Remarks at a Luncheon for Members of the College of Physicians in Philadelphia, Pennsylvania

April 1, 1987

You know, I can't help thinking what a great place this would be, and a great moment, to get a pain in the neck -- [laughter] -- or maybe even a lower back pain -- [laughter] -- but I left Congress in Washington. [Laughter] I don't mean that personally. [Laughter] For me, politics is forgive and -- as you may have heard sometimes -- forget. [Laughter] One thing I didn't forget today, it was to bring with me someone special. I am told that he may be only the seventh physician ever to serve in a Presidential Cabinet from George Washington times until now: Dr. Otis Bowen.

This year throughout America our eyes are turned to Philadelphia as Americans everywhere remember that here 200 years ago a small group of men fashioned the greatest experiment in self-government in the history of man: the Constitution of the United States. The founders represented the people of the Nation, and they submitted their work to the Nation for ratification, which marked a turning point in history. Yes, that's what I told Ben Franklin at the time. [Laughter] Never before had an entire people joined together so peacefully and so effectively to govern themselves.

The Constitution called for a limited government, and in the two centuries since then, many around the world have asked: How is it possible that self-government and limited government work so well in America? Well, the answer is simple, and you're a part of it. As the Frenchman de Tocqueville found, when we Americans want to do something, we don't wait for government. We join together, and do it ourselves. And there's no better example of Americans joining together for a common good than the founding, almost 200 years ago, also in this city, of one of America's first academies for the discussion of medical issues, the College of Physicians.

Yes, it was in January 1787, under the guidance of Dr. Benjamin Rush, 24 physicians joined together ``to advance the science of medicine and lessen human misery.'' And for 200 years the college has done just that. Its leadership in public health began with efforts to combat the Philadelphia yellow fever epidemic of 1793, and it continues to this day. And as a leader in medical studies, the college boasts one of the world's finest and most used medical libraries, one of the best medical history libraries in the world, one of the few medical museums in America, and a skull collection that would make Hamlet delirious. [Laughter] For two centuries the College of Physicians has made a living reality of its motto -- ``Not for oneself, but for all'' -- and in the process has helped make all of American medicine what it is today: the best in the world.

Now, I know that as doctors sometimes you're asked to take the spirit of ``not for yourselves, but for all'' a little far. And this is my way of sliding into an anecdote; doctors somehow inspire a lot of anecdotes. Have you ever noticed, you're in a profession where when you're introduced sometimes at a social gathering to someone you've never met before, and the first thing that you know, when they hear that word ``doctor'' they start right out by saying, ``Well, Doctor, I've been having -- -- '' and they go on with that? Well, we had a fellow in the business I used to be in, in show business -- Moss Hart, the playwright -- and he was an inveterate along that line. Anytime he was introduced to a doctor, he had a complaint. And one night at a party in Hollywood, he was introduced to a Dr. Jones and immediately started talking about this low back pain that he was having. And the fellow that introduced him was embarrassed, and he said, ``Moss, Dr. Jones is a doctor of economics.'' [Laughter] That didn't stop Moss. He turned right back to the doctor and said, ``I bought some stock last week.'' [Laughter]

But in this bicentennial year, as we look back, I believe we must also look forward. We must ask ourselves: How will we prepare America for the journey ahead? How will we prepare America for the 21st century? What kind of country will we pass on to our children? And will our children be ready for the jobs and opportunities of America's future? This challenge, preparing America for the 21st century, includes finding ways to make the best use of our science and technology. It includes building a fair, open, and growing world economy, which will be the source of many of the jobs of our future. It includes making use -- or, sure that American education is the best in the world, investing in our human and intellectual capital, so our children are ready for those jobs.

It includes improving the climate for entrepreneurship and growth here at home, so that the only limits on what our children can achieve are the limits of their dreams. The key here is lower tax rates and fewer needless regulations. We've made great progress in both those areas, but the job won't be done until we get control of Federal spending so that tax rates won't go up again. And that's why it's time for Congress to cut the Federal budget and leave the family budget alone.

And finally, and the reason why I'm here today, the challenge includes preparing American medicine for the 21st century. I said that American medicine is the best in the world, and on that we need no second opinions, because there are no other opinions. Our competitive system has produced the finest health care in history. And with each year that passes, it saves more lives, finds cures to more diseases, makes life better for more people than ever before.

