Document.. Ministry of Health, Ottawa, Canada, 1974. 6. Forward Plan for Health-FY 1976-1980. DHEW, U.S. Government Printing Office, Washington, DC, June, 1974. 7. Law, S. A. Blue Cross, What Went Wrong. Yale University
Press, New Haven, 1974. 8. Blair, P. A. General Revenue Sharing in American Cities: First Impressions. National Clearinghouse on Revenue Sharing, Washington, DC, 1974.
TOWARD A NATIONAL HEALTH POLICY-VALUES IN CONFLICT From time to time the Congress and the President of the United States have agreed on something akin to a National Health Policy. These agreements have been reached through compromise and they bear the signs of compromise. The first real national effort at health planning (P.L. 89-749), in 1966, contained words about national purpose, healthful living, and assuring the highest level of health attainable for every person, but it also declared that nothing was to be done which might change the traditional practices of medicine, dentistry, and related healing arts. The copayment and coinsurance features of Medicare were a form of compromise between ideals and ideology. This particular compromise is both intra- and interpersonal: that is, everyone should have the right of access, but the means of access should be tempered by some degree of personal sacrifice, sometimes an unreasonable one. We are a compassionate people, but the social Darwinism of our American frontier fantasy persists. It may be useful. Compromise, in American politics, has undergone a subtle change in process as we have moved from a confederation to a nation. The pork barrel has changed to a stew pot. Once upon a time a legislator with a particular goal could gain the votes needed by agreeing to support another legislator's goal in another unrelated bill. Laws were more regional and less national a century ago. But the process has become more national and more pragmatic. The legislator's desired objective is described accurately and then, through head counting, the contents of the bill are selectively modified to gain the number of votes needed. From inter-bill compromising we have shifted more toward intra-bill compromising. The process is, in some respects, faster, and our general societal acceleration has demanded this, but it is more difficult to find a clear sense of policy in the final law since the resulting bills reflect the ambivalence inherent in compromising values. The result is often left to administrative determination of national policy (which is less responsive to the electorate than is the political process) and to occasional judicial surprises. That values can conflict with surprising results is apparent in some recent remarks by former DHEW Secretary Caspar W. Weinberger. Appearing before the American Pharmaceutical Association on April 23, 1975, he spoke about the problem of drug prices and urged new rules which would allow substitution of the lowest priced version of the drug available. He was quoted as saying: "No one is more opposed to unwarranted federal intrusions than I; but any time the federal government invests, as we do, over $2.5 This commentary was prepared for presentation at the meeting "Toward a National Health Policy," sponsored by the National Association of Regional Medical Programs, Atlanta, Georgia, May 6, 1975.
billion for drugs provided to other Americans, then any proposal that is designed to bring about a real savings at no cost to quality has to be the government's business."' The National Health Planning and Resources Development Act of 1974 (P.L. 93-641) is a result of the stewing process-somewhat of a Mulligan stew at that. The original author of the progenitor of the final bill had a fairly clear sense of what he was trying to do. He attempted to improve a much heralded but largely ignored 1966 effort at health planning by putting teeth in the process and shifting control from communities to the Secretary of Health, Education, and Welfare. Considering the generally weak acclaim earned by Comprehensive Health Planning between 1966 and 1974, the heat of the cooking process in the last few months of 1974 was probably unexpected. The battle, of course, was over control, and others, in addition to the directors of Comprehensive Health Planning Agencies and Regional Medical Programs, had something to gain or lose. Hospital associations saw the significance of the Act, as did some state and local government officials, but physicians, who really don't want the sort of planning needed, were caught napping. Now the frenzy over boundaries and agency control is intense because the potential for controlling or being controlled is evident. But what is it all to accomplish? The 1974 Act contains 10 priorities which are to be considered in formulating national health planning goals. (It is not clear whether these are priorities for the planning process or part of the health goals themselves, but it is useful to assume the latter.) The priorities can be grouped as follows: * Primary care services should be available to those populations presently underserved; * Comprehensive "systems" should be developed, to include all services. These should include sharing agreements between institutions and subsystems, the formation of group practices as parts of the systems rather than as independent entities, and consolidation of high cost, low volume services and functions; * More physician assistants and nurse practitioners should be trained and used; * Quality should be improved; * Costs should be studied, compared, and, presumably, at least contained; and * More emphasis should be given to disease prevention, particularly through better understanding of nutrition and environmental factors and by better education of consumers in how to appropriately use available services and protect their health. There are a number of potential value conflicts inherCOMMENTARIES
1335
