Dr. J. Edward Hill
Immediate Past-President
American Medical Association

It is a privilege and an honor to speak to The City Club, an organization dedicated to the dialogue of democracy. Obviously, democracy works best with an informed electorate. And, speaking on behalf of the nation's physicians, I would add, democracy works best with a healthy electorate, as well.

It is a pleasure to be here and to represent the American Medical Association, and the nation's more than 800,000 physicians and surgeons. As I have traveled up and down the nation these last several months, I've listened to a large number of individuals, from presidents to ordinary citizens in every walk of life.
And I've learned a number of things:

* First, I've learned that average America is in real pain. Two trillion dollars a year is a mighty hefty price to pay for health care in this country. A Gallup poll tells us the second most important financial problem households face is health care costs, second only to the specter of bankruptcy, itself. But, when I dig down beyond the data to the people themselves, I have found some real surprises which I will share with you in a minute.

* Second, I've learned that nearly 47 million Americans without health care insurance constitute not a challenge so much as a national disgrace. That works out to 769,000 uninsured are right here in Colorado, 17 percent of your non-elderly population.

* Third, I've learned people are quite concerned about the future of Medicare and Medicaid, that when they learn that Congress has mandated cuts in the payments to be made to physicians under the Medicare system, and that those cuts translate into potential harm to seniors as more and more physicians can no longer afford to see new Medicare patients. When people learn that, they become very upset.

* And, fourth, I've learned people are going to have to take the initiative in dealing with these concerns, about costs, about the uninsured, about the fate of Medicare and Medicaid.

There is a broad streak of common sense and common decency in this great democracy of ours. And those two characteristics lead Americans to see that their health care system is tragically disordered, seemingly designed with a helter-skelter magnificence that gets in the way of patient care, and that this has got to change.

For some time now, the AMA has warned America of the dire consequences of the grow health insurance gap in this country.Today 46.6 million Americans are uninsured and another 15 million are under-insured; a fifth of the nation standing as living testimony to that prediction.

As I said, 770,000 of your neighbors live sicker and die younger for want of health care insurance coverage. That unpleasant truth today stares us in the face.
America's physicians have a plan to correct the situation. After years of study and analysis, the AMA has proposed a series of steps to leverage free-market economics in battling the uninsured problem.

First, we believe there should be direct cash payments to those least able to afford insurance, to give them the wherewithal to buy their own policies, minimum coverage, preventive care and coverage for their children.

That will mean, second, regulatory reform so that health insurance firms can come up with creative, tailored policies matching the special needs of those with the fewest resources.
Third, we've urged the states to take the lead in experimenting with these ideas, and several test-bed projects are under way.

Lastly, the AMA believes those who have the resources, but have not bought insurance, should be given incentive to buy coverage.

Specifically, we believe those making five times the Federal Poverty Level, that means individuals making $49,000 a year, or more, and families of four brining in $100,000 a year or more, These middle class Americans should be required to own health insurance.

All of these programs, taken together, would eliminate the billions of dollars drained from the economy every year by treating the uninsured only when they show up in the emergency rooms of America.

I admit, 47 million Americans is a large population to treat. But, trusting to free-market economics is a proven strategy, a winning strategy, and one we are advocating right now to begin wiping out this national disgrace.


There is another potential national disgrace on the horizon. And it has the name "Medicare." As you well know, Medicare is our nation's experiment with socialized medicine. And, as with all so-called single payer systems, this approach has produced rising prices and shortages.

Strip away all the rhetoric about Medicare and single payer systems, and you'll find, at heart, they are just 25-dollar words for "price controls." And price controls produce only two things in any economy, anywhere, at any time in history. They produce shortages, which means Black Markets, and they produce higher prices, in the name of controlling costs.

In the case of Medicare:

* Premiums that seniors pay will go up later this year. Medicare revenues aren't covering costs.

* Second, means-testing is inevitable and, combined with higher premiums, are the early warning signs of an impending financial tsunami.

* Medicare payments to physicians, meanwhile, are scheduled to be cut, nearly 40 percent by 2015, 5 percent next year alone, unless Congress acts.

Those statistics take on real meaning when translated into terms Coloradans can understand. From 2007 to 2015, Medicare payments in Colorado will be cut by $1.61 billion; $28 million of it next year alone.

Ten percent of your state population, 481,000 men and women are Medicare beneficiaries. Where will they get care if the physicians of this state can no longer afford to take new Medicare patients?

And a cumbersome, costly bureaucracy gobbles up tax dollars and, predictably, end up wasting from 30 to 40 cents of each Medicare dollar, according to two recent studies. Today we have shortages of primary care and key medical specialties, with a projected shortage of 166,000 doctors by the year 2020.

