FORUM on Health Policy

"What Are the Presidential Candidates Saying About Health Policy Reform"

University of Michigan, April 7, 2000

Marilynn Rosenthal, Director of the University Michigan Forum on Health Policy

Welcome to our twelfth Forum. The Forum began in 1994 as a non-partisan, interdisciplinary, educational series. It is sponsored by the Program in Society and Medicine, of the University of Michigan Medical School. We bring together national, university and community experts representing different points of view on important health policy issues. The Forum is made possible through the generous support of community organizations and the various schools and colleges in the University. Our supporters are credited at the end of this program, along with our interdisciplinary planning faculty for these Forums. We appreciate the on-going support of both groups.

Today's Forum examines a subject of great national importance and interest, ideas for the reform of America's health care system put forth by the presidential candidates during this pre-election season. With us today are three of the major presidential candidate's senior health policy advisors. The McCain campaign was unable to join us today, but we welcome major health policy advisors from, in alphabetical order, the Bradley campaign, the Bush campaign, and the Gore campaign. During the first part of the program each advisor will present their candidate's ideas for health policy reform. They will then question each other, followed by a few questions from the audience. Then we will launch what promises to be a very lively and informative interchange between the three presidential campaign advisors and a panel of university and community experts.

The first part of the program will be moderated by Professor Gene Feingold and the second part by the Executive Vice President of Medical Affairs, Gil Omenn.

Professor Gene Feingold

Professor Rosenthal talked about the candidates in alphabetical order, I'm going to call, in alphabetical order, the spokesperson for each candidate. I will introduce all three of the spokespersons and then step down.

The first spokesperson is Dr. Richard Boxer, Health Advisor for Vice President Gore's campaign. Dr. Boxer is an urologist in private practice in Wisconsin. He's also a professor with both the Medical College of Wisconsin and the University of Wisconsin School of Medicine. He has been given the Presidential Citation by the American Urological Association and chosen in every survey as one of the best urologists in Milwaukee. He also has had long health policy career. He has been on advisory groups to the National Institutes of Health and has been associated either with the Clinton campaign or the Gore campaign since 1987. In addition to being a practicing physician he has recovered from a serious cancer disorder, so he has had the opportunity to think about medical care both from the perspective of the physician and the perspective of the patient.

The second advisor is James Haveman, here on behalf of Governor Bush's campaign. A social worker, he ran the community mental care program in Kent County, Michigan for a number of years and then came to the Engler Administration as Director of Mental Health for the State of Michigan. When the mental health department was merged with all the other health activities in Michigan, he became Director of the new Department of Health, a very large operation that spends somewhere in the order of 8-9 billion dollars a year. Most of that goes for Medicaid and other community health programs. It is one of the state's largest departments, in terms of expenditure. He also has won a number of awards, including the National Governor's Association Distinguished Service Award, and is generally regarded as a leading state administrator.

The third spokesperson, Margy Heldring, speaking on behalf of Senator Bradley, is a clinical psychologist who taught and practiced clinical psychology for a number of years in the other Washington, on the West Coast. She then moved to the Washington that most of us are familiar with, Washington, D.C., where she worked on the staff of Senator Bradley and also Senator Paul Welsco and eventually come to her present position as Senator Bradley's Senior Health Advisor. She also has a distinguished career. She has won awards in the State of Washington, has worked in the area of primary care as a psychologist, and is the only one of our speakers today who herself has run for elected office. She was a candidate for the Washington State Legislature.

I will now turn the Program over to the speakers. The first is of course, will be Dr. Boxer.

Gore's Health Plan

Dr. Richard Boxer

It's an honor to be here. Today, I'm representing the Vice President of the United States, but more importantly the man about to become the Democratic nominee for the Presidency of the United States. Al Gore believes very strongly that health care is and must be a centerpiece not only for the campaign but far more important for the American people in the twenty-first century.

Al Gore strongly believes his health plan has to be realistic, has to be fiscally responsible and has to be incremental in its approach. We learned a lesson in 1993 and 1994 about what happens when you propose massive changes to a significant portion of the economy. The health care industry represents 12 _% of the economy. And so we understand that we need to approach this in an incremental fashion, so the economy stays robust.

But, in every poll that has been taken over the last couple of years, Health care has been very much on the minds and hearts of the American people. For example, the Harris pole shows education being the top priority, followed closely by health care, taxes and Medicare. But when you realize that Medicare is part of health care, you see that providing health care is the second most frequent topic of concern. And if you ask the public if you would favor a plan that would reduce taxes by a 110 billion versus using that money to help forty million people or more who are uninsured, they say in a 4 to 1 fashion they would prefer to have people who are uninsured get insurance.

Al Gore put together a plan that he believes will improve the health care for the American people. First he wants to ensure that by 2005 every child in every community in America has affordable health coverage. Second, he wants to expand health coverage for working parents, because he knows that parents who do not have insurance do not bring their children to physicians either. Therefore, he wants to insure as many of those people as possible. He wants to invest 30 billion dollars a year from this budget surplus in order to keep Medicare strong. He wants to allow Americans age 55 to 65, the most rapidly growing uninsured population in this country, the ability to buy into the program. He wants to add prescription drug benefits to Medicare and offer catastrophic drug coverage. People should not have to choose whether they are going to eat, pay rent or take their medications. He believes very strongly that pharmaceuticals are intricate parts of the Medicare system. If the Medicare system were being designed today, no one in their right mind would leave out pharmaceuticals, the drugs that are so important to everyone's health care.

He wants to pass a strong and a forceful bill of rights for patients that includes as many people as possible, much greater than the numbers covered by the bill the Republican Congress was interested in passing. Finally, he wants to make health insurance more affordable both personally and for small business through tax credits.

The ultimate goal, as I said, is to have all kids covered by 2005. To have the patient's bill of rights passed. To make quality prevention, research, and personal responsibility the center portion of health care. 400,000 people a year die premature deaths due to tobacco. If there were a thousand 747's falling out of the sky every year, do you think you would be crawling into a 747? That's how many people die every year by smoking cigarettes. Personal responsibility is important. And research is also important. That is why the Vice President wants to double the NIH budget. He wants to preserve and protect Medicare as well as Medicaid--but not by having a new bureaucracy. That is why he proposed to use the CHIP program Children's Health Insurance Program, in order to achieve his goal. We must live in a real world. We know that the White House and Congress have to work together. That is why he wants to cover the kids through a program that is already established. He wants to increase the CHIP program.. He wants to allow people with incomes up to 250% of the Federal poverty level, which currently would be people with incomes up to $41,000, to be eligible through a tax credit to buy into the CHIP program or Medicaid. This program would expand coverage for 12 million uninsured kids. It would be the largest increase in the health benefits in a generation.

As I said earlier, most kids cannot go to a pediatrician or a family doctor unless their parents bring them. And their parents won't bring them unless they are also insured. Therefore, the Vice President believes he should bring in as many parents as possible--(he estimates 7 million working poor or other poor parents) to be part of the CHIP program.

Here's what I mean when I say we will use the existing bureaucracy. In 1997 a bi-partisan bill was passed by both Republicans and Democrats in Congress to improve health insurance for children. Unfortunately it is not very successful in many states. We recognize that, and plan to use as many incentives as possible to make it work. Those states that enroll more people will get more money, and those states will get less that enroll less. But we also believe in the Willy Sutton approach to this. As you know, Willy Sutton was a famous bank robber. When asked why he robbed banks, he said, "that's where the money's at". Well, where the kids are at, is at schools. So we want to enroll them and break down some of the ridiculous barriers that prevent sharing information. Federal programs that fund food for children in schools do not share data with health programs for kids. Kids in the Federal food programs are exactly the same kids that need health care. We want to meld those two groups together, using existing computer data and enroll children in schools.

The perfect should not be the enemy of the good. We recognize that any proposed program isn't perfect. The Vice President's ultimate goal is to have universal health coverage. He believes that it can't be done instantly. That is why he wants to do it incrementally. But that should not be an impediment to what he ultimately wants to do. If the perfect is what is desired, the good will help America reach that goal.

Small businesses will be encouraged to participate, with a tax credit of 25% to help pay for health insurance. A large number of people not insured are employed in small businesses that say they can't afford health insurance.

The Medicare prescription drug benefit is essential for the elderly population. I deal with these individuals every day as a practicing urologist. You know by talking to people that they must have the prescription drug benefit. The Vice President has proposed that there will be a prescription drug benefit with no deductible or co-pay for people whose income is less than 135% of the Federal poverty level. Remember the poverty level is $16,000, so for Medicare recipients with income less than about $20,000, no premium and co-pay will be charged. There is also a diminishment of the premium or co-pay for those people who are between 135% and 150% of Federal poverty level. For those with income above 150% of poverty--i.e., above $24,000- there will be a $5,000 cap. This means that after $5,000 of prescriptions those Medicare recipients will receive a $2,500 payment back, with all further prescription costs covered by the Federal government. All these things have nuances, but the point is that the Vice President believes that we have to have better--in fact, significantly better--coverage for those people who are not covered presently for pharmaceuticals.

In addition the Vice President has proposed a "Medicoverage" plan, which caps out of pocket expenses for prescription drugs at $4,000. Thus, if a patient has $8,000 of bills for prescription medications, the patient pays $2,500 for the first $5,000 and $1,500 for the next $1,500 of charges. However, the patient does not pay any more even if the expenses are greater than $8,000 (or $4,000 out of pocket).

The three pillars of Al Gore's health plan for seniors is Medicaid for long-term (nursing home) care, Medicare (securing it for the future), and Medicare prescription drug benefits.

Younger people are worried about Medicare in the future, believing Medicare won't be around when they will need it. The Vice President strongly believes that Medicare must be preserved and enhanced now, and be solvent for future Medicare beneficiaries. Because people who are 55-65 are the fastest growing population of uninsured, he believes they should be able to buy into the program. The same thing is true of people with disabilities who now are eligible for Medicare only if they remain unemployed. He believes America should eliminate this pervasive disincentive. This encourages people who are disabled to get back into the workforce.

As I said earlier, Al Gore has proposed doubling NIH monies for cancer research. He believes it is essential that we pursue our passion for the unknown, and putting light upon the darkness of the unknown and commit our resources for discovery. However, that obviously takes money. That is one of the many reasons he believes that the Bush concept of giving a tax cut of 1.7 trillion dollars is risky at best and would eliminate the possibility for health care improvement, for Medicare, for Social Security, for research, etc. The Vice President's proposal is 312 billion over ten years which is about 31 billion dollars a year of the surplus and another 35 billion over ten years for Medi coverage (the pharmaceutical coverage). We believe this is realistic, we believe it is doable, and we believe it is essential.

