NO

Thomas S. Szasz, M.D., Professor of Psychiatry Emeritus, Upstate Medical University, Syracuse, NY; George J. Alexander, J.D., JSD, Santa Clara University Law School, Santa Clara, CA; Jeffrey A. Schaler, Ph.D., Adjunct Professor, School of Public Affairs, American University, Washington, DC.

YES

Victor Sidel, M.D., Professor of Social Medicine, Albert Einstein Medical College of Medicine and Montefiore Medical Center, Bronx, N.Y.; Ron Pollack, Esq., Executive Director, Families U.S.A. Foundation, Washington, D.C.; Barry Levy, M.D., MPH, President, American Public Health Association, Washington, D.C.

Moderator: Welcome to this week's television debate "Is An Egalitarian Healthcare Workable?" I'm Mark Nix, I'm the Timekeeper. We're ready for introductions, we'll start with Victor Sidel. Will you please stand up and introduce yourself.

Sidel: I'm Victor Sidel. I'm Professor of Social Medicine at the Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx. This topic, "Is An Egalitarian Healthcare Workable?," is really to be divided into two pieces. One part of it is healthcare: that is, what is done in a society, to make sure that the food is safe, that the water is safe, that people don't get injured from breathing bad air.-That indeed has got to be the full meaning of the word "egalitarian." That is, that everyone in society must be equally protected in terms of the fact that they don't get sick from what they eat or from what they breath. In terms of medical care, what we mean by egalitarian is equitable. In a medical care system, people who are sick need a lot of medical care and people who are not sick may need less. But everyone, everyone in the society must have access to medical care at a time when they are sick. If that is not the case in a society, we are in trouble in many ways.

Moderator: Thank you. Dr. Thomas Szasz, will you please introduce yourself.

Szasz: I'm Thomas Szasz, Professor of Psychiatry Emeritus at the State University of New York in Syracuse. My understanding of the subject before us is private health, not public health. We are in complete agreement that public health, by definition, should be egalitarian. So, let us, I will confine myself to private health, that is healthcare. Now, in that situation, egalitarianism makes no sense. The idea of equality is a legal, not a medical, concept. It means equality before the law. With respect to health, there are three major players in healthcare: the patient, the doctor, and the payer, usually the state or insurance company. Now, each of these parties has a different idea of what is needed. Therefore, it is not even clear, when one speaks about equality of healthcare, equality as defined by who? If it's defined by the patient, traditionally that is usually amounted to what is called "quackery," that is, people want all kinds of things which are not good for them. If it's defined by the doctor, it's called medical tyranny, "professionalism." And if it's defined by the state, then it's what I called many years ago, the "therapeutic state," then the government is in a position, the government after all, the state is an organizational power, not only to provide things for people, but to impose it on them. And the whole system of involuntary treatment of course, includes itself, then, at that point. As illustrated for example by the whole problem of treating drug abuse involuntarily. Thank you.

Moderator: Thank you. Victor Sidel, you will introduce your first teammate.

Sidel: Yes, let me introduce Mr. Ron Pollock. Ron is the Executive Director of Families USA, the national organization of healthcare consumers and was recently appointed to the President's Commission on the Quality of Healthcare as consumer representative.

Pollock: Thank you, Dr. Sidel. We, in America today, do not have an equitable healthcare system. We've got tens of millions of Americans who do not have health insurance coverage. In 1965, we had similar problems with respect to America's senior citizens. There were millions of seniors who couldn't get healthcare coverage, and we created the Medicare program, which today covers every single senior citizen. Unfortunately, we today have approximately 40 million people without healthcare. That includes 10 million children who are uninsured. And those who are uninsured do not get anywhere near the same kind of healthcare that people who are insured receive. They have difficulty gaining access to physicians, to hospitals, to dental care, to prescription drugs. Now, we are unfortunately finding the situation getting worse because most people get their health coverage through their employers. But increasingly employers are finding the costs of healthcare unaffordable, so more and more people are finding themselves uninsured. We've made a good start very recently by covering approximately half the uninsured children in America, as a result of legislation recently adopted. We need to finish the job.

Moderator: Thank you, Thomas Szasz, will you introduce your first teammate?

Szasz: I introduce Professor George Alexander from Santa Clara University.

Alexander: Thank you. Well, I hate to say this, but I believe the topic as I understand it has been conceded by Dr. Sidel and been joined in that respect by Mr. Pollock. We're not talking about whether the poor need more healthcare or wealth redistribution. We're talking about an egalitarian system. Providing equality requires legal steps that the law has demonstrated very well over time it is not prepared to provide. Our major effort has been through the 14th Amendment, where we provided quality protection of the laws, and gave that gave us first separate equality, which meant that blacks got to ride in other railroad cars. And when that was seen as an obvious failure, it gave us the notion that equality meant that some people were more equal than others, that only a small group of people could be given equality. In point of fact, equality provided by the state has never worked, cannot work, and should not work. And that is the topic that I think we're debating: whether it is equitable or not equitable, in the short time I have, I suspect I can't address right now, but I guess we'll get back to it. The question is, can it be egalitarian? The answer is, of course not.

Moderator: Thank you. Victor Sidel, your final teammate.

Sidel: It is my pleasure to introduce Dr. Barry Levy. Dr. Levy is the President of the American Public Health Association, which is the oldest and largest public health association in the world. He is also the Adjunct Professor at the Tufts Medical School.

