Louis Sullivan : Can Health Policy Be Set Without Confrontation?

Louis W. Sullivan, secretary of health and human services, is controversial because he avoids controversy.

Two weeks ago, Rep. Pete Stark (D-Oakland) called Sullivan, who is a doctor and one of the few blacks in the Bush Administration, a “disgrace to his race and profession,” for opposing national health insurance. Sullivan, in a speech last month, had called for a “public-private partnership” to provide medical coverage to 37 million uninsured Americans. In June, demonstrators protesting the Administration’s low-visibility AIDS policies drowned out Sullivan’s efforts to address an international conference of AIDS researchers in San Francisco. Sullivan was defending Bush policy. In early 1989, when Sullivan came up for nomination as secretary of HHS, conservatives attacked his support for legalized abortion, a position he promptly changed at the suggestion of the White House.

In person, Sullivan is serene and stiff. He does not seem comfortable reflecting on the ethical and political dilemmas in health policy. He prefers to discuss his anti-smoking crusade, or his efforts to build bureaucratic and legislative consensus behind the Bush Administration’s modest Health and Human Services agenda. Sullivan’s corporate style of leadership contrasts with that of former Surgeon General C. Everett Koop, whose rigorous conservatism led him to stake out bold and surprising positions on such issues as safe-sex education and the effects of abortion on women’s health. Sullivan, it is safe to say, will not talk publicly about safe sex.

Professionally, Sullivan is a biomedical researcher. Born in Atlanta, in 1933, he graduated magna cum laude from Moorhouse College in 1954 and spent much of his professional life as a professor of medicine at Boston University School of Medicine. In 1975, he returned to his alma mater as a professor of biology and medicine. In 1985, he became president of Moorhouse Medical School.

Question: What did you think of your time at the recent AIDS conference in San Francisco? Was it worth going?

Answer: I felt it was important to demonstrate to the nation, as well as to the individuals involved, in addressing the problem of AIDS and show the federal concern and commitment for the problem, as well as to outline what the federal government is doing. Among the various controversies surrounding AIS is the fact that much of what we are doing is often overlooked or forgotten.

I knew in going that there would be a demonstration. . . . Our country is founded on demonstration, but fundamental to this country is the idea of freedom of speech. So when it turned out the demonstration was really an effort to keep me from speaking, I became very angry--and am still angry--because I think that’s counterproductive. . . .

Q: At all of the other AIDS conferences, the president of the host country--with the exception of the United States in 1987--has addressed the convention. Why couldn’t President Bush address this convention?

A: The President, as you probably know, has an incredible number of demands on his time.

Q: Of course, but AIDS is an incredibly serious problem. Every other president of a host country has seen fit to show commitment to attacking the AIDS problem by welcoming participants in the AIDS Conference. Don’t you think it shows the U.S. commitment is, at least on a political level, different than the other countries?

A: No, I wouldn’t say that. The other input here is this: Remember President Bush, as vice president, did address the conference along with Secretary (Otis R.) Bowen, my predecessor here in Washington. When President Bush went he was booed there, as well as Secretary Bowen. Again, one of my responses is: Is the role of our President to go to a conference simply to be booed?

Q: The next conference in the United States will be in Boston, in 1992. Would you recommend Bush address that conference?

A: I would recommend it, yes. But I would also add to that, I do make a number of recommendations to the President that he doesn’t always follow, in the same way that my staff makes a number of recommendations to me . . . .

Q: Let’s talk about why people are angry, why they are booing the government. A major point in San Francisco was the travel ban on people testing HIV-positive. The General Accounting Office has said you have the right to nullify the travel ban right now. Do you think you do?

A: No. I reviewed this question even after this came up from the GAO with our attorney general. Their interpretation is that no, I do not have that authority.

Q: Would you like to have that authority? Congress is considering the bill right now. Are you in favor of that bill?

A: Let me put it this way. I would feel it would be very appropriate for the Secretary of Health and Human Services to have that authority because that would really return the situation to what it was prior to 1987.

Q: So you would like to nullify the travel ban?

A: What I’m saying and have said is this is a problem that Congress has caused by passing that legislation in ‘87, and therefore, it’s a problem for Congress to address.

Q: Why is it so difficult for you to say that you’d like to nullify the travel ban? What is it about the politics of AIDS that makes it so difficult to say that?

A: In one sense, the issue is what is appropriate Administration responsibility, what is appropriate congressional responsibility. We deal in that all the time--whether it’s food labeling or foster care or what have you.

Q: You say you’re going to start a conversation with the American people about what we can do about health costs. What are you going to tell them?

A: Several things I’ll be focusing on. One is the fact that we already have started a process of health-care cost containment with physician payment reform that we are now in the process of implementing. That will first take effect Jan. 1, 1992. That’s only one strategy.

Another is continued education of the public about things they can do and must do in terms of personal responsibility for maintaining and enhancing their health . . . . The top 10 causes of death and disability in our society are conditions which are heavily influenced by personal behavior. Heart disease, still our No. 1 killer. Appropriate diet, reducing salt intake, improving exercise and other activities will help there. Cancer is still our No. 2 killer . . . . Our ability to fight it involves having people come in for appropriate screening tests. We look at problems of violence and deaths from violence and accidents. We are supporting community-based organizations designed to try and find ways to reduce violence in our communities, and on down the list. . . .

