National Health Insurance; J. Wollstein

High administrative costs. In the U.S., adminis trative costs consume nearly 12 percent of health dollars compared to one percent under Canada's socialized system. More than 1,100different insur ance forms are now in use in the United States. Americans without insurance coverage. At any given time, over 13 percent of Americans have incomes that are too high to qualify for Medicare or Medicaid, but are too low to pay for medical insurance themselves.1 The free market in health care, we are told, has failed. The solution offered by a growing chorus of commentators and candidates is universal, mandatory, national health insurance; in other Jarret B. Wollstein is a director of the International Soci ety for Individual Liberty. words, socialized medicine. Is socialized medicine the answer, or will it only make things worse? How WellHas Socialized MedicineWorked Elsewhere? Most of the developed countries of the world presently have some form of socialized medicine.

How well has it worked? Great Britain. Great Britain adopted socialized medicine in 1948,with the creation of the National Health Service (NHS). The political rhetoric in Britain exhorting the adoption of nationalized health insurance is similar to what we are hearing in the U.S. today. In 1942,Prime Minister Winston Churchill declared: The discoveries of healing science must be the inheritance of all.... Disease must be attacked whether it occurs in the poorest or the richest man or woman, simply on the ground that it is the enemy.... Our policy is to create a national health service, in order to secure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date med ical and allied services available.2 With the adoption of national health insurance, Labour Minister Dr. David Owen predicted, "We were going to finance everything, cure the nation and then spending would drop."3 Unfortunately things didn't work out exactly as planned.

The first problem with Britain's National Health Service was skyrocketing demand. With health 381 382 THE FREEMAN • OCTOBER 1992 care paid for entirely by the government, there was no reason not to go to a doctor. Why take aspirin or wait out a cold, when professional medical care is free? As Michael Foot observed, within months "the demand [for health care] was exceeding any thing [its creators] had dreamt of."4 First-year operating costs of NHS were 52 million pounds higher than original estimates.5 NHS soon found itself in direct competition for funds with national defense, pensions, and all oth er governmental functions. Budget cuts for NHS quickly followed. British economists John and Sylvia Jewkes estimated that between 1950 and 1959 the United States spent six times more per capita on hospital construction than England.6 As a result, there was a steady deterioration in the quality of British medical care.

By 1977,British general practitioners rarely had any medical instruments except for stethoscopes and blood-pressure meters. They had to send their patients to hospitals even for such routine proce dures as X-rays and blood tests. The waiting time for routine, non-emergency surgery had increased to years. 7 By the mid-1970s, more than 700,000 English men, women, and children were on hospi tal waiting lists at any given time.8 The average British doctor now has over 3,000 patients, com pared to 500-600for the average American doctor. NHS doctors spend an average of less than five minutes with their patients, who usually wait hours to see them.9 In 1975 Bernard Dixon, then editor of the British magazine New Scientist,provided this sum mary of the state of National Health Insurance: The plight of Britain's Health Service conflicts desperately with the avowedly utopian ideals of its founders. For most of us, it is only when we join a year-long hospital waiting list, or have to take an injured child to a hospital casualty department, that we realize just how thread bare and starved financially the service really is. Not only is there an acute shortage of resources, but the expertise and facilities that are available are all too often dispensed via a conveyer-belt system which can at times be positively inhuman. IO As a result of widespread public dissatisfaction, in 1989the British government began dismantling its National Health Service, and reintroduced mar.ket-based health care competition. ll Canada.What of the Canadian National Health System, which many U.S. politicians are now championing as a less expensive and more efficient alternative to our supposed free market system?

