ORIGINAL

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DRESS
By

C. Everett Koop. M.D., Sc.D,
SURGEON GENERAL
OF THE
U.S, PuBLic HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

PRESENTED AT THE UNIVERSITY OF MASSACHUSETTS AT BOSTON
June 3, 1989
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

FIRST, LET ME THANK YOU FOR THE HONOR YOU'VE GIVEN ME TODAY.
I DO APPRECIATE IT VERY MUCH, FOR I KNOW THAT THIS IS A GREAT
UNIVERSITY AND YOU CAN HAVE YOUR PICK OF PEOPLE TO COME TO THIS
PODIUM.

AND THIS IS A VERY IMPORTANT DAY NOT ONLY FOR THOSE OF YOU
WHO ARE GRADUATING, BUT ALSO FOR YOUR FAMILIES AND YOUR FRIENDS.
] WOULD GUESS THAT MANY OF YOU ARE NOW THE FIRST ONES IN YOUR
FAMILIES TO COMPLETE A COLLEGE EDUCATION AND, THEREFORE, YOU'RE
MUCH BETTER EQUIPPED TO TAKE ADVANTAGE OF MORE OPTIONS IN LIFE
THAN YOUR PARENTS HAD.
2
AND THAT’S THE WAY IT SHOULD BE, IN OUR SOCIETY,

WHICH LEADS ME TO REMIND YOU THAT YOU DON’T REACH YOUR
GRADUATION DAY BY BRAIN-POWER ALONE ... ALTHOUGH IT CERTAINLY
HELPS. YOU GET HERE WITH THE POWER OF THE HEART AS WELL ... THE
ENORMOUS POWER GENERATED BY THE LOVE AND AFFECTION THAT OTHERS
HAVE FOR YOU,

THAT’S THE REAL POWER THAT KEEPS YOU GOING DURING THOSE DARK
PERIODS WHEN YOU’RE ABSOLUTELY POSITIVE YOU CANNOT TAKE ANOTHER
STEP.
3
BUT YOU DO. BECAUSE THE PEOPLE WHO ARE CLOSE TO YOU AND

WHO LOVE YOU AND BELIEVE IN YOU ... THEY WANT YOU TO KEEP GOING.
AND YOU KNOW IT. AND SO YOU DO KEEP GOING.

I] SUPPOSE THERE ARE SOME ENGINEERING AND PRE-ENGINEERING
STUDENTS GRADUATING TODAY. AND I GUESS YOU'VE STUDIED PHYSICS
AND CHEMISTRY AND ALL THE OTHER SUBJECTS THAT DEAL WITH ENERGY,
FUELS, AND POWER.

BUT IN MY BOOK THERE'S NO ENERGY SOURCE MORE POWERFUL
ANYWHERE IN THE WORLD THAN A PARENT OR A SPOUSE WHO LOOKS YOU IN
THE EYE AND SAYS, “YOURE DOING OKAY ... BUT I JUST KNOW YOU’LL
DO BETTER TOMORROW,”
4
SO, YOU CAN HAVE YOUR SOLAR POWER AND YOUR GAS POWER AND

YOUR WIND POWER. I[’LL TAKE FAMILY POWER ANYTIME.

T HAVE LOTS MORE THINGS TO. SAY TO YOUR PARENTS AND SIBLINGS
AND FRIENDS. BUT THIS IS YOUR DAY ... AND, IN ANY CASE, |
REALLY DO WANT TO TALK SERIOUSLY WITH YOU ABOUT AN ISSUE THAT HAS
BEEN WORRYING THE COUNTRY FOR SOME TIME -- BUT WHICH, I’M
AFRAID, IS NOW ON YOUR PLATE ... YOU, AS TODAY’S GRADUATES AND
TOMORROW'S COMMUNITY AND NATIONAL LEADERS.
5
YOU KNOW, THERE ARE RESPONSIBILITIES THAT COME WITH YOUR NEW

POSITION AS THE MOVERS AND SHAKERS OF MASSACHUSETTS ... AND OF
AMERICA. AND ONE OF THOSE RESPONSIBILITIES IS TO BE
KNOWLEDGEABLE AND CRITICAL -- IN THE POSITIVE SENSE OF THAT WORD
-- REGARDING THE DELIVERY OF HEALTH CARE IN THIS COUNTRY.

