 If there can't be abstinence from the Surgeon General, there should be other means you, do you agree? I don't quarrel with that. I've been lacking in much of the education. But the Surgeon General says that there has to be specific sex education about the needs for sex education at a very young age. I said that that education was accompanied by values. But one of the things that's been wrong with too much of our education is that no kind of values are right and wrong are being taught. In the educational process, I think that young people expect to hear from adults ideas of what is right or wrong. What do you have to give away to win the highway veto over? What are you going to do to Terry Sanford? It's still up in the air there. I'm waiting for it to get straightened out. Are you really spending enough money on AIDS, a lot of people? We have increased the spend budget. Just Congress has doubled what you've proposed. President of the United States, accompanied by Secretary Bowen and Dr. Corrielle. President, I'm Lou Corrielle, President of the College of Positions of Philadelphia. And it is a great pleasure to welcome you to the college. The audience consists of fellows of the college and some of the staff. Mr. President and Secretary Bowen, the college is the oldest medical organization of its kind in the United States. It was founded in 1787 by 24 physicians who were concerned about the quality of healthcare being delivered. Philadelphia at that time was the largest city in the nation, the capital, the center of commerce, and became the cradle of medicine in America, largely due to the actions of this college fellows. The college fellows were the prime movers in founding the first medical school in the United States, the first medical journal, the first pharmacopeia, the first nursing center, all of the Philadelphia hospitals, the free library, even the American Philosophical Society. And I could go on, but to get on, the college today is a dynamic part of the medical community. Most importantly, the college is a nonprofit academy or collegium of the leading minds in medicine in the region. For 200 years, they've gathered here to discuss how is the best way to deliver healthcare. We can call on the expertise of 2,000 physicians and various doctrines. So we are proud of our heritage and of our continuing commitment to healthcare policy. The motto of the founders was not for oneself, but for all, and we've been doing that. This is sufficient introduction. We are delighted to welcome you, Mr. President, to College Hall. No greater tribute could be imagined than to have the President of the United States visit the college on the occasion of its 200th anniversary. Now, to do our part in this exchange, I have asked Bill Blumly, President of Thomas Jefferson University and past President of this college to organize and moderate an exchange. But before that, Mr. President, again, thank you, and if you wish to... Well, I thank you all for coming here today, and I'm looking forward to what this distinguished panel has to say. Medicine today is saving lives and raising the life expectancy of all Americans. I know what that means firsthand. I've already lived some 23 years beyond my life expectancy when I was born. That's a source of annoyance to a number of people. And as you know, I've had a few stays in the hospital over the last six years. The surgeons were so skillful, I'm thinking of having them work on the budget. But I've seen the life-saving power of modern medicine. And I know that we have here in America a medical community that's the best in the world. Not only is medical care here the best, it's also more widely available than anywhere else in the world. As we prepare for the 21st century, our goal is to make sure that in the year 2000, that is still the case. This is why I've come here today. I'm ready to listen and learn. What are the challenges ahead for keeping America healthy, for developing the science and the art of medicine, for making sure that good health care remains available to all our people? So that's what I've come to hear about and the floor is yours. Thank you very much, Dr. Blumling. Mr. President, I'd like to begin by introducing the members of our panel. On my immediate left and going around the room clockwise is Dr. Robert Ostrin, who is president of the elect of this college and professor and chairman emeritus of the Department of Research Medicine at the University of Pennsylvania. Next to him is Dr. Paul Brucker, professor and chairman department of family medicine of Jefferson Medical College, Thomas Jefferson University, and an officer of the American Board of Family Practice. Dr. Edith Levitt is president emeritus of the National Board of Medical Examiners and a member of the Council of this college. Next to her is Dr. Maurice Clifford, obstetrician, gynecologist and recently retired president of the Medical College of Pennsylvania, now commissioner of health of the city of Philadelphia. And on the other side of the room is Dr. Richard Rothman, chief of orthopedic surgery at both the Pennsylvania Hospital and Thomas Jefferson University. He's also the founding director of the Rothman Institute. Next to him is Dr. William Kissick, professor of research medicine and healthcare systems also at the University of Pennsylvania. Additionally, Bill directs the Center for Health Policy of the Leonard Davis Institute of Medical Economics. Next to Bill is Dr. Claire Fagan. Dr. Fagan is the dean of