Reflections on Health Care: Oregon State Board of Medical Examiners [and] Oregon Foundation for Medical Excellence, Portland,
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67 (2,517,269 Bytes)
1989-10-06 (October 6, 1989)
Koop, C. Everett
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Medical Subject Headings (MeSH):
Health Care Costs
Health Care Economics and Organizations
Health Care Reform
Reproduction and Family Health
"Reflections on Health Care: Oregon State Board of Medical Examiners [and] Oregon Foundation for Medical Excellence, Portland,
Oregon" and "Remarks to Physicians, Oregon State Board of Medical Examiners, Portland, Oregon" [Reminiscences]
Remarks to Physicians, Oregon State Board of Medical Examiners, Portland, Oregon (October 6, 1989)
Box Number: 9
Folder Number: 1989 Oct 6
Reflections on Health Care
Oregon State Board of Medical Examiners
Oregon Foundation for Medical Excellence
(Also with City Club of Portland)
October 6, 1989
Speech by C. Everett Koop, M.D.
Greetings to Dr. Johnson, Congressman Widen, guests, etc. - Delighted to be part of the 100th anniversary of the Oregon State
Board of Medical Examiners.
Not too long ago, a luncheon talk about health care in America would have been a pleasant dessert, something to make us feel
good about ourselves and our health care system. Not today.
In a word, -- we have big problems. Sometimes I used to wonder if there should not have been another Surgeon General's
warning: "Warning! The American health care system can be hazardous to your health!"
To begin with, this is a time in which we have very high expectations for medicine and health. We've put a great deal
of faith into new technologies, new pharmaceuticals, new surgical procedures, and so on, and we continue to have faith in
the magic of medicine.
We routinely expect miracles to happen -- even though the real world of medicine isn't always able to deliver.
We have that situation right now with AIDS. For the past 8 years, scientists and clinicians have been working around-the-clock
to understand and conquer the disease of AIDS. But it still remains a mystery. I'm sorry to say this, but I doubt that
will get full control over the AIDS virus before the turn of the century.
But, as far as the general public is concerned, the AIDS situation is the exception and not the rule. The American people
still maintain high hopes for what medicine and health care can do for them.
But I think it's also becoming clear that those high expectations are fast outrunning our ability to pay for them.
In other words, we will clear gap in our society today between what we would like to see happen in health care . . . and what
can realistically happen in health care. And so the American people are engaged in a debate in respect to aspirations versus
This is a debate that touches on many aspects of American life . . . but I'll focus just on health care, which is profoundly
affected by the growing tension between aspirations and resources. Many of our great expectations come from our abiding faith
in ever-improving medical technology. But now, I believe the public wonders if medical technology might be a mixed blessing.
Thanks to an explosion of new knowledge in science and technology over the past several decades, we know how to do many new
and fascinating things: but knowing how to do something has never been enough. People also want to know why . . . or why not?
And today, as the cost of our magic technology soars, we're asking "Why?" more often and more insistently.
In regards to prolonging life, for example, both the lay public and the medical profession are even now debating the wisdom
of using so-called "extraordinary" measures to save or prolong the lives of people profoundly traumatized or terminally
ill. For many people who must decide the fate of loved ones, high-tech medicine sometimes acts like a friend . . . and sometimes
it acts like an enemy.
Hence, some people are turning to legal instruments like the so-called "Living Will" and the "Durable Power of
Attorney" to protect themselves from runaway medical technology, in the event they one day have a terminal illness or
condition. Hence, in many real-life situations, technology is a mixed blessing . . . at best . . . and can be a curse, at
Is our society still ready and willing to deliver high-quality, technology-intensive medical care to everyone, regardless
of cost? I'd have to say that societies answer is approaching a "probably not."
Or, perhaps, the most sophisticated medical technology is often simply irrelevant. According to one survey of physicians,
the largest category of patient complaints involved "conditions without illness." In other words, the average practice
-- not just among family physicians but also among many specialists -- has a significant number of patients who are in relatively
good physical and mental health, but don't believe it . . . and what they want from their physician is some display of
reassurance, understanding, solace, or sympathy . . . some demonstration of what Shakespeare called the "milk of human
kindness." What we have, then, is a rise in the new technologies available to physicians . . . but, at the same time,
a decline in their significance for a substantial number of patients.
But we didn't see it . . . or, if we did see, we preferred not to worry about it today, we still have an inflated health
care economy . . . But we also have inflated health care aspirations. And we simply can't afford any inflation in all.
But when I or other people talk like this, our critics come back at us and say that things really aren't that bad . .
