telegram writer, The Atlanta Journal and Constitution, August 8, 1992, Section A; Page 13, HEADLINE: Special interests rig health-care debate \\VT 93-94
	 In other words, be very, very careful of where you get your information on this issue, because a whole lot of the information is bought and paid for. 

N191/JULIE KOSTERLITZ, The National Journal, February 15, 1992, Pg. 376 HEADLINE: A Sick System \\VT 93-94
	 "All the politicians are lying a lot," Yankelovich [national pollster] said. "They're all minimizing the consequences of their own plans." 

N192/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	Q: Do these estimates take into account what reforms would cost down the road? 
	A: [Employee Benefit Research Institute] None of these take into account what seems to be an overriding concern of the public and politicians and of business people: That is the rate of cost escalation. These numbers simply take what health spending was at a particular year and then estimate what the change would be if the reform plan in question were already in place in that year. 

N193/PR Newswire, January 17, 1992, HEADLINE: REPORT BLASTS NATIONAL HEALTH INSURANCE Nexis \\VT 93-94
	" National health insurance does not address any of the real causes of high spending and creates new reasons why spending will increase," says Bast [The Heartland Institute ]. "In exchange for empty promises of cost containment, we will see care withheld from the elderly, life-threatening queues for medical procedures, and too little investment in new technology and facilities. 

N194/DEBORAH SHALOWITZ, Business Insurance, June 1, 1992, Pg. 36, HEADLINE: Health care dissatisfaction grows; But a national plan is no cure \\VT 93-94
	 However, 83% of the 131 human resources executives who responded to the written survey said they do not believe the government would be able to manage health care costs more effectively than the current private health care system. Eighty-three percent of the 271 human resources executives who participated in a telephone survey three years ago gave the same response. 

N195/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	Eliminate excess hospital capacity. Many policy-makers have suggested that because U.S. hospitals have an average occupancy rate of about 65 percent, they are a major source of wasted dollars and a ripe target for cost-containment efforts. But eliminating surplus beds and closing hospitals that have low occupancy rates would have almost no impact on costs. Chronically empty hospital beds impose virtually no costs on the system. They make no demands on nursing care, food, laboratories or supplies -- the activities that account for 85-90 percent of a hospital's expenses. Even closing an entire hospital and transferring its patients saves little money because the costs of labor and supplies follow the patient. Moreover, rural and small urban hospitals are those most likely to be closed because of low occupancy; transferring their patients to a larger neighboring institution that provides more expensive care could well consume any theoretical savings. 

N196/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	Eliminate unnecessary hospital care. Eliminating unnecessary care is obviously a good idea. Unfortunately, it will provide only a brief respite in the war against rising health-care costs. The reason is simple: Eliminating unnecessary care does not affect the factors that cause costs to increase over time. Experience during the last decade strongly supports this position. 

N197/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	Even new medical practice guidelines -- the latest rage among policy-makers -- can at most buy only a short additional respite. In the unlikely case that we were able to cut hospital days by another 10-20 percent over the next few years, the effect on the rate of increase in costs would be almost imperceptible. 

N198/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 Action cannot come too soon for the millions without coverage and millions more who see their coverage threatened. However, an effective system cannot be put into place overnight. The commission therefore recommends that its recommendations be implemented one step at a time over a 5-year period. 

N199/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	The fact is, true control of the cost spiral can be achieved only through the denial of some medically beneficial services -- even to the affluent and well-insured. But before we can come to grips with the painful reality of such rationing, we much first move beyond the seductive myths of cost containment. Here are the leading examples: 

N200/AVRAM GOLDSTEIN; DWIGHT E.M. ANGELL; The Detroit News, GANNETT NEWS SERVICE, March 20, 1993, HEADLINE: HEALTH-CARE RATIONING AS WAY TO CONTROL COSTS IN DOUBT, Nexis \\VT 93-94
	 A growing number of medical ethicists and economists say the nation must limit lavish, high-tech treatment for dying patients so everyone can get basic health benefits. Called "rationing," the approach involves new restrictions on people who may be unaccustomed to them. The concept makes many policy-makers and politicians uncomfortable because it raises the specter of the government deciding who is worth saving. 

N201/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 This leads some advocates of rationing in the U.S. to call for the rationing decision to be made as close as possible to the patient, ideally by the doctor. To be sure, that would fit in with the attitudes of most Americans. Most Americans strongly oppose rationing. But when asked who should make rationing decisions if that were the law, they overwhelmingly want their own doctor or local doctors to do so. Government officials come well down the list of preferences. 

N202/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 202 \\VT-JHH
We fear that as medicine advances and new and more expensive interventions are developed, we will be rationed out of the market. Once we admit that price rationing of care is proper, we put ourselves at risk.

N203/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Moreover, attempts to mitigate the aspects of rationing that would most offend Americans are not likely to succeed. For example, rationing is made more palatable and humane in Canada and Britain because the particulars of the rationing system for the most part are carried out by physicians. With his or her eye on the budget, it is the doctor who makes case-by-case decisions that match course of treatment with available funds. This works tolerably well because patients are far more inclined to accept  rationing by their doctor than by some faceless official in the department of health, and unlike the official, the doctor can take into account the many unique and subjective features of an individual patient. 

N204/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 King: But we decided years ago that the citizenry has a right to choose private education. Why not allow them that option in health care? Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: And in so doing we have failed to adequately fund our public schools, and I think that's a serious problem for our country. King: You would worry that the same thing would take place in medicine? Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: I think that has already happened in a comparison society. That's one of the reasons I'm reluctant to use Great Britain as an example. 

N205/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: Sure, that's right. Twenty percent of the surgery [in Great Britain] is being done in the private system. Everybody's talking over there about how to get more private hospitals and new technology. It's going to be the end of the national health service. 

N206/B.D. Colen, medical correspondent, Newsday, December 29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	  If those don't sound like "limits" to my correspondent and others like him,  consider Great Britain. That nation, with its program of socialized medicine for all, long ago determined that no one older than 55 would be offered kidney dialysis. What happens to a 60-year-old with kidney disease? Well, since  60-year-olds are not felt to be of enough value to society, they are condemned  to die of kidney disease. After all, hard choices must be made and all that. 

N207/JACK D. DAVIS, The Atlanta Journal and Constitution, April 28, 1992, Section A; Page 13 HEADLINE: 'Easy' answer is the wrong one \\VT 93-94
	 The truth about national health insurance - or socialized medicine, as some call it - is that under such a program, health-care services would have to be rationed in accordance with the government's budget limit. If the experience of other countries is any indication of the impact of nationalized health care, then elderly and low-income people would be hurt the most. Rationing programs tend to favor the young and well-off. 

N208/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: Yes, they vote. And I think the politicians have to maintain a certain level of satisfaction. But they will penalize certain people, and the elderly are going to get it worst. The kidney dialysis issue in socialized countries is a tremendous one, where you have large numbers of people over the age of 65 who cannot get kidney dialysis. The elderly are going to suffer very badly when this first comes in, because the technology is going to be cut off to them. They are going to lose, I'll guarantee it. 

N209/DEBORAH SHALOWITZ, Business Insurance, June 1, 1992, Pg. 36, HEADLINE: Health care dissatisfaction grows; But a national plan is no cure \\VT 93-94
	 And, nearly three-quarters of those surveyed -- 74% -- said they thought the quality of health care would deteriorate under a national health insurance program. Eighteen percent thought health care quality would remain the same and 4% thought it would improve. Four percent had no opinion. 

N210/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 Under national health insurance, Mackinac Center economists Dr. Gerald L. Musgrave and Dr. John C. Goodman found: -- Countries limit access and spending on life-saving, modern technology. -- The poor, the elderly, racial minorities and rural residents wait longer for health care than the wealthy, the powerful and the well- connected. -- Although health care is proclaimed a "right," access is often guaranteed only to those with private health insurance or the ability to pay out-of-pocket. [The Mackinac Center for Public Policy] 

N211/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 A system of government- provided national health insurance would significantly lower the standards, quality and availability of health care in Michigan and the United States, according to a study released today by The Mackinac Center for Public Policy. 

N212/B.D. Colen, medical correspondent, Newsday, December 29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	  Thus anyone who thinks other nations provide universal health care without setting limits is fooling themselves. The only question for us, then, is what should our limits be, and how should we determine them? It is unlikely that Americans will accept limitations based on age, the value of the individual to society, or on the individual's quality of life - such  cutoffs would, in fact, probably be illegal under current law. 

N213/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 Rationing is essential to every national health system in the world. The Administration contends, correctly, that health care is already rationed in this country -- by price. Those who can afford it get it. Those who can't afford it live in anxiety. But the experience with gasoline lines in the late 1970s suggests that Americans may be far more willing to accept price rationing than bureaucratic rationing. 

N214/ELI GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE:
PHYSICIANS, POLITICIANS, AND THE PUBLIC, p.281 \\VT-JHH	Prevention. The matter, however, is not quite so simple. The Surgeon General has recently defined tobacco as an addictive substance, and Americans engage in many other habits and activities that are injurious to their health, from eating unwholesome foods to driving at excessive speeds. In theory there may be justification for differentiating in the expenditures for, and access to, health care among people with differing lifestyles. Nevertheless, it is important to remember some obvious facts, many who jog develop orthopedic impairments; many who are overweight suffer from glandular, not eating, disturbances; a great number of chronic medical conditions are inherited; and even the most health-conscious, exercise-oriented, cautious individual is not immune to cancer or other devastating diseases.

N215/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 If you watch t.v., you may have seen a commercial featuring a barely middle-aged woman examining her breasts in a mirror. "Mary Brodie won't feel the tiny lump in her breast for another two years," the voice-over proclaims. "But she'll discover it tomorrow after her first mammogram--thanks, in part, to a new
x-ray film created by DuPont that makes it safer to start mammography early..."
Given the ad's public service announcement tone, one might think that no one quarrels with the American Cancer Society view that women aged 40-49 should have mammograms every year or two. Not so. Lower radiation doses have made the tests safer, and mammograms may indeed detect lumps.

N216/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 But there is considerable disagreement over the American Cancer Society's views about early mammography (and those of the American College of Radiology and the National Cancer Institute). The American College of Surgeons was asked to endorse the Cancer Society's position but declined. And two eminent professional groups--the American College of Physicians and the U.S. Preventive Services Task Force, an advisory panel to the Department of Health and Human Services--openly oppose it.

N217Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 The truth is that the value of mammography, which has been clearly shown for older women, has not been demonstrated for younger women. These groups advise women to delay having mammograms until they are 50 unless they already have had breast cancer or have a mother or sister who has. Indeed, they point out that unless their relatives were stricken before 50, even women from breast cancer families are often at no higher risk than anyone else until their 40s are behind them. As for those women under 50 who do get breast cancer, controlled studies have found that in many cases early detection and treatment does not improve the prognosis.

N218/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 Part of the problem is a misunderstanding of the familiar Cancer Society statistic that breast cancer is the fate of one in nine women. Many women don't realize that this risk is spread over a lifetime and that it rises with age. The average woman's chances of contracting breast cancer in her 40s have been computed by Dr. David Eddy of Duke University Medical School. They are 128 in 10,000, which works out to about one-eighth of 1 percent in any year of that decade. The odds climb at 50 and more steeply after 60, but don't reach one in nine until a woman is 85. And even that figure has been questioned by an American Cancer Society adviser.

N219/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 Dr. I. Craig Henderson, professor of medicine at the University of California-San Francisco, recently took a close look at the data behind it. "It's the Cancer Society's own data," he says. "But if you analyze it you find that an average woman's chances of getting breast cancer are one in nine only if she lives to be 110."

N220/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 And mammography itself is fallible. According to Lou Fintor, a National Cancer Institute biostatistician, it misses about 10 percent of breast cancers (so-called false negatives) and has a false positive rate of 60 percent to 70 percent, meaning that areas that appear suspect on the film turn out to be benign. Both types of error are more common in younger than older women because younger breasts are denser, making the films murkier and harder to read.

N221/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 But the acid test of mammography is its impact on breast cancer death. Controlled trials, which typically run four or five years, are the gold standard here. They have shown that when the women screened are over 50, breast cancer mortality falls by 20 percent to 40 percent. In only one of them--conducted in the 1960s by the Health Insurance Plan of Greater New York and usually called the hip trial--has there been a suggestion of benefit for younger screenees. And this too is arguable. The first analysis of the data found that in the decade after the trial ended, there was no significant difference in the number of deaths among women who had and had not been screened. In 1988 the National Cancer Institute reinterpreted the data and found a 24 percent survival advantage for the screened group. But Dr. John Bailar, a statistical consultant to the New England Journal of Medicine, has called the claim "seriously biased." And Dr. John Lawrence of the Rockefeller Foundation, a former chairman of the U.S. Preventive Services Task Force, says, "When you look at the data on women who enrolled in the hip trial in their 40s, you see that most who appear to have profited from screening were closer to 50 than 40 at the time they started, and that their tumors were detected not while they were still in their 40s, but when they were in their 50s. The clear implication is that the results would have been the same if they had waited until 50 to start mammography."

N222Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 Meanwhile, a study done with newer technology has been following 50,472 women in Canada who were 40-49 in the years 1980-'85. Half had annual mammograms and physical examinations, and half served as "controls," undergoing only a single hands-on breast exam. (Testing ended in 1988; screenees who entered the trial before 1984 had five dual examinations, and those entering later had four.) Dr. Anthony Miller, the University of Toronto physician- epidemiologist who heads the study, has reported in the American Journal of Preventive Medicine that no fewer of the women who were screened than unscreened have died of breast cancer. He and the study's associate director, Dr. Cornelia Baines, will say little more until November, when the Canadian Medical Association Journal will publish their findings. 

N223/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 Caution, however, is unlikely. The United States now has 12,000 mammography units, three times as many as in 1986, and the number is growing. Because most charge patients who are under 65 considerably more than the $66.70 limit set by Medicare for examinations of the elderly and eligible disabled--and only every other year at that--many rely on the larger pool of able-bodied younger clients to survive. If they were to lose the screening market for 40-49-year-olds (indeed, some go out of their way to attract even younger women by not mentioning age in their ads), some would likely have to close.
But this is exactly the kind of choice that should be made at a time when health care costs are spinning out of control. It would also fulfill what is supposed to be the basic tenet of medicine: primum non nocere--first do no harm.

N224/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Forty centuries of failure should be enough to convince any policy maker that price controls are an unambiguous mistake. No matter where they have been tried, the results have always been the same. There is no reason to think health care price controls will succeed. Price controls also hamper the ability of industries, such as pharmaceuticals, to compete internationally. The U.S. International Trade Commission, in a study prepared for the Senate Finance Committee, notes that, "Several countries that have implemented such programs [price controls] have seen their pharmaceutical industries weaken or shift outside their borders." n46 The study notes that price variations for particular drugs resulting from the imposition of different drug price control schemes in eleven of the twelve nations of the European Community have resulted in the growth of "parallel trade" in pharmaceuticals. Parallel trade refers to the practice of "brokers" buying a drug in a country that sets the price low and reselling it in countries that set the price higher, taking their profits out of the margin. For example, Glaxo makes its popular and very effective ulcer treatment drug, Zantac, in both France and Britain. In France, the price is set low, so Zantac is imported from there by British parallel traders. 

N225/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Congress should resist the idea of imposing price controls on the health care industry as a solution to the soaring cost of medical care. Inevitably, such a remedy will end in failure or create more problems than it solves. 

N226/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Price controls would not work in healthcare because they attack the symptoms of runaway costs, not the cause. Medical costs today are soaring because consumers are largely insulated from them by the illusion that employers pay for their health insurance coverage, and because the tax system discourages consumers from seeking good value for money in health care. This situation leads to calls for price controls on visible out-of-pocket medical costs, such as outpatient pharmaceuticals, and on insurance premiums, while more rapidly rising medical costs go unnoticed by most Americans who do not pay them directly. 

N227/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Because the problems of today's U.S. health care system result from policies that distort the health care market and introduce perverse incentives for consumers and providers, trying to suppress costs with price controls only tackles the symptoms, not the root cause. Like clamping down the lid of a pot of boiling water in an effort to stop it from boiling -- rather than turning down the heat -- price controls ultimately are ineffective and often produce greater harm. Price controls inevitably lead to serious effects that compound the original problems they were intended to solve. This has been the case in every part of the economy in which they have been applied, in the U.S. or in other countries. 

N228/United Press International, March 29, 1993, HEADLINE: HEALTH CARE TASK FORCE PANEL HEARS IDEAS ABOUT HEALTH REFORM, Online America, Transmitted: 93-03-29 20:25:00 EST \\VT 93-94
	 Representatives from hospitals and the pharmaceutical industry urged the panel to reject price controls to control health care costs. "Price controls will freeze in place inequities" in the system, said Michael Bromberg, executive vice president of the Federation of American Health Systems. 

N229/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #1: Price ceilings result in shortages of the goods or services subject to control. History shows that shortages occur after government mandates lower prices. Perhaps the clearest and most frequent examples found throughout history are the food shortages which quickly follow the imposition of price controls on farm products. Unable to obtain a reasonable price for their goods, farmers simply withhold their existing produce from the market and cut future production. The same is true of other commodities, resulting in an energy shortage or "crisis." As later sections of this study will show, when the controlled price of a medical service is below the market clearing price, patients demand more than doctors and hospitals are willing or able to supply 

N230/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Price controls not only do not work, but international and U.S. experience shows they produce severe side effects that would be unacceptable to the vast majority of Americans, including: * Price controls lead to shortages of the goods or services subject to control which, in turn, results in waiting lists for the limited supply. Example: At any given time, approximately 1 million Britons and 250,000 Canadians are waiting months or even years for needed tests and operations because their governments limit the funding of hospitals through global budgets. 

N231/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #2: Price ceilings lead to reductions in the quality of the goods or services subject to control. Since imposing a cap on the price of a service does not change the cost structure of providers, one common side effect of price controls is that providers cut quality, and hence cost, to maintain their income. This is a common response to price controls by manufacturing industries, and, for example, was a widespread result of price controls in the U.S. and Canada during World War II. As indicated later, the same phenomenon occurs in medical care. In countries with a price-controlled health system, such as Britain, the system remains popular despite offering poor quality service. Typically, citizens express the view that "the care may not be great, but at least it's free," and complain that not enough is spent on the system. 

N232/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Indeed, if price controls were to be imposed on the U.S. health care system, not only would they fail, but they would undermine seriously the quality and availability of medical care. 

N233/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #3: Price ceilings divert economic activity and investment from heavily controlled sectors into less controlled, or uncontrolled, sectors. Price controls on oil and natural gas dramatically reduced the amount of money spent searching for new energy sources. The money did not disappear; it was invested in other areas of the economy. Similarly, as later sections of this Backgrounder will show, government-imposed price controls prevent doctors, hospitals, research organizations and pharmaceutical companies from realizing a competitive return on certain types of investments. That distorts investment, leading to medical investments determined by bureaucratic regulation rather than potential value to society. 

N234/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #4: Price controls benefit well-connected and richer consumers at the expense of others. When prices are controlled, those with good contacts or plenty of money receive a larger slice of a smaller pie. When gasoline price controls were in effect, friends of the gas station owner received a full tank despite the shortages. In rent-controlled New York, the rich simply pay "under the table" to obtain an apartment, while the less affluent wait or move into shoddy buildings. The same holds true of health care. Canadian and British politicians -- and their friends -- receive good care, as do the affluent. The others have to compete for what is left. The wealthy and well-connected can also go elsewhere to obtain medical care. 

N235/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 * Price controls benefit well-connected and richer consumers at the expense of others. Example: When Robert Bourassa, the Premier of Quebec, needed treatment for potentially fatal skin cancer, he crossed into the U.S. and obtained treatment at his own expense at the National Cancer Institute in Bethesda, Maryland. 

N236/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #5: Price controls encourage black markets. A typical consequence of price controls is the evolution of black markets for controlled goods and services. Many buyers and sellers will simply make mutually beneficial transactions regardless of legal prohibitions. The back streets of price-controlled Eastern Europe thrived for decades with sales of black market goods. Black market prices are almost always above true market prices, since sellers incur greater costs and risks in producing the product and finding customers. This would especially be true of medical services, where the demand is intense for cures or treatments to preserve life or increase the quality of life. Moreover, doctors prepared to circumvent the law would want to be compensated for their added costs and risks. 

N237/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 * Price controls encourage black markets and bribery. Example: In Japan, patients seeking quicker and better quality care can expect to pay bribes of between $ 1,000 and $ 3,000 to obtain treatment from a senior specialist in a university hospital. 

N238/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #6: The longer price controls are in effect, the more serious the shortages of goods and services become and the more painful the adjustment process back to market prices. Long-term imposition of price controls causes deep distortions in an economy. Much of the problem today in former communist nations is in making the transition from controlled to market prices. One reason policy makers often give for not removing long-standing price controls is that removing the controls will cause prices to soar immediately, while it will take time for supply to grow to meet pent-up demand and bring prices down again. Consequently, any period of adjustment following decontrol will have high transitional costs, leading to public anger, which politicians fear. 

N239/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #7: Price controls lead to costly and unpopular methods of allocating goods and services, such as queuing, rationing, and bribes. Since price controls create shortages, there has to be an alternative way of allocating the quantity of the product being supplied among consumers. Unfortunately there are no good replacements for market prices. One traditional method is simply forcing citizens to wait in line. But queuing, whether for bread in the old Soviet Union or gas lines in America during the 1970s, is widely recognized as a waste of human resources. Every man-hour spent waiting in a line is time unavailable for more productive or enjoyable activities. 

N240/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #8: Price controls reduce the penalties for discrimination by sellers. In a free market, sellers who try to favor one group and discriminate against another penallize themselves by avoiding possible business. A landlord who does not rent to blacks, for instance, or a car dealer who ignores female potential customers will pay a price in lost income. But with heavy demand and shortages of supply induced by price controls, discrimination imposes no costs on the seller. In the health care field, this problem becomes acute. If a doctor harbors certain prejudices, say, against AIDS patients or the poor, then the doctor can choose not to supply the same level of limited services to those he or she dislikes. Since shortages created by price controls mean the doctor is assured of being able to find enough patients to justify the maximum funding he or she is allocated by the government, there is no loss of income to punish discriminatory behavior. The government's likely response: more laws, more regulations, and more officials to enforce them. 

N241/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Among the side effects generally associated with price controls: Side Effect #9: Price controls reward those sellers who "game" the system, and penalize those who do not. Any seller willing to evade price controls, such as by offering goods and services under the table for a premium, or by offering only the goods and services that provide the best return, can maintain or even increase his income under price controls. Those sellers who obey the rules strictly, by contrast, invariably see their incomes fall. The same is true in medical care. When controls are placed on fees for certain procedures, as they are in Medicare and in many other countries' doctors who simply increase their volume by providing unnecessary tests and treatments maintain their income. Those doctors who continue to practice as they did before controls -- doing only what is medically necessary -- see their incomes fall. 

N242/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Indeed, a whole private sector consulting industry has sprung up selling conferences, manuals, and computer software designed to help doctors and hospitals outmaneuver price controls (Side Effect #9). For example, a brochure for the 1993 edition of one such product for hospital officials claims that, " . . . the DRG Working Guidebook helps you check whether cases are being assigned to the correct and highest-paying DRG allowed." In similar fashion, a direct mail solicitation for the 1993 edition of another handbook and companion software is headlined, "Get every Medicare dollar you're entitled to under the new RBRVS payment system." 

N243/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 Federal price controls would only slow temporarily rising costs without improving health care, the speakers warned. The government should confine its role to tax and policy incentives to encourage reform in the private sector and regulations to curb fraud, they said. "The private sector is the largest bill-payer for employees and you should have a lot to say about changes in the health care system," Sean Sullivan, president of the National Business Coalition Forum on Health, told employer representatives in the audience. 

N244/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Setting a global budget for any part of the health care system also begs a question -- what counts as health spending? If a hospital's budget is controlled, how does the government deal with the explosion of spending that no doubt would occur in substitutes for hospitals, such as clinics, skilled nursing homes, and even doctors' offices. A budget might be set for prescription drugs, but what about non-prescription medications, such as antihistamines, cough syrup, or aspirin? Every attempt to clamp down on one definition simply would mean an increase in spending somewhere else less subject to control. 

N245/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Medicare's experience with price controls should give cold comfort to Clinton aides who see price controls as the key to achieving global budget. Medicare's attempt in the 1980s to hold down costs with standard fees for each treatment quickly led to an explosion of Medicare physician costs, as hospitals shifted costs to evade controls. Moreover, hospitals which played by the rules lost money, while those that gamed the price controls prospered. Attempts to limit physician costs through government fiat have had similar results. Many conscientious doctors have found their incomes falling while others maximized their incomes by such tactics as shorter and more frequent office visits for patients, and by routinely using procedures and diagnoses that yield high reimbursements. n16 

N246/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 A Meaningless Budget. But a national budget may in practice be devoid of any real meaning other than a hoped-for outcome. In other words, it may be like any entitlement budget within the federal budget -- not a limit on spending but merely the projected spending outcome of other policies. 

N247/The National Journal, February 15, 1992, Pg. 384 HEADLINE: Searching for A Treatment \\VT 93-94
	 Conservative critics argue that such an approach undoubtedly would lead to shortages of needed health care. "Putting a spending cap will create rationing in the worst way," said Joseph L. Bast, president of the conservative Heartland Institute, in Chicago. "Lots more people will end up waiting for care." 

N248/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 A Meaningful Budget. If a national budget really means something then it means Americans as a whole, by law, can spend only a certain amount on their health care. Once that figure is reached, say on December 12th in a particular year, health care services must cease, hospital doors must be closed and doctors' offices shut down. To be sure, well-managed hospitals and prudent doctors can spread their resources carefully over a whole year, as they try to do in Canada, so that there is no end-of-year shutdown. But even that will happen only if each hospital or group of providers has its own government-mandated budget, which means another extensive layer of bureaucracy. Otherwise each hospital or doctor has the incentive to maximize earnings without regard to any national or state budget. If every provider is, in a sense, cutting a slice from a limited pie, none has the incentive to cut a small slice so that someone else can cut a larger one. 

N249/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 But for lawmakers, the biggest problem is that for a global budget to mean anything, it must involve denying some Americans health care they are willing and able to pay for -- in other words, to ration care. While the citizens of some countries grudgingly accept explicit rationing, surveys of public opinion in the U.S. suggest that Congress and the new Clinton Administration risk an enormous backlash if they enact a rationing system. n13 

N250/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 A fixed "global" budget also would attack the symptom, not the cause. Further, the international experience shows that enforcing a tight budget not only produces unwelcome results and inefficiency, but also would require the kind of tough rationing decisions few lawmakers seem prepared to make. 

N251/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  Professor Enthoven has said it best: global budgets and price controls imposed at the national  level are akin to "bombing from 35,000 feet"; from very high altitudes in your  Washington office you don not see the people you are "killing."  

N252/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Some lawmakers believe government-imposed national health budgets would lead to a more careful allocation of medical resources, reducing costs and improving efficiency. But the real effect has been bluntly but accurately summed up by Stanford University Professor Alain Enthoven as more similar to "bombing from 35,000 feet, where you don't see the faces of the people you kill." n1 

N253/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Global budgets can, if rigorously enforced, constrain health care spending simply by denying funds to the medical industry. The problem is that they do nothing to restrain consumer demand -- since patients view medical care as a free good, resulting in virtually unlimited consumer demand. The result is the classic first effect of price controls: the creation of shortages (Side Effect #1). These shortages are expressed primarily in the form of waiting lists for medical care (Side Effect #7). According to official government figures, almost 1 million Britons (the equivalent of 5 million Americans) are on a waiting lists for medical care at any given time. Independent experts estimate that the real figure may be as much 200,000 greater than the official figure. 

N254/Best's Review -- Life-Health Insurance Edition, January, 1992 Pg. 8 HEADLINE: Too rosy a picture; National health care system Opinion Brief Article \\VT 93-94
	Although countries with national health insurance often maintain that health care is a right," people living in these countries often cannot get the care they need unless they pay for it themselves, the study says. In Britain, for example, 10% of the population has purchased private health insurance, and 20% of all elective surgery is performed in the private sector. 

N255/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 A national health insurance solution is an old solution. It started in Germany 100 years ago - 40 years ago in Great Britain and 20 years ago in Canada. I don't think that when you look at those countries - who are now looking at what we're doing with managed care - that they've got all the answers. 

N256/David J. Gross, staffwriter, Roll Call, February 1, 1993, HEADLINE: Health Care Lessons From Abroad France, Germany, Japan All Have Universal Access, Control Spending Growth Better,Nexis \\VT 93-94
 Despite their success at restraining health care spending, none of these  systems offers a panacea to resolving the health care cost dilemma. Government officials in France, Germany, and Japan are grappling with many of the same  deep-rooted forces that strain the US system. Each country is facing increases  in the number of elderly citizens, the proliferation of expensive new medical technologies and treatments, and the demand for greater and more sophisticated  health care services.  

N257/BNA PENSIONS & BENEFITS DAILY, Feb. 21, 1992, COUNTRIES WITH NATIONAL HEALTH INSURANCE HAD HIGHER PER CAPITA INCREASES OVER TIME Nexis \\VT 93-94
	 The United Kingdom, France, and Canada, each with a program of national health insurance, had per capita increases in health care spending from 1970 to 1989 higher than those of the United States, according to the Health Insurance Association of America. Over that 19-year period, per capita health care spending grew 12.85 times in the United Kingdom, 11.57 times in France, and 8.97 times in Canada, compared with 8.12 times in the United States. Only Germany had significantly slower growth in health care costs than did the United States, while Japan's costs grew at about the same rate, HIAA said. 

N258/Pension Reporter, February 3, 1992, Pg. 207 TITLE: COUNTRIES WITH NATIONAL HEALTH INSURANCE HAD HIGHER PER CAPITA INCREASES OVER TIME. \\VT 93-94
	The United Kingdom, France, and Canada, each with a program of national health insurance, had per capita increases in health care spending from 1970 to 1989 higher than those of the United States, according to the Health Insurance Association of America. Over that 19-year period, per capita health care spending grew 12.85 times in the United Kingdom, 11.57 times in France, and 8.97 times in Canada, compared with 8.12 times in the United States. Only Germany had significantly slower growth in health care costs than did the United States, while Japan's costs grew at about the same rate, HIAA said. 

N259/B.D. Colen, medical correspondent, Newsday, December 29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	  I guess my reader missed the recent news that in Germany, which is often  described as having one of the world's best health-care systems, health-care costs are roaring out of control and the Germans are looking to trim their health budget by more than $ 6 billion next year. Germany, by the way, has a system - advocated by many in the United States - that combines national and private health insurance, and allows health-care  practitioners to see private, as well as public, patients. 

N260/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Clinton and his health-care planners will not want to copy everything they find across the Atlantic. European-style health care is hardly trouble-free. Inflexible bureaucracies sometimes interfere with the delivery of care. Some doctors, unwilling to settle for government-prescribed fee schedules, take part of their payments under the table. For a minor operation to correct nearsightedness, a Brussels clinic charges not only the official rate of about  $300 but also another $900 in unreported cash. 

N261/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 -- In Britain, New Zealand and Canada, from one-fifth to one-fourth of all hospital beds sit empty and another 25 percent are used by nursing-home patients. [The Mackinac Center for Public Policy] 

N262/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 In a range of European countries, rising costs have triggered reform movements that have a distinctly American flavor. The Netherlands, for example, is edging toward competition between insurance companies in an effort to  introduce incentives to control costs. 

N263/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Medical services are rationed, especially in countries that spend relatively little on health care. In Britain, which spends less than all but the poorest Western European nations, the elderly frequently wait two years for hip replacements and cataract operations. Even in the Netherlands, which spends 30% more per person than Britain for health care, a recent survey found that one-third of all hospital admissions came only after excessive waits. At the same time, under pressure from health care providers and patients, the Dutch government pays for such dubious treatments as herbal medicine and psychic healing. 

N264/Best's Review -- Life-Health Insurance Edition, January, 1992 Pg. 8 HEADLINE: Too rosy a picture; National health care system Opinion Brief Article \\VT 93-94
	Advocates of a national health care system have painted too rosy a picture of the health care systems of other countries, according to the National Center for Policy Analysis, a research institute in Dallas. An NCPA study says that most countries with "free" health care ration access to services, and the rationing, which is greatest when expensive technology is involved, tends to discriminate against the poor, the elderly, people who live in rural areas and members of racial minority groups. 

N265/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 -- Many people are waiting for surgery: 25,000 in New Zealand, 250,000 in Canada and more than 1 million in Britain. Canadians wait as long as seven months for open-heart and coronary bypass surgery. [The Mackinac Center for Public Policy] 

N266/LEONARD ABRAMSON, Health Journalist, 1990, HEALING OUR HEALTH CARE SYSTEM, p. 63 \\VT-ADPL 
	In the United Kingdom, the NHS pays family practitioners an annual amount for each patient, similar to a capitation.. Great Britain, unlike Canada, does allow physicians to practice outside the system. Budget restrictions in both countries have been responsible for delays in care up to six months. In the English system, the infrastructure is crumbling compared to a stronger hospital network in Canada.
N267/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Kenneth J. O'Donnell, National Electronic Information Corp., a trading partner network of health care providers and payers: It is, therefore, unrealistic to hold up foreign systems as equal to or more cost-effective than ours. They have benefitted from our technological advances without experiencing the associated costs. Other countries would be hard-pressed to provide low-cost services if they had to bear the burdens of expense that we Americans have willingly undertaken. 

N268/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	Canadian system would impose a more expensive, less effective program on the U.S. 

N269/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 In fact, Canadian-style health insurance would wreak major changes here. Hospitals and doctors would act differently; certain operations would be impossible to get and certain technologies would be unavailable. Some people would pay substantially more for health care and some would not receive the medical attention they once took for granted. 

N270/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 FRANCES LANKIN, Ontario Health Minister: There's an impending crisis and that crisis is the threat to the national standards and the national health care system. What we have in Ontario are some very, very difficult times. 

N271/HOWARD J. COLIER, M.D., The Atlanta Journal and Constitution, March 21, 1992, Section A; Page 18, HEADLINE: Canadian health system is unworkable in U.S. \\VT 93-94
	 Politicians and editors who advocate national health insurance, or implementation of a Canadian system, are looking through rose-colored glasses. 

N272/Reuters News Service, January 10, 1992, HEADLINE: CANADIAN-STYLE HEALTH SYSTEM SAID TOO COSTLY FOR UNITED STATES Nexis \\VT 93-94
	[REP.] Armey said the GAO overstated the administrative savings from replacing private plans with one national system and underestimated the costs of providing health care to everyone. "A government monopoly in health insurance would cost vastly more than it saves and health care quality, innovation and timeliness would suffer," Armey said. 

N273/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 The lessons for America in Canada's health care crisis should be clear. Ultimately, a government-run health system does not hold the hope of both restraining health care costs and expanding access to health care. While such systems may provide universal access to health insurance, and may initially bring some savings, inevitably, over time they prove that they can only control costs by denying access to medical care. 

N274/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Roger F. Greaves, chief executive officer of the California-based HMO, Health Net : I do not believe that Canada has achieved long-term success in providing universal coverage while holding down cost. Costs are going up more rapidly in Canada than they are in the United States. Canada has a clearly different culture from the United States. When we make comparisons we must remember that more people are covered by HMOs than live in all of Canada. More people live in California by far than live in all of Canada. Canada's population is primarily focused within 100 miles of the United States border. 

N275/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 As Canadians increasingly debate the future of their health system and wonder how long it can survive in its present structure, the lesson for America should be clear. The existence of an ideal health system that offers unlimited, "free" government-funded medical care, while simultaneously limiting health spending without restricting patient choice or provider decision making, is a myth. If it ever did exist in Canada, it does not any more. Pursuing the ephemeral mirage of a government-run health care Utopia, never will lead to a high quality, low cost health system in America or anywhere else. 

N276/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 The point is not to ridicule the Canadians. They are justifiably proud of a system that guarantees everyone quality medical care at no direct cost. It's a humane system, superior in some ways to that in the U.S. But as appears increasingly clear, the system's reputation exceeds its performance. The United States will not solve its health care crisis by looking north. 

N277/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: We would maintain, those of us who are against the single payer, that that has nothing to do [Canada's better health results] with the method of payment for their system or the fact that they are all covered. Canada does not have the AIDS problem that we have, does not have the drug addiction problem that we have, does not have pockets of poverty as we have. These factors in our country are one of the reasons we have higher costs. In general, if we give at public expense to all of those disadvantaged people - most of whom are not on insurance in the United States - the best we have to offer, it's going to be a very expensive thing. 

N278/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 There are other reasons to be wary of comparison with Canada. Proportionately, fewer Canadians are poor or old, the costliest patients. Homicide rates are a third those in the U.S. And the system saves money in ways U.S. patients might find intolerable -- by restricting access to advanced technology and quick treatment. 

N279/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	Eleven percent of the Canadian population is over 65 years of age as against 12.2 percent in the U.S. In addition, the large U.S. inner-city population accounts for a higher national incidence of drug abuse and teen-age pregnancy. Both factors add to the U.S. health care bill. According to a 1990 study, the elderly account for up to one-fifth of the difference in health spending between the U.S. and Canada. 

N280/National Review, March 2, 1992, Pg. 15, HEADLINE: Healthy competition; National health insurance Editorial \\VT 93-94
	 The argument for socialized medicine is a statistical illusion: in 1990 Canada spent $ 1,481 per capita on its centralized, government-run health-insurance system, while total health-care spending in the U.S. came to $ 2,659 per capita. The apparent cost advantage reflects differences in demography rather than in the modes of delivery: Canada is a younger country with proportionately less of the inner-city health problems that afflict us. Even the much-touted administrative cost savings claimed for Canada's single-payer system appear, as Jacques Krasny pointed out in our last issue, to be a statistical mirage. 

N281/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 Population mix comes next, for health-care demand is highly dependent on the demographic profile of the served population. In the United States, it is estimated that the 12 per cent of the population that is elderly accounts for well over 50 per cent of health-care consumption; an increase of 1 percentage point in the 65-and-older population can raise health-care costs by 4.4 per cent. The U.S. cohort of 65-plus, which is 1.2 per cent larger (proportionately) than the Canadian, accounts for a full 5.3 per cent of U.S. health-care costs. In other words, were the Canadian system required to care for a population demographically equivalent to the U.S. population, it would face a 5.3 per cent increase in its health-care costs. This adjustment adds a further 0.5 points to the percentage-of-GNP figure. 

N282/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 The net effect of these adjustments for costs of capital, health benefits for health-care workers, population mix, and R&D is to increase Canada's share of GNP spend on health by 1.6 points. That in turn reduces an apparent 2.1-point advantage over the U.S. system to a modest 0.5. Even then, we have made no adjustment for other factors which heighten both cost and demand for medical care in the United States (and which have no parallels in Canada). They include the large number of Vietnam veterans; inner-city phenomena resulting from more intense urbanization (violent crime, substance abuse, sexually transmitted disease, teenage pregnancy); substantially greater costs of malpractice liability and insurance; and administrative costs of the health-care system, which in Canada are absorbed into general government expenditures, with little of the real cost allocated back to health care. 

N283/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 Increasingly, the U.S. health-care system serves as a safety valve for the Canadian system - the latter can succeed within its limitations because there is a medical version of "overdraft protection" to help it cope with the vagaries to adopt the Canadian system, not only would the resulting limitation of resources affect American healthcare consumers, it would also eliminate the Canadians' safety valve. And what country would then serve as a safety valve for the United States? 

N284/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 Above all, we have made no allowance for the significant (currently unmeasured) use of the U.S. system by Canadian citizens. Each dollar spent by a Canadian in the United States increases the apparent cost of the U.S. health-care system, and decreases the apparent cost of the Canadian system. Thus, a more sophisticated analysis would almost certainly yield a percentage of GNP equal to, or perhaps greater than, that of the U.S. health-care system. 

N285/Ed K. Gloeggler, Newsday, January 14, 1992, Pg. 81 HEADLINE: Canada's Plan Won't Fly Here \\VT 93-94
	The U.S. General Accounting Office reported last June that "the United States acts as a 'safety valve' for Canada." At least two provinces have agreed to pay for certain surgeries performed in U.S. hospitals. According to the Edmonton Journal of Jan. 6, 1990, one-half of all lithotripsy patients at Buffalo General Hospital in New York are Canadians. As any Canadian can tell you, Canadians with money can always come to the United States for quality medical care. 

N286/Judi Hasson, USA TODAY, August 6, 1992, Pg. 6A, HEADLINE: Health care: Plenty of politics but few answers \\VT 93-94
	 Deputy Health and Human Services Secretary Kevin Moley said U.S. hospitals near the Canadian border are filled with Canadian patients who can't get the specialized care they need at home. But if the United States adopts Clinton's plan, there will be ''no place for us to go.'' 

N287/Health Line, March 23, 1993, HEADLINE: SINGLE-PAYER: SUPPORTERS DEMONSTRATING PUBLIC BACKING, Nexis \\VT 93-94
	 W.S. JOURNAL editorial notes a U.S. insurer will soon begin offering a policy for Canadians who are on waiting lists of more than 45 days. The policy provides treatment in the U.S. and "even covers food and lodging for a loved one, plus airfare back to Canada." JOURNAL: "Everyone knows that Canadians all along have had the U.S. as a safety valve for serious problems. Where's our safety valve? Cuba?" (3-23). 

N288/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Ann Dudero, Jostens Inc., manager of health care welfare benefit plans: Culturally and philosophically, the United States and Canada are very different and have arrived where they are today from different historical perspectives. Americans would not accept Canada's solution as appropriate on a carte blanche basis, though some elements of Canada's approach may be acceptable and very instructive. 

N289/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 But there is a more profound reason for the Canadians' acceptance of a system with so many restrictions. Healthcare systems reflect a society's deepest values; they cannot be examined in isolation from the culture that spawned them. Canada and the United States appear to be culturally similar in terms of language, media, educational systems, and technologies. But that is misleading. Social attitudes toward individual rights and the direct authority of government over daily life differ substantially. In its gradual evolution from a colonial to a democratic society, Canada has maintained many of the centralized characteristics of the colonial administration from which it grew and a corresponding deference to authority among the citizenry. These traditions persuade Canadians to accept limitations on individual rights unknown in the U.S. Among them: no access to punitive damages if wronged by a medical practitioner, no contingent legal fees; no class-action suits (with minor exceptions); no right to sue government officials or ministries of health for medical negligence; no effective chioce between the various provincial medical systems; no private alternatives. None of these limitations would be acceptable to Americans. 

N290/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 The United States will have to devise its own health care cost reform, if only for reasons of politics. The Canadian system works well in Canada's disciplined parliamentary democracy. Compare that with Washington, where 535 members of Congress compete for the political spotlight. The Canadian health care system is good, but not good enough to meet America's needs. 

N291/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Alain C. Enthoven, Prof. at Stanford University: Canada has a fundamentally different political culture and system of government (i.e. ''top down'' parliamentary, vs. limited government with checks and balances). Our form of government couldn't make it work. 

N292/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Dallas Salisbury, Employee Benefit Research Institute: Evidence indicates that the difference in gross domestic product proportionally spent on health is largely attributable to social factors. Dallas Salisbury, Employee Benefit Research Institute: The government has shown it is unwilling to limit what benefits are delivered. Cost control has been achieved through cost-shifting. A single government program could eliminate the ability to explicitly shift cost, but does not mitigate other problems. 

N293/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Gerald L. Maatman Jr., attorney: The health care industry is a different animal in the United States as compared to Canada. Physicians, employees, employers and uninsured individuals also stand in a different relationship to their government and one another in the Canadian system as compared to the United States. 

N294/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	No wonder health care seems less expensive in Canada -- services that cost Americans hundreds of billions of dollars each year are simply not counted under the Canadian system. Americans actually get more for their health care dollars than Canadians. Even though per capita health spending in America and Canada is roughly the same, Americans have 40 percent more surgical procedures than Canadians. Though too much surgery is conducted in the U.S., Canadians do not have enough surgery -- at least not enough of the surgery they need the most. 

N295/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	Moreover, Canada's 79,315 annual abortions are not fully covered under the health program. Government policy varies widely: some provincial governments pay for abortions, other don't. In the U.S., 1.6 million abortions are performed each year. Though abortions in the U.S. are "elective," they add at least $1 billion annually to the U.S. health-care bill. 

N296/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991, p.143 \\VT-MDS
 And the cost is not measured solely in dollars. Much more important costs are a lack of access to health care personnel institutions, diagnostic and therapeutic facilities; waits for essential services and surgery that run into years; and what I regret to have to refer to as the "lowest-common-denominator" quality of medical care. More about the last later.N297/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LARRY GROSSMAN, Former Ontario Health Minister: The reality is, I wouldn't call it universally accessible if you've got a four or five month waiting list for surgery - high-tech surgery - and you die while you're waiting for that surgery. 

N298/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: Managers of the Canadian health system say they can compensate for the loss with greater efficiencies. Others aren't so sure. LARRY GROSSMAN, Former Ontario Health Minister: Canadian governments in every province, in my view, are aware of the fact that they need to introduce user fees or - as the socialists call them - co-payments. 

N299/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 In the final analysis, access to health insurance is meaningless if it does not also give access to medical care. Contrary to the fond hopes of many Americans, including some members of Congress, Canada's national health system is finding that it is no exception to this rule. 

N300/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 The result is that while health insurance may be universally provided, access to actual health care is limited. There is, in effect, rationing by delay. Canadian residents may wait two months for a CAT scan or cataract surgery, four weeks or more for elective surgery (sometimes even in urgent cases), six to ten months for hip replacements. Two of Canada's most affluent provinces - Ontario and British Columbia - have contracted with U.S. hospitals near the border to provide coronary bypass surgery for Canadian citizens, with the relevant provincial ministry of health paying for the procedure. 

N301/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 Various estimates put the uninsured population of British Columbia at between 2 percent and 5 percent, or 50,000 to 100,000 individuals. Were this figure applied to all of Canada, some 530,000 to 1.3 million people would be uninsured. And were this figure then transposed to the U.S., some 5 million to 12.5 million Americans would be uninsured -- this is still a significant one-sixth to one-third of the present U.S. uninsured population. 

N302Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 The only mechanism holding down costs is a rule capping government payments at $ 450,000 per doctor yearly. This means a physician who reaches the cap early (for example, a high-charging specialist) has no incentive to continue working. Torontonians joke that the best place to find a dermatologist in the last quarter of the year is in Florida. 

N303/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Opponents of single-payer systems point to long waiting lists for certain procedures in Canada and claim the quality of care there is diminishing because of budget limitations. 

N304/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	American doctors, on average, have more training than Canadian doctors. In Canada, 50 percent of all physicians are general practitioners compared to only 10 percent in the U.S. This means that 90 percent of the doctors in the U.S. have pursued specialties, requiring a minimum of two years' additional medical training, as against only 50 percent in Canada. 

N305/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	Americans are receiving better care than Canadians for about the same price. Although health care costs in the U.S. continue to rise, it's clear that the Canadian system offers no solution. Until health care providers devise an effective means to discourage frivolous claims by those they insure, the cost of health services will continue to skyrocket. 

N306/Health Line, October 30, 1992, HEADLINE: CANADIAN SYSTEM: CRITICISM FROM AN INSIDER Nexis \\VT 93-94
	FLORIDA TIMES-UNION reports Canadian Michael Billett, head of Heartbeat Windsor, which helps Canadian cardiac patients get into U.S. hospitals, has "leveled his attacks" on the Canadian health system. Billet, speaking at a seminar sponsored by Associated Industries of FL and the FL Hospital Assn. warned, "Do not be fooled. It does not work." Billet said that "a big problem with national health insurance ... is that the quality of care depends on the amount of taxes collected." Billet: "If your country is in a recession like ours is, what happens to your tax base? Goes down. And if your health care is based on taxes, what happens to your health care? Gone. ... Canada's going to have to go privatized. We're going to have to get competition in our country" (Chuck Springston, 10-26). 

N307/WILLIAM GOODMAN, Canadian Physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE--THE REFERENCE SHELF, 1991 p.151 \\VT-MDS
Ail they would know is that they had to pay nothing out of pocket at the time and place of actual medical service, at least initially. The vast majority of Canadians had and still have similar difficulties in associating 'free' benefits on one hand with massive increases in taxes, public debt, and inflation on the other. Canadians still do not understand that their rapidly decreasing access to first-class medical care is an inevitable consequence of these "benefits."
N308/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 [JEFF LEVINE, Medical Correspondent] Many insist the U.S. system offers more choice and higher quality for those who have insurance. And some Canadians fret their approach is sinking under the same cost pressures that are straining the U.S. health care system. 

N309/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 Doctors would behave differently. In a system with more sick people than beds, doctors make constant rationing decisions. And in a system where a hospital gets a flat fee at the beginning of the year instead of a payment for each patient, doctors have to think not only about what is good for the patient, but about what the hospital can afford. In other words, when you look at a doctor, your expectations of what will be done have to change. 

N310/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Frank B. McArdle, Employee Benefit Research Institute: The Canadian approach is excellent for Canada but is politically infeasible at this juncture in the U.S. We have the capability of devising even better health care delivery systems in the United States if we focus attention on the quality of health care. If employers and consumers are convinced of quality health care, they will be more willing to surrender the idea of unfettered choice and more willing to pay the full cost of universal coverage. 

N311/Mike Snider, USA TODAY, January 21, 1992, Pg. 1D HEADLINE: Older doctors distrust reforms \\VT 93-94
	''I think there are a lot of doctors out there with a lot of misconceptions'' about the Canadian system, says Dr. David U. Himmelstein, Harvard Medical School, Cambridge, Mass. 

N312/HOWARD J. COLIER, M.D., The Atlanta Journal and Constitution, March 21, 1992, Section A; Page 18, HEADLINE: Canadian health system is unworkable in U.S. \\VT 93-94
	 The American people have been used to quick service and no wait when it comes to tests and surgery. They will not stand for the drawbacks of the Canadian system, nor will they stand for a heavy increase in taxes, which would be necessary. 

N313/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Kevin E. Flint, Bausch & Lomb Inc., director of benefits finance: Americans with health care coverage are used to making their own decisions on health care and having ready access to health care. Under the Canadian system, everybody has access, but not everybody gets the treatment needed because health care is rationed as a means to control costs. 

N314/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 The bad news: No more network of insurance companies looking over doctors' shoulders making sure they don't just see patients to line their own pockets. Canadian physicians perform about 20 percent more diagnostic and therapeutic procedures per patient than Americans and have 56 percent more office visits. Such extra care is thought somewhat unnecessary and a major factor in pushing Ontario's health care costs up faster than U.S. costs. 

N315/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991 p.144 \\VT-MDS
Apart from any political philosophy that you may espouse, be it free-enterprise or welfare-state, it's essential to realize that the basic and unalterable flaw in any system like the Canadian model is that, in economic terms, it is an open-ended scheme with closedend funding. In other words, the potential demands are completely unrestricted, but the money to pay for them is not. It's like giving the public a no-dollar-limit, no-responsibility-for-payment medical credit card--an open invitation to unlimited abuse by both patients and doctors.
N316/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Alain C. Enthoven, Prof. at Stanford University: Moreover, Canada's system suffers from a total lack of incentives to impose efficiency. We need to create a system with powerful incentives for doctors and hospitals to improve quality and service and cut cost. 

N317/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 Many U.S. proposals for controlling hospital costs call for adopting Canada's system of global budgets -- setting annual payments independent of actual admissions and outlays. But recent studies should temper enthusiasm. They show hospital stays 70 percent longer than in the U.S. -- presumably because the system encourages hospitals not to release recovering patients rather than admitting expensive-to-treat new patients. 

N318/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 Put another way, a Canadian system means that no area hospital could afford to do anything but the most basic of improvements to the most basic, like roof repair or a better ventiliation system. 

N319/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 The answer is that the [Canadian hospital] administrator tends to avoid admitting many patients who are costly to treat (Side Effect #8), but keeps recuperating patients, whose costs are lower and more predictable, in the hospital longer. As one Canadian doctor puts it, "The best way to stretch a fixed hospital budget is by keeping sick people out and healthy people in." This is why hospital stays are longer in Canada and Britain than in the U.S. and why Canadian and British hospitals tend to have a higher proportion of older patients needing less acute care services. 

N320/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 [JEFF LEVINE, Medical Correspondent] Hospitals in Canada are being strained to live within their annual budgets. In Ontario, 3,000 employees may be laid off this year. 

N321/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Sen. David Durenberger, Republican-Minnesota: Even so, the cost of Canadian health care is rising at about the same rate as the cost of U.S. care. The differences can be explained by the fact that Canadian spending starts from a lower base (a limited supply of doctors, hospital beds and technology). 

N322/David A. Ridenour, vice president National Center for Public Policy Research, The New York Times, February 7, 1992, Section A; Page 29; HEADLINE: The Wrong Way to Health Care \\VT 93-94
	Congressional advocates of Canadian-style national health insurance are quick to conclude that Canada's health costs are substantially lower. They are wrong. While the U.S. figure includes all spending on health care, public and private, the Canadian figure includes only the amount the Government will pay. Expenses for dental care, prescriptions, ambulance service, private hospital rooms and glasses are not covered by the Canadian Government. They are included in the U.S. figure. To provide such services while preserving Canada's "universal" program would cost Canadians an additional $420 per year. In 1990, Americans spent $452 per capita on these items and services. 

N323/EDITORIAL, PROGRESSIVE MAGAZINE 1990, "A healthy democracy," in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991, p128\\VT-MDS
But the Canadian system is no cure-all. U.S. experience under Medicare and Medicaid demonstrates that some of the most difficult problems--and highest costs--are inherent in the practice of fee-for-service medicine. Physicians in private practice have little or no incentive to impose cost-control measures. And health maintenance organizations have shown a proclivity to dump highcost, high-risk patients.N324/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Steve Wetzell, Business Health Care Action Group: A single-payer system could streamline administration and reduce those costs, but it won't address the crisis at its root level: the point of service. Even the Canadian system has unacceptable increases in health care expenditures relative to the real growth in the economy. 

N325/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Dallas Salisbury, Employee Benefit Research Institute: Costs have risen at about the same real rate in Canada as those in the United States. There is a health cost crisis in Canada today. 

N326/Health Line, March 23, 1993, HEADLINE: SINGLE-PAYER: SUPPORTERS DEMONSTRATING PUBLIC BACKING, Nexis \\VT 93-94
	 OPINIONS: Univ. of Guelph's Brian Ferguson writes in Toronto GLOBE & MAIL, "Few Americans seem to be suggesting any more that the United States should adopt a Canadian-style medicare plan. ... It seems they have realized that the country with the most expensive health care system in the world has little to learn from the country with the second most expensive system" (3-22). 

N327/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Ann Dudero, Jostens Inc., manager of health care welfare benefit plans: Also, Canada's program has not been totally successful in holding down cost increases. 

N328/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 Bleak Future. When health care spending trends are analyzed, the future of the Canadian health system is as bleak as that of its U.S. counterpart. In both countries, the rates of growth in health care costs are outstripping general inflation rates by wide margins. Indeed, comparative data show that, during the past two decades, the rates of growth in real (inflation adjusted) per capita health spending in the two countries have been virtually identical. In fact, real per capita health spending has grown faster in Canada than in the U.S. in recent years. 

N329/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 The lesson for America should be clear. Genuine success in bringing soaring health care costs under control will require a far better solution than simply adopting a national health system modeled on Canada's experience. 

N330/Ed K. Gloeggler, Newsday, January 14, 1992, Pg. 81 HEADLINE: Canada's Plan Won't Fly Here \\VT 93-94
	A study by the National Center for Policy Analysis reported that a " national health insurance program similar to Canada's would require at least $ 339 billion in new taxes . . . If funded by a payroll tax, the tax rate would rise from the current level of 15 percent to a rate of at least 29 percent. . . . The income tax rate will increase by at least 14 points." 

N331/Ed K. Gloeggler, Newsday, January 14, 1992, Pg. 81 HEADLINE: Canada's Plan Won't Fly Here \\VT 93-94
	The Canadian health care system is doomed to fail in America. Along with destroying the world's best health care system, it certainly would drag our economy deeper in the hole, while each working American's wealth would be further redistributed. 

N332/Daily Report For Executives, January 13, 1992, PG. A-8, HEADLINE: Health Care, CANADIAN-STYLE HEALTH PROGRAM WOULD COST U.S. $81 BILLION, JEC REPUBLICANS SAY \\VT 93-94
	Instituting a Canadian-style health care system in the United States would cost American taxpayers as much as $81.5 billion annually, the Republican staff of the Joint Economic Committee asserted in a report released Jan. 10. 

N333/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991 p.144 \\VT-MDS
However even if we accept the estimate of the percentages of our respective GNPs devoted to health care costs, the expense of health care in Canada is one of the major factors in a Canadian federal per capita debt and per capita annual deficit that is twice as bad as yours. As to provincial budgets, over a third of the . revenue is already committed to health care, and the proportion is rising inexorably.
N334/Reuters News Service, January 10, 1992, HEADLINE: CANADIAN-STYLE HEALTH SYSTEM SAID TOO COSTLY FOR UNITED STATES Nexis \\VT 93-94
	A Canadian-style national health insurance system would cost U.S. taxpayers more than $81 billion a year, a House Republican said Friday. "A Canadian-style system would cost Americans $81.5 billion per year, with less efficiency and innovation and higher prices in the health care industry," Rep. Dick Armey, R-Texas, said at a news conference. Armey said his conclusions were based on a study of the Canadian system he requested by the Republican staff of the Congressional Joint Economic Committee. 

N335/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 "We, the taxpayers of Canada, are not willing to pay for the level of service that we, the users of medicare want. After 25 years of congratulating ourselves on having one of the finest health-care programs in the world, we have begun to wonder whether we can afford it." 

N336/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 In the November 22, 1991, edition of The Vancouver Sun (British Columbia), for example, columnist Geoffrey Stevens wrote: "The irony is that at the very moment American politicians and health care professionals are asking whether the U.S. can afford not to adopt Canadian-style medicare, Canadians are asking whether we can afford to keep it. There isn't a province that is not desperately worried about health costs. There isn't a province that is not struggling, not to make medicare better, but to cut back." An editorial in The Toronto Star expressed similar sentiments last summer, noting that: 

N337/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 In present day Canada unlimited demand for "free", government-funded medical care has collided headlong with limited resources. As such: * Canada's health system is plagued by soaring costs, with spending in recent years escalating at rates as great or greater than those of the U.S. system. * The Canadian federal government, burdened with large budget deficits, is steadily reducing its share of funding for provincial health plans. * Provincial health ministers are struggling to control their hemorrhaging budgets by closing hospital beds, laying off health workers, capping doctors' incomes, and limiting entry to medical schools. 

N338/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 In Canada, "25 percent of the hospital beds are filled with the chronically ill elderly while 250,000 patients are waiting for surgery," said George L. Berry Sr., a consulting actuary for Milliman & Robertson Inc., Philadelphia. "People die while waiting," added Berry, a native of Canada who lives there part of the year. Sullivan said the health care cost crisis is worldwide and it affects even national insurance systems in Canada and most of Europe. 

N339/HOWARD J. COLIER, M.D., The Atlanta Journal and Constitution, March 21, 1992, Section A; Page 18, HEADLINE: Canadian health system is unworkable in U.S. \\VT 93-94
	 National health insurance will work only if health care is limited. There would be a cap on the amount of money spent on MRIs, gall bladder operations, heart bypass surgery, etc. The government would take an X amount of dollars, and only this would be available to spend on health care for the year. That is why there would be a three-month wait to have a heart bypass or a four-month wait for a complicated MRI exam. 

N340/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 Dr. LAIDLAW: I would consider it a crisis if people are waiting more than six to eight weeks for radiation therapy after the need has been indicated. That does happen. 

N341/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 A patient with suspected ligament damage in the knee is a next-day patient in Washington but a nine-month wait or not-at-all in Toronto. Lower back pain with a suspected herniated disk is an automatic MRI here, but in Toronto it probably would be a milogram -- a cheaper, less advanced technology involving spinal injections that can cause splitting headaches, occasional seizures and an overnight hospital stay. An MRI is painless and takes 30 minutes. They rarely do milograms anymore in Washington. 

N342/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 "I can point to about a dozen cases a year at my center where someone's health was directly jeopardized because they couldn't get an MRI," said Walter Kucharzyk, chairman of radiology at the University of Toronto. He said Toronto should have at least 14 MRIs to deliver a minimum standard of quality of care. 

N343/Cable News Network, May 30, 1992, Transcript # 120 - 2, HEADLINE: Part II - American and Canadian Health Care Systems, Nexis \\VT 93-94
	 Dr. CAROLE GUZMAN, Canadian Medical Association: We certainly have waiting lists that are unacceptably long for some elective procedures such as hip replacements where patients are in pain for long periods of time before they can get that done. 

N344/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 Quentin Macmanus, a cardiac surgeon at Fairfax Hospital, describes a typical patient of his as an active 79-year-old man who plays golf, lives alone, but whose medication is no longer controlling his chest pain. In today's system he gets the bypass and goes back to his golf. In a Canadian-style system he doesn't and has to slow down, quit playing golf and maybe live with his children. "It's not mortality," said Macmanus. "It's quality of life." 

N345/Judi Hasson, USA TODAY, August 6, 1992, Pg. 6A, HEADLINE: Health care: Plenty of politics but few answers \\VT 93-94
	 That government-financed system provides basic care, but Canadians must wait months for specialized procedures like heart bypass surgery. 

N346/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 * Waiting lists are now endemic in Canada's health system, and a recent study estimates 260,000 Canadians are currently waiting for major surgery. 

N347/VICTORIA A. WANZER, The Atlanta Journal and Constitution, September 29, 1992, Section A; Page 7, HEADLINE: Nationalized health care will bankrupt nation \\VT 93-94
	 Great Britain and Canada are upheld as models for the U.S. health-care system. Both systems have been unable to meet their citizens' needs. Patients wait up to four years for elective surgery. Many die before their turn for treatment unless they can pay for private treatment. In Great Britain, Canada and Sweden, some care is deliberately denied some people, generally the elderly or those whose disease is most advanced. 

N348/Ed K. Gloeggler, Newsday, January 14, 1992, Pg. 81 HEADLINE: Canada's Plan Won't Fly Here \\VT 93-94
	But the devastation of the world's finest health care system cannot be measured merely in dollars and cents. There are 15 magnetic resonance imaging scanners in all of Canada compared to 2,000 in the United States. Delays in medical procedures are as accepted in socialized Canada as the bread lines are accepted in Russia. Canadians must wait weeks, months or years for advanced procedures such as radiology scans, heart bypass and brain tumor operations and lithotripsy (kidney stones). 

N349/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 No Canadians wait for emergency surgery, but they routinely wait weeks for urgent surgery, like heart bypass operations, and up to a year for non-urgent procedures like hip replacements. Even so, Canadian costs by far exceed those of any industrialized nation except the U.S. 

N350/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991, p. 152-3 \\VT-MDS
if you define "could the Canadian model work here?" to mean "would it improve quality and accessibility of health care for a majority of Americans?" my answer is yes--but only temporarily. Your citizens, like ours, will experience only briefly the medical Utopia that they have been promised, and at an enormous and eventually unbearable cost. Given your governments already astronomical deficits, I would guess that the time before imminent financial collapse would be much shorter than in Canada--perhaps five years.
N351/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Sen. David Durenberger, Republican-Minnesota: The United States should not look to Canada as a model for health care reform. To create a single-payer, government-administered national health insurance program might well ensure universal access to health care in the short term, but it would not provide the cost-control mechanisms that would make it sustainable over the long term. 

N352/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 A comparison of U.S. and Canadian access to higher (i.e., newer) medical technologies shows the per-capita ratio of accessibility ranged from 200 to 800 per cent higher in the United States. 

N353/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Kenneth J. O'Donnell, National Electronic Information Corp., a trading partner network of health care providers and payers: Any aspiration to mimic the Canadian system is shortsighted. For decades, American ingenuity and dedication of resources to research and development have been utilized by the Canadian government and others in the delivery of health care services. 

N354/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 CAT-scans, used predominantly to diagnose brain injuries, are the other big-ticket medical technology. In Washington there are between 75 and 100 of these machines. Toronto has 21. "I think that is an absurdity beyond belief," said David Davis, chairman of radiology at George Washington University Hospital. "We do 4,000 scans a year, most of them head trauma. I suppose that with some of them, you could say well he got dinged but he's probably all right, and if he dies later of an epidural hematoma then you could say, well, I guess we had no way of knowing that." 

N355/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 Still, a number of Canadians come here seeking treatment they have to wait for or that simply does not exist at home. LEVINE[JEFF LEVINE, Medical Correspondent]: Here at the border, some Canadians do cross over into the U.S. in search of medical care. In some cases, they're searching high-tech treatments not readily available in Canada. 

N356/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 Consumer Choice. If Americans are to achieve an affordable, universal, high quality health system, they cannot follow the Canadian path. The way to genuine reform of America's health system lies in consumer choice and true market competition, coupled with more effective government assistance for the needy and disadvantaged. 

N357/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Canadian Experience. Shortages produced by global budgets in the Canadian health system are less severe that those found in Britain. But Canada's track record in controlling health care costs with budget limits also is much less impressive. Unlike Britain, the Canadian federal government does not impose a national health budget or the provincial governments, who are responsible for most of the financing and virtually all of the management of the system. But in recent years, the Canadian federal government has tried to keep its spending down by steadily reducing the size of its contributions to provincial health plans, from the original 50 percent to less than 38 percent today. 

N358/Edmund F. Haislmaier, Policy Analyst, The Heritage Foundation, Heritage Foundation Reports, February 19, 1992, No. 883 , HEADLINE: PROBLEMS IN PARADISE: CANADIANS COMPLAIN ABOUT THEIR HEALTH CARE SYSTEM Nexis \\VT 93-94
	 To be sure, the Canadian health system has not yet reached the degree of crisis as in the U.S. But that day may not be far off. And while there are major differences between the U.S. and Canadian systems, there is an eerie similarity in some of the problems on both sides of the border. This similarity should induce more sober reflection by U.S. policy makers, particularly those inclined to advocate the adoption of a health system resembling Canada's. 

N359/The Vancouver Sun, May 27, 1992, Pg. A17 HEADLINE: Canada's medicine not good for U.S. \\VT 93-94
	 But data analyzed by Health Policy International, a non-profit research group in Princeton, N.J., show that this seeming success occurred because Canada's economy grew rapidly, not because medical costs rose slowly. Indeed, after adjusting for inflation, health costs in the 1980s rose faster in Canada than in the U.S. 

N360/James J. Kilpatrick, syndicated columnist, The Buffalo News, December 23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	  An acceptable plan to achieve universal coverage presents as many difficulties. The latest buzzword on Capitol Hill is "managed competition," an  oxymoronic construction in a class with "partial monopoly." Many conservatives  will like the idea of competition; it's the idea of management that worries  them. 

N361/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Your two-part editorial ("The Answer: Managed Competition," Dec. 2 and 3) is an exercise in self-deception. The oxymoronically named "managed competition" will not solve America's health problems but will make them worse. If managed competition is "the answer," then the question must be: "How can we design a health care reform strategy that preserves the power of the insurance industry?" It is certainly not the answer to the right question: "How can we guarantee high-quality coverage for all Americans while holding down  costs?" The answer to that question has already been found, and is working well, in Canada. 

N362/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Widely different plans and approaches now go by the name managed competition, and many of the old debates over single-payer and play-or-pay have re-emerged within its framework. The real question about Clinton's program is not whether it will be managed competition, but what kind of managed competition it will be. 

N363/The Economist, February 27, 1993, Pg. 30, HEADLINE: Health care; A dose of the HIPCs \VT 93-94
  Details of the scheme [managed competition] need further work. It foolishly relies, for instance, on requiring employers offer health insurance rather than on making employees buy it. This preserves America's nonsensical link between a person's  health-care and his current job, which does so much to impede labour mobility.  It weakly leaves Medicare outside its scope. The respective roles of federal and state governments, which are always complicated, need defining. And to  avoid adding immediate extra costs to a system that is already too expensive, it should be more wary of extending the state-sponsored coverage of HIPCS to the uninsured. 

N364/B.D. Colen, medical correspondent, Newsday, December 8, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 79, HEADLINE: Health Care at Square One \\VT 93-94
	 For "managed competition" is simply the naive proposition that health care is a commodity like any other and its price  can be controlled by making the "merchants" of health care compete for your  dollar like auto makers. And the insurance industry's "radical" proposal is that everyone should buy private health insurance, or have the federal government buy it for them.  

N365/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  While the managed competition approach is gaining a more popular currency beyond the Washington Beltway, is is an approach that is undergoing various mutations, reflecting both the exigencies of practical politics and  differing programmatic or ideological inclinations. President Bill Clinton, for example, has embraced a comprehensive health care reform proposal, with a managed competition component at its core; the Democratic Leadership Council's  Progressive Policy Institute (PPI) has also unveiled a comprehensive managed competition proposal, replete with tax credits for individuals and families; and the Conservative Democratic Forum (CDF), a group of influential conservative House Democrats led by Congressman Charles Stenholm of Texas, also favors the approach. Perhaps the chief health policy expert among conservative Democrats  in the House, Congressman Jim Cooper of Tennessee has introduced a bill (H.R. 5936) which embodies the main ingredients of the managed competition agenda. Furthermore, a growing number of business, insurance, and professional medical  organizations are endorsing the concept.  