Levy: The question we're debating today is "Is An Egalitarian Healthcare Workable?" and the answer is definitely "yes." We only need to look to Canada, to the countries of Western Europe, to even our own Medicare system, to see that, indeed, an egalitarian healthcare is workable. I also think that it's foolish to think that we can have egalitarianism when it comes to public health and not have egalitarianism when it comes to medical care. It makes good sense to have egalitarianism in medical care for financial reasons, we don't want people to get sick, to get care only when they're at death's door. It doesn't make good financial sense or humanitarian sense, it's the right thing to do. And also from a public health point of view, we don't want people with infectious diseases, for example, not getting healthcare. It's in the interest of the public at large that indeed not only should we have an egalitarian healthcare, but indeed we only need to look to other countries and to some systems in our own country to see that indeed, an egalitarian healthcare is workable

Moderator: Thank you, Thomas Szasz, your final teammate.

Szasz: Our final teammate is Dr. Jeffrey Schaler from American University

Schaler: Thank you, Tom. There are several issues I'd like to address in this debate. One is the fact that 75 percent of the un-, or under-insured, are in fact, employed, or they're dependents of employed persons. Now, the fact of the matter is, they are not able to afford health insurance or they choose not to purchase health insurance. Now, my concern is, why is health insurance not affordable to them? And one area that I don't think we talk enough about is how government-mandated insurance benefits, particularly those requiring coverage for mental illness and for addiction, in fact are unfair and drive the cost of premiums up. So, I have very real concerns there that government is dictating the kind of coverage that insurers must provide, and I think that there is a tremendous loss in terms of monies there for treatments that essentially do not work. The other concern I have though, is that what we have in terms of mandated coverage or mandated healthcare is in fact moralism masquerading as medicine. And what we have is an imposition of morality, in the name of medicine. And as Dr. Szasz mentioned, how we define healthcare is critical here, for the purchaser, for the provider, and for the payer, it may vary a great deal. Also, I'd like to say that we differentiate in this debate between biological illnesses and behavior disorders, because I do not believe you can treat, legitimately, a behavioral disorder. And also, we differentiate between behaviors a person engages in that harms primarily themselves versus others. Thank you.

Moderator: Thank you. We're ready to start the debate now. Thomas Szasz, will you please stand and be prepared to be questioned by the other side?

Pollock: Yes, I'd like to ask Dr. Szasz, do you think it's egalitarian or equitable or fair for millions of Americans not to have health insurance coverage, people who are working, working families, but simply can't get it because their employer doesn't provide it and they simply can't afford to pay for it?

Szasz: Well, I would first state that life isn't fair, so I obviously don't think it's fair, but I think, in this discussion, we should . . . past the point where we take it for granted that health can only be obtained by employment and being provided through the employer, which is really a fallout from our tax system. If there was no tax system, as it exists, we would not have to ask if it was a nontaxable income and so on. So, of course it's not fair. But the issue is not, well, it's not fair, the whole issue of health is not fair. Is it fair to be born with a congenital defect? Is it fair to have an accident? Illness and good health are largely a matter of genetics, that's crucial, we must agree, and secondly to health habits. Healthcare itself is only one aspect of being healthy.

Sidel: Let me ask, if I may ask, Dr. Szasz, is not healthcare, medical care, actually, is what you're talking about, is not medical care an important part, perhaps genetics is important, it is, habits are important, they are, but if someone is denied medical care when they have an infectious disease, such as tuberculosis, and could spread it to other people, is that a right thing for a society to do?

Szasz: Excuse me, Dr. Sidel, but who is talking about denying anything? I take it for granted that if people cannot afford something, whether it's food or housing, or medical care, the state should provide it for them.

Pollock: Unfortunately, we don't, as you know, we don't have that system today . . .

Szasz: . . . . We have that system . . . .you can always go to the emergency room of a university hospital . . . .

Pollock: . . . Only, of course, if you have a true emergency. If you have a regular health condition, you have no right to healthcare. You think we should change that, don't you?

Szasz: Well, when I went to medical school, there was no such thing as healthcare provision as we now know it. No one was without healthcare, because that's what University hospitals were for. That was what community hospitals were for.

Levy: Was that not an egalitarian system?

Szasz: Of course not. Not egalitarian. It was not egalitarian any more than our system of providing food. Food stamps are not the same as the food you and I choose.

Levy: But egalitarian, I mean, if we use a different dictionary definition, the dictionary makes a differentiation between egalitarian and equal. We're not saying equality is going to be imposed on everybody. We're not saying that people couldn't purchase more healthcare if they wanted to and if they had the money. We're talking about a decent level, a standard level of healthcare available to everyone. Maybe we're in agreement on that.

Szasz: I am entirely in agreement with that, on the analogy, let's say, of food stamps. Healthcare stamps. Let's give people healthcare stamps. But will you give them the option of converting them into buying cigarettes? Because health is only one value. A lot of people value smoking more, or climbing mountains. Every day you read about people falling off the alps.

Pollock: But it seems to me, then, that you're in effect saying that an egalitarian healthcare is workable. From what you've said?

Szasz: But that's not egalitarian. Is it egalitarian to ride a subway and ride a Rolls Royce? . . . It's not egalitarian? You can get from one place to another with a subway too, but it's nicer to do it in a chauffer-driven limousine . . .

Pollock: . . . So, it depends on how you define the word "egalitarian." If, as we define egalitarian, it's the provision of decent services for all Americans . . .

Szasz: . . . Sir, . . .

Pollock: . . . .You would agree with that, if the question was does it have to be precisely equal, that's where you would disagree.

Szasz: Right, but excuse me, you don't have a right to define egalitarian as you want it. It's in Webster's Dictionary. "Egalitarian" means equal, it does not mean minimal or decent. Of course, I am for minimal and decent healthcare, who isn't?