THAT’S THE ISSUE I WANT TO TALK ABOUT. AND IT’S A BIG ONE.

TO BEGIN WITH, THIS IS A TIME IN WHICH WE HAVE VERY HIGH
EXPECTATIONS FOR MEDICINE AND HEALTH. WE’VE PUT A GREAT DEAL OF
FAITH INTO NEW TECHNOLOGIES, NEW PHARMACEUTICALS, NEW SURGICAL
PROCEDURES, AND SO ON, AND WE CONTINUE TO HAVE FAITH IN THE MAGIC
OF MEDICINE.
6
WE ROUTINELY EXPECT MIRACLES TO HAPPEN -- EVEN THOUGH THE

REAL WORLD OF MEDICINE ISN’T ALWAYS ABLE TO DELIVER. WE HAVE
THAT SITUATION RIGHT NOW WITH AIDS.

FOR THE PAST 7 YEARS, SCIENTISTS AND CLINICIANS HAVE BEEN
WORKING AROUND-THE-CLOCK TO UNDERSTAND AND CONQUER THE DISEASE OF
AIDS. BUT IT STILL REMAINS A MYSTERY. I’M SORRY TO SAY THIS,
BUT I DOUBT THAT WE’LL GET FULL CONTROL OVER THE AIDS VIRUS
BEFORE THE TURN OF THE CENTURY,

BUT, AS FAR AS THE GENERAL PUBLIC IS CONCERNED, THE AIDS
SITUATION IS THE EXCEPTION AND NOT THE RULE. THE AMERICAN PEOPLE
STILL MAINTAIN HIGH HOPES FOR WHAT MEDICINE AND HEALTH CARE CAN
DO FOR THEM,
/
BUT I THINK IT’S ALSO BECOMING CLEAR THAT THOSE HIGH EX-

PECTATIONS ARE FAST OUT-RUNNING OUR ABILITY TO PAY FOR THEM. IN
OTHER WORDS, WE HAVE A CLEAR GAP IN OUR SOCIETY TODAY BETWEEN
WHAT WE WOULD LIKE TO SEE HAPPEN IN HEALTH CARE ,.. AND WHAT CAN

REALISTICALLY HAPPEN IN HEALTH CARE,

AND SO THE AMERICAN PEOPLE ARE ENGAGED IN A DEBATE IN
RESPECT TO ASPIRATIONS VERSUS RESOURCES. IT’S A DEBATE THAT
TOUCHES ON MANY ASPECTS OF AMERICAN LIFE ... BUT I’LL FOCUS JUST
ON HEALTH CARE, WHICH IS PROFOUNDLY AFFECTED BY THAT GROWING
TENSION BETWEEN ASPIRATIONS AND RESOURCES.
8
SOME CRITICS WILL SAY THAT THE CHIEF CAUSE IS THE BUDGET

DEFICIT. ONCE WE GET RID OF THE DEFICIT, SAY THESE CRITICS, WE
WILL ALSO GET RID OF THAT GAP BETWEEN ASPIRATIONS AND RESOURCES
»+1 BETWEEN DREAMS AND REALITY.

MAYBE ... BUT I DON’T THINK SO. WELL BEFORE WE HAD A BUDGET
PROBLEM, WE ALREADY HAD A HEALTH CARE ECONOMY THAT CONSISTENTLY
RAN AT AN ANNUAL INFLATION RATE THAT WAS 2.70 3 TIMES THE
INFLATION RATE FOR THE REST OF THE AMERICAN ECONOMY.

BUT WE DIDN’T SEE IT... OR, IF WE DID SEE IT, WE PREFERRED
NOT TO WORRY ABOUT IT.
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TODAY, WE STILL HAVE AN INFLATED HEALTH CARE ECONOMY ... BUT

WE ALSO HAVE INFLATED HEALTH CARE ASPIRATIONS. AND WE SIMPLY
CAN'T AFFORD ANY INFLATION AT ALL.

