I’m Sorry, the Doctor Is Busy Making Money

I

“I am horrified,” Senator Kennedy writes, “that we in America have created a health care system that can be so callous to human suffering, so intent on high salaries and profits, and so unconcerned for the needs of our people.” His book In Critical Condition is largely excerpts from the testimony taken by his Subcommittee on Health as it toured the country to promote the Kennedy-Griffiths Health Security Act, the most comprehensive of the several health insurance bills now before Congress, and the one supported by Senator McGovern (see box on next page).

We hear testimony from a Mr. Johnson of Chicago, whose ten-year-old son died in convulsions after a private hospital refused to treat the boy until Mr. Johnson could prove he could pay the bill. Mr. Tresky of Garfield Heights, Ohio, describes the $5,200 medical bill for his wife’s kidney disease that is draining his $140 a week salary, although he carried Blue Cross and another medical plan before his wife got sick. Others were callously ejected from hospitals in the middle of illnesses because they ran out of funds. Some were bankrupted by medical bills, submitted to unnecessary operations for the sake of a physician’s profit, or were treated like scum in a municipal hospital because they could not go anywhere else.

One of these real-life stories supporting the liberal attack on health care in America comes not from one of the witnesses before the Senate subcommittee but from Senator Harold Hughes of Iowa:

Last year in the state of Virginia my second daughter was seized one night with severe pain in the abdomen. We called an ambulance. We rushed her to a hospital, where we could get no medical help because we couldn’t find a doctor who knew us. The doctor whom we called on—and, as a United States Senator, I called the Senate physician—couldn’t make a recommendation to me. The pain was almost impossible to bear, yet they would give her absolutely nothing to relieve the pain. Seven hours later I was calling physicians in Des Moines, Iowa, trying to find out the types of pain relievers and drugs given to her during earlier illnesses…. When finally medical care was found and a diagnosis was made, she had suffered from an inversion of the small intestine, and gangrene set in three days later.

I threatened a doctor in the hallway of that hospital and told him I’d break his neck if he didn’t come in and do something about my daughter.

At the end of each chapter of testimony in Kennedy’s book he gives us an unexceptional statement, in the style of a political speech, of his conviction on the problem, such as, “No American in our affluent age should be forced to mortgage everything he owns for health care” or “People who are injured, sick and frightened should not have to pound on the system’s doors, overcoming obstacles, to reach health care.”

Unquestionably, national health insurance would give millions of people access to more care than they can now afford. As many others have pointed out, our disorganized, fee-for-service system of health care delivery, by virtue of the enforced scarcity of physicians, has made many if not most doctors rich. It has concentrated medical care in prosperous areas, and left the poor and those living in rural parts of the United States with virtually nowhere to turn. But Kennedy’s solution to the tragic situations described in the book is to “guarantee the doctor’s right to be both businessman and healer by taking actions which make sure that it is good business to respond to the needs and demands of the people for healing.”

A mixture of science, business, witchcraft, and occasional human tenderness, the enterprise of medicine serves many functions ranging from healing to generating profits for its practitioners. There are those who say we can make it good business for oil companies not to pollute. It remains to be seen whether the profit motive can be used to stop medicine from being, as Kennedy puts it, “callous to human suffering, intent on high salaries and profits, and unconcerned for the needs of our people.” Private physicians have traditionally argued that the best hope for humane medical treatment lies in finding a good “personal physician”—someone who will take some trouble over your welfare. This in turn requires payment of a fee, goes the argument, because no one in America will really help you unless you pay him cash.

Michael Halberstam, an internist in private practice in Washington, DC, argues for the traditional system of paying a fee for a doctor’s treatment in an intelligent essay in Ray Elling’s National Health Care, a collection of papers on the current debate. Pointing out the advantages that a doctor gains by knowing his patient when he makes a diagnosis, he argues that private practice should persist because “medicine still amounts to one man asking another for help. In many…fields of medicine effectiveness depends on a deep and continuing personal relationship between healer and patient.”

Another person’s interest is indeed comforting when you are sick. Medicine remains as much an art as a science, and even where scientific knowledge is crucial, someone’s concerned attention might guard against injections of the wrong drug, removal of the wrong organ, or any of the other horrendous possibilities that crop up when patients are processed like faceless bodies. Unfortunately, however, the “deep and personal relationship” offered by a private physician often resembles that offered by a ticket scalper. For as many others have pointed out, medicine in America is a scarce commodity offered to those who pay the price.