Levy: But the dictionary, and we looked it up last week knowing that we would be on the program, but it doesn't define it synonymously as "equal." I believe it's as, with respect to . . . , equality, with regard to social, political and economic rights, and I don't think we necessarily want to get into a discussion of rights tonight, tonight, but they are not synonymous terms. We're not talking that everyone should have exactly the same Rolls Royce, or that everyone should have exactly the same food or that everyone should have exactly the same healthcare, and maybe, indeed, we are in agreement that everybody, including the 40 million people who don't have good access to healthcare in our country really deserve that.

Szasz: I am certainly in agreement with that. Thank you very much for putting it so plainly.

Moderator: Okay, well, thank you very much. Victor Sidel, it's your turn, first question.

Alexander: Well, perhaps we are so much in agreement it's hard to ask a question, but if "egalitarian" meant anything like "equal," I take it you would stand by your concession that in terms of private healthcare, that can't happen. That's what you said.

Sidel: If, by "equal," we mean that somebody who is not sick, has medical care that he or she doesn't need, then we're in agreement . . .

Alexander: . . . Well, how about . . .

Sidel: . . . Let me continue with the answer . . .

Alexander: . . . Please . . .

Sidel: . . . If we mean that someone who is ill, and someone who is ill and needs medical care for that illness, doesn't have access to that care, that's unequal and that is something that we're against.

Alexander: Yeah, which means that everyone who has the same illness is entitled to the same excellent surgeon who is the best in the country.

Sidel: It's impossible for one surgeon, of course.

Alexander: It's impossible. That's the answer that I was looking for in the beginning.

Sidel: Yes but, but this is not a play on words, sir. What it is is a debate about what we're talking about . . . what we're . . . let me finish, if I may . . . we're talking about equitable medical care. Equitable medical care means that not everyone has to go to the same surgeon, but that the surgeon that you have access to, has the skills to the job to treat you for your illness. If you lack medical care insurance in the United States today, you, shown over and over again, do not get the same quality of medical care, do not get decent quality of medical care as people who are insured. The 40 million people, as has been said, therefore lack decent access to medical care. That's what we're talking about.

Schaler: Could I ask something here? For me, one of the problems is, who defines what constitutes decent or adequate medical care, and who defines what is a legitimate illness. All right? Now, let's assume for example-and I don't think that this is equitable here, and I don't think it can be as long as it's defined by the state-let's say, a person has depression. Is depression a legitimate illness? Is Prozac or counseling a legitimate form of treatment? Let me add something else. Let's say a person has cancer and wants to use a European homeopathic remedy called "Iscador," which is not considered to be a legitimate form of medicine. Yet, that person wants to use this form of treatment. Would state-mandated health coverage allow for differences in treatment approach? I don't think that it would. And this is the problem here when you have a select group of people defining what is appropriate medicine for legitimate illness. It varies tremendously.

Sidel: You're asking some very important questions. But in so doing, you're missing the most important question. Which is that for illnesses, that all of us would agree, society would agree, need medical care, for illness even more than that, that are dangerous to other people, such as infectious diseases, those illnesses, in my view, clearly fall on the side of having decent medical care available and accessible to people who need it. On the margins, there are going to be debates.

Szasz: But the margins are economically where the issue is greatest. That is, at the end of life. We all agree that someone let's say 80 years old, with far-advanced cancer of the colon, who let's say may have six months to live, or three months to live, let's assume he wants some extensive surgery which costs hundreds of thousands of dollars which may prolong his life by a few days-how much of this should be paid? Someone referred to the European system, but in England, they've limited kidney transplants at some very, relatively early age. So what you are arguing really is some kind of a minimal healthcare, and we would not be against that.

Sidel: What I am arguing is the following: That for the vast bulk of the population, and for the vast bulk of the medical care problems, people need decent access to medical care . . .

Szasz: . . . Well, we agree with that, but, let me make the point, is most of the money going at the end of life . . . .

Sidel: . . . Let me go on to the margins. Now, at the margins, which the three of you seem to be talking about, although I don't quite understand why, at the margins, there indeed have to be debates. There has to be a public discussion of what kinds of treatments are efficacious, of what kinds of treatments people need and want.

Szasz: But those are not the margins, Dr. Sidel. No one debates that taking out an appendix for acute appendicitis, everybody should have. We are talking about the large expenditure at the end of life . . .

Sidel: . . . And societies and communities . . .

Szasz: . . . which doctors themselves now confuse that. Now, if you have money, you simply pay for that care and insurance companies themselves, people have insurance, are denied care, so you talk as though insurance was the answer. But insurance companies limit care. You talk, if someone has insurance, that in definition, he has his Rolls Royce. Yes, he has his Rolls Royce, but the company says we won't buy the gas for it.

Sidel: . . . But by saying that . . .

Moderator: Thank you. That's a quick cutoff there. George Alexander, it's your turn. Please stand. First question, the other side.

Pollock: Yeah, I'd like to ask Dr. Alexander, Dr. Alexander, do you know what the profile is of these large numbers of Americans who really don't have access to healthcare today, who are uninsured, do you know what their work status is? I ask you that question because I got the impression from your opening statement that you thought these were poor people, these were people on welfare, and I think the facts show otherwise, but I was wondering if you wanted to answer that.

Alexander: Well, I am certainly willing to concede that in addition to people who are poor, there are a number of people who are uninsured. I don't think our disagreement at all is based on whether some minimal resources, some resources, I strike minimal, ought to be provided to people so that they could manage healthcare. And for that purpose, I don't care whether they are poor, or whether despite their affluence for some reason they don't have the ability to get the healthcare that they want. The point is that it seems to me to provide egalitarian, or even equitable, healthcare, which I think is not what we're discussing, you have to have the state involved in deciding what provides equal treatment. That gets you into the kind of problem Dr. Schaler talked about and the kind of problem that is uniquely dealt by Dr. Sidel by saying it's on the margin. It's not on the margin. For most people, what they most want, most of the people I speak to and read about, is the right to decide how they get treated for what they think they have. Not the right to go to some state agency and try to argue that what they have is a medical condition for which the state ought to dispense some resources. It is the waste of money and the waste of time in trying to have the government prescribe not healthcare, but health appropriateness, that seems to me to be the basic reason.

