 to stop me was a great big sign that this private property, but on the other side it didn't say nothing. That's why it was made for you and me. One more time this land is yours, this land is mine. From Dallas Farmer to the New York Highland, from the musical sting wall. This afternoon we're very proud to have with us Dr. Milton Terrace who has lived in South Burlington for the last seven years and Dr. Terrace is a member of the Task Force on Health Care that I recently put together. And we were especially delighted to have Dr. Terrace participate on that task force because he is in fact one of the national experts in the whole area of public health. And Dr. Terrace, perhaps before we even get into the heart of the discussion, maybe you might want to share with the viewers a little bit about your background and how you became interested in the area. Well, I've been in public health all my life. I'm a physician. I am past president of the American Public Health Association. I've done research and teaching in public health. I was at one time chair of the Committee on Medicine and Society of the New York Academy of Medicine and I'm currently a visiting professor in the Faculty of Medicine, both at the University of Toronto and the University of Montreal. I presume that makes me some kind of an expert. Let's start off with the health care problems that we see in the state of Vermont, some of which have come up right before us on the Task Force. As you know, we have a situation where about 62,000 Vermonters lack any health insurance whatsoever. We have a situation where for people who have blue cross, blue shield or private health insurance, the cost that they're paying has gone up radically in the last few years and it's now taking a big chunk out of people's limited incomes. We have a situation in which for our elderly people, almost 50% of their health care costs are now coming out of their own pocket, despite Medicare. The Medicare in many ways has not done what people had thought. Elderly people had thought that it would do and the scary thing about all of that is that as bad as the situation is now, what all of the experts tell us, that if present trends continue, we have no reason to believe that the situation is not going to get increasingly worse in terms of higher and higher health care costs. What's going on? What might we do to improve that situation? Well, I think the problem is that in the United States, including Vermont, of course, we've approached these problems in a fragmentary kind of way. Voluntary health insurance, Medicare, Medicaid, there's been no overall or unified approach to the problems. This is very unusual in our world because every other industrial country except South Africa and the United States, every other country has some kind of medical care system which is either national health insurance or a national health service where the government essentially operates the program. Without that, you can't really solve the problem. We have large numbers of people in the U.S. today who are losing their medical care insurance because they're losing, they've lost their jobs. And that's a tremendous problem. Many people who work at low wages don't have coverage or they have inadequate coverage. Now, people talk about the number of individuals who have health insurance. The truth of the matter is that a lot of that health insurance doesn't cover very much. It's only in the big industries, big steel, big auto, and so on, that you get fairly good coverage really because of the power of the labor unions and their collective bargaining. You're absolutely right. And that problem is becoming worse as we see the decline of manufacturing in this country and the growth of service industries. And I think one of the points that we've all made is that when we look at the 62,000 people, you're not just talking about unemployed people. In fact, as I understand, the two-thirds of those people are working people who are working in the service industries, and the McDonald's and the Burger King's ski industry, who are not getting the type of coverage that workers got to work for GE or Ivory M or the University of the City. Well, the curious thing is that Vermont would be in great difficulty trying to deal with this problem because so much of Vermont industry is small industry. And I really think that we would have a serious problem asking very small industries with five or 10 employees to pay for medical care at the ruinous prices that the ruinous cost that we have at the present time. What this would mean really is helping in the destruction of small business in Vermont and elsewhere and the aggrandizement of big business, which is the only kind that could handle the situation. I might say, by the way, this is a burden for big business too. And it's a competitive burden vis-à-vis country like Canada where the payment for medical care, the national medical care program, doesn't depend on payroll taxes, comes out of general tax revenues. And essentially a lot of it is coming out of income taxes, which means that it's a progressive tax. The people who are better off pay more. And I think that's only fair. And I am absolutely opposed to the use of social security for medical care because that's a regressive tax. So that poor of people are paying more than they should. And you recall, so just to pick up on the point that you're making, you recall that Lee Iococo, when he became head of Chrysler, did a study as to the expenses that Chrysler was incurring. And he found out that I think per automobile, the single largest expense was not steel, it was health insurance. And I think that the point that you're making is that in our country where large employers have to pick up the very significant costs of health care themselves, in Canada it in many instances is spread out of the general population of progressive manner. So the hour industry is in a negative position competing with other countries. That's absolutely true. I think it would be to the best interests of Vermont business as well as the people of Vermont. And I would say U.S. business and the people of the United States to adopt something like the Canadian system. Canadian system has many wonderful things about it. Everybody is covered. Nobody is left out of the program. Okay, let's get into that. I know that we went up to Canada twice and I know you teach in Canada, so you know a heck of a lot about it. Let's contrast if we might. I know you're just in the process of starting that. What goes on in Canada with what goes on in the United States? And I think the first point that I want to make for your consideration is that some people say, well, that's great that Canada provides insurance for all people, but gee, it