Discussion and Perorations


Mr. Kempner: What we thought we'd do is give Dr. Stobo a shot at all the questions and comments that you wanted to make and didn't have time to in the program. I have sat where you're sitting an awful lot of times and have always griped about the fact that there isn’t enough time to talk or to hear from people. Jack's here as a resource, as the medical resource; the rest of us are here institutionally. I'm here to fade heat when they don't want to, but I'll manage this. It's wide open. If anybody wants to ask Jack any questions or make any statements now is the time.

Audience: Yesterday you spoke about the hurricane evacuation efforts. I know you have a large prison hospital on the campus. What were the logistics of that evacuation?

Dr. Stobo: Well, we do have a prison hospital on campus. In fact it’s the only prison hospital associated with an academic health center and it’s been here since the early 1980s. There’s roughly 220 beds with about 80 to 85 percent occupancy, which is the normal occupancy rate for hospitals.

When it was clear that Rita was coming into the Gulf we started a process where we did not accept transfers from the outlying units to the hospital, so there weren't a lot of patients coming into the hospital. On Wednesday when we evacuated we probably had 50 patients in the hospital. Thirty of those went to Tyler and they were cared for in Tyler. I can't tell you where the other 20 went. Of course, there are issues that have to do with security, et cetera. So we were very fortunate and pleased that Tyler was able to take such a bolus of patients. Again, that went without any untoward event.

There is an interesting anecdote here. On Tuesday night we xeroxed the medical records of all the patients that were going to have to be transferred except for the prison population. And the reason we didn't do that is because we have an electronic medical record. So it was assumed that wherever they went there would be the ability on the other end to access the electronic medical record and that it would be electronically transferred. Well, Tyler isn't able to access electronic medical records. So those patients went to Tyler without much in the way of a medical record. We had to xerox the medical records once we found that out and ship them to Tyler. It shows the importance of having universal electronic medical records.

Mr. Wright: Dr. Stobo, I'm Larry Wright from Austin. Thank you so much. We thought it was a really brilliant program that you put on for us. I was very impressed with the facility you have here, and what you're doing here is really interesting.

One of the things that occurred to me during the presentation at lunch about remote medicine is that one of fastest growing areas of medical practice on the internet is where people are treating themselves, basically a contract between the drug suppliers and the internet user. Instead of the illness or the symptoms, it starts with the drug. You click on the drug you want and you can get pretty much anything you want on the internet. It's completely circumvented the physician. There is a doctor I suppose on the other end, but he agrees to whatever you ask for. Typically it's Viagra or Prozac, but you've decided what you want. You can get Cipro, you can get Amantadine; you can get a lot of common drugs. And I notice on television an increasing number of ads for prescription medicines that are going to consumers that definitely are going to get it some other way than going to their doctor.

I was puzzling over how you get a medical professional into that loop, because that is probably going to be the largest growing area of medical practice. And I wondered, is there some way also of bringing pharmacists back into the medical world because now they've been sidelined.

Dr. Stobo: Well, you're absolutely right. There is an easy solution. Part of it relates to what Ken and I were talking about yesterday in terms of this team of health professionals. The team would include a pharmacist. If you can get an informed consumer who can have easy access to a member of that team then that team, whether it be a pharmacist, a nurse practitioner, physician's assistant, or a physician, could participate in that decision making. It's going to require a lot of education on the part of individuals who are accessing health information through the internet, as well as a real attempt on the part of health professionals to make their expertise more easily accessible.

Ms. Kleberg: Sally Kleberg from San Antonio and New York. Yesterday there was one interesting question asked about the impact of women in the medical profession. And since the nurse's study first came into being and women are now seen more as different from men in the way they're treated. How much of that is impacting the way medical education is being presented in the classroom? I know that there's one doctor in New York at Columbia named Marianne Legato, who actually has a Center for Gender-Specific Medicine. Duke University Medical Center also has a Women's Health Initiative.

And it's speaking specifically to conditions like heart disease, osteoporosis, which both men and women have, but presents completely differently and should be treated completely differently. With more women coming into the medical field as MDs, are we going to see a ramp-up of this gender-specific medicine being taught broadly in the medical schools, not just in these isolated medical centers where there's been a push by the women in senior positions to get it done?

Dr. Stobo: Well, the short answer is yes. But the bigger answer relates to what we were talking about yesterday in terms of having a healthcare workforce whose diversity reflects that in the population we are serving. For example, you can't understand the differences in the way diabetes affects Hispanics, Anglos, and African-Americans or men versus women, unless you have a workforce that reflects that diversity because they bring that interest to the educational and to the practice sphere.

So I think the emphasis on looking at different ways in which women present with myocardial infarction (heart attacks) for example, will occur more rapidly with the increase in the proportion of women in medical school, just like emphasis on the presentation of diabetes in Hispanics will increase if there's more Hispanics in medicine.

Ms. Kleberg: Why isn't it increasing even if there aren't Hispanics? We already have the women in the classroom, but somehow the way medical profession treats it is lagging.