WHEN I OR OTHER PEOPLE TALK LIKE THIS, OUR CRITICS COME BACK
AT US AND SAY THAT THINGS REALLY AREN’T THAT BAD ... THAT ALL WE
NEED TO DO IS PUT A REIMBURSEMENT CAP ON THIS ... OR CHANGE THE

ELIGIBILITY REGULATIONS FOR THAT ... OR CUT BACK A LITTLE HERE
1+ OR PRUNE BACK A LITTLE THERE.
10
DURING 8 YEARS AS YOUR SURGEON GENERAL, I’VE LISTENED TO

THESE DEBATES AND I’VE THOUGHT ABOUT THE TRUE HUMAN COSTS
ASSOCIATED WITH THAT KIND OF A PATCHWORK APPROACH, AND TODAY I’M
MORE CONVINCED THAN EVER THAT OUR WHOLE HEALTH CARE SYSTEM NEEDS ©
TO BE STUDIED WITH AN EYE TO MAKING A NUMBER OF VERY MAJOR
CORRECTIONS.

NOW, I CAN ALREADY HEAR THE CRITICS SAYING, “WAIT A MINUTE,
DR. KOOP. THE SYSTEM AIN’T BROKE, SO DON’T FIX IT.”

TO WHICH I WOULD REPLY, “YOU’RE WRONG. THE SYSTEM LS BROKE
oss AND IT MUST BE FIXED.”
11
HOSPITAL COSTS ARE STILL CLIMBING ... AND NO ONE CAN PROVE

TO THE AMERICAN PEOPLE THAT THE QUALITY OF HOSPITAL-BASED CARE IS
UNIFORMLY GOING UP AS WELL,

WORSE STILL, AS THE COST OF HOSPITAL-BASED CARE INCREASES,
THE HOSPITALS THEMSELVES ARE TRYING TO NARROW THEIR PATIENT POOL
«1+ FOR EXAMPLE, ELIMINATING THE NEED TO PROVIDE IN-PATIENT
MEDICAL CARE FOR POOR AND DISADVANTAGED AMERICANS.

I] SAY THERE'S SOMETHING TERRIBLY WRONG WITH A NATIONAL
SYSTEM OF HEALTH CARE THAT CHARGES MORE AND MORE MONEY TO SERVE
FEWER AND FEWER PEOPLE.
12
AND WE HAVE MUCH THE SAME PROBLEM IN RESPECT TO PHYSICIAN

SERVICES AND FEES.

I CAN TELL YOU THAT MANY OF MY FRIENDS AND COLLEAGUES IN
MEDICAL PRACTICE ARE TRYING TO DO WHAT THEY CAN TO INCREASE THE
QUALITY OF CARE THEY DELIVER WITHOUT INCREASING THEIR COSTS.
BUT THEY ARGUE THAT THEY HAVE LITTLE OR NO CONTROL OVER SOME OF
THE INFLATIONARY THINGS THEY DO.

MAYBE SO... LET’S FOR THE MOMENT GIVE THEM THE BENEFIT OF
THE DOUBT. BUT THE FACT STILL REMAINS THAT PHYSICIAN FEES ARE
GOING UP, AND THEY DO ADD TO A BURDEN ON THE PUBLIC THAT IS
BECOMING INSUPPORTABLE.
13
AND, AGAIN -- AS WITH HOSPITAL-BASE) CARE -- THE AMERICAN

PEOPLE HAVE NOT BEEN ASSURED, IN ANY RATIONAL AND MEASURABLE
WAY, THAT THE HIGHER COSTS OF A PHYSICIAN’S CARE WILL IN FACT
BUY THEM A PROPORTIONATELY HIGHER QUALITY OF SUCH CARE.

WE SIMPLY DON’T KNOW. WE DON’T YET HAVE THE TOOLS OR THE
MECHANISMS TO MAKE THOSE KINDS OF NECESSARY, MARKETPLACE
JUDGMENTS.

BUT, BEFORE | GO ANY FURTHER, LET ME SAY THAT IN GENERAL |
SUPPORT THE CONCEPT OF A LAISSEZ-FAIRE MARKETPLACE AND I BELIEVE
IN A FREELY COMPETITIVE ECONOMY.
14
I THINK A LAISSEZ-FAIRE ECONOMY WORKS BEST FOR ALL OUR

CITIZENS AND I’M THRILLED -- AS I’M SURE ALL AMERICANS ARE
THRILLED -- TO SEE SO MANY COUNTRIES WITH STATE-CONTROLLED
ECONOMIES COMING AROUND TO OUR POINT OF VIEW,

NOW, HAVING SAID THAT, LET ME GO ON TO SAY THAT THE HEALTH
CARE MARKETPLACE IS LAISSEZ-FAIRE ... BUT IT’S NOT FREELY
COMPETITIVE AND, HENCE, IT HAS VIRTUALLY NO MODERATING CONTROLS
WORKING ON BEHALF OF THE CONSUMER, OR THE PATIENT.