N366/Newsday, March 22, 1993, NEWS; Pg. 15 , HEADLINE: Multiple Voices for Single Payer; Growing demand for national health care \\VT 93-94
	 The Congressional Budget Office, meanwhile, has said there would be no savings under managed competition for the first five years, at least. "There's a concern that these industries have never competed very well anyway, and so you'd have to make sure there's no incentive for collusion or anything like that," said Gene Kimmelman, president of the Consumer Federation of America. "It's really very hard to squeeze out excess costs; they're just generally very difficult to police." 

N367/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Additionally, managed competition would do nothing to attack the source of the greatest waste in our current health care system, namely the bureaucracy required by our system of multiple insurers.  

N368/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Nowhere in the world is there a working model of "managed competition." It has never been tried. However, evidence suggests the strategy will not hold down costs. The past decade has seen enormous growth of H.M.O.'s and of  managed-care programs, at the same time that health costs have risen at record  rates.  

N369/MODERN HEALTHCARE, February 8, 1993, "Critics attack CBO's reform assessments," p. 22 \\VT-MDSCongress' chief accountant last week threw some cold water on the managed-competition portion of President Clinton's healthcare reform plan, saying it probably wouldn't save any money.'N370/MODERN HEALTHCARE, February 8, 1993, "Critics attack CBO's reform
assessments," p. 22\\VT-MDS 
	The assertions were made during a hearing on healthcare reform before the House Ways and Means health subcommittee. Robert Reischauer, director of the Congressional Budget Office, told the panel a managed-competition reform scheme that lacks price controls won't' significantly reduce healthcare inflation.
N371/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 Unfortunately, there's not the slightest evidence that the sacrifices entailed by managed competition will pay off in lowered costs. Managed competition has never been tried, anywhere in the world. But managed care, represented by HMOs, PPOs and other ghostly amalgams of insurance plus actual care, has been abundantly tested right here in the U.S. -- and found ineffective at curbing health-care costs. 

N372/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Reischauer speculated that in the long run expenditures "would gradually slow" as more consumers choose hmos, but other experts doubt even the long-term benefits of managed competition. Brookings Institution's Henry Aaron dismisses Enthoven and Cooper's claims of cost savings as "expressions of faith, not experience." As Aaron notes, the experience of California's Public Employees' Retirement System (Calpers)--thought to be the closest approximation of managed competition--is not reassuring. Calpers buys health insurance for 900,000 state and local employees. Like one of Enthoven's hipcs, it offers its members insurance from nineteen hmos and from two preferred provider organizations (ppos) of fee-for-service physicians. It annually bargains with providers to ensure the lowest rates. And there is a financial incentive for Calpers members to select hmos, since they require less out-of-pocket expenses. 

N373/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 Consumers groups and those who work with the poor are especially wary of managed competition. Will it offer consumer choice and quality care for those only able to afford the minimum benefits? Will the higher-quality health plans be inaccessible to the poor because they are located far from poor neighborhoods, do not provide translators or other services, or otherwise shun the business of poor people? 

N374/Judi Hasson, USA TODAY May 14, 1993, Friday, Pg. 4A HEADLINE: Study says managed competition will hurt \\VT-MDS
Rep. Pete Stark, D-Calif., released a study by the Congressional Budget Office that found such a system, called "managed competition," could result in less choice of doctors and fewer medical services for consumers.

N375/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Problem #3: Limiting plans to standard packages reduces consumer choice and innovation, and will lead to intense lobbying by specialty groups. One concern expressed by many advocates of managed competition is that if rival plans can compete directly for customers, "cherry-picking" will occurr. This means some plans will offer low-cost basic services aimed at healthy individuals, or give healthy individuals a discount to get their business, leaving less healthy families in increasingly expensive plans with more services. A related concern is that families would sign up for a basic plan until they want extensive elective treatment, and then switch temporarily to a more elaborate plan. This "adverse selection" problem exists to a degree within the FEHBP, where each plan must charge all employees and retirees the same premium. 

N376/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Advocates of managed competition would force most patients into huge health  maintenance organizations run by insurance giants. Anyone who wants better care than the "minimum benefit package" would face steep financial penalties. Many who now have first-rate insurance plans would suddenly find themselves forced into cut-rate-type H.M.O.'s. 

N377/MICHAEL R. McGARVEY, health benefits planner, The San Francisco Chronicle , NOVEMBER 11, 1992, Pg. A21; HEADLINE: Solution to Health Care: Keep It Simple \\VT 93-94
	 The health-care debate has produced some interesting ideas. The ''Jackson Hole'' plan for ''managed competition'' is a compelling notion that captured the imagination of both serious presidential candidates. It's probably something like what U.S. health care will look like in 15 years. But for now, its basic building blocks -- effective managed care organizations -- have a significant presence in only a few parts of the country and are still viewed with suspicion by many patients and physicians. The administrative structures required to manage the approach are complex and will be a long time coming. And, most significantly, for all its surface appeal, it doesn't provide for all the uninsured. 

N378/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 Critics say that managed competition is absurdly complex, setting up an elaborate structure with the chief purpose of preserving the health insurance industry. They question whether there will any cost savings. They point out that managed competition has never been tried--here or elsewhere--while many other countries have well-functioning health care systems that could serve as models. 

N379/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] So we do not think that managed competition in any of  the forms that have been discussed are a very good idea, because what they do is they write in the wasters. They essentially say  if you believe that waste at the tune of $ 100 billion is the characteristic of this system here, as opposed to Canada,  managed competition writes the waste in because it essentially says we're going to keep including the health insurance industry and its new spinoffs, managed care companies. Many of the  insurance companies have bought up delivery mechanisms, for-  profit HMOs. All of these people are going to be written in and  somehow, magically, we're going to save money. 

N380/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  If you consider the current level of regulation, bureaucracy, and administration and all of their attendant costs -- on doctors and patients alike -- to be a serious problem in our health care system, then managed competition  is not likely to relieve that problem. Rather, it likely to aggravate it. As  Professor Enthoven himself has said, "Managed competition is not deregulation.  It is new rules, not no rules." n6 He is right about that. And the new rule-making infrastructure, depending upon which incarnation of managed competition you are talking about, ranges anywhere from the merely big to the gargantuan. 

N381/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  Having said that, I must tell you that we have grave misgivings. These misgivings do not center on the sincerity of the managed competition advocates  of market-oriented reform. It is not so much about where they want to take us, but rather where we are likely to end up: in a government controlled, even more heavily regulated health care system, in which market forces not only are  frustrated, but where costs, for a variety of reasons, are also likely to continue to increase. We fear that this effort will result in a health care system in which the net role of government is not less, but even more. 

N382/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 But managed competition seems to be designed for yet another patient, the private insurers. The insurance industry has been languishing because demand for its product keeps shrinking as prices shoot through the roof, and whimpering because a majority of Americans -- the ones who favor a single, public-sector insurer -- would just as soon see it in hospice care. 

N383/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	 [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] Doctors are going to be able to make much less money. Hospitals  are going to be able to spend much less money. There are some slight possibilities there, but the biggest source of waste is going to basically be left untouched, because the administrative bureaucracy that we now have is going to be increased, not decreased by the addition of yet another layer, the people who negotiate between the employers and the employees, and the insurance companies. 

N384/Newsday, March 22, 1993, NEWS; Pg. 15 , HEADLINE: Multiple Voices for Single Payer; Growing demand for national health care \\VT 93-94
	 A big one is the insurance companies. Under managed competition, while only the largest companies would likely survive, their role still would be prominent. They would compete for the business of health care consumers, who would be organized into large purchasing cooperatives. These cooperatives would shop and bargain for the best quality health plans at the lowest price. Nichols and other single payers advocates argue that this extra administrative layer is unnecessary, that private insurance companies are not as efficient as government, and would actually end up micromanaging patients and harassing doctors. 

N385/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 Dreaming of universal, comprehensive health insurance, Americans are about to wake up to a byzantine new arrangement called "managed competition." More than 60% of the public tell pollsters they want a Canadian-style system of national health insurance, which would make health care, quite simply, a right. But managed competition, which Bill Clinton is on record as favoring, may more nearly resemble an amputation of the limited health rights most Americans already have. Even its boosters are expecting the public to warm to managed competition with the enthusiasm usually reserved for root-canal work. 

N386/RATE CONTROLS: HEALTHCARE TRENDS & DEVELOPMENTS, April 15, 1993, "Washington issues," p.4\\VT-MDS 	Melvin Konner, M.D., in an opinion published in Newsweek about the representation of insurance and industry on the Health Reform task force. "The people Mrs. Clinton is consulting most actively are the same people other countries have simply kicked out of health care-with excellent results .Managed competition is a Bard-Aid. America urgently needs a more sensible, serious and informed intervention--not the minor tinkering of managed competition that leaves the greatest inequities and waste of our present system virtually intact."N387/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Calpers's experience suggests that managed competition, if allowed to operate on normal market principles, will not lead to dramatic cost reductions. Costs begin to decelerate only when the government intervenes to impose severe budgetary restraints. But in the process, the quality of services may decline. 

N388/The Economist, February 27, 1993, Pg. 30, HEADLINE: Health care; A dose of the HIPCs \VT 93-94
  Critics say that such controls [managed competition] would distort desirable competition and could raise the spectre of rationing. That may be true in fee-for-service medicine,  as the price and volume controls imposed by Medicare, the federal programme for the old, have shown. But the Starr-Zelman scheme would cap not the prices of individual plans but the rates of contribution demanded of employer and employee, leaving competing managed-care providers free to set their own terms. There would still be some rationing -- there has to be whenever cash limits are reconciled with limitless possible demands -- but less waste means less rationing, and managed care is probably less wasteful than fee-for-service.  

N389/Sandy Lutz Modern Healthcare March 22, 1993 Pg. 16 HEADLINE: Reform may require physician incentives \\VT-MDS
Some critics have argued that a system of managed competition wouldn't succeed in rural areas. Under managed competition, networks of providers would compete to offer a standard national benefits package at the lowest cost. Critics contend there aren't enough physicians and hospitals in rural areas to compete on the basis of price.
N390/Sandy Lutz Modern Healthcare March 22, 1993 Pg. 16 HEADLINE: Reform may require physician incentives \\VT-MDS
The government may have to provide financial incentives to rural physicians to make "managed competition" work in rural areas, said a newly revised report from the Jackson Hole Group.
N391/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  WOLFE [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] : One other comment on that, which is if you ask  a bunch of people do you care who your doctor is, a large  proportion, particularly those who have had a medical problem and are going to the doctor, will say yes; if you ask the same group of people, do you care who your insurer is, most of them will say no. And it's interesting that managed competition doesn't disrupt the insurance industry, but disrupts the doctor- patient relationship, whereas in Canada patients are free to  choose any doctor and any hospital they want to go to, an  increasing number of Americans are being separated from their physicians as a result of the games being played by these  managed health care and managed competition plans. 

N392/DAVID HIMMELSTEIN, M.D., associate professor of medicine at Harvard Medical School, The New York Times, December 10, 1992, Section A; Page 26; HEADLINE: 'Managed Competition' Is Not Healthy Answer \\VT 93-94
	  Stripped to its essence, managed competition would complete the  transformation of American medicine from one-on-one doctor-patient relationships to a medical system controlled by enormous, faceless corporate entities. It  would establish a highly bureaucratic health care system that would deprive  patients of their ability to choose doctors and hospitals. 

N393/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Problem #4: Most managed competition proposals do not sufficiently reform the tax treatment of health costs. Today's tax treatment of health care costs discourages sensible choices by consumers. By limiting full tax relief to company-sponsored health plans, the tax code encourages gold-plated "company-paid" plans while penalizing any employee who would prefer a leaner plan offered outside his company. By providing relief only for premiums, the code encourages over-insurance, with employees routinely "insuring" themselves against such things as $ 5 prescriptions and routine dental care just to receive a tax break. The result is more costly insurance forms and little incentive for families to shop wisely for even the most basic medical items. 

N394/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 The managed competition proposals generally do not adequately address the need for tax reform. Clinton has endorsed the idea of limiting the degree to which companies can deduct the cost of health care plans. The CDF bill would do nothing to change the tax treatment for employees, but it would introduce a tax penalty benefits, yet leave well-paid employees with large tax breaks and all employees with the incentive to press for expensive company-sponsored plans while resisting reasonable attempts by firms to make workers more attentive to costs by paying more out-of-pocket for their coverage. 

N395The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] Certainly we do not believe the answer is the New York Times' favorite phrase, managed competition. It should be known  that the person who has written now somewhere around two dozen editorials in the New York Times is a former student of Elaine Enthoven, the Harvard economist who believes that in the medicine area, in the health area, the marketplace will solve all the problems. 

N396/FAZLUR RAHMAN, practicing cancer specialist in San Angelo, Tex, April 18,
1993; The New York Times, "Viewpoints; Let's Hear It for Low-Tech Medicine,"
Section 3; Page 11 \\VT-AGL
.. * Finally, the Health Care Task Force must include practicing professionals 'physicians, administrators and technologists. We should not be unduly swayed by the intellectual prowess of the "Jackson Hole group," the leading proponents of "managed competition." President Clinton accepted the basic blueprint of the group .during last year's campaign. But in truth, the group is dominated by academics and insurance executives. If the Clintons rely heavily on individuals and organizations that are more interested in furthering their own agenda, the reform will fail.N397/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * The relationship between the spread of managed care and utilization review--which now cover an estimated 95% of all those whose health benefits are employment-related--and the growing numbers of uninsured and underinsured people bears further investigation beyond the resources available for the current study. While the relationship may not prove to be causal, the association of these factors over time is notable. (This observation comes from "Tension, Compression, and Shear: Directions, Stresses, and Outcomes of Health Care Cost Control," by R.G. Evans, Journal of Health Politics, Policy, and Law, Spring 1990.) 

N398/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 But now that companies have been using managed care for several years, many are finding the savings elusive. In fact, a recent survey of more than 2,400 employers by A. Foster Higgins & Co., a Princeton, N.J.-based benefits consultant, found that nearly three-quarters offered some form of managed care, but many found those programs as expensive or more expensive than traditional medical insurance. Others can't figure out whether they are saving money or not. "It doesn't seem to have been the answer, as it was promised to be, does it?" said Patsy Clemons, corporate benefits administrator at Baker Hughes. 

N399/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	Q: What if we expanded managed care and used the savings on waste and unnecessary care to expand access? 
	A: [Employee Benefit Research Institute] Let's assume that the companies that are doing aggressive managed care now are getting at some of that waste and getting their spending growth rates down. But even the lower rates are still running higher than general inflation. And in the practice of medicine, is it the fourth test that was wasteful, or the second test? Where the fifth test provided the answer but the first four didn't, are the first four wasteful, or are they necessary to get to the fifth test? One man's waste is another person's necessity. 

N400/Health Line, October 21, 1992, HEADLINE: MANAGED CARE: DEBATING ITS EFFECTIVENESS Nexis \\VT 93-94
	 THE DOWNSIDE: Harvard's Dr. David Himmelstein, a founder of Physicians for a Nat'l Health Program: "What this plan really is, is a way to force Americans into cut-rate HMOs chosen for them ... by their employer and run by an insurance company. It's a way to try and save money by 'managing care' and what that really means is adding bureaucrats to the incredible number of bureaucrats we already have in the system. ... In contrast, a national health insurance program similar to Canada's or other nations' can clearly provide complete coverage, control costs and give people the free choice of any doctor or hospital in the country. This plan takes away your choice, keeps the insurance companies in the middle of the health care system and we don't think it can even control costs." 

N401/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 "Even the best companies, the ones that have done everything right," such as Southern California Edison, tell Congress that their costs are still rising at unacceptable rates, said Sen. John D. Rockefeller IV (D-W.Va.). 

N402/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 Beyond that, the HIPCs and insurance companies will be doing their best to herd us all into "managed care" plans featuring a limited choice of physicians and strong financial incentives against anything that could be regarded as overutilization. Never mind that utilization has remained constant for the past 10 years, while costs have soared, and that Americans are actually less likely to use doctors and hospitals than citizens of other industrialized nations. 

N403/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 Officials at several companies said they had seen costs returning to the same curve as before, but having implemented managed care over the objections, or at least reservations, of their workers, these companies did not wish to be quoted by name on the issue. "We are still going to go off the edge of the earth" on costs, said one. "It's just going to be a few years later." 

N404/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 "The bottom line from what I see," said Kenneth E. Thorpe of the University of North Carolina School of Public Health, is that, depending on how sophisticated the employer is in selecting a plan and how expensive the previous plan was, companies realize savings that range "from zero to maybe 10 to 15 percent." "But these are generally not continuing savings," he added. The company is usually "not ratcheting down" its costs each year. 

N405/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 With managed care, many companies are "getting a one-time lowering of costs but are not really [dealing with] the forces that keep driving those costs up," said Kenneth Sperling, a health care consultant with Hewitt Associates, a benefits consulting firm based in Lincolnshire, Ill. 

N406/JAMES M. BURCKE, staffwriter, Business Insurance, March 26, 1993, Pg. 16, HEADLINE: Timetable for change; Expect Congress to pass significant reform by 1994 \\VT 93-94
	 But, even some of those who answered ''yes'' had their reservations. Ken Feltman, executive director of the Employers Council of Flexible Compensation, a Washington lobbying group, remarked that managed care's ''effectiveness is diminishing with its growth.'' And while North Carolina Insurance Commissioner Jim Long said managed care is holding down cost increases, he added: ''But not as much as originally thought.'' 

N407/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 "The good news is managed care is working. The bad news is why it's working," said Sperling. "Most of the why is [that firms are getting] discounts with providers, and discounts can only be a short-term solution. Once everybody has discount," the advantage disappears. 

N408/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 78 \\VT-JHHManaged care programs are not likely as now conceived to cope with the full scope of the economic problem, a problem generated in great part by a system badly ridden with internal contradictions. It is hard to fault the judgment of the distinguished economist Eli Ginzberg in his conclusion, "Until we approach the upper limit' of acceptable health care expenditures... cost containment is likely to remain the elusive hare that the hounds pursue but never overtake"; or to take issue with Dr. William B. Schwartz in his even starker conclusion that cost containment, at its best, can provide only temporary relief to cost increase.
N409/CAROL GENTRY, staffwriter, St. Petersburg Times, March 13, 1993, Pg. 1A , HEADLINE: 'We will have to make some very hard decisions' \\VT 93-94
	 Some doctors raised warning flags against managed-care companies, saying they have a vested interest in scrimping on care. "They have pressured me to take care of patients in a substandard way," Dr. Cornelius Turalba of Manatee County said. "We need to decide that our goal is to serve the patient and not our pockets." 

N410/Health Line, October 22, 1992 , HEADLINE: PRESCRIPTION DRUGS: THEIR DRUGS ARE CHEAPER, EH? Nexis \\VT 93-94
	 However, drug manufacturers disagree with the findings, saying GAO did not account for Medicaid rebates and discount negotiations between HMOs and drug companies. Pharmaceutical Manufacturers Association Pres. Gerald Mossinghof: "I think if you overlaid the Medicaid rebate and other discounts, you'd determine that half the drugs cost more and half cost less." John Skule of American Home Products Corp., the parent co. of Wyeth-Ayerst: "There's no question that there's a difference between Canadian and U.S. prices. But the issue is the data presented by the GAO are more than flawed; they're exaggerated" (Stout, 10-22). 

N411/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 Second, a more prevalent source of consumer and provider concern [WITH MANAGED CARE] was the limitation of benefits for the treatment of psychiatric illness, emotional disorder or distress, and substance abuse. Dissatisfied enrollees and providers complained that a "benefits backlash" against the surge of costs that followed the inclusion of mental health and substance abuse service in benefits plans prevented those with legitimate needs for continued treatment from accessing that treatment. (See the box on pages 46-47 for a discussion of the state of the art in mental health.) 

N412/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * Managed care shares with other health insurance systems the failure to address in adequate fashion the problems of catastrophic illness. In addition, the lack of benefit portability for enrollees with preexisting illnesses or conditions may induce workers to remain in jobs they do not want to the detriment of their own potential and to organizational productivity. 

N413/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * It should not be assumed that the sole objective of managed care, with its focus on increasing cost effectiveness of health care, is the containment of overall health-care costs. Equally viable objectives may include increasing the share of wealth and power of the industry in an ever-increasing cost-escalation environment, and-or the shifting of costs and risks to employers, enrollees, and the public sector through termination or transfer of the coverage of cost-burdensome risk pools and individuals. (This observation comes from the Medical Society of Virginia Review Organization.) 

N414/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * A frequently discussed unintended consequence of the current situation is the possibility of reimbursement mechanisms creating incentives for withholding care. Managed care often, for example, shifts some financial risk for covering health care to providers through such limitations as capitations or as potential income collected in risk pools. Shifted financial risk is intended to prevent unnecessary care. The same incentives, however, could prevent appropriate care in some cases. There is, however, no documented evidence that this type of unintended consequence occurs with any detectable frequency. 

N415/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Kevin E. Flint, Bausch & Lomb Inc., director of benefits finance: At Bausch & Lomb, we have found that employees like the ability to choose doctors and providers at will. We have also listened to other employers voice their employees' concerns as managed care seeks to limit employees' choice of providers and treatments. I do not believe that Americans will readily accept health care rationing if they do not readily accept health care choices under managed care. 

N416/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 Growing numbers of doctors would buy into that, but not the health insurance industry or the medical conglomerates such as Humana, whose very existence depends on diverting dollars from patient care to bureaucracy. When the New York Times isn't bashing Canada, it is chanting the mantra of "managed care" as the key to health care reform, U.S. style. If managed care simply meant a family doctor for everyone, fine. But managed care also can mean that someone whose primary obligation is to the stockholders' profits will be picking and supervising your doctor for you. It's socialized medicine without the socialism. 

N417/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * A great deal of the concern about "unintended effects" came from providers who are frustrated by the "hassle factor" of managed care and utilization management. Hospitals and large group practices must often deal with scores of payers, each with idiosyncratic review criteria that insurers refuse to disclose. At the most basic level, the intermediaries employed by providers to secure appropriate benefits must cope with hundreds of unique claim forms. 

N418/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * Managed-care systems have not fulfilled their potential to promote and support innovative, cost-effective service delivery. Insurers who rely on licensing systems as a basis for credentialing providers and to delineate systems inhibit innovation in allocation of tasks within the health-care workforce. (This observation is from "Breaking American Health Policy Gridlock," by Uwe E. Reinhardt, Health Affairs, Summer 199 1.) 

N419/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * Placing the liability for procedural compliance with patients (i.e., for precertification or admission notification) may inappropriately match responsibility and behavioral expectations. Unless they are informed of the requirement by their physicians, patients may not be aware of their responsibility despite education efforts by employers and insurers. Expecting compliance behaviors from emotionally and physically stressed people may be inappropriate. 

N420/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: HMOS, Online America, Better Health and Medical Forum, Transmitted: 93-03-16 17:36:56 EST \\VT 93-94
	 Their disadvantages may include: 1. Limited freedom of choice to select health care providers, including physicians. Selection is limited to only those physicians or health care professionals who have contracted with the HMO for services. 2. Limited freedom of choice to select a hospital or inpatient facility, in the event that inpatient care is needed. 3. Possibly limited mental health services. 4. Possibly impersonal delivery of services. 5. Possibly less convenient locations of clinics or facilities, or physicians' offices. 6. Often, longer waiting times for appointments. 7. Possibly inappropriate care because of financial incentives to minimize tests and treatments. 

N421/ ROBERT KAPLAN, Prof. of Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, p.53-4 \\VT-ADPL
Several other problems suggest that HMOs will not provide the ultimate solution. First, HMOs are not attractive to everyone because they limit consumer choice. HMOs also differ considerably in the contractual agreements they offer to providers. The incentive structure in HMOs has recently become the focus of some very interesting investigations. For example, Hillman (1990) compared HMOs that offered different financial incentives for their providers. Physicians who are salaried and who do not receive extra income from hospitalizing their patients 'tend to send their patients to the hospital less often. There have also been studies of situations in which primary-care physicians have a fixed sum that can be used to pay for patient referrals and there is a financial disincentive for physicians to overexpend the money. Under these circumstances, fewer patients are referred to specialists or for special evaluative tests.N422/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 77 \\VT-JHH
The hopes vested in the HMO movement show a similar lack of insight into the ways things work. It was assumed that HMOs would provide self-contained care systems, where the costs could well be managed by internal staff and technological discipline. As it happens, however, the same attitudes that exist in the larger society are readily brought into the HMO system: expensive physician and patient choices, high technological expectations, and bureaucratic inefficiencies. In order to gain and keep patients, moreover, HMOs are very often forced to compete with each other by offering superior service, a practice that increases costs. The many HMOs in financial difficulty, the general slowing of the growth of HMOs, the dissatisfaction with the way many are managed, and the quality of care they provide have all served to dampen the early enthusiasm for their cost containing potential.

N423/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 Today there are some 550 organizations that have adopted the HMO label. Some have been formed by hospitals, some by physician groups, some by entrepreneurs. They still provide health care for their members for a fixed monthly premium. But they range from the restrictive arrangements found in traditional prepaid group plans to loose confederations of doctors whose practices look, feel, and smell like old-fashioned fee-for-service medicine. 

N424/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 Besides the myriad HMOs, a number of look-alikes have appeared that seem like HMOs but often lack the health-care-management features of the real thing. We discuss those plans in the report about "PPOs, EPOs, Etc. THE NEW BREEDS OF MANAGED CARE". 

N425/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 Out in Texas, however, a funny thing is happening with Baker Hughes Corp.'s managed care program. Costs for employees in the Houston area using health maintenance organizations (HMOs), usually regarded as the most intense form of managed care, are higher than for those in the company's traditional medical insurance plan. Currently, about the only benefit the company derives from offering HMOs in Houston is that it provides employees a choice that some of them prefer. 

N426/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 But within a health care system still dominated by fee-for- service medicine and less integrated forms of managed care, these savings often went unrealized. With little incentive to hold down costs, hmos "shadow-priced" insurance companies, charging only slightly less than their competitors. Enthoven thought he could encourage a trend toward cost-conscious hmos and away from fee-for- service medicine by injecting price competition into the purchase of health care premiums. He proposed limiting employers' tax deduction on health insurance to the lowest-cost plan and encouraging small businesses and uninsured individuals to band together in health insurance purchasing cooperatives (hipcs, pronounced "hippicks") to purchase insurance on the best terms and at the lowest cost. Enthoven reasoned that only the most efficient provider-insurance companies could survive such a reorganized health care system. 

N427/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 If quality of care is difficult to measure, quality of service is not. Delays in getting through on the telephone, waits for appointments or in doctors' offices, the doctor's bedside manner, and the plan's responsiveness to questions and complaints all affect a member's happiness with an HMO. Generally, the top-rated HMOs scored well on those dimensions, and the ones at the bottom fared relatively poorly. Overall, nearly half of our readers waited at least one week to get an appointment for nonemergency care. But at HMOs rated above average, less than 25 percent experienced such waits. 

N428/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 Some HMOs point to their consumer-satisfaction surveys, which invariably show that members are happy with the plan and, by implication, with the quality of care they received. But what a member thinks is high-quality care may not be that at all. When HMOs themselves have seriously investigated quality, they've found it wanting. 

N429/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 What instead passes for quality assurance in many HMOs are chart reviews in which the HMO determines whether the chart is legible and notes if a doctor has told patients to stop smoking or has checked their blood pressure. But simply totaling the number of doctors' offices that checked patients for hypertension hardly addresses how well doctors treated patients with the disease. 

N430/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 Ask any HMO or managed-care outfit about the quality of care it provides, and its answer will probably focus on how it chooses its doctors or what their offices look like, rather than on whether their doctors practice clinically appropriate medicine. Most plans don't have scientific measures for determining the quality of health care for various conditions. 

N431/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 In the area of preventive care, many HMOs have yet to fulfill their mission. Consider immunizations, for example. Immunization rates for children have been falling across the country, leaving children at risk for such easily preventable diseases as measles and diphtheria. HMOs could lead the medical community by making sure that all their young members have been immunized, but they haven't done so. Although immunizations are free to HMO members, and HMOs could easily remind members when it's time to come in for shots, immunization rates at HMOs range only from 60 to 85 percent. 

N432/ROBERT KAPLAN, Prof. Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, P.53 \\VT-ADPL 
Health maintenance organizations provide all care for patients based on a flat fee. HMOs have been of great interest because the financial incentives are the reverse of those in traditional fee-for-service medicine In HMOs there is an incentive to provide less care. The exception is when avoidance of care results in a preventable complication or a serious illness that is more expensive for the program. • . . .
N433/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 What you think is an emergency may not be the same as your HMO's definition of an emergency. One-fifth of our readers who had emergencies and were seen by non-HMO doctors said the plan covered only part of the bill. About 10 percent received no payment at all. 

N434/Consumer Reports, August, 1992, Pg. 519, HEADLINE: HEALTH CARE IN CRISIS, ARE HMOs THE ANSWER? \\VT 93-94
	 We also found that members in HMOs and those with traditional insurance were equally satisfied with the way medical personnel explained diagnoses and treatments, their willingness to listen to questions, the times when doctors and labs were available for appointments, and the thoroughness of exams. 

N435Jerry Geisel, staffwriter, Business Insurance, December 28, 1992, Pg. 15, HEADLINE: The crisis of the uninsured spotlights health system ills; Partisan battles, special interests are obstacles to consensus \\VT 93-94
	 Play or pay ''reduces choice, '' she [Secretary of Labor Lynn Martin] said. ''It is a health plan managed by  politicians and it means fewer jobs. Play or pay is no answer to our problems in health care.'' 

N436/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p.23 \\VT-JHH 
Though hardly equitable--the tax benefit was of no value to the unemployed or to people whose employers did not contribute to the premium cost and of greatest value to those with higher incomes and in the highest marginal tax brackets--health insurance coverage did spread.N437/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Enthoven and Kronick [n1] have proposed mandatory employer health coverage of full-time workers, continuation of Medicare and Medicaid, and federal incentives for states to act as "public sponsors" of private insurance plans for those individuals who are not otherwise covered. Their plan emphasizes choice by the consumer of managed-care plans that are competitive on the basis of cost and service. It is not immediately evident that their "public sponsor" program, in concert with the present Medicare and Medicaid programs, would be able to achieve universal access to health care. 

N438/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  WOLFE [DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] : The lowest is Hawaii. Ironically, Hawaii has been touted as the model for the country in terms of the play or pay kind of system, and yet one out of 14 people in Hawaii are uninsured.  

N439/Business Insurance, January 20, 1992, Pg. 8 HEADLINE: 'Play or pay' doesn't pay \\VT 93-94
	A 7% tax would not -- as play-or-pay advocates often fail to note -- cover the government's real cost to provide coverage to the uninsured, according to the study. As a result, additional taxes would have to be raised. In short, as Ms. Martin says, a play-or-pay system does become national health insurance: tax-financed and government-provided health care. 

N440/Business Insurance, January 20, 1992, Pg. 8 HEADLINE: 'Play or pay' doesn't pay \\VT 93-94
	With a program of that size, a play-or-pay system would become, as Secretary of Labor Lynn Martin said, "backdoor national health insurance" with the government providing coverage to most Americans. 

N441/BNA PENSIONS & BENEFITS DAILY, Jan. 13, 1992, ADMINISTRATION OFFICIALS RELEASE STUDY CRITICIZING PLAY-OR-PAY REFORM PROPOSALS, Nexis \\VT 93-94
	The "big surprise" in the study is the large number of persons who would be enrolled in the public plan, Martin noted. According to the study, under a 9 percent payroll tax rate nearly 40 percent of non-elderly individuals would be enrolled in the public plan. Under a 7 percent payroll tax assumption, the study said, the percentage of those enrolled in the public plan would increase to 52 percent. "This would create a public plan approximately four times as large as Medicare--with all the red tape, bureaucracy, uncertainty, and delay of large government bureaucracies," Martin said. In addition, Martin asserted, almost 52 million people who now get their health care through an employer-sponsored plan would be forced into the government plan. 

N442/Business Insurance, January 20, 1992, Pg. 8 HEADLINE: 'Play or pay' doesn't pay \\VT 93-94
	Advocates of play or pay -- so named because employers would have to either "play" by offering a health care plan or pay new taxes to fund a government health plan for the uninsured -- say the approach builds on the current employment-based health care system. But, according to an Urban Institute study commissioned by the Labor Department (BI, Jan. 13), a play-or-pay system would begin to supplant, not supplement, coverage from employers. 

N443/Business Insurance, January 20, 1992, Pg. 8 HEADLINE: 'Play or pay' doesn't pay \\VT 93-94
	If employers were given a choice of offering a health care plan or paying a new 7% payroll tax, many employers would find it much less expensive to pay the tax rather than continue to offer a health care plan. With a 7% payroll tax -- the tax rate suggested by the Senate Democratic leadership in its health care reform legislation -- the number of employees and dependents covered by employer-sponsored plans would decline to 104.7 million from the current 142.2 million, the study says. So many employers would terminate coverage that the new public plan for the uninsured would be larger than all employer plans put together and would be four times larger than the current Medicare program. 

N444/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 * In states where basic-benefit plans are available, interest among small companies has been slow to develop. For example, after a year on the market, only 27 small companies, like Johnston's, have purchased basic health plans in Virginia. These plans cover a total of 200 people in a state where approximately 1 million residents are uninsured. 

N445Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Problem #2: Basing a family's choices of plan to those offered through an employer-based co-operative retains many of the drawbacks of today's employment-based system. Under the Clinton plan, the place of employment still would determine the range of health plans available to a family. Each company could calculate whether its bottom line would be better if it continued to provide insurance, or simply dumped its employees into a managed care network. This is the same dumping incentive for employers that would result in millions of Americans losing their current coverage under the major "play or pay" bills languishing in Congress. n18 

N447/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 The counter view is that providing a social benefit through the workplace is not the responsibility of business but rather the result of a decades-old strategy that may be inappropriate to continue. At the end of World War II, employers began contributing to the health insurance costs of their employees during a period of wage freezes. Opponents of employer-financed insurance wish to discontinue this practice. They point to the fact that many employers do not provide or subsidize other types of insurance besides health care for their employees. Furthermore, they believe compelling employer coverage will lead some companies to reduce the size of their work force or even to go out of business. They see the loss of jobs as a more serious social problem than the lack of health insurance by some working Americans. 

N446/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 However, the [pay or play] plan is challenged for its potentially costly requirements on employers who do not now offer coverage and the significant expansion in government coverage and regulation it would entail. 

N448/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Opponents of a play-or-pay scheme dislike the added complexity and administrative and financial burdens placed on businesses. Furthermore, play-or-pay leaves everyone not employed full-time in a separate government plan, such as Medicaid, which raises concerns about equity in benefits and payments to providers. This could lead to a larger, more formalized two-tiered health care system than exists today. 

N449/William A. Glaser, Best's Review -- Life-Health Insurance Edition, January, 1992 Pg. 16 HEADLINE: NHI: it's better than you think; National health insurance \\VT 93-94
	Apparently, the reformers think the only problem in American health insurance is the shortfall in coverage. In reality, American health insurance has many other fundamental problems, as indicated earlier, that would not be solved by such legislation. While each employer would be required to pay for his or her workers' benefits, employers could still force insurance carriers into cutthroat bidding for contracts. The legislation would not protect the carriers against employers' cutting prices in this manner, or against price hikes by hospitals and doctors. 

N450/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 And that, say critics of play-or-pay, is the system's inherent failing. Either the savings are so tempting that everyone jumps into the government plan, in which case it's just a single-payer system, or "it becomes an adversely selective program," as Weizmann charges. The theory is that employers with the highest costs -- say, Rust Belt manufacturers with aging workers and rich benefits -- would transfer to the government plan and cut their losses in the short run. But "those claims aren't suddenly cheaper," explains Dymowski. "Their experience goes into the pool, pushes the pool up, and over time the 6 or 8 percent tax will have a tendency to rise." 

N451/BNA PENSIONS & BENEFITS DAILY, Jan. 13, 1992, ADMINISTRATION OFFICIALS RELEASE STUDY CRITICIZING PLAY-OR-PAY REFORM PROPOSALS, Nexis \\VT 93-94
	Play-or-pay would be a "fatal step down the slippery slope toward nationalized medicine," Sullivan said. Proponents of this type of reform "have not looked hard enough at the true ramifications of such a plan," he said. 

N452/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Not even the best national health insurance program can succeed in assuring access to care at a reasonable, responsible expenditure level if health restructuring is limited to insurance enrollment, financing and payment. Medical education and training must be reformed. So also must the financing of medical education. Its high cost can lead to indebtedness and consequently cause students to choose lucrative specialties. 

N453/EDITORIAL .PROGRESSIVE MAGAZINE, 1990; "A healthy democracy," reprinted in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991 p.127 \\VT-MDS
But the Kennedy-Waxman approach and the voucher plan share some fatal flaws. Both would perpetuate--and intensify-every significant defect in the current health-delivery system, including the inexorable pressure for higher and higher costs. Both would preserve the present irrational system of fee-for-service medicine, and both would perpetuate the power and enhance the profit. s of the insurance industry.

N454/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 However, even many proponents of this approach recognize that significant tax credits (to people with incomes of up to 150% of the federal poverty standard in the Bush proposal) would leave insurance too expensive for millions of Americans. Further, while the proposals would promote managed care, greater administrative efficiencies, and changes in malpractice, analysts agree that they provide little hope of a major slowdown in escalating health care costs. [n8] 

N455/James P. Pinkerton, John Locke Foundation, Los Angeles Times, March 18, 1993, Part B; Page 7; HEADLINE: AN OFFER AMERICANS CAN'T REFUSE \\VT 93-94
	 My guess is that about 10 minutes after the President signs a bill, Americans will figure out how to "game" the new system. The cleverest doctors and lawyers in the country will match wits with bureaucrats. Guess who will win. For Americans who missed out on the opportunity to own a savings and loan, this will be that rare thing in life: a second chance to milk the government. 

N456/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 It's a shame that Big Business seems willing to put its commitment to free enterprise, i.e., the insurance industry, ahead of an obvious and effective solution. It would be worse than a shame -- a betrayal -- if the Clintons were to ignore public demand and go for a cumbersome, jerry-built plan designed to benefit the most parasitical element of the health-care system. 

N457/EDITORIAL, PROGRESSIVE MAGAZINE, 1990; "A healthy democracy," reprinted in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991 p.127 \\VT-MDS 
Those conservatives who remain committed to privatization despite the fiascoes of recent years are likely to push for a voucher system of some sort that would allow all citizens to buy health insurance through private insurers. The first problem with such a "solution"--as with similar schemes proposed for school reform--is that it would almost certainly be grossly underfunded, providing subsidies for the affluent but not enough to pay for decent coverage for the poor. And an immediate effect would be to compel workers to assume a greater portion of the costs of health insurance.
N458/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 A variation on the tax credit approach is to provide individuals with a voucher to purchase insurance. This solution is criticized as even more complex and difficult to administer. For example, many peoples' incomes vary sharply during the year because they are temporarily out of work, divorced, etc, and once-a-year certification for one's ability to purchase insurance would be inadequate. 

N459/ROBERT KAPLAN, Prof. Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, p.61 \\VT-ADPL
There are also some serious concerns about the Heritage Foundation proposal. For example, the proposed system would make the access problem worse. Despite credits for low-income individuals, it is highly likely that there will be great disparities in access. High-income individuals may be more likely to use their resources to purchase good quality health care even though they get a lesser tax credit. Low-income and less engaged individuals may not recognize that insurance is a wise investment and may not participate.N460/ROBERT KAPLAN, Prof. Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, p.61 \\VT-ADPL 
One of the major concerns with the Heritage Foundation proposal is that it will cause adverse selection. Well individuals or those without chronic illnesses will be able to purchase lower-cost insurance than those who have the misfortune of a chronic disease. The Heritage Foundation argues that there could be a cross-subsidy that allows those with high health care expenses to obtain a greater tax write-off. Yet the proposal provides little assurance to those unfortunate enough to be limited in income because of their illnesses. Another major problem is that the proposal does not provide for long-term care. Purchase of long-term care the Those with fewer resources insurance is left to the discretion of would be less likely to obtain this type
N461/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992; CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p. 168-9 \\VT-ADPL
Should the existing tax subsidy for employer-sponsored coverage . be eliminated? No. Elimination is argued for because it inequitably gives a subsidy to employed persons, but not to the unemployed (who may need it more), and because the higher one's tax bracket, the greater the subsidy. But elimination of the tax subsidy would lead to a greater inequity. Without the subsidy, many employers would drop insurance entirely, and the low-paid would be hurt the worst. Also, health coverage is part. of the bargained compensation in many large firms, yet its cash equivalent in take-home pay would most likely not immediately replace it. 
N462/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 The opponents of replacing Medicaid with tax credits say that, because Medicaid beneficiaries are disproportionately disabled and ill and have many concurrent social problems, they would be unlikely to find an equivalent policy to cover their current Medicaid benefits. Rather, they will end up with less-comprehensive benefits and coverage for the same amount now spent by Medicaid. 

N463/Business Insurance, January 18, 1993 Pg. 8, HEADLINE: Ending an unhealthy silence \\VT 93-94
 We are no fan of taxing health care benefits, because we believe that the administrative problems associated with calculating the tax would be significant. But pragmatically, we also recognize that a health care benefit tax appears inevitable as a revenue source to help fund coverage for low-income uninsured individuals. 

N464/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Opponents also point to lessons learned from other tax credit programs that have not been as easy to administer in practice as in theory, especially income-based programs. For example, some lower-income Americans might have to wait up to a year to be reimbursed through the tax system for their outlays for health insurance. 

N465/Elaine S. Povich, Chicago Tribune correspondent, Chicago Tribune, April 23, 1992, Pg. 20; HEADLINE: Free choice often no choice, Federal experience with health plans exposes problems \\VT 93-94
	 But the federal government's own experience with free choice in health insurance shows it has vast problems. The system that insures federal employees, from President Bush down to the lowliest clerk, is having so many difficulties with its free-choice system that those running the plan would like to scrap it. Many insurers, unable to justify the cost of staying in the program, have left. 

N466/Elaine S. Povich, Chicago Tribune correspondent, Chicago Tribune, April 23, 1992, Pg. 20; HEADLINE: Free choice often no choice, Federal experience with health plans exposes problems \\VT 93-94
	 But Curt Smith, associate director for retirement and insurance at the government's Office of Personnel Management, says there are so many problems with the federal employees insurance program that he would like to reverse course and eliminate individual choice. 

N467/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Despite the advantages of this [The Pepper Commission] proposal in terms of programs for health and long-term care, the authors believe that comparable results can be obtained in a more straightforward manner by the reform and restructuring of Medicaid and Medicare. In view of the additional costs that this program would add to the nation's health care budget, the plan does not appear to contain sufficiently rigorous cost containment strategies. 

N468/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 The Pepper Commission report offers a sound plan for universal access to health care through the replacement of Medicaid with a comprehensive public plan for the uninsured and a series of incentives for expanded health insurance coverage in the workplace that is similar to our proposal. [n4] A comprehensive approach in the commission's report designed to meet the increasing need for access to long-term care by all segments of society deserves high marks. In this plan, the financing of long-term care would be a shared responsibility of state and federal government and the individual. The commission's public insurance plan, when fully implemented, would cost $66.2 billion ($23.4 for full access to health care and $42.8 for access to long-term care) expressed in 1990 dollars. This estimate includes existing Medicaid dollars, new tax revenues, and payment from employers who choose not to provide private insurance. How the additional revenues required for the public health insurance program would be generated is not specified. 

N469/DENNIS L. BREO, Journal of the American Medical Association, August 28, 1991; 266: 1131-1133, TITLE: Sidney Wolfe, MD -- healing the system or just raising hell?\\VT 93-94
	 He [Sidney Wolfe, MD] dismisses out of hand the AMA proposal to provide universal access to health care by building on the strengths of the existing system as "not very progressive." Wolfe says that the AMA plan, known as "Health Access America," is "little more than expanded Medicaid," and "Medicaid amounts to nothing more than poor care for poor Americans." 

N470/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Health care and budget experts have raised real doubts about whether Enthoven and Cooper's pure market approach will hold down costs. According to Congressional Budget Office director Robert Reischauer, the enactment of Cooper's bill "would leave national health expenditures at approximately the same level they would reach otherwise." 

N471/Peter E. Scheer is editor and publisher of The Recorder, Legal Times, December 21, 1992, Pg. 17, HEADLINE: HEALTH INSURANCE: A RISKY BUSINESS \\VT 93-94
	 This thinking is a fine example of free-market analysis run amok. Fein is fixated on economic subsidies, which he regards as a disguised form of social welfare. Why should healthy people subsidize the care of unhealthy people in the central question underlying Fein's diatribe.  

N472/John Judis, staffwriter, The New Republic, March 29, 1993, Pg. 20, HEADLINE: Whose managed competition? The battle among the Clintonites \\VT 93-94
	 Eventually, many of these plans [Starr model], unable to compete on cost, would merge into hmos and other larger care networks; but in the short term, they would be likely to fight for survival by using bureaucratic review to discourage both necessary and unnecessary medical procedures. The sick could be inhibited from seeking treatment and doctors from providing it. Laments Washington internist Daniel Ein, "From the physician's standpoint, global budgets and managed care are the worst of all worlds." Starr's plan, in other words, could represent at least a short-term trade- off between curtailing costs and expanding coverage on the one hand and maintaining quality on the other hand. Americans who can immediately join a quality hmo will benefit, but those who have to depend on a preferred provider plan may wish that national health reform had never occurred. 

N473/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted, in THE CRISIS IN HEALTH CARE-THE REFERENCE SHELF, 1991 p.151 \\VT-MDS 
As to industry, unionized facilities such as Lee lacocca's Chrysler Corporation and many members of the National Association of Manufacturers have already indicated that they would welcome Canadian-style medicine with open arms. Why not? It l would allow them to foist onto the general taxpayer most of the cost of their present employee health plans.N473a/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 If Clinton cuts costs and maintains his commitment to universal coverage, then something is going to have to give. In the long run, that could be the quality of services. The public will have to accept limitations on choice, restricted access to technology and delays in nonessential care. Those are all forms of rationing. 

N474/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 Health care reform has to seek a balance between three objectives: cost, access and quality. They are not compatible. If any one objective gets too much emphasis, the other two will suffer. Tradeoffs must be made. 

N475/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: The control in a bureaucracy of socialized medicine, as I understand it, is in the hands of very few people and the average citizen has nothing to do with it. 

N476/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  In any case, the creation of a National Health Board with such broad powers  compromises the very market-oriented policy that proponents of managed competition seek to realize. Even in the stripped down version proposed by  conservative Democrats, this national health care board would constitute an  enormous concentration of power, serving as the command and control center of the $ 840 billion health care system. One doesn't have to be a conservative Republican or a Jeffersonian Democrat to be concerned about this. 

N477Knight-Ridder News Service, May 18, 1993, TITLE: Clinton says all US employers should provide health care coverage, Online America, Transmitted: 93-05-18 03:39:00 EDT \\VT 93-94
 "Everybody gets health care in this country, but its too late, 
 too expensive and often at the emergency room," Clinton said. The unpaid bills of the non-insured leads to higher costs for everyone else, he said. 

N478/Howard Dean, MD, Governor, State of Vermont, Journal of the American Medical Association, October 16, 1991; 266: 2080 TITLE: Caring for the Uninsured and Underinsured \\VT 93-94
	 Second, the major shortcoming of many plans (including that of the American Medical Association) is the lack of serious provision for cost containment. That also applies to the Pepper Commission and many of the other plans that rely on trying to patch together the present system to cover more individuals. The most sensible approach is Rashi Fein's, [n1] which contains all three of what I consider to be the essential elements of a universal health insurance program: all individuals must be covered, cost containment must be tough, and states must administer the program either directly or through the private insurance system. The federal bureaucracy is too inefficient and too large to make national health insurance work. 

COUNTERPLANS

STATE COUNTERPLAN
1. States can solve the medical crisis C1-3
2. Variations mean it will not be comprehensive C4
3. Competition: 
	a. if the federal government does not act, the states will C5-11
	b. If the states act, the federal government is less likely to act C11a
4. States are acting now C12-17
5. Specific state programs (models)
	a. Vermont C18-26
	b. Hawaii C27-32
	c. Washington C33-34
	d. Virginia C35
6. Implemented by 2000 C36
7. No federal changes required C37-38
8. States can choose from different options C39-41
9. Federal can support state action 
	a. Clinton supports C42
	b. Federal money to the states C43
	c. Use Medicaid model C44
10. State action uniquely increases federalism
	a. Insurance is a state power C45
	b. Medicine is a state power C46
	c. Coverage is a state issue C47
	d. Health is a state responsibility C48
	e. Each decrease in state sovereignty is bad C49
	f. Lower level of administration is better C50
11. States are better able to solve the medical crisis C51-54
12. States are better administrators C55-61
13. States are closer to the people C62-68
14. States can adapt to local needs and innovate C69-74
15. States can control costs C75-76
16. State programs will reduce disparities C77
17. State program better for hospitals C78
18. States may end fee for service medicine C79

AFFIRMATIVE RESPONSES TO NEGATIVE STATE COUNTERPLAN
1. Health coverage at the state level is a bad idea C80-81
2. State action of medical care will be counterproductive C82-83
3. State approaches are failing now C84-85
4. Need a national-federal approach C86-92
5. Will not increase access C93
6. Need to change federal laws in order for states to act C94-100
7. Competition: we can do both at the same time C101-104
8. There is too much of a crisis to use state experimentation now C105-106
9. Public wants a federal approach C107-109
10. States will underfund - Medicaid example C110
11. States would implement a fragmented approach C111
12. States act without planning C112
13. States fail at reform -- welfare example C113
14. State minimum coverage approaches are bad C114-117
15. Hawaii model is inappropriate C118-121

MARKET SYSTEM COUNTERPLAN
1. Market approach is the answer to the health care problem C122
2. Market approach is competitive with NHI
	a. Must choose between the two C123-124
	b. NHI is incompatible with a market approach C125, C130-131
	c. Net benefits: doing just the market would be better C126-128
	d. Right to health competes with the market approach C129
	e. Each increase in government action hurts the market C132-133, C146
3. Market is the best way to reach our health goals C134-135
4. Market approach would lower costs C136-138
5. Choice is the key to market success C139-140
6. Competition is the key to market success C141-142
7. Government action is what has hurt the way the market works in health C143-145
8. Profits can be good C147
9. Nations with NHI are moving towards a market approach C148
10. Private insurance is a superior method of administration C149-151
11. Doctors prefer the market approach C152
12. Specific plans for a market approach
	a. Heritage Foundation C153-154
	b. Voucher plan C155
	c. Federal Employee Health Benefit Program model C156
	d. Committee for Economic Development model C157
	e. Deregulation model C158-159
	f. Tax code changes C160-161
AFFIRMATIVE ANSWERS TO THE MARKET APPROACH
1. Do both: government and private action together C162-165
2. Market approach is counterproductive C166
3. Market approach to medicine is a vestige of the past C167
4. Market theory in health care is wrong C168
5. Must have a government role in medical care C169-171
6. The market is the reason why we are in our current mess C172-175
7. Health and medical care is not a market system, so market approaches are inappropriate C176-184
8. Market approach means decreased caring C185
9. Market system will open the doors for abuse and greed C186-188
10. Market approach will not increase access C189
11. Insurance companies are evil C190
12. Market approach hurts doctor patient relationship C191
13. Tax approaches are inappropriate C192-193

NON-COMPREHENSIVE, NON-UNIVERSAL COUNTERPLAN
1. No need to cover those who are covered now C194-195
2. No need for broad medical reform C196
3. Non-NHI approaches explained:
	a. Combinations C197-199
	b. Cover the uninsured with Medicaid expansion C200-204
	c. Education to improve health C205-213
	d. Just cover kids and moms C214-217
	e. Give votes to kids C218-220
	f. Publicity about medical successes can increase quality C221-222
	g. Limit coverage of tobacco, alcohol, and drug related illnesses C223
	h. Care guidelines C224 & 242
	i. Just cover populations at special risk C25
4. Incremental approach would be best C240-241

AFFIRMATIVE ANSWERS
1. Incremental approach fails C226-229
2. Need a universal approach C230-232
3. Without universality, a harmful two-tiered system will be created C233-235
4. Need universality to lower costs C236
5. Any program just for the poor will be underfunded C237-239

OTHER COUNTERPLAN APPROACHES
1. Study before any action C243-252
2. Enlist public participation before any action C253-266

C1/Reuters News Service, April 23, 1992, HEADLINE: U.S. GROUP SAYS PRIVATE HEALTH INSURANCE WASTEFUL, Nexis \\VT 93-94
	 The consumer group Citizen Action said Americans could save about $17 billion a year in health insurance costs if national health insurance replaced the 1,500 commercial health insurance companies. The study, Premiums Without Benefits, said that for every dollar these companies pay out in health claims they spend 37.2 cents on administration, marketing, commissions and overhead expenses. 

C2/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p.201 \\VT 93-94 There is much to commend a universal health insurance program with a single central enrollment mechanism. Nevertheless, the arguments for state enrollment appear stronger. If we choose to rely on the states to monitor their health delivery systems and to provide incentives for efficiency and cost control, they must have a financial stake in doing .so. It is administratively cumbersome to organize an insurance program that is federal and at the same time puts the states at financial risk. It is far simpler to require states that want to participate in the program (and receive financial assistance) to certify that all their residents are enrolled in an insurance program that meets defined federal standards. 
C3/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 206 \\VT-JHH
We must accept the fact that any system we would enact will be complicated. The program that I suggest would not be as simple in its enrollment patterns as a universal social insurance program, but it would be simpler and far better than a federally mandated system of enrollment.
C4/Julianne Malveaux, USA TODAY, April 3, 1992, Pg. 10A, HEADLINE: Insist on national reform \\VT 93-94
	 State variations in health services also would move us away from the more comprehensive goal of making health care and insurance available for every American. 

C5/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 The likely alternative to comprehensive reform of the health care system at the national level is a variety of local solutions introduced state by state. Widespread activity on health care issues is under way in most state governments and many proposals for health care reform are pending or are in the process of being enacted. One of the most comprehensive, UNYCare, has been proposed by the New York State Commissioner of Health. Individual state action on health care, however, may prove to be inefficient in both administrative and fiscal terms. From the point of effectiveness, the local approach may leave important gaps in access to care, and could present problems for nationally based corporate employers who seek uniform benefits and rates from insurance intermediaries and-or providers. 

C6/Lynn Wagner, Modern Healthcare, August 10, 1992, Pg. 2, HEADLINE: Rejection of Oregon plan appears to diminish chances for state reform initiatives \\VT 93-94
	 But some observers predicted that the decision against state experimentation ironically could have the unintended effect of intensifying the push for the kind of sweeping national healthcare reforms that President Bush opposes 

C7/USA TODAY, February 10, 1992, Pg. 11A HEADLINE: States aren't waiting for the feds \\VT 93-94
	Q: Do you think the states, rather than the federal government have to take the initiative on health care? 
	[Washington Gov. Booth Gardner] A: Yes, because it's a tremendous burden for the states in terms of the costs, keeping up with health care inflation. And, cynically, we could die waiting for the feds to act. 

C8/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 While Congress seems unwilling or unable to tackle America's continuing health care crisis, reform already is underway in several states. A variety of approaches are being proposed or enacted, ranging from "single payer" government insurance systems, to "play or pay" mandates on employers, to small group insurance market reform initiatives. In the unique federal order that characterizes America's political system, the states are thus fulfilling a traditional role as laboratories of democratic government. 

C9/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 While the federal government seems paralyzed at the prospect of trying to reform America's $ 800 billion dollar health care system, several states are beginning to experiment with promising alternatives to meet the pressing problems of rising health care costs and the growing number of the uninsured. 

C10/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 While Congress endlessly debates what to do about the 36 million uninsured Americans--the latest Census Bureau count--states are taking action and clearly are leading in forging a national reform agenda. "States don't see much movement on the federal level; meanwhile cost and access problems continue to get worse," says John Luehrs, director of health programs for the National Governors' Association. 

C11/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 The states should take the lead in fashioning an affordable, universal health care system because the federal government has demonstrated it cannot do the job itself, Vermont Gov. Howard Dean (D), said Oct. 14. 

C11a/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 More important, the IBM and AFL-CIO representatives doubted whether state-by-state reforms were even the right way to go, pointing out that they might dilute efforts to develop better and stronger national health insurance legislation. 

C12/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 In addition, 22 states--19 of them in 1991--passed more narrow bills to reform rating and renewability of coverage. And at least half of the states, according to HIAA estimates, expanded their Medicaid programs over the last two years to reduce the number of uninsured individuals. 

C13/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform \\VT- ACS
	 The states, meanwhile, are not waiting to see what happens in Congress. Virtually every state either has taken action on the problem or is considering legislation. According to the Health Insurance Association of America, 92 measures related to health care access were enacted in various states during 1991. And the HIAA, which lobbies to get the industry's imprint on these measures, reports that it worked on more than 700 such bills during this period. These access measures address issues like reform of the small-group market, guaranteed issue of health coverage, restrictions on insurers' rating and renewability practices, Medicaid expansion and high-risk pools, as well as plans for universal coverage. 

C14/Robert E. Moffit, Ph.D., Deputy Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, June 17, 1992, BACKGROUNDER; No. 902, NEXIS \\VT 93-94
	 While the focus of the debate over health care reform has been on federal policy, the states actually have been reforming health care within their own borders. n19 Major initiatives are underway in states ranging from Florida to Minnesota. Vermont and Maine have enacted significant insurance market reforms. Hawaii is already a model for employer mandates. And Oregon may prove to be America's first reat test of explicit government rationing of health care in the Medicaid program; providing treatment for patients with government-approved diseases and reimbursing doctors for government approved procedures, while withholding care and reimbursement for unapproved diseases or procedures. 

C15/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 "There is a feeling that [states] can't wait for Congress," says Luehrs [director of health programs for the National Governors' Association]. "They need to put together their own solutions. And No. 1 on everybody's list 

C16/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 Since 1974, Hawaii has required employers to provide employees with a comprehensive package of health insurance benefits. In 1988, Massachusetts approved a universal health-care law and while its complete implementation has been postponed, it is still on the law books and has begun some coverage for a previously uninsured 100,000 people. While Oregon's controversial ''rationing'' experiment has gotten wide public attention, it has been less well-recognized that this was only part of a state plan aimed at universal health insurance coverage in that state. 

C17/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 THERE IS a lot of talk about ''health care reform'' these days and most of it focuses on what the federal government might do, thanks to the arrival next week of Bill Clinton's administration. The irony is that some of the most interesting health-care reform developments already have been taking place on the state level and may produce important changes long before the Clinton administration and the Congress decide what it is they really want to do. At the present time, more than 22 states have either presented health-care reform legislation or are considering it. This is in addition to several states like New Jersey and Maryland, where some aspects of health-care reform have been in effect since the 1970s. 

C18/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 Vermont's health care reform bill passed earlier this year created a new state agency to develop proposals for a single-payer and a regulated multiple payer system for the 1994 Legislature to consider. The reform package also included a system for budgeting total health care spending in the state, insurance industry reforms, establishment of a health care purchasing pool for state and municipal employees, malpractice reform, and expansion of Medicaid coverage for children. 

C19/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Dean [Vermont Gov. Howard Dean (D)] prescribed a national, state-based health insurance system that would provide universal care and have cost containment features, but would be free of the type of micro-management now done by Medicare. Such a new system, in Vermont or nationally, would be marked by fewer specialists and fewer insurance companies, he said. Moreover, a more rational system must move away from compensating physicians on the number of procedures they do toward preventative care, he said. 

C20/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Dean was the keynote speaker at a one-day conference on financing health care sponsored by the Oregon Health Forum. He was a major force in the passage earlier this year of Vermont's innovative health care reform law that will ensure universal access to care to all state residents by October 1994 (19 BPR 833). [Vermont Gov. Howard Dean (D)] 

C21/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Vermont's health care reform law created a new state agency to develop proposals for a single-payer and a regulated multiple payer system for the 1994 Legislature to consider. The reform package also included a system for budgeting total health care spending in the state, insurance industry reforms, establishment of a health care purchasing pool for state and municipal employees, malpractice reform, and expansion of Medicaid coverage for children. 

C22/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Dean [Vermont Gov. Howard Dean (D)] said it is especially important for new health care systems to move away from paying providers for performing procedures and toward total health compensation. For example, physicians could be put on salary at hospitals or clinics, or they could be paid a fixed amount per patient through a managed care organization. In such ways physician pay would not be linked to the number of procedures done, he said. 

C23/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 Dean prescribed a national, state-based health insurance system that would feature universal care, cost containment, and be free of the type of micromanagement now done by Medicare. Such a new system, in Vermont or nationally, would be marked by fewer specialists and fewer insurance companies, he said. Moreover, a more rational system must move away from compensating physicians on the number of procedures they do toward preventative care, he said. [Vermont Gov. Howard Dean (D)] 

C24/USA TODAY, 23February 10, 1992, Pg. 11A HEADLINE: Greater state role pushed \\VT 93-94
	Q: What would you like to see happen on health care reform in Vermont? 
	A [Howard Dean, Governor of Vermont] : We've introduced a system which will gradually change over to either a multiple plan - that is, a small number of insurance companies - or a single- payer system. It will take a few years, but we think we'll get the legislation through this year to start. Initially, it calls for a health care authority, with most health care functions of state government in it - including a lot of heavy regulatory functions. With a large pool of people, the health care authority would negotiate to cover them with very strict cost controls. We imagine the pool growing substantially as private employers join it. Ultimately, that would lead to the state being able to negotiate with providers. It would be run by the state, but administered by people in the private insurance industry. 

C25/USA TODAY, 23February 10, 1992, Pg. 11A HEADLINE: Greater state role pushed \\VT 93-94
	Q: Will doctors in your state be willing to negotiate their fees? 
	A [Howard Dean, Governor of Vermont] : They are, provided two things: First, we get malpractice reform. Second, we get a waiver from Medicare, which proposes incredibly onerous bureaucratic restrictions. 

C26/USA TODAY, 23February 10, 1992, Pg. 11A HEADLINE: Greater state role pushed \\VT 93-94
	Q: What would persuade people to join this system? 
	A [Howard Dean, Governor of Vermont] : Because it is under much better control than in the private sector. Our cost increases would be substantially lower. For example, if you're a business, the chances are your cost increases are going up at a double-digit rate for the last 20 years. We think we can confine those cost rates to single digit. 

C27/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 Long before it became a hot-button issue in the rest of country, Hawaii was a laboratory for getting people health insurance coverage. The year was 1975. The issue was health costs. And Hawaii figured out an answer to a problem that has federal, state and local governments on the mainland still stumped. Under a state law passed that year, every employer in the state was required to provide health insurance to every person who works more than 19 hours a week, and the employer must pay at least half of the premiums. The unemployed are covered by a separate, state-funded plan. 

C28/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Hawaii's system has only recently gained national attention as the issue of health care reform has achieved prominence. While it is too soon to evaluate fully the more recent reforms undertaken in other states, it seems certain that federal legislators will be looking for models to emulate as they develop their own proposals. And those reforms may multiply because the federal debate is unlikely to produce results any time soon. One informed observer, Dr. C. Everett Koop, former U.S. surgeon general, has noted that even if the impossible were to occur-- if a national consensus on reform were to be reached quickly amid optimal economic conditions--it would take at least a decade to implement any real change at the federal level. 

C29/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 ''You are not seeing people missing immunizations,'' says Louise Iwaishi, a pediatrician at the Kapiolani Medical Center in Honolulu. ''We are seeing kids almost every two months ... and it's these kinds of visits that hopefully will prevent illness and accidents.'' 

C30/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 Although Hawaii has the highest cost of living in the United States, its health care costs are lower than any other state and below countries with much-admired health plans, such as Canada. The result: It has the lowest death rate from breast cancer because of early detection, one of the lowest infant mortality rates in the country and citizens far less likely to have to be hospitalized than residents of other states. 

C31/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 Today, 98% of the state's 1.2 million residents have health insurance, though some of the small businesses that must provide it say it drives up their costs. ''It's not weather, genetics or demographics,'' state health director John Lewin tells those who say the nation can't copy the plan. ''It's a health care system that works.'' 

C32/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 ''We were not too crazy about it,'' says Lois Faison, vice president of the Chamber of Commerce of Hawaii, which feared higher business costs. ''We don't like mandated benefits. However, it has worked out very well.'' 

C33/USA TODAY, February 10, 1992, Pg. 11A HEADLINE: States aren't waiting for the feds \\VT 93-94
	Q: How does it expand access to the system? 
	A [Washington Gov. Booth Gardner] : We plan to make our basic health care plan a larger, more available program for people who have no insurance, are underinsured or for smaller players who wish to buy into the state plan as opposed to providing their own insurance. 

C34/UNITED PRESS INTERNATIONAL, MAY 18, 1993, TITLE: FIRST LADY GIVES BLESSING TO WASHINGTON STATE'S UNIVERSAL HEALTH CARE PLAN, Online America, Transmitted: 93-05-18 06:59:00 EDT \\ VT 93-94
 Washington state received the blessing of first lady Hillary Rodham Clinton for its newly passed universal health care program, signed into law late Monday by Gov. Mike Lowry. 
She congratulated the state for its foresight and for being a leader in the health care reform movement. 

C35/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 Virginia is one of 23 states that in the past two years have passed laws allowing--or requiring--insurers to offer low-cost, basic insurance plans to small employers. Seventeen more states considered, but took no action on, similar plans last year. (See the chart on Page 23.) In most of those states, the bills will come up again this year. 

C36/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	While no specific timetable was detailed in the report, Steelman said the demonstrations should be started as soon as possible so that a national reform plan could be implemented by the end of the decade. 

C37/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 However, states can do things without federal waivers, he added. Through the establishment of purchasing pools and other means, states can surmount federal barriers such as Medicaid waivers and certain provisions of the Employee Retirement Income Security Act, he said. [Vermont Gov. Howard Dean (D)] 

C38/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 President Bush has demonstrated he is unfriendly toward state health plans, Dean said. However, states can do things without federal waivers, he added. Through the establishment of purchasing pools and other means, states can surmount federal barriers such as Medicaid waivers and certain provisions of the Employee Retirement Income Security Act, he said. [Vermont Gov. Howard Dean (D)] 

C39/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Proposals for health care reform in individual states, like those on the federal level, can be categorized in three general groups. Like the president's plan, which calls for tax incentives to buy insurance, vouchers to enable poor people to purchase insurance and inducements for small employers to join together to buy coverage, many state legislative proposals would build on the current health care system. This is the so-called incremental approach which, predictably, the health insurance industry favors. 

C40/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	The council's report [Advisory Council on Social Security] lists a range of prototypes for comprehensive reform suggested by individual council members that "warrant demonstration." Those include: -- four versions of plans that would require employers to provide health insurance to their employees, including two "play-or-pay" versions; -- eliminating all employer-based insurance and establishing an individual tax deduction for the cost of a standard benefits package; -- creating a new federal insurance plan covering only catastrophic illness, which would be secondary to all other public and private insurance coverage; -- establishing a single-payer health insurance plan run by the federal government, with global budgeting established for all providers; and -- tightening regulation of the insurance market for small business, addressing such matters as pre-existing condition exclusions and premium-setting practices. 

C41/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Many other states are in the throes of deciding among several different approaches. In Washington state, for example, three different plans are competing for approval. 

C42/MODERN HEALTHCARE, March 29, 1993, "Ore. waiver gives rationing a shot," pp.20-21 \\V'1'-MDS
 In fact, as of last week, only two things were clear. First and foremost, President Clinton has sent a powerful message to states that he intends to give them broad flexibility in designing their own solutions to health care ills.C43/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. p. 202-3 \\VT-JHHFederal financial assistance should be related to the economic and demographic characteristics of the individual states. States with more low-income individuals and with greater unemployment will need more help. But it would be important to apply one of the lessons learned from the Medicaid experience: federal funds should not be provided as a percentage of state expenditures. The open-ended ex-post allocation system should be replaced with one of ex-ante annually determined fixed amounts; the states should operate within predetermined budgets.
C44/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 Such a national system should be modeled closer to Medicaid, which is administered by the states, than to Medicare, which is administered in Washington, he said. [Vermont Gov. Howard Dean (D)] 

C45/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p.15 \\VT-JHH
 Then as now, the power to regulate insurance was reserved to the states. 

C46/E.W. Kelley, 1987, Policy and Politics in the United States: The Limits of Localism, p. 163. 
Medical societies are organized at the state level and endowed with public authority and responsibility through state law.
C47/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 William L. Roper, MD, administrator of the Health Care Finance Administration (the agency that oversees Medicaid and Medicare) under President Reagan, has stated that indigent care "is strictly a state problem." He defends this by further stating that "the federal government is broke, far more so than the states in aggregate." [n2] 

C48/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 The federal government's health care role is thus limited to what cannot be effectively performed by states; the states' to what cannot be effectively performed by local government; and government's itself to what cannot be effectively performed by individuals and voluntary associations. 