Pollock: Where does the government prescribe healthcare? I'm not aware of government prescribing healthcare. We have a private healthcare system. We have public and private payers of healthcare, but we have a private healthcare system. I'm not aware that there is this red herring of government prescribing healthcare. I've never heard that before . . . We don't have that in the Medicare program or the Medicaid program or private insurance. The government does not make those decisions.

Alexander: But it does make the decision in setting the standards in Medicare as to what is appropriate for reimbursement, what is not appropriate for reimbursement, and in that way, it excludes a large number of things that doctors would like to do and patients would like to have, and that people not called doctors would like to offer people, like acupuncture and a variety of other treatments. Now, you don't get those.

Levy: Right. Let me just make a couple, make a point and ask you a question. The NIH is having a conference on acupuncture, in fact, this month, the month that this program is going to be aired, on in fact assessing acupuncture and making some recommendations as to how it should be used in medical care. You keep on making a distinction about the state. Isn't the state in a democratic society like our own a reflection of the people, isn't it the will of the people to say what the standards are?

Alexander: No, sir. The will of the people is expressed by the people. What I want is that if I'm ill and think that acupuncture will work for me, that you give me acupuncture, or make sure that I have the resources to get it, not that you convene a governmental group to tell me whether it's the right choice. That's what a democratic society is fundamentally about.

Sidel: Let's talk about the will of the people. You started out by saying that the people you talk with want certain specific things. The people I talk with are mothers in the Bronx and they want primary care for their babies. They want their babies to be immunized, they want their babies to get checkups. They can't get that easily if they're uninsured, they can't even get that easily if they have Medicaid, which is severely underfunded in our society. Let's talk about those people in the society. Do they have some rights to care?

Alexander: Well, you know, I find it difficult to respond to you both, Dr. Pollock doesn't want me to talk about, Mr. Pollock doesn't want me to talk about poor people, you want me to talk about poor people. I can't do both at the same time. I think that the government has a role in dealing with poverty. And if poverty means that you can't get your babies treated the way you want them treated, I say the government, as Dr. Szasz does, has a role in making sure that doesn't continue. Then I say, if parents want their babies treated in a way that seems appropriate to them and that hasn't yet passed an NIH review, they should get the care that they want, not the care that the government wants to give them. And especially if we're talking in economic terms, as we have to be when we talk about ameliorating the position of the poor, let's not waste the money that we're wasting, in funneling all of this through a bunch of decision makers.

Levy: I'm sorry, to interrupt, but . . .

Moderator: I'm sorry I have to interrupt here too. Ron Pollock, it's your turn, first question.

Schaler: Mr. Pollock, you seem to agree that 75 percent of the un- or under-insured were in fact employed, is that correct?

Pollock: It's actually larger than that but you are approximately correct.

Schaler: Good, 75 percent, conservative. Then, I'm curious, why is it that they can't afford health insurance, if in fact that's the case that they can't afford it, or do they choose not to purchase it? And a subpart of that question is: What role do you think government-mandated benefit packages has in driving the price up, so that it becomes unaffordable? In other words, and an additional question, related is, how come, then, K-marts in insurance coverage don't pop up and provide lower-cost health insurance for people who want it at a lower price?

Pollock: With the few seconds I have left . . .

Schaler: . . . Sorry.

Pollock: . . . I would, I would say to you that you're absolutely right. That the vast majority of people who don't have health coverage are people who work, or if they're children, their parents work. Now, the reason those people or children don't have health coverage is because most of us in America get our health coverage from the workplace, we get our healthcare coverage from our employers. And, the people who are uninsured in America tend not, actually, to be the poor, although there are some who are poor, most of the poor get their coverage through the Medicaid program, there are some who are poor and don't get it. But, it's working families who are typically working for small businesses. Those small businesses pay a relatively smaller amount of money than do employers in larger businesses. And they don't provide any health insurance coverage. Now, if you're working at something modestly above the minimum wage, or double the minimum wage, for that matter, and you don't have health insurance coverage through your employer, as most of us get our coverage through our employer, then if you have very little discretionary income, you can't afford to pay say four or five thousand dollars for an insurance package for your family. That's the predominant situation in America and we're not talking really any question about egalitarianism, everybody has to get the exact same amount . . .

Schaler: . . . Excuse me . . .

Pollock: . . . We're so far from that kind of reality in America, we unfortunately have forty million people at any point in time who are uninsured, and if you look at the American population over a longer period of time, say you look at them over two years time, we're talking about considerably more than 40 million Americans. Now, you asked the question what is the impact of mandates, I'm not sure you used that exact terminology . . .

Schaler: . . . Well, there was a question before that. Why is it so expensive, why can't they afford it?

Pollock: Well, unfortunately, healthcare costs have risen both in the private sector and in the public sector, at double or in different years three times the rate of inflation. And so, as a result, a lot of businesses are saying they simply can't afford to provide coverage. And if you're talking about for a family that is making 25 thousand or 30 thousand dollars income, which could be double the poverty line, to pay another five thousand dollars for health insurance is simply unaffordable.

Schaler: But from a free market perspective, that doesn't make sense. The insurance company would have an investment in providing coverage, getting people to purchase their product. If they set a price too high and people can't afford it, they'll go out of business. Why wouldn't they adjust? Doesn't the government have . . .

