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�THE
WHITE HOUSE
O f f i c e o f t h e Press S e c r e t a r y
For I n t e r n a l Use
September 20, 1993
REMARKS OF THE FIRST LADY
AT HEALTH CARE UNIVERSITY
Capitol
11:55
Hill
P.M. EDT
Thank you v e r y much. I am e x t r e m e l y g r a t i f i e d by t h i s
g a t h e r i n g and I want p a r t i c u l a r l y t o thank t h e l e a d e r s h i p o f b o t h
Houses and b o t h p a r t i e s f o r t h e i r g r a c i o u s n e s s and c o o p e r a t i o n
w i t h me and t h o s e i n t h e a d m i n i s t r a t i o n who have been w o r k i n g on
t h i s p r o p o s a l f o r many months. I'm p a r t i c u l a r l y g r a t e f u l f o r t h e
h e l p o f Congressman M i c h e l and t h e l e a d e r s h i p o f t h e Republican
s i d e o f t h e House and a l s o Senator Dole and t h e Republican
Senators. I a l s o am e x t r e m e l y t h a n k f u l f o r t h e good counsel and
a d v i c e t h a t I r e c e i v e d from Senator M i t c h e l l , Speaker Foley and
M a j o r i t y Leader Gephardt.
I a l s o want t o thank those who p u t
t h i s event t o g e t h e r . I t h i n k t h a t i t ' s a remarkable event t h a t
w i l l i n many ways g i v e a boost t o t h e c o n f i d e n c e l e v e l o f t h e
American people t h a t a l l o f us -- Democrats, Republicans — from
d i f f e r e n t p o i n t s o f view have come t o g e t h e r t o t a l k about an
i s s u e t h a t i s on t h e f o r e f r o n t o f t h e American agenda. And f o r
t h i s e v e n t , I want t o thank Congressman Hoyer and Senator
Daschle, Senator N i c k l e s and Congressman Armey f o r e n l i s t i n g t h e
numbers o f people t h a t p u t an event l i k e t h i s on.
I came from t h e White House t h i s morning where we had over
two hundred l e a d i n g d o c t o r s from around t h e c o u n t r y , come
together t o voice t h e i r general support f o r the d i r e c t i o n t h a t
r e f o r m i s moving. And former S o l i c i t o r General C. E v e r e t t Koop
has agreed t o t a k e a l e a d e r s h i p r o l e i n c o n t i n u i n g t o work w i t h
p h y s i c i a n s a l l over t h e c o u n t r y , so t h a t t h e k i n d s o f concerns
t h a t R e p r e s e n t a t i v e M i c h e l mentioned w i l l always be a t t h e
f o r e f r o n t o f our c o n s i d e r a t i o n . I was p e r s o n a l l y d e l i g h t e d t h a t
not o n l y someone l i k e Dr. Koop, b u t t h e CEO o f Mayos t h a t heads
the numerous o f our m e d i c a l s c h o o l s , f a m i l y p r a c t i c e d o c t o r s ,
s p e c i a l i s t s , t h o s e from d i f f e r e n t k i n d s o f medicine were t h e r e
t h i s morning t o say i n a u n i f i e d v o i c e , "We b e l i e v e i n t h e
p r i n c i p l e s t h a t u n d e r l i e r e f o r m . " We may d i s a g r e e about some o f
the d e t a i l s and t h e t e c h n i c a l i t i e s , b u t t o have reached a p o i n t
f i n a l l y a f t e r s i x t e e n years o f e f f o r t by b o t h Democratic and
R e p u b l i c a n P r e s i d e n t s , by l e a d e r s i n b o t h p a r t i e s t o reach a
p o i n t where we are agreed t h a t we must make changes i n o r d e r t o
p r e s e r v e what i s b e s t about American h e a l t h care and t o f i x what
�- 2 i s wrong. I t i s , indeed, an e x t r a o r d i n a r y moment i n t i m e . And I
hope t h a t a l l o f us w i l l approach t h i s o p p o r t u n i t y i n t h a t way.
There i s no doubt t h a t t h e r e i s n o t any i s s u e t h a t has more h o l d
on a l l o f you as p u b l i c stewards and members o f t h i s body. What
I hope we w i l l be a b l e t o do i s t o work t h r o u g h a l o t o f t h e
concerns t h a t many o f you have brought t o me and t o o t h e r s over
the p a s t months. I have p e r s o n a l l y met over one hundred t h i r t y
t i m e s w i t h members o f Congress here i n t h e C a p i t o l . Others who
have worked w i t h me have added many, many hundreds o f meetings t o
t h a t . We have met w i t h over a 1,100 groups o f people concerned
about h e a l t h c a r e . Sometimes, many, many t i m e s t o work o u t a
good approach t o s o l v i n g a problem.