The public really doesn’t, in general, understand this yet--that there are pressures we put on the health-care systems by our own actions. Half of our drivers around the country are still not using seat belts . . . . The reason that’s important is this: Our trauma centers are under tremendous pressure. If there are things we could do to reduce the demand on our trauma centers, such as a simple thing as using seat belts, that’s going to help.

Q: Is it fair to say that changing these individual behaviors is a major aspect of what to do about health care costs?

A: What I’m saying and will be saying to the American people is we have, as individuals, certain roles to play, not only to protect our health but also to reduce health-care costs, and this is by changes in behavior . . . . If you look at it from the standpoint of what are the things that would most improve or best improve our health status during the decade of the ‘90s, it’s really going to be health promotion and disease prevention . . . .

The other things that we have as part of our overall plan that we’ll be focusing on . . . we are committed to the premise that every American needs to have access to necessary care. So part of our plan has to be how do we provide that. I’m saying this has to be a combination of helping individuals get health insurance--because of the 31 million people without health insurance, two-thirds of these are people who are working. They’re working generally in low-wage jobs and in small businesses, and health insurance is so expensive that for a number of these small businesses they simply cannot afford it. So we have a balance, were we to put mandates on small businesses that might actually sink some of the small businesses and therefore increase unemployment. Having said that, however, part of our overall plan is to find ways to see that these individuals do get insurance. But we’re not yet far enough along to say what is going to be the answer.

Q: How soon can you achieve the goal of every American having access to health care?

A: That’s going to take some time. I would say that’s going to take a period of years . . .

Q: Is that achievable in five years, to get access to everybody?

A: I would think that is achievable, yes.

Q: Some organizations and voices in the medical community are coming around to this point of view. The College of Physicians is expressing a basic sympathy with some kind of national health insurance. Why do you say that’s a mistake?

A: The reason I say that would be a mistake in that direction is this: There are certain things the federal government does well; others that it doesn’t. I’m saying we have a health-care system that, while it has some problems we need to address and we will be addressing them, that we have fundamentally a system that has been very successful. The life expectancy of our citizens in the United States was about 45 years in the 1900s. Now it’s about 75 years. We have almost gotten rid of polio completely, other childhood diseases, vitamin deficiencies, etc. So we’ve done a lot.

The problems we have now are problems that don’t demand doing away with our system, but requires addressing the problems and deficiencies and stresses that exist in our system. Eighty percent of insurance now is employer-sponsored in the private sector. What I’m saying is let’s not chuck that. Let’s address ways to increase the number of our citizens who are covered by health insurance . . . .

Q: While the U.S. health profile is good in many respects, in some ways it’s shockingly bad. Infant mortality in Washington is higher than in Havana. Why can’t we as a society do better?

A: I agree with you, that really is surprising--not only D.C., but generally. We rank between 19th and 22nd among the industrialized nations of the world, and we really should do better. There’s no question about that. Here again, there is an area where there is shared responsibility. Certainly the federal government must do more, and we’re planning to do more. For example, we have in our FY (fiscal year) ’91 budget a $63-million line item for outreach services for pregnant mothers to bring them into prenatal care . . . .

We are expanding our Medicaid program. As you know, the President, in February of ‘89, in his first budget message to Congress, proposed expanding Medicaid eligibility for pregnant women and young children from 100% of the federal poverty level to 130% and the Congress passed that and it was implemented starting April 1. Actually Congress went to 133% of the poverty level. That we will see some results on, but it’s going to take some time . . . .

Q: To go back to the uninsured. What you’re saying to people who don’t have health-care coverage is: one, they should change their behavior to so they don’t get sick as much; and two, some day, we hope within five years, they’ll get coverage, but it’s up to the free-enterprise system. For a tenth of the American people without coverage, that’s not a comforting message.

A: That’s really not my total message. We have now in the United States systems for health care for those people without insurance. They are charity hospitals like D.C. General Hospital or Grady Hospital in Atlanta or Cleveland Metropolitan Hospital, Los Angeles County. Then we have community and migrant health centers in urban and rural areas. Many of these clinics are not being utilized by many of the eligible people . . . .

While we have these people without health insurance, they are not without health care. The care they’re getting is not ideal. It’s very episodic, it can be very inconvenient with long waiting times, we’re using our facilities in the wrong way--say with emergency rooms rather than clinics . . . .

Q: Let me ask about one specific group--the million-plus people now HIV-positive, people extremely unlikely to get private health-care coverage. Most are not eligible for Medicaid. Even if they are, Medicaid is not going to cover a big part of their bill--which may be up to $100,000 a year. In 10 years, all those million people may be extremely sick. There’s a big bill coming due. Do you need to take special action?

A: My approach to this is to address this as part of our overall health-care system. As you probably are aware, we have stated that while we are sympathetic and concerned about that problem, that the Congress’ earmarking treatment monies for one disease represents a slippery slope. Who’s to prevent people with diabetes or with cancer or heart disease saying, “I want treatment money there set aside for that”?

Q: Do you have a goal?

A: Our goal is to really have a smoke-free society by the year 2000. I think there’s a good question as to whether we can achieve that, but we still have that as a goal.