the School of Nursing of the University of Pennsylvania. And next to her is Dr. Brooke Roberts, professor emeritus and past chairman of the Department of Surgery at the University of Pennsylvania. Brooke is also a past president of this college. And finally, Dr. Bowen, we'd like to welcome you as the secretary of health and human services and distinguished general practitioner, former governor of the state of Indiana, home of the NCAA champions. May I also present Mr. President, the other members of the council and staff of the college who are in the audience. We welcome you. By way of background for our discussions today, when this college was founded in 1787, medical care was rather primitive. It didn't cost very much and it really wasn't worth very much because it couldn't change the course of many diseases. Today, by contrast, medical care can work miracles, which you know so well. But its costs are fast becoming prohibitive. 200 years ago, those early Americans who were fortunate enough to make it through childhood faced all kinds of communicable diseases which are no longer a threat to us, a serious threat anyway, like tuberculosis, typhoid, fever, yellow fever and the like. Indeed, the early American expectations for health and longevity were quite modest compared to our own, which now tend to border on the unrealistic. Woody Allen spoke for many of us when he said, there are those who seek immortality through their children or their work. I prefer to seek immortality by not dying. And while we want the best care that money can buy when we're sick, when we're well, we tend to think that the hospital and the doctor bills are too high and we wish that somebody else would pay them, like the insurance policy, the employer or the government. Somehow, Mr. President, we've got to build a better connection between the responsibility for financing health care and the individual's responsibility for adopting healthy lifestyles. We must in short find better ways to promote the health of all Americans and to do so economically. Mr. President, our panelists are prepared to expand on these and related issues since our time is very limited. I suggest we proceed around the room. That's all right with you. First, could we hear from Dr. Kessig? Thank you, Dr. Blumlee. Mr. President, after family Thanksgiving dinners on the farm in Massachusetts, my mother-in-law would lean back in her chair and say, I've had a great plenty. Today, despite vast frontiers of biomedical science yet explored, modern medicine must digest a technological great plenty that ranges from a cornucopia of pharmaceutical discoveries to laser surgery to the sonic pulverization of kidney stones. We are challenged to use our technology to achieve cost-effective health care. Health care expenditures totaled $425 billion last year, 10.7% of our gross national product, and two-and-one-half times the total sales of the American auto industry. Organization and management of the delivery of health services is essential if these vast sums are to produce the health care required by 250 million Americans. Otherwise, our great plenty of technology could yield an escalation of health care costs rather than improved health status for the entire population. My quarter of a century in government service and academic medicine, Mr. President, has convinced me that regulatory and institutional reforms combined with health services research and development are imperative to translate our technological great plenty into equity, excellence, and cost-effectiveness in health care. Our society can tolerate no less than health care of appropriate quality for all of its citizens, and we can afford no more. Thank you, Mr. President. Bringing the benefits of all of our knowledge to the public. Nursing is part of the solution to these very pressing problems of access to affordable, could be possible if either of these professions tried to go it alone. We've seen life-and-death differences because of physician-nurse collaboration in intensive care, but nowhere is collaboration more prompt to make it happen, though. We must continue to attract the very best and the brightest to nursing and to medicine as we prepare for the 21st century. The health of Americans requires a new joint venture of nurses andists to occur. Nursing as a national resource and properly used can help to solve the problems that we face today and anticipate tomorrow. Thank you, Mr. President. Thank you, Claire. I'll turn to Dr. Rothman. Mr. President, please allow me to add my personal welcome to the city of Philadelphia. From a surgeon's perspective, I see our country's medicine as the finest in the world. Top quality, readily available, and personalized. The issue of concern is to how to control the cost without impairing these qualities. The principles that I feel we share are threefold. First, health care is a right to be shared by all. Second, physicians must be allowed to continue to focus on quality. Third, government and the health care system must become partners in the care of the aged, the poor, and the chronically ill. I agree with my colleagues that we must accept the reality of finite resources. We cannot compete in the world market when the medical care component in a new Chrysler product is $450. Three facets of the solution seem apparent to me as a surgeon working in the trenches. Number one, maintain Medicare, but strengthen it by improving its insurance base. Consider a means test so that the well-to-do