Canada has had socialized medicine for 20 years, and the same pattern of deteriorating facili ties, overburdened doctors, and long hospital wait ing lists is clear. A quarter of a million Canadians (out of a population of only 26 million) are now on waiting lists for surgery.12 The average waiting period for elective surgery is four years. Women wait up to five months for Pap smears and eight months for mammograms. 13 Since 1987,the entire country spent less money on hospital improve ments than the city of Washington, D.C., which has a population of only 618,000.14As a result, sophis ticated diagnostic equipment is scarce in Canada and growing scarcer. There are more MRIs (mag netic resonance imagers) in Washington State, which has a population of 4.6 million, than in all of Canada, which has a population of 26 million.15 In Canada, as in Britain under socialized medi cine, patients are denied care, forced to cope with increasingly antiquated hospitals and equipment, and can die while waiting for treatment. Canada controls health care costs the same way Britain and Russia do: by denying modern treatment to the sick and letting the severely ill and old die.16 Despite standards far below those of the United States, when variables such as America's higher crime and teenage pregnancy rates are factored out, and when concealed government overhead costs are factored in, Canada spends as high a percentage of its GNP on health care as the United States,17 Today a growing chorus of Canadians, including many former champions of socializedmedicine, are callingfor return to a market-based system.

The WorldwideFailure of SocializedMedicine Throughout the world the story is the same: socializedmedicine results in skyrocketing demand for nominally "free" health care, doctors are over burdened, medical services steadily deteriorate, and there are endless waiting lists for health care. In the Soviet Union before the collapse of Commu nism, anesthetics, painkillers, and most drugs were rationed; 57 percent of hospitals had no hot running water; and it was standard practice to clean needles with steel wool and reuse them.18 In New Zealand, which has a population of just 3 million, there is a waitinglistof 50,000for surgery.19 Socialized medicine doesn't even fulfill its promiseof equal accessto treatment regardlessof ability to pay. For example, in Canada "a small childwitha skinrash is 22 timesmore likelyto see . a dermatologistif the childis livingin Vancouver [a major city] than in the East Kootenaydistrict[a remote rural area]." In Brazil,"residents of urban areasexperienceninetimesmoremedicalvisits,15 timesmore related services,2.7 timesmore dental visitsand 4.5 timesmore hospitalizations,"than do rural dwellers.20 Throughoutthe world,there are more and more refugees from socialized medicine. Middle-class Canadians flock across the U.S. border to avoid waitingmonthsor yearsfor routine procedures.In Englanda systemof private,quasi-legalclinicshas developed to care for patients who can no longer tolerate the abysmalmedicalservicesprovidedby national health insurance. In Russia, desperate patients bribe doctors and secretlyvisitthem after hours to get decent treatment and scarcedrugs.

Socializedmedicine,like all forms of socialism, has been a world-widefailure.As people through out the world from the Soviet Union to South America are learning, socialism cannot work. Socialism is fundamentally incompatible with human nature. Socialismfailsbecauseitdeniesanddegradesour essentialhumanityby treatingus as objects.Social izedmedicinetakes awayour controloverour own health and body, and gives that power to the state. Underasocializedmedicalsystem,thegovernment, not you or your doctor, decides what treatments, doctors, and drugs you get. If you don't like the servicethe governmentgives you, your only alter nativeis to flee to another countryor to break the law and bribe a doctor.Under socializedmedicine, the exerciseof free choicebecomesa crime. Even after it destroys quality health care and individualliberty,socializedmedicine still cannot achieveequal treatment for all. When plannerstry to make all people equal, they confront the inescapable paradox of equality: Abolishing inequality requires massive government power.

