The professionalization of reform II - Thirtieth Anniversary Issue

Daniel Patrick Moynihan

THIRTY years ago, in the first article of the first issue of The Public Interest, I published some observations on "The Professionalization of Reform," which 30 years later can be read, selectively, without overmuch embarrasement. The essay began with a passage from Wesley C. Mitchell, who had been for near quarter a century (1920-1945) director of research at the National Bureau of Economic Research, then based at Columbia University.

Our best hope for the future lies in the extension to social organization

of the methods that we already employ in our most

progressive fields of effort. in science and in industry ... we do

not wait for catastrophe to force new ways upon us.... We rely,

and with success, upon quantitative analysis to point the way., and

we advance because we are constantly improving and applying

such analysis.

This in turn was taken from a report on "The Concept of Poverty," published by the Chamber of Commerce of the United States.

Then, as ever, I was writing from my experience as informed by the insights of Nathan Glazer who, two years earlier in the British journal The New Society, had described the process as it crested in the Kennedy administration.

Without benefit of anything like the Beveridge report to spark

and focus public discussion and concern, the United States is

passing through a stage of enormous expansion in the size and

scope of what we may loosely call the social services - the public

programs designed to help people adapt to an increasingly complex

and unmanageable society. While Congress has been painfully

and hesitantly trying to deal with two great measures - tax

reform and a civil rights bill - and its deliberations on both have

been closely covered by the mass media, it has also been working

with much less publicity on a number of bills which will contribute

at least as much to changing the shape of American society.

I had served as Assistant Secretary of Labor for Policy Planning and Research in the Kennedy years and had carried on under Johnson. In the article, I cited examples of such legislation that the Department of Labor had helped shape. The Manpower Development and Training Act, the Area Redevelopment Act, the Community Mental Health Construction Act. As regards the latter, I was very much the initiate, having been present at the meeting in the Governor's office in Albany in the spring of 1995 when the new Governor Averell Harriman agreed to the proposal of Paul Hoch, his new Commissioner of Mental Hygiene, to use the first clinically tested tranquilizer, reserpine, on a system-wide basis. This in turn led to the notion that a great number of the mentally ill need not be confined to mental hospitals but could live independently and be cared for at community mental-health centers. Kennedy had created a cabinet committee for which I wrote the final report. We were to build 2,000 such centers by 1980. The President approved the bill on October 31, 1963, his last public bill-signing ceremony. He gave me a pen.

Deinstitutionalization, as it would be called, was altogether the work of professionals, mediated by lawyers and the odd sort such as I. The public never knew anything was much changing. I continued.

the most interesting thing about all this sudden expansion of

social services was that it had behind it, as Glazer noted, "nothing

like the powerful political pressure and long-sustained intellectual

support that produced the great welfare measures of the

New Deal - Social Security, Unemployment Insurance, Public

Welfare, Public Housing." The "massive political support and intellectual

leadership that produced the reforms of the thirties"

simply did not exist; yet the reforms were moving forward.

The Johnson War on Poverty was the most dramatic example of professionalization. It began with various initiatives designed to help the Appalachian region. Again, the Department of Labor was much involved on behalf of workers, but with little involvement from workers themselves. I commented:

War on poverty was not declared at the behest of the poor. just

the opposite. The poor were not only invisible ... they were also

for the most part silent. John F. Kennedy ventured into Appalachia

searching for Protestant votes, not for poverty. There he

encountered the incredible pauperization of the mountain people,

most particularly the soft coal miners, an industrial work force

whose numbers had been reduced by nearly two-thirds in the

course of a decade - but with hardly a sound of protest. The

miners were desperately poor, shockingly unemployed, but neither

radical nor in any significant way restive.

As for miners, so for the public at large. The early sixties, whatever else, were prosperous. But closer analysis, again at the Department of Labor (we were good), had shown all manner of trouble brewing.