Pollock: . . . Well, I think you have a misconception about the insurance industry in America. The insurance industry does a lot of its business in trying to reap a profit by doing as much on the not-providing-health insurance as providing health insurance. For example, and you know this probably as well as I, that a lot of insurance companies, in order to get their profit margins up, what they want to do is they don't want to insure people who they think are going to be health risks. And they don't market to them, they try to avoid providing health insurance coverage for them, and so, for most products in America, you'd think you'd want to have as big a buyer base as possible. With insurance companies, they want to cherry-pick. They want to find the youngest, they want to find the healthiest, and that's how they make money. For those people who are sicker, those people who are older, the insurance companies don't want to do with it. And insurance companies are not in the business of providing cheap premium products, and to the extent, some do, and there are some that do, but they also provide lousy health coverage.

Moderator: Thank you, Jeffrey Schaler, it's your turn. First question, the other side.

Levy: There's recently been a discussion here about waste and inefficiency and using the money most appropriately that we could for healthcare. But to do that, we really need to look at the efficacy and the safety of various kinds of treatments. And in fact, acupuncture is one of the treatments that our government is now looking at in a systematic way to see whether it's safe and efficacious, and if it's effective, what kinds of illnesses it's effective for. So, wouldn't you want, indeed, the government to be doing those kinds of analyses so we don't waste money?

Schaler: I'm not interested in the government doing it because I don't think it's objective. I think it's influenced by the private market and their drug companies. There are people who have an interest in not seeing acupuncture approved, or other forms of treatment.

Levy: But if not the government, would you want the private sector making those decisions?

Schaler: I think that each individual has a right to choose whatever form of treatment or no treatment he or she sees fit and I suspect that there are insurance companies that are interested in providing coverage for those alternative forms of treatment because there's a market for them, which, I think as you know, there's a tremendous boom in those people seeking alternative forms of treatment, most of which are likely not to be approved by state licensing bodies, the NIH in particular. And as you know, NIH is a very political organization that is not exactly objective in its assessment

Levy: I would disagree with that, but that's not the topic . . .

Schaler: . . . Oh well . . .

Sidel: To continue the line of the question and indeed to share in Dr. Levy's view of this, if people are going to base their decisions on what they want, whether they want acupuncture or whether they want something that's poisonous to treat them, they have to base it on some information, and there has to be data out there on which to base it. Do you want that data to come from the private sector where people are interested, specifically, clearly, in making profits from selling that particular modality? Or do you want it to come from some public body that has the responsibility and that is being oversight presence to permit them to look at it and provide decent information?

Schaler: In fact, I trust the private market far more than the government and I trust the selfish interest of the private market far more than the allegedly altruistic and selfless interest of government because the private market, if it sells a bad product, that will eventually be revealed. There are other private organizations . . .

Sidel: How many people have to die before that's revealed?

Levy: And in doing so, does that mean that you trust Columbia HCA to do right finding . . .

Schaler: I don't subscribe to that . . .

Pollock: Or Phillip Morris?

Schaler: Do I trust Phillip Morris?

Pollock: Well, that, yes.

Schaler: I have no reason to trust or distrust Phillip Morris.

Pollock: I think the issue clearly put is for these decisions to be made, should the decisions be made by a company that has a financial stake in that decision . . .

Schaler: . . . Absolutely, it most certainly should be . . .

Levy: . . . or, or, or in terms of consumers having a sense of unbiased decision making, should it be made by parties that do not have an economic self-interest in that decision?

Schaler: And you're saying that, that the government does not have an economic or political interest in this?

Pollock: I would say between Columbia HCA, and we just have to pick up every day's newspapers to see what that private sector organization has done with respect to healthcare and the way it treats people, that I would like somebody protecting me.

Schaler: And I think the private sector has a vested interest in exposing fraudulent or negligent business practices . . .

Sidel: . . . Does the tobacco industry have that interest?

Schaler: That's why we have Consumer Reports, consumer unions. People, the free market, finds a solution to these problems. People are willing to purchase. Private market is willing to donate money to private groups to be investigated to pass their tests of quality control, etc. . . . The economic interests and selfish interests of the private market is far more reliable than the government, far more reliable.

Levy: I see, so, who is it who's exposing the problems with respect to, going back to Columbia HCA? Has Columbia HCA come forward and said these various practices, these fraudulent practices, I might underscore, we want to reveal them to you because we think what we're doing is wrong . . .

Schaler: . . . In fact, other healthcare . . .

Levy: . . . It's been oversight agencies . . .

Schaler: But other healthcare organizations have a vested interest in exposing fraud and negligence on the part of competitors, don't they? Their economic life is at stake. So they have an interest . . .

Levy: . . . But they haven't . . .

Schaler: . . . Well, but I think eventually they do . . .

Levy: Take a look at the tobacco industry as a wonderful example. Which of the various competitors in the tobacco industry have revealed their fraudulent practices?

Schaler: We certainly do not need the United States government to inform us . . .

Moderator: . . . Short answer, Doctor.

Schaler: . . . that cigarette smoking is potentially dangerous. We don't need the government to do that. And in fact, what the government is now doing is relying on the tobacco companies to admit that cigarettes are dangerous!

Moderator: That's short enough. I think we can move on. Barry Levy, it's your turn. First question. Dr. Szasz?

Sidel: Speechless.

Szasz: Yeah, I'm speechless. Well, there's an argument . . . that, afterwards, there's an economic issue here. And no one wants to talk about where most of the money is going. Now, a great deal of the money is going at the end of life, and it is going for interventions which are, which cater to people's bad habits. And this is where the whole discussion about insurance companies is really quite misleading because if you have a car insurance with a company, the insurance company, and keep having accidents, your premium is raised and pretty soon it's cancelled. But if you have health insurance and don't eat, that's called "anorexia nervosa." If you smoke, that's called "due to the tobacco company." If you climb mountains and fall off it, that's an accident and they have to pay for you because you're paralyzed for life. So, all of these are life habits. Now, an enormous amount of money is going there and you all want to talk about treating pneumonia. Well, we're all in agreement that pneumonia should be treated . . .

