- Email: [email protected]
MISSING: A NATIONAL HEALTH PROGRAMME IN THE USA
279
ineffective, an alternative drug, possibly chloroquine or sulphasalazine, is substituted. Suggestions were made that the longterm use of these drugs should be compared with gold or penicillamine for 6 months only, or with placebo, and that new approaches, such as drug combinations and intermittent treatment
Health Watch MISSING: A NATIONAL HEALTH PROGRAMME IN THE USA
regimens, should be tested.
THE two most frequent questions addressed to Americans in connection with medical care are (a) when will you get a national health service? and (b) why don’t you have a national health service? Europeans are scandalised by the cost of medical care in the USA, the lack ofuniversial coverage, and, of course, the added fear of falling sick while travelling there. They are puzzled as to why such a wealthy country, with such abundant medical resources, should retain an outmoded uninhibited entrepreneurial system. Almost every other industrialised nation, even those with more modest capability for meeting national health needs than the USA, has evolved some kind of national health programme. Why not the USA? It is 75 years since the first rumblings of popular agitation for a national health programme were heard. At present public interest in the topic seems low. This year’s Democratic political platform has no health plans-so an astute grouping of politicians, who balance off the interests of their
Corticosteroids Before the meeting,
a
questionnaire
about corticosteroid
prescribing was sent by Dr M. Byron to 250 consultant rheumatologists; 198 replies were received. Replies to the question "do you ever initiate corticosteroid therapy in uncomplicated RA?" were: 33% occasionally; 4% frequently; 51% very infrequently; and 12% never. Further analysis of the experience at one centre revealed a discrepancy between the clinician’s stated opinion and his actual practice. Such a discrepancy is well recognised in clinical decision-
rnaking.12 Thus, the belief that corticosteroids should be avoided in RA is not generally practised. In early studies comparing cortisone with aspirin in RA 13,14 no clear therapeutic advantage for cortisone was demonstrated in the medium term (ie, 3 years). However, when prednisolone was compared with analgesics (usually aspirin or phenylbutazone) in a 3-year trial, the corticosteroid group showed improvement in both clinical features and laboratory indices of disease activity and significantly less radiological progression. IS Another trial suggested that low-dose prednisolone was unlikely to be so effective. 16 Even if corticosteroids are of benefit, such benefit must be weighed against their side-effects. There was general agreement that two main studies of corticosteroids are required: a study of long-term low-dose prednisolone (ie, 7’ 5-10 mg daily) given early in the course of the disease to test for possible disease modification, and a study of intermittent high-dose prednisolone (ie, 100-125mg by mouth or injection every 4-6 weeks) to test for a fundamental effect on the evolution of the disease.
R. C BUTLER AND D. H. GODDARD: REFERENCES
Immunosuppressive Drugs In controlled studies
cyclophosphamide,17 azathioprine, 18
and
chlorambucili9 have been shown to reduce synovitis in RA. In one study of cyclophosphamide, a reduction in the rate of formation of erosions was observed. 17 Methotrexate2° may also be valuable, but controlled data are awaited. The risk of oncogenesis is the greatest barrier to the use of these drugs in RA. The magnitude of the risk has yet to be quantified though these data should eventually be available through the EULAR registry.21 Long-term trials of single drugs using conventional dosage regimens were considered to be of limited value, and it was suggested that different treatment strategies should be tried.z2 These included: intermittent use of a single agent in high dose; use of a single agent in conventional doses in combination with gold or penicillamine; and use of combinations of cytotoxic drugs given either as low-dose continuous or high-dose intermittent regimens. Patients with severe progressive disease who had not responded to other treatments
were
considered
-to
be
most
suitable for these
studies, but the need for identifying predictive factors of
malignancy in such patients was emphasised. Cost
versus
Benefit
No definite decision was reached as to whether the beneficial effect of the drugs outweigh their cost in terms of toxicity and patient and NHS resources. Many felt that the success of future management of RA would depend upon a new approach to treatment in which aggressive drug regimens are used early in the course of the disease. For ethical reasons, such a policy will only be permissible when patients at risk from severe and progressive disease can be identified with accuracy. Whether such a treatment strategy will enable clinicians to abort RA in its earliest stages is a question of fundamental importance that urgently requires an answer.