Whereas the public, both high and low in the intellectual hierarchy,

saw income distribution steadily compressing, saw the Negro

American more and more winning his rightful place in society,

saw prosperity spreading through the land, the men in the government

saw something quite different: an income distribution

gap that had not budged since the end of the war, and had in

fact worsened sharply for Negroes, a rising measure of social

disorganization among poor families and poor communities, a widening

gap between the prospects of the poor and those of the

middle class.(1)

I broke off at this point to try to account for all this energy in the executive. First, "The Economic Revolution," next, "The Professionalization of the Middle Class," finally, "The Exponential Growth of Knowledge." The latter two subjects are self-evident enough, although it is useful to keep in mind just how recent most social statistics are. But the great event had been the economic revolution. There had occurred "a genuine discontinuity, a true break with the past. Men are learning how to make an industrial economy work.... Nothing like it has ever happened before in history." The central political issue of most industrial nations over the past century and a half" had been how to do this. Not two decades earlier it was widely held to be impossible. Then professionalism took over. In the beginning was the theory. With but little data either to support or confound them, economic theories multiplied and conflicted. But gradually more and better data accumulated: progress begins on social problems when it becomes possible to measure them. As the data accumulated and technology made it possible to calculate more rapidly, the theories gradually became able to explain more, and these in turn led to the improvement in the data. John Maynard Keynes at King's College, Cambridge, and Wesley C. Mitchell at the National Bureau of Economic Research in New York are supremely good symbols of the two processes that ended up in a deeply symbiotic relationship. And then one day it all more or less hangs together and the world is different, although of course not quite aware of the change. Governments promise full employment - and then produce it. (In 1964 unemployment, adjusted to conform more or less to United States' definitions, was 2.9 percent in Italy, 2.5 percent in France and Britain, and 0.4 percent in Germany. Consider the contrast with post-World War I). Governments undertake to expand their economy at a steady rate - and do so. (In 1961 the members of the Organization for Economic Cooperation and Development, which grew out of the Marshall Plan, undertook to increase their output by 50 percent during the decade of the 1960s. The United States at all events is right on schedule.)

The ability to predict events, as against controlling them, has developed even more impressively - The Council of Economic Advisers' forecast of GNP for 1964 was off by only $400 million in a total of $623 billion; the unemployment forecast was on the nose.

Now came a new proposition, which may have been first set forth in The Public Interest. The new economics required new government initiatives.

The more immediate impact of this econometric revolution in the United States is that the Federal government will be endowed, more often than not, with a substantial, and within limits predictable, rise in revenues available for social purposes. Significantly, the war on poverty began in the same year of the great tax cut. The President was not forced to choose between the measures; he was able to proceed with both. in that sense, the war on poverty began not because it was necessary (which it was), but because it was possible.

The singular nature of the new situation in which the Federal government finds itself is that the immediate supply of resources available for social purposes might actually outrun the immediate demand of established programs. Federal expenditures under existing programs rise at a fairly predictable rate. But under conditions of economic growth, revenues rise faster. This has given birth to the phenomenon of the "fiscal drag" - the idea that unless the Federal government disposes of this annual increment, either by cutting taxes or adding programs, the money taken out of circulation by taxes will slow down economic growth, and could, of course, at a certain point stop it altogether.

Thus, assuming the continued progress of the economy in something like the pattern of recent years, there is likely to be $4-5 billion in additional, unobligated revenue coming in each year. But this increment will only continue to come on condition that it is disposed of. Therefore one of the important tasks to which an administration must address itself is that of devising new and responsible programs for expending public funds in the public interest.

This is precisely the type of decision-making that is suited to the techniques of modern organizations, and which ends up in the hands of persons who make a profession of it. They are less and less political decisions, more and more administrative ones. They are decisions that can be reached by consensus rather than conflict.

The memory is almost lost now, but the Kennedy years were a time of almost feverish efforts to get around the disinclination of Congress to spend money. My first meeting in the Oval Office involved a pay raise for government employees (Even Congress would want to side with the Letter Carriers!); then a double dividend for Veterans Administration life insurance, next a tax cut; then revenue sharing - the chairman of the Council, Walter E. Heller, reasoning that, if Congress would not spend the money, possibly the governors would. This mode took us through the decade with but a single recession at the very end. The Nixon administration continued in just this vein. Revenue sharing was enacted. A guaranteed income was proposed, and almost enacted. George P. Shultz became director of the new Office of Management and Bud get. A University of Chicago economist, he set about elaborating a formal definition of a full-employment budget, one in which outlays equal revenues at full employment. Absent full employment, a deliberate deficit would stimulate the economy in that direction. On into the seventies when five successive tax cuts were enacted.

