Address to the Student National Medical Association Convention in Washington, DC

I have chosen this occasion to discuss national health policy with you who have crossed a sometimes impassable border of discrimination and financial barriers to achieve your dream.

Over two-thirds of black medical students come from families with incomes of less than $10,000 a year. In 1975 there was a drop in the number of minority students who entered medical school for the first time in five years.

This has made it more difficult for you to become doctors—but it has also given you a clearer sight of critical illnesses which no X-ray can show. They are the illnesses not of one patient, but of an entire system. The causes and cures will not be found in medicine alone; the diseases have begun and spread from politics and society itself.

Some of our medical advances have been remarkable; we have researched and developed new wonders of science and technology. We have made history by our near-conquering of communicable diseases. New technology extends the lives of thousands of patients, as for example with cardiac surgery. Some advances have been matters of basic social justice; we have passed Medicare and Medicaid to provide care for the poor, the disabled, and the aged. We have more hospitals, more equipment, and more clinics, community health and mental health centers.

But the point of any health care system is its end result—not for bureaus, or hospitals, or universities, or budgets—but for human beings.

There is a difference between the capacity of our health care system and the state of our health. This nation, first in the genius of its technology and the wealth of its resources, ranks 15th in infant mortality. Our life expectancy is lower than the average lifespan in several western countries. We lead the developed world in areas where we would prefer to be last, in the diseases of highly industrialized nations—the rate of heart disease and cancer.

Such statistics measure social injustice as much as medical inadequacy. Every shortfall in the health of Americans short-changes poor and minority Americans the most. Life expectancy for all of us is too short, but it is six years shorter for black people.

In 1965, Americans spent $39 billion, or less than 6 percent of GNP, for health services. By 1975, that expenditure had multiplied three times—to about $550 per year for every man, woman and child in our nation—more than 8.2 percent of GNP. Experts now estimate that, if these trends continue, the costs of continuing the present system will double over the next five years and could triple over the next ten.

Cost and access barriers are the normal accepted reasons for our problems and the expected focus of political concern. But the deeper causes of ill health, at least equal in their effects, are living conditions which breed half lives of sickness and early death. The problem with lead paint is not so much the price of a doctor to detoxify, but life within the poison painted tenements. The health problem among urban slums and rural shacks is not just a lack of nearby doctors to treat the preventable diseases which fester there, but die environment in which people live.

What are some of the tragic inadequacies of health care?

We have failed so completely to control medical costs that only 38 percent of Medicare expenses are now being met, and the elderly have increasingly limited access to needed services.

Medicaid has become a national scandal. It is being bilked of millions of dollars by charlatans.

For the first time in our history, we are in the midst of a medical malpractice crisis. Some of the blame for this surely rests on a record of poor quality controls in monitoring health care.

Overhospitalization, another cause of major national concern, results all too frequently from insurance policy payments limited to inpatient care.

The Nixon-Ford Administrations have slashed one essential health program after another in the fields of maternal and child health, community mental treatment centers, health manpower, health maintenance organizations, and biomedical research, among many others.

We have built a haphazard, unsound, undirected, inefficient nonsystem which has left us unhealthy and unwealthy at the same time.

The complex reality is that health care is one strand of a seamless social web. Our nation's health problems must be attacked from many approaches, one of which is national health insurance. We must begin by considering how best we can spend the health dollar. But first we must ask:

Sophisticated and costly medical technology has improved our health. But its duplication and misutilization waste our wealth—and the scarcity of resources then restrains the budget for other social needs.

Hospital beds often seem to be occupied longer than patients need them because we do not have alternatives or agreed-upon standards.

The structure of our health insurance encourages in-hospital care. A patient with the same illness would be kept in the hospital an average of four days in Santa Rosa, California, and thirteen days in Brooklyn, New York. We have no adequate explanation for the difference.

Similarly, the likelihood of surgery is related to the state where a person resides as much as the state of his or her health. A patient in a New York City hospital is twice as likely to be wheeled to the operating room as a patient on the Upper Peninsula of Michigan. Whether it is the practice pattern or the availability of surgeons is unclear.