Private doctors may be willing to give good treatment, but only if you pay. Their humanity, as well as their medicine, is sold as a product. Profits increase so long as both commodities are offered only by private doctors and are thus held in short supply. An indigent patient may obtain medical treatment in a municipal hospital, but the system carefully guards against his being treated competently and with dignity. So long as medicine is viewed not as a service but as a product, with financial incentives necessary to induce the providers to give decent care to more people, scarcity seems inevitable. Even the phrase “health consumer,” originated by liberal reformers and now used regularly by nearly everyone from the AMA to the most radical critics of health care, perpetuates the notion of health care as a product. Consume is defined as “to do away with completely; to spend wastefully; to use up.” The term hardly seems consistent with the notion of the right to physical well-being.

As with many other consumer products, health services have been kept out of the reach of the poor, and this could doubtless continue. The current wave of reforms began when many middle-class people found their efforts to obtain the medical care they were expecting only led to experiences such as those described before Kennedy’s subcommittee The reasons for this shortage of medical services have been set out ad infinitum in the reams of books and documents accompanying the current debate over health care. For one thing, the AMA overdid its efforts to limit the number of doctors, so that even those who could afford an MD’s office fee were buying a twominute encounter instead of that “deep and continuing personal relationship.” At the same time, already inadequate medical facilities were subjected to an even greater strain by Medicare and Medicaid.

To deal with this shortage facing the middle class, Kennedy would first try to increase buying power by having the federal treasury pay for everyone’s treatment. But this is not enough. In National Health Care, Elling writes that “additional money suddenly added in the form of universal health insurance, without increases in health manpower or change in medical care organization, would only generate more inflation and general chaos.” Experience with Medicare and Medicaid has taught health policy makers that enabling more people to buy treatment without regulating the sellers leads only to rampant profiteering and higher prices.

Kennedy, the liberal reformers in academic medicine, and the Nixon Administration all offer nearly identical solutions to keeping the price down. All offer the same product being sold now, but in a different package. The “good personal doctor” will be found not in his office for a fee but working for a salary in a health maintenance organization (HMO) or group practice with full prepaid coverage for each person who consults the group. Kennedy’s plan offers strong, and Nixon’s mild, financial incentives to encourage such new arrangements. These reforms, go the arguments, would make services cheaper, spread them more widely and efficiently, and cut back on needless treatment that might have been performed merely for profit under fee-for-service. In addition, the government or insurance companies would be able to budget accurately the costs of care for a given population.

Reformers point out that as a bonus under prepaid systems more money could be spent for preventive medicine, now only a small part of American health care. In The Biological Imperatives, Allan Chase quotes Dr. Wallace Cook, director of one of the hospitals in the West Coast Kaiser Permanente Health Plan, the first, largest, and now prime example of a health maintenance organization.

With prepayment to the provider of medical care, the usual economics of medical care are reversed; that is, the healthy member is the asset and the sick member is the liability.

Here the business-minded prodding of the medical profession clearly comes into play. Preventive medicine is obviously needed, but no matter how much prevention is offered, people will still need acute treatment, and that is the worst time to be a liability. HMO gets a certain amount of money for its year’s operation, and the less service it provides the more profit it earns. In view of the profit seeking of the medical profession to date, it is not difficult to imagine that, with prepayment, shortages of some services could become even more severe than they are now. In fact one of the criticisms most often heard about the Kaiser Plan is that while it strongly supports giving regular check-ups and administering elaborate diagnostic tests, you may have a hard time when you need to see a doctor.

As another cost-controlling device, the Kennedy-Griffiths bill would set limits on the budget for medical care for each region of the country. Congress has demonstrated that when health costs more than it anticipated, as with Medicaid, it will choose to cut back services rather than to put out more money. There is no reason to think it would not do the same if the Kennedy bill were law. Furthermore, while the reorganization of medical services into larger units would rationalize services and offer increased efficiency, larger health care institutions are in themselves no more a guarantee of a break for the public than replacing the corner grocery store with a Safeway or an A&P.

There is no doubt [writes Halberstam in his essay in National Health Care] that fee-for-service tempts the greedy physician to provide unneeded services. On the other hand salaried practice tempts

the lazy physician to prolonged coffee breaks and extra reasons for not operating on a weekend. Institutions can provide ancillary services that the individual doctor cannot. However, it is axiomatic that the physician working for an institution, paid by the institution, must at times divide his loyalty between the patient and the institution.

