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Transcript of The 2004 Saward Lecture

The Cost of Preserving Privilege in American Health Care - What are you paying for, Sam?

By Dr. Robert G. Evans

Dr. Evans: Thank you very much for that very kind introduction. It's the sort of introduction that you wonder how anybody could live up to, and I hope I come close. I'd like to thank you too [the audience] for coming tonight because it really wouldn't be the same without you. [Group laughter.]

The invitation to give the Saward lecture was a considerable honor. I didn't really have very much trouble at all about accepting, but it's also a personal pleasure, because although I come from out of town, my training originally was in the US. And at that time, I spent a lot of time reading the contrasting experiences of the regular and mainstream health care system and the role of what were then known as pre-paid group practices or closed panel plans. There were no HMOs in those days; we're talking the late '60s, early '70s. I guess that was when I was still at a very impressionable age. I was under 30 at that point and so was capable of having new ideas. [Group laughter.]

Those contrasting experiences played a very important part of forming my outlook on how health care systems worked, because it was pretty clear that there was quite a lot of discretion in how a health care system could be organized. And some ways of organizing them worked a lot better than others. That sort of perception has stayed with me and has made a big difference to my career.

In those days I was reading people like Milton Roemer and Max Shain and Ray Trussell, and some of the early history of the Kaiser Permanente plans in California. That was really quite extraordinary stuff. It was a whole other way of looking at the system, and that's been very valuable to me.

Then tonight, although I didn't have the opportunity to know Dr. Saward, I met his widow, Elizabeth Saward, and, again, circles closed. Connections snapped into place. She brought greetings from my old friend and colleague Gene Vayda in Toronto who, again, played an important role in the early history of what are now called HMOs.

I don't feel I come here entirely the stranger. In a very important way there are things from the beginning of my career that now are connecting up. Well, I won't say at the end of my career, but I am closer to the end than the beginning, so there we are. [Group laughter.] So I feel very good about this on a personal level.

By the way, one of the people that I read in those days, a very useful book by a lady named Jane Cassels Record. When I was going over my notes this morning, I was in the Jane Cassels Record conference room at the Center for Health Research. I looked around and there behind me was the little book on staffing primary care, which may still be on my shelves. But it's probably been stolen because all of the good books get stolen. That's part of the history. You're left with the ones that you never use. [Group laughter.] As I say, on a personal level this is very satisfying for me.

My friend and fellow health economist based in London, Charles Norman, maintains that all generalizations about the United States are true. [Group laughter.] Now, if he's right, this is very helpful to a speaker from out of the country because the problem with giving a talk when you come from outside is that you've really got to work in terms of generalities. There's no getting around the fact that some, at least, of the local folks will know everything that you do and more about the systems that you're talking about.

It's always a bad idea to give lectures to people who know everything and more than you do. This can lead to embarrassment. So, the natural response is to stick to generalities. If you are in an environment where all the generalities are true, then you're home free, aren't you? [Group laughter.] So I've taken great comfort from Charles' comment.

It's particularly important if you come from Canada, because the "let me tell you how it is in my country" phrase is death at any international conference. Because people want to hear about themselves, and Americans even more so. [Group laughter.]