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�Clinton Presidential Records
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�TWINLAB
VOLUME 2, NO. 3 , 1 9 8 7
PDA
Published by A d v a n c e d R e s e a r c h Press, Inc.,
A n affiliate of T w i n L a b o r a t o r i e s , Inc.
EDITOR'S NOTE: Carnitine
belongs to a group of food
factors known as nonvitamin nutrients. Scientific
interest
has
increased
dramatically in the last few
years, as evidenced by a
rapid
increase
in the
number
of
scientific
publications. Carnitine first
gained widespread
public
recognition in 1984 with the
publication
of my book
"Carnitine—The Vitamin B,
Phenomena'". Since then,
a grass roots interest in
dietary supplements
has
BY B R I A N E. L E I B O V I T Z , P h . D .
factors best described as non-vitamin nutrients. Carnitine,
like many other biological molecules, comes in two forms: Lcarnitine and D-carnitine. These isomers are mirror images of
Continued on page 2
THE FACTS ABOUT
GLUTATHIONE
Q: "What is glutathione and what does it do?"
—Kathi Lewis
Boulder, CO
Dr. Brian E. Leibovitz
blossomed, and a number of carnitine-containing
formulations
are now available. Recent studies have uncovered a number
of important clinical applications, including heart disease,
hyperlipidemia, diabetes, certain muscular disorders, exercise
performance,
and various genetic carnitine
deficiency
syndromes. In this issue, carnitine's fundamental aspects as
well as medical uses will be examined.
CARNITINE
Carnitine was first found in muscle extracts by two Russian
scientists in 1905, and was so named from the Latin carnis
( m e a n i n g flesh or m e a t ) . In the late 1940's, Fraenkel
discovered that carnitine was a necessary substance for the
mealworm Tenebrio molitor. He named it vitamin B , although
it was later established that carnitine is not a vitamin for higher
organisms including man. The next important breakthrough
was made in 1959 by Fritz, w h o f o u n d that c a r n i t i n e
stimulated the rate of fat burning (called 'beta-oxidation').
Subsequent investigations revealed the mechanism of
carnitine's a c t i o n : fats are t r a n s p o r t e d by a carnitinedependent mechanism into the mitochondria where they are
burned for energy (as discussed below). The role of carnitine
in nutrition received little attention until 1973, when the first
carnitine-deficient patient was described. Since then, many
clinical investigations have focused on biomedical aspects of
c a r n i t i n e d e f i c i e n c y , as w e l l as on the e f f e c t s of
supplementary dietary carnitine on disease processes. A
more detailed description of carnitine's history is available' .
T
2
C a r n i t i n e is c h e m i c a l l y t e r m e d 3 - h y d r o x y - 4 - N - t r i methylamino butyric acid; it is similar to choline and a close
cousin to amino acids. [NOTE: unlike amino acids, carnitine is
not used for protein synthesis]. Carnitine was given B vitamin
status by Fraenkel because it contains nitrogen and is very
soluble in water—two characteristics of the B-complex group.
Strictly speaking, however, carnitine is not a vitamin since part
of the human requirement is fulfilled by biosynthesis. [NOTE:
a vitamin, by definition, is a substance essential to the body
that cannot be produced by the body and must therefore be
obtained in the diet]. Like vitamins B3 and D (which are also
produced in the body), carnitine belongs to a group of food
A: Glutathione is a tripeptide (or, in other words, contains
three amino acids) composed of cysteine, glycine and
glutamic acid. It is found in both the reduced (GSH) and
oxidized (GSSG) forms. The main function of GSH in the body
relates to antioxidant status, since it is essential for the
enzyme glutathione peroxidase (GP). GP detoxifies lipid (and
other) hydroperoxides and thus helps to mitigate oxidative
damage.
Glutathione
also helps to detoxify
foreign
compounds and drugs (collectively termed "xenobiotics") by
a system involving glutathione-S-transferases.
These
enzymes link GSH to lipid-soluble
xenobiotics
thereby
increasing
their water-solubility;
subsequently,
the
xenobiotic-GSH complex is excreted in urine and feces. GSH
is now available as a dietary supplement, and is preferred
over cysteine since GSH is less prone to autooxidation. GSH
has been demonstrated to benefit a number of diseases (as
have the other antioxidants), as discussed in future issues of
NUTRITION UPDATE.
s
GOT A QUESTION?
Send'it to "NUTRITION UPDATE" Each issue we'll "
•havela^uestion^andianswercolumn wheresyou.cahA
personally ask Dr'Brian Leibovitz any questions you ,»
"h'avefabout fnealth:and nutrition^.Rlease'address :all4 i
.questionsto • .
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Dr BrianrUeibbvitz. ffh Dv>"NUTRITION URDATE","
2552^6013 DrivefDaYis, Calif "95616 ' ,« ' ^
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ABOUT DR. LEIBOVITZ
Dr. Brian Leibovitz holds an M.S. degree in Biology from
Portland State University (in conjunction with the University of
O r e g o n M e d i c a l School) and a P h . D . in Z o o l o g y and
Physiology from the University of W y o m i n g . He was a
research associate to Nobel Prize Laureate, Dr. Linus
Pauling, and completed his post doctoral research in the
D e p a r t m e n t of Food S c i e n c e and T e c h n o l o g y at the
University of California/Davis. Dr. Leibovitz has published
numerous scientific articles in the field of nutriton and the
book "Carnitine" (Dell Publishing Company, NY, 1984). Dr.
Leibovitz is the Editor-in-Chief of The Journal of Applied
Nutrition, and has a nutritional consulting practice in Davis,
California.
© 1987 ADVANCED RESEARCH PRESS, INC.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
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�TWINLAB' MT 1
VOLUME 3, NO. 1, 1988
PDA1
Published by Advanced Research Press, Inc.,
A subsidiary of Twin Laboratories, Inc.
COMPILED AND EDITED BY BRIAN E. LEIBOVITZ, Ph.D.
Editors Note: Coenzyme Q
(COO) was first isolated
from beef heart mitochondria
in 1957, and was subsequently demonstrated to be
essential for energy production in virtually all living
organisms. In the last
decade, a number of important clinical applications of
COQfiave been uncovered,
including: cardiovascular
diseases, immune responsiveness, microbial infections, periodontal disease,
and certain muscle disorders. Although many
Dr. Brian E. Leibovitz
foreign
investigators—
particularly the Japanese—have extensively studied its
therapeutic benefits, COO has yet to gain a strong foothold in
Europe and the United States. The reasons for this disparity
have recently been detailed by Professor Karl Folkers—one
of the formost scientists in this field'. Nevertheless, it is my
belief that COO is a nutrient whose time has come. Since
1976, five symposia have been held and six scientific books
published on biomedical and clinical aspects of COO. In
addition, Bliznakov and Hunt released a book entitled "The
Miracle Nutrient Coenzyme Q" in January of 1987', which
should serve to increase public recognition of this molecule.
In this issue of NUTRITION UPDATE, fundamental and clinical
aspects of COO will be examined.
COENZYME Q
COQ is ubiquitous to all animal and plant life, and refers td a
group of fat-soluble compounds with a common ring structure
(termed "quinone"). It is also known as ubiquinone, which
reflects these two attributes. The structure of COQ is illustrated
in Figure 1. In man and most higher animals, COQ10 is the
predominant form (except in rats and mice where COQg is the
main homolog). Plants contain both COQ9 and COQ10, while
COQs is the form present in most bacteria. [NOTE: The
subscripts indicate the number of "isoprenoid" side-chains].
For simplicity, COQ will be used to denote COQ10 in this
UPDATE (except where indicated).
Chemically speaking, the most important attribute is its ability
to undergo reversible oxidation-reduction, as shown in Figure
2. The reduced form (ubiquinol) is converted to oxidized COQ
(ubiquinone) by the loss of two electrons. This propensity to
donate electrons is the basis of COQ's antioxidant action
(discussed below), and is virtually identical to the mechanism
of other antioxidants such as vitamin E, vitamin C, and the food
preservative BHT). The reversible nature of this reaction allows
COQ to act as a carrier of electrons, which is, in fact, how it
works in mitochondrial energy production. Inside the cell, COQ
is found in a variety of sites. The bulk is contained in
mitochondria, where most of the cellular energy is produced.
Tissues with a high density of mitochondria (for example heart
muscle) would therefore be expected to exhibit high levels of
COQ. Such is the case, as described below. Other cellular
membranes (such as endoplasmic reticulum and golgi
Continued on page 2
READER'S QUESTION
Q: I am a 52 year-old female, in excellent health except that I
am hypothyroid and 2 years ago was diagnosed as having
"Spinal Muscular Atrophy". This is due to a gene mutation
resulting in anterior horn cell degeneration, causing extreme
primary muscular weakness, almost total exhaustion and
shortness of breath. I was told by my neuro-muscular doctor
that nothing could be done. I started taking carnitine, 11 days
later I was about 50% better and back to taking long daily walks.
I then discovered your book "Carnitine" and am filled with
enthusiastic questions. They are: 1) how much carnitine would
you initially recommend for maximum benefit? 2) how much for
maintenance? and 3) how do you test for fat and carnitine
levels in your muscles?
—Mrs. Merta Cota
Bend, OR
A: Carnitine does play a critical role in muscle function, as
detailed in the previous issue of NUTRITION UPDATE.
Myopathic carnitine deficiency has similar characteristics:
progressive muscular weakness and severe fatigue. The use
of carnitine in this instance was therefore justified, and, more
importantly, effective from the patient's point of view. Mrs.
Cota's experience also illustrates the general frustration with
traditional medical approaches.
With respect to maximal benefit, the optimal amounts have
not yet been established; however, clinical trials have generally
used doses of 1 -4 grams/day of L-carnitine. [NOTE: as with
all nutritional regimens, consult a physician before using
therapeutic levels of L-carnitine]. I recommend 500 mg/day for
maintenance of good health. Both fat and carnitine can be
determined in muscle tissue by biopsy, although this test is
somewhat specialized and is only performed by a handful of
clinics.
A**
GOT A QUESTION?
•
Send rt-to "NUTRITION'UPDATE" Each issue we'll "
1 haveVquestion'and answer .column where you^can >
^personally ask Dr Brian"'Iteibovitz anysquestions-you;, fj,!
.v-haveiJaboufchealth" 'afkl? nutnlion^^leasei!?Sddr£&»!^|rirt
* Regis Drive, Davis Calif 95616 ». /,*„,'
^
i/-
,X
ABOUT DR. LEIBOVITZ
Brian E. Leibovitz holds an M.S. degree in Biology from Portland
State University (in conjunction with the University of Oregon
Medical Schoo) and a Ph.D. in Zoology and Physiology from the
University of Wyoming. Author of numerous scientific articles and
the book, "Carnitine" (Dell Publishing Company, NY 1984), Dr.
Leibovitz is currently doing post-doctoral research in the Department of Food Science and Technology at the University of
California/Davis.
© 1988 ADVANCED RESEARCH PRESS, INC.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William j . Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�TWINLAB
VOLUME 6, NUMBER 1,1992
Published by Advanced Research Press, Inc.
An affiliate of Twin Laboratories, Inc.
Editor's Note:
Bioflavonoids are a very large,
and quite remarkable, group of
naturally-occurring compounds
sharing a similar
chemical
structure. They are members of
a larger group called
polyphenols — arguably the most
exciting field in nutrition
at
the present time. Over the last
two decades, a great deal has
been learned about their nature
and medical applications. This
is reflected
in the
growing
number of scientific articles and
books , such as the two-volume
set entitled "Plant Flavonoids In
Biology
And
Medicine"
(published in 1986 and 1988).
which many consider
the
BY BRIAN E. LEIBOVITZ, Ph.D.
READER'S QUESTION
Question:
If the skin is burned or if you have a cut or a wound, should
you increase your vitamin C, E, and A and also zinc?
J. Billingsley
Franklin, TN
Answer:
Dr. Brian E. Leibovitz
bioflavonoid "bible." More recent books include: "Fruit Phenolics" (1990)
and "Dietary Tannins" (1990).
This is an extremely fertile field for investigation, and many of our
future medicines will undoubtably come from among their ranks. In this
Update we'll focus on polyphenols in health and disease, and on how
bioflavonoids
fit into this enormous group of
naturally-occurring
molecules.
POLYPHENOLS AND
BIOFLAVONOIDS:
THE MEDICINES OF
TOMORROW
Our world is filled with polyphenols. They form the deep red
and blue pigments of fruits, berries, and wine; in citrus flavedo
they are white. Polyphenols can be bitter tasting, tart, and —
very surprisingly — even sweet. They are astringent and can
kill viruses, bacteria, and other microbes. Polyphenols
contribute the aroma to coffee, tea, and wine, bananas, and
vanilla ice cream, as well as to the bite of hot peppers. They tan
our leather goods, protect our foods from unwanted oxidation,
and cause the browning reaction commonly seen after a piece
of fruit is sliced.
The most phenomenal attribute of polyphenols, however, is
what they can do in terms of preventing and treating a variety of
human diseases and conditions.
In this Nutrition Update, the biological and medical roles of
bioflavonoids and polyphenols will be explored. The chemistry
is really complex, but there is no way to avoid it if one intends to
gain any sort of understanding. To help speed the process I'll
present two ways of looking at this phenomenal class of
compounds. Don't worry if it all seems a little confusing at the
beginning; the picture will get clearer as more pieces of the
puzzle are added.
The inherent complexity of natural products (herbal)
chemistry is a result of the thousands of organic compounds
(bioflavonoids, phenolics, terpenes, carotenoids, alkaloids, etc.)
which have been chemically isolated and identified. Figuring
out the exact chemical composition of foods and herbs is not a
Continued on page 2
Yes indeed! Increasing your dietary intake of vitamin C
speeds the rate of wound healing — from cuts as well as from
burns. Vitamin C acts as a cofactor in the enzymes (prolyl
hydroxylase and lysyl hydroxylase) which cross-link collagen
(the protein which makes up connective tissue). In fact, the
classic sign of vitamin C-deficiency is bleeding gums, which is
the result of insufficiently cross-linked collagen.
Vitamin E has also been shown to enhance the rate of
wound healing in animals, although careful studies in humans
are not available. Vitamin A is essential for growth and
differentiation of skin, and has proven extremely useful for
treating photo-aged skin, psoriasis, and other skin conditions.
Moreover, stresses of various kinds — including burns and
wounds — increase the need for vitamin A. Finally, zinc
supplements increase the tensile strength of wounds as well as
to enhance the healing process.
In addition to increasing one's dietary intake, all of these
nutrients can be applied topically. Various commercial
ointments and oils are available, but you can always mix up
your own (just add the nutrients to a lotion base, mix and apply
to the affected site). Topical application is a very effective
means of getting sufficient quantities of the nutrients to the site
where they're needed.
^Send^que^onsaboWlth'knd'nutntKJn \
t o l
- •
ABOUT DR. LEIBOVITZ
Dr. Brian Leibovitz holds an M.S. degree in Biology from
Portland State University (in conjunction with the University of
Oregon Medical School) and a Ph.D. in Zoology and
Physiology from the University of Wyoming. He was a research
associate to Nobel Prize Laureate, Dr. Linus Pauling, and
completed his post-doctoral research in the Department of
Food Science and Technology at the University of
California/Davis. Dr. Leibovitz has published numerous
scientific articles in the field of nutrition and the book "Carnitine"
(Dell Publishing Company, NY, 1984). Dr. Leibovitz is the
Editor-in-Chief of The Journal Of Optimal Nutrition, and has a
nutritional consulting practice in Davis, California.
11992 ADVANCED RESEARCH PRESS, INC.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. resume
SUBJECT/TITLE
DATE
n.d.
re: Brian E. Leibovitz (partial) (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Marjorie Tarmey
OA/Box Number:
1338
FOLDER TITLE:
[Letters 1] [Loose] [3]
2006-0885-F
.ip2792
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information [(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA]
Release would violate a Federal statute |(aX3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfilc defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�CURRICULUM VITAE
Brian E. Leibovitz. Ph.D,
1°*3
2552 Regis Drive
Davis, CA 95616
,
i
(
:
P6/(b)(6)
�EDUCATIONAL EXPERIENCE
9/66 to 6/69
Attended John Marshall High School (Los Angeles, CA).
Graduated with honors and a life membership in
the California Scholarship Federation for excellence in
academic achievement.
1/70 to 6/71
Attended Los Angeles City College, Los Angeles, CA.
9/71 to 6/74
Attended Sonoma State University, Rohnert Park, CA.
Received a Bachelor of Arts Degree in Chemistry with
a Minor in Music.
9/74 to 1/76
Attended the University of California at Santa Cruz as a
graduate student in Organic Chemistry.
7/76 to 6/77
Attended Stanford University, Stanford, CA, as a nonmatriculated graduate student while working with
Professor Linus Pauling (Linus Pauling Institute of
Science and Medicine) and Professor George A. Feigen
(Department of Physiology, Stanford University).
9/77 to 9/81
Attended Portland State University, Portland, OR, as a
graduate student under the direction of Professor David
Clark in the Department of Biology. My research was
conducted in the laboratory of Professor Benjamin V.
Siegel at the University of Oregon Health Sciences Center
(Department of Pathology). Received a Master of Science
Degree In Biology (June, 1980). Elected a Fellow of the
Institute On Aging at Portland State University, and
received an Award Of Special Commendation for
outstanding graduate research.
9/82 to 5/86
Attended the University of Wyoming, Laramie, WY,
as a doctoral candidate under the direction of Professor
Joan Smith-Sonneborn in the Department of Zoology and
Physiology. Received a Ph.D. Degree in Zoology and
Physiology in May, 1986.
�EMPLOYMENT EXPERIENCE
6/73 to 9/73
and
6/74 to 9/74
Summer Research Assistant at Occidental Petroleum
Corporation, La Verne, CA. Projects included:
synthesis of metal chelating agents, inorganic phosphate
assays, and water desalination systems.
7/75 to 8/76
Research Assistant to Linus Pauling, Ph.D., Director
of the Linus Pauling Institute of Science and Medicine,
Palo Alto, CA. Conducted an exhaustive literature
search on nutrition and cancer, which resulted in a
review on ascorbic acid and cancer published in the
March 1979 issue of Cancer Research.
9/76 to 7/77
Research Assistant to George A. Feigen, Ph.D., Professor
of Physiology, Stanford University. Participated in two
studies on ascorbic acid and immune responses in
guinea pigs (including C1 esterase activity, antibody
production, and anaphylactic shock).
9/76 to 7/77
Clinical Laboratory Technician for Keith B. Taylor, M.D.
Chairman of the Gastroenterology Department of
Stanford University. Duties included: vitamin Be assays
and purification of human intrinsic factor using
Sephadex and Sepharose gels.
12/76 to 7/77
Phlebotomist in the Department of Hematology
at the Palo Alto Veterans Hospital, Palo Alto, CA.
6/77 to 6/79
Consultant to the Foundation For Nutritional
Advancement, Washington, D.C.
8/77 to 6/81
Research Assistant (and graduate student) to Benjamin
V. Siegel, Ph.D., Professor of Pathology, University of
Oregon Health Sciences Center, Portland, OR. Conducted
numerous experiments on roles of vitamin C in various
murine disease models: Rauscher virus-induced
leukemia, spontaneous leukemia/lymphoma in AKR and
SJL strains, spontaneous mammary cancer in C3H mice,
autoimmune disease in NZB mice, and anaphylactic
shock. Studied the effects of age and dietary ascorbic acid
supplements on tissue vitamin C levels in fast- and
normal-aging strains. Developed an aging assay based on
the ratio of oxidized to reduced vitamin C, and examined
�the effect of dietary antioxidants on this aging
measurement. Other experiments included aspects of
vitamin C in immune responses and its relationship with
tissue histamine.
9/82 to 1/86
Research Assistant to Joan Smith-Sonneborn, Ph.D.,
Department of Zoology and Physiology, University of
Wyoming, Laramie, WY, while working for my doctorate.