All
correspondence should be addressed
to
R. C. B.
Empire Rheumatism Council. Gold therapy in rheumatoid arthritis Report ofa multicentre controlled trial. Ann Rheum Dis 1960; 19:95-119. 2. Research Committee of the Empire Rheumatism Council. Gold therapy in rheumatoid arthritis. Report of amulticentre controlled trial. Ann Rheum Dis 1960; 20: 315-34. 3. Sigler JW, Bluhm GB, Duncan H, Sharp JT, Ensign DC, McCrum WR. Gold salts in the treatment of rheumatoid arthritis. A double-blind study. Ann Intern Med 1974; 80: 21-26. 4. Dixon AStJ, Davies J, Dormandy TL, et al. Synthetic D(-) penicillamine in rheumatoid arthritis Double-blind study of high and low-dosage regimen. Ann Rheum Dis 1975; 34: 416-21: 5 Andrews FM, Camp AV, Day AT, et al. Controlled trial of D(-) penicillamine in severe rheumatoid arthritis Lancet 1973; i. 275-80. 6. McConkey B, Davies P, Crockson RA, Crockson AP, Butler M, Constable TJ, Amos RS Effects of gold, dapsone, and predmsone on serum C-reactive protein and haptoglobin, and the erythrocyte sedimentation rate in rheumatoid arthritis. Ann Rheum Dis 1979; 38: 141-44 7. Fries JF. Towards an understanding of patient outcome measurement. Arthritis Rheum 1983; 26: 697-704. 8. Iannuzzi L, Dawson N, Zein N, Kushner I. Does drug therapy slow radiographic deterioration in rheumatoid arthritis? N Engl J Med 1983; 309: 1023-28. 9. Scott DL, Grindulis KA, Struthers GR, Coulton BL, Popert AJ, Bacon PA. Progression of radiological changes in rheumatoid arthritis. Ann Rheum Dis 1984; 43: 8-17. 10. Sambrook PN, Browne CD, Champion GD, Day RO, Vallence JB, Warwick N. Terminations of treatment with gold sodium thiomalate in rheumatoid arthritis. J Rheumatol 1982; 9: 932-34. 11. Day AT, Golding JR, Lee PN, Butterworth D. Penicillamine in rheumatoid disease: a long-term study. Br MedJ 1974; i: 180-83. 12. Kirwan Chaput de Saintonge DM, Joyce CRB, Currey HLF. Clinical judgement in rheumatoid arthritis. II Judging "current disease activity" in clinical practice Ann Rheum Dis 1983; 42: 648-51. 13. Joint Committee of the Medical Research Council and Nuffield Foundation. A comparison of cortisone and aspirin in the treatment of early cases of rheumatoid arthritis. Br Med J 1955; ii: 695-700. 14. Empire Rheumatism Council. Multicentre controlled trial comparing cortisone acetate and acetyl-salicylic acid in the long-term treatment of rheumatoid arthritis. Ann Rheum Dis 1957, 16: 277-89. 15. Joint Committee of the Medical Research Council and the Nuffield Foundation. A comparison of prednisolone with aspirin and other analgesics in the treatment of rheumatoid arthritis. Ann Rheum Dis 1960; 19: 331-37. 16. Harris ED, Enikey RD, Nichols JE, Newberg A. Low-dose prednisolone therapy in rheumatoid arthritis a double-blind study. J Rheumatol 1983; 10: 713-21. 17. Co-operating Clinics Committee of the American Rheumatism Association. A controlled trial of cyclophosphamide in rheumatoid arthritis. N Engl Med 1970; J 283: 883-99. 18. Urowitz MB, Gordon DA, Smythe HA, Pruzanski W, Ogryzlo MA. Azathioprine in rheumatoid arthritis. A double-blind cross-over study. Arthritis Rheum 1973; 16: 411-18. 19. Amor B, Mery C. Chlorambucil m rheumatoid arthritis. Clinics Rheum Dis 1980; 6: 567-84. 20. Groff DG, Shanberger KN, Wilks WS, Taylor TH. Low-dose oral methotrexate in rheumatoid arthritis an uncontrolled trial and review of the literature. Seminars Arthritis Rheum 1983; 12: 333-47. 21. Kay A. EULAR register of patients on immunosuppressive drugs. Ann Rheum Dis 1. Research Committee ofthe
JR,
‘
22.