What I am s t r u c k by i s t h e
s p i r i t t h a t has permeated these d i s c u s s i o n s from t h e v e r y
b e g i n n i n g , which I hope w i l l be m a i n t a i n e d as we move t o w a r d
l e g i s l a t i o n and a c t u a l l y implementing changes i n t h e system.
One o f t h e o r i g i n a l ideas behind t h i s g a t h e r i n g was t o g i v e
members who had n o t been i n v o l v e d w i t h h e a l t h care a chance t o
ask q u e s t i o n s and t o v o i c e t h e i r concerns.
Because c e r t a i n l y i n
the many, many meetings t h a t I have been p r i v i l e g e d t o have, I
have o f t e n seen some o f you many t i m e s over because o f t h e
p a r t i c u l a r committees t h a t you serve on, and I have n o t seen some
of you a t a l l because o f t h e p a r t i c u l a r committees you serve on.
What we hope today, p a r t i c u l a r l y , i s t h a t those members who have
not been p a r t o f t h e ongoing c o n s u l t a t i o n f o r whom t h i s may be
the v e r y f i r s t meeting t h e y have had about h e a l t h care c o n c e r n i n g
the p r o p o s a l and t h e d i r e c t i o n we want t o move i n , w i l l f e e l f r e e
t o ask t h e i r q u e s t i o n s and w i l l perhaps even be w i l l i n g t o be
g i v e n t h e o p p o r t u n i t y t o ask more q u e s t i o n s t h a n t h o s e who a r e so
much more f a m i l i a r w i t h a l o t o f t h e d e t a i l s .
I mean, I have t o
c o n f e s s , when I s t a r t e d t h i s e i g h t months ago, I was n o t i n my
own mind r e a l l y sure about a l o t o f these concepts.
I won't go so
f a r as t o say t h a t I d i d n ' t know t h e d i f f e r e n c e between Medicaid
and Medicare, b u t I o f t e n found myself u s i n g one when I meant t h e
o t h e r . And I t h i n k i t ' s i m p o r t a n t t h a t a l l members here who have
not been i n v o l v e d i n t h e h e a l t h care debate, i t has n o t been p a r t
of your r e s p o n s i b i l i t y , b u t you a r e anxious t o l e a r n and you hear
a l o t about i t from your c o n s t i t u e n t s , f e e l p a r t i c u l a r l y f r e e t o
ask your q u e s t i o n s and t o know t h a t even those who a r e much more
knowledgeable because o f what t h e y have done over decades,
s t a r t e d o f f where you a r e s t a r t i n g o f f and n o t t o f e e l i n any way
c o n s t r a i n e d from a s k i n g whatever q u e s t i o n s m i g h t c r o s s your mind
about what we a r e a t t e m p t i n g t o a c h i e v e .
What we would l i k e t o do t h i s morning i s t o spend j u s t a few
minutes t a l k i n g , g e n e r a l l y about t h e p r o p o s a l and t h e n what I
would r e a l l y l i k e t o do i s t o have t i m e t o hear your q u e s t i o n s so
t h a t we can t r y t o respond t o them. I f we s t a r t w i t h t h e idea
t h a t there are c e r t a i n p r i n c i p l e s t h a t underlie the President's
p r o p o s a l , t h e n we can move from those p r i n c i p l e s t o t h e d e t a i l s
and t e c h n i c a l aspects o f i t and t a l k b o t h g e n e r a l l y and
�- 3 s p e c i f i c a l l y about where we are
heading.
L e t me j u s t b r i e f l y r u n over those p r i n c i p l e s because you
w i l l hear much from both t h e P r e s i d e n t and from t h e members o f
the Cabinet who are here about how t h e r e i s so much room f o r
t a l k i n g t h r o u g h how we g e t t o achieve c e r t a i n p r i n c i p l e s . And we
mean t h a t v e r y s i n c e r e l y . We welcome t h e k i n d o f a d v i c e and
counsel t h a t you are g i v i n g us on a r e g u l a r b a s i s . We know t h a t
many o f you a l r e a d y have good q u e s t i o n s and s u g g e s t i o n s o f f o f
the ( i n a u d i b l e ) t h a t have a l r e a d y been c i r c u l a t e d .
So p a r t o f
what we hope i s t h a t t h i s w i l l c o n t i n u e t h a t process.