Developed the Paramecium bioassay of lipid peroxidation
for studies of antioxidant efficacy. Conducted studies of
dietary antioxidants and longevity using the Paramecium
model system. Demonstrated that an immortal, ciliated
protozoan (Tetrahymena thermophila) was resistant to
lipid peroxidation, and was capable of completely
blocking peroxidation in Paramecium. Peroxidation
assays included: thiobarbituric acid-reactive substances
(TBARS), fluorimetric assay of glutathione, fluorescent
aging pigments (lipofuscin), conjugated dienes, and
oxygen uptake.
8/85 to present Scientific and nutritional consultant for Twin Laboratories,
Inc., Ronkonkoma, NY. I am responsible for writing and
editing a quarterly scholarly newsletter on nutrition entitled
Nutrition Update (NU). NU is heavily referenced (50100 legitimate references for each lead article), contains
no advertisements of any kind, and has never mentioned
specific products or promoted sales in any way.
I write three monthly columns entitled "Nutrition And
Performance", "Nutrition Basics", and "Nutrition and
Performance Research" for Muscular Development,
and my insistence on using references set the
standard for this industry. Other responsibilities include:
teaching/training sales personnel, public seminars, technical
writing, and legal/regulatory problems. I am very involved in
the formulation of products based on the latest scientific data.
However, I am not, and have never been, financially
rewarded from the sale of any product or nutrient
Equally important, I am not required to write about,
speak about, or support in any way a nutrient or product
that I believe is not sufficiently documented.
2/86 to 12/89
Post-Doctoral Research Assistant to Professor Al
Tappel, Ph.D., Department of Food Sciences and
Technology, University of California, Davis, CA.
Developed and characterized the tissue slice model
�system for use in lipid peroxidation studies. Examined
halogenated hydrocarbons as inducers of lipid peroxidation and protein damage from lipid peroxidation.
Explored the effects of combined dietary supplements
of vitamin E, selenium, coenzyme Q10, and B-carotene
on susceptibility to lipid peroxidation in various rat
tissues. Compared fish oil- and corn oil-containing
diets at varying intakes of vitamin E with regard to
tissue lipid peroxidation. Assays included:
fluorimetric determination of thiobarbituric acidreactive substances (TBARS), fluorescent aging
pigments (lipofuscin), conjugated dienes, oxidized
hemoglobin, oxidized and reduced flavins, various
aldehydes and peptides via HPLC, SDS-PAGE of
liver proteins, oxidized and reduced glutathione, nonprotein sulfhydryls, and blood/tissue tocopherol.
1/90 to present
Nutritional Consultant, Davis, CA. I work with physicians
on nutritional supplement programs for a variety of
conditions and diseases.
3/91 to 3/92
Editor-in-Chief of the Journal Of Applied Nutrition (JAN). I
build JAN into a respectable journal, with a prestigious
Editorial Board of 50+ scientists and clinicians. My issues
averaged 74 pages as compared to 19 pages in the issue
preceding mine.
10/91 to present Assistant Editor of AGE News, a quarterly publication of the
American Aging Association (AGE). I contribute articles
for each issue which are reviewed by the Editor (Sheldon
Ball, Ph.D.) and other Assistant Editor (Don Ingram, Ph.D.).
3/92 to present
Editor-in-Chief of The Journal of Optimal Nutrition (JON).
Executive Director of The Institute for the Study of
Optimal Nutrition, Inc. (ISON).
6/92 to present Editorial Board Member- The Journal of Nutritional
Immunology.
7/92 to present
I am currently writing the Second Edition of my book
Carnitine, to be published either by Advanced Researc
Press. Linus Pauling, Ph.D. has asked me to co-autho
Second Edition of How To Live Longer And Feel Better
�MEMBERSHIP IN SCIENTIFIC SOCIETIES
1.
American Association For The Advancement Of Science (AAAS) (1978)
2.
Sigma Xi, The Scientific Research Society (1979)
3.
The American College Of Nutrition (ACN) (1979)
4.
The New York Academy Of Sciences (NYAS) (1979)
5.
The American College Of Sports Medicine (ACSM) (1980)
6.
The Gerontological Society Of American (GSA) (1981)
7.
The American Aging Association (AGE) (1984)
8.
The International Association Of Biomedical Gerontology (1985)
9.
The International Academy Of Nutrition And Preventive Medicine (1987)
10.
The Oxygen Society (1988)
11.
The International Society For Free Radical Research (1988)
12.
The Union Of Concerned Scientists (UCS) (1989)
13.
The Council Of Biology Editors (CBE) (1992)
14.
The American Institute of Nutrition (AIN) (1992)
15.
The Institute for the Study of Optimal Nutrition (ISON) (1992)
�PUBLICATIONS
1.
Leibovitz, B., and Siegel, B.V. Ascorbic acid, neutrophil function, and the
immune response. International Journal for Vitamin and Nutrition
Research 48: 159-164, 1978.
2.
Leibovitz, B., Siegel, B.V., and Morton, J.I. Tissue vitamin C levels as a
function of age in healthy and autoimmune mice. Age 1:164-165,
1978.
3.
Cameron, E., Pauling, L, and Leibovitz, B. Ascorbic acid and cancer: a
review. Cancer Research 39:663-681,1979.
4.
Siegel, B.V., Hodges, R.B., and Leibovitz, B.E. Tissue vitamin C levels in
the mouse and the effect of supplementary dietary ascorbic acid. IRCS
Medical Science 7: 248, 1979.
5.
Leibovitz, Brian. "Ascorbic Acid, Lipid Peroxidation, And Aging". A
Thesis presented to the Department of Biology, Portland State
University, for the degree of Master of Science, 1979.
6.
Siegel, B.V., and Leibovitz, B. Role Of Vitamin C In Aging And Cancer,
IN "Vitamin C: Recent Advances And Aspects In Virus Diseases, Cancer,
And In Lipid Metabolism", A. Hanck and G. Ritzel (editors), Hans Huber
Publishers, Bern, Switzerland, 1979, pp. 9-24.
7.
Leibovitz, Brian E., and Siegel, Benjamin V. Aspects of free radical
reactions in biological systems: aging. Journal of Gerontology 35:4556, 1980.
8.
Leibovitz, B., and Siegel, B.V. Antioxidants and carbon tetrachloride
toxicity. Federation Proceedings 39: 511,1980.
9.
Leibovitz, B., and Siegel, B.V. "Vitamin C And The Immune Response".
Proceedings of the 179th American Chemical Society Meetings, Division
of Agriculture and Food Chemistry, 1980.
10.
Leibovitz, Brian, and Siegel, Benjamin V. Ascorbic Acid And The
Immune Response, IN "Diet And Resistance To Disease", M. Phillips and
A. Baetz (editors), Plenum Publishing Co., New York, 1981, pp. 1-25.
11.
Feigen, G.A., Smith, B., Dix, C, Flynn, C, Peterson, N., Rosenberg, L,
Pavlovic, S., and Leibovitz, B. Enhancement of antibody production and
protection against systemic anaphylaxis by large doses of vitamin C.
�8
Research Communications in Chemical Pathology and Pharmacology 38:
313-333, 1982.
12.
Siegel, B.V., and Leibovitz, B. The multifactorial role of vitamin
C in health and disease. International Journal for Vitamin and
Nutrition Research 23 (suppl.): 9-22, 1982.
13.
Siegel, Benjamin V., Leibovitz, Brian, and Morton, Jane I. The
Reticuloendothelial System And Tissue Injury, IN "The Reticuloendothelial System: A Comprehensive Treatise, Volume 4:
Immunopathology", N.R. Rose and B.V. Siegel (editors), Plenum Press,
New York, 1983, pp. 1-23.
14.
Siegel, Benjamin V., Leibovitz, Brian, and Morton, Jane I. T-CellMediated Injury, IN "The Reticuloendothelial System: A
Comprehensive Treatise, Volume 4: Immunopathology", N.R. Rose and
B.V. Siegel (editors), Plenum Press, New York, 1983, pp. 25-42.
15.
Leibovitz, B., and Schlesser, J. Effect Of L-Ascorbic Acid On
Leukemia Development And Breast Cancer In Various Inbred Strains
Of Mice, IN "Modulation And Mediation Of Cancer By Vitamins", F.
Meyskens and K.N. Prasad (editors), S. Karger, Basel, Switzerland,
1983, pp. 140-143.
16.
Leibovitz, B., and Smith-Sonneborn, J. Effect of supplementary
L-ascorbic acid on clonal longevity in Paramecia. Proceedings of the
Symposium on Nutritional Intervention in the Aging Process, SpringerVerlag, New York, 1984.
17.
Leibovitz, Brian. "Carnitine", Dell Publishing Company, Inc., New
York, 1984.
18.
Leibovitz, Brian, and Smith-Sonneborn, Joan. Effect of dietary
fat-soluble antioxidants on in vitro lipid peroxidation in Paramecia.
Age 8: 92,1985.
19.
Leibovitz, Brian, and George, Robert. Protective effect of intact and
sonicated Tetrahymena on in vitro peroxidation in Paramecia.
Proceedings of the 15th Annual American Aging Association
Meetings, San Francisco, CA, 1985.
20.
Leibovitz, Brian. Lipid peroxidation and aging: in vitro peroxidation in
Paramecia and Tetrahymena. Proceedings of the 38th Annual Meeting
of the Gerontological Society of America, New Orleans, LA, 1985.
�21.
Leibovitz, Brian. "Lipid Peroxidation, Antioxidants, And Aging In
Paramecium Tetraurelia. Doctoral Dissertation, University of Wyoming,
May 1986.
22.
Fraga, C.G., Leibovitz, B., Sano, M., and Tappel, A.L. Use of tissue slices
in nutrition and toxicology: measurement of lipid peroxidation.
Proceedings of the AIN/ASCN Meetings in Davis, CA, 1986.
23.
Fraga, C.G., Leibovitz, B., and Tappel, A.L. Use of tissue slices to
measure lipid peroxidation: effect of halogenated compounds.
Proceedings of the 1987 Federation of American Societies for
Experimental Biology Meeting, Washington, D.C, 1987.
24.
Fraga, C.G., Leibovitz, B.E., and Tappel, A.L. Halogenated compounds as
inducers of lipid peroxidation in tissue slices. Free Radical Biology and
Medicine3:119-123, 1987.
25.
Fraga, C.G., Leibovitz, B.E., and Tappel, A.L. Lipid peroxidation
measured as thiobarbituric acid-reactive substances in tissue slices:
characterization and comparison with homogenates and microsomes.
Free Radical Biology and Medicine 4:155-161,1988.
26.
Leibovitz, B.E., Hu, M.L, and Tappel, A.L. Effect of combined dietary
antioxidant supplements on lipid peroxidation in tissue slices.
Journal of the American College of Nutrition 7: 411, 1988.
27.
George, R.P., and Leibovitz, B.E. Tetrahymena extract protects
Paramecium from oxygen free radicals. Age 11:66-69,1988.
28.
Leibovitz, B., and Smith-Sonneborn, J. A method of lipid peroxidation
in Paramecium Tetraurelia. Age 11:128-134,1988.
29.
Hu, M.L., Frankel, E.N., Leibovitz, B.E., and Tappel, A.L. Effect of
dietary lipids and vitamin E on in vitro lipid peroxidation in rat liver
and kidney homogenates. Journal of Nutrition 119:1574-1582,1989.
30.
Leibovitz, B., Hu, M.L., and Tappel, A.L. Dietary supplements of
vitamin E, B-carotene, coenzyme Qio, and selenium protect tissues
against lipid peroxidation in rat tissue slices. Journal of Nutrition 120:
97-104, 1990.
31.
Leibovitz, B.E., Hu, M.L., and Tappel, A.L. Lipid peroxidation in rat
tissue slices: effect of dietary vitamin E, corn oil-lard and menhaden
oil. Lipids 25:125-129,1990.
�10
32.
Fraga, C.G., Tappel, A.L, Leibovitz, B.E., Kuypers, F., Chiu, D.,
lacono, J.M., and Kelley, D.S. Lability of red blood cell membranes to
lipid peroxidation: application to humans fed polyunsaturated lipids.
Lipids 25: 111-114, 1990.
33.
Packer, L., and Leibovitz, B. Antioxidants and degenerative diseases:
highlights of conference findings. Free Radical Biology and Medicine 8:
509-511, 1990.
34.
Leibovitz, B. The new focus of the Journal of Applied Nutrition. Journal
of Applied Nutrition 43:1-4, 1991.
35.
Leibovitz, B. On resignations and regulations. Journal of Applied
Nutrition 44:1-2, 1991
36.
Leibovitz, B. Bioflavonoids. Part I. AGE News 22: 2-5, 1992.
37.
Leibovitz, B. Bioflavonoids. Part II. AGE News 22:11-14, 1992.
38.
Leibovitz, B. An introduction to The Journal Of Optimal Nutrition.
Journal Of Optimal Nutrition 1:1-3, 1992.
39.
Leibovitz, B. Nutrition: At the crossroads. Journal Of Optimal
Nutrition 1: 69-83, 1992.
40.
Leibovitz, B. Bioflavonoids. Part III. AGE News 22:19-24, 1992.
�11
SYMPOSIUM PRESENTATIONS
Oct. 21,1978
"Ascorbic acid and spleen function", presented at the
Northwest Chapter of the Society for Experimental
Biology and Medicine, Newport, OR.
Jan. 17,1979
"Free radicals, lipid peroxidation, and aging", presented
at the Biology of Aging Conference, University of Oregon
Medical School, Portland, OR.
April 12, 1979
"How far can we go with vitamin C", presented at the
Fifth Annual Food Additives and Nutritional Supplements
symposium, Oregon State University, Corvallis, OR.
Aug. 1,1979
"Vitamin C and the immune response", presented at the
Conference on Nutrition and Immunology, organized by
Sir Peter Medawar and held at the Rockefeller Villa,
Lake Como, Italy.
Oct. 3, 1979
"Biochemical measurements of aging", presented at the
Biology of Aging Conference at the University of Oregon
Medical School, Portland, OR.
Oct. 15, 1979
"Nutrition and disease", presented at the Miriam-PolkYamhill counties Dental Society, 15th Annual Meeting,
Salem, OR.
Mar. 26, 1980
"Ascorbic acid and the immune response", presented at
the 179th Annual Meeting of the American Chemical
Society, Houston, TX.
April 15, 1980
"Antioxidants and carbon tetrachloride toxicity".
presented at the 64th Annual FASEB Meetings in
Anaheim, CA.
Mar. 21, 1982
"Effect of supplemental ascorbic acid on leukemia
development and breast cancer in various inbred strains
of mice", presented at the 1st International Conference on
the Modulation and Mediation of Cancer by Vitamins, The
Cancer Center of the University of Arizona, Tucson, AZ.
Aug. 10,1983
"Effect of supplemental dietary L-ascorbic acid on clonal
longevity in Paramecium Tetraurelia", presented at the
Biology of Aging section of the Gordon Conference,
Plymouth, NH.
�12
Sept. 12,1983
"Effect of supplementary L-ascorbic acid on clonal
longevity in Paramecia", presented at the Symposium on
Nutritional Intervention in the Aging Process, Saint Louis
School of Medicine, Saint Louis, MO.
Nov. 17,1984
"Lipid peroxidation in Paramecium Tetraurelia",
presented at the 37th Annual Meeting of the
Gerontological Society of America, San Antonio, TX.
July 10,1985
"Effect of dietary fat-soluble antioxidants on in vitro lipid
peroxidation in Paramecia", presented at the 1 st
International Congress of Biomedical Gerontology, New
York, NY.
July 15, 1985
"Lipid peroxidation in Paramecium Tetraurelia",
presented at the 13th International Congress of
Gerontology, New York, NY.
Oct. 10,1985
"Protective effect of intact and sonicated Tetrahymena on
in vitro lipid peroxidation in Paramecia", presented at the
15th Annual Meeting of the American Aging Society, San
Francisco, CA.
Nov. 24,1985
"Lipid peroxidation and aging: in vitro peroxidation in
Paramecia and Tetrahymena", presented at the 38th
Annual Meeting of the Gerontological Society of America,
New Orleans, LA.
July 20, 1986
"Use of tissue slices in nutrition and toxicology:
measurement of lipid peroxidation", presented at the 5th
Joint Meeting of the American Inst, of Nutrition (AIN)
and American Society of Clinical Nutrition (ASCN), Davis,
CA.
Sept. 6,1986
"Role of fish oils and aarlic in heart disease", presented at
the Annual Northern California Nutritional Foods
Association Meeting, San Francisco, CA.
Mar. 14, 1987
"Nutrition research: on the forefront", presented at the
Annual Natural Foods EXPO Meeting, Anaheim, CA.
April 2,1987
"Use of tissue slices to measure lipid peroxidation:
effect of halogenated compounds", presented at the 71st
Annual FASEB Meetings, Washington, D.C.
�13
Dec. 5,1987
"Nutrition, AIDS, and the immune response", presented
at the Annual Southern Health Organization Meeting,
Orlando, FL.
Feb. 27, 1988
"Nutrition, the immune response, and AIDS", presented
at the Annual Meeting of the North West Nutritional
Foods Association, Tacoma, WA.
April 10, 1988
"Nutrition and the immune response: role in AIDS",
presented at the Annual Natural Foods EXPO Meeting,
Anaheim, CA.
Sept. 14, 1988
"Effect of combined dietary antioxidant supplements on
lipid peroxidation in tissue slices", presented at the 29th
Annual Meeting of the American College of Nutrition, New
Orleans, LA.
Mar. 20, 1989
"Combined supplements of vitamin E, 8-carotene,
coenzyme Qio, and selenium protect tissues against
lipid peroxidation", presented at the 73rd Annual FASEB
Meetings, New Orleans, LA.
Mar. 12, 1990
"Nutrition and fatigue", presented at the 10th Annual
Natural Foods Exposition, Anaheim, CA. Received an
"Outstanding Service Award" for my seminar.
April 1,1990
"Simulation modeling of the protection against lipid
peroxidation by vitamin E, selenium, beta-carotene,
and coenzyme Qio", presented at the Annual FASEB
Meeting, Washington, DC.
Nov. 17,1990
"Nutrition and athletic performance", presented at
the Sports Nutrition Symposium, Long Beach, CA.
Feb. 23,1991
"Latest breakthroughs in nutrition", presented at the
Annual Convention of The Northwest Nutritional Foods
Association, Tacoma, WA.
July 22,1991
"Nutritional protection against heart disease", presented at
53rd Annual Convention of the National Nutritional Foods
Association (NNFA), Las Vegas, NE.
�i
14
Feb. 15, 1992
"The latest nutritional discoveries for prevention and
treatment of heart disease", presented at the Annual
Convention of the Southwest Health Organization,
Dallas, TX.
FELLOWSHIPS
Fellow -- The Hearst Foundation in 1978
Fellow -- Portland State University Institute On Aging Fellow in 1979
�6"
A M E R I C A N A M P U T E E F O U N D A T I O N , INC.
NATIONAL H E A D Q U A R T E R S
A p r i l 16, 1993
Mr. Mack McLarty
Chief o f S t a f f
White House
Washingtori, D.C.
Dear Mack:
During t h i s b r a i n s t o r m i n g p e r i o d regard.!.ng economic
recovery and c u t t i n g o v e r a l l e x p e n d i t u r e s , I have had some
c r e a t i v e thought t h a t I want t o share w i t h you. Furthermore,
s i n c e e d u c a t i o n and r e t r a i n i n g a r e o f v i t a l importance t o t h e
A d m i n i s t r a t i o n , I have some suggestions r e g a r d i n g t h i s area as
vei] .
I t seems t o me the.'c w i t h so •vicmy i n d i v i d u a l s o u t t h e r e t h a t
have never p a i d t a x e s , are evading t a x e s , o r have g o t t e n behind
and are a f r a i d r.c come f o r w a r d ; our c o u n t r y and the IRS should
o f f e r a s p e c i a l i n c e n t i v e t o g o t these i n d i v i d u a l s on t h e r i g h t
path and p a y i n g t a x e s .
