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conditions","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=647.4,649.61"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/236","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"is almost certainly cost-effective.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=649.61,652.703"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/237","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I could give many other 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about","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=660.62,662.59"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/240","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"prior to Medicare and that illustrate","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=663.58,668.32"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/241","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"that we are now looking at health","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=668.32,671.49"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/242","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"in an entirely different way,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=671.49,674.29"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/243","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and health services in an entirely different way,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=674.29,677.87"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/244","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"than we did back in the early '60s.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=677.87,680.393"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/245","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"But I won't give any more examples just now.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=683.28,686.18"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/246","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Maybe we can get into them in a discussion period","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=686.18,688.54"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/247","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"that will follow.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=688.54,689.453"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/248","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Well, with this background,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=691.8,693.66"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/249","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I will devote myself to what I consider","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=693.66,696.39"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/250","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"the key problems confronting society","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=696.39,699.18"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/251","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and healthcare delivery and financing","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=699.18,701.04"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/252","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"at this time.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=701.04,702.55"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/253","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Among the large number of problems","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=702.55,704.31"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/254","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"that I might have identified for discussion","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=704.31,706.67"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/255","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"in this presentation,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=707.67,709.4"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/256","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I have selected four","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=709.4,711.55"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/257","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"that seem to me to be central","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=711.55,713.78"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/258","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and that seem to encompass most of the others.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=713.78,717.21"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/259","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"These are financing,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=717.21,719.913"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/260","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"costs, access,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=721.29,724.49"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/261","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"that is access to service,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=724.49,726.69"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/262","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and effectiveness, the effectiveness","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=726.69,728.63"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/263","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"of the service.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=728.63,730.44"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/264","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Although these are related,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=730.44,732.93"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/265","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"it is possible to discuss each of them separately.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=732.93,735.62"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/266","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"And let me introduce each of them briefly.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=735.62,737.52"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/267","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"First of all, the problem of financing.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=737.52,739.763"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/268","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Pardon, I seem to have a nose drip here.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=741.0,742.88"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/269","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I don't, bear with me.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=742.88,745.811"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/270","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"(Robert S. blows nose)","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=745.811,748.7"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/271","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I hope I'm not catching something out here.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=748.7,750.85"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/272","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Let's talk about the problem of financing.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=753.47,756.224"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/273","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I think the financing 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States,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=763.23,766.1"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/276","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"medical care represents","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=766.1,769.27"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/277","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"an ever-present and growing threat","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=769.27,772.79"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/278","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"to personal financial security.