ent in these priorities. On the whole, however, they point clearly toward the need for total governmental control of the health industry in the United States. The goals-if priorities do reflect goals-cannot otherwise be achieved. That may not be what Congressmen voted for and it may not be widely popular (important goals are rarely achieved without offending someone's values), but the basic American ambivalence toward health and welfare is moving painfully toward some conclusions. Access for the Underserved. Congress has declared that primary care services should be provided for the medically underserved. This means that we have to find ways to guarantee that those with less than some amount of medical care receive as much as some others who are supposed to be getting an adequate amount. If this is accomplished for primary care services, it presumably must be accompanied by appropriate access to secondary and tertiary care as well. No one knows what the optimal amount of medical care is. Is it 4.5 visits per year, or 2 per month, or 24 per year? Does the provider determine the amount? If so, the traditionalist-expansionist (that is, the professional provider) described by Batistella2 will prevail, and the standard amount will be (1) unequally applied or (2) if equally applied, unaffordable. Most professional providers must and do assume that the world would be a better place if more of what they do were provided to everyone. This is true of lawyers, doctors, teachers, social workers, and plumbers. Most professional workers assume that what they do has a generic positive value. Res ipsa loquitur, and the more that is provided the better. This is not unique to private providers and can be seen clearly in Alice Tetelman's article about public urban health providers.3 The managerial rationalists described by Batistella (the skeptics) suggest that the value of a health service is open to some doubt and that the burden of proof rests on the provider. Lacking that proof, the service should not be provided, at least at public expense. Batistella's democratic humanist approach will probably set the pace, tempered by the forced constraints of political tax policy. However we solve the problem of amount, the total number of services delivered and paid for will have to increase substantially if those receiving too little are to get as much as those receiving enough. Newhouse, Phelps, and Schwarz suggest that this increase may be as much as 30 to 75 per cent.4 The services may be provided through public or private systems, but it will be economically and politically necessary to control the cost of what is provided through controlling unit costs, the amount of service provided, or both. This involves the design and use of incentives or restraints, and, with or without intermediaries, government workers will be involved. Moreover, to assure access, further controls will be necessary, possibly involving training, licensing, and reimbursement mechanisms. It is stated that government presently pays for 40 per cent of the medical care provided in the United States, and the costs have frightened economists and politicians. With 8 per cent of the gross national product spent on health services currently, and 10 per cent a possible proportion in 1336 AJPH DECEMBER. 1975, Vol. 65, No. 12
the near future, stable economic growth requires control rather than the traditionalist-expansionist approach of the professional providers. Yet government now can directly try to control only 40 per cent of the market. If controls are established in the publicly financed sector only, the controllers will be rightfully accused of prejudicial actions, and equal access will remain a priority rather than become a reality. Only by obtaining an equal amount of control over the remaining 60 per cent, the "private sector," can controls be equally and equitably implemented. This is not to suggest that such controls will be widely popular or even necessarily beneficial. The Development of Comprehensive Systems. We are to develop comprehensive systems. The American Public Health Association has identified 21 elements in a comprehensive health care program.5 It is important not only that they be available but that the consumer be able to use them appropriately. Most of these elements are presently available as single strands of yarn, unwoven and uncontrolled. To weave a tailored cloth for each consumer, someone must bring the strands together. This involves changing and establishing control of the loom. The new law also proposes that certain institutional services be consolidated. Presumably this means consolidating high cost, low volume services. In many communities this will involve such tasks as consolidating pediatrics and obstetrics in one hospital. It is not clear what changes this may create in shopping patterns for adult medicine and surgery, but it will certainly cause some significant alterations in patient flow, the location of office practices, and the programs of other hospitals. Consolidation also means that communities must decide whether all general hospitals should purchase such expensive tools as computerized axial tomographic equipment (an expensive new machine for X-raying certain organs, particularly the brain, which offers substantial diagnostic benefits). Many hospitals have already purchased such equipment at a price of half a million dollars, and they hope to use it 8 hours a day, 5 days a week, and get their costs back in 2 years. Leaving aside a discussion about the role of profit in designing the industry, such practices raise significant questions not yet faced by most communities. One hospital with one such machine could serve the needs of a large area, especially if it were operated more than 40 hours a week. Yet this would necessitate that hospital A lose a patient to hospital B when this particular service is needed. What tradeoff will A require-and will it be an equal trade? Someday a victim of an automobile accident will be admitted to hospital A and need this service, available only at hospital B. To transport the patient will be life-threatening, and to use existing X-ray procedures at hospital A will result in a less precise diagnostic information package. The result may be death. How much will we pay to avoid that? Engineers talk about protection against hundred-year floods; what will we pay for medical protection against the rare accident? Most communities lack the experience to identify the question, let alone answer it. The provider has a ready and expensive answer, but the consumer really has the responsibility.
