Medicare: What It Did for Medicine, It Can Do for Dentistry
Copyright Salvatore J. Durante, DDS, FAGD, 1988. Published in Journal of Dental Practice Administration, July-September 1988. Reprinted in the Chicago Dental Society Review, October 1988; Greater Milwaukee Dental Association Bulletin, December 1988; Connecticut State Dental Association Journal,Winter 1989; Journal of the Colorado Dental Association, January 1989; Texas Dental Journal, June 1989; Wisconsin Dental Association Journal, June 1989; Dental Management, September 1989; Today’s FDA: Official Monthly Journal of the Florida Dental Association, March 1990.
Think of all the patients you presently treat who are eligible for Medicare, but who can still comfortably pay their dental expenses through private means. It is a large percentage for many of us, and will increase over the next decades. Now imagine that it is five years after the ADA succeeded in expanding Medicare to include dentistry. The cosmetic safeguards, such as voluntary enrollment of beneficiaries and voluntary assignment of benefits by dentists, have long been legislated out of existence. You are now part of the government’s program whether you like it or not; it is a requirement for licensure in your particular state. You must now accept government-established fees from all Medicare-eligible patients. Do not ask the patient to make up the fee-difference–it is illegal. The government has been telling the patient for the last five years that he is entitled to your services. By now he believes it, so do not consider conspiring with the patient to get around the government’s guidelines–if your actions were discovered you would be fined and your license to practice would be suspended or revoked.
The above scenario is actually occurring in medicine today, as will soon be shown. And for all the reputed differences between medicine and dentistry, there is at least one principle that pertains equally; that is, if the government is paying the bill for a particular service, then the government must eventually take control of the providers of that service.
To understand the consequences of government funding of dentistry one must examine the history of medicine under Medicare. The beginning, for our purposes, is the early nineteen-sixties, when our country’s intellectuals and politicians created and enforced a newly discovered “right”–a “right to health care.” It all sounded so well intentioned. The government would merely direct funds where the medical community decided it was necessary; physicians and their patients were assured that control of treatment would remain in their hands. In the words of then-President Kennedy, what they were suggesting was not “something radical and new or violent. We are not suggesting that the government come between the doctor and his patient.”
In fact however, with Medicare legislation a new principle was introduced into American politics: government should assume responsibility for the nation’s health. Until this time, unless you could demonstrate severe need, you paid your own way. But no longer–politicians said. From then on, “routine medical care” was to be considered a “right.”
What were the immediate results? Politicians were able to claim that they had created health care out of thin air. They were seen as heroes. The patients covered by the new program no longer had to pay much attention to costs, and demand skyrocketed. The types of services covered while in a hospital became virtually unlimited; different doctors and patients define the word “routine” in different ways, so Washington covered essentially anything doctors billed it for. In the beginning, most physicians were delighted. Now, many of them felt, the sky is the limit, and they proceeded to build hospitals, purchase equipment and administer tests accordingly.
At the same time as government funding caused this increase in demand, medical costs began spiraling upward, as unlimited government funding suspended normal market forces. There simply was no reason to control costs. The result was a steady rise in prices of medical services in addition to the general inflation rate.
It is necessary to note here that improved technology is not the cause of higher industry-wide costs. New, science-fiction technology does temporarily raise costs to those who choose to use it. But because it can be afforded by very few, businessmen and inventors persevere until the costs are low enough to make the new technology available to a mass market, hence profitable. The result is better technology at an affordable price, and most likely a decrease in the price of the older, less desirable service. This pattern has been observed over and over again, from automobiles to computers. What has prevented much medical technology from following this general pattern during the past twenty-two years is the flood of dollars from Washington that facilitated the use of new technology by masses of consumers who were not at all concerned with cost, since the government was paying the bills.
From this very brief overview of the developments under Medicare, two general principles can be identified. The first is that a so-called “right to health care” cannot be limited to only certain aspects of care or to only one segment of the population. Costly heart transplants and much simpler exams both fall within the concept of “health care.” As for rights, the very nature of the concept is such that it applies to all human beings by virtue of being alive. Therefore, one should not be surprised by the fact that although Medicare began as government funding for a limited number of services for a limited segment of the population, it unleashed demands for every kind of health service from every special interest in the country.