must be awfully expensive. And in fact, what we learn when we are up there in terms of per capita, it is significantly less expensive. And the point that I know that we have been making is that while we have 15% of our national population without any insurance at all, it's not because this country is not spending a fortune on healthcare. But why don't you take it from that? Talk a little bit about the Canadian system and how it contrasts with ours. Well, the costs in the U.S. run to about 11% of gross national product. In Canada, it's 8.5% of gross national product. In U.S. dollars, it's about $1,400 per capita, $1,400 U.S. dollars per capita in the United States, and about, oh, 900 to 1,000 perhaps, U.S. dollars in Canada. So it's much cheaper. And I would say, based on what I've seen, that the quality of medical care in Canada is just as good as in the United States. And they're doing it much more cheaply because they're administer, among other things, their administrative costs are low. They only, the cost of the whole program in Canada is 2.5%. To his minister. To his minister. I know, when you and I, well, we were up there to Quebec, and we spent, there was a gentleman there who was very, very proud of the very highly computerized administrative system that they have in terms of billing positions in hospitals and so forth. My memory is correct. When we deal here as a city with Blue Cross, Blue Shield, when most companies or businesses deal with their insurance company, usually the administrative costs are somewhere 8, 9, 10%. And with the point that Dr. Terrace is very importantly making is that in Canada, aside from the fact that healthcare itself is less expensive, the administrative costs are significantly less expensive. He was talking about 2, 2.5%. 2.5% as against about 9.5% for Blue Cross Blue Shield for all private insurance. Which means significant savings to healthcare consumers when you're not paying for paper, shufflers, and bureaucracy. You have to realize that we're talking about a publicly administered program in Canada. Everyone talks about the superiority of private business and private management. The truth of the matter is that under public administration, the programs are administered by the provinces, by a health agency, either the health department, or another health agency in the province. There's no private insurance company involved. So what you're saying is there is no Blue Cross, there is no Connecticut General, there is no Medicaid, there is no Medicare. You have one source of funding. And one of the important things is everybody has the same Medicare card, rich or poor. There's no such thing as charity. There's no means test. You don't have to declare that you're a pauper in order to get medical care in Canada. I think that's terribly important. That's basically the most important issue. I remember about the five or six years ago, not long after I was elected, we invited two Burlington gentlemen who was in charge of that, the Quebec health insurance system. And he said, this guy was no great radical, but he said with a great deal of pride that in Quebec and in Canada, healthcare was a right. It was not a privilege. And basically, you know, it's a funny thing. You go up there and no one makes a big deal about it. You know, in the same sense that we call the police department here and the police officer comes and he doesn't charge you, right? We assume that to be a part of our rights as an American citizen. And what they now understand in Canada is that, of course, when you go to the doctor, you don't take out your wallet. And when you go to the hospital, when you go to a nursing home, you don't have to go broke to pay that. They now understand that as part of their rights. You know, and while we talk about the Canadian system, the American system where people argue the pros and the cons, there's one point that I do want to make. And it's an interesting point. No one is suggesting that the Canadian system is perfect or that we have to copy every detail of it for the United States. We're a different nation. But it's interesting. In Canada now, they have a three-party system. They have a conservative, actually a pro-Reagan prime minister, a pretty conservative guy who recently came to office, Mulroney. Nobody in his party has ever dreamed of whispering one word of changing that healthcare system because they understand any politician worth assault in Canada understands that that system is very popular, that the people have fought very hard to get that as a right, and they're not tampering with it. In the United States, on the other hand, virtually every poll indicates that people want major changes in our healthcare system. And I know your publication, your journal, published an interesting item on a referendum that was held in Massachusetts, which you might at some point want to chat about. Well, in Massachusetts, they voted on the question of a national health program, and it was the victory for the referendum, for asking Congress to establish a national health program was two to one, 67% of the voters. But the interesting thing was, this was not a big city thing by any means. All of the cities voted for it, but of the 307 towns in Massachusetts, 302 gave a majority to the request to Congress to establish a national medical care program. But of course, you know, our political parties don't always listen to the public. I might add, by the way, that the reason we have the program in Canada is the development of the New Democratic Party, first in Saskatchewan, where they established a provincial health program to cover every citizen of Saskatchewan. Then later, they did that with physician services. And it was because of their example that the more conservative parties in Canada decided that they had better pick up this issue and they established a federal program of aid to the provinces to develop the Canadian system. I want to get back to, I might also add, and the mayor hasn't asked me to say this, that I don't think we will get a real national medical care program, health program in this country until we have the development of independent political action as we have in the city of Burlington and the state of Vermont. I think that's a very important lesson. It was true all over Europe. It was true in Canada. It's been true in Latin America. All over the world, you find that it is only when you get independent political action by the people that you get the more conservative parties reacting with the development of a national health program. Yeah, I'm very glad that you raised that issue. I know I've heard in the past you raised that and needless to say, I agree with you absolutely. The heart of the issue is that we should not look