To deal with such problems effectively will mean that we will have to learn about negotiating quality rather than assume that it is a constant, and that we will have to chance shifting control from providers to consumers, with government either as the broker or as the administrator. The Use of Physician Assistants and Nurse Practitioners. Congress has also stated that we should prepare and use more such personnel. Many health planners agree. It is assumed that the concern is about access and cost. Yet such personnel may not reduce costs. If they could practice independently or under institutional or agency licensure, some cost, benefit might be achieved. But as assistants to a physician, they can make medical care more labor-intensive and thus more costly. While the picture is complicated, there is some evidence that such innovative practices lead to an increase in the income of the physician. In some cases, the unit cost to the consumer may be lowered but the volume of services delivered and, therefore, the gross cost of the system, may be increased.6 To use non-MD "physicians" effectively will require significant changes in education and licensure. These changes will require additional political action and governmental intervention and control. Educational costs, however, could be sharply reduced if we also stopped producing as many MDs and controlled their distribution. Quality Should Be Improved. Congress has also stated that we should "promote activities to achieve needed improvements in . . . quality" and specifically mentioned Professional Standards Review Organizations. It is clear that PSROs are designed to control cost more than to improve quality. It is often stated that American medical care is the best in the world. In many respects this may be true but many people believe that our attitudes, perceptions, and personal health knowledge need a change in quality and emphasis more than do our machines and our technology. This has been very difficult to achieve and probably cannot be achieved without some change in the control of our institutions. Other quality quandaries exist. If every community hospital is to be a full service hospital, then some services will certainly have very high costs and very low utilization. Low utilization leads to lower quality. To improve quality and control costs, mergers are required, which many providers and consumers see as a loss of convenient access and control. Raising these questions and, more difficult, answering them, requires a change in control.
Uniform Cost Accounting and Better Management Control. The new law also emphasizes uniform accounting practices, better reporting, and improved institutional management. It is clear that the goal is to reduce high cost systems to lower cost patterns. Many states have tried to accomplish this through various forms of rate regulation. This can and will involve forcing some hospitals to absorb deficits, declare bankruptcy, or reduce services. Some isolated areas which want and often get hospitals will incur high costs in order to achieve high quality. Those which emphasize community education and training will also
incur higher costs. These variances must either be separately funded, discontinued, or continued at the cost of other forms of quality. Disease Prevention and Consumer Education. Disease prevention and better consumer use of the health system are also stated as priorities. The problems are well and frequently described: alcoholism, smoking, accidents, obesity, etc. It is noted just as often that people want a pill but are faced with the problem of behavior change. It has proven to be very difficult for Americans to cope with the need for behavior change through political action. We need more information, yet research itself is controversial. Moreover, when faced with the choice of funding preventive services or paying for the care of the sick and injured, our political and social processes are not up to making the choice for prevention. Even a cursory examination of recent federal budgets reveals the decline of support for public health. Warren and Sydenstricker wrote about this problem in 19197: "With the appropriations for 'health insurance' running into millions of dollars annually it goes without saying that legislative bodies will not materially increase the appropriations for their health departments. Owing to this fact there is a decided probability of sickness insurance acts endangering the very existence of State health departments by absorbing all of the funds available for health work. Our statesmen and lawmakers must therefore be careful that proper and ample provisions are made for health machinery in any sickness insurance act."
The priorities enumerated in the National Health Planning and Resources Development Act, when examined one by one, are, for the most part, laudable and acceptable. They are generally consonant with the policy of the American Public Health Association, although the Association's Policy Statement is more direct in its language and implications.8 But taken together our new national priorities are in conflict with one another. Better, more equal access and higher quality cannot be obtained, realistically, at a lower cost-even at the same cost. Something has to give-some value. To make any real progress in achieving the goals enumerated by Congress, a substantial expansion and change in control would be necessary. It is not clear that this would ultimately mean a government-managed National Health Service. But it is clear that, if all the priorities were to be attained, control of the industry would have to be wrested from the providers and transferred to the consumers, who would hopefully combine democratic humanism with managerial rationalism. If this really happens, it is hoped that government will broker the transfer and not assume the arrogance of control. We may not all like the results. George Pickett, MD, MPH Director San Mateo County Department of Health and Welfare San Mateo, CA REFERENCES 1. San Francisco Chronicle, April 24, 1975.