And we have yet to feel the impact of the Baby Boomers turning 65. The Center for Studying Health System Change tells us nearly 30 percent of American physicians cannot afford to accept new Medicare patients now. Imagine what the figure will be if Congress follows through on physician payment cuts now scheduled through the Year 2015, as much as 37 percent at the same time the costs of operating a practice are to increase 22 percent or more.

So, the AMA is working to establish reasonable prices, stable prices and predictable prices, in a badly under-funded Medicare system.

Trillion dollar solution

There is a third potential revolutionary change badly needed in this country. It's a trillion-dollar solution to part of the cost problem, as well.

I'm talking about the unhealthy lifestyle choices so many of our fellow Americans are making. We've compiled a list of estimates of the societal costs, not just health care costs but lost wages, lost taxes, lost investment from the eight scourges of public health:

* Violence and abuse, $300 billion in medical and societal costs;
* Alcohol and other drug abuse-another $246 billion;
* Traffic accidents, $150 billion;
* Work-related accidents, $156 billion;
* Tobacco, $182 billion;
* Obesity, as much as $102 billion.
* And, unfortunately, there are no estimates for the social impact of teen pregnancy, STDs and suicide.

Now, I must qualify these numbers by saying the sources are many and varied, and so are the methods used. But the magnitude is unmistakable.

The fact is that proper choices by individuals, can dramatically reduce those societal costs and the suffering and priceless loss of life. To change these behaviors, we have to change habits.

Take alcohol abuse. Drilling down into the numbers, you discover nearly 10 percent of 4th graders in this country, for example, one in 10, have started drinking. One study found that alcohol use among those 4th graders will triple by 6th grade.

That is an epidemic, and we don't seem to care. Well, I care. I am a passionate advocate for comprehensive school health education.

Children need to know how to read food labels, which now include information on things like fat content, an advance the AMA supported. Evidence suggests, that healthy habits must be set early, because by the age of 7 or 8, patterns have been set for a lifetime.

That's why we should start with pre-K students and go straight through high school. We need full funding for health education teachers, counselors, physicians, nurses and others, to develop classes and courses in everything, from the food pyramid to understanding what health insurance will mean for them when they get out in the real world. The Centers for Disease Control has developed and refined a comprehensive curriculum over the last 35 years.

Well, then, how can we afford such a new, major, labor-intensive addition to our school curriculum, staffing and budgets?

Here's an idea. Why not adapt the state-federal highway construction model to push funding for comprehensive programs? Why not give matching funds to states or school districts that fit a federal framework? And why not expect our children to profit from comprehensive health education?

The idea is apolitical. I've found interest in Washington from the left and the right, from Democrats and Republicans. Moreover, the idea does not rely totally on Washington. It's grassroots nature means it can bubble up rather than percolate down.

Further testimony to the power of individual action, individual accountability and the force of local activism.


I have seen local accountability work before. Way back in the 1960s, my new partner and I were opening our little clinic in Hollandale, Mississippi. For those of you unfamiliar with the area, Hollandale, Mississippi, was almost a forgotten third-world corner of America.

One day, I became acutely aware of conditions that simply had to change. That day, a farmer called me at my clinic. The wife of one of his hands had delivered a baby at home two days earlier. She was still bleeding, and couldn't get out of bed.

When I got to the farm, I saw a woman couldn't lift her head without losing consciousness. Her blood pressure was too low to measure. I couldn't move her. We had no suitable emergency transportation. With some difficulty, I drew a tube of blood and sped back to town to have it typed and matched, and to get a bigger car.

When I returned, I hung a unit of blood from a nail in the wall. We then put the woman into our station wagon and drove her to Hollandale, where she quickly recovered.
That evening, I went home and turned on the television. It was July 20th, 1969, the day Neil Armstrong took that giant leap for humankind.

And I thought, "We have the technology to put a man on the moon. But here on earth, in the United States of America, a woman almost bled to death because she lacked access to the most basic medical care."

Things had to change in Washington County, Mississippi. It then was among the worst in America in infant death rates. So we went to work, with the state health department. We got donations from churches and from the March of Dimes, hired certified nurse midwives, and developed a very strict protocol under which they acted.

We trained women with not even a high school diploma to do home visiting including prenatal, perinatal and postnatal visits. We educated and communicated and, in short order, infant mortality rates dropped below the national average and have stayed there to this day.

Activism at the local level
The moral of the story: All health care is local.

And, when folks at the local level get moving, they solve their problems. First, at the local level, then across the continent. When we mobilize, the results can be revolutionary.

The American Medical Association recognizes that. And we have developed plans and programs that are beginning to ring true in the ears of America, an America that is ready for major change. America is asking, no pleading for leadership

And that is why this afternoon I want you to think about what I consider to be the coming revolution in U.S. health care.

In so many ways, the U.S. health care system is the envy of the world. Life expectancy is up significantly since we opened our clinic in Mississippi back in the 1960s, now 77.9 years, 12 percent longer life.