. that all we need to do is put a reimbursement cap on this . . . or change the eligibility regulations for that . . . or
cut back a little here . . . or prune back a little there. During 8 years as your Surgeon General, I listened to these debates
and I thought about the true human costs associated with that kind of a patchwork approach.
And today I'm more convinced than ever that our whole health care system needs to be studied with an eye to making a number
of very major corrections. Now, I can't Artie hear the critics saying, "Wait a minute, Dr. Koop. The system ain't
broke, so don't fix it."
To which I would reply, "You're wrong. The system is broken . . . and it must be fixed." Band-Aids won't do.
Hospital costs are still climbing . . . and no one can prove to the American people that the quality of hospital-based care
is uniformly going up as well. On the contrary, our people complain that they are paying more and more for medical care, and
are getting less and less.
Worse still, as the cost of hospital-based care increases, the hospitals themselves are trying to narrow their patient pool
. . . for example, eliminating the need to provide inpatient medical care for poor and disadvantaged Americans. I say there's
something terribly wrong with the system of health care that spends more and more money to serve fewer and fewer people.
And we have much the same problem in respect to physician services and fees. I can tell you that many of my friends and colleagues
in medical practice are trying to do with they can to increase the quality of care they deliver without increasing their costs.
But they argue that they have little or no control over some of the inflationary things they do. And that's true. I've
been there -- so it's not just giving them the benefit of the doubt.
But the fact still remains that physician fees are going up, and they do add to a burden on the public that is becoming insupportable.
And, again -- as with hospital-based care -- the American people have not been assured, in any rational and measurable way,
that the higher costs of a physician's care will in fact buy them a proportionately higher quality such care.
Whether speaking of doctors or hospitals, -- it is not a matter of morality -- it is survival -- everybody is "doing it"
-- whatever "it" you focus on. The reality is that doctors and hospitals cannot not do "it" or they fail to
The great truth is that the health system will never revamp itself. The change has to come from the environment -- and that's
[NOTE: These sentences are crossed out: We simply don't know. We don't yet have the tools or the mechanisms to make
those kinds of necessary marketplace judgments. But,] before I go any further, let me say that in general I support the concept
of a laissez-faire marketplace and I believe in a freely competitive economy.
I think a laissez-faire economy works best for all our citizens and I'm thrilled -- as I'm sure all Americans are
thrilled -- to see so many countries with state-controlled economies coming around to our point of view. Now, having said
that, let me go on to say that the health care marketplace is laissez-faire . . . but it's not freely competitive and,
hence, it has virtually no moderating controls working on behalf of the consumer, or the patient. In most other areas of our
economy, the marketplace does exercise some control over arbitrary rises in charges to the consumer. There really is competition.
Here and there it might be rather thin . . . but it does exist and it does provide some assurance that ineffective, uncompetitive,
high-cost, low-quality enterprises will fail. But in health care, right across the board, prices have gone up your irrespective
of the quality of care being delivered or of any other marketplace control.
Try as they might, I don't see the medical profession achieving much success in self-regulation. Granted it's no simple
task. But as I said a moment ago -- until the purchasing public -- "buys right" -- as Walter McClure puts it -- the
market cannot change.
Physicians can help put the brakes on some general expenditures, there are very few physicians who can honestly and effectively
control the delivery of service -- much less control the costs of that service -- while caring for a specific, individual
patient at the bedside. We seem to have, therefore, a system of health care is distinguished by a virtual absence of self-regulation
on the part of the providers of that health care -- that is, hospitals and physicians -- and distinguished as well by the
absence of such natural marketplace controls as competition in regard to price, quality, or service. What is the effect of
such a system anyway?
One very serious effect has been the emergence of a three-tier framework of health care. We've always said we never wanted
even a two-tier system. But we have it . . . and a third tier, also. In the first tier . . . the bottom tier . . . are upwards
of perhaps 30 million Americans -- about 12 percent of the population -- who fall between the cracks have no health insurance
coverage . . . no high options . . . no low options . . . no options at all.
They're not old enough for Medicare and not poor enough for Medicaid. What, then, does this "Health Care System"
of ours do for the uninsured? In the vast majority of cases the answer is . . . very little . . . or nothing. And they are
suffering the consequences. Study after study indicates the correlation between no medical insurance and increasing health
The health problems of the lowest tier, if ignored by society now, will be borne by society later. Then we have a second-tier.
This tier receives a narrow range of basic medical and health services with more or less fixed levels of reimbursement. This
is low-option coverage . . . Medicare and Medicaid coverage . . . with the patient paying many costs out-of-pocket or with
the help of some form of supplemental insurance, which is -- in my book -- just another kind of out-of-pocket expense.