The second relevant principle is that government funding and interference in any field distorts market forces that normally make state-of-the-art services and products affordable to a general market. If taxpayers’ money floods any industry, distortions in supply and demand will develop. These distortions cannot be evaded forever.
Indeed, the results are with us. Medical expenditures in the United States were 4.3% of GNP in 1952; by 1982 they had doubled, exceeding 10% for the first time, and were still rising. Meanwhile, government’s share of these ballooning expenditures also nearly doubled, from 22% to over 40%. Demand for services showed no sign of decreasing. As a result of government funding, fully one percent of the nation’s GNP is now spent on the dying in their last weeks of life.
Consider what this means in practical terms. One-third of the Medicare budget goes to patients in their last year of life. Today, one-half of a man’s lifetime medical expenses occur in the last six months of his life. In a free-market system, such as we had prior to Medicare, a person could do the same thing if he wished. He could defer vacations and new cars and many other forms of consumption year after year, if he wanted to go on a spending spree as he died in the hospital. However, without the government’s help he would have to do so without looting other taxpayers.
In the face of these developments, a consensus began to form among medical economists. By the early 1980s, the Medicare system was threatening to bankrupt the entire Social Security system. Although taxes had been raised, this would not be enough; something drastic had to be done to control costs.
The government, which was by now the leading purchaser of health care, could have admitted its mistakes. It could have chosen a return to a truly free market, allowing each person to decide what medical services he would or would not purchase. The government could have chosen a gradual step-by-step dismantling of Medicare. Needless to say, this is not what it did. Instead, Washington instituted a system of rigid price-controls.
Very briefly, the system of price controls works like this. DRGs, Diagnosis Related Groups, were established which placed all hospital admissions into one of 468 categories. Medicare pays the hospital according to the specific admitting diagnosis. For example, Mr. Jones is admitted with a diagnosis of myocardial infarction. If the fee for that diagnosis in that region of the United States is set at $5000, the hospital receives $5000. It makes no difference what the hospital does for Mr. Jones; it receives the same amount no matter what services Mr. Jones actually requires. If the patient recovers quickly and costs the hospital only $4000, then it makes a profit. If the patient requires a lengthy stay and numerous services, then the hospital suffers a loss. One can see immediately that the incentive to the hospital administrators, who now take on a dictatorial role, is to provide the least amount of services possible. The best case for the hospital is for the patient to die immediately after admission–it still gets the $5000.
This does not necessarily mean that physicians are skimping on services. However, the best among them must constantly fight with hospital administrators, who are watching the hospital balance sheets. An enormous pressure is placed on physicians to withhold services from the patient. There is even pressure to hide from the patient certain facts about his condition and expensive treatment alternatives. Unlike today’s dental patients, these medical patients are no longer sovereign individuals to be treated as self-supporting adults, but puppets on the dole to be squeezed into government-mandated programs. The incentive is to get the patient out of the hospital quickly.
In response to this development, the government merely created another acronym–PRO. Peer Review Organizations, installed at each hospital, ostensibly insure quality of care for Medicare beneficiaries. What they in fact do is remove responsibility for treatment decisions from the treating doctor and place it in the hands of bureaucrats whose ultimate concern lies in satisfying government edicts. The chain of developments from government funding to bureaucratic micromanagement of patient care is now complete.
But this is only the tip of the iceberg. The government has done almost everything imaginable to control costs. (Everything, that is, except remove the cause.) As previously noted, the cost of new medical technology can be extremely high. The government, therefore, requires hospitals to submit “Certificates of Need”, or CONs, before trying to purchase equipment. This, they claim, is to avoid “wasteful duplication of machinery.” Under this regulation, hospitals–and in some cases, physicians in their own offices–must convince government bureaucrats that they need the equipment. Memorial Sloan Kettering was initially denied the right to purchase a Nuclear MRI machine under this regulation.
In fact, some hospitals now answer to over 100 separate governmental agencies. Within one year, state legislatures–in addition to the federal legislature–enacted almost 300 pieces of health-cost containment legislation. These often included the mandatory offering of HMOs.
The recent growth in Health Maintenance Organizations is a perfect illustration of the insidious process of government controls leading to total control. Most dentists think that HMOs are a free-market phenomenon, but they are not! The recent success and growth of HMOs is due wholly to government interference. So, in order to understand HMOs one must see how they are related to Medicare and vice versa. It should be clear that the government’s price control system of DRGs is very similar to the HMO system, in which the patient basically pays one fee regardless of the services he receives. The treating physician or dentist receives one fee regardless of the services he provides. In a variation on the theme, certain higher priced procedures will carry a nominal copayment. This copayment is never enough to make doing the procedure worthwhile.