COMMENTARIES
1 337
2. Batistella, R. M. Rationalization of Health Services. Int. J. Health Serv. 331-348, Aug., 1972. 3. Tetelman, A. Public Hospitals-Critical or Recovering? Health Serv. Rep. 88:295-304, 1973. 4. Newhouse, J. P., Phelps, C. E., and Schwarz, W. B. Policy Options and the Impact of National Health Insurance. N. Engl. J. Med. 290:1345-1359, 1974. 5. Health Maintenance Organizations: A Policy Paper. Am. J. Public Health 61:2528-2536, 1971.
6. Bailey, R. M. Economics of Scale in Medical Practice. In Empirical Studies in Health Economics, edited by Klarman, H. E., pp. 255-273. Johns Hopkins Press, Baltimore, 1970. 7. Warren, B. S., and Sydenstricker, E. Health Insurance, the Medical Profession and the Public Health. Public Health Rep. Vol. 34, No. 16, 1919, quoted in Public Health Rep. 90:77, 1975. 8. A National Program for Personal Health Services. Am. J. Public Health 61:191, 1971.
PUBLIC HEALTH: ALIEN ETHIC IN A STRANGE LAND? For the past several decades this country has attempted to attack its massive and growing alcohol problems by answering a simple question: why are some people unable to control their drinking? The clear assumption of this question is that avoiding alcohol problems is a behavioral ability, skill, or capacity and that the alcoholic "fails" as a drinker because he lacks these behavioral capacities. Despite the logical confusion and the many myths that arise when we treat drinking in an individual idiom of abilities, power, and capacities,1, 2 many alcoholism experts persist in seeing this failure as a disease condition predisposed by psychological, genetic, social, or cultural factors.3` There is another and strikingly different theory of alcohol problems-the alcohol control approach.6' 7 This approach argues that the primary factors contributing to alcohol problems are inadequate legal, social, and cultural controls over the availability and use of alcohol. This public health viewpoint argues that protection of the community from rising alcohol problems is not primarily achieved by strengthening individual abilities or capacities to use alco-
hol correctly, but rather by imposing community and societal rules that are designed to limit and control the use of alcohol and to minimize problems for the largest feasible group. A growing body of scientific research tends to bear out this public health thesis. A group of scientists at the Addiction Research Foundation in Canada have demonstrated persuasively that it is the low overall or per capita consumption of alcohol in society (and by implication the factors that influence this low consumption, such as the rules governing the use of alcohol) that produces low rates of such major alcohol problems as cirrhosis.6' 8' 9 The Canadians have gathered data that show this clear relationship: in countries where the per capita consumption of alcohol is high, alcohol-related cirrhosis rates are high. In countries where the per capita consumption of alcohol is lower, the rates of alcohol-related cirrhosis are lower. Further, as the per capita consumption of alcohol goes up, so does the rate of heavy or damaging drinking. Many other experts have confirmed these findings."0-3 The implication of these findings for public health policy for alcohol would be the development of policies at all levels of government to reduce the per capita consumption of alcohol through more adequate public and private controls over the manufacturing, marketing, advertising, and consumption of alcohol. (Recently a leading Finnish authority-Kettil Bruun-has even called for international 1338 AJPH DECEMBER, 1975, Vol. 65, No. 12
controls. 14) The thrust of these policies-both official and private-would need to be conservative and should frankly discourage the use of alcohol. The overall goal would be to encourage high rates of minimal use of alcohol so as to encourage low rates of excessive use of alcohol. The most crucial and controversial implication of these findings is that all who manufacture, distribute, market, sell, and consume the substance of alcohol would be subject to fair and just controls over this substance in order to minimize problems. It goes without saying that these policies would be obligatory and involuntary, since controls imply burdens that are more than a given individual might voluntarily choose to bear. The public health approach for alcohol controls contrasts sharply with the current policy of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for alcohol problems. The NIAAA has absolutely no policy for alcohol controls. Instead the NIAAA has focused almost exclusively on developing treatment resources and launching a voluntary campaign to teach people "how to drink responsibly." This emphasis on training people "how to drink" is a logical consequence of the confusion that occurs when drinking problems are conceptualized as a behavioral failure. The interesting question, however, is why the public health movement and public health leaders in the U.S. (with the notable exception of Milton Terris1l6 16) are not calling for more stringent controls over alcohol in this country. Prohibition is undoubtedly one reason, despite the fact that alcohol controls in no way entail prohibitionism. Also, it may be that many in public health are simply unaware of this accumulating research. I believe, however, that the major reason for the silence of public health in the U.S. on this and related issues lies in another direction. The public health movement-at least ideally-is based on the ethical claim that preventable death and disability ought to be minimized. This ethical claim has roots in the tradition of social justice and entails a commitment to prevention, collective action, and-most importantly-acceptance of the principle that minimizing death and disability necessitates the fair sharing of the burdens of prevention. In practical terms this means that majorities and powerful producer groups must (and ought to) accept the burdens of controls over hazardous or essential substances or conditions so as to maximally protect the public's health. Public health's roots in the tradition of social justice
Press, New Haven, 1974. 8. Blair, P. A. General Revenue Sharing in American Cities: First Impressions. National Clearinghouse on Revenue Sharing, Washington, DC, 1974.