George Bush has not offered a healthcare plan. The Governor, and I'm anxiously waiting to hear about his plan soon, has not addressed this issue as vigorously as we believe it should be. We look forward, in fact relish the debate about this. Al Gore wants you to vote as if your patients' lives or your loved ones' lives or those in your community depend upon it--because actually that is exactly what is going on. This is a central focus of our campaign because we believe it is a central focus of what is necessary for this country. There are 44 million people who are uninsured and millions more underinsured. There are millions more that will be losing insurance. Millions more will be eligible for Medicare. And they will desperately need coverage. There are people now on Medicare who require a pharmaceutical benefit so they don't have to make choices about whether to have food, rent, or their supply of medication. We urge you to consider that the program of the future is the program that Al Gore has proposed. We look forward to a spirited debate. Al Gore's vision for a better America, healthier America will be superior to that of any candidate who comes forth.

Thank you very much.

Bush's Health Plan

James Haveman

It is a pleasure to be here today and speak as a health advisor for George W. Bush, Governor Bush of Texas. Governor Bush sends his best as well. We're awfully proud of what we're doing in health care now in Texas but also here in Michigan where I work. My boss where I work, Governor Engler, is a fine supporter of Governor Bush. Hopefully we will paint for you today a picture of what health care is going to look like under the Bush administration once he arrives in Washington. I think it is great when we can get together and debate our health policy. There was a time when that wasn't done. Health policies and School of Public Health just weren't at the forefront of a lot of discussions that especially affect citizens. As people approach health care more holistically and more realistically we see the important part in the economy that health care plays. We're beginning to see in the polls and we've seen this for some time, that health care has emerged as a primary campaign issue. Much like education and crime and all of the other issues, health care is right up there. It's good that we can have these discussions and debates. There are a lot of months to go before November, so you will hear a lot more about health care in the future as well.

I'm going to try to share with you very specific parts of the campaign that we are working with in health care. Governor Bush believes that there should be universal health care access. We are not talking about universal health care; we're talking about universal access to health care and that quality, affordable health care should be available to all citizens. Individuals with limited income should be subsidized by the government in order to insure that they receive necessary health care. Health care systems should be patient driven, not government run. We believe very strongly that the market place should determine the rates that are paid, not complex formulas established by Washington, and we that believe medical decisions about what is best for patients should be left up to the physician.

The health care system should provide tax incentives to employers, employees, and others. Long term care should have some type of tax deduction. Individuals should be allowed in this country to really become part of large health care purchasing groups, whether it is the Farm Bureau or the National Federation of Independent Businesses. There is much that stands in the way of that happening today.

The health system should encourage private and government research. Governor Bush would double the size of the budget of the National Institute of Health particularly to support research, prevention and education, and also to support our fine academic institutions like the University of Michigan.

What I am going to be talking a lot about today is the reform of Medicare. We know that Medicare is solvent until about 2023 to 2027. We feel very strongly that just to dump additional money into Medicare right now would be a big mistake. Now is the time to step back and really reform Medicare and really make it into an effective, purposeful, meaningful, relevant health care delivery system with fine outcomes free from 130,000 pages of rules and regulations. Even the Medicaid program today functions with about 80,000 pages of rules. Much of that red tape, much of that Federal bureaucracy could be eliminated. We could really streamline health care so that the innovation that states have attempted could really take place. That's what we believe.

If elected President, Governor Bush would ensure that all individuals, including the uninsured, would have more choices of affordable insurance plans that cover their basic health care needs. He would reform and expand Medical Savings Accounts to ensure that anyone who wants to purchase one has that option. We've had a hard time expanding those under the Clinton Administration. Right now that is prohibited for many types of people.

We'd remove Federal bureaucratic barriers that don't allow states to be innovative and creative. There is a lot of innovation and creativity in states. We believe that one set universal health care plan run out of Washington that's the same for everybody just isn't going to work. This is true whether it is established by HCFA or anyone else. It's going to work against a lot of innovation that states have proposed. We've been able to prove that. Texas, under Governor Bush's leadership has been one of the ten leaders in the country on welfare reform. We could do the same with health reform if given the opportunity. Give the man a chance. We'd allow business operatives to come together to pool resources in purchasing health care. We'd also greatly expand the number of community health centers that exist around the country, in particular letting states provide services to the indigent and to the poor and those that need health care.

Medicare is probably one of the most important issues facing America today. Especially with all the baby boomers coming on, long-term care is an issue that people didn't want to talk about. We feel that long-term care premiums should be deductible. There should be tax credit for purchasing long term care. You realize that, for the people in this room, that only about five per cent of you will ever use your health insurance or fire or home insurance. There's about a 50% chance that you'll use long-term care insurance. Probably most of the adults or the people in this room haven't thought about that. We've got to address it because two-thirds of the Medicaid budgets today in states go to one third of the people, the elderly and the disabled. If you see the demographics of the people coming on, long-term care is a major issue that needs to reform and addressed, Governor Bush would do that.

As I said earlier, we'd eliminate a lot of the pages of bureaucracy that exist within the Medicare program. Recently, as you know, the Medicare trustees said that the program will be solvent up to 2023, so I don't think we need the billions of dollars that the previous speaker talked about to pour into the Medicare program and we have got to do more that just take in surplus dollars and put them into the program. We've got to really step back and take a look. We have a Medicare program that is many decades old built on an old system of health care. Lets move it to where it is going to go. We need fundamental changes so that seniors can have some choices and options with the health care delivery systems that are available through the various health plans that might be in their particular town. If they are not available they certainly will continue to be part of a fee for service plan unless a managed, more organized approach to health care is available.

Governor Bush also believes that people up to 135% of poverty should have those premiums paid for and he also would insist that there be a prescription benefit, which would be part of that plan as well. If you take a look at what is going on in this country now with seniors and prescriptions, I think both Republicans and the Democrats accept the fact there has to be some coverage and Governor Bush supports that as well.

There recently have been some interesting discussions in Washington regarding the bipartisan approach to Medicare Reform. Unfortunately, many of the recommendations that were made were not voted in place. Since then other groups began to talk about what they can do and they came up with recommendations. They talked about compensation in health care, about quality indicators, and about best practice. They talked about quality, evidence-based medicine, and about leaving the graduate medical education programs in tact. The previous plans would carve it out and I don't think we want graduate medical education to stand by itself. I think we want it part of a holistic approach to health care.

We would extend and try to take care of some of the heavy emphasis of the balanced budget act that took billions of dollars out of the hospital network. In fact, the Clinton/Gore budget recommendation of next year takes another 10 billion dollars out of the hospitals. So, we would address the solvency of Medicare by reforming it, by changing it, and then begin taking a look at what type of resources might be needed. Changes may be needed not only in revenue but also in premiums. We will consider different support for employer groups and tax deductions, payroll deductions as well.

Long term care: You will see President and Governor Bush address that. Not only deductibility of long term cares premiums but also giving tax credits to additional families, particularly those who are caring for disabled individuals.

Patient bill of rights and managed care: Governor Bush has done much in Texas. He has led the country in many ways. We don't think there needs to be a complete overhaul of what currently is being discussed in Washington concerning a patient bill of rights. In Texas, if you have concerns you can appeal if you feel you have not been accurately heard. You can sue the provider, you can't sue the employer but you can sue the provider. Out of the thousands of cases that have come to appeal less than five have gone past that point. One of the things we have learned here in Michigan is that if you do set up a proper appeals process, people will use it and people will respect the findings of that appeals process as well.

We can talk a little bit about what Governor Bush has done with the tobacco settlement money. Much of that money in Texas has gone to educational institutions and health research. Health insurance programs for children are expanded. Up to 450,000 children belong to the CHIPS program, which you can be sure we will talk more about today with the Federal program for children. We have expanded that in Texas. The money has gone to purchase a new site for drugs to treat people with mental illness, for capital improvements, and for expansion of community based clinics that I think provide support for the type of services that he would like to see nation wide.

He would like to implement what we are finding out in health care about how mistakes have been made in hospitals, about the importance of screening, the importance of prevention, the importance of early identification of disease, and getting people involved in best practice responses. Governor Bush will continue that not only what he has done in Texas but also he will continue it at the Federal level as well.

In Texas there is the tax-care partnership program which brings the children's health insurance program into the Medicaid program. It also brings in the Texas Health Care Corporation, which was established to find ways to provide services to the uninsured who might not otherwise be eligible for services. Texas' example might be useful to other states. In Texas, it is constitutionally mandated that hospitals provide services to the indigent, which is somewhat unique. Many of the states don't have this.

Under the whole issue of how to reform HCFA, the Health Care Finance Administration, you'll see Governor Bush take a long look. HCFA has never really run anything. HCFA is good at writing rules, good at writing regulations, but it doesn't run the Medicaid program. The states run the Medicaid program. You'll see Governor Bush step back and take a look at Medicaid, particularly at how he can free up the states to work with their health care providers to really provide the type of health care services that citizens of the state need. He will be particularly concerned about those who aren't covered now. They have a right to health care, a right not only as citizens of this country, but also as citizens of their great states. What you will see under the Bush Administration is universal access to health care, the reform of the Medicare program. You'll see the commitment to work with physicians as the primary decision makers of health care. You'll see the expansion of the enhancement of health care by getting rid of a lot of the Federal red tape that exists not only in the Medicare program but also the Medicaid program. You'll see us start to focus on outcomes and build on equality institutions and health care systems that we have in the states. Much of it is going to be state driven with support from the Federal government, not controlled by the Federal government for a universal health care delivery system.

Bradley's Health Plan

Margy Heldring

I want to thank you all very much for including the Bill Bradley campaign in this Forum today. We may not have had our best fourth quarter and the actual presidential campaign may be over, but the campaign to carry on our work especially in health care is hardly over. I'm also grateful to the warm outreach that has come from the Vice President's campaign, by Dr. Boxer, to look at the points that we may have in common and how we can exchange information and develop some consensus around this really important issue so that we do carry it forth in a very collaborative way. You are hearing distinct differences between how the Democratic Party and how the Republican party approaches health care. This is good. This is what a campaign should be about. This is what feeds democracy. There should be clear distinctions and it will important to make them as sharp as possible so people have a good choice.

I want to talk about some of the specifics of Bill Bradley's health care plan to which we are very committed. We think that they are good proposals and deserve serious consideration. But I want to frame this a little bit for you. During the course of the primary, the Senator was now and again described as perhaps engaged in academic exercise. Let me take advantage of that accusation, especially since we are in a University setting, and talk about some of the theory, some of the contexts with which we have approached health care. I would ask you to think of our approach as talking about more than about America's health care delivery system. We are also talking about how we can create a more effective and vibrant system for America's health. Here's what I mean by that: we have been interested not only in making sure that all Americans have access to affordable health care insurance but that all children in this country actually have health care insurance and that it provides quality health care. But we've also been very interested in how we can create health for Americans for American families and American communities. These are not disjointed separate efforts. These need to be very much thought as two parts of a whole.