Dr. Stobo: Well, it is changing. And in the world of medicine it's probably quicker than it may seem. It's a cultural issue, but it is changing.

Mr. McCowan: I'm Scott McCowan, and I'm a new member. I just want to say it was a fabulous program. I have one comment. We didn't talk about the financing of healthcare. That wasn't an issue that we directly addressed. I'm head of a small group that does research and advocacy around access to healthcare. So I do just want to make the comment that while we didn't directly address it, there were a lot of pro-consumer, pro-market forces which I'm convinced, had we talked about it at length, those would not have proven to be the answer. We're creating a world, we're actually accelerating a world, where the haves have healthcare and the have nots don't.

We really have to focus because that's going to be politically unsustainable. We have to focus on how we are going to provide healthcare. And, Doctor, you mentioned it was a matter of political will, which I agree with. But the second half of your sentence, and I don't actually think you meant this, was that we can't afford it. I think it is a matter of political will. I think we can afford it, and I think we need to begin to have a serious discussion in the nation about how we're going to afford it.

I just wanted to flag for the group that we really didn't tackle that issue and that what little we said about it I didn't agree with and have an answer to. And so I just wanted to flag that for an ongoing discussion. But it was a fabulous program. Thank you very much.

Mr. Kempner: Well, thank you very much for those comments. I agree with you. It is an issue of political will, and there is enough money in the system that could pay for increasing access. But somebody asked me afterwards what I thought was going to happen in terms of financing. And I'm afraid what's going to happen over at least the near term, unless there's some major cataclysmic event which changes this, is that we're just going to continue to see incremental change. This is what's happened over the past several years and it doesn't get at the issue that there are 46 million Americans in this country who can't get the healthcare they need and deserve simply and solely because they lack health insurance. And it's going up yearly.

Mr. Taylor: Lonn Taylor from Fort Davis, Texas. This is really a follow-up to Scott's comment. Dr. Stobo, in your opinion what are the main causes for the rising cost of healthcare in this country? And what can we do about it?

Dr. Stobo: The major cause is technology. As Ken said yesterday, probably 40 percent of the cost of healthcare and the rising cost of healthcare are the new technologies. As new scans come out, et cetera, they add a lot of money into the system. But associated with that is the fact the many Americans are willing to pay for it, irrespective of the cost. And it gets back to, again what we were talking about yesterday, the downside of employer-based health insurance where individuals who have health insurance don't know anything about the true cost of what they are accessing other than the co-payment or the deductible they may have to pay.

But if you just look at the numbers, technology is a major driver in terms of the cost. Then after that you have things like liability insurance, which is actually a pretty small part. Pharmaceuticals are about 15 cents of the healthcare dollar, but they have over the past two or three years been the portion of the healthcare dollar that has increased most rapidly.

Compare the cost in the United States to the cost of developed countries in the remaining part of the world and ask what the difference is. Our costs are greater than any other developed nation in the world. Is it because we have too many doctors, too many hospitals, folks stay in the hospitals longer? The answer is to all those is no. We have fewer doctors than many other countries. We have fewer nurses than many other countries. The length of hospital stay is the United States is less than it is for the average developed countries. But the cost per incident, per hospitalization, per hospital visit is higher than any other nation.

Now, there are places where we do lead the rest of the developed world. We have more MRIs than any other developed nation. We do more renal dialysis than any other nation. Per capita we do more interventions in heart disease than any other nation. So it is technology and it is that the cost per incident or per hospital visit or per hospitalization that is a major driver. There are other things like liability insurance and pharmaceuticals, but they are down further in the list.

Mr. Kempner: Just to remind you about pharmaceuticals, there has been an awful lot of attempts to import from Canada drugs because they're substantially cheaper. And the reason, of course, is that in Canada there's a single purchaser. It's their government and they are able to bargain prices in a way that no major healthcare plan can here. And these are the same drugs by competent manufacturers that they sell literally across the border at 30 and 40 percent less than they do here. That's true worldwide. It is, as Jack says, as far as anybody can tell, the fastest growing expense of them all. And it's taking a bigger and bigger piece of the total dollar. That's just one piece of it.

Dr. Stobo: Let me just add to that, Shrub. If you look at the total amount of healthcare spending in the United States compared to other developed countries and look at the part of that that's represented by pharmaceutical costs, it's higher than any other developed nation in the world just emphasizing what you were saying.

Mr. Kempner: Same drug, costs more.

Mr. Martin: I'm Bob Martin from Corinth, Texas. Dr. Stobo in your presentation yesterday you touched on a number of demographic issues. But one that you just barely glanced through is the incredible increase in longevity of the population in the United States. There are a lot of projections, but the factoid that has hit home to me the hardest is that a female infant born in the United States today stands a 50 percent chance of living to be at least 100 years old.

We are witnessing a dramatic increase in the length of life, and projections for the 21st century are at least a 20-year increase over the length of the century. And that, in fact, with the results of genomics and other research could be quite a conservative estimate. Because of the increased healthcare needs of an aging population I wonder if you would comment on the long-term significance and impact of that on the general healthcare picture.