The success was stunning: so much that it has gone almost unnoticed. The wild gyrations of a capitalist economy gave way to a sequence of more or less uniform business cycles in which the economy grew and then did not grow, with only one significant decline. Before 1929 the average business-cycle contraction lasted nearly 21 months following an average expansion of slightly more than 25 months. About even. Over the past 50 years, however, the average recovery has lasted 50 months, with contractions shortened to an average of 11 months. A very different world. In all this past half century, the largest decline in output was 2.2 percent, in 1982. Compare that with a drop of 9.9 percent in 1930; followed by 7.7 percent in 1931; followed by 14.8 percent in 1932! As of mid-1995, for example, we are in our tenth postwar expansion, which reached its fiftieth month in May. During the half-century period, the size of our economy has quadrupled, and real income per person has more than doubled.

Reform went forward: but society seemingly regressed. Thus the "deinstitutionalization" of mental patients anticipated in the 1963 legislation was promptly carried out. At the end of 1963, there were 504,604 resident patients in state and county mental hospitals. By 1993 (the latest data available), this had dropped to 76,653. But the 2,000 community mental-health centers never got built. Six hundred or so were set up, but then the program got folded in, moved about, and generally forgot. When, in the mid-1970s, "homeless" people began to appear on city streets all across the nation, it aroused no significant enquiry as to what was going on but, rather, a new demand on the part of housing professionals for more "affordable housing."

The health-care imbroglio

A pattern emerges. Great undertakings are proposed in political campaigns, often crafted by professional techniques such as polling and focus groups. If the campaign succeeds, the undertaking is taken as validated. Experts are set to work and the bill emerges. In this regard there has been no equal to the health-care reform project of the Clinton administration during the 103rd Congress. Health insurance had been on the national agenda at least since 1934 when Roosevelt set up the Committee on Economic Security, which drafted the Social Security Act of the following year. It had not been solely a Democratic concern; the Nixon administration, as usual, had proposed a very considerable measure. But it was rejected by a Democratic Congress out of a proprietary sense that this was by rights a Democratic issue. Now, seemingly, its moment had come.

But, whereas New Deal initiatives came, in the main, as responses to popular demand, variously expressed, by 1993, health-care insurance was a latent issue. Five in six Americans had health insurance; most of the poor got it free from the government, it was heavily subsidized for all of the elderly. Hence, it was an issue mostly for those who thought it should be an issue: Which is to say, professionals. In 1965, I had cited Everett C. Hughes: "Professionals profess. They profess to know better than others the nature of certain matters, and to know better than their clients what ails them or their affairs." Further, Hughes wrote, professionals had asserted primacy in formulating public policy in their area of expertise.

And so now it came to health care. The administration organized a task force of some 500 persons, sworn to secrecy, who set about reorganizing and pretty much taking control of one-seventh of the American economy. After the better part of a year, they produced a 1,342-page bill. Martha Derthick commented: In many years of studying American social policy, I have never read an official document that seemed so suffused with coercion and political naivete as the draft report of the president's health security plan that emerged last fall, with its drastic prescriptions for controlling the conduct of state governments, employers, drug manufacturers, doctors, hospitals, and you and me.

I was by now chairman of the Senate Finance Committee, which had principal jurisdiction over the measure in the Senate, and perforce, I came to know the details of the proposal with a measure of thoroughness. In that process, I became one of possibly a dozen persons outside the task force who knew that the legislation would cut the number of doctors in the United States by one-quarter and the number of specialists by one-half.