My idea i n v o l v e s e s t a b l i s h i n g a grace p e r i o d . During t h i s
t i m e frame anyone t h a t comes f o r w a r d and r e g i s t e r s as a taxpayer
w i i l be g r a n t e d immunity from p r o s e c u t i o n and t h e i r past taxes
would e i t h e r be waived o r o n l y a s m a l l percentage would be due i n
i n s t a l l m e n t s . This would m o t i v a t e these people t o come f o r w a r d
and g e t a f r e s h s t a r t toward paying t a x e s . I t i s my u n d e r s t a n d i n g
t h a t by g e t t i n g these persons t o pay taxes a g a i n , b i l l i o n s o f n^w
tax d o l l a r s would be c r e a t e d . Secondly, our government would
reduce t h e tremsndcuc expenses i n v o l v e d i n t r y i n y t o l o c a t e
d e l i n q u e n t taxpayers and c o l l e c t what i s owed.
Another idea wnich occurs t o me i s t h e f a c t t h a t t h e
government' seems t o own and operate a g r e a t deal o f p r o p e r t y and
a s s e t s . This i n c l u d e s , b u t i s n o t l i m i t e d t o , b u i l d i n g s , l a n d ,
t o u r i s t p r o p e r t i e s , v e h i c l e s , o l d m i l i t a r y equipment and o t h e r
such a s s e t s . My idea i n v o l v e s t h e s a l e o f a p p r o p r i a t e p r o p e r t i e s
and assets t o p r i v a t e e n t e r p r i s e f o r p r i v a t e e n t r e p r e n e u r i a l
o p e r a t i o n , Jeasing back o n l y t h a t which i s e s s e n t i a l t o
government o p e r a t i o n and s e r v i c e s . C e r t a i n l y , I understand t h a t
such t h i n g s as nationaJ. p r o p e r t i e s s e t asi.de as w.i iderness areas
would p r o b a b l y be best managed as they a r e c u r r e n t l y ,
P. O. Box 250218 - Hillcrest Station - Little Rock, Arkansas 72225 - (501)666-2523
�Page 2
As you know my background i s i n t h e h e a l t h care f i e l d and
not i n t h e f i e l d o f economics; however, someone on your s t a f f
might t h i n k about t h i s and come up w i t h some f a i r l y c r e a t i v e
ideas based on t h i s concept t h e r e b y c r e a t i n g a new w i n d f a l l o f
f u n d i n g which i s s e l l a b l e t o a l l s i d e s . Regarding t h e o l d
w a r s h i p s , planes and t h e l i k e , why don't we go ahead and s e l l
t h i s m a t e r i a l f o r salvage and t o r e c y c l i n g d e a l e r s . They should
be w o r t h a g r e a t d e a l o f money.
L a s t l y , r e g a r d i n g r e t r a i n i n g , and s e t t i n g up an e d u c a t i o n a l
network which t r a i n s i n d i v i d u a l s f o r market demands o f today and
i n t o t h e f u t u r e , why don't we b e g i n a process o f c l o s i n g t h e o l d
v o c a t i o n a l schools which a r e m a i n l y t r a i n i n g i n d i v i d u a l s f o r
watch r e p a i r , c a r p e n t r y , d r a f t i n g , auto r e p a i r and body work, and
the l i k e . We don't need v o c a t i o n a l schools i n every s t a t e d o i n g
e x a c t l y t h e same t r a i n i n g . I n Arkansas we have w e l l over 70 o f
such programs and t h e y a l l teach about t h e same t h i n g .
The new Math & Science school i n Hot Springs i s a g r e a t example
of t h e idea and approach a t which we should be l o o k i n g ,
However,
l e t s i n v o l v e p r i v a t e i n d u s t r y t o a d v i s e us on what t h e i r market
demand and needs a r e f o r t r a i n e d p e r s o n n e l . Let's c o n v e r t
e x i s t i n g schools and f u n d i n g i n a l i g n m e n t w i t h these i n d u s t r i e s
w i t h an agreement t h a t t h e y h i r e t r a i n e d graduates. The p r i v a t e
i n v e s t o r i n these programs would b e n e f i t two f o l d . They would be
g r a n t e d t a x c r e d i t s and d e d u c t i o n s f o r , ( 1 ) t h e i r support and
s t a f f t e c h n i c a l i n p u t ; and (2) f o r h i r i n g graduates t h r o u g h t h e
e x i s t i n g t a r g e t e d j o b t a x c r e d i t program.
The programs would be r e g i o n a l l y l o c a t e d t o support these
companies and we would a l s o e s t a b l i s h programs where new i n d u s t r y
i s p r o p o s i n g t o l o c a t e . Most o f t h e programs which d u p l i c a t e
s e r v i c e s would be e l i m i n a t e d over a s e t t i m e frame based on
a c t u a l market demand f o r graduates.
Granted many o f t h e o l d t r a d e s a r e needed, b u t l e t me ask
j u s t how many watch r e p a i r graduates a r e needed n a t i o n a l l y ?
How
many auto mechanics a r e needed? We must answer these q u e s t i o n s
and p l a n f o r new and growing j o b markets o f today and i n t o t h e
21st c e n t u r y . Your s p e c i a l i s t s should be a b l e t o address t h e
issues d i s c u s s e d and i d e n t i f y t r e n d i n f o r m a t i o n , t o come up w i t h
some c r e a t i v e approaches which do n o t upset v a r i o u s c o u n t i e s ,
c i t i e s and s t a t e s by c l o s i n g o b s o l e t e programs.
I hope my t h o u g h t s a r e u s e f u l and I would be happy t o
d i s c u s s t h i s f u r t h e r w i t h you. I am v e r y proud o f t h e
A d m i n i s t r a t i o n ' s a g g r e s s i v e e f f o r t s and my t h o u g h t s and p r a y e r s
are w i t h ^ y o u .
Sincere
^ s ^ c k / M / E a s V , LSW/MA R e h a b i l i t a t i o n
Execut:
.^AMERICAN AMPUTEE FOUNDATION, INC.
Counseling
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002a. letter
DATE
SUBJECT/TITLE
Mack McLarty to Minot D. Hill; re: Forwarding to Hillary Clinton
(partial) (1 page)
04/29/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Marjorie Tanney
OA/Box Number:
1338
FOLDER TITLE:
[Letters 1] [Loose] [3]
2006-0885-F
ip2792
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P5 Release would disclose confidential advice between the President
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b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�THE WHITE HOUSE
WAS H I NGTO N
April 29, 1993
Ma. Minot D. H i l l
P6/(b)(6)
Dear Ms. H i l l :
Thank you for writing and l e t t i n g me know of your l e t t e r to F i r s t
Lady H i l l a r y Clinton regarding health care costs and benefits.
As requested, I have forwarded i t on for her attention.
Your interest i n the future of this country and this
Administration i s appreciated.
I t i s important that we hear from
a l l Americans as we face the challenge of structuring a
government that i s capable of leading us into the twenty-first
century.
Again, thank you for writing.
Personally,
Mack McLarty
Chief of Staff to the President
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002b. letter
SUBJECT/TITLE
DATE
Minot D. Hill to Thomas McLarty; re: Health Care Costs (partial) (1
page)
04/21/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Marjorie Tarmey
OA/Box Number: 1338
FOLDER TITLE:
[Letters 1] [Loose] [3]
2006-0885-F
ip2792
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - |5 U.S.C. 552(b)]
PI National Security Classified Information 1(a)(1) of the PRA]
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA]
P3 Release would violate a Federal statute |(aX3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA]
b(l) National security classified information [(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRIM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�. P6/(b)(6)
A p r i l 21, 1993
Mr. Thomas McLarty
Chief of S t a f f , the White House
1600 Pennsylvania Ave.
Washington, D. C. 20500
Dear Mr.
McLarty,
The f i r s t two pages of my l e t t e r w i l l serve as cover pages f o r
the main p a r t of my correspondence, which a t t h i s time w i l l deal
w i t h h e a l t h care costs and b e n e f i t s , which have now become the
focus of Mrs. C l i n t o n and her s p e c i a l p r o j e c t s t a f f .
I am a CPA who now works as a Finance Examiner f o r the State
of New Hampshire Public U t i l i t i e s Commission. For the b e t t e r p a r t
of the l a s t year, we and a l l the other s t a t e commissions have been
looking a t the h e a l t h care issues being generated by the
promulgations of the F i n a n c i a l Accounting Standards Board (FASB) as
contained w i t h i n t h e i r Statement No. 106, "Employers' Accounting
f o r Postretirement Benefits Other than Pensions". As a r e s u l t of
the research t h a t the Commission has conducted, and responses t h a t
we have received from our l a r g e r regulated e n t i t i e s , I am going t o
pass on a few thoughts t h a t may be of help, or at l e a s t of
interest.
I n a d d i t i o n I am going t o make a b r i e f commentary on some
other matters.
F i r s t of a l l , whatever new n a t i o n a l programs the president may
put i n t o place, the t r a c k i n g system t o monitor such programs i s
already a v a i l a b l e . Everyone has t o have a s o c i a l s e c u r i t y number
now, v i r t u a l l y from the day he i s born. So, those numbers should
s u f f i c e , and the i n f o r m a t i o n paths are already i n existence.
Second, before we increase the taxable p o r t i o n of s o c i a l
s e c u r i t y b e n e f i t s , l e t ' s a t l e a s t a d j u s t the taxable f l o o r f o r
i n f l a t i o n . The p r i n c i p l e of t a x i n g s o c i a l s e c u r i t y went i n t o e f f e c t
on January 1, 1984. The income f l o o r was $25,000 f o r a s i n g l e
person and $32,000 f o r a married couple. Those taxable income
f l o o r s have never been adjusted f o r i n f l a t i o n the way v i r t u a l l y a l l
the other basic or standard amounts on a tax r e t u r n have been,
( i . e . standard deductions, exemptions, earned income c r e d i t s e t c . ) .
This o v e r s i g h t may have been d e l i b e r a t e or a c c i d e n t a l , but I t h i n k
t h a t i t should be adjusted now, upwards by some 40%. Second, I
would leave the maximum taxable a t 50% t o around $60,000 gross
income f o r a s i n g l e person and $75,000 f o r a married couple.
�I w i l l elaborate further
subsequent correspondence.
on
these
following
issues i n
(1) America's i n a b i l i t y t o be a b l e t o maximize t h e t a l e n t s o f
i t s i n d i v i d u a l c i t i z e n s , once t h e y r e a c h t h e w o r k p l a c e . T h i s f a c t
w i l l be c r i t i c a l i f t h e P r e s i d e n t ' s p l a n s and recommendations a r e
t o succeed.
(2) The former S o v i e t Union, as I have been t h e r e t w i c e , t h e
second t r i p c o n t a i n i n g s e v e r a l business meetings ( a c c o u n t i n g ) .
(3) America's preparedness o r l a c k t h e r e o f t o handle a major
n a t u r a l d i s a s t e r , ( c o l l e g e major and hobby, geology, and number one
hobby, m e t e o r o l o g y .
However, a t t h i s p o i n t I s h a l l n o t g e t ahead o f m y s e l f .
Is i t p o s s i b l e f o r t h e average c i t i z e n t o o b t a i n a copy o f t h e
P r e s i d e n t ' s new proposed budget. I w i l l g l a d l y pay t h e c o s t f o r i t
u n l e s s i t runs i n t o t h e hundreds.
Best wishes t o everyone f o r b r i n g i n g honesty and t r u t h f u l n e s s
back t o t h e White House. We have n o t seen such enthusiasm i n t h i r t y
years.
I u n d e r s t a n d t h a t t h e P r e s i d e n t has a " f r e e l a n c e c o n s u l t a n t "
a l r e a d y i n Concord. We have t h e same l a s t name, b u t so f a r as I
know, we a r e n o t r e l a t e d .
I , t o o , f e e l a r e s p o n s i b i l i t y t o h e l p t h i s c o u n t r y . Having no
c h i l d r e n , I would hope t o l e a v e an i d e a , a t h o u g h t as my l e g a c y .
Other members o f my f a m i l y have, from t i m e t o t i m e , s i n c e t h i s
nation's b i r t h .
Very t r u l y y o u r s ,
Minot D. H i l l , CPA
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002c. letter
SUBJECT/TITLE
DATE
Minot D. Hill to Health Care Commission re: Medical Health Cost
Crisis (partial) (1 page)
04/21/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Marjorie Tarmey
OA/Box Number: 1338
FOLDER TITLE:
[Letters 1] [Loose] [3]
2006-0885-F
IP
2792
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office [(a)(2) of the PRA]
P3 Release would violate a Federal statute |(aX3) of the PRAJ
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA)
b(l) National security classified information [(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency |(bX2) of the FOIAJ
b(3) Release would violate a Federal statute [(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�• . '\ : P6/(b)(6)
A p r i l 21,
1993
To t h e H e a l t h Care Commission:
1 am a CPA who now works as a Finance Examiner f o r t h e S t a t e
o f New Hampshire P u b l i c U t i l i t i e s Commission. For t h e b e t t e r p a r t
o f t h e l a s t y e a r , we and a l l t h e o t h e r s t a t e commissions have been
l o o k i n g a t the h e a l t h care issues being generated
by
the
p r o m u l g a t i o n s o f t h e F i n a n c i a l A c c o u n t i n g Standards Board (FASB) as
c o n t a i n e d w i t h i n t h e i r Statement No. 106, "Employers' A c c o u n t i n g
f o r P o s t r e t i r e m e n t B e n e f i t s Other t h a n Pensions". As a r e s u l t o f
t h e r e s e a r c h t h a t t h e Commission has conducted, and responses t h a t
we have r e c e i v e d from our l a r g e r r e g u l a t e d e n t i t i e s , I am g o i n g t o
pass on a few t h o u g h t s t h a t may be o f h e l p , o r a t l e a s t o f
interest.
Sometime w i t h i n t h e l a s t year o r so, p r o b a b l y i n c o n n e c t i o n
w i t h t h e FASB pronouncement mentioned above, someone s a i d t h a t i f
each l i v i n g American c o u l d s e t a s i d e $50,000 which would earn 8% t o
8 1/2% per y e a r , t h a t t h e i n i t i a l d e p o s i t and a l l o f i t s f u t u r e
e a r n i n g s on an average, would t a k e c a r e o f each American's h e a l t h
care expenses from t h e p r e s e n t u n t i l t h e d a t e o f h i s d e a t h . T h i s
sum i n keeping w i t h t h e t e r m i n o l o g y o f Statement #106, c o u l d be
c a l l e d "America's P r o j e c t e d H e a l t h B e n e f i t O b l i g a t i o n " . W i t h a
p o p u l a t i o n t h a t now t o t a l s c l o s e t o 280 m i l l i o n p e o p l e , t h e t o t a l
amount o f t h e o b l i g a t i o n i s $14 T r i l l i o n . T h i s i s a s t a g g e r i n g sum,
s l i g h t l y more t h a n two y e a r s ' w o r t h o f Gross N a t i o n a l P r o d u c t . But
when one steps back and l o o k s a t t h e c u r r e n t annual e x p e n d i t u r e s
f o r h e a l t h c a r e , even a t today's r a t e , w i t h no f u t u r e i n f l a t i o n ,
t h a t amount o f money would be spent i n 16 y e a r s .
I t h i n k the f i r s t p a r t of the medical h e a l t h cost c r i s i s t h a t
must be r e s o l v e d i s t h a t which p e r t a i n s t o people 65 and o v e r . I t
i s e s t i m a t e d t h a t o f t h a t $14 t r i l l i o n , people aged 65 and over
w i l l spend a t l e a s t h a l f o f t h e t o t a l b e f o r e t h e y d i e . I f t h e
H e a l t h Care S t a f f can b r i n g t h e c o s t s f o r t h e e l d e r l y under
c o n t r o l , c o r p o r a t e America w i l l b r e a t h e a huge s i g h o f r e l i e f . I am
g o i n g t o say a t t h i s p o i n t t h a t c o r p o r a t e America i s n o t r e h i r i n g
t h e way i t used i n t h e p a s t p r e c i s e l y because o f t h i s problem. Who
wants t o t a k e on a p r o j e c t e d $7 t r i l l i o n l i a b i l i t y t h a t w i l l
p r o b a b l y double i n t e n years? C o r p o r a t e America would be b a n k r u p t
and i n t h e h o l e by t r i l l i o n s .
�The f a c t t h a t most h e a l t h b e n e f i t p l a n s are c l a s s i f i e d as
d e f i n e d b e n e f i t plans and not d e f i n e d c o n t r i b u t i o n plans i s t h e
main d r i v i n g f o r c e behind pushing up f u t u r e c o s t s . A d e f i n e d
b e n e f i t i s p r e c i s e l y t h a t , i . e. t h e company w i l l pay a l l o r most
of your h e a l t h i n s u r a n c e c o s t s , no m a t t e r . I f one s w i t c h e s t o a
d e f i n e d c o n t r i b u t i o n p l a n t h e n t h e company can say "We w i l l p r o v i d e
you w i t h up t o $150 per month towards your h e a l t h care premiums".
Now t h e c o s t i s d e f i n e d , can be c o n t a i n e d , and i s d e f i n i t e l y a l o t
e a s i e r t o p r o j e c t o u t i n t o t h e f u t u r e . And you w i l l f i n d t h a t t h e
p r o j e c t e d c o r p o r a t e c o s t s w i l l plummet, p r o b a b l y by c l o s e t o 75%.
I am no e x p e r t on law o r l e g i s l a t i o n , b u t i f d e f i n e d c o n t r i b u t i o n
needs t o be l e g i s l a t e d t h e n i t should be done.
A major p o r t i o n of these c o s t s i s generated by i n c o n s i s t e n c i e s
between u n i o n - b a r g a i n e d ,
and o t h e r worker non-bargained p l a n
settlements.
I n union-bargained
settlements, future
medical
i n f l a t i o n r a t e s are a l l o w e d as p a r t o f t h e p l a n s e t t l e m e n t s . What
t h i s does i s t o make t h e p r o j e c t e d c o s t s o f u n i o n - b a r g a i n e d plans
much h i g h e r t h a n o r d i n a r y non-bargained s e t t l e m e n t s . I n examining
two of t h e SFAS 106 c o s t p r o j e c t i o n s from d i f f e r e n t companies
s u b m i t t e d t o t h e NHPUC, t h e u n i o n - b a r g a i n e d s e t t l e m e n t s were about
t h r i c e t h e o r d i n a r y non-bargained s e t t l e m e n t s . I f p o s s i b l e I would
recommend l e g i s l a t i o n o r whatever i s needed t o put a l l p l a n
p a r t i c i p a n t s on an equal f o o t i n g . And t h a t equal f o o t i n g would be
at t h e non-bargained r a t e . Once a g a i n one has t o ask h i m s e l f what
t h e i n c e n t i v e i s t o save i f these p r o j e c t e d f u t u r e i n f l a t i o n
i n c r e a s e s have a l r e a d y been agreed t o as p a r t of a c o n t r a c t
s e t t l e m e n t . I am w i l l i n g t o bet "the more t h e m e r r i e r . "
T h i s i s not t o say t h a t companies should be r e s t r i c t e d from
d o i n g more, i f t h e y wanted t o . E x t r a b e n e f i t s p a i d f o r an
i n d i v i d u a l beyond a c e r t a i n l e v e l c o u l d be c o n s i d e r e d t a x a b l e
income, and an a p p r o p r i a t e 1099 c o u l d be i s s u e d . I n a d d i t i o n ,
former employees o f companies, i f t h e y had t h e funds a v a i l a b l e
c o u l d buy a d d i t i o n a l h e a l t h i n s u r a n c e themselves. This way t h e r e
would be no a d d i t i o n a l c o s t t o employer companies. By g i v i n g
companies a range o f manageable c h o i c e s , each o f which would have
l i t t l e o r no t a x consequence; would a l l e v i a t e a l o t o f concerns
c u r r e n t l y expressed by them.
Another area o f a s t r o n o m i c a l c o s t s c o u l d be brought under
c o n t r o l by t r a n s f e r r i n g t h e r e s p o n s i b i l i t y f o r h e r o i c medical
measures back t o t h e i n d i v i d u a l and h i s f a m i l y . That way t h e
i n s u r a n c e company w i l l not get tagged f o r huge expenses ( l o s s e s )
i n c u r r e d i n t r y i n g t o save a person's l i f e . The concept o f "Hemlock
S o c i e t i e s " o r "Managed Death Measures" i s f a s t g a i n i n g p o p u l a r i t y .