Levy: . . . Well, let me go by extension . . .

Szasz: . . . Wait, let me . . . this . . . The real issue before America now is, all you have to do is open the New York Times and all they talk about is: What is a disease? All of life is now a disease! And our argument is that this is the encroachment of the state. The state can't control people because they are Jews or Blacks or Women anymore. They can control them because they are sick. How do they control them? By paying for the treatment or not paying for the treatment, all this manipulation. The insurance companies are not private. You can't get the auto insurance companies, the state doesn't tell the auto insurance company what kind of drivers it has to insure. But, it does . . . the insurance company has to insure non-diseases like alcoholism, which the AMA and the government says is a disease. Smoking is not a disease. These are all habits, and all this has to be insured and you are not touching on this.

Levy: I don't get your question . . .

Szasz: . . . Well, this should all be ruled out. It should not be covered. No health insurance company should be compelled at present the government, you cannot operate . . . you and I couldn't open an insurance company tomorrow and say "we will not insure for alcoholism for schizophrenia, for depression, we will only insure for real diseases, a la Virchow."

Levy: . . . Yeah, yeah . . . but I maintain . . .

Szasz: . . . Back to pathology.

Levy: . . . Yeah, but I maintain, and think I hinted at this before, I really maintain that what we're doing, what the government is doing, is a reflection of what we in society want to do. I see healthcare . . . Let me just finish please . . . I see healthcare as a subset of public health, and public health is what we do as a society, collectively, to assure the conditions in which people can be healthy. And I see that the government making decisions on setting standards for what Medicaid or Medicare will pay for or not pay for, and I agree that influences the private insurance market, and so forth, but I see those government decisions being made at the will of the people. Now it may not be the six of us making those decisions, but we as a society have a tremendous impact on what our government does. And if you have a belief for example, that drug addiction is not a disease, or mental illness is not a disease, and it should not be covered, then, this is a free society, you can, and I know you do, express that view to others. And I would encourage you to express that to the government. I have faith in the system.

Schaler: But in the meantime you're penalized for that. You have to pay higher premiums.

Szasz: You're very cavalier about the fact that government is an oppressive institution. After all, the persecution of Jews was a health, was done by the medical . . .

Levy: . . . We're talking about the United States today. I mean, our government is not a perfect government . . .

Szasz: . . . What about Tuskegee? What about Tuskegee? . . .

Levy: . . . but it's a democratic government . . .

Szasz: . . . What about the "Gulf War Syndrome?" It took them a year for them to reveal that there was a nerve gas . . .

Levy: . . . But it was revealed . . .

Schaler: . . . and how many people are thrown into jail for being drug users?

Levy: But it was revealed because of the New York Times and other newspapers, it was revealed because of public oversight. It was revealed because colleagues of ours who are specialists in the area of toxicology and environmental occupation, on that commission, said that indeed the Gulf War Syndrome was real and was related to exposure . . .

Szasz: The public health service ran the Tuskegee experiment . . .

Levy: . . . I'm sorry, I didn't hear you . . .

Szasz: The public health service itself ran the Tuskegee experiement . . .

Levy: . . . That was horrendous . . .

Szasz: . . . That's not enough. The health service runs the entire mental health system, in which John Hinckley is confined forever . . . as mentally ill.

Alexander: Dr. Levy, I just want to make sure I understand you. Is it your position that if a problem will ultimately be solved, it's not a problem? You know, you said, "Well yes, that's true, but they'll take care of it. Well, this is a problem for later."

Levy: No. I didn't say that.

Alexander: Well, what did you say? I mean, all of these problems . . .

Levy: . . . I realize there are some lawyers in the room, here. No, what I did say is this: I have a belief that in a democratic society like ours, that when the state is making decisions, ultimately there is public oversight. And the state, maybe not always, not all of the time, but ultimately, the state is expressing the will of the people. That's what I said.

Alexander: That's got to be correct. But there is another notion which is that the state is limited in the amount of interference it can impose on people. Is that not another equally important?

Levy: There are checks and balances in our system. Yes, there are limits to which the state can impose.

George: You're getting back to saying they eventually can be cured . . .

Moderator: . . . Well, I need to impose that we go to the one-on-one debate. Victor Sidel, Thomas Szasz, will you please stand. Victor Sidel, you can begin questioning first.

Sidel: First, let me say how much I have admired your work, I have disagreed with much of it . . .

Szasz: . . . It's mutual, Dr. Sidel. Thank you.

Sidel: Let me go to a couple of things you specifically talked about. At one point, you said let's go back to pathology, and you mentioned the glorious name of Dr. Virchow, Rudolf Virchow, who was a pathologist in Prussia, in the last century, and was sent by the Prussian government out to Silesia (sp), to investigate an outbreak of typhus fever. And Virchow came back and said there was a role for government in dealing with that outbreak of typhus fever. He talked about what had to be done in terms of changing the standard of living of people. And he came back and he worked for the rest of his life in pathology as well as in social medicine. Now, while I understand that you have very strong beliefs, and I respect them, about certain kinds of illnesses and whether they should be treated or not, for people who have typhus fever, Dr. Szasz, do we not need both a public health system and a medical care system that provides to every single person, who needs that kind of care, decent equitable care?

Szasz: We do. I agree.

Sidel: Number two . . . Fine. I'm glad we agree. In that case, somebody needs to organize that system. Now, many of the members of your panel, perhaps you as well, believe that should be entirely in the hands of the private sector. But then the question arises . . .