Americans might not know all the statistics. But, they value the quality of care they are receiving. Two statistics tell the story. And I would guess these are numbers you have not heard before.

The first one has to do with the trust Americans place in their physicians. The AMA and Harris Interactive conduct a quarterly survey, a rock-solid piece of research, asking Americans how much trust they have in their primary care physician.

Quarter by quarter, year-by-year, the numbers are the same: More than 85 percent of Americans trust their physician. A quarter say they have complete trust, and more than 40 percent, a great deal of trust.

I'm sure you're familiar with the kinds of trust numbers Congress and lawyers and other groups receive. Not even close to 85 percent.

But, a second statistic is even more dramatic, in my mind. And that has to do the value Americans place on their personal health care. Again, the AMA turned to Harris Interactive to measure just how Americans rate the value of each dollar they spend on health care.
One in 10 Americans told us they value their health care investment as an excellent investment. Twenty-seven percent rated it a good investment. Thirty-three percent, a fair investment.

That means 7 out of 10 Americans believe they are getting their money's worth.

To me, this is a dramatic finding, in the wake of all the negative press about rising health care costs, the waste in health care spending, the seemingly exorbitant profits of big health care insurers.

Those concerns are valid concerns, but maybe they are blown out of proportion. Just maybe a healthier and wealthier country sees additional spending as wise investment, not unreasonable cost.

Health care is a terrific investment but is locked between the jaws of two price control mechanisms, The Federal government's Medicare pricing mechanism and the insurance industry's pricing schedules that are a mirror image of it.

Nobel laureate Milton Friedman recently told an interviewer, "We have a socialist-communist system of distributing medical care. Instead of letting people hire their own physicians and pay them, no one pays his or her own medical bills. Instead, there's a third party payment system."

And, I would add, those third parties are very resistant to change. Their solution is not less regulation but more, not free-market pricing but price controls. Such that those who provide medical and health care have been eating the payment cuts they impose.

And everyone wonders, "How long can we sustain a system that relies on good will and the benevolence of physicians, nurses and others more interested in serving patients than in their own ledger sheets and quarterly earnings statements? "


The forces of free market economics are working their magic in health care. We for our part have always trusted that our approach is the right one. One which welcomes change and embraces free-market forces. One which focuses on patient needs and the technology that best serves it.

A simple approach I describe as care-based costs rather than cost-based care.
We believe millions of uninsured Americans can be taken from that list with a few simple changes.

We believe Medicare can be saved, can be put on a sound fiscal basis, by prior funding mechanisms rather than the hand-to-mouth system now in place.
We believe Medicare physician payments need to be fair and equitable, and an incentive for doctors to see new Medicare patients, not a penalty situation.

And, we believe healthy lifestyles, wholesome choices, can not only save hundreds of billions of dollars,

But make life richer and more meaningful for millions of Americans.

O.K. Corral

Let me wind things up with a brief lesson from history. On this day in 1881, 925 miles southwest of here, in Tombstone, Arizona, the Earp brothers shot it out with the Clanton-McLaury gang at the O.K. Corral.

Historians say both sides were looking for revenge for what they perceived as pretty serious insults over the years. It was a classic zero-sum game.

No one knows who drew first. But when the 30-second fight ended, The Earps were bloodied but alive. Billy Clanton and Tom and Frank McLaury lay dead or dying.

Well, today, I am not proposing a zero-sum O.K. Corral scenario. I'm proposing a win-win scenario.

One in which free-market solutions begin to take effect at the margin.

One that puts patients back in the driver's seat, determining for themselves how their dollars will be spent, how their trust will be used, how the future course of medicine should proceed.

One, finally, that eliminates waste and errors, embraces new technologies and innovation, and relies on local decisions not arbitrary dictates from Washington or a corporate headquarters.

One that relies on the innate intelligence of the American people not ledger sheets and earnings statements, not politics and tax revenues and Congressional spending impulse, but the good judgment of you and your neighbors.

The power of one
So the basic question, at last, becomes: Well Doctor Hill what can I do? What can just one person do?

Well, what could Rosa Parks do about segregation? What could Gandhi do about imperialism? What could you, one of our nation's leaders do?

The answer is: A great deal. Begin with your intellect and your circle of friends. Talk about these ideas, and especially talk about bringing comprehensive, and mandatory, health education back into the schools. Talk with your elected representatives, especially those in Washington.

The AMA has a very effective, million-person grass roots advocacy program you might consider. If you want to join, just go to www.ama-assn.org, and enter the words: "Patient Action Network" in the search box. You will find direct channels to e-mail your members of Congress. And you'll be adding your voice to the chorus of individuals call for change.

No issue is more critical and far-reaching in America today than health care. We are at a desperate time in history where leaders have to step up to the plate. Denver and Colorado and America need you. And, I salute you for your efforts We all need the absolute best that is in you.

5 January 2007