But powerby its nature is unequal:there are those that have it and those that do not. Givinggovern ment the power to make everyoneequal necessar ily creates the worst form of inequality: that of master and subject. In practice under socialized NATIONAL HEALTH INSURANCE 383 medicine, those with more money and friends in the government get vastlybetter health care than those without power and connections. Socializedmedicinewill not work any better in the United States than it has in England, Canada, Russia or elsewhere.Considerjust the economics of socializedmedicine in the U.S. Medicare and Medicaid costs are already skyrocketing out of control. State governments cannot afford the 20 percent of their budgets that Medicareand Medi caid now consume. Where will government get hundreds of billions of dollars more for national health insurance? A complete Canadian-style national health insurance system for the U.S.

would initiallycost over $339 billion and require that payroll taxes be nearly doubled, or require a new, national 10 percent businesstax.21 Socializedmedicinedoes not work, but has the free market failed as well?If freedom works,why is American health care now in crisis? Government Intervention and Health Care Costs The answeris that Americadoesnot havea free market in health care, and in fact has not had one for 50 years.What we have had is a halfcenturyof mounting government encroachment upon medi calfreedom,leadingto more and more health care problems. Over 42 percent of funds spent on American medical care are now controlled by government. Over 700 state laws,some hundreds of pageslong, governall health care providersand institutions.22 Accordingto some estimates,for every man-hour of health servicesprovided by doctors, two hours are spent by clerks fillingout government paper work.Dr. FrancisA. Davisestimatedin the March 1991issueof PrivatePracticethat governmentreg ulationshavealreadyincreasedthe costofmedical care by up to 50 percent!

Government regulations and controls now intrude upon virtuallyevery area of health care in America.These regulationsincreasetremendous ly the costofhealth care.Here are someexamples: The War on Dmgs. U.S. federal drug certifica tion requirementsare the mostburdensomein the world.It presentlycan cost $231 millionand takes 12 years to develop, test, and certifya single new drugin the U.S.23The introductionofmanydrugs, 384 THE FREEMAN • OCTOBER 1992 which have been thoroughly studied and used safely in Europe, has been delayed for years or even decades in the U.S. by the Food and Drug Administration. FDA delays in the introduction of just one drug, the beta-blocker propranolol, used to treat angina and hypertension, caused· at least 30,000avoidable deaths in the U.S.24 Literally hundreds of thousands of Americans have died in the last two decades, and millions have suffered needless pain and expense, as a result of government drug regulations. 25 Further, the prohi bition of marijuana, heroin, and cocaine has creat ed a growing public health crisis in America.

Consider the medical implications of the gov ernment's ban on marijuana. On September 6, 1988,Drug Enforcement Administration (DEA) Administrative Law Judge Francis L. Young stated: "The evidence in this record clearly shows that marijuana has been accepted as capable of relieving the distress of great numbers of very ill people, and doing so with safety under medical supervision. It would be unreasonable, arbitrary and capricious for DEA to continue to stand between those sufferers and the benefits of this substance in light of the evidence in this record. "26 Judge Young concluded that many classes of patients could potentially benefit from medicinal use of marijuana, including sufferers from glauco ma, chemotherapy, multiple-sclerosis, spasticity, and hyperparathyroidisim. 27 Glaucoma sufferers alone currently number over two million Ameri cans. Despite this finding by the DEA's own admin istrative judge, marijuana continues to be totally banned for all uses, including medical applications.

Indeed, penalties for possession and use of mari juana have steadily increased over the last 20 years. Medicare, Medicaid, and Tax Policy. A growing chorus of politicians and social activists decry the "high cost" of medical care in the United States and the increasing percentage of our Gross Domestic Product that it consumes. What is sel dom mentioned is that mounting health care spending and prices are largely a result of escalat ing demand, public policies, government health care entitlements, and tax policies. Medicare and Medicaid, our major. health care entitlements, were enacted in 1965. Closely allied with the Social Security system, Medicare provides health insurance for approximately 30 million Americans, primarily the elderly. Medicaid provides health care for tens of millions more of the disabled and indigent, and is administered by the states. In the last 25 years Medicare and Medicaid expenditures have soared: from less than $5 billion in 1967,to $79 billion in 1984,to over $160 billion in 1990.28 Prior to 1983,Medicaid used a "cost-plus" sys tem for reimbursing medical providers. Doctors were allowed to base their billings upon the cost of the services they provided. Thus the higher a doc tor's costs, the more a doctor would make. The cost-plus system made it in a doctor's self-interest to make his costs as high as possible, contributing to a rapid growth in health· care costs.