Dr. Stobo: We are an aging society and the projection is by the year 2020 roughly 20 percent of the population will be 55 years of age and older. And that does have important implications in terms of healthcare professionals and costs. There will be more chronic diseases, for the cost does increase with that. So it is an important driver in terms of how we deliver healthcare and the cost of healthcare. And you're absolutely right about the longevity. At the turn of the century the average longevity was roughly 43 years, and now it is just shy for the overall population of 80 years. So it has essentially doubled in a hundred years.

Now, if you look within that though there are tremendous disparities, again some related to differences in ethnicity, geographic location, et cetera. This came home to me when I was talking to the TIAA-CREF, which is the organization that provides retirement benefits for organizations like academic health centers. An individual said, Well, you know, when we look at the average age of longevity of individuals who are in TIAA-CREF it's 93 years old. Now, that's far longer than the average longevity in the United States. So there are portions of the United States population that have longevity that is far less than that. Again it's related to difference in equality with regard to access to healthcare, quality of healthcare, available to these populations, et cetera.

Mrs. Hershey: I'm glad that some of us make it to 100. In the past civilizations, you know, the older women were the wisdom of the tribe. And if we can get through to 100 living with you guys, we're pretty smart.

I am a member of the National Recreation and Park Association, the Houston Parks Board, and the park people and all those things and former member of the Texas Parks and Wildlife. There hasn’t been much on the program about preventive medicine. It's cheaper in the first place, and it's better for you. And I'm talking about walking, hiking, running, outside exercise. And Dr. Corona, who is the Surgeon General of the United States, spoke to that at RPA two years ago. And most of his talk was on the need for us to get up and get out and walk and do things.

What I wanted to call to your attention today is the deplorable state in the State of Texas of our parks. We have giving away parks. We've closed down four of them. Tomorrow night we will talk about taking away the 5,000-acre Lake Houston park and giving it to the city, which is willing to take it, because the Parks Department in the state of Texas can't afford to keep our parks open any more. And if you want real statistics you can talk to Andy. He probably doesn't want to talk about this having just being a brand new member. But this is a real problem. And I wanted to alert you all to it, because our own Legislature is not funding our own state Parks Department and we're giving away parks. We're closing parks. We're shutting parks down. And since 97 percent of the private land in Texas is privately owned, it's those parks where people that don't own their own ranches or living in a secluded neighborhood go. We don't build sidewalks any more. We have to go exercise and get out and do what the Surgeon General of the United States is telling us to do: walk and exercise before you get all these maladies that are so expensive to cure.

Incidentally, they have cut the park department program of helping cities. So there's no money coming into cities to help your parks. We used to get 50 percent of what came in. We don't now. Talk to your legislators.

Senator Krueger: Bob Krueger from New Braunfels, the only person from New Braunfels of our 40,000 members.

Mr. Kempner: How the hell did you sneak in?

Senator Krueger: Before they knew where I lived. But I think that what our society has been very reluctant to address directly and what we haven't quite addressed directly here is that we take in this country education as being a given for all people. We take the attitude that if people in an emergency go to the emergency room they should get care whether they have money or not. If a person has a fire we don't say give us your credit card number before we send the fire truck. The fire truck is there.

Now, we have one in every six persons in this country who do not have health insurance. What we haven't, in my judgment, as a nation addressed is the question of is education an entitlement for all or is a fire truck an entitlement for all, but is healthcare an entitlement only to the five-sixths of the population that is more or less able to pay for it, but not to the rest of society. Our political figures, all of us have been reluctant to admit, that we are not really wanting to address the question of whether everyone should be entitled to healthcare.

And then if that is the case then how do we finance it. Let's not start with how do we finance more healthcare for more people, but let's approach it perhaps another way around. Is it something that everyone ought to have access to? And then if we take that attitude that it is I suspect that in America we can find the way.

Mr. Kempner: I agree with that. Well said. Just as a matter of perspective I will recall 1992/1993 where exactly that attitude was taken and ran into a buzz saw of the most enormous proportions. And because what you eventually come down to I think when you take that stance is something approaching single payer. That's the elephant in the room that needs to be said when we have this discussion, at least in my opinion. And I'm not going to go into that, but it's part of the discussion that we had in the early days of the Clinton administration and it’s been a third rail far more electric than social security in my opinion.

Dr. Stobo: But the nation did it in 1965 when it said that it's unconscionable that we let the poor of a country not have access to healthcare and the elderly, because at that time the elderly were an important part of the poor of the country. Medicare and Medicaid were passed very quickly.