Insurance has helped many Americans meet health care bills. Unfortunately, it may also be an incentive for inefficiency in delivery. Typical public and private insurance plans reimburse hospitals on the basis of costs incurred, frequently with limits on patients benefits, with no real control on the level of hospital costs and physician charges.

We have not until now controlled costs with incentives for efficiency. For the first time, legislation which is pending in the U.S. Senate makes a serious effort to place controls on hospital costs and physician charges under Medicare and Medicaid.

Federal policy is equally a problem. Federal programs are fragmented among at least fifteen departments—and the health responsibilities of H.E.W. are subdivided further among ten parts of that one cabinet-level agency. This bureaucratic sprawl of agencies cannot provide effective direction and coordination. Instead, it is a "disorganization" of overlapping jurisdictions and redundant programs, each of them with separate grant and reporting requirements. The result is more loss of money and time, and the wasted talents of administrators.

The administration of Medicare and Medicaid presents a perfect example of the need for government reorganization. The two programs often serve the same people. Each program is in a different agency of HEW. Neither agency is a health agency. Neither relates to programs to provide more professional and allied health manpower, or to research programs. Both Medicare and Medicaid have experienced massive cost increases that were not planned or anticipated. Our government now tries to shift part of the inflation back to the poorest of our citizens in the form of increased deductibles, co-insurance, and consequently reduced benefits.

First, our emphasis must be on prevention of the killers and cripplers of our people. Our purpose must be to promote health, not just to provide health care as such, and this includes initiative in insuring adequate family incomes and a clean environment as well as reforming the financing of health care. Reform of the welfare morass may prevent more sickness and disease during the next generation than could be achieved by placing $600,000 body scanning X-rays in every hospital.

The control of occupational hazards can save many workers each year who die prematurely because they are exposed to toxic chemicals, dust and pesticides. These are usually low income workers. Occupational health and safety can reduce cancer, accidents, and respiratory disease.

The abatement of air and water pollution would protect millions from breathing and drinking poisons which will lead to long, costly illness and disability 10 or 20 years from now.

Continuing education and information about proper nutrition and selfcare could reduce the $30 billion annual cost of the sicknesses that afflict Americans who eat or drink or smoke too much. Yet, the federal government spends less for this purpose than is planned for a single B-l bomber, and medical schools don't teach enough about nutrition or preventive health care.

Reorganization of our government is one of the most important steps we can take. A random system tends to perpetuate every effort of the past, no matter what its record may be, because each agency defends its own fragment of the policy. A consolidated system and coherent planning can weigh competing alternatives, judge comparative results, and budget resources for the best returns in terms of health.

It would be both cost-efficient and health-effective to use less expensive treatment methods where possible and to improve out-patient services instead of overbuilding and overusing hospitals. And it should be normal rather than exceptional to balance benefits and costs before deciding how and where to distribute the new developments of medical technology.

Medical care costs must be controlled. We must find incentives for productivity and efficiency.

Any comprehensive health policy must bring care within the reach as well as the means of all our people.

The most generous insurance program cannot pay doctors or hospitals that are not there.

In the county where I farm, there is not a doctor, dentist, pharmacist or a hospital bed. The National Health Services Corps has designated almost three hundred areas of similar shortage across the country. (Even nearby hospital services are remote for indigent people without transportation.) The ratio of physicians to population is three times higher in New York City than in South Dakota. Yet in the New York City ghettoes, physicians are scarce. Metropolitan centers generally have twice as many doctors for each thousand citizens as rural America.

The changing nature of medical practice compounds the numerical shortage of health personnel. There has been a substantial increase in specialists and a decline in family practitioners and primary care physicians.

The maldistribution of medical resources is neither inadvertent nor inevitable. It is partly the consequence of government action and the advance of technology. And therefore government can help redirect the trends of the past.

Medical education is an essential part of the reorientation of our national health care. The way medical schools teach, and the type of physicians they graduate, should reflect national projections of health needs and the rational planning of health services. The medical establishment has not responded to the shortage of primary care services and practitioners. But because of the strong federal and state support of undergraduate medical schools and graduate training, there is an obligation to the taxpayers to direct those funds in the public interest. Our national needs require redirecting medical education toward primary care as one means to correct the geographical and professional maldistribution of services and personnel.