And as people get o l d e r , when t h e y know t h e y have seen t h e b e s t and
t h a t was i n t h e p a s t , t h e y do not w i s h t o be kept a l i v e as
v e g e t a b l e s . They f i n d i t d e g r a d i n g and f i n a n c i a l l y immoral. My own
f a t h e r r e q u e s t e d t o leave t h i s way. I t t o o k him o n l y 10 days.
�The o t h e r area o f concern as f a r as a s t r o n o m i c a l h e a l t h
i n s u r a n c e c o s t s go, i s a t t h e b e g i n n i n g o f l i f e , when we humans
poke our l i t t l e heads i n t o t h e w o r l d f o r t h e f i r s t t i m e . Should a
m i l l i o n d o l l a r s be spent on a "crack" baby t r y i n g t o keep i t a l i v e .
The baby's f a t h e r / m o t h e r i s v e r y p r o b a b l y poor, p r o b a b l y i s not
covered by any t y p e o f h e a l t h i n s u r a n c e except M e d i c a i d , i s
p r o b a b l y unemployed, and may be unemployable unless he(she) i s
t a u g h t new work s k i l l s . However, I t h i n k t h e t a s k f o r c e i s w e l l
down t h e road towards agreement on t h i s i s s u e . I would have t o say
"No h e r o i c e f f o r t s beyond t h e proposed b a s i c h e a l t h care b e n e f i t s
as p r o v i d e d by t h e new n a t i o n a l h e a l t h i n s u r a n c e " . I f i n t h e
u n l i k e l y s i t u a t i o n , t h a t a p a r e n t as d e s c r i b e d above, does have
funds t o be a b l e t o pay f o r a d d i t i o n a l measures, t h e n f i n e l e t them
pay t h e e x t r a .
A f o u r t h problem w i t h our c u r r e n t system i s t h a t when you
reach age 65, you are r e q u i r e d t o go on Medicare. T h i s i s t e r r i b l e ,
and
tends
t o c r e a t e i n e f f i c i e n c i e s and
indifference.
Basic
governmental
h e a l t h insurance
should
be
an o p t i o n , not
a
r e q u i r e m e n t . Once a g a i n , based on some o f t h e l a t e s t i n f o r m a t i o n
coining o u t o f Washington, however, i t sounds as i f t h i s i s s u e has
a l r e a d y been s e t t l e d u s i n g an " o p t i o n " o r a " s a f e t y n e t " system.
L a s t l y , a t t h i s p o i n t i n t i m e , t h e t a x t r e a t m e n t o f any
postretirement benefit
funds
o t h e r than pensions
that
are
t r a n s f e r r e d t o e x t e r n a l i r r e v o c a b l e t r u s t s i s not as f a v o r a b l e as
t h a t s e t up f o r pension p l a n s . Such p e n a l t i e s as 100%
tax
surcharges, and o t h e r u n f a v o r a b l e t a x t r e a t m e n t , s e v e r e l y h i n d e r
t h e a b i l i t y o f a company t o go o u t t h e r e and e s t a b l i s h h e a l t h care
t r u s t s . I f t h e t a x law c o u l d be changed so t h a t these t r u s t s were
viewed as pensions (which t h e y a r e ) , and got pension p l a n t a x
t r e a t m e n t f o r t h e i r t r a n s a c t i o n s , t h e n i t would be a l o t s i m p l e r
and e a s i e r f o r t h e companies t o a t l e a s t e s t a b l i s h a t r u s t v e h i c l e ,
and then fund i t l a t e r as t h e need a r i s e s . And I t h i n k you would
f i n d t h a t p l a n a d m i n i s t r a t i v e c o s t s would d e c l i n e s i g n i f i c a n t l y .
The i d e a o f t h e h e a l t h b e n e f i t F i n a n c i a l A c c o u n t i n g Standards
Board"s pronouncement were d r i v e n by t h e main theme o f t h e Reagan
and Bush a d m i n i s t r a t i o n s o f "Let's get government o f f t h e backs o f
t h e people". For any o f t h i s t o have worked, i t would have r e q u i r e d
r e a l economic growth o f around 6%. W e l l , i t d i d n ' t happen, i t
c o u l d n ' t have happened, so now some d i f f i c u l t c h o i c e s must be made.
Here are some numbers t h a t might be o f i n t e r e s t . S i x and one
h a l f days o f wasted medical care w i l l o f f s e t a l l o f t h e P r e s i d e n t ' s
s t i m u l u s package f o r t h i s year. S i x and one h a l f months o f wasted
m e d i c a l care w i l l wipe o u t a l l o f t h e P r e s i d e n t ' s proposed d e f i c i t
r e d u c t i o n package over t h e next f o u r t o f i v e y e a r s .
Very t r u l y y o u r s ,
Minot D. H i l l ,
CPA
�AMERICAN AMPUTEE FOUNDATION, INC.
NATIONAL HEADQUARTERS
o
April 13, 1993
Mr. Mack McClarty
Chief of Staff
White House
Washington, D.C. 20500
RE: Oregon Plan
Dear Mack:/
I have just read with grave concern of President Clinton's intention to adopt the Oregon
Plan. As you know, our Foundation serves as a national information center for 2.5 million
amputee consumers. Based on prior review of the Oregon Plan, said program will deny
funding access for prosthetist services.
Any health care program which is adopted by the Clinton administration should consider
and cover medically appropriate technology for mobility, including artificial limbs and
bracing.
I appreciate your time and efforts regarding this concern and hope things are going well
for you.
Sincerely,
JagtOVI. East
Executive Director
AMERICAN AMPUTEE FOUNDATION, INC.
P. O. Box 250218 - Hillcrest Station - Little Rock, Arkansas 72225 - (501)666-2523
�THE WHITE
WAS
HOUSE
H I N G T O N
May 6, 1993
Mr. Jack M. East
Executive D i r e c t o r
American Amputee Foundation, Inc.
Post O f f i c e Box 250218
H i l l c r e s t Station
L i t t l e Rock, Arkansas 72225
Dear Mr. East:
I t was good t o hear from you, and I appreciate your keeping i n
touch and sharing your thoughts on a v a r i e t y of issues, mainly
h e a l t h care reform and our economy.
Your l e t t e r on the Oregon Plan and how i t would a f f e c t
p r o t h e s t i s t services has been noted and forwarded on t o the
Health Care Task Force f o r f u r t h e r consideration. I do not know
of any concrete plans t o come from the Task Force t o date, but I
do know t h a t they are s t i l l i n the process of formulating a f i n a l
package.
Your thoughts on ways t o help stimulate our economy were also
very h e l p f u l . I t i s important f o r t h i s A d m i n i s t r a t i o n t o have
input from people across the country regarding ways t o cut our
spending and reduce our d e f i c i t .
Again, thank you f o r w r i t i n g and keeping i n touch.
Personally,
Mack McLarty
Chief of S t a f f t o the President
cc: Health Care Task Force
�THE WHITE H O U S E
WAS
May
12,
H IN
G T O N
1993
Mr. Robert M. Welham, J r .
President
Danks Department Stores
Post O f f i c e Box 1005
Lewistown, Pennsylvania 17044-1005
Dear Mr. Welham:
Thank you f o r w r i t i n g regarding h e a l t h care reform and the costs
t o business of p r o v i d i n g mandatory h e a l t h care coverage t o a l l
employees. I appreciate your sharing w i t h me how such a plan
could a f f e c t Danks Department Stores.
As the Health Care Task Force moves forward i n the f o r m u l a t i o n of
h e a l t h care p o l i c y , i t i s important f o r t h i s A d m i n i s t r a t i o n t o
have your suggestions and your i n p u t . As you know, the Health
Care Task Force i s s t i l l working on a f i n a l proposal, and I have
taken the l i b e r t y of forwarding your l e t t e r t o them f o r
a d d i t i o n a l consideration.
Again, thank you f o r t a k i n g the time t o w r i t e .
Personally,
Mack McLarty
Chief of S t a f f t o the President
cc: Health Care Task Force
M
/
�P.O. BOX 1005 LEWISTOWN, PA. 17044-1005
PHONE 717-248-6794
^ ^ ^ F
May
3,
Department Stores
Established 1924
1993
The H o n o r a b l e Thomas F. M c L a r t y
Chief o f S t a f f
W h i t e House, West Wing
Washington,
D.C.
20500
Dear Mr. M c L a r t y :
The P r e s i d e n t ' s p l a n t o mandate h e a l t h c a r e c o s t s t o b u s i n e s s i s
ludicrous.
We d e f i n i t e l y need h e a l t h c a r e r e f o r m , b u t an e m p l o y e r mandate f o r h e a l t h c a r e c o v e r a g e i s j u s t s i n k i n g a n o t h e r n a i l
i n t h e c o f f i n o f f r e e e n t e r p r i s e (one o f t h e c o r n e r s t o n e s t h a t
made t h i s c o u n t r y g r e a t ) .
I am t h e P r e s i d e n t o f a 69 y e a r o l d , 6 s t o r e , c l o t h i n g c h a i n .
Mandated h e a l t h c a r e w i l l most p r o b a b l y f o r c e us t o c l o s e o u r
doors.
We c u r r e n t l y employ 187 p e o p l e .
We o f f e r h e a l t h c a r e
c o v e r a g e t o 1 0 0 % o f a l l e m p l o y e e s w o r k i n g 30 h o u r s a week o r
more.
T h a t amounts t o 104 o u t o f t h e 187 p e o p l e .
Of t h a t 104,
55 t a k e a d v a n t a g e o f o u r h e a l t h c a r e p l a n .
Our a n n u a l b o t t o m l i n e p r o f i t i s n o n e x i s t e n t ( s e e a t t a c h e d Income
Statement).
We, however, a n n u a l l y pump i n t o t h e economy $47,650
p e r employee when y o u t a k e i n t o c o n s i d e r a t i o n s a l a r i e s , b e n e f i t s ,
inventory
and s e r v i c e s p u r c h a s e d .
T h i n k a b o u t t h i s number when
mandating h e a l t h care.
The f i r s t y e a r we c l o s e , t h e n a t i o n w i l l
be f o r c e d t o r e p l a c e $8,910,550 i n l o s t economic a c t i v i t y , n o t t o
m e n t i o n l o s t t a x e s , c o s t o f unemployment b e n e f i t s f o r 187 p e o p l e ,
and w h a t e v e r h e a l t h c a r e w i l l c o s t .
We a r e a s m a l l b u s i n e s s and n o t a l o n e i n o u r f i n a n c i a l
situation.
The p r o p o s e d mandate i s a d e a d l y p i l l t o s w a l l o w .
Now's t h e t i m e
t o make s u r e i t ' s n o t m a n u f a c t u r e d !
Sincerely,
R o b e r t M. Welham, J r .
President
�DANKS AND COMPANY
STATEMENTS OF INCOME
(See Accountants' Compilation Report)
YEARS ENDED JANUARY 31, 1993 AND 1992
PERCENT
GROSS SALES
Company departments
Leased departments
TOTAL GROSS SALES
Less leased department sales
retained by lessee
1991
1992
$7,384,016
690,185
91. 53
8.47
91. 45
8.55
8,074,201
100.00
100.00
1993
1992
$7,279,867
673,616
7,953,483
(588.480)
(603,331)
(7. 40)
(7. 47)
SALES AND COMMISSIONS - NET
7,365,003
7,470,870
92 60
92 53
COST OF SALES
4.527.704
4,596,698
56 93
56 93
GROSS MARGIN
2,837,299
2,874,172
35 67
35 60
1,612,275
20 27
258,861
163,051
195,120
244,446
80,073
35,280
17,452
85,824
114,302
98,467
17,949
1,720
2,631
14,130
1,541,339
6,200
209,806
163,500
234,617
276,930
95,589
53,598
24,769
79,361
113,425
91,074
26,344
2,868
7,019
11,848
3.25
2 05
2 45
3 07
1 .01
.44
.22
1 .08
1 .44
1 .24
.23
.02
.03
.18
19 09
08
2 60
2 02
2 91
3 43
1 .18
.66
.31
.98
1 .40
1 .13
.33
.04
.09
.15
50.233
86.816
.63
1 .07
2.991.814
3J)25 JO 3
37 .61
37 .47
(1 .94)
(1 .87)
OPERATING EXPENSES
Salaries
Profit-sharing plan
Rent
Advert i s i ng
Taxes and licenses
Supplies
Servi ces
Mi seel 1aneous
Travel
Communications
Insurance
Depreciation
Professional services
Donations
Equipment rental
Bad debts - net
Maintenance and service
contracts
TOTAL OPERATING EXPENSES
OPERATING LOSS
-
(154,515)
(150,931)
-
�PERCENT
1993
OPERATING LOSS - FORWARD
INTEREST EXPENSE - NET
OTHER INCOME (EXPENSE)
Rental
Services charcjes - net
Mi seel 1aneous
Loss on disposition of property
and equipment
Fire loss settlement
1992
1993
1992
(154,515)
(150,931)
(1.94)
(1.87)
(70,045)
(63,498)
(.88)
(.79)
46,827
136,815
3,666
44,069
140,766
187
.59
1.71
.05
.55
1.74
(12,323)
54,216
(.10)
(-15)
.67
2.25
2.81
(7,983)
-
-
OTHER INCOME - NET
179,325
226,915
INCOME (LOSS) BEFORE INCOME TAXES
(45,235)
12,486
(.57)
.15
INCOME TAXES (BENEFITS)
Current
Deferred
(30,097)
3,126
(3,005)
2,464
(.38)
.04
(.04)
.03
TOTAL INCOME TAX BENEFITS
(26,971)
(541)
(.34)
(.01)
13,027
(.23)
.16
NET INCOME (LOSS)
$
(18,264)
$
See notes to financial statements
which are an integral part of these statements,
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003a. letter
SUBJECT/TITLE
DATE
Mack McLarty to William E. Thomas; re: Health Care Reform
(partial) (1 page)
05/12/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Marjorie Tarmey
OA/Box Number: 1338
FOLDER TITLE:
[Letters 1] [Loose] [3]
2006-0885-F
£2792.
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(bXl) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute [(bX3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOI A|
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells ((bX9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute |(aX3) of the PRA)
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�THE WHITE H O U S E
WAS HIN G T O N
May 12,
1993
Mr. William E. Thomas
Dear Mr. Thomas:
Thank you for writing and contacting me as both a friend from
home and someone who i s interested i n t h i s Administration and
health care reform. I t was good to hear from you, and I do
remember you and your parents i n Hope. Your swimming lessons
were always f i r s t rate!
As you know, this Administration has put health care reform at
the top of i t s l i s t of p r i o r i t i e s . Your generous offer to a s s i s t
in this momentous task i s greatly appreciated. You certainly
have had a l o t of "hands on" experience i n the health care f i e l d
and related industries, and your insight into how we may improve
on certain problem areas i s important for us to have as we move
ahead with the Task Force's agenda.
I have taken the l i b e r t y of forwarding your l e t t e r to the Health
Care Task Force for further attention. Although I do not know i f
they are planning on putting together any support groups once the
proposal i s announced, I do know your suggestions w i l l be
welcomed and you w i l l be given f u l l consideration should any
opportunity a r i s e .
Again, thank you for writing and for your support. Your interest
in this Administration i s greatly appreciated, as i s your offer
to help.
Personally,
Mack McLarty
cc: Health
Care to
Task
Chief
of Staff
theForce
President
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003b. letter
DATE
SUBJECT/TITLE
Bill Thomas to Thomas "Mack" McLarty; re: Swimming Lessons
(partial) (1 page)
04/23/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Marjorie Tarmey
OA/Box Number:
1338
FOLDER TITLE:
[Letters 1] [Loose] [3]
2006-0885-F
ip2792
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - [5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(bXI) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute [(bX3)of the FOIAJ
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
National Security Classified Information [(a)(1) of the PRA]
Relating to the appointment to Federal office 1(a)(2) of the PRA]
Release would violate a Federal statute 1(a)(3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�, ; P6/(b)(6) r • •
William E. Thomas
[ao3l£]
::.;-..:; f'..';.P6/(b)(6
;
April 23,1993
Thomas "Mack" McClarty
Chief of Staff
THE WHITE HOUSE
1600 Pennsylvania Avenue
Washington, DC 20500
Dear Mr. McClarty:
You might not remember me, since I graduated from Hope High School in 1955, but I may have
taught both you and President Clinton swimming lessons at the Fair Park pool during the
summers of 1954 or 1955. I'm also a graduate of the University of Arkansas. My parents,
Charles O. Thomas and Emma Green Thomas, lived at 1210 South Main Street. Dad had a
consulting engineering practice with offices in the old Citizens National Bank Building in Hope.
During the 1930s he was the resident WPA engineer for the construction of Hempstead County
Courthouse, Hope City Hall, and Hammonds Stadium. My father was also a very good friend of
your grandfather, Thomas "Tom" McClarty.
I am writinfi today to offer my services and "hands on" knowledge and experience as a member
of the President'^ Task Fnmp nn Hpalth Care Reform. Recently while reviewing a list of the
Task Force participants, I recognized a void that could create serious problems if not addressed.
Few on the task force appear to have any significant "hands on" experience in health care
delivery or any direct experience in the actual purchase and use of for-profit health care products
and/or services. Although this might not seem to be a problem in the creative stage, it could
become a serious flaw in the implementation process that could jeopardize long-term success.
In addition to the current creative team, I believe the President needs a tactical trouble-shooting
team whose leadership and personnel have considerable experience at thefieldlevel. These
individuals must possess incisive diagnostic skills and be capable of directingrapid,tactical
revisions that prevent the President's plan from going off target. Perhaps the group would be like
a health care SWAT team of sorts. I would like to assist the Administration in constructing and
managing such a team and believe my long experience in health care—over thirty-seven (37)
years—highly qualifies me to make this contribution to my country.
Here is an example of one of thefirstproblem areas to tackle. Recent reports indicate the Clinton
Administration would like to save $3.1 billion by eliminating excessive Medicare payments for
lab tests. I know that at least $5 billion could be saved without reducing the quality of patient
care. However, one mustfirstknow precisely where to look and how to take appropriate
corrective action. Other areas of diagnostic testing as well as pharmaceutical products could
benefit from the same scrutiny, but only if your tactical team has the right experience and skills.
�<v
Mr. Thomas McClarty
April 23, 1993
Page 2
Since graduating from Hope High School I have served in health care while in military service as
well as private sector businesses. Some of these include ethical pharmaceutical products,
commercial clinical laboratory services, environmental and occupational health testing, and
diagnostic instrumentation. I have strong experience in both field management and executive
direction and flourish best in situations where my diagnostic and trouble-shooting skills are
utilized to the fullest. In addition to my depth of experience in the health care arena, I have the
right mix of skills to lead a successful tactical team.
Although I'm not in a position to offer detailed recommendations until the President's plan is
unveiled, I'd like you,. President Clinton, and Hillary Rodham Clinton to know that should the
Administration agree with my suggestion to create a Health Care Tactical Support Team, I'd like
to participate in building it. I look forward to hearing from you.
In conclusion, let me offer my personal congratulations to you. President Clinton, Vince Foster
and Dave Watkins. I join the citizens of Hope and the nation in wishing great success to this
Administration, and hope to be invited to contribute to its success. The needs are many, the goals
are clear and the tasks, although difficult, can be achieved.
With sincere and warm regards,
William E. Thomas
�THE
WHITE
HOUSE
^
1
r
March 16, 1993
David R. Pfleger
Thornton Pfleger, Inc.
Suite 1002
2052 Lincoln Park West
Chicago, IL 60614
Dear Mr. Pfleger:
Thank you for writing and sharing your views on health care
reform. We are soliciting dialogue throughout the country from all
segments of the health care industry in this tremendous undertaking
to find solutions to the incredibly complex health care problems
facing us. I am directing your paper to the Task Force for further
review and consideration.