elderly contribute more, include the younger and healthier workers, and include catastrophic coverage. Two, reallocate our resources. We have too many physicians and too many hospital beds. Let us educate our citizens that good health is their responsibility. Three, limit the waste of defensive medicine by tackling the malpractice crisis. The cost of defensive practice is immense when one adds up the unnecessary x-rays, the extra hospitalizations, and the useless consultations prompted by fear of legal action. These pernicious practices can only be solved with strong federal support of tort reform. Finally, Mr. President, let me reaffirm my faith in our healthcare system and our citizen patients. Together they can and will understand the problem of better uses of our resources. I firmly believe that this country will continue to be the bastion of the world's finest medicine, now and in the 21st century. And finally we'll turn to Dr. Clifford. Thank you, Bill. Mr. President, the paradox of modern medicine is that today we can transplant the human heart, but not transform it. We do well at curing disease, but not very well at correcting behavior. And our behavior is killing us. The things we do to ourselves, smoking and cholesterol and drugs, violence, frenzied striving, and loveless sex, we are careless about our personal health. And we don't care enough about our health as a people. Alone among great nations, America has no plan of universal health care. And too many American babies are dying because they are born too soon and too weak, born to mothers too young, too ignorant, too malnourished, too poor. In my view, Mr. President, as we approach the 21st century, we need to set ourselves two goals. For the sake of our health as individuals, we must control our habits. For the sake of our health as a nation, we must do better as our brother's keeper. The physician leaders of your administration are on course. Surgeon General Koop with his vigorous campaign against smoking, and Secretary Bowen with his strong advocacy of coverage for catastrophic illness. Moreover, today, a day made memorable by the honor your visit does our college, this auspicious day marks the effective date of national legislation increasing eligibility for Medicaid benefits for millions of Americans. Now let us press on, Mr. President and Mr. Secretary, to put a better, healthier life for each of us and for all of us. Thank you, Mr. President. Mr. President, this completely prepared statements of the panelists. We'd be delighted to hear either questions or comments from you, sir. Well, if I could just say I find myself in great agreement with everything that I have heard here today and being married to a nurse's aide, that includes your statement about their importance. I made great use of that a few weeks ago. But yes, in these last statements, it seems to me that we have a great deal still to do in education in the sense of informing our people of some things. As governor of California and several widely publicized catastrophic family cases that came to view there, we set out and worked out a plan with the private insurance companies in which if we would agree to be compulsory to compel everyone who worked in California to take out catastrophic health insurance at that time, they could have provided that insurance limitless as to cost for $35 a year. And when I say speaking of education or something about this, the frequency of that is not sufficient that everybody thinks it won't happen to them. We couldn't even get a postcard. We were going to make this available to the people to decide. We just couldn't get any attention at all about it and it just died a warning. No one ever thought it would happen to them. And I think here maybe this is a field for us to work harder than we have. Incidentally, Dr. Bowen there may have some comments if I may be so bold. I'm not in charge here, but Dr. Bowen nearly as I have been able to figure out is only the seventh physician to ever serve in a presidential cabinet in the history of the United States. And having been a governor doesn't hurt at all. I had just remarked to him a little while ago, we need more governors in Washington. Otis, do you have something? Thank you, Mr. President. I want to express my gratitude to each member of the panel for expressing their objectives very forthrightly. They have given me added incentives to continue to work for the quality of care, to adequate access to care, and proper methods of the delivery of care. And that includes a lot of things such as the financing which has been mentioned. And especially as Dr. Clifford mentioned, the prevention of the illnesses and the changing of lifestyle. And I'm grateful for the endorsement of the long-term care and the other catastrophic insurance programs. We must learn how to use effectively and economically all of the new technology that is coming out and must not let the cost containment reduce the amount of new technology that is coming out. So I'm grateful, Mr. President, that you asked me to come along. I've learned a lot. Mr. President, I know you are due shortly for another speech. I will turn the program back to Dr. Corriell. Dr. Corriell will say that our time is about up. Your visit, Mr. President, has given the College of Physicians of Philadelphia a new impetus, and I hope perhaps we can work together to do some of these things better than we did in the past. Thank you very much. I hope so. Thank you all very much.