If we step back and take a look at what creates health, or what obstructs health, we learn some very important things. We learn that it has a lot to do with behavior. It has a lot to do with lifestyle. Of course there are important genetic pre-disposing variables and biological factors and things that cannot be controlled. But those things that can be controlled--the use of tobacco, the use of alcohol or the uses of other substances; whether we wear seat belts or bicycle safety helmets; our nutrition, what our diet is like, whether we exercise; whether we live in too much social isolation or whether we feel part of something larger. What our race, our ethnicity, our gender, our age, our income is, also are very important factors affecting health. If we overlook them or if we minimize their role in creating health, and their impact on health care, we're only looking at a small part of the picture. We're missing the opportunity that is at hand. So our effort has been to look at health and to look at health care. With that in mind, we've talked a lot about the issue of access, but we have also talked a lot about revitalizing America's public health care system and investing in community health.

Let me begin with that part first. Very early on the Senator put a price tag on his overall health care proposal. That price is between 55 and 65 billion dollars a year. That is a large amount of money. There is no doubt about it. A part of that money, two billion dollars a year, is intended to be used for investment in public community health. We want to be able to research communities, and stake out which factors contribute to health and discover what is the mechanism by which that occurs. We want to put a lot of new money into these things. We want to be able to distribute incentive grants, matching grants to communities, so that communities can set their own good health agendas. Perhaps a community wants to cut back on adolescent tobacco use or perhaps it wants to increase pre-natal care or perhaps reduce social isolation among the elderly. Whatever the community wanted to do would be fine. The funds would come through CDC for that. We also doubled the budget for community health centers. It is currently 900 million dollars and we absolutely wanted to double that. Not only to increase the number of community health centers around the country but to enable them to broaden and extend their missions. To enable them to become partners with schools, with places of business, with faith based communities. With organizations within communities where people take screening, prevention, health promotion, and health education activities out to people. It's really astounding to look around at even some of the most affluent communities and neighborhoods in this country and find a very low grade of access to preventive services. I am talking about clinical screening services, simple things like blood pressure screens, monography screens, things that can really make a difference in people's health status and in the aggregate health of a community.

We also wanted to invest in NIH. But our plan was to create a whole new institute that we were going to call something like The Institute for the Study of Public Health Sciences, or community based public health sciences. It is our belief that over the next decade, and of course beyond, we are going to learn a lot about how some of the non-specific factors I've been talking about influence health. How do early childhood experiences for example, effect health status in adulthood? How do different neighborhood characteristics correlate with, or even help shape the health of individuals and communities? What really is the mechanism between race, ethnicity and health? Is it access or is it the experience of discrimination? It somehow has a real physiological impact on people. What is the role of faith, of prayer, in recovery or in health? These are important and exciting areas to explore. It was Senator Bradley's intent and still will be to encourage exploration of those questions.

Meanwhile, we felt very powerfully concerned, and we still do, about the fact that there are 44, 45 million uninsured people in this country. We are in a time of such national prosperity. This is a point in our history where we have more economic wealth for a longer period of time than we have ever had. The inconsistency, the contradiction between that and having the number of uninsured Americans that we do should be for all of us unacceptable, intolerable. So, with all due respect to the Vice President and Dr. Boxer's excellent presentation of his plan, I would say that the Gore campaign learned the wrong lesson from the Clinton health care reform effort. We don't need to do this in an incremental way. We chose incrementalism because the initial effort overwhelmed people. It frightened people to make the 1993 Clinton Plan effort. Now, why were people not brought along sufficiently in this process to feel comfortable, to feel a forum, to feel they had a voice? Incrementalism is of course the result of that, not because it's the more practical way. We have the resources needed to take care of our uninsured people and to improve our health care system now. We don't really need to do this in smaller bites if we are honest with ourselves. So how do we want to do this, all at once or as quickly as possible?

I've appreciated the Gore campaign's and other people's recognition of the fact that it really was Bill Bradley whose leadership help put health care back on the agenda at the beginning of 1998. Everybody was very shy, very skittish about healthcare. Oh Margy, oh don't. This is nothing but a train pulling through a land mine, why would you possibly move into this area? After spending nearly two years traveling around the country trying to understand what is on the American people's minds, where are the needs, Bradley came back to Washington and said, it's health care. That's one, we're going there. And we all said, whoa! This is a big risk. He said that is why we're going there. That is how important it is, that is what leadership is. He said we're going to do something big and bold. We're going to challenge some of the assumptions. People will talk about health care in this country.

Our intent was to take what we call a life stages approach to health care. This means that we did not want people to be separated out in health care by race, or by ethnicity, or by income, or by social status, by any of those artifacts that we have created as a society.

If people are going to be organized or grouped in any way it would be by where they are in life. What are they able to do for themselves at different stages of life? When at different times do they need help? Whether it is from the Federal Government, State Government, or from a neighbor? He began with children. We said, there is no resource more important to the future of our country, economically, socially, and spiritually, than the investment in our children. There is no reason we have 11 million uninsured children in this country. No good reason. Therefore, we will require that all children have health care insurance. We will say, Parent, you may meet this requirement in a number of ways. If you have currently something that works for you-an employer provided plan, your own plan-stay with it. Keep it, nothing needs to change. We're not intending to upset what works, genuinely works.

If you don't have that or you loose that, or if you find there is a preferable alternative, you may use it. That alternative would be to enroll you child through one of the private sector health plans that currently covers all government employees. All Federal Government employees. This is called the Federal Employee's Health Benefits Plan, the FEHBP. There are nine million Federal employees in every state of the country that are involved in this. It's a collection of hundreds of private sector plans, HMO's, PPO's, old indemnity kinds of plans. It's a forty-year-old system. It's not perfect. There isn't a great plan available today in every state in the country, but there could be if we all got behind this. But it is an established, stable system that provides people choice. Every plan in the FEHBP must provide prescription drug benefits, thanks to the good work of the Vice President to the President. Starting January 2001, every plan, which participates, will have to offer mental health benefits on parody with physical health benefits. Those are some important aspects. We want to let America families use the same health plan that insures members of Congress, President and Vice President for that matter, and Federal employees all over the country.

In our discussion period I can discuss the subsidies that we developed to support families. For children it was up to 300% of poverty. And full subsidies for premiums of all Medicaid and Chip participants.

After childhood, adulthood. Again we wanted to say to adults, if you're in a situation where you are currently covered and that works for you, great. Keep it. We're going to add something. We're going allow you to deduct from your income costs any out of pocket premium expenses to help it be more affordable for you. But nothing needs to change. For those people that don't have insurance you may buy into the FEHBP. Enroll in one of those plans. We would again pay for the premiums for all Medicaid adults and all adults under 200% poverty on a sliding scale basis.

For the Medicare Program, coverage was obviously not the issue. The Medicare Program is about coverage. But just as everyone here has been saying, the Medicare Program does need some restructuring and updates. Senator Bradley served on the Senate Finance Committee, which has congressional jurisdiction over the Medicare Program and Medicaid Program. For 18 years he was on that committee and fought to preserve Medicare and to expand Medicaid. His commitment is absolutely firm to that. He wanted to do two things. Once again, add a prescription drug benefit. If we took a slightly different approach, the Vice President's and our approach are coming very nicely together. We want to begin with people who have catastrophic drug needs. So our plan had no cap on it, but it did have a $500 deductible and a monthly premium and a co-pay requirement. But nobody would reach a point where all of sudden they ran out of their insurance. It was true insurance. Again, with eyes on the future, we looked to an increasing role for pharmaceuticals, thank goodness, in health and the restoration of health following an illness or injury. We wanted to make sure that people would have access to those pharmaceuticals.

Second we looked again at the demographics of the country and realized, as we all know, that we are an aging society. But the fastest growing cohort is over 80 or over 85. There are 8 million over 80 today and there will be 12 million over 80 in a few short years. What's going to happen to all these elderly people as their functional status diminishes, with an increasing degree of frailty? We do not want to send all of these people to nursing homes. We do not want people to spend the last years of their life in nursing homes when there is an alternative available. An alternative is to take a model that has been called Social HMO's. Take what has been basically a demonstration project and make that a Medicare benefit. These are health plans that integrate medical and social services in a way that allows the elderly stay at home in their communities, to age with a degree of independence and a sense of dignity that might be otherwise be missing. So there is attention to the need for transportation to the Doctor's office. There is an attention to what food is in the cupboard. There is attention to what social interaction this person is experiencing. There is attention to whether the prescription drugs being taken are appropriate. Are they coming from different physicians or different nurse practitioners where there might be a different interaction effect that somebody is missing? These programs could really keep people at home and out of nursing homes and at a far, far less economic cost to us as a nation. We feel very strongly that these are achievable goals and that strong bipartisan effort can be built around them.

We also have a great commitment to quality of care and to patient protection. I think it's always a helpful reminder, at least I always enjoy giving people the helpful reminder, that there really is only one Federal law in the nation today that provides real patient protection. That's the bill that Bill Bradley sponsored in 1996. The Newborn and Mother Health Protection Act allows mothers and new borns to stay in the hospital for a certain amount of time after childbirth. Our interest in that was not so much in how many hours specifically somebody stayed in the hospital. The important text in that bill, the important language in that bill, concerns who shall make those decisions. The answer in that bill is the health care provider, in consultation with the mother. It was an effort to restore decision-making and it was an effort to protect the health of newborn and mothers, to lay the groundwork for the larger effort that is going on right now to bring some balance back to our health care system. Our whole intent, our whole approach is to create a respectful balance.

We wanted to respect, as Bill Bradley always has and always will, what the strengths in the private sector are, what the strengths of the public sector are, and what the strengths of the community are. Clearly the public sector provides protections, assures equities, levels the playing field and looks after those who need looking after. The private sector has the capacity to innovate, to adapt, change, to experiment, to find the most efficient way to use new technologies very quickly including new information technologies. The community has the capacity and the strength to create health in the first place. That has the impact of allowing people to have greater quality in their lives and reducing the economic burden on our health care system. So you can see we tried to take a very rich approach to all that. I'll be glad to talk about it and discuss it more. Thank you.

Questions From The Audience

Medical Savings Accounts

Man: Many of us are very ignorant about medical savings accounts and they have been pretty controversial. I know quite well that some people recommend that individuals should stand accountable for their use of health resources and that they should get something back if they use their health care resources wisely. I know there has been a lot of criticism that medical savings accounts might just attract people who spend a relatively low amount of money for health care, leaving the high expenditure people in the traditional insurance field and thus making health insurance unaffordable. I wonder if you, Mr. Haveman, or some of the other representatives might have some prudent words about medical savings account?