1982; 41 (suppl 1): 30-31. McCarty DJ, Carrera GF. Intractable rheumatoid arthritis. Treatment with combined cyclophosphamide, azathioprine, and hydroxychloroquine. JAMA 1982; 248: 1718-23
280
constituents against those of pressure groups, felt no urgency on this account. The commonly accepted explanation of the US failure to have a national health programme is the intransigence of the medical profession, but this is unlikely to be the whole answer. Poll after poll has demonstrated that the American people are heavily in favour of a national health programme. The trade-unions through their overall national body, the AFL-CIO, have passed resolutions almost unanimously, year after year, demanding national health insurance. The American Public Health Association has long supported a national health programme. Other professional groups, in national assembly, support a national health programme. If then, at a time when the pressures of high medical costs have never been greater (nearing 11% of gross national product) and when the Reaganite welfare policies have deprived more and more low-income people from eligibility, the Democratic Party does not feel the necessity even to speak out on the subject, more than medical professional obduracy is at work. In the early years, the legislatures were cautious. They feared being overwhelmed by the costs. And today also some of the reluctance on the part of legislative bodies, whether in the States or in the Congress, stems from cost and tax considerations. But some believe that the opposition has more to do with the American temperament. Americans are traditionally averse to compulsory nationally ordered activities, and the American Medical Association and its allies (the pharmaceutical industry, private insurance companies, and medical equipment manufacturers) have sought to augment this trait. There is a value system among Americans, related to the origins of the republic and its citizens, in which entrepreneurial activities are commended and Government intervention is deplored. Also, even after the experience of the great depression, Americans have a suspicion that poverty and inability to cope is a form of personal deficiency, not to be encouraged with public programmes. Health programmes are not the only national social programmes lacking in the USA: we have no full-scale family or children’s assistance
Round the World
United States THE COMING CLASH OF PHILOSOPHIES
GOVERNMENT proposals to cut rapidly rising hospital costs and doctors’ fees will, if imposed, give rise to substantial changes in health care in the US. The costs of the Federally supported Medicare program have been rising rapidly and some doubt its financial stability without drastic reform. Thus it is the Medicare patients who have been the major target of the attempts to economise because, inevitably, the ailments of the aged are so common and so costly to deal with. But it would seem unwise to ask this increasingly large proportion of the population to bear a disproportionate share of cuts in health costs, especially if physicians do not bear what the public perceives as a fair share. Foreseeing the future, many physicians have accepted the February suggestion of the American Medical Association to freeze some Medicare and Medicaid fees. This response has met with disagreement and, indeed, the retired persons’ association claims that up to 70% of physicians charge extra fees anyway. Whatever the true figure, many Medicare patients have to dig into their pockets and they will face higher premiums under the new proposals. Fees will be frozen for 15 months and those physicians who accept the basic fee will be asked to submit statements of their costs to allow, on a doctor-to-doctor basis, calculation ofa new scale once the freeze ends. Participating doctors who charge additional fees will be
in Europe. There is no national leave. policy maternity Below the surface, too, simmers the long tradition of "institutional racism", despite twenty years now of civil rights activity and the elimination of many formal legal barriers to inclusion of non-whites in daily life. While most poor people are white, there is greater poverty proportionately among the non-white. Whether consciously or unconsciously, the majority are reluctant to undertake and pay for expensive social programmes whose beneficiaries will be heavily from among the non-white population. There are also political factors that distinguish the US from other countries, powerfully modifying the capacity of the Congress to legislate nationally unless there is a deeply felt consensus. Political party leaders do not have the hold on legislators of their party that the leaders do in parliamentary governments. Each US legislator is elected on his platform; the party designation is a convenience, and not necessarily an accurate label. "Party discipline" cannot be enforced. Furthermore, the USA inherits a strong "states rights" strain, so the Federal Government must remain with the states. In the past two centuries, important national legislation has always been preceded by examples in state actions; experience in the states is then incorporated into national legislation. This has been true in a wide range of social issues-for example, wage and hour laws, civil rights, social security, unemployment compensation. Despite the numerous obstacles, progress can be discerned. Until 1978 there had been no state compulsory health insurance legislation. Then Hawaii obtained such a law; but, because of fierce opposition from growers and physicians, it was obstructed in the courts and it was implemented only in the spring of 1983.I have no doubt that the experience will be repeated now in a few other states-Colorado missed by a narrow margin only a year or so ago-and will eventually become a national pattern. programmes