Finally, we have the third tier, the top tier. The people in this tier receive a full range of medical and health services.
They are covered by high-option health insurance and also have a few dollars left over to pay the 15 or 20 percent difference
between the actual bill from the doctor and the check from the insurance company. Many of our largest business and industrial
organizations are in this top tier. Years of tough collective-bargaining made it possible for millions of their unionized
employees and their families to be in that top third tier.
But now it's no secret that health care inflation has become the major sticking-point in their collective bargaining,
also. But how does the bargaining and? That's easy: more money is promised for employee health benefits . . . and the
increased health costs translate into higher prices for the customer or the utility rate-payer.
In other words, employee health plans have really become "pass-along" mechanisms through which dollars, are passed
along and into the health care system. It is working that way for the past 20 years or so. But I don't think Americans
can keep feeding the health care system quite that way anymore. We've got to make some changes.
And business itself is finally coming around to understand this. It cannot continue to bury inflated costs of health care
in the price-tags of their goods and services. Since 1984 the average premiums for employer-provided health insurance have
approximately doubled . . . to $3,117 per year, and have risen from 8 percent of business payroll costs to 13.6 percent this
Businesses can't absorb these costs and also expect to be competitive. American businessmen and labor leaders are finally
coming to understand what this means. There is a "health benefits surcharge", if you will, on every car that General
Motors manufactures in this country. It amounts to about $600 per car. In contrast, cars made at the new Nissan plant in Tennessee,
the "health benefits surcharge" is only $60 per car. The General Motors health plan is a generous one, and it covers
retired employees as well as active workers. Nissan, on the other hand, offers a limited plan that does not even provide maternity
benefits or pediatric care for its active employees.
But, while economic pressures make business consider cutting back on the health-care benefits they provide, social pressure
compels providing even more. We have seem current labor disputes focus on health benefits packages, not wages or hours.
I'm reminded, for example, of the recent report of the "National Commission to Prevent Infant Mortality." Among
other things, the commission recommended that the American people must . . . "Provide universal access to early maternity
and pediatric care for all mothers and infants." In other words, let's get rid of any and all barriers to health care
for each and every mother and child in America.
Of all industrialized nations, only the United States does not guarantee access to basic health care. But this recommendation
amplifies the concept of "access" in a new and very important way. It says that . . . "Employers must make available
health insurance coverage that includes maternity and well-baby care."
The commission was evenly balanced with physicians and non-physicians . . . Republicans and Democrats . . . Federal and state
officials . . . and so on. Hardly a radical bunch by anyone's standard. Yet, the members came out for a much greater role
for private employers.
Why do they do that?
Because today, of the more than 56 million American women of child-bearing age, roughly 16 to 44, almost 28 million of them
are employed full-time in the American work-force. That's 50 percent of all women in that crucial child-bearing age group.
In addition, well over half of all mothers of small children -- kids three years old or younger -- are working full-time.
On a day-to-day basis, is now clearly the managements of business and industry who exercise the most critical influence upon
the health of America's mothers and children. The health care system in America today is a terrible moral burden for society
to bear, in that the system does not respond at all to some 12 to as high as 15 percent of our population.
It is a terrible economic burden for society to bear, in that the system satisfies its own uncontrolled needs at the expense
of every other sector of American society. We need to change that system.
Not just a little change here and a little change there. We need to bring about a profound change, across-the-board, in the
way we make medical and health care available to all its citizens.
But can we do it? I'd like to think we can . . . because we have to . . . and especially because we've done it before.
Some 50 years ago, for example, we Americans knew that it was morally wrong for our society to allow its old people to drift
into poverty and starvation. We knew that we could no longer standby helpless in the face of such human misery. And so we
enacted a Social Security Law to make sure that every American would be assured of a measure of human dignity and respect
in his or her twilight years. It was an act of fundamental decency. We knew we had to do it. And we did it.
We met a similar challenge more recently than that. Back in the 1950s and early 1960s, the people of this country became painfully
aware of the terrible unfairness of "separate but equal" education. And so, through our courts and our legislatures,
we released America from the crushing official legal burden of segregated schools. That's over. And thank goodness it
Did we get rid of those burdens once and for all? Well, not exactly.* We haven't yet solved every problem associated with
"growing old in America." We know that.
*And we haven't yet produced the perfect, egalitarian school system. We know that, too.
But at least we've lifted from the shoulders of our people a large measure of the burden of shame and guilt that came
with doing nothing. We did what was morally right for this country. And I believe we can -- and must -- do that again.
