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184  Health Care Costs Inflated
     By Dollars Without Doctors
     The Washington Post,  December 13, 1969

     The health budget of the United States is now about $60 billion a
year.  At the one-third mark in the transition from private to public
responsibility for citizens' health, it is obvious, however, that the
benefits of health services are very unequally distributed among rich
and poor.

     We do not have adequate indicators of health status, for health 
depends on quality of the environment, the style of life, preventive
measures and the genetic endowment more than it does on medical care.
Nor may we dismiss the truism that poor health reinforces poverty by
draining earnings.  However, if we need statistics to buttress our 
commonsense observations, we have the shameful range in infant 
mortality, from about 19 per 1000 among Midwestern whites to 55 per 1000
among Mississippi rural blacks.

     If money were all that was needed, we might seek about $40 billion
more to give the entire population the same standard of care under the
present system.  Our experience with Medicare, however, has shown that
pushing dollars into the consumer side of the system will inevitably
inflate the costs when qualified manpower is the bottleneck item.

     Medicare and Medicaid were not enacted as parts of a carefully
designed improvement in health care, for they made negligible 
provisions for increasing medical services and manpower.  They had some
desirable side effects -- for example, in modernizing the wage
structure of nursing and other hospital employment.  They have made
some progress toward their original objective of lessening the burden
of private health care for over-65s and more indigent people.  But
they have also pushed hospital costs sky-high, and the massive center
of the citizenry is probably in worse shape than ever in finding and
paying for good care.

     The medical schools have been caught at the center of the 
grievances about health.  As a constituency, they are weak and divided,
not to be confused with organized medicine either in ideological 
orientation or in political power.  Far from being benefited by the 
increased consumer buying power of Medicare/Medicaid, educational costs 
are systematically disallowed and the teaching hospitals are in a 
worsening crunch, as shown by John Walsh in Science magazine.

     The medical research budget is around $1.5 billion, almost all of
it coming from Federal agencies like the National Institutes of Health.
For some time, this investment has been at a standstill -- actually
being eroded by inflation, and providing shrinking opportunity for new
graduates to attack new problems.  

     I was dismayed recently at a meeting of the Mayo Clinic Alumni to
hear HEW Secretary Robert H. Finch address this problem with little of
the customary regret about competing needs in a budget limited by
military commitments on one side and rival social investments on the 
other.  He implied instead that federal support of biomedical research
was a drain on manpower resources that should be diverted back to
patient care.

     Finch undoubtedly shares this misconception with many legislators
and citizens who have been taking misdirected potshots at research.
In fact, the most avidly research-oriented schools have rarely 
succeeded in keeping as many as 15 per cent of their medical graduates 
in academic medicine, and these are not only the researchers but also 
the teachers of further generations.

     The medical schools are more than eager to answer the need for 
manpower.  They are obstructed above all by the fact that direct federal
support of medical education is mostly rhetorical.  The institutions
train medical graduates have been developed in the name of research in
compliance with the congressional mandate.

     They should be training many more M.D.'s; they should be developing
new levels of health professions; they should be working to fill
the near-vacuum of education for environmental health.  Attacking the
support of research may spear a convenient scapegoat, but it serves us
ill to dismantle these institutions when we have not developed the 
national commitment, the policy or the budget to fulfill their wider
role in serving human needs.
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