The
p r i n c i p l e s , though, t h a t u n d e r l i e a r e : number one, we have t o
p r o v i d e h e a l t h s e c u r i t y f o r every American. That means two
t h i n g s — i t means r e a c h i n g u n i v e r s a l coverage so t h a t every
American has t h e s e c u r i t y o f knowing t h a t he or she w i l l be a b l e
t o o b t a i n h e a l t h care when needed. I t a l s o means t h a t we b e l i e v e
every American should be e n t i t l e d t o a guaranteed b e n e f i t s
package. And t h a t package should be a v a i l a b l e t o you as an
American, n o t because o f who you work f o r or whether you've ever
been s i c k b e f o r e or what r e g i o n o f t h e c o u n t r y you l i v e i n . And
i t ' s p a r t i c u l a r l y i m p o r t a n t t h a t t h e b e n e f i t s package t r y t o
s t r e s s p r i m a r y and p r e v e n t i v e h e a l t h c a r e . Because i n t h e
absence o f t r y i n g t o s t r e s s p r i m a r y p r e v e n t i v e h e a l t h c a r e , we
b e l i e v e we w i l l c o n t i n u e t o pay more money i n t h e l o n g r u n , t h a n
we w i l l i f we t a k e care o f some o f these medical problems t h a t
c o u l d be p r e v e n t e d b e f o r e t h e y g o t worse.
The second i s s u e i s t h a t i n a d d i t i o n t o s e c u r i t y , t h e system
has t o be s i m p l i f i e d .
I t should be s i m p l i f i e d f o r a l l p a r t s o f
i t , b u t p a r t i c u l a r l y f o r those who a c t u a l l y d e l i v e r h e a l t h care
— our p h y s i c i a n s , our nurses, our o t h e r p r o f e s s i o n a l s . We have
i n b o t h t h e p u b l i c s e c t o r and t h e p r i v a t e s e c t o r added l i t e r a l l y
b i l l i o n s o f d o l l a r s on t o t h e d e l i v e r y o f h e a l t h c a r e . We have,
by adding those b i l l i o n s o f d o l l a r s , r e q u i r e d d o c t o r s and nurses
t o spend l i t e r a l l y m i l l i o n s o f man-hours f u l f i l l i n g b u r e a u c r a t i c
and r e g u l a t o r y and p r i v a t e i n s u r a n c e company r e q u i r e m e n t s .
I
don't know i f any o f you were a b l e t o hear what t h e P r e s i d e n t and
Vice P r e s i d e n t heard a t C h i l d r e n ' s H o s p i t a l on F r i d a y , b u t I
t h i n k t h i s p o i n t i l l u s t r a t e s what we are a t t e m p t i n g t o achieve
t h r o u g h s i m p l i f i c a t i o n . The P r e s i d e n t and t h e V i c e P r e s i d e n t met
w i t h t h e s t a f f o f t h e Washington, D.C. C h i l d r e n ' s H o s p i t a l . As
p a r t o f t h e i r e f f o r t t o r e a c t t o r e f o r m , t h e y have been d o i n g
t h e i r own surveys. They have determined t h a t f o r t h e average
d o c t o r t h a t serves on t h e i r s t a f f — t h e y have over two hundred
d o c t o r s — t h e k i n d o f paperwork r e q u i r e m e n t s t h a t have n o t h i n g
t o do w i t h p a t i e n t r e c o r d s , b u t paperwork h a v i n g t o do l a r g e l y
w i t h f i n a n c i n g and r e i m b u r s i n g care are so e x t r a o r d i n a r i l y heavy
t h a t i f you c o u l d remove t h a t paperwork from those d o c t o r s , t h e y
would have t i m e t o see, on average, an a d d i t i o n a l f i v e hundred
p a t i e n t s a year. Now, t h a t i s t h e i r c a l c u l a t i o n . They b e l i e v e
�- 4 t h a t we have so burdened t h e i r d o c t o r s w i t h unnecessary paperwork
t h a t we have d e p r i v e d 10,000 c h i l d r e n from seeing d o c t o r s d u r i n g
t h e course o f t h e year.
Now i t ' s t h a t k i n d o f s t a t i s t i c we have
run i n t o t i m e and t i m e a g a i n i n l o o k i n g a t t h i s system, and can
g i v e you many more examples o f i t .