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=772.79,775.67"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/279","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"And even with the bulk of the 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out","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=787.5,789.97"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/284","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"a family's savings and plunge them into debt","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=789.97,793.77"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/285","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and expose them to a means test bureaucracy,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=793.77,796.23"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/286","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"which may or may not be more horrifying","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=796.23,798.26"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/287","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"to contemplate than to 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meaningless","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=828.58,829.73"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/298","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"in terms of feasible legislation.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=829.73,831.93"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/299","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"We'll discuss this further later.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=831.93,834.023"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/300","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Second problem is costs,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=835.12,838.33"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/301","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"not how to pay for it,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=838.33,839.46"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/302","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"but what to do about the cost.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=839.46,840.97"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/303","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"And what is the cost 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care","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=846.34,850.32"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/306","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"has been absorbing an ever-increasing share","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=850.32,853.62"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/307","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"of the gross national 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villains.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2657.87,2661.3"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/964","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"And that point was made this afternoon.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2661.3,2663.0"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/965","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"There really is no purpose in 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regulation","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2681.19,2682.88"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/974","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"than relief of suffering.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2682.88,2684.53"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/975","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"It's very easy to 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financing.,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2718.53,2720.96"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/990","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I think one can expect to see a shift","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2720.96,2723.22"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/991","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"in the next few 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services,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2734.6,2737.053"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/996","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"with no universal entitlement for services","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2738.13,2741.41"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/997","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"that would be 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involved,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2757.74,2760.58"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1004","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"but so will taxation","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=2760.58,2762.54"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1005","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and so will other 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institutions,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3315.13,3316.76"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1178","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"especially hospitals, financing agencies,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3316.76,3320.21"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1179","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"planning agencies","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3320.21,3321.94"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1180","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and various levels of government.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3321.94,3323.843"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1181","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"The key is to develop effective 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institutions","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3470.14,3472.15"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1238","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and professional groups","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3472.15,3473.81"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1239","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and a variety of governmental 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take,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3480.45,3481.943"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1242","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"but as community institutions,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3483.0,3484.78"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1243","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I believe they really have no 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opportunity","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3500.24,3502.77"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1250","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"for self-determination of what goes on","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3502.77,3504.93"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1251","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"within their own 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hospitals,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3522.088,3522.98"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1258","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"talking about health professionals.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3522.98,3525.48"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1259","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"I think for health professionals,","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3525.48,3527.313"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1260","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"translation, that means physicians and others.