Overall, the effect of Medicare, Medicaid, and other rapidly expanding government health care spending has been greatly to increase the demand for medical services and facilities of all types, which has led to rising health care prices. Government tax policies are another major fac tor in escalating demand for and prices of medical services. When health insurance is provided as an employee benefit it is fully tax-deductible; in other words, it is paid for with pre-tax dollars. But when health care is paid for by employees directly, it is paid for with very expensive after-tax dollars, and is not fully tax-deductible. Hence there is an incen tive for health care to be provided by employers in the form of insurance, rather than for employees to pay for health care directly out of their own pockets. Largely as a result of U.S. tax policies, "The share of health care spending paid by busi ness increased from 17 percent in 1965 to 28 per cent in 1987,while the share paid directly by indi viduals fell from almost 90 percent in 1930 to just 25 percent in 1987."29 The growing reliance of Americans upon insur ers (public and private) to pay their medical bills has destroyed virtually all incentive for health care consumers to monitor and control costs. As Louise B. Russell noted in her 1977Brookings Institution study: This incentive structure means that at the point at which decisions are made about the use of resources, the people who make those deci sions are able to act as if the resources are free.

Rationally they can and do make decisions that bring little or no benefit to the patient, since the resource costs of the decisions-to the people making them-are also little or nothing .... [T]here are virtually no economic constraints left to prevent decisionmakers in medical care from doing everything they can think of, no matter how small the benefits nor to whom they accrue.30 MedicalLicensing.U.S. doctors are among the most regulated in the world. State medical boards, monopolized by American Medical Association members, license doctors, hospitals, and medical schools. The declared purpose of medical licensing is to assure quality health care. The actual effect has been to limit the number of doctors, increase the cost of health care, and promote medical prac tices favored by the AMA at the expense of less costly alternatives. Many alternative practitioners -such as osteopaths and chiropractors-were almost run out of business by AMA-dominated medical boards.

The AMA has opposed prevention and treat ment alternatives that would greatly reduce medical costs, such as midwives, nurse-practition ers, and nutritional therapy. There is mounting sci entific evidence that·many suppressed alternative forms of treatment are not only less expensive, but are more effective than government-approved medicine. Alternative practitioners are often much more compassionate as well. The AMA has used its monopoly to exclude women, blacks, and alternative practitioners from the medical profession. Artificially restricting the number of doctors makes health care much more expensive for everyone. As Dr. Mary Ruwart reports in HealingOur World: By the early 19OOs,every state had agreed to the aggression of physician licensing.... One half of the existing medical schools were approved, so most of the others had to close their doors by 1920. By 1932, almost half the medical school applicants had to be turned away....

Licensing of physicians was largely a result of lobbying by the AMA .... Not surprisingly, the established practitioners suggest giving licenses to those already in practice, setting high stan dards for new entrants, and denying approval to practitioners who use different techniques from theirs .... In 1910, there were seven medical schools specializing in training black physicians. By 1944, only two had survived. Women were excluded from the medical profession in the same manner. In 1938,students of homeopathic, osteopathNATIONAL HEALTH INSURANCE 385 ic, and chiropractic medical schools could no longer qualify for licensing as medical doctors. Hospitals or medical schools that dared to employ them risked losing their approved sta tus.... Alternative practitioners were frequently denied other privileges as well. So blatant were these discriminatory practices that in 1987 the American Medical Association wasfound guilty under the antitrust laws of having "conspired to destroy the profession of chiropractic in the United States" by using the political power afforded them by licensing laws.31 Another tragic effect of medical licensing has been the disappearance of competent medical ser vices from most poor communities, particularly rural ones. Thanks to government regulations and the litigation explosion, many rural communities and small towns now have no doctors at all.