While the family doctor working in his office might be greedy for the patient’s money, the physician in a large institution, along with the institution itself, might be seeking authority, prestige, interesting research, or any number of other things that have even less to do with the patient than does the money in his pocket. Without direct payment, the patient will have lost the only potential bargaining tool he had in dealing with the doctor. The Kennedy-Griffiths bill responds to this dilemma by setting up advisory boards with consumer majorities at all levels of the health care system. But advice is not control, and the power would remain in the hands of the medical profession.

A lack of humanity in medicine is seen most often in large medical institutions. For each complaint they make about the incompetent or indifferent professionals they encounter in institutions, patients are likely to offer more about the rest of the staff, including nurses, clerks, orderlies, cleaners, technicians, etc. The stratification and resentment of the workers are at least as severe in a large medical institution as they are in a private factory. What is mainly offered in clinics and hospitals is the service of the doctor combined with access to medical technology. Nurses, maintenance staff, laboratory technicians, secretaries, and other workers face constant reminders of just how insignificant they are. Even if the nurse actually saves the patient’s life, by draining off puss and urine, the doctor gets the credit. When an absolutely sterile room is needed for a surgical procedure, no one thanks the cleaning staff, but glory is heaped on the surgeon, and perhaps on the heart-lung machine as well.

Much of the talk of medical reform mentions the “health care team,” but as the doctor is transplanted from his private office to an institution, his service is still marketed as the prime product, and this is backed with enormous inequalities in the pay and treatment of workers who are not doctors. In clinics, group practice centers, hospitals, we generally find badly paid females and nonwhites subservient to doctors who are usually white, male, and rich, or on the way to becoming so. Hospital and clinic workers often display an amazing ability to offer selfless humanitarian services. But they may feel the same impulses to sabotage the quality of their institution’s product as the worker on a General Motors assembly line does when he puts a wrench into the crankcase of a new Vega.

The patient may thus be left longing for the private waiting room of an old-fashioned fee-charging doctor, with its nurse and National Geographic. But such a place never existed for most of the poor and it is getting beyond the reach, of the middle class, as Senator Kennedy has learned. The person needing medical help sees the selfless exploits of Marcus Welby, MD, on television and hears about the latest miracle medical treatment, but is finding the “product” to be increasingly scarce. This is a situation not likely to be reversed in the near future, with or without passage of the Kennedy-Griffiths bill—even though that bill would eliminate the flow of large quantities of health care dollars into the pockets of insurance companies and give a great many more people access to some kind of medical care.

II

While arguing for fee-for-service practice, doctors have long emphasized a need for “freedom of choice” as a necessary component of good care. But good health requires other freedoms, such as freedom from pollution, occupational hazards, poisonous drugs and food, bad housing, and other dangers. These freedoms have been denied the American public at least as frequently as they have been denied the choice of a good physician, and the consequences are often more severe.

In “Outwitting the Developed Nations,” the concluding essay in National Health Care, Ivan Illich writes about the poor nations, but what he says also bears on our own problems. He writes of the Latin American doctors who “get training at the New York Hospital for Special Surgery, which they apply to only a few while amoebic dysentery remains endemic in the slums where 90 percent of the population live.” He points out that “every dollar spent in Latin America on doctors and hospitals costs a hundred lives [because] had each dollar been spent on providing safe drinking water, a hundred lives could have been saved.” Illich describes expensive advertising campaigns for Coca-Cola during a drought in Central America that left people dying. The marketing of private doctors’ services and expensive medical technology in the United States itself has also obscured many of our most basic needs.

Last year, just as President Nixon was announcing his multimillion-dollar “moonshot” crash program to cure cancer, the Public Health Service warned that because of cutbacks in federal funds for vaccinations, outbreaks of polio and other preventable diseases could occur, particularly in ghettos. According to government statistics, lead poisoning, a disease primarily of urban ghettos, now kills and cripples more children than polio did before the discovery of the Salk vaccine. Unlike polio before the Salk vaccine was available, lead poisoning can be prevented by simply cleaning and painting the walls of decaying slum housing.