IT MIGHT AS WELL BE STATE-CONTROLLED. THE EFFECT UPON THE
CONSUMER IS ABOUT THE SAME,
15
IN MOST OTHER AREAS OF OUR ECONOMY, THE MARKETPLACE DOES

EXERCISE SOME CONTROL OVER ARBITRARY RISES IN CHARGES TO THE
CONSUMER. THERE REALLY 1S COMPETITION. HERE AND THERE IT MIGHT
BE RATHER THIN ... BUT IT DOES EXIST AND IT DOES PROVIDE SOME
ASSURANCE THAT INEFFECTIVE, UNCOMPETITIVE, HIGH-COST, LOW-QUALITY
ENTERPRISES WILL FAIL.

BUT IN HEALTH CARE, RIGHT ACROSS THE BOARD, PRICES HAVE
GONE UP IRRESPECTIVE OF THE QUALITY OF CARE BEING DELIVERED OR OF
ANY OTHER MARKETPLACE CONTROL.
16
AND FRANKLY I DON’T YET SEE THE MEDICAL PROFESSION ACHIEVING

MUCH SUCCESS IN SELF-REGULATION. GRANTED, IT’S NO SIMPLE TASK.
PHYSICIANS CAN HELP PUT THE BRAKES ON SOME GENERAL EXPENDITURES,
BUT THERE ARE VERY FEW PHYSICIANS WHO CAN HONESTLY AND
EFFECTIVELY CONTROL THE DELIVERY OF SERVICE -- MUCH LESS CONTROL
THE COSTS OF THAT SERVICE -- WHILE CARING FOR A SPECIFIC,
INDIVIDUAL PATIENT AT THE BEDSIDE.

WE SEEM TO HAVE, THEREFORE, A SYSTEM OF HEALTH CARE THAT’S
DISTINGUISHED BY A VIRTUAL ABSENCE OF SELF-REGULATION, OR “SELF-
CONTROL,” ON THE PART OF THE PROVIDERS OF THAT HEALTH CARE --
THAT IS, HOSPITALS AND PHYSICIANS -- AND DISTINGUISHED AS WELL
BY THE ABSENCE OF SUCH NATURAL MARKETPLACE CONTROLS AS COMPETI-
TION IN REGARD TO PRICE, QUALITY, OR SERVICE.
17
WHAT IS THE EFFECT OF SUCH A SYSTEM ANYWAY?

ONE VERY SERIOUS EFFECT HAS BEEN THE EMERGENCE OF A THREE-
TIER FRAMEWORK OF HEALTH CARE. WE’VE ALWAYS SAID WE NEVER WANTED
A TWO-TIER SYSTEM. BUT WE HAVE IT ... AND A THIRD TIER, ALSO.

IN THE FIRST TIER ... THE BOTTOM TIER ... ARE UPWARDS OF 37
MILLION AMERICANS -- ABOUT 15 PERCENT OF THE POPULATION -- WHO
FALL BETWEEN THE CRACKS AND HAVE NO HEALTH INSURANCE COVERAGE ...
NO HIGH OPTIONS ... NO LOW OPTIONS ... NO OPTIONS AT ALL.
18
THEY'RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR ENOUGH FOR

MEDICAID. WHAT, THEN, DOES THIS “HEALTH CARE SYSTEM” OF OURS DO
FOR THE UNINSURED? IN THE VAST MAJORITY OF CASES THE ANSWER IS
ooe VERY LITTLE ... OR NOTHING,

THEN WE HAVE A SECOND TIER. THIS TIER RECEIVES A NARROW
RANGE OF BASIC MEDICAL AND HEALTH SERVICES WITH MORE OR LESS
FIXED LEVELS OF REIMBURSEMENT. THIS IS LOW-OPTION COVERAGE ...
MEDICARE AND MEDICAID COVERAGE ... WITH THE PATIENT PAYING MANY
COSTS OUT-OF-POCKET OR WITH THE HELP OF SOME FORM OF SUPPLEMENTAL
INSURANCE, WHICH IS -- IN MY BOOK -- JUST ANOTHER KIND OF OUT-OF-
POCKET EXPENSE.
19
FINALLY, WE HAVE THE THIRD TIER, THE TOP TIER. THE PEOPLE