so common
on
Department of Public Health, Yale University School of Medicine, New Haven, CT 06510, USA
GEORGE SILVER
limited in these, fined if they charge more, and will not be eligible for submitting statements on additional costs. Those who do not join the scheme will not be affected but they may forfeit any future Medicare-fee increases and be prevented from ever joining the scheme. The AMA is disappointed by the Government’s attempt to coerce doctors into joining the scheme and its intention to punish those who do not. It also feels that the Government should look more closely at high-technology medicine and hospital costs in order to reduce expenditure. Soaring costs are not confined to the Medicare and Medicaid program. All Federally supported schemes are under review, and an attempt is being made in New York to rebuild a general practitioner service rather than subsidise a collection of specialists. Comprehensive health-care centres are being planned for urban areas, and physicians will receive contracts to serve patients in rural areas. Clinics will be subsidised to provide for such patients. Physicians’ fees for total patient management will be increased as well as payments to hospitals for emergency-room visits. The participating physician will make all referrals to specialists, and be responsible for all clinical tests and hospital admissions. Such fundamental changes will doubtless have considerable impact on the hospitals, many of which are in a financially precarious state, and will stimulate medical education. All this points towards more public control of health care in the US. When asked if the proposals were not in contrast to the Administration’s backing for a free-market economy, a Government spokesman replied that "in searching for a number of ways to control the spiralling costs of the health-care system we had to make a departure from that philosophy. There did not seem any other way to deal with this issue".
ineffective, an alternative drug, possibly chloroquine or sulphasalazine, is substituted. Suggestions were made that the longterm use of these drugs should be compared with gold or penicillamine for 6 months only, or with placebo, and that new approaches, such as drug combinations and intermittent treatment
Health Watch MISSING: A NATIONAL HEALTH PROGRAMME IN THE USA
regimens, should be tested.
THE two most frequent questions addressed to Americans in connection with medical care are (a) when will you get a national health service? and (b) why don’t you have a national health service? Europeans are scandalised by the cost of medical care in the USA, the lack ofuniversial coverage, and, of course, the added fear of falling sick while travelling there. They are puzzled as to why such a wealthy country, with such abundant medical resources, should retain an outmoded uninhibited entrepreneurial system. Almost every other industrialised nation, even those with more modest capability for meeting national health needs than the USA, has evolved some kind of national health programme. Why not the USA? It is 75 years since the first rumblings of popular agitation for a national health programme were heard. At present public interest in the topic seems low. This year’s Democratic political platform has no health plans-so an astute grouping of politicians, who balance off the interests of their
Corticosteroids Before the meeting,
a
questionnaire
about corticosteroid
prescribing was sent by Dr M. Byron to 250 consultant rheumatologists; 198 replies were received. Replies to the question "do you ever initiate corticosteroid therapy in uncomplicated RA?" were: 33% occasionally; 4% frequently; 51% very infrequently; and 12% never. Further analysis of the experience at one centre revealed a discrepancy between the clinician’s stated opinion and his actual practice. Such a discrepancy is well recognised in clinical decision-
rnaking.12 Thus, the belief that corticosteroids should be avoided in RA is not generally practised. In early studies comparing cortisone with aspirin in RA 13,14 no clear therapeutic advantage for cortisone was demonstrated in the medium term (ie, 3 years). However, when prednisolone was compared with analgesics (usually aspirin or phenylbutazone) in a 3-year trial, the corticosteroid group showed improvement in both clinical features and laboratory indices of disease activity and significantly less radiological progression. IS Another trial suggested that low-dose prednisolone was unlikely to be so effective. 16 Even if corticosteroids are of benefit, such benefit must be weighed against their side-effects. There was general agreement that two main studies of corticosteroids are required: a study of long-term low-dose prednisolone (ie, 7’ 5-10 mg daily) given early in the course of the disease to test for possible disease modification, and a study of intermittent high-dose prednisolone (ie, 100-125mg by mouth or injection every 4-6 weeks) to test for a fundamental effect on the evolution of the disease.