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=3529.04,3532.05"},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1261","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Okay, for health professionals, a wide 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[Transcript]"]},"items":[{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29657/annotation/1439","type":"Annotation","motivation":"subtitling","body":{"type":"TextualBody","value":"https://d9jk7wjtjpu5g.cloudfront.net/file_transcripts/associated_files/000/029/657/original/AV167964_Rostrum_a.vtt?1624892487","format":"text/vtt","language":"en"},"target":"https://d9jk7wjtjpu5g.cloudfront.net/file_transcripts/associated_files/000/029/657/original/AV167964_Rostrum_a.vtt?1624892487"}]},{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29658","type":"AnnotationPage","label":{"en":["AV167964_Rostrum_a.txt [Transcript]"]},"items":[{"id":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383/transcript/29658/annotation/1440","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"- Now we present \"Rostrum.\" On today's program, you'll hear Robert M. Sigmund, special advisor on hospital affairs for the Blue Cross Association and former executive vice president of the Albert Einstein Medical Center in Philadelphia, speaking on the topic America 11 Years After Medicare: The Problems Confronting Society and Healthcare Delivery and Financing. The lecture was taped at Iowa State University on September 20th, 1977, during a symposium on America's health and the human condition. Here to introduce the speaker is Robert Crom, assistant dean and director of extension at Iowa State.\r\n\r\n- Our speaker tonight is Robert Sigmund. He has the most impressive and appropriate set of credentials that relate to this issue. Currently, he's special advisor on hospital affairs to the Blue Cross Association in Chicago. And just prior to that position, he was consultant to the Blue Cross in Philadelphia. Prior to those associations, he served for seven years as executive vice president of the Albert Einstein Medical Center in Philadelphia. At the same time, he's been active in the academic community and highly productive. He holds degrees from what's now Pennsylvania State University. Currently holds academic appointments on two faculties, Temple University's School of Business Administration and the University of Pittsburgh's Graduate School of Public Health. In 1968, he served as a visiting professor at the University of Iowa in their graduate program in hospital and health administration. He has written prolifically in the health field, over 50 topics to my count. Among them, articles on determining community needs, emergency service planning at the area-wide level, hospital planning at the individual level, capital and fiscal concerns, income expense ratios, hospital effectiveness, home care, mental health, and educational and training needs for administrators and staff. He currently serves or has served as a consultant on over 50 boards, committees, commissions and councils. And among those in which he currently serves is included the Institute on Health Economics of The Wharton School, University of Pennsylvania. Speaking on the topic America 11 Years After Medicare: The Problems Confronting Society and Healthcare Delivery and Financing, I'm most pleased to present Robert M. Sigmund.\r\n\r\n- Thank you, Dr. Crom, for that generous introduction. And thank you folks out there for applauding in advance. That's playing safe, I guess. I'm gonna take that rather pompous title that was given to me seriously. I am just gonna make one amendment to it. The title, as you heard Dr. Crom describe it and as it's listed in your program, is America 11 Years After Medicare: The Problems Confronting Society and Healthcare Delivery and Financing. And I just want to treat it just a little differently and talk about America 11 Years After Medicaid and Medicare. It happens that 11 years ago, both laws were passed. And for those of you who don't follow the legislative history, Medicaid was a piece of federal legislation that provided for federal government involvement in a rather significant way, more significant than they knew at the time, in financing healthcare for the people on public assistance and other poor people just above the line. Medicare, of course, as I think you all know, provided for federal financing of services to the elderly, since expanded to include some other groups. But it was 11 years ago that both of those laws passed, and they had the effect of, by their combination, of changing the governmental involvement in health services in this country significantly, at least as measured by the percentage of the dollar that is governmental. We still have well under 1/2 of the healthcare dollar outside the federal government, but it was increased significantly at that time. Well, the 11-year period since the passage of Medicare and Medicaid in 1966 has been a most exciting time in the history of healthcare services in the United States. It's been a period characterized by fantastic accomplishments in improved access to health service as financial barriers were reduced. Also, new discoveries and new applications of old discoveries, and significant improvement in the health status of the population by the measures that we have available to us. I really could devote this entire evening to a description of the important accomplishments during this period, but that is not my assignment and I do feel some responsibility to stick to the topic assigned, at least as amended. My assignment is to discuss the problems that are now confronting society following the significant accomplishments of the last 11 years. I'm sure that the panel discussion tomorrow will go into the accomplishments in some detail, but I don't want anyone who listens to the rest of this discussion about the problems to think that I believe that everything is wrong about our healthcare delivery and financing systems, and that nothing is right. That's certainly not the case. The fact is that almost all of the problems that I will identify and discuss are a direct outcome of the accomplishments of the past 11 years. Most of the problems that we'll be discussing tonight are problems that were not even perceived 11 years ago by very many people. And in a real sense, most of the current problems reflect entirely different points of view and different expectations with respect to healthcare services than most people had prior to the passage of Medicare and Medicaid. As an example, look for a moment at something that was mentioned briefly this afternoon, something called end-stage kidney disease. As many of you know, the kidneys clean waste material from the bloodstream. If these waste materials are not removed, the individual dies. Not too long ago, if the two kidneys stopped functioning, death inevitably followed. Advances in medical science, growing out of research, developed two very expensive solutions to this problem, which were virtually unknown prior to Medicare. One involved kidney dialysis through the invention of artificial dialysis machines which carry out the function of the kidney by a machine being attached to the body from time to time. At one time, these machines were so rare that institutions owning them had to form special committees to decide which patients would benefit from their life-giving services. The committees literally had the tough decision of deciding who should live and who should die. A second approach developed by medical science was kidney transplant, either from a live donor or from cadavers. This is a very complex and expensive and traumatic experience which has been increasingly perfected so that it now plays a significant role in restoring individuals with end-stage kidney disease to normal living without lifelong dependence on the dialysis machine. All of this was so expensive that the federal government decided to add a new category to Medicare a few years ago, providing end-stage kidney treatment benefits for all individuals, irrespective of age. This universal entitlement led to a very rapid expansion of the availability of the new covered services, with the result that the total cost of this national benefit has far exceeded anyone's expectations