TOWARD A NATIONAL HEALTH POLICY-VALUES IN CONFLICT From time to time the Congress and the President of the United States have agreed on something akin to a National Health Policy. These agreements have been reached through compromise and they bear the signs of compromise. The first real national effort at health planning (P.L. 89-749), in 1966, contained words about national purpose, healthful living, and assuring the highest level of health attainable for every person, but it also declared that nothing was to be done which might change the traditional practices of medicine, dentistry, and related healing arts. The copayment and coinsurance features of Medicare were a form of compromise between ideals and ideology. This particular compromise is both intra- and interpersonal: that is, everyone should have the right of access, but the means of access should be tempered by some degree of personal sacrifice, sometimes an unreasonable one. We are a compassionate people, but the social Darwinism of our American frontier fantasy persists. It may be useful. Compromise, in American politics, has undergone a subtle change in process as we have moved from a confederation to a nation. The pork barrel has changed to a stew pot. Once upon a time a legislator with a particular goal could gain the votes needed by agreeing to support another legislator's goal in another unrelated bill. Laws were more regional and less national a century ago. But the process has become more national and more pragmatic. The legislator's desired objective is described accurately and then, through head counting, the contents of the bill are selectively modified to gain the number of votes needed. From inter-bill compromising we have shifted more toward intra-bill compromising. The process is, in some respects, faster, and our general societal acceleration has demanded this, but it is more difficult to find a clear sense of policy in the final law since the resulting bills reflect the ambivalence inherent in compromising values. The result is often left to administrative determination of national policy (which is less responsive to the electorate than is the political process) and to occasional judicial surprises. That values can conflict with surprising results is apparent in some recent remarks by former DHEW Secretary Caspar W. Weinberger. Appearing before the American Pharmaceutical Association on April 23, 1975, he spoke about the problem of drug prices and urged new rules which would allow substitution of the lowest priced version of the drug available. He was quoted as saying: "No one is more opposed to unwarranted federal intrusions than I; but any time the federal government invests, as we do, over $2.5 This commentary was prepared for presentation at the meeting "Toward a National Health Policy," sponsored by the National Association of Regional Medical Programs, Atlanta, Georgia, May 6, 1975.
billion for drugs provided to other Americans, then any proposal that is designed to bring about a real savings at no cost to quality has to be the government's business."' The National Health Planning and Resources Development Act of 1974 (P.L. 93-641) is a result of the stewing process-somewhat of a Mulligan stew at that. The original author of the progenitor of the final bill had a fairly clear sense of what he was trying to do. He attempted to improve a much heralded but largely ignored 1966 effort at health planning by putting teeth in the process and shifting control from communities to the Secretary of Health, Education, and Welfare. Considering the generally weak acclaim earned by Comprehensive Health Planning between 1966 and 1974, the heat of the cooking process in the last few months of 1974 was probably unexpected. The battle, of course, was over control, and others, in addition to the directors of Comprehensive Health Planning Agencies and Regional Medical Programs, had something to gain or lose. Hospital associations saw the significance of the Act, as did some state and local government officials, but physicians, who really don't want the sort of planning needed, were caught napping. Now the frenzy over boundaries and agency control is intense because the potential for controlling or being controlled is evident. But what is it all to accomplish? The 1974 Act contains 10 priorities which are to be considered in formulating national health planning goals. (It is not clear whether these are priorities for the planning process or part of the health goals themselves, but it is useful to assume the latter.) The priorities can be grouped as follows: * Primary care services should be available to those populations presently underserved; * Comprehensive "systems" should be developed, to include all services. These should include sharing agreements between institutions and subsystems, the formation of group practices as parts of the systems rather than as independent entities, and consolidation of high cost, low volume services and functions; * More physician assistants and nurse practitioners should be trained and used; * Quality should be improved; * Costs should be studied, compared, and, presumably, at least contained; and * More emphasis should be given to disease prevention, particularly through better understanding of nutrition and environmental factors and by better education of consumers in how to appropriately use available services and protect their health. There are a number of potential value conflicts inherCOMMENTARIES
1335