IN THIS TIER RECEIVE A FULL RANGE OF MEDICAL AND HEALTH SERVICES.
THEY ARE COVERED BY HIGH-OPTION HEALTH INSURANCE AND ALSO HAVE A
FEW DOLLARS LEFT OVER TO PAY THE 15 OR 20 PERCENT DIFFERENCE
BETWEEN THE ACTUAL BILL FROM THE DOCTOR AND THE CHECK FROM THE

INSURANCE COMPANY.

MANY OF OUR LARGEST BUSINESS AND INDUSTRIAL ORGANIZATIONS
ARE IN THIS TOP TIER. YEARS OF TOUGH COLLECTIVE BARGAINING MADE
IT POSSIBLE FOR MILLIONS OF THEIR UNIONIZED EMPLOYEES AND THEIR
FAMILIES TO BE IN THAT TOP THIRD TIER.
20
BUT NOW IT’S NO SECRET THAT HEALTH CARE INFLATION HAS BECOME

THE MAJOR STICKING-POINT IN THEIR COLLECTIVE BARGAINING, ALSO,

BUT HOW DOES THE BARGAINING END? THAT’S EASY: MORE MONEY IS
PROMISED FOR EMPLOYEE HEALTH BENEFITS ... AND THE INCREASED
HEALTH COSTS TRANSLATE INTO HIGHER PRICES FOR THE CUSTOMER OR THE
UTILITY RATE-PAYER.

IN OTHER WORDS, EMPLOYEE HEALTH PLANS HAVE REALLY BECOME
“PASS-ALONG” MECHANISMS THROUGH WHICH DOLLARS, TAKEN FROM THE
POCKETS OF THE GENERAL PUBLIC IN THE OPEN MARKETPLACE, ARE

0
PASSED ALONG AND INTO THE PEKETS OF THE HEALTH CARE SYSTEM.
21
IT'S BEEN WORKING THAT WAY FOR THE PAST 20 YEARS OR SO. BUT

I DON’T THINK AMERICANS CAN KEEP FEEDING THE HEALTH CARE SYSTEM
QUITE THAT WAY ANY MORE. WE‘’VE GOT TO MAKE SOME CHANGES.

AND BUSINESS ITSELF IS FINALLY COMING AROUND TO UNDERSTAND
THIS. IT CANNOT CONTINUE TO BURY INFLATED COSTS OF HEALTH CARE
IN THE PRICE-TAGS OF THEIR GOODS AND SERVICES. YOU CAN’T DO THIS
AND ALSO EXPECT TO BE COMPETITIVE WITH FOREIGN GOODS, MUCH LESS
OTHER AMERICAN-MADE GOODS.

IT DOESN'T MAKE SENSE TO BE TOUGH WITH THE JAPANESE, FOR
EXAMPLE, BUT THEN MEEKLY GIVE YOUR HEALTH PLAN THE 10 PERCENT ...
12 PERCENT ... OR 15 PERCENT ANNUAL INCREASE IT DEMANDS.
22
IT MAKES NO SENSE ... AND AMERICAN BUSINESS AND LABOR

LEADERS ARE FINALLY COMING TO UNDERSTAND THAT FACT OF LIFE,

THE HEALTH CARE SYSTEM IN AMERICA TODAY IS A TERRIBLE MORAL
BURDEN FOR SOCIETY TO BEAR, IN THAT THE SYSTEM DOES NOT RESPOND
AT ALL TO SOME 15 PERCENT OF OUR POPULATION,

AND IT IS A TERRIBLE ECONOMIC BURDEN FOR SOCIETY TO BEAR, IN
THAT THE SYSTEM SATISFIES ITS OWN UNCONTROLLED NEEDS AT THE
EXPENSE OF EVERY OTHER SECTOR OF AMERICAN SOCIETY,
23
WE NEED TO CHANGE THAT SYSTEM. NOT JUST A LITTLE CHANGE

HERE AND A LITTLE CHANGE THERE. WE NEED TO BRING ABOUT A
PROFOUND CHANGE ACROSS-THE-BOARD IN THE WAY WE MAKE MEDICAL AND
HEALTH CARE AVAILABLE TO ALL OUR CITIZENS.