InsuranceRegulations.Insurance underwriters, like doctors and hospitals, are subject to hundreds of government-issued mandates. As a result they seldom pay for drugs or treatments which the gov ernment has not approved. Again, the effect is to make many safe and inexpensive forms of treat ment unavailable to American citizens, while rais ing health care costs for everyone. OtherFactors.Government regulation is not the only factor in escalating U.S. health care costs.Oth er major factors include mounting social violence, which is overloading urban emergency rooms. Many hospitals are closing their ERs to avoid bankruptcy. The explosion of litigation against doc tors and the willingness of juries to give multi million dollar punitive damage awards have made $100,000-a-year malpractice premiums common place, and litigation is causing many doctors to abandon high-riskspecialtiessuch as pediatrics and obstetrics. Finally, the expense of coping with the AIDS epidemic and the medical needs of an aging populace have increased the demand for medical services and hence their cost. Some of these factors have been greatly aggravated by government poli cies.Others have little or nothing to do with govern ment regulations. In either case,socializedmedicine will do nothing to alleviate these problems.

HealthCareAlternatives Fortunately, socialism and inaction are not our only two options. We can make health care more 386 THE FREEMAN • OCTOBER 1992 affordable and more available while preserving quality and freedom of choice. Here are some pos itive steps we can take now: Privatize Health Care. Medicare and Medicaid are imposing horrendous costs upon American taxpayers. There is no free lunch. When health care is "free" (i.e.,indirectly financed by taxation), there is little incentive for either patients or doc tors to minimize costs. Government-guaranteed medical services raise prices and costs, result in massive waste, and create a bureaucracy in a futile attempt to control costs. Government should get out of the medical in surance business. We will get far better value for our health care dollars if we spend them directly ourselves. Free Insurance Companies from Govemment Regulations. Government insurance mandates specifying how insurance policies must be written, what illnesses may be covered, and what fees can be charged-put a straitjacket on health insurance providers and cost the U.S. economy over $60 bil lion a year. There are now over 700 mandates enforced by state governments. These mandates prohibit inexpensive policies with limited cover age-leaving 8.5 million Americans uninsured.32 Using medical insurance to pay for small claims is also highly inefficient. As Joseph Bast points out in Why We Spend Too Much on Health Care, "it costs as much as $50 to process a $50 claim,"

adding billions to medical costs.33 Insurance companies should be free to innovate and introduce new policies which meet the diverse needs of the American people. Relieved of the governmental regulations currently imposed on them, health care insurers could become leaders in cutting costs and creating inexpensive coverage for currently uninsured Americans. The single reform of ending all mandates would reduce health care insurance costs in the U.S. by 30 percent!34 Deregulate Medical Research and Marketing. Burdensome government testing and certification requirements have added years of delay and bil lions of dollars in cost to the development and marketing of new drugs. Government has made it economically impossible for small pharmaceutical manufacturers to survive, or for any manufacturer to develop drugs for diseases that affect small pop ulation groups. Hundreds of thousands of lives have been needlessly lost as a result of delays and added costs imposed by government regulations.

Drugs which could alleviate the suffering of mil lions are kept from the market because they don't meet the government's arbitrary standards.35 The decision whether or not to take a drug should be made by the patient and his doctor. In a deregulated market, misleading or dangerous claims would be minimized by natural market forces, including the threat of legal action by con sumers. Unlike government regulatory agencies which are protected from lawsuits for their mis takes by sovereign immunity, non-governmental businesses are always subject to legal action. Deregulating medical research and marketing would save tens of thousands of lives a year, make it economical to develop many new drugs, and drastically cut the cost of drugs for everyone. End Medical Monopolies. The American Med ical Association is a coercive monopoly which makes it difficult or impossible for alternative health care providers-such as nurse-practition ers, midwives, osteopaths, chiropractors, and nutritionists-to market their services. State med icallicensing boards are composed virtually entire ly of AMA-certified physicians and have created "medical standards" which make it impossible for medical schools to survive unless they adopt cur ricula approved by the AMA.