Diseases that can be prevented are rampant not only in ghetto areas, although the neglect there is by far the most severe. In The Biological Imperatives, Chase points out side effects from automobiles, such as cancercausing asbestos from brake linings, pollution from exhausts, consumption of natural fuels, and deaths from collisions, and he concludes:

Unless the fulminating health hazards created by our present and growing population of motor vehicles are not significantly reduced (if not entirely eliminated) from our total environment, then all of the medical community’s current plans for creating more rational systems of delivering medical care will not materially improve our biological chances of surviving much beyond this century.

Along with a plea for a more rational system of preventive medicine, Chase presents “examples of major causes of sickness and death whose prevention is not the province of doctors, dentists, and nurses but plumbers, cobblers, farmers, engineers, and legislators.” These include malnutrition, auto accidents, war, pollution, and a number of less obvious factors, many of which, Chase says, threaten our survival.

In spite of Chase’s good intentions, and a valuable perception of the symptoms, his book unfortunately remains a disorganized set of problems in search of a cure. He assumes that the current threats to health result simply from a failure of our leaders to understand the biological consequences of their actions. “Mr. [John] Ehrlichman [the Presidential adviser] and Governor Rockefeller,” he writes at one point, “are only too typical of the intelligent and resourceful nonbiologists in high government and corporate positions” who have an “essentially shallow understanding of the biological dangers of what they see, basically, as the unmixed blessings of industrialized national growth and prudent social welfare budgets.”

Chase concludes his book by calling for “kindergarten to graduate school” education in biology for everyone and a committee of biologists to advise the President and the Congress of the consequences of their actions. As if you need a biologist to tell you that the war leaves maimed babies in Vietnam and paraplegics in VA hospitals, that the lack of adequate coal mine safety fostered by the Department of the Interior kills miners.

Halberstam readily acknowledges that the product the doctor sells in his private office is not about to remove any of the serious social menaces to health. He quotes John Knowles, head of Massachusetts General Hospital, “It is a cruel paradox that medicine generally has had the least effect on these disease-provoking conditions and instead has restricted itself to traditional curative after-the-fact…functions.” Halberstam argues that even if his treatment were offered for prepaid sale it would not serve the preventive function that the health care reformers say it would. “We know what we should do for our health, but few of us are willing to do everything we should (which is reassuring, since the purpose of life, whatever it may be, is clearly not just to see who can live longest). Some, however, are unwilling to do anything.”

That people should continuously indulge themselves in energetically marketed health hazards such as cigarettes and high cholesterol foods, while seeking relief from both when they see their doctor, is certainly illogical. But it is no less so than the government’s decision to spend millions more on a crash program to cure cancer at the very time it condones the spew of tons of cancer-causing industrial pollutants into the environment. Health lags far behind profit and productivity as a priority, be it the production of automobiles, research, medical equipment, or doctor’s services.

Many of the current plans for medical care reform include schemes to make doctors produce more by sub-contracting some of their “nonessential” tasks to paramedical assistants and midwives. The main issue regarding paramedics, writes William L. Kissick in “Health Manpower in Transition,” another essay in National Health Care, “is how long even a wealthy society can rationalize the investment of years of education and training…in individuals who will subsequently devote significant portions of their time to routine duties that might be performed by people trained in half the number of years.”

The issue goes beyond just “routine duties.” A doctor may or may not have become skilled in his work when he graduates, or finishes his internship, or completes his residency. Clearly an experienced midwife will be much better at delivering a baby than a new graduate of medical school who spent a few weeks in his third year on Ob-Gyn service. But many women, because they are taught that the doctor gives the best service available, would want the newly trained MD to deliver their baby.

At times the emphasis on “expertise” leads to absurd situations. When in 1970 New York passed its liberalized abortion law, there were few doctors around who had performed many abortions. The technique, particularly for abortions before the twelfth week, is fairly simple and hundreds of doctors easily became abortionists overnight. Because it is legally necessary for a doctor to carry out the procedure, the cheaper abortions, which take about ten minutes, now cost about $125. A doctor who aggressively promotes his services, and there are many, can line up twenty or more patients and walk away with $2,000 profit for a day’s work even if he pays a nurse and a secretary. Even the nonprofit clinics in New York City pay their salaried physician-abortionists more than $500 for an eight-hour shift. If short-term abortions could be performed by nurse-abortionists, who could, say, work in a clinic where they would be backed by a physician in case of an emergency, it is safe to say that the price for abortions would be less than $20.