James Haveman: I'll speak from our experiences here in Michigan. I have often thought, and have said to the policy people, let's not implement medical savings accounts for the whole state at once. Lets try to take a particular Medicaid population group and let them manage some of those dollars. Also let them have some incentives to stay well. It's crucial for them to have something to gain from staying healthy while having a medical savings account over which they could have some flexibility in decision-making. Just to get through the rule process and even to get away or even to allow to let us to try this, however, has been hard. Even though Congress has been intrigued by it on both sides of the isle, it has been extremely difficult to implement medical savings accounts and make that happen. I would like to try it, evaluate it and measure it before you put it nation wide or statewide. I think Governor Bush would feel the same way.

Margy Heldring: I'll say, while passing this to Dr. Boxer, that our concern about medical savings accounts has been just what the question was referring to. They could problematize the risk pool and actually set up situations where people with high needs would end up with higher premium costs. That is completely inconsistent with our whole approach in health care, which is to share responsibility. Part of that means that we share risks and broaden the risks as much as possible.

Richard Boxer: I completely agree with Margaret that the basic principal of insurance is that all should pay premiums to lessen the financial risk for the few. If you cherry-pick out the few that are either wealthy or healthy or both, and leave those that are neither into a smaller pool then their expenses get to be prohibitively large. We already have enough people who are uninsured. We don't have to create a program that will uninsure more. Furthermore, there are some early programs for MSA's through one particular insurance company called Golden Rule. It advertises everyday in the Wall Street Journal, in the corner of the "Policy and Politics" page. They have demonstrated their commitment to this. Some people are participating, but not nearly the numbers that they had anticipated would join. It will have a negative impact upon preventive health care. If you have people who wonder whether they should take that money and go to some Caribbean island in the winter, because they can get the money out if they don't spend it for their health care, then this is a dis-incentive to go for that mammogram or the prostate test or the colonoscopy or whatever else would eventually lead to better health. So it has a negative impact on preventive health care as well as diminishing the pool of people in general health insurance.

Universal Access vs. Universal Coverage

Woman: When you were speaking about proximity, universal health coverage, are you referring to something along the lines of what Canada has now? I've been a nurse for twenty years and I work for M-Care currently. Having the Federal government control my health care gets me personally nervous. I would like to know how you are referring to it. I'm much more comfortable with universal health care access, as discussed. I'd also like you to speak more about social HMO's. That's comforting and interests me very much. Is that different than a system where people can go to get care? Is that different from assisted living? There would be cost savings from people staying in their homes, but what is the premium that is paid per month? How would that be paid for? And who is being charged for something like that?

Richard Boxer: First, before I answer your question, let me say that your profession of nursing is sorely needed. Gore's plan encourages more people to enter the nursing field and other paramedical fields. He recognizes how important nursing is to the health of the nation. But on to your question about universal access versus universal coverage: We have 44 million people uninsured in this country. People are not dying in the streets, thankfully. They have access to an emergency room. In fact Gov. Bush talked about that in an interview about how that people have access in Texas, they go to an emergency room, then readily stated that it is not the smartest way of having health care. We agree with that. The access is there, but people don't use the access for several reasons. First of all, they aren't encouraged by virtue of not having health insurance. If they have a card that tells them they can actually go to a health provider--not necessarily through the emergency room, which gives inconsistent health care and is the most expensive form of health care, it is a measure of confidence in the system and themselves. Therefore we believe that universal coverage is important and our eventual goal. The Vice President and myself, personally, completely agree with what Margy said earlier, which is that the country has a forum now because Senator Bradley put this forth. And through Margy using her good offices to pursue this and develop policy. We congratulate Senator Bradley in bringing this to the forefront.

Getting back to the difference between what we are proposing and what Canada has, as an example, we are absolutely for universal coverage but through a private health care system. We are not interested in having a system whereby there is a single payer, the Federal government for example. We believe that would be counter-productive for economic growth, as well for pursuing the ultimate goal of getting everyone covered. But there is a major difference between access and coverage.

Margy Heldring: I'll briefly address the social HMO's, at your request. The social HMO's provide a great opportunity for care coordination. I do think nurses are in a tremendous position to provide that care coordination. Your question was how would this be paid for?

Woman: How would the system handle something like that? Would it be a premium that we would pay for, how would the system pay for it?

Margy Heldring: Our assumption was that it would be a Medicare benefit. It would be part of your overall Medicare premium cost. You would have the option to participate, to enroll in a social HMO. The costs: there would actually be some costs savings. By keeping people out of nursing homes and letting them enroll in a social HMO, we would save money.

And here ends part one.

Part Two

Marilynn Rosenthal: This has been very informative. I know it is going to set the standard for the second part of the program where we have a panel of university and community experts, who will pose questions to the campaign health policy advisors. We hope to have a very lively interchange between these two groups and then to open it up again to the floor for any questions you might have. I'm very pleased now to turn the microphone over to Gil Omenn, the Executive Vice President for Medical Affairs at the University of Michigan, who will be the moderator for this part of the program.

Gill Omenn: Thank you Marilynn. First of all I think we should have a round of applause for Professor Rosenthal for putting the program together. She has an uncanny nose for topics that will be timely many months ahead of time. A good record, so it's great that we are able to attract outstanding people that are connected with these campaigns. There's a lot at stake. There are some very serious issues to discuss and there is still time to do so and really develop these complicated issues that most of the public isn't ready to dig in on. That health care hasn't shown it's enhancing the health of the communities is certainly where the issue is, that is right up there with China Trade, Elian Gonzalez, and Microsoft! Okay, I think you all have a program with a list of the panel. I don't want to take too much time introducing, but I will say a word or two about each one of them and then we will launch into the discussion.

First of all, alphabetically, Denise Clement, Director of International Clinical Operations for the Ford Motor Company. I think many of you know that here at the University of Michigan Health System we have a spectacular new program developed jointly with Ford Motor Company and under the leadership Jack Billi of our health system and involving M-Care and other units. She was previously at Abbott Laboratories and IBM, and the Public Health Service at CDC. We are delighted to have you in the Region and on the panel.

Keith Crocker is the Hildrebrand Professor of Risk Management Insurance in our acclaimed School of Business here at University of Michigan. He was previously at Penn State and the University of Virginia and was on the staff for the Federal Trade Commission. That hasn't been mentioned today, but the Federal Trade Commission actually has a serious role regarding various issues about consumerism and responsibility in advertising and promotion in the health care business.

Zelda Geyer-Sylvia we were very proud to recruit less than two years ago from Kaiser Northeast. She is the Executive in charge of M-Care and has brought terrific management skills as well as high values for an integrated health system. We're glad that you are here.

Professor Max Heirich, is an Emeritus Professor of Sociology here at the University of Michigan, a distinguished figure in the Institute of Labor Industrial Relations. The whole business of employment-based health insurance is an experiment that began in World War II and has been with us ever since. There are a lot of anomalies in our economy and lot of anomalies in the coverage for Americans as a result.

Professor Richard Lichtenstein, here in the School of Public Health, is a leading figure in the Department of Health Management and Policy and an important leader for helping our students here in the School of Public Health get involved in real world experiments, demonstrations in the community, in particularly Detroit.

Finally, our colleague, Howard Weinblatt, is one of the distinguished pediatricians in this area with a number of integrated health associates. He is a partner with us in the care of children, in community outreach to children, and helps maintain good relations with St. Joe's and the Mercy Health System as well as our own University of Michigan Health System.

Mr. Crocker, I'll ask you if you would like to ask the first question?

Changes in Medicare

Keith Crocker: I will start with the representative of the Bush campaign. It appears that you are out numbered here today. I gather that Senator McCain has left the Bush campaign in the lurch once again. But, it is nice to see that some things never change. When I listen to the Gore campaign representative, what I heard is this, we're going to solve the problems by spending more money. When I listen to the Bush campaign representative, I hear: we're going to solve the problem by cutting red tape. So, some things never change and that is always good to hear. But in particular, Mr. Havemen, I'd like to pursue your plan to modify Medicare to generate more choice for the enrollees in the Medicare Plan. I suspect that if we put a panel of experts together they wouldn't design the plan we currently have, but it is indeed the plan we do have. How do you plan to explain to the elderly, whose health care is being treated under the Medicare Program, that they will be better off from the plans the Bush campaign has? Could we be a little more specific than merely cutting red tape?

James Haveman: I think Margy talked about the Federal Employee Health Benefit Program, which covers a lot of the Federal employees. Governor Bush would build upon many of those models that exist in this country at this time. My mother happens to be 91 and I happen to see the complexity of her Medicare forms that she has to fill out. I sometimes don't understand them. I almost need an instruction book to figure them out. There is an easier way to do this. We would also allow elderly people to make some choice of plans they would be part of, particularly the rates that are paid. Right now a lot of the rates for the Medicare Choice Plan are set through some complex formulas. There isn't a lot of choice out there. We would allow families to have choice. We also would continue to let the elderly know that Medicare is an entitlement. It's not that the entitlement is going to be taken away; for persons with incomes up to 135% above poverty that premium would be paid and there would be decreased amounts as income goes higher from there. I think sometimes we discount the interest and knowledge and desire that some people have to manage their own health care. People learn about health care not only by reading now days, but also by talking to other people. It's something for which they want to have more personal responsibility. We have not done a very good job educating people that health care is your personal responsibility. It is too easy to use that card, I think we ought to get back to encouraging greater personal choice and responsibility.

I think we can assure the elderly that a) there will continue to be entitlement to health care, b) that premiums will be paid for all persons with incomes up to 135% of poverty, c) that you will be able to participate in health care plans which are known to offer quality services to Federal employees if those plans are available in your particular community. Additional plans will be established that will provide the benefit level currently available to Federal employees. If such plans do not exist in a particular area, services will be on a traditional fee for service basis. I think there is value added when you go back to local communities, encourage more local control, putting more emphasis on prevention and education and personal responsibility.

Children's Access to Health Care

Keith Crocker: I want to follow up on the issue of choices and innovation in Medicare and Medicaid. Mr. Havemen, you spoke before about plans to give all states authority to innovate in the development of new programs. It's the hallmark of Republican philosophy that innovation at a state level is beneficial, and that a Federal program is too bureaucratic and won't fit all the needs of people in the state. I want you to explain, then, why Medicare, which is a Federal program, is so loved by all of the beneficiaries when the Federal program is the same everywhere. Yet Medicaid is universally despised. It has allowed states to innovate and basically they have all come up with unacceptable results.

James Haveman: Well first of all in Michigan we have 750,000 people on the Medicaid program; 500,000 of the 750,000 are women and children. We cover about 1,250,000 a year in Texas, somewhat greater numbers, so people are part of the Medicaid program. I think the Medicaid program could be more innovative at the state level with some premiums paid by the Federal government. Medicare is a Federalized program and has always been. Elderly people feel comfortable with it and have adjusted to it. I don't think there is any desire of the Bush campaign to change that. But there is a desire for the Medicaid program to have Federally paid premiums but to allow it to have the innovation of the states, particularly as it relates to the number of uninsured and particularly the number of uninsured kids. I don't think right now we would support, for instance, what we were talking about with the Bradley camp--kind of a Medicare type program for children.