President Clinton is committed to reforming our nation's
health care system - making affordable health care accessible and
providing security to every American family. It won't be easy and it
won't happen overnight, but we can bring costs under control while
maintaining quality medical care and preserving the choice so
important to us all.
Again, thank you for your ideas. I hope we can count on
your support for the success of this endeavor.
Sincerely yoi
Hillary R< dham Clinton
cc: Task Force
�'Thornton Pfleger, Inc.
2052 Lincoln Park West, Suite 1002
Chicago, IL 60614
312-248-2494
T P I
February 10, 1993
Ms. H i l l a r y Rodham C l i n t o n
Task Force on H e a l t h Care Reform
The White House
Washington, D.C. 20500
Dear Ms. C l i n t o n ,
I am a l o n g t i m e c o l l a b o r a t o r , business p a r t n e r and c l o s e
f r i e n d o f M i c h a e l B e n n e t t , whom you know from Southern
Development/Shorebank. He and I d i s c u s s e d my sending you
the enclosed t h o u g h t s on h e a l t h care r e f o r m .
I am sure your r e a d i n g t i m e i s l i m i t e d so I have h i g h l i g h t e d
c r i t i c a l a s s e r t i o n s ; t h e r e s t o f t h e paper supports these
assertions.
My b i a s i s o f a m i d d l e c l a s s s m a l l business owner who pays
the f u l l c o s t o f h e a l t h c a r e . I am a p a r t n e r i n a
c o n s u l t i n g f i r m which s p e c i a l i z e s i n p r o d u c t i v i t y
improvement, o r g a n i z a t i o n a l development and p u b l i c p o l i c y .
Some o f my c l i e n t s a r e i n t h e h e a l t h care i n d u s t r y and t h i s
have g i v e n me t h e o p p o r t u n i t y t o l e a r n a g r e a t d e a l . I
suspect t h a t my c l i e n t s would n o t s u p p o r t s e v e r a l o f my
c o n c l u s i o n s , however. I submit them s t r i c t l y as a c i t i z e n
who wishes t o a i d your t a s k .
I would welcome a chance t o d i s c u s s t h i s i s s u e w i t h you o r
your c o l l e a g u e s a t any t i m e .
Sincerely/
David R. P f l e g e r
o 2
•a 2
2 o
12
�Thornton Pfleg-er, Inc.
2052 Lincoln Park West, Suite 1002
Chicago, IL 60614
312-248-2494
T P I
A REALISTIC LOOK AT AMERICAN HEALTH CARE
David P f l e g e r
ABSTRACT: There i s no genuine h e a l t h care c o s t
"crisis".
Rather, t h e c h o i c e o f American consumers t o
seek h i g h q u a l i t y care i s a v i t a l component o f economic
g r o w t h , as can be seen when h e a l t h care i s compared t o
o t h e r segments o f t h e economy. The p e r c e p t i o n o f a
cost " c r i s i s " i s the r e s u l t of the h i s t o r i c a l accident
o f an employment l i n k e d h e a l t h care payment system,
and, more r e c e n t l y , government l i n k e d payments. A
n a t i o n a l p o l i c y designed t o f i x a problem t h a t does n o t
r e a l l y e x i s t w i l l r e s u l t i n damage t o t h e economy and a
lower q u a l i t y o f care f o r most Americans. Such a
p o l i c y w i l l make worse t h e a l l t o o r e a l problem o f
access t o h e a l t h c a r e . I f on t h e o t h e r hand, changes
t o n a t i o n a l h e a l t h p o l i c y focus on access, i t w i l l
r e s u l t i n improved h e a l t h care f o r many, m a i n t a i n h i g h
q u a l i t y care f o r o t h e r s , and c o n t r i b u t e t o an improved
economy f o r t h e n a t i o n as a whole.
There i s a widespread b e l i e f t h a t t h e r e i s a h e a l t h care
c o s t " c r i s i s " i n the U.S.
I n f a c t , no such c r i s i s e x i s t s ,
r a t h e r h e a l t h care i s a p r o s p e r i n g i n d u s t r y i n an o t h e r w i s e
l a c k l u s t e r economy. The p e r c e p t i o n o f a c r i s i s i s r e l a t e d
t o t h e mechanism o f p a y i n g f o r h e a l t h care t h a t has
developed h i s t o r i c a l l y .
There i s a r e a l danger t h a t the
m i s u n d e r s t a n d i n g s about h e a l t h care - an e x c e e d i n g l y complex
i s s u e - w i l l l e a d t o an i l l c o n s i d e r e d , r a s h government
p o l i c y . T h i s i n t u r n c o u l d s e v e r e l y damage a h e a l t h care
d e l i v e r y system t h a t i s second t o none.
The p r o p o r t i o n o f GDP t h a t i s spent on h e a l t h care i s o f t e n
c i t e d as t h e s i g n t h a t demonstrates t h e h e a l t h c o s t
"crisis."
High spending on h e a l t h care i s no d i f f e r e n t from
spending on any o t h e r consumer good. As can be seen by
comparing t h e h e a l t h care s e c t o r w i t h , f o r example, the
a u t o m o b i l e s e c t o r o f t h e economy. I n c r e a s e s i n h e a l t h
spending are announced w i t h alarm. I n c r e a s e s i n spending on
p r i v a t e automobiles are u n i v e r s a l l y regarded as good news
and a s i g n o f an i m p r o v i n g economy. Yet t h e impact o f these
two s e c t o r s o f t h e economy i s s i m i l a r .
it
•3 a
S o
s =
n
a.
15
3
�The o u t l a y s on the p a r t o f households f o r t h e a c q u i s i t i o n ,
maintenance and o p e r a t i o n o f p r i v a t e a u t o m o b i l e s and t r u c k s
consumes more than 13% o f GDP.-'- T h i s does n o t t a k e i n t o
account t h e a d d i t i o n a l 1.4% o f GDP spent by government on
highways, nor the e x p e n d i t u r e s by b u s i n e s s and government
f o r t h e a c q u i s i t i o n and o p e r a t i o n o f n o n - p r i v a t e a u t o s ,
nor household expenses on p u b l i c t r a n s p o r t a t i o n . As w i t h
h e a l t h c a r e , expenses f o r p r i v a t e a u t o m o b i l e s are r i s i n g
rapidly:
from 1980 t o 1989 t h e average annual i n c r e a s e i n
•I a u t o m o t i v e expenses was 3.4% compared t o 4.0% f o r h e a l t h
c a r e . The year t o year i n c r e a s e from 1988 t o 1989 was
a c t u a l l y g r e a t e r f o r autos (4.5%) t h a n f o r h e a l t h care (2.4%)
ft
As w i t h h e a l t h c a r e , Americans have chosen a more expensive
t r a n s p o r t a t i o n system t h a n i n o t h e r n a t i o n s : we l e a d the
w o r l d i n t h e number o f cars per c a p i t a , b o a s t i n g 44% more
t h a n t h e median o f 18 i n d u s t r i a l n a t i o n s and 17% more autos
per person than the runner up n a t i o n (West Germany).
i.i A l t h o u g h we g r e e t t h e news o f our " l o v e a f f a i r w i t h t h e
f ! a u t o m o b i l e " as a s i g n o f our p r o s p e r i t y t h e s t o r y i s n ' t
[} r e a l l y a l l good: p r i v a t e c a r s p o l l u t e , i n c r e a s e our
. ; dependency on f o r e i g n energy, c o n t r i b u t e t o urban s p r a w l ,
^ r e s u l t i n m o r b i d i t y and m o r t a l i t y from a c c i d e n t s , and c o s t
l i t h e government funds f o r i n f r a s t r u c t u r e , p o l i c i n g and o t h e r
( s u p p o r t . Yet t h e r e i s no hue and c r y t h a t " t h e c o s t s o f
p r i v a t e automobile ownership i s making America
u n c o m p e t i t i v e . " Why not? Fundamentally, because the person
Iiwho chooses t o buy o r o p e r a t e and a u t o m o b i l e i s t h e person
!'who pays t h e b i l l .
Automotive d e c i s i o n s are u n i v e r s a l l y
regarded as p r i v a t e d e c i s i o n s . I f a c i t i z e n cannot a f f o r d a
; .! new L i n c o l n he may buy a used Geo, o r perhaps s t i c k t o
; t a k i n g the bus. Furthermore, c i t i z e n s do n o t expect
employers o r government t o p r o v i d e them w i t h " f r e e "
:'... a u t o m o b i l e s . A l t h o u g h l a b o r c o s t s r e f l e c t t h e c o s t o f the
p r i v a t e automobile l i f e s t y l e we have chosen, these c o s t s do
not come t o t h e a t t e n t i o n o f employers as a separate l i n e
,1 i t e m , nor does government show a u t o m o b i l e ownership as an
(""•j " e n t i t l e m e n t " expense.
;
i j T h i s i s n o t an argument f o r cutbacks i n t h e automobile
i n d u s t r y ; t h a t i n d u s t r y i s an i m p o r t a n t and v i t a l p a r t o f
our economy and c o n t r i b u t e s t o our n a t i o n a l w e a l t h . So does
i i h e a l t h c a r e . H e a l t h care does so i n two ways.
First
the o u t p u t o f t h e h e a l t h care i n d u s t r y i s i n c r e a s e d
,.• s u r v i v a l ; p u t another way, i n c r e a s e d human c a p i t a l . A l l
: s u r v i v o r s c o n t r i b u t e t o t h e economy as consumers and most as
,' w o r k e r s . L i k e t h e a u t o m o t i v e i n d u s t r y , t h e h e a l t h care
• s e c t o r c r e a t e s w e a l t h . ( U n l i k e some s e r v i c e i n d u s t r i e s .
I I n v e s t m e n t b a n k i n g , f o r example, moves w e a l t h around b u t
does n o t c r e a t e i t . )
!
; \ Secondly, h e a l t h care i s a v i t a l e m p l o y e r .
z
Between
1970
�n and 1990 h e a l t h care's share o f t h e GNP i n c r e a s e d by 67%.
I n t h e s l i g h t l y s h o r t e r p e r i o d o f 1970 t o 1989 h e a l t h
'employment as a p e r c e n t o f t o t a l employment a l s o i n c r e a s e d
,.by 67%. This r e p r e s e n t s a 245% i n c r e a s e i n t h e number o f
persons w o r k i n g i n h e a l t h care over t h e p e r i o d . A t a t i m e
';when j o b c r e a t i o n must be regarded as a n a t i o n a l p r i o r i t y
' i t h e Labor Department f o r e c a s t s c o n t i n u e d s t r o n g growth i n
h e a l t h care j o b s . (Between 1990 and 2005 o v e r a l l j o b growth
• i s expected t o be 20%. Jobs f o r h e a l t h care workers
S a r e expected t o i n c r e a s e more t h a n t w i c e t h a t f a s t : by over
jf.;}4o%.
j "l Another b e n e f i t o f h e a l t h care i s t h a t h e a l t h d o l l a r s a r e
It m o s t l y spent on U.S. goods, s e r v i c e s and l a b o r . Not many
A m e r i c a n s who d r i v e a Toyota seek m e d i c a l care i n Japan. On
t h e o t h e r hand, h e a l t h care i s an e x p o r t i n d u s t r y .
F o r e i g n e r s do come here t o seek our b e t t e r , more a c c e s s i b l e
m e d i c a l care. Canadians, f o r i n s t a n c e , f l e e t h e i r own
r a t i o n e d system and seek care i n t h e U.S. More i m p o r t a n t l y ,
t h e r e s e a r c h done by t h e i n d u s t r y does r e s u l t i n s i g n i f i c a n t
export products.
0
R e s t r a i n i n g t h e growth o f t h e h e a l t h care i n d u s t r y would be
r! a drag on t h e economy, b o t h i n terms o f employment and i n
terms o f underinvestment i n human c a p i t a l . On t h e o t h e r
hand, i n c r e a s i n g access t o h e a l t h care w i l l have economic
benefits.
i
j;
i;
\ i
Since t h e h e a l t h care i n d u s t r y i s o f g r e a t economic b e n e f i t ,
why i s t h e r e a p e r c e i v e d c o s t " c r i s i s " ? The most i m p o r t a n t
reason Americans t h i n k t h a t t h e r e i s a " c r i s i s " i n h e a l t h
care c o s t s i s because o f t h e employment-based payment l i n k
t h a t leads businessmen t o f e a r l o s s o f c o m p e t i t i v e n e s s due
"•• t o o u t o f c o n t r o l l a b o r c o s t s . The i s s u e i s n o t h e a l t h
i c o s t s , t h e i s s u e i s r e a l l y p r o d u c t i v i t y . T h i s employmentI based payment l i n k i s n e i t h e r bad nor good i n and o f i t s e l f ,
• ; but the series o f h i s t o r i c a l accidents t h a t created t h i s
l i n k have shaped our view o f h e a l t h care today.
H i s t o r y Shapes the Present Debate
To understand t h e c u r r e n t circumstances i n American h e a l t h
care i t i s necessary t o l o o k a t h i s t o r y .
Until fairly
r e c e n t l y p h y s i c i a n s c o u l d p r o v i d e l i t t l e i n t h e way o f
e f f e c t i v e t r e a t m e n t . The i n j u r e d and i l l r e q u i r e d r e s t and
n u r s i n g care w h i l e they r e c u p e r a t e d and t h i s was p r o v i d e d a t
home. As i n d u s t r i a l i z a t i o n spread across t h e c o u n t r y ,
workers m i g r a t e d from r u r a l areas and o t h e r n a t i o n s . Since
t h e y were f a r from t h e i r o r i g i n s , these persons l a r g e l y
l a c k e d t h e homes and f a m i l y necessary f o r r e c u p e r a t i o n i n
t h e event o f i n j u r y o r i l l n e s s . H o s p i t a l s came i n t o
e x i s t e n c e as p l a c e s where these workers ( a l o n g w i t h t h e v e r y
poor and t r a v e l l i n g seamen) c o u l d r e c u p e r a t e .
I t was
3
�n a t u r a l f o r employers t o s u p p o r t these h o s p i t a l s as a means
of g e t t i n g workers back t o t h e j o b . L a t e r , t h e concept o f
compensation from the employer f o r work r e l a t e d i n j u r y
s t r e n g t h e n e d t h e l i n k between employers and t h e f i n a n c e o f
h e a l t h care.
M e d i c a l p r o g r e s s changed t h e dynamics. A n e s t h e s i a i n the
l a s t c e n t u r y and a n t i b i o t i c s i n t h e m i d d l e o f t h i s c e n t u r y
meant t h a t p h y s i c i a n s c o u l d o f f e r e f f e c t i v e t r e a t m e n t .
Since World War I I m e d i c a l advances have come a t an
a c c e l e r a t i n g r a t e and these advances r e q u i r e d i n - p a t i e n t
c a r e . H o s p i t a l s became p l a c e s f o r t h e m i d d l e c l a s s and r i c h
as w e l l as t h e poor and w o r k i n g c l a s s . P h y s i c i a n s who had
been a b l e t o do l i t t l e more t h a n p r o v i d e c o m f o r t (and who
were p a i d a c c o r d i n g l y ) now c o u l d t r u l y "save l i v e s " and
t h e i r compensation r o s e . The drugs and equipment needed f o r
t h i s newly e f f e c t i v e medicine were expensive. M e d i c a l care
had been an i n s i g n i f i c a n t expense f o r employers b u t now t h e
c o s t s began t o m a t t e r . S t i l l employers c o n t i n u e d t o g l a d l y
f i n a n c e t h e h e a l t h care system.
Some d i d so f o r w e l l meaning p a t e r n a l i s t i c reasons, o t h e r s i n o r d e r t o compete
f o r workers by o f f e r i n g a t t r a c t i v e b e n e f i t p l a n s , and s t i l l
o t h e r s under p r e s s u r e from l a b o r u n i o n s .
.f/This l i n k between employment and h e a l t h care f i n a n c e was
i unique t o t h i s c o u n t r y . Employers t h o u g h t o f h e a l t h care as
j p a r t o f l a b o r c o s t s . As l o n g as h e a l t h care r e p r e s e n t e d a
, s m a l l percentage o f t o t a l l a b o r c o s t s i t caused l i t t l e
i concern. R e c e n t l y these c o s t s began t o grow v e r y r a p i d l y .
Employers became alarmed, n o t because h e a l t h care c o s t s per
v! se were g r o w i n g , b u t because l a b o r c o s t s were i n c r e a s i n g ,
and i n c r e a s i n g i n an u n c o n t r o l l e d way.
A company can
! b a r g a i n w i t h employees and n e g o t i a t e the pace o f wage
j i n c r e a s e s . But t h e h e a l t h care b i l l i n c r e a s e was based on
• I what p r o v i d e r s charged, and f i r m s found an ever l a r g e r chunk
;\of t h e i r l a b o r c o s t s moving beyond t h e i r immediate c o n t r o l .
;
1
The average consumer o f h e a l t h care t h i n k s t h e r e i s a c o s t
c r i s i s f o r t h e same h i s t o r i c a l reason: t h e l i n k between
h e a l t h care and employment. H e a l t h care c o s t s were p a i d by
employers so employees t h o u g h t care was " f r e e . "
As
companies pushed more and more c o s t s o n t o employees (by
p a y r o l l d e d u c t i o n f o r premiums, h i g h e r d e d u c t i b l e s and
, ico-payments) and as access began t o be r e s t r i c t e d (by
i managed care and u t i l i z a t i o n r e v i e w ) employees began t o have
•, t o pay a more s i g n i f i c a n t p a r t o f t h e i r h e a l t h care c o s t s .
I Where b e f o r e t h e y p a i d n e x t t o n o t h i n g f o r c a r e , now
' employees t y p i c a l l y pay s i g n i f i c a n t amounts f o r coverage and
[ ' s e r v i c e . I t i s n o t the o v e r a l l i n c r e a s e i n c o s t s t h a t has
j'_ j f r i g h t e n e d t h e average American, i t i s t h e i n c r e a s e i n c o s t s
' d i r e c t l y o u t o f pocket.
''c)f c o u r s e , h e a l t h care i s never f r e e .
One
o f t h e dangerous
�aspects o f t h e c u r r e n t debate i s the conunon use o f t h e t e r m
" f r e e " t o r e f e r t o h e a l t h care i n o t h e r n a t i o n s . H e a l t h
c a r e may be p a i d f o r by t a x a t i o n , by employers as p a r t o f
l a b o r c o s t s , o r d i r e c t l y by consumers. But i t i s never
free.
The Tax On S i c k People
The myth o f f r e e h e a l t h care i s p e r s i s t e n t and p e r n i c i o u s
and has been exacerbated by government a c t i o n .
Politicians
promised " f r e e " h e a l t h care t o r e t i r e d Americans i n t h e
Medicare program. As Medicare c o s t s have gone up,
government has f a i l e d t o r a i s e t a x e s t o m a i n t a i n b e n e f i t
l e v e l s . Rather, government has u n d e r p a i d p r o v i d e r s .
P r o v i d e r s i n t u r n are f o r c e d t o s h i f t t h e unpaid balance
t h i s underpayment c r e a t e s t o the b i l l s o f p a t i e n t s whose
care i s p a i d f o r by themselves or t h e i r employers.
In
essence, t h e U.S. f i n a n c e s a s u b s t a n t i a l p a r t o f the c o s t s
o f Medicare/Medicaid by a t a x on s i c k people. Since r o u g h l y
h a l f t h e h e a l t h care b i l l goes f o r pub.l.i.c__programs, t h i s
c o s t s h i f t i n g i s v e r y s i g n i f i c a n t : ^non-government p a t i e n t s
are vestima'teH "to pay 28'%""rnore"' f o r 'ea"ch s e r v i c e than" t h e y
•r_
o t h e r w i s e would. • ; T h i s 28!% t a x on s i c k peop'le r e p r e s e n t s a •?
major p o r t i o n o f t h e i n c r e a s e i n h e a l t h care c o s t s p a i d f o r
by employers, thus i n c r e a s i n g t h e i r a l a r m and, i n t u r n , t h e
a l a r m o f employees h a v i n g t o pay a g r e a t e r p r o p o r t i o n o f
t h e i r health costs.