AMA-dominated, politicized state medical licensing ought to be abolished and replaced by independent certification of doctors. Consumers, not politicians or powerful groups of doctors, should decide which health care practitioners we can patronize. End Drug Prohibition. Drug prohibition is a contributing factor to America's health care crisis. Legalizing drugs would eliminate many deaths from adulterated substances, permit addicts to seek treatment without fear of arrest, enable those suffering from glaucoma and cancer to use mari juana and cocaine therapeutically, and permit patients and doctors to use drugs now legally avail able in other countries. Ending the war on drugs would reduce health care expenditures in the United States. A Warning If you want to know how national health insur ance would work in America, we have a model.

For more than 60 years the Veterans Administra tion has been charged with handling the health needs of millions of disabled and discharged ser vicemen and women. With a fiscal 1990 budget of $30 billion, the VA runs America's largest health care system, including 172 hospitals, 233 outpa tient clinics, and 122 nursing homes. 36 Investigations of the VA have found abom inable conditions: long waiting periods for surgery, filthy hospitals, severe shortages of staff and drugs, antiquated equipment, incompetent staff, indiffer ent and hostile administrators. 37 Here is just one example: On January 15, 1992, CBS News reported that Walter Reed Army/Navy Medical Hospital had been refusing to provide amputees coming back from the Gulf War with artificial limbs. Other veterans were given shoddy prosthetics using antiquated technology. Compounding the tragedy, Walter Reed refused to accept donations of modern prosthetics offered by sympathetic Americans.

Commenting on why soliders were denied mod ern artificial limbs, a Medical Services colonel re torted, "I am not going to spend the taxpayers' money if you will just be sitting at home. Why should I spend $5,000for something that you will just look on?" Commenting on the refusal of Wal ter Reed hospital to accept donations of modern limbs for veterans, the colonel stated, "We disap prove it because we are the primary health-care providers and we believe that we provide the best total care to the patient. And the patients belong to us." 38 The most callous Soviet bureaucrat could hardly have been more arrogant. This incident gives us a glimpse of the future of health care in America-if national health insurance is enacted. 0 1. David Holzman, "Seeking Cures for an Ailing System," Insight,April 8, 1991,pp. 50-53. 2. Quoted in Paul F. Gemmill, Britain's Search for Health (Philadelphia:Universityof PennsylvaniaPress,1960),p. 20.

3. SundayTimes,London,October 12, 1975,p. 6. 4. Michael Foot, Aneurin Bevan: A Biography (New York: Atheneum, 1974),Vol. 2, p. 191. 5. Ibid. 6. John and SylviaJewkes,Valuefor Moneyin Medicine(Oxford: BasilBlackwell,1963),pp. 59-60. 7. Harry Schwartz,"The Infirmity of British Medicine," in R. Emmett Tyrell, Jr. editor, The Future That Doesn't Work: Social Democracy'sFailurein Britain(NewYork:Doubleday,1977)p. 29. NATIONAL HEALTH INSURANCE 387 8. Loc. cit.,p. 33. 9. Loc. cit. 10. New Scientist,August21,1975,pp. 410-11. 11. John C. Goodman and Gerald L. Musgrave,Twenty Myths About NationalHealthInsurance(Dallas:NationalCenterfor Policy Analysis,1991),p. 1. 12.Estimateofthe FraserInstitutequotedin GoodmanandMus grave,p. 17. 13. Ibid.,pp. 11, 12. 14. MalcolmGladwell,"Why Canada'sHealth Plan Is No Remedy for America," The WashingtonPost,March22, 1992,p. C-3. 15. Goodman & Musgrave,op. cit.,p. 11.