C49/Timothy J. Conlan, asst Prof. Gov't and Politics, George Mason Univ., "Federalism at the' Crossroads", THE JOURNAL OF STATE GOVERNMENT, January/February, ]989, P. 52. 
Problems may result from the "tyranny of small decisions," as Laurence Tribe has put it: "No one expects Congress to obliterate the states, at least in one fell swoop. If there is any danger, it lies in the tyranny of small decisions--the prospect that Congress will nibble away at state sovereignty, bit by bit, until someday essentially nothing remains but a gutted shell." 
C50/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 An associated issue is the need for a prudent political arrangement for the health care arena, one that preserves simplicity in authority and decision making. By its very nature, "prudence" is a debatable standard. But one traditional principle may be useful in the contemporary debate. According to the principle of subsidiarity, lower, more decentralized elements of society should not be absorbed into larger, more centralized wholes unless their tasks cannot be performed adequately at the lower level. [n28] Thus, the principle entails that individuals should be left to do for themselves what they can do most effectively. Only if individuals cannot adequately perform the needed functions should they be assigned to local government. Local governments, in turn, should have their own range of authority consistent with the effective execution of tasks, passing on to states only what they cannot effectively accomplish. The federal government inherits those tasks that cannot be effectively performed short of national regulations or initiatives. 

C51/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 While that is a national problem, it might be better dealt with at a state or local level. 

C52/Richard B. Saltman, director of the Division of Health Policy at Emory University's School of Public Health, The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 3, HEADLINE: NATIONAL HEALTH INSURANCE: CAN IT WORK IN THE U.S.? \\VT 93-94
	 A central lesson from Scandinavian countries, however, is that it is possible to construct publicly run health care systems at the county or municipal level that don't suffer from many of the problems of "government-run" agencies. In Denmark and Sweden, hospital and primary care services are operated by county councils whose members are elected by local residents every three years. In Finland, local municipal government has a similar role. In all three countries, these publicly elected bodies are forced to support their health care decisions through the local tax rate. If a majority of county representatives want to expand long-term care services for the elderly, for example, they have to increase taxes or find alternative savings to pay for it. Moreover, if a majority of citizens in that county or municipality disagree with a major decision, they can - and do - vote their representatives out of office at the next election. 

C53/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	Steelman [Advisory Council on Social Security] strongly endorsed demonstrations as a way to "engender debate" among the public on how to reform health care. She noted that enactment of any major change at the national level "would have to involve the American public in a way that hasn't been done in years." 

C54/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 King: Could some of those decisions be made at the state level? Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: I have no reason to think that a Georgia health agency, if it should be called that, would do any worse than any of dozens of Blue Cross-Blue Shield, Prudential or Aetna equivalents do currently, because they don't have the overall public health in their interest, whereas a political entity does. 

C55/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 200-1 \\VT--JHHThere is no doubt that a program with major administrative responsibility delegated to states will be complex. It will exhibit wide variation. In the past that was considered its fundamental weakness. And yet, perhaps that is its strength. If we want to maximize innovation and flexibility we may gain much from multiple and smaller programs. If, further, we recognize that there is no guarantee that government will always act wisely and appropriately, we may want to act as risk averters. Multiple state programs are like a diversified portfolio: we will not do as well as we might if we bet on a single winning pro, am, but neither will we do as badly if we were to commit a blunder.
C56/ John Scholz and Feng Heng Wei, State U. of NY at Stony Brook, 1986. AMERICAN POLITICAL SCIENCE REVIEW, "Regulatory Enforcement in a Federalist System." p. 1258. "
 State bureaucracies are small enough to be able to rely more on informal, personal supervision than can federal bureaucracies, which require more formal procedures, standards, and reports to ensure uniformity of actions in geographically dispersed areas.C57/ John Scholz and Feng Heng Wei, State U. of NY at Stony Brook, 1986. AMERICAN POLITICAL SCIENCE REVIEW, "Regulatory Enforcement in a Federalist System." p. 1258.
State bureaucracies generally have fewer levels of hierarchy between field personnel and political appointees. who are more sensitive to the political environment than civil service professionals. Even state civil servants are more likely to identify career opportunities with the state and , therefore be more sensitive to state political interests.
C58/USA TODAY, 23February 10, 1992, Pg. 11A HEADLINE: Greater state role pushed \\VT 93-94
	Q: What happens if the federal government moves toward a ''pay or play'' or tax-credit system? Is there a way to work together with them? 
	A [Howard Dean, Governor of Vermont] : Yes. But I don't want a national health insurance system that's administered by the federal government. The federal government already administers Medicare, and it's one of the worst programs that's ever been devised. We need a system that's like the Medicaid system, which is administered by the states, so that it's possible to deal with the state capital instead of calling Washington to solve your problems. 

C59/USA TODAY, 23February 10, 1992, Pg. 11A HEADLINE: Greater state role pushed \\VT 93-94
	Q: When you were practicing medicine, what was the biggest problem you faced with the current system? 
	A: [Vermont Governor Howard Dean] Medicare was a tremendous problem. The bureaucracy and hassle of dealing with the federal government was just incredibly anti-patient. It really discouraged us from dealing with anybody with federal insurance. 

C60/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 "We already have a national health insurance system," Dean said, referring to Medicare. "And it's an example of why the federal government shouldn't administer a national health system. It's a disaster for patients and providers. It's one of the least user-friendly programs in federal government," he said from his experience as a practicing physician. [Vermont Gov. Howard Dean (D)] 

C61/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 The states are the key in developing a national health care insurance system, according to Dean. [Vermont Gov. Howard Dean (D)] "We already have a national health insurance system," Dean said referring to the Medicare program. "And it's an example of why the federal government shouldn't administer a national health system. It's a disaster for patients and providers. It's one of the least user-friendly programs in federal government," he said from his experience as a practicing physician. 

C62Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 State Administration. -- For those who favor government administration of a health plan but are concerned about the responsiveness of the federal government to local health needs, some proposals would move parts of the program administration to the states, where it would be closer and, presumably, more accessible to the people who need the health services. 

C63/J. Edwin Benton,. U. South Florida, 1985, POLICY STUDIES JOURNAL, March, "American Federalism's First Principles and Reagan's New Federalism Policies." P. 573.
Furthermore, decentralization of the regulatory role of government serves to fix political responsibility and accountability. That is, citizens will have a better idea as to where responsibility is lodged and to where inputs should be directed.C64/Thomas R. Dye, Prof. PoliSci, Florida State Univ., AMERICAN FEDERALISM: COMPETITION AMONG GOVERNMENTS, 1990, P. 177
Federalism stimulates political participation. Although fewer people vote in state and local elections than in national elections, more people run and win office at the state and local level. There are over eighty-three thousand governments in the United States: states, counties, townships, municipalities, towns, special districts, and school districts. Nearly a million people hold some kind of public office. The opportunity to exercise political leadership contributes to popular support of the political system. By providing more opportunities for direct citizen involvement in government, state and local governments contribute to the popular sense of political effectiveness and well-being. Public opinion studies consistently report that people believe that local government is more understandable, that they have greater confidence in it, and they feel more capable of affecting its policies.

C65/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 With the increasing decentralization of governmental health services, the states have taken on new roles as conveners, fostering alliances and common interests among many potential participants in disease prevention and health promotion activities. These alliances can occur both horizontally, among statewide organizations, and vertically, among community, state, and national groups. 

C66/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Local governments can form partnerships with grassroots organizations, such as neighborhood associations and tenant councils, in a cooperative effort to reach specific populations on topics of special local concern. 

C67/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 200 \\VT-JHH State government is certainly not responsive to all its citizens, but may be more responsive to the inherent differences that prevail. It may be better able to explain how various Changes might affect at the local level the care that people seek and/or their pocketbooks. It may be better able to set appropriate incentives, educate the public about the implications of various choices, and respond to different tastes and priorities.
C68/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 To be viable, a health care system must incorporate a sense of community, a sense of solidarity with others. That demand, it seems to me, argues in favor of a plan administered by states rather than by a distant federal government. A series of insurance packages administered by the states, rather than one federal program, would not violate the concept of universality. The details of the meshing of federal and state responsibilities would be important. The federal government would have to define benefits and cost-containment goals, as well as provide some funding. But in my judgment, the gains associated with state administration and more direct citizen involvement would outweigh the additional complexity. 

C69/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 Years ago, Justice Louis Brandeis remarked that the states were the social laboratories for the nation. As health-care reform efforts move ahead on both state and national levels, 1993 should be an interesting year to watch. 

C70/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 States with innovative health plans should be allowed to proceed, despite some faults the plans may have, Dean said. Through state innovation, other states and the federal government will learn what works and doesn't work. Vermont, Oregon, Minnesota, and Hawaii have state plans that are attempting to tackle the health care problem, he noted. [Vermont Gov. Howard Dean (D)] 

C71/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	The Advisory Council on Social Security issued Dec. 19 its long-awaited report, recommending that consensus on national health care reform could best be achieved by first testing various reform options at the state and local level. 

C72/ Daniel J. Elazer, Ctr for Study of Federalism, Temple University, 1987. EXPLORING FEDERALISM. P. 188.
Non centralization makes it possible for local governments to develop policies and programs of their own within systems that are often too complex to allow them the luxury of isolation, to acquire outside aids for carrying out those policies and programs, and to adapt those aids to their own needs.
C73/ Paul Paterson, dir. Govt. Studies at Brookings Institute, 1986, WHEN FEDERALISM WORKS. p. 11. 
It has been cogently argued, in fact, that to the extent all services can be decentralized a better fit can be achieved between what the public demands (what services it is willing to pay for) and what is publicly provided.C74/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 200 \\VT-JHH
Furthermore, as the health sector has changed, the different states have developed and face widely disparate patterns in the organization and delivery of care. Homogeneity has given way to differential enrollment patterns in HMOs and PPOs, to different degrees of competition in ambulatory and hospital care. The individual patterns found across the land are best understood and best addressed at a locus of control that is closer to those delivery systems and to the people they serve. California is not the same as West Virginia, and the systems and incentives that would best suit the one are (not necessarily appropriate for the other. Given the different patterns of medical care delivery and the very different costs across geographic areas, there is a need to erect different incentives and different types of cost control mechanisms.
C75/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS p.210 \\VT-JHHThe importance of the cost containment component of a universal health insurance program argues for greater rather than less state participation. A large participatory role for the states also responds to economic and political realities. While the states cannot finance an NHI program by themselves, the size of the current and projected federal deficit hardly suggests that the federal government could do so without their help. Furthermore, there is more pressure for and interest in new patterns of financing at state levels. The more distant Congress can more readily ignore the problems of those without protection, of cost-shifting and of uncompensated care, and of the burden , carried by local institutions who serve the under- and uninsured. 

C76/S. Kenneth Howard, fmr exec dir., Advisory Commission on Intergovernmental Relations, STATE AND LOCAL GOVERNMENT: THE THIRD CENTURY OF FEDERALISM, 1988, P. 338. 
 'We find state and local leaders emerging as a new class of government entrepreneurs, taking the lead in spurring economic development, in containing, health care costs, in rebuilding public facilities and in improving education. With columnist David Broder, whom Howard quoted, he agreed that by the mid 1980s, "more and more of the critical decisions in our domestic government {were} being made in state capitals." 
C77/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 210-1 \\VT-JHHBut a federally administered program would not eliminate all disparities. A single program legislated in and administered from Washington is not the same program in every locality. Because medical care is a service, the local delivery systems exhibit great variability. As long as local health systems and costs differ, as long as health resources are not distributed equally, as long as incomes and living conditions differ, some Americans will receive better medical care and will have a better health status than others.C78/Lynn Wagner, Washington bureau chief, Modern Healthcare, February 24, 1992 Pg. 44 HEADLINE: Forces dig in on reform strategies, boosting likelihood of a stalemate \\VT 93-94
	 They would be "better off with government at the local and state level that recognizes the importance of their existence," he [Altman of ProPAC] said. "Hospitals that have thrown their allegiance to the unfettered market could get what they deserve." 

C79/Daily Labor Report, October 19, 1992, PG. A-3, TITLE: STATES KEY TO DEVELOPMENT OF NATIONAL HEALTH CARE SYSTEM, VERMONT GOVERNOR SAYS. \\VT 93-94
	 Dean said it is especially important for new health care systems to move away from paying providers for performing procedures and toward total health compensation. For example, physicians could be put on salary at hospitals or clinics, or they could be paid a fixed amount per patient through a managed care organization. In such ways physician pay would not be linked to the number of procedures done, he said. [Vermont Gov. Howard Dean (D)] 

C80/Julianne Malveaux, USA TODAY, April 3, 1992, Pg. 10A, HEADLINE: Insist on national reform \\VT 93-94
	 USA TODAY's editors have put their hearts on their sleeves and their brains on vacation in suggesting that states be allowed to experiment with the health-care and health-insurance system. 

C81/BNA PENSIONS & BENEFITS DAILY, Jan. 2, 1992 REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES, Nexis \\VT 93-94
	The recommendation [Advisory Council on Social Security] also met with immediate criticism from Families United for Senior Action, a senior advocacy group, which called the report "an outrageous attempt to give an appearance for action while it actually delays meaningful reform until the next century." 

C82/BNA PENSIONS & BENEFITS DAILY, Dec. 10, 1992, HEADLINE: FEDERAL POLICY PREVENTS STATES FROM REFORMING HEALTH SYSTEM, REPORT SAYS, Nexis \\VT 93-94
	 According to the study [by the National Center for Policy Analysis] , state governments will only make their problems worse if they try to force employers to provide health insurance, control spending through "global budgets," or adopt a state-based version of national health insurance.  

C83/Newsday, February 21, 1993, Pg. 2, HEADLINE: An Appeal To Solve Health Care Gridlock \\VT 93-94
  NEW YORK  state Sen. Hugh T. Farley A patchwork of differing health plans across all 50 states would seem more likely to create problems than to solve them.  

C84/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Although local initiatives are often innovative, and sometimes successful at correcting specific local problems, there is mounting evidence that they are failing; for example, there are excessively restrictive eligibility requirements and subcost reimbursement levels in the Medicaid programs of many states, there are budget shortfalls that preclude funding for recent health care initiatives in Massachusetts and New York, and there are low enrollments in some state risk pool ventures for the medically uninsurable. Although more difficult to achieve, a set of coherent health care system reforms enacted at the national level will be necessary, in our opinion, to solve the problems in our present system. 

C85/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 Thus, it remains an open question whether well-intended reforms will have their desired impact. 
C86/Newsday, February 21, 1993, Pg. 2, HEADLINE: An Appeal To Solve Health Care Gridlock \\VT 93-94
 Sen. Manfred Ohrenstein . . . The need for a universal health care plan, available to every citizen, has gained a great deal of attention as New York and the nation encounters a serious health care crisis. I believe that the ultimate responsibility for adoption of universal health insurance lies with the federal government.  

C87/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 In order to address public health issues that are in flux with changing social, behavioral, and economic environments, sustained Federal leadership is necessary to improve the health of the American people. 

C88/JASJIT S. AHLUWALIA, MD, MPH, Department of Internal Medicine, University of North Carolina Medical Center, Archives of Internal Medicine Feb. 1990; 150: 256-258 TITLE: Health Care in the United States; Our Dynamic Jigsaw Puzzle \\VT 93-94
	 Many other leaders in health care planning have stated that the burden of providing for the medically indigent must rely on the federal government, especially if other forces have not been able to do so. The argument used is that health care is a right to which every American is entitled. Just as the federal government provides for education, postal delivery, and certain other services, it should do the same for at least a minimal amount of basic health care. 

C89/Julianne Malveaux, USA TODAY, April 3, 1992, Pg. 10A, HEADLINE: Insist on national reform \\VT 93-94
	 We've already seen patient dumping from one state to another. Two years ago, a Florida man with AIDS was given a one-way bus ticket to San Francisco, where it was perceived that he could get better care than in his home state. The abandonment of an Oregon Alzheimer's patient at a race track in Idaho last month was another form of dumping. Both of these cases illustrate the need for national health insurance, not weak half-measures that avoid the issue. 

C90/JAMES M. BURCKE, staffwriter, Business Insurance, March 26, 1993, Pg. 16, HEADLINE: Timetable for change; Expect Congress to pass significant reform by 1994 \\VT 93-94
	 More than half of the respondents [panel of (health reform) experts] -- 65% -- said that health care reform should be implemented on a nationwide basis. Eighteen percent said they favored reforms that could be implemented on a state-by-state basis, while 17% said reforms need to be implemented on both levels. 

C91/BNA PENSIONS & BENEFITS DAILY, Dec. 10, 1992, HEADLINE: FEDERAL POLICY PREVENTS STATES FROM REFORMING HEALTH SYSTEM, REPORT SAYS, Nexis \\VT 93-94
	 "For the past four years, Congress and the Bush Administration have encouraged state governments to experiment with health care reform," John C. Goodman, president of the NCPA [National Center for Policy Analysis] and co-author of the study, said. "But the states can't solve the problems the federal government created," he added. 

C92/BNA PENSIONS & BENEFITS DAILY, Dec. 10, 1992, HEADLINE: FEDERAL POLICY PREVENTS STATES FROM REFORMING HEALTH SYSTEM, REPORT SAYS, Nexis \\VT 93-94
	  A study released by the National Center for Policy Analysis in Dallas concluded that state governments cannot reform the  country's health care system because it has been shaped and molded by federal policy, particularly tax policy. 

C93/Julianne Malveaux, USA TODAY, April 3, 1992, Pg. 10A, HEADLINE: Insist on national reform \\VT 93-94
	 I understand their motivation - 37 million people have no access to health insurance. If state adjustments can make health care more accessible, more power to them. I just don't think state experiments will make health care more accessible; instead, I think the quality of health care will vary widely by state, possibly causing people to decide where to live based on the health care they can get in a given state. 

C94/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 To help ease the way for state health-care reform on the federal level, two separate Senate bills have been introduced to provide waivers from the federal Employee Retirement Income and Security Act (ERISA). These waivers probably would be necessary in most states for any significant health insurance reform involving employers to take place. 

C95/LYNN WAGNER, Crain News Service, City & State, August 24, 1992 - September 6, 1992, Pg. 3, HEADLINE: Health-care initiatives suffer setback; But Oregon's lesson could revive reform \\VT 93-94
	 Oregon state Senate President John Kitzhaber, a Democrat and the chief architect of the proposal, said, "The decision constitutes a de facto endorsement of the current flawed and failing health-care system which excludes millions of Americans, many of whom die needlessly for want of basic care." 

C96/LYNN WAGNER, Crain News Service, City & State, August 24, 1992 - September 6, 1992, Pg. 3, HEADLINE: Health-care initiatives suffer setback; But Oregon's lesson could revive reform \\VT 93-94
	 Prospects for state health-care reform initiatives that require federal approval appear to have been diminished severely by the Republican administration's rejection of Oregon's controversial Medicaid rationing plan. But some observers predict that the decision against state experimentation ironically could have the unintended effect of intensifying the push for the kind of sweeping national health-care reforms that President George Bush opposes. 

C97/Lynn Wagner, Modern Healthcare, August 10, 1992, Pg. 2, HEADLINE: Rejection of Oregon plan appears to diminish chances for state reform initiatives \\VT 93-94
	 Prospects for state healthcare reform initiatives that require federal approval appeared to be severely diminished last week by the Bush administration's rejection of Oregon's controversial Medicaid rationing plan. 

C98/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	To entice states or communities to test reform options, the council [Advisory Council on Social Security] recommended that the federal government dedicate $3 billion as seed money for states to use in implementing one of several basic reform prototypes. 

C99/BNA PENSIONS & BENEFITS DAILY, Dec. 10, 1992, HEADLINE: FEDERAL POLICY PREVENTS STATES FROM REFORMING HEALTH SYSTEM, REPORT SAYS, Nexis \\VT 93-94
	 The report [by the National Center for Policy Analysis ], titled "State Health Care Reform Under the Clinton Administration," found that since states cannot change federal policies, they cannot address the root causes of most health care problems. However, the report concluded that some needed reforms can be enacted at the state level. 

C100/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 At the same time, the abilities of states to set their own direction in health policy has been overwhelmed by the political failures of the Medicaid program. Local governments have little authority in this arena at all. 

C101/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. p201\\VT-JHH
State control of the administrative and cost containment structure does not preclude an important role for the federal government. Whatever the enrollment method, Congress must make certain that all residents are insured. If the program is based on state rather than federal enrollment, there must be a federal backup program for individuals who live in states that elect not to participate (and perhaps
for employees of national corporations.

C102/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. p 206 \\VT-JHH
A series of state-run programs requires more from the federal government than financial assistance. To achieve equity among the states and their residents, the federal government will have to define the benefit package and make certain it is made available to all without discrimination. Benefits should include physicians' services as well as hospital care. Special attention should be directed toward procedures that encourage early diagnosis and care, enhance health status, and prevent disease. Again there is a lesson to be learned from Medicare: a benefit program can be so oriented toward acute care that it negates efforts at prevention. It can also be made so complicated that it engenders confusion and fear. We pay an unnecessary price in both complexity and dollars for a two-part program that also encourages individuals to purchase supplementary private insurance. 

C103/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. p.211 \\VT-JHH
What is incumbent on the federal government is to work to reduce disparities and promote equity in the provision of services. That task may be more difficult in a program administered by the states, but it is doable. Indeed, it is quite possible that the federal government will protect equity more diligently in the type of program outlined than it would in a purely federal program. We would not be forced to rely on self-monitoring and self-evaluation, on what we know is suspect. Nor would we be lulled into a false sense of security derived from the assumption that centralized administration assures equitable access at the point of service delivery.

C104/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 What then will happen if, by some fortunate chance, this country carries out health-care reform in a number of states and the Clinton administration successfully introduces a national plan? And if the federal and state approaches differ markedly, how would they be reconciled? How would the state efforts be integrated into a larger national plan? Who would pay the bill and how would the plans be administered? 

C105/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	The prototype demonstration approach was not unanimously supported by the council, however. In a dissenting statement included in the report, four council members -- Robert M. Ball, former commissioner of Social Security, John Dunlop, a Harvard University professor, Karen Ignani, director of the AFL-CIO's department of employee benefits, and John J. Sweeney, president of the Service Employees International Union -- said that the council has failed in its major mission to devise a comprehensive reform plan that addresses the issues of controlling cost and access. "When the flood came, Noah did not build demonstration arks," the dissenting statement said, "[B]road support for a nationwide initiative already exists and further delay is unwarranted and costly. The overwhelming need now is for national leadership." 

C106/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	Speaking at the press conference, Ball [Advisory Council on Social Security] said "this is not a town meeting issue . . . where solutions can bubble up from the bottom." The time has come, he said, for health care providers, private business, and others involved in health care to negotiate a comprehensive solution. 

C107/United Press International, April 7, 1992, HEADLINE: Americans united on who should fix health care system, Nexis \\VT 93-94
	 More than half of all Americans believe the federal government is responsible for fixing the nation's failing health care system, but hardly anyone can name a politician with the solution, a survey said Tuesday. 

C108/United Press International, May 12, 1993, TITLE: MOST AMERICANS FAVOR UNIFORM HEALTH-CARE PLAN, SURVEY SHOWS, Online America Transmitted: 93-05-12 14:23:00 EDT\\VT 93-94
"In an era of strong anti-Washington sentiment, we were surprised by the public's nervousness about granting discretion to the states," said foundation President Drew Altman. 
"Our interpretation is that people have been convinced that this is a national problem requiring a national solution and that they want to be assured they will have adequate health insurance regardless of the state in which they live." 

C109/United Press International, May 12, 1993, TITLE: MOST AMERICANS FAVOR UNIFORM HEALTH-CARE PLAN, SURVEY SHOWS, Online America Transmitted: 93-05-12 14:23:00 EDT\\VT 93-94
 In unexpected results, a survey Wednesday showed most Americans prefer a centralized, uniform health-care plan over one that offers flexibility to the states. Of 1,252 men and women questioned, 61 percent favored one nationwide system, while only 36 percent thought states should be granted wide discretion in establishing health-care reform. 

C110/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 * Despite the willingness of the federal government to cover up to 78% of the Medicaid costs of low-income states, many states have resisted the incentive. From the mid-1970s to the mid-1980s, the proportion of poor persons covered declined from two of three to two of five, with some reversal in the last years as Congress has forced the states to expand coverage for pregnant women and young children. [n4] 

C111/San Francisco Chronicle, JANUARY 16, 1993, EDITORIAL; Pg. A16; HEADLINE: Health-Care Reform Takes Off in States \\VT 93-94
 Still, all experts do not agree that initiatives at the state level is the way to achieve reform. In recent congressional testimony, representatives of organizations as diverse as IBM and the AFL-CIO cautioned Congress not to ''Balkanize the health-care system by inviting states to take 50 different approaches to health care reform.'' They pointedly reminded Congress of the great variability in the way individual states implement federal health regulations, noting that Medicaid eligibility standards vary from 13 percent of the federal poverty level in Alabama to 79 percent of that same level in California. If left on their own, the variability among state-controlled health insurance plans might be even greater. 

C112/Janet O'Keefe, policy analyst at the American Psychological Association, The Recorder, June 2, 1992, Pg. 11, HEADLINE: Risk Factors In the Failure Of Health Care Reform \\VT 93-94
	 Because the United States, unlike all other industrialized Western nations, treats health insurance as a commodity to be sold in a comparative market, most Republicans and many Democrats continue to oppose a single-payer system of national health insurance. Since this seems to limit the options for near-term reform to variations on the current multipayer system, it behooves us to think more boldly about what can be done within this system. 

C113/Julianne Malveaux, USA TODAY, April 3, 1992, Pg. 10A, HEADLINE: Insist on national reform \\VT 93-94
	 So-called welfare reform has yielded disaster when states have experimented. Illinois says it will provide public assistance for only nine of 12 months a year. California and New Jersey say they will provide assistance only for a certain number of children and will cut benefits to balance budgets. Other states have tinkered, but none has improved on the federal model, providing more, not less, for recipients. If state experiments with health services are even slightly similar to experiments with public assistance, we should expect the quality of health care to erode, not improve. 

C114/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Although premiums for bare-bones plans in various states are on average 40% to 50% lower than the costs of standard coverage, according to one estimate, many observers note that they still are costly to the consumer. This is because costs are shifted to high co-payments and deductibles, and the plans are subject to lowered benefit ceilings and reduced benefits. 

C115/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Woodrow E. Eno, director of legal-state affairs at HIAA, makes a related point. He says that when barebones bills were approved by legislatures "a lot of the 'pet' provider programs got stuck into them," resulting in more benefits and increased premiums. (More than 20 states so far have passed such measures, but many are not yet marketing the policies.) Even true limited-benefit policies are more expensive than the industry would like, Mr. Eno says, because health insurance simply is an "expensive commodity. " 

C116/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 However, in a 1991 publication entitled "Barebone Coverage: Health Insurance That Doesn't Insure," Families USA Foundation, a Washington, D.C., consumer advocacy group, criticizes states for allowing groups that have not been without coverage for a specified period of time to purchase the coverage, saying this allows for benefit "erosion." It also says the lower premiums for the plans are attributable primarily to the high cost-sharing requirements, rather than the elimination of mandates, and estimates that the most that can be saved by scrapping all mandates except maternity care is 14% of premium costs. This contrasts with industry estimates of about 20%. 

C117/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Further, Families USA says the states "that waived mandates to encourage barebones policies still allow insurers exclusions for preexisting health conditions," which does nothing to help small employers that are having difficulty finding insurance. Mr. Eno concedes that only states that have passed guaranteed-issue models along with bare-bones laws (and only Oregon and North Carolina have) can deny this accusation. However, he says 19 states that have bare-bones laws currently are in the process of implementing such small-group market reform. 

C118/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Although some observers think Hawaii's system could be successfully implemented in other states, others believe the plan works because of factors unique to the state. According to Mr. Eno, Hawaii gives a lot of grants to employers to help them buy coverage. It is very expensive to mandate coverage, he says, but Hawaii, unlike most states, has a surplus of revenue because of tourism and a stillgrowing economy and can afford the expense. In addition, he says, although it is common wisdom that if coverage is mandated, employers will move somewhere else, Hawaii's geography makes this unlikely. 

C119/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 The health care plan isn't perfect. Hawaii still is struggling to cover mental health and drug abuse services, and it has yet to implement a plan to provide long term care for the elderly. 

C120/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 * In Ohio, the legislature this year bowed to small-business pressure and killed a proposal sponsored by the insurance industry to guarantee access to health insurance for small firms without regard to employees' health status. Actuarial studies concluded that the proposal would significantly boost health-insurance costs for most small employers while bringing few previously uninsured people into the health-insurance system. 

C121/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 * In Connecticut, regarded as a model for a small-group reforms, small employers are guaranteed access to health insurance, but employers say it is still too expensive. Shirley Sokolowski, owner of Albert's Beauty Salon, in Willimantic, says the monthly premium for her oldest employee, who is 64, is $ 549. "That's astronomical," says Sokolowski. "I don't see [the state's reform law] as a good reform by any means." 

C122/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
the key to fundamental health reform in the United States is through the private sector. 

C123/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  At least among policy makers, there is another emerging consensus: we are at a fork in the road. We have no choice but to take one of two paths. Either we open up the health care markets or we close the health care markets even more.  Either we genuinely change the current, costly system, dominated by employer-based insurance and huge government outlays, and allow the American people more personal freedom of choice and introduce more genuine competition into the system, or, alternatively we can simply build on what we already have, make no structural changes in the tax structure and insurance markets and expand the role of government over the American health care financing and delivery  system. If we follow this latter path, in effect we will close the system up even more, increase the role of bureaucracy, and expand the existing regulatory regime over providers and health insurance industry, reducing doctors and hospitals to the status of even more highly regulated public utilities. 

C124/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  This kind of centralized government decision-making in health care is clearly incompatible with the promotion of flexibility, innovation, and pluralism that  should characterize a market-oriented approach to resolving the health care  crisis. It is a closing, rather than an opening, of the system. 

C125/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 At the same time, however, [NHI] government control is perceived by many as an undesirable loss of flexibility and an unnecessary and massive shift from private to public responsibility for financing and managing the nation's health care system. 

C126/Elaine S. Povich, Chicago Tribune correspondent, Chicago Tribune, April 23, 1992, Pg. 20; HEADLINE: Free choice often no choice, Federal experience with health plans exposes problems \\VT 93-94
	 The Heritage Foundation research organization, in a recent position paper, advocated free choice as the most palatable alternative to the current health-care system - far more acceptable, for instance, than proposals for national health insurance or the "pay-or-play" schemes advocated by Democrats. 

C127/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Mr. SCHRAMM [CARL SCHRAMM, Health Insurance Association of America] : Absolutely not. My view is that the American people are much better served by having a private financing system that funds their medicine than having the government stand in the place. One thing we know for sure people don't want government in between them and their providers. 

C128/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 As suggested earlier, saving money is not the only issue in choosing an administrator for a national plan. Authors of the more pluralistic proposals are also responsive to current unfavorable attitudes of the public and of health professionals toward large-scale government programs. Many are skeptical about the government's ability to manage effectively a health program even larger than Medicare and are concerned about its politicization. They would prefer to keep the administration in the private sector, with more discretion left to the judgment of employers, employees, providers, and insurance executives. They point to the perceived negative experiences with the US Postal Service as evidence that the government has a limited capacity to handle large programs responsively and argue that, in an area as sensitive as medical care, more pluralistic and private decision making is preferable. 

C129/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Advocating the values of an NHCS does not mean that we abandon the values that are currently incorporated into our health care ethic. Quite to the contrary, it is a matter of how these conflicting value systems are blended together. For example, the business approach to health care would become subservient to regulations based on the moral ideal of health care as a human right. 

C130//LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 In attacking Brown's VAT proposal, Citizens for Tax Justice (CTJ), a labor-backed research group, declared: "A national sales tax not only would be regressive, it also would be fraught with complexity, as the European experience makes clear. Indeed, an army of new lawyers, accountants and tax administrators would be required to run a national sales tax, and many of the same issues involved in the income tax would have to be dealt with." 

C131/Richard B. Saltman, director of the Division of Health Policy at Emory University's School of Public Health, The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 3, HEADLINE: NATIONAL HEALTH INSURANCE: CAN IT WORK IN THE U.S.? \\VT 93-94
	 As a result, many people who are attracted to the notion of making health insurance available to everyone find themselves rejecting the idea of a "government-run" program that would be hopelessly bureaucratic and unresponsive to their personal needs. 

C132/JAMES MORONE, NY Academy of Medicine, 1990, "Beyond the words: the politics of health care reform," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 218 \\VT-MDS 
However, as the market solution has declined, American government has slowly developed its .capacity for sustained administrative action within the health arena. The progress has been slow, hesitant, obscure, and often contradictory. Nevertheless, what appears, at first blush, to be a random succession of programs can also be interpreted as the government's progress from deference to control.

C133/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 The problem is that health care markets are dysfunctional, both in the U.S. and abroad, because they have been disrupted by unwise government policies. The biggest disruption occurs when governments make medical services "free," or artificially inexpensive, to consumers at the point of service. This policy generally characterizes national health insurance systems. In Britain, for example, this is accomplished by the government operating a single, nationalized system of health insurance which pays health care providers directly. In Canada, most of the funding and administration is carried out at the local (provincial) level, under uniform guidelines established by the national government. In still other cases, such as Germany, the government compels citizens to purchase health insurance from regulated quasi-private plans. 

C134/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. ix \\VT-ADPL
Market incentives in public and private health care policies can improve the efficient allocation of health care resources and help us achieve more of our health care goals.

C135/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 In short, lawmakers will discover that a health system that works with market forces, and not against them, is the best way to achieve the goal of controlling health care costs and expanding access to millions of Americans who do not now enjoy it. 

C136/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Solution: Abandon price controls in the Clinton plan, including for Medicare, and allow competitive markets to control costs. Let consumer choice of plan, or direct payment for medical services, be the instrument of cost control. 

C137/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 1 \\VT-ADPL 
The primary theme of this policy statement is that such a reduction can be achieved most efficiently through market incentives in the financing and delivery of health care services.

C138/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 Will rising physician supply on its own slow the rapid rate of inflation of expenditures per physician? According to classic market theory, an increase in physician supply should lead to a decrease in expenditures per physician. [n23] Increasing competition among physicians for patients might give organized payers greater leverage to bargain discounted fees or to employ physicians on a salaried basis. Supply might outstrip demand, resulting in declining volumes of service per physician. 

C139/Elaine S. Povich, Chicago Tribune correspondent, Chicago Tribune, April 23, 1992, Pg. 20; HEADLINE: Free choice often no choice, Federal experience with health plans exposes problems \\VT 93-94
	 Robert Moffit, deputy director of domestic-policy studies at the Heritage Foundation, insists that freedom of choice in health insurance would force insurance companies to compete with each other for business and bring better benefits to the insured. Moffit said that members of Congress, instead of looking at new ways to reform health insurance, should use the federal plan as a model. "I'm in favor of national health reform based on consumer choice," Moffit said, pointing to Congress' own choices available. 

C140/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Consumer choice and competition should be at the heart of any structural reform of America's health care system, as Clinton has suggested. But that means rejecting the remnants of health care central planning contained in the Clinton proposal. Instead it means enacting a major reform of the tax code to give Americans the incentive and the means to choose the plan that is best for them within a framework of wide choice and strong competition. With that reform in place, America could achieve the illusive goal of affordable access to quality care for all its citizens. 

C141/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Government price controls have proven ineffective in the past, and what is needed is competition among managed care providers, according to Alain Enthoven, an economist at Stanford University and a former policy adviser to several administrations. 

C142/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Kenneth J. O'Donnell, National Electronic Information Corp., a trading partner network of health care providers and payers: America, the home of a free enterprise system, should not give up its prerogative to maintain a health care delivery program that is driven by incentives to achieve quality. Competition is the foundation of our society and the driving force behind much of our nation's accomplishments. 

C143/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
 And finally, the American health care industry -- doctors, hospitals, clinics, insurance companies, pharmaceutical companies, medical equipment suppliers, and so on -- is already  one of the most highly regulated sectors of the American economy. Please keep  in mind that whatever we do to "fix" this broken system it is this peculiar, politically manipulated system that we are "fixing." 

C144/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Rising American health care prices are not the result of free market forces. The reason: there is no "free market" in health care. In a normal market, consumers would buy medical care and health insurance directly and consider the relative costs and benefits in making their purchases, as they do, say, in buying automobiles or houses. In other words, consumers would seek the best value for money in medical care and health insurance. Health care providers and insurers would then compete to satisfy consumer demand by adjusting the price and quality of their goods and services to provide consumers with the best value for their money. Government's role would largely be limited to providing the disadvantaged with subsidies to help them buy needed medical care and health insurance at market prices. 

C145/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 27-8 \\VT-ADPL 
Extensive government intervention in the market for hospital services through Medicare illustrates how public policy can contribute to market failure. Although hospitals have no strong incentive to minimize cost, they do compete with other institutions that can offer alternative services. Consequently, nonprofit hospitals attempt to increase the number of patients they serve by offering an extensive range of diagnostic and therapeutic ser vices in order to encourage more physicians to recommend their patients.

C146/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p.26 \\VT-ADPL
In markets for most products and services, economic efficiency is enhanced if government intervention is minimal and competition thrives. Efficiency is achieved through the strong incentive for suppliers to minimize costs and respond to demand by allocating resources to their most productive uses.

C147/Journal of the American Medical Association July 24, 1991; 266: 574 SECTION: BOOKS TITLE: The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals, by Bradford H. Gray\\VT 93-94
	 Profit-making is not a new phenomenon in medical care. Physicians' incomes are essentially the profits of private medical practice. Pharmaceutical and medical equipment manufacturers have long been flourishing profit-oriented industries. For services such as medical care, though, the market sometimes doesn't distribute services in ways that are acceptable to society. 

C148/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 Countries with national health insurance are increasingly turning toward private-sector and market-based reforms, the study showed. In 1989, the British government began to allow private hospitals to compete against public hospitals for National Health Service funds. More recently, New Zealand has signaled its intent to end 40 years of socialized medicine by giving people tax incentives to purchase private health insurance. [The Mackinac Center for Public Policy] 

C149/Thomas Sowell, senior fellow at the Hoover Institution at Stanford, Forbes, September 28, 1992, Pg. 83 , HEADLINE: Mispricing the risks \\VT 93-94
	 Private insurance is more efficient than government in a more fundamental way as well. Economic pressures not only operate on the insurance companies, but also on their customers, who can minimize their insurance premiums by minimizing the risks they run in the first place. Premiums are higher for people who choose to live in higher-risk locations, work in higher-risk occupations or operate their businesses in higher-risk ways. While insurance companies vary the premiums with the risk as a matter of economic self-preservation, the systemic effect on the economy as a whole is that risks are minimized throughout the society, consistent with other objectives that make people willing to pay a certain amount to do risky things. 

C150/Thomas Sowell, senior fellow at the Hoover Institution at Stanford, Forbes, September 28, 1992, Pg. 83 , HEADLINE: Mispricing the risks \\VT 93-94
	 Under these conditions, it is hardly surprising that insurance companies, operating under the pressures of competition, find it necessary to move faster than government employees, who get paid the same salaries whether the money reaches disaster victims earlier or later. 

C151/Thomas Sowell, senior fellow at the Hoover Institution at Stanford, Forbes, September 28, 1992, Pg. 83 , HEADLINE: Mispricing the risks \\VT 93-94
	 AS PEOPLE STRUGGLE to put their lives back together in Florida and Louisiana in the wake of Hurricane Andrew, they are likely to get the money they need from their insurance companies far more quickly than they get much-heralded, but slow-moving, help from the federal government. 

C152/Research Alert, September 4, 1992, HEADLINE: Health Care Reform Nexis \\VT 93-94
	 Free enterprise wins hands down among America's physicians as the preferred approach to health care reform. The most popular approach, endorsed by 46%, would require individuals to buy health insurance and claim a tax deduction for its cost. The poor wo uld receive government vouchers to offset their insurance costs. 

C153/Lynn Wagner, Washington bureau chief, Modern Healthcare, February 24, 1992 Pg. 44 HEADLINE: Forces dig in on reform strategies, boosting likelihood of a stalemate \\VT 93-94
	 Heritage has proposed eliminating employer-based insurance, instead giving workers the value of their health-care benefits in wages to enable them to buy their own insurance. Tax credits and deductions would be used to help low-income individuals buy insurance. The plan is intended to reduce healthcare costs by fostering competition and putting healthcare decisions directly in the hands of consumers. 

C154/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 The modifications needed to make these consumer-choice proposals work effectively are contained in the comprehensive plan developed at The Heritage Foundation. The essential features of the plan are contained in S.3348, sponsored in the Senate by Orrin Hatch, the Utah Republican. This plan would introduce tax and insurance reforms which would, in effect, open up an improved version of the federal employee health system to all Americans. It would allow them to choose plans offered by unions, churches, farm bureaus, or employer groups. They could make a choice without regard to their place of work. And the plan's tax reform would give Americans the means and the incentive to choose wisely and economically. And in doing so, it would provide all American families with essentially the same health system enjoyed for many years by their repreentatives in Congress. 

C155/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 76 \\VT-ADPL 
The government should offer beneficiaries a choice of health plans and provide incentives for selection of cost effective plans. 
This principle is the public-sector counterpart to the notion that private employers should offer a choice of plans and reward cost-conscious selections. Its advantage is that it fits the pluralistic nature of U.S. health care delivery and financing arrangements. Traditional government policy has operated under the concept that a single plan should be offered to government beneficiaries. Under a more pluralistic approach, a variety of plans and insurance packages could vie for the government's dollar, generating both savings to the public sector in the long run and more options for those being assisted. The government should, of course, screen plans to assure that they provide adequate protection to consumers and should generate sufficient information to facilitate consumers' selections.

C156/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 * Even the imperfect market competition present in the 9-million strong Federal Employee Health Benefits Program (FEHBP), in which they themselves participate, has produced a rate of cost growth in that program that is lower than the growth rates of private employer-sponsored plans, despite the fact that its benefit packages have become progressively richer and that is covers over 1.5 million retirees and their families, including retiress without Medicare. 

C157/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. ix \\VT-ADPL
'We believe it is essential that the private sector take the lead in health care reform. Through efficient selection of health care insurance and better management of expenditures on health care, businesses can improve the efficiency of our health care delivery system. Government's major role should be to help provide for the estimated 30 million or more Americans who now lack either private or public insurance coverage.

C158/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Competition. -- Alternatively, others support the adoption of extensive competitive market reforms to reduce health care spending. The approach and reasoning of this group are similar to those of proponents of deregulation and increased competitive activity for the airline, trucking, banking, and long-distance telephone industries. They believe that, because government planning and price setting in these industries ended, prices dropped and the quality of products and services improved. Thus, they believe the government needs to completely revamp its policies to encourage more competition in health care, as it did in these other industries. In particular, the federal government would provide substantial financial incentives through the tax system to individuals and businesses to enroll in less costly health plans, such as health maintenance organizations (HMOs) or managed care plans. As envisioned, individuals who did not choose to enroll in the less costly plans would pay considerably higher taxes and premiums as a result. Advocates of this approach believe that, with the right tax incentives for individual consumers and the proper procompetitive regulatory structures, there would be a sharp rise in the number of new managed health care organizations (involving various combinations of hospitals, medical groups, and insurers) competing for enrollees based on the lowest price and most effective use of health resources, or at least a shaking out, leaving the most efficient to survive. 

C159/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Followers of this second approach [Competition] share a number of common beliefs about our current health care system. First, health care costs will be lowered only if consumers can be given sufficient incentives to utilize lower-cost health care delivery systems and insurance plans. The decision to choose less costly health care arrangements would be made during a period of open enrollment on a regular basis rather than when ill or confronting an individual physician. Under this strategy, there would be little need for government to concentrate directly on the behavior of health care providers (ie, no need for price controls or rate setting for hospitals or physicians). Providing strong incentives for patients to concern themselves with their own health costs would indirectly lead to cost-reducing behavior by all the other parties. Ultimately, most physicians and hospitals would be compelled for financial reasons to join well-organized managed care organizations and HMOs. Advocates of this approach have as their model the state of California, which has nearly one third of its population enrolled in competing HMOs and has a state policy to encourage competitive contracting by employers with selected hospitals. 

C160/Health Line, October 20, 1992, HEADLINE: COMMENTARY: READY (AND WAITING) FOR REFORM, Nexis \\VT 93-94
	 LAY-OFF EMPLOYMENT-BASED SYSTEM: Heritage Fdn.'s Edmund Haislmaier writes in the WASH. TIMES that "neither candidate calls for what is really needed: an overhaul of America's health care financing system." Haislmaier: "The reason America has an employment-based health system is simply that the tax code encourages it. However, there is no economic or social justification for retaining this system. On the contrary, substantial evidence shows it creates more problems than it solves." He says, "the two basic options for genuine reform" are a consumer-based system, in which individuals and families would purchase their own health insurance and medical care, or a government-based system of national health insurance, in which the government would pay for health care for all" (10-17). 

C161/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  Newsweek's economist Robert J. Samuelson: "We already have socialized medicine. Government pays 42 percent of health care and lavishly subsidizes private insurance through tax breaks." As Dr. Samuelson notes, our so-called private employer-based system, which covers most Americans through their place  of work, is dominated by a huge, dramatically regressive and largely unexamined tax break for only one type of insurance, employer-based health insurance. This is the dominant feature of our health care system. 

C162/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 Individual and market-oriented efforts in the marketplace have plainly failed to provide basic health care for all Americans or to restrain costs. A rethinking of the proper role of individuals and government, the private and public sectors, and local, state, and federal relationships must be a part of the health care reform debate if the instrumental value of simplicity is to be realized. 

C163/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p.199 \\VT-JHH
Nor are we likely to opt for a pure free-market health system. Government (at all levels) is deeply involved in paying for care, in setting reimbursement rates, in financing medical education and research, in monitoring quality and performance standards. Whatever our irritations with government, we are not prepared for nor would we accept its withdrawal from the medical care arena. We look to government for protections that we cannot provide by ourselves and that we do not believe can be provided by the market. The lessons available from the performance of competitive markets can be built .upon without destroying the complex web of existing public initiatives.

C164/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 73 \\VT-ADPL
In fact, when public policy incorporates market incentives, desired social objectives can be achieved with the least resources possible, freeing resources for alternatives.

C165/Robert E. Moffit, Deputy Director of Domestic Policy Studies at The Heritage Foundation, February 25, 1993, Heritage Foundation Reports, THE HERITAGE LECTURES; No. 441, HEADLINE: Overdosing on Management: Reforming the Health Care System Through Managed Competition \\VT 93-94
  Walter McClure, president of the Center for Policy Studies and a leading health care policy expert from Senator Durenberger's home state of Minnesota, recently made a keen observation on the role of government in a sound market: "A market without government oversight is like a football game without a referee -- a mere brawl in which the cheaters win."  

C166/JAMES MORONE, NY Academy of Medicine, 1990; "Beyond the words: the politics of health care reform," reprinted in UNDERSTANDING, UNIVERSAL HEALTH OPTIONS, 1992, p. 217 \\T-MDS 
Perhaps what is most remarkable about all this activity is the extent to which it failed. Indeed, the competition revolution has exacerbated the major dilemmas of contemporary health care policy.

C167/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 We might as well recognize that our unregulated private system of health care is a thing of the past. John Donne's words now fit our profession: "No man is an island, to himself alone. Each man is a part of the continent, a piece of the main. Therefore, never send to know for whom the bell tolls; it tolls for thee." [n8] Donne was talking about a funeral bell; with luck, we may have a warning bell instead. 

C168/Paul Starr, professor of sociology at Princeton. The New York Times, February 4, 1992, Section A; Page 21; HEADLINE: The Ideological War Over Health Care; Conservatives Ignore History \\VT 93-94
	The right upholds a theory, the free market, which is not applied to health insurance anywhere in the West. Conservative thinkers issue theoretical designs for free market reform and managed competition (related but distinct ideas); when confronted with the record of market failure in health insurance and the disappointing results of market-oriented reforms, they often respond that the true market has yet to be tried, much as some on the left still say true socialism has yet to be tried. 

C169/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 At the same time, individuals and voluntary associations, including the marketplace, ought not to be expected to perform health care functions that can only be performed by government; local governments should not take on tasks that only states can perform; and states should not be assigned tasks that must be performed at the national level. 

C170/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 5 \\VT-ADPL
 Even with greater reliance on market incentives government will still have a crucial role in improving the performance of health care markets and intervening when market outcomes leave some people with inadequate access to care.

C171/JAMES MORONE, NY Academy of Medicine, 1990, "Beyond the words: the politics of health care reform," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 216 \\VT-MDS
Free market competition offers a powerful image and a politically effective solution. Over time, different political interests have infused it with entirely different meanings and advanced it as an answer to all kinds of troubles. I shall argue that the recent difficulties of the market approach changes the politics of health system reform-essentially shifting the action into the government

C172/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Our society has treated health care as a commodity, which has led to the primacy of the business ethic in the health care delivery system. This ethic rationalizes the distribution of health care resources according to the economic characteristics of the individual. The business ethic in health care has ended professional immunity from antitrust laws and given rise to the medical-industrial complex. [n34-n39] 

C173/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 77 \\VT-JHH
The competitive market system that we know as capitalism in the United States has been supported precisely because it is thought to foster growth, prosperity, and . income. The belief that those same forces in the case of the healthcare system could be used to reduce prosperity, to bring down costs, and to keep budgets within control was a triumph of hope over logic. That dynamic, interacting with the way the system is internally organized, all but guarantees an increase in cost, and generated from the inside, not just the outside.

C174/Bill Clinton, USA President, May 5, 1993 , President's Remarks at Ceremony for National Nurses Week, The Rose Garden 4:27 P.M. EDT Transmitted: 93-05-07 08:54:04 EDT, Online America\\VT 93-94
	 And what I say to you is that we don't want to just keep trying to give people things in a system that is broken. You can't give people government money, you can't give people tax cuts if the system is broken. What we have to do is to attack 

C175/Health Line, March 23, 1993, HEADLINE: SINGLE-PAYER: SUPPORTERS DEMONSTRATING PUBLIC BACKING, Nexis \\VT 93-94
	 Stanford Univ.'s Spyros Andreopoulos, however, argues "the marketplace has produced precisely those distortions that many experts feared would result from national health insurance" (Balto. SUN, 3-23). 

C176/ELI GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p. 40 \\VT-JHH
A few economists, in particular Kenneth Arrow, Robert Evans, and I, are convinced that the paradigm of the competitive market cannot be applied to health care, surely not in an affluent economy in which insurance plays a major role? Accordingly, I see no prospect for further large-scale privatization of the U.S. health care system beyond its current level--the 60, 50, or 30 percent mark depending on the criterion that is used: insurance plus consumer out-of-pocket payments, direct governmental outlays plus tax expenditures , or solely consumer out-of-pocket payment.

C177/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Advocates of a libertarian approach to health care conveniently overlook the fact that medical demand will always exceed supply and that free-market forces will not equitably resolve the conflict between the limited supply of and the continuing need for health care. Given this oversight, these advocates tolerate or even deny the meritorial system of rationing health care resources. The wealthy individuals are free to buy boutique medical care, and the poor are at liberty to choose free or charitable medical care, if available. 

C178/Kevin Grumbach, MD, Philip R. Lee, MD, Institute for Health Policy Studies Journal of the American Medical Association, May 8, 1991; 265: 2369-2372 TITLE: How Many Physicians Can We Afford? \\VT 93-94
	 The simultaneous rise of supply and physician gross income in the past decade in the United States [n16] and in many other nations [n24,n25] does not, however, instill confidence that this "inhibitory" feedback of supply on gross income will necessarily occur. Some observers have interpreted the failure of rising supply to reliably reduce costs as evidence of supplier-induced demand and physician-generated target incomes. [n24,n26,n27] Others contend that recent trends merely indicate unrequited patient-initiated demand rather than market failure. [n7,n28] In either case, it is unlikely that payers can simply count on physician supply reaching a critical density in the year 2000 that will spontaneously alter recent trends in expenditures per physician. It also does not seem that the growing proportion of female physicians will dramatically reduce projections of the "effective" (or "full-time-equivalent") physician labor force for the year 2000. [n29] 

C179/The National Journal, February 15, 1992, Pg. 384 HEADLINE: Searching for A Treatment \\VT 93-94
	 Some economists, however, argue that health care lends itself poorly to market competition. "You have a situation in which the consumer has very little knowledge and ability to determine what to purchase, and how much to purchase, while the provider has an interest in selling and often very little knowledge about how much things costs, either totally, or to the consumer," Robert D. Reischauer, director of the Congressional Budget Office, said. 

C180/The National Journal, February 15, 1992, Pg. 384 HEADLINE: Searching for A Treatment \\VT 93-94
	 Competition would weed out only the most obvious forms of waste and unnecessary care, critics say, and do little to diminish the appeal of innovations that promise some measure of improved care. In free-market theory, individuals decide how much of their incomes to spend on health care and how much to spend on other consumer goods. In practice, critics say, it's hard to imagine very many consumers willingly choosing a health insurance plan that doesn't offer state-of-the-art treatments, even if it's cheaper. "I don't observe anyone trying to enter this market saying, 'I'll save you a bundle by not offering you these,'" said Harvard's Newhouse. 

C181/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 191 \\VT-JHH
The competitive market system, while creating more individual choice and furthering more self-regulation, leads to its own difficulties, many of which are related to our desire to build a sense of community and achieve greater equity in the face of an unequal distribution of income. The special characteristics of health care make it difficult for us to behave as economic men and women. Most of us believe that health care is "different." More than that, many of us want it to be different. In health care as in other areas (such as education or legal services), we recognize that the distribution of income, of economic and political power, and of information is likely to yield a market distribution of services that is at variance with our value system.

C182/Janet O'Keefe, policy analyst at the American Psychological Association, The Recorder, June 2, 1992, Pg. 11, HEADLINE: Risk Factors In the Failure Of Health Care Reform \\VT 93-94
	 Policies which treat health as a commodity are doomed, until Congress sees the purpose of care is to serve those who need it, not those who provide it 

C183/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 7 \\VT-JHH
We can shift from coffee to tea, drive fewer miles or in more efficient cars, watch TV instead of going to the theater, encourage our children to attend state rather than private universities, but is it realistic to boycott health insurance, use less medical care, or look for health bargains?

C184/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 On what basis can anyone call such a market efficient? Surely the elderly and small business firms have the incentive to act as prudent purchasers. If even they cannot seem to discipline the health-insurance market, what makes us think that harried working mothers with children or other low-income families will be able to drive the market toward greater efficiency? Yet that is precisely the assumption underlying proposals, such as the administration's, that would achieve universal health-insurance coverage simply by granting low-income families and small-business firms tax credits toward the purchase of individual policies. 

C185/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 The increased penetration of the business model of health care provision can also undermine caring. [n13] Commercialization of health care in the United States since the mid-1970s has altered the image of medicine. The widespread use of advertising to promote hospitals, nursing homes, and physicians' practices has given health care the appearance of just another business in a competitive marketplace. This presentation of medicine as a commodity produced and sold for profit has reinforced a product-liability mentality in the public and exacerbated the malpractice liability problem. If health care is simply another product in the marketplace, when the outcome of a medical exchange is less than perfect, the physician producer or supplier should be sued. Physicians on their part have responded with "defensive medicine," thus moving a step away from an unqualified fiduciary relationship by virtue of placing self-protection first. And there has been a rise in professional arrangements and joint ventures in which financial self-interest compromises or appears to compromise fiduciary responsibility. [n14] 

C186/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 As a consequence of how the business ethic influences the administration of health care policies and debates about those policies, economic considerations override concerns for the basic health care needs of the uninsured. Too much time is devoted to concerns over who will pay for the rising costs of health care. Too little time is spent on how to set a finite budget on health care expenditure and on how to distribute limited resources equitably so as to maximize the health of all members of society. 

C187/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 The current reliance (despite rapidly fading optimism) on free-market forces purports to increase competition and efficiency in health care delivery, and to reduce health care costs. [n40] In fact, the for-profit sector provides less charity care, avoids high-risk patients, and is not any more efficient than the nonprofit sector. [n34,n41,n42] The for-profit sector shows no promise of alleviating the ailments of the health care system, such as administrative waste or the poor distribution of physicians and health care resources. [n43,n44] This sector, which is at liberty to divert profits away from the provision of health care in favor of investments in other business ventures, has no motive to restrict growth or to reduce the national expenditure for health care. This approach will not and cannot solve the problem of rising health care costs nor can it solve the problem of inequitable access to health care. 

C188/The Reuter Transcript Report, December 21, 1992, HEADLINE: PHYSICIANS FOR A NATIONAL HEALTH PROGRAM AND PUBLIC CITIZEN'S HEALTH RESEARCH GROUP NEWS CONFERENCE,Nexis \\VT 93-94
	  DR. SIDNEY WOLFE (Director, Public Citizen Health Research Group)] I think that what is more likely to happen, based on the past instances of competition in the health care area, is that the competitors have competed for greed rather than competing in any way that will really benefit people. There's hardly been a slow-up of the rate of inflation, of expenditure in the health area, even in states or jurisdictions where  there's a lot of so-called managed care. 

C189/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 26 \\VT-ADPL 
But private-sector markets do not always achieve the desired results; outcomes may be socially unacceptable. In health care, this is especially important because some reasonable minimum level of access for everyone is as important as the goals of good cost management and a high rate of innovation.

C190/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 "IF YOU like the U.S. Postal Service, you will just love National Health Insurance! " goes an adage that has made millions of red-blooded Americans blanch at the mere mention of health-care reform. After all, who likes the neighborhood post office? It is true that the U.S. Postal Service is not a lovable institution, though it probably is one of the cheapest mail services in the world. But think about the flip side of the adage. Imagine if our mail was in the hands of the friendly folks who run our private health-insurance system. Would that make you sleep better? If you think so, think again. 

C191/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 All these measures undermine what Bradford Gray [n2] calls "the fiduciary ethic," stated most succinctly by the American Medical Association's code of ethics: ". . . under no circumstances may the physician place his own financial interest above the welfare of his patients." [n3] Arnold Relman of the New England Journal of Medicine put it another way, "The doctor-patient relationship [cannot] be adequately described in purely business terms. It is not that doctors are more ethical than businessmen. They aren't. It is simply that patients have to depend on doctors to take care of them, and this trust places legal and ethical obligations on doctors that do not apply to businessmen . . ." (Wall St Journal. July 2, 1986:27). 

C192/ROBERT A. ROSENBLATT and STUART SILVERSTEIN, TIMES STAFF WRITERS, Los Angeles Times, March 20, 1993, Part D; Page 1; Column 2; HEADLINE: NEWS ANALYSIS; MEDICAL COVERAGE REFORM WILL COST PLENTY\\VT 93-94
	 "Washington Redskins' tickets are fully deductible as a legitimate business expense, so we strongly oppose any notion of limiting employer deductions for something as important as health insurance," said Kristin Bass, a policy manager for the U.S. Chamber of Commerce. Businesses with good benefits, including costly programs such as preventive examinations, and "fitness" exercise gyms, "would feel they are being penalized when they are the good guys," Bass said. From the union point of view, "people gave up pay raises for these benefits" and it would be unfair to lose them because of changes in the tax laws, said Paul B. Worthman, director of research and negotiations for Local 399 of the Service Employees International Union, many of whose 25,000 members in Los Angeles County are health care workers. Worthman also expressed concern that requiring most workers to pay up to 25% of the cost of health insurance might keep coverage beyond the reach of many working-class families. 

C193/ROBERT A. ROSENBLATT and STUART SILVERSTEIN, TIMES STAFF WRITERS, Los Angeles Times, March 20, 1993, Part D; Page 1; Column 2; HEADLINE: NEWS ANALYSIS; MEDICAL COVERAGE REFORM WILL COST PLENTY\\VT 93-94
	 In Los Angeles, for example, a company with a rich menu of health benefits might now be spending an average of $4,500 a year for each worker's health insurance. But the low-priced plan might have a cost of $2,000 a year, and this would become the limit for the tax deduction. Companies would immediately switch to the lower-priced plan, and any worker who wanted the more extensive benefits from a $4,500 plan would have to buy additional coverage out of pocket. Thus, workers at major corporations with costly benefits could find themselves with slimmed-down benefits, just as they were hit with the new, separate health care payroll tax. 

C194/Andrew Bates, NEW REPUBLIC, 02/03/92, TITLE: Middle-class Medicaid, Online America, Transmitted: 92-11-26 01:30:00 EST \\VT 93-94
Like it or not, it is not the birthright of upper-income and middle-class Americans to have their medical bills paid by the rest of us. At least not yet. 

C195/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Voluntary Coverage. -- Others believe that federally guaranteed access to insurance is not necessary in part because eight out of 10 Americans already have some health insurance coverage. Instead, they favor increased insurance subsidies or tax incentives from the government for uninsured individuals and families to voluntarily purchase their own insurance and for underinsured Americans to obtain more comprehensive coverage. They believe people should be allowed to make purchasing decisions based on their own priorities for spending, which may include other goods that contribute to health, such as food, housing, and education. Similarly, they believe businesses should also have the choice of whether or not to provide insurance for their employees because requiring insurance coverage could create an economic burden that threatens business' financial well-being and long-term viability. For these reasons, they favor approaches that include government incentives for businesses and individuals to purchase private health insurance but do not favor the government requiring employers to provide coverage to their employees. 

C196/JACK D. DAVIS, The Atlanta Journal and Constitution, April 28, 1992, Section A; Page 13 HEADLINE: 'Easy' answer is the wrong one \\VT 93-94
	 Our problems are not so overwhelming that we should destroy a health- care system considered the best in the world in favor of something that we already know doesn't work. 

C197/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	 Most of the factors forcing up costs lie outside the the health industry, including general inflation, higher personal income that results in greater use of medical care, and liability laws that lead to defensive medicine, Sullivan contended. "Our legal system is unique, to put it mildly. No other country has anything remotely like our liability system," which "piles on the cost" of health care, he said. "We can't leave out the necessity of legal reform," he added. 

C198/Pension Reporter, January 6, 1992, Pg. 4 TITLE: REFORM PLANS SHOULD BE TESTED AT STATE LEVEL FIRST, PANEL ADVISES. \\VT 93-94
	To control health care costs, the council's [Advisory Council on Social Security] recommendations included promoting healthier lifestyles by prohibiting all forms of advertising of tobacco products, developing an alternative procedure to adjudicate malpractice claims, and developing educational materials on personal financial management to help students plan for their elder years. 

C199/JACK D. DAVIS, The Atlanta Journal and Constitution, April 28, 1992, Section A; Page 13 HEADLINE: 'Easy' answer is the wrong one \\VT 93-94
	 There is a way to control costs that will work: Hospitals and physicians must work together with those in our community who pay for health insurance to examine ways to eliminate unnecessary care; encourage the use of managed care (HMOs, PPOs); urge our legislators to enact sane malpractice laws; and create incentives to help smaller employers afford health insurance for their workers. 

C200/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 The Expansion of Medicaid Despite the resistance of the state governors, we believe that Congress should continue to enact, as it has since 1984, mandates and incentives for the states to enlarge Medicaid coverage. In the last 6 years this effort has resulted in adding approximately 900 000 persons to the rolls. Despite federal and state fiscal constraints, we urge, at a minimum, that the present rate of expansion be continued and that, as the political and economic environment becomes more favorable, Congress accelerate the enrollment of all persons below the federal poverty standard. This policy change has been recommended by the American Medical Association, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. 

C201/Eli Ginzberg, PhD, Journal of the American Medical Association May 15, 1991; 265: 2559-2562 TITLE: Beyond Universal Health Insurance to Effective Health Care \\VT 93-94
	 Subsidized Coverage for the Near Poor Some state experiments are under way to permit persons with incomes between 100% and 200% of the federal poverty level to buy into Medicaid. Since the federal government covers on the average 55% of state Medicaid outlays, and in low-income states as much as 78%, we urge the adoption of program models that, after critical assessment, have been found to be effective. This would represent, at the optimum, an addition of some 18 million people. At an average expenditure of $2319 per recipient (fiscal year 1989), the estimated gross cost would be $42 billion, but the net cost would be considerably less. [n9] 

C202/Spencer Rich, Washington Post Staff Writer, The Washington Post, January 11, 1992, PAGE A11 HEADLINE: 2 Studies Differ Sharply On Health Care Overhaul \\VT 93-94
	A second part of the CBO study looked at what would happen if the current system continued, with private insurers playing a central role, but with the nation's uninsured covered by Medicare and doctor and hospital payment rates tied to Medicare. The cost increase would be $ 5.6 billion, but the program would be providing universal coverage. 

C203/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Retain Medicaid. -- Advocates of retaining Medicaid favor its much lower payment rates than either Medicare or private insurance. They also argue that Medicaid is already in place and is known by the public and health care providers. 

C204/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 193 \\VT-JHH
Conceptually, a comprehensive and universal national health insurance scheme is not synonymous with a non market control mechanism. After all, it is possible to create a universal health insurance program without budget control, an open-ended program that simply paid the bills--a larger version of the early years of Medicare. Alternatively, one could create a budgeting system that set an upper bound to health care expenditures but did .not provide for universal access or coverage.

C205/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Multiple opportunities exist for community health education and promotion efforts on the part of government, voluntary and self-help groups, businesses, and schools. 

C206/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Such local community programs are often more efficient than centralized programs managed far from the point of delivery. Community-based programs can also maintain greater sensitivity to family and neighborhood values that can significantly impact the health and lifestyles of individuals who live, work and play within the community. 

C207/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Many important disease prevention and health promotion activities, such as smoking cessation, diet modification, and physical conditioning, can be accomplished at the worksite in an effective and efficient manner. Company policies can help create a healthy work and living environment and contribute to the ecology of the communities in which they are based. 

C208/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 4. Schools: Schools have a special role in enhancing and maintaining the health of their community's children, since roughly one-quarter of a young person's time is spent in this environment. 

C209/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 School health education can foster healthful behaviors and help prevent hazardous ones, particularly in the areas of physical fitness, smoking, drug, and nutrition. 

C210/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Standard course curricula can be modified to include health promotion, as, for example, through the addition of environmental health components to science classes. Provision of healthy meals, safe work and play areas, and physical education courses that stress the acquisition of lifetime exercise habits can be instituted as well to foster the long-term health of our youth. 

C211/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Most of all, Payer [veteran medical journalist and author] feels an ''informed consumer is probably the best defense. . . . We the public should insist that health care providers compete, not on the basis of the number of glitzy machines that mostly serve to convince us we are ill when we're not, but on the basis of superior service using an honest appraisal of the risks and benefits of diagnosis and treatment.'' 

N212/THOMAS CLAVIN, The New York Times, February 9, 1992, Section 12LI; Page 12; HEADLINE: The Impact of No Health Insurance \\VT 93-94
	Ms. Donovan said the schools should address the problem because it affected children's health and absenteeism. When a child is sick, she said, an uninsured family is less likely to seek early medical attention. That not only increases the risk of a child's becoming seriously ill, she noted, but also infects classmates if the child continues to attend school. 

C213/ELl GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p. 88 \\VT-JHH
Health promotion and environmental Health. The Henry J. Kaiser Family Foundation, after a two-year reevaluation of its grant-making strategy, decided to support a new major commitment to "health promotion" as well as a new emphasis on improving the results of health care "in ways that enhance the patients' functioning in their everyday lives." One of the oldest but also one of the smallest of the health foundations--the Milbank Memorial Fund, with a long-term commitment to public health--is phasing out its five-year program of clinical epidemiology fellowships for talented young physicians and has selected environmental occupational health as the focus of its future grant-making, starting with a hard look at the health problems of migratory farm workers.

C214/EDWIN CHEN and ROBERT A. ROSENBLATT, TIMES STAFF WRITERS, Los Angeles Times, January 8, 1992, Part A; Page 4; HEADLINE: CHILDREN'S HEALTH CARE PLAN URGED \\VT 93-94
	In the divisive debate over health care reform, one consensus is emerging: the need to provide care for tens of millions of children and pregnant women who do not qualify for Medicare but cannot afford private insurance. "There's a broad consensus across the political spectrum -- in both the private and public sectors -- that you have to take care of these highly vulnerable populations," said Richard I. Smith, policy director of the Washington Business Group on Health. 

C215/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 24, 1993, Part A; Page 14; HEADLINE: DEBATE FLARES ON WHO'S FIRST IN HEALTH PLAN\\VT 93-94
	 Clinton's health policy analysts argue that the needs of low-income women and children are paramount, saying that childhood immunizations and perinatal care are not only "the right thing to do" but will also avert treatments for low-birth-weight babies and other costly conditions often caused by neglect. "Women and children shouldn't be seen as a typical liberal move," said one analyst. "An easy case can be made that the wisest application of new resources, and with biggest payoff, would be to go after this group." 

C216/National Public Radio, SHOW: ALL THINGS CONSIDERED, March 26, 1992, HEADLINE: INFANT MORTALITY REMAINS HIGH IN USA, Nexis \\VT 93-94
	 Neighmond: And the commitment to maternal and child health, says McCormick, goes beyond just money. In most of the developed world, she says, healthy babies are a high priority. For example, in Japan, pregnant women are given an official handbook to chart their health through pregnancy and the health of their babies after birth. Parents celebrating various benchmarks are awarded presents throughout pregnancy and the baby's first year of life. That may sound like a gimmick, say health experts, but the bottom line--it works. Japan leads the world when it comes to healthy births. In Los Angeles, I'm Patricia Neighmond reporting. 