ent in these priorities. On the whole, however, they point clearly toward the need for total governmental control of the health industry in the United States. The goals-if priorities do reflect goals-cannot otherwise be achieved. That may not be what Congressmen voted for and it may not be widely popular (important goals are rarely achieved without offending someone's values), but the basic American ambivalence toward health and welfare is moving painfully toward some conclusions. Access for the Underserved. Congress has declared that primary care services should be provided for the medically underserved. This means that we have to find ways to guarantee that those with less than some amount of medical care receive as much as some others who are supposed to be getting an adequate amount. If this is accomplished for primary care services, it presumably must be accompanied by appropriate access to secondary and tertiary care as well. No one knows what the optimal amount of medical care is. Is it 4.5 visits per year, or 2 per month, or 24 per year? Does the provider determine the amount? If so, the traditionalist-expansionist (that is, the professional provider) described by Batistella2 will prevail, and the standard amount will be (1) unequally applied or (2) if equally applied, unaffordable. Most professional providers must and do assume that the world would be a better place if more of what they do were provided to everyone. This is true of lawyers, doctors, teachers, social workers, and plumbers. Most professional workers assume that what they do has a generic positive value. Res ipsa loquitur, and the more that is provided the better. This is not unique to private providers and can be seen clearly in Alice Tetelman's article about public urban health providers.3 The managerial rationalists described by Batistella (the skeptics) suggest that the value of a health service is open to some doubt and that the burden of proof rests on the provider. Lacking that proof, the service should not be provided, at least at public expense. Batistella's democratic humanist approach will probably set the pace, tempered by the forced constraints of political tax policy. However we solve the problem of amount, the total number of services delivered and paid for will have to increase substantially if those receiving too little are to get as much as those receiving enough. Newhouse, Phelps, and Schwarz suggest that this increase may be as much as 30 to 75 per cent.4 The services may be provided through public or private systems, but it will be economically and politically necessary to control the cost of what is provided through controlling unit costs, the amount of service provided, or both. This involves the design and use of incentives or restraints, and, with or without intermediaries, government workers will be involved. Moreover, to assure access, further controls will be necessary, possibly involving training, licensing, and reimbursement mechanisms. It is stated that government presently pays for 40 per cent of the medical care provided in the United States, and the costs have frightened economists and politicians. With 8 per cent of the gross national product spent on health services currently, and 10 per cent a possible proportion in 1336 AJPH DECEMBER. 1975, Vol. 65, No. 12
the near future, stable economic growth requires control rather than the traditionalist-expansionist approach of the professional providers. Yet government now can directly try to control only 40 per cent of the market. If controls are established in the publicly financed sector only, the controllers will be rightfully accused of prejudicial actions, and equal access will remain a priority rather than become a reality. Only by obtaining an equal amount of control over the remaining 60 per cent, the "private sector," can controls be equally and equitably implemented. This is not to suggest that such controls will be widely popular or even necessarily beneficial. The Development of Comprehensive Systems. We are to develop comprehensive systems. The American Public Health Association has identified 21 elements in a comprehensive health care program.5 It is important not only that they be available but that the consumer be able to use them appropriately. Most of these elements are presently available as single strands of yarn, unwoven and uncontrolled. To weave a tailored cloth for each consumer, someone must bring the strands together. This involves changing and establishing control of the loom. The new law also proposes that certain institutional services be consolidated. Presumably this means consolidating high cost, low volume services. In many communities this will involve such tasks as consolidating pediatrics and obstetrics in one hospital. It is not clear what changes this may create in shopping patterns for adult medicine and surgery, but it will certainly cause some significant alterations in patient flow, the location of office practices, and the programs of other hospitals. Consolidation also means that communities must decide whether all general hospitals should purchase such expensive tools as computerized axial tomographic equipment (an expensive new machine for X-raying certain organs, particularly the brain, which offers substantial diagnostic benefits). Many hospitals have already purchased such equipment at a price of half a million dollars, and they hope to use it 8 hours a day, 5 days a week, and get their costs back in 2 years. Leaving aside a discussion about the role of profit in designing the industry, such practices raise significant questions not yet faced by most communities. One hospital with one such machine could serve the needs of a large area, especially if it were operated more than 40 hours a week. Yet this would necessitate that hospital A lose a patient to hospital B when this particular service is needed. What tradeoff will A require-and will it be an equal trade? Someday a victim of an automobile accident will be admitted to hospital A and need this service, available only at hospital B. To transport the patient will be life-threatening, and to use existing X-ray procedures at hospital A will result in a less precise diagnostic information package. The result may be death. How much will we pay to avoid that? Engineers talk about protection against hundred-year floods; what will we pay for medical protection against the rare accident? Most communities lack the experience to identify the question, let alone answer it. The provider has a ready and expensive answer, but the consumer really has the responsibility.