Mr. Kempner: It's not to say it can't be done. It's just to say that's what we are talking about the implication of what Bob is saying and what Scott McCowan was saying

Mr. Prado: Ed Prado from San Antonio. Dr. Stobo, my question has to do with the DNA research. I understand that with DNA they're finding out that not all medication works for everybody, that they can find out that something works for somebody and might not work for somebody else. For example, it might work with an Anglo but not African-American and vice versa. And that also they can find out through DNA that what diseases someone might be susceptible to that could result in preventive treatment knowing that this particular individual might catch a certain disease down the road and they can set up a diet or something to prevent that disease from occurring in that individual. What role or where does Texas stand with regard to DNA research?

Dr. Stobo: Well, you're absolutely right. Post the sequencing of a human genome, it has become clear that there are differences in the reaction to the side effects in terms of benefit, et cetera, to the same drug based on differences in ethnicity DNA makeup. So there's a lot of talk and effort now to do what's called customized medicine, that is to look at certain genomic sequences before an individual is put on a drug to understand the right dose, whether that's the right drug, et cetera.

So we're going to see a lot more of that. And it's going on in different places in the country. Duke University, their health system has a major effort in this area. To tell you the truth I'm not sure what's going on in the state of Texas, but I'm sure that there are institutions that are looking at this in the context of customizing medicine based on genomic sequences.

Mr. Prado: Well, with regard to preventive medicine I guess that's the same.

Dr. Stobo: Same thing. There's no doubt that preventing a disease makes a lot more sense than doing something to try to stem or intervene when somebody has a disease. That just makes good solid sense, and there are a lot of efforts going on prevention. The problem is that it's difficult to get somebody to support it. Health insurance companies won't pay for it because they don't see the immediate benefit of it. Prevention has in my view enormous positive consequences: 2, 5, 10, 15, 20 years after you start the preventive measure. And health insurers don't see that they would benefit from that. They take a short-term view of it and so are unwilling to pay for it.

Now, companies that have implemented preventive programs see enormous benefits in terms of productivity on their employees, lower health costs, et cetera. And I know at UTMB we started an intervention program called Commit to Fit for our employees about a year-and-a-half ago. And other institutions are starting to do the same.

And soon genomics will play an important part of that. Based on genomic sequence we think that it's possible that you could contract Disease X in the next 20 years. And we know that the Disease X is multifactorial: part is genomic, but also part of it is dependent on something in the environment and that that can be prevented by doing this. And so that interplay will occur in the future.

Audience: Let me just say something about universal access. You know, a universal access does not have to be equivalent to single payer. There are different ways of financing healthcare in this country that don't require a single payer, particularly a single governmental payer, but can get at the same issue of universal access. I happen to think that a single payer is not acceptable to Americans and that there are other solutions which are more compatible with how we financed things in the past and more compatible with our entrepreneurial capitalistic approach.

Dr. Gunter: My name's Pete Gunter. I'm from Denton. These talks we heard yesterday were all excellent. And we've heard, but no one else will ever hear them. I make the suggestion that we think about videotaping the lectures, the talks that are given to this Society and then having a committee to decide which of these might be released for educational television or classroom use or something like that so that the really good stuff that happens here could get out to a further audience. And I'm not saying that we open the floor to people coming in, you know, that you get a big audience here. No, that's not it. But some of these things really should be preserved, and I think would be wonderful if they could be more broadly understood. So that's just a suggestion.

Secondly, I wanted to ask about this sort of alternative medicine going on today with acupuncture and herbal medicine and bathing in strange viscous liquids and I don't know what all. Is there really any push in the medical community to use more of this or is just a sort of verbal, well, we'll accept some of this though we don't like it.

Dr. Stobo: No. The use of alternative and complementary medicine is a major force in medicine and increasing yearly. My own view on that is that there are important things that alternative and complementary medicine can add to medical care, as long as the use is based on evidence that the alternative and complementary medicine really works. And there are some areas that that clearly does have a beneficial effect. But there are areas in which evidence is lacking. And I wouldn't support using a type of alternative and complementary medicine where there wasn't scientific evidence available that, in fact, has a positive effect.

Mr. Kempner: Jack, excuse me. You have a department at the UTMB, or at least a group, that works in it. Would you tell them a little bit about that?

Dr. Stobo: Well, we have a grant from the NIH that is one of a handful of grants given to do research relative to alternative and complementary medicine, again, in the context of what I was saying, to develop evidence that aromatherapy or acupuncture actually has a beneficial effect in whatever disease or disorder. Now, Shrub, one thing I do is ask Senator Zaffirini if she wants to makes some comments. She's given a lot of thought to healthcare. And I know she may have something to add to this discussion.

Senator Zaffirini: Thank you so much. I'm Judith Zaffirini. I'm the State Senator from Laredo, District 21. In the Legislature I have often raised the question of who lives, who dies, who decides? We do. We make decisions about who lives and who dies. And, basically, we do that through funding. And the fact of the matter is that I have heard references to political will for funding, and the fact of the matter is that there are those who do not have the political will to fund healthcare at the appropriate level.

Years ago I heard a surgeon general talk about the six As of healthcare. She said that healthcare had to be accessible, accountable, adequate, affable, affordable, and available. Dr. Stobo, have we met those six As of healthcare? Affable perhaps in some areas, but certainly not everywhere. And this is what we worry about, that in Texas we have not done enough for healthcare.