C217/The Houston Chronicle, January 9, 1992, SECTION: HOUSTON; Pg. 1 HEADLINE: SAVE THE CHILDREN; Surveys: Kids top priority list for tax dollars \\VT 93-94
	Three in five Americans list guaranteeing all children health care, quality education, safe neighborhoods and economic security as one of their top three priorities for tax dollars. In Texas, there is overwhelming support (93 percent) for providing children with the basic necessities -- affordable health care, public education, protection from abuse and crime 

C218/Martin Dyckman, associate editor, St. Petersburg Times, January 21, 1993, Pg. 17A, HEADLINE: What if children could vote? \\VT 93-94
 Peterson attributes the differences to the fact that the elderly vote - and with a single mind on some issues - while children do not. Then he posits the tantalizing question: What if children - who outnumber the elderly 2 to 1 - could vote? Among other things, he speculates, "benefits to children would become a matter of right rather than a public benefaction" (that is, charity) and would be standard nationwide, including a family allowance regardless of income. There would be national health insurance for everyone. Families would get education vouchers to purchase schooling wherever they preferred. Costs of the health and educational systems would be capped. Social Security benefits would be scaled back, but the existing penalty to beneficiaries who continue to work to age 70 would be repealed. "I do not specifically recommend these policy innovations," Peterson writes, "But neither am I alarmed by them. What is alarming is the current imbalance in the structure of the American welfare state and the nation's political incapacity to do anything about it." 

C219/Martin Dyckman, associate editor, St. Petersburg Times, January 21, 1993, Pg. 17A, HEADLINE: What if children could vote? \\VT 93-94
 But of course children aren't going to be voting anytime soon. It was hard enough to lower the voting age from 21 to 18, and that might never have happened but for a moral imperative - the military draft - that no longer exists. For new imperatives, though, one need look no further than the impoverishment of today's children and the scandalous debt they will inherit from elders who wanted to have a good life without paying for it. 

C220/Martin Dyckman, associate editor, St. Petersburg Times, January 21, 1993, Pg. 17A, HEADLINE: What if children could vote? \\VT 93-94
 We talk about "one person, one vote," yet 65-million Americans - more than the entire population of Britain - are disenfranchised by age, and their interests often go unrepresented. It will be said children are not wise enough to vote - as if their elders always did so well at the polls. That argument could be met by allowing each child, even one who cannot yet read, a proxy that a parent would cast. One person, one vote. Why not? 

C221/Advertising Age, February 17, 1992, Pg. 32, HEADLINE: Time to treat medical customers \\VT 93-94
	 If advertising the cost of eyeglass prescriptions had the effect of dramatically bringing down costs, wouldn't the same formula be worth a try at hospitals? Why shouldn't a hospital with a good track record and lower costs advertise those facts to the public? 

C222/Advertising Age, February 17, 1992, Pg. 32, HEADLINE: Time to treat medical customers \\VT 93-94
	 Something like, "Before you have your bypass, check the statistics. American General has a lower incidence of mortality (I would think they'd want to stay away from 'death rate') than any other hospital in the region. And our prices are competitive, too." The hospital would offer to send the government's analysis. 

C223/VICTORIA A. WANZER, The Atlanta Journal and Constitution, September 29, 1992, Section A; Page 7, HEADLINE: Nationalized health care will bankrupt nation \\VT 93-94
	 Before we destroy the world's highest quality medical care, limiting care for everyone, begin by limiting care to those who do not care for their own health. Stop Medicare-Medicaid for illnesses related to tobacco and alcohol and drug abuse. That's what the "play or pay" plan should entail. 

C224/ROBERT KAPLAN, Prof. Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, p.21\\VT-ADPL
Hadorn & Brook (1991) suggested the development of basic benefit insurance packages that use practice guidelines to guide physician decision making. These guidelines would. direct providers away from excessively costly and unnecessary procedures. The assumption is that enough money would be saved by elimination of unnecessary services to create access to basic services for all people.

C225/ELI GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p. 87-8 \\VT-JHH 
Many foundations in the health field, with the Robert Wood Johnson Foundation in the lead, have directed sizable resources over several decades to improving the delivery of health care to various populations at risk, in particular low income-groups, people who live in underserved areas, newborns requiring costly and prolonged care, trauma victims, the homeless, patients discharged from mental hospitals, and others. The aim and expectation underlying such foundation support has been the development of successful models that could be widely replicated.

C226/B.D. Colen, medical correspondent, Newsday, December 8, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 79, HEADLINE: Health Care at Square One \\VT 93-94
	 That's right. It's time to recognize that halfway measures will not succeed  in "reforming" the health-care system, because we do not have a system. Instead, we must recognize that the time has come to build a totally new system, taking  the best, and attempting to avoid the worst, from the various health-care systems we can observe. 

C227/SAMIR N. BANOOB, professor of health policy at the University of South Florida's College of Public Health, St. Petersburg Times, February 7, 1993, Pg. 4D, HEADLINE: Health care: Painful remedies are needed \\VT 93-94
 This issue has been evolving since the 1950s. A number of incremental actions have been aimed at solving the problem, but none has worked. Our  inability to face the issue with a defined national health care policy has made it even more complex and perhaps even unsolvable. 

C228/SAMIR N. BANOOB, professor of health policy at the University of South Florida's College of Public Health, St. Petersburg Times, February 7, 1993, Pg. 4D, HEADLINE: Health care: Painful remedies are needed \\VT 93-94
 Second, incrementalism will not work. "Business as usual" - i.e., free  choice of physicians, hospitals and services - will not work. The only chance for success lies in providing for all a basic-managed care (HMO) model. Those who want more can pay for it. We must look to other countries' experiences,  learn from their mistakes and come up with a custom-tailored plan that fits  our needs. 

C229/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Citizens should not adopt the posture that many analysts and politicians have chosen: to reject what they agree is an efficient and workable program because they presume it is too big a step and cannot pass the legislative hurdles. The less efficient incremental approaches that seem "better" may prove as challenging to enact as the single enrollment program outlined here. Nothing will come easily, but on health insurance reform, as on other matters, the public may be ahead of the representatives. 

C230/Sen John D. Rockefeller IV, Journal of the American Medical Association, May 15, 1991; 265: 2507-2510 TITLE: A Call for Action; The Pepper Commission's Blueprint for Health Care Reform \\VT 93-94
	 1. Health insurance coverage must be universal. Only if everyone is adequately covered can we assure all Americans access to care when they need it and bring an end to "cost shifting" and underservice to the uninsured. 

C231/MICHAEL R. McGARVEY, health benefits planner, The San Francisco Chronicle , NOVEMBER 11, 1992, Pg. A21; HEADLINE: Solution to Health Care: Keep It Simple \\VT 93-94
	 Unless the president's single top priority for health care reform is universal coverage -- financial access to health services for all Americans -- no progress on correcting our most basic health-care problems will happen. Forces protecting the status quo are simply too rich, too powerful and too well-connected. 

C232/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 DICK DAVIDSON (PRESIDENT, AMERICAN HOSPITAL ASSOCIATION): We've developed a system that makes no sense, that penalizes people who pay their own bills, and we need to develop a system that has equity in it. And in that sense, we've got to start with the first premise, and that is, that we must move to universal access for all Americans. Without that, you don't get true reform in this system, and to develop a level playing field, and fairness and equity in the treatment of all citizens of the United States as well as the providers who take care of people in their communities. 

C233/Teri Randall, Journal of the American Medical Association, November 4,1992; 268: 2352 TITLE: An Ethicist's Perspective on Health Care Reform \\VT 93-94
	 The two-tiered system is especially problematic, Dougherty says, when the majority of people receive high-quality, comprehensive care and the remaining 25% or so receive "low quality, frustrating, disrespectful care." 

C234/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 A single universal program has another positive feature - one that becomes apparent when we compare Social Security with welfare and Medicare with Medicaid. Social Security and Medicare do not discriminate on the basis of income. Conversely, welfare and Medicaid are solely for the poor. The first two are strong programs that, by including everyone, protect low-income individuals from the vagaries of funding; the fates of diverse income groups are inexorably intertwined. In contrast, we fund welfare and Medicaid for "them" - and we all know or think we know who "they" are. These programs rely on the milk of human kindness, but this milk sometimes curdles. To minimize the development of disparities in access and in quality, it is important to erect programs that do not enroll persons according to socio-economic characteristics and sources of funding. 

C235/Charles Marwick, December 23, 1992-December 30, 1992, Journal of the American Medical Association; 268: 3415, 341, TITLE: Science Organization Sponsors Discussions About What Constitutes Health Care Reform \\VT 93-94
		 WHEN IT COMES to deciding what goes into the health care package -- services that would be covered by a national health insurance plan -- the first thing is to put everyone in the same boat. A two-tiered system, one that provides coverage for those who can pay or are covered by insurance, and another for the poor, the unemployed, or the inadequately insured, is unacceptable. And coverage should be universal. These are conclusions from a draft document being discussed by the American College of Physicians (Philadelphia, Pa) for dealing with one aspect of health care reform -- the services to which all should have access. 

C236/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Enrolling everyone in the same plan will certainly not solve or even address all the shortcomings of the current system. But the approach would enable us to tackle the issue of cost containment in a direct way. A single enrollment program means a single payer or, more appropriately, a single purchaser of services. This situation leads to the standardization of forms, to electronic building and to various measures that reduce confusion, delay and the costs of administration in today's system. The purchaser would not only pay the bill for services but also accept a broader responsibility to focus on issues of quality of care, unnecessary services and value for money. Each of these activities contributes to cost control. 

C237/Teri Randall, Journal of the American Medical Association, November 4,1992; 268: 2352 TITLE: An Ethicist's Perspective on Health Care Reform \\VT 93-94
	 A more ethically acceptable two-tiered system, he says, would resemble the British system, in which 90% of the people use the National Health Service, and 10%, the very wealthy, buy additional care. The second tier provides an "inevitable social safety valve," he says. The fundamental difference between the two systems is which tier -- the upper or the lower -- the middle class finds itself. This ultimately determines the system's fairness: "If middle America is in the top tier, they don't identify with, or care about, or vote to fund the bottom tier," Dougherty says. 

C238/Teri Randall, Journal of the American Medical Association, November 4,1992; 268: 2352 TITLE: An Ethicist's Perspective on Health Care Reform \\VT 93-94
	 An example is the differences in political support given Medicare and Medicaid. "Medicare, in spite of its multiple problems, is a politically popular program, and politicians defend it," Dougherty says. "Why? Because we are all going to use Medicare when we are 65. But Medicaid, generally speaking, is 'the other guy's problem.'" 

C239/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Of course, there can be no guarantee that underspending will not occur. Nevertheless, it is possible to structure national health insurance to reduce the likelihood of such a phenomenon. The most important protective device is universality - the fact that everyone is covered by the same financing scheme. Although individuals will be able to opt out of the publicly funded program in favor of private insurance, the incentive to exercise that option can be reduced by requiring payment of the universal tax even if one elects to receive privately funded care. Moreover, stipulating that providers be entirely in or out of the program would guard against underspending. 

C240/ RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 211 \\VT-JHH
A universal health insurance program is not an untested idea; the United States already has Medicare, and other nations (including our neighbor Canada) have even more extensive programs covering their entire populations. Adding cost containment features to insurance is also not a novel venture; individual states, private insurers, and Medicare are moving in that direction, albeit haltingly and, because there are multiple payers, without a well-conceived, coherent plan that eliminates cost-shifting. Nevertheless, it would be foolish to argue that universal health insurance is only a minor change that should arouse no opposition. Consequently, even some who favor a universal and comprehensive program might argue that to implement a complete plan would be too large a single step. They would suggest that we move in incremental fashion, in a series of small steps. 

C241/RASHI FEIN, Prof. Medicine Harvard, 1986, MEDICAL CARE, MEDICAL COSTS, p. 212 \\VT-JHH
It is useful to consider the possible risks and benefits to be derived phasing in universal insurance over a defined period. The benefits seem clear: the fiscal impact would be spread over a number of years and the shock in any given year would be reduced. In addition, the necessary administrative capability could be built up gradually. A phasedin program would appear to be more responsible and therefore might be more appealing to the body politic. But there are costs associated with such a strategy. The most obvious, of course, is that we would postpone full implementation of the program, and thus the attainment of equitable access and the development of both effective and equitable cost control measures. Our health care system would grow more complex and engage in more and yet more creaming. The health financing problems faced by an expanding number of our citizens would increase. The longer take to reach our goal, the more difficult our task becomes.

C242/Business Wire, June 16, 1992, HEADLINE: Health policy experts call for better data to improve health care quality, NEXIS \\VT 93-94
	 Williamson [Williamson, director of the Salt Lake Regional Medical Center] said diagnostic errors are the most serious problem in medicine today, but use of the expert systems with clinical guidelines would greatly improve quality. 

C243/AMERICAN MEDICAL ASSOCIATION; 268: 3415, 341, TITLE: Science Organization Sponsors Discussions About What Constitutes Health Care Reform \\VT 93-94
	 However, says economist Mary Ann Baily, PhD, George Washington University, Washington, DC, another speaker at the meeting, this process has to be a dynamic, ongoing one that responds to changes in medical practice. "It can't be a fixed amount of dollars or fixed amounts of care," she says. "And there has to be some way for societal preferences to influence the process, informing the health care system what the trade-offs are between one benefit and another and between health benefits and everything else. It requires the input of medical professionals, but also there has to be input from the public, from the political process." 

C244/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 For many, making a decision will not be easy. They would prefer to look at the actual experience with each solution proposed, assess the independent research as to its effectiveness, and then make an informed decision. The reality is that the United States has only had limited experience with many of these approaches to containing costs and covering the uninsured. In the next several years there are likely to be additional research findings that will elucidate but not completely resolve many of the underlying questions. Even when this information is available, the public and health professionals will ultimately have to form their judgments based on their assessment of other, similar changes 

C245/HARVARD HOLLENBERG, The New York Times, December 27, 1992, Section 4; Page 10; HEADLINE: Bringing the Doctors In \\VT 93-94
	 Any advice from Dr. C. Everett Koop must be granted serious consideration, including his recommendation that medical care reform be further studied  (letter, Nov. 30).  

C246/Business Wire, June 16, 1992, HEADLINE: Health policy experts call for better data to improve health care quality, NEXIS \\VT 93-94
	 Health care providers, the government and private insurers must trust each other enough to share information if the quality of health care in America is going to improve, an executive of The Travelers said at the opening of the National Health Care Quality Management Conference. 

C247/Business Wire, June 16, 1992, HEADLINE: Health policy experts call for better data to improve health care quality, NEXIS \\VT 93-94
	 Dr. David M. Eddy, professor of health policy and management at Duke University, underscored a needs for information systems to gather better data on who patients are and what treatment they receive, in order to improve efficiency. ''The assumption that practioners instinctively know the right thing to do is being challenged,'' Eddy said. Eddy cited variations in practice patterns, questions of what constitutes appropriate care, and the fact that up to 30 percent of all medical procedures have never been studied as reasons why better data is needed by physicians. 

C248/Business Wire, June 16, 1992, HEADLINE: Health policy experts call for better data to improve health care quality, NEXIS \\VT 93-94
	 Speaking on variations in hospital quality, Dr. Haya Rubin, director of quality of care research at Johns Hopkins, said hospitals have a serious quality problem with adverse events and death rates varying dramatically among similar hospitals. She noted that hospital performance could be improved through new and better data collection to accurately compare outcomes. 

C249/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 There's defensive medicine--doctors ordering test after test to cover themselves in case of a suit. There's competition among hospitals, each spending millions on duplicative technology in the hope of attracting patients. And there's the simple fact that medicine has more to offer than ever before--more tools, more pills, more procedures, more solutions for more problems--yet little objective information on what works best. 

C250/Herman A. Kohlman, FHFMA, is a retired healthcare executive, Healthcare Financial Management , October, 1992 , Pg. 89, HEADLINE: The American healthcare dilemma: is there a solution? \\VT 93-94
	 The effect of demographics on any meaningful solution to the healthcare dilemma cannot be underestimated; yet, very little is heard in the way of serious discussion on this subject. Instead, the public is offered proposals that suggest changes in delivery mechanisms, improved access to health care, introduction of new technology, and so forth. While these suggestions are important and deserve serious consideration, there can be no meaningful discussion of possible long-term solutions until the impact of demographics is considered. 

C251/PR NEWSWIRE, March 23, 1993, TITLE: VETERANS & HEALTH REFORM: PVA STUDY STATES HEALTH-CARE REFORM MUST CONSIDER VA'S ROLE, Online America, Transmitted: 93-03-23 16:46:00 EST \\VT 93-94
	 "We feel that veterans' dependence on VA health care, the system's immense resources, and its service to national needs and values, should be more than an arbitrary afterthought," Etherton [Paralyzed Veterans of America] stated. 

C252/ROBERT KAPLAN, Prof. Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, p.185 \\VT-ADPL 
This book has emphasized the crisis in contemporary health care. However, there is a second crisis---the crisis of ignorance. Our understanding of the effects of contemporary health care upon health outcomes is shameful. When new treatments are introduced we typically know something about the biological theory, the mechanism of action, and the effect of treatment upon some specific biologic outcome. However, the effects of treatment upon everyday functioning and quality of life are rarely evaluated.

C253/Bob Boorstin, White House Press Officer, April 22, 1993, HEALTH PROFESSIONALS TO REVIEW CLINTON PROPOSAL AS IT DEVELOPS, WHITE HOUSE PRESS RELEASE, Transmitted: 93-04-23 09:19:37 EDT, Online America//VT 93-94
	"The practical test for implementation of any health plan must be a critical review by health professionals and the patients they serve," said Ira Magaziner, the director of the Health Care Task Force.

C254/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 Despite the proper emphasis on grassroots public involvement in these efforts, physicians and organized medicine have leadership roles to play. Physicians have a unique perspective on clinical realities and patient needs that must be a part of all public assessments of the common good in health policy. 

C255/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 An assessment of these prior efforts to reform aspects of our national policies will play a role in making choices about national health care reform. Our hope is that the framework presented here will improve the ability of a broad range of people to participate more effectively in this debate and bring it to closure by developing a solution that would resolve one of America's most serious problems. 

C256/Howard Dean, MD, Governor, State of Vermont, Journal of the American Medical Association, October 16, 1991; 266: 2080 TITLE: Caring for the Uninsured and Underinsured \\VT 93-94
	 Any enactment of universal health insurance is going to be pushed through by a coalition that must include America's corporate leadership as well as the traditional groups who advocate universal health insurance in the United States. 

C257RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 Applying the concepts of prejudice, discrimination, and moral hypocrisy to this health care debate cannot be done without causing some defensiveness and discomforting controversy. Such a reaction will cause ethical dissonance, which occurs when the values of individuals and-or society are challenged by conflicting or alternative values such that individuals and-or society reevaluate their value system and consider other values. Health care debates are needed to generate ethical dissonance in society. Such debates could help our society to adopt the value system of an NHCS. 

C258/Capital District Business Review, January 4, 1993, Sec 1; pg 20, HEADLINE: This year gets health care off the back burner with a start of national health insurance reform \\VT 93-94
 "Everybody wants to be at the negotiating table," said Jeannie Cross, a spokeswoman for the Hospital Association of New York State, which supports the American Hospital Association's call for universal health care provided by an employer-based, pay-or-play insurance plan. 

C259/B.D. Colen, medical correspondent, Newsday, December 1, 1992, Pg. 85, HEADLINE: Health-Care Reform: Time To Define Its Parameters \\VT 93-94
	 WITH ALL THE DISCUSSION and debate about the need for health-care reform, and the form that reform should take, it is astounding how little thought has been  given to the most basic element in such a discussion - the precise meaning of the term "health." Before we can begin making any changes in the ways in which we deliver, or pay for, health care, and before we begin providing health care to people who do not now receive it, we must come to some sort of national agreement on exactly  what it is we are going to deliver and pay for. 

C260/SAMIR N. BANOOB, professor of health policy at the University of South Florida's College of Public Health, St. Petersburg Times, February 7, 1993, Pg. 4D, HEADLINE: Health care: Painful remedies are needed \\VT 93-94
 Lastly, and most importantly, the public should be fully informed and mobilized to stand up for radical reform. Caring for the health of the people should and must exceed the power of the special interests. 

C261/St. Petersburg Times, June 22, 1992, Pg. 7A, HEADLINE: There are no quick solutions to health-care crisis \\VT 93-94
	 Kevin DiLallo, Associate Executive Director, Humana Hospital Northside, St. Petersburg: There is a strong push for a Canadian-style health care system by the St. Petersburg Times and others in the nation when there is a cry for less government involvement in our daily lives sort of a national health insurance with no government involvement. Good leaders and the public should not expect quick solutions. Attitudes toward health care have taken a long time to evolve to their present position. All reforms now being debated by leadership cannot succeed without a substantial level of public understanding and support. Until the public concerns are taken seriously and responded to, reforms will come slowly. 

C262/St. Petersburg Times, June 22, 1992, Pg. 7A, HEADLINE: There are no quick solutions to health-care crisis \\VT 93-94
	 Jack Bila: I don't know what all the fuss is about concerning health care in this country. I say let's put a referendum on the November ballot and let the people decide whether or not they want socialized medicine. 

C263/Business Wire, June 16, 1992, HEADLINE: Health policy experts call for better data to improve health care quality, NEXIS \\VT 93-94
	 Several speakers including Leslie Michelson, president and chief executive officer of Value Health Science, stressed the need to standardize existing data and encourage more active patient participation in decision making. Michelson released new figures collected by 18 users of his company's Medical Review Systems (MRS). Over a database of 93,000 cases, Value Health has identified 10 percent to 15 percent of MRS-screened procedures as inappropriate. He said Value Health is saving its customers nearly $10 million each quarter with use of the new system. 

C264/Herman A. Kohlman, FHFMA, is a retired healthcare executive, Healthcare Financial Management , October, 1992 , Pg. 89, HEADLINE: The American healthcare dilemma: is there a solution? \\VT 93-94
	 The issues facing American society in the '90s and beyond are truly challenging, with health care being in the forefront. It will take the collective efforts of business, government, and society in general to assure that an effective national health policy is developed and appropriately financed so that the healthcare needs of U.S. citizens are addressed. 

C265/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 2. Voluntary Organizations: Voluntary organizations have long worked to improve health through research, public education, and other program activities. The spirit of volunteerism is one of our strongest national traditions. Groups that have not traditionally been involved in reducing health risks should begin to define their role in community health education. 

C266/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 By working together -- by mobilizing individuals, families, neighborhoods, schools, businesses, churches, the media, and government -- we can make great strides toward helping Americans become healthier, more productive, and more fulfilled. It is what we do collectively and personally that will move us as individuals and as a Nation towards a healthier future. 

DISADVANTAGES

DRUG BREAKTHROUGHS LOST

A. National health insurance will lower drug prices
	1. Adopting the Canadian system would lower drug prices
		a. Canadian system actively fights higher drug prices D1-3
		b. Americans pay higher prices to subsidize Canadian drugs D4
		c. Drugs are 83% more expensive in the USA D5
	2. Health care reform threatens to lower drug prices
		a. Drug industry is a target for reformers D6-8
		b. The threat of health care reform is enough to slow price increases D9-10
		c. Payments lead to price controls D11
B. High drug prices are needed to pay for drug research and development
	1. Drug R&D is increasing now D12
	2. Drug R&D is risky and costly D13-15
	3. Drug prices pay for drug R&D
		a. High prices finance drug R&D D16-17
		b. Drug industry invests more in R&D than any other health related industry D18
		c. Drug industry is the major source of new R&D D19
	4. Price controls will ruin drug R&D
		a. Drug R&D becomes a poor investment under controls D20
		b. Resources vanish under controls D21
		c. Increased regulation sends R&D overseas D22
		d. Regulation trades off with drug R&D D23
		e. Under controls, funds shift to marketing D23a
	5. Other countries prove NHI hurts drug research
		a. Price controls mean fewer new drugs D24
		b. Innovation was destroyed in France D25
		c. German companies slashed R&D D26
C. New drugs promise astounding benefits NHI would squander
	1. Better drugs mean better care and less cost D27-30
	2. Drug innovation offsets the trade deficit D31
	3. New drugs will save thousands of lives and billions of dollars 
		a. Only the current system will deliver new drugs D32-34
		b. New drugs will stop AIDS, Alzheimer's, and cancer D35-37a
		c. New drugs cure mental illness and addiction D38
		d. New drugs will revitalize the brain D39
	4. New drugs aid 2-3 million heart failure victims
		a. Over 20 million with heart failure D40
		b. 270,000 Americans die each year from heart failure D41
		c. New drugs stop this suffering D42-44
	5. There are no problems with new drugs D45
	6. Drug R&D restores America's competitiveness D46
AFFIRMATIVE RESPONSES
1. Nations with price controls spend more on drugs than Americans D47
2. Drug prices are soaring in Canada D48
3. Drug companies invest in marketing, not R&D D49
4. Price controls do not stop innovative drugs D50
5. Faster approval would speed up drugs D51-53
6. There are no miracle drugs coming D54-55
7. Drug costs are too high for the elderly now D56
8. 80% of new drugs are only a market gimmick D57-58
9. Drug companies mislead doctors D59-62
10. Drug companies prevent international environmental cooperation D63

MEDICAL TECHNICAL BREAKTHROUGHS LOST

A. Links: national health insurance will restrict medical technical innovation
	1. Single payer system reduces tech D66
	2. Cost controls reduce tech D67-82
	3. Increased access threatens tech D83-84
	4. Decreased profits reduce tech D85-86
	5. Limits on care reduce tech D87-88
	6. Government control reduces tech D89
B. Brink, uniqueness, linearity
	1. Linear: every loss of medical tech is bad D90-91
	2. Unique: USA is #1 in medical tech now D92
	3. Status quo is not wasteful, but legitimate demand for new tech D93
	4. Public opinion supports more medical tech D94-95
	5. Unique: the status quo will increase tech D96-98
	6. Market system is he best way to guarantee new tech D99-101
	7. Canadian system decreases tech D102-110
C. Impacts: medical technology is wonderful and NHI will reduce it
	1. Tech essential to improving health care D111-112
	2. Tech saves lives D113-114
	3. Tech serves the needs of the people D115
	4. Tech expands treatable afflictions D116
	5. Tech will expand youthfulness D117-118
	6. Tech will end major diseases D119
	7. Medical tech is cost beneficial D120-122
	8. Tech will increase human potential D123
	9. Tech will decrease costs D124
	10. Biomedical research has many other applications D125
	11. Biotech solves major world problems D126
	12. Biotech solves pollution D127
	13. Tech means abundance D128
	14. Less tech means the decline of the human spirit D129
	15. Tech solves specific illnesses
		a. Alzheimer's D130
		b. AIDS D131-133
	16. Example: gene therapy D134-138
	17. Example: human growth hormone D139-140
	18. Example: computer diagnosis D141-147
	19. Examples: magnetic resonance imaging D148

AFFIRMATIVE ANSWERS
1. We do not need all of this medical tech D149-150
2. Federal money accounts for 85% of R&D D151
3. Need reforms so that tech can be properly used D152
4. Tech is no better than traditional methods D153
5. Tech focus is the cause of many of our medical problems D154
6. Should use the tech we already have first D155
7. We can cut waste and use it to fund tech D156
8. Most modern tech is just a fad D157
9. Too much tech makes for a bad medical system D158-159
10. Canada does not have less tech D160-161
11. Less tech will not cost lives D162
12. More tech means less cost beneficial prevention D163-164
13. Tech will not lower costs D165
14. More medical tech will increase infections D166
15. Increased dependence on tech means increased problems D167-169
16. More tech threatens survival D170-172
17. Tech deadens the human spirit D173-174
18. Tech medicine is much like death D175
19. Tech medicine creates economic contradictions D176
20. Tech deadens compassion D177
21. Biotech is dangerous D178
22. Tech leads to social disharmony D179
22. Immortality would be bad D180
23. New techniques do not help cancer D531-533

AFFIRMATIVE SPENDING WILL CAUSE SCIENCE CUTS

A. Affirmative program will be expensive
	1. It is going to cost a lot D181-183
	2. Affirmative cost figures are soft D184-189
	3. NHI will NOT save money D190-191
	4. Affirmative savings figures are soft D192-193
	5. Savings must be in the first year to stop the need for new funds D194
	6. Savings payback will be long-term, at best, so new money will still be needed D195-198
	7. Coverage will be expanded so costs will rise D199
	8. All NHI plans will need new funds D200
	9. Affirmative must disclose the cost and how they think they are going to pay D201-202
	10. Specific cost estimates (also, see N section)
		a. Employer mandate D203
		b. Pay or Play D204
		c. Medicaid expansion D205
	11. State contributions will be lost D713
B. Affirmative budget options will be changed to program cuts
	1. Cannot raise taxes for NHI, so it will have to be cuts D207-214
	2. Can't use payroll tax D215
	3. Consumption taxes suspect D216-219
	4. No Social Security tax potential D220
	5. Problems with Value Added Tax (VAT) D221-225
	6. Middle class revolt if too many taxes D226
	7. Sin taxes will be inadequate D712
C. Affirmative spending will lead to science cuts -- the Supercollider (SC)
	1. Health and SC trade off D227
	2. SC is targeted for congressional cuts D228-235
	3. Congress will not use scientific criteria to determine cuts in SC D236-237
	4. Clinton wants SC, but may be forced to cut it D238-244
	5. Clinton may have to give in D245
	6. SC cut because of short term focus D246-247
	7. Science spending  does not jack up the deficit significantly D248-250
	8. Space station will not be cut instead D251
D. Alternatives are unacceptable
	1. Must be in USA D252
	2. No cost sharing D253-254
	3. Cuts now will waste our past SC investment D255
	4. Cuts will mean secrets of the SC will be lost for  generation D256
	5. SC will not lead to cuts in other research D257
	6. SC costs as much as two nuclear submarines D258
E. Cuts in the Supercollider mean a science disaster for the USA
	1. Science projects like the SC have certain benefits D259-262
	2. Consensus of scientists say it is needed D263-264
	3. SC will mean huge rewards D265-266
	4. SC essential to the future of the USA D267-272
	5. SC will answer the key questions of existence D273-276
	6. SC will reveal he secrets of matter D277-278
	7. SC will reveal new energy sources D279-280
	8. SC will produce incredible technical spin offs in many other areas D281-285
	9. SC cuts will lose USA competitive advantage over other industrial nations D286-291
	10. SC cuts will cause a scientific brain drain D292
	11. Electronics breakthroughs D293
	12. SC is crucial for the economy D294-295
	13. SC is crucial for the American spirit D296
	14. SC is not duplicated by the C.E.R.N. establishment in Europe D297
	15. SC has a budget which is on-target and is cost beneficial D298

AFFIRMATIVE RESPONSES TO SUPERCOLLIDER
1. SC will be cut anyway D299-300
2. SC is one of our lowest scientific priorities D301
3. SC trades off with other important research D302-305

MEDICAL NEMESIS

A. More medical care is bad for society and health
	1. Medical care does more harm than good on a societal level D307
	2. Fastest growing health threat is medical care itself D308
	3. Iatrogenesis (medical damage) is epidemic D309-310
	4. Huge damage is done by medical care D311-313
	5. We are beyond the medical care which society needs now D314
	6. We cannot ignore the iatrogenic threat D315
B. We have too much medical care now
	1. 1/3 of medical service is unnecessary and inappropriate D316
	2. 40% of medical care is unnecessary D317
	3. 20% of medical encounters are iatrogenic D318-319
	4. 50% of hospitalization is unnecessary D320
	5. 50% of health factors are pure invention D321
C. Affirmative expansion of coverage and care makes things worse
	1. Increased access increases medical damage D322-324
	2. Prevention allows doctors to recruit more victims D325-326
	3. Advanced medical techniques make health worse D327
	4. Malpractice guarantees doctors will overcare D328
D. Specific harm scenarios
	1. Death by diagnosis -- fearful diagnosis kills the patient D329-338
	2. Drug damage D339-344
	3. Infections from medical interventions D345-347
	4. Surgical risk D348
	5. Social control D349-358
	6. Hospital death D359-360
	7. Doctor negligence D361

UNIVERSAL MEDICAL CARE LEADS TO DECREASED EMPHASIS ON HEALTHY LIFESTYLES

A. Uniqueness: lack of coverage now emphasizes healthy lifestyles
	1. Medical crisis and move to healthy lifestyles feed each other D362
	2. Decreased medical emphasis causes increased lifestyle changes D363
B. Links: NHI causes a neglect of lifestyles for health
	1. Increased emphasis on medical care decreases emphasis on lifestyle changes D364-373
	2. Increased emphasis on medical care decreases personal health responsibility D374-376
	3. Increased emphasis on medical care decreases individual health action D377-383
	4. Increased emphasis on medical care decreases other health approaches D383
	5. Cost coverage decreases lifestyle changes and increases risk taking D384-388
	6. Emphasis on doctors decreases lifestyle changes for health D389-390
	7. Increased emphasis on medical care decreases attention to social factors in health D391, D353
	8. Medical prevention outreach causes increased dependence on medical care D392
	9. Use of drug treatments decreases emphasis on lifestyle changes D393
C. Impacts: Lifestyle changes for health are far more important than medical care
	1. Access to medical care is not the key to good health D394
	2. Increased emphasis on medical care means a net loss in health D395-396
	3. Decreased medical emphasis would increase health D397
	4. Focus on personal lifestyle responsibility is the key to health D398-399
	5. Lifestyle changes are the best approach to better health than medicine D400-415
	6. Lifestyle and preventive actions save millions of lives D416-417
	7. Examples: examples of avoidable health problems D418-422

AFFIRMATIVE RESPONSE: NHI will lead to safety legislation as cost control D534

EXPANDING MEDICAL ACCESS DECREASES ENVIRONMENTAL PROTECTION

A. Expanding medical approaches to health decrease environmental focus
	1. NHI props up our deadly social patterns D423
	2. Increased emphasis on medical care decreases focus on the environment D424-426 D536
	3. Increased emphasis on medical care masks social causes of poor health D427-429, D537
	4. Increased emphasis on healthy lifestyles decreases attention to the environment D430-431
	5. Doctor domination of health issues lead to environmental neglect D432
	6. Increased emphasis on medical care stops social action
		a. Increased emphasis on medical care stops social action D433-436
		b. Need social action to promote health D437
	7. Access to medical care leads to environmental neglect D438
	8. Increased emphasis on medical care makes cultural changes harder D439
B. The environment is more important to health than medical care
	1. Health improvements have come from environmental improvement, not medical care D440-441
	2. Environmental effects of health outweigh medical effects D442-444
	3. Must reject medical domination of health D445
	4. Must address broad environmental concerns D446
C. Environmental degradation threatens humanity
	1. We are destroying the planet with pollution D447-457
	2. We must act to save the planet D458-467
	3. We must prevent future pollution D468-469
	4. Lists of environmental crises D470-472
	5. Humanity is dependent on the natural world D473-476
	6. Pollution crisis is real and immediate D477-480
	7. Mega Impacts
		a. Destruction of human civilization D481-482
		b. Millions of deaths D483-484
		c. War and conflict D485-487
		d. Starvation D488
		e. Poverty D489
	8. NOW we are on the brink of disaster D490-496

AFFIRMATIVE RESPONSES: Environment is not central to health D561-566

HYPOCHONDRIA - NATIONAL HEALTH INSURANCE GUARANTEES OVERCARE

A. The stage has been set for NHI overcare
	1. People want more medical care whether they need it or not D497-500
	2. Doctors are trained to give too much care D501
	3. Malpractice promotes overcare D502
	4. Medical system incentives mean overcare D503-504
	5. Many incentives for overcare exist D505
	6. New treatments promote overcare D506
	7. Our culture promotes overcare D507
B. Affirmative coverage opens the gates to overcare
	1. Increased coverage by affirmative will lead to overcare D508-515
	2. Health education and outreach leads to overcare D516-519
	3. High costs currently keep overcare down D520
	4. Coverage without changing the fee for service system means overcare D521-524
	5. Increased efficiency increases overcare D525
C. Overcare is extremely bad
	1. Increases costs and risks to patients without any benefits D526-527
	2. Overcare specifically victimizes women D528-529

AFFIRMATIVE RESPONSES: People will not overrun the system D530-531

NATIONAL HEALTH INSURANCE WILL CAUSE A PERSONNEL CRISIS

A. Doctors oppose the Affirmative
	1. Doctors dislike NHI D538-540, 560
	2. Doctors oppose salary controls D541
	3. Doctors oppose changes in fee for service medicine D542
	4. Doctors fear a loss of autonomy D543-544
	5. Doctors oppose cost controls D545
	6. Concern by doctors is not just rhetoric D546
B. Doctors will leave the system 
	1. Many will quit D547-548
	2. Young people will not go into medicine D549
	3. Doctors will opt out of the system D550
C. The health system will be crippled 
	1. It takes doctors to have NHI D551-552
	2. Doctors will strike D553
	3. The Canadian system destroyed their personnel base D554

AFFIRMATIVE RESPONSES:
1. Doctors will like NHI D555-556
2. Not unique: doctors are resigned to NHI D557-558
3. Doctors like insurance companies even less than the government D559

AFFIRMATIVE REFORMS HURT DOCTOR-PATIENT RELATIONSHIP

A. Affirmative actions will hurt the relationship between doctors and patients
	1. Medical reforms will deteriorate the doctor patient relationship D567
	2. Implementing social policy through doctors will deteriorate the doctor patient relationship D568
	3. Changing the fee for service medical system will deteriorate the doctor patient relationship D569
	4. Increasing access will deteriorate the doctor patient relationship D570
	5. Utilization review will deteriorate the doctor patient relationship D571-572
	6. Cost reforms will deteriorate the doctor patient relationship D573
	7. Regulation of doctors will deteriorate the doctor patient relationship D574
	8. Managed care will deteriorate the doctor patient relationship D575-578
	9. Competitive benefit plans will deteriorate the doctor patient relationship D579
	10. Sharing medical data about patients will deteriorate the doctor patient relationship D580
B. Damaging the doctor patient relationship must be avoided
	1. A good doctor patient relationship is critical for healing D581
	2. Reform must protect doctor patient relationship D582
	3. Decreased doctor patient relationship will increase malpractice suits D583

AFFIRMATIVE RESPONSES:
1. Patients don't care D584
2. Not unique: doctor patient relationship is poor now D585-586, D714
3. Increased prevention improves the relationship D587
4. Change does not automatically hurt the relationship D587
5. Doctor patient relationship does not lead to social change D588

SMALL BUSINESS WILL BE RAVAGED

A. Small business is vulnerable to health plans linked to employment
	1. Most uncovered employees are in small business D589-590
	2. Small businesses fear employer based plans D591
B. Specific plans will cripple small business
	1. NHI based in the workplace D592-593
	2. Employer mandates threaten jobs D594-599
	3. Jackson Hole plan D600-601
	4. Play or Pay D602-605
	5. California system D606
C. Small businesses will be ravaged by NHI
	1. Decrease entrepreneurial initiative D607
	2. Small businesses are the main creators of new jobs D608
	3. Many small businesses will be killed D609-611
	4. Decrease international competition D612
	5. Would prefer wages instead D613

INSURANCE INDUSTRY WILL BE RAVAGED

A. Insurance industry is vulnerable now
	1. Each infringement hurts insurance industry D614
	2. Insurance industry is on the brink now D615-617
B. Affirmative actions will hurt the insurance industry 
	1. Reform threatens insurance industry 618-619
	2. NHI threatens insurance industry D620-621
	3. Will not solve health care problems D622
	4. HMO plans hurt insurance industry D623
	5. Managed competition hurts insurance industry D625-625
C. Impact: insurance industry will be crippled
	1. Property and casualty insurance D626-629
	2. Liability insurance D630-631
	3. Auto insurance D632-633
	4. Workers' compensation insurance D634
	5. Insurance is essential to communities D635

AFFIRMATIVE RESPONSES
1. Regulation helps insurance D636
2. Insurance will adapt D637
3. Insurance industry will survive D638
4. NHI improves auto insurance D639-641
5. Private insurance approach will help insurance industry D642
6. Fears are false D643

NATIONAL HEALTH INSURANCE TRIGGERS MALPRACTICE CRISIS

A. Malpractice system is ripe for crisis
	1. Improper incentives abound, affirmative doesn't change that D644
	2. Costs over $66 billion now D645
B. Affirmative reform will increase malpractice suits 
	1. Rationing decisions will increase malpractice suits D646
	2. Fewer tests and other efficiencies decrease malpractice defense D647
	3. Cost controls increase malpractice suits D648
C. No way to avoid this problem
	1. Malpractice reforms will fail D649-650
	2. Malpractice reform is extratopical -- it is legal reform, not medical reform D651-652
D. Impacts: increased malpractice suits are harmful
	1. Leas to iatrogenesis D653
	2. Increases costs D654-658
	3. Doctors will discontinue care D659
	4. Will destroy NHI budgeting D660
	5. Might require new medical computer systems D661

AFFIRMATIVE RESPONSES:
1. NHI will decrease malpractice awards D662-665
2. Malpractice problems are not significant now D666
3. Malpractice system does not favor the plaintiff D667
4. Tort reform would solve D668
5. Award caps would solve D669
6. Malpractice does not substantially increase costs D670-671
7. Can use licensing procedures to control doctor malpractice D672

AFFIRMATIVE REFORMS COSTS MANY JOBS

A. Medical sector is central to the economy
	1. Huge portion of productive jobs D674-675
	2. Millions of jobs at stake D676-677
	3. Medical care is not bureaucratic, just labor intensive D678
	4. Major portion of the urban workforce D679-680
	5. One of the few sectors of the economy creating new jobs D681-683
B. Medical savings will cost jobs
	1. Reforms threaten jobs
	2. Hospital closings threaten jobs D685
	3. Decreased tech decreases jobs D686-687
C. Employment is good, unemployment is bad D688-700

OVERDEVELOPED POPULATIONS

A. Affirmative plan will save many lives in overdeveloped nations
B. Overdeveloped nations have a stable population now D701
C. Higher populations in overdeveloped nations are harmful
	1. Use too many resources D702-704
	2. Overdeveloped populations hurt the environment far more 
		a. Overconsumption by the rich nations causes 			plundering of the environment D705-706
		b. Multiplier effect
			1. 35 times D707
			2. 70-20-10 times D708
	3. Threatens world security and leads to war D709
	4. Overdeveloped populations must be controlled first D710
	5. Worse problem than LDC overpopulation D711

D1/MILT FREUDENHEIM , The New York Times, November 16, 1992, Section D; Page 1; HEADLINE: Canadians See Rise in Drug Costs \\VT 93-94
	 Canada's success at delivering drugs at costs lower than those in the United States is an important feature of its medical system, which has been a model for many health policy experts seeking to contain soaring costs in the United States. Medical costs are about 28 percent lower per capita in Canada than in the United States, although spending on health care has been rising there, too. 

D2/Health Line, October 22, 1992 , HEADLINE: PRESCRIPTION DRUGS: THEIR DRUGS ARE CHEAPER, EH? Nexis \\VT 93-94
	 WHY?: According to the JOURNAL, the GAO study attributes much of the price differential to Canadian gov't regulation of health care costs, including prescription drug prices. JOURNAL: "But findings suggest that U.S. consumers may be subsidizing patients in countries with price controls at a time when U.S. health care costs are escalating out of control" (Stout, 10-22). N.Y. TIMES notes GAO found several ways Canada keeps prices down, including reimbursement for only the cost of the lowest-priced treatment; annual drug price reviews by a nat'l board; the alignment of price increases with inflation; and by encouraging competition by allowing generics to be sold after 7-10 years of exclusive rights, compared to 17+ years in the U.S. 

D3/Health Line, October 22, 1992 , HEADLINE: PRESCRIPTION DRUGS: THEIR DRUGS ARE CHEAPER, EH? Nexis \\VT 93-94
	 REAX: Subcmte. chair Henry Waxman (D-CA) said the study shows that "Once again, the U.S. is behind the rest of the world in providing affordable health care to our people" (Milt Freudenheim, 10-22). Waxman: "Canada and other countries in the world have a national health insurance system that bargains with the drug companies to pay the lower price, and the United States has no such system." NBC's Robert Bazell reported on the price differences as "a strong argument for reform" ("Nightly News," 10-21). 

D4/MILT FREUDENHEIM , The New York Times, November 16, 1992, Section D; Page 1; HEADLINE: Canadians See Rise in Drug Costs \\VT 93-94
	 Representative Henry A. Waxman, the Democrat from California who is chairman of a House Energy and Commerce subcommittee on health, said American consumers "are subsidizing the lower prices that Canadians and Europeans pay for pharmaceuticals." Mr. Waxman, who requested the G.A.O. study of American and Canadian prices, said the disparity was "another reason why we need a national health insurance system to get some control over the cost of health care." 

D5/Health Line, October 22, 1992 , HEADLINE: PRESCRIPTION DRUGS: THEIR DRUGS ARE CHEAPER, EH? Nexis \\VT 93-94
	 According to a GAO report released yesterday, pharmaceutical companies charge an average of 32% more for common prescription drugs in the U.S. than they do in Canada. The GAO report, compiled for the health subcmte. of the House Energy and Commerce Cmte., compared drug prices for 121 drugs commonly prescribed in both countries and found that almost half of the drugs cost over 50% more in the U.S. (GAO release, 10-21). W.S. JOURNAL: "But the extent of the price differences varied widely" (Hilary Stout, 10-22). GAO report: "The five most commonly dispensed products exemplify U.S.-Canadian price differentials." Respectively, the drugs Amoxil, Lanoxin, Zantac, Premarin, and Xanax cost 5%, 16%, 30%, 162% and 183% more in the U.S. (10-21). 

D6/James J. Kilpatrick, syndicated columnist, The Buffalo News, December 23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	  Cost controls? Pharmaceutical manufacturers felt a cold wind last week, when their emissaries had an audience with Clinton's people. Apparently the Clinton  camp made no direct threats of out-and-out price controls, product by product,  but the manufacturers felt something ominous in the air. Prescription drugs reportedly represent a fairly small part -- about 7.2  percent -- of total spending on health care, but that part is a highly visible  and painful part. Domestic drug prices have soared in recent years, far beyond  the general increase in inflation. As a political matter, the drug manufacturers offer an irresistible target. We may confidently expect that the Clinton bill,  whatever else it attempts to do, will give the pharmaceutical industry a very bad headache. 

D7The Reuter Transcript Report, February 24, 1993, FOX MORNING NEWS INTERVIEW, Guest: Rep. Henry Waxman (D-Calif.), Nexis \\VT 93-94
 REP. WAXMAN: I want us to have prescription drugs as part of the benefit, because it is very much part of health care services, the same as a doctor or hospital or other services, but when we decide to provide this benefit, we've got to come up with a way to control the costs that will be paid. And when  government is a buyer for a large number of people, I think we'll have the leverage to negotiate with these pharmaceutical companies to get the kind of prices that will be reasonable.  

D8/The Reuter Transcript Report, February 24, 1993, FOX MORNING NEWS INTERVIEW, Guest: Rep. Henry Waxman (D-Calif.), Nexis \\VT 93-94
 I think we're going to have to look at different alternatives because we just can't continue with the system,  especially when we have national health insurance where  prescription drugs, I believe, must be part of the benefit package. You can't just pay whatever the pharmaceutical companies want us to pay. We have to figure out what is a reasonable price. 

D9/Health Line, October 22, 1992 , HEADLINE: PRESCRIPTION DRUGS: THEIR DRUGS ARE CHEAPER, EH? Nexis \\VT 93-94
	 THE POLITICS OF PRICING: WASH. POST reports, "Fearful that Congress and a new administration may force drug companies to reduce their prices, at least six major firms have held their annual price increases to below the rate of inflation this year." Drug prices measured by the consumer price index grew 5.9% between Sept. '91 and Sept. '92 -- the lowest annual percentage increase since '77. POST: "Lower pharmaceutical prices -- or at least smaller price jumps -- appear to be a concrete public dividend from this campaign season and its attention to health care reform, according to drug market analysts and manufacturers." Analyst Hemant Shah said the drug co. message is: "We will self-regulate ourselves so there is no need for legislation" (Dana Priest, 10-22). 

D10/MILT FREUDENHEIM , The New York Times, November 16, 1992, Section D; Page 1; HEADLINE: Canadians See Rise in Drug Costs \\VT 93-94
	 The drug makers reported about $41 billion in American sales of patent-protected products last year. Generic drug sales added about $5 billion. Drug prices, which rose twice as fast as general inflation in the 1980's, have slowed somewhat, the Labor Department said. But drug prices paid by consumers still rose 6.3 percent in the 12 months ending in October, while the overall Consumer Price Index was up only 3.2 percent. 

D11/JULIE KOSTERLITZ, Staff Reporter, 7/18/87 NATIONAL JOURNAL p1845 
Medicare payments for drugs might seem to offer a boon to drug companies because they would guarantee that seniors could buy their products. But the industry sees a specter that overshadows any potential business gain  federal cost controls.
D12/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 In the case of pharmaceuticals, a leading research intensive industry, the results would be particularly damaging. A recent study calculated that during the 1980s the average cost of researching and developing a new drug for market was $ 213 million. n39 Collectively, pharmaceutical companies currently spend almost $ 11 billion annually on research and development, or approximately the same as the entire annual budget of the federal government's National Institutes of Health (NIH). Indeed, investment in research and development (R&D) by pharmeceutical companies has been growing steadily since 1970, at a rate that doubles every five years. 

D13/ Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Drugs are a high-risk enterprise. Only one in every 5,000 compounds mixed in a lab ever becomes a marketable drug, and many drugs never recover their costs. 

D14/ W.D. Reekie & M.H. Weber 1979 (industrial economist) PROFITS POLITICS AND DRUGS. p 13
Pharmaceutical R&D is thus a lengthy, complex and costly business. An increase in the supply and application of basic knowledge would of course cheapen and shorten the entire process. At present roughly one compound in 10,000 which enters the screen ultimately emerges as a drug, the rest being discarded.
 D15/ Theodore Schlie, 1984 (former director o£ Industrial Dept. of Commerce) A COMPARATIVE ASSESSMENT OF THE US PHARMACEUTICAL INDUSTRY. p. 52. "' Thus the key cost factors in bringing a new drug to market are the R & D expenditures required to create the product and the costs required to carry the product through the regulatory approval stage.
D16/MILT FREUDENHEIM , The New York Times, November 16, 1992, Section D; Page 1; HEADLINE: Canadians See Rise in Drug Costs \\VT 93-94
	 The American drug makers say the high prices of many new drugs are necessary to finance the often risky investments in innovative drugs that may take a decade, and $200 million each, to develop. The drug makers have also promised to increase their research efforts in Canada once the patent law is changed. 

D17/ Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Only 7 cents out of every health care dollar goes for prescription drugs. But drugs are often not covered by insurance. When people have to pay for drugs out of their own pockets, they feel the bite more. The average prescription costs only about $ 25, but some drugs cost more. Here's why: It costs about $ 231 million to research and develop a new drug, according to a Tufts University study. 

D18/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 According to another study, pharmaceutical manufacturers invests 16.1 percent of sales in R&D. In contrast, the rest of the health care industry invests only 8.8 percent of sales in R&D, while the comparable figures for other "high-tech" industries are even lower: 7.9 percent for the computer industry, 5.5 percent for the electronics industry, and 3.7 percent for the aerospace industry. n40 

D19/Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Despite what critics say, the pharmaceutical industry is doing the lion's share of research on new medicines. Pharmaceutical companies will invest nearly $ 13 billion this year to discover and develop new medicines. That's more than the entire government budget for health research. And none of these research and development funds go for marketing _ as some critics have alleged _ although marketing is needed to inform doctors about new medicines. 

D20/John Hechinger, The Charlotte Observer, N.C., Knight-Ridder/Tribune Business News, May30, 1993, Headline: Health-Care Reform Fears Keep Investors from North Carolina Biotech Firms, Online America, Transmitted: 93-06-01 13:54:00 EDT \\VT 93-94
	 Investors are especially fearful that the government will impose price controls on drugs. That would make drug makers with their expensive research and development a less attractive investment. 

D21/ Bohumir Pazderka (school of economics Queen's University) MULTINATIONAL R & D ACTIVITY IN THE PHARMACEUTICAL INDUSTRY 1986. p. 35.
They believe that regulation caused resources to flow out of the drug industry into the economy in general. The government imposes taxes to encourage research in areas other than drugs (including other forms of therapy).
D22/ Bohumir Pazderka (school of economics Queen's University) MULTINATIONAL R & D ACTIVITY IN THE PHARMACEUTICAL INDUSTRY 1986. p 36.
Apart from the effect on the rate of new product introductions, the tightening of regulatory standards in the U.S. has been held responsible for several other developments: First, shift of R&D from the U.S. to other countries.
D23/Elizabeth Jensen. Sept. 1987 (dept. of economics Hamilton College) Journal of Industrial Economics. p. 94.
The results of this paper support the evidence of previous researchers that an increase in regulatory stringency decreases the expected number of new drug discoveries. The tradeoff between tighter regulatory standards and the number of new drug discoveries found to exist in the 1960s has persisted as pharmaceutical firms adapted to the new regulatory environment. Furthermore, this tradeoff is estimated to be quite steep. Finally, an exogenous decrease in the probability of discovering a new drug is found over the sample years.
D23A/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Price controls in fact encourage manufacturers to shift resources from research and development to marketing. The reason: investing money in experimental R&D is much riskier than investing money in increased marketing or incremental R&D, are justifiable strategies. Of course, with or without price controls, the reason for investing more in marketing is to increase profits by increasing sales volume. 

D24/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 The results [of price controls] are: 1) fewer innovative new drugs; 2) increased consumption of existing drugs; and 3) a consequently higher level of individual and national spending on drugs, despite lower prices. These are, of course, exactly the opposite effects of what the price controllers intended. 

D25/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 France is a good example of how pharmaceutical price controls can backfire in just such a fashion -- simultaneously destroying innovation while boosting total costs. One analyst notes that, "In France, the calibre of pharmaceutical research is seen as having deteriorated, because severe price control has encouraged French companies to give priority to small therapeutic improvements which are useful in price negotiations. Such systems tend to stifle originality and induce risk aversion." n44 Indeed, the French drug industry produced only three of the 66 world class drugs brought to market between 1975 and 1989, while the U.S. drug industry produced thirty -- or ten times as many. 

D26/Miriam Widman, The Journal of Commerce, Knight-Ridder/Tribune Business News, May 12, 1993, TITLE: Health-Care Reform Hurts German Drug Companies, Online America, Transmitted: 93-05-11 18:11:00 EDT \\VT 93-94
 Germany's pharmaceutical industry estimates it will lose 600 million deutsche marks ($375 million) in sales this year due to government- mandated price cuts and tighter controls required since a widespread health- care reform program took effect early this year. Some 90 percent of all Germans enjoy public health insurance. The government also has ordered a 5 percent price cut for most major drugs and is applying pressure on health care facilities to buy the cheaper generic drugs. Patients also have to pay a token portion of their drug costs, ranging from $1.90 to $4.40. 
Schering AG takes a different view. "Research is the reason for our being. It's the name of the game for Schering," said a firm spokesman. 
 Of the 119 companies surveyed, 48 percent said they plan to cut their R&D budgets. The industry fears a second health-care reform, to take effect in the mid-1990s, will cut income further. 

D27/ Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 As we move forward on health reform, it's important to remember the value of prescription medicines. They are part of the solution to increasing access to care while holding down costs and maintaining quality. Some people want to make radical changes to the way drugs are developed and sold by taking away tax incentives, imposing price controls and restricting access to the newest drugs. This would be a grave mistake.

D28/ Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Prescription drugs can keep people out of hospitals and nursing homes, which cost many times the price of the drugs. For many conditions, including ulcers and heart disease, prescription medicines can help people avoid costly surgery. Medicines can get people back to work faster. 

D29/ Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Let's look at the value this industry gives: Prescription medicines save lives, ease suffering and allow people to function better. Although these values are priceless, they can sometimes be expressed in terms of cost savings. 

D30/Theodore Schlie 1984 (former Dir. of Industrial Anal Dept. of Commerce) A COMPARATIVE ASSESSMENT OF THE US PHARMACEUTICAL INDUSTRY p. 23.
A strong domestic, research intensive pharmaceutical industry is an important national asset for several reason. First, the industry produces essential components of a costeffective health care system. Second, it is an important foreign exchange earner. Third, it contributes to a productive research climate in the biochemical and biological fields.
D31/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	The health care industry has helped offset the U.S. trade deficit with exports of medical technology and pharmaceuticals, which consistently are among the nation's largest trade surpluses. 

D32/ Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Research on medicines to cure dread diseases such as AIDS, Alzheimer's and cancer must be financed by sales of existing drugs. 

D32A/Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 Uncured diseases cost hundreds of billions of dollars every year. As our population ages, these costs will escalate. Continuing drug research is our best _ and, in some cases, our only _ hope for checking this devastating human and financial toll. 

D33/Gerald J. Mossinghoff USA TODAY March 2, 1993, Pg. 13A HEADLINE: Drugs save lives and ease suffering \\VT-MDS
	 The astounding progress already achieved in curing diseases was made under our current system _ which encourages innovation. If we change the system, we may deprive future generations of drugs that will never be discovered. 

D34/Thomas P. O'Neill former speaker of the U.S. House The Atlanta Journal and Constitution May 1, 1991 SECTION A; PAGE 13 HEADLINE: Medical research: Don't snip off funds \\VT-MDS
	 The promise is great that many fatal disease This presents us with a choice. We can continue to treat the symptoms of disease or we can invest a few more dollars to find cures. One example of how relatively small sums directed to medical research offer the possibility of tremendous payoffs is in drug research. 

D35/ Oregon Business April, 1992 SECTION: Vol 15; No 4; Sec 1; pg 34 HEADLINE: The Biotech Challenge \\VT-MDS
	 They're called "silver bullets" or "designer drugs." They're miracle drugs for the most tragic human ailments--Alzheimers, schizophrenia, cancer. Synthetech in Albany is the leading producer of peptide building blocks, chemically-altered amino acids critical to the discovery of such miracles. It's a peptide that brings Nutrasweet (TM) to the breakfast table. That same peptide technology may someday bring us a cure for AIDS. 

D36/Thomas P. O'Neill former speaker of the U.S. House The Atlanta Journal and Constitution May 1, 1991 SECTION A; PAGE 13 HEADLINE: Medical research: Don't snip off funds \\VT-MDS
	 The promise is great that many fatal disease More exciting new advances in medical science are at hand. How soon we get them depends on how hard we go after them. 

D37/ Theodore Schlie 1984 (former Dir. of Indust. Anal Dept. of Commerce) A COMPARATIVE ASSESSMENT OF THE US PHARMACEUTICAL, INDUSTRY, p.66
More specifically, the products of what some have called impending "second pharmacological revolution" may include the following
* Immunodulators which will help regulate the body's immune system and could lead to a solution for such diseases as AIDS;
*Neurotransmitters which will have clinical applications for such neurological afflictions as Alzheimer's and Huntington's disease and ALS (amyotropic lateral sclerosis).D37a/Ronald E. Cape, President, CETUS Corp., PLANNED RELEASES OF GENETICALLY ALTERED ORGANISMS..., House Hearings before the Subcomm. on Investigations and Oversight, Comm. on Science & Tech., December 4, 1985, P. 27.
In human health care, promising new drugs and diagnostic tests are at hand. We possess powerful tools to determine the mechanisms of cancer, the causes of heart disease, the vulnerabilities of viruses, and the therapies to address these problems. 
D38/ Theodore Schlie 1984 (former Dir. of Industrial Anal Dept. of Commerce) A COMPARATIVE ASSESSMENT OF THE US PHARMACEUTICAL INDUSTRY, p. 66.
The marriage of such fundamental research with the drug development chemistry of the Pharmaceutical industry appears to ensure further medical advances. Such advances will not only provide new treatment against virus and autoimmune diseases and for cancers, but also for the reversal of disturbed mental states and addictions and for the prevention and treatment of inborn metabolic disorders. Drugs of the future ( (many now in experimental testing) will include compounds that are able to stimulate or retard sexual desire, human growth (counteract the deficiency that causes dwarfism in children), memory, and even predetermine the sex of a child.
D39/THEODORE SCHLIE, Former Dir. Industrial Analysis, Dept. of Commerce, 1984, A COMPARATIVE ASSESSMENT OF THE US PHARMACEUTICAL INDUSTRY, p.67
 Finally, as noted earlier, there is the prospect of new drugs that enhance mental functions. Scientists here and in Europe are examining the potential of peptides to regulate a multitude of brain functions, including learning, euphoria, sleep, wakefulness, depression, response to stress, etc. Such drugs may not be on the market very soon, but pharmaceutical companies are intensifying research in this area.
.. D40/ LAWRENCE K. ALTMAN The New York Times August 1, 1991, Section B; Page 7; HEADLINE: Studies Find Drug Cuts Heart Failure Deaths \\VT-MDS
	 Chronic heart failure affects from 2 million to 3 million people in the United States and up to 20 million people elsewhere. The number of deaths and hospitalizations has risen over the last 20 years because more people have survived heart attacks. 

D41/LAWRENCE K. ALTMAN The New York Times August 1, 1991, Section B; Page 7; HEADLINE: Studies Find Drug Cuts Heart Failure Deaths \\VT-MDS
	 Still, heart failure kills 40,000 Americans, contributes to an additional 230,000 deaths and leads to more than 645,000 hospital stays each year. Many patients need repeated admissions. 

D42/ LAWRENCE K. ALTMAN The New York Times August 1, 1991, Section B; Page 7; HEADLINE: Studies Find Drug Cuts Heart Failure Deaths \\VT-MDS
	 Dr. Claude J. Lenfant, the head of the National Heart, Lung, and Blood Institute in Bethesda, Md., which financed one of the studies, said wider use of enalapril and similar drugs could prevent up to 20,000 deaths and 100,000 hospitalizations and save $1 billion a year in the treatment of heart failure. 

D43/LAWRENCE K. ALTMAN The New York Times August 1, 1991, Section B; Page 7; HEADLINE: Studies Find Drug Cuts Heart Failure Deaths \\VT-MDS
	 The authors of one study, headed by Salim Yusuf of the National Heart, Lung and Blood Institute, concluded that for every 1,000 patients with chronic heart failure who were treated with enalapril, 50 deaths and 350 admissions to hospitals could be prevented over a three-year period. 

D44/ Ridgely Ochs. STAFF WRITER Newsday May 1, 1993, Saturday, SECTION: NEWS; Pg. 7 HEADLINE: Better Clot-Buster? Study gives biotech drug the edge in heart attacks \\VT-MDS
	 Giving heart-attack victims quick doses of an expensive, clot-busting drug appears to save more lives than use of a less costly drug, according to a study released yesterday. 

D45/JAMES FLANIGAN Los Angeles Times May 12, 1993, SECTION: Business; Part D; Page 1; HEADLINE: JAMES FLANIGAN: BIOTECH DRUGS MAY SAVE DAY FOR PHARMACEUTICALS \\VT-MDS
	 That's why the Genentech finding is so promising. It means that "science-driven, cost-effective drugs will have no real problems," said Viren Metha, co-founder of Mehta & Isaly, a New York research firm that studies 400 pharmaceutical and biotech companies worldwide. 

D46/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 This higher level of investment in R&D has helped make pharmaceuticals one of America's most globally competitive industries. In 1990, for example, nine of the world's top twenty drug companies were based in the U.S., n41 and thirty of the 66 innovative new drugs marketed worldwide between 1975 and 1989 originated in the U.S. n42 

D47/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Outpatient prescription drugs account for only 8.3 percent of total U.S. health spending. Furthermore, the share of national health spending devoted to pharmaceuticals in eight developed countries is more than twice the U.S. figure. Indeed, the U.S. percentage is the third lowest among 23 developed nations. Only Sweden and Norway spend proportionately less, and Australia spends the same share as the U.S. Ironically, Japan, Canada, and eleven of the twelve nations of the European Community (EC) all have some type of pharmaceutical price controls, yet spend proportionately more than the U.S. on drugs. 

D48/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 That bears on one of the reasons why Canada's overall health care costs are increasing almost as fast as ours. Drugs have been leading the way, posting a 14.3 percent increase from 1989 to 1990 as against 10.6 percent for the entire health sector. While doctors, hospitals and capital outlay are costing Canadians roughly four times as much as in 1975, drugs are up more than sevenfold. And where, for the most part, does Canada purchase its drugs? From pharmaceutical companies based in the United States. 

D49/The Reuter Transcript Report, February 24, 1993, FOX MORNING NEWS INTERVIEW, Guest: Rep. Henry Waxman (D-Calif.), Nexis \\VT 93-94
 REP. WAXMAN: I don't think it can be defended. The  pharmaceutical manufacturers argue they have to put more money into research and development, yet we found out that they put  more money into promotion and advertising of their drugs than they do into research and development. What they are doing is having Americans subsidize the rest of the world's lower prices  in order to make the drug companies more profitable, and they're extremely profitable. No other industry in this country does as well in terms of the return on its investment than the  pharmaceutical industry.  

D50/John Hechinger, The Charlotte Observer, N.C., Knight-Ridder/Tribune Business News, May30, 1993, Headline: Health-Care Reform Fears Keep Investors from North Carolina Biotech Firms, Online America, Transmitted: 93-06-01 13:54:00 EDT \\VT 93-94
	 Burns [North Carolina biotech executive] said biotech companies have marketed drugs successfully for use in European countries that have cost controls. "If you take the longer-term view, I think these reforms are going to be positive for us for the simple reason that these are innovative drugs, and they are less likely to be impacted by price controls," Burns said. 

D51/ MELLISSA SHON,Chemical Marketing Reporter October 12, 1992 SECTION: Vol. 242 ; No. 15 ; Pg. 3 HEADLINE: FDA moves to shorten drug approval route; Food and Drug AdministrationDrugs & Fine Chemicals \\VT-MDS
	 Under a deal struck shortly before Congress adjourned for the year last week, Food & Drug Administration has been granted authority to charge user fees to pharmaceutical and biotechnology companies applying for new drug applications. The measure is expected to raise $ 330 million over the next five years and cut by nearly half the time it takes to bring new drugs to market. 

D52/ MELLISSA SHON,Chemical Marketing Reporter October 12, 1992 SECTION: Vol. 242 ; No. 15 ; Pg. 3 HEADLINE: FDA moves to shorten drug approval route; Food and Drug AdministrationDrugs & Fine Chemicals \\VT-MDS
	 "This is a major turning point for the agency -- it's a milestone," says FDA commissioner David A. Kessler. "In the end, it may be the most important thing we have done. It means extra people coming on board at the Center for Drugs and the Center for Biologics. We're talking about a commitment to approve drugs in six to 12 months. That's a radical change." 

D53/ MELLISSA SHON,Chemical Marketing Reporter October 12, 1992 SECTION: Vol. 242 ; No. 15 ; Pg. 3 HEADLINE: FDA moves to shorten drug approval route; Food and Drug AdministrationDrugs & Fine Chemicals \\VT-MDS
	 Agency officials estimate that it costs an average of $ 10 million a month, per drug, for every additional month of delay that a products is held off the market. 

D54/Hospitals, Journal of the American Hospital Association December 5, 1991 SECTION: Vol. 65 ; No. 23 ; Pg. 32 HEADLINE: Biotechnology drugs create new maze of concerns for hospitals \\VT-MDS
	 Pharmacologists and clinicians add that it's too soon to estimate the impact that biotech drugs will have on health care delivery. But they emphasize that biotech drugs aren't likely to serve as "magic bullets" or miracle cu re-alls. 

D55/Hospitals, Journal of the American Hospital Association December 5, 1991 SECTION: Vol. 65 ; No. 23 ; Pg. 32 HEADLINE: Biotechnology drugs create new maze of concerns for hospitals \\VT-MDS
	 Most [biotech drugs] are very good potential agents for treating specific indications, but they won't be a panacea or the sole treatment for anyone's problem. They will be used as adjuncts or in combination with other therapies," says James Koeller, associate professor of clinical pharmacy at the University of Texas, Austin, and an oncology specialist at Audie L. Murphy Memorial Veterans Hospital, San Antonio. 

D56/Consumer Reports February, 1992 SECTION: Vol. 57, No. 2; Pg. 87 HEADLINE: PUSHING DRUGS TO DOCTORS \\VT-MDS
	 High drug prices are a special burden for elderly people, who make up 12 percent of the population but consume 34 percent of prescription drugs. Surveys by the American Association of Retired Persons have found that prescription drugs are the single largest out-of-pocket medical expense for three out of four Americans over 65, and that four out of ten have no prescription drug insurance coverage whatever. One in seven say they have failed to take prescribed medicine because it was too expensive. 

D57/Consumer Reports February, 1992 SECTION: Vol. 57, No. 2; Pg. 87 HEADLINE: PUSHING DRUGS TO DOCTORS \\VT-MDS
	 	 Sometimes the drugs being marketed really are more effective, less costly, or safer than their competitors. But others are unoriginal products seeking to take market share away from established, and frequently less expensive, formulations. Of the 20 or so new drugs the FDA approves in a typical year, the agency usually rates no more than four as truly meaningful therapeutic advances. That leaves the rest to slug it out in the arena of image, promotion, and marketing. 

D58/MILTON SILVERMAN, Lecturer UCSF & Stanford Schools of Medicine, PRESCRIPTIONS FOR DEATH, 1982, p.101
Over 50% of drugs on the market constitute fixed combinations, Very few have documented and established evidence to show their superiority over their single active ingredients. Drug companies are promoting them through fierce competition which sometimes neglects the ethical aspects of medicine.
D59/Consumer Reports February, 1992 SECTION: Vol. 57, No. 2; Pg. 87 HEADLINE: PUSHING DRUGS TO DOCTORS \\VT-MDS
	 Though doctors insist their scientific training, high intelligence, and sophistication enable them to resist manipulation, the truth is that skillful marketers can influence M.D.s just as easily as they can sway the rest of us. 