Yes, the pulse of American medicine is strong. And as a result, life expectancy has been rising. Once-common diseases like tuberculosis, diphtheria, and polio are distant memories. Infant mortality is falling. The rate of Americans who die from heart problems drops each year. More cases of cancer are found quickly and treated with total success each year, and I have reason to be grateful for that. Operations like cataract surgery, which once were difficult and required long recoveries, have become simple office procedures. And for those who do go to the hospital, average hospital stays have fallen dramatically in the past two decades. A stock scene in the movies has a father rushing his gravely injured child to a hospital. But now when he gets there, he finds doctors are more ready for him than ever before. Intensive care units have become not the exception but the rule, as have trauma centers staffed around the clock with surgeons. This is an important reason auto crash deaths have fallen over the last 10 years. Crash victims have a much better chance of living if they're treated within that first critical hour, and more are.

Almost every disease we know can be rapidly diagnosed and treated. The most obvious and disturbing exception is AIDS. And yet here, too, medicine is vaulting ahead. Six years ago the world had never heard of AIDS. Since then the AIDS virus has been isolated and identified. A test has been developed that is helping to ensure that transfusions are free of contamination. One drug, AZT, has been developed that may help treat AIDS patients, and it received FDA approval just 2 weeks ago. Other medicines are on the way, and American researchers will soon begin testing vaccines. This is unprecedented progress against a major virus. It took 40 years of study to learn as much about polio. It took 19 years to develop a vaccine against hepatitis B. But then our battle against AIDS has been like an emergency room operation: We've thrown everything we have into it.

We've declared AIDS public health enemy number one. And this fiscal year we plan to spend $416 million on AIDS research and education and $766 million overall. Next year we want to spend 28 percent more on research and education and a total of $1 billion. That compares to $8 million just 5 years ago. Spending on AIDS has been one of the fastest growing areas of the budget. And that's not all. Recently, Prime Minister Chirac and I announced an agreement that opens the way for cooperation between researchers in France and the United States. We are also unlocking the chains of regulation and making it easier to move from the pharmaceutical laboratory to the market with AIDS drugs. AZT received FDA approval in just 4 months, and that is one-fifth the average time for reviewing drugs. No, the limit on AIDS research today is not money or will but the physical limits of research facilities and the number of people trained in the necessary techniques.

But all the vaccines and medications in the world won't change one basic truth: that prevention is better than cure. And that's particularly true of AIDS, for which right now there is no cure. This is where education comes in. The Public Health Service has issued an information and education plan for the control of AIDS. The Federal role must be to give educators accurate information about the disease. Now, how that information is used must be up to schools and parents, not government. But let's be honest with ourselves. AIDS information cannot be what some call ``value neutral.'' After all, when it comes to preventing AIDS, don't medicine and morality teach the same lessons?

Some time ago I heard the story of a man who received what turned out to be a transfusion of blood contaminated with the AIDS virus. He was infected, and in turn his wife was infected. And within 2 years, they both had died. Well, I'm determined that we'll find a cure for AIDS. When the Carthaginian general Hannibal was preparing to cross the Alps and was told there was no way across, he said: ``We'll find a way, or make one.'' And that's the kind of determination we all have about curing AIDS. We'll find a way, or make one.

American medicine is making miracles commonplace, and that's good news as America prepares for the 21st century. But while our quality is the highest in the world, so are our prices. Last year medical costs climbed seven times faster than the rate of inflation. It's getting to where many patients feel that the recovery room should be next to the cashier's office. Doctors, patients, insurers -- everyone feels sick about the rising cost of getting well. As a nation, we spend up to twice the proportion of gross national product on health care as such major trading partners as Japan, Britain, and Canada. One of our greatest challenges in preparing for the competitive world of the 21st century is to get this medical cost crisis under control. Worst hurt are the uninsured and the elderly citizens on Medicare who face a catastrophic illness. Our catastrophic illness proposal will help those on Medicare. And as part of the package, we will also encourage the States to use their authority to require catastrophic coverage in insurance available through employers. The aim here is to make sure the guy who pumps gas or works in the corner store can get coverage, too.

But as we protect those who are most vulnerable, we must also do something to hold costs down. And let's face it, government has played a large role in the inflation of medical costs. As the head of one suburban hospital told a reporter not long ago: ``The incentives used to be to keep people in the hospital, to perform more tests and procedures, to increase costs.'' When we came into office, Medicare was facing bankruptcy, and when it came to the public assigning liability, doctors were hurt, too. Stories of soaring costs and excessive bills tarnished the profession's reputation. Four years ago we changed the Medicare hospital payment system. We also allowed health maintenance organizations and competitive medical plans to contract to give care, and the results were astonishing. Health care inflation was cut in half. Efficiency rose. Service did, too. And the Medicare trust fund was pulled back from the brink. And still, to ensure that the fund remains strong through the year 2000, we must do more. And that's why I've sent a new package of proposals to Congress.