Medical societies have generally regarded proposals for more medical assistants with guarded optimism. All right, they say, so long as the doctor makes all the decisions and the assistants work for a “reasonable” salary. The doctor then spends more of his time on “interesting cases” and he makes more money because his productivity increases. Halberstam warns, however, that the public might not be so happy about the assistants. “How often,” he asks, “has one heard a young mother complain, ‘I like our pediatrician, but he’s got so many assistants running around weighing babies and giving shots and talking to mothers that you never have enough time to talk to him‘?” Doctors have convinced the public that they alone are competent to give good medical care but then are unwilling or unable to make good on the expectations they create.

III

Is it possible to conjure up a fantasy where everyone in a hospital, from the janitor to the neurosurgeon, is interested in a patient’s welfare; where the more complex aspects of care are assigned no more or less dignity than the routine ones; where doctors, other hospital workers, and patients all treat each other, as equal human beings? We might also include a government that takes people’s health seriously. Yet it is impossible to envisage this happening on a large scale in our society.

Those interested in pursuing this fantasy should read Joshua, Horn’s Away With All Pests. Horn, a distinguished traumatologist, Fellow of the Royal College of Surgeons, and former lecturer at Cambridge, left England in 1954 to live and practice medicine in China. Whatever its implications for health in America, Horn’s lively account of his fifteen years as a surgeon in Peking’s Chi Sui Tan hospital should prove fascinating to anyone interested in either China or medicine.

Horn had visited China briefly in 1939 while working as a ship’s surgeon, and upon his return he, like many of those who returned to the mainland last year for the first time since the revolution, was astounded by the elimination of most of the poverty and disease that he had seen under the old regime. In describing how China has and still is bringing health care to a country that had been ravaged by disease, where virtually no medical services had existed, Horn writes as a stanch pro-Maoist. This is not an unbiased account, although recent visits by Westerners have confirmed much of what Horn describes.

Horn’s political bias is important to the book for he would say that every decision in health care—from a surgeon’s choice whether to operate to the nationwide allocation of resources—is a political one that cannot be made outside of the values of the entire society. In Chinese hospitals, he writes, the privileges enjoyed by medical experts are diminishing as it becomes accepted that other workers contribute quite as much to the common good. Where he worked, decisions about medical procedures, working conditions, and hospital policy were made in meetings of all the hospital workers with, he says, equal respect given to everyone’s opinion, irrespective of their positions. As an experienced surgeon, Horn at first objected to the continual meetings. “Gradually,” he writes,

I understood their value and importance. Many of the problems discussed could have been quickly settled by a decision from above and if this had been done we might have got through more work. But…unless the persons actually concerned have had an opportunity to debate problems and formulate policy, decisions handed down from above are liable to be wrong. Moreover, unless those who have to operate a policy are convinced of its correctness, it is likely to remain a policy on paper only.

Whenever possible, different or boring tasks were distributed among the various workers in the hospital. Even the hospital administrator spent one day a week cleaning floors or stoking the furnace—a practice designed, in Horn’s words, “to nip bureaucracy in the bud.” The patients also worked in the hospital assisting and comforting other patients and following doctors and nurses on their rounds, offering advice where they could. Horn’s book is filled with detailed histories of cases where ordinary people pushed the health professionals to accomplish more than they thought was possible. He describes a nationwide campaign to save a worker who was burned over 90 percent of his body, which yielded new information about the treatment of burns. He was impressed by simple techniques being improvised for treating peasants in areas where few medical facilities are available.

He also describes the campaign that virtually eliminated syphilis from China, although before the revolution as much as 50 percent of the population in some regions was infected. The campaign began with the assumption that the disease was a product of imperialism and the invading armies of soldiers and civilians that came with it. Houses of prostitution were closed, and women generally were freed from the feudal bondage that had characterized their position in China for thousands of years. Thousands of workers were given short, simple training as case finders, and the people were encouraged to come forward for screening with the slogan that “you can’t bring syphilis into socialism.” Treatment was more difficult. At first the old-line medical profession objected to the idea that anyone except doctors could cure syphilitics; but after a trial in one province, it was decided that specially trained workers could treat the millions of people who had the disease. This cleared up about 90 percent of the cases, and professional doctors were able to handle the rest.