The t h i r d p r i n c i p l e t h a t comes from s i m p l i f i c a t i o n i s t h a t
we b e l i e v e t h a t t h e r e a r e savings i n t h i s system. Now I know
t h a t i s an i s s u e we should g e t i n t o and t a l k about i n t h e
q u e s t i o n and answer p e r i o d , because I know t h a t t h e r e a r e members
who a r e concerned about where those savings come from, how we
c a l c u l a t e those s a v i n g s . And we do advocate r e d u c i n g t h e r a t e o f
growth — n o t c u t t i n g — b u t r e d u c i n g t h e r a t e o f growth i n b o t h
Medicare and Medicaid, and a l s o c r e a t i n g i n c e n t i v e s i n t h e
p r i v a t e market t o reduce t h e r a t e o f growth i n t h e p r i v a t e
s e c t o r , h e a l t h care e x p e n d i t u r e s . Now one o f t h e key i s s u e s
about r e d u c i n g t h e r a t e o f growth i n our p u b l i c programs i s t o
analyze v e r y c a r e f u l l y where t h e money now goes. I f you conduct
t h a t k i n d o f a n a l y s i s — as n o t o n l y have t h e people we have
worked w i t h have done, b u t many o t h e r s o u t i n t h e c o u n t r y have
done — i t i s v e r y hard t o j u s t i f y t h e c u r r e n t e x p e n d i t u r e s i n
b o t h o f those p u b l i c programs i n terms o f t h e range o f c o s t
around t h e c o u n t r y compared t o t h e r e a l c o s t o f d e l i v e r i n g h e a l t h
care i n those same r e g i o n s o f t h e c o u n t r y . L e t me j u s t g i v e you
two examples: t h e s t a t e o f Minnesota i s much f u r t h e r a l o n g t h a n
o t h e r s t a t e s i n o r g a n i z i n g t h e d e l i v e r y o f h e a l t h c a r e . So t h a t
t h e y have many more o f t h e i r c i t i z e n s , t h a n my s t a t e o f Arkansas
f o r example, who belong t o some k i n d o f p r e - p a i d h e a l t h
o r g a n i z a t i o n , some k i n d o f h e a l t h maintenance o r g a n i z a t i o n , t h e y
l i t e r a l l y have most o r n e a r l y a l l o f t h e i r p o p u l a t i o n now i n
those k i n d s o f networks o f h e a l t h care d e l i v e r y . They have many
of t h e i r Medicare p a t i e n t s i n o r g a n i z e d h e a l t h care d e l i v e r y
systems.
I n Minnesota t h e average c o s t o f t a k i n g care o f a Medicare
p a t i e n t i s one h a l f o f what i t i s i n P h i l a d e l p h i a . I n New Haven,
C o n n e c t i c u t , t h e average c o s t i s o n e - h a l f o f what i t i s i n
Boston. And you can go down example a f t e r example. I f you
analyze t h e e x p e n d i t u r e s and i f you t r y t o h o l d c o n s t a n t any
v a r i a t i o n between p o p u l a t i o n , s i c k n e s s . . . t h e r e i s s t i l l no
adequate e x p l a n a t i o n f o r those k i n d o f d i f f e r e n t i a l s o t h e r t h a n
t h e way t h e systems a r e o r g a n i z e d and t h e c o s t i n t h e v a r i o u s
systems and how t h e y compare w i t h one another.
So our p o i n t i s
t h i s — i f you l o o k a t t h e r a t e o f i n c r e a s e c u r r e n t l y p r o j e c t e d
f o r our p u b l i c system, even a f t e r t h e r e c e n t budget
r e c o n c i l i a t i o n , Medicare i s p r o j e c t e d t o i n c r e a s e a t 1 1 % f o r t h e
next two y e a r s , Medicaid a t 16%. N e i t h e r t h e Medicare
p o p u l a t i o n , n o r t h e Medicaid p o p u l a t i o n i s expected t o i n c r e a s e
a t a n y t h i n g near those percentages.
So even i f we were t o say,
we want everyone t o have a CPI o r a c o s t o f l i v i n g i n c r e a s e , an
�- 5 i n f l a t i o n i n c r e a s e ; we want t o t a k e care o f t h e p o p u l a t i o n t h a t
w i l l be g e t t i n g a t Medicare e l i g i b l e o r Medicaid e l i g i b l e , we
b e l i e v e t h a t t h e r e i s a s i g n i f i c a n t amount o f money i n those
systems t h a t can be b e t t e r a l l o c a t e d t h a n b e i n g p u t i n t o t h e same
s e r v i c e s as t h e y a r e c u r r e n t l y b e i n g p a i d f o r by f e d e r a l
government.
There's another i s s u e here. Even though t h e d i r e c t
a d m i n i s t r a t i v e c o s t s o f Medicare a r e s i g n i f i c a n t l y lower t h a n t h e
p r i v a t e insurance a d m i n i s t r a t i v e costs, t h e costs t h a t doctors
and h o s p i t a l s i n c u r i n d e a l i n g w i t h t h e Medicare system a r e n o t .
So p a r t o f what we b e l i e v e i s t h a t we can save money f o r
p h y s i c i a n s and f o r h o s p i t a l s by b e t t e r o r g a n i z i n g t h e Medicare
system and by i n t e g r a t i n g i n t o t h e o v e r a l l h e a l t h care system.