16. Ibid.,pp. 29-31. 17. Aldona and Gary Robbins, What a Canadian-StyleHealth Care System Would Cost U.S. Employers and Employees (Dallas: NationalCenter for PolicyAnalysis,1990). 18. For excellent discussions of the realities of socialized medicinein the SovietUnion,see DavidK. Willis,"SovietMedicine: A Matter of Privilege" in Klass: How RussiansReally Live (New York: St. Martins Press, 1985),pp. 183-204;and Konstantin Simis, "Free MedicalCare and Corruption"in USSR: The CorruptSociety (NewYork:Simonand Schuster,1982),pp. 221-228. 19. Choicesfor HealthCare:Reportofthe HealthBenefitsReview (WellingtonHealth BenefitsReviewCommittee,1986),pp. 78-79. 20. Goodman and Musgrave,op. cit.,p. 51. 21. Robbins,op. cit.,p. 3. 22. Joseph L. Bast, Richard C. Rule, and Stuart A. WesburyJr., Why We Spend Too Much on Health Care (Chicago:The Heartland Institute,1992),pp. 14-15. 23. WilliamH. Walker,"National Health Care: BringingSoviet Medicineto the U.S.," The BuckeyeLibertarian,July/August1991.

24. LouisLasagna,"Congress,the FDA, and New Drug Devel opment: Before and After 1962," Perspectives in Biology and Medicine,32: 322-343,1969; WilliamM. Wardell,"Rx: More Regu lation or Better Therapies?" Regulation3:30,1979. 25. See "The Denial of MedicalMarijuanato Sick People," pp. 83-106,and"ForcingPeopleto FaceDeath fromAIDS,"pp. 125-150 in Arnold S. Trebachand KevinB. Zeese, DrugProhibitionand the ConscienceofNations(Washington,D.C.:The DrugPolicyFounda tion), 1990. See also Arnold S. Trebach, "The Sacrifice of Our Sick-By BanningHated Drugsin Medicine,"The GreatDrugWar (NewYork:The MacmillanPublishingCompany),1987. 26. FrancisL. Young,"MarijuanaShouldBe Medicine,"in Drug Policy1989-1990:A Reformer'sCatalogue,Arnold S. Trebach and KevinB. Zeese,editors(Washington,D.C.:DrugPolicyFoundation, 1989),p. 358. 27. Ibid.,pp. 325-358. 28. SeePaulB. Ginsburg,"PublicInsurancePrograms:Medicare and Medicaid,"in H. E. Frech III Editor, Health Care In America: The PoliticalEconomyofHospitalsandHealthInsurance(SanFran cisco:PacificResearch Institute, 1988),pp. 179-218.Additionalfig ures on Medicare and Medicaid expenditures for 1990 are taken from The StatisticalAbstractof the UnitedStates:1991,111th edition (Washington,D.C.:U.S. Bureau ofthe Census,1991),p. 93.

29. Bast,op. cit.,p. 52. 30. LouiseB. Russell,"MedicalCare Costs,"in SettingNational Priorities:The 1978Budget,edited by JosephA. Pechman(Washing ton, D.C.:The BrookingsInstitution,1977),p. 182. 31. Dr. Mary J. Ruwart, "Harming Our Health," Healing Our World (Kalamazoo,Mich.,SunStarPress,1992),pp. 57-62. 32. Bast,op. cit.,pp.14, 63, 65. 33. Ibid,. p. 1. 34. Ibid.,p. 65. 35. Arnold S. Trebach,"The Sacrificeof Our Sick-By Banning Hated Drugs in Medicine," The Great Drug War (New York: Macmillan),1987,pp. 290-328. 36. Janet Novack,"Hands Off My Pork Barrel," Forbes,May28, 1990,pp. 183, 186. 37. Robert Klein, Wounded Men, Broken Promises:How the VeteransAdministration Betrays Yesterday'sHeroes (New York: Macmillan,1981). 38. CBS EveningNews (transcript),January15,1992(Livingston, N.J.: Burrelle'sTranscripts,1992),pp. 7-9.