Szasz: . . . No, I don't necessarily agree with that.

Sidel: You don't, okay. Good. I think you perhaps disagree with some of your panel members. But that's fine.

Szasz: When do I get to talk?

Moderator: You'll get your chance. You can disagree in a second.

Sidel: The question is, if we leave it entirely to the private sector, can there be indeed be a system that will make certain that every human being . . . the poor, which I am particularly concerned about, as well as others in society, got the care ?

Szasz: Yes, I agree again. Can I talk?

Moderator: Go ahead, this is your turn, now. You can turn it around and ask questions.

Szasz: No, I want to make a statement. I don't want to ask questions. I have also admired your work, and perhaps because we are addressing, we are looking at two different parts of the elephant. You are talking about public health, in other words, you are talking about health issues which if you have got the disease, you are a danger to me. I want to separate those from diseases where if I have got the disease, I am of no danger to you, whatsoever, which is true for virtually all of the diseases which are not fairly directly contagious, even for diseases like AIDS. I have to go out of my way to get it . . . If I am careful in my lifestyle, I will not get it, even if you got it. So, let's forget the contagious diseases. Those endanger other people very much like lawbreaking and they belong into this in-between land that is to public health, which is correctly called public health. But let's talk about cancer, pneumonia, smoking, all of the diseases which . . . I don't have to enumerate them. Now, those are my problem. And there are three agencies which are interested in them. I, we already talked about that, the medical profession, and the payers. Now, we all have different interests in here, now you don't address that. Now, for example, you spoke about the poor woman with the child, and she has no health insurance. Well, how many children can she have before she can say, "Look, I got another child that I can't take care of"? Do we have no responsibility for having children?

Sidel: . . . Before you go along those . . .

Szasz: . . . Have we no responsibility for overeating?

Sidel: May I just interrupt for a second? Before you go along those lines, do you have any idea how many children, on the average, women on welfare have, in the United States? When you talk about having these many, many children, and damning the poor.

Szasz: I'm not damning the poor.

Sidel: You just talked about if she has more children, and what will happen. 1.9 children is the average among people who are on welfare in the United States. What happens is people get up and they talk about not serving poor people.

Szasz: I didn't say that. All I said is that having a child is a responsibility. This sick child certainly does not appear out of heaven. You have done something to have a child without being able to afford having a child. And that is an assault on the public purse. Exactly like contagious illness, or similar to contagious illness.

Sidel: My point was that overstating that assault on the public purse, overstating as I believe you're doing, this whole body of illness that I think needs to be treated when people want to treat it, is an assault on our sensibilities.

Moderator: Thank you, it's time to move on. Ron Pollock, George Alexander. Ron Pollock, you begin questioning first.

Pollock: Sure . . . Dr. Alexander and I actually are lawyers. We're past law school deans.

Alexander: That's a double indictment, I believe.

Pollock: It is, I'm enticed to say that what I said to a lot of law students when I was a law school dean, I told them, if you got a problem, get a lawyer, then you got a bigger problem because you got a lawyer. I'd like to ask you, Dr. Alexander, do you believe that the steps that we have recently taken, Congress and the President, in providing healthcare coverage for half of America's uninsured children, do you think that is a good step?

Alexander: I think the intention is a good intention, which is somewhat different. I completely agree, if now you'll let me talk about the poor.

Pollock: No . . . Wait a minute. I did not say that those were poor children. You did not hear the word poor out of my mouth. In fact, as I said before, that the children, as well as the parents who are uninsured are in working families.

Alexander: But, I need to talk about the poor, if you ask me whether it's a good idea, because I'm not sure that it's a terribly good idea to provide health insurance for people of adequate means. I think the remedy there is to deal with the problems in the insurance industry that keeps Dr. Schaler's suggestions from working out. The insurance industry . . .

Pollock: . . . What do you mean by that? How would you have us deal with the insurance industry?

Alexander: I think probably that's a bit far a-field for this discussion . . . Yes, yes, as lawyers would say, I opened the question, and I'm happy to continue, though I think it's a digression. What I would like to see is something that has already begun. I would like to see the anti-trust efforts that have been taken against the insurance industries pressed a bit harder than they have been pressed of late, so that the insurance companies have a greater difficulty in agreeing with each other as to what will and what will not be insured, so that the market forces Dr. Schaler was talking about can help provide people of means adequate insurance. I don't think that's a government role.

Pollock: What about the children in America who are uninsured today who are in working families? These are not wealthy families, they are not poor, they are not below the poverty line, but their parents are working in a small business. They are being paid modest wages, and they're not getting coverage. Would you extend that . . .

Moderator: George, you can open up your next question, now.

Alexander: Yes, why won't you hear my answer?, is my next question. My question is why shouldn't the insurance industry be forced to operate like a business, which would take care of most of that problem?

Pollock: Well, I actually do think the insurance industry should be forced to do a wide variety of things. Of course, it's government that's the instrumentality for doing that, it's not other insurance companies. . . . But I do believe that government should prevent insurance companies from denying insurance to people who have got a health condition. I think that government should prevent people from being denied health coverage because they are over a certain age point. I think government can protect people from some of the abuses that occur in the insurance industry.

Alexander: And then, you said that you didn't really want to trust Columbia. Do you want to trust the FDA?

Pollock: FDA does not deal with a provision of healthcare . . .

Alexander: . . . Oh, certainly they do . . .

Pollock: . . . but if you ask me would I prefer to place my confidence in the FDA for things like tobacco smoking and regulating that so that children don't continue to be plagued by being addicted to smoking, sure I would.

Alexander: How about the FDA in its role in keeping from the American market a number of drugs that have proved safe and efficacious in the rest of the world?