M e d i c a i d r e c i p i e n t s t h e y s h o u l d be p u t i n t o an o v e r a l l h e a l t h
care system j u s t l i k e you and I , t h e y s h o u l d n o t be i d e n t i f i e d ,
t h e y s h o u l d n o t be m a r g i n a l i z e d and we b e l i e v e t h e i r h e a l t h care
can be d e l i v e r e d more e f f i c i e n t l y and, i n some ways, w i t h more
d i g n i t y t h a n t h e c u r r e n t Medicaid system c u r r e n t l y a l l o w s .
A f o u r t h p r i n c i p l e i s c h o i c e . We b e l i e v e t h a t we s h o u l d n o t
o n l y p r e s e r v e , b u t enhance t h e c h o i c e o f consumers t o choose
t h e i r h e a l t h p l a n . The way c u r r e n t t r e n d s a r e g o i n g now, most
employers p r o v i d e some c o n t r i b u t i o n t o t h e i r employees' h e a l t h
c a r e , f o r those w o r k i n g Americans who a r e i n s u r e d . The employers
make t h e c h o i c e . And i n c r e a s i n g l y employers a r e l i m i t i n g t h e
c h o i c e o f t h e i r employees. Yes, you w i l l g e t t h e i n s u r a n c e , b u t
you w i l l o n l y be a b l e t o use Plan X, o r maybe a c h o i c e between
Plan X and Plan Y. We t h i n k t h e a p p r o p r i a t e c h o i c e s h o u l d r e s t
of t h e i n d i v i d u a l , t h a t b e t t e r i n f o r m e d consumers w i l l make
b e t t e r c h o i c e s . And we a l s o b e l i e v e t h a t d o c t o r s s h o u l d have t h e
c h o i c e as t o what p l a n s t h e y w i l l p r a c t i c e i n . So we want t o
p r e v e n t t h e d i s c r i m i n a t i o n t h a t i s now growing up a g a i n s t
d o c t o r s , and p e r m i t them t o p r a c t i c e i n s e v e r a l d i f f e r e n t p l a n s .
We t h i n k t h a t i s i m p o r t a n t f o r d o c t o r s , c r i t i c a l f o r consumers.
A f i f t h principle i squality.
I f were t o do a l l t h a t we
t h i n k s h o u l d be done and i t d i d n o t p r e s e r v e and enhance q u a l i t y ,
we would n o t have made a s t e p f o r w a r d . We b e l i e v e q u a l i t y w i l l
be enhanced t h r o u g h b e t t e r o r g a n i z a t i o n and b e t t e r u t i l i z a t i o n o f
the money t h a t we a r e c u r r e n t l y spending.
We have evidence o f
the f a c t t h a t more e f f i c i e n t d e l i v e r y o f h e a l t h care does n o t
decrease q u a l i t y , i n f a c t , t h e r e i s o f t e n no d i f f e r e n c e and maybe
even some argument t h a t you have b e t t e r q u a l i t y because you a r e
s e r v i n g more people e f f i c i e n t l y .
L e t me g i v e you an example, t h e
s t a t e o f Pennsylvania f o r a number o f y e a r s , has done an
e x c e l l e n t s e r v i c e t o i t s c i t i z e n s and a l s o t o t h e e n t i r e c o u n t r y
by c o l l e c t i n g i n f o r m a t i o n about how much c e r t a i n procedures c o s t
i n d i f f e r e n t h o s p i t a l s t h r o u g h o u t t h e s t a t e . I f you t a k e one
p a r t i c u l a r procedure t h a t i s commonly performed, t h e c o r o n a r y
bypass o p e r a t i o n . That o p e r a t i o n can be performed i n a
�- 6 Pennsylvania h o s p i t a l f o r $21,000 or f o r $84,000 or f o r a l o t of
d i f f e r e n t c o s t s between 21 and 84.
Based on t h e q u a l i t y a n a l y s i s
of p a t i e n t outcomes t h e r e i s no d i f f e r e n c e . Some of t h e people
t h a t looked a t t h e Pennsylvania data would argue t h a t i f t h e r e i s
a d i f f e r e n c e , i t ' s an advantage f o r t h e $21,000, n o t t h e $84,000.
There i s no d i f f e r e n c e i n q u a l i t y between those o p e r a t i o n s .
And
t h a t i s h o l d i n g c o n s t a n t f o r the l e v e l of s i c k n e s s , t h e age of
t h e p a t i e n t , so we're n o t comparing apples and oranges, we're
comparing apples and apples.