The following scenario is taking place in dental offices across the country. In an effort to reduce downtime, dentists are jumping on the HMO bandwagon. The treating doctor receives a set fee for treating a certain number of families, whether or not any of these patients are ever treated. Sometimes the copayment for elaborate dental procedures is initially adequate, but after one or two years of losses the Organization must lower, or fail to raise, the copayment. The result is that the treating doctor is rewarded if he actively discourages patients from seeking treatment. One can do this either by demanding immediate full payment of any copayments, or by repeatedly postponing the patient’s appointments, until the patient gets disgusted and goes somewhere else.
This is how all HMOs operate, as a matter of principle. To consistently earn a profit, which all businesses must do, HMOs must discourage treatment. They want healthy patients; if a member wants too many services or too-high quality, then he is discretely, but actively, encouraged to leave the Organization. For example, a well-established and prestigious New England HMO reported a patient-turnover rate in 1987 of about 40%. This is not atypical. One can see that the incentive, as with the DRG price fixing, is to take responsibility for many patients and then avoid providing treatment. While this article is not about the merits of HMOs, in the present discussion it is important to note that they operate on a bizarre business principle that could never stand the test of a free market. In fact, they operated only on the fringe of health care for over fifty years because most people decided not to use them. What changed? How have insurance companies managed to get HMOs off the ground?
HMOs began to flourish only after the federal government enacted the HMO Act in 1976. At that time, the federal government placed its enormous financial and legal weight behind HMOs, in an effort to curtail spiraling medical costs. Remember that it was government interference that caused this price spiral. The government offered taxpayer-funded grants to new HMOs; it provided subsidized loans; it advertised nationally on their behalf. As was noted earlier, Congress and local legislators even passed laws which required large employers to contract with HMOs. In 1985 the federal government, in further efforts to control costs, authorized HMOs to accept Medicare patients. The latest boost came in November 1987, when Administration officials announced a campaign to get Medicare recipients to switch from fee-for-service to prepaid capitation plans. (For more on managed care, see Salvatore J. Durante, Publications: HMOs, PPOs.)
All of this–DRGs, PROs, CONs, HMOs, the explosion in local “legislative solutions” to rising costs of health care–illustrates another point we must focus on: The one who pays the bills eventually must dictate what services will be performed and by whom. This fact is obvious and inescapable if it’s you who are consuming–buying a car, planning a vacation, or buying services from a dental laboratory. The same is true of government, with one essential difference. In deciding which lab technician to deal with, you and the technician are each free to disagree and to act on your own judgement. That is one of the characteristics of a free market. If you do not like his work or his fees, you can do business elsewhere; the lab technician has the same freedom. Neither of you can force the other to work under terms with which he disagrees. The government, in contrast, does have the power to force its decisions on unwilling individuals. When politicians decided not to phase out Medicare in 1983 and instead instituted price controls, doctors and patients had to comply.
So the politician who is paying the bill is in the same position as you are when buying services–but with a very important twist. He, like you, must decide how and where the money will be spent, but unlike you, after he has made his decision he can force you to act on it–against your own judgement. Your lab technician cannot compel you to accept his fees or treatment plans by threatening you with criminal prosecution. Today’s politician can. In fact, today’s politicians force physicians to obey disruptive regulations and then blame all problems on the “greedy doctor,” rather than admit that government interference has caused the problems the politicians claim to be correcting.
In summary: once the government recognized the fictitious “right to health care” and began funding through Medicare, it was only a matter of time before the resulting economic and political disruptions surfaced. Rather than admit their mistake, politicians seized control of one area of health care after another. The Congressional HMO Act of the early seventies, the DRG price controls of the early eighties, and the hundreds of regulatory health-care agencies were all predictable results of the government funding that began back in 1965.
If there is any doubt left that government funding must lead to absolute government control, the following development should convince the skeptics. In 1984, one year after it passed price-control legislation, Congress considered a bill that would have forced all physicians to accept Medicare assignment. Either accept our fee as full payment, they said, or find another job. Although this particular bill never made it out of the House Ways and Means Committee, it is being implemented state by state.