Pollock: I believe there are some changes we can make in the FDA in terms of doing testing at a faster basis and approving drugs on a faster basis. But I very strongly believe that a system like what we have with the FDA will protect us from making sure that drugs that have no efficaciousness are not going to protect people or that could cause problems for people . . .

Moderator: We need to move on. Sorry. Barry Levy, Dr. Schaler. Barry Levy, begin questioning.

Levy: Dr. Schaler, your side in this debate has made a distinction between, I think, between the infectious disease we've been talking about and diseases or disorders like drug abuse . . .

Schaler: . . . Which I do not consider to be a disease.

Levy: I understand and I've read some of the things that you've written that in effect, that explicitly make a distinction between physical disorders that you call "real," and mental disorders, that you call "fake." If I read correctly.

Schaler: Metaphorical.

Levy: Let me just go on and ask, an analogy here. I would see that with regards to let's say drug abuse, that the same three things that we were saying earlier that pertain to infectious disease, that there's a humanitarian reason to treat, but beyond that there's also fiscal, financial economic reasons to treat those people, before they cause greater cost to society, and there's also greater risk to society at large-the public at large. Somebody who is a drug addict is probably more likely to commit a crime that might affect somebody who is not a drug addict. They may be a danger to the rest of society. So it surprises me that you would oppose, that you would withhold treatment for somebody who has drug abuse who is willing to be treated, or indeed wants to be treated. Did I misunderstand you?

Schaler: No. You understand me partially.

Levy: You would withhold treatment from these people?

Schaler: Well, one because I don't consider it to be treatment, I consider it to be moral or religious indoctrination. And I don't think that that should pass as medicine. However, let's look, let's move from the macro to the micro in specific examples in terms of the efficacy of drug treatment for drug addiction. And another thing, let me add that when you talk about crimes that allegedly may stem from drug addiction . . .

Moderator: . . . .Okay, Dr. Schaler, you're within your questioning period now.

Schaler: Okay. If we talk about allegedly criminal activity stemming from addiction, well, that's a problem within the criminal justice system, not a medical issue. But let's look at the efficacy of treatment for addiction. In fact, despite what you say about the objectivity of government, there are numerous studies that show that treatment is as effective as no treatment whatsoever. One. That is a fact. Two, that the most sophisticated forms of treatment for drug addiction, alcoholism, in cognitive psychology, are no more effective than what essentially goes on in Alcoholics Anonymous. Alcoholics Anonymous and 12-step programs are free. There is no reason for insurance companies to pay for treatment when people can get it free in the form of self-help groups, which are developing as a part of the interest of the people around the country. And I'm sure that you're aware of Project Match: 35-million-dollar study, that shows that basically 12-step self-help treatment is just as effective as the other . . .

Levy: . . . So you would, or you would have the government make decisions to withhold those kinds of treatments from people who need it?

Schaler: No, I don't think . . . you see, what my concern is . . . let's go back to the issue of why the people, the 75 percent of people who are un- and under-insured can't afford healthcare treatment, health insurance. And the issue is because it's too costly. Now, why is it so costly? You suggest that it's because the private sector has an interest in stepping up the price. But let's look at what happens with the Kennedy-Kassenbaum bill that mandates coverage for mental illness and addiction . . .

Levy: . . . What's your question, though?

Schaler: . . . The concern here is this: that the government mandating coverage drives the price up. It drives the price up. Let's assume, for example that you're the insurance agent, insurance company, and you have a drug addiction problem, and you don't. Now, you're going to have to pay a higher premium because of coverage for his treatment of addiction. The government mandates that you cover for him. But you don't want to cover that because it isn't cost effective and it doesn't work. Now, there it drives the price up . . .

Levy: . . . You seem to be disagreeing with your earlier points, that somebody should be deciding what's cost effective or not and that the decisions of payment be made . . .

Schaler: . . . No . . .

Moderator: . . . Thank you. We need to move on to concluding statements . . .

Schaler: . . . No, the private sector has already made the decision, the government is not allowing the private sector to make its decisions.

Moderator: Dr. Thomas Szasz, your concluding statement.

Szasz: Well, I have a very simple concluding statement. This country is founded, was founded, and remains to be founded on the proposition that spiritual health is extremely important, but there should be no alliance between the state and the church that provides it. Now, physical health is also extremely important, but my position, and that of our teammates, my teammates, is that this is a very dangerous alliance, because the state is fundamentally an apparatus for coercion, not for doing good. It is an apparatus for protecting us from foreign enemies and from local enemies called "criminals." It is not a system devised over 5,000 years for providing health. Health can only be provided by doctors in cooperation with cooperative patients.

Moderator: Thank you, Dr. Victor Sidel, your concluding statement.

Sidel: In the 30 seconds that I have got, I think all I can do is say number one, I think we've agreed on many of the points that we came here to make. Which is that it is necessary to have people have access to care for their illnesses when they arise. We may differ some definitions of illness, but that is the fundamental point on which I think we've agreed. I think we've also agreed in debate that the government has a very important role in making sure that tobacco companies, to make sure that private industries, do not poison or injure the American people. These are some of the principles that we wanted to point out as we came here today, we have done it, and we are very pleased to have been able to.

Moderator: Thank you. That ends this week's television debate. Next week, a new debate, but this debate continues on our website, which is http://www.debatesdebates.com, that's http://www.debatesdebates.com. On the website, you'll be able to download free transcripts and live audio of all our programs. You'll also be able to leave your comments on this and past shows, as well as see topics of future debates. I look forward to reading your comments and suggestions, and once again, make sure you write to us at http://www.debatesdebates.com. We look forward to reading those suggestions and seeing what the futures shows will be about. And thanks to Ruth and our audience, and our television audience. Goodnight.

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