R. C BUTLER AND D. H. GODDARD: REFERENCES
Immunosuppressive Drugs In controlled studies
cyclophosphamide,17 azathioprine, 18
and
chlorambucili9 have been shown to reduce synovitis in RA. In one study of cyclophosphamide, a reduction in the rate of formation of erosions was observed. 17 Methotrexate2° may also be valuable, but controlled data are awaited. The risk of oncogenesis is the greatest barrier to the use of these drugs in RA. The magnitude of the risk has yet to be quantified though these data should eventually be available through the EULAR registry.21 Long-term trials of single drugs using conventional dosage regimens were considered to be of limited value, and it was suggested that different treatment strategies should be tried.z2 These included: intermittent use of a single agent in high dose; use of a single agent in conventional doses in combination with gold or penicillamine; and use of combinations of cytotoxic drugs given either as low-dose continuous or high-dose intermittent regimens. Patients with severe progressive disease who had not responded to other treatments
were
considered
-to
be
most
suitable for these
studies, but the need for identifying predictive factors of
malignancy in such patients was emphasised. Cost
versus
Benefit
No definite decision was reached as to whether the beneficial effect of the drugs outweigh their cost in terms of toxicity and patient and NHS resources. Many felt that the success of future management of RA would depend upon a new approach to treatment in which aggressive drug regimens are used early in the course of the disease. For ethical reasons, such a policy will only be permissible when patients at risk from severe and progressive disease can be identified with accuracy. Whether such a treatment strategy will enable clinicians to abort RA in its earliest stages is a question of fundamental importance that urgently requires an answer.
All
correspondence should be addressed
to
R. C. B.
Empire Rheumatism Council. Gold therapy in rheumatoid arthritis Report ofa multicentre controlled trial. Ann Rheum Dis 1960; 19:95-119. 2. Research Committee of the Empire Rheumatism Council. Gold therapy in rheumatoid arthritis. Report of amulticentre controlled trial. Ann Rheum Dis 1960; 20: 315-34. 3. Sigler JW, Bluhm GB, Duncan H, Sharp JT, Ensign DC, McCrum WR. Gold salts in the treatment of rheumatoid arthritis. A double-blind study. Ann Intern Med 1974; 80: 21-26. 4. Dixon AStJ, Davies J, Dormandy TL, et al. Synthetic D(-) penicillamine in rheumatoid arthritis Double-blind study of high and low-dosage regimen. Ann Rheum Dis 1975; 34: 416-21: 5 Andrews FM, Camp AV, Day AT, et al. Controlled trial of D(-) penicillamine in severe rheumatoid arthritis Lancet 1973; i. 275-80. 6. McConkey B, Davies P, Crockson RA, Crockson AP, Butler M, Constable TJ, Amos RS Effects of gold, dapsone, and predmsone on serum C-reactive protein and haptoglobin, and the erythrocyte sedimentation rate in rheumatoid arthritis. Ann Rheum Dis 1979; 38: 141-44 7. Fries JF. Towards an understanding of patient outcome measurement. Arthritis Rheum 1983; 26: 697-704. 8. Iannuzzi L, Dawson N, Zein N, Kushner I. Does drug therapy slow radiographic deterioration in rheumatoid arthritis? N Engl J Med 1983; 309: 1023-28. 9. Scott DL, Grindulis KA, Struthers GR, Coulton BL, Popert AJ, Bacon PA. Progression of radiological changes in rheumatoid arthritis. Ann Rheum Dis 1984; 43: 8-17. 10. Sambrook PN, Browne CD, Champion GD, Day RO, Vallence JB, Warwick N. Terminations of treatment with gold sodium thiomalate in rheumatoid arthritis. J Rheumatol 1982; 9: 932-34. 11. Day AT, Golding JR, Lee PN, Butterworth D. Penicillamine in rheumatoid disease: a long-term study. Br MedJ 1974; i: 180-83. 12. Kirwan Chaput de Saintonge DM, Joyce CRB, Currey HLF. Clinical judgement in rheumatoid arthritis. II Judging "current disease activity" in clinical practice Ann Rheum Dis 1983; 42: 648-51. 13. Joint Committee of the Medical Research Council and Nuffield Foundation. A comparison of cortisone and aspirin in the treatment of early cases of rheumatoid arthritis. Br Med J 1955; ii: 695-700. 14. Empire Rheumatism Council. Multicentre controlled trial comparing cortisone acetate and acetyl-salicylic acid in the long-term treatment of rheumatoid arthritis. Ann Rheum Dis 1957, 16: 277-89. 