To deal with such problems effectively will mean that we will have to learn about negotiating quality rather than assume that it is a constant, and that we will have to chance shifting control from providers to consumers, with government either as the broker or as the administrator. The Use of Physician Assistants and Nurse Practitioners. Congress has also stated that we should prepare and use more such personnel. Many health planners agree. It is assumed that the concern is about access and cost. Yet such personnel may not reduce costs. If they could practice independently or under institutional or agency licensure, some cost, benefit might be achieved. But as assistants to a physician, they can make medical care more labor-intensive and thus more costly. While the picture is complicated, there is some evidence that such innovative practices lead to an increase in the income of the physician. In some cases, the unit cost to the consumer may be lowered but the volume of services delivered and, therefore, the gross cost of the system, may be increased.6 To use non-MD "physicians" effectively will require significant changes in education and licensure. These changes will require additional political action and governmental intervention and control. Educational costs, however, could be sharply reduced if we also stopped producing as many MDs and controlled their distribution. Quality Should Be Improved. Congress has also stated that we should "promote activities to achieve needed improvements in . . . quality" and specifically mentioned Professional Standards Review Organizations. It is clear that PSROs are designed to control cost more than to improve quality. It is often stated that American medical care is the best in the world. In many respects this may be true but many people believe that our attitudes, perceptions, and personal health knowledge need a change in quality and emphasis more than do our machines and our technology. This has been very difficult to achieve and probably cannot be achieved without some change in the control of our institutions. Other quality quandaries exist. If every community hospital is to be a full service hospital, then some services will certainly have very high costs and very low utilization. Low utilization leads to lower quality. To improve quality and control costs, mergers are required, which many providers and consumers see as a loss of convenient access and control. Raising these questions and, more difficult, answering them, requires a change in control.
Uniform Cost Accounting and Better Management Control. The new law also emphasizes uniform accounting practices, better reporting, and improved institutional management. It is clear that the goal is to reduce high cost systems to lower cost patterns. Many states have tried to accomplish this through various forms of rate regulation. This can and will involve forcing some hospitals to absorb deficits, declare bankruptcy, or reduce services. Some isolated areas which want and often get hospitals will incur high costs in order to achieve high quality. Those which emphasize community education and training will also
incur higher costs. These variances must either be separately funded, discontinued, or continued at the cost of other forms of quality. Disease Prevention and Consumer Education. Disease prevention and better consumer use of the health system are also stated as priorities. The problems are well and frequently described: alcoholism, smoking, accidents, obesity, etc. It is noted just as often that people want a pill but are faced with the problem of behavior change. It has proven to be very difficult for Americans to cope with the need for behavior change through political action. We need more information, yet research itself is controversial. Moreover, when faced with the choice of funding preventive services or paying for the care of the sick and injured, our political and social processes are not up to making the choice for prevention. Even a cursory examination of recent federal budgets reveals the decline of support for public health. Warren and Sydenstricker wrote about this problem in 19197: "With the appropriations for 'health insurance' running into millions of dollars annually it goes without saying that legislative bodies will not materially increase the appropriations for their health departments. Owing to this fact there is a decided probability of sickness insurance acts endangering the very existence of State health departments by absorbing all of the funds available for health work. Our statesmen and lawmakers must therefore be careful that proper and ample provisions are made for health machinery in any sickness insurance act."
The priorities enumerated in the National Health Planning and Resources Development Act, when examined one by one, are, for the most part, laudable and acceptable. They are generally consonant with the policy of the American Public Health Association, although the Association's Policy Statement is more direct in its language and implications.8 But taken together our new national priorities are in conflict with one another. Better, more equal access and higher quality cannot be obtained, realistically, at a lower cost-even at the same cost. Something has to give-some value. To make any real progress in achieving the goals enumerated by Congress, a substantial expansion and change in control would be necessary. It is not clear that this would ultimately mean a government-managed National Health Service. But it is clear that, if all the priorities were to be attained, control of the industry would have to be wrested from the providers and transferred to the consumers, who would hopefully combine democratic humanism with managerial rationalism. If this really happens, it is hoped that government will broker the transfer and not assume the arrogance of control. We may not all like the results. George Pickett, MD, MPH Director San Mateo County Department of Health and Welfare San Mateo, CA REFERENCES 1. San Francisco Chronicle, April 24, 1975.
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2. Batistella, R. M. Rationalization of Health Services. Int. J. Health Serv. 331-348, Aug., 1972. 3. Tetelman, A. Public Hospitals-Critical or Recovering? Health Serv. Rep. 88:295-304, 1973. 4. Newhouse, J. P., Phelps, C. E., and Schwarz, W. B. Policy Options and the Impact of National Health Insurance. N. Engl. J. Med. 290:1345-1359, 1974. 5. Health Maintenance Organizations: A Policy Paper. Am. J. Public Health 61:2528-2536, 1971.