Since at least the 1960s, a debate had been going on within the various professions involved concerning these two questions, driven not least by the fact that much of medical education and training is subsidized with public monies. Economists such as Alain Enthoven have addressed such questions as "physician oversupply" and "geographic maldistribution." Writing in the Journal of the American Medical Association in 1994, Richard A. Cooper, M.D., of the Medical College of Wisconsin, observed that A consensus has developed that better balance in the proportion of primary care physicians and specialists must be achieved,, and that this consensus was being quantified. more of the former, fewer of the latter. He noted, however, that primary care is "population based" - indeed, had settled in at about 75 to 85 primary-care physicians per 100,000 population. By contrast, "The driving force behind much of specialty medicine is science, and the specialty workforce is largely technology based." Good subject, not least in this heroic age of medical science, the first such era to occur in the United States as against Europe. The problem was that the Clinton task force did not want. to debate the issue; they desired, rather, to decree the outcome and to enact it surreptitiously as a mode of cost control.

The story of the Clinton Task Force may one day be written. As the result of a lawsuit, some documents are now available in the National Archives. As luck would have it, we appear to have retrieved the essential documents in this area. On March 31, 1993, "Workgroup 12" addressed the problem in "TOLLGATE 5":

Problem: An increasingly overabundant number of medical graduates are entering specialty fields instead of primary care fields family practice, general pediatrics, general internal medicine).

(A word to the wise. pediatrics is not a specialty. The Workgroup proposed the following solution:

* Provide [by Federal law] that at least 50% of residency graduates enter primary care practice. * Limit Federal funding for first-year residency positions to no more than 110% of the size of the graduating class of U.S. medical schools. This would further support the action to limit spcialty residency positions. [Emphasis in original.]

The Working Group 12 dissent

There followed on April 26, 1993, a quite remarkable dissent signed by some thirteen members of WORKING GROUP 12" (capitalization never got quite uniform in task-force us age) having been written by a physician at the Veterans Administration.

FOR OFFICIAL USE ONLY

SUBJECT. Proposal to cap the total number of graduate physician (resident) entry (PCY-1) training positions in the USA to 110% of the annual number of graduates of US medical schools.

ISSUE: Although this proposal has been presented in Tollgate documents as the position of Group 12, it is not supported by the majority of the members of Croup 12 (listed below).