at the time that this amendment to Medicare was passed. The cost now literally runs into the billions. Accordingly, a great deal of attention is now being given by the current Congress to legislation that could bring the cost of these services under control. So here is a problem that was not even visualized 11 years ago. The cost is now so great that the nation must clearly begin to give greater attention to the development of methods of preventing damage to kidneys in the call for such large national expenditures. And given the existing financing of this particular service, it is now clear that research and avoidance of end-stage kidney conditions is almost certainly cost-effective. I could give many other examples of problems that were not even thought about prior to Medicare and that illustrate that we are now looking at health in an entirely different way, and health services in an entirely different way, than we did back in the early '60s. But I won't give any more examples just now. Maybe we can get into them in a discussion period that will follow. Well, with this background, I will devote myself to what I consider the key problems confronting society and healthcare delivery and financing at this time. Among the large number of problems that I might have identified for discussion in this presentation, I have selected four that seem to me to be central and that seem to encompass most of the others. These are financing, costs, access, that is access to service, and effectiveness, the effectiveness of the service. Although these are related, it is possible to discuss each of them separately. And let me introduce each of them briefly. First of all, the problem of financing. Pardon, I seem to have a nose drip here. I don't, bear with me. I hope I'm not catching something out here. Let's talk about the problem of financing. I think the financing problem can be stated most simply in this way. For most individuals in the United States, medical care represents an ever-present and growing threat to personal financial security. And even with the bulk of the population already covered by some form of insurance, Blue Cross, commercial insurance or some government entitlement program, a major illness can still wipe out a family's savings and plunge them into debt and expose them to a means test bureaucracy, which may or may not be more horrifying to contemplate than to experience. Obviously, something must and will be done to solve this particular problem within the next decade. And there seems to be a national consensus that the problem will be solved by some form of national health insurance, but there is very little agreement on the details, and some possibility that the phrase embraces so many different ideas as to be meaningless in terms of feasible legislation. We'll discuss this further later. Second problem is costs, not how to pay for it, but what to do about the cost. And what is the cost problem? Simply stated, I think, for the nation as a whole, medical care has been absorbing an ever-increasing share of the gross national product during the last 11 years, and thereby interfering with allocation of limited national resources to other pressing human service requirements. Medical care costs have been rising much faster than the cost of living, and now absorb close to 10% of the gross national product, more than double the ratio of 50 years ago. Costs are increasing at the rate of 15% a year, with no real sign of let up, which means that the total cost will double every five or six years, and no sign of let up. As of now, this nation must work about five weeks per year simply to meet the cost of health services, which is kind of frightening to contemplate. And as it moves up, it could go to six weeks, seven weeks. It wouldn't likely go over 52. Now, whether this five weeks per year is too much or too little is very difficult to say, and involves deep ethical and moral issues. Nevertheless, with no sign of let up in the increase in the proportion of our energies devoted to health services, it seems clear that the nation will devise some method of establishing a limit. The discipline of the marketplace has never worked well with a product like medical care. And with the growth of insurance mechanisms and government entitlement programs that have the effect of cushioning the consumer and the provider from economic consequences of their decisions, any reliance on the basic laws of supply and demand become ludicrous. So already, President Carter has proposed that the country contain inpatient hospital costs by passing a law. Clearly, this is an overriding problem in healthcare services that must be addressed. The issue involves questions of efficiency and effectiveness, a degree of waste and slack, and some relationship to unmet need. But fundamentally, the issue is priority for limited dollars, and the day of unlimited priority for health is over, irrespective of the issues of need and slack. Let's talk a little bit about access to health services. The accessibility problem, I believe, has two aspects relating to two quite different groups of the population. First, many people who are geographically isolated, either in rural areas or in urban ghettos, have great difficulty in obtaining medical care, except on an emergency basis or when medical problems happen to coincide with special interests of health professionals or governmental units. That's one problem. But secondly, many individuals who are more fortunately located are not really able to establish orderly ongoing arrangements to obtain the kind of care they want in the place that they want to receive it and at the time that they want to obtain it. These problems of accessibility, or lack of accessibility, stem particularly from the increasing specialization of medical practice, with a gradual disappearance, and most rapidly during the last 11 years, of the old-fashioned general practitioners, and the concentration of the new breed of specialists in limited locations and in absorbing activities which divert them from direct concern with primary patient relationships. Recognition of these problems became so pronounced after the passage of Medicare that much national activity was stimulated, including expansion of medical schools, both in number and size, to produce a greater supply of physicians. And steps to increase the attractiveness of general practice by identifying it as a new specialty known as family practice. And creation of new sub-physician occupations to substitute for general practitioners. Creation of a National Health Service Corps for medically deprived communities. Stimulation of team approaches to medical practice in group practice, HMOs, health centers and so forth. There've been a lot of different initiatives to address this problem of inadequate access, but limited successes of all of these efforts, and the many failures, have emphasized the complexity of the problems and make it clear that no quick solutions to improved accessibility are in sight. Solutions involving better organization appear to be more important than solutions designed to produce more or different types of trained personnel, although both directions will undoubtedly have to be pursued. The fact is that we have eliminated the wide differences in health service use rates that used to exist among different income groups, but problems of matching required services with people in need is still very much with us. Let's talk a minute or two about the problem of effectiveness. A fourth problem, much more subtle and disturbing than the first three, centers around the nagging question emerging as a widely understood public policy question only in the last few years, the question of the extent to which most of the medical care currently being dispensed really benefits its recipients. That's a question that was hardly ever addressed pre-Medicare, and you will hear more and more along that line in the next few years. For the nation as a whole, and for most population groups, added medical care investments and expenditures has little demonstrated effect on health status. Of even greater current significance, there's no evidence, no evidence, that substantial reductions in the general level of medical care expenditures would adversely affect health status. Prior to the '60s, when available health indices such as life expectancy, age-specific death rates, infant mortality