at health care as something abstract and removed from politics in general. In this country, what you have is in terms of the medical industrial complex, a tremendous, I don't know if there's any particular force that is more powerful and wealthy than these people. I'm not just talking about the American Medical Association, you've got the drug companies, you've got the medical equipment suppliers who keep coming up with new and expensive technology who are making, you know, when we talk about health care, I always find this humorous and the cause is zooming up and everyone's, oh my god, just can't figure it out why it must be some mystical, magical thing. Then you look at drug companies making billions of dollars, you look at individual physicians making three, four, five hundred thousand dollars, sometimes more than that, you look at hospitals making nifty profits themselves, you look at these medical equipment companies making a fortune, you look at the fact that we're probably putting more physicians out on the street than we need to and no one is talking about that. It is not, it's not magic and I think the point that you're making that I very strongly agree with is that until you have working people, low income people, elderly people beginning to stand up and fight for their rights and I happen to think it's outside of the democratic and republican party. Until you have that force and people saying hey we are human beings, we don't have to have to sell our homes or go bankrupt in order to get into a nursing home or figure out that we have to pay a third of our income for health insurance, we can do better than that and until we have that movement organized politically I think you're right, I think we're not going to get that. You know the question you raised about nursing home care, my wife and I in addition to many millions of elderly Americans live in absolute fear that one of us will have to go into a nursing home for six months a year, two years and we will be pulparized because that's what happens. Everything gets taken away from you to pay for the many many thousands of dollars that you have to pay for nursing home care over a long period. That does not happen in Canada. Nobody gets pulparized in Canada because of the need for nursing home care. You're touching on an issue that I want to elaborate a little bit about because I fear that there is a misconception out in TV land and the rest of this country about what Medicare provides for people and I think you have many people who have the illusion that when they're over 65 and they get their Medicare card that they are in pretty good shape and they're not going to have to worry about nursing homes or prescription drugs or the other additional costs that elderly people have. Well I'm one of the more well-to-do recipients of Medicare and I can tell you it's it would be amusing if it weren't so sad. I keep getting explanations from Medicare that well you have this charge that's been sent in but you haven't yet taken care of your deductible so you have to pay it or you have to pay coinsurance or and this is one of the big differences between the Canadian system and the U.S. system. Your doctor can charge in the U.S. more than he gets for Medicare. You have extra charges that's not allowed in Canada and one of the reasons that the cost of medical care is so great is that physicians and hospitals can charge more and this is a very serious problem for the American people. I think one of the points that we understand that I think was reinforced when we went through the world to Canada is that at least as I see it and I'm not an expert on it but this is the way I see it. Number one you want to guarantee that all people have access to health care as you do in Canada but I think what we understand is that unless we change the funding system and the control mechanisms in this country to do that for example if we expanded Medicaid to everybody right give everybody a Medicaid card we would be spending such an astronomical sum of money that you know we would bankrupt the nation so maybe you want to talk a little bit about that and why in Canada under their national health system you can have access for all people and yet per capita it is less expensive than in the United States. Well for one thing you don't have extra charges for another the fees are negotiated between the medical profession for example and the provincial government. As far as hospitals are concerned it's simple they get a global budget from the province based on their performance and I must say the provinces have been rather good to the hospitals if for a very good reason the costs go beyond what the global budget afforded they will make it up to the hospital if it's a necessary expense at the same time there is pressure from the provincial governments to provide efficient care not to waste money and so on. Let me just jump in and give you an example a couple things I know when we were in Montreal you were mentioning I think you had a friend who had a coronary bypass here in this country and the contrast between the cost of that operation in Quebec I think it was and in the United States? A physician friend of mine had a coronary bypass here in Burlington it was done at the MCHV it cost him $10,000 for the operation and $10,000 for the hospital and when we had our hearing the other day Mr. Taylor the director of MCHV indicated that this was in the ballpark I think he said it's something like $15,000 to $20,000 total cost I was very much interested in that question and when we were in Montreal I asked the administrators there what they paid a surgeon for a coronary bypass and the answer was you won't believe it $1,200 Canadian which means about $800 US and this kind of differential between the astronomical charges of physicians in the United States and the negotiated reasonable charges in Canada is something that we have to think of I think business has to think of this I think citizens have to think of this One of the other things that we learned and I especially when we were there we had a lovely chat with some people in public health physicians at the University of Montreal and one of the points that came out there and elsewhere is talking about the number of physicians you know one of the things that's interesting right here in the state of Vermont that I hope this session the legislature will begin to deal with is we spend the tax play as appropriate $6 million to the UVM medical school and to the best of my knowledge there is no real discussion as to where that money goes and how it values how it improves life for the people of Vermont for example what happens to these physicians whom when they graduate whom we are subsidizing right now do they