I f t h e r e i s t h a t k i n d of
d i s c r e p a n c y , which indeed t h e r e i s , a l l over t h e s t a t e s , n o t j u s t
P e n n s y l v a n i a , we b e l i e v e t h e r e ' s a tremendous o p p o r t u n i t y f o r
enhancing q u a l i t y as we work w i t h and educate consumers and
p h y s i c i a n s about a p p r o p r i a t e m e d i c a l care, t h e c h o i c e s t h a t t h e y
w i l l make, and more e f f i c i e n t , q u a l i t y - d r i v e n ways f o r a c h i e v i n g
those outcomes. We enhance q u a l i t y t h r o u g h t h i s p r o p o s a l , we
c o l l e c t i n f o r m a t i o n about t h e d e l i v e r y of h e a l t h care t h a t has
never been made p u b l i c t o people b e f o r e and we w i l l ask h e a l t h
p l a n s t o p u b l i s h r e p o r t cards so t h a t you as a consumer can
d e t e r m i n e based on c r i t e r i a t h a t are i m p o r t a n t , which h e a l t h p l a n
you m i g h t choose.
The f i n a l p r i n c i p l e i s r e s p o n s i b i l i t y . T h i s e n t i r e system
needs more r e s p o n s i b i l i t y . And when I say system I mean everyone
i n i t and a l l o f us who e i t h e r use i t or are p o t e n t i a l users of
it.
There are people, as we a l l know, who have never p a i d a
penny f o r t h e i r own h e a l t h care and r e a l l y don't ever want t o pay
a penny f o r t h e i r own h e a l t h care.
There are people who are
t o t a l l y w i t h o u t h e a l t h care and who when t h e y f i n a l l y do o b t a i n
some k i n d o f t r e a t m e n t , do i t a t t h e l a s t p o s s i b l e moment a t t h e
most expensive c o s t , which t h e n t h e r e s t of us pay f o r —
through
e i t h e r t h e p u b l i c or p r i v a t e insurance system. There are many
i n s t a n c e s i n which p h y s i c i a n s and p r o v i d e r s make d e c i s i o n s which
have n o t h i n g t o do w i t h being r e s p o n s i b l e , b u t e v e r y t h i n g t o do
w i t h t h e reimbursement stream t h a t i s p u s h i n g them t o make a
d e c i s i o n . We have people making d e c i s i o n s because o f t h e
m a l p r a c t i c e problems t h a t a r e n ' t r e s p o n s i b l e p h y s i c i a n s , b u t are
b e i n g d r i v e n t o do so because o f t h e i r f e a r of l i t i g a t i o n .
If
you go t h r o u g h t h i s system, you can see p o i n t a f t e r p o i n t a t
every l e v e l o f i t , people making d e c i s i o n s t h a t t h e y w i l l t e l l
you are n o t t h e r e s p o n s i b l e d e c i s i o n s , b u t which t h e y f e e l
compelled t o make. We must r e q u i r e r e s p o n s i b i l i t y f o r everybody.
We have a number o f f e a t u r e s i n our p r o p o s a l t h a t we t h i n k
enhance r e s p o n s i b i l i t y . We t h i n k p r o v i d i n g p r e v e n t i v e h e a l t h
care enhances r e s p o n s i b i l i t y . We t h i n k f i n a n c i n g t h e system by
j o i n t employer-employee c o n t r i b u t i o n s , b u i l d i n g on our e x i s t i n g
system enhances r e s p o n s i b i l i t y . We b e l i e v e changing t h e
reimbursement systems, t h e m a l p r a c t i c e system w i l l enhance
r e s p o n s i b i l i t y . We b e l i e v e changing t h e a n t i t r u s t laws, some of
which we announced a week ago w i l l enhance r e s p o n s i b i l i t y because
h o s p i t a l s w i l l , w i t h o u t f e a r o f b e i n g sued be a b l e t o come
t o g e t h e r t o agree t o buy one c a t - s c a n i n s t e a d o f i r r e s p o n s i b l y as
�- 7 t h e y t e l l us g o i n g o u t each b u y i n g t h e i r own c a t - s c a n because
they a r e a f r a i d t o t a l k t o g e t h e r because o f t h e a n t i - t r u s t laws.
On many, many f r o n t s we can enhance r e s p o n s i b i l i t y .
But l e t me j u s t t a l k s p e c i f i c a l l y about t h e one t h a t I know
many o f you have asked about and t h a t i s t h e employer-employee
shared c o n t r i b u t i o n . When you l o o k a t a l l o f t h e systems t h a t
are a v a i l a b l e i n t h e w o r l d and t h e systems t h a t a r e a v a i l a b l e i n
our c o u n t r y i n p l a c e s l i k e Rochester, New York o r Rochester,
Minnesota o r t h e s t a t e o f Hawaii o r what i s happening i n
Washington and C a l i f o r n i a and F l o r i d a and p l a c e s l i k e t h a t .