rates and so on, were improving steadily as health expenditures increased, a cause-and-effect relationship was assumed and no one thought to raise questions of effectiveness. But just about the time that Medicare was passed, increasing attention was directed to data which seemed to show conclusively that health status indices in the United States had leveled off, and at considerably higher levels than in some other developed countries, especially in Europe. For some age groups, as a matter of fact, like middle-aged men like me, death rates were actually rising. Questions were inevitable, and they began to be raised. They were not different from the kinds of questions that were being raised in other fields, such as education, social welfare, race relations, defense. A concern with effectiveness in those areas suggested that most problems are not solved, and many are often exacerbated, by simple expansion of the established ways or even by prematurely investing large sums of money in new and untested ideas. In the medical care field, during the growth period of Medicare, there were many questions raised about effectiveness. Continued expansion of the hospital bed supply was the first activity to come under attack. Mental hospital beds, which have dropped drastically. Other specialized beds, which have dropped drastically. And finally, even acute general beds, where recommendations are coming out almost monthly for a shrinkage in the bed supply. Then came a concern with highly specialized facilities, such as cobalt therapy units, facilities for open-heart surgery and other high-technology applications which often seem to serve individual hospitals more than the public. Next in line was medical research, carried out with little attention to its relevance to the problems faced by practitioners serving patients. And there was a cutback there. More recently, one begins to hear pointed questions about the relationships between input and output in psychoanalysis, in surgery, in medical education, in health centers and even in coronary care units. England made some detailed studies of coronary care units. You all know what coronary care units are. And England developed some very scientifically selected sample work and put matched pairs, certain ones in the coronary care unit and certain ones went right home. And it's turned out, on the basis of the study so far, that on the average, the people that went home have done better than the people that went to the coronary care units. The original studies were done only on men, as men have a higher rate of heart attacks. And now they're trying to see if the same thing applies to women. They know that it works because the men have the women taking care of them at home, but maybe it won't work for women. So far, the preliminary data on women shows the same thing. You might say, \"Well, why would people do better \"at home than in a coronary care unit?\" Well, there's a lot of hypothesis about that. Actually, if you have a heart attack, the major treatment is to rest and let nature take its course, which it normally will unless ya happen to, you know, your heart stops beating in the middle. The evidence seems to be that the tensions in the coronary care unit, which have an effect on patients that's adverse, even though they have all that scientific equipment available, at home, they don't have that kinda tension. They feel much more comfortable, so they do better. That's one hypothesis. But you see, England had to make a basic decision. Should they put coronary care units in all their hospitals? 'Cause the government owned them all and they couldn't just put 'em in a few. So they studied it out and they've come to the conclusion that it's not cost-effective. It isn't really good for ya. We look at things a little differently here. It's obviously, it gives a sense security to the cardiologist, which may be important. The guy that did most of those studies, a fellow named Archie Cochrane, he's afraid to accept any lectures here in the United States because he figures if he happens to have a heart attack, he's sure to go to a coronary care unit and either it'll kill him, or worse yet, it won't, and then he'll be in trouble in England. Anyway, there are these very serious questions being raised, but we go right ahead, you see, and tend to introduce this new technology without studying whether it does good or it doesn't do good. The latest example along that line is fetal monitoring. You all know about fetal monitoring? They now have equipment so they can monitor the heartbeat of the fetus so that if anything goes wrong, they can run right in there and get it, do a Cesarean and save the mother and the baby. Every hospital that's put that in, the Cesarean section rate had quadrupled, mainly because it just kinda makes everybody nervous. They just weren't familiar with how little babies' hearts beat, and so they rush right in. The Cesarean section rate had quadrupled. There hasn't been any effect yet that we've noticed on the infant mortality rate or the maternal mortality rate, but it's a great technological advance and so we use it. Now, in the past, there have been major cutbacks in resources available for medical care in the United States, primarily during periods of war and economic depression. And although no systematic studies are available, a good case could undoubtedly be made that the reduced resources were more than offset by improved effectiveness during these periods. Let me just say a word or two about World War II. There's some people that look old enough in the audience to remember World War II. That was in the early '40s. Just three wars back. But World War II, we took a very large segment of the healthiest part of our population, along with a major segment of all our doctors and nurses, and shipped them overseas and loft out of society to play real war games. And so you were left with what was obviously a sicker population, as well as for absence of and whatnot, and many fewer doctors and nurses and no money for hospital building. And what happened, what happened to the health indices? Well, you go look at 'em. If you saw some, the curves without the dates underneath, you wouldn't be able to see anything happen in '42 or '43 or '44 or '45 look different. The health expenditures were very seriously limited, but there's a lot of evidence that people were healthier during that period. And there's a lot of innovation. It was during that period, ya see, there wasn't any hospital building going on that all the hospitals in the country started to pay attention to some nuts back in the '30s who used to talk about the values of early ambulation in connection with surgery. They got interested in early ambulation because there wasn't enough beds. And it turned out to be a much better thing to get the surgical patients up and about and out. They might not have happened if there wasn't a inability to build new beds. Certainly wouldn't have happened if we had HSAs around to recommend it. That was a bad joke. Well, as I say, there have been these periods of cutback in resources in previous periods in our history, and no evidence that health status was adversely affected. And even some perverse evidence that it was improved. But we don't have systematic studies as to whether or not when those kind of cutbacks occur, is there more than a corresponding increase in effectiveness? Are we in trouble? Well, hopefully we will develop evaluation and assessment techniques in advance for the next resource reduction because the next one may not wait for depression or war. It may be just ahead. Well, those are the four problems that I've identified, problems in financing, problems in cost, problems in accessibility and problems centering around effectiveness. Let me make a few general observations about these four problems before I suggest how we're gonna solve 'em. Of these four problems, financing, cost, access and effectiveness, only one, namely financing, was seen as crucial prior to Medicare. Passage of Medicare and Medicaid was designed to solve the problems of financing for the poor and elderly, and thereby to relieve the rest of the voluntary and private insurance mechanism from these heavy burdens so that the entire financing problem could be much easier to solve on a voluntary basis. Furthermore, it was assumed in the early '60s by many that with the elimination of the element