For example, since 1985, any Massachusetts physician who treats Medicare beneficiaries loses his license if he refuses to accept as full payment the fee set by the United States Secretary of Health and Human Services. Vermont and Rhode Island enacted similar laws in 1987. This infringement of doctors’ inalienable rights, and other measures such as proposed legislation to require Medicaid participation by physicians, have prompted the Massachusetts Medical Society to issue dire warnings to other states.  This movement is not limited to New England: currently eight other states are considering similar restrictions on licensure. Such developments could have been predicted in 1965–in fact they were by some–after thoroughly studying the principles that underlie Medicare and government funding. 
Today, medical economists are predicting even more ominous developments. The director of the Hastings Center, a bioethical think tank in Briarcliff Manor, N. Y., recently recommended that almost no-one past a certain (unspecified) age should have access to aggressive lifesaving medical treatment.  A medical economist at Tufts University even suggests outright banning of new technology–since not everyone can afford it, no one should be able to have it. 
It is generally agreed that quality of care will continue to suffer under the pressure of arbitrary government guidelines. The best physicians are expected to continue retiring earlier and earlier in their careers rather than to try to maintain their integrity in today’s environment. Disaffection among practitioners is discouraging medical students and potential students. While Social Security has been “rescued” for the near term through hospital price controls, the cost of physicians’ services continues to rise unchecked; price controls must eventually be imposed on all physicians, not just those in Massachusetts, Vermont, and Rhode Island. Health care will eventually become a commodity that must be dispensed by the good grace of the government. Medical economists agree that, at the very least, rationing of all health care in the 1990s will have to be considered. [7,8,9] Physicians and patients will have become government tools.
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So this is what we, as dentists, should learn from American physicians’ experience with the government:
Number one: government interference in health care, as in any field, creates market disorders that necessitate more government interference. This must continue unless the initial interference is actually removed.
Number two: government funding of a service not only gives politicians the right to dictate policy, the funding ultimately makes total government control necessary.
It must be stressed here that it makes no difference what the intentions of the government-funding advocates are. They may want more business for health-care providers, or they may sincerely want to alleviate pain and suffering within a specific area of society. Good intentions make no difference; if one advocates government funding, one is advocating government control. The increase in government control will culminate in total control–the American health-care system will be managed like the federal postal system, with government bureaucrats dictating who can provide what services to whom, where, and at what salary.
This is clearly a nightmare in the making that organized dentistry should be fighting, but instead the American Dental Association–if not the American dentist–is eager to become part of the government program. Until 1977, the ADA had consistently opposed inclusion of dental benefits under Medicare. That year, when the resolution to seek inclusion was being debated, at least one delegate from Massachusetts saw the real danger: “If we are included,” he argued, “we will be on a fixed fee schedule and when the government is paying the bill, the government will call the tune. This is a giant step toward a full national health program.”  The ADA House of Delegates ignored his warnings and adopted the resolution.
Of course, this Massachusetts delegate’s predictions were absolutely right. Fixed fees and giant steps toward total government control of the profession have occurred–in medicine. But they have not occurred in dentistry, yet, because we have escaped government funding through Medicare; “basic” dental benefits are still excluded from Medicare. The economic and political evidence allows for only one conclusion to be drawn: the only rational policy for organized dentistry is active opposition to government funding.
Some justified the ADA’s actions in 1977, because at that time it seemed that American physicians had struck gold–Medicare was seen as an endless gravy train. What is the excuse today? Why does the ADA ignore the latest developments in Medicare law? Why does it ignore the warnings of the Massachusetts Medical Society? Why does the ADA still actively petition Washington to be included in Medicare?
The reasons given by ADA representatives range from the simplistic belief that an attack on Medicare would be equivalent to an attack on “motherhood” or “apple pie”–as some of them like to say–to the notion that dentists somehow will gain either financially or politically by advocating an expansion of Medicare. Some maintain, in private discussions, that we can get the senior-citizen lobby to support our position against denturists and hygienists if we support an expansion of Medicare. This is seen as a low-risk concession because Congress is currently unlikely to provide the necessary funding for dental inclusion. (If the ADA believes that the case against denturists and hygienists is so weak, or so important, that they must risk the fundamental freedoms of dentists, then there may be something wrong with their position on these issues, too. But that is for another study.)