D60/ Consumer Reports February, 1992 SECTION: Vol. 57, No. 2; Pg. 87 HEADLINE: PUSHING DRUGS TO DOCTORS \\VT-MDS
	A landmark 1982 study by Dr. Jerry Avorn of Harvard showed that doctors' opinions of two popular, heavily advertised drugs came straight from the ads and sales pitches. The doctors believed they'd gotten their information from objective scientific sources, but those sources, in fact, had said all along that the drugs were not effective for their advertised uses. 

D61/Consumer Reports February, 1992 SECTION: Vol. 57, No. 2; Pg. 87 HEADLINE: PUSHING DRUGS TO DOCTORS \\VT-MDS
	 Over the past 15 years or so, the $ 63-billion-a-year pharmaceutical industry has made physicians the targets - sometimes willing, sometimes unwitting - of sophisticated, subtle, and highly effective marketing techniques that permeate nearly every aspect of medical practice. Drug companies organize "educational symposia" that are actually disguised promotional efforts for their products. They pay for sober-looking "supplements" to respected medical journals and fill those supplements with articles selected and edited to make their products look good. They pay doctors to use drugs in "clinical trials" organized not by drug researchers but by drug marketers. And they offer doctors all sorts of gifts and perks, from ballpoint pens to lavish banquets and concerts. 

D62/Consumer Reports February, 1992 SECTION: Vol. 57, No. 2; Pg. 87 HEADLINE: PUSHING DRUGS TO DOCTORS \\VT-MDS
	 Evidence that this is so comes from the industry itself. One trade publication, Medical Marketing & Media, recently ran an admiring account of a campaign on behalf of Anaprox, one of a number of anti-arthritic drugs jostling for position in a lucrative market. Physicians received direct-mail invitations to send away for a series of exercise-related gifts bearing the drug's logo: a Walkman-type stereo; a jumprope; hand and ankle weights; a fanny pack; an exercise log. Presumably, most physicians could easily afford these items. Yet the promotion appeared to work; after one year, Anaprox's share of prescriptions for exercise-related injuries increased from 33 to 43 percent. The trade journal didn't seem troubled by the fact that Anaprox offers no demonstrable benefits over generic ibuprofen, a similar drug which costs much less. 

D63/ Viveca Novak; senior staff writer. Common Cause Magazine July, 1992 / August, 1992 / September, 1992 HEADLINE: THE OTHER DRUG LORDS; When the pharmaceutical industry comes calling, Congress listens. , Nexis \\VT - MDS The drug industry played a large role in the Bush administration's decision last spring not to sign the international biological diversity treaty, a centerpiece of the Earth Summit in Rio de Janeiro. The treaty requires signers to share research, profits and technology with nations whose genetic resources they use, and obliges industrialized nations to help fund conservation programs in developing countries. Every other major nation signed it, and a number of U.S. scientists backed it as well. The White House, though, said the treaty, two years in the making, would endanger patent protection for biotechnology companies, weaken the industry and threaten jobs, arguments laid out by Vice President Quayle's Council on Competitiveness. 

D66/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Opponents [of Single- or All-Payer Systems, Budgets] believe that budget-driven priority setting by committees of health professionals, public health planners, scientists, and government budget setters is likely to have two important negative consequences. First, the decision-making process will inhibit new health care organization or medical practice innovations and will retard the development of new medical technologies. Second, this approach will ultimately lead to rationing of high-technology care and long queues of patients waiting for nonemergency care from hospitals and physicians. 

D67/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 30, 1993, Part A; Page 1; HEADLINE: LID ON HEALTH COSTS NEEDED, GORE SAYS \\VT 93-94
	 But G. Kirk Raab, president and CEO of Genentech Inc., a pioneering California-based high-tech firm, warned that such [cost] controls would "strangle investment" in the biotechnology industry. 

D68/Felice J Freyer, staffwriter, The Providence Journal-Bulletin, March 21, 1993, Sec A; pg 1, HEADLINE: Managed competition: Cure for an ailing health care system? \\VT 93-94
	 Yet this incoherent system has incubated some breathtaking advancements in treating and diagnosing illness. An oft-expressed fear is that efforts to control costs will blunt America's cutting edge in medical research and technology. 

D69/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 That presents planners with an unpalatable scenario: It may be impossible to curb health costs without also limiting or rationing new technologies that can enhance human health and well-being, according to William B. Schwartz, a physician and health policy analyst at Tufts University medical school. 

D70/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 And so it is with just about every other cost-cutting measure. Cuts--in doctors' salaries, pharmaceutical profits, etc.--will partly negate the rising cost of technology, so overall spending may level out. But you can't keep cutting these things indefinitely. As technological forces return to center stage, overall spending growth returns to previous levels. It's fine to cut out fat, but unless that fat has been growing--unless it is part not just of overall costs but of annual increases in overall costs--cutting it will have no long-term effect on the rate of cost increases. (And in recent years, many kinds of fat have been shrinking.) 

D71/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 In his book Serious and Unstable Condition: Financing America's Health Care, Henry Aaron of the Brookings Institution shows that these sorts of technological advances greatly outweigh all other factors commonly blamed for rising health care costs, such as the aging of the population and malpractice litigation. And William B. Schwartz of the University of Southern California, co-author with Aaron of the 1984 book The Painful Prescription: Rationing Hospital Care, has demonstrated that many cost-cutting measures other than rationing have largely run their course. 

D72/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 As Thurston's case illustrates, technological advances can produce better health results, but at a high cost. Changes in technology are a major cause of rising health care costs -- accounting for as much as 25 to 50 percent of the annual increase after inflation is taken into account, according to specialists. 

D73/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 "The impact of technology is particularly great in the health field because good health is such a preeminent personal value that people are willing to spend much more on it than on other goods and services. This, in turn, encourages technology groups and firms to do the necessary research and development in order to bring new products to market," said Donald A. Young, executive director of the Prospective Payment Assessment Commission, which advises Congress on hospital issues. 

D74/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992; CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p. 72\\VT-ADPLProbably the only safe statement one can make is that the geometric rate of increase in expensive technologies, both machines d procedures for using them, is a majorperhaps the marcause of health care expense escalation. This increase rate is still exacerbating both the costcontainment debate and the access issues, because the more valuable the miracles we can perform, the more troublesome become the financial barriers to access.
D75/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Joseph Newhouse, a professor of health policy at Harvard, estimates that  "technological change, or what might loosely be called the march of science and the increased capabilities of medicine," accounts for at least half the explosive growth of U.S. medical costs in the last half-century. 

D76/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	Unfortunately, these strategies offer no hope of solving the underlying problem. An ongoing explosion of valuable new medical technologies will keep relentless upward pressure on expenditures throughout the coming decade despite any conceivable savings from eliminating inefficiencies. 

D77/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	The simple fact is that the genius of the biomedical community has provided a cornucopia of benefits that cannot be fully exploited if we mean business about slowing the cost spiral. Fair and efficient cost control will inevitably require the denial of expensive tests or treatments in cases where costs are high and anticipated benefits small. Serious cost containment will force us, for example, to abandon the use of magnetic resonance imaging in the thousands of patients where there is only a remote chance of finding disease. 

D78/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p.162 \\VT-JHHThe belief that the key to the cure or amelioration of in technological progress is deep and abiding, even though there is powerful evidence of long standing that health status is determined by many things other than the availability of stateoftheart technology. The cost of that progress, in the United States and elsewhere, is enormous. What has been called "intensification of care"by which is usually meant the application of technological advances and intensified services to individual patient careaccounts for approximately 25 percent of the inflationary cost of healthcare over and above general inflation.
D79/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Even if we somehow dodge this trade-off for the time being, we'll have trouble escaping it in the long run. It is pressed upon us by basic technological forces that show no signs of abating: the relentless creation of ever more subtle and ever more expensive treatments for an ever expanding array of maladies (some of which, indeed, aren't considered maladies until the treatments arrive). Coping with this trend through rationing--making hard choices about the quality of people's lives, and even about who gets to live--won't be a pleasant enterprise. But surely it's preferable to the only likely alternative: a world in which the market remains the primary rationer and an ever rising standard of physical well-being leaves low-income Americans entirely behind. 

D80/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 Making sure that the technology is justifiably used would keep the lid on costs, both for the country and patients. 

D81/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 "We are receiving better care, but the cost is killing us," said Rep. Fortney "Pete" Stark (D-Cal.), chairman of the House Ways and Means health subcommittee. 

D82/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	The proliferation of high-technology equipment and services and the growth of financially rewarding specialties - surgery, anesthesiology, radiology and subspecialties of internal medicine - have contributed to expanding costs. 

D83/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 "In America, part of your population is accustomed to getting every available medical technology," said Henk ten Have, a professor of medical ethics at Catholic University in Nijmegen, the Netherlands. "But another large part gets  no care at all." 

D84/Dolores Kong, Globe Staff Writer, February 26, 1992; The Boston Globe, “ High-tech and basic medicine get boosts,” p.23\\VT-AGL
	 The struggle between basic care and expensive new technologies has intensified because of heightened concerns about escalating health care costs and about the number of poor and uninsured people not getting basic care. 

D85/ JAMES FLANIGAN Los Angeles Times May 12, 1993, SECTION: Business; Part D; Page 1; HEADLINE: JAMES FLANIGAN: BIOTECH DRUGS MAY SAVE DAY FOR PHARMACEUTICALS \\VT-MDS
	 But medical and financial experts worry that price pressures could stunt development of biotech companies. Drug research and the lengthy process of getting Food and Drug Administration approvals are very costly. A young company needs high profit to recover those costs and to develop other products. 

D86/JAMES FLANIGAN Los Angeles Times May 12, 1993, SECTION: Business; Part D; Page 1; HEADLINE: JAMES FLANIGAN: BIOTECH DRUGS MAY SAVE DAY FOR PHARMACEUTICALS \\VT-MDS
	 "Any indication that biotech companies -- risky to begin with -- would have trouble making good profits would chill their chances on Wall Street," said Robert Teitelman, author of "Gene Dreams" and other books on technology and finance. 

D87/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 King: In a single-payer system, who would make those decisions about how much technology is enough? Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: You are talking about the United States Congress as a political football. [Congress would have] to balance [health care] against all the other things you need money for that year. The defense budget could skyrocket with another war. The United States is a wealthy country, but when we put a limit on things, technology will suffer first. It has in the socialized countries historically. They have never made up for it. 

D88/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Rationing health care would have the added virtue of slowing this whole process down. Health insurance distorts investment patterns. By giving Americans more elaborate care than they would buy if they felt the true costs, it signals capital markets to divert more resources toward the development of medical technology than America actually "wants." So "artificial" spending constraints such as rationing only neutralize an artificial investment stimulus that, left to its own devices, will bring us a rapidly growing array of grotesque political dilemmas. They'll come soon enough anyway. Why rush? 

D89/NEWSWEEK MAGAZINE 1989 "Biting the insurance bullet" reprinted in THE CRISIS IN HEALTH CARETHE REFERENCE SHELF, 1991, p140 \\VT- MDS
 Doctors' groups contend that these approaches would erode the quality of care. 'Big business is saying, 'Let's let the government do it,' without realizing it would cause the slowing of technological innovation and make access to health care increasingly difficult," says Dr. James Todd of the American Medical Association. He notes that in Canada, some advanced medical devices aren't easily available and some surgery requires long waits.D90/Thomas P. O'Neill former speaker of the U.S. House The Atlanta Journal and Constitution May 1, 1991 SECTION A; PAGE 13 HEADLINE: Medical research: Don't snip off funds \\VT-MDS
	 The promise is great that many fatal disease More exciting new advances in medical science are at hand. How soon we get them depends on how hard we go after them. 

D91/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 Numerous new -- and expensive -- technologies, drugs and procedures are available. Just three of them could add $ 5 billion to the nation's yearly health tab, Schwartz said. 

D92/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 Dr. JACK LAIDLAW, Canadian Cancer Society: There's no question that American medicine as it's practiced technically is tops in the world. It's just too bad that it isn't as easy for people to get to it as I believe it is in this country. 

D93/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 90 \\VT-JHH
There have been responses to these general objections. The first is that it is not technology that is the culprit but "the degree to which the deployment of new medical technology reflects legitimate consumer demand for higher quality care.  But that is precisely the problemthe desire for care of ever higher quality, which makes real control of costs all but impossible, and the belief that the desire is "legitimate," which undercuts any solid reason to resist the technology. What is by critics called "medical excess" is, by defenders, translated into an acceptable expression of "widespread patient and professional demand for greater technological research and sophistication.'' Which is exactly why we have a problem.
D94/Thomas P. O'Neill former speaker of the U.S. House The Atlanta Journal and Constitution May 1, 1991 SECTION A; PAGE 13 HEADLINE: Medical research: Don't snip off funds \\VT-MDS
	 Public-opinion polls have repeatedly shown that people favor investing much more than we do in medical research. Yet just 1 percent of the budget goes to fund the twin engines of medical progress: the National Institutes of Health (NIH) and the Alcohol, Drug and Mental Health Administration. 

D95/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: I feel that the American public has tasted a lot of technology and a lot of services and it is just hard to go back. And we won't go back. 

D96/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 But over the last few years, more focus has been given to high-tech and high-cost procedures involving sophisticated, even if not new, equipment. This would include procedures like coronary bypasses, balloon angioplasty (a procedure in which a balloon is inflated into an artery to clear a blockage) and the use of the magnetic resonance imaging scanner, which uses a large magnet and radio frequency waves to generate pictures for diagnosis. 

D97/ELl GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p.268 \\VT-JHHMoreover, our efforts will focus more on advancing the accomplishments of hightech medicine and diffusing its benefits broadly than on assuring equality of access.
D98/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 Keeping tabs on these would prevent the technology war currently raging in the United States where one technology quickly replaces another as hospitals race to upgrade their services. 

D99/The National Journal, February 15, 1992, Pg. 384 HEADLINE: Searching for A Treatment \\VT 93-94
	 As for decisions about whether to acquire new technology, the marketplace would be the arbiter. "I think it's [up to] individual citizens -- who may attach quite different values to different technologies -- to decide, not some health care czar," said the University of Pennsylvania's Pauly, who has been consulted by the Bush Administration. 

D100/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 26 \\VT-. ADPL
The market also enhances the goal of innovation by providing powerful incentives for management to surpass both its own past performance and that of its competitors.D101/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p. 6 \\VT-ADPL
An important goal of U.S. health care policy is to encourage innovations that will contribute to cost reductions and more effective treatment. There is no reason to believe that the application of market incentives will make this goal more difficult to achieve. Indeed, such powerful incentives are likely to stimulate the quest for costsaving technologies and encourage the commercialization of successful R & D.

D102/Business Insurance, March 26, 1993, Pg. 48, HEADLINE: A single-payer health care plan? \\VT 93-94
	 Sen. David Durenberger, Republican-Minnesota: In this regard, Canada offers an extremely valuable case study. The Canadians have succeeded in holding down costs, not because of their single-payer system -- if anything, such a system actually encourages prices to rise -- but because they have avoided the high-technology costs that account for so much of the price of U.S. health care. 

D103/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 LEVINE [JEFF LEVINE, Medical Correspondent]: The Bush Administration says the preeminent U.S. position in high-tech would be threatened if the nation adopted a Canadian system. Dr. LOUIS SULLIVAN, Health and Human Services Secretary: If I get sick with a heart attack or with some other situation like that, I want it to happen here in the United States because of the quality of our personnel and the quality of our system. 

D104/Editorial, The New York Times, May 26, 1992, Section A; Page 16; HEADLINE: Canada's No Medical Model \\VT 93-94
	 Beyond all such details hovers the question of innovation. Like most of the world, Canada freeloads off U.S. research and innovation. If the U.S. adopted the Canadian model, to whom would the world look for progress? 

D105/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 The United States has eight times more MRI and radiation therapy units per capita and three times more cardiac catheterization and open-heart surgery units per capita than Canada. 

D106/PR Newswire, September 16, 1992, HEADLINE: NATIONAL HEALTH INSURANCE NO SOLUTION, REPORT SAYS Nexis \\VT 93-94
	 -- Seattle (population 490,000) has more CAT scanners (to detect brain tumors, for example) than the entire province of British Columbia (population 3 million). [The Mackinac Center for Public Policy] 

D107/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 Less tech. Between Annapolis and Leesburg, there are about 35 magnetic resonance imagers (MRIs). These $ 2-million diagnostic machines are the best -- in some cases the only -- way of looking at spines, brains and soft-tissue problems in joints, heart and abdomen. Toronto has five. The arithmetic on this is easy. If each local machine sees 12 patients a day -- about average -- that's 420 patients a day. If each Toronto machines does 16 a day, that's 80 patients. So in a Canada-style system, 340 Washingtonians a day wouldn't get state-of-the-art radiological diagnosis. 

D108/Cable News Network, Health Works, May 30, 1992, Transcript # 120, HEADLINE: Part I - American And Canadian Health Care Systems, Nexis \\VT 93-94
	 [JEFF LEVINE, Medical Correspondent] High-tech procedures aren't as widely available here as in the States, but Canadians point out that could be a plus. Many U.S. patients get expensive treatments that are useless and potentially dangerous. Perhaps 44% of bypass operations are either unnecessary or questionable and could be avoided along with their associated suffering and considerable cost. 

D109/Theodore R. Marmor and John Godfrey, Canadian Institute for Advanced Research, The New York Times, July 23, 1992, Section A; Page 23; HEADLINE: Canada's Medical System Is a Model. That's A Fact. \\VT 93-94
	 Are some high-tech items in shorter supply in Canada than in America? Undoubtedly. Were America to disappear, Canada would have the world's most ample supply of intensive-care units and diagnostic machinery. The real question is whether the U.S. is oversupplied with marginally effective high technology, not whether Canada is in the medical stone age. 

D110/Jacques Krasny, Canadian health-care consultant, National Review, February 17, 1992, Pg. 43, HEADLINE: The wrong health-care model. Is Canada's health-care system really cheaper? \\VT 93-94
	 Finally, if Canada were to spend the same proportion of total health-care costs on R&D as the U.S., it would face a 2.4 per cent overall increase in costs, and a resulting 0.2-point increase in health care's percentage of GNP. 

D111/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 Advances are being made all the time in all fields of medicine -surgery, diagnostic techniques, gynaecology, medicine, ophthalmo-logy, paediatrics, you name it. No one would question that progress in technology is essential to good health care. 

D112/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION, p.65 \\VT-ADPL
The continued flow of new medical procedures is essential to future improvements in the quality of, and advances in U.S. health care.
D113/H.W. LEWIS, AUTHOR, 1990; TECHNOLOGICAL RISK p. 333-4
It cannot be a matter of reasonable dispute that technology has had a dramatic positive influence on the safety, health, and longevity of our population. Our life expectancies have not gone up by more than 20 years since 1920, and doubled in the last hundred-odd years, just because the stars are in the right places. It is because technology has given us safer and easier ways to do the things we do, has provided energy to replace much of our manual labor, has provided through science ways to make nature an ally in our activities, has endowed us with an enormously productive agricultural system, and has supplied the means for both prevention and cure of many of the most life-threatening scourges of mankind. To believe that we can simply reject technology and go back to a simple, wonderful, safe life is just plain nutty.

D114/ HARPERS MAGAZINE, MARCH 1983; SCIENCE, technology AND SOCIAL PROGRESS, 1990 p. 297
Life as we know and want it would be impossible without modern technology - in agriculture, industry, communications, health care, transportation, housing, and a thousand other spheres.

D115/ HARPERS MAGAZINE, March 1983; SCIENCE TECHNOLOGY AND SOCIAL PROGRESS p. 297
Technology to serve people must continue to be nurtured and strengthened and honed and put to the tasks in society that need to be done.

D116/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 There is an even larger problem with miracle cures. True, hgh and gene therapy may reduce the cost of particular treatments. But, like so much medical technology, they also expand the range of the treatable, making more and more maladies targets of health care. In an important sense, they redefine health itself, making it a more expensive concept. 

D117/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p.48 \\VT-JHHThere are no known theoretical limits. Mortality from heart disease has fallen in recent decades and continues to decline, and while cancer has yet to be conquered, there is no reason not to expect continuing progress. Organ transplantation becomes gradually more successful, and while there is a limit because of the availability of organs for transplant purposes, there is no necessary limit to the possibility of artificial organs. A gradual sharpening of the distinction between growing old (which can . not be helped) and becoming sick (which can be dealt with) does not make old age as such (in the eyes of some, at any rate) a necessarily fatal condition. Our need to live, then, admits of no discernible medical boundaries. There is no individual medical condition that does not, in principle, admit of the possibility of an eventual cure or possible amelioration.D118/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 And again: the lines will almost certainly not be drawn equally for rich and poor. The increasingly unavoidable choice will be between gross disparities and grosser disparities. Both options look particularly repulsive as the range of the treatable expands and things like intelligence and youth itself--or at least selected dimensions of intelligence and youth--become purchasable. Some of these things (assuming we don't ban them altogether) will have to be universally available if we're to keep paying even lip service to our egalitarian ideals. And we won't be able to afford that unless other things aren't universally available. The urgency of this argument will be doubled as some parents start using technology to choose genes for their unborn children (see "Achilles' Helix," tnr, July 9 & 16, 1990). 

D119/ JAMES FLANIGAN Los Angeles Times May 12, 1993, SECTION: Business; Part D; Page 1; HEADLINE: JAMES FLANIGAN: BIOTECH DRUGS MAY SAVE DAY FOR PHARMACEUTICALS \\VT-MDS
	 A lot is at stake. The biotech industry is not just a bunch of companies with funny names producing odd new substances. It is an industry that in this decade could produce cures for cancer and AIDS, heart disease and stroke, and grow into a $50-billion business -- with U.S. firms maintaining global leadership. 

D120/Thomas P. O'Neill former speaker of the U.S. House The Atlanta Journal and Constitution May 1, 1991 SECTION A; PAGE 13 HEADLINE: Medical research: Don't snip off funds \\VT-MDS
	 The promise is great that many fatal disease We should. Medical research is popular, it is productive and it is profitable for the country. We should do more of it. 

D121/Thomas P. O'Neill former speaker of the U.S. House The Atlanta Journal and Constitution May 1, 1991 SECTION A; PAGE 13 HEADLINE: Medical research: Don't snip off funds \\VT-MDS
	 Historically, the return on investment in medical research has been equally impressive. For every dollar so invested between 1900 and 1975, $ 13 was saved in medical costs, hospital care, loss of productivity and related expenses. Vaccines for measles and polio, lithium for treatment of depression and heart and liver transplants are just a few of the multitude of medical advances I have seen. And the best is yet to come. 

D122/Irwin Arieff, Reuters News Service, March 6, 1991, Wednesday, AM cycle HEADLINE: NEW STUDY PREDICTS MEDICAL ADVANCES WILL SAVE LIVES, MONEY , Nexis \\VT-MDS
	 For example, the gains would prevent nearly 2 million cases of crippling osteoarthritis from becoming disabling, saving $170 billion in productivity over the next 25 years, the center's report found. 

D123/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 And finer tunings of our mental selves. Designer drugs will increasingly go beyond the correction of severe mental illness and offer to make people a bit more serene, say, or more gregarious--without the self-defeating side effects of sedatives, stimulants and other crude drugs of past generations. Memory capacity, verbal fluency, math skills--all are likely to respond to the manipulation of brain chemistry, and some show signs of doing so already. (The northern California rage for "smart drugs" is largely ill-informed but not wholly offtrack.) With mental as with physical "health," we are headed toward an era when medicine makes people not just healthily human, but healthier than humans, raising them above the frailties to which our species has always been heir. 

D124/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 The other theory holds that technological advances will be cheaper than the treatments they replace, reducing costs in the long run. 

D125/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 124 \\VT-JHH Biomedical research not only contributes to health, but also has environmental, agricultural, and other benefits (especially through recombinant DNA research). The stimulation of technological developments creates devices, equipment, and drugs that can be sold abroad and, at the same time, provides additional forms of stimulation to technological innovation of use outside of medicine. 
D126/Report of the House Subcomm. on Investigations and Oversight of the Comm. on Science & Tech., ISSUES IN THE FEDERAL REGULATION OF BIOTECHNOLOGY: FROM RESEARCH TO RELEASE, December, 1986, p. 1.
Biotechnology has the promise to provide the United States and the world a wealth of organisms geneticallyengineered to fight disease, cleanup pollution, enhance food production, and decrease the use of harmful chemicals.
D127/ Tidewater Technology Assoc., Biotechnology," THE TECHNOLOGY TEACHER, December, 1987, P. 20 ,
Through the use of biotechnological methods, "waste eaters'" can be produced to consume solid and wastewater products. In addition to disposing of garbage and sludge, RDNA methods are currently under study to separate ores from rocks and wastes and also to assist in retrieving petroleum from 'spent' (economically pumped dry) wells

D128/ EDWARD WENK, AUTHOR, 1986; TRADEOFFS p. 6-7
Indeed, technology has demonstrated a fabulous capacity to generate new wealth even faster than capital alone, with a conspicuous virtue of enhancing material standards of living. By both developed and developing nations, it is regarded as a crucible for economic growth. Partly, this arises because technology has proven to be a key to abundance. Partly, too, this admiration is accentuated because economic growth is itself heralded as desirable.

D129/ HARPERS MAGAZINE, March 1983; SCIENCE TECHNOLOGY AND SOCIAL PROGRESS p. 297
To curb technology would be to squelch innovation, stifle imagination, and cap the human spirit.

D130/Irwin Arieff, Reuters News Service, March 6, 1991, Wednesday, AM cycle HEADLINE: NEW STUDY PREDICTS MEDICAL ADVANCES WILL SAVE LIVES, MONEY , Nexis \\VT-MDS
	 Expected advances in the ability to control or prevent memory loss could reduce by 440,000 the number of Alzheimer's patients requiring special care over the next 25 years, avoiding $76 billion in direct medical costs, it predicted. 

D131/John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 In this time when the world is ravaged by the AIDS epidemic, we must continue to promote medical education and research, the only true preventive medicine measures. The warning is that funds for these purposes are in danger of being lost because of the cost of patient care. 

D132/Reuters News Service, January 20, 1992, HEADLINE: AIDS WILL KILL 20 MILLION BY YEAR 2000, SAYS TOP U.N. OFFICIAL Nexis \\VT 93-94
	AIDS will kill 20 million people worldwide by the year 2000, the head of the United Nations Development Program said Monday. And UNDP chief William Draper said that AIDS, which costs Americans billions of dollars in health care, could jeopardize the economies of several Asian nations. 

D133/Maggie Fox The Reuter Library Report April 3, 1993, HEADLINE: DOCTORS HOLD OUT HOPE FOR AIDS RESEARCH AFTER DRUG SETBACK, Nexis\\VT - MDS 
	The World Health Organisation says about 10 million people worldwide are HIV positive but not yet suffering from AIDS. 

D134/ Jeff Lyon & Peter Gorner, correspondents for Chicago Tribune, 1986, in ALTERED FATES: THE PROMISE OF GENE THERAPY, p.1
Many genetic researchers foresee a day when such inherited killers and disablers as cystic fibrosis, muscular dystrophy, hemophilia, sickle cell anemia, beta thalassemia, TaySachs disease, phenylketonuria, Huntington's chorea, and neorofibromatosis may be treated and cured by gene therapy.D135/Tidewater Technology Assoc., "Biotechnology, " THE TECHNOLOGY TEACHER, December, 1987, p. 19.
The potential for the application of biotechnology in the area of human health care is great. Current research focuses on  the use of RDNA and monoclonal antibodies to detect congenital diseases, in cancer detection and treatment, to produce vaccine, in human growth and hormone studies. and to produce insulin.
D136/David Suzuki & Peter Knudtson, Prof., Zoology, U. British Columbia & Journalist, GENETHICS: THE CLASH BETWEEN THE NEW GENETICS AND HUMAN VALUES, 1989, p. 331.
By analyzing mounds of raw DNA sequencing data, geneticists should be able to uncover important clues to the structure of individual human genes and the interactions between them. They should be able to recognize recurring patterns of control sequences adjacent to genes that will help explain how the gene in living cells are switched off and on during growth and development with such exquisite timing. And by comparing the DNA content of healthy and ill individuals, they may be able to monitor the passage of highly mobile, pathogenic DNA sequences, including retroviral genes that are relics of previous vital infections, as well as other categories of restless DNA such 82 oncogenes. Perhaps most important of all, a complete inventory of human DNA sequences will help future researchers to pose far more meaningful questions about the many mysteries of human genetics will undoubtedly remain.
D137/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Biotechnology certainly could lower the costs of some treatments. Consider gene therapy, in which defective cells--blood cells, brain tumor cells--are corrected by amending their dna. Now in experimental stages, gene therapy is still unthinkably expensive, and it will never be dirt cheap. But "cheap" is a relative thing. With the immune disorder called adenosine deaminase deficiency--the "bubble boy" disease, made famous in a made-for-t.v. movie--the alternatives to gene therapy are (a) keeping the patient in a sealed, sterilized world (until he dies at, say, age 12, after a germ somehow sneaks in); or (b) giving him a bone marrow transplant that costs around $100,000 and may well fail. In the case of cancer, now treated capital-intensively, labor-intensively and often unsuccessfully, the eventual savings from an effective gene therapy could be large. 

D138/ Theodore Schlie 1984 (former Dir. of Industrial Anal Dept. of Commerce) A COMPARATIVE ASSESSMENT OF THE US PHARMACEUTICAL INDUSTRY, P. 68.
Genetic engineering has offered not only ways of making and improving old products (e.g. human insulin) and what are currently very expensive products (e.g. interferons) but also ways of creating entirely new products promising new and effective therapies.
D139/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Another candidate for (relatively) cheap cure is human growth hormone. In 1990 a researcher found something that he insisted was "not the fountain of youth" but that bore a strong resemblance to it. Men over 60 who were given shots of hgh for six months saw health improvements "equivalent in magnitude to the changes incurred during ten to twenty years of aging." Skin thickened, body fat dropped, muscles grew. Internal organs--heart, kidneys, intestines--seemed to have regained some long-lost vigor. (Alas, no help for brain cells from hgh.) 

D140/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Confident interpretation awaits more research, but hgh may eventually be used to broadly forestall organic failures that, taken one by one, are now treated at great expense. hgh treatment now costs more than $10,000 a year, but the price will probably drop as its production, via genetically engineered bacteria or mammals, is refined. (Already the hormone is much cheaper than in the days when it was scavenged from the brains of cadavers.) 

D141/ Brendan Pereira, Staff Writer, December 12, 1992; The Straits Times, “Faster and safer brain surgery with computers,” p.25\\VT-AGL
	 FASTER and less risky for patients -that is what brain surgery at the Singapore General Hospital has become with the use of computers. The use of high-tech equipment also has not resulted in higher costs for the patients. These assurances were given by Dr Prem Pillai, head of SGH's Neurosurgery Department, during a briefing on computer-assisted surgery yesterday. 

D142/ Brendan Pereira, Staff Writer, December 12, 1992; The Straits Times, “Faster and safer brain surgery with computers,” p.25\\VT-AGL
	 (Dr Prem Pillai) said that another advantage is that the risk of complications is reduced as the computer software, developed in Boston, is able to map the exact size and location of a tumour. 

D143/ Brendan Pereira, Staff Writer, December 12, 1992; The Straits Times, “Faster and safer brain surgery with computers,” p.25\\VT-AGL
	 Said Dr Pillai, who noted that he is aware that high-tech medicine is often seen as the culprit in rising health-care costs: "The use of computers does not increase the bill. The costs remain the same." He added that there could be savings on ward charges instead. While the average stay for a patient who undergoes normal brain surgery is seven to 10 days, some people who go through computer-aided operations can be discharged in five days. 

D144/Lewis Cop,Staff Writer, March 18, 1992; Star Tribune, “ Tomorrow's doctors: diagnosis by computer, surgery by robot ,” p. 1E\\VT-AGL
	 If a computer can do the job better, it would be unethical not to use it unless costs are astronomical, said Kenneth Goodman of the University of Miami School of Medicine. But while computers have the potential for cutting costs, they could raise costs if they simply add to what doctors already do. 

D145/Lewis Cop,Staff Writer, March 18, 1992; Star Tribune, “ Tomorrow's doctors: diagnosis by computer, surgery by robot ,” p. 1E\\VT-AGL
	 The panelists said that computers are showing promise in becoming expert in various types of medical diagnosis. Yet even computers can lose out to technology advances. One computer in the 1970s was doing a great job of helping some doctors determine which antibiotics would work best in each patient's case. But so much new information about these drugs became available that the smart machine quickly got out of date, the panelists noted. 

D146/Lewis Cop,Staff Writer, March 18, 1992; Star Tribune, “ Tomorrow's doctors: diagnosis by computer, surgery by robot ,” p. 1E\\VT-AGL
	 And will more computers mean that fewer doctors will be needed? Probably not, the panelists said. Computers are likely to do some jobs better than others, so they might shift what some doctors do. Even then, somebody has to "teach" the computer, then read the results, then interpret the results, then deliver the care to patients. 

D147/Lewis Cop,Staff Writer, March 18, 1992; Star Tribune, “ Tomorrow's doctors: diagnosis by computer, surgery by robot ,” p. 1E\\VT-AGL
	 In another session at the AAAS meeting, Dr. Lucian Leape of the Harvard Medical School suggested that lives could be saved in hospitals by using computers to screen all medications before patients get them. This would guard against medication mixups or adverse reactions that a check of the patient's medical history could prevent. 

D148/Jacqueline Frank, The Reuter Library Report, January 31, 1992, HEADLINE: U.S. AWED BY MEDICAL ADVANCES, LOST SIGHT OF COSTS, Nexis \\VT 93-94
	Marilyn Moon of the private Urban Institute noted that improved safety and accuracy of diagnoses and treatment have led to more value for the dollar and more dollars spent. For example, exploratory surgery which was once needed to diagnose internal disorders has been replaced by magnetic resonance imaging and CAT scans. Hospitals compete for this technology, passing the costs along to patients who may not need it. Those who are insured are forced to pick up the tab for patients who cannot pay. 

D149/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, P. 155 \\VT-JHH
We cannot have, nor should we even try to have, everything that might be conceivable to biomedical research to be free of all illness, to live to an average age of 100, to have a life utterly devoid of psychological stress, for instance but we can achieve many of our dreams. The challenge is to devise some that are reasonable, that can be prudently pursued, and that would be conducive to a coherent individual life, one that has aspirations but is willing to understand that, for the good of all, there must be some firm limits. We need to direct future medical progress to goals different than have been common in recent decades and, at the same time, be willing to admit the need for restrictions on heavy expenditures to promote progress.

D150/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p.94 \\VT-JHHThe most common and misguided assumption is that, if a therapy is efficacious, particularly highly so, we should therefore use it and we should therefore be able to afford it. Yet what expensive ineffective technologies have in common with expensive effective technologies is that they are both expensive. That the efficacious technology is effective does not, however, mean that it is any more affordable than the ineffective one. Efficacy and affordability are two entirely different matters, and their implicit conflation in much technology assessment promotion contributes enormously to the illusion that the key to cost containment lies in determining which technologies will be efficacious. This could well be called the efficacy fallacy : if it works, we should therefore be able to afford it.
D151/ELI GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p. 33 \\VT-JHH Some 85 percent of all funding for basic biomedical research provided by the federal government, primarily through the National Institutes of Health (NIH}; almost all of the development and manufacturing of the technological armamentarium of modern medicine is performed under the aegis of the private (forprofit) sector; and most of the major advances in technology are actually used in hospitals that are predominantly nonprofit institutions.
D152/The National Journal, February 15, 1992, Pg. 384 HEADLINE: Searching for A Treatment \\VT 93-94
	 The country must "have in place a financing system that permits, or even forces, a debate" over how many sophisticated diagnostic machines you want to have, said Henry J. Aaron, director of the economic studies program at the Brookings Institution. "Unless you create . . . a budgeting system, or something that makes it natural to have this debate, you aren't going to have it. There's no way within the current system in which decisions to curtail beneficial care can be ethically made." 

D153/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 The rationale is that state-of-the-art technology would, of course, be more expensive, and doctors may be tempted to over-prescribe its use just to recover the cost of acquiring it, when traditional methods would do as well. 

D154/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 As a society, we are captivated by the successes of the biomedical paradigm: the achievements of specialization, modern technology, and tertiary care. Our society places higher priorities on the values of this paradigm at the expense of primary care and long-term care. These priorities have given rise to sovereignty of the biomedical paradigm. As a consequence, primary care has an inadequate number and poor distribution of physicians, [n43] and long-term care is poorly organized within a two-tier system, ie, Medicaid and private pay. [n45-n47] Without a controlled health care budget and without primary care physicians controlling access to more costly levels of health care, it is not surprising that cost containment measures have given only a temporary reprieve from rising health care costs. [n48-n50] 

D155/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, pp.1667 \\VT-JHH We should also give priority to those who can be saved by existing technologies over the saving of still more lives by the creation of still more new technologies designed to press beyond present frontiers. We should not, in short, go beyond those frontiers until we know how to . improve life for those already existing, but poorly, within the present frontiers. To use a military analogy: If we are going to conduct a war on various diseases, we should not extend our advance beyond our supply lines. That is the classic way of turning victory into defeat.
D156/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 One theory holds that there is so much waste in the medical system that eliminating it not only could save enough to pay for future technological marvels but also could provide insurance for the tens of millions of people who lack adequate coverage. 

D157/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 One doctor pointed out that a good reason for caution in adopting new technology is that new advances, like any novelty, may just be a fad. 

D158/Jacqueline Frank, The Reuter Library Report, January 31, 1992, HEADLINE: U.S. AWED BY MEDICAL ADVANCES, LOST SIGHT OF COSTS, Nexis \\VT 93-94
	Sometime in the past thirty years, Americans became mesmerised by all the sophisticated new medical technology they could buy and failed to see that their reliable, cheap health care system was slipping away. 

D159/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Robert Brook, senior health services researcher at the RAND Corp. in Santa Monica, said the use of costly technology often does not help and sometimes is  downright dangerous to patients' health. "Perhaps one-third of the financial resources devoted to health care today are being spent on ineffective or unproductive care," Brook and Kathleen Lohr of RAND's Washington office wrote recently.  

D160/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 While Canada spends less than half as much per capita on research and development as the United States does, it holds its own. Canadian scientists have had some spectacular successes recently in the search for the causes and ultimate cures of such genetic diseases as myotonic dystrophy and cystic fibrosis. 

D161/Martin Dyckman, associate editor of the St. Petersburg Times, June 7, 1992, Pg. 3D HEADLINE: Don't dismiss Canadian care \\VT 93-94
	 This country's dominance in research, development and manufacturing is a direct result of its much greater population and overall wealth. But it is dishonest to argue, as does the New York Times, that this would be lost if the United States emulated Canada's more humane and historically more cost-effective national health insurance system. We would continue to spend what we choose to spend. The difference is that we would get more for it. 

D162/Business Wire, January 7, 1992, HEADLINE: Distrust of government, less 'noblesse oblige' hamper chances for national health insurance for now, Nexis \\VT 93-94
	Fuchs [Victor Fuchs, Stanford University economics professor] said the price that Canadians and Europeans pay for such controls is delay and inconvenience in receiving high-tech services, or sometimes not receiving such services at all. Whether delays or denials have a significant effect on the health of the population is not known with certainty. ''The limited evidence now available suggests that they do not,'' he said. 

D163/Richard Lamm , former Gov. Colorado, MEGATRAUMAS, 1985. p 42.
Many of these expensive high-tech procedures and machines drain our ability to pay for other medical procedures. The exorbitant cost of high technology medicine is one of the main factors cited for declining funds for prenatal care and health care for the indigent.
D164/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: We won't go back. We have technology here that exceeds anything else in the world. But I suspect that we will be more judicious in extending that technology as rapidly as we have, simply because it has a lesser benefit for the overall health of the country than the basic expenditures that we still fail to make, such as vaccines and preventive care. 

D165/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Of course, there's always the hope for a miracle cure, hope that technology will solve the crisis it has created. As biotechnology makes medical interventions less elaborately mechanical and more molecular, couldn't treatment get cheaper? This hope is almost sure to be dashed. Still, the dashing is of an instructive sort. 

D166/JANNY SCOTT, TIMES MEDICAL WRITER, July 28, 1992; Los Angeles Times, "HOSPITALS CAN MAKE YOU SICK," Part A; Page 1\\VT-AGL
	 To some extent, such infections are a price of medical progress. More patients are getting the benefit of high-tech medicine; but every time a person receives a new organ, an immunosuppressive drug, even an intravenous catheter, he runs a risk of infection. Paradoxically, one of the main causes is advanced medical technology. Although new procedures and drugs have vastly improved many patients' prospects for survival, they have also left many patients more vulnerable to infection than in the past. 

D167/Lewis Cop,Staff Writer, March 18, 1992; Star Tribune, “ Tomorrow's doctors: diagnosis by computer, surgery by robot ,” p. 1E\\VT-AGL
	 But Dr. Richard Cook, an anesthesiologist and expert on high-tech medicine at Ohio State University, cautioned against a rush to impose a new level of technology. Too much complexity tends to increase the chances of unexpected problems, he said. 

D168/Sharon Loh , Staff Writer, August 17, 1992; The Straits Times, "High-tech medicine" nexis\\VT-AGL
	 There is another good reason for not adopting new techniques too eagerly. Dr Mohan said that while laparoscopic procedures are catching on rapidly in the US, there is a higher complication rate associated with this, not because the procedures are necessarily more dangerous, but because practitioners are not well-trained enough. 

D169/ GEORGE MITCHELL, Senator, Maine, 199l WORLD ON FIRE: SAVING AN ENDANGERED EARTH p. 217
If we have learned anything over the past four decades it is that not all new technologies are benign. Some are deadly. At the heart  of the matter is society's ever-rising dependance on rapidly devised, hurriedly deployed technologies whose complex side-effects are unknown, unpredictable, or - most often - ignored. The ramifications of these technologies need to be known, predicted, and controlled. The last thing they need to be is ignored.

D170/  EDWARD WENK, Author, 1986; TRADEOFFS p. 1
But humankind has also come face to face with the ominous side - the threat of nuclear war, of climate modification, of unwanted genetic transformations, and the loss of freedom, along with heightened risks and ethical dilemmas. Some of these effects imperil survival , survival to be both alive and free.

D171/ CHRISTOPHER MANES, ECOLOGY WRITER, 1990; GREEN RAGE: RADICAL ENVIRONMENTALISM AND THE UNMAKING OF CIVILIZATION, p. 153
As Gregory Davis says in Technology - Humanism of Nihilism, "Never before have so few been able to bring about so much damage to so many" as under the authoritarian regime of modern technology.

D172/ ALBERT GORE, Senator, Tennessee, 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT p. 318
Unless we come to a better understanding of both the potential and the danger of technology, the addition of more technological power simply ensures further degradation of the environment.

D173/ CHRISTOPHER MANES, Ecology Writer, 1990; GREEN RAGE: RADICAL ENVIRONMENTALISM AND THE UNMAKING OF CIVILIZATION P. 226
In questioning the validity of the industrial state, radical environmentalists find themselves in good company, Martin Heidegger took up the theme of the technological domination of humanity and nature in the 1950s with the essay "The Question Concerning Technology." According to Heidegger, the threat of technology consists not of the proliferation of its ugly and dangerous instruments, although they are certainly deplorable enough. Rather, technology represents a relationship between humanity and the world, a portrayal of the entirety of existence as a standing reserve of raw material valuable only insofar as it augments human power. Technology totalizes existence along one axis, the axis of utility, and all the other rich, poetic, wild ways in which a human being is able to encounter the world are excluded.

D174/ CHRISTOPHER MANES, Ecology Writer, 1990; GREEN RAGE: RADICAL ENVIRONMENTALISM AND THE UNMAKING OF CIVILIZATION P.227
Jacques Ellel developed the same theme of humanity's subjection to the dominion of techniques in THE TECHNOLOGICAL SOCIETY. Lewis Mumford's MYTH OF THE MACHINE: THE PENTAGON OF POWER continues this explication of the totalizing effect of monolithic technologies that destroy and debase human values in the name of progress.

D175/ Daniel Callahan, dir., The Hastings Center, SETTING LIMITS: MEDICAL GOALS IN AN AGING SOCIETY, 1987. p. 160A.
It is often and accurately said that the elderly do not want excessive and useless treatment They greatly fear a death marked by technological oppressiveness, wrapped in a cocoon of tubes and machines
D176/Howard Waitzkin. Medical Scholar. THE SECOND SICKNESS. 1983 p6
The promotion of high technology also reinforces economic contradictions. Sustained corporate profit generally requires expansion, diversification into different product lines. and creation of new markets. Medical technology provides a lucrative direction for numerous industries. as rates of profit in other areas become sluggish Meanwhile, as expensive technology proliferates. cheap and mundane medical practices receive little attention, even though they may be more appropriate.
D177/Howard Waitzkin. Medical Scholar. THE SECOND SICKNESS. 1983. p27
The goals of compassion and humanism are beyond reproach: an overemphasis on technologic medicine has tended to impede these goals.
D178/Seth Shulman, Journalist, "Biological research and military funding," TECHNOLOGY REVIEW, April, 1987 p.17
.Testifying before the EPA, Cornell professor Martin Alexander said, "Alien organisms that are inadvertently or deliberately introduced may survive, they may grow and they may find a susceptible host or other environment, and they may do harm. I believe that the probability of all these events occurring is small, but I feel that it is likely that the consequences of this low probability event may be enormous."
D179/ EDWARD WENK, Author, 1986; TRADEOFFS p. 8
Because the pace of technology evolves more swiftly than social institutions that husband it, it has sparked disharmony in purpose and economic and social instability.

D180/ Christian Bernard, performed first open-heart surgery, GOOD LIFE GOOD DEATH, 1980. P, 1342.
At present there is ample evidence to indicate that man's search for immortality is gaining ground. The thought is disturbing. Although long-term survival may benefit the individual, there is cause to think that it would be of great harm to the species as a whole. Senescence and death are an evolutionary necessity. The built in cell program in each species allows enough time, whether measured in hours or years, for each individual in lifetime to mature, adapt to its short-term environment, and reproduce. If the individual cannot cope with the environment, he will not reproduce, and his genes will die with him. On a large enough scale this can wipe out a whole species. The fossil record of the earth shows that this has happened many times in the past,D181/James J. Kilpatrick, syndicated columnist, The Buffalo News, December 23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	  Clinton has not asked for national health insurance in the British or Canadian pattern. No one knows exactly what he will request, but this much is certain: It won't come cheap, and somebody will have to pay. 

D182/National Journal's CongressDaily January 26, 1993 HEADLINE: Kennedy: Health Reform This Year A 'Realistic Target', Nexis \\VT 93-94
 And Kennedy, long a leading congressional advocate of universal health coverage, said he does not favor a single-payer system. "I quite frankly think that's unrealistic in today's world," said Kennedy, who in the past has advocated a system of national health insurance. "I don't think we should wait another five to 10 years to get it, and I think it would take that long, given the size of new revenues needed." 

D183/U.S. News & World Report, March 1, 1993, Pg. 67, HEADLINE: Sort of a taxing program \\VT 93-94
Bill and Hillary Clinton have also promised to present a national health insurance plan by spring -- and somebody's going to have to pay for it.  
    
D184/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 Future costs for medical care are very difficult to predict accurately. That's because the system is very complex and because economic models developed for other areas of the economy don't work well in this economic sector. 

D185/Spencer Rich, Washington Post Staff Writer, The Washington Post, January 11, 1992, PAGE A11 HEADLINE: 2 Studies Differ Sharply On Health Care Overhaul \\VT 93-94
	A study by Rep. Richard K. Armey (R-Tex.) found that health costs would jump by $ 81.5 billion a year under a national insurance system covering all Americans, while a report released by Rep. Fortney "Pete" Stark (D-Calif.) estimated that such a system would save $ 26.3 billion. 

D186/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	[Employee Benefit Research Institute] First, they [VOTERS] should view all of the cost numbers people will toss around with a healthy dose of skepticism. They should take for granted that those who favor significant reform will tend to use the low number while those who are opposed to reform will tend to use a high number. The truth will lie somewhere in between. 

D187/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	Q: What's missing from the political debate on health care reform? 
	A: [Employee Benefit Research Institute] Agreement on what it could cost and honesty over where the money could come from - and when. 

D188/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	[Employee Benefit Research Institute] You have to use a number of assumptions that mainly have to be guessed at. How much would a particular strategy save on administrative and marketing costs? How much would it increase or decrease demand for care? How do you set a value on care the uninsured are getting now? You also find, when you dig into these reports, insufficient explanation of methodology used to come up with estimates. 

D189/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	Q: Isn't another access for the 35 million uninsured? How much money would we have to throw at the problem of access to solve it? 
	A: [Employee Benefit Research Institute] For this interview, we took a detailed look at seven major estimates of what various types of reform would cost employers and government, and how much overall spending would rise. As you can see, there are multibillion- dollar variations. 

D190/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 There has been and will continue to be an avalanche of numbers flowing from policy analysts and politicians concerning the cost of medical care and what changes to expect under various health reform proposals. It's important to understand that NO health reform plan is expected to decrease the overall expenditures on medical care services -- now or in the foreseeable future. Reform plans are directed at decreasing the rate of rise of costs. 

D191/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	Q: Isn't there some money we're wasting that could be used to offset the added costs of expanding care to all? 
	A: [Employee Benefit Research Institute] There are a lot of statements being made that national health insurance can save us enough in cutting administrative costs alone to pay for universal access to care for everyone. But they don't mention the time lag involved. Yes, last fall Health and Human Services did estimate up to $ 50 billion a year could be saved by having a universal system, which if we started now could be fully in place by the year 2000. So there's enough to be saved in administrative reform to pay for that approach. But the added costs for access are going to shoot up tomorrow, and the savings won't balance out until the year 2000, not tomorrow. 

D192/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 When savings figures are reported, they are based on the amount projected to be spent under a specific reform plan -- as compared to the projected amount that would have been spent under the present system. Also, the projected saving from reform plans are reported in two ways: 1. The amount saved per year. 2. The total or accrued savings over a number of years. 

D193/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 930318 20:16:27 EST \\VT-ACS
Each change that is recommended under any reform plan will cause a similar cascade or rippling effect on costs throughout the medical care delivery economic sector. Reform plans with multiple effects are like throwing man)/rocks into a pond at the other. The precise the same time and watching he ripples interacting with each results of multiple changes are very hard to predict.
D194/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 In assessing the amount saved per year, it's important to know what year is being referenced. For example, two plans may both be projected to save ten percent of total expenditures. But one plan may be reported to save $140 billion dollars per year and the other $180 billion dollars. The first figure, however, may have been based on the projected expenditures for 1998 and the second on the year 2000. 

D195/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	[Employee Benefit Research Institute] Solving the access problem can happen fairly quickly, but we have to find new money to put into it now and over the next few years. That means committing more resources - taxes, employer premiums - for the time being. Politically, it's not being sold that way. The appeal leaves voters with the impression this can happen immediately. It leads to tremendous potential voter dissatisfaction. They think we can have it tomorrow, and then they learn its an eight- or nine-year payback. 

D196/RASHI FEIN, professor of the economics of medicine at Harvard Medical School, Scientific American, November, 1992, Pg. 46 HEADLINE: Health care reform; Proposed national health care program \\VT 93-94
	 Nevertheless, the savings would occur only over a number of years. Determining what constitutes appropriate care would require research into and consensus about the meaning of unnecessary care. Patterns of practice would have to be altered. We would have to pursue an active labor-market policy to assure jobs for those who would be displaced by change. 

D197/Peter Passell, staffwriter, The New York Times, February 25, 1993, Section D; Page 2; HEADLINE: Economic Scene; Clinton's plan pales before the 900-pound health-care gorilla. \\VT 93-94
  "Even if we win the health inflation war," Robert Reischauer, the director of the Congressional Budget Office, believes "the fruits of victory" will not show up on the budget until the next century. 

D198/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, March 18, 1993, TITLE: HEALTH CARE REFORM COSTS, Better Health and Medical Forum, Online America, Transmitted: 93-03-18 20:16:27 EST \\VT 93-94
	 Although the immediate savings are important, the longer term total or accrued savings will probably have more overall impact on budget deficits and the economic well being of America. 

D199/FRAN HAWTHORNE, staffwriter, Institutional Investor, May, 1992, Pg. 37, HEADLINE: Why play-or-pay can tame health care costs \\VT 93-94
	 Skeptics warn that there will inevitably be pressure to enrich the nationwide core package. "The first time a person dies because they didn't have renal dialysis, you'll see a hundred politicians beating their breasts," Aetna's Weizmann says. 

D200/Judith Feder, PhD, Diane Rowland, ScD, Kaiser Commission on the Future of Medicaid, Baltimore, Md, Journal of the American Medical Association July 15, 1992: 268: 362-364 TITLE: Government \\VT 93-94
	 Even if proposals slow long-term health care costs, they all require substantial increases in taxes, ranging from $ 35 billion to $ 40 billion for the President's proposal, or pay or play, to 10 times that amount for a government-run national health insurance system that would replace private premiums with tax-financed insurance coverage. 

D201/B.D. Colen, medical correspondent, Newsday, December 1, 1992, Pg. 85, HEADLINE: Health-Care Reform: Time To Define Its Parameters \\VT 93-94
	  Once we know what reform will cost, then we can decide if we are willing to pay the price. If we aren't, we will have to begin trimming the bill by expressing our willingness to live with the "diseases" we can't afford to cure. 

D202/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	[Employee Benefit Research Institute] Second, be aware that there are immutable trade-offs involved in any proposal. Individuals need to get fairly aggressive in asking the politicians, how are you going to pay for it - pay for it today? 

D203/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	USA TODAY asked the Employee Benefit Research Institute to survey the literature for estimates of what various health care reform strategies would cost. What EBRI found was a statistical Tower of Babel. (Estimates are for 1991 unless otherwise specified.) 
New spending (billions-first year) 
Type of reform Employer mandate 
Overall(1) 	By gov't. 	By employer 	Analysis by 

$ 13.0 	-$ 8.0 	$ 26.0 	Cong. Budget Office 
$ 5.4 (2) 	-$ 3.7 (2) 	$ 22.2 (2) 	Lewin-ICF (1989) 
$ 9.7 		-$ 3.1 (2) 	$ 19.4 (2) 	K.E. Thorpe (1989) 
N.A. 		N.A. 		$ 29.6 	Urban Inst. (1988) 

D204/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	USA TODAY asked the Employee Benefit Research Institute to survey the literature for estimates of what various health care reform strategies would cost. What EBRI found was a statistical Tower of Babel. (Estimates are for 1991 unless otherwise specified.) 
New spending (billions-first year) 
Type of reform Play or pay 
Overall(1) 	By gov't. 	By employer 		Analysis by 

$ 20.0 	$ 7.0 		$ 26.0 		Cong. Budget Office 
$ 11.3 	$ 8.0 		$ 26.4 		Lewin-ICF (1989) 
$ 12.0 	$ 24.0 	$ 14.7 		Pepper Comm. (1990) 
$ 12.5 	$ 5.1 		$ 16.8 (2) 		K.E. Thorpe (1989) 

D205/USA TODAY, January 23, 1992, Pg. 11A HEADLINE: Health care reform: Cost estimates are elusive \\VT 93-94
	USA TODAY asked the Employee Benefit Research Institute to survey the literature for estimates of what various health care reform strategies would cost. What EBRI found was a statistical Tower of Babel. (Estimates are for 1991 unless otherwise specified.) 
New spending (billions-first year) 
Type of reform Medicaid expansion 
Overall(1) 	By gov't. 	By employer 		Analysis by 

$ 13.0		$ 16.0 	$ 0.5 			Cong. Budget Office 
$ 2.1 		$ 14.7 	none 			Lewin-ICF (1989) 
$ 2.3 		$ 10.5 (2)	none 			K.E. Thorpe (1989) 

D206Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 The major concern of opponents of comprehensive benefits is the large cost of such benefits for taxpayers or employers. The US Bipartisan Commission on Comprehensive Health Care has estimated that the cost of providing long-term care coverage for those over age 65 years exceeds the cost of providing basic universal coverage for those who are uninsured under age 65 years. [n6] 

D207/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Mr. SCHRAMM [CARL SCHRAMM, Health Insurance Association of America] : Well, I think it's about as feasible- I should have probably qualified it. Americans aren't going to pay new taxes for a government program. One poll after another shows us that. There was a recent poll done by Democratic and Republican pollsters together that suggest that they could get 41 percent of the electorate up to $ 100 a year for a new federal system. So, I think it's about as feasible as anybody else's. 

D208/Health Line, September 14, 1992, HEADLINE: BROOKINGS INSTITUTION: NEW TAX NEEDED FOR HEALTH CARE Nexis\\VT 93-94
	 AP-INQUIRER: "The most expensive proposal was one to guarantee health care to all Americans. Universal health care is affordable only with a new tax, the report said, and even then the country must abandon the idea that all possible care can be provided to everyone. Some procedures just are not worth it." To guarantee universal access for all Americans, the report called for "extending the current system of employer-sponsored health insurance with a government backup plan for people not covered through work or a family member's policy." The proposed financing for the suggested health care reforms was a "value-added tax -- a hidden national sales tax" (Feinsilber, 9-12). Aaron, "who has done extensive work on health care financing reform," rejects two other health care reform proposals, " national health insurance and a system of tax credits as politically impractical because each would require large tax increases" (Brookings release, 9-11). 

D209/The National Journal, February 15, 1992, Pg. 386, HEADLINE: Politics and Health Policy \\VT 93-94
	 Why the split? A single-payer plan could mean more-progressive financing and more administrative savings, and make it easier to keep a lid on spending. But it would also mean raising hundreds of billions of dollars in payroll and income taxes. Arguably, the taxes would primarily offset expenditures now made by employers and individuals for private insurance. But voters are seldom enthusiastic about proposals to turn more money over to the government. 

D210/ Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Taxes. -- The first approach, increased taxation, allows for a redistribution of money from healthier Americans to subsidize the care of sicker people. Both progressive taxes (which require an individual's tax payment to be proportional to his or her income, such as an income or payroll tax) and regressive taxes (which are the same regardless of ability to pay, such as the value-added tax or "sin" taxes on alcohol and cigarettes) have been proposed as mechanisms for financing insurance. Income taxes are seen as more equitable to lower-income Americans, while sales and excise taxes are better for the economy because they encourage more saving and investment. However, raising taxes of any type is unpopular because many people believe they are already overtaxed and that current tax levels need to be reduced, not raised. 

D211/Sabin Russell, Chronicle Staff Writer, The San Francisco Chronicle, DECEMBER 16, 1992, Pg. A5, HEADLINE: Economy, Deficit Bigger Worries Than Health Care, Study Says \\VT 93-94
	 Public concern over health-care reform is eclipsed by worries about the  economy and the deficit, a new study shows, but nevertheless the issue remains  critical for President-elect Bill Clinton.  

D212/WILLIAM SCHNEIDER, The National Journal, March 20, 1993, Pg. 730, HEADLINE: THE HAIRY POLITICS OF HEALTH REFORM \\VT 93-94
	 During the campaign, Clinton said that he could finance health coverage for all Americans by using the savings that result form reforming the system. But the President's advisers have now told him that that will be impossible. "Even limited expansions in coverage before 1997 would require new revenues," Clinton was informed in a confidential report leaked to The Washington Post. That means new taxes -- up to 175 billion over four years. The Administration is considering raising "sin taxes" on cigarettes and alcohol, as well as imposing new taxes on business and health care services. But a second round of tax hikes this year could overload the agenda and endanger Clinton's economic plan. 

D213/Peter Passell, staffwriter, The New York Times, February 25, 1993, Section D; Page 2; HEADLINE: Economic Scene; Clinton's plan pales before the 900-pound health-care gorilla. \\VT 93-94
  Keeping the budget deficit in the $200 billion ballpark until cost  containment pays off is thus likely to take hundreds rather than tens of  billions of dollars in new revenue annually. And such sums could not be raised  by clipping the rich or tacking a few more pennies onto the price of gasoline.  

D214/ANNE WILLETTE; Gannett News Service correspondent, GANNETT NEWS SERVICE, February 23, 1993, HEADLINE: NATIONAL SALES TAX YEARS AWAY BUT WOULD BE A MONEY GENERATOR, Nexis \\VT 93-94
 "The income tax alone cannot sustain the political and economic demands being put on it," said Mark Bloomfield, president of the American Council for Capital Formation, which supports a consumption tax. A general 5 percent consumption tax that excludes food, housing and medical  care would raise $ 152 billion between now and 1997, according to the  Congressional Budget Office. 

D215/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 A different payment method. Instead of paying health insurance, everyone would pay a payroll tax, probably of about 8 percent. The big losers here are small businesses, particularly restaurants and bars, about 75 percent of whom currently don't buy any employee health insurance. To pay the tax, they would have to raise prices. The other losers are the upper-middle class. Assuming a family insurance policy now costs $ 5,000 a year, any family making over $ 62,500 would pay more under a payroll tax. A lawyer making $ 100,000, for example, would pay $ 8,000. 

D216/LAWRENCE J. HAAS, The 'National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT-ACSIn attacking Brown's VAT proposal, Citizens for Tax Justice (CTJ), a labor backed research group, declared: "A national sales tax not only would be regressive, it also would be fraught with complexity, as the European experience makes clear. Indeed, an army of new lawyers, accountants and tax administrators would be required to run a national sales tax, and many of the same issues involved in the income tax would have to be dealt with."
D217/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 * State officials fear that with a national consumption tax in place, they will encounter increased opposition to the sales taxes on which they rely for much of their revenue. 

D218/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 Experts disagree over how successfully the government can encourage personal and corporate savings, through tax incentives or other means. But on one point, they almost universally agree: The surest way to increase national savings is to reduce the deficit. That logic argues for applying all revenues from a new tax to deficit reduction. The impact could be sizable. For instance, if no items were exempted from it, a 5 per cent VAT would raise about $ 150 billion a year by 1997. 

D219/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 A CRS report, "New Tax Proposals: Flat, VAT and Variations," challenges the assumption that a switch from income to consumption taxes will necessarily have much effect on savings rates. "Despite claim that shifting from an income to a consumption tax base will increase saving, this effect is by no means certain," the CRS said. "Economic evidence does not strongly support the presumption that private savings can be affected by eliminating the tax on capital income." 

D220/THOMAS J. BRAZAITIS and MICHELLE RUESS, The Plain Dealer, March 21, 1993, Pg. 1C, HEADLINE: BUSTERS VS. GEEZERS; YOUNG WANT CUTS IN SOCIAL SECURITY \\VT 93-94
	Once the baby boomers begin collecting their Social Security checks, the fund, which now has a surplus on paper at least, will dry up, forcing young workers to be taxed 35% or more to keep monthly payments flowing to their elders. 

D221/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 * Tax technicians warn that implementing a VAT could prove difficult, taking 18 months or longer and costing the government and private businesses billions of dollars. 

D222/ANNE WILLETTE; Gannett News Service correspondent, GANNETT NEWS SERVICE, February 23, 1993, HEADLINE: NATIONAL SALES TAX YEARS AWAY BUT WOULD BE A MONEY GENERATOR, Nexis \\VT 93-94
 There also are costs. A Congressional Budget Office report out last week  estimated that the Internal Revenue Service would need more than a year to set  up a system for collecting the [value added] tax. The government would spend $ 750 million to $ 1.5 billion a year administering the tax, while businesses would spend $ 4 billion to $ 7 billion a year complying with it.  

D223/ANNE WILLETTE; Gannett News Service correspondent, GANNETT NEWS SERVICE, February 23, 1993, HEADLINE: NATIONAL SALES TAX YEARS AWAY BUT WOULD BE A MONEY GENERATOR, Nexis \\VT 93-94
 Critics point out that a value-added tax would be regressive: poor people would end up sending a higher proportion of their income to the government than rich people. And states, which rely on sales taxes for much of their revenue, do not want competition from the federal government. 

D224/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 * Most liberals believe that as with sales taxes, the burden of a VAT would fall most heavily on low-income taxpayers. 

D225/LAWRENCE J. HAAS, The National Journal, June 6, 1992, Pg. 1336, HEADLINE: Bubbling VAT \\VT 93-94
	 * Most conservatives figure that once a VAT is in place, Congress will repeatedly raise its rate to finance increased federal spending. 

D226/ROBERT A. ROSENBLATT and STUART SILVERSTEIN, TIMES STAFF WRITERS, Los Angeles Times, March 20, 1993, Part D; Page 1; Column 2; HEADLINE: NEWS ANALYSIS; MEDICAL COVERAGE REFORM WILL COST PLENTY\\VT 93-94
	 "The middle class may well find itself paying more for health care and getting less," said Gail Shearer, director of health care policy for Consumers Union. Universal access is costly, requiring billions of dollars to finance coverage for 37 million Americans now without health coverage. This means "taking resources from those who now have insurance and giving it to those who do not," said William Custer, research director for the Employee Benefit Research Institute. "Somebody will have to pay for it, and the only money available is from the huge middle class," said Richard Berman, executive director of the Employment Policies Institute, representing firms in the food-manufacturing and restaurant businesses, which typically do not provide insurance for their large numbers of part-time and low-wage workers. 

D227/Peter Baker, Washington Post Staff Writer , The Washington Post October 10, 1992, PAGE B3 \\VT 93-94
	 Byrne stressed the need to solve the nation's health care crisis and said she would cut funding for "toys" like the supercollider. 

D228/The Energy Daily June, 22, 1992 HEADLINE: House Votes To Kill SSC Nexis \\VT 93-94
	 As such, the SSC was a prominent target for budget cutters in a year of extremely tight spending allowances. 

D229/Robert C. Cowen, Staff writer, The Christian Science Monitor February 18, 1993, Pg. 8 HEADLINE: Clinton Adviser Sees Science, Technology as Key to Growth \\VT 93-94
	 * Hard choices have to be made about support for fund-hogging projects such as the space station and the supercollider project in Texas. 

D230/USA TODAY June 9, 1993, Pg. 5A HEADLINE: Supercollider in political spin / Election, budget combine to hit Texas project \\VT 93-94
	 "It's an awfully tough budget climate now, and that's what's changed," said Rep. Pete Geren, D-Texas, another supporter. "People are looking for cuts where they can find them." 

D232/Lionel Van Deerlin, Representative in Congress for 18 years, San Diego Union-Tribune, March 9, 1993 SECTION: OPINION; B-5 HEADLINE: On a collision course with the budget ax \\VT-JHH 
 The huge supercollider could smash funding for other urgent research. You would get an argument on this down Texas way, of course. But if we're really serious about budget cuts, wouldn't the 53-mile superconducting supercollider be a logical place to start? 
 
D233/Gloria Borger, U.S. News & World Report , March 8, 1993 Pg. 32 HEADLINE: There's got to be a better way \\VT-JHH 
What's more, deficit-conscious Budget Committee Democrats pledge at least $ 5 billion more in budget cuts -- and the space station and supercollider, both gifts to Texas members, could be slated for extinction. 
 
D234/USA TODAY, February 17, 1993, Pg. 4A HEADLINE: Budget woes may delay science projects \\VT-JHH 
 The Clinton administration says it's trying to figure out how to pay for multibillion-dollar science projects it supports. In the spotlight: NASA's space station Freedom and a superconducting supercollider under construction in Texas. While they're not expected to be killed outright, White House science adviser John Gibbons says delays in the projects can be expected. "No one has a magic pot of money . . ." Gibbons told reporters Monday. "We're all going to have to take some cuts." 
 
D235/MICHAEL KRANISH, staffwriter for Boston Globe, The Times-Picayune February 23, 1993 Pg. A1 HEADLINE: CUTS: PET PROJECTS IN THE WAY \\VT-JHH 
 But Gramm is highly sensitive to charges that he is all for cutting programs except those that benefit his home state. So he put out a challenge to Clinton: If the president will name a level of spending that he wants to cut, Gramm will match him. Gramm said he can cut spending to any level without harming the supercollider, but he said that in principle he would put the supercollider on the table. 

D236/CLIFFORD KRAUSS, Special to The New York Times, The New York Times August 3, 1992, Section A; Page 12; HEADLINE: Washington Talk; Science, Maybe, but Politics for Sure \\VT 93-94
	 "The truth is, I do not think there is a single person in this body who has the scientific background to know for sure whether this is the greatest investment ever or the worst investment," said Representative Newt Gingrich of Georgia, the Republican whip, in a rare moment of the House floor debate on the supercollider. 

D237/CLIFFORD KRAUSS, Special to The New York Times, The New York Times August 3, 1992, Section A; Page 12; HEADLINE: Washington Talk; Science, Maybe, but Politics for Sure \\VT 93-94
	 So, like the debates over the space station planned by NASA, the debates over the supercollider are dominated by economic and electoral, not scientific, issues. 

D238/USA TODAY June 9, 1993, Pg. 5A HEADLINE: Supercollider in political spin / Election, budget combine to hit Texas project \\VT 93-94
	 So far the Clinton administration continues to back both, though its budget lowered immediate spending by stretching out both projects. White House spokeswoman Dee Dee Myers on Monday said the president supports both "at this point." 