of the financing problem represented by the poor and aged, problems with access would be eased and eliminated. And actually, the cost and effectiveness issues were not central at that time. Although a few voices warned of uncontrolled inflation ahead, not many were listening. Some saw Medicare and Medicaid as the initial steps in an incremental approach to solving the financing problem by the government adding on healthcare financing arrangements for the unemployed, for children and other groups added to the government's entitlement programs so that eventually, the entire financing problem would be resolved by governmental insurance programs. It certainly was not anticipated at that time that the emergence of the other three problems, cost and access and effectiveness questions, would create the current situation in which, interestingly enough, there is now a general consensus on national health insurance to solve the financing problem, which wasn't true before. There were major ideological differences between the medical profession and hospitals and government and so on. But today, those differences don't exist on national health insurance. There's a general consensus that we should have national health insurance to solve the financing problem. But there's also widespread consensus that nothing further should be done to resolve the financing issue by national health insurance until cost is contained, until there's better assurance of effectiveness. So that's essentially the position of the Carter administration. They're all for national health insurance, but they're not gonna touch it 'til we got things under control. So now they got all these liberals running around trying to control costs, which is kind of an interesting situation that Carter and this group have created. Problems of cost inflation and uncertain effectiveness, I should mention, are worldwide. They are not peculiar to the United States. Both in this country and elsewhere, there is much confusion and lack of consensus even about how one should think about these problems, let alone how to formulate solutions. It seems that solutions to these problems will require entirely new ways of thinking about health, and that matters, therefore, will get worse before they get better because action that has to be based on development of new ways of thinking takes a little bit of time. It appears that in a most dynamic way, we will have to look beyond the health of the individual. I'm now talking about what I think is the only approach that we know about today to address these issues. And it appears that in a most dynamic way, we will have to look beyond the health of the individual, not past it, but beyond it, and beyond the health services that an individual requires and uses, and examine the totality of health services for each community and for regions and states and nations. Further, we will be examining the relationship between health services, lifestyle and environment, and the organizational structures through which these various elements interact. We really must take a whole new look at the patient-physician relationship and at the concept of delivering healthcare services to people. And really, can health service be delivered like the mail or like a ton of coal? And as Walter McNerney has said, we need a new philosophy of health, nothing less. Health and health services must be seen in the context of the totality of the person, in the context of a larger societal whole, and the interactions between the person and the environment. Now, that's a lot of big words and big ideas. I'm gonna try to bring it down to something specific. But I think we would be well-advised first to re-examine some of the weaknesses in our approach to thinking about health and health services which have led us to the current situation in which we face these very tough four problems. Let me just briefly mention three. First, in recent years, by recent years, I think I mean in the last few decades, we have tended to think of the human body and health services in much the same way that we have thought about automobiles and auto repair shops. We have thought about the human body as a machine which responds to scientific diagnosis and treatment almost mechanically. We have not given enough thought to the responsibility of the individual for maintaining his or her own health and the responsibility of the family to take care of the individual family member in time of illness. We may not have had enough respect for the human body and its ability to recover from illness and abuse. We have tended to shift more and more of the responsibility for individual health onto the health system, which has tended to treat the individual with increasing scientific precision in the most impersonal way, especially in the hospital. Where we take the person's clothes away and put 'em in a gown and talk about the individual by his diagnosis. And, generally speaking, don't expect any cooperation from the individual in his own care. We are now aware of the probabilities that this approach can lead to endless refinement of cost-increasing procedures and services while overlooking many opportunities for the individual to play an active role in improving his own health condition. The advances of medical science from the late 1890s through the beginning of Medicare have probably led us to develop unreal expectations of the values of technological health services. Many key members of the medical profession have warned us for many years about the importance of the individual patient-physician relationship and the necessity to adapt services to the unique requirements of each individual, but these warnings have gone largely unheeded. Only after a number of years of Medicare, our mechanistic approach is beginning to be questioned generally. Secondly, we've had a tendency in health, as in other human services, to develop unreal expectations that we can solve any problem by throwing enough money at it. Certainly, the experiences during the '60s have demonstrated the fallacy of this approach to complex human and community problems. We are beginning to hear more only recently that smaller may be better. That more cost and more benefits don't necessarily go together. That there are situations where we could have high quality and lower costs. That high quality and greater efficiency are not necessarily conflicting ideas. Somebody suggested at the afternoon session that anyone who suggested that we oughta cut back on health services might get stoned in the streets. Well, I'll take my chances because I really think we have certain opportunities for cutting back health services and improving health. That may be a new thought, but it's a thought that I suggest to you gives consideration to a thought that I think you will hear more and more about in the years ahead. Thirdly, prior to the development of large-scale nationwide programs of health services, such as Medicare and Medicaid, we were not used to seeing health services in the overall aggregate. We were not used to thinking about health services in relation to populations. We were not used to thinking about health services as a system. And we were not sensitive to the gross impact of individual decision-making in health on the overall input to the health system and on the overall net outcomes. All of these factors must be taken into consideration in formulating a new approach to health services that can lead towards solution of the problems that I've enumerated and that, coincidentally, once we solve them, will inevitably lead to the discovery of new problems not yet thought about. The other day, Bob Derzon, who's just joined the federal government, made the observation that the most interesting thing to him about health services, having spent quite some time in a number of very good hospitals and seeing some very good services provided, and then going to the national scene and looking at the health services from a national viewpoint and the overall expenditures and the overall result, he said the thing that strikes him the most is that in this field, in contrast to almost anything else he's ever seen, the sum of the whole seems, somehow or other, to add up to less than the sum of the parts. And that's something to cogitate about. Well, let's talk about approaches to solutions to these problems, assuming that they really are problems. In developing solutions