In the final analysis, at the base of all the political and economic arguments for seeking dental inclusion in Medicare lies one moral premise. After one refutes each of their arguments, and demonstrates that the long-term loss of our rights as dentists greatly outweighs any perceived short-term gains, the advocates of Medicare inclusion will always fall back on this: doctors, including dentists, are “public servants,” and therefore should be willing, even eager to serve their fellow man–through government-enforced programs, if that is what the “public” demands at the present moment. In fact, this “public service” notion and the “right to health care” idea are corollaries; one idea necessarily implies the validity of the other.
Just as the word “right” in “right to basic health care” is intended to be taken literally, so is the word “serve” in “public servant.” Price controls and Medicare-restrictions on the licensure of physicians are justifiable only if physicians truly live to give the public what is the public’s by right. However, a little thought will show that no one is properly a public servant, in the sense used to describe doctors. The American Revolution and the Civil War should have settled this issue long ago. There is no such thing as one man’s right to another man’s effort; there is no right to enslave, in Massachusetts or in any other state. The Hippocratic Oath is not the surrender of one’s inalienable rights–it is a pledge of honesty and integrity. By choosing medicine or dentistry as our life’s work we do not give up any of our Constitutional rights. We provide services because people pay us, not because our patients are in any way entitled to our efforts. (For more doctors as “public servants,” see Salvatore J. Durante, Publications: Dentists as Public Servants.)
Observe that physicians are losing, one by one, every legitimate right recognized in the Constitution. This is because, in 1965 and up until this day, they (through the AMA) have advocated selfless service to the public.  It is true that the American Medical Association sometimes challenges the practicality of Medicare, but such challenges are futile if, in the next breath, they assert that doctors are selfless servants. They do not stop to consider that, in principle and so eventually in practice, this means they are slaves waiting for the voice of the “public”–politicians–to tell them whom to serve next.
But what of the patient who cannot afford the latest science-fiction cures, or even moderately priced treatment? He must accept that fact. He can morally,rightfully, seek private voluntary charity, but it is immoral for him to use the government as a club over the heads of doctors and other taxpayers so that he can receive whatever services he wants. Likewise, if a doctor wants to provide voluntary charity-service, that is his choice; he violates no-one’s rights by this action. However, it is foolish and ultimately destructive to advocate a program such as Medicare, which survives at the expense of doctors’ Constitutional rights.
An article in a recent national dental magazine contains a revealing quote from an ADA official; the context is the ADA’s policy to seek inclusion of dental benefits under Medicare. “Our primary objective is the health of the public.”  Shouldn’t the primary objective of the ADA be the protection of the Constitutional rights of its dues-paying members? If it concentrated on protecting our rights, then the dental health of the public would improve as a matter of course. Perhaps in 1977, the ADA decided that inalienable rights are old-fashioned and irrelevant, but the recent history of Medicare provides firm evidence contradicting that decision.
The promise of independence is usually a main factor in one’s decision to become a dentist. However, independence is not guaranteed, even in the United States, as the foregoing demonstrates. Today, dentists are oblivious to the details of the recent political upheaval in medicine, and are equally oblivious to the fact that the principles responsible for this upheaval threaten their freedom, also. Likewise, the “thinkers” in dentistry–those responsible for the long-term course of the profession–spend a disproportionate amount of time dealing with the day-to-day operations of a practice. This is a luxury we can no longer afford. Unless we rediscover our primary political value–freedom from government interference–and reassert the principles on which this value rests, studies about the day-to-day operations of a dental practice will become academic.
1. Transactions of the American Dental Association, 1977; pp. 900-901.
2. Transactions of the American Dental Association, 1986; Resolution 29H.
3. “ADA Addresses Catastrophic Illness Plan,” ADA News, April 20, 1987.
4. “Time the U. S. Caught Up,” The New Republic, November 9, 1963; p. 35. President John F. Kennedy is addressing the National Council of Senior Citizens, Inc., on June 13, 1963.
5. “Massachusetts Doctors Irked by Rules, Warn Others Away” (see Bibliography).
6. Rand A., Peikoff L. “The Forgotten Man of Socialized Medicine: The Doctor” (see Bibliography).
7. Otten A. “Ethicist Draws Fire With Proposal For Limiting Health Care to Aged,” The Wall Street Journal, January 22, 1988.