15. Joint Committee of the Medical Research Council and the Nuffield Foundation. A comparison of prednisolone with aspirin and other analgesics in the treatment of rheumatoid arthritis. Ann Rheum Dis 1960; 19: 331-37. 16. Harris ED, Enikey RD, Nichols JE, Newberg A. Low-dose prednisolone therapy in rheumatoid arthritis a double-blind study. J Rheumatol 1983; 10: 713-21. 17. Co-operating Clinics Committee of the American Rheumatism Association. A controlled trial of cyclophosphamide in rheumatoid arthritis. N Engl Med 1970; J 283: 883-99. 18. Urowitz MB, Gordon DA, Smythe HA, Pruzanski W, Ogryzlo MA. Azathioprine in rheumatoid arthritis. A double-blind cross-over study. Arthritis Rheum 1973; 16: 411-18. 19. Amor B, Mery C. Chlorambucil m rheumatoid arthritis. Clinics Rheum Dis 1980; 6: 567-84. 20. Groff DG, Shanberger KN, Wilks WS, Taylor TH. Low-dose oral methotrexate in rheumatoid arthritis an uncontrolled trial and review of the literature. Seminars Arthritis Rheum 1983; 12: 333-47. 21. Kay A. EULAR register of patients on immunosuppressive drugs. Ann Rheum Dis 1. Research Committee ofthe
JR,
‘
22.
1982; 41 (suppl 1): 30-31. McCarty DJ, Carrera GF. Intractable rheumatoid arthritis. Treatment with combined cyclophosphamide, azathioprine, and hydroxychloroquine. JAMA 1982; 248: 1718-23
280
constituents against those of pressure groups, felt no urgency on this account. The commonly accepted explanation of the US failure to have a national health programme is the intransigence of the medical profession, but this is unlikely to be the whole answer. Poll after poll has demonstrated that the American people are heavily in favour of a national health programme. The trade-unions through their overall national body, the AFL-CIO, have passed resolutions almost unanimously, year after year, demanding national health insurance. The American Public Health Association has long supported a national health programme. Other professional groups, in national assembly, support a national health programme. If then, at a time when the pressures of high medical costs have never been greater (nearing 11% of gross national product) and when the Reaganite welfare policies have deprived more and more low-income people from eligibility, the Democratic Party does not feel the necessity even to speak out on the subject, more than medical professional obduracy is at work. In the early years, the legislatures were cautious. They feared being overwhelmed by the costs. And today also some of the reluctance on the part of legislative bodies, whether in the States or in the Congress, stems from cost and tax considerations. But some believe that the opposition has more to do with the American temperament. Americans are traditionally averse to compulsory nationally ordered activities, and the American Medical Association and its allies (the pharmaceutical industry, private insurance companies, and medical equipment manufacturers) have sought to augment this trait. There is a value system among Americans, related to the origins of the republic and its citizens, in which entrepreneurial activities are commended and Government intervention is deplored. Also, even after the experience of the great depression, Americans have a suspicion that poverty and inability to cope is a form of personal deficiency, not to be encouraged with public programmes. Health programmes are not the only national social programmes lacking in the USA: we have no full-scale family or children’s assistance
Round the World
United States THE COMING CLASH OF PHILOSOPHIES
GOVERNMENT proposals to cut rapidly rising hospital costs and doctors’ fees will, if imposed, give rise to substantial changes in health care in the US. The costs of the Federally supported Medicare program have been rising rapidly and some doubt its financial stability without drastic reform. Thus it is the Medicare patients who have been the major target of the attempts to economise because, inevitably, the ailments of the aged are so common and so costly to deal with. But it would seem unwise to ask this increasingly large proportion of the population to bear a disproportionate share of cuts in health costs, especially if physicians do not bear what the public perceives as a fair share. Foreseeing the future, many physicians have accepted the February suggestion of the American Medical Association to freeze some Medicare and Medicaid fees. This response has met with disagreement and, indeed, the retired persons’ association claims that up to 70% of physicians charge extra fees anyway. Whatever the true figure, many Medicare patients have to dig into their pockets and they will face higher premiums under the new proposals. Fees will be frozen for 15 months and those physicians who accept the basic fee will be asked to submit statements of their costs to allow, on a doctor-to-doctor basis, calculation ofa new scale once the freeze ends. Participating doctors who charge additional fees will be