6. Bailey, R. M. Economics of Scale in Medical Practice. In Empirical Studies in Health Economics, edited by Klarman, H. E., pp. 255-273. Johns Hopkins Press, Baltimore, 1970. 7. Warren, B. S., and Sydenstricker, E. Health Insurance, the Medical Profession and the Public Health. Public Health Rep. Vol. 34, No. 16, 1919, quoted in Public Health Rep. 90:77, 1975. 8. A National Program for Personal Health Services. Am. J. Public Health 61:191, 1971.
PUBLIC HEALTH: ALIEN ETHIC IN A STRANGE LAND? For the past several decades this country has attempted to attack its massive and growing alcohol problems by answering a simple question: why are some people unable to control their drinking? The clear assumption of this question is that avoiding alcohol problems is a behavioral ability, skill, or capacity and that the alcoholic "fails" as a drinker because he lacks these behavioral capacities. Despite the logical confusion and the many myths that arise when we treat drinking in an individual idiom of abilities, power, and capacities,1, 2 many alcoholism experts persist in seeing this failure as a disease condition predisposed by psychological, genetic, social, or cultural factors.3` There is another and strikingly different theory of alcohol problems-the alcohol control approach.6' 7 This approach argues that the primary factors contributing to alcohol problems are inadequate legal, social, and cultural controls over the availability and use of alcohol. This public health viewpoint argues that protection of the community from rising alcohol problems is not primarily achieved by strengthening individual abilities or capacities to use alco-
hol correctly, but rather by imposing community and societal rules that are designed to limit and control the use of alcohol and to minimize problems for the largest feasible group. A growing body of scientific research tends to bear out this public health thesis. A group of scientists at the Addiction Research Foundation in Canada have demonstrated persuasively that it is the low overall or per capita consumption of alcohol in society (and by implication the factors that influence this low consumption, such as the rules governing the use of alcohol) that produces low rates of such major alcohol problems as cirrhosis.6' 8' 9 The Canadians have gathered data that show this clear relationship: in countries where the per capita consumption of alcohol is high, alcohol-related cirrhosis rates are high. In countries where the per capita consumption of alcohol is lower, the rates of alcohol-related cirrhosis are lower. Further, as the per capita consumption of alcohol goes up, so does the rate of heavy or damaging drinking. Many other experts have confirmed these findings."0-3 The implication of these findings for public health policy for alcohol would be the development of policies at all levels of government to reduce the per capita consumption of alcohol through more adequate public and private controls over the manufacturing, marketing, advertising, and consumption of alcohol. (Recently a leading Finnish authority-Kettil Bruun-has even called for international 1338 AJPH DECEMBER, 1975, Vol. 65, No. 12
controls. 14) The thrust of these policies-both official and private-would need to be conservative and should frankly discourage the use of alcohol. The overall goal would be to encourage high rates of minimal use of alcohol so as to encourage low rates of excessive use of alcohol. The most crucial and controversial implication of these findings is that all who manufacture, distribute, market, sell, and consume the substance of alcohol would be subject to fair and just controls over this substance in order to minimize problems. It goes without saying that these policies would be obligatory and involuntary, since controls imply burdens that are more than a given individual might voluntarily choose to bear. The public health approach for alcohol controls contrasts sharply with the current policy of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for alcohol problems. The NIAAA has absolutely no policy for alcohol controls. Instead the NIAAA has focused almost exclusively on developing treatment resources and launching a voluntary campaign to teach people "how to drink responsibly." This emphasis on training people "how to drink" is a logical consequence of the confusion that occurs when drinking problems are conceptualized as a behavioral failure. The interesting question, however, is why the public health movement and public health leaders in the U.S. (with the notable exception of Milton Terris1l6 16) are not calling for more stringent controls over alcohol in this country. Prohibition is undoubtedly one reason, despite the fact that alcohol controls in no way entail prohibitionism. Also, it may be that many in public health are simply unaware of this accumulating research. I believe, however, that the major reason for the silence of public health in the U.S. on this and related issues lies in another direction. The public health movement-at least ideally-is based on the ethical claim that preventable death and disability ought to be minimized. This ethical claim has roots in the tradition of social justice and entails a commitment to prevention, collective action, and-most importantly-acceptance of the principle that minimizing death and disability necessitates the fair sharing of the burdens of prevention. In practical terms this means that majorities and powerful producer groups must (and ought to) accept the burdens of controls over hazardous or essential substances or conditions so as to maximally protect the public's health. Public health's roots in the tradition of social justice