BUT CAN WE DO IT?

ID LIKE TO THINK WE CAN ... BECAUSE WE HAVE TO... AND
BECAUSE WE’VE DONE IT BEFORE,
24
SOME 50 YEARS AGO, FOR EXAMPLE, WE AMERICANS KNEW THAT IT

WAS MORALLY WRONG FOR OUR SOCIETY TO ALLOW ITS OLD PEOPLE TO
DRIFT INTO POVERTY AND STARVATION, WE KNEW THAT WE COULD NO
LONGER STAND BY HELPLESS IN THE FACE OF SUCH HUMAN MISERY,

WE WERE BETTER THAN THAT ... WE HAD TO BE BETTER THAN THAT
.1+ BECAUSE OUR SOCIETY COULD NOT CARRY SUCH A BURDEN OF
UNFAIRNESS AND STILL EXPECT TO SURVIVE AS A CIVILIZED SOCIETY.
25
AND SO WE ENACTED A SOCIAL SECURITY LAW TO MAKE SURE THAT

EVERY AMERICAN WOULD BE ASSURED OF A MEASURE OF HUMAN DIGNITY AND
RESPECT IN HIS OR HER TWILIGHT YEARS. IT WAS AN ACT OF FUNDA-
MENTAL DECENCY. WE KNEW WE HAD TO DO IT. AND WE DID IT.

WE MET A SIMILAR CHALLENGE MORE RECENTLY THAN THAT. BACK IN
THE 1950s AND EARLY 1960s, THE PEOPLE OF THIS COUNTRY BECAME
PAINFULLY AWARE OF THE TERRIBLE UNFAIRNESS OF “SEPARATE BUT
EQUAL” EDUCATION,
26
THAT ALSO WAS A BURDEN WE KNEW AMERICA COULD NO LONGER BEAR,

IT WAS TOO GREAT A BURDEN FOR A SOCIETY THAT BELIEVED IN THE
BIBLICAL INSTRUCTION OF “JUSTICE ... JUSTICE .., ABOVE ALL,

JUSTICE.”

AND SO, THROUGH OUR COURTS AND OUR LEGISLATURES, WE RELEASED

AMERICA FROM THE CRUSHING OFFICIAL, LEGAL BURDEN OF SEGREGATED
SCHOOLS. THAT’S OVER. AND THANK GOODNESS IT IS.

DID WE GET RID OF THOSE BURDENS ONCE AND FOR ALL? WELL,
NOT EXACTLY:
27
* WE HAVEN'T YET SOLVED EVERY PROBLEM ASSOCIATED WITH

"GROWING OLD IN AMERICA.” WE KNOW THAT.
* AND WE HAVEN'T YET PRODUCED THE PERFECT, EGALITARIAN
SCHOOL SYSTEM. WE KNOW THAT, TOO.

BUT AT LEAST WE‘VE LIFTED FROM THE SHOULDERS OF OUR PEOPLE
A LARGE MEASURE OF THE BURDEN OF SHAME AND GUILT THAT CAME WITH

DOING NOTHING. WE DID WHAT WAS MORALLY RIGHT FOR THIS COUNTRY.

AND I BELIEVE WE CAN -- AND MUST -- DO THAT AGAIN,
28
LET'S FINALLY SAY WHAT WE’VE HESITATED TO SAY FOR T00 MANY

YEARS, AND THAT IS ... OUR CURRENT SYSTEM OF HEALTH CARE IS NOT
FAIR .«. IT'S NOT JUST ... AND, THEREFORE, IT IS NOT THE MORALLY
STRONG SYSTEM THAT OUR SOCIETY NEEDS.

I KNOW THAT THE SENIOR SENATOR FROM MASSACHUSETTS AND A
GREAT FRIEND OF THIS UNIVERSITY, SENATOR EDWARD KENNEDY, HAS
DEVOTED MANY YEARS TO SUCH AN EFFORT AND WE OWE HIM AND LIKE-
MINDED COLLEAGUES A DEBT OF THANKS AND A COMMITMENT TO HELP MOVE
THAT EFFORT FORWARD,
29
T BELIEVE THIS IS SOMETHING THAT REQUIRES THE LEADERSHIP OF

THE PRESIDENT. IN THE PAST, AMERICAN PRESIDENTS HAVE LOOKED ON
FROM THE SIDELINES, WATCHING TO SEE WHAT THE CONGRESS OR THE
HEALTH PROFESSIONS OR CONSUMER GROUPS MIGHT COME UP WITH.

