Another thing that's going to impact on cost once the cost of the total resources are determined, is the level of benefits that will be available.

For a national program, it should be-the level of benefits should be the same for all recipients of care.

You know, in New Jersey we have unique problems, and your hearings today were to center on New Jersey. We have, and some other witnesses have testified to it earlier, a unique situation where a large group of people are not medicaid eligible, are not covered by medicare and do not have private insurance. These are the medically needy, the medically indigent. They're supposed to be the responsibility of the county municipality. Counties and municipalities for numerous and varied reasons are increasingly unable, because of spending caps and other reasons in New Jersey, to come up with the dollars that are required to pay for the care for the medically indigent.

If we're going to have medicaid and if medicaid is going to be a Federal program, it's our feeling that medicaid should be standardized throughout the country. There should be standard coverage under medicaid programs. As you know, New Jersey medicaid-the New Jersey legislature for probably good reasons decided to have the minimum medicaid program, the minimum program eligible for Federal matching dollars. That leaves us, as Mr. Mellman said earlier, with a hole-a big hole in the middle. Those who make too much to be eligible for medicaid, and those that are either not employed or for other reasons, don't have health insurance of any kind.

Again, in New Jersey we're unique in having a virtually total nonprofit hospital system. There are very few proprietary hospitals, not to knock proprietaries, but we're sort of unusual in that respect. To the extent that we're not paid for the services rendered by somebody, the hospital has to eat it. And, we've had a couple of hospitals, for various reasons go bankrupt.

The other thing that happens is, and Mr. Mellman indicated also, there's a disparity between cost payors such as medicare, medicaid and Blue Cross, and the commercial insurers and the private paid patient. Recent legislation in New Jersey should take care of that, but the differential was-still is-about 27 percent. If you, as a private paying patient would go into a hospital, you would pay 27 percent more on average for the same services than the Government would pay for medicare patient or Blue Cross would pay for a Blue Cross patient.

I think everybody in the delivery system in New Jersey recognizes that that was-it was inequitable and shouldn't be allowed to continue. As I say, recent State legislation should take care of that. That remains to be seen.

We think, by way of summary, we've got an excellent health delivery system in the United States. We think that the Federal Government has an obligation to maintain that kind of a system. We should not end up with a national health insurance system that's underfunded and results in mandated mediocrity in health care delivery. Whatever is undertaken should be undertaken with the full knowledge that it's going to have to be paid for, either by the public or by private dollars, and that there is a commitment to

continue whatever kind of program we start. Whatever we start, if we back off on it later on, we're all going to have to pay the price of the wrath of the public. In our view, that's not wise.

Just to recapitulate, we think accessibility ought to be equal for all without discrimination. The payment ought to be based on the ability to pay. That financing and delivery mechanism ought to be through a combination of public and private, building on what's currently available and that it should be phased in over a period of time, whatever program you decide upon.

One thing I haven't mentioned, but I think it's very important and it's been alluded to a couple of times earlier today, that is the remolding of the consuming public, the attitudes and behavior of the consuming public. We need to educate people more, as with the screening program that you were talking about this morning. The Hospital Association is running a program called CHIP, child health_immunization program, that is geared-and we have a small Federal grant to assist us in doing this-it's geared to identify those kids in the State who are not immunized and to make sure they are immunized.

You know, it's a small program, but we think a worthwhile

program.

There needs to be a lot more done in terms of consumer health education. A dollar spent in this area is a dollar wisely spent for good programs, and should, in the long run, save all of us a lot of money when it comes to paying for health care later on. If we can avoid those problems, it becomes very costly in later life, otherwise. I happened to have been in Washington last week while there was some other legislation being considered on the House side, and the Rules Committee were taking up a rule on the Child Health Assessment Act, which is a very worthwhile piece of legislation and I know you have supported that legislation. They got into a big hassle there about how much money it was going to cost. The Rules Committee, I thought it was to make rules, but they also get into the merits of the legislation, apparently.

Senator WILLIAMS. A misnomer, is a matter of fact.

Mr. BAKER. Yes, it really is a misnomer. But, they got into the cost of the program and a couple of members of the committee simply would not be persuaded that the expenditure of a couple of million dollars early on in life to detect and correct child health ailments would save many times over the original cost later on in life.

What I'm suggesting is, that in any national health insurance plan that we include that kind of forward thinking that's not going to skimp on a few bucks now, when we can save it many times over later on.

Senator WILLIAMS. I sure do agree.

Mr. BAKER. That concludes my remarks, Senator. I thank you very much for the opportunity.

Senator WILLIAMS. We thank all of you. I'm sure we could benefit by a longer discussion, but I have to get back to work. This has been uplifting in every way and very helpful. This will be a most invaluable record, not for me, but for all of our members. Thank you very much.

I will try to answer in writing the questions that have been giver to me by the audience. You have the cards, Becky.

At this point I order printed all statements of those who could not attend and other pertinent material submitted for the record [The material referred to follows:]

LET ME SAY AT THE OUTSET THAT THE TESTIMONY I AM ABOUT TO GIVE REFLECTS THE OPINION OF SELECTED GROUPS IN THE COUNTY OF GLOUCESTER WITH A SPECIFIC INTEREST IN HEALTH CARE. AS FREEHOLDER DIRECTOR OVERSEEING THE COUNTY HEALTH DEPARTMENT, I FELT IT WISE TO SOLICIT RESPONSES FROM DOCTORS, NURSES, AND CONSUMERS. ADDED TO THIS IS THE INPUT OF THE HEALTH DEPARTMENT; THE AGENCY MOST LIKELY TO ACT AS A DELIVERER SHOULD NATIONAL HEALTH INSURANCE BECOME A REALITY.