8. Greene R. “What Price Life?” (see Bibliography).
9. Stipp D. “Medical-Cost Trend After 1990 Disputed. Growth Rate May Soar Unless Care Is Rationed” (see Bibliography).
10. Hotchkiss W. S. “President”s Address: Doctor as Patient Advocate,” Journal of the American Medical Association, 1987; 258(7): 947.
11. Simpson E. “Medicare Foe Fears Control by Government,” Dentist, November/ December 1987.
Theory and principle
Anderson W. H. “HMOs’ Incentives: A Prescription for Failure.” Wall Street Journal, January 2, 1987. An excellent examination of the operating principle common to all HMOs and other prepaid health schemes.
Peikoff L. “Medicine: The Death of a Profession” (1985). This speech is the single best introduction to the principles involved in Medicare from 1965 to the present. A copy is available by writing or calling the Ayn Rand Institute, http://www.aynrand.com/ (4640 Admiralty Way, Suite 406, Marina del Rey, CA 90292; phone 310-306-9232; e-mail firstname.lastname@example.org).
Rand A., Peikoff L. “The Forgotten Man of Socialized Medicine: The Doctor” (1963). Uncovers and clarifies the fallacy in the destructive notion that doctors are “public servants.” A copy is available by writing or calling the Ayn Rand Institute, http://www.aynrand.com/ (4640 Admiralty Way, Suite 406, Marina del Rey, CA 90292; phone 310-306-9232; e-mail email@example.com).
White B. B. Falling Arches; The Case Against Federal Intervention in the Practice of Medicine. Hicksville, New York: Exposition Press, 1977. This must be read critically, but the last part explains the following point very well: Doctors must learn to use constitutional law to defend themselves against all government intervention.
The results of putting a false theory into practice
“Canada Puts Heat on ‘Coldhearted’ Doctors.” Wall Street Journal, August 22, 1986. The principles governing state funding of health care apply to all countries. This article contains some helpful lessons for us–Canada created a comprehensive national-health system in 1966.
“Disaffection of Doctors is Discouraging Medical Students and Potential Ones.” Wall Street Journal, April 10, 1987.
Easterbrook G. “The Revolution in Medicine.” Newsweek, January 6, 1987. An exhaustive look at the recent upheaval in health-care delivery. This article contains some useful statistics, but in looking for solutions to current problems it simply assumes that socialized medicine is the ultimate answer (“doctors are servants of the public”). Needless to say, the author offers no long-term solutions; instead, he is part of the problem.
Goodman J. National Health Care in Great Britain: Lessons for the U.S.A. Dallas, Texas: Fisher Institute, 1980. 212 pp. An excellent analysis of the British health care system. After reading this book, you will understand why the best medical minds of Britain fled to the United States long ago. But this is not just a study of Britain; the author identifies the economic reasons nationalized health care must result in a lower quantity and quality of health care in any country, including the United States. It is an excellent companion to the Ayn Rand and Leonard Peikoff analyses.
Greene R. “What Price Life?” Forbes, September 7, 1987. This article contains some interesting statistics, but is most notable for its negative conclusion: it simple-mindedly advocates the rationing of health care as if no other alternatives were possible.
“Massachusetts Doctors, Irked by Rules, Warn Others Away,” New York Times, October 24, 1987. Massachusetts was the first state to require acceptance of Medicare assignment as a condition of licensure (1985).
“Medicare Payment Plan is Blamed for Hasty Release of Aged Patients.”Wall Street Journal, June 25, 1985.
Menghini M. V. “Mandatory Medicare Assignment.” New York State Journal of Medicine, October 1987. This article reviews, state by state, the various state proposals mandating acceptance of Medicare assignment. There are different ways to force physicians to toe the government line: acceptance of Medicare can be tied to licensure; it can be mandated in a state’s consumer protection legislation. Failure to accept assignment can be treated as unprofessional conduct leading to revocation of one’s license; it can be considered a criminal violation resulting in stiff penalties and imprisonment.
Prior J. T. “The Myth Called Medicare.” New York State Journal of Medicine, October 1987. The current state of confusion in government-controlled health care is explored by the Medical Director, Empire State Peer Review Organization.
Stipp D. “Medical-Cost Trend After 1990 Disputed; Growth Rate May Soar Unless Care is Rationed.” Wall Street Journal, January 9, 1987. The likelihood of rationing health care is explored.