Let's finally say what we've hesitated to say for too many years, and that is . . . our current system of health care
is not fair . . . it's not just . . . and, therefore, it is not the morally strong system that our society needs -- and
deserves. We are at a crossroads. We cannot afford to do nothing, to continue business as usual. The pressure for radical
changes is coming from all directions: from members of Congress, from business, from labor, and from the general public.
Increasingly we hear the demand for restructuring the financing and delivery of healthcare United States. Even some business
leaders who normally cringe at the thought of government intervention or regulation find themselves calling for a system of
national health care as a solution to rising insurance costs. Now I just bet you think I'm here pumping for another governmental
entitlement. I am not. But if we don't offer something better, we will get a government controlled medical system and
lose forever the present potential for the best system possible.
Recently I've noticed a strange interest in the Canadian system. Everywhere I go people say to me, "We need the Canadian
system." So I say, "Tell me, what is it that you like about the Canadian system?" They always answer, "I don't
really know, but it's a good system." The growing infatuation with foreign national health services is based more
upon dissatisfaction with our system that upon understanding of another one. Most Americans do not realize that a national
health service, like the one in the United Kingdom, is based upon planned scarcity.
Experience the world over has shown that when government economic controls are applied to health they prove -- in time --
to be detrimental. Eventually there is an erosion of quality, productivity, innovation, creativity. Then lack of responsiveness
to patients (the Canadian system is not controlled by physicians) -- finally rationing and waiting lines. Americans to not
patiently queue up for anything, especially for medical care. We have become accustomed to available care, if not accessible
We desire personal care.
Now, it may not be possible to have the same personal relationship between doctors and patients that our grandparents had.
Today, urban people, especially, rely upon emergency room care and group practices, and the efficiency they bring half come
at the cost of that personal relationship.
But, we can do a lot to restore the doctor-patient relationship, a relationship that is unfortunately becoming changed to
a provider-consumer relationship. I realize that there are some built-in problems. People are happy about being ill, needing
to go to the physician. Having to pay a high price for it makes it even more unpleasant.
But we need to subordinate the economic aspect of the relationship to the climate of trust between the doctor and the patient.
If the patient thinks of himself primarily as a consumer, getting the most for his money, he automatically puts the doctor
in the role of the seller, getting the most for his services. If the doctor is primarily concerned about collecting his feet,
he automatically arouses the consumer mentality in his patient. We also need to reform the malpractice mess, the tortured
tort system that forces doctors and patients to view each other as legal adversaries.
We need to get past the standoff between doctors and lawyers. Perhaps a committed group of retired lawyers and doctors, men
and women without a direct personal economic stake in the system, could perform the public service of adjudicating claims,
deciding which cases should go to court. I'm sure that both the doctor and the patient would prefer to have that old relationship
of trust they used to have.
It can be restored.
But it will take commitment by people on both sides of the stethoscope. Let me tell you how I think that change take place:
we need a Presidential Commission -- the bluest of blue ribbon panels to consider the future of health care in America.
The fallacy of economic controls that you attempt to force change -- and reorganization against the will of those providing
health care -- it is not in their own interest, as they see it, because the more inefficient the provider, the more revenue
regardless of health produced. There is a better way -- and it presents further intrusion by the government into the delivery
of health care.
I stress, again, what I mean by working members -- Congressman and Senators themselves, not their staff appointees. I believe
that the professions, business, and industry should join in on a sincere effort to make sure that every man, woman, and child
in America has available a basic array of health and medical service.
To ensure the "buy right" outcome of such deliberations we need a potent, large constituency. You could and should
be part of it. You corporate leaders -- purchasers of health plans must get together -- choose health coverage that rewards
quality and productivity. The savings will pay for the cost of those presently without access. But there is no quick fix --
from here to there could take a decade -- but we'd improve all along the way and eventually every American should be able
to expect and to receive adequate health service anywhere in this country. Putting together such a morally strong and fair
system of health care will be a major task for this country. I have no illusions about that. But we must not let such considerations
stop us from doing what we know is right.
That we have one tier of health care in America to which everyone is entitled. Some people want more service will pay for
it. And that should be their privilege.
On that commission we need the health professions. You may think I've been hard on them in these remarks today, but I
know their leaders and I know that their sense of fairness and justice is not one ounce less than mine.
When asking for today is what they want, also, and I believe they, too, would join in a truly just effort to improve the system
of health care delivery in this country. We need statesmen -- and there are a few left.
We need the insurance industry, because it's people are knowledgeable -- and threatened.
We need -- most of all -- working members on that panel from both parties and both houses of Congress. Members of Congress
who will develop a proprietary interest in the panel's conclusions and taken to the floors of the House and the Senate,
for debate and passage of legislation to make sure something gets done.
And as I've said -- that doesn't mean government economic control.