There a r e r e a l l y i n g e n e r a l , o n l y t h r e e ways t o f i n a n c e
u n i v e r s a l coverage. A f t e r you s t r i p i t a l l away we're g o i n g t o
get everybody i n t h e system, and everybody b e i n g r e s p o n s i b l e .
There a r e o n l y t h r e e ways o f d o i n g i t . There i s a s i n g l e payer
approach which I know i s s u p p o r t e d v i g o r o u s l y by many i n t h i s
chamber. I t i s a sure f i r e way o f g e t t i n g everybody covered
because, we s u b s t i t u t e , under t h e s i n g l e payer approach t h e
e n t i r e p r i v a t e s e c t o r i n v e s t m e n t f o r t a x money t h a t w i l l fund t h e
h e a l t h c a r e system. And t h e s i n g l e payer p r o p o s a l s , p a r t i c u l a r l y
the most c u r r e n t v e r s i o n would do j u s t t h a t .
I t would r a i s e
about 500 b i l l i o n d o l l a r s , ( t h r o u g h t a x i n g ) and t o t a l l y e l i m i n a t e
the c o s t s t o any employer o r employee whether i t s i n s u r a n c e
premiums, o u t - o f - p o c k e t , whatever. That i s one way o f f i n a n c i n g
h e a l t h care.
Another approach, which i s embodied i n b o t h t h e Senate
R e p u b l i c a n and t h e House R e p u b l i c a n approach i s t o p u t t h e
r e s p o n s i b i l i t y on t h e i n d i v i d u a l .
E i t h e r t h r o u g h some k i n d o f
IRA o r Medi-save o r t h r o u g h an i n d i v i d u a l mandate, which i s t h e
core f i n a n c i n g p r i n c i p l e i n t h e Senate Republican's approach.
S i m i l a r , as you m i g h t guess t o what t h e s t a t e s have t r i e d t o do
w i t h a u t o i n s u r a n c e . Everybody has t o have h e a l t h i n s u r a n c e —
everybody has t o g e t i n t o t h e m a r k e t p l a c e . We applaud t h e idea
of i n d i v i d u a l r e s p o n s i b i l i t y t h a t u n d e r l i e s b o t h o f t h o s e
approaches. We do have and w i l l c o n t i n u e t o d i s c u s s w i t h our
c o l l e a g u e s on t h e R e p u b l i c a n s t a f f s i d e and w i t h t h e members, how
we would a c t u a l l y make t h o s e approaches work t o w a r d a c h i e v i n g
u n i v e r s a l coverage.
We have some q u e s t i o n s about whether o r n o t t h a t would work,
whether o r n o t an IRA would r e a l l y h e l p produce t h e k i n d o f
p r e v e n t i v e h e a l t h c a r e t h a t we t h i n k would save money o r
encourage people t o h o l d back from c a r e so t h a t t h e y c o u l d pocket
the remainder. We have some i s s u e s about how we would a c t u a l l y
s u b s i d i z e t h e m i l l i o n s o f people t h a t would be needing a s u b s i d y
under an i n d i v i d u a l mandate approach, how we would keep t r a c k o f
them, whether you would have t o use t h e IRS o r some o t h e r
bureaucracy t o p o i n t them o u t t o make sure t h a t t h e y ( g i v e ) o r
don't go over t h e i r voucher l e v e l and t h e r e a r e a l o t o f t e c h n i c a l
�- 8 i s s u e s t h a t we w i l l have t o work t h r o u g h and analyze t o g e t h e r .
For a l o t o f reasons, we b e l i e v e t h a t b u i l d i n g on t h e
e x i s t i n g employer-employee system t h a t most people who are
i n s u r e d a r e f a m i l i a r w i t h does t h e l e a s t t o change t h e e x i s t i n g
h e a l t h care system. As one o f our g o a l s , we want t o make t h e new
system as f a m i l i a r t o Americans as t h e o l d system. I n employeremployee systems, you would s t i l l g e t your h e a l t h care coverage
from t h e work p l a c e . But i n s t e a d o f t h e employer making t h e
c h o i c e , you would make t h e c h o i c e as t o what p l a n s you s i g n e d up
for.
I n t h e employer-employee, you would n o t have t o w o r r y
about any employer e i t h e r pushing wages down so t h a t t h e
i n d i v i d u a l was e l i g i b l e f o r a s u b s i d y which would r e l i e v e t h e
employer o f t h a t r e s p o n s i b i l i t y . Or even f o r employers b e g i n n i n g
t o back o f f on t h e i r i n s u r a n c e c o n t r i b u t i o n s because now t h e
government would p i c k up i n d i v i d u a l s .