Richard Lichtenstein: We want all children to have health insurance. The University of Michigan has helped sponsor a program in Detroit, which tries to recruit children into CHIPS. Very few low-income families have been willing to join, because of its links to Medicaid, which they despise. Do you really think CHIPS will be able to enroll the uninsured children, given public disillusionment with Medicaid?

James Haveman: I think we haven't given the CHIPS Program, which is less than two or three years old, time to really take root in particular states. I think there is a lot we can do with HCFA to be even more creative with a child health insurance program. That is something we currently are prohibited from doing. I think HCFA has recently changed some of the rules in ways that allow us to do more aggressive marketing and be more creative in finding these kids. I don't think there are 150,000 more kids to find in Michigan, for instance, but we certainly want to find as many as we can. We know for instance, right now about 99% of the children in Michigan are covered with health insurance under the age of 18. We would like to be at 100%. I think in Texas we have seen about 450,000 children added to the insured. In Texas 50% of the uninsured are Hispanic youngsters. We believe most of them are eligible either for the CHIPS type program or the Medicaid program. We talked previously today about the importance of outreach for finding these kids and then getting them signed up. I think it is a continuing challenge for all of us.

Employers' Role in Health Care Reform

Denise Clement: I would like to address this question to each of our guests today. My question concerns the role of the employer in health care reform, beyond just paying for benefits. I think employees would like to have the employer pay for health care benefits and so would the government, but what other roles can the employers claim in health care reform?

Richard Boxer: The Vice President believes the employer/employee benefit package that has been so difficult over the decades to work out, should not be interfered with by the government. Beyond that, he believes that people who are not part of an insurance plan because they are part of a small business that does not have insurance should get help from the government in paying for premiums. This could be done either on a personal basis or their small business could get tax credits up to 25% in order to pay for the insurance. The Vice President doesn't want to interfere with employee-based health insurance at all. I think it would be good to have more plans available for the employee to choose from. Some employers now effectively choose the Dr. for the patient, or the hospital for the patient, by limiting the number of choices that the employee has. I think the Vice President would be interested in seeing more choices available. Ford Corporation is of course, very large, and there may be numerous choices available. Part of the Federal Employee Health Benefits insurance plan that is attractive is that there are numerous choices available for the individual. It, of course, is covered by the Federal government, which is the employer. But there are smaller companies that limit choices considerably. I think by expanding the choices available to the employer it would help expand choices for the employee.

Margy Heldring: I will put this into historical context and then talk a little bit about the future. As most people know, the whole concept of employer-based insurance grew up during World War II when there were price freezes and employers needed to have some mechanism to attract and retain employees, some competitive mechanism. That was basically the beginning of the employer-based health insurance system, and it has worked beautifully in many regards for many years. But there are a couple of problems with it that I think are only going to increase and multiply over the next several years. One is that the nature of work is changing in this country. People are not typically affiliated with one company for as long a period of time as they used to be. People make tremendous job changes. People work on a contract basis, on a part-time basis; the entry of women into the work force has been a powerful stimulus for that. What this means is that a principle of employer-based insurance, which is basically predicated on having a stable ongoing relationship between employer and employees, may be outdated. If we want to provide people with true portability of health care insurance--and we do and should--the individual should own it. That means a different relationship with the employer. That leads me to talk about an idea worth investigating, the concept of defined contribution versus defined benefit from the employer. (I.e., Here is a certain amount of money that I will contribute toward your purchasing health care insurance. Take it out to the market, or take it out into whatever choices are available.) It's clear that from a small business perspective that the provision of health insurance by the small employers has been a tremendous problem. I think it important to talk about this not as a unitary construct, "all employers", but to consider the differences between large employers and small employers. That is again one reason why we wanted to open up the FEHBP. We actually think it would be a tremendous asset to the economic growth of the country and to employers to provide to them an option for their employees other than their having to directly provide health insurance. To create an option for their employees that would take advantage of the lower insurance costs available from being part of a large pool of insured persons. Then small businesses would not have to use so much of their budget for health insurance or to lose their competitive edge. But they would know their employees have some health plans to which they could buy in, even as individuals, at the group rate. My third comment, briefly, and I know there is a lot going on here in Michigan in regard to this: I think the opportunities for employers to work on prevention, health promotion, employee health and well being, to work on managing diseases or chronic illness when they arise--to use disease management techniques--is powerful and very important.

Gil Omenn: It is noteworthy that Senator Bradley re-ignited interest in health issues and health insurance to cover all Americans, after these topics became taboo in the aftermath of the failed Clinton Administration initiative of 1993-1994. It is striking that the private sector adopted many of the features of the Clinton Health Plan, but of course did nothing to bring the 44 million Americans without health insurance under private coverage or encourage government to fill the gap. There are many costly consequences of lack of insurance and, as Dr. Heldring said, lack of priority for health promotion and disease prevention. Ironically, most people without insurance do get care--it is just later, less effective, and therefore more costly.

As the front-runners for the presidential nomination build their platforms and anticipate the really major problems facing the country, I hope that they and their advisers will utilize proposals from their colleagues across the board to sustain public interest in health care, health insurance, and public health. Each could strengthen his base by considering these needs and encouraging open discussion about the most effective and most affordable ways to achieve health care reforms.

James Haveman: Thank you Doctor Omenn, for that interpretation of basic political process. That was good. The Bush people believe as I do that employer based insurance is really the cornerstone and we don't want to do anything to not let that develop. It's interesting to look at evidence-based medicine. You know only about 30% of decisions today are really based on evidence-based practice. We have multiple best practices. That is why I encourage what I see Ford doing and Daimler Chrysler, GM and some of the other large firms here in Michigan and others around the country. We are coming into agreement on what is the best practice and then doing it, rather than having multiple best practices for individual physician's offices. I think that is what we want to encourage. We want to support that kind of local initiative by employer groups. We also recognize that many small employers are being forced out of offering insurance to their employees because of the rise in cost of premiums, 20 or 30% a year. That is why Governor Bush has said he supports people buying into Farm Bureau pools as farmers and others as well and also into the National Federation of Independent Businessmen. They can pool and become part of a broader purchasing base that might exist in a particular state or a particular area. Employers should also have the flexibility to build incentives to stay healthy. It goes back to what we believe, that people have to have more personal responsibility. Sometime you need to build an incentive to do that, whether it is medical savings accounts or other menus that people can choose from, or even a particular coverage might be waived to cut cost.

There is a lot you can do without spending a whole lot more on health care. First we have to fix the existing system and then move forward. That is why these debates and discussions are so interesting. In so many ways health care in this country has a lot of reforming to do. It's got to step back and assume some of the responsibility amongst itself. Then you can talk about what it means to payroll taxes, what it means for increased federal revenue or increased premiums. We want to build up the employer and employee relationships that currently exist.

Doctor's Rights to Organize

Howard Weinblatt: I would like to ask the representatives how you would see physicians organizing to participate and negotiate with the other partners in the health care delivery system, whether that be employers, HMO's, other insurance cooperatives or the Federal government?

Margy Heldring: That is really an excellent question. How would we see physicians organizing to work cooperatively to be voices in the system? One of the most unfortunate, in many cases sad, dynamics in health care over the last several years has been the loss, the break down of trust between the different stake holders, the loss of trust between the different participants in the delivery of health care. We should not shy away from addressing that. We must create systems and strategies that can rebuild and restore that trust. Without that trust, we can talk abstractly of policy for a long time but policies will not really be implemented, we will not be able to take steps forward. We are trying to approach the restoration of trust through the creation of what we call a public/private commission that would essentially oversee health care in this country. Again, it's an extension of the principle of balance that I talked about earlier. This commission would be composed of all the stakeholders in health care, the purchasers, the payers, the physicians, the nurses, other providers, the consumers, the insurers, everybody who had a voice in health care. The commission would have basically three functions: develop a comprehensive benefits package that the health plans would have to compete for around quality and choice. It would determine for us some guaranteed patient protections and it would really look at the application of information technology to health care to try to generate some costs savings and improves quality of health care. But the most important part of this proposal is that decision making, authority, the power, and the responsibility in health care would not be sequestered off in any one aspect of the system more than another. Through this the mechanism would be broadly shared.

James Haveman: Governor Bush believes that in a quality health care delivery system you need consumers to be able to have some choices and options and to be actively involved in their own healthcare, but he is also concerned about physicians. He has said this over and over again. The primary key to any health care delivery system is the physician. Take a look at his commitment to graduate medical education, his commitment to double the budget of NIH. The patient bill of rights, which he signed into law in Texas, allowed a lot of protection for physicians. For example, if a person was part of an HMO and the particular specialist they felt was needed was not part of that network, they could go outside the network to that physician. That law recognizes the importance of the physician in doing that. Also, if an HMO denied something, which a physician felt strongly about, there could be an appeal, which would be held very quickly in the best interest of the consumer. I think Governor Bush feels very strongly about the importance of the consumer in choice and alternatives, but about physician choice as the key decision-maker in a health care delivery system.

Howard Weinblatt: How would your system allow physicians to organize to make that a realty in the face of the other aspects the health care delivery system being large corporate or governmental entities?

James Haveman: I think the physicians in many places around the country are feeling outside of the decision making and the best care of the patient. I think whatever health care delivery system that he is involved in reforming would bring that physician back to a key decision making role, not only at the table in the design of the program, but also in the decisions at the HMO level and the hospital level or wherever, when it comes to patient care. I think that is key to the way our health care delivery system is put together.

Howard Weinblatt: There's not a specific idea about the mechanism for accomplishing this?

James Haveman: The commitment that the physicians will be the key decision maker, Governor Bush feels, is a key foundation of what the health care system will look like in the future.

Howard Weinblatt: We hear that from a lot of people.

James Haveman: Well, hold us accountable!

Richard Boxer: The Vice President believes that physicians and all health care providers have every right to negotiate and develop whatever organizations they wish in order to negotiate with the payers. There is a great deal of reluctance, in my experience as a physician in private practice, to have any sort of organization what so ever. In fact at times it would be difficult to have physicians organizing a two car funeral procession. If you have two physicians you have eight opinions, but having said that and having experienced it in trying to organize physicians into HMO's or IPA's or whatever the alphabet soup is of the day, the Vice President believes that physicians can, if they wish, organize and negotiate. Of course the interns and residents developed their union with the help of one of the national unions in this country. And other physicians organize into IPA's or HMO's or various forms of collectivization and then they negotiate. It's ongoing. There is nothing that really needs to be done except the commitment of the health care providers to that institution. Nurses are an example of a group who are very effective in getting a union together and have effectively negotiated with their employers, specifically the hospital or hospital systems. Therefore, anybody can do it. It is a free country.