D239/USA TODAY June 9, 1993, Pg. 5A HEADLINE: Supercollider in political spin / Election, budget combine to hit Texas project \\VT 93-94
	 A leading supporter, Rep. Martin Frost, D-Texas, argued that the project would be protected by the White House, but other supporters acknowledged the project faces a difficult fight. 

D240/New York Times April 11, 1993, Section 1; Page 20; HEADLINE: President's Budget Plans Worry Some Scientists \\VT 93-94
	 The future of the supercollider, which is strongly supported by the Clinton Administration, may depend partly on winning support from materials scientists. 

D241/CNN Transcripts, February 21, 1993, Nexis \\VT 93-94
	 DAVID FRENCH, Anchor: Privately, senior administration officials conceived the president could have cut more deeply. They cite NASA's space station whose scientific benefits, they say, are dubious. They also cite the Supercollider. There was intense pressure to kill both programs and save $ 30 billion or $ 40 billion, but aides say this was impossible for two reasons. Mr. Clinton had endorsed both during the campaign and tens of thousands of jobs would have been lost, especially here in California and in Texas. 

D242/Lionel Van Deerlin, Representative in Congress for 18 years, San Diego Union-Tribune, March 9, 1993 SECTION: OPINION; B-5 HEADLINE: On a collision course with the budget ax \\VT-JHH 
 President Clinton has said what we would expect concerning this -- that the supercollider has not been targeted among his administration's spending cuts because our nation remains committed to the project, as it does to Boeing's bonanza, the space station. 
 
D243/Lionel Van Deerlin, Representative in Congress for 18 years, San Diego Union-Tribune, March 9, 1993 SECTION: OPINION; B-5 HEADLINE: On a collision course with the budget ax \\VT-JHH 
 Translation: Clinton has no intention of taking on the powerful congressional blocs gathered around projects like these -- not yet, anyhow. The president is no dummy. He will need the loyal support of congressional leaders to pass any semblance of a plan for righting the economy. And Clinton knows the supercollider has a wide constituency on Capitol Hill. But let someone else suggest dropping or postponing it -- Republican cost-cutters, say, or those antsy Democratic House freshmen -- and watch how quickly Clinton goes along with them. 
 
D244/MICHAEL KRANISH, staffwriter for Boston Globe, The Times-Picayune February 23, 1993 Pg. A1 HEADLINE: CUTS: PET PROJECTS IN THE WAY \\VT-JHH 
 Some of his advisers urged him to cut or eliminate the most visible signs of questionable spending, such as the supercollider and the space station. Cutting just those two programs would have saved $13 billion over five years. But Clinton was intensely lobbied by members of Congress who fought to save their pet programs. In the case of the supercollider, Clinton's political advisers warned him that he would be breaking a campaign promise if he killed it - and that he also might be endangering the election prospects of Democrat Robert Krueger, who is running to replace Lloyd Bentsen in the Senate. Bentsen, now Treasury secretary, also lobbied Clinton to keep the supercollider intact. 
 
D245/Kimberly C. Moore, States News Service, March 10, 1993, HEADLINE: SENATOR SPENDING TIME AT BILL'S HOUSE, Nexis \\VT-JHH 
	Nevada Democratic Sen. Richard Bryan's status as a moderate conservative is earning him a a lot of time at the White House these days in meetings with President Clinton. Clinton is aligning himself with moderate to conservative senators, whose support he views as vital to the passage of his economic package. Many of those, like Bryan, seek additional budget cuts as a condition of support. "I recommended cutting the supercollider, the space station, SDI -- or Star Wars -- and farm subsidies," Bryan said of the hour-long meeting. The senator added that Clinton seemed willing to "go for" additional cuts. 
 
D246/USA TODAY, February 17, 1993, Pg. 4A HEADLINE: Budget woes may delay science projects \\VT-JHH 
 "Big science has been a target (of cuts) because people look at short-term rather than long-term benefits," says Tom Williams, of McDonnell Douglas, which is building the space station's first pieces. 
 
D247/USA TODAY February 17, 1993, Pg. 4A HEADLINE: Delays in science projects can be expected \\VT 93-94
	 "Big science has been a target (of cuts) because people look at short-term rather than long-term benefits, " says Tom Williams, of McDonnell Douglas, which is building the space station's first pieces. 

D248/Chicago Tribune August 4, 1992, Pg. 8; HEADLINE: Senate vote OKs funds for collider \\VT 93-94
	 "If you cancel this project and 22 others like it, you would save one percent of the budget," said Sen. Bennett Johnston (D-La.), a key supporter. 

D249/EDITORIAL; Chicago Tribune July 2, 1992, Pg. 18; HEADLINE: Don't sacrifice the supercollider now \\VT 93-94
	 Congress should get serious about budget cutting, but it's folly to lop off investment in basic research and America's future just to make a political point. Science isn't busting the budget. Programs like Social Security, Medicare and other entitlements, which are growing faster than the economy, are. 

D250/MICHAEL KRANISH, staffwriter for Boston Globe, The Times-Picayune February 23, 1993 Pg. A1 HEADLINE: CUTS: PET PROJECTS IN THE WAY \\VT-JHH 
 Eliminating the program would save $3 billion over five years, according to the Congressional Budget Office. Gramm leaves no doubt he wants to protect the project. "We spent 5.2 percent of the budget on science 25 years ago, and today we are spending 1.8 percent of the budget on science," Gramm said. "I do not believe that science spending is the problem." 
 
D251/MICHAEL KRANISH, staffwriter for Boston Globe, The Times-Picayune February 23, 1993 Pg. A1 HEADLINE: CUTS: PET PROJECTS IN THE WAY \\VT-JHH 
 Sen. Richard Shelby, D-Ala., embarrassed Vice President Al Gore by telling him in front of reporters last week that President Clinton's plan did not cut enough spending. So what about saving $10 billion by killing the space station, which benefits aerospace workers in Alabama? Shelby would be "very concerned" about any cut and would oppose it, his press
secretary said. 
 
D252/TERRY L. BRUCE Member of Congress, The New York Times October 3, 1987, Section 1; Page 26, HEADLINE: For a Made in U.S.A. Supercollider \\VT 93-94
	 Nonetheless, I believe the interests of this project and of American science and technology require that it be built here. 

D253/Lionel Van Deerlin, Representative in Congress for 18 years, San Diego Union-Tribune, March 9, 1993 SECTION: OPINION; B-5 HEADLINE: On a collision course with the budget ax \\VT-JHH 
 Indeed, there is widespread feeling that the huge undertaking in Texas is more than a single nation should underwrite. When unveiling the plan in February 1987, Reagan's secretary of energy, John Herrington, predicted that other countries, notably Japan, would share as much as half the expense. This has not happened. 
 
D254/TERRY L. BRUCE Member of Congress, The New York Times October 3, 1987, Section 1; Page 26, HEADLINE: For a Made in U.S.A. Supercollider \\VT 93-94
	 But it is unlikely that international cost sharing on the supercollider would result in significant saving. There simply is not that much money to be saved. The total proposed authorization for the project this year represents one-tenth of one-hundredth percent of our Federal budget. While that proportion may increase in subsequent years, total spending will never approach a single percent of Government expenditures. 

D255/The Atlanta Journal and Constitution June 2, 1991 SECTION C; PAGE 05 HEADLINE: Roll call \\VT 93-94
	 Defenders also argued that the $ 748 million taxpayers have already invested in the collider would be nullified if the project were shelved. 

D256/The New York Times July 7, 1992, Section C; Page 1; HEADLINE: Physicists Struggle To Save Supercollider From Budgetary Ax \\VT 93-94
	 If the supercollider should now die, supporters believe, the chance to discover the cosmic origin of whatever it is that endows objects with mass could be lost for at least a generation. A team of some 2,000 scientists assembled and carefully tuned for their roles in the supercollider venture would be scattered at enormous cost, and to the regret of many scientists. 

D257/Skip Derra, Research & Development April, 1990 Pg. 20 HEADLINE: Is SSC worth the $ 7 billion cost; Superconducting Supercollider \\VT 93-94
	 DOE insists that building the SSC will not take money out of other researcher's hands. 

D258/The New York Times July 7, 1992, Section C; Page 1; HEADLINE: Physicists Struggle To Save Supercollider From Budgetary Ax \\VT 93-94
	 "We're now going through the most dangerous period the S.S.C. project has ever faced," Dr. Schwitters said. "We hope our Government will bear in mind that the S.S.C. will cost no more than two nuclear submarines, but it will give the human race knowledge of enduring value." 

D259/LEO STEG, technology consultant , The New York Times July 14, 1990, Section 1; Page 20, On Mega-Science; 'Big' Research Honors Human Spirit \\VT 93-94
	 Many of the technical benefits we currently enjoy were ''big science'' in their time - the airplane, the jet engine, the computer, to mention a few - that were denigrated by contemporary scientists. Scientific training and particular eminence do not bestow upon the holder the gift of prophecy. Edison assigned no commercial value to the phonograph, Einstein foresaw no possibility of nuclear energy, and Lord Kelvin felt that radio had no future and heavier-than-air flying machines were impossible. 

D260/LEO STEG, technology consultant , The New York Times July 14, 1990, Section 1; Page 20, On Mega-Science; 'Big' Research Honors Human Spirit \\VT 93-94
	 Science does not have to prove relevance; it can stand on its record. Computer science and artificial intelligence are not the frontiers of science, but of engineering. The true frontiers of science are the understanding and origin of the universe and of life. 

D261/Dennis L. Breo, Chicago Tribune , November 6, 1988, SUNDAY MAGAZINE; Pg. 10; HEADLINE: IN THE BEGINNING... ARMED WITH THE TEVATRON AND, THEY HOPE, THE SUPERCOLLIDER \\VT 93-94
	 "If the Supercollider fails to produce equivalent practical benefits, " Lederman says, "it would be the first time in history that pure science did not produce practical technology." Kolb adds: "Physicists think in terms of pure science, not applied technology. I mean, when Einstein made the theoretical findings that made lasers possible, he was not thinking that someday there would be techniques to zap hemorrhoids or heal detached retinas." 

D262/EDITORIAL; Chicago Tribune May 10, 1988, Pg. 12; PUSH AHEAD WITH THE SUPERCOLLIDER \\VT 93-94
	 These scientists contend they need the supercollider to learn more about the nature of subatomic matter and, perhaps, to solve the mystery of how the universe was created. Beyond this quest for greater fundamental knowledge and thousands of construction and permanent scientific jobs, other rich, long- range benefits are certain to emerge from supercollider research. 

D263/The New York Times July 7, 1992, Section C; Page 1; HEADLINE: Physicists Struggle To Save Supercollider From Budgetary Ax \\VT 93-94
	 High-energy physicists were dismayed by the House vote on June 17, and many have sent or signed letters to United States officials urging continued support of the supercollider. Some of America's preeminent scientists, including 17 winners of Nobel prizes, wrote to President Bush, warning that cancellation would have a "destructive effect" on the entire United States scientific enterprise and raise questions about America's "ability to carry out long-term scientific projects." 

D264/EDITORIAL; Chicago Tribune July 2, 1992, Pg. 18; HEADLINE: Don't sacrifice the supercollider now \\VT 93-94
	 American physicists agreed six or seven years ago that they needed the supercollider to keep the world lead in high-energy physics research. They would use it to unlock the fundamental mysteries of matter and to re-create the reactions of the universe's birth. 

D265/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 The supercollider is on the forefront of scientific research in high-energy physics. In the past, this kind of research has repaid itself many times over in terms of new knowledge, new technologies, new jobs, medical advances and economic returns. 

D266/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 Most knowledgeable people on this subject agree that the supercollider is clearly our next step toward learning about the fundamental forces that govern the cosmos so that we may experience the unparalleled adventure of looking backward in time and using the enormous resources that such new knowledge would generate. It won't come easy and costs and risks will be high, but the stakes are also high with rewards that have the potential of being extraordinary. 

D267/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 Perhaps critics would be correct if gaining scientific information about the fundamental structure of matter were the only reason for building the huge accelerator. But these otherwise intelligent people - many of whom I know and for whom I have great respect - have never understood that the supercollider holds the potential for a new revolution in science and technology. The benefits of that I wouldn't even attempt to calculate. 

D268/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 It's a mistake to underestimate the supercollider's potential. The supercollider is close to indispensable if certain scientific gains are to be made in the search for elementary particles and forces. It will reveal worlds that would otherwise remain hidden from our view. 

D269/EDITORIAL; Chicago Tribune May 10, 1988, Pg. 12; PUSH AHEAD WITH THE SUPERCOLLIDER \\VT 93-94
	 The supercollider is far too valuable to the nation's future to be sunk by petty politics, a lack of visionary leadership and a failure to find less destructive ways to cut the federal deficit. 

D270/The New York Times, February 5, 1987, Section A; Page 26, HEADLINE: Pursue the Boson, and Beyond \\VT 93-94
	 Rejecting the gamble of building the supercollider would have been a sorry retreat from a leading frontier of research. 

D271/United Press International October 2, 1992, HEADLINE: Bush signs supercollider bill Nexis \\VT 93-94
	 Bush said the 54-mile circular partical accelerator that will bring 7,000 jobs to Waxahachie, Texas, ''is to basic research what the All- star game is to baseball.'' ''In the longer term, the tangible benefits will be felt by every single American,'' he said, bringing ''new jobs, new breakthroughs. Our frontier is the human imagination, our vessel, the supercollider, '' he said, reading from index cards. 

D272/Chicago Tribune August 4, 1992, Pg. 8; HEADLINE: Senate vote OKs funds for collider \\VT 93-94
	 "The SSC is good for America," said Sen. Harry Reid (D-Nev.). "This project will keep our nation on the cutting edge of science and technology." 

D273/Dennis L. Breo, Chicago Tribune , November 6, 1988, SUNDAY MAGAZINE; Pg. 10; HEADLINE: IN THE BEGINNING... ARMED WITH THE TEVATRON AND, THEY HOPE, THE SUPERCOLLIDER \\VT 93-94
	 The Supercollider will create energies that were in force within one- billionth of one-trillionth of a second after the "Big Bang," which, according to most physicists was the moment of creation. At this energy and temperature, the universe was still a fiery seed that was only beginning to expand and cool. The fundamental particles and the forces that govern them were beginning to form and reform. The Supercollider's high energy will enable scientists to turn back the clock billions of years and re-create some of the conditions that prevailed at the beginning. 

D274/Dennis L. Breo, Chicago Tribune , November 6, 1988, SUNDAY MAGAZINE; Pg. 10; HEADLINE: IN THE BEGINNING... ARMED WITH THE TEVATRON AND, THEY HOPE, THE SUPERCOLLIDER \\VT 93-94
	 Astrophysicist Kolb says, "Nothing on Earth will ever match the Big Accelerator in the Sky, which was built without the U.S. Department of Energy and without any community protest, but the Supercollider will put us close enough to be able to understand some of the original forces." 

D275/PHILIP S. GUTIS, The New York Times December 23, 1987, Section B; Page 1, HEADLINE: In Collider Project, Lundine is Lightning Rod \\VT 93-94
	 Scientists express hope that the collisions would produce subatomic particles that could help provide answers to age-old questions of matter, energy, space and time. 

D276/The New York Times July 7, 1992, Section C; Page 1; HEADLINE: Physicists Struggle To Save Supercollider From Budgetary Ax \\VT 93-94
	 But to particle physicists interested in pure science rather than potential technological spinoffs or economic and political benefits, the supercollider has a special quality. It is seen as a kind of Philosopher's Stone, a key to at least partial understanding of the ultimate basis of existence. 

D277/The New York Times, February 5, 1987, Section A; Page 26, HEADLINE: Pursue the Boson, and Beyond \\VT 93-94
	 The justification for the supercollider is much simpler. Study of the fundamental constituents of matter is central both to physics and cosmology. In supporting particle physics, America contributes to the disinterested pursuit of knowledge whose only benefit may be better understanding of the natural world. 

D278/Robert C. Cowen, natural science editor, The Christian Science Monitor March 26, 1985, Pg. 25 HEADLINE: Is high-energy physics worth its high cost? \\VT 93-94
	 The high-energy particle accelerator has extended the frontiers of knowledge to an extent undreamed of at the beginning of this century, when the atom itself was considered to be outside the mainstream of physics. Although considerable mystery remains, the accelerator has thrown much light onto the ultimate nature of matter. 

D279/Dennis L. Breo, Chicago Tribune , November 6, 1988, SUNDAY MAGAZINE; Pg. 10; HEADLINE: IN THE BEGINNING... ARMED WITH THE TEVATRON AND, THEY HOPE, THE SUPERCOLLIDER \\VT 93-94
	 -The study of particle physics, which is unifying the forces governing the world of the atom and the world of outer space and may eventually solve the world's energy shortage. 

D280/ROBERT GILLETTE, Times Staff Writer, Los Angeles Times November 11, 1988, Part 1; Page 1; HEADLINE: TEXAS SELECTED FOR $4.4-BILLION SUPERCOLLIDER \\VT 93-94
	 Wright, for one, said the supercollider was needed to "re-establish the primacy of the United States" in high-energy physics. He also said the facility "could lead to heretofore untapped sources of energy," a claim that goes well beyond the speculative benefits advanced by most of the project's scientific proponents. 

D281/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 There is also good reason to believe that the industrial production of superconducting magnets for the supercollider could open a window of opportunity for many new uses of superconductivity - from powerful and compact electric motors to high-speed computers to more sophisticated techniques in medical diagnosis and treatment. 

D282/TERRY L. BRUCE Member of Congress, The New York Times October 3, 1987, Section 1; Page 26, HEADLINE: For a Made in U.S.A. Supercollider \\VT 93-94
	 The knowledge we take from the superconducting supercollider could ultimately be as valuable to our economy as electromagnetics or quantum theory, which provided the intellectual foundation for today's billion-dollar communications and semiconductor industries. More immediate spinoffs from its construction also promise to benefit our economy and even other sciences. For example, the nation's first hospital-based proton accelerator designed for cancer treatment will soon be installed at Loma Linda University Medical Center. This accelerator, which some say will rank with the development of the X-ray as a therapeutic tool, was designed by Fermi National Laboratory (the world's largest accelerator) and based on accelerator-technology spinoffs. 

D283/Cass Peterson, Washington Post Staff Writer The Washington Post January 31, 1987, PAGE A1 HEADLINE: $ 6 Billion Particle Accelerator Wins President's Endorsement \\VT 93-94
	 Scientists contend, however, that similar research has yielded significant benefits in nuclear medicine, computer development and other high-technology fields. 

D284/USA TODAY June 19, 1992, Pg. 4A HEADLINE: Scientists at odds on supercollider's usefulness \\VT 93-94
	 Backers say the superconducting supercollider, now under construction in Texas, holds the promise for breakthroughs in transportation, medicine and computers. 

D285/USA TODAY June 19, 1992, Pg. 4A HEADLINE: Scientists at odds on supercollider's usefulness \\VT 93-94
	 Potential applications include magnetically elevated trains, new cancer treatment using proton radiation, and high-speed computers. 

D286/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 Under the best circumstances, the supercollider will take a decade to build, and we Americans are not that good at long-term commitments. If we are not careful, that aspect of our national character could damage our leadership in high-energy physics, unraveling the fabric of a great national effort, playing into our foreign competitors' hands and leading to a bad end for U.S. science and technology. 

D287/Dr. John K. Hulm, Chief Scientist Emeritus of Westinghouse Science & Technology Center, Orlando Sentinel Tribune October 25, 1990 Pg. A23 HEADLINE: STAY THE COURSE ON THE SUPERCOLLIDER \\VT 93-94
	 Europe and Japan would dearly love to turn the tables on the United States and have us, not them, lose our competitive advantage in high-energy physics. That would allow them to pose as the uncontested leaders in this important area of science and chip away at one of the basic ingredients to our success in technological development. 

D288/EDITORIAL; Chicago Tribune May 10, 1988, Pg. 12; PUSH AHEAD WITH THE SUPERCOLLIDER \\VT 93-94
	 If that thinking prevails, the United States could lose the international race to develop new technology such as superconductivity and relinquish its world leadership in high-energy physics and other frontiers of science. If the supercollider isn't built in America, it will be built elsewhere. Bet on it. The Europeans, for example, are waiting to see what the supercollider's fate will be in the United States before embarking on their own project. 

D289/EDITORIAL; Chicago Tribune May 10, 1988, Pg. 12; PUSH AHEAD WITH THE SUPERCOLLIDER \\VT 93-94
	 Meanwhile, Congress should decide whether it wants to relegate this nation to second-rate status in high-energy physics. If it does, it can continue stalling and cutting corners. If it doesn't, it should commit to building the supercollider and get on with selecting other worthwhile projects in which to invest. 

D290/TERRY L. BRUCE Member of Congress, The New York Times October 3, 1987, Section 1; Page 26, HEADLINE: For a Made in U.S.A. Supercollider \\VT 93-94
	 The United States leads the world in basic high-energy physics research. However, Western Europe and the Soviet Union are constructing powerful accelerators, which will give them the lead when the accelerators become operational in the mid-1990's. Do we really want to give up our world lead in one of the few fields of fundamental science where the United States is still recognized as the world leader? 

D291/Lionel Van Deerlin, Representative in Congress for 18 years, San Diego Union-Tribune, March 9, 1993 SECTION: OPINION; B-5 HEADLINE: On a collision course with the budget ax \\VT-JHH 
 Meanwhile, a dozen European countries were planning their own shared atom smasher, the Large Hadron Collider near Geneva. Although less powerful than the one in Texas, the European device, with an up-front outlay of $3 billion, will mark a major advance in the field. 
 
D292/TERRY L. BRUCE Member of Congress, The New York Times October 3, 1987, Section 1; Page 26, HEADLINE: For a Made in U.S.A. Supercollider \\VT 93-94
	 Should we voluntarily cede our world-leading role in high-energy physics, we can fully expect to lose our world-leading scientists as well. Scientists routinely gravitate where the best equipment is for their research. Building the supercollider here will bring a new generation of scientists to this country. Failure to build it here could well result in a ''brain drain'' of our top scientists abroad. America should avoid relinquishing such a vital national resource as it prepares to enter the 21st century. 

D293/Dennis L. Breo, Chicago Tribune , November 6, 1988, SUNDAY MAGAZINE; Pg. 10; HEADLINE: IN THE BEGINNING... ARMED WITH THE TEVATRON AND, THEY HOPE, THE SUPERCOLLIDER \\VT 93-94
	 -The development of quantum mechanics, the science of how particles behave within the atom, which has created measurements that are extraordinarily accurate and has led to everything from transistor radios to computers. 

D294/EDITORIAL; Chicago Tribune May 10, 1988, Pg. 12; PUSH AHEAD WITH THE SUPERCOLLIDER \\VT 93-94
	 The national budget for scientific programs must have limits, but the United States is still far from reaching them. This country must continue to fund innovative research, big and small-projects such as the supercollider and those Frank Press advocated. All are crucial to driving the economy and assuring that America will be competitive for years to come. 

D295/Robert C. Cowen, Staff writer, The Christian Science Monitor February 18, 1993, Pg. 8 HEADLINE: Clinton Adviser Sees Science, Technology as Key to Growth \\VT 93-94
	 SCIENCE and technology will now take center stage as the dual engine for economic growth in the United States, says John Gibbons, President Clinton's science adviser. 

D296/LEO STEG, technology consultant , The New York Times July 14, 1990, Section 1; Page 20, On Mega-Science; 'Big' Research Honors Human Spirit \\VT 93-94
	 These ventures are much more than science. They are triumphs of the human spirit, of unforeseeable significance or benefit. By all means let us, as the human race, build monuments to that spirit! 

D297/The New York Times July 7, 1992, Section C; Page 1; HEADLINE: Physicists Struggle To Save Supercollider From Budgetary Ax \\VT 93-94
	 Rebutting critics who say the supercollider's hoped for discoveries will substantially overlap those of a new machine planned by CERN called the Large Hadron Collider, the CERN statement said the two machines would be complementary. 

D298/Chicago Tribune August 4, 1992, Pg. 8; HEADLINE: Senate vote OKs funds for collider \\VT 93-94
	 But supporters said the supercollider is meeting its budget and that its benefits far outweigh its cost. 

D299/USA TODAY June 9, 1993, Pg. 5A HEADLINE: Supercollider in political spin / Election, budget combine to hit Texas project \\VT 93-94
	 The superconducting supercollider, a 53-mile circular tunnel being built outside Dallas, may be a loser in the charged political climate this year after barely surviving last year. 

D300/USA TODAY June 9, 1993, Pg. 5A HEADLINE: Supercollider in political spin / Election, budget combine to hit Texas project \\VT 93-94
	 "I think the supercollider is probably going to be killed," said Sen. Byron Dorgan, D-N.D., a Finance Committee member. 

D301/Skip Derra, Research & Development April, 1990 Pg. 20 HEADLINE: Is SSC worth the $ 7 billion cost; Superconducting Supercollider \\VT 93-94
	 An independent survey recently released by the Industrial Research Institute Inc., Washington, DC, asked its members to prioritize the five mega-projects. Respondents ranked SSC last when compared with the human genome project, the hypersonic airplane, the space station, and the strategic defense initiative. 

D302/Rep. Claudine Schneider, Committee on Science, Space, and Technology, The Christian Science Monitor November 23, 1987, Pg. 14 HEADLINE: The superconducting supercollider: a collision course \\VT 93-94
	 While the project could bolster America's high-energy physics standing, it would at the same time slow down much of our country's badly needed research. The collider comes down to a question of priorities. This decade has seen a steady erosion of America's civilian research budget. Understandably, there are many in the scientific and commercial communities with serious reservations about the prospect of the SSC's gobbling up almost one-third of the available civilian research pie. 

D303/Rep. Claudine Schneider, Committee on Science, Space, and Technology, The Christian Science Monitor November 23, 1987, Pg. 14 HEADLINE: The superconducting supercollider: a collision course \\VT 93-94
	 Roland Schmitt, chief scientist at General Electric and chairman of the National Science Board, says that our top science priority should be ''getting the academic research and education base fixed first,'' not building the SSC. A White House Science Council study, the Packard-Bromley Report, underscores that conclusion. It calls for another $10 billion to improve America's sagging university research facilities. 

D304/Rep. Claudine Schneider, Committee on Science, Space, and Technology, The Christian Science Monitor November 23, 1987, Pg. 14 HEADLINE: The superconducting supercollider: a collision course \\VT 93-94
	 The list of research efforts the supercollider would elbow from the table is long and notable. Funding for acquired immune deficiency syndrome research would likely be hurt, as would R&D on vital forward-thinking programs like materials research, global warming, genetic engineering, energy efficiency, and biodiversity. 

D305/Rep. Claudine Schneider, Committee on Science, Space, and Technology, The Christian Science Monitor November 23, 1987, Pg. 14 HEADLINE: The superconducting supercollider: a collision course \\VT 93-94
	 According to the National Science Foundation, more than half of all productivity increases in the US since the end of World War II have resulted from new technology, the byproduct of civilian research. By funneling funding for such R&D away from commercial research and into the supercollider, who knows what potential breakthroughs we are delaying or missing altogether. 

D307/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p.61There is good reason to conclude that, throughout most of history, medical care was more harmful than beneficial.D308/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, pl314
Although almost everyone believes that at least one of his friends would not be alive and well except for the skill of a doctor. there is in fact no evidence of any direct relationship between this mutation of sickness and the so-called progress of medicine. The changes are dependent variables of political and technological transformations, which in turn are reflected in what doctors do and say; they are not significantly related to the activities that require the preparation, status, 'and costly equipment in which the health professions take pride. In addition, an expanding proportion of the new burden of disease of the last fifteen years is itself the result of medical intervention in favor of people who are or might become sick. It is doctor made, or iatrogenic.
D309/ Ivan Illich, author/researcher, MEDICAL NEMESIS, 1976, p.3. 
The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic. Iatrogenesis, the name for this new epidemic, comes from iatros, the Greek word for "physician," and genesis, meaning "origin." 
D310/Howard Waltzkin, Medical Scholar, THE SECOND SICKNESS, 1983, p91 
In the first place. one can imagine some possible ways in which intensive care could interfere with recovery after a latrogenic disease may arise, example, because of disturbances in body chemistry stemming from intravenous solutions. Life threatening Infections also are more likely to occur in the hospital. In addition, the intensive care setting can be a fear provoking experience. Emotional upset can be life threatening after an MI: for example. patients in CCUs have died suddenly after witnessing other patient's deaths.
D311/Ivan Illlch, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p26
The pain, dysfunction, disability, and anguish resulting from technical medical intervention now rival the morbidity due to traffic and industrial accidents and even war related activities, and make the impact of medicine one of the most rapidly spreading epidemics of our time. Among murderous institutional torts. only modern malnutrition injures more people than iatrogenlc disease in Its various manifestations.
D312/lvan Illich, MEDICAL NEMESIS, 1975, p212
Unfortunately, the futility of medical care is the least of the torts a proliferating medical enterprise inflicts on society. The impact of medicine constitutes one of the most rapidly expanding epidemics of our time. 'The pain, dysfunction, disability and even anguish which result from technical medical intervention now rival the morbidity], due to traffic. work and even war related activities. Only modern manipulation is clearly ahead. The technical term for the new epidemic of doctor made disease. iatrogenesis; is composed of the Greek words for 'physician' (iatros) and for 'origins' (genesis). Iatrogenic disease comprises only illness which would not have come about unless sound and professionally recommended treatment had been applied. Within this definition, a patient can sue his therapist if the latter. in the course of his treatment, has not applied a recommended treatment and thus risked making him sick. In a more general and more widely accepted sense, clinical iatrogenic disease comprises all clinical conditions for which remedies. physicians or hospitals are pathogens of 'sickening' agents. I will call this plethora of therapeutic side effects clinical iatrogenesis.
D314/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 21 \\VT-JHH
 My goal m this book is to show that we have a more difficult problem on our hands, that the standard nostrums of neither right nor left will any longer suffice to cope with the problem before us. That problem can be directly stated: The very nature of medical progress is to pull to itself many more resources than should rationally be spent on it, often more than can be of genuine benefit to many individuals, and much, much more than can be socially justifiable for the common good.
D313/Robert Moser. MD, DISEASES OF MEDICAL PROGRESS: A STUDY OF IATROGENIC DISEASE, 1969, p ix
...it is no secret that certain drugs, surgical procedures. and other forms of therapy, even when properly employed, can create unfavorable, often harassing, and sometimes fatal side effects. Unhappily, it is also true that drugs are frequently administered. or other procedures followed, apparently without due regard for their disquieting and sometimes dangerous potentialities.D315/Robert Moser, MD, DISEASES OF MEDICAL PROGRESS: A STUDY OF IATROGENIC DISEASE, 1969, p819
'Diseases of medical progress' will be with us forevermore. They cannot be swept under the rug, either by clinician or drug producer.
D316/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 14, 1993, Part A; Page 1; HEADLINE: HEALTH PACKAGE DILEMMA: WHAT SHOULD IT COVER? \\VT 93-94
  In a meeting with the First Lady and her two top health policy advisers, Ira Magaziner and Judy Feder, Mitchell suggested that any basic insurance package must avoid funding the estimated one-third of all medical services and treatments that, studies show, are either ineffective or inappropriate. Such research, pioneered by Dartmouth College's John Wennberg, have shown, for instance, that people in some regions of the country receive as much as 70% more medical treatment than those who live elsewhere for the same conditions, with no difference in outcome. The disparities appear to reflect different practice patterns of doctors based on their training and community standards. 

D317/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Mr. SCHRAMM [CARL SCHRAMM, Health Insurance Association of America] : The New England Journal of Medicine tells us repeatedly, time after time-Dr. Himmelstein may have written one of these articles-that 20 to 30 to 40 percent of the medicine delivered in the United States is unnecessary. Talk about useless work, there are people in the United States paying for operations this morning that are clinically unnecessary and I think that's really where we have to focus. 

D318/Dr. Fritjof Capra. Prof. Physics. U.Calif. Berkeley, THE TURNING POINT. 1982. p149
It has been estimated that one out of every five patients admitted to a typical research hospital will acquire an iatrogenic illness with half of these episodes resulting from complications of drug therapy and a surprising percent from diagnostic procedures.

D319/Ivan Illlich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976. p32
It has also been established that one out of every five patients admitted to a typical research hospital acquires an iatrogenic disease. sometimes trivial, usually requiring special treatment, and in one case in thirty leading to death. Half of these episodes result from complications of drug therapy, amazingly, one in ten comes from diagnostic procedures.
D320/Dr. Fritjof Capra. Prof. Physics. U Calif. Berkeley. THE TURNING POINT, 1982. p149
Some 30 to 50 percent of present hospitalization is medically unnecessary, but alternative services that could be therapeutically more effective and economically more efficient have almost disappeared.
D321/Robert Wright, The New Republic, March 29, 1993, HEADLINE: HILLARY RODHAM CLINTON'S REAL ENEMY - THE TECHNOLOGY TIME BOMB, Online America, Transmitted: 93-03-11 08:21:46 EST \\VT 93-94
	 Willard Gaylin of the Hastings Center, a biomedical ethics institute, says that "half of what we call health today would not have been considered health fifty years ago." 

D322/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976, p7
The self medication of the medical system cannot but fail. If a public, panicked by gory revelations, were browbeaten into further support for more expert control over experts in healthcare production, this would only intensify sickening care.D323/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p. 9
A professional and physician based healthcare system that has grown beyond critical bounds is sickening for three reasons: it MUST produce clinical damage that outweighs its potential benefits, it cannot but enhance even as it obscures the political conditions that render society unhealthy, and it tends to mystify and to expropriate the power of the individual to heal himself and to shape his or her environment. Contemporary medical systems have outgrown these tolerable bounds.
D324/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 Access, in the health reform debate, refers to the ability to get medical services. Access discussions often don't address the issue of whether the medical services that are accessed are needed or beneficial. 

D325/ Barbara Ehrenreich. Asst. Prof. Health Science, and John Ehrenreich. Asst. Prof. American Studies, SUNY, Westbury, SOCIAL POLICY, May/June 1974. p34
It should be stressed that these features of the doctor patient relationship do not apply only to doctors and 'sick' patients: people seeking preventive care, prenatal care, contraceptives. or abortions, or cosmetic surgery all experience intimate and authoritarian relationships with doctors. To a lesser degree, so do people who are only indirectly involved in the encounter  parents of children needing care, children aged parents. To enter a situation of professional dominance. you do not have to enter a sick role. In fact you do not even have to be a patient.
D326/ Robert Moser, MD, DISEASES OF MEDICAL PROGRESS: A STUDY OF IATROGENIC DISEASE. 1969. p8I3
What the physician must not do is fall prey to sins of Pride or hurry or vexation and charge the patient with the ominous admonition, 'We can't find anything wrong with you, but check back with me in a few weeks.' Another distressing gambit is the portentous expression. 'Take 1t easy and let me know if it gets worse or anything new develops.' This 1s the scene whence springs the thorn tree of iatrogenic disease.
D327/Ivan Illich. MEDICAL NEMESIS: EXPROPRIATION OF HEALTH, 1976. p34
The unwanted physiological, social, and psychological byproducts of diagnostic and therapeutic progress have become resistant to medical remedies. New devices, approaches, and organizational arrangements. which are conceived as remedies for clinical and social iatrogenesis. themselves tend to become pathogens contributing to the new epidemic. Technical and managerial measures taken on any level to avoid damaging the patient by his treatment tend to engender a self reinforcing iatrogenic loop analogous to the escalating destruction generated by the polluting procedures used as anti pollution devices.D328/ DR. FRITJOF CAPRA, Prof. Physics Univ. Calif. Berkeley, THE TURNING POINT, 1982 p.149
 There is an almost paranoid fear of litigation among American doctors, who try to protect themselves from lawsuits by practicing "defensive medicine," ordering even more diagnostic technologies which further increase the costs of health care and expose patients to additional risks.
D329/ Ivan Illich, MEDICAL NEMESIS: THE Expropriation OF HEALTH, 1976, P114
Henry K. Beecher, "Nonspecific Forces Surrounding Disease and the Treatment of Disease," Journal of the American Medical Association 179 (1962) 43740. 'Any fear can kill, but fearful diagnosis can almost guarantee death from diagnosis.'
D330/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, pl07
The patients who have suffered cardiac infarction themselves tend to express a preference for home care, they are frightened by the hospital, and in a crisis would rather be close to people they know. Careful statistical findings have confirmed their intuition: the higher mortality of those benefited by medical care in the hospital is usually ascribed to fright.
D331/Dr. Fritjof Capra, Prof. Physics, U Callf Berkeley, THE TURNING POINT, 1982, p330
On the other hand, negative attitudes of the patient. the doctor, or the family may produce an 'inverse placebo effect.' Experience has shown repeatedly that patients who are told they have only six to nine months to live will, indeed, not live longer. Statements of this kind have a powerful impact on the patient's mind/body system they seem to act almost as a magic spell and should therefore never be made.
D332/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p934
Diagnostic bias in favor of sickness combines with frequent diagnostic error. Medicine not only imputes questionable categories with inquisitorial enthusiasm; it does so at a rate of miscarriage that no court system could tolerate. In one instance, autopsies showed that more than half the patients who died in a British university clinic with a diagnosis of specific heart failure had in fact died of something else. In another instance, the same series of chest X-rays shown to the same teams of specialists on different occasions led them .to change their mind on 20 percent of all cases.D333/Robert Moser, MD, DISEASES OF MEDICAL PROGRESS: A STUDY OF IATROGENIC DISEASE, 1969, p 81O
All that I have said up to this point sets the background for the subject of this discussion the production of iatrogenic disease by the words and actions of the physician or "psychosemantic disease."
D334/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976. p 96
Diagnosis always intensifies stress, denies incapacity, imposes inactivity, and focuses apprehension on non recovery, on uncertainty, and on one's dependence upon future medical findings, all of which amounts to a loss of autonomy for self definition, It also isolates a person in a special role. separates him from the normal and healthy, and requires submission to the authority of specialized personnel.
D335/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1975, p89
Diagnoses made by the physician and his helpers can define either temporary or permanent roles for the patient. In either case, they add to a biophysical condition a social state created by presumably authoritative evaluation. When a veterinarian diagnoses a cow's distemper, it doesn't usually affect the patient's behavior. When a doctor diagnoses a human being, it does.
D336/ Dr. Fritjof Capra. Prof. Physics, U Calif. Berkeley, THE TURNING POINT,1982, p331
The development of illness involves the continual interplay between physical and mental processes that reinforce one another through a complex network of feedback loops. Disease patterns at any stage appear as manifestations of underlying psychosomatic processes that should be dealt with in the course of therapy. This dynamic view of illness specifically acknowledges the organism's innate tendency to heal itself to reestablish itself in a balanced state which may include stages of crisis and major life transitions.D337/ Fritjof Capra, Prof. Physics, U Calif. Berkeley. THE TURNING POINT, 1982. p142
Stress has only very recently been recognized as a significant source of a wide range of diseases and .disorders, and the link between emotional states and illness, although known throughout the ages, still receives little attention from the medical profession.
D338/ Dr. Fritjof Capra, Prof. Physics, U Calif. Berkeley. THE TURNING POINT,1982. p142
Cancer studies are typical. The connection between emotional states and cancer has been well known since the late nineteenth century, and the evidence reported in the psychological literature is substantial. But very few physicians are aware of this work. and medical scientists have not integrated the psychological data into their research.
D339/Dr. Fritjof Capra. Prof. Physics. U CaIif. Berkeley, THE TURNING POINT. 1982. p 155
During the past two decades adverse drug reactions have become a public health problem of alarming proportions, producing considerable pain and discomfort for millions each year. Some of these effects are inevitable, and many of them are clearly the fault of patients but many others are the result of careless and inappropriate prescriptions by doctors who adhere rigidly to the biomedical approach.
D340/MILTON SILVERMAN, Lecturer UCSF & Stanford Schools of Medicine, PRESCRIPTIONS FOR DEATH, 1982, p83
With many important products, the dangers of serious or lethal side effects are minimized, glossed over, or totally ignored. In the case of some drugs that can produce serious injury or death, specific warnings to physicians are included in the labeling in some Third World countries but not in others. Included here are such effects as the serious or deadly blood damage produced by chloramphenicoll, aminopyrine, and dipyrone, the crippling and blindness associated with cliocluinol, the growth stunting in children and the masculinization in girls and women by anabolic hormones, and the serious or fatal blood clots caused by oral contraceptives.
D341/LEONARD SAGAN MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, P. 66 \\VT-MDS
Last, antibiotics may themselves produce complications. Some are simply annoying; skin rashes, for example, are usually transient. Others may be life threatening. There is clear evidence that the use of antibiotics predisposes to infection. This may occur through several mechanisms. By the inhibition of normally occurring bacteria in the body, other drug resistant organisms are stimulated to proliferate. There is also evidence that antibiotics suppress the normal immune system; deleterious effects of antibiotics on the formation of antibodies and on the function of white blood cells have been observed (Eickhoff 1986; Hauser and Remington 1982). Indeed, some antibiotics may occasionally destroy bone marrow.
D342/LEONARD SAGAN M D & Epidemiologist 1987, THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELL BEING, p.66 \\VT-MDS
According to infectious disease experts, studies indicate that enough antibiotics are manufactured and dispensed each ),ear in the United States to treat two illnesses of average duration for every man, woman, and child. On the other hand, they estimate that illnesses which would significantly benefit from antibiotic medication occur about once every five to ten years. 
D343/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 66 \\VT-MDS
 Other studies show that about half of the antibiotics prescribed are not needed, or that the inappropriate agent is prescribed, or the dosage is incorrect. Forty-five percent of responses from 4,513 physicians to a survey questionnaire posing typical clinical cases devised infectious disease experts were incorrect (Neu and Howrey, 1975). D344/ A. H. Johnson, MD, NEUROPSYCHIATRIC SIDE EFFECTS OF DRUGS IN THE ELDERLY, 1979, p27 
..careful. studies in hospitals show that more than half of the antibiotics used are not needed; that an inappropriate agent is chosen; or that the dose is incorrect. Therefore, this practice is both wasteful and expensive, and can produce a high frequency of adverse side effects.
D345/JANNY SCOTT, TIMES MEDICAL WRITER, July 28, 1992; Los Angeles Times, "HOSPITALS CAN MAKE YOU SICK," Part A; Page 1\\VT-AGL
	 Hospital-acquired infections are one of the leading causes of death in the United States, the direct or indirect cause of about 80,000 fatalities every year. As many as 6% of all people admitted to hospitals end up with infections that they would not otherwise get. 

D347/JANNY SCOTT, TIMES MEDICAL WRITER, July 28, 1992; Los Angeles Times, "HOSPITALS CAN MAKE YOU SICK," Part A; Page 1\\VT-AGL
	 The problem has been further complicated by the widespread use of antibiotics: Some infectious organisms have grown resistant to standard treatments. As a result, some hospitals harbor bugs that have become unusually difficult and expensive to treat. 

D348A/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 10 \\VT-MDS
 Part of the reason for the rising number of hospital acquired infections is the increasing use of invasive procedures, such as the insertion of tubes into various organs, and the more frequent use of surgery. How ever, another reason is almost certainly the frequently unnecessary ad ministration of antibiotics to hospitalized patients. For example, in one survey over 30 percent of patients were receiving antibiotics, yet only 38 percent of persons treated had evidence of infection. A panel of experts reviewing antibiotic use in a series of hospitals found more than half the uses unnecessary (Eickhoff, 1986). 

D348//LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 58 \\VT-MDS
Yet in spite of these examples, there is reason to question whether the medical care system significantly contributes to the life span of large populations. Although some medical treatment confers some benefit (in prolonging life), all medical and surgical therapy imposes some risk. Every surgical procedures that requires an anesthetic carries some small risk of an anesthetic death or some other complication.
D349/Michael Goldstein, Prof. public health at UCLA, THE HEALTH MOVEMENT, 1992, p.4.
The medicalization of everyday life has become a major feature of western society, particularly in the United States and Canada. Every transition and development in the lives of normal individuals has been proposed as an appropriate ground for medical observation, judgment, instruction, and control. Almost every imaginable facet of childrearing and family life from the spacing of children to their feeding schedules, discipline, and social skills falls under the purview or pediatricians and other therapists.D350/Michael Goldstein, Prof. public health at UCLA, THE HEALTH MOVEMENT, 1992, p.3.
The medicalization process has not restricted itself to medicalizing conditions, behaviors, and attitudes that are usually considered to deviate from the norms of society. Increasingly, the medical model has been applied to aspects of "normal" life that may or may not be problematic to people. For example, birth and death the two experiences all human beings share have come to be seen as medical events. Typically, they are monitored, controlled, and certified by medical authorities.
D351/ Barbara Ehrenreich, Asst. Prof. Health Sci, and John Ehrenreich. Asst. Prof. American Studies, SUNY, Westbury, SOCIAL POLICY, May/June 1974, p26
...to analyze something as a system of social control  as a mechanism for creating or reinforcing acquiescence to the given order of society  is not to view it as a conspiracy. The social control functions we will describe grow out of the social structure of the medical system, and not, in our analysis, out of the conscious motivations of men.
D352/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976, p271 . The most profound iatrogenic effects of the medical technostructure are a result of those nontechnical functions which support the increasing institutionalization of values. The technical and nontechnical consequences of institutional medicine coalesce and generate a new kind of suffering: anesthetized, impotent, and solitary survival in a world turned into a hospital ward. Medical nemesis is the experience of people who are largely deprived of any autonomous ability to cope with nature, neighbors. and dreams, and who are technically maintained within environmental, social, and symbolic systems.
D353/Ivan Illich, Prof. History U. Gottingen (Germany), 1977, DISABLING PROFESSIONS, pg. 18
It is a fact that only during the last twenty-five years .medicine has turned from a liberal into a dominant profession by obtaining this power to dictate what constitutes a health need for people in general. Health specialists as a corporation have acquired the authority to determine what health care must be provided to society. It is no longer the individual client, but a corporate agency that imputes to entire classes of people their needs, and claims the mandate to test the whole population in order to identify all those who belong to the group of potential patients. D354/Ivan Illich, Prof. History U. Gottingen (Germany), 1977, DISABLING PROFESSIONS, pg. 31 
People become prisoners to time-consuming acceleration, stupefying education and sick making medicine because beyond a certain threshold of intensity dependence on a bill of industrial and professional goods destroys human potential, and does so in a specific way. Only up to a point can commodities replace what people make or do on their own. Only within limits can exchange values satisfactorily replace use values. Beyond this point, further production serves the interests of the professional producer who has imputed the need to the consumer and leaves the consumer befuddled and giddy, albeit more affluent. Needs satisfied rather than merely fed must be determined to a significant degree by the pleasure that is derived from personal autonomous action. There are boundaries beyond which commodities cannot be multiplied without disabling their consumer for this self affirmation in action.
D355/ Irving Kenneth Zola, Prof. Sociology, Brandeis, 1977, DISABLING PROFESSIONS pg.667
A web of political, economic, and even social psychological forces support this system, and only with awareness can the dismantling begin. It is for all these reasons that I am !convinced that the health area is the example par excellence of today's identity crisis what is or will become of the !self. It is the battleground not because there are visible !threats and oppressors but because they are almost invisible, !not because the perspective, tools, and practitioners of medicine and the other helping professions are inherently evil, but because they are not. It is so frightening because there are elements here of the banality of evil so uncomfortable written about by Hannah Arendt. But here the danger is far greater for not only is the process masked as a technical, scientific objective one but one done for our own good. In short, the road to a healthiest society may well be paved with supposedly good intentions.
D356/ YAIR AHARONI, Prof. Business Policy Tel Aviv Univ., 1981, THE NO RISK SOCIETY, p. 179
"Finally, dependency creates a dynamic demand for more government intervention: if the public pays the bill, the government feels entitled to tell the individual how to behave. The rights of the individual to make his or her own choice are constrained by the right of the public who pay the cost to restrict these choices to reduce the outlays of public funds."
D357/ YAIR AHARONI, Prof. Business Policy Tel Aviv Univ., 1981, THE NO RISK SOCIETY, p. 72
The total demands for insurance imposed and administered by the state far exceed the willingness pay and attempts to control the moral hazard results in severe constraints on individual freedom.
D358/ Irving Kenneth Zola, Prof. Sociology, Brandeis, 1977, DISABLING PROFESSIONS, pg. 412 
Medicine is becoming a major institution of social control incorporating the more traditional institutions of religion and law. It is becoming the new repository of truth, the place where absolute and often final judgments are made by supposedly morally neutral and objective experts. And these judgments are no longer made in the name of virtue or legitimacy but in the name of health. Moreover this is not occurring through any increase in the political power of physicians. It is instead an insidious and often undramatic phenomenon, accomplished by 'medicalizing' much of daily living, by making medicine and the labels of "healthy" and "ill" relevant to an ever increasing part of human existence.
D359/ President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, DECIDING TO FOREGO LIFE SUSTAINING TREATMENT, 1983. p. 107.
It is estimated that 6070 % of the two million Americans who died in 1981 did so in a hospital.
D360/ Derek Humphrey & Ann Wickett, THE RIGHT TO DIE: UNDERSTANDING EUTHANASIA, 1986. P 217.
In 1949, 50% of the population died in institutions hospitals, medical centers, or nursing homes. In 1958, the figure was 61%. Two decades later, the number had risen 10%. Finally, in the 1980's, 80% of the chronically ill died in institutions.D361/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 59 \\VT-MDS Besides complications that result from largely unavoidable risks, there are also injuries and deaths that are the result of negligence. Although the frequency of these cannot be known with any certainty, the evidence is that the number is not small. For example, one study of the records of patients discharged from two large hospitals revealed that about 7 percent had experienced injuries during their hospital stay, and of these, approximately one third were the result of negligence, mostly by physician . 
D362/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992; CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p. 140 \\VT-ADPL
Sullivan says it is time to stop using the medical system "as a fixit shop for our sloppy lifestyles."' Happily, we do as a nation seem to have been making progress in the right direction. Death rates from heart disease and stroke went down in the 1980s, thanks partly to medications but mostly to lifestyle changes: reduced overall smoking rates and diets lower in fats and cholesterol.
D363/ Arabella Melville, CURED TO DEATH: THE EFFECTS OF PRESCRIPTION DRUGS, 1982, p233
The alternative to joining the iatrogenic trail is to adopt more positive attitudes towards health. Inevitably this will mean not only changes in outlook, but also changes in habits and lifestyle. The first step may be to accept preventive regimes as a preferable substitute for crisis care. Next, to be rational and realistic about our reliance on current medical systems. This is not a plea for 'alternative medicine', which is notorious for fads and fancies that do not stand the test of time, but more as an encouragement to know ourselves better and understand what can be done to maintain ourselves as healthier individuals. Doctors have made the mistake of treating people as identical mechanical beings; as individuals we must avoid this error.D364/ Irving Kenneth Zola, Prof. Sociology, Brandeis, 1977, DISABLING PROFESSIONS, pg. 412 
Medicine is becoming a major institution of social control incorporating the more traditional institutions of religion and law. It is becoming the new repository of truth, the place where absolute and often final judgments are made by supposedly morally neutral and objective experts. And these judgments are no longer made in the name of virtue or legitimacy but in the name of health. Moreover this is not occurring through any increase in the political power of physicians. It is instead an insidious and often undramatic phenomenon, accomplished by medicalizing' much of daily living, by making medicine and the labels of "healthy" and "ill" relevant to an ever increasing part of human existence.
D365/John McKnight, Prof. communication studies and urban affairs, Northwestern, 1977, DISABLING PROFESSIONS pg. 867
The critical disabling effect of professional coding is its impact upon citizen capacities to deal with cause and effect. If I cannot understand the question or the answer the need or the remedy I exist at the sufferance of expert systems. My world is not a place where do or act with others. Rather, it is a mysterious place, a strange land beyond my comprehension or control. It is understood only by professionals who know how it works, what I need and how my need is met. I am the object rather than citizen. My life and our society are technical problems rather than political systems.
D366/Ivan Illich, MEDICAL NEMESIS, 1975, p267
On a third level. the so-called health professions have an even deeper. structurally health denying effect Insofar as they destroy the potential of people to deal with their human weakness, vulnerability and uniqueness in a personal and autonomous way. Structural iatrogenesis which I shall discuss 1n part III is the ultimate backlash of hygienic progress and consists in the paralysis of healthy responses to suffering. It strikes when people accept health management designed on the engineering model, when they conspire in an attempt to produce something called 'better health' which inevitably results in the heteronomous. managed  maintenance of life on high levels of sublethal illness. This ultimate backlash of medical 'progress' must be clearly distinguished from both clinical and social iatrogenesis.
D367/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HUMAN HEALTH 1976, p. 62
 Therefore the prestige of medical staples must sap the cultivation of health, which, within a given environment to a large extent depends on innate and inbred mettle. The more time, toil, and sacrifice spent by the population in producing medicine as a commodity, the larger will be the byproduct, namely, the fallacy that society has a supply of health locked away which can be mined and marketed. The negative function of money is that of an indicator of the devaluation of goods and services that cannot be bought. The higher the price tag at which well being is commandeered, the greater will be the political prestige of an expropriation of personal health.

D368/ Ivan Illich, Prof. history U. Gottingen (Germany), 1977, DISABLING PROFESSIONS pg. 312 
Women or men, who have come to depend almost entirely on deliveries of standardized fragments produced by tools that are operated by anonymous others, cease to live human lives, and at best barely survive  even though they do so surrounded by glitter. Ultimately, they lose even the even the 
ability to discriminate between living and survival. .
D369/LEONARD ABRAMSON, Health Journalist, 1990, HEALING OUR HEALTH CARE SYSTEM, p. 99 \\VT-ADPL American medicine has come a long way and continues to make progress in building greater understanding of how the human body works and how to treat its malfunctions. We now understand genes and how they influence our behavior and our health. However, in the most recent decades, we have become a society that is overtreated, overmedicated, overtested and is less responsible for its own health than ever before.
D370/Harry Schwartz, writer who specializes in healthcare topics, USA TODAY, October 26, 1992, Pg. 14A , HEADLINE: Public health no cure-all \\VT 93-94
	 The stress on public health measures actually hurts the quest for real solutions. Because real solutions can only come from changing culture and behavior, and that's beyond medical school skills. 

D371/VICTORIA A. WANZER, The Atlanta Journal and Constitution, September 29, 1992, Section A; Page 7, HEADLINE: Nationalized health care will bankrupt nation \\VT 93-94
	 Health-care costs can be controlled without resorting to socialized medicine. Health and Human Services Secretary Louis Sullivan states that every one of the top 10 causes of death in America in 1992 is influenced by the behavior of the individual. Before we vote for national health insurance, we should demand personal accountability. For those who will not accept responsibility for their behavior, we should enact laws to enforce responsibility. 

D372/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p1312
The modern medical enterprise represents an endeavor to do for people what their genetic and cultural heritage formerly equipped them to do for themselves.
D373/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976, p1278
Professionally organized medicine has come to function as a domineering moral enterprise that advertises industrial expansion as a war against suffering. It has, thereby undermined the ability of individuals to face their reality., to express values, and to accept inevitable and often irremediable pain and impairment, decline and death.
D374/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p89
The medicalization of prevention thus becomes another major symptom of social iatrogenesis. It tends to transform personal responsibility for my future into management by some agency. 
D375/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976, p 114
Medical procedures turn into black magic when, instead of mobilizing his selfhealing powers, they transform the sick man into a limp and mystified voyeur of his own treatment. Medical procedures turn into sick religion when they are performed as rituals that focus the entire expectation of the sick on science and its functionaries instead of encouraging them to seek a poetic interpretation of their predicament or find an admirable example in some person long dead or next door who learned to suffer.
 D376/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976. p131 Wherever in the world a culture is medicalized. the traditional framework for habits that can become conscious in the personal practice of the virtue of hygiene is progressively trammeled by a mechanical system, a medical code by which individuals submit to the instructions emanating from hygienic custodians. Medicalization constitutes a prolific bureaucratic program based on the denial of each man's need to deal with pain, sickness, and death.
D377/Ivan Illlch, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976. p275 ; Man's consciously lived fragility, individuality, and relatedness make the experience of pain, of sickness, and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy, he renounces his autonomy and his health must decline.D378/Barbara Ehrenreich. Asst. Prof. Health Sci, and John Ehrenreich. Asst. Prof. American Studies, SUNY, Westbury May/June 1974, p3l
...one thing seems clear: the expansion of the medical system has been accompanied by a deepening public dependency on that system, and this dependency now extends in varying degrees to all strata of society.
 ' D379/Barbara Ehrenreich. Asst. Prof. Health Sci, and John Ehrenreich, Asst. Prof. American Studies, SUNY Westbury, ' '. 'SOCIAL POLICY, Hay/June 1974, p35 
The authoritarianism of the relationship fosters a magical transference of the problem from patient to doctor. This transference phenomenon is probably related to the inability of American medicine to deal adequately with problems which require the patient's willed participation in the cure, e.g., by giving up smoking. Patients expect to be cured, or at least to gain legitimate exemptions from work: they do not expect the doctor to impose new hardships.
D380/ Ivan Illich, Prof. history U. Gottingen (Germany), 1977, DISABLING PROFESSIONS pg. 1314
It would be pretentious to predict if this age, when needs were shaped by professional design, will be remembered with a smile or with a curse. I do, of course, hope that it will be remembered as the night when father went on a binge, dissipated the family fortune, and obligated the children to  start anew. Sadly, and much more probably, it will be remembered as the age when a whole generation's frenzied pursuit of impoverishing wealth rendered all freedoms alienable and, after first turning politics into the organized gripes of welfare recipients, extinguished itself in a benign totalitarianism. I consider such a descent into technofascism as unavoidable unless the major thrust of social criticism begins to change from the support of a new radical professionalism into the endorsement of a patronizing and skeptical attitude towards the experts especially when they presume to diagnose and to prescribe.
D381/ Barbara Ehrenreich, Asst. Prof. Health Science, and John  Ehrenreich, Asst. Prof. American Studies, SUNY Westbury, SOCIAL POLICY, May/June 1974, p345
 ...quite apart from the technology, the relationship itself has a kind of therapeutic value: if the doctor cannot solve your problem and .in a society characterized  by insidious chronic disorders the likelihood is that he cannot 'solve' it  he can at least manage it. The therapeutic value of professional dominance, from the  patient's point of view, is that the problem becomes the  doctor's problem. It is not for you to fret or. question the treatment, it's in the doctor's hands now and 'he ought to know what he's doing".D382/ John McKnight, Prof. Communication studies and Urban affairs, Northwestern, 1977, DISABLING PROFESSIONS pg. 834 
In spite of the democratic pretense, the disabling function of unilateral professional help is the hidden assumption that "You will be better because I, the professional, know better." The political implications of this assumption are central to antidemocratic systems. Indeed, it is possible that societies, dependent on economies of unilateral professional servicing, are systematically preparing their people for antidemocratic leaders who can capitalize upon the dependencies created by expert, professionalized helpers, who teach people that "they will know better because we, the professional helpers, know better."
D383/ FAZLUR RAHMAN, practicing cancer specialist in San Angelo, Tex, April 18, 1993; The New York Times, “Viewpoints; Let's Hear It for Low-Tech Medicine,” Section 3; Page 11\\VT-AGL
	 * Americans have come to expect too much from medicine. Academic physicians and the scientific community have fostered the impression that every ailment, real or imagined, can be cured. The President and the medical profession must disabuse the public of this notion. For a vast number of our citizens, a moderate diet and exercise will be more helpful than a host of doctors. 

D383A/ Dr. Fritjof Capra. Prof. Physics. U Callf Berkeley. THE TURNING POINT. 1982. p148
The mechanistic view of the human organism and resulting engineering approach to health has led to an excessive emphasis on medical technology, which is perceived as the only way to improve health.
D384/Thomas Sowell, senior fellow at the Hoover Institution at Stanford, Forbes, September 28, 1992, Pg. 83 , HEADLINE: Mispricing the risks \\VT 93-94
	 In other areas as well, the government promotes riskier behavior by putting the costs of those risks on other people, rather than on those who choose to take the risks. 

D385/PR NEWSWIRE, Transmitted: 93-05-07 11:00:00 EDT, NEW JOHNSON & JOHNSON TV SPOT URGES PREVENTION TO HELP CURB HEALTH CARE COSTS, Online America//VT 93-94
	 - Ralph S. Larsen, chairman of the board and chief executive officer, said: "We view with great concern the high cost of medical care to the nation, but in the rush to deal with spiraling costs, we believe that individual responsibility for lifestyle behavior that impacts health care costs has been overlooked." 

D386/Toya Richards Hill, Lexington Herald-Leader, Ky., Knight-Ridder/Tribune Business News, May 15, 1993, TITLE: More Businesses See Value in Helping Workers Stay Fit, Online America, Transmitted: 93-05-16 19:33:00 EDT \\VT 93-94
 More and more businesses are turning to employee fitness centers to help trim the fat. "These days and times of health-care costs being out of control as they are ... has stimulated many of them," said Douglas Semenick, president of Semenick & Associates Inc., a Louisville health and wellness consulting firm whose customers include Capital Holding and Blue Cross & Blue Shield. 

D387/Toya Richards Hill, Lexington Herald-Leader, Ky., Knight-Ridder/Tribune Business News, May 15, 1993, TITLE: More Businesses See Value in Helping Workers Stay Fit, Online America, Transmitted: 93-05-16 19:33:00 EDT \\VT 93-94
 Ashland Oil Inc. has three fitness centers among its corporate sites, and Toyota Motor Manufacturing USA Inc. just opened a state- of-the-art fitness facility at its Georgetown plant. Toyota said the main reason was that employees asked for it.  GE Aircraft reported that after a year, medical costs dropped from $1,044 to $773 an employee for those enrolled in its corporate fitness program, but costs for non-members rose 21 percent, said Ed Towle, a recreation and fitness supervisor for Ashland Oil. 
The Travelers, an insurance company, shows a savings of $3.40 for every dollar spent on corporate fitness, Towle said. 

D388/Toya Richards Hill, Lexington Herald-Leader, Ky., Knight-Ridder/Tribune Business News, May 15, 1993, TITLE: More Businesses See Value in Helping Workers Stay Fit, Online America, Transmitted: 93-05-16 19:33:00 EDT \\VT 93-94
 Towle said Ashland is a pioneer in corporate fitness centers. The company has fitness centers at its chemical headquarters in Columbus, Ohio; its petroleum headquarters in Ashland; and in Lexington for subsidiaries Valvoline and SuperAmerica. The one in Ashland has been there more than 20 years, Towle said. 
"One of the reasons (for the center) initially was to help control health-care cost," he said. 

D389/ John Mcknight, Prof. communication studies and urban affairs, Northeastern, 1977, DISABLING PROFESSIONS pg. 86
The language of modernized professional services mystifies both problem and solution so that citizen evaluation becomes impossible. The only people "competent" to decide whether the servicing process has any merit are professional peers, each affirming the basic assumptions of the other.
D390/ John McKnight, Prof. communication studies and urban affairs, Northwestern, 1977, DISABLING PROFESSIONS pg. 83
The first of these assumptions is the mirror image of the individualized definition of need. As you are the problem, the assumption is that I, the professionalized servicer, am the answer. The central assumption is that service is a unilateral process. I, the professional, produce. You, the client, consume.
D391/ Dr. Fritjof Capra. Prof.' Physics. U Calif. Berkeley, THE TURNING POINT, 1982. p1578
According to the biomedical model, only the doctor knows what is important for an individual's health, and only he can do anything about It, because all knowledge about health is rational. scientific knowledge, based on objective observations or clinical data. Thus laboratory tests and measurement of physical parameters in the examining room are generally considered more relevant to the diagnosis than the assessment of the patient's emotional state, family history, or social situation.D392/Ivan Illich. MEDICAL NEMESIS. THE EXPROPRIATION OF HEALTH, 1976, p96.
Once a society organizes for a preventive diseasehunt, it gives epidemic proportions to diagnosis. This ultimate triumph of therapeutic culture turns the independence of the average healthy person into an intolerable form of deviance.
D393/LEONARD ABRAMSON, Health Journalist, 1990, HEALING OUR HEALTH CARE SYSTEM, p. 98 \\VT-ADPLPrevention is obviously a prime factor in reducing our health care bills, but it is certainly not a uniform goal, judging from the kinds of drugs most Americans take. Most of them are remedies for illnesses we already suffer. Periodically, the American drug industry lists the top ten drugs and among them are tranquilizers, ulcer medication, headache pills, pain tablets,. heart and bloodpressure medications, and diabetic medication.

D394/Pension Reporter, November 16, 1992 ,Vol. 19, No. 45; Pg. 2058 TITLE: LACK OF PUBLIC CONSENSUS COULD SLOW NEW ADMINISTRATION'S REFORM EFFORTS. \\VT 93-94
	 "Reformed hospital administration, changes in insurance forms, and even national health insurance address only access to medical care -- not the health of our people," APHA [American Public Health Association] said. "They will not eliminate drug use that drives people to violence and spreads disease; they will not make up for a lack of education and access to birth control; they will not improve hazardous workplace conditions; they will not improve the lives or lower the hospital bills of low birth weight infants or babies born with alcohol poisoning, drug addiction, or HIV infection

D395/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976, p.58
More health damage is caused by people's belief that they cannot cope with their illness unless they call on the doctor than doctors could ever cause by foisting their ministrations on people.
D396/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976. p. 114
It can be argued that in precisely those narrow areas in which highcost medicine has become more specifically effective, its symbolic side effects have become overwhelmingly health denying. The traditional white medical magic that supported the patient's own efforts to heal has turned black. D397/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1975. p2745 
A world of optimal and widespread health is ' a world of minimal and only occasional medical intervention. Healthy people are these who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery, and ever imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die.
D398/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976. p7
In part at least, the health of a population depends on the way in which political actions condition the milieu and create those circumstances that favor self-reliance, autonomy, and dignity for all, particularly the weaker. In consequence, health levels will be at their optimum when the environment brings out autonomous personal, responsible coping ability. Health levels can only decline when survival comes to depend beyond a certain point on the heteronomous (other directed) regulation of the organism's homeostasis. Beyond a critical level of intensity. institutional healthcare  no matter if it takes the form of cure, prevention, or environmental engineering  is equivalent to systematic health denial.
D399/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS, p.85. 
Granting that some health benefits have been experienced as a result of improvements in the food and water supply, and that some specific medical therapies are efficacious, the evidence that these factors alone provide an explanation for the dramatic fall in death rates is inadequate. Furthermore, there is strong evidence that changes in personal behavior associated with improved sanitation and nutrition are as important as the quality of the air, food, and water.
D400/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992;
CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p. 10\\VT-ADPL
Promoting good health habits and providing preventive services clearly can reduce many costs while making us a more fit nation an excellent example of the medical model approach to cost containment. D401/Pension Reporter, November 16, 1992 ,Vol. 19, No. 45; Pg. 2058 TITLE: LACK OF PUBLIC CONSENSUS COULD SLOW NEW ADMINISTRATION'S REFORM EFFORTS. \\VT 93-94
	 "Policy-makers must recognize that programs which make the link between education, prevention and public health as a whole will ultimately be the most cost-effective approach to the health crisis," APHA [American Public Health Association] President Joyce Lashof said in a statement accompanying the report. 

D402/GEORGE F. WILL, Staff Writer, January 5, 1993; The Vancouver Sun, “Health depends on behavior, not medicine,” p. A11\\VT-AGL
	 That story, from Dr. John A. Meyer's article "Cigarette Century" in the December American Heritage, illuminates like a lightning flash this fact: much - probably most - of America's hideously costly health care crisis is caused by unwise behavior associated with eating, drinking, driving, sex, alcohol, drugs, violence and, especially, smoking. Therefore, focusing on wellness - on preventing rather than curing illness - will reduce the waste inherent in disease-oriented, hospital-centred, high-tech medicine. 

D403/Michael J. Dattoli, M.D., St. Petersburg Times, October 18, 1992, Pg. 3D, HEADLINE: Doctors are 'wrongly blamed' for increase in health costs \\VT 93-94
	 Each is a serious problem, each comes with an enormous price tag. Yet, in the face of facts as cold and hard as these, it is the doctors who still get blamed for the high cost of health care in America today. No type of health-care reform will change these societal realities - unless, of course, doctors should be responsible for curing social ills, too. 

D404/Herman A. Kohlman, FHFMA, is a retired healthcare executive, Healthcare Financial Management, October, 1992 , Pg. 89, HEADLINE: The American healthcare dilemma: is there a solution? \\VT 93-94
	 For any reform program to succeed, however, it must focus much greater attention on the effect of demographics on American health care and on the need to keep people well instead of restoring them to health after they have become ill. Also, the nation must develop a formal national health policy. 

D405/Harry Schwartz, writer who specializes in healthcare topics, USA TODAY, October 26, 1992, Pg. 14A , HEADLINE: Public health no cure-all \\VT 93-94
	 There is a widespread illusion among liberals that if we only had national health insurance and everybody got free medical care, all our problems would disappear. A good example of that illusion is the touching faith USA TODAY's editors place in extending the resources of public health. What this naive view misses is that many of our problems are behavioral and cultural in origin. Public health doctors can do little, for example, about the epidemic of teen-age homicides afflicting our inner cities. Doctors can't change the culture in which young people kill each other for little or no provocation. 