We must insure more medical education for students from minority and low-income families, and for women, so they may take their rightful place in medicine. A major barrier to medical schools for minorities is financial. Most of your families had more hope than money to contribute to your dream. The government should assure scholarships and low-interest loans to make it financially possible to reach this goal.

To improve the availability of services, especially preventive services, the work of nurse practitioners and physicians' assistants is critical. In addition to these new clinicians, we need more paraprofessionals and allied health personnel who can free doctors and nurses for the work that only they can da A project in Portsmouth, Virginia, and others that we started in Georgia have demonstrated that many of the poor can fill paraprofessional roles, instead of being forced onto welfare rolls. The preventive work they do in their own neighborhoods reduces sickness and the expense of treatment.

Health care is so complex that it requires specialists, generalists and professionals of all levels to analyze problems and offer health services. A cooperative approach maximizes the use of professional time. That is why I support organized approaches to delivery of services.

Availability is linked to quality in other vital respects. Availability of different kinds of care is one example. Many of the aged live out their lives in nursing homes or hospitals that violate minimal safety, sanitation, and even fire standards. Many of the elderly end their years in impersonal, high cost institutions when lower cost residential and supporting services would permit them to continue living with dignity in their homes and communities.

Adequate enforcement of hospital and nursing home standards or the expansion of services like meals-on-wheels for the homebound elderly can certainly help. Other needs may be met by development of community-based counselors, themselves older citizens, to act as facilitators for services.

Quality of care must be a matter of concern for the nation. The public should be protected by explicit standards of competence. The Professional Standards Review system is potentially an important initiative to monitor the quality of medical care. This system needs to correct its internal deficiencies and improve implementation nationally.

An efficient, cost-effective health care system will deliver and not just promise national health care. We must follow the basic principle that the amount of personal wealth should not limit the state of a person's health.

National health insurance alone cannot redistribute doctors or raise the quality of care. So we must plan, and decisively phase in, simultaneous reform of services and refinancing of costs. Reform will enable us to set and secure the following principles of a national health insurance program:

• Coverage must be universal and mandatory. Every citizen must be entitled to the same level of comprehensive benefits.

• We must reduce barriers to early and preventive care in order to lower the need for hospitalization.

• Benefits should be insured by a combination of resources: employer and employee shared payroll taxes, and general tax revenues. As President, I would want to give our people the most rapid improvement in individual health care the nation can afford, accommodating first those who need it most, with the understanding that it will be a comprehensive program in the end.

Uniform standards and levels of quality and payment must be approved for the nation as part of rational health planning. Incentives for reforms in the health care delivery system and for increased productivity must be developed.

• We must have strong and clear built-in cost and quality controls. Necessary machinery for monitoring the quality of care must be established.

• Rates for institutional care and physician services should be set in advance, prospectively.

• Maximum personal interrelationships between patients and their physicians should be preserved; freedom of choice in the selection of a physician and treatment center will always be maintained.

• Consumer representation in the development and administration of the health program should be assured.

• National priorities of need and feasibility should determine the stages of the system's implementation. While public officials have continued to dispute whether coverage should be catastrophic at first or comprehensive immediately, the system has become a comprehensive catastrophe. We must achieve all that is practical while we strive for what is ideal, taking intelligent steps to make adequate health services a right for all our people.

• A basic concern shall be for the dignity of the person, not for the individual's wealth or income.

• Incentives for the reorganization of the delivery of health care must be built into the payment mechanism.

• We must have resources set aside to encourage development of alternative approaches and to spur new distribution of health personnel.

The accomplishment of comprehensive national health insurance will not be quick or easy. It requires a willingness to seek new solutions, to keep an open mind. The problems are obvious, the solutions less so.

Reinhold Niebuhr said, "The sad duty of politics is to establish justice in a sinful world."

Our nation is still a place of many injustices. There are bars of hunger as well as iron. There are manacles of disease as well as metal. There is the solitary confinement of neglected old age. There are high walls of prejudice and repression. There is the capital punishment of war.

These prisons will not be unlocked by mere good intentions or political promises in dubious faith. If they could be, humanity would have wished them away long ago.

There are many doors to be opened—to sounder health, a cleaner environment, racial equality and economic fairness—to all those things to which we pledge our allegiance in a single phrase—"with liberty and justice for all."