REASONS NOT TO CAP THE TOTAL NUMBER OF US RESIDENCY

TRAINING POSITIONS FOR PHYSICIAN GRADUATES

1. This proposal has been advanced by several Commissions within the last two years as a measure to control the costs of health care. While ostensibly advanced as a manpower policy, its rationale lies in economic policy. Its advocates believe that each physician in America represents a cost center. He not only receives a high personal salary, but is able to generate health care costs by ordering tests, admitting patients to hospitals and performing technical procedures. This thesis may be summarized as. TO CONTROL COSTS, CONTROL THE NUMBER OF PHYSICIANS. 2. Capitalist economic theory does not support this argument. Manpower theory does not support this argument. 3. Economic theory would argue that to reduce costs one should increase the number of physicians. If each physician is a cost center then one should reduce incentives to increase procedures, admissions and tests, or control the costs of these items, rather than limit the number of physicians. Those desiring to limit physician numbers point out that while the number of graduates was doubled beginning in 1975 from 7500 to 15,000 per year, costs of care rose markedly. The physician increase was deliberate social policy to address shortages of physicians and access problems, which were partially but not wholly solved by this increase. The growth of health care costs in the same l@ year span can certainly be attributed more accurately to distorted reimbursement incentives for physicians and the entire health care sector and to runaway inflation in technical costs. 4. Capitalist manpower theory would argue that controlling demand by limiting supply is perverse. Managed competition seeks to control demand and uses physicians as the agents to manage access to services. By reversing the incentives, the same provider becomes the controller rather than the generator of costs. 5. On the demand side of the supply/demand equation there is little support for limiting the number of health care providers. Under the Clinton Health Plan the demand for primary care and generalist physicians vastly outstrips supply. Insuring universal access will add n million people to the health care network and no modeling has been done of the manpower requirement to assure access to care for this influx. Even under present access to care we do not have enough minority physicians, primary care physicians or physicians willing to work in remote rural and embattled inner city areas. 6. While there is agreement that the US needs a better balance in its physician production between generalists and specialists, there is not even strong evidence that there are too many specialists in practice for the actual needs of the population under current access to health care, let alone what might be needed under universal access. Manpower modeling under universal access was not undertaken by Group 12. While the last major physician manpower study, the GEMNAC [Graduate Medical Education National Advisory Committee Report (1974) projected physician excess in some specialties by 1990 under unchanged access, a recent examination of only 6 specialties by COGME [Council on Graduate Medical Education] (1900) [sic] found shortages for generalist physicians, psychiatrists, child psychiatrists, and surgeons. The AAMC [Association of American Medical Colleges] study (1989) concluded that current rates of production of physicians would not lead to a surplus. All manpower studies done to date have a heavy emphasis on studying the pipeline for supply of MD/DO [Medical Doctor/Doctor of Osteopathy], and are very poor tools for determining demand, even under present conditions. No modeling of universal access has been done. It is of interest that pediatrics societies contested the finding of COGME that there would not be a shortage of pediatricians, arguing for a model examining the need for pediatricians to care for the uninsured. 7. Some who argue for capping physician supply invoke the ratio of physicians to total population in other industrialized countries. At the present time the US ratio of MD/DO to population is exactly at the median for industrialized nations.... On the face of it this does not seem a strong argument for limiting physicians. This raw ratio also does not address the US problems of physician mix or patient access. 8. Attempts within the profession to limit physician number are severely limited by the FTC [Federal Trade Commission]. The FTC has brought suit against the ACGME [Accreditation Council on Graduate Medical Education] and physician specialties who believe they have too many members. Despite the FTC, these specialties have reduced the number of physicians in certain disciplines by strict quality control of resident training programs. More could be done in this area by private sector mechanisms if the ACGME were granted some relaxation of FTC restrictions. 9. The proposal under consideration, to cap the number of entry resident training positions to 110% of US graduates, is not even a true manpower control policy. The number of graduates of US medical schools is not limited by this policy. In effect, the policy would merely limit the entry of foreign medical graduates into US practice, since they must take US residency training to achieve licensure. At worst, enactment of this proposal could lead to US medical graduates, whose average debt upon graduation is $57,000 unable to entry [sic] residency training because of displacement by foreign physicians in competition for a limited number of slots. 10. The most insidious part of the proposal to cap entry slots to graduate medical education is that it carries in its wake the necessity to create a vast regulatory apparatus to implement it. The total number-of GME [Graduate Medical Education) slots is not under central control, nor are they federally funded. Medicare pays an estimated 22% of the salaries for resident physicians as part of its fair share because they provide care for Medicare patients.

11. If it were to prove necessary in the future to control physician supply, the control point would be the number of entry positions to medical schools in this country. In 1990 the AAMC manpower study concluded that the number of entry positions should not be increased but did not need to be decreased. Through private sector accreditation of medical schools LCME [Liaison Committee on Medical Education] the annual number of allopathic physician graduates has not increased in the last decade. While the number of osteopathic graduates is increasing because of a doubling of the number of schools of osteopathy since 1975, these graduates tend to go into primary care and practice in non-urban settings.

12. The physician manpower problems to be solved in this country try are ones of specialty mix, current shortages of generalists and certain specialists, and potential greater shortages once universal coverage is achieved, geographic distribution of physicians to rural and inner city sites and achieving greater racial, ethnic and gender diversity in the physician workforce. NONE OF THESE PROBLEMS IS SOLVED, AND SOME ARE EXACERBATED, BY LIMITING ACCESS TO GRADUATE TRAINING FOR PHYSICIANS OR ATTEMPTING THROUGH OTHER MEANS TO LIMIT THE TOTAL SUPPLY OF PHYSICIANS IN THE US.

13. To end on a philosophic note, when the proposal to cap training slots was presented to the presidents of the major US universities last weekend, they were incredulous that the US government would advance as sound social policy a proposal to limit access to one of the three learned professions with its millennial history of achieving social good. They further recognized that in America open access to careers in these professions has been a traditional path for immigrant social mobility.