I WOULD LIKE TO BEGIN BY SAYING THAT I ENDORSE THE CONCEPT OF NATIONAL HEALTH INSURANCE. THE RISING COST OF LIVING HAS MADE STAYING HEALTHY A NECESSARY PREREQUISITE OF AVOIDING BANKRUPTCY. UNFORTUNATELY, THERE ARE HUNDREDS OF THOUSANDS OF AMERICANS WHO CANNOT SO PROGRAM THEIR LIVES. THE COST IS EXPENSIVE, BUT THE ALTERNATIVES ARE ECONOMICALLY GROTESQUE. WE IN NEW JERSEY MUST ALSO RECOGNIZE OUR UNIQUE POSITION. ANY STATE WHOSE CITIZENS CAN APPROVE THE SPENDING OF MONEY IN CASINOS, CAN CERTAINLY JUSTIFY THE SPENDING OF MONEY TO PROVIDE ADEQUATE HEALTH CARE. LET IT NOT BE LOST ON OUR CITIZENS THAT WE LIVE IN A "CANCER BELT" WITH MOUNTING STATISTICS DEMONSTRATING THE HORRIFYING FAMILIARITY THIS DREADED DISEASE HAS WITH SO MANY AMERICAN FAMILIES.

IN SHORT, WE HAVE A MORAL OBLIGATION TO ADDRESS THE NEEDS FOR PRENATAL CARE. MULTI-DISEASE SCREENINGS, GERIATRIC SERVICES, MENTAL HEALTH FACILITIES, AND GENERAL PREVENTIVE MEDICAL EDUCATION AND TRAINING. IT IS FELT THAT S-1720 TAKES A GREAT STEP FORWARD IN THIS AREA. BEFORE TOTAL SUPPORT CAN BE GIVEN SOME CLARIFICATION MUST BE MADE AND QUESTIONS RAISED.

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ONE MAJOR CONCERN RELATES TO THE PROVIDERS OF HEALTH CARE. THE BILL, IN ESSENCE, IS PHYSICIAN ORIENTED AND SEEMS TO IGNORE OUR LARGEST GROUP OF HEALTH CARE PROVIDERS--REGISTERED NURSES. THIRD PARTY REIMBURSEMENT FOR NURSES WOULD ALLOW THE CONSUMER MORE OF A SAY IN THE KIND OF CARE HE OR SHE WANTS. IT WOULD HOLD NURSING ACCOUNTABLE FOR THE CARE IT IS GIVING, AND BE ECONOMICAL IN THAT, AT PRESENT, MUCH OF ITS POTENTIAL IS BEING STIFLED. WE SHOULD NOT HAVE A PROGRAM WHERE INSURANCE COMPANIES PAY PHYSICIANS FOR REIMBURSEMENT OF A SERVICE PROVIDED BY A NURSING AUTHORITY.

THE DELIVERY OF HEALTH CARE IS IMPORTANT. PRESENTLY IN OUR COUNTY 40% OF OUR PHYSICIANS LIVE IN AN AREA COMPOSING 5% OF OUR TOTAL AREA. IN OTHER WORDS THERE IS A NEED FOR THE CARE TO BE LOCATED NEAR THE CLIENT. FOR THE STATE OF NEW JERSEY TO BETTER ADDRESS THIS NEED, IT WOULD NECESSITATE THE AUTHORIZATION OF NURSE PRACTITIONERS. UNDER N.H.I. THERE WILL BE AN INCREASED DEMAND FOR SERVICE; WE MUST BE ABLE TO MEET THAT DEMAND. WE HAVE TO BE COMMITTED TO TREATING NOT ONLY THE WELL CHILD, BUT THE SICK CHILD. PREVENTIVE MEDICINE AND HEALTH EDUCA TION ARE A MUST, AND IT IS ENCOURAGING TO NOTE THAT THIS BILL ADDRESSES BOTH ISSUES.

THROUGH REIMBURSEMENT PROCEDURES UNDER N.H.I., I CAN ENVISION AN EXPANDED ROLE OF COUNTY HEALTH DEPARTMENTS. BY ALLEVIATING A DIRECT TAX BURDEN ON COUNTY RESIDENTS, ADDITIONAL SERVICES SUCH AS OBSTETRICIAN FULL-TIME PEDIATRICIANS, PRENATAL CLINICS AND PERIODIC SCREENING AND DIAGNOSTIC TREATMENT MIGHT BE PROVIDED.

WHILE I MENTIONED THE EXPANDING ROLE OF A COUNTY HEALTH DEPARTMENT--IT IS LEFT UNCLEAR IN S-1720 JUST WHAT IF ANY THAT ROLE MAY BE. NORMALLY LEGISLATORS ARE CRITICIZED FOR ESTABLISHING PROGRAMS WITHOUT FUNDING. MY CONCERN WITH N.H.I. IS THAT WE ARE ESTABLISHING FUNDING WITHOUT A PROGRAM.

THE MERITORIOUS ASPECTS OF THIS BILL, WHICH ARE MANY, ARE MEANINGLESS IF WE HAVE NO HEALTH CARE DELIVERY SYSTEM. HMO'S, NURSE PRACTITIONERS, AND EXPANDED HEALTH DEPTS ARE ALL VIABLE OPTIONS BUT THEY MUST BE IN PLACE SO THAT THERE ARE IN FACT PROVIDERS ON HAND TO SERVICE THE PUBLIC NEED.