THAT SIDELINE ATTITUDE DOESN’T HELP. WE NEED A PRESIDENT
AND AN ADMINISTRATION THAT IS COMMITTED TO ACTION ... AND THAT
AGREES TO BE ONE OF THE ACTORS.

WE NEED THE CONGRESS. WE NEED THE COMMITMENT OF BOTH
PARTIES TO PROPOSE LAWS THAT ARE FAIR ... THAT WILL WORK ... AND
THAT CAN BE PASSED IN BOTH HOUSES AND ACCEPTED BY THE PRESIDENT.
30
WE NEED THE HEALTH PROFESSIONS. I’VE BEEN HARD ON THEM IN

THESE REMARKS TODAY, BUT I KNOW THEIR LEADERS AND I KNOW THAT
THEIR SENSE OF FAIRNESS AND JUSTICE IS NOT ONE OUNCE LESS THAN
MINE. WHAT I’M ASKING FOR TODAY IS WHAT THEY WANT, ALSO, AND I
BELIEVE THEY, TOO, WOULD JOIN IN A TRULY NATIONAL EFFORT 10
IMPROVE THE SYSTEM OF HEALTH CARE DELIVERY IN THIS COUNTRY.

I BELIEVE THAT THE PROFESSIONS IN PARTICULAR WOULD JOIN IN
AN HONEST, NATIONAL EFFORT TO MAKE SURE THAT EVERY MAN, WOMAN,
AND CHILD IN AMERICA HAS AVAILABLE -- BY RIGHT -- A BASIC ARRAY
OF HEALTH AND MEDICAL SERVICE ... THAT WE HAVE ONE TIER OF HEALTH
CARE IN AMERICA TO WHICH EVERYONE IS ENTITLED.
31
SOME PEOPLE WILL WANT MORE SERVICE AND WILL PAY FOR IT. AND

THAT SHOULD BE THEIR PRIVILEGE.

BUT IT SHOULD BE THE RIGHT OF EVERY AMERICAN TO EXPECT AND
TO RECEIVE ADEQUATE HEALTH SERVICE ANYWHERE IN THIS COUNTRY,

PUTTING TOGETHER SUCH A MORALLY STRONG AND FAIR SYSTEM OF
HEALTH CARE WILL BE A MAJOR TASK FOR THIS COUNTRY. I HAVE NO
ILLUSIONS ABOUT THAT. BUT WE MUST NOT LET SUCH CONSIDERATIONS
STOP US FROM DOING WHAT WE KNOW IS RIGHT,
32
OTHER COUNTRIES HAVE TRIED IT AND HAVE MADE SOME HEADWAY.

WE MUST TRY, ALSO.

OUR NATION CANNOT CONTINUE TO CARRY THE BURDEN OF THE
PRESENT UNFAIR, COSTLY SYSTEM OF DELIVERING HEALTH CARE,

THE AMERICAN PEOPLE DESERVE BETTER THAN THAT. AND I
BELIEVE THE TIME HAS COME FOR US TO DEMONSTRATE THAT FACT ONCE
AGAIN BOTH TO OURSELVES AND TO THE WORLD,
33
IT 1S A CHALLENGE TO ALL OF US ... BUT IT IS ESPECIALLY

IMPORTANT TO YOU, TODAY'S GRADUATES, AS YOU BEGIN TO PARTICIPATE
FULLY IN AMERICAN LIFE.

WE CAN ~- AND WE MUST -- FIND A WAY TO HAVE BOTH EXCELLENCE
AND FAIRNESS IN AMERICAN HEALTH CARE. AND WE MUST BEGIN ... NOW
»» TO WORK TOGETHER TO ACHIEVE SUCH A SYSTEM.

IN THE WORDS OF THE PROPHET, “IF I AM NOT FOR MYSELF, WHO AM
I FOR? BUT IF I AM ONLY FOR MYSELF, WHAT AM I? AND IF NOT NOW
one WHEN?”

THANK YOU.
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