4-26-93

A sin of omission

The administration bill, when it came, included a "Subtitle A - Workforce Priorities Under Federal Payment," which provided for a National Council on Graduate Medical Education in the Department of Health and Human Services that would ensure that, by 1998-1999, "not less than 55 percent" of medical-school residents complete a program in primary care. The explicit 110 percent residency cap was replaced by a cap to be determined by the Council. In the Congress, the House Education and Labor Committee bill was specific, setting the 110 percent ratio, others left it to the Council but clearly this was to be its goal. The one exception was the bill reported by the Senate Committee on Finance which would have nothing to do with either.(2)

These are, were, legitimate issues of debate. The problem, and I take this to be the fatal failing of the process, is that neither was debated. The dissenters on WORKING GROUP 12, for all the quirkiness - just what is "capitalist manpower theory?" - made legitimate points, but they were never made public. The Clinton administration devoted most of its energies for a year and more to health-care reform without once touching on this crucial detail - not even in the semi-privacy of the Cabinet Room. ("Incidentally, you might want to know...") The central document of the campaign was Health Security, The President's Report to the American People, an ambitious, all-purpose, glossy affair issued in October 1993. Of 136 pages, there is one section, "Doctors in the United States: An Unhealthy Mix," 11 lines in all, devoted to primary-physician supply:

Health care reform will increase the demand for primary care physicians, nurses and other health professions, correcting the long-standing incentives that discouraged medical students from becoming family doctors. But change won't happen quickly. To encourage American teaching hospitals to switch some residency positions from specialist to primary care, the federal government must make it more worthwhile to train them.

Consequently, rather than pay for graduate medical education without regard to specialty, public and private investment will redistribute the balance between residency slots devoted to primary care and those devoted to specialty training.

There is no mention whatever of limiting the number of hospital residencies to 110 percent of U.S. medical-school graduates. In retrospect, it is not hard to understand the administration's reluctance to be open about all this. Begin with the fact that this was an administration of fervid and professed liberals; the children of the 1960s at long last in power. To be liberal means to wish the Third World well; surely not to slam the golden door on the swarthy sons and daughters of India, Pakistan, and the Filipinos - like some nasty, hateful, racist Chinese Exclusion Act. (Recall the point made by the WORKING GROUP 12 dissidents: The 110 percent ratio would not reduce the number of residents if U.S. schools increased their enrollment.)

Then there was the problem of the poor. The municipal hospitals of a city such as New York depend heavily on the services of interns who have come from elsewhere. Some are Americans who went abroad for medical school. Some are young doctors who have come to Boston or Dallas or wherever for the best internships in the world, fully intending to return home. (Much as Americans once interned in Paris.) But most are, in fact, immigrants, and fine doctors we are fortunate to have. Take them out of New York City, hospitals and health care in New York collapse. The world's leading liberals could hardly be seen to propose that either. As for specialists, all right-thinking folk know them to be Park Avenue elitists; but then, they do help when complications set in. Best be discrete. And then there was the dirty little secret. The health-care reformers soon discovered that they had no money. And so to provide universal health insurance, they had to provide less health care - by cutting the number of doctors. Now, not all would agree with that characterization, but something very like that did happen.

The professions said nothing. The final paragraph in the WORKING GROUP 12 dissent refers to a conference on healthcare reform sponsored by the Association of American Universities in Washington, April 17-18, 1993. Pretty much everyone was there. The Executive Summary gets the facts straight.

The implications of health care reform for academic health centers fall into three broad categories. teaching, research and patient care. Following are the general trends presented at the conference:

Education * Inevitable limits on number of sub-specialty training programs and positions in US. Reduction of the overall number of positions to 105-110 percent of US medical school graduates.

But if any of the university officials present was "incredulous" at the suggestion, they remained silent. An exception was Walter Reich, M.D., Senior Scholar at the Woodrow Wilson International Center for Scholars. He was in touch with the Finance Committee regularly on the subject of "a deliberate dumbing down of medicine." A letter of August 29, 1994, had this:

There's also something profoundly anti-intellectual, even medieval about the effort to abolish medical specialization. Knowledge, in the case of modern medicine, can result in large expenses. Get rid of that knowledge, some argue, and you can get rid of those expenses. In fact, this approach is so illogical and strange that characterizing it as medieval does a profound disservice to what was, in comparison to this age of anti-medical-scientism, an intellectually luminous epoch. Attempting to dismantle the edifice of specialization seems akin, somehow, to the deliberate torching of the great library in Alexandria. This is enlightened social policy?