Friends like Mrs. Hershey talk about the will of the Legislature. I have to tell you that there are some members of the Legislature who simply will not vote to fund the programs that we need adequately. You do need to talk to your Senators. You do need to talk to your Representatives. But you also need to talk to the members of Congress. There are so many issues that simply are not understood. For example, when we talk about Medicaid and we talk about CHIP we know how important these programs are to the people of Texas. Which is more important, Medicaid or CHIP? I say Medicaid.

Which is more popular? CHIP. Why? The Children's Health Insurance Program. It is easy to support a program that favors children. It is easy to sell a program that focuses on children. It's also realistically important to understand that treating children is less expensive than treating adults and that Medicaid is not only for children, but it's also for the elderly and for people with disabilities. So I say Medicaid is more important. But people don't understand the issues. And that is why I was so very, very pleased when I heard about the focus of this conference on healthcare. I do wish that we had focused more in the morning on stem cell research because so many of us were watching the game. But I was so grateful that you did focus on these issues. And I do hope that you will speak loudly and clearly about these very important issues.

I do have a question for Dr. Stobo, related to the one posed by Bob Krueger. Is healthcare a right or a privilege? Ladies and gentlemen, that is the dividing line in the Texas Legislature today, not only about healthcare but also about education. And in Texas we have decided that education is a right from the level of first grade, not kindergarten, first grade through twelfth grade. There are many of us who would like to extend that right to higher education. We can't afford it. So is education a right or a privilege? And if it is a right at what level should it stop? Is healthcare a right or a privilege? And if it is a right to what extent? And that is my question. Thank you.

Dr. Stobo: I happen to think that healthcare , universal access to healthcare, is a right, but that just starts the discussion.

Senator Zaffirini: To what extent?

Dr. Srobo: Yes, to what extent, who pays for it, what do you mean by right. Is that just a basic benefit package? Does a right mean that any American can access Viagra or any American can have a cosmetic surgery? Or does a right mean that any American can get access to basic healthcare, which is immunizations, et cetera? And if the answer is basic healthcare then what does that look like? In states that have tried, they start out with ten things that constitute a basic healthcare package. And then the interest groups get involved and it goes from 10 to 20 making it unaffordable.

Mr. Whittenburg: George Whittenburg from Amarillo. I graduated from law school with Carlos Zaffirini, and I agree with everything Judith has said. The problem we face as optimistic Americans who have good will, who want to solve all the problems, is that there is a shortage of money. There's a cost to everything, and, consequently, you have to allocate scarce resources. I agree that the parks ought to be funded. But if funding the parks is the answer to exercise for Americans we're not going to do it because no one's going to get in a car and drive to a park for because parks are distant. It's got to be education to encourage everyone to exercise within two blocks of their home.

The problems of the baby boomers, I'm very concerned about whether our society, as strong as it is, and our economy, as strong and as good as it is, can pay the cost of two looming issues. One is healthcare and we're addressing it. But this is a very difficult problem. And we can address little pieces of it, but the overall issue is as the baby boomers move through their old age can we fund it? The cost of healthcare is soon going to be 17 percent of GDP.

I agree. Universal healthcare ought to be a right. But there are choices to be made. And we have two major things happening in this country. One is the baby boomers going through their old age and the healthcare for them. And the other thing is the war on terror. And we already have social security. And I applaud social security, and I support it. But it takes a certain percentage of the budget. And healthcare takes a certain percentage of the budget. And we may have just scratched the surface right now on the war on terror. We may be dealing with it not on our shores. But just as the avian flu can fly around the country you can have an attack in the United States.

I don't know whether this country's going to have enough money to solve all the problems. And so there have to be many difficult choices. I applaud this society for addressing it. I think that yesterday's program was excellent. It raised lots of thought-provoking issues. One thing I do want to point out. We live in a free market system. It's not perfect and there are many disadvantages, but it's what we've chosen and it seems to have worked pretty well. And I support it. But the reason preventative medicine is not supported by the insurance companies or anyone else is there's no money in it. If people don't get sick there's no money. And on universal healthcare what about the people who smoke? Can people make a decision to smoke and get lung cancer and absorb a large part of the dollars allocated for healthcare in this country? And that's an individual decision.

These are very difficult problems in a free society. And I don't think we're going to solve them all today, and we may never solve them all. But I think we've got to continue to struggle and address these issues.

Dr. Stobo: Could I just add, in terms of having the money to do this, if we could decrease administrative costs associated with healthcare - if we could reduce errors, as Ken pointed out yesterday, that's going to take at a minimum millions, probably billions out of the system. If we could remove the duplication that many of you mentioned yesterday, where you go to one facility, have an MRI, go to another facility for the same disorder and they repeat the MRI for whatever reason, it's estimated that 20 percent of the cost of healthcare is due to unnecessary procedures and duplication of procedures. You add all that up and pretty soon you're talking about significant amounts of money, enough to address the issue of universal access.