to the problems that I've enumerated, it is important to recognize that the basic problems do grow out of the complex system and grow out of how we conceptualize the system as contrasted with particular villains. And that point was made this afternoon. There really is no purpose in looking for villains, as some do, whether you want to identify as villains physicians who earn too much money or individuals who neglect their health or hospitals who are insensitive to the suffering in their immediate community or bureaucrats who are more concerned with conformance to regulation than relief of suffering. It's very easy to identify those kind of villains, but it's unlikely that that's the root of the problem, that we could root out some villain and we'd solve it. It's the whole complex system. And not only are there no villains, but there also doesn't appear to be one right way to solve the problems. A variety of approaches to complex problems on a community basis would appear to be the most likely way to find solutions, but there may be some common themes. With respect to financing., I think one can expect to see a shift in the next few years from solutions based exclusively on national health insurance to solutions embracing universal entitlement for services, with no universal entitlement for services that would be received with no significant requirement to pay anything at the time of receipt of the services. I think we can expect development of a variety of methods of assuring payment for services other than from the patient's pocketbook. Insurance mechanisms will be involved, but so will taxation and so will other approaches. We can expect to see more and more employed groups and other community groups jointly raising funds through a variety of prepayment mechanisms to support specific health services which they expect to be accountable to them. Now, the combination of all of these methods of providing assurance may be identified as a national health insurance, may be called national health insurance, but few of these devices will incorporate any of the classical principles of insurance taught in a basic college course in insurance. The situation may be quite similar to what now exists in England, where individuals pay a sum of money for health insurance, but this covers probably less than 10% of all health services to which they are entitled. Basically, Great Britain has a national health service, as contrasted with national health insurance. And undoubtedly in the United States, we will involve our own unique mechanisms for organizing and financing health services, incorporating some of the elements of classical insurance. Basically, however, most of the concepts and mechanisms of pure insurance become extra baggage and extra paperwork as soon as the nation makes a total commitment to universal entitlement. Other mechanisms than insurance are able to deal more directly and more appropriately with issues of limits and issues of accessibility and effectiveness, issues which will be the major concern in the years ahead. One way or another, we can be sure that within a decade, we will have achieved a variety of arrangements that will add up to virtual universal entitlement, a situation which is inherently inflationary unless protections are built in. So this gives us only a very few years to develop the philosophy, concepts and mechanisms for addressing problems of limits, effectiveness and accessibility because we will have universal entitlement by that time. Now, if we don't develop approaches to limits, approaches to effectiveness, to measuring effectiveness and controlling it, then healthcare services can well get out of hand, both in terms of cost and waste, and possibly even in actual interference with the health of the people. Ivan Illich thinks we've already passed that point, but he's a rather dramatic guy and I'm not sure I agree with him, but we may be approaching it. As far as costs are concerned, in the next few years, the only approach that can be expected to have significant impact will be the imposition of direct limits on a national scale. These limits will necessarily. And that's only because I don't see the voluntary hospitals and voluntary groups being able to pull together and do it for themselves, so it will be done by government. Unfortunately, these limits will necessarily have to be arbitrary until we develop more sophisticated approaches to control than we have at this time. Limits will have greatest long-term impact if they are applied primarily to capital investment, as contrasted with current expenditures. We now know that continuing capital investments, that's when you spend money now for the future, that's what capital investment is, you know, Economics 101. We now know that continuing capital investments in research and manpower and facilities have a tendency to predetermine the ongoing operating expenditures for many years ahead. Only as we make significant changes in the nature of our capital investment can we be sure that there will be changes in the direction of our ongoing expenditures. Since we are about to enter, I feel sure, a period of 10 years or more of transition in our conceptualization about health and in our approach to health services, this is the time for imposing as close to a moratorium, to a total moratorium on capital investment as is possible. There's every reason right now to slow down, especially the construction of health facilities and the expansion of health equipment, but also to take a new look at our research programs and at our educational programs that determine the character of our health personnel. We are now spending over $5 billion a year for new plan and equipment in the health industry. Obviously, there will be strong resistance to even a temporary moratorium in this level of expenditures. A moratorium and limits will be acceptable only if seen in the perspective of the transitional period we are about to enter and the value of that kind of moratorium in improving our health in the long run. Now, the twin issues of accessibility and effectiveness will necessarily have to be addressed at all levels in our society, but primarily at the community level. Greatest progress will be made when these issues are addressed simultaneously. To quote from Anne Somers and Herman Somers, thoughtful people in this field, \"any new design \"that will improve health service effectiveness \"must be based on two broad assumptions.\" First, that \"responsibility for personal health \"must rest primarily with the individual, \"not with government, not with physicians \"or hospitals, not with any \"third-party financing program. \"National health policies must be directed \"to increasing, rather than eroding, \"the individual sense of responsibility \"for her own health and her ability \"to understand and cope with health problems.\" That's number one. Number two, \"if the individual's responsibility \"is to be effectively discharged, \"it must be supported by social policies \"designed to provide the individual \"with essential environmental protection, \"health information \"and access to healthcare when needed. \"The overriding goal of our health programs \"must be the creation and maintenance \"of conditions under which individual Americans \"are most able and most likely \"to optimize their own health potential.