D406/Pension Reporter, November 16, 1992 ,Vol. 19, No. 45; Pg. 2058 TITLE: LACK OF PUBLIC CONSENSUS COULD SLOW NEW ADMINISTRATION'S REFORM EFFORTS. \\VT 93-94
	 The United States should immediately begin to reduce health costs associated with three of the most expensive long-term health problems with several changes in public policy, the report said. The number of low birth weight infants could be reduced through more family planning services, nutrition education, and comprehensive prenatal care services; tobacco use could be curtailed by raising cigarette taxes, eliminating subsidies, and helping growers find alternative crops; and more injuries could be prevented through gun control, increased taxes on alcohol, and better enforcement of highway speed limits and drunk driving and child safety seat laws, APHA [American Public Health Association] said. 

D407/Daily Report For Executives, November 10, 1992, 1992 DER 218 d9 HEADLINE: Health Care, SOCIAL, TECHNOLOGICAL FACTORS DRIVING HEALTH CARE CRISIS, APHA SAYS Nexis \\VT 93-94
	 "Policy-makers must recognize that programs which make the link between education, prevention and public health as a whole will ultimately be the most cost-effective approach to the health crisis," APHA President Joyce Lashof said in a statement accompanying the report. [American Public Health Association] 

D408/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 14, 1993, Part A; Page 1; HEADLINE: HEALTH PACKAGE DILEMMA: WHAT SHOULD IT COVER? \\VT 93-94
  Coverage for diet-counseling and smoking-cessation also can yield "enormous  benefits" in helping avoid or delay costly surgery and other procedures,  

D409/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 14, 1993, Part A; Page 1; HEADLINE: HEALTH PACKAGE DILEMMA: WHAT SHOULD IT COVER? \\VT 93-94
  "Our special view in cardiology is that the answer to the problem is in prevention and not late cure," says cardiologist Rod Starke, senior vice  president for scientific affairs for the American Heart Assn. An association committee is considering making recommendations on what cardiac-related services a basic benefits package should cover and how often, such as physical  examinations, cholesterol measurements and blood pressure-taking. 

D410/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 The individual is the starting point for healthier lifestyles and more informed health care decision making. Through the many roles that each of us fulfills in our daily lives, we are afforded numerous opportunities for promoting health and preventing disease. 

D411/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Improving personal health behavior can count among the most potent means to prevent disease and promote health. Measurable decreases in risks to health can result from changes in diet, exercise, tobacco use, alcohol and other drug use, injury prevention behavior, and sexual habits. Each of us, however, must choose to make these changes a personal priority. 

D412/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS:  TRUE CAUSES OF SICKNESS & WELLBEING, p.173 \\VT-MDS 
What public policy implications follow from these conclusions? Should we not divert resources and personnel from our expensive and often ineffective treatment efforts to conduct research and intervention into the social and psychological sources of illness related behavior? I clearly favor this approach. Preventing alcoholism has to be more effective than treating cirrhosis. Sex education is clearly more effective than treating AIDS. Educational efforts and economic incentives directed toward the prevention of cigarette smoking has to be more effective than treating lung cancer. 

D413/Irwin Arieff Reuters News Service, March 6, 1991, Wednesday, AM cycle HEADLINE: NEW STUDY PREDICTS MEDICAL ADVANCES WILL SAVE LIVES, MONEY , Nexis \\VT-MDS
	 "Declining deaths and illness will depend upon improving lifestyles, attention to prevention and continued support of biomedical research," said the Battelle Medical Technology Assessment and Policy Research Center. The center prepared the report under a contract from Schering-Plough Corp. of Madison, N.J., and released it at a news conference here. 

D414/Irwin Arieff, Reuters News Service, March 6, 1991, Wednesday, AM cycle HEADLINE: NEW STUDY PREDICTS MEDICAL ADVANCES WILL SAVE LIVES, MONEY , Nexis \\VT-MDS
	 For heart disease alone, the center concluded that research and lifestyle gains could prevent as many as 23 million cases and 13 million deaths over the next 25 years. About half of this improvement would come from lifestyle changes that lower disease risk while about 40 percent would come from drug research, the center predicted. 

D415/Rudolph J. Mueller, MD, Rush Medical College, Journal of the American Medical Association, March 13,1991; 265: 1258-1259 TITLE: A National Health Insurance Tax on Tobacco and Alcohol: The Puritan HIT \\VT 93-94
	 However, I believe more can be done to discourage smoking and other unhealthy behaviors while providing financial support for those with little or no insurance. [n1] Adults may legally smoke tobacco and drink alcohol; however, these behaviors account for significant health care costs and mortality rates. Estimated smoking-related health care and insurance costs and lost productivity are $ 53.7 billion annually (1984) with direct medical care costs at $ 23 billion (43%). [n2] Sixteen percent of all deaths are tobacco related. In 1988, alcohol-related direct costs were $ 17.4 billion and deaths accounted for 4.5% of costs. [n3] Obviously, these "self-induced" illnesses are expensive and fatal. 

D416/ Irwin Arieff, Reuters News Service, March 6, 1991, Wednesday, AM cycle HEADLINE: NEW STUDY PREDICTS MEDICAL ADVANCES WILL SAVE LIVES, MONEY , Nexis \\VT-MDS
	 Medical research advances and lifestyle improvements expected over the next 25 years will save millions of American lives and prevent billions of dollars in productivity losses, a research center said Wednesday. 

D417/Irwin Arieff, Reuters News Service, March 6, 1991, Wednesday, AM cycle HEADLINE: NEW STUDY PREDICTS MEDICAL ADVANCES WILL SAVE LIVES, MONEY , Nexis \\VT-MDS
	 Similarly, new resarch findings and behavioral changes could prevent more than 2 million deaths from lung cancer, leukemia and bowel cancer by 2015, it said. Some 30,000 deaths from AIDS would be prevented and another 52,000 cases averted altogether, the center said. 

D418/Office of Disease Prevention and Health Promotion,Healthy People 2000, 1993, TITLE: THE ECONOMICS OF PREVENTION, Online America, Better Health and Medical Forum, Transmitted: 93-03-17 17:39:24 EST \\VT 93-94
	 Virtually all of these above conditions can be prevented through informed health and lifestyle decision making. 

D419/Office of Disease Prevention and Health Promotion,Healthy People 2000, 1993, TITLE: THE ECONOMICS OF PREVENTION, Online America, Better Health and Medical Forum, Transmitted: 93-03-17 17:39:24 EST \\VT 93-94
	 Coronary artery disease, a preventable disorder, effects about 7 million Americans and causes about 1.5 million heart attacks and 500,000 deaths each year. 

D420/Office of Disease Prevention and Health Promotion,Healthy People 2000, 1993, TITLE: THE ECONOMICS OF PREVENTION, Online America, Better Health and Medical Forum, Transmitted: 93-03-17 17:39:24 EST \\VT 93-94
	 2. Alcoholism: 18.5 million individuals abuse alcohol. Every year, 105,000 individuals die from alcohol-related deaths. A liver transplant to treat the damages caused by alcohol abuse is estimated to cost $250,000. 

D421/Office of Disease Prevention and Health Promotion,Healthy People 2000, 1993, TITLE: THE ECONOMICS OF PREVENTION, Online America, Better Health and Medical Forum, Transmitted: 93-03-17 17:39:24 EST \\VT 93-94
	 3. Drug Abuse: An estimated 1 million to 3 million people abuse cocaine, 900,000 individuals are IV drug abusers, and 500,000 individuals are heroin addicts. Yearly, 375,000 babies are exposed to drugs. The estimated 5-year costs of treating a baby affected by drugs is $63,000. 

D422/Office of Disease Prevention and Health Promotion,Healthy People 2000, 1993, TITLE: THE ECONOMICS OF PREVENTION, Online America, Better Health and Medical Forum, Transmitted: 93-03-17 17:39:24 EST \\VT 93-94
	 4. Low Birth Weight Babies: 260,000 low birth weight babies are born each year. Low birth weight also contributes to 23,000 deaths each year. The average neonatal intensive care costs of treating and caring for a low birth weight baby is about $10,000. 

D423/lvan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p 61 
...the fundamental reason why these costly bureaucracies are health denying lies not in their instrumental but in their symbolic function: they all stress delivery of repair and maintenance services for the human component of the megamachine, and criticism that proposes better and more equitable delivery only reinforces the social commitment to keep people at work in sickening jobs. The war between the proponents of unlimited national health insurance and those who stand up for national health maintenance, as well as the war between those defending and those attacking all private practice, shifts public attention from the damage done  by doctors who protect a destructive social order to the fact that doctors do less than expected in defense of a consumer society. 

D424/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p198 
Just as compulsory educational consumption came to be c used as a device to obviate concern about work, so medical consumption became a device to alleviate unhealthy work, dirty cities, and nerve-racking transportation, What need is there to work out a murderous environment when doctors are  industrially equipped to act as life savers!D425/ Dr., Fritjof Capra, Prof. Physics, U Calif. Berkeley, THE TURNING POINT, 1982, p1623
Furthermore, as a society we tend to use medical diagnosis as a cover-up of social problems. We prefer to talk about our children's 'hyperactivity' or 'learning disability' rather than examine the inadequacy of our schools, we prefer to be told that we suffer from hypertension rather than change our over competitive business world; we accept ever increasing rates of cancer rather then investigate how the chemical industry poisons our food to increase its profits. These health problems go far beyond the concerns of the medical profession, but they are brought into focus, inevitably as soon as we seriously try to go beyond current medical care.
D426/ Ivan Illich MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p. 169 
An advanced industrial society is sick making because it disables people from coping with their environment and. when they break down, from substituting a 'clinical' prosthesis for the broken relationships. People would rebel against such an environment if medicine did not explain their biological disorientation as a defect in their health, rather than as a defect in the way of life which is imposed on them or which they impose on themselves. The assurance of personal political innocence that a diagnosis offers the patient serves as a hygienic mask that justifies further subjection to production and consumption,
D427/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p9
The medical and paramedical monopoly over hygienic methodology and technology is a glaring example of the political misuse of scientific achievement to strengthen industrial rather than personal growth. Such medicine is but a device to convince those who are sick and tired of society that is they who are ill, impotent, and in need of technical repair.
 D428/ Barbara Ehrenreich, Asst. Prof. Health Sci, and John Ehrenreich, Asst. Prof. American Studies, SUNY, Westbury, SOCIAL POLICY, May/June 1974, p3940 
The medical system itself has deluded us into thinking that the problems addressed by medicine are : indeed 'medical' or 'technical' problems  that they are properly the preserve of specialists and experts who stand outside of culture and politics. But the problems which our society relegates to the medical system  the care of the disabled and dependent, the management of . reproduction, individual suffering, and death  are no less than some of the central problems which confront any human society. Medicine has allowed us to evade them too long,D429/ Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS, 1983, pl5l
Drug treatment objectifies a complex series of psychological and social questions. Symbolically, scientific medicine shifts the focus to the physical realm, depoliticizes the social structural issues involved, and mutes the potential for action by the patient to change the conditions that trouble him.
D430/Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS, 1983, p217
Nor can selfcare offset the necessity of struggle against illness generating conditions in the workplace, environment, and organization of society. Despite its progressive ring, the new reductionism fosters change that is reformist at best and  to the extent that it supports a suffering acquiescence to the social status quo  reactionary at worst.
D431/ Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS. 1983. p545 
As critics even within government have recognized. the disease centered approach has reduced the level of analysis to the individual organism and often inappropriately, has stimulated the search for unifactorial rather than multifactorial causation. During the last decade, analyses emphasizing the importance of individual lifestyle as a cause of disease have received prominent attention from state agencies in the United States and Canada. Clearly, individual differences in personal habits do affect health in all societies. On the other hand. the life style argument, perhaps even more than the earlier emphasis on specific cause, obscures important sources of illness and disability in the capitalist wok process and industrial environment. It also puts the burden of the health squarely on the individual, rather than seeking collective solutions to health problems. 

D432/ Dr. Fritjof Capra. Prof. Physics. U Calif. Berkeley. THE TURNING POINT, 1982. p141 
Confronted with environmental or social problems. medical researchers often argue that these are outside the boundaries of medicine. Medical education, so the argument goes, must by definition be dissociated from social concerns, since those are caused by forces over which physicians have no control. But doctors have played a major part in bringing about this dilemma by insisting that they alone are qualified to determine what constitutes illness and to select the appropriate therapy. As long as they maintain their positions at the top of the hierarchy of power within the health care system. they will have the responsibility of being sensitive to all aspects of health.D433/ Dr. Fritjof Capra. Prof. physics, U Calif. Berkeley, THE TURNING POINT, 1982. p333 
Moreover. many health problems arise from economic and political factors that can be modified only by collective action. Individual responsibility has to be accompanied by social responsibility,. and individual health care by social actions and policies. "Social health are" seems an appropriate term for policies and collective activities dedicated to the maintenance and improvement of health.
D434/ Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS, 1983. p34
The technologic complexity of scientific medicine tends to mystify and depoliticize the social. origins of disease and early death. The same technologic orientation diverts attention from simple solutions that would challenge current patterns of social organization. both inside and outside medicine.
D435/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1975, p275
The true miracle of modern medicine is diabolical. It consists in making not only individuals but whole populations survive on inhumanly low levels of personal health. Medical nemesis is the negative feedback of a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.
D436/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976, p33
On a second level, medical practice sponsors sickness by reinforcing a morbid society that encourages people to become consumers of curative, preventive, industrial, and environmental medicine. On the one hand defectives survive in. increasing numbers and are fit only for life under institutional care, while on the other hand, medically certified symptoms exempt people from industrial work and thereby remove them from the scene of political struggle to reshape the society that has made them sick.D437/ Dr. Fritjof Capra. Prof. Physics, U Calif. Berkeley. THE TURNING POINT. 1982. p334
One physician who has recognized this quite clearly Is Leon Eisenberg:
Our daily practice with human ailments makes us aware of the extent to which problems of ill health flow from failures in our political, economic and social institutions. The redesign of these institutions is the central challenge for the coming century, and gives the greatest promise for improving public health.
D438/ Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH. 1976 p6
The social commitment to provide all citizens with almost unlimited outputs from the medical system threatens to destroy the environmental and cultural conditions needed by people to live a life of constant autonomous healing. This trend must be recognized and eventually be reversed.
D439/Harry Schwartz, writer who specializes in healthcare topics, USA TODAY, October 26, 1992, Pg. 14A, HEADLINE: Public health no cure-all \\VT-ACS
The stress on public health measures actually hurts the quest for real solutions. Because real solutions can only come from changing culture and behavior, and that's beyond medical school skills.
D440/ Howard Waitzkin, Medical Scholar. THE SECOND SICKNESS, 1983. p278
A convergence in public health research has shown that. with a few exceptions, the technical advances of modern medicine have not led to major improvements in measures of health, illness, life expectancy, or death. Instead. the health status of large populations seems more closely related to broad changes In society. Including socioeconomic development, better sanitation, environmental conditions, and nutrition.
D441/ Dr. Fritjof Capra, Prof. Physics. Berkeley, THE TURNING POINT, 1982, p134
The relation between medicine and health is difficult to assess because most health statistics use the narrow, biomedical concept of health, defined as the absence of disease. A meaningful assessment would deal with both the health of the Individual and the health of the society; it would have to include mental illnesses and social pathologies. Such a comprehensive view would show that although medicine has contributed to the elimination of certain diseases. this has not necessarily restored health.D442/Daily Report For Executives, November 10, 1992, 1992 DER 218 d9 HEADLINE: Health Care, SOCIAL, TECHNOLOGICAL FACTORS DRIVING HEALTH CARE CRISIS, APHA SAYS Nexis \\VT 93-94
	 The cost of medical care should be a crucial issue in the health care reform debate, but the overriding goal of reform should be to attack social problems that lead to poor health, such as air pollution and unsafe drinking water, poverty and crime, drug abuse, and unsafe sexual practices, APHA [American Public Health Association] said in America's Public Health Report Card. 

D443/ Ivan Illicb, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976 p21
In contrast to environmental improvements and modern nonprofessional health measures, the specifically medical treatment of people is never significantly related to a decline in the compound disease burden or to a rise in life expectancy. Neither the proportion of doctors in a population nor the clinical tools at their disposal nor the number of hospital beds is a causal factor in the striking changes in overall patterns of disease.
D444/ Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS, 1983, p237
Confronting the contradictions between profit and safety is necessary to modify the social origins. of illness. This problem becomes ever more critical as illness generating conditions of the workplace and environment threaten humanity's survival.
D445/Ivan Illich, MEDICAL NEMESIS: THE EXPROPRIATION OF HEALTH, 1976 p.42
The malignant spread of medicine has comparable results: it turns mutual care and self medication into misdemeanors or felonies. Just as clinical iatrogenesis becomes medically incurable when it reaches a critical intensity and then can be reversed only by a decline of the enterprise, so can social iatrogenesis be reversed only by political action that retrenches professional dominance.

D446/U.S. Department of Health and Human Services, Public Health Service, 1993, TITLE: REFORM & SHARED RESPONSIBILITY, Better Health and Medical Forum, Online America, Transmitted: 93-03-17 17:39:54 EST \\VT 93-94
	 Policy decisions are made regularly that can assist health professionals and the public in reaching our national health goals. These decisions range from health care legislation to legislation that bears on the environment, business, farming, production, energy, housing, information dissemination, education, and the economy. 

D447A1/ GEORGE MITCHELL US Senator Maine. 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH, p. 20
Planet Earth is sending out distress signals. They carry ominous messages. They tell us that the world is about to grow warmer, warmer than at an time in recorded history and that the warmth will bring catastrophe.  They tell us that holes as wide as the US and as deep as Mount Everest are being ripped in our stratosphere's ozone layer, which is our only protection from the lethal ultraviolet rays of the sun.  They  tell us that the planet's vast topical rain forests so rich in life and so necessary to it are being stripped away at a breakneck pace‑ nearly an acre every second-turning once-lush, teeming portions of earth into farmland, bushland, grassland or desert. And they tell us that a silent stalker, acid rain, continues to fall like a shroud over our planet, killing plant life on land and fish in the water and threatening human health.  These four dark phenomena-all of them the creations of humankind-are a figurative Four Horsemen of the Apocalypse riding over today's world environment.

D448A2/ SENATOR GEORGE MITCHELL, Maine, 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH, p. 21
If we cannot check this deadly quartet now loose on our planet and in our atmosphere, life as we know it will change dramatically in the twenty-first century and much of it will end. This terrible foursome-the greenhouse warming of the planet the rifts in the ozone layer of the stratosphere life-killing acid rain it the skies, and wholesale tropical deforestation on the ground- are bringing global environmental catastrophe.  They are killing our water our air, our plats, our animals and eventually, if not checked, they will kill us.  Together they present us with the most pervading international security problem of the coming century, a lethal and long-term threat, the most serious pollution challenge in human history.

D449A3/ SENATOR GEORGE MITCHELL, Maine, 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH, p. 124
The ultimate risk, in not stemming as best we can the headlong gallop of these Four Horsemen of global environmental change is to turn the world into a lifeless desert.  After extinction there is nothing.  There is no computer no ingenious mechanism, no sleight of hand that can recreate even one of the lowest forms of life when it is wiped from the face of the earth.  We are in grave danger of losing forever the world's priceless genetic heritage in the coming crisis.  It is our duty to see that this does not happen that the songbird and all other life threatened with it, live. To fail in this will be an unforgivable dereliction of our duty to our planet, to ourselves, and to our children, and their children.

D450A4/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 80 
If we do not, if we instead persist in our willful ignorance of the powerful changes we are setting in motion,, we ma ultimately leave little more than a mystery to puzzle some new human community in the distant future, trying to understand what happened to the ancient lost civilization that made such grand structures of concrete and steel and plastic so long ago.

D451A5/ SENATOR GEORGE MITCHELL, Maine, 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH, pp. 122-3
To find ways of doing that is a monumental challenge. Humankind has never faced a greater one.  We cannot continue our wa of life.  It is too dangerous to all species, including our own.  It will no longer be acceptable.  Certain acts of the past- detonation of nuclear weapons within the biosphere, control of pests with persistent toxins- are simply not acceptable. To these we must now add still others- control of the outpouring of greenhouse gases in the atmosphere a halt to the chemical mayhem we have caused an end to the destruction of life in the rain forests, and end to the biotic hemorrhage that is also of our making.

D452A6/ THOMAS GLADWIN, Prof. Management New York University 1987; MULTINATIONAL CORPORATIONS ENVIRONMENT AND THE THIRD WORLD p. 10
The consequences of such shortcomings are serious. A recent cataloging includes rapid degradation of agricultural land via desertification, pesticide-related deaths estimated an 10,000 per year in developing countries, with persons suffering acute pesticide poisoning estimated at 1.5 million to 2 million rapid deforestation with severe environmental effect; accelerating habitat destruction and rates of species loss; air pollution from major urban centers exceeding commonly accepted standards set to protect human health; widespread water contamination and a staggering incidence of environmentally related disease‑ afflicting over one billion people.

D453A7/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 124
Some of the worst damage is occurring in the Himalayan nations of Nepal, Bhutan, Tibet and areas of India, including Sikkim and Kashmir.  These mountain lands, which boast some of the most spectacular natural beauty on earth are now being devastated to briefly quench the needs of a single generation.  This degradation has far reaching effects.

D454A8/ HILARY FRENCH, worldwatch Institute, 1991; THE WORLDWATCH READER ON GLOBAL ENVIRONMENTAL ISSUES, p. 112
Under the assault of air pollution and acid depositions, Eastern Europe's medieval cities are blackened and crumbling, whole hillsides are deforested, and crop yields are falling.  Rivers serve as open severs, and clean drinking water is in short supply. Life expectancies in the dirtiest parts of the region are as much as five years shorter and rates of cancer, reproductive problems, and other ailments far higher than in relatively clean areas.

D455A9/ LYNTON KEITH CALDWELL, Prof of Pol Sci-Indiana University 1990; INTERNATIONAL ENVIRONMENTAL POLICY, p. 222
The nature of the impending ecological disaster is threefold: first a great loss in genetic and evolutionary diversity; second, a loss in the restorative and reproductive capabilities of those areas that can be reforested; and third; further impoverishment of the people who can no longer derive even the basic necessities from the area.  But the losses are not limited to the tropics; they are felt in places far removed.  A study published by the Smithsonian Institution reveals a major decrease in the migratory songbirds that have wintered in the mature forest of Central and South america and fly north each spring to breed.  Thus the quality of life and environment diminishes in the northern latitudes with the loss of "one of natures most colorful vocal and visual exhibits-as woodlands die, so do songbirds.

D456A10/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 223
The disharmony in our relationship to the earth, which stems in part from our addiction to a pattern of consuming ever-larger quantities of the resources of the earth, is now manifest in successive crises, each marking a more destructive clash between our civilization and the natural world; whereas all threats to the environment used to be local and regional, several are now strategic.  The loss of one and a half acres of rain forest ever second the sudden, thousandfold acceleration of the natural extinction rate for living species, ,, the ozone hole  above Antarctica and the thinning of the ozone layer at all latitudes, the possible destruction of the climate balance that makes our earth livable- all these suggest the increasingly violent collision between human civilization and the natural world.

D457A11/ JEREMY RIFKIN, Science Writer 1991; BIOSPHERE POLITICS: A NEW CONSCIOUSNESS FOR A NEW CENTURY, p. 91
The global environmental crisis has dashed the hopes and dampened the spirit of the industrial age.  The godlike autonomy we sought has now metamorphosed into a cruel joke as we find ourselves more vulnerable and less secure than at any time in our history.

D458A12/ SENATOR GEORGE MITCHELL, Maine, 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH, p. 129
There is still time.  But we must begin now.  We must act.  The four-decade chemical experiment we have been conducting on our planet and on ourselves and all living things must be controlled. We must now use our great knowledge and resources to save ourselves.

D459A13/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, pp. 172-3
We ought to heed that lesson today.  By failing to provide world leadership in the aftermath of the victory over communism and in the face of the assault by civilization on the global environment, the US is once again inviting a descent toward chaos.  History is change, and change is a relentless, driving force. Now that the human community has developed into a truly global civilization, we have a choice: either we search for the means to steer the changes shaping our new common history or we will be steered by them- randomly and chaotically.  Either we move toward the light or we move toward the darkness.

D460A14/ JOEL HIRSCHHORN AND KIRSTEN OLDENBURG Office of Technology Assessment, 1991; PROSPERITY WITHOUT POLLUTION: THE PREVENTION STRATEGY FOR INDUSTRY AND CONSUMERS, pp. 2-3
Losing a bridge a highway and underground water main a satellite, or a jumbo jet aircraft is one thing; losing planet Earth is quite another matter, The margin for error has disappeared.  The margin of safety has been eaten up by a lack of pollution prevention in the past.  It is irrational to ignore pollution prevention for the future.

D461A15/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 204
The world as a whole has now arrived at a watershed comparable in some was to the challenge that confronted the founders two hundred years ago. Just as the thirteen colonies faced the task of defining a framework to unite their common interests and identity, the people of all nations have begun to feel that they are part of a truly global civilization, united by common interests and concerns- among the most important of which is the rescue of our environment.

D462A16/ HELEN CALDICOTT, MD, 1992; IF YOU LOVE THIS PLANET: A PLAN TO HEAL THE EARTH, p. 194
It is not too late, though, for our planet. We have ten years of work to do, and we must start now.  If we do not, it may be too late for the survival of most species, including, possibly, our own.

D463A17/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, pp. 179-80
But as we attempt to make other governments more accountable to their citizens, we need to pay close attention to the problems that currently inhibit the proper functioning of our democracy- and remedy them.  By strengthening our own political system, we will empower new environment stewards in areas where they are needed the most.

D464A18/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, pp. 179-80
Moreover, in spite of the inevitable disruptions that the transition to a new pattern for our civilization will entail the consequences of not making that transition are unthinkable.

D465A19/ SENATOR GEORGE MITCHELL, Maine, 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH, p. 225
If we do not succeed if we do not rise to this occasion, if we do not rein in the four-decades-long chemical experiment we have been conduction on our one and only earth we risk turning our world into a lifeless desert in the coming century, and bringing to pass the grim final environmental judgment to fa world on fire.  It is our obligation to see that this does not happen. Each of us is on this earth for a short time.  We do not own forever the land we inherited from our ancestors.  Rather we are stewards, holding the earth's natural resources in trust for our children and their children.  We can and we must convey to them the very  basics of healthy human life- clean air pure water, unpoisoned land.  The grim future that I pictured for the Eric's and Luisa's of the world, for all of our children, at the beginning of this book will happen- unless we act.  I am committed to preventing it from happening. This country and this world must also be committed to it. Our lives depend upon it.

D466A20/ JOHN CARROLL, Prof Forest Resources Univ Of New Hampshire 1988; INTERNATIONAL ENVIRONMENTAL DIPLOMACY; "Introduction:", p. 7
Governments must perceive more clearly the role that forceful efforts to redress the ongoing environmental destruction could play in preventing the development of international crises that will become more difficult to control and contain.

D467A21/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. 215
Our civilization is now entering dangerous times; all of us can help alleviate the dangers by demanding government policies that will promote a more sustainable agricultural system. one that is robust enough to see us through the population outbreak, even if severe disruptions occur because of global warming.

D468A22/ JOEL HIRSCHHORN AND KIRSTEN OLDENBURG, Office of Technology Assessment, 1991; PROSPERITY WITHOUT POLLUTION: THE PREVENTION STRATEGY FOR INDUSTRY AND CONSUMERS, p. 356 
The message must be translated into universal action: pollution prevention is a necessity for individual and collective well‑ being and survival.  There is no other comparable, intelligent choice.  Enough evidence is in; 100 percent certainty about the exact cause and magnitude of environmental problems is unnecessary and impossible.  The natural equilibrium and life‑ sustaining capabilities of planet Earth have been greatly disturbed by the darker side of modern science and technology, as well as by greed and stupidity.  There is a limit to the pollution that the planet can assimilate without being permanently changed.  Restoring equilibrium and habitability requires a new prevention-based strategy.  Pollution prevention does not threaten our economic prosperity or standard of living, although there are bound to be winners and losers as new processes and products replace old ones.  And of course the style of living must change for many people in affluent nations.

D469A23/ JOEL HIRSCHHORN AND KIRSTEN OLDENBURG, Office of Technology Assessment, 1991; PROSPERITY WITHOUT POLLUTION: THE PREVENTION STRATEGY FOR INDUSTRY AND CONSUMERS, p. 2
Pollution prevention means eliminating or reducing wastes and pollutants where the first are (or would otherwise be) produced so that there is less to manage and less entering air, water and soil. Moreover, this must happen for all wastes and pollutants without trying to prove beyond a shadow of a doubt that a particular waste or pollutant is a big enough or certain enough problem or threat.

D470A24/ LYNTON KEITH CALDWELL, Prof of Pol Sci-Indiana University 1990; INTERNATIONAL ENVIRONMENTAL POLICY, p. 7
Critical at Present: Immediate action necessary if the threat is to be countered
1. Genetic loss (threatened extinction of presently endangered species).
2. Ecosystem disruption and destruction (massive loss of habitat genetic material, quality of life and regenerative capabilities, marine as well as terrestrial).
3. Devegetation: deforestation and overgrazing (many of the above effects as well as destruction of forest-dwelling peoples soil deterioration including laterization., flooding, siltation, and possible reduction of atmospheric oxygen).
4. Desertification (caused or exacerbated by human activities reducing food and fiber productivity and simultaneously causing erosion of top soil by wind and water and impairment of atmospheric clarity by dust).
5. Contamination of the environment-air, water, soil and biota (by industrial toxicants including radioactive materials).
6. Degrading and depletion of fresh water (many of the above effects eutrophication or acidification of lakes and streams and exhaustion or contamination of groundwater and aquifers and destruction of wetlands).

D471A25/ LYNTON KEITH CALDWELL, Prof of Pol Sci-Indiana University 1990; INTERNATIONAL ENVIRONMENTAL POLICY, pp. 17-8
Proceeding toward Critical: Prompt response needed but a lead time of some (?) years allows solutions to be found before general disaster occurs. A systematic search for solutions should begin now.
7. Overpopulation b humans (a critical factor in most environmental issues and requiring early corrective action to counter already escalating ecological and social impoverishment).
8. Deterioration and erosion of top soil (especially disastrous in tropical countries and closely related to overpopulation and deforestation).
9. Climate change and deterioration of atmospheric quality, sea‑ level risk caused by global warming, disruption of stratospheric ozone layer, precipitation of acidic and other contaminants and impairment of atmospheric clarity by industrial particles and dust.
10. Sources and used of energy (progressive reduction in existing sources and dangers from their environmental effects make this issue ultimately critical; no adequate solutions are apparent).
11. Disruption of biogeochemical cycles (relates to all of the above; a combination of destructive trends could-at least in theory- break the linkages that permit regenerative capabilities of the biosphere to function, resulting in massive extinction of life on earth).
12. Maintenance of man's built environment and loss of cultural heritage in arts and architecture (the large environment-shaping public works of modern man, e.g., dams, canals, highways, large buildings, entail costs projected indefinitely into the future, and regardless of their continuing utility-which ma not always be assured-encumber the future allocation of societies' resources).

D472A26/ LYNTON KEITH CALDWELL, Prof of Pol Sci-Indiana University 1990; INTERNATIONAL ENVIRONMENTAL POLICY, p. 133
Six large issues, presently described encompass major anthropogenic threats to the integrity and renewability of the biosphere.  Laws, treaties, and technology all other things unchanged will be insufficient to arrest their destructive effects-much more will be necessary, not less than a new set of human behaviors in relation to human life on Earth.  The following comprehensive trends lead to environmental issues that are basic to choices for the future of man and the biosphere.
1. Loss of topsoil through erosion and qualitative deterioration.
2.Depletion and degradation of fresh water.
3. Contamination of the biosphere: of air, water, soil, and living things.
4. Devegetation of the land by:
      a) deforestation especially of the equatorial rainforest,         and by
      b)desertification especially of grasslands in semi-arid regions.
5. Destruction of natural habitats caused by all of the foregoing and in addition, by the damming and channelizing of rivers, filling or draining of lakes, estuaries, and marshes and by expanding urbanization and agriculture.
6. Loss of biological variety and diversity-species' extinctions.

D473A27/ L. MARGULIES, Prof. Univ. of Massachusetts, 1989; CHANGING THE GLOBAL ENVIRONMENT; From planetary atmosphere to microbial communities", pp. 66-7
We must be aware that our well-being and health is entirely embedded in that of our planet-mates.  The concept of independence form the biosphere is illusory and dangerous. People do not dominate nature, nor have they ever done so in spite of ancient and weighty prose arguing the contrary.  Our attempts to wrest control and independence form the rest of the biota will simply assure us of unpleasant death and hasten the extinction of our species.

D474A28/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. xii
The connections of the Gulf situation to the environment are indirect but excellent examples of the complex webwork of the human predicament. Unwise environmental policies were central to creating the Gulf crisis, and it in turn caused enormous environmental destruction through the greatest oil spill of all time in Kuwait.  Smoke from the fires was causing severe respirator illness among Kuwaitis soon after the fighting stopped, as well as acid precipitation and sooty fallout hundreds of miles down-wind.The fires and spill cleanup will pose problems for years.

D475A29/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 50
We should assume with great confidence that if we upset the ecological balance of the entire earth in one way, we will upset it in related ways as well.

D476A30/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 50
This phenomenon of interdependency is probably best illustrated by what scientists call positive feedback loops which magnify the force with which change occurs.  In fact almost everywhere throughout the ecological system, natural mechanisms tend to accelerate the pace of change once it is set in motion.

D477A31/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 16
The global environmental crisis is, as we say in Tennessee, real as rain and I cannot stand the thought of leaving my children with a degraded earth and a diminished future.

D478A32/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, pp. 118-9
The list of reasons is long and complex, but the essential point yis simple: in the daily battle between a growing, always ravenous civilization and an ancient ecosystem, the ecosystem is losing badly.

D479A33/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 269
Modern industrial civilization, as presently organized, is colliding violently with our planet's ecological system. The ferocity of its assault on the earth is breathtaking and the horrific consequences are occurring so quickly as to defy our capacity to recognize them, comprehend their global implication and organize and appropriate and timely response.

D480A34/ JOEL HIRSCHHORN AND KIRSTEN OLDENBURG, Office of Technology Assessment, 1991; PROSPERITY WITHOUT POLLUTION: THE PREVENTION STRATEGY FOR INDUSTRY AND CONSUMERS, pp. 5-6
Arguably, the most important lesson from the past few decades and from mountains of technical reports is that severe and perhaps catastrophic environmental damage has already occurred or been set in motion.  This is absolutely the case because of destruction of the protective ozone layer, which has resulted from past uses of chemicals. Contaminated air and water have already harmed many people.  The general perception that more environmental damage could occur for most of the planet's inhabitants within a few years or a decade or two is backed up by a lot of solid scientific evidence-even without 100 percent certainty. As with the destruction of the ozone layer so much damage, has already been set in motion that regardless of what we now do additional planetary deterioration is unavoidable. The only uncertainty is what level of damage to health and the environment will result.  The choice facing each of us is whether to stem the tide of deterioration as soon as possible. Individuals will change industrial process, practices,and products.

D481A35/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 366
Apart from our growing threat to the integrity of the global ecological system, the dramatic changes now taking place within civilization are also likely to pose serious threats of their own to the integrity and stability of civilization itself.

D482A36/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. 4
The continued destruction and degradation of natural ecosystems will affect most human beings primarily through declines in food security and conflicts over scarce resources and secondarily through the enhanced vulnerability of huge hungry populations to diseases like AIDS. Famine, war, and plague are much more to be feared than cancer.

D483A37/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. 4
Still, although there is ample reason to be concerned about the possibility of direct and severe damage to human beings, the greatest threat to ourselves and future generations is the indirect one posed by the dismantling of natural ecosystems. Curing all cancers, after all, would extend the average life expectancy by only a little over three years, and the subtle poisonings ma lower fertility or the quality of life for some individuals.  But impairment of Earth's life-support systems could subtract a decade or two from the average person's life-and much of the quality to boot.

D484A38/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. 5
According to UNICEF (the United Nations Children's Fund), 14 million children die annually from causes related to environmental degradation-to what Mustafa Tolba Director of the United Nations Environment Programme (UNEP). calls "the shambles of global environmental destruction.

D485A39/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. xii-xiii
Yet the Gulf Confrontation and war were just recent dramatic symptoms of a much deeper problem.  Although too few people realize it, the gigantic and still-expanding scale of human activities has already set the stage for much vaster environmental disasters. A substantial portion of the life that shares Earth with us is now doomed to go extinct.  Partly as a result, a billion or more people could starve in the first few decades of the next century, hundreds of millions of environmental refugees could be created, the health and happiness of virtually every human being could be compromised, and social breakdown and conflict could destroy civilization as we know it.

D486A40/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, p. 284
The conflict in the Persian Gulf could all to easily be a grabinger of many bloody global battle over dwindling resources and deteriorating ayes.  We hope that our grandchildren and yours would rather try to help others, directly or indirectly, than add fuel to struggles that can only wound humanity further.

D487A41/ NATIONAL RESOURCE COUNCIL, 1992; Committee on the Human Dimensions of Global Change; GLOBAL ENVIRONMENTAL CHANGE; UNDERSTANDING THE HUMAN DIMENSIONS, p. 109
An important consequence of global environmental change is conflict, because global change affects what humans value, and different people value different things.  When US energy use threatens the global climate or land clearing in Brazil threatens the extinction of large numbers of species people around the world are understandably concerned.  The may express a desire-or even claim a right- to influence the choices of people or governments continents away.  And the people or countries subjected to those claims may resist especially when they feel that changing their behavior will mean suffering. The further global change proceeds the more likely it seems that it will be a source of conflict, including international conflict, over who has a right to influence the activities implicated as causes who will pay the costs of responding, and how disputes will be settled.

D488A42/ LESTER BROWN, CHRISTOPHER FLAVIN & SANDRA POSTEL Worldwatch Institute, 1991; SAVING THE PLANET: HOW TO SHAPE AND ENVIRONMENTALLY SUSTAINABLE GLOBAL ECONOMY, p. 94
Satisfying future food needs also depends on reversing the trends of environmental degradation originating outside agriculture that are now showing up at harvest time such as deforestation, air pollution, and quite possibly, global warming. Reversing deforestation can help reduce the frequency of crop-damaging floods.  Adopting the agroforestry practices discussed earlier can also help alleviate the firewood scarcity that is forcing villagers to use cow dung and crop residue for cooking fuel.

D489A43/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 247
In today's world, the links between social injustice and environmental degradation can be seen everywhere; the placement of toxic wasted dumps in poor neighborhoods the devastation of indigenous peoples and the extinction of their cultures when the rain forests are destroyed disproportionate levels of lead and toxic air pollution in inner-city ghettos the corruption of many government officials by people who seek to profit from the unsustainable exploitation of resources.

D490A44/ JESSICA MATTHEWS Worldwatch Resources Institute, 1991; PRESERVING THE GLOBAL ENVIRONMENT, p.29
Rapid change is the keynote. Keyfitz explains how a "window now open could close within a generation or two" because of the scale and characteristics of human population growth and the strongly nonlinear relationship between human activities and their environmental impact.  Threshold effects occur when consumption of resource even slightly exceeds its sustainable yield. Suddenly, the past relations between population growth and production are changed, and can produce a crisis even without further additions to the population or technological development. An interaction is set up between "the social and biological system that, if allowed to persist, ends with the destruction of both." The rapidity of current tropical forest loss and even more, of the biological extinction rate, underscores how quickly such change can occur, even on a global scale.  o, in a different way does the sudden appearance of the Anartic ozone hole after decades of chlorofluorocarbon use.

D491A45/ PAUL AND ANNE EHRLICH, Center for Conservation Biology Stanford Univ., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS, pp. 12-13
In fact we fear that time is very short; the fate of Earth as an abode for a large-scale technological civilization is likely to be determined by the turn of the century, even though many of the bills for failure will come due later.  By 2000, people everywhere must understand the perils inherent in promoting rapid climatic change and allowing acid deposition ozone depletion, soil erosion, overdrafts of groundwater, and the loss of biodiversity to go unchecked.  It is also imperative that they grasp the limits to agricultural expansion and humanity's growing vulnerability to epidemic disease and see the interrelationships of these phenomena with the decay of critical ecosystem services the declining long-term carrying capacity of the planet population growth, economic growth, and a welter of social problems.

D492A46/ ALBERT GORE USSenator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p. 75
Our increasingly aggressive encroachment into the natural world and the resulting damage to the ecological systems of the earth have weakened the resilience of the global environment itself and threatened its very ability to maintain its equilibrium.

D493A47/ SENATOR GEORGE MITCHELL, Maine 1991; WORLD ON FIRE: SAVING AN ENDANGERED EARTH,pp. 120-1 It is this pervasive human intrusion into the ages old workings of the natural world that has caused the problem.  And it is that human intrusion that must now be reined in if we are to survive. We must curb wanton human disruption of the plant and animal world as surely as we must curb the outpouring of the greenhouse gases, the CFC's, and the precursors of acid rain into the atmosphere. "These are the thresholds," the World Commision on Environment and Development told us in 1987 "that cannon be crossed without endangering the basic integrit of the system. Toda we are close to many of these threshholds; we must be ever mindful of the rish of endangering the survival of life on Earth. Moreover the speed with which changes in resource use are taking place gives little time in which to anticipate and prevent unexpected effects."

D494A48/ SENATOR GEORGE MITCHELL, Maine, 1991; WORLD__ ON FIRE: SAVING AN ENDANGERED EARTH, p. 64
As with so much that we must now do to steady the planets' reeling systems we are running out of time.  It may already be too little too late to adequately restock the store of the world's keepers of CO2.  With every tick of the clock the Four Horsemen continue to gallop.

D495A49/ ALBERT GORE, US Senator from Tennessee 1992; EARTH IN THE BALANCE: ECOLOGY AND THE HUMAN SPIRIT, p.3 
But whatever its genesis our willingness to ignore the consequences of our actions has combined with our belief that we are separate from nature to produce a genuine crisis in the way we relate to the world around us.

D496A-50 /Senator George Mitchell, maine, 1991; World on Fire: Saving an Endangered Earth p. 45-46
Speaking during a U.S. Senate Committee hearing, Columbia University geochemist Wallace Broeker put it a little differently from Pogo but his meaning was the same: "The inhabitants of the planet Earth are quietly conducting a gigantic environmental experiment. So vast vast and so sweeping will be the impact of this experiment that, were it brought before any responsible council for approval, it would be firmly rejected as having potentially dangerous consequences. Yet, the experiment goes on with no significant interference from any jurisdiction or nation.  

D497/Sandra G. Boodman, staffwriter, The Washington Post, May 5, 1992, HEALTH; PAGE Z12 HEADLINE: Are You Underinsured?; For Millions Of Americans, The Answer Is Yes \\VT 93-94
	 "It's a real problem, because just about everybody has something," he [Michael P. Mullen, an independent insurance broker] said. "If it's not your toe or your leg or your side, well, then maybe you see a psychiatrist, which makes [insurance] companies really nervous." 

D498/James J. Kilpatrick, syndicated columnist, The Buffalo News, December 23, 1992, VIEWPOINTS; Pg. 3, HEADLINE: A PROBLEM FOR CLINTON AND ALL OF US \\VT 93-94
	  Private insurers say they're not to blame; if our hypochondriac people insist upon buying so much treatment, there's not much they can do about it.  Policyholders have to pay for the coverage they buy.  

D499/NEW REPUBLIC, April 6, 1992, TITLE: The Flight into Sickness, Online America, Transmitted: 92-11-26 02:00:00 EST \\VT 93-94
 The foolishness seems to be getting worse recently, says Dr. Shorter, referring to the paradigm shift from "spinal irritation" to "chronic fatigue." "Although the amplification of normal bodily symptoms and phobias about disease have existed in all times and places," he writes, "it is this delusional clinging to the belief in a given illness that marks the last decades of the twentieth century." Shorter points out that in the nineteenth century pa-
tients willingly accepted the doctor's diagnosis, correct or not. These days patients remain happy in their self-
diagnosis of chronic fatigue or other syndromes whether or not the doctor agrees. 

D500/ DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 33 \\VT-JHHWe cannot separate health needs from health desires in our own lives, and neither can we devise a public policy that can adequately separate them. I am not referring only to the common escalation of what we want into what we need, though that will be a potent force here as elsewhere. The fundamental problem stems from uncertainty about the limits of our health potential. How long a life can we live, ought we want to live, or do we need to live? How much pain and suffering can and should we be ready to endure? How much. disability can we survive, and how much fitness do we need? How much unhappiness is compatible with mental health? How much psychological stability do we require? Those are questions about the place, and extent, of health in our lives, and about the human needs that underlie our unending quest for better health. The uncertainty that such questions generate is well exploited by a technological progress whose basic purpose is ostensibly to help us meet our needs, but which in fact systematically blurs the line between need and desire. We have lost our way because we have defined our unlimited hopes to transcend our mortality' as our needs, and we have created a medical enterprise that engineers the transformation. 

 D501A//Derek Humphrey and Ann Wickett,, THE RIGHT TO DIE: UNDERSTANDING EUTHANASIA, 1986, p200 
Physicians collude in the pattern of overtreatment for a variety of reasons. Certainly. medical schools emphasize technological progress and sophisticated therapies, concentrating on attacking the disease without necessarily weighing the ethics of such treatment, After medical school, most doctors specialize. This means that, unlike the old-fashioned doctor patient relationship in which patient and disease were treated as a whole, today the doctor tends to the specific area that Interests. him; the organ or body function that is his particular specialty.D502/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992,
CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p.70 \\VT-ADPL
Dr. Robert H. Brook of UCLA and RAND has expressed the belief that from a third to a half of what we do is of such little benefit that insurance should not pay for it. One reason for such overuse is the lack of guidelines a doctor can rely on to determine appropriate use of technology which means that the charge of over utilization might be as meaningful as Monday morning quarterbacking. Overuse also occurs because doctors practice defensive medicine (itself stimulated by medical uncertainty) in order to minimize malpractice suits, insurance companies are willing to cover these therapies (fewer uninsured patients have these performed), and the payment system rewards procedures over the prescribing of medications. 
D503/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Are we a nation of hypochondriacs, worried about ailments that in fact pose little or no threat to most of us? Lynn Payer [veteran medical journalist and author] thinks so but says it's mostly not our fault. The American health care complex conspires to frighten us into fearing we are at risk of contracting relatively rare illnesses, and then encourages us to spend piles of money to avoid them or get well. 

D504/Barbara Ehrenreich, Asst. Prof. Health Sci, and John Ehrenreich. Asst. Prof. American Studies, SUNY, Westbury, SOCIAL POLICY. May/June 1974, p28
Freidson's moral concern is aroused not by the power of the medical professIon to manage the sick but by its power to define what Is meant by 'sick.' He describes the medical system as continually expanding its definition of "sickness" to embrace more and more of social deviance, thus advancing the frontiers of its ]jurisdiction and recruiting more and more patients into sick roles.
D505/ LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, pp.601\\VT-MDSEven where effective and lifesaving procedures or medications do exist, these are often administered to those persons with conditions 'for which there is no evidence of efficacy; for example, penicillin is effective for certain conditions but is far more often prescribed for minor colds where it is not effective. Powerful forces  psychological, economic, and .. legal  act on both physicians and patients to administer some means of therapy whether effective or not. That is true of both surgical procedures (such as coronary artery bypass, hysterectomy, caesarean section) and medical procedures (such as the use of antibiotics and many hormones).D506/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	 When a new treatment is medically better and cheaper than an old one, the result is often that far more people use it, so the total cost to society goes up rather than down, said Young of the Prospective Payment Assessment Commission. 

D507/NEW REPUBLIC, April 6, 1992, TITLE: The Flight into Sickness, Online America, Transmitted: 92-11-26 02:00:00 EST \\VT 93-94
 By means of telling examples, Shorter convinces us that social norms shape medical fashion, and that medical fashion in turn shapes the symptoms that patients select. The unconscious mind, writes Shorter, "desires to be taken seriously and not be ridiculed. It will therefore strive to present symptoms that always seem, to the surrounding culture, legitimate evidence of organic disease." As a result, "Most of the symptoms ... have always been known to Western society, although they have occurred at different times with different frequencies: Society does not invent symptoms; it retrieves them from the symptom pool." The symptoms are often real, not invented; but the important point is that the patient must present symptoms that the medical culture will not reject.

D508/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT 93-94
	Factors within the health care system include high technology, which Americans demand, and a payment system that encourages them to think of health care as "a free good," he added. "Third-party payment for anything encourages more use of whatever that thing is," Sullivan noted. 

D509/COMMITTEE FOR ECONOMIC DEVELOPMENT, Research and Policy Committee, 1987; REFORMING HEALTH CARE: A MARKET PRESCRIPTION. p.32 \\VT-ADPL
This raises the difficult issue of the extent to which individuals should pay part of their medical care cost under both government programs such as Medicare and private employment based health insurance plans. If a third party pays the full cost of care, with no direct contribution from the individual, consumers are unresponsive to price and quality differences and tend to select the most expensive care and most desirable amenities.

D510/Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 This strategy to decrease cost by increasing access to insurance, will decrease costs on one hand, but may increase costs on the other hand by increasing demand for unnecessary or inappropriate medical services. 

D511/Arnold Relman. editor New England Journal of Medicine, TECHNOLOGY AND THE AGING: RATIONALIZING OR RATIONING, Hearings House Subcommittee on Health and long-term Care. March 15, 1984, p4O 
At this point, however, we have a surfeit of technology and a scarcity of reliable and objective information about when and how to use it. As a result, physicians tend to use a procedure or test whenever they think the patient might benefit, and whenever there is insurance to pay for it.
D512/Derek Humphrey and Ann Wickett, THE RIGHT TO DIE: UNDERSTANDING EUTHANASIA, 1986. p194 
While many life-support systems and techniques are beneficial, too often they are used simply because they are there, and because they reinforce the notion that death can be eluded indefinitely. Studies have shown.. that many terminal patients are isolated from others and receive less personal attention from the staff than recovering patients. Insofar as the physician believes that to care for means 'to cure he is as helpless to act in the face of suffering as the terminal patient is. Thus, not only are many dying patients secluded: they are also overtreated  but by machines and therapies rather than personal contact. Any acknowledgment of death is avoided. 

D513/Jesse A. Kane, M.D., St. Petersburg Times, January 30, 1992, Pg. 17A HEADLINE: Why target doctors when discussing health-care reductions? \\VT 93-94
	Despite the fact that physician fees account for, at most, 20 percent of health-care expenditures, they seem to be the target for reduction every time health-care financing is mentioned. I debate the fact that a national health care system would save money. In the free clinic where I volunteer my services, 80 percent of the people that I see have a problem that could be corrected by elective surgery. Now these people can't afford surgery, so they go without. Once there is "free" care, I predict that these people will be tremendously over-utilizing the health-care system, driving up costs. In addition, the federal bureaucracy wastes money at a tremendous rate. 

D514/RICHARD J. BOTELHO, MD, Department of Family Medicine, Jacob W. Holler Family Medical Center, Archives of Internal Medicine, May, 1991; 151: 863-869 TITLE: Overcoming the Prejudice Against Establishing a National Health Care System \\VT 93-94
	 In an analogous fashion, individuals with health insurance coverage have become addicted to their medical "benefits," the overuse and misuse of investigations, death-defying technological interventions, and procedures. Unfortunately, these addictions monopolize and inefficiently use our limited health care resources in a way that is detrimental to the overall health of our nation. In making this analogy, the metaphor of addiction is intended to highlight the discrepancy between what we say in public opinion polls and what we do with our health care policies and practices. This analogy does not explain the reasons for this discrepancy. 

D515/Barbara Ehrenreich, health policy analyst, Time , March 29, 1993, Pg. 70 , HEADLINE: A Cure for the Wrong Disease \\VT 93-94
	 That might be a small price to pay in order to cover the 37 million Americans who presently lack insurance, but what about the rest of us? Here's where managed competition starts looking more like Dr. Jekyll than Dr. Welby. All the analysis behind it -- cooked up by academics and insurance-company reps schmoozing at comfortable seminars in Jackson Hole, Wyoming -- assumes that given a little insurance, Americans greedily drive up expenditures by "overutilizing" care. 

D516/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LlFE: THE LIMITS OF MEDICAL PROGRESS, p.55 \\VT-JHH Barsky also notes that a focus on health promotion stimulates greater attention to the body and enhanced nervousness about its condition; that can occasion still more visits to a physician. The growing acceptability of the sick role and better insurance coverage to support it also enhance a heightened social tolerance of illness and medical intervention.D517/ Renee Fox, DAEDALUS, 1977, p11
At least two studies have noted that as much as 90 percent of their apparently healthy sample had some physical aberration or clinical disorder.... It seems that the more intensive the investigation, the higher the prevalence of clinically serious but previously undiagnosed and untreated disorders,
D518/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Payer [veteran medical journalist and author] provides plenty of examples and case studies to show how a kernel of truth about an undeniably serious medical condition may be inflated into global pronouncements of how we are all at risk. She cites and explores heart conditions, cholesterol levels, generalized aches and fatigue, allergies, menopause, ''precancerous'' breasts, cosmetic ''abnormalities,'' questionable ''addictions,'' genetic predispositions and psychiatric ''disorders,'' especially those diagnosed in children, as examples of conditions in which both the risks and cures have been blown out of proportion. In such cases, she writes, even the mention of one of the above conditions, which may be harmless, can be enough to trigger numerous tests, prescriptions, diets and even surgeries -- mastectomies, hysterectomies, heart or plastic surgeries -- where the real risks and benefits of the problem and supposed cure are far from known. 

D519/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Public and patient education about health risks walks a fine line between alerting people to health threats and unduly frightening them in the process. There is also the risk of blaming real victims of real disease for their suffering. 

D520/ Daniel S. Greenberg, Special to The Bee, March 13, 1993; Sacramento Bee, “DEBUNKING THE CAREFREE THEORY OF HEALTH CARE,” p. B7\\VT-AGL
	 IF PATIENTS feel the financial sting of health care, will they be more hesitant about visiting the doctor and undergoing tests and treatment? Sure, a lot of them will be. The health economists have studies to prove that going to the doctor is a rational economic decision, no different from buying hamburger rather than strip sirloin. 

D521/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 But since the United States is a capitalist economy, and health care is a part of that system, what's the problem? Plenty, says Payer [veteran medical journalist and author]. Disease-mongering as a marketing strategy for health care services generates an insidious paranoia leading to huge amounts of unnecessary tests and treatment. 

D522/ The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Payer, a veteran medical journalist and author of ''How to Avoid a Hysterectomy'' and ''Medicine and Culture,'' says that ''disease-mongering -- trying to convince essentially well people that they are sick, or slightly sick people that they are very ill -- is big business . . . ''This is because nearly everyone along the way'' -- she includes medical researchers, journalists, doctors, hospitals and drug companies -- ''has an interest in convincing you that a given disease is widespread and serious.'' In this scenario, normal, benign conditions are redefined as ''diseases,'' tests of marginal benefit are pushed upon ever larger numbers of people and questionable cures held out as more effective than they are. 

D523/Judith Randal, past president of the National Association of Science Writers, NEW REPUBLIC, October 12, 1992, TITLE: Another health-care absurdity -- MAMMOSCAM, Online America, Transmitted: 92-11-30 10:45:09 EST \\VT 93-94
 Why, then, do the American Cancer Society and other health organizations continue to promote mammograms for younger women--especially given their high cost? (In 1990 5.5 million women under the age of 50 spent, by conservative estimates, approximately $550 million on the test.) Partly it's a triumph of hope over experience, an attempt to save lives by promoting early testing. As an advocacy group, the American Cancer Society looks only to the potential benefits, no matter how remote, not the costs. But there is another reason: Each year, $2 billion is spent on mammograms. Simply put, mammography clinics and radiologists stand to benefit if increasing numbers of younger women believe that early and frequent mammograms may save their lives.

D524/ The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Payer [veteran medical journalist and author] does have some worthy suggestions for improving things. Removal of financial incentives for overtreatment (by putting more health care providers on salary or giving them a lump sum per patient) is already under way, but it does bring with it the risk of changing the incentives too far toward undertreatment. 

D525/DANIEL CALLAHAN, Medical Economist, 1990; WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS, p. 32 \\VT-JHH
The widespread belief that we can all get all we need if only we deliver healthcare efficiently is hopelessly wrong, a deep and fundamental illusion. We will never get all we think we need as individuals and will have to settle for something less. But it is .possible that, if we can alter our understanding of individual need, and place it within a more meaningful societal context, we may actually be better served than we are at present. Quite apart from its impossibility as an actual achievement, the ideal of meeting individual need does not even promise to serve the human good, either that of individuals or that of society. It leads us to reckless aspirations, and to an inability to separate hopeful desire and genuine necessity.
D526/The San Francisco Chronicle, JANUARY 3, 1993, SECTION: SUNDAY REVIEW; Pg. 7, HEADLINE: Disease as Big Business \\VT 93-94
 Besides wasting money, disease-mongering exposes people to the adverse risks of those procedures. In addition, the labeling of many generally healthy people as sick can lead to denial of health insurance and jobs, not to mention scaring the joy out of their lives. 

D527Allen Douma, MD, Medical Director of Health ResponseAbility Systems, 1993, TITLE: ACCESS TO SERVICES, Online America Better Health and Medical Forum, Transmitted: 93-03-18 20:16:08 EST \\VT 93-94
	 Having access generally benefits an individual. However, if having increased access results in people getting more unnecessary or inappropriate services -- especially those that carry increased health risks -- it may be more costly and less healthy for everyone. 

D528/NEW REPUBLIC, April 6, 1992, TITLE: The Flight into Sickness, Online America, Transmitted: 92-11-26 02:00:00 EST \\VT 93-94
 This book [by Dr, Shorter] offers disheartening evidence that the medical profession, which until recently had reserved its ranks for males, has been beating up on female patients. Shorter does not claim to be the first to make this accusation. According to the feminist criticism of conventional medicine, a system of diagnosis and treatment developed by dead, white, European males cannot achieve "gender neutrality." I have usually taken comfort in the obvious response that dwems have given us habeas corpus and digitalis, cantatas and penicillin, "Leaves of Grass" and prednisone. But Shorter's careful study has persuaded me that it is not only feminist critics who can trace the foolish practice of today to its roots in medical misogyny. 

D529/NEW REPUBLIC, April 6, 1992, TITLE: The Flight into Sickness, Online America, Transmitted: 92-11-26 02:00:00 EST \\VT 93-94
 What I find quite embarrassing about Shorter's analysis of medical symptom-shaping is how close he hits to home. He has made me realize that for almost a decade I seem to have been sold a bill of goods by my fellow rheumatologists as to the diagnosis of "fibromyalgia." The victims of this will-o'-the-wisp syndrome happen to be female (85 to 95 percent), and Shorter has convinced me that well-meaning male physicians, for at least a century and a half, have been committing women to pernicious remedies for complaints that nowadays we would call fibromyalgia. Indeed, only its name has changed. What to the nineteenth century appeared as "spinal irritation," or "Charcot's hysteria," or "neurasthenia," has returned in our day as "fibromyalgia," as "irritable bowel syndrome," as "chronic fatigue syndrome." The pain is as real for the tired women of today as it was for those palsied by spinal irritation yesterday. The symptom is never "invented" by the patient, it is a marker of a deeper hurt, of which only the surface display has changed over time. Shorter argues persuasively that observation is constant while labels change and folly persists.

D530/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 What are these false fears? - The system will be overrun with new patients. Back when Medicare was looming, even in medically sophisticated Boston, otherwise perspicacious leaders like the late Dr. John Knowles, then director of Massachusetts General Hospital, envisioned "every old man with a neglected hernia lining up around the block" on the day Medicare coverage began. Nothing of the kind took place, of course, although over time millions of elderly Americans did seek needed care. Among the almost forgotten improvements that Medicare brought was to close down the huge, open wards where indigent patients were kept in old beds without a shred of privacy or any way to summon a nurse. Medicare made hospitals switch to two-, four- and six-bed rooms, a change that benefited patients of all ages. 

D531/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 Now the same predictions are made about the 37 million Americans, mostly low-paid workers and their families, who lack any coverage. It is said they will flood the system with demands for treatment. Ditto for the 37 million others with inadequate coverage. The cost, worriers gasp, could be stratospheric. Not likely. The 37 million with no coverage are already in the system. They are not left unattended when injured or stricken with illness. They are treated on emergency terms at the highest cost. Similarly, inadequately insured patients receive needed care even though they cannot completely pay their bills. Unpaid bills for these 70 million people are being paid now through higher bills for patients with coverage. 

D531a/Robert Bazell, science correspondent for NBC News, NEW REPUBLIC, March 15, 1993, TITLE: GROWTH INDUSTRY, Online America, Transmitted: 93-02-25 09:32:20 EST \\VT 93-94
 The lack of progress also can be affirmed by a casual look at medical literature. A review of head and neck cancer treatments in a recent issue of The New England Journal of Medicine is typical. It lists standard therapies as well as many new experimental treatments and concludes that clinical investigations "have led to new insights. However, improved survival has not yet been achieved." When Food and Drug Administration commissioner David Kessler recently announced the approval of Taxol as a treatment for ovarian cancer, he emphasized that the drug works in only 30 percent of the cases, and then for a maximum of seven months. Krakoff, who has supervised several trials of Taxol, calls Kessler's assessment "quite optimistic."

D532/Robert Bazell, science correspondent for NBC News, NEW REPUBLIC, March 15, 1993, TITLE: GROWTH INDUSTRY, Online America, Transmitted: 93-02-25 09:32:20 EST \\VT 93-94
 Statistics compiled by the government also belie the assumption that cancer survival rates are improving. The overall death rate for cancer, adjusted to account for the aging population, is actually rising. In 1975, 162.2 out of every 100,000 Americans died of cancer. By 1989, the last year for which figures are available, the rate had risen to 173.1. Some cancer specialists argue that the epidemic of lung cancer caused by smoking should be taken out of the equation. If it is, the death rate remains about the same as it was before.

D533/Robert Bazell, science correspondent for NBC News, NEW REPUBLIC, March 15, 1993, TITLE: GROWTH INDUSTRY, Online America, Transmitted: 93-02-25 09:32:20 EST \\VT 93-94
 Most Americans probably assume that cancer treatment is better today than it was a few decades ago. It certainly is more expensive. Thirty years ago a patient with metastatic pancreatic cancer, for example, would have received little more than pain killers and been allowed to die peacefully. Today that patient will likely undergo several rounds of chemotherapy at a cost of thousands of dollars, even though few doctors would maintain that it will succeed in prolonging life or alleviating suffering. Indeed, nowadays many patients with all sorts of cancer that cannot be treated with surgery or radiation undergo chemotherapy. Dr. Irwin Krakoff of M.D. Anderson Cancer Center, one of the founders of the field of oncology and one of its most respected practitioners, told me: "There is little we can do" for most cancers that have returned after surgery. "Typically we are giving the patients a few extra months. It is seldom years."

D534/NORMAN EDWIN LIDKIE, The Toronto Star, August 7, 1992, Pg. A20, HEADLINE: A democratic right \\VT 93-94
	 With the cost of national health insurance in jeopardy from public overuse, any attempt by government to promote better health and decrease accidents - whether it be from a fall from a bicycle or being thrown out of a vehicle because of a detached seat belt - is part of its democratic right. 

D535/Federal News Service, MARCH 29, 1993, HEADLINE: PRESIDENT'S HEALTH TASK FORCE HEARING, PANEL EIGHT, Nexis \\VT 93-94
	 DICK DAVIDSON (PRESIDENT, AMERICAN HOSPITAL ASSOCIATION): And the goal should be improving health status in communities, and focussing on prevention, and focussing on fellness. Our system today focuses on sickness and illness, and we need to change that. In doing this, we need to change the way for care. We think we need to move to a fixed annual payment system with these community care networks. 

D536/Arabella Melville, CURED TO DEATH: THE EFFECTS OF PRESCRIPTION DRUGS, 1982, p234
HeaIth requires that we be adequately fed, that we be protected from a wide range of hazards in our environment, and that we do not depart radically from the pattern of personal behavior under which we have evolved. These lessons had been learned by the end of the 19th century, and their practical application marked the decline of the major infectious diseases. This decline can only be adversely affected by the change in emphasis in health care away from environmental and lifestyle factors and towards concepts of 'care' which ignore the importance of cause. 'Medical care can assist when we become unavoidably ill, but it cannot prevent us becoming ill, nor can we rely on it to provide a cure.D537/Pension Reporter, November 16, 1992 ,Vol. 19, No. 45; Pg. 2058 TITLE: LACK OF PUBLIC CONSENSUS COULD SLOW NEW ADMINISTRATION'S REFORM EFFORTS. \\VT 93-94
	 The health care system's reliance on treatment rather than prevention and its emphasis on high technology intervention instead of primary care have brought it to the verge of collapse, the American Public Health Association said in a report released Nov. 9. The report calls for renewed emphasis on improving the social, economic, and environmental factors that affect health. The cost of medical care should be a crucial issue in the health care reform debate, but the overriding goal of reform should be to attack social problems that lead to poor health, such as air pollution and unsafe drinking water, poverty and crime, drug abuse, and unsafe sexual practices, APHA [American Public Health Association] said in America's Public Health Report Card. 

D538/RONALD L. NUMBERS, Univ. of Wisconsin, 1982; "The specter of socialized medicine: American physicians and compulsory health insurance," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 21 \\VT-MDS
.As seen by organized medicine compulsory health insurance was unnecessary, unsuccessful, and uneconomical. But even worse, it threatened to affect adversely the income of physicians, to strip them of their freedom, and, consequently, to reduce the quality of medical care.
D539/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Nugent [Jeffrey T. Nugent, Medical Association of Georgia]: A number of people are looking at the idea of national health insurance, although I'm not sure the average person looks at it as single-payer reform. It seems to me that there isn't any physician who wouldn't go for health reform. But when it comes to national health insurance, the physicians I deal with and most of my patients are quite skeptical. There are a lot of unanswered questions about how it will work here; fear that we in America might lose something that we've got, particularly technology, lose access to the newest and best things that American medicine gives. 

D540/Research Alert, September 18, 1992, HEADLINE: Factoids Nexis\\VT 93-94
	 Four out of five U.S. physicians (81%) think medical societies should try to implement reforms through a combination of government and private programs, rather than support a government-financed national health insurance program (14%) or resist any si gnificant change in the health care system, according to the American Medical Association. 

D541/JOEL HAVEMANN, TIMES STAFF WRITER, Los Angeles Times, December 30, 1992, Part A; Page 1; HEADLINE: HEALTHIER IN EUROPE \\VT 93-94
	 Medical salaries are another part of the cost-quality equation. General practitioners in the United States earned an average income of $77,900 in 1985  after covering their expenses but before paying taxes, according to the American Medical Assn.'s most recent data. That compares with $48,200 in Germany, $32,400 in the Netherlands, $24,700 in France and $19,700 in Belgium. 

D542/RONALD L. NUMBERS, Univ. of Wisconsin, 1982; "The specter of socialized medicine: American physicians and compulsory health insurance," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 23 \\VT-MDS
American physicians repeatedly cited the experience with contract practice at home and compulsory health insurance abroad as proof that such arrangements dehumanized medical service, causing doctors to view patients as "mere number." There is no other service so individual and so personal as medical service," explained one practitioner:
D543/RONALD L. NUMBERS, Univ. of Wisconsin, 1982; "The specter of socialized medicine: American physicians and compulsory health insurance," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 22 \\VT-MDS
From the earliest protests to the present, concerned physicians have predicted that compulsory health insurance would turn them into mere "cogs" in a giant government controlled medical machine. Government insurance, they believed, would demote them to employee status  like schoolteachers  robbing them of their professional identity and respect. It would "enslave burden and belittle all parties to it." D544/ JAMES MORONE, NY Academy of Medicine, 1990, "Beyond the words: the politics of health care reform," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 215 \\VT-MDS
The entire range of innovations ultimately share a common ideal: reshaping provider behavior to some murky standard of efficiency. As a result, a vague sense of gloom has developed among many physicians, especially younger ones.
D545/NEWSWEEK MAGAZINE, 1989, "Biting the insurance bullet," reprinted in THE CRISIS IN HEALTH CARE - THE REFERENCE SHELF, 1991, p.140\\VT-MDS
Whether it's business or government that takes the lead, any serious effort to roll back costs will involve limiting medical fees and volume and that's bound to produce a political backlash from doctors and hospitals.
D546/RONALD L. NUMBERS, Univ. of Wisconsin, 1982; "The specter of socialized Medicine," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 22 \\VT-MDS
Undoubtedly, some of the rhetoric about bureaucratization and regimentation reflected a suspicion that the government would control fees as well as other aspects of medical practice, but I think we should not dismiss the medical profession's repeated pleas for freedom as mere camouflage. D547/Mike Snider, USA TODAY, January 21, 1992, Pg. 1D HEADLINE: Older doctors distrust reforms \\VT 93-94
	- If the U.S. started a national health plan, 17% of older doctors would retire immediately; another 33% would retire early. - 61% would not recommend medicine as a career to a son or daughter. 

D548/Mike Snider, USA TODAY, January 21, 1992, Pg. 1D HEADLINE: Older doctors distrust reforms \\VT 93-94
	Half of all doctors age 55 or older might retire immediately - or at least sooner than they had planned - should the USA adopt a nationalized health care plan like Canada's, a new survey suggests. 