So that's what I mean. There's money in the system, but it takes discipline. It takes more than a political will. It takes a moral will, particularly among health professionals themselves, which are the problem here in terms of cost. Don't forget, although doctors' compensation is roughly 20 cents on the healthcare dollar, what they add or what they order and what they tell patients adds up to be about 70 to 75 percent of the healthcare cost. Physicians play a very important role in this.

Audience: I'd like to ask you this. We often hear that 90 percent of the insurance money is for people who are in the last two years of their lives who have procedures like dialysis, which are extremely expensive, and the patient may have other illnesses as well in at late age. What about that?

Dr. Stobo: Well, I forget the exact numbers, but they are roughly like that. Eighty or 90 percent of the cost occurs in the last several years of life. But it's also true that 80 percent of the healthcare costs go to 20 percent of the population. And that's true no matter what population the segment of the population get. Individuals with chronic diseases, for example diabetes and arthritis. Healthcare costs associated with that are enormous.

So the answer is, yes, that is true. We're used to having everything made available to an individual in terms of therapeutic interventions, et cetera. And that has to change. But it's not ingrained in medical education making those choices. When I went through medical school the framework of the education was you do everything you can for that individual patient. Now, that paradigm is shifting, particularly as we have to look at finding healthcare dollars to address the health needs of large populations. So how do you balance what's best for the individual patient versus what's best for 100,000 individuals?

When I came to UTMB I found that my patient was no longer the individual in the arthritis clinic, but an individual who doesn't receive the healthcare that they should to East Texas and along the Gulf Coast. Because our clinic extends far beyond Galveston Island - 120,000 inmates, 110,000 pregnant women below income who we treat in over 30 regional maternal and child health clinics all through East Texas, along the Gulf Coast, and even down into the Valley. And so how do you make decisions saying, now, what's in the best interest of those 110,000 women versus what's in the best interest of the patient who's sitting in front of me. And that's a different paradigm, and one we're moving into.

Audience: I feel very passionate about the fact that our system, although it's really great, has us in the middle, as I understood from the lectures yesterday, in the middle on providing healthcare worldwide, but toward the higher reaches of cost. And that's part of the free enterprise system. And it comes back to accountability at the point of sale - price resistance at the point of sale decisions. And whether it was by intention or whether it just worked out that way the insurance companies and the establishments have it in shape where no one knows what the cost is and there's no price resistance. And nobody realizes that they're the ones who ultimately pay. Some of the employers realize that we all ultimately have to pay.

But the other thing I want to address is Governor Lamm of Colorado several years ago took a lot of heat for saying, You know, sometimes the leaves just need to fall off the trees. We have a pluralistic society. Lots of us in this country are Christians and we want to go to heaven, but nobody wants to die.

Mr. Kempner: It's really highly illogical, isn't it?

Audience: Now, there is a religious sect that is willing to die. And that's what makes this whole war on terrorism so ominous, is because this is a religion where people want to go to heaven, and they're ready to die - some of them. All of these issues come down to the fact that we as a society collectively have to do some triage and decide, as Judith Zaffirini says, who's going to live and who's going to die and who's going to decide.

Maybe the taxpayers through their elected representatives are the ones who have to decide. And that's where it's fought out and that's where it should be fought out. I's a great system. I had a law partner who smoked for a long time. Got on an elevator in a no-smoking building. He just couldn't wait to fire up. He gets on, he fires up a cigarette, puts it behind him and looks the other way as a woman gets on the elevator. And she goes, Sir, are you smoking? Yes. Pulls the cigarette out. She says, Well, don't you know that's against the law? He says, Lady, I am the law.

Well, he is dead, and he made a decision and the last year of his life was not very pleasant. I'll bet you that the government and the insurance and the taxpayers and Medicare paid $500,000 in the last year of his life, which wasn't high quality. He was a Christian, but all of us loved him and he didn't want to die, and we kept hoping on hope that it would turn around and he wouldn't die. But those are the kinds of decision that we're facing.

My youngest of nine children is now out of college and has a job. They've all got jobs. My wife and I are healthy, and I love to be with her. But I want to say right now, I do not want to be kept alive at the expense of my children or the taxpayers. When my time comes I want to go. I don't smoke, I don't drink. Neither did my Dad and he got prostate cancer and died within a year. So you never know what's going to happen. But these are fundamental issues that everybody's got to face. And we are kidding ourselves if we go along with the insurance industry and decide that at all cost we're going to provide the ultimate in healthcare for every last one and extend some miserable years right at the end of someone's life at a huge cost to society.

Mr. Kempner: You can rest assured that few people have as many witnesses as you do to your living will. Very few. Yes, ma'am.

Ms. Stuart: I'm Claudia Stuart from Amarillo, and I want equal time. I just wanted to say that when you look at healthcare and the people who are getting healthcare, delivery of services is very, very important. We know that there are physicians who don't want to go into some of our rural areas, who don't want to go into some of our inner-cities for their practices. As I looked at your demographic chart yesterday I noticed that in the upper Panhandle of Texas there's still some underserved areas out of the loop. How can we get those services to those areas? Do they have to be at the table for them to be recognized?