1
By assuming r e s p o n s i b i l i t y f o r a p o r t i o n o f t h e m e d i c a l
b i i l s - o f t h e r e t i r e d and some o f t h e i n d i g e n t , government
..became a t h i r d p a r t y payer. J u s t as employers f e a r a r i s i n g
wage b i l l , government f e a r s a r i s i n g d e f i c i t .
So t h e second
T-r.eas.on- -Americans p e r c e i v e ; a h e a l t h c o s t" c r i s i s " i s a l s o
r e l a t e d t o t h e h i s t o r i c a l , a c c i d e n t o f payment system.
R e g r e t t a b l y , government l e a d e r s have been u n w i l l i n g t o admit
t h a t m e d i c a l care f o r Medicare/Medicaid r e c i p i e n t s i s
underfunded.
(Of course, America has no monopoly on
irresponsible politicians.
Compare t h e decades - l o n g
p o l i t i c a l debate on " r e f o r m " o f t h e NHS i n B r i t a i n .
There,
as i n most c o u n t r i e s where the government p r o v i d e s c a r e ,
government has obscured t h e f a c t s about " f r e e " care.)
;
1
But even i f t h i s h i s t o r y e x p l a i n s why Americans p e r c e i v e a
h e a l t h c o s t c r i s i s i t does n o t e x p l a i n away growing c o s t s .
I f , as argued h e r e , t h e r e a l i s s u e s c a u s i n g t h e p e r c e i v e d
c r i s i s are l a b o r c o s t s and p r o d u c t i v i t y i n o t h e r i n d u s t r i e s
and t h e d e f i c i t , n o t h e a l t h care c o s t s per se, i s n ' t t h a t
s t i l l reason t o "do something" t o c u t c o s t s ?
Surprisingly,
t h e answer i s no.
The Reasons f o r I n c r e a s e d Costs
'Increased c o s t s are, r e l a t e d t o i n c r e a s e d e f f e c t i v e n e s s .
'And
�American m e d i c i n e i s t h e most e f f e c t i v e i n the w o r l d .
U n f o r t u n a t e l y t h e r e are no simple and easy ways t o s u p p o r t
t h i s a s s e r t i o n . Measurements such as i n f a n t m o r t a l i t y are
n o t u s e f u l f o r comparative purposes because the U n i t e d
S t a t e s has s p e c i a l s o c i a l problems (a h i g h r a t e o f drug
a d d i c t i o n , poverty, r a c i a l d i s c r i m i n a t i o n , high incidence o f
teenage pregnancy) t h a t u n f a v o r a b l y i n f l u e n c e the simple
comparison i m p l i e d by m o r t a l i t y s t a t i s t i c s . Some
r e s e a r c h e r s have a t t e m p t e d comparisons t h a t c o r r e c t f o r
s o c i a l and demographic f a c t o r s and found t h a t American
medicine s t a c k s up w e l l . A c c o r d i n g t o S . A . M i t c h e l l :
I n t e r n a t i o n a l comparisons o f h e a l t h c o s t s and crude
measures o f h e a l t h s t a t u s can be h i g h l y m i s l e a d i n g
w i t h o u t c a r e f u l a n a l y s i s o f the e f f e c t s o f l i f e s t y l e
and demographic d i f f e r e n c e s . These e f f e c t s can be so
s t r o n g t h a t n a t i o n s a g a i n s t whom t h e U.S. i s compared
u n f a v o r a b l y would spend a g r e a t e r share o f the G.D.P.
on h e a l t h than t h e U.S. i f t h e i r p o p u l a t i o n s had
comparable l i f e s t y l e s and demographic mix.
M i t c h e l l goes on t o demonstrate t h a t h e a l t h expense as a
p e r c e n t o f G.D.P. i s i d e n t i c a l i n Germany and a r e g i o n
s i m i l a r t o Germany i n t h e U.S.: Wisconsin, t h e Dakotas and
Minnesota.^
A c t u a l . measures_-Of m e d i c a l e f f e c t i v e n e s s can o n l . y _ r e a l l y be.
addressed on a disease by disease b a s i s . A r e v i e w o f
medical l i t e r a t u r e surrounding s p e c i f i c , treatments f o r
s p e c i f i c i l l n e s s e s shows g r e a t p r o g r e s s . ,For example, t h e
f o u r year s u r v i v a l r a t e o f one l a r g e s e r i e s o f p a t i e n t s
s u f f e r i n g from m y o c a r d i a l i n f a r c t i o n s improved by 35% f o r
men and 27% f o r women over a t e n year p e r i o d .
In a series
of women s u f f e r i n g from i n t r a d u c t a l b r e a s t cancer, t r e a t e d
w i t h b r e a s t c o n s e r v i n g s u r g e r y and i r r a d i a t i o n , the t e n year
a c t u a r i a l c a u s e - s p e c i f i c s u r v i v a l r a t e was 97%.'
But what
does t h i s mean e x a c t l y ?
6
1.
S u r v i v a l r a t e s (how l o n g someone l i v e s a f t e r an
event l i k e a h e a r t a t t a c k o r b r e a s t surgery) have been
g r e a t l y increased.
S u r v i v a l r a t e s are p r o b a b l y t h e
b e s t measures o f the e f f e c t i v e n e s s o f m e d i c a l
interventions.
2. T h i s says n o t h i n g about i n c i d e n c e r a t e s (how many
people g e t t h e disease i n t h e f i r s t p l a c e ) . I n c i d e n c e
i s n o t u s u a l l y a measure o f m e d i c a l e f f e c t i v e n e s s
because m e d i c a l i n t e r v e n t i o n s m o s t l y occur a f t e r the
onset o f t h e disease.
The i n c i d e n c e o f b r e a s t cancer,
f o r example, i s c l i m b i n g w h i l e t h e s u r v i v a l r a t e i s
a l s o c l i m b i n g . Since more women are c o n t r a c t i n g t h e
disease and t h e y are l i v i n g l o n g e r t h i s means t h a t t h e
prevalence r a t e ( t h e percentage o f t h e p o p u l a t i o n t h a t
�has the disease a t any g i v e n t i m e ) i s r i s i n g v e r y f a s t .
I n c r e a s i n g p r e v a l e n c e i s a c t u a l l y a s i g n o f good
m e d i c a l care t o t h e e x t e n t t h a t s u c c e s s f u l m e d i c a l
i n t e r v e n t i o n has c r e a t e d a r i s e i n s u r v i v a l .
(Bypass
s u r g e r y , f o r example, does n o t "cure" u n d e r l y i n g
c a r d i o v a s c u l a r d i s e a s e , i t s i m p l y p r o l o n g s the l i f e o f
a person w i t h t h e disease.)
3. T h i s s i t u a t i o n r a i s e s c o s t s two ways. I n t h e f i r s t
p l a c e , e f f e c t i v e m e d i c a l i n t e r v e n t i o n s o f t e n c o s t more
than i n e f f e c t i v e measures. Secondly, t h e s u r v i v o r s
r e q u i r e c o n t i n u i n g f o l l o w up c a r e . The r o u t i n e care o f
a cancer or h e a r t disease s u r v i v o r c o s t s more t h a n
r o u t i n e care f o r someone who has never had a major
disease.
4. The success o f cheap, e f f e c t i v e and e a r l y m e d i c a l
i n t e r v e n t i o n s w i l l i n c r e a s e t h e demand f o r l a t e and
expensive i n t e r v e n t i o n s : the c h i l d who does n o t d i e o f
d i p t h e r i a because he was immunized w i l l l i v e t o develop
heart disease.
I n t i m e , everyone i s a m o r t a l i t y s t a t i s t i c ,
E f f e c t i v e m e d i c a l care has the e f f e c t o f a l l o w i n g
people t o s u r v i v e e a r l y diseases so t h a t they w i l l
e v e n t u a l l y c o n t r a c t the diseases o f o l d age, such as
h e a r t disease and cancer. These diseases can a l s o be
e f f e c t i v e l y t r e a t e d , but a t considerable cost.
/^The bottom l i n e i s t h a t good, e f f e c t i v e medical care r e s u l t s
i n i n c r e a s e d s u r v i v a l f o r many d i s e a s e s , i n c r e a s e d
p r e v a l e n c e o f diseases t h a t cannot be d e f i n i t i v e l y "cured"
.< and i n c r e a s e d i n c i d e n c e o f the diseases o f o l d e r persons.
, A l l o f these outcomes r e s u l t i n i n c r e a s e d per c a p i t a c o s t s .
j Of course, i n c r e a s e d s u r v i v a l has a t a n g i b l e b e n e f i t t o
; s o c i e t y t h a t g a i n s from t h e c o n t r i b u t i o n s o f i t s s u r v i v i n g
' members, n o t t o m e n t i o n t h e overwhelming i n t a n g i b l e b e n e f i t
) o f l i f e i t s e l f t o p a t i e n t s and t h e i r f a m i l i e s .
1
8
i, •"
One i m p o r t a n t c h a r a c t e r i s t i c o f American medicine i s f r e e
c h o i c e o f p r o v i d e r . T h i s i s a p o w e r f u l t o o l f o r consumers
i f t h e y choose t o use i t because outcomes do d i f f e r by
p r o v i d e r . At t h i s stage the m e a n i n g f u l measurement o f
outcomes i s i n i t s i n f a n c y b u t i t appears t h a t p a t i e n t s get
s i g n i f i c a n t l y b e t t e r care from board c e r t i f i e d p h y s i c i a n s
•^.....^nd l a r g e t e a c h i n g h o s p i t a l s . For example, acute m y o c a r d i a l
i n f a r c t i o n p a t i e n t s are more l i k e l y t o s u r v i v e i f t h e i r
a t t e n d i n g p h y s i c i a n s t r e a t a h i g h volume o f AMI cases and/or
are board c e r t i f i e d .
S u r v i v i n g a h e a r t a t t a c k i s a l s o more
r s l i k e l y i n a t e a c h i n g h o s p i t a l . " Board c e r t i f i e d p h y s i c i a n s
.'','and t e a c h i n g h o s p i t a l s o f t e n charge h i g h e r u n i t c o s t s t h a n
' t h e i r l e s s s u c c e s s f u l c o u n t e r p a r t s , however, so a wise
'consumer needs t o balance outcome h i s t o r y a g a i n s t p r i c e .
I
HMO's and PPO's have r e s t r i c t e d choice i n an e f f o r t t o save
• t
�<' c o s t s . Many f i n e p h y s i c i a n s p a r t i c i p a t e
but those p h y s i c i a n s who need a d d i t i o n a l
are most l i k e l y t o be a t t r a c t e d t o these
i one s t u d y o f care i n 981 h o s p i t a l s found
\ where HMO e n r o l l m e n t was high.-*-^
i n these programs
p a t i e n t s t h e most
programs. A t l e a s t
higher m o r t a l i t y
/( I n medicine c o s t does c o r r e l a t e w i t h q u a l i t y , a t l e a s t i n
l'; some cases.
Cost c u t t i n g can l e a d t o lower q u a l i t y care and
!> lower s u r v i v a l . There i s s y s t e m a t i c evidence t h a t
• > . r e g u l a t i o n and c o s t c o n t r o l do h u r t q u a l i t y . One study o f
^ o v e r 214,000 medicare p a t i e n t s found m o r t a l i t y r a t e s 6 t o
10% h i g h e r i n s t a t e s w i t h t h e most s t r i n g e n t programs t o
r e v i e w and c o n t r o l h o s p i t a l r a t e s .
Another study found
f e d e r a l r e g u l a t i o n s e f f e c t i v e a t l o w e r i n g h o s p i t a l costs b u t
t h a t t h e savings came b o t h from g r e a t e r e f f i c i e n c y and from
reductions i n the q u a l i t y of c a r e .
1 1
1 2
None o f t h i s i s i n t e n d e d t o defend t h e i n e f f i c i e n t d e l i v e r y
of h e a l t h c a r e . There i s p l e n t y o f o p p o r t u n i t y t o improve
e f f i c i e n c y , j u s t as o p p o r t u n i t i e s e x i s t i n every o t h e r
business segment. P r o d u c t i v i t y and e f f i c i e n c y improvements
come t h r o u g h hard team e f f o r t s and a t t e n t i o n t o t h e d e t a i l s
of r u n n i n g a b u s i n e s s . Such improvements never come from
top down r e g u l a t i o n o r o t h e r c o e r c i o n . P r o v i d e r s should do
more i n t h i s area b u t t h e i r e f f o r t s w i l l n o t be enough t o
overcome t h e o t h e r f o r c e s pushing up c o s t s .
The E f f e c t of Government
One o f these major f o r c e s i s t h e a c t i o n o f government.
Government a c t i o n i n h e a l t h care can be c h a r a c t e r i z e d as
h a v i n g good humane i n t e n t b u t y i e l d i n g much i n t h e way o f
unintended r e s u l t s , i n c l u d i n g higher costs.
I n t h e f i r s t t h r e e p o s t - W o r l d War I I decades t h e t h r u s t o f
government a c t i o n was t h e encouragement o f new and expanded
f a c i l i t i e s ( H i l l Burton) and expanding t h e percentage o f
Americans t h a t had access t o care ( M e d i c a r e / M e d i c a i d ) . I n
the l a t e s i x t i e s , government p a i d f o r o u t r e a c h workers who
encouraged b e n e f i c i a r i e s t o s i g n up and use these new
programs. These e f f o r t s worked: demand f o r h e a l t h care
i n c r e a s e d . As i n most cases o f i n c r e a s e d demand, p r i c e s
went up, p a r t i c u l a r l y d r i v e n by l a b o r c o s t s . P h y s i c i a n s had
achieved e l e v a t e d esteem and pay i n c o n t r a s t w i t h t h e i r l o t
i n t h e f i r s t h a l f o f t h e c e n t u r y . W i t h Medicare, o t h e r
h e a l t h care workers would do t h e same.
Nurses, o r d e r l i e s and o t h e r n o n - p h y s i c i a n h e a l t h workers
had been c h r o n i c a l l y u n d e r p a i d . I t seems t h a t t h e n a t i o n
expected people who t o o k care o f o t h e r s t o pay f o r t h e
p r i v i l e g e o f d o i n g good works by s e t t l i n g f o r r e l a t i v e l y low
pay.
Sexual and r a c i a l d i s c r i m i n a t i o n a l s o p l a y e d a p a r t i n
keeping wages low. W i t h i n c r e a s e d demand f o r h e a l t h c a r e .
�p r o v i d e r s c o u l d a f f o r d t o pay t h e i r workers c o m p e t i t i v e
wages. They were s p u r r e d t o do so by newly aggressive
u n i o n s , by c i v i l r i g h t s g r o u p s , and i n some cases by
government i t s e l f .
Even today h e a l t h care wages are low.
Compare s a l a r i e s f o r
nurses and t e a c h e r s : two j o b s i m p o r t a n t f o r s o c i e t y t h a t
r e q u i r e s i m i l a r p r e p a r a t i o n . When t h e l e n g t h o f t h e work
year and days o f f are c o n s i d e r e d , nurses earn c o n s i d e r a b l y
l e s s . This d i s p a r i t y grows when n i g h t s h i f t and weekend
work i s c o n s i d e r e d .
By t h e 1970s t h e government had become alarmed a t the r a p i d
c o s t i n c r e a s e s and began a l o n g s e r i e s o f r e g u l a t i o n s
designed t o c o n t r o l these c o s t s . Each r e g u l a t i o n c r e a t e d
i t s own v i c i o u s c i r c l e .
The government h i r e s e x p e r t s t o
c r e a t e and e n f o r c e t h e r e g u l a t i o n .
P r o v i d e r s become a f r a i d
and h i r e t h e i r own e x p e r t s , a t f i r s t t o h e l p w i t h
compliance, l a t e r t o f i n d ways around the i n t e n t o f the
regulation.
Whole new i n d u s t r i e s have sprung up i n response t o
r e g u l a t i o n . An example i s t h e i n d u s t r y s u r r o u n d i n g p l a c i n g
the c o r r e c t DRG code on p a t i e n t r e c o r d s . There are coding
c o n s u l t a n t s , coding t r a i n i n g companies and coding computer
programs. There i s an huge i n c r e a s e i n p e r s o n n e l .
P r o v i d e r s s t r i v e t o use t h e code w i t h the l a r g e s t
reimbursement. Payers s t r i v e t o c h a l l e n g e codes t h a t may
overpay p r o v i d e r s .
P r o v i d e r s have seen t h a t t h e i r own s u r v i v a l depends on
p l a y i n g t h e r e g u l a t o r y game w e l l and so t h e s t a t u s , pay and
numbers o f h o s p i t a l a d m i n i s t r a t o r s have a l l i n c r e a s e d i n
o r d e r t o d e a l w i t h t h i s brave new w o r l d . The r e g u l a t o r y
a d m i n i s t r a t i v e burden i s huge: one s t u d y found t h a t t h e
p r i c e t a g f o r m e d i c a l r e c o r d s , u t i l i z a t i o n review and
a d m i n i s t r a t i v e departments i n Pennsylvania H o s p i t a l s alone
exceeded $2.4 b i l l i o n .
N a t i o n a l a d m i n i s t r a t i v e c o s t s have
been e s t i m a t e d a t $163 b i l l i o n .
1 3
jrKs t o t h e r e s u l t s o f these e f f o r t s : p l a i n l y c o s t s have not
been c o n t a i n e d . Worse, as noted above, w e l l i n t e n d e d
r e g u l a t i o n s have h u r t p a t i e n t c a r e . For example, the
^ C l i n i c a l L a b o r a t o r y Improvement A c t was i n t e n d e d t o reduce
v e i r r o r s by imposing standards on l a b s . One r u l e r e q u i r e s a
t e s t specimen be r u n t w i c e each day on c e r t a i n b l o o d count
machines. This makes sense i n a h i g h volume r e f e r e n c e l a b .
But a s o l o p r a c t i t i o n e r who may see a dozen p a t i e n t s a day,
some o f whom do n o t need b l o o d c o u n t s , f i n d s i t t o o c o s t l y
t o comply w i t h t h i s r e g u l a t i o n . He must now send simple
b l o o d counts out t o a r e f e r e n c e l a b . T h i s c o s t s p a t i e n t s
more, takes a d d i t i o n a l s t a f f t i m e t o process the incoming
and o u t g o i n g paperwork and means p a t i e n t s cannot be g i v e n
�10
r e s u l t s a t the time o f t h e i r v i s i t .
T h i s i s an example o f a
law d r a f t e d w i t h good i n t e n t i o n s b u t which r e s u l t s i n
g r e a t e r c o s t s and l e s s e r m e d i c a l c a r e .
Consumers or Government as D e c i s i o n Makers?
I n t h e f i n a l a n a l y s i s h e a l t h care c o s t s have gone up i n
l a r g e measure because consumers make i n d i v i d u a l d e c i s i o n s t o
"go t o t h e d o c t o r . " When t h e y g e t t h e r e t h e y choose from
among s e r v i c e s f a r more e f f e c t i v e t h a n ever b e f o r e
a v a i l a b l e . Some o f t h e s e r v i c e s chosen may n o t be t h e most
cost e f f e c t i v e .
I n t h e same way consumers go t o automobile
showrooms. Some choose power windows, w h i c h a r e s u r e l y l e s s
c o s t e f f e c t i v e t h a n o l d f a s h i o n e d h a n d l e s . But i f someone
suggested t h a t we have a c r i s i s i n a u t o m o t i v e c o s t s , o r t h a t
the government must adopt a n a t i o n a l a u t o m o t i v e c o s t
containment p l a n t h e s u g g e s t i o n would be c o n s i d e r e d
ludicrous.
Imagine an employer t h a t r e q u i r e d employees t o
c a l l a "managed a u t o m o t i v e purchases o r g a n i z a t i o n " t o
r e c e i v e advance p e r m i s s i o n t o buy an o p t i o n on a new c a r .