D549/Jesse A. Kane, M.D., St. Petersburg Times, January 30, 1992, Pg. 17A HEADLINE: Why target doctors when discussing health-care reductions? \\VT 93-94
	Surely intelligent, diligent, young people are not going to select the rigorous road that current physicians have traveled. They will not spend thousands of dollars and study countless hours to get the grades needed to obtain admission to medical school. They will not spend four years in medical school, toiling countless hours to learn important facts about human anatomy, physiology and disease processes, and all the while paying upwards of $ 15,000 to $ 20,000 at some medical schools even though some of those schools receive state funding. They will not spend another three to seven years learning their clinical specialty and then go into practice to find that Medicare or some national health insurance reimburses them at levels that don't even allow them to meet their overhead and repay their loans. 

D550/B.D. Colen, medical correspondent, Newsday, December 29, 1992, Pg. 51, HEADLINE: Making the Tough Choices \\VT 93-94
	  The German government has proposed slashing dental coverage, so no one would be entitled to a bridge with more than four teeth. German dentists are responding by saying they will opt out of the system and accept only privately  insured patients, rather than those covered by National Health. On top of that, German physicians are describing cuts in medical coverage as medical euthanasia. 

D551/Donald O. Nutter, Northwestern University School of Medicine, Journal of the American Medical Association May 15, 1991; 265: 2516-2520 TITLE: Restructuring Health Care in the United States; A Proposal for the 1990s \\VT 93-94
	 Universal access to care at an affordable cost will require an adequate supply of primary care physicians. Undergraduate and graduate medical education programs must play a responsible role in meeting this need. 

D552/Mike Snider, USA TODAY, January 21, 1992, Pg. 1D HEADLINE: Older doctors distrust reforms \\VT 93-94
	While the survey included only a fraction of the nation's nearly 173,000 older doctors - 29% in the U.S. are over 55 - it shows ''the U.S. needs a policy that will attract and keep the people best suited to be physicians,'' says Joe Hawkins, head of the search firm. 

D553/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Multiple Private Insurers. -- Those who would favor a more pluralistic approach to managing a national health system believe that adequate savings can be achieved through the regulation of certain expensive insurance practices. Advocates of this approach would favor simplifying the paperwork needed to file insurance claims through standardization and reducing the number of administrative staff in hospitals and physicians' offices. They would also encourage small businesses to join together in pools to purchase health insurance at lower administrative costs. 

D554/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE - THE REFERENCE SHELF. 19.91, p150 \\VT-MDS
But there are many others,  equally important: the total loss of medical confidentiality; the loss of morale and dedication among medical personnel; the loss health care workers by emigration, change of vocation, or early retirement; the massive intrusion by the bureaucracy into the doctor patient relationship; the civil servantization and inevitable unionization of the medical profession; and so on. It would take five more lectures of this length to describe in detail all the pernicious ramifications of socialized medicine, Canadian style.
D555/WILLIAM GOODMAN, Canadian physician, 1990, "The Canadian model," reprinted in THE CRISIS IN HEALTH CARE - THE REFERENCE SHELF, 1991 p151 \\VT-MDS
As to physicians, most would, sad to say, also approve of the Canadian scheme whether because of inertia, as in older doctors; or out of a fatalistic resignation to what many consider inevitable; or because they realize, from the experience of the medical profession after introduction of national health insurance in other countries, that they will earn far more money than at pre sent, at least for the first few years; or because they actually welcome increasing government intervention out of philosophical convictions. possibly due to having grown up in an increasingly welfare state, do-gooder environment. Whatever the cause, I predict that over 80 percent of your doctors would raise no significant  objection to national health insurance.

D556/JAMES MORONE, NY Academy of Medicine, 1990, "Beyond the words: the politics of health care reform," reprinted in UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p.222 \\VT-MDS
 Second, physicians themselves might find relief in a national system. To be sure, it would likely end the steady transfer of national resources to the medical sector, but it would also end the steady diet of new bureaucratic and economic techniques designed to push and pull American physicians into practicing more "efficiently." Most nations with a fixed medical budget defer to providers as to how to allocate those funds. They do not need to change the practice of medicine because they control total costs more directly. D557/Research Alert, September 4, 1992, HEADLINE: Health Care Reform Nexis \\VT 93-94
	 In a complete turnabout from their position on current health care concerns, doctors are quite opinionated about the future. A huge majority (94%) expect substantial restrictions on fees, and a significant 66% anticipate expansion of Medicare to include everyone below the poverty level. A majority (61%) also expect to see government-financed national health insurance. 

D558/Los Angeles Times, January 17, 1993, Part E; Page 6; HEADLINE: DOCTOR PRESCRIBES SOME BIG CHANGES FOR AMA \\VT 93-94
 A doctor is telling physicians: "Get ready for a bumpy ride. Like it or not, we're in for change." This realistic physician -- Ray Scalettar, a rheumatologist here -- says doctors must recognize that change in American medical care is inevitable and try to make it change for the better. 

D559/The Atlanta Journal and Constitution, April 5, 1992, Section V; Page 1, HEADLINE: CONDITION CRITICAL-A doctors' debate on national health insurance \\VT 93-94
	 Kahn [Dr. Henry S. Kahn, Physicians for a National Health Program]: That's a feeling I'm sure many of us would share, because we've all had, at some point in our lives, doubts about the government's capability to administer things well. But in fact the only thing I hear is a much more intense suspicion and worry about the arbitrary way in which the insurance companies have handled their responsibilities. There's no question they have created a very large, cumbersome and costly bureaucracy that leads to expenditures of perhaps 23 percent of every health care dollar. No one is seriously suggesting the government could do worse than that. 

D560/Research Alert, September 4, 1992, HEADLINE: Health Care Reform Nexis \\VT 93-94
	 An alternative, endorsed by 34% of doctors, requires employers to provide health insurance; people not covered by employers would be eligible for government-financed coverage. Only 18% of U.S. doctors favor national health insurance. 

D561/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 31 \\VT-MDSThe argument, then, that a better environment explains the fall in infectious disease deaths has a high degree of plausibility; however, there are also reasons for skepticism regarding this explanation and powerful evidence supporting the alternative explanation, namely that improvements in the environment are less important than improvements in human resistance to disease. These two possibilities are, of course, not mutually exclusive, and I shall argue that both have likely played a role in the extension of modern life expectancy. 

D562/LEONARD SAGAN; MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 128 \\VT-MDS,
We overly emphasize the role of a hostile environment in producing disease. Just as we presume that the smallest amount of radioactivity in the environment is harmful, we assume that the smallest amount of stress is harmful, ignoring the stimulating benefits to human development of environmental challenge.D563/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 31 \\VT-MDS
I am skeptical about the role of environmental sanitation in bringing about the decline in infectious disease deaths because most of the decline in deaths over the past two hundred years has not been from those "named" infections such as typhoid and cholera, but rather have been the result of a decline in the diarrheas and pneumonias of infants and children. These are not the result of exposure to organisms brought into the household by contaminated water or food but are the result of infection with viruses that are omnipresent; these organisms are not susceptible to water or food purification. In addition, efforts to introduce sanitation, particularly piped water, into premodern communities have largely failed to produce improvements in health. 
D564/ LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 41 \VT-MDSImprovements in sanitation of food and water supply have undoubtedly produced benefits to health; yet these benefits are likely to have been small compared to the benefits associated with the increased resistance of the human population.
D565/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 41 \\VT-MDS
The decline in mortality rates began prior to the great sanitary movement of the nineteenth century. 
D566/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELLBEING, p. 32 \\VT-MDS 
Second, the decline in infectious disease deaths appears to have preceded, rather than followed, improvements in sanitation and to have  occurred long before the decline in infection. That is, there is evidence that exposure to infectious organisms continued long after the decline in death rates from those organisms had declined. As sanitary conditions were worsening in cities, mortality rates were in decline.

D567/United Press International, March 29, 1993, HEADLINE: HEALTH CARE TASK FORCE PANEL HEARS IDEAS ABOUT HEALTH REFORM, Online America, Transmitted: 93-03-29 20:25:00 EST \\VT 93-94
	 "Physicians cannot help but be concerned that some of the changes reportedly being considered by the administration will make it difficult for physicians to represent the best interests of patients," said Raymond Scalettar, board of trustees chairman for the American Medical Association. 

D568/Malcolm Gladwell, Washington Post reporter, The Washington Post, March 22, 1992, OUTLOOK; PAGE C3, HEADLINE: Why Canada's Health Plan Is No Remedy for America \\VT 93-94
	 "We doctors, when we sit across from you patients, have considered what is good for you first and looked at social policy secondarily . . . ," said Stuart Sides, a Washington cardiologist. "I look on myself as the patient's advocate in the system. To try to layer social policy on top of that will intrude in the relationship between doctor and patient. It will take a certain retooling in the mind of the American patient." 

D569/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 But fee for service is the way medicine has always been, and most Americans like the choice it provides. The idea of an outside party interjecting itself into the doctor-patient relationship does not sit well with many patients, and doctors are even less enthusiastic about it. 

D570/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 In an attempt to increase the availability and quality of a basic and necessary service--medical care--are we placing unwarranted constraints on the traditional patient-provider relationship? 

D571/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	1. The process of utilization management and associated changes in course of treatment cause anxiety among and inconvenience to some patients. 2. Utilization management adds to the administrative burden of practitioners and institutional providers and contributes to resentment about reduced professional autonomy and satisfaction. 

D572/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * Some providers feel insulted and irritated by challenges to their autonomy and by the monitoring of their clinical decision making. They believe that the influence of utilization reviewers, most of whom have less clinical training, inappropriately challenges the legitimacy of the decisions they reach. In a similar vein, second guessing of provider decisions reduces the confidence patients have in the abilities of their providers. 

D573/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 Increased financial pressures on physicians and hospitals have stressed these relationships. The rise in the acuity level of hospital inpatients and the decline in their average length of stay, for example, have made it very difficult for physicians and nurses to cultivate personal relationships with hospital patients. The spread of group practices, health maintenance organizations, and freestanding medical, surgical, and imaging centers has made it hard for physicians to know their patients well. 

D574/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 30, 1993, Part A; Page 1; HEADLINE: LID ON HEALTH COSTS NEEDED, GORE SAYS \\VT 93-94
	 A more strident doctor's voice came from Jane Orient, a Tucson practitioner and executive director of the American Assn. of Physicians and Surgeons. Orient railed about government regulation of doctors and warned that the Clinton Administration may "destroy the art and science of medicine." 

D575/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 The increasing emphasis on managed care leads to some significant ethical considerations. In an attempt to increase the availability of a basic and necessary service (medical care) certain constraints are placed on the traditional patient-provider relationship. 

D576/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 "Patient satisfaction" may not be a completely valid measure of access to health care, but most of the concerns consumers expressed were related to problems of access and choice. 

D577/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 Two types of complaints occurred frequently in testimony and written comments submitted to the task force. First, enrollees complained of their inability to access specific types of providers, either because contract provisions do not provide for the reimbursement, or because the practice ideologies of primary care "gatekeepers" prevented access. 

D578/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * By its nature, managed care limits patient choices to a greater or lesser degree. Some managed-care enrollees complained that their access to alternative or midlevel providers (chiropractors, nurse midwives, physical therapists, etc.) was limited either by the terms of their group contract or, when allowed by the contract, by the philosophies or ideologies of utilization managers or primary care gatekeepers. 

D579/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 Opponents of the competitive approach believe multiple competing plans would cause discontinuities in care because people would be required to switch health plans frequently to pursue the lowest prices. They believe many people with established medical relationships would have to discontinue their current arrangements and join tightly managed care plans with limits on their choice of physicians and hospitals. Opponents also doubt whether people could make informed decisions about the quality and value of health care in selecting among health plans.

D580/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 * Patients who know that the details of their injuries and illnesses (particularly mental health issues) will be discussed with third parties may not confide completely in their physicians or other providers. 

D581/Dr. Fritjof Capra, Prof. Physics, U Calif. Berkeley, THE TURNING POINT, 1982, p330 
The patient's will to get well and confidence in the treatment are crucial aspects of any therapy, shamanistic healing rituals to modern medical procedures. As the writer and editor Norman Cousins has noted, "Many medical scholars have believed that the history of medicine is actually the history of the placebo effect." 

D582/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 Serious attention to the intrinsic value of caring in the physician-patient relationship, of one person caring for another, should shape the health care reform debate. Any acceptable reform must protect the vulnerability of patients and support the fiduciary responsibilities of physicians. It must check the development of the factors that make caring therapeutic relationships increasingly difficult to establish and sustain. 

D583/BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 After analyzing the five health reform proposals, CONSAD researchers concluded that the 21st Century American Health System--also referred to as the Jackson Hole plan--would lead to the greatest loss of small business jobs. 

D584/ Barbara Ehrenreich, Asst. Prof. Health Sci, and John Ehrenreich, Asst. Prof. American Studies, SUNY-Westbury, SOCIAL POLICY May/June, 1974, p34 
...most patients accept the authoritarianism of the doctor and would be nonplused or even let down by more egalitarian treatment. 

D585/ FAZLUR RAHMAN, practicing cancer specialist in San Angelo, Tex, April 18, 1993; The New York Times, “Viewpoints; Let's Hear It for Low-Tech Medicine,” Section 3; Page 11\\VT-AGL
	 One reason medical care has become so impersonal and high-priced is that physicians are not rewarded for bedside medicine. In our society, primary-care doctors do not exert as much influence as specialists do. Much can be achieved by low-tech medicine and personal contact, but high-tech tests are more lucrative and less time-consuming. 

D586/JEFF WILSON, Prof. Psychiatry Univ. Pittsburgh, 1990, HOMELESSNESS IN THE UNITED STATES pg. 108 
The elder statesman of the biopsychosocial model in medicine, Engel, has described these forces well: "The power of vested interests, social, political, and economic, are formidable deterrents to any effective assault on biomedical dogmatism. The delivery of health care is a major industry, considering that more than eight percent of our national economic product is devoted to health. The enormous existing and planned investment in diagnostic and therapeutic technology alone strongly favors approaches to clinical study and care of patients that emphasize the impersonal and the mechanical. 

D587/LEONARD SAGAN, MD.. & Epidemiologist, 1987; THE HEALTH OF NATIONS: TRUE CAUSES OF SICKNESS & WELL-BEING p.84 \\VT 
Unfortunately, that which is most. noble about the medical profession, the ability to provide comfort and compassion, is rapidly being eroded in favor of increasingly sophisticated, mechanical, and dehumanized treatment of unproven benefit. Heroic means of treating the dying are consuming much of our medical resources while effective means of preventing illness and disease, which will be elaborated on in subsequent chapters, are being ignored. 

D587a/ROBERT KAPLAN, Prof. Family & Preventive Medicine, UCLA, 1993; THE HIPPOCRATIC PREDICAMENT: AFFORDABILITY, ACCESS, AND ACCOUNTABILITY IN AMERICAN MEDICINE, p.173 \\VT-ADPL 
A variety of different arguments have suggested that the implementation of a general health policy model will destroy the way medicine is practiced. It is true, that the system will change the way medicine is practiced, but whether or not this will be a negative result remains to be determined. 

D588/Howard Waitzkin, Medical Scholar, THE SECOND SICKNESS, 1983. p. 181 
Further, It is foolish to think that changing the doctor-patient relationship in itself would lead to wider social change. Although medical encounters may reinforce structural patterns of domination and oppression, the struggle toward non dominating, non oppressive doctor-patient relationships will not create social revolution (notwithstanding ardent claims by alternative health movements of various persuasions). Basic change in doctor-patient relationships needs to accompany change in the lager contradictions that impede a decent and humane health-care system. Just as medical encounters are only part of the problem, their modification will be only part of the solution. 

D589/Roger Thompson, staffwriter, Nation's Business, April, 1992, Pg. 18, HEADLINE: States take lead in health reform VT- ACS
	 As a result, approximately 40 percent of all the nation's uninsured--or about 15 million people--are small-business owners or workers, or their family members. 

D590/ROBERT A. ROSENBLATT and STUART SILVERSTEIN, TIMES STAFF WRITERS, Los Angeles Times, March 20, 1993, Part D; Page 1; Column 2; HEADLINE: NEWS ANALYSIS; MEDICAL COVERAGE REFORM WILL COST PLENTY\\VT 93-94
	 Businesses, particularly smaller firms, balk at the Clinton proposal for mandated coverage. "Anyone who isn't providing health insurance at the moment isn't doing so for one reason, and one reason alone: They can't afford it," said Martyn Hopper, California director of the National Federation of Independent Business, whose members employ an average of eight workers. About 38% of the 50,000 member firms in California do not provide health insurance. A mandate will be bad "for most of my members," said Barry Rogstad, president of the American Business Conference, a diversified group of fast-growing companies. "If something adds to the cost of hiring workers and doing business, we have to darn well worry about it." 

D591/The Journal of Commerce Editorial: Saying No to Clinton, The Journal of Commerce, May 12, 1993, Knight-Ridder/Tribune Business News, Online America, Transmitted: 93-05-11 18:22:00 EDT \\VT 93-94
 Consumers and businesses, facing new taxes and employer mandates, have a case of the jitters. After an early rally fueled by the promise of deficit reduction, business confidence is slipping. Employers are holding off on new hiring, keeping the unemployment rate stuck at 7 percent. The public is losing faith, too: In the past two months, the spread between approval and disapproval for the president's plan dropped from 31 to 10 percentage points. 

D592/DEBORAH SHALOWITZ, Business Insurance, June 1, 1992, Pg. 36, HEADLINE: Health care dissatisfaction grows; But a national plan is no cure \\VT 93-94
	 Although a growing number of human resources executives are dissatisfied with the present system of employer-sponsored health insurance, they believe government-sponsored national health insurance would be worse, according to a survey released last month. And, fewer executives now favor national health insurance than did three years ago, the survey results indicate. 

D593/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 Companies, for their part, are increasingly desperate for relief from rising costs. A survey of 131 large employers by Buck Consultants Inc. of New York found three-quarters dissatisfied with the current system and three-quarters opposed to national health insurance (up from 60 percent three years ago). 

D594/ BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 The Heritage Consumer Choice Plan, developed by the Heritage Foundation, also would cause no job loss, according to the study. Under this plan, employers would not be required to supply health insurance for their employees. Rather, a new federal tax credit for health insurance would be available to all families, who could then choose their own health plan. Employers who continued to offer health insurance to their workers would have to add the value of the coverage to employees' taxable incomes. 

D595/Laurie Aucoin, Columbus Ledger-Enquirer, Ga., Knight-Ridder/Tribune Business News, May 17, 1993, Title: Small Businesses to Take Biggest Hit from Clinton Health Plan, Online America, Transmitted: 93-05-16 16:53:00 EDT \\VT 93-94
 "I wonder if the 7 percent they are talking about is on top on what we're already requiring," said Tom Durst, director of human resources development and communications. "If it is, it could have a very serious effect on small business. The amount of money we're paying now is already in part subsidizing the ones not insured. 

D596/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 30, 1993, Part A; Page 1; HEADLINE: LID ON HEALTH COSTS NEEDED, GORE SAYS \\VT 93-94
	 A government mandate to provide health coverage would cost small businesses at least $40 billion, according to Margaret Smith of National Small Business United. 

D597/DAVID KINDIG, Prof. Medicine Univ. of Wisconsin, 1992, UNDERSTANDING UNIVERSAL HEALTH OPTIONS, 1992, p. 30 
"Mandating Health Coverage for Working Americans," by Alan Monheit and Pamela Farley, is a very important policy analysis of mandating that employers provide health coverage to various categories of workers and dependents; they estimated that approximately two-thirds of the uninsured population would be covered by mandates for employees working 20 or more hours per week. Estimates of the employment impact of such mandates suggest that 2.5 percent of the workforce, or 847,000 workers, would have their jobs jeopardized. 

D598/BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 The researchers found that, under the plans with mandates, millions of jobs in small business were "at risk," while the plans with incentives had employment impacts that were "minimal." 

D599/ BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 Requiring small businesses to provide health insurance for their employees could lead to the loss of between 390,000 and 900,000 U.S. jobs over the first two or three years of the plan and erode the quality of millions of other jobs, according to a study released May 20 by the National Federation of Independent Business. 

D600/ BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	After analyzing the five health reform proposals, CONSAD researchers concluded that the 21st Century American Health System -- also referred to as the Jackson Hole plan -- would lead to the greatest loss of small business jobs.

D601/ BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 Under the Jackson Hole proposal, 899,530 small business jobs would be lost, the researchers estimated. In addition, 18.2 million private sector jobs in small business--almost a quarter of the total--would be put "at risk," the study said. 

D602/BNA PENSIONS & BENEFITS DAILY, Jan. 13, 1992, ADMINISTRATION OFFICIALS RELEASE STUDY CRITICIZING PLAY-OR-PAY REFORM PROPOSALS, Nexis \\VT 93-94
	Administration officials Jan. 9 released a study which charges that "play-or-pay" health care reform proposals would result in "lost jobs, higher employer costs, higher taxes, and a huge new government-run health program." 

D603/BNA PENSIONS & BENEFITS DAILY, Jan. 13, 1992, ADMINISTRATION OFFICIALS RELEASE STUDY CRITICIZING PLAY-OR-PAY REFORM PROPOSALS, Nexis \\VT 93-94
	At a press conference, Labor Secretary Lynn Martin and Health and Human Services Secretary Louis Sullivan released a study, conducted by The Urban Institute, which analyzed the effect of such proposals on health insurance coverage and its costs. According to Martin, play-or-pay would cost employers an additional $30 billion annually to cover the uninsured and would cost taxpayers $36 billion a year more than what the federal government now spends on health care. 

D604/Laurie Aucoin, Columbus Ledger-Enquirer, Ga., Knight-Ridder/Tribune Business News, May 17, 1993, Title: Small Businesses to Take Biggest Hit from Clinton Health Plan, Online America, Transmitted: 93-05-16 16:53:00 EDT \\VT 93-94
 Small businesses will suffer the most under the proposed Clinton health reform plan that would require all employers and workers to pay for health insurance, according to Columbus employers. Last week, a Clinton aide said an employer-worker payroll tax is a likely option to pay for coverage of uninsured Americans. The proposed payroll tax would extend coverage to millions of uninsured Americans, according to White House adviser Ira Magaziner. About 85 percent of the uninsured live in families headed by workers, according to Census Bureau statistics. 

D605/BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 The researchers said that HealthAmerica: Affordable Health Care for All Americans Act (S 1227), introduced by Senate Democrats in June 1991 (18 BPR 959) would lead to the second greatest loss of jobs. This plan, often described as "play or pay," would require employers either to provide health insurance to their workers or to pay a payroll tax. While similar to the Jackson Hole plan in many ways, it also would include a tax credit to help small businesses provide insurance to lower income employees. Nevertheless, the researchers estimated that the Senate proposal would result in 635,230 job losses, with an additional 12.1 million jobs put "at risk." 

D606/BNA PENSIONS & BENEFITS DAILY May 27, 1993 NFIB SAYS MANDATED HEALTH COVERAGE COULD COST 900,000 SMALL BUSINESS JOBS , Nexis \\VT-MDS
	 The California Health Care System for the 21st Century--a plan backed by John Garamendi, California insurance commissioner (20 BPR 1079) would lead to the third greatest loss of jobs, the NFIB study said. The California proposal would result in 386,940 jobs lost and an additional 7.4 million jobs put at risk, according to the study. 

D607/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 The real cost of the medical cost mess is the stifling of initiative, ingenuity, and risk taking--the very things we need more of. No charts, graphs, or expert opinion can measure what might have been. 

D608/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	 Every day people propose well-thought-out, well-researched, well-documented business plans, and are ready to start their own enterprises. The risk is formidable but probably manageable. Self-employment is, after all, the American dream. The data reveal that small firms have provided most (upward of 85%) of the private job growth in the United States in the last few years. While large firms were restructuring, cutting, down-sizing, and moving overseas, small firms have stabilized the economy. The fact is that the Fortune 500 keep cutting jobs in the United States while the small firms have taken up the slack. 

D609/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, March 30, 1993, Part A; Page 1; HEADLINE: LID ON HEALTH COSTS NEEDED, GORE SAYS \\VT 93-94
	 A number of small businesses vehemently argued against a government requirement that they pay for the health insurance of all workers, saying that would be a burden that many small firms cannot bear. The requirement would "sound the death knell" for many restaurants, Elmont said. 

D610/Marian Freedman, Best's Review -- Life-Health Insurance Edition, April, 1992, Vol. 92 ; No. 12 ; Pg. 36, HEADLINE: Stating the case for health care reform; While the congressional debate on health care reform rages, the states craft plans that could provide a model for national policy \\VT- ACS
	 Critics of this approach ["play or pay"] say that many small businesses, unable to afford the cost of health insurance, would be forced to close. They also criticize the plans for not addressing the issue of rising costs and say an increased demand for services under these schemes would exacerbate this problem. 

D611/USA TODAY, October 15, 1992, Pg. 5A, HEADLINE: While mainland debates, Hawaii's system works \\VT 93-94
	 Sam Slom - president of Small Business Hawaii, which represents 3,100 small businesses - says health care costs have been a burden on business. ''Talk to any small businessman who's meeting a payroll and he will not advise you to follow this direction,'' Slom says. ''Health care would be our No. 1 issue if we didn't have so many other No. 1 issues.'' 

D612/DEBORAH SHALOWITZ, Business Insurance, June 1, 1992, Pg. 36, HEADLINE: Health care dissatisfaction grows; But a national plan is no cure \\VT 93-94
	 More than one-third of those surveyed -- 35% -- believe a national health insurance program would hurt their companies' competitiveness in global markets, according to the survey. Forty-one percent said there would be no change, 13% had no opinion and 11% thought it would make their companies more competitive. 

D613/PANEL FOR HUMAN RESOURCES ADMINISTRATION, 1993, DRIVING DOWN HEALTH CARE COSTS: STRATEGIES & SOLUTIONS, p. 16 \\VT-ADPL 
In this country, a person's employer is the usual source of health insurance. Many small businesses, which tend to be newer and less fiscally stable, with few or no administrative personnel, can't afford to offer coverage to their employees. In fact, 90 percent of firms that do not offer a health insurance benefit have fewer than 10 employees. Their employees, who tend to be lower--wage workers--two thirds of uninsured workers earn less than $10,000 per year--cannot afford to pay for coverage, either. Given the choice, such workers might well prefer higher wages to an insurance benefit that typically costs $4,000 per year. 

D614/ROGER VANCE, researcher for a major insurance company, National Underwriter, March 15, 1993 , Pg. 21, HEADLINE: Will Health Care Reform Rescue Auto Insurance? \\VT 93-94
	 These games might be amusing were they not seemingly part of an ominous, step by step progression, in which basic insurance becomes either a right or compulsory . . . Rates and classes are thereby politicized . . . Politics, not the freemarket, determines price and terms for mandated coverage . . . The disease metastasizes into non-compulsory insurance . . . Insurers are reviled for excessive, invidious taxation . . . Their autonomy erodes . . . At last, insurers serve government, eunuch-like, as functionaries and repositories of blame. 

D615/James Srodes, Sunday Telegraph, March 21, 1993, Pg. 42, HEADLINE: Wall Street View: Braced for Hurricane Hillary \\VT 93-94
	 One solution scares the industry mightily. Last week the President allowed the Oregon state government to proceed with a plan stopping state payments for nearly 20 per cent of the 688 treatments most often required by patients. This scheme will allow more of Oregon's poor to get treatment for those left on the list. But treatment for certain cancers, hepatitis and other ailments would have to be covered by private insurers through pools of funds offered to lower income clients. Another scheme, being debated in Florida, would force private insurers to pool revenues in a fund that would guarantee health services to all. In turn, the state would enforce caps on medical charges and guarantee the insurers a certain return. Whichever plan Hillary offers her First Husband, the impact on insurers will be as painful as the weather. Adjustments seem inevitable, even if profits no longer are, as the second "Year of the Cat" prowls on. 

D616/James Srodes, Sunday Telegraph, March 21, 1993, Pg. 42, HEADLINE: Wall Street View: Braced for Hurricane Hillary \\VT 93-94
	 IN THE United States, insurers call 1992 "The Year of the Cat". This is not a Chinese astrological reference. For Cat, read Catastrophe, or an insurance claim costing $ 5 million or more. There is only one problem: 1993 is shaping up the same way as 1992. And America's insurers are not just worried about natural disasters. There is also a human one looming in the shape of Bill Clinton's rush towards a national health insurance sheme, which is being headed by his wife, Hillary. 

D617/James Srodes, Sunday Telegraph, March 21, 1993, Pg. 42, HEADLINE: Wall Street View: Braced for Hurricane Hillary \\VT 93-94
	 How bad was 1992? Credit rating agency A M Best reckons the property and casualty insurance losses rose by 36 per cent to a record $ 34 billion. Last August, Hurricane Andrew went on a rampage across Florida and Louisiana, creating claims approaching $ 18 billion. A month later another hurricane lashed Hawaii and caused $ 1.6 billion worth of damage. On top came the Los Angeles riots ($ 775 million), flooding in Chicago ($ 300 million) and a series of north east storms in December ($ 650 million). 

D618/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 More important than the dollar decline for the industry is the reduction in resources needed to service this vanishing segment of business. Companies need to start planning now for such an eventuality. It is likely that the health care system will become very muddled with a wide variety of approaches and programs in place. Social programs in the United States tend to be diverse and lacking in coherence, reflecting the fundamental diversity and individualism of the nation's culture and people. 

D619/James Srodes, Sunday Telegraph, March 21, 1993, Pg. 42, HEADLINE: Wall Street View: Braced for Hurricane Hillary \\VT 93-94
	 While property and casualty insurers cope with Hurricane Andrew, health and life insurers will have to face Hurricane Hillary - and the cost here could be as high as $ 200 billion. Hillary Clinton, the wife of President Bill, is head of the White House task force charged with producing a national health insurance scheme. 

D620/Peter H. Stone reporter, Legal Times, February 17, 1992, Pg. 11, HEADLINE: NATIONAL HEALTH INSURANCE Say It Isn't So \\VT 93-94
	 Long derided as figment of some socialist's fevered imagination, national health insurance has become a hot political issue. And no group is feeling the heat more than the Health Insurance Association of America, the major group of commercial health insurers. 

D621/DENNIS L. BREO, Journal of the American Medical Association, August 28, 1991; 266: 1131-1133, TITLE: Sidney Wolfe, MD -- healing the system or just raising hell?\\VT 93-94
	 Returning to NHI, Wolfe says, "We have to get rid of the health insurers in this country. That's what Canada did and that's what we need to do. "In America, the health insurers have bought off the unions and the American Association of Retired Persons and they are running the show. The debate over NHI is a life-or-death struggle for them, because if we win and they lose they're out. Totally out.." 

D622/JOHN MACDONALD; Courant Senior Washington Correspondent, The Hartford Courant, April 25, 1992, Pg. A2 HEADLINE: In health care debate, numbers sometimes can mislead \\VT 93-94
	 Health Insurance Association of America, "Citizen Action attempts to convey the impression," the statement said, "that eliminating the private health insurance industry -- or at least eliminating administrative expenses -- is the 'silver bullet solution' to health care financing reform." It just isn't so, the association said. 

D623/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 From the point of view of the p-c industry, this feature of Super-HMOs would have an impact on insurers similar to a nationalized health insurance system. Consider workers' comp. If a worker was injured on the job, medical care would be provided by the Super-HMO. This facility would, in most cases, be familiar to the worker. It would have the worker's prior medical history and probably data based on recent checkups. So it is logical that the worker would turn to the Super-HMO for treatment. Likewise, in auto insurance, the Super-HMO would supplant the current medical part of the system. The alternative, as in the case of nationalized insurance, would be a fee-for-service system treating only auto accidents. 

D624/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 Still, requiring insurers to offer coverage to anyone, irrespective of medical condition at a fixed price (community rating) or even within a band (modified community rating) for a standard package or benefits, as proponents of managed competition would do, still leaves the insurers open to adverse selection by families. This problem is endemic to all forms of community rating, because it forces insurers to accept high-risk individuals without fully factoring their cost into premiums. 

D625/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 My analysis so far has centered on the extreme case of a national health system. Most observers view the adoption of such a system in this country as unlikely. However, even in a less extreme system of managed competition, where medical care remains in private hands, the impact on p-c insurance would be similar to that described above. 

D626/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 To see how changes in the health care system could impact the p-c insurance business, let's first look at an extreme example: a nationalized health care system, somewhat similar to that of the United Kingdom. Although national health care is unlikely to be adopted in this country, this kind of system presents a clear framework through which to understand how changes in the health care system would impact p-c insurance, especially since similar effects are likely under less extreme versions of reform. Under a national health care system, all U.S. medical care would be provided by the government. Doctors, nurses and other medical practitioners would be employees of the government and would be paid out of tax revenues. Medical care would be provided either free of charge or with low fees to discourage overuse. Such a system [national health insurance] would have a profound impact on workers' compensation, auto insurance and commercial liability insurance. With medical care freely available, the medical portion of workers' compensation would probably disappear, while payment for loss of earning power would remain as part of the system. If a worker was injured on the job, medical care would be provided through the national health care system. It is theoretically possible that a private sector fee-for-service system could still handle workers' comp. medical claims. However, such an arrangement would appear to most policymakers to be wasteful. 

D627/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 If President Bill Clinton succeeds in making substantial changes in the U.S. health care system, the property-casualty insurance industry could shrink by about 10 percent, or $ 25 billion in today's dollars, as a result. 

D628/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 The transfer of medical claim costs from workers' comp. and auto insurance to other health care providers would result in a significant reduction in premium volume for the p-c insurance industry. For the whole industry, the decline would be at least 10 percent, or about $ 25 billion in today's dollars. 

D629/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 However, the direction of change in the health care sector is toward managed competition and, as such, the impact on p-c insurers is likely to be profound. It is not too early for p-c insurers to prepare themselves for this new world. 

D630/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 National health insurance would also have an impact on bodily injury liability cases, like slip and fall accidents or injuries caused by defective products. Under the current liability insurance system, payment for medical care plays a very critical role in liability claims. 

D631/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 For example, consider a person who receives a few cuts and bruises following a fall on a slippery floor in a supermarket. Under the current fee-for-service medical care system, treatment for the cuts and bruises can be built up to several hundred dollars, particularly if the claimant is given tests and X-rays. The injured person's lawyer will make a claim based on a multiple -- frequently three times -- the cost of medical care for pain-and-suffering damages. Now, consider the same slip and fall accident under a national health insurance system. The person would receive medical treatment free or at a nominal rate. The treatment would be relatively simple and probably would not include the buildup elements of extra tests and X-rays typical of a personal injury case. And without the evidence of a huge medical bill, a jury would not be likely to award thousands of dollars for pain and suffering. 

D632/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 Turning to auto insurance, a national health system probably would eliminate the need for medical payments insurance and the medical portion of no-fault personal injury protection coverages. Over time, a national health system also would reduce the scope of auto liability insurance. Persons injured in auto accidents simply would go to public health facilities. Under such a system, it would be difficult to sustain a private sector system of doctors and trauma centers that catered only to victims of auto accidents where another party was deemed at fault. 

D633/ROGER VANCE, researcher for a major insurance company, National Underwriter, March 15, 1993 , Pg. 21, HEADLINE: Will Health Care Reform Rescue Auto Insurance? \\VT 93-94
	 Clearly, a national health plan would undermine the need for compulsory insurance and financial responsibility laws by reducing the need for tort to pay for auto injuries. As a side effect, it would reduce the costs auto insurers could be blamed for. 

D634/Sean Mooney, senior vice president and economist at the Insurance Information Institute, National Underwriter, January 25, 1993 Pg. 23 HEADLINE: Health Care Reform Will Impact P-C Insurers \\VT 93-94
 As a result, it is likely that workers' comp. laws would be rewritten so that employers would no longer be required to provide compensation for medical care for on-the-job injuries, except in a number of special areas. For example, certain types of rehabilitation not available in the national health system could be compensated directly by employers. The indemnity portion of workers' comp. -- payment for loss of earning capacity -- would remain. Employers would therefore still need insurance to cover this exposure under the workers' comp. law. In some cases, disability payments under the employer-provided benefit package might be considered the equivalent to benefits currently available from workers' comp. 

D635/Federal News Service, MARCH 31, 1993, HEADLINE: PREPARED TESTIMONY OF J. ROBERT HUNTER, PRESIDENT NATIONAL INSURANCE CONSUMER ORGANIZATION BEFORE THE HOUSE SUBCOMMITTEE ON CONSUMER CREDIT AND INSURANCE Nexis, \\VT 93-94
	 "Insurance is essential to revitalize our cities. It is a cornerstone of credit. Without insurance, banks and other financial institutions will not -- and cannot -- make loans. New housing cannot be constructed, and existing housing cannot be repaired. New businesses cannot be opened and existing businesses cannot expand, or even survive. "Without insurance, buildings are left to deteriorate; services, goods and jobs diminish. Efforts to rebuild our nation's inner cities can not move forward. Communities without insurance are communities without hope." (Emphasis added.) (FOOTNOTE #1: Meeting the Insurance Crisis of Our Cities -- A Report by the President's National Advisory Panel on Insurance in Riot Affected Areas (1968), p.1.) 

D636/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 In the end, nothing short of stiff and pervasive government regulation will make our private insurance industry a more trustworthy and accessible partner. Smart executives within the industry already know that; smart voters should know it too. 

D637/ROGER VANCE, researcher for a major insurance company, National Underwriter, March 15, 1993 , Pg. 21, HEADLINE: Will Health Care Reform Rescue Auto Insurance? \\VT 93-94
	 Those who wanted additional protection in case of auto accidents could seek it in the free market. Auto insurers would write freemarket auto injury coverage around basic health insurance, just as life insurers write free-market life coverage around Social Security. 

D638/Uwe Reinhardt, professor of political economy at Princeton, The Washington Post, March 22, 1992, PAGE C3, HEADLINE: Neither Is the Free Market; And the U.S. Health Industry Ultimately Needs Strict Regulation \\VT 93-94
	 And herein lies a lesson that should not be lost on the private insurance industry. If the industry is to be the successful cornerstone of our nation's health system, it will eventually come to resemble a model it has long decried as "socialism": the social-insurance systems of Western Europe whose semi-private insurance carriers are led towards socially desired ends through tight public regulation. 

D639/ROGER VANCE, researcher for a major insurance company, National Underwriter, March 15, 1993 , Pg. 21, HEADLINE: Will Health Care Reform Rescue Auto Insurance? \\VT 93-94
	 Could the essential irrationality of compulsory insurance be confronted and its baneful effects reversed? The prospect might daunt even the strongest and most creative insurance leaders. Nevertheless, there are philosophical levers waiting to be pulled. Among them are national health insurance and pure no-fault. A promising opportunity for auto insurance reform may arise from a national health plan covering all citizens. It has been said that the automobile insurance "crisis" in the United States has no counterpart in other industrialized countries partly because their "safety nets" (social security and government health plans) are less permeable than ours. Consequently, in those countries, financial need is less of a spur to litigation. 

D640/ROGER VANCE, researcher for a major insurance company, National Underwriter, March 15, 1993 , Pg. 21, HEADLINE: Will Health Care Reform Rescue Auto Insurance? \\VT 93-94
	 A minimum level of auto injury coverage could be subsumed into national health insurance. Group rating would be extended to subsumed auto coverage, thereby eliminating class criteria (territory, age, gender, marital status) now deemed politically incorrect. 

D641/ROGER VANCE, researcher for a major insurance company, National Underwriter, March 15, 1993 , Pg. 21, HEADLINE: Will Health Care Reform Rescue Auto Insurance? \\VT 93-94
	 Forthright socialization through a national health plan would distinctly separate basic auto injury protection from other, free-market, auto coverage. The need for litigation would lessen and, to that extent, reliable contractual recovery would replace the uncertainty, fraud and transactional waste associated with tort. For many persons who forgo auto insurance, a considerable amount of basic auto injury coverage has already been displaced by group health. 

D642/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 The outlook is similar under a national health insurance plan. Health insurers may well gain millions of new customers - those not covered, all workers, the unemployed and probably the millions of poor Americans now enrolled in the federal-state program called Medicaid who will be moved into private plans. Further, a new line of "luxury" coverage is likely. 

D643/Loretta McLaughlin,Globe Staff, The Boston Globe, March 28, 1993, OP-ED; Pg. 75 , HEADLINE: Medicare's foes were wrong, but their fears haunt the health debate \\VT 93-94
	 What are these false fears? - Insurance companies will lose business. The government will be an unfair competitor for customers. The reverse happened under Medicare. Instead of losing business, two new segments of health insurance were spawned. One is the coverage created to fill in gaps in Medicare payments; the other the huge contracts for processing Medicare claims for the government. 

D644/ John L. Glover, MD WESTERN SURGICAL ASSOCIATION: PRESIDENT, ArchIVES OF SurgERY 1992; 127: 766-769 TITLE: Medicine in the Nineties; Expectations, Priorities, and Realities \\VT 93-94
	 A fifth thing we must do is to continue our efforts to bring sense to the problem of professional liability. It is madness to continue a system in which 80% of the costs are overhead, a system that equates a bad result with negligence, and a system that makes patients our adversaries. Concerted efforts by physicians have brought actions in times of crisis before, as in a passage of a reasonable law in Indiana in 1975. And when costs of liability amount to at least 10% of all medical expenditures, a crisis certainly still exists. 

D645/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Mr. SCHRAMM [CARL SCHRAMM, Health Insurance Association of America]: Well, that's just not the case and we really ought to start with the medical malpractice 'cause if that represents 10 percent of the cost, that's over six- that's about $ 66 billion. 

D646/Stuart M. Butler, Director of Domestic Policy Studies, The Heritage Foundation, Heritage Foundation Reports, January 12, 1993, BACKGROUNDER; No. 924, HEADLINE: THE CONTRADICTIONS IN THE CLINTON HEALTH PLAN, Nexis \\VT 93-94
 But it is difficult to see how such a localized rationing system could function in the U.S. without a sweeping overhaul of the malpractice laws. In Canada or Britain a patient may be angry when a doctor refuses care, but he must accept it. In America the patient hires an attorney and sues when he does not like the doctor's decision. Yet Congress shows little inclination to confront the powerful trial lawyers' lobby and provide health practitioners with the type of immunity enjoyed by Canadian or British doctors. 

D647/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Mr. SCHRAMM [CARL SCHRAMM, Health Insurance Association of America] : But when every doctor in the country says that the first issue you have to attack is malpractice 'cause I'm giving unnecessary tests. Every doctor in the country is saying that, 'I have to practice this defensive medicine. It's 10, it's 12, it's 20 percent of the cost of doing business.' It's critical for the president to take steps in that direction. 

D648/Albert B. Crenshaw, Washington Post Staff Writer, June 28, 1992, PAGE H1, HEADLINE: 'Managed' Care Not Always Managing Costs \\VT 93-94
	 This introduction of traditional market forces into health care is highly controversial. There are horror stories about patients who were discharged from the hospital prematurely or denied some specific treatment because the insurer deemed it unnecessary. A new field of malpractice law has grown up around the question of who is liable for damages arising from such situations. 

D649/Cable News Network, Crossfire, February 6, 1992, Transcript # 503 HEADLINE: The Prescription for Change in Health Care? Nexis \\VT 93-94
	Dr. HIMMELSTEIN: [Dr. DAVID HIMMELSTEIN, Harvard Medical School] But, Carl, that number is completely made up. In fact they've passed these tort reforms that Bush is talking about in several states and the health costs in those states haven't gone down a bit despite those tort reforms. 

D650/WILLIAM B. SCHWARTZ, professor of medicine at Tufts University, The Houston Chronicle, January 20, 1992, Outlook; Pg. 11 HEADLINE: True cost controls in denying health services\\VT 93-94
	Limit payments for malpractice injuries. The Bush administration recently targeted the malpractice system as a focus of its cost containment efforts. The centerpiece of their proposal is a limit on the size of malpractice awards. But even effective capping of awards would have little impact on health-care costs. Malpractice insurance costs in recent years have contributed less than one-tenth of a percentage point to the annual rise in health-care costs. 

D651/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 Do congressional price controllers plan to eliminate, or heavily restrict, the ability of a patient to sue providers over the denial of treatment or the provision of poor quality care? If so, that will require sweeping reforms of the legal system. The prospects for such reforms in Congress are dim. 

D652/BNA PENSIONS & BENEFITS DAILY, Nov. 10, 1992 , U.S. SYSTEM FACES "MELTDOWN" WITHOUT MAJOR REFORM, SYMPOSIUM TOLD Nexis \\VT-ACS
	 Most of the factors forcing up costs lie outside the the health industry, including general inflation, higher personal income that results in greater use of medical care, and liability laws that lead to defensive medicine, Sullivan contended. "Our legal system is unique, to put it mildly. No other country has anything remotely like our liability system," which "piles on the cost" of health care, he said. "We can't leave out the necessity of legal reform," he added. 

D653/ELI GINZBERG, Prof. Columbia Univ., 1990, THE MEDICAL TRIANGLE: PHYSICIANS, POLITICIANS, AND THE PUBLIC, p..90-1 \\VT-JHH 
Iatrogenic {treatment-induced} illness and premature death from improper use of prescription drugs and substandard performance in medical practice have achieved prominence in the context of malpractice litigation, soaring malpractice insurance rates, and their effects on style of practice and the crisis of care. 

D654/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 ASK A PHYSICIAN or insurance executive why health-care costs have risen so obscenely high in the past decade, and if he doesn't ask, "What do you mean?" the odds are overwhelming that he will give you a two-word reply: "Malpractice suits." 

D655/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 Asked to justify their contention that the "malpractice crisis" is the engine propelling health-care costs ever upward, physicians - and hospital administrators - point to individual physician malpractice insurance premiums that for some specialties exceed $ 100,000, and jury verdicts in malpractice cases in the tens of millions of dollars. 

D656/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 They also freely admit that physicians are practicing "defensive medicine,"  ordering expensive, often superfluous, tests and treatments in the fear that if they don't, and the patient sues, some attorney will convince a jury that the physician was negligent for not ordering a particular treatment or test.  

D657/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 While studies indicate that the vast majority of true malpractice goes unchallenged by patients and the legal system, what does the so-called "malpractice crisis" add to the nation's medical bill? No one knows for sure. But the American Medical Association, which is unlikely to be underestimating,  says that malpractice premiums, legal costs, jury awards AND defensive medical  practice add $ 20 billion to the annual health-care tab. 

D658/Spencer Rich, Washington Post Staff Writer, July 12, 1992; The Washington Post, “Demand for High-Tech Medicine Hampers Efforts to Curtail Health, p. A1\\VT-AGL
	Doctors may be greedy, ignorant or afraid of being sued for malpractice if they do not use every possible test. 

D659/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	The prospects for such reforms in Congress are dim. But without them there is little reason to believe that doctors and hospitals will long continue to practice medicine with government policies forcing them to deny services, while the legal system threatens to drive them into bankruptcy if they do deny care. 

D660/Edmund F. Haislmaier, Senior Policy Analyst , The Heritage Foundation, Heritage Foundation Reports, March 8, 1993, SECTION: BACKGROUNDER; No. 929 , HEADLINE: WHY GLOBAL BUDGETS AND PRICE CONTROLS WILL NOT CURB HEALTH COSTS, Nexis \\VT 93-94
	 The malpractice problem is crucial to a policy of global budgets because in practice it is doctors and hospital administrators who will be expected to make the actual on-the-spot decisions to withhold treatments to keep within a budget. But if an angry patient or relative can sue a doctor or hospital administrator for withholding care to abide by a government budget limit, the entire system is likely to break down. 

D661/Lewis Cop,Staff Writer, March 18, 1992; Star Tribune, “ Tomorrow's doctors: diagnosis by computer, surgery by robot ,” p. 1E\\VT-AGL
	 Before the end of the 1990s, doctors may face malpractice lawsuits for substandard care if they don't use computers to help diagnose and treat patients, a panel of ethicists concluded at a recent American Association for the Advancement of Science (AAAS) meeting in Chicago. 

D662/Theodore M. Pappas, President, The McLaughlin Co., Legal Times, March 23, 1992, Pg. 22, HEADLINE: Looking For Lawyers' Angle In Health Care \\VT 93-94
	 What happens to the lawyers if we really do get national health insurance, and the contingent-fee cases disappear, and we go to court based only on pure negligence? The reason is that currently we cannot bring in other sources to limit the claims such as insurance payment. However, with a level of insurance for everyone, there would be the assumption by the court that each person has medical coverage. There would be no need for restitution on that portion. 

D663/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 In cases in which a patient is seriously injured by a physician, the cost of lifetime medical care can be astronomical - which is why, particularly in cases involving infants who suffer brain damage during delivery, you sometimes read of malpractice awards in the tens of millions of dollars. But if everyone in this  country has the same access to quality health care, fully paid for by the government through tax dollars, rather than private insurance premiums, one of  the main needs for malpractice litigation is instantly eliminated.  

D664/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 If your child needs lifetime medical care, your child gets lifetime medical  care. If you need years of physical therapy, you would get it. And it would all be paid through the national health-insurance plan. There would be no need for a massive malpractice payout. 

D665/Theodore M. Pappas, President, The McLaughlin Co., Legal Times, March 23, 1992, Pg. 22, HEADLINE: Looking For Lawyers' Angle In Health Care \\VT 93-94
	 It has been my experience that without large medical bills, there does not tend to be large judgments. I find it interesting that this fact has not been brought up in any of the legal press over the years. 

D666/MICHAEL REAGAN, Prof. Health Policy Univ. California at Riverside, 1992; CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p.76 \\VT-ADPL 
This welcome cost decline reportedly results in part from a better kind of defensive medicine, use of monitoring devices to prevent deaths from anesthesiology errors and training of doctors to minimize the risk of errors in the types of cases most likely to result in lawsuits. Another reason is statutory: state laws that penalize frivolous claims, making attorneys more selective in cases they are willing to file. 

D667/MICHAEL REAGAN, Prof.. Health Policy Univ. Calif.-Riverside, 1992  CURING THE CRISIS: OPTIONS FOR AMERICA'S HEALTH CARE, p. 76\VT-ADPL 
Despite headlines about million-dollar jury awards, a major study  published in 1990 (covering 1984 data) showed that only one law  suit was filed for every 10 cases of medical negligence; that plaintiffs  lose a majority of the cases; and that a jury awards damages in only  20 percent of the cases that go to trial. Insurance premiums for  doctors make headlines when they rise rapidly but less so when they   go down, as began to happen in 1990. 

D668/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 To listen to physicians, their advocates and payors, the cost of medical care has risen out of all proportion to the rest of the cost of living because of all the costs associated with what has admittedly been a litigation plague. Thus the way to reduce medical costs, these players contend, is to institute "tort reform" - radically alter the circumstances under which an aggrieved patient may file suit, and reduce the amount the patient can collect if he or she wins.  

D669/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 While there is no question that someone injured by a physician should be  compensated, as states such as California have already determined, it is  possible to allow compensation and at the same time not turn a tragedy into a winning lottery ticket. If we were either nationally, or state by state, to  follow the California lead and place caps of, say, $ 250,000, on the amount  awarded for "pain and suffering," we would see a dramatic decrease in the number of lawsuits filed. After all, how many attorneys are going to bother with suits that, after three, four or even 10 years, can only pay expenses plus one-third  of $ 250,000? 

D670/BNA PENSIONS & BENEFITS DAILY, Oct. 20, 1992, STATES SHOULD TAKE LEAD IN DEVELOPING UNIVERSAL SYSTEM, VERMONT GOVERNOR SAYS Nexis \\VT 93-94
	 Medical malpractice is not a driving force in health care costs, claimed Lawrence Wobbrock, president of the Oregon Trial Lawyers Association. Malpractice litigation accounts for some $6 billion to $7 billion annually in the country, less than 1 percent of the $850 billion annually spent on the health care, he said. "Victims who get hurt are not the problem," Wobbrock said. Limits on attorney fees, such as adopted in California, simply deprive all but the worst cases from achieving justice, he said. 

D671/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 Which means that even if we eliminated all costs attributable to malpractice litigation and fear of litigation, we would only trim the health care bill by about 2.5 percent. While that is indeed a small reduction, reducing the litigiousness in the health-care world might go a long way toward making other, more meaningful, reforms possible. And, in fact, some of those other reforms would in and of themselves lead to the sharp reduction in malpractice damage awards. 

D672/B.D. Colen, medical correspondent, Newsday, December 22, 1992, SECTION: DISCOVERY; TAKE CARE; Pg. 57, HEADLINE: About Malpractice ...\\VT 93-94
	 But if we eliminate malpractice suits, how will we discipline physicians who violate the standards of medical practice? That's easy. Part of any reform of the health-care system has to be a radical restructuring of the licensing system so that any patient complaint is dealt with immediately, and any finding that a physician violated the standards of medical practice results in an immediate suspension - or permanent revocation - of the license to practice medicine in all states. 

D674/Charles J. Dougherty PhD, Medical Ethicist, Journal of the American Medical Association November 4, 1992; 268: 2409-2412 TITLE: Ethical Values at Stake in Health Care Reform \\VT 93-94
	 An expanding health care sector creates jobs and stimulates the economy; one person's cost is another person's income. And the public has come to expect a great deal from contemporary health care, perhaps too much. 

D675/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	Government figures also show that nearly 8% of the nation's non-agriculture workers are in health services, including doctors, nurses, hospital administrators, physical therapists, pharmacists, technicians, orderlies, consultants and analysts. And the nation's 8.5 million health care workers account for more than 12% of the gross national product, or nearly $700 billion annually. 

D676/MODERN HEALTHCARE, January 11, 1993; "Health spending hits $838 billion in 1992," p.2\VT-MDS 
Employment in the healthcare industry also will continue to rise. Last year, 10 million people worked in the healthcare industry, up about 1 million from 1991. Employment in physicians' and surgeons' offices grew the most. 

D677/MICHAEL R. McGARVEY, health benefits planner, The San Francisco Chronicle , NOVEMBER 11, 1992, Pg. A21; HEADLINE: Solution to Health Care: Keep It Simple \\VT 93-94
	 Meanwhile, health care has become the nation's largest non- agricultural employer. A booming part of a bust economy. 

D678/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	"Health care is a very labor-intensive endeavor," said Ed Howard, executive vice president of the Alliance for Health Reform. "What's bureaucratic waste to one person can be another person's paycheck." 

D679/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	Caught in the middle of such proposals are the health care workers. They now make up more than 10% of the work force in some cities, said Richard Devens, a senior economist at the Bureau of Labor Statistics. 

D680/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	In many communities today, hospitals are the largest employer, said Samuel Davis, a health care consultant and former chief executive officer of New York's Mt. Sinai Hospital. 

D681/George W. Rimler [professor of management at Virginia Commonwealth University], R. D. Morrison, executive director of the Virginia Board of Health Professions, Compensation and Benefits Review, American Management Association, May, 1992, Pg. 38 HEADLINE: Managed care \\VT 93-94
	Anybody with a calculator can determine the dollar amount of the cost, and basic unimaginative data compilation reveals that more jobs were created in the health-care industry than were lost in the construction industry during the past three years. These are the hard data that are recognized. 

D682/David R.H. Hiles, Monthly Labor Review, U.S. Bureau of Labor Statistics, November, 1992, Pg. 3 HEADLINE: Health services: the real jobs machine \\VT 93-94
	 More than 8 million U.S. workers have jobs in the health services industry, which indicates the great economic importance of the industry, in addition to the fundamental life-and-death nature of the services it delivers. Its employment growth rate has been little affected by changes in the growth of the overall economy, with the result that the industry has become a primary source of new jobs during economic downturns. 

D683/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	The industry's importance to the nation's economy was underscored Friday when the Bureau of Labor Statistics reported that the number of jobs in health services increased by 395,000 in 1991, while the nation lost 663,000 jobs overall. 

D684/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	The rising nationwide clamor to cut health care costs contains a painful paradox that President Bush and members of Congress must confront: The health care industry is the only major sector of the ailing economy that continues to grow, and efforts to reduce spending could end up costing jobs. 

D685/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	The economic impact of the health care industry on a community can be illustrated in towns throughout Texas, which leads the nation in hospital closings, industry officials say. When Golden Plains Community Hospital in Borger, Tex., closed in 1988, it not only put 130 people out of work but also indirectly threatened the jobs of 3,000 other residents of the small Panhandle town. 

D686/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	One reason for the growth in health care jobs in recent years is the explosion of medical technology, which has created demands for more skilled personnel. "We're far and away the world's most innovative country in terms of new pharmaceuticals, medical devices, biotechnology and diagnostics," said Wayne Roe, chairman of Health Technology Associates Inc. in Washington, a business consulting firm. "And that employs a lot of people." 

D687/EDWIN CHEN, TIMES STAFF WRITER, Los Angeles Times, February 8, 1992, Part A; Page 19; HEADLINE: HEALTH CARE REFORM COULD ENDANGER JOBS, EXPERTS WARN \\VT 93-94
	The relatively new diagnostic tool called magnetic resonance imaging, for example, requires specially trained doctors and technicians to operate it and skilled mechanics and engineers to maintain it, Roe said. "The more sophisticated the tools become, the more they may require additional doctors and support personnel," he added. [Wayne Roe, chairman of Health Technology Associates Inc.] 

D688/REP COYNE, CONGRESSIONAL RECORD, 7/28/83 p H4639 
Unemployment directly affects the mental and physical health as well as family relations. While not easily documented, these are among the uglier aspects of joblessness. 

D689/REP COYNE, CONGRESSIONAL RECORD 7/28/83 p H4639 
As unemployment rises so does suicide, .homicide, infant mortality, cirrhosis, circulatory disease, and hospitalization for mental problems. 

D690/REP CROCKETT, CONGRESSIONAL RECORD, 8/3/83 p H 6390 
As the unemployment rate increases, the negative effects on physical and mental health increase exponentially. 

D691/HARVEY BRENNER, Prof. Johns Hopkins Univ., Hearings before the Subcommittee on Domestic Monetary Policy, Aug. 82, p 40 
The 1.4 percentage point rise in unemployment during 1970 accounted for 51,570 more deaths between 1970 and 1975 than would have occurred had the unemployment rate not risen in 1970. 

D692/HELEN GINSBURG. Prof. Brooklyn Col,1983; FULL EMPLOYMENT AND PUBLIC POLICY: THE US & SWEDEN p96 
A one-percentage point rise in the jobless rate is associated with: 36,887 total deaths, including 20,240 cardiovascular deaths, 920 suicides, 648 homicides, 495 deaths from cirrhosis of the liver, 4,227 state mental hospital admissions, 3,340 state prison admissions. 

D693/HARVEY BRENNER, Prof. Johns Hopkins Univ. , Hearings before the Subcomm. on Labor & Human Resources, 7/24/80 p23.- 
I would like to begin by pointing out that for the last fifty years we have known certainly that virtually all major sources of social pathology, whether we are referring maternal and child to mental disorder, infectious diseases,health problems, mortality rates and illness generally in the United States, has been shown to be universally related to income and employment status. These studies over the last fifteen years or so have been developed as well over time. Perhaps the single clearest and most consistent relationship is between economic change, deleterious economic change, and social pathology, 

D694/HARVEY BRENNER, Prof. Johns Hopkins Univ., Hearings before the Subcomm. on Domestic Monetary Policy, Aug., 1982, p. 43 
These analyses have been replicated for Canada and for England and Wales with substantially the same results. 

D695/HARVEY BRENNER, Prof. Johns Hopkins Univ., Hearings before the Subcomm. on Domestic Monetary Policy, Aug., 1982, p 43 
The study for the Joint Economic Committee (JEC) found very powerful relationships for the period 1940-1973 between national economic indices, per capita income, unemployment and inflation, and a number of measures of mortality, as well as of mental Health and criminal aggression. While the study for the JEC has not yet been brought up to date research over the past six years has reinforced and corroborated the results of that study. 

D696/KENNETH EATON, Chairman, Michigan Office of Substance Abuse, Hearings before the Education & Employment Task Force, ,3/1O/83, p 23 
That begins to suggest some of the same kind of things that Dr. Brenner's work was suggesting - that unemployment itself may be a very serious factor in the development of chemical dependency, alcoholism, drug addiction, and so forth - and the most frightening implication is that today's sharp increase in unemployment may very well be spawning a substantial increase in the incidence and prevalence of chemical dependency, and that this increase is likely to remain with us for the next several decades. 

D697/HARVEY BRENNER, Prof. Johns Hopkins Univ., Hearings before the Select Committee on Aging, 10/8/83 p 42 
In the fall of 1976, the Joint Economic Committee of the U.S. Congress published the results of a study on the basis of which it was estimated that the l.4 percentage point rise in unemployment during 1970 accounted for .51;57O more deaths between 1970-75 than would have occurred had the unemployment rate not risen in 1970. The study demonstrated that rates of mortality, mental hospitalization, and imprisonment for periods of approximately 25 years, beginning between 1935 and 1940 and ending between 1970 and 1973, could be explained by measures of economic activity: per capita income, unemployment and inflation rates: The data showing the association between the unemployment rate and all the pathological indices was statistically significant. Consistency was also shown in these relationships across age, sex, and racial groups, among different states and for three different countries. . /

D698/REP FORD, CONGRESSIONAL RECORD, 5/2/83, p H2527 
Victims of plant closings typically suffer from hypertension, abnormally high cholesterol and blood sugar levels, a higher incidence of ulcers, respiratory disease, unduly high propensities to gout and diabetes, and hyper allergic reactions. 

D699/REP. MILLER, CONGRESSIONAL RECORD, 3/3/83 P E837 
Dr. Margoils also noted that "unemployment appears to make children more vulnerable to the usual childhood illnesses such as respiratory infections and gastrointestinal infections." 

D700/HELEN GINSBURG, Prof. Brooklyn College, 1983; FULL EMPLOYMENT & PUBLIC POLICY: THE US & Sweden, p 97-8 
A substantial and growing body of empirical evidence backs up his findings. There are also explanations of the complex ways in which health may be affected by unemployment, in addition to the adverse impact of physical privation that might result from declining income. 

D701D292-VT/ERVIN LASZLO, UNITAR, 1983, SYSTEM SCIENCES AND WORLD ORDER: SELECTED STUDIES, p. 223.
Fertility in the U.S. has dropped so significantly to about 2.1 children per family - just below replacement level when infant mortality and the number of unmarried persons are taken into account.

D702D293-VT/MICHAEL D. SAYLES, WESTMINSTER INST. FOR ETHICS AND VALUES, 1980, MORALITY AND POPULATION POLICY, P. 6.
Because the per capita consumption of goods is such higher in developed than in less developed countries, population growth in developed countries creates more demand for world resources that does comparable growth in less developed countries.

D703D294-VT/RAFAEL SALAS, EX. DIR. UN FUND FOR POP. ACTIVITIES, 1980, REFLECTIONS ON POPULATION, 1984, p. 64.
In the developed world, where each person born will consume 20 to 40 times more in his or her lifetime than a person born in a developing country, the drive to fulfill continuously rising material aspirations will have a major impact on the environment, on the possibilities for meeting the most basic needs for the poor majority in the developing world and on the struggle for more just economic relationships within and between nations.
  
D704D295-VT/PAUL AND ANNE EHRLICH, CENTER FOR CONSERVATION BIOLOGY, STANFORD UNIV., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS,  p. xi-xii 
Suppose the United States population had stopped growing when it reached 135 million people, and that Americans had gone on to become as wasteful of energy per person as they are now.  Everything else being equal, the smaller population would not need to burn one drop of imported oil or one once of coal (the premier source of the greenhouse gas carbon dioxide).
 
D705D296-VT/PAUL AND ANNE EHRLICH, CENTER FOR CONSERVATION BIOLOGY, STANFORD UNIV., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS,  p. 9
Viewed in this light, the United States is the world's most overpopulated nation.  It is the world's fourth largest nation in population, now numbering more than a quarter-billion people, and the average American consumes more of Earth's riches than an average citizen of any of the other 'big ten" nations with more than 100 million people: China, India, the Soviet Union, Indonesia, Brazil, Japan, Nigeria, Bangladesh, and Pakistan.  Furthermore, the technologies used by Americans to support their opulent consumption are environmentally damaging and needlessly wasteful of energy.  Because of this combination of a huge population, great affluence, and damaging technologies, the United States has the largest impact of any nation on Earth's fragile environment and limited resources.

D706D297-VT/PAUL AND ANNE EHRLICH, CENTER FOR CONSERVATION BIOLOGY, STANFORD UNIV., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS,  p. 15
Although population growth rates are highest in poor countries, overpopulation and continuing population growth in rich countries are the prime threat to global resources and environmental systems, simply because the average individual in rich nations has a large impact on resources and environment.  One of the best available measures of that impact is a nation's per capita use of commercially produced energy.  in the united States, the average person use the commercial energy equivalent of about 10,000 kilograms of coal annually.  In contrast, an average South American uses about 1,000 kilograms, an Asian about 600, and an African about 425.  By this measure the birth of an average baby in the United States will be about 200 times as disastrous for the world as the commercial equivalent of some 45 kilograms of coal annually.

D707D298-VT/NATIONAL RESOURCE COUNCIL, 1992;  COMMITTEE ON THE HUMAN DIMENSIONS OF GLOBAL CHANGE; GLOBAL ENVIRONMENTAL CHANGE: UNDERSTANDING THE HUMAN DIMENSIONS, p. 2
Each person makes some demand on the environment for the essentials of life-food, water, clothing, shelter, and so on.  If all else is equal, the greater the number for the provision of resources and the absorption of waste and pollutants.  However, all else is not equal.  For example, a new individual with the standard of living and technological base of an average North American would use about 35 times as much energy as an individual living at India's average standard - with a roughly proportional impact on the global environment.

D708D299-VT/PAUL AND ANNE EHRLICH, CENTER FOR CONSERVATION BIOLOGY, STANFORD UNIV., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS,  p. 8-9
Measured by commercial energy use, each American, on average, causes some 70 times as much environmental damages as a Ugandan or Laotian, 20 times that of an Indian, 10 times that of a Chinese, and roughly twice that of citizens of Japan, the United Kingdom, France, Sweden, or Australia.  Americans use 50 percent more commercial energy than Soviet citizens, (who nonetheless have caused even more havoc by using it with minimum efficiency and virtually no effort to prevent environmental damage).  In terms of per-capita energy use, only Canada, Luxembourg, and a few oil producers are really in our league.  Since the United States also has a large population, our total impact is gigantic--about 100 times that of Bangladesh.

D709D300-VT/PAUL AND ANNE EHRLICH, CENTER FOR CONSERVATION BIOLOGY, STANFORD UNIV., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS,  p.  xi
That overpopulation and overconsumption in rich nations are threatening global security was dramatical highlighted by the military action in the Persian Gulf.  The war, undertaken to protect the access of the United States and other nations to Gulf oil, might never have occured if American population growth had stopped in 1943 when the United States had 135 million citizens.  No one has ever suggested a sane reason for having even that number of Americans, except a possible need for military manpower.  And 135 million was clearly sufficient in that respect, since in 1943 America was winning the largest land war in history.

D710D301-VT/WILLIAM NORMAN GRIGG, STAFFWRITER FOR THE NEW AMERICAN, JUNE 1, 1992, THE NEW AMERICAN: "THE GREEN REGIME: THEIR TOTALITARIAN AGENDA," p. 32.
Of course, the primary target of the anti-natal movement is population growth in America,  In Earth Day - The Beginning, a "survival guide" published in 1970.  David Brower declared, "That's the first thing to do - start controlling the population in affluent white American will use about fifty times the resources of a child born in the black ghetto."

D711D302-VT/PAUL AND ANNE EHRLICH, CENTER FOR CONSERVATION BIOLOGY, STANFORD UNIV., 1991; HEALING THE PLANET: STRATEGIES FOR RESOLVING THE ENVIRONMENTAL CRISIS,  p.  9
These numbers starkly illuminate the fallacy of the notion (common even among environmentalists that population problems are restricted to poor nations.  While rapid population growth in developing countries is a major factor in deepening them poor and does contribute to environmental destruction, the still-increasing overpopulation in rich nations poses the truly overwhelming threat to Earth's life -support systems.

D712/Lynn Wagner, staffwriter, Modern Healthcare, March 22, 1993, Pg. 28, HEADLINE: Reform may be tough sell -- polls \\VT 93-94
	 The study cited a survey conducted by the foundation late last year that found the greatest public support for ''sin taxes'' on cigarettes and alcohol. But raising the federal cigarette tax to $ 2 per pack from the current 24 cents per pack and boosting the tax on alcohol to $ 18 per proof gallon from the current $ 13.50 would yield just $ 25 billion. That amount would fund a program of gradual access expansions but would fall far short of the estimated $ 250 billion needed to fund a single-payer plan, the study said. 

D713/Robert J. Blendon, Harvard School of Public Health, Journal of the American Medical Association, May 13, 1992; 267: 2509-2520 TITLE: Making the Critical Choices \\VT 93-94
	 In addition, a national plan would lose the current state and local health contribution of $ 87 billion and would have to make up this amount through new federal funding or by using current intrastate health expenditures to help underwrite a national plan. 

D714/LANIE JONES, TIMES STAFF WRITER Los Angeles Times October 1, 1991, : Part A; Page 1; HEADLINE: LEARNING BEDSIDE MANNERS; \\VT-MDS
 A 1990 survey by the Miles pharmaceutical division found that one in four Americans had switched physicians at least once because the doctor made them feel uncomfortable, did not relieve their anxiety or failed to answer questions. A 1991 AMA survey reported that only 42% of respondents thought doctors explained things well to their patients.