Gil Omenn: Here at the University of Michigan Health System we have five unions--no surprise to me coming to Michigan in 1997, but it was a surprise to learn that most other health systems in the state have few to none. Our organized units include the nurses and the house officers. The house officers (residents) have an "Association" which is specific for the University of Michigan, not part of any national federation. We feel that we have a win-win approach with all of our unions and the House Officers Association.

At the national level, I think this matter reflects great frustration among physicians over control of patient care decisions by non-physicians at the end of phone lines to the plethora of health plans. Ironically, the movement by the AMA and others toward such organizing comes at a time when physicians who band together by specialty and by multi-specialty practice or geographic network have increasing leverage over health plans and lots of support from politicians and the public. Everyone seems to be beating up on HMO's--though our own M-CARE gets very high marks from members and providers alike. There is no doubt in my mind that a compromise patients' bill of rights, more focussed on assuring prompt resolution of clinical care coverage disputes and less on generating business for attorneys, would be widely acceptable; unfortunately, the advocates on each side have staked out extreme positions.

Howard Weinblatt: Does this mean then that you, the Gore campaign, are in favor of removing restrictions the FTC might have now on physicians organizing in an effective way?

Richard Boxer: I think we would be willing to work with the construct you envision would be put into practice. In other words, if there are impediments to reasonable negotiation they should be removed. I know you run into price fixing and monopolies and things like that. I have certainly seen that myself in Milwaukee, but I think whatever is reasonable is possible.

The Rising Cost of Prescription Drugs

Zelda Geyer-Sylvia: I would like to change gears a little bit and ask you about prescription drugs. I think all of you mentioned that prescription drugs are part of what you would like to see for Medicare beneficiaries and being part of the Medicare Plus Choice Program that offers prescription drugs. We can understand why that is an important component of a Medicare program. However, it is becoming increasingly challenging to offer the kinds of benefits you are talking about, even within our existing Medicare Plus Choice environment. We are really being challenged by the fact that prescription drug prices are increasing at rates 18 to 20% above the general inflation rate. From the public policy standpoint, I believe that this is going to affect Medicare Plus Choice Programs and if you intend prescription drug coverage to be part of the regular Medicare benefit it will affect the entire Medicare program. This increase in price of drugs, in fact, is one of the main reasons for increases in costs of health insurance for employer commercial programs as well. I wonder if you all have thought about what the public policy issues surrounding that would be?

Richard Boxer: You have outlined very well the positives and the negatives of the problem. We all spoke about the need for pharmaceuticals to be available to the elderly as well as to the non-elderly, in other words to everyone, because the absolutely fantastic pharmaceutical industry in this country has provided us with amazing new medications. They have introduced new medications to conquer some of the miseries of disease. Or sometimes not disease, but areas of healthy functioning that you would like to improve. Having said that, one of the problems is that the pharmaceutical industry has a policy of charging far more dollars for the pharmaceuticals in this country than anywhere else in the world. For example, if you want to obtain a medication in Ann Arbor, the same medication might be one-third the price if it were bought somewhere in Mexico, or in Toronto, or elsewhere in the world. The pharmaceutical industry said that without the profit made from the greatest consumption nation in the world, namely the United States, they would not have the ability to develop new products. There is a lot of resonance with that argument. It certainly has a lot of truth. However, if it is the nation's policy to nurture the pharmaceutical industry to produce new drugs, if that is our national policy, then we should talk about that. We should not simply be taxed, so to speak, by the pharmaceutical industry for their research and development. We're really talking about a relatively small number of drugs, the trade name drugs. What is truly problematic is that the pharmaceutical industry, that is, Merck, Smith Kline Beecham, and Glaxo as well and the rest, have purchased the generic drug companies. Then they throw roadblocks into letting these generic companies produce the drugs as soon as products are no longer covered by a patent. So it isn't all as the pharmaceutical company describes it. They want the money for research and development. We prize research and development and we support it through the NIH, we all do. Every one of you supports it through the NIH and through other methods of payment. We believe there has to be some fairness in how these drugs are distributed to those people who are ultimately paying for the recent development anyway. That's where we have to develop some kind of consensus and compromise in discussion with the pharmaceutical industry, so that the billions and billions and billions of dollars that the consumers are spending for their new and wonderful--or old and wonderful-drugs can be more equitably shared and so that we don't double pay.

Margy Heldring: I'd be hard pressed to beat that answer. I think that was a very thorough description of the situation. I think it's really reflects the changing nature of health care in this country. The pharmaceuticals are now emerging and will continue to emerge as such a predominant treatment, methodologically. There are some interesting responses developing around the country that are going to be important to watch. I think this is the most explosive issue we're likely to see this year, because the burden falls on health plans. The burden on the consumer is intense. There is no doubt about it. It raises the whole issue of when are profits excessive in health care, in any industry, but in particularly in health care. Some interesting responses are beginning to develop around the country. Some of the New England states are looking at forming purchasing cooperatives together. States are looking at how they can support the elderly in the purchase of their drugs. I think just as Rick said, it's going to be about sitting down with the pharmaceutical companies and trying to do some negotiating with them. I really wouldn't be able add more to the point, to be honest.

James Haveman: Governor Bush isn't interested in micro-managing the free enterprise spirit of pharmaceuticals who have certainly brought to us really creative and innovative drugs. I think one of the interesting things we all see in health care is that we have in some ways a health care system built on a model that is kind of pre-pharmaceutical. When we talk about reforming Medicare and talk about getting rid of lot of the red tape and doing things differently, we say very clearly that we think pharmaceuticals should be part of the Medicare entitlement and should be part of that Medicare benefit. But this has got to be done in cooperation with reforming Medicare. Once you do that together you must develop a model of health care delivery in which the Federal government provides the entitlement for Medicare. Hopefully you will have the funds to pay for that benefit, rather that just say we are going to spend $170 billion dollars on pharmaceuticals for the next ten years. Then you step back once you've got the reform direction set, once you've got the pharmaceutical benefit negotiated and in place. In working with the pharmaceutical companies you make sure they become aware that Medicare needs to have a pharmaceutical benefit, a position somewhat different than where we were a few years ago. Then you decide whether you can afford it at that point, and at what level you can afford it. We know we're going to pay the premium up to 135% of poverty. You then step back and say, do we need more revenue? Rather than just assume that we are going to add it on to a system that needs to be reformed.

Gil Omenn: The Prescription drug benefit for Medicare beneficiaries is the dominant health insurance issue for this year, even more than the patients' bill of rights. Credible analysis of the candidates and congressional proposals requires examination of the proposed benefit structure, skepticism about the cost estimates, and consideration of incentives for change.

The benefit in most proposals is a combination of a voluntary premium (with income-based subsidies), a deductible, high co-pay (typically 25%), and a maximum Federal payment (which leaves the insured person vulnerable to really high cost drug regimens). Ironically, after the Vice President attacked Bill Bradley's proposal, President Clinton modified the administration proposal to be much closer to Bradley's scheme of greater protection for "catastrophically" high prescription drug costs per individual patient.

The cost estimates on a national basis will come from multiple sources, but all parties generally rely upon the Congressional Budget Office (CBO). The CBO has lost a lot of credibility recently due to greatly underestimating the consequences of the balanced budget amendment of 1997 for payments under Medicare--a combination of the congressional action and the HCFA implementation. Health economists among the faculty, students, staff, and guests in this audience (live and readers) should consider this example in depth. Briefly, CBO estimated a $115 billion cut in payments to providers, compared with what would have been paid under current law before the BBA97, over five years. By the end of the second year, re-estimates put the "savings" (for the Federal budget), "cuts" for the providers and their patients, at $195 billion, corresponding to an $80 billion under-estimate and a lot of red ink for hospitals, home care, and other providers. A campaign for redress yielded the BBA revision of 1999, which were estimated to restore about $16 billion of the unintended $80 billion excess. Hardly an adequate action. And during 2000, estimates of the impact of BBA97 continue to grow, with the latest an additional $62 billion. Together with a robust economy, these cuts are fueling the big Federal surplus--a small part of which needs to be used to sustain medical care for Medicare beneficiaries. So, be wary of the cost estimates and probe aggregate figures.

How to Finance More Prevention

Max Heirich: I did not ask a question earlier when some of the others were speaking because I couldn't figure out a way to ask it that wasn't terribly loaded. We were talking about the role of employers, the cost of health insurance and the question of what could be done. So far the conversation has focused entirely on group-purchasing solutions. I just want to comment that the State of Michigan has had some other interesting innovations, including partial self-insurance and wellness programs for small businesses. These have resulted in enormous reduction in costs for small businesses, school systems and the like. If anybody is interested I'd be delighted to share more about this. I can't think how to ask a question about it, so I plant that as an idea. Now I want to really change topics.

I was quite struck with Marge Heldring's statement about the importance of pursuing health. That is very different from disease care, which has been the primary focus in this session thus far. I have a series of questions, which are related to that.

As I think many of us know there has been a demonstrated payoff, both in terms of improved health and cost savings, from prevention services. This is especially true when they are well enough done to model the delivery of health care differently--so that they are provided proactively on a regular basis. The problem has been that there is usually a three to five year lag between the cost incurred for providing pro-active prevention services and the cost savings that then come back to the system. Managed care plans with fixed capitalization payments hesitate to add additional prevention services for members because they have about a 20% turn-over in membership each year Thus they are not sure that eventual cost savings will come back to them. Who should provide these services, which will save all of us money in the long run? It seems to me that almost all groups now have been avoiding responsibility for providing the kind of prevention services that you and others have recommended. This question is to you and I will ask the others to comment as well. How do you feel about this? How would you create incentives for it? Who should be providing these kinds of services, and how can we get it started?

Margy Heldring: One of the reasons Bill Bradley chooses to open up the Federal Employee Health Benefits program for all Americans, up to the time when they are eligible for the Medicare Program, is that typically people enroll in and stay in those health plans for a longer period of time than for other health plans. Correct me if I'm wrong, but I believe the average enrollment period is about eighteen months. It's fairly short. People enroll and dis-enroll. That is not a stable relationship. That is not a sufficient amount of time for a health plan or an employer purchasing the health plan for its employees to invest that kind of money. But suppose someone is enrolled in a health plan for five or six years, or twenty years, as can happen when you own your insurance. It goes with you job to job, health status to health status, geographical location to geographical location--as it could if you were enrolled in one of the FEHBP plans. Then there is an incentive for health plans. The health plan looks and says, ahh I have this new enrollee and I know I'm going to have this enrollee for seven or eight years. That is a whole different ballgame for people to invest in prevention. However, prevention should be broadly shared. It should not be just the task or mission of the health care system. It should be also the task and mission of schools, employers, of YWCA and YMCA's around the country, Boys and Girls Club, and faith communities. If everybody saw how our health and our health care is really an Eco system, and understood that we're all part of this together, I think there would be a greater willingness to invest. There is a larger principle that we need to understand. I may invest in-patient X today, then lose that patient to another health plan, or another city or another job. But at the same time I'm going to gain somebody who has been the recipient of preventive care from somewhere else. We begin to see that what goes around, comes around. It is bigger than just our own piece of the pie. There is a broader perspective on the value of this investment in prevention. I think there are ways we could structure really concrete financial incentives to help people put serious efforts into this.