I live in an area where there's 4 percent African-American population. I'm at a number of tables, but I can't be everywhere. And just because I'm not there doesn't mean that I don't have to be considered. I still have needs that need to be considered by the people who are making some of the decisions all over the country. Look at delivery of services to low-income families; if we have a policy in this country of no child left behind in our schools why can't we start delivering services in healthcare to children in Head Start programs at school? You know, bring back the school nurse. Give her more importance and give her more duties. And also take care of our kids.

Dr. Stobo: Well, I agree with what you're saying. But one of the problems is we're still operating in the old paradigm which says the only way you can provide healthcare is if you send a doctor to the rural areas. I would submit that we have to use a new paradigm. And we happen to think that telemedicine can be part of that paradigm. I think that other health professionals can be part of that paradigm. But we have to stop solving this problem or thinking of solving this problem in every case by having a doctor at the table. In other countries in the world other health professionals play a critical role in the health of the populations. And they provide healthcare to the entire countries.

Mr. Kempner: Yes, I think it's important that everybody recognize, as I'm sure most of you did, that when you saw the telemedicine yesterday you always saw a paraprofessional or a nurse practitioner or even another doctor, but usually not, alongside the patient that was being seen by the machine and the doctor that's distant.

And that is certainly a mechanism by which some of this can be handled; clinics manned by those kinds of people and seen by doctors on a scheduled basis. But it's by no means the only answer. I happen to believe that you're absolutely right that delivery and the lack of same is a primary reason why you see some of the demographic differences in the way people survive these days.

Mr. McCowan: Scott McCowan from Austin. Just quickly on this question of what can we afford. I want to point out that as the state of Texas, in terms of state and local taxes, we rank 41st in the country in the percentage that we put into government. In other words, as a percentage of all of our income state and local taxes rank us 41st in the country. We are not making the kind of investment that our sister states are making.

And in terms of the federal government, at no time since the 1960s has the percentage of our total personal income that has gone into federal taxes been lower. We have had massive tax cuts in the last several years. So when we talk about what we can afford we need to look at what we're making and realize that, in fact, our tax effort is getting less and less.

And then one last comment on medicine share of the Gross Domestic Product. We also have to remember that medicine contributes to the Gross Domestic Product. One of the ways it contributes is in increased longevity, which means increased productivity, as well as the fact that it contributes as a business itself. So while its share of Gross Domestic Product may be rising Gross Domestic Product is also rising. And we have to remember medicine's contribution, and we have to look at bigger percentage but bigger pie. And of that pie we're putting less and less into both federal government and state and local government, which we could increase that effort and provide additional healthcare. And we have to look at that whole picture.

Mr. Kempner: Just one observation. Even though tax rates on income are lower I'm quite confident that you'll find that the total amount of taxes collected has risen rather substantially. So, obviously, there's a tradeoff in economic activity. Ithe subject of a totally other debate. But I when you say that we're paying less out of our current income, which is quite correct

Mr. McCowan: Not less in dollars, but less in percent.

Mr. Kempner: Percent. But the dollars have increased overall quite substantially and against some people's projections. So it's dynamic and it changes. There's grades of opinion on both sides of that issue.

Mr. Powell: Boone Powell from San Antonio. There's something that we hinted at a little bit yesterday and we've talked about this morning and that is increasing longevity. But what we haven't talked so much about is increasing productivity and I think Scott just hinted at that.

I think that UTMB has a considerable program in wellness and increasing the quality of life. And I guess my question is do we see that as increasing the productive life of people in society? We've got the idea of retirement. Some people now think they ought to retire by 55 and so on. This has profound implications in a society where people are going to be living to 90 or 100 years old. I just want to throw that out.

Dr. Stobo: Well, I agree with you, Boone. I think that as we increase longevity we do increase productivity. Part of living longer is living better. The advances of medicine are allowing that to happen.

Mr. Randall: I'm Edward Randall from Houston. However, I was born on the island. I want to compliment all those that have taken part in putting this session together. It's been very philosophical, as it was supposed to be. And listening to the differences of opinion in how to solve problems has been most interesting. Certainly we appreciate the medical profession in extending the lives of all of us so that we'll have more time to address the problems that will be created.

And it seems to me that to really address many of these things that we should have a benevolent dictator elected by a democracy. That's not likely to happen, but it's great that we're going to be around longer to work on these problems. And thank you very much for a wonderful session.

Dr. Keck: Ray Keck from Laredo. I wasn't going to speak to this, but I just can't let it go. It's always the hale and hearty that say, Don't keep me alive, don't do this, I want to go when my time comes. I've just been living in Laredo with a situation, not in my own family but one very close to me, that has preyed on me for the last several months because I haven't know what to make of it. And I’ll just throw it out. I realize anecdotes are only anecdotes, but I saw this happen, and I'm sure everyone in this room has seen something similar.