in Europe. There is no national leave. policy maternity Below the surface, too, simmers the long tradition of "institutional racism", despite twenty years now of civil rights activity and the elimination of many formal legal barriers to inclusion of non-whites in daily life. While most poor people are white, there is greater poverty proportionately among the non-white. Whether consciously or unconsciously, the majority are reluctant to undertake and pay for expensive social programmes whose beneficiaries will be heavily from among the non-white population. There are also political factors that distinguish the US from other countries, powerfully modifying the capacity of the Congress to legislate nationally unless there is a deeply felt consensus. Political party leaders do not have the hold on legislators of their party that the leaders do in parliamentary governments. Each US legislator is elected on his platform; the party designation is a convenience, and not necessarily an accurate label. "Party discipline" cannot be enforced. Furthermore, the USA inherits a strong "states rights" strain, so the Federal Government must remain with the states. In the past two centuries, important national legislation has always been preceded by examples in state actions; experience in the states is then incorporated into national legislation. This has been true in a wide range of social issues-for example, wage and hour laws, civil rights, social security, unemployment compensation. Despite the numerous obstacles, progress can be discerned. Until 1978 there had been no state compulsory health insurance legislation. Then Hawaii obtained such a law; but, because of fierce opposition from growers and physicians, it was obstructed in the courts and it was implemented only in the spring of 1983.I have no doubt that the experience will be repeated now in a few other states-Colorado missed by a narrow margin only a year or so ago-and will eventually become a national pattern. programmes
so common
on
Department of Public Health, Yale University School of Medicine, New Haven, CT 06510, USA
GEORGE SILVER
limited in these, fined if they charge more, and will not be eligible for submitting statements on additional costs. Those who do not join the scheme will not be affected but they may forfeit any future Medicare-fee increases and be prevented from ever joining the scheme. The AMA is disappointed by the Government’s attempt to coerce doctors into joining the scheme and its intention to punish those who do not. It also feels that the Government should look more closely at high-technology medicine and hospital costs in order to reduce expenditure. Soaring costs are not confined to the Medicare and Medicaid program. All Federally supported schemes are under review, and an attempt is being made in New York to rebuild a general practitioner service rather than subsidise a collection of specialists. Comprehensive health-care centres are being planned for urban areas, and physicians will receive contracts to serve patients in rural areas. Clinics will be subsidised to provide for such patients. Physicians’ fees for total patient management will be increased as well as payments to hospitals for emergency-room visits. The participating physician will make all referrals to specialists, and be responsible for all clinical tests and hospital admissions. Such fundamental changes will doubtless have considerable impact on the hospitals, many of which are in a financially precarious state, and will stimulate medical education. All this points towards more public control of health care in the US. When asked if the proposals were not in contrast to the Administration’s backing for a free-market economy, a Government spokesman replied that "in searching for a number of ways to control the spiralling costs of the health-care system we had to make a departure from that philosophy. There did not seem any other way to deal with this issue".