James Haveman: Governor Bush found that the immunization rates in Texas were very low. He just set the expectation that these people, youngsters and families, would walk into the physician's office and request immunizations. Whether through the Medicaid program or organized medicine the actual immunization rate doubled for a period of time.

There was a time when we felt that when you do preventive screening work you wouldn't see the results for four or five years. However, I think we've come to realize that for some of the beta-blockers, available prevention stroke treatment, if you are really practicing best practice, you can prevent lengthy hospitalizations or lengthy rehab. This is what we have learned about screening in Texas. Governor Bush established a plan where if you offered diabetes coverage then you also paid for the strips needed for personal testing, or whatever. Too often health plans cover inpatient hospitalization but not the preventive. So Governor Bush signed legislation that required that they cover these types of expense as well. We need to have the expectation in the purchasing of health care that we expect screening, we expect testing, we expect the evaluation of people, up front. That's what we mean when we talk about reforming the health care system--to put the emphasis, to put purchasing more up front. I think we will be seeing those savings not ten years down the way. Sometimes you can see them fairly immediately. I know that is what Governor Bush wants.

Richard Boxer: We are tremendous advocates of prevention. The Vice President believes very strongly in preventive care and in encouraging people to take responsibility for their health care. He has said a number of times that self-responsibility will reduce preventable health problems enormously. For example, 400,000 people died prematurely and often a miserable death, because of tobacco. That is self-responsibility and also corporate responsibility. For a while, and possibly still, tobacco corporations have been targeting children to hook them on tobacco. Violence is another important preventable health care issue. And so, of course is consumption of alcohol and other drugs. The Vice President believes very firmly that responsibility is on the consumer. But there also is some corporate responsibility as well as responsibility taken throughout the environment as a whole.

Margy Heldring: May I say something else about this that hasn't come up yet today? Bill Bradley has talked a lot about this and I believe the Vice President cares very deeply about it too. In terms of prevention we need to create greater parody in respect to mental health issues and mental illness in this country. I'm thinking and he's thinking particularly of what happens in the primary care sector. How many people go to the pediatrician, their internist, and their family doctor, nurse practitioner, with a symptom or complaint that really is not probably biological or biomedical based? It has different origins, whether it is a real mental illness or whether it is just behavioral psychological factors or stress. I think there are tremendous opportunities, especially in the primary care sector, to develop collaborative approaches to health care, to prevention and screening. There are multi-disciplinary teams, which understand that health is a combination of these factors. As long as we persist in applying a more narrowly defined view of health and health care, we're going to miss opportunities to screen and prevent. I have worked for many, many years in primary care and often saw how missed problems, missed depression, missed anxiety disorders, missed substance abuse disorders, missed parent/child problems--snowball into greater expenses and poor health for the individual and for families.

Gil Omenn: The need for adequate coverage of mental health services is great. Part of the justification is the much higher utilization of other medical services by patients with various kinds of mental health problems. For example, patients with depression have an estimated three time's higher utilization of other services than patients without depression. Most lay people would predict that there are links between medical and mental health problems.

Here in the Ann Arbor area, the University of Michigan Health System and the Washtenaw County Mental Health Program are launching a first-of-its-kind demonstration in integrated health care for Medicaid patients with mental health problems--including substance abuse, developmental disabilities, and chronic mental illness. The County Mental Health Board dissolved itself, to be re-created as the Washtenaw County Health Board, with equal numbers of members nominated by the county and the University. The UM Health System is accepting a certain amount of financial risk under a capitated scheme in order to test whether outcomes can be improved and costs be reduced through such integrated medical management. After approvals by the Legislature, the Attorney General, and the Governor's Budget Office, we expect enrollment to begin in Summer 2000. Public Health and social work faculty has already been engaged to build a baseline for an objective, independent assessment of the program. If successful, this kind of integrated service model should be considered throughout the State of Michigan and the rest of the country.

Margy Heldring: I just wanted to follow up on that because I think one of the things that has been a hallmark of managed care has been their coverage of preventive services as opposed to many indemnity plans which do not cover preventive services. One of these things I think managed care companies through NCQA and HEDIS are doing is not only covering them but now measuring preventive care and really going out publicly and showing the world how we're doing in those kinds of statistics. And I was wondering if you could comment on when that is going to become more broad based, because it would be very helpful for the public to know not only some of the anecdotes that are being told about managed care versus fee for service medicine, but seeing some of the actual hard data about what the differences are in provision of preventive care, and in outcomes related to provision of preventive care.

Richard Boxer: The Vice President believes that evidence based medicine and outcomes of research are important. John Eisenberg, head of Health Care Research and Quality in the Health Human Services Department, has been promoting prevention vigorously and he is greatly respected in his research. The Vice President is an advocate not only of prevention, but also of developing a system whereby it will occur. That's one of the good aspects of health maintenance organizations. Thus, we applaud the fact that health maintenance organizations have used their resources both financial and personal in order to promote preventive care.

Margy Heldring: Agreed.

Keith Crocker: A question: how about going beyond the HMO's. . . . trying to challenge the rest of medical practice?

James Haveman: Governor Bush supports that. He understands the importance of the integration of heath care. In Texas, under the leadership of Don Gilbert, he has brought together many of the health care providers under one umbrella for health care. They traditionally operated kind of like solos in states, much like we used to have in Michigan. The other thing we want to do is to challenge established health care systems to think more about outcomes and to regularly issue report cards, to evaluate their performance so that people can make choices in terms of what plans do and don't achieve. I think the key is information. A lot of the groups have come forward that could easily take those evaluations and bring them to the other health care providers so that we could get some true comparison. In Michigan we have found it has made a big difference in getting appropriations. You can find this in any state right now where people can show results of interventions. Before, we said, you spend a dollar, you save seven. Now we can actually show them the data, and it makes a big difference. I think that Governor Bush would want to spend money for demonstrated results as well.

Race and Class Disparities in Health

Richard Lichtenstein: I want to talk about public health. We're in a public health building here and I actually teach in this building every fall. I want to talk about what is probably the biggest health problem that we face in the United States. You know that 45 million people not having health insurance are bad. But when you look at the ratio of disparities in health among Americans that is unconscionable. Every fall I stand in front of that computer there and project really nice slides on this wall. Every year they show the same thing. Blacks suffer much worse health than whites, Native-Americans suffer much higher diabetes rates and other types of diseases, Latinos. . . These things are things that I have been teaching about in a course here for over 20 years, and these have always been with us. But I don't think that they have to be with us.

Dr. Heldring and the Bradley people have talked about these racial differences and the fact that we need to address the race question in this country. But I haven't heard very much from the other candidates. So the question is, lets not talk about medical services but let's just talk about health. How are we going to improve the health of our minority populations? And how are we going to change or decrease these disparities between the whites and the non-whites of America?

James Haveman: Governor Bush has said many times that when it comes to health care delivery and availability of these types of services, one's racial background--black, white, Asian-American, or whatever, should not affect the quality of care that is provided. That will be a cornerstone of this campaign and also a cornerstone of what we will do with health care. You recognize us for wealth, in Texas for instance, where a large population is Hispanic. He has reached out in the Hispanic community with culturally relevant programs, provided by people that understand the language and culture. We have also seen that here in Michigan. In drug prevention and community health we designed programs that are built through the African American community. They are managed by many of the church pastors for outreach; you recognize that the traditional health care delivery system isn't the most unique system to reach people. That's where you start, where the communities act. That's why we would like to expand the number of community based clinics through the base centers. And if you have the expectation that the outcome should be the same, it can happen. I think we've got to learn how to bring to this country a relevant sensitivity in the design of the health care delivery systems. If we do that, you don't have to stand up there year after year--like I do year after year--and still show a sudden impact on the uninsured. In some areas we're doing a fine job. In some areas we have some challenges. I think we have to go out and listen to some people and also loosen up a little bit our assumptions that we know what's best for everybody, we need to generate ideas that complement communities, faith organizations and community organizations.

Richard Boxer: The Vice President has talked a lot about the needs of special populations. Minority communities in this country must have the same health care as the majority. That is why he put forth his health care plan, which I enumerated earlier. Specifically, to first insure the children, many of whom are not Caucasian and also to insure many adults who are parents of those children, who also are sometimes not Caucasian. Through this means he wants to incrementally develop a health care system which will ultimately be universal. I am very pleased that Governor Bush feels the same way. I hope that if he were to become President he would carry forth his wishes. The problem is that with a 1.7 trillion-dollar tax cut that goes to a particularly small population of people, it doesn't leave any money left for increasing access to health care. For example, there will be no money for increasing monies available for Medicare or increasing the monies available for Medicaid or increasing the monies available for CHIP. Now, at the beginning of this session someone suggested that the Democrats want to spend money and the Republicans want to reduce regulations. In order to cover more individuals, certainly there needs to be increased funding available. The Vice President, through his program of re-inventing government during the first years of the Clinton/Gore Administration, reduced regulations or at least reduced the increase of regulations, and the Clinton/Gore administration also reduced the number of Federal employees down to the lowest level in a generation. The Vice President does not like regulations. Unfortunately, there are thousands and thousands of pages that need to be culled to find out exactly what regulations are necessary and what are not. The Vice President has put forth a plan. He and President Clinton, in the last seven years, have made their best effort to get more non-Caucasians health insurance or health coverage. It is my recollection that the Republican Congress has been more of an impediment than a method of encouraging this kind of effort. The Gore administration will use continuing, renewed, vigorous methods to try to insure as many people as possible and to allow them to have the same benefits from the health care system as Caucasians.

Finally, I'd like to say something that I believe very strongly. If there is one thing we could do to improve the health of this nation, in particular, it would be improve the treatment of cancer. It is not just that we should have more research and development, for which I am a passionate advocate. In addition, we must use and apply the research and development so that it is available to all people in this country. We have to understand that there are tens of millions of people who do not have access to the research that is already there--that the research is not being applied to them.

Gil Omenn: Let me just cut in here. I don't think my question was clear or else this is a teachable moment . I want to try and explain something. Let's not use the words health insurance, let's not talk about business as a health care purchaser, let's not use the word hospital, because I don't think that is how we're going to change the racial disparities. You've got to get much more fundamental, broad issues like communities, like empowerment, like income levels, like families, you know, all the things that go into creating the good life. How are we going to do that so that all Americans get that rather than present data in these meetings about disparity between the groups? And it's not going to be solved by giving people equal health care.