A lady is 93 years old. She goes to vigil mass every single Saturday night and has gone for the last 75 years. She prays His will be done, Thy will be done, every single night. Actually, she wants to thwart His will, as we all do and medicine does. We want to put it off. She needed a pacemaker a couple of years ago when she was 91. She can’t walk, she can only watch T.V. She can’t read. She can't even get herself in and out of the bed, but her mind is very, very clear.

Medicare paid $25,000 to install a pacemaker. She has eight children. Somebody might have said, You all just divide this up if you want your mother to have the pacemaker. But that's not the way the law works. And her children, two of them have said to me that they couldn't have afforded to do it, but they understand the dilemma. We all contributed. Now all she can do is watch T.V. and eat and sleep. But her mind is clear and she doesn't want to die. Who is going to confront her and say, I'm sorry. Senator Zaffirini's point of who will live and who will die and who will be the one to sit there and say, If you had $25,000 you could continue to eat and sleep and watch T.V. with a clear mind. Or you don't have the money? You're going to have to die.

It's a wrenching problem. Going back to what was suggested, I think what we all want is some kind of bureaucratic process that saves one human being from telling another human being that we can't pay for this. And no one has figured out how to do it. So my concern is even if the will were there for all the money imaginable I wonder if we would still not come back to the same question of do you really want this. And when a human being looks at you and says, Yes, I really want it, who's going to say you can't have it. It's a very, very difficult problem. I think only of those sitting here healthy, just having eaten a good breakfast, can breezily say, When my time comes please let me go. Of course you will when your times comes. But we'll also all of us work to postpone the time, and that's the human dilemma.

Mr. Kempner: What you've also posed, as well as a social policy problem, is a medical ethics problem. And that's the one part that we did not have to get into sufficiently in this program because we were working on policy and cures or possible avenues of cure. It would have taken an entire meeting to really get into it because this discussion has been a medical ethics discussion if I've ever heard one about how to allocate resources, how to choose for an individual between life and death, and the inferential medical ethics problems of lack of delivery to certain parts of the population which we make as a medical ethics decision even unknowingly.

So we advisedly left it away because of exactly this. I was hoping that maybe we'd get into this kind of discussion this morning. But we advisedly let Ron Carson moderate instead of participate in the discussions. But keep in mind that that is the dimension you're talking about along with these others. And there are no easy answers to this, in my opinion at least.

Dedie Taylor: I'm Dedie Taylor from Fort Davis, Texas. Lonn and I moved to Fort Davis from Washington, D.C. three-and-a-half years ago. In D.C. we had the best possible medical care. When Lonn had a heart attack at G.W. the teamwork that you talked about yesterday really happened. Well, since getting to Fort Davis we've had a adventure of doctors, as it were. Lonn has a chronic medical problem, and we ended up finding locally a fabulous internist after finding one other internist was overworked: he is the only person who delivers babies in three counties, and he's not an obstetrician.

I myself have had the recent experience of trying to find a gynecologist, which has been hell because there isn't one. Well there was one where we lived and he should have been disbarred or had his license taken away. He gave me very bad advice, and it's only because I'm intelligent that I didn't take his advice. Then I went to try to find a doctor in San Antonio. They forgot that I had made an appointment and their office was horrendous after making a seven-and-a-half hour drive. This is a very successful practice in San Antonio. I've now recently found one in Midland. But it's been an adventure that I wasn't planning on having. I'm very, very healthy, and I'm very intelligent, which helps a hell of a lot. So I can say no. But I had taken the advice of the one doctor I'd probably be dead or having a very bad reaction to drugs that shouldn't have been prescribed for me.

This is just by way of voicing the dilemma of some of us who live in extraordinarily rural areas. And the part of my preventive medicine is just the necessity to educate people. We had a boy in Fort Davis who died last year horribly at the age of 19 of mouth cancer because the stupid kid chewed tobacco. And the whole town gathered together for fundraisers for him and his family. But little macho boys are told, Well, you know, you're supposed to have a can in your back pocket. And it happens in front of us every single day.

I submit that part of the job of intelligent people is not necessarily go to the medical profession, but part of the job of intelligent people, such as myself in this instance, is to say to the little kid, Do you know it really isn't a very bright idea to do that? And sometimes they get defensive about it, but bit by bit it gets into them. So that it's not just about money. It's about using your own knowledge to say, Are you sure you really want to follow that doctor's advice. We have a friend who's doing all of these homeopathic things because she is definitely ill. But there's questions, Are you really sure you should be doing this in combination with that? And you don't have to be an M.D. to ask those questions.

Mr. Kempner: We seem to have exhausted this subject, at least as far as this group is concerned for the moment. So it's now my pleasure to do one more chore. Roger, would you please come up? This is my last shining moment as your president. This is a gavel that Senator Zaffirini gave to the Society. It's a monster. You'll enjoy wielding it. But I'm here officially passing it over to you, Roger, so you can take charge of us for the next year.