I t i s t h e l i n k between employment and payment f o r h e a l t h
care and t h e i n v o l v e m e n t o f government t h a t has r e s u l t e d i n
the p r a c t i c e s t h a t would seem absurd i n any o t h e r segment o f
the economy.
But, i t may be argued, h e a l t h care i s d i f f e r e n t . . . i t i s a
n e c e s s i t y . R e g r e t t a b l y perhaps, h e a l t h care r e a l l y i s n ' t
d i f f e r e n t . A l t h o u g h a new c a r w i t h power windows i s h a r d l y
a n e c e s s i t y , t r a n s p o r t a t i o n i s . Think about t h e v a s t number
of Americans who a r e unemployed because t h e y cannot g e t t o
j o b s l o c a t e d i n suburbs f a r from t h e i r homes. The problem
t h e y face i s n o t caused by a u t o m o b i l e m a n u f a c t u r e r s o r gas
s t a t i o n owners, t h e problem i s e i t h e r n o t enough money t o
purchase t r a n s p o r t a t i o n o r some o t h e r problem u n r e l a t e d t o
making and s e r v i c i n g c a r s . I s p o v e r t y a major problem f o r
America? E m p h a t i c a l l y yes. B u t t h e p o v e r t y problem i s n o t
s o l v e d by c o n t r o l l i n g t h e c o s t s o f c a r s n o r o f h e a l t h c a r e .
American consumers a r e g e n e r a l l y c o n s i d e r e d capable o f
s e l e c t i n g among t r a n s p o r t a t i o n o p t i o n s . To t h i n k these same
people are i n c a p a b l e o f making d e c i s i o n s about t h e i r own
bodies i s p a t e r n a l i s t i c i n t h e extreme.
One i n d i v i d u a l may
s e l e c t a bypass o p e r a t i o n , a n o t h e r may r e j e c t t h i s
a l t e r n a t i v e . I n state-managed systems, such as operated by
Canada o r B r i t a i n ( o r proposed i n Oregon) t h e s t a t e decides
who w i l l g e t a p a r t i c u l a r p r o c e d u r e , u s u a l l y on supposedly
s c i e n t i f i c grounds such as age and a c u i t y o f i l l n e s s . I n
those systems some persons d i e because i t i s deemed t o o
expensive t o t r e a t t h e i r i l l n e s s e s . T h i s state-imposed
r a t i o n i n g i s a f u n c t i o n o f c o n s t r a i n t s t h a t f o r b i d exceeding
budgets.
I n d i v i d u a l s , w i t h a d v i c e from p h y s i c i a n s ,
s p i r i t u a l a d v i s e r s and f a m i l y , can b e s t make t h e i r own
r a t i o n i n g d e c i s i o n s . L i s t e n t o t h e d i s c u s s i o n i n an
�11
o n c o l o g i s t ' s w a i t i n g room and i t becomes a p p a r e n t t h a t
p a t i e n t s and those c l o s e t o them are capable o f making l i f e
and death d e c i s i o n s r a t i o n a l l y .
R a t i o n i n g access by g l o b a l budget c o n s t r a i n t s as opposed t o
making d e c i s i o n s about i n d i v i d u a l p a t i e n t s i s analogous t o
d r o p p i n g a bomb as opposed t o hand t o hand combat.
The
r e s u l t i s the same: someone w i l l d i e . But t h e bombardier,
o r the government p o l i c y maker, w i l l n o t see or f e e l a
t h i n g . The d e s p a i r and s u f f e r i n g o f p a t i e n t s and f a m i l i e s
who cannot get care, t h e p a l p a b l e presence o f d e a t h , are f a r
from the budget s e t t e r ' s o f f i c e .
Yet the d e c i s i o n t o l i m i t
t h e a v a i l a b i l i t y o f c e r t a i n types o f m e d i c a l care has the
same e f f e c t on s u r v i v a l as s t i c k i n g a k n i f e i n t o the neck o f
a v i c t i m . The p a t i e n t , or enemy, d i e s ; t h e s o l d i e r gets
b l o o d on h i m s e l f ; the p o l i c y maker can go home and s l e e p .
T h i s i s a s t a r k analogy but i t i s p r e c i s e . Consider the
r e s u l t s of studies of s u r v i v a l rates of a p a r t i c u l a r kind
and stage o f cancer: s e r i e s o f p a t i e n t s i n t h e U.S. a l l had
f i v e year s u r v i v a l r a t e s exceeding 90%.
A National Health
s e r i e s i n a r e g i o n o f B r i t a i n showed a 65% s u r v i v a l r a t e .
A c c o r d i n g t o the B r i t i s h a u t h o r s the d i f f e r e n c e was due t o
a v a i l a b i l i t y (or more p r e c i s e l y , n o n - a v a i l a b i l i t y ) o f
megavoltage r a d i a t i o n equipment. B r i t i s h h e a l t h care i s
cheaper t h a n American c a r e , b u t a t a s t e e p non-monetary
p r i c e . The W h i t e h a l l o f f i c i a l who d e c i d e d upon the budget
f o r r a d i a t i o n oncology k i l l e d 25% o f t h e p a t i e n t s i n t h a t
s e r i e s j u s t as s u r e l y as i f he had t a k e n aim w i t h a gun.
The h i s t o r y o f h e a l t h care i n t h i s c o u n t r y has c r e a t e d a
payment system t h a t i s employment r e l a t e d backed up by
government e n t i t l e m e n t programs. Costs have r e c e n t l y r i s e n
r a p i d l y due t o more e f f e c t i v e m e d i c a l i n t e r v e n t i o n ,
i n c r e a s e d demand and c o s t s h i f t i n g .
The c o l l i s i o n o f these
two f a c t s ( h i s t o r y and r i s i n g c o s t s ) has c r e a t e d the
p e r c e i v e d h e a l t h care c o s t c r i s i s .
This perceived c r i s i s i s
illusory.
T h i s becomes apparent when we view h e a l t h care as
an i n d u s t r y r a t h e r t h a n a s o c i a l w e l f a r e program.
As
consumers choose t o spend money on h e a l t h t h e y g a i n
i n d i v i d u a l b e n e f i t s . S o c i e t y g a i n s as w e l l , i n terms o f
i n c r e a s e d a v a i l a b i l i t y o f human c a p i t a l and i n terms o f
jobs.
The
Real Problems
A t t e n t i o n t o i n c r e a s i n g l a b o r p r o d u c t i v i t y and t o s o l v i n g
! America's p o v e r t y problem would make t h e h e a l t h care c o s t
• " c r i s i s " d i s a p p e a r . Reduced p o v e r t y would mean t h a t h e a l t h
, care u n s u b s i d i z e d by government would be a f f o r d a b l e t o more
. , Americans. I n c r e a s e d p r o d u c t i v i t y would make t h e h e a l t h
'care component o f l a b o r c o s t s l e s s a l a r m i n g t o b u s i n e s s .
�12
r; \ A l t h o u g h t h e American h e a l t h care system i s no more a drag
: on t h e economy than t h e a u t o m o b i l e i n d u s t r y i s , t h e r e are
• genuine problems w i t h t h e system i t s e l f :
Most i m p o r t a n t l y ,
access i s r e s t r i c t e d f o r some Americans. (This access
••. problem i s exacerbated p r e c i s e l y because h e a l t h care i s
..^effective.)
l i l t i s t h e a u t h o r ' s b e l i e v e t h a t a l l Americans s h o u l d have
. easy access t o h i g h q u a l i t y m e d i c a l care i f t h e y choose t o
'^jseek i t . But t h i s i s n o t n e c e s s a r i l y a s e t t l e d i s s u e .
P o l l s show Americans want u n i v e r s a l access b u t t h e p o l l s
a v o i d t h e c o s t i s s u e s . Even P r e s i d e n t C l i n t o n has been
r e p o r t e d as showing i m p a t i e n c e toward a d v i s e r s who t o l d him
i n c r e a s e d access and c o s t savings were i n c o m p a t i b l e . The
o n l y f a i r approach i s t o h o n e s t l y c a l c u l a t e t h e c o s t o f
u n i v e r s a l access and t h e n ask t h e v o t e r s i f they are w i l l i n g
t o pay t h a t c o s t . Former R e p r e s e n t a t i v e Gradison once s a i d
" I have become convinced t h a t Americans are n o t w i l l i n g t o
pay one dime more f o r anyone's h e a l t h care o u t s i d e o f t h e i r
own f a m i l y . " He may be r i g h t .
1
1 1
; ; America does r a t i o n access t o care now.
We do so somewhat
u n c o n s c i o u s l y on t h e b a s i s o f employment, c l a s s , and r a c e .
We a l s o r a t i o n access c o n s c i o u s l y f o r members o f managed
, care p l a n s . To many o f us i t i s deeply repugnant t o use
these f a c t o r s t o l i m i t c a r e . I f someone wants t h e b e s t , he
j s h o u l d be a b l e t o g e t i t .
.i
However, i t i s easy t o o v e r s t a t e t h e s e r i o u s n e s s o f t h e
•^access i s s u e : most Americans do have access t o m e d i c a l c a r e
I comparable t o t h a t a v a i l a b l e i n t h e government o p e r a t e d
i p l a n s o f some o t h e r n a t i o n s . Any American can go t o a
j p u b l i c h o s p i t a l or any emergency room and n o t be t u r n e d
'away. He w i l l have t o w a i t a l o n g t i m e , he may n o t see t h e
..professionals o f h i s c h o i c e and he may be t r e a t e d w i t h o u t
i t h e r e s p e c t he deserves. Yet i t i s l o n g w a i t s f o r scarce
.•',' c a r e t h a t c h a r a c t e r i z e t h e Canadian and B r i t i s h systems,
; t h e v e r y systems t h a t are o f t e n t o u t e d as models f o r
.. America. I n Canada and B r i t a i n even medium-tech care i s
h a r d t o come by. I n t h e l a s t B r i t i s h e l e c t i o n t h e T o r i e s
' campaigned t o reduce t h e w a i t f o r e l e c t i v e s u r g e r y t o 18
!: months. And even i n these n a t i o n s w i t h s e v e r e l y r a t i o n e d
c a r e , h e a l t h system spending as a p e r c e n t o f GNP has been
" a c c e l e r a t i n g r e c e n t l y , d r i v e n i n e x o r a b l y by demographics and
^ i n c r e a s i n g l y e f f e c t i v e treatments.
'/ The f a c t i s t h a t t h e 36 m i l l i o n u n i n s u r e d Americans do have
access t o h e a l t h care r o u g h l y comparable t o t h e h e a l t h c a r e
o f f e r e d t o everyone i n n a t i o n s w i t h government-run systems.
The access problem i s n o t t h a t every American doesn't have
I care as good as t h a t a v a i l a b l e i n o t h e r n a t i o n s . The r e a l
i ; access problem i s t h a t most Americans have access t o care
'; i t h a t i s b e t t e r t h a n t h a t a v a i l a b l e t o some o t h e r Americans.
u
�13
V i r t u a l l y a l l Americans can g e t access t o h i g h t e c h n o l o g y
c a r e : w e l f a r e r e c i p i e n t s r e c e i v e h e a r t t r a n s p l a n t s . What
i s l a c k i n g i s easy access t o r o u t i n e , non-acute c a r e .
The e x p e r i e n c e o f t h e u n i n s u r e d American g o i n g t o an ER
d e s c r i b e d above sounds l i k e a v i s i t t o t h e p o s t o f f i c e , IRS
or w e l f a r e o f f i c e doesn't i t ? And indeed t h a t i s j u s t what
i t i s : government employees o r government-paid c o n t r a c t o r s
t r e a t i n g c i t i z e n s b a d l y . I t has been s a i d t h a t government
p r o v i d e d h e a l t h care would be d e l i v e r e d w i t h t h e c o s t
c o n t r o l s o f t h e Pentagon, t h e compassion o f t h e IRS and t h e
e f f i c i e n c y o f t h e p o s t o f f i c e . W e l l documented and w e l l
p u b l i c i z e d cases from m i l i t a r y and v e t e r a n s h o s p i t a l s l e n d
s u p p o r t t o t h i s view.
j ^ T h e r e i s another p a r t o f t h e access problem: Americans who
are covered by p r i v a t e o r p u b l i c payment programs b u t who go
t o p r o v i d e r s w i t h a h i s t o r y o f poor outcome. T h i s paper
e a r l i e r addressed t h e demonstrated d i f f e r e n c e s among
providers.
I n some cases people s e l e c t t h e poor p r o v i d e r s
themselves.
Easy a v a i l a b i l i t y o f outcome data and consumer
e d u c a t i o n can e f f e c t i v e l y a m e l i o r a t e t h i s p a r t o f t h e
problem.
But i n o t h e r cases people a r e f o r c e d t o accept
l e s s t h a n o p t i m a l care because o f c o s t containment
j' r e g u l a t i o n s , because o f HMO, PPO and u t i l i z a t i o n r e v i e w
)! p r a c t i c e s o r because o f r a c i s m . Any n a t i o n a l p o l i c y
ii d i r e c t e d a t access i s s u e s needs t o improve t h e a v a i l a b i l i t y
)l o f outcome data and encourage consumers t o use i t . The
,1. p r e s e r v a t i o n and expansion o f f r e e c h o i c e o f p r o v i d e r i s
crucial.
L.)
These access problems a r e v e r y r e a l and deserve a t t e n t i o n ,
but we must r e c o g n i z e t h a t s o l v i n g them w i l l r a i s e c o s t s ,
j u s t as Medicare r a i s e d c o s t s . P o l i c y makers must be sure
t h e y do n o t d e v i s e a n a t i o n a l program t h a t a c t u a l l y makes
the access problems worse because t h e y i n c o r r e c t l y
comprehend t h e c o s t " c r i s i s " .
C o s t s , E f f i c i e n c y and Consvuner Power
A l t h o u g h h e a l t h care c o s t s have n o t c r e a t e d a c r i s i s , t h e r e
are t h i n g s t h a t can be done t o m a r g i n a l l y c u t c o s t s . J u s t
as t h e American automobile i n d u s t r y became b l o a t e d ,
u n r e s p o n s i v e and b u r e a u c r a t i c , h e a l t h care has p l a c e s where
p r o d u c t i v i t y can be improved. As i n any p r o d u c t i v i t y
improvement p r o j e c t , t h e s o l u t i o n s a r e b e s t a p p l i e d i n
r e l a t i v e l y s m a l l u n i t s . Very l a r g e s i z e and e f f i c i e n c y a r e
g e n e r a l l y i n c o m p a t i b l e . N a t i o n a l h e a l t h care p l a n s t h a t
v i s u a l i z e l a r g e networks competing w i t h each o t h e r a r e
l i k e l y t o result i n inefficient oligopolies.
Some h e a l t h care r e f o r m p l a n s p r o v i d e f o r e n t i t i e s t h a t
would have t h e c l o u t t o n e g o t i a t e w i t h p r o v i d e r s on b e h a l f
�14
1;of i n d i v i d u a l s and s m a l l b u s i n e s s . These a g g r e g a t i o n s a r e a
c o m p l e t e l y unnecessary a d m i n i s t r a t i v e burden.
Individual
consumers a r e q u i t e capable o f d i s c i p l i n i n g t h e h e a l t h care
i n d u s t r y , j u s t as t h e y have humbled -the l a r g e s t
m u l t i - n a t i o n a l companies. When Coca-Cola changed t h e
f o r m u l a o f t h e i r p r o d u c t , consumers f o r c e d a r e t u r n t o t h e
o r i g i n a l f o r m u l a by s i m p l y b u y i n g another p r o d u c t . I t was
i n d i v i d u a l consumer d e c i s i o n s t o buy f o r e i g n autos t h a t
r e s u l t e d i n t h e q u i t e genuine c r i s i s i n American a u t o m o b i l e
f m a n u f a c t u r i n g . Consumers have n o t e x e r c i s e d t h i s same power
i n h e a l t h care f o r two reasons:
t h e y t h i n k h e a l t h care i s
" f r e e " and t h e r e f o r e t h e y i g n o r e p r i c e , and they l a c k e a s i l y
( a c c e s s i b l e c o m p a r a t i v e i n f o r m a t i o n about p r i c e and q u a l i t y .
! To a l e s s e r e x t e n t , Americans' r e l u c t a n c e t o c h a l l e n g e
m e d i c a l a u t h o r i t y a l s o c o n t r i b u t e s t o l a c k o f consumer z e a l .
A t t e n t i o n t o these problems would be a more e f f i c i e n t way o f
^ r e s t o r i n g d i s c i p l i n e t o t h e h e a l t h care marketplace t h a n
c r e a t i n g new expensive e n t i t i e s .
1
1
1
I n a d d i t i o n t o a t t e n t i o n t o i n d i v i d u a l a c t i o n s on t h e p a r t
o f p r o v i d e r s t o spur e f f i c i e n c y and t o i n j e c t i n g consumer
d i s c i p l i n e i n t o t h e market, there are f a c t o r s t h a t a f f e c t
h e a l t h care c o s t s system wide which s h o u l d be addressed and
curbed:
- R e g u l a t i o n which adds d i r e c t compliance c o s t s and
c r e a t e s t h e need f o r more a d m i n i s t r a t i v e s t a f f .
- U t i l i z a t i o n r e v i e w t h a t s h i f t s some c o s t s and
increases o t h e r s .
1 4
-Cost s h i f t i n g , d e s c r i b e d above as a 28% t a x on s i c k
people. T h i s has n o t stopped w i t h government.
Large
companies seeing t h e success t h e government had w i t h
c o s t s h i f t i n g has p u t p r e s s u r e on p r o v i d e r s t o g i v e
l a r g e t h i r d p a r t y payers p r i c e breaks. T h i s has tended
t o s h i f t a d d i t i o n a l c o s t s t o persons w i t h l e s s e r
n e g o t i a t i n g s k i l l and c l o u t . F i n a l l y , some Americans
a r e n o t covered by any p u b l i c o r p r i v a t e h e a l t h p l a n .
When these people seek care ( o f t e n i n expensive
emergency rooms when t h e i r c o n d i t i o n i s t h e most acute
and t h e most c o s t l y t o t r e a t ) m e d i c a l p r o v i d e r s d e l i v e r
t h e care and charge i t o f f as "uncompensated c a r e . "
T h i s t o o , ends up b e i n g p a i d f o r by p r i v a t e paying
patients.
- L i t i g a t i o n , b o t h t h e d i r e c t c o s t and t h e p r a c t i c e o f
defensive medicine.
What I s To Be Done
G e n e r a l l y , t h e American h e a l t h care system i s seen as h a v i n g
�15
two problems: h i g h c o s t and l i m i t e d access. I t has been
shown t h a t t h e c o s t i s s u e i s o f much l e s s importance than
g e n e r a l l y b e l i e v e d . U n i t c o s t s can, and s h o u l d , be
m a r g i n a l l y reduced, as t h e y can be i n most i n d u s t r i e s . But
t o t a l c o s t s can, and s h o u l d , i n c r e a s e due t o i n c r e a s e d
e f f e c t i v e n e s s o f m e d i c a l i n t e r v e n t i o n s and demographic
changes. T h i s w i l l b e n e f i t t h e economy, n o t h u r t i t .
rl
Any n a t i o n a l h e a l t h p o l i c y changes should focus on access,
w i t h secondary a t t e n t i o n g i v e n t o c o s t s . I n c o n s i d e r i n g
a l t e r n a t i v e s i t i s f a r more i m p o r t a n t t o a v o i d damaging
mistakes t h a n i t i s t o come up w i t h a "magic" s o l u t i o n t h a t
^ i s p o l i t i c a l l y acceptable.
F i r s t , we need t o r e c o g n i z e t h a t access cannot be i n c r e a s e d
w i t h o u t i n c r e a s i n g t o t a l c o s t s . I t may be good f o r s o c i e t y
t o i n c r e a s e access b u t l e t us n o t delude o u r s e l v e s about t h e
e f f e c t on c o s t s . R e g u l a t i o n never reduces c o s t s o f a n y t h i n g
because compliance i s c o s t l y . Government a t t e n t i o n never
s o l v e s c h r o n i c problems. The h i s t o r y o f h e a l t h care i s a
good example i t s e l f .