Woman: My name is Debra Rosenthal. I teach in public school and I am a public health social worker with youths and I'm trained as a professional. Part of my training told me 80% of all health issues related to social inequalities, not whether I can get to the doctor. I have to say I'm a little frustrated with continuing the discussion of personal responsibility for health. It is true that if I were to make a rather poor choice to smoke, to expose myself to other illnesses, taking personal responsibility for my health would be an issue. But I also live in a social environment and I would like to see or to hear how the campaigns talk about changing and improving social environments so we can reduce those issues of disparity. Not just among our original racial and ethnic groups, but also among our social class groups- and that doesn't mean give me another card to go to the doctor.

James Haveman: That's interesting. You know consumers has get a lot of their information from the 14,000 Web sites on health care that are out there, increasingly. When consumers are told about a position they are going to the Web to educate themselves to learn. Good, bad, or indifferent, that is what they are doing. Now we have to figure out whether it is through early education of youngsters, or by going back and listening to people talk about what it would mean for them to have good lives that we can make a difference. I do like to work with personal responsibility. I think it is key for a lot of health care. Especially when it comes to behavioral risk. For some reason the American public doesn't understand that there is a relationship between not wearing a seat belt and injury, and smoking and cancer and violence and health. Governor Bush talks about this; many of the governors talk about it because they know there is an impact. It relates to issues of violence. That's why in Texas you're seeing an 85% increase in domestic violence expenditures, because we know that has an impact on health care. And that is why I really appreciate what I see happening here at the University of Michigan where you have social workers with a public health background. And you're beginning to see the mergers of those types of professions, figuring out new techniques of educating people to understand that you always can't use that card. Because there is a lot you can do by not using that card.

Margy Heldring: I remember the first time I read Altman, from the Kaiser Foundation, writing that a good job, and a strong family is the best health-in-human-services program. That really jumped off the page at me. That's why Bill Bradley keeps trying to take a much broader approach to what health is. Health is a home, health is a job, health is sense of being respected, and health is a sense of attachment to a community or to other people. Health is a result of not being exposed to environmental toxins because you're poor and live in the wrong part of town, or breathe the wrong kind of air. Health is the food you get because you have income to afford that. So all those things are what I think you are referring to and they are powerful. If there is anything that Bill Bradley wants to keep pushing, it's this. The connection. The connector between all these things. To stay focused, as you suggested, on one part is important, but it is limited and it limits our potential.

Gil Omenn: Another question?

Person: I'm a second year medical student. I have two questions for Dr. Haveman. The first is this: President Clinton for the first time is taking seriously American racial inequalities in health. He established a deputy to the Secretary of Health to deal with these issues and has convened a conference to address these problems. Will Governor Bush continue this conference? Secondly, what is Governor Bush's interest in supporting an agency for health care policy research?

James Haveman: I know for a fact that from the tobacco settlement money of 1.7 million dollars that has been allocated for 2000-2001 in Texas, one million dollars has gone for education and research. I assure you that this money is reserved for that type of activity. I think this is part of the reason Bush wanted to double the NIH research budget in national health. In regards to the particular office you spoke about, when Bush gets to Washington he will step back and evaluate what offices are doing. Certainly with his background and his tremendous respect for minority populations he will be extremely sensitive to new populations and their needs. I personally don't see changes occurring right away.

Support for New Approaches: Complimentary & Alternative Medicine, Prevention, Hospice

Woman: I have a comment. I would like to commend the Bradley campaign for actually looking at culture as one of the aspects that influence health. A lot of times it is ignored, so I think that is commendable. But my question is to the Governor's campaign: when you are decreasing the amount of red tape that is involved with getting health care and access, how do you plan to improve quality? I understand there is a lot of red tape and a lot of times it is hard to get to the actual health provider, but quality is a lot more important in some cases than just being able to go to the doctor. Because everyone can go to the hospital. If I break my arm and I don't have insurance, they'll fix it, but it could be fixed wrong and I have no way of actually going back to influence quality if there is no red tape.

James Haveman: We have discovered that when outcomes are reported outcomes and the health purchasers determine what outcomes they want to purchase, it is amazing how the providers begin to adapt to this. When I talk about red tape and Governor Bush talks about red tape here is what troubles us: if you take a look at a lot of health care, many people get specific treatments because that is where the money is. That is where the rule is, that's where the code is, that's where the categories are. When the CHIPS program came down supposedly giving each state more responsibility this past year, 450 pages of rules came in. You had a stack this thick. We've got to spend more time deciding what's the outcome we want, which is to get kid's coverage and have them get the helpers they properly deserve.

I agree with you. We've got to improve quality. Now that's where we need skilled students in public health because health care is much like the dilemmas facing social workers. We always had a difficult time determining what outcomes we really want to purchase, what they really are and how much to pay for them. I think a whole new field of evaluation is developing that is going to help determine what outcomes are best. The red tape that Governor Bush wants to get rid of are the ones that just get in the way of good decisions to meet those outcomes. A regulation, by the way, never really provides that much guarantee of quality.

Mary Bailey ( a retired Nurse from the University Health System): I'm concerned about two issues and address my questions to all three of our guests. One relates to the fact that many, many Americans are now doing a lot outside the regular medical system, relating to complimentary therapies. How are we going to handle that? How are we going to establish health alliances that search for better answers? Number two, not any of you really questioned or looked at end of life issues. Increasingly, major dollars go into the last six months of life for patients. How are we going to stop depending on costly, high tech approaches to dying and help patients discover how to end life well? You're sitting in a state that has a very not-so-nice atmosphere relating to Dr. Kevorkian's answer for us. How can we work together for more humane solutions?

James Haveman: An interesting question about complimentary and alternative medicine. Statistics will show you that almost twice as many people are involved in complimentary and alternative medicine, as there are in what we know as primary health care. I think Governor Bush and many of the health leaders around the country realize the next few waves of discussion are going to be how to integrate complimentary and alternative medicine into what we know of physical care today. I think Governor Bush supports those types of discussions because I think this is going to happen whether you have these discussions or not. That's just reality.

Second, in regards to end of life, Governor Bush is certainly not for physician assisted suicide, but he is supportive of Hospice, of palliative care, of people preparing a living-will document they can draw up after the discussions with their family. We know that sometimes when that isn't done, many dollars are spent, at times unnecessarily, and not even at the wish of the patient. These are the types of discussions we should have. The other day somebody said, in life people believe the only option, that death is an option. Well it's not an option, it's part of a life cycle. I think Governor Bush recognizes that and would encourage those types of programs with available Hospice care. We must engage people much earlier in discussion of these matters. Most people want to get to Hospice the last two or three days of their life. We've got to do a better job of preparing people throughout that cycle. Governor Bush supports that.

Margy Heldring: I'll be very brief. I think the growth of complimentary medicines in health care is very exciting. One of Bill Bradley's principles for health and health care is, we must do what works. So we can look at the whole issue of complimentary medicine in health care with an eye to what works. Of course, everybody is free to pursue whatever avenue they want to pursue. In terms of what the public sector should pay for, we should think about that and study it. As we learn- and I believe we will learn-about the benefits of alternative treatments or complimentary treatments, of course they should be covered, they should be included. It would be very self-defeating not to do this. As to end of life issues, I think we're having a national avoidance experience. We're very uncomfortable talking about this. It requires moving away from just the technology side and economics, and moving into ethics. It requires moving into a kind of conversation that we are not really experienced in as a nation. I don't have the answer now, but I know Bill Bradley feels very strongly that we can't be shy about this.

Richard Boxer: I have nothing to add other than this: I think that the nation is growing and maturing its way through this problem. Technology has far outstripped our understanding of morals and the ethics of what to do. Therefore, we are able to keep people alive longer than they are living. By now, virtually millions upon millions of people take advantage of the end-of-life legal documentation. I think we are developing a method of working our way out of this, rather than having the government or any particular campaign dictate how it should be handled. This involves the maturing of the nation.

Man: I have a question in the form of a case to present to you. It talks about prevention and how important it is or may not be. It talks about the high cost of developing drugs and making them available. It talks about health care economics in terms of how do we weigh what something costs vs. what we want to pay for it? Where is that balance? It talks about culture and race. It talks about the value of encouraging research for things we may not be willing to pay for once their cooked. (Laughter) When we put that all together, here's the scenario: a new vaccine hits and is developed for a germ called pneumacoss. The advisory committee of The Public Health Service that is supposed to do those sorts of things has approved this vaccine. When they looked at it they recommended that everyone under five be given it. For kids under two there is no question that it is important, that it is cost effective and needs to be done. From ages two to five there are some questions, but they have recommended that everyone aged two to five should do it. However, when their recommendations went back to CDC and the public became involved, we said no, it's too expensive, it's not cost effective to give it to everyone between two and five. Partly because it is a very expensive vaccine. Now they said it should only be given to high-risk groups, not to everyone. Well, one of the high-risk groups is African Americans. So, the question would be, should we give this vaccine to anyone because it is available, even to a Caucasian four year old who is not in daycare and is not a cost effective risk, and to an African American kid who is four years old and lives next door, and belongs to a social group that has a somewhat higher incidence--which makes it in someone's classification cost effective. Given that sort of quandary, not to mention the cultural implications of suggesting that we give one race a vaccine and not give it to another, paying for it for one reason and not paying for another, how do you think your candidates would handle this real life situation?

Richard Boxer: The Vice President would not have the Federal government get involved with that kind of decision. It would depend upon the research and development of what has been described through the process of the panels that have developed it. What I really mean to say is we would rely upon the extraordinary people that are on those panels to make the decisions and would not micro-manage any particular decision. So it would be evidence-based medicine.

Man: Yeah, they haven't been able to make the decision yet. So it is ultimately going to be a political decision.

Gil Omenn: This is starting to be too complicated, okay? (Laughter) Not to mention the distrust that might occur if you are saying we are going to give injections to one particular racial and none to others. There is a lot of history, a lot of cultural, a lot of racism behind that kind of decision. I think I had better call a deadline. Our time is up. I know there are a few questions left for the speakers. I urge you to resolve that.

I want to say on behalf of the public that I appreciate all the thoughtful answers given by you and I want to say that your candidates are well served by each of you.

Thank you all. (Applause)

Credits & Acknowledgements

Edited by Max Heirich

Transcribed by Lorraine Hickson

FORUM Director, Marilynn Rosenthal


Blue Cross/Blue Shield Foundation of Michigan

Greater Detroit Health Care Council


University of Michigan:

Business School
College of Arts, Sciences, and Letters
Law School
Medical School:
Program in Society and Medicine
Inteflex Program
Nursing School
Pharmacy School
Social Work School

Planning Committee

John Billi, M.D.

Eugene Feingold, Ph.D.

Susan Goold, M.D.

Connie Greene, Ph.D.

Max Heirich, Ph.D.

Duane Kirking, ParMD, Ph.D.

Sallyanne Payton, LLB

Marilynn Rosenthal, Ph.D.

Howard Young, MA, CPA