become just another specialist and help raise the cost of health care to a level that most of our people can't afford right now do they leave the state do they go where they are in fact needed do they work with a homeless do they go to the women's clinics and I think one of the points that what we learned in Montreal and in Quebec is they pay physicians they say to physicians if you want to practice in an area where we already have an overabundance of physicians you're really not needed if you want to go there you can go there but we're paying you I think 70 percent of the rate was that at the something like something like right so in other words they are discouraging people to go into an area where they're not needed and on the other hand where they do need physicians right I think up in the northern part of the province they're saying why we will pay 120 percent of the fees that you had otherwise have gotten and they are using there for public money to bring health care areas where it's needed and using their power to discourage you know do we need how many more specialists do we need in the city of brook it is not really our major health care crisis I think it's a mistake for the state to spend six million dollars to produce more and more physicians we have an overabundance of physicians now in the United States to produce specialists to produce people who are leaving Vermont I think that money could be spent for very good purposes we heard from the visiting nurse association for example that they are in grave trouble for lack of funds we heard from the Vermont state health department that all of their programs are suffering because they don't have enough money to meet the needs I think the money should go to the you said this in that statement to the press the other day that the money should go to the vna the money should that six million could do a lot for the vna the state health department programs for many programs around the state the problem is and it's the point that you made a while back is that we don't have a system you have a fragmented structure so that we learn through our task force that Jim Letty made a passionate discussion from the Howard mental health they're getting cut all over the place they can't do the desperately needed work they have to do for alcohol prevention and many other important pieces of work they do the vna which does excellent home-based health care is in desperate economic trouble the state department has been the state health department as I as I recall has been losing federal funds where they are very excellent preventative health programs we don't have physicians in certain parts of the state where we need them and yet do we need we're putting six million dollars into the medical school there is no public discussion as to what we as a society as taxpayers get out of that and nobody is sitting down and taking the overview and saying look we need more money and preventative health care we need more money in community-based health care we need less specialists and I think I mean that's pretty much at the root of the problem isn't it well and you have to realize this is a medical school that is one of the few in the United States that does not have a department of community and preventive medicine so all of their focus is in terms of tertiary care specialist care not in terms of meeting the health needs of the community not only for treatment but for prevention and as a person who's been in public health for some 40 years I can attest to the fact that much more money should go into prevention and that money should be taken out of the swollen budgets for treatment because we would gain tremendously by not having to treat diseases like heart disease like lung cancer like stroke that could be prevented we have all the knowledge now as a result of the work of our epidemiologists we know how to prevent these diseases and we we have simply failed to put the money where the where the knowledge is and where the opportunity is that is to keep people from getting sick and having these tremendous medical bills you know the issue of public health and health in general is such a deep issue there are a few issues that I that I deep up because it almost it relates to everything that we do it's obviously a political issue not only in terms of availability and cost and accessibility but in terms of the quality of the lives of our people I don't know you showed me a study that I thought was it was very interesting needless to say the medical establishment in this country with their billions of dollars for research somehow doesn't do studies like this but why don't you briefly describe that Canadian study that well what what that study indicated was that medical care although it plays an important role in the health of the public is not as important as two other factors one is prevention the other is the standard of living and what this study showed was that if you you take Canada which has now an effective medical care system there is equity everyone has the right has access to medical care and yet there are still big differences by by economic level the poorest fifth of the Canadian people have a an expectation of life that is an average life span of four and a half years less than the highest fifth in terms of income level okay but if you look at life expectancy in terms of the years free from disability what we call health expectancy or disability free life expectancy what we find out is that the poor people of Canada have only 55 years expected for healthy living that is without disability and the rich people of Canada have 66 health years average life an 11 year difference in life expectancy on a healthy basis without disability so it seems to me you have to look at other issues at employment there's a 10% unemployment rate in Canada and in the maritime it's up to 14% it resembles Detroit and our middle western cities you have to look at housing you have to look at education you have to look at nutrition all of these factors play tremendous roles in health and I frankly think that between prevention and the standard of living you're dealing with the key factors in health but the point being there we're going to have to end the program right now is that health is more than going to the doctor it's the quality of life that you experience and that has a great deal to do with class and if it's true in Canada everything being equal I would say those figures might even be more stock in the United States but we don't know that I think they would be okay Dr. Terrace thank you very much for joining with us this afternoon I think we almost only began to touch the surface I hope you'll come back and thank you all for viewing the program thank you