Horn describes his experience as a member of a 107-person mobile medical team sent by the Peking hospital to provide treatment for 80,000 people on twelve communes in a desolate region where there had been virtually no medical care at all. The members of the team gave check-ups and immunizations, and assisted with public health and sanitation problems, but most interesting of all was their training of peasants. Together with the peasants they built in the center of the region a mud and straw medical school-hospital where, in spite of the lack of electricity and running water, thirty-two peasants studied medicine for the four winter months between the harvest and the planting. After the four months, the thirty-two again returned to their work in the fields, but at the same time they offered medical help to their fellow workers.

Horn shows in detail the amazing amount of medicine that the peasant doctors were able to learn in four months. When they could not help a patient themselves they were able to direct him or her to the services of the mobile team. The following winter the peasant doctors again returned to school, joined this time by new students, for more training, and thus service was quickly established in an area where none had existed before.

Horn largely describes representative successes in his book. He readily acknowledges that there is still nothing like free comprehensive medical care in China. He also writes,

I do not want to give the impression that deeply rooted attitudes and prejudices have been abolished as though by magic and that all problems have been solved. What has been accomplished has been the result of unremitting struggle and there is still much room for improvement. Selfishness, irresponsibility and careerism are still to be found among our medical staff. Avoidable medical mishaps still occur. Patients sometimes complain unreasonably. Some administrators and party functionaries pay lip-service to the virtue of participation in manual labor but when it comes to the point consistently avoid it.

Still, he has little doubt that, as the trends of the past twenty-three years continue, the Chinese people will soon have access to most of the medical services they need. Chinese medicine, at least as Horn represents it, is based on the notion that essential service need not be offered as a product—a concept wholly foreign to the American experience.

It remains to be seen whether Horn’s optimism about China is justified and whether his personal account fully describes what is happening. But it is impossible to read his book without thinking of our own expenditure of increasing billions for health and what we are getting for it.

MEDICAL BILLS

The Kennedy-Griffiths Health Security Act (Rep. Martha Griffiths of Michigan introduced it in the House) would provide everyone in the country with health insurance covering all hospitalization, doctor’s care, lab tests, dental care for children, 120 days per year of nursing home care, and drugs and psychiatric help in a few limited situations. The program would be financed through a federal fund resembling social security and paid for by a 1 percent across-the-board income tax for employees and a 3.5 percent tax on employers (a regressive tax which some critics charge would put an especially hard burden on low wage earners and marginal employers).

This would be coupled with economic incentives for physicians to join group practice and accept payment on a prepaid, per patient (“capitation”) basis or to work for a salary in a large health maintenance organization. Advisory boards with consumer majorities would be set up to advise the government in running the program at the national, regional, and local levels. Five percent of the total funds collected would be set aside for programs aimed at improving services and training new personnel. The bill would eliminate Medicare, Medicaid, and most medical insurance programs including Blue Cross and Blue Shield.

Passage of the Kennedy-Griffiths bill is thought to be most unlikely. It is tied up in the House in Wilbur Mills’s Ways and Means Committee and in the Senate under the thumb of Russell Long of Louisiana, and it will probably never emerge from committee. Supporters of the bill, including the United Auto Workers and the health philanthropist Mary Lasker, hope to generate enough popular support for the concept of socialized medicine (a term they never use) to attach portions of the bill to whatever health plan reaches the floor of Congress.

The other major health plan now before Congress, also not likely to be passed without compromise, is the Administration’s three-pronged health insurance program. Under these plans, employed people would be covered by a minimal program of private insurance paid for by a 65 percent employer and 35 percent employee contribution—again a regressive method of payment. The total premium for a family is expected to be about $290 per year, of which the family itself will pay about $100. To encourage, in Nixon’s words, “cost consciousness,” the coverage itself will contain certain deductibles and co-insurance factors so that a family could be liable for some $1,720 per year in medical costs in addition to its insurance premium payments.

For families of four earning less than $3,000 per year, the Nixon schemes offer private insurance paid for by the government. For families earning between $3,000 and $5,000 the government would pay for part of the premiums on a sliding scale. The precise benefits under this second part of the Nixon program have yet to be worked out. For the aged, the Nixon plan would retain the current Medicare plan with some minor modifications. It is estimated that the Nixon health plans would yield private insurance companies premiums of at least $3 billion more per year than they now receive.

In fact, by October, “health care” had failed to catch on as the big political issue that both Republicans and Democrats had expected it would. Both Senator Kennedy and the Nixon Administration have recently been backing off from any large plans to replace private practice as the major form of medical care.