A lot is wrapped up in that package: more choices for Medicare beneficiaries, more incentives for doctors to improve efficiency, more incentives for States to give more choices to those on Medicaid. But let me tell you one thing that will not be in that or any future package from my administration: a mandatory cost containment system. I know some want to go that route, but a mandatory system would discourage innovation, restrict services, and be a step toward government control of the entire medical profession. American medicine is the world's best because it is private, and it must stay that way.

Now let me turn to one of the most important cost issues facing medicine and many fields today: liability insurance and tort reform. When I hear of what goes on in the courts, it reminds me of the hypochondriac who was complaining to the doctor. He said, ``My left arm hurts me and also my left foot and my back. And, oh, there's my hip and, yes, my neck.'' Well, the doctor muttered something to himself, sat the man down, had him cross his legs, tapped him there -- you know, that spot, with the little rubber hammer. He says, ``How are you now?'' The patient said, ``Well, now my knee hurts, too.'' [Laughter] Sometimes it seems as though the courts are ready to award damages even to that man. Last year a jury awarded one woman a million dollars in damages. She'd claimed that a CAT scan had destroyed her psychic powers. [Laughter] Well, recently a new trial was ordered in that case, but the excesses of the courts have taken their toll.

As a result, in some parts of the country, women haven't been able to find doctors to deliver their babies, and other medical services have become scarce and more expensive. This is both a State and Federal matter. When Secretary Bowen was Governor of Indiana, Indiana reformed its liability law. Two-thirds of the States, including Pennsylvania, have taken action since the beginning of 1986. It's time to make it 50, and for Congress to follow, too. We can debate the details, but doesn't it make sense, in effect, to give lawyers a Hippocratic oath so that they will, as you swear to do, ``abstain from every voluntary act of mischief.'' Although I guess, for some lawyers -- and I emphasize some -- mischief is a compulsive act. [Laughter]

I've talked today about some of the challenges facing American medicine as we prepare for the 21st century. Sometimes it's easy, particularly on the cost issues, to turn to government for the answers. Yes, government has a role, but in the end, physicians are in charge of this operation. And just as a surgeon must decide when to call for the scalpel, clamps, and thread during an operation, you must decide when to call for the tools that will help you remove enlarged costs from the body of medicine. I heard from a panel in the college library today about bringing down costs by making better use of nurses and other health professionals.

Well, you must decide how and when to do this. A few negligent doctors can raise the health care and liability insurance costs for everyone. You must decide if medical societies will get tough on those guilty of negligence or of failing to conform to the ethical standards of medicine. As patients expect more from medicine, and as they pay more, they also want to know more about their choices. And you must decide how to get the information to them. As less expensive, simpler procedures come available, you must decide when to use them. In your hands is American medicine's great tradition of healing all in need regardless of their wealth.

And let me add one other thing that is vital to our nation's future that in many ways is in your hands as well: the war on drug abuse. You can teach your patients about the health risk of drugs. You can show them, particularly your young patients, why it's important to them, their families, and their communities to just say no to drugs.

Yes, your hands will fashion the future of American medicine. But I believe that's just saying that American medicine is in the best hands in the world. Compare your healing powers to the doctors of any other country. Take, for example, the Soviet Union, which talks so much about the superior quality of its medicine, but where sanitation is so poor that, as recently as 2 years ago, a third of all operations there left patients with postoperative infections, where a third of all hospitals do not have adequate facilities for blood transfusions, and where, partly as a result of poor medicine, life expectancy has been falling and infant mortality climbing. There's no contest there or anyplace else. You are the best.

I say that with confidence, because I know the quality and commitment of America's physicians, not only firsthand but through my family as well. My father-in-law was a physician. My brother-in-law is. I saw their dedication to medicine. I saw my father-in-law's devotion to his patients and to his students. I saw his enormous dignity. And I saw his dedication to excellence, how he constantly searched for better ways to diagnose and cure. Yes, I saw how he helped people, whether or not they could pay, and treated all patients with the same courtesy and respect.

As our nation prepares for the 21st century, I'm confident that American medicine remains in hands like his. So I say to you, some of America's most distinguished doctors: Let us begin to get ready now, so that in the year 2000, American medicine will still be the best and most widely available in the world and physicians across our land will say with pride, ``Not for oneself, but for all.''

Thank you, and God bless you.

Note: The President spoke at 2:03 p.m. in the Wyndham Ballroom at the Franklin Plaza Hotel. In his opening remarks, he referred to Secretary of Health and Human Services Otis R. Bowen.