\" We will, I think, evolve a policy which combines individual responsibility and social responsibility, recognizing that these are complementary, and not antithetical. We must recognize that neither can be fully effective without the other. Now, this approach will require new balance of responsibilities as among individuals, the professions, the health service institutions, especially hospitals, financing agencies, planning agencies and various levels of government. The key is to develop effective interactions between individuals and health service institutions at the community level so there is a sense of mutual responsibility and mutual accountability. Let's look briefly at the implications for this kind of health program for each of the various elements that I've referred to. And after we've looked briefly at the implications for each, I'll stop and maybe we can have some discussion. First of all, for hospitals, the new approach to health and health services, which I've outlined, requires clearer definition of the service population of the individual hospital. Clearer identification of that population with the institution, and the institution with the population. Clearer definition of the health problems of the target population, and adaptation of all the hospital's programs to the solution of these problems, of these people. For the individual hospital, this will mean investment in resources for measuring the health status of the population served. I think it's significant. Check with your nearest hospital and ask them if they know what the death rate is in the immediate neighborhood. Ask them if they know what the leading cause of death is. Try to find somebody that's responsible for knowing. And if you do find somebody, let me know. It'll be a unique thing. Hospitals have not invested in resources for measuring the health status of the population served, so how can they have an effective program? But they must develop those kind of resources. They must develop resources for promoting positive health and preventive health services, and for placing primary healthcare services ahead of secondary and tertiary specialized services. Entirely new systems of internal accountability and management will be required to match this kind of system of evaluation and programming. Furthermore, new kinds of relationships with other institutions will be required, and a new set of interactions with other community and other nonprofit institutions and professional groups and a variety of governmental levels. These are all new, tough directions for hospitals to take, but as community institutions, I believe they really have no choice once the direction's set out 'cause if they do not face up to this kinda challenge, hospitals will end up as little more than technical resources with little influence on the evolving system and with little opportunity for self-determination of what goes on within their own walls. Let me say a few words about the implications of this new approach to health services for health professionals. This is treading on even touchier ground than talking about hospitals, talking about health professionals. I think for health professionals, translation, that means physicians and others. Okay, for health professionals, a wide variety of changes in approach and attitude can be expected, which will probably take a few decades to unfold in different ways in different communities and community settings. Most important will be gradual acceptance and promotion of the idea by health professionals that the individual is responsible for his own health, including his health maintenance and health services. This means recognition that in the typical patient-physician relationship, who's in charge? This will mean recognition that in the typical patient-physician relationship, the patient should be in charge. The physician is the patient's educator, consultant, advisor, but not his boss. In fact, the physician is working for the patient and can carry out specific procedures legally on the patient only with his informed consent. Failure of physicians and patients to carefully define the relationship in terms of mutual expectations and clear understanding of who's in charge of the relationship is, in my opinion, at the root of most medical malpractice suits. Closely related, health professionals can be expected to redefine the relationship between specialists and generalists, and to gradually shift these relationships so that the generalists are back on top, rather than the specialists. The specialist will find better ways to protect their important special interests than by dominating the entire system. Various trade-offs will be involved, but the role of primary care practitioners will gradually become dominant as specialists are increasingly on tap, rather than on top. These developments will stem in part from changes in medical nursing education, but in more instances will stimulate changes in the educational institutions themselves. Adaptation of health professionals to changing concepts of health and health services will be facilitated as health professionals increasingly form team relationships in organized settings so that allocation of tasks can be accomplished in ways that will maximize professional satisfaction and results, and minimize waste of valuable professional resources and waste of money. One thing is clear, the role of the nurse and of other health professions and occupations associated with medical care allied to the physician will be greatly enhanced as tasks are traded down. Health maintenance organizations provide one structure within which these changes can be expected to occur, but there will be others. Very difficult transitions are involved that will be worked out most expeditiously and with least tension in those communities blessed with outstanding medical leadership, medical leadership who are able to focus on the individual patient and on the people and their health requirements and on the big picture at the same time. During a period of transition that we will be going through, comparable to the transition in transportation from the horse and buggy to the automobile and then to airplanes, we will run serious risk of building brand-new outmoded facilities that we will be stuck with for decades. Resource development should focus on promoting innovation, preferably on a small scale in a variety of settings, reflecting community initiative in attacking specific problems and with evaluation programs built in so that we can learn quickly what innovation works and what doesn't. Finally, government can be expected to develop new approaches to one of its basic functions, regulation. Regulation must shift from its current emphasis on regulating processes and procedures, and focus on outcomes and local accountabilities. This will require massive upgrading of control capabilities at hospitals and other health service institutions, as well as at the state government level. Again, a long transitional period lies ahead with no instant solutions, but there's no better time to start on this kind of thing than now. The kind of transitional period that I visualize in redefining health and in redefining health services in relation to new definitions of health in the next decade, community financing agencies, like Blue Cross and Blue Shield, will have to face new challenges, just like everyone else. 'Cause even if the marketplace becomes less important as government provides national health assurance, it is never possible to sterilize the impact of money. Whether money is flowing from patients to the health system, money's gotta be flowing into the health system. The Blue Cross and Blue Shield will become less involved in marketing and more involved in how they pay for care and how their payments can influence the shape of the service provided for good, rather than for ill. This type of activity can never be totally computerized and programmed, and it's best carried out as close to the servicing as possible. If the blue plans are able to work effectively with the hospitals and the professions on the one hand, and the government on the other, they can play a key role in maintaining balance at the community level in relation to government. Primary responsibility for spreading the word about new approaches to health and health services will rest with the area health planning agencies, now known as health systems agencies, which are now being formed in every part of the country in response to Public Law 93-641, passed in 1974. These agencies can promote new understanding in their communities. They can help to develop new relationships and new accountabilities. They will have greatest impact if they avoid the pressures to develop master plans that may have the effect of freezing the system when it should be most flexible and innovative. These agencies are almost all organized as nonprofit associations, but they are mandated by law and they get all their money from government. They're mandated by law to concentrate on 10 national health priorities, and they'll do it, including primary care, multi-institutional systems. These are the national priorities as set forth by Congress. Primary care, multi-institutional systems, medical group practice, physician assistance, disease prevention and preventive health.","format":"text/plain"},"target":"https://iastate.aviaryplatform.com/collections/1150/collection_resources/45426/file/118383#t=0.0,4013.92327"}]}]}]}