When all else fails, the press is supposed to step in. It did not. A search of the Nexis database located only three articles - out of thousands on the general subject - that focused on this issue: the Los Angeles Times, March 22, 1993, "U.S. Incentives for More Family Doctors Weighed" by Marlene Cimons; the New York Times, September 15, 1993, "Clinton Seeks to Regulate Medical Specialties" by Robert Pear; the New York Times, January 24, 1994, "New York Hospitals Fear Harm in Plan to Reduce Specialization" by Todd S. Purdum.

Toward the end of the 103rd Congress there were occasional articles citing protests by me and Senator Alfonse D'Amato that the administration bill would devastate the New York City hospital system, which for most of this century has, in fact, provided universal health care. But these were pretty much of the "Congressman Opposes Base Closing" genre. The best explanation is that there was no national debate, and accordingly, the press did not report one. Here, for example, is the 1993-1994 Nexis tabulation for the Times, East Coast and West Coast:

                          New York Times   Los Angeles Times

Articles with "health
reform" or "health-care
reform" in headline or
lead paragraph.                  324               819

Articles with "health
reform" or "health-care
reform" anywhere in
body.                          1,286             1,979

Articles with Clinton
workforce proposal as
primary subject matter.          2                 1

(1) At the Policy Planning staff of the Department of Labor, we had indeed picked up the first tremors of "a rising measure of social disorganization among poor families and poor communities." Thirty years later this would be a subject at, or near to, the center of domestic politics. If there is a better case for professionalization, none comes readily to mind. On the other hand, there was, at the time, almost no popular perception of anything amiss, and the proposition received a decidedly mixed reception. I leave it to my betters to judge, but we may have an instance here of what Joseph A. Schumpeter termed the "decomposition" of bourgeois society attendant on its very success. The relentless rationality of capitalism will, he conjectured, "eventually kill its roots," which is to say, in Eugene D. Genovese's words, the "pre-capitalist institutions and values necessary for social and political stability." Thus, Chapter XIV of Capitalism, Socialism and Democracy:

Still more important however is another "internal cause," viz., the

disintegration of the bourgeois family. The facts to which I am referring

are too well known to need explicit statement. To men and women in

modern capitalist societies, family life and parenthood mean less than they

meant before and hence are less powerful molders of behavior; the rebellious

son or daughter who professes contempt for "Victorian" standards is, however

incorrectly, expressing an undeniable truth. The weight of these facts is not

impaired by our inability to measure them statistically.

To anticipate, we had begun to get a statistical fix on the subject.

In The Public Interest, Winter 1968, I would publish an article, "The Crises in Welfare," which included this passage:

In general, many persons active in the evil-rights movements, as in most

social-reform efforts in recent American history, bring to the undertaking a

considerable disenchantment with the traditional "middle-class" values of

the society. Although they are likely to be-or because they are - the

products of quite successful families. Ideas of family stability and morality

tend to be seen by such persons as part of the bourgeois apparat. And they

say to hell with it. Thus, a recent article on Harlem in the Urban Review,

published by the Center for Urban Education in New York City, spoke with

scorn of "Victorian notions about broken homes." Somehow or other, the

idea that sexual repression is bad has gotten mixed up with the idea that

illegitimacy, or whatever, is good. In a curious way, the more liberated

youth of the present seem to be affected by a culture lag of sorts: The

newest and best thinking about such matters is considerably more respectful

of the "nuclear family" than they seem to know. Or care to know. (2) The five Congressional committees with jurisdiction over health-care reform reported legislation with the following provisions limiting the total number of medical-school graduates permitted to enter resident training: House Ways and Means Committee - a cap determined by the Secretary of Health and Human Services; House Education and Labor Committee - residency slots limited to 110 percent of U.S. medical graduates; House Energy and Commerce Committee did not report legislation; Senate Labor and Human Resources Committee - a cap determined by a council; and Senate Finance Committee - no provision. The leadership bill debated on the floor of the Senate initially included a provision to cap the number of residency positions at 110 percent of U.S. medical graduates (unless modified by the Secretary of Health and Human Services). Senator Mitchell later modified his bill so that the cap was, determined by a council.

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