For a n o t h e r c o n s i d e r e d u c a t i o n . Up
u n t i l r e c e n t l y , e d u c a t i o n was e n t i r e l y l o c a l .
Since t h e
l a t e s i x t i e s f e d e r a l money has poured i n t o elementary and
secondary e d u c a t i o n b u t r e s u l t s have been d i s m a l .
Tests
s c o r e s , competencies, e d u c a t i o n a l achievement have n o t gone
up, b u t r e g u l a t i o n s and expenses have.
Even i f waste i s reduced and p h y s i c i a n income i s l i m i t e d ,
!; t o t a l c o s t s w i l l go up w i t h i n c r e a s e d access.
(Costs p e r
j person c o u l d c o n c e i v a b l y f a l l . )
Access i s p o s i t i v e l y
c o r r e l a t e d w i t h c o s t because h e a l t h care i s l a b o r i n t e n s i v e .
I f 36 m i l l i o n more people g e t r e g u l a r m e d i c a l c a r e , who w i l l
> draw t h e b l o o d , read t h e pap smears, f i l e t h e medical
. records?
S i g n i f i c a n t i n c r e a s e s i n t h e numbers o f p a t i e n t s
....seen w i l l r e q u i r e more employees, f a c i l i t i e s , equipment,
^training.
1
;
Second, we a l s o need t o r e c o g n i z e t h a t t h e o n l y way t o
reduce c o s t s i n a b s o l u t e terms i s t o r a t i o n access.
( I t may
be p o s s i b l e t o reduce t h e r a t e o f c o s t i n c r e a s e s w i t h o u t
j r e s t r i c t i n g access, b u t n o t t o t a l c o s t s i n a b s o l u t e terms.)
iThe a u t h o r vehemently opposes r a t i o n i n g by p o l i c y .
Rather
^this should be done by i n d i v i d u a l s making d e c i s i o n s about
y t h e i r own l i v e s .
T h i s paper has so f a r p r e s e n t e d f a c t s and o p i n i o n s supported
by evidence.
Any s u c c e s s f u l p o l i c y changes must take
account o f these f a c t s and should c o n s i d e r c a r e f u l l y t h e
r e s u l t i n g o p i n i o n s . There a r e , however, p r o b a b l y s e v e r a l
d i f f e r e n t s p e c i f i c p o l i c y p r o v i s i o n s t h a t conform t o these
criteria.
The s u g g e s t i o n s t h a t f o l l o w a r e o f f e r e d as
examples f o r d i s c u s s i o n r a t h e r than as t h e "best p l a n . "
�16
One p o s s i b l e p l a n i s a system o f u n i v e r s a l access, b u t w i t h
a r e c o g n i t i o n t h a t t h e r e w i l l be s t e a d i l y r i s i n g c o s t s i n
p r o p o r t i o n t o demographic changes ( a g i n g and p o p u l a t i o n
growth) and i n p r o p o r t i o n t o i n c r e a s e d e f f e c t i v e n e s s .
E f f o r t s t o reduce m a r g i n a l c o s t s and i n c r e a s e e f f i c i e n c y and
p r o d u c t i v i t y should be made i n e a r n e s t . S p e c i f i c p r o v i s i o n s
follow:
1.
Require a l l employers t o buy a minimum h e a l t h p l a n a f t e r
a phase-in p e r i o d . There s h o u l d be a r e c o g n i t i o n t h a t from
t h e employers' p o i n t o f view h e a l t h coverage i s i d e n t i c a l t o
wages. T h e r e f o r e c o s t s s h o u l d be regarded as pay and t h e
phase-in p e r i o d should t r a d e o f f i n c r e a s e s t h a t o t h e r w i s e
m i g h t be made i n t h e minimum wage f o r i n c r e a s e d c o s t o f
c o v e r i n g low wage employees.
(Although
employment-linked
m e d i c a l coverage i s a source o f some m i s c o n c e p t i o n s , t h i s
does n o t d i m i n i s h t h e convenience o f having employers a c t as
p u r c h a s i n g agents f o r m e d i c a l p l a n s . A t t h e end o f t h e day,
r e t a i n i n g employment-based coverage i s t h e l e a s t d i s r u p t i v e
way t o i n i t i a t e change i n t h e system.)
T h i s i s n o t " p l a y o r pay:" every employer must choose among
competing p r i v a t e p l a n s . These p l a n s may be t r a d i t i o n a l
i n d e m n i t y plans o r managed care p l a n s . Persons n o t engaged
i n f u l l t i m e employment who meet l e g i s l a t e d income
t h r e s h o l d s ( i n c l u d i n g those who r e t i r e more than f i v e years
a f t e r t h e date o f enactment) must buy a p r i v a t e p l a n . Each
p r i v a t e p l a n a v a i l a b l e t o employers o r i n d i v i d u a l s must meet
minimum r e q u i r e m e n t s .
2. People below t h e income t h r e s h o l d w i t h o u t f u l l t i m e
employment, persons p r e v i o u s l y r e c e i v i n g Medicare and
persons who r e t i r e w i t h i n f i v e years o f enactment must
choose among p r i v a t e plans t h a t w i l l be p a i d f o r by
government subsidy.
( A f t e r a l l , p r i v a t e companies
a d m i n i s t e r Medicare now.) Each p l a n must o f f e r a package o f
minimum b e n e f i t s and a l l w i l l be p a i d i d e n t i c a l fees on a
c a p i t a t i o n b a s i s . S u b s i d i z e d p l a n s can compete on
a d d i t i o n a l b e n e f i t s o f f e r e d a t no charge and on t h e b a s i s o f
o p t i o n a l b e n e f i t s a t e x t r a charge.
(Much as t h e p l a n f o r
f e d e r a l employees works today.)
3. End c o s t s h i f t i n g and t a x e s on s i c k n e s s .
I n the public
s e c t o r , t h e f u l l c o s t o f t h e government-subsidized
plan w i l l
be p a i d f o r o u t o f g e n e r a l t a x revenue.
Require each p r o v i d e r t o o f f e r one posted p r i c e f o r each
service.
(Which he may change a t any t i m e . )
Allow
d i s c o u n t s f o r guaranteed volume and/or revenue b u t t h i s
d i s c o u n t s t r u c t u r e must a l s o be p u b l i c l y posted and t h e same
d i s c o u n t must be o f f e r e d t o a l l who meet t h e r e q u i r e m e n t s .
( E s s e n t i a l l y , t h i s a p p l i e s t h e p r i n c i p l e s o f t h e Robinson
Patman a c t t o h e a l t h care.)
Plan a d m i n i s t r a t o r s , employers
�17
and i n d i v i d u a l consumers can t h e n choose p r o v i d e r s on t h e
b a s i s o f p r i c e . C o m p e t i t i o n among p l a n s w i l l focus on
s e l e c t i n g a vendor w i t h a c o s t e f f e c t i v e o f f e r e d p r i c e , n o t
on n e g o t i a t i n g s k i l l s e x e r c i s e d b e h i n d c l o s e d doors.
Require each p r o v i d e r t o f u r n i s h comparative outcome data i n
an a c c e s s i b l e f o r m a t . Such data f o r a procedure or
t r e a t m e n t regimen should i n c l u d e e x p e r i e n c e and frequency
i n f o r m a t i o n , t r a i n i n g and c e r t i f i c a t i o n , m o r t a l i t y , and
m o r b i d i t y . I n f o r m a t i o n provided should include both
n a t i o n a l and p r o v i d e r - s p e c i f i c d a t a . C u r r e n t l y t h i s cannot
be done w i t h t h e d e t a i l and accuracy needed. T h e r e f o r e , t h e
most i m p o r t a n t f u n c t i o n o f t h e f e d e r a l government under t h i s
p l a n i s t o a g g r e s s i v e l y encourage and fund r e s e a r c h and
d i s s e m i n a t i o n o f outcome d a t a .
4.
Require a l l p l a n s t o have d e d u c t i b l e s and
coinsurance.
5. A l l plans must p r o v i d e f u l l c a t a s t r o p h i c coverage and
encourage p r e v e n t i v e measures. The degree o f coinsurance
f o r medium p r i c e d i l l n e s s e s may v a r y .
6. Encourage, or as a l a s t r e c o u r s e r e g u l a t e , p h y s i c i a n
compensation so t h a t pay i s based on f u l l y a l l o c a t e d t i m e
r e q u i r e d t o d e l i v e r t h e care and a c t u a l c o s t s .
(This
i n v o l v e s enhancing t h e new r e l a t i v e v a l u e approach.)
The
problem i s g e t t i n g p h y s i c i a n s who are procedure o r i e n t e d t o
accept a c u t i n income i n f a v o r o f t h e c o g n i t i v e
s p e c i a l i s t s . Perhaps t h i s c o u l d be phased i n over a l o n g
p e r i o d o f t i m e , a p p l y i n g s t r i c t l y t o those d o c t o r s who
s e l e c t a s p e c i a l t y a f t e r enactment. T h i s p r o v i s i o n i s
designed t o encourage p h y s i c i a n s t o e n t e r p r i m a r y care
specialties.
7. A l l o w f u l l t a x d e d u c t i b i l i t y ( f o r employer, employee or
an unemployed i n d i v i d u a l ) f o r an amount equal t o t h e
c a p i t a t i o n fee p a i d by government. T a x a t i o n o f b e n e f i t s
would be d i s r u p t i v e and would s i m p l y make more people
e l i g i b l e f o r the p u b l i c l y s u b s i d i z e d p o r t i o n o f t h e program.
Employers making j o b o f f e r s o r i s s u i n g p a y r o l l stubs must
show t o t a l wages i n c l u d i n g h e a l t h i n s u r a n c e and a l s o show
t h e r e d u c t i o n i n n e t pay due t o t h e c o s t s o f h e a l t h c a r e .
T h i s p r o v i s i o n i s designed t o communicate the t r u e c o s t s o f
t h e p l a n t o the employee. Encourage c a f e t e r i a s t y l e p l a n s .
8.
Undertake t o r t r e f o r m as advocated by many e x p e r t s .
9. L i m i t p r o v i d e r reimbursement f o r overhead i n excess o f
agreed-upon percentages.
10. A l l u t i l i z a t i o n r e v i e w c o s t s , i n c l u d i n g those o f the
p r o v i d e r , must be p a i d f o r by t h e UR agency.
�18
Footnotes
These notes a r e by no means e x h a u s t i v e b u t s i m p l y g i v e an
i n d i c a t i o n o f the type o f supporting, data t h a t i s a v a i l a b l e .
1. C a l c u l a t i o n s i n t h i s s e c t i o n a r e based on government
s t a t i s t i c s from t h e f o l l o w i n g sources: U.S. Bureau o f t h e
Census, STATISTICAL ABSTRACT OF THE UNITED STATES 1991,
Washington D.C, pp. 93, 431, 437, 844; and Bureau o f Labor
S t a t i s t i c s Consumer Spending Survey c i t e d i n M.K. Ambry,
1990-1991 ALMANAC OF CONSUMER MARKETS, I t h i c a , 1989, pp. 74,
180, 232, 284, 336.
2. On employment see STATISTICAL ABSTRACT, o p . c i t . pp.384,
401; R.E. K u t s c h e r , Bureau o f Labor S t a t i s t i c s MONTHLY LABOR
REVIEW, Nov 1991, p. 8; K.R. L e v i t e t . a l . , " N a t i o n a l H e a l t h
E x p e n d i t u r e s 1990," HEALTH CARE FINANCING REVIEW, F a l l 1991,
pp. 29-54. These numbers can be t a k e n as an o r d e r o f
magnitude o n l y s i n c e sources d i f f e r as t o c l a s s i f i c a t i o n o f
c e r t a i n o c c u p a t i o n s , e.g., a p h a r m a c i s t may be c l a s s e d as a
r e t a i l e r or health technologist.
3. The a u t h o r ' s t h i n k i n g about how h i s t o r y has shaped t h e
c u r r e n t debate about h e a l t h care has been i n f l u e n c e d by t h e
f o l l o w i n g : J. D u f f y , THE HEALERS: A HISTORY OF AMERICAN
MEDICINE, Urbana, 1979; E. S h o r t e r , BEDSIDE MANNERS, New
York, 1985; L.S. K i n g , MEDICAL THINKING, P r i n c e t o n , 1982;
Paul S t a r r , THE SOCIAL TRANSFORMATION OF AMERICAN MEDICINE;
C E . Rosenberg, THE CARE OF STRANGERS, New York, 1987; R.
Stevens, IN SICKNESS AND I N WEALTH, New York, 1989; M.J.
Vogel, THE INVENTION OF THE MODERN HOSPITAL, Chicago, 1980;
J. Bowman, GOOD MEDICINE, Chicago, 198 7; L. Payer, MEDICINE
AND CULTURE, New York, 198 8; S. B. Nuland, DOCTORS, New
York, 1989; and D. J. Rothman, STRANGERS AT THE BEDSIDE, 1991,
4. A. Muray; " H e a l t h Care: A Magic A s t e r i s k "
JOURNAL, Jan 25, 1993, p. 1.
WALL STREET
5. S.A. M i t c h e l l , "Demographics and H e a l t h Spending,"
HEALTH SYSTEMS REVIEW, Oct.19 91, pp. 14-16.
6. M.O. Gomez e t . a l . , "Improvement i n Long Term S u r v i v a l
Among P a t i e n t s H o s p i t a l i z e d w i t h Acute M y o c a r d i a l
I n f a r c t i o n , " NEW ENGLAND JOURNAL OF MEDICINE, May 28,198 7,
pp. 1353-1359.
7. L.J. S o l i n e t . a l . , "Ten Year R e s u l t s o f B r e a s t
Conserving Surgery and D e f i n i t i v e I r r a d i a t i o n f o r I t r a d u c t a l
Carcinoma...," CANCER, Dec 1 , 1991, pp. 2337-2344.
8. See, f o r example: M. H i g g i n s and T. Thorn, "Trends i n
CHD i n t h e U n i t e d S t a t e s , " INTERNATIONAL JOURNAL OF
EPIDEMIOLOGY, 1989, (3 Suppl 1) pp. 558-566; J.W. Y a r b r o ,
�19
Changing Cancer Care i n t h e 1990s and t h e Cost," CANCER, Mar
15, 1991, pp. 1718-1727; K.B. Manton e t . a l . "Cancer
M o r t a l i t y , Aging, and P a t t e r n s o f C o m o r b i d i t y i n t h e U n i t e d
S t a t e s : 1968 t o 1986," JOURNAL OF GERONTOLOGY, J u l 1991,
pp. 5225-5234; J . Byrne e t . a l . , "The Prevalence o f Cancer
Among A d u l t s i n t h e U n i t e d S t a t e s : 1987," CANCER, A p r i l
15, 1992, pp. 2154-2159.
9. T y p i c a l outcome study r e s u l t s can be found i n L.
Wyszewianski, MEDICAL CARE CHART BOOK, Ann A r b o r , 1991, pp.
304-309; J.V. K e l l y & F.J. H e l l i n g e r , "Heart Disease and
H o s p i t a l Deaths: an E m p i r i c a l Study...," HEALTH SERVICE
RESEARCH, Aug 1987, pp. 369-395.
10. S.M. S h o r t e l l & E.F. Hughes, "The E f f e c t s o f R e g u l a t i o n ,
C o m p e t i t i o n and Ownership on M o r t a l i t y Rates Among H o s p i t a l
I n p a t i e n t s , " NEW ENGLAND JOURNAL OF MEDICINE, Apr 28, 1988,
pp. 1100-1107.
11. D.J. S h u l k i n e t . a l . , "The Cost o f M o n i t o r i n g M e d i c a l
Care i n P e n n s y l v a n i a , " PENNSYLVANIA MEDICINE, Sep 1991, pp.
14-18; " H e a l t h Care D o l l a r s , " CONSUMER REPORTS, J u l y 92,
pp. 435-448.
12.
S h o r t e l l , op. c i t .
13. J . Hadley & J. Swartz, "The Impact on H o s p i t a l
C o s t s . . . o f H o s p i t a l Rate R e g u l a t i o n , " INQUIRY, S p r i n g 1989,
pp. 35-47.
14. T.M. W i c k i z e r e t . a l . , " . . . A n a l y s i s o f t h e S u b s t i t u t i o n
E f f e c t A s s o c i a t e d w i t h H o s p i t a l U t i l i z a t i o n Review,"
MEDICAL CARE, May 9 1 , pp. 442-51.
�HEALTH CARE TASK FORCE SORTING SHEET
CODER:
TYPE OF MATERIAL:
General mail
Personal stories
Casework
Letterhead
Offers to help
Employment
Requests:
-speech
-meeting
Advocacy
Other
Letter Campaign
.Policy
Explanation:
ADVISORY PANEL?
physician
r.n.
other health provider
large employers
seniors
small business
other consumers
Explanation:.
PRIMARY INTEREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
.PUBLIC HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
GOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration, Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
FINANCING
OTHER
Explanation:.
PLAN PREFERENCE: (Support = +; Oppose = -)
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�T H E WHITE H O U S E
WASHINGTON
Kay 23,
1993
Ms. Kathy Griffith
SouthvMt-ArkanMs
D«v«lopBuit Councili Inc.
P. 0. Box 1544
Magnolia, Arkansas 71753
Daar Kathy:
Thank you for your lattar and By apologias for not
getting back to you sooner. We have been overvhelaed
by the unprecedented volume of s a i l ve have received
since ve arrived at the White House.
The President i s ooaaitted to reforming our
nation's health care systea, by controlling runaway
costs and providing security to every ABerioan family.
I welcome your views about akilled personal care and
have forwarded your letter to the Task Force on
National Health Care Ref on.
I t was good hearing from you.
Sincerely yours,
Hillary ludham Clinton
2260
�'
P. 2/2
APR 05 '93 13=54
tmmm. mxm mm, INC.
P.O. Box 1544 • Magnolia, Arkansas 71753
Phone (501)234-7752
Tom WoXifd
Imcuri* Gitoior
OHMWI
Hewart
Ut1W«IV»r
Kathy Griffeth
P.O. Sox 1544
Magnolia, AR 71753
Bioxy PoMULW
atputyOinetv
9WMntl«
April 5, 1993
Dear Hillary:
I continue to look forward to your health car*! package. My
nursing career hes spanned from prenatal to geriatrics, and
currently my l i f e i s home health. My greatest tonc^rn i s for
those who f a i l between Medicaid and Elder Choice.
Marie UingfielcJ. a 74 y/o female with rheumatoid a r t h r i t i s and
other multiple health prob]«rr*. i s unable to do ADL'S. She hae
nothing and was denied Elder Choice even after an appeal. The
reason for denial was * *4000.00 burial policy, even though
medicine exceeded $200. a month. Most of our referrals are old
peopJrt 1 i kpi her uihc hav* uiorked hard a l l thoir livod, sp«nt s i l
their savings on medical b i l l s and now must live in f i l t h y conditions with l i t t l e food and extrae.
P»r»onal car* i s wonderful, in that, the provider car© in the
home helps minimize the patient's stress level and allows the
nur*e to plan homo ad&ptations that will maximize the patient's
ability to perform AOL's independently.
With your father's stroke, you can see f i r s t hand the self care
d e f i c i t , bath/hygiene, dsy/groominy, feeding, toileting, ect. due
to decreased mobility and activity intolerance. I t ' s a dark day
for many who have every door closed and must be placed in nursing
homes as a l l revenues have been used up.
Skilled cere i s wonderful, our agency also does this, but this i s
expenaiiv* in comparison to personal care. I wouid love to volunteer my vacation ti»v»e to be used in any way to help you. I
really am (sincere in my concern for a i l health care, I have seen
prices 90 up at unbelievable rates ir, the past few years.
My regards to my old classmate, Mac McLarty, and I can't
t i l l our class reunion next year to see himi;
sincerely,
Kathy errffeth, RN
KS'.th
"Serving the Great Southwest"
wait
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Letters 1] [Loose] [3]
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Marjorie Tarmey
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 41
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
Date Created
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2/6/2015
Source
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42-t-12092971-20060885F-Seg2-041-007-2015
12092971