I n t h e employer-employer
approach, we have t r i e d v e r y h a r d t o be open and s e n s i t i v e t o t h e
l e g i t i m a t e concerns o f business - b o t h b i g b u s i n e s s , s m a l l
b u s i n e s s , e v e r y t h i n g i n between, which i s why we have c o n s t r u c t e d
a system t h a t would l i m i t t h e amount o f money any b u s i n e s s - b i g
or s m a l l — has t o c o n t r i b u t e and p a r t i c u l a r l y g i v e a s i g n i f i c a n t
d i s c o u n t t o s m a l l businesses w i t h low wage employees under t h e
size of f i f t y .
The k i n d o f s u b s i d y t h a t we're t a l k i n g about would enable
the v a s t m a j o r i t y o f s m a l l businesses t h a t c u r r e n t l y i n s u r e t o
save money. We have t o , when we t h i n k about t h e s m a l l business
community, make a d i s t i n c t i o n between t h o s e s m a l l businesses who
are c u r r e n t l y s t r u g g l i n g i n t h e m a r k e t p l a c e t o i n s u r e a g a i n s t
g r e a t odds and t h o s e s m a l l businesses who have n o t i n s u r e d ,
e i t h e r because t h e y d i d n o t t h i n k t h e y c o u l d a f f o r d i n t h e
c u r r e n t market o r t h e y don't want t o . For t h o s e b u s i n e s s t h a t do
i n s u r e , t h e v a s t m a j o r i t y w i l l be r e c e i v i n g b e n e f i t s a t an
a f f o r d a b l e r a t e t h a t w i l l be no more t h a n t h e y pay now, i n most
instances less.
For s m a l l business t h a t do n o t now i n s u r e , we have a
p r i n c i p l e response, as w e l l as a p r a c t i c a l one. Given our
c u r r e n t h e a l t h care system, you can walk down any main s t r e e t i n
any town t h a t you r e p r e s e n t . And you can p o i n t t o a d r y c l e a n e r
t h a t i n s u r e s and you can p o i n t t o a car wash t h a t doesn't.
You
can p o i n t t o a r e t a i l e r t h a t does a l i t t l e b i t , b u t n o t a l o t .
You can go down, as we have l i t e r a l l y done, t a l k i n g t o i n d i v i d u a l
s m a l l b u s i n e s s l o o k i n g a t t h e i r books, h e l p i n g them c a l c u l a t e
t h e i r c o s t s . The problem i s t h a t when t h e employee a t t h e c a r
wash who has no i n s u r a n c e g e t s s i c k , t h e ambulance comes and
p i c k s them up, t a k e s them t o t h e h o s p i t a l , t r e a t s them — we
don't t u r n people away i n t h i s c o u n t r y , t h e y g e t t h e r e
e v e n t u a l l y . And t h e n t h e c o s t s t o t h e n e i g h b o r i n t h e
d r y c l e a n i n g s t o r e go up. Because t h a t ' s how we pay f o r
uncompensated c a r e f o r t h e w o r k i n g u n i n s u r e d .
�- 9 For l a r g e businesses, and many o f you w i l l have a m i x t u r e o f
l a r g e and s m a l l l i k e R e p r e s e n t a t i v e M i c h e l does i n h i s d i s t r i c t ,
f o r l a r g e businesses, b i g businesses have s u b s i d i z e d s m a l l
businesses f o r years w i t h h e a l t h i n s u r a n c e . They've done i t f o r
years w i t h h e a l t h i n s u r a n c e . They've done i t i n s e v e r a l ways
because t h e y u s u a l l y have p i c k e d up t h e c o s t s o f t h e
uncompensated c a r e , b u t i n r e c e n t years t h e y have done i t
d i r e c t l y because t h e y i n s u r e u s u a l l y t h e e n t i r e f a m i l y which
r e l i e v e s t h e business where t h e spouse works from h a v i n g t o make
any c o n t r i b u t i o n whatsoever. There has been a hidden t a x on
businesses w i l l i n g t o i n s u r e f o r a v e r y l o n g t i m e .
And t h a t
hidden t a x i s one t h i n g we want t o e l i m i n a t e . We want t o
e l i m i n a t e f r e e r i d e r s , we want everybody t o be a p a r t o f t h i s
system, we a r e open t o ways o f d o i n g i t t o ( i n a u d i b l e ) , we
a b s o l u t e l y h o l d t o t h e a b s o l u t e zero l e v e l t h e l e g i t i m a t e
business concerns t h a t might r e s u l t i n some k i n d o f l o s s t o them.
We want t o be v e r y open on t h a t , b u t we t h i n k b u i l d i n g on t h e
e x i s t i n g system i s t h e f a i r e s t , most e f f i c i e n t , most f a m i l i a r way
f o r i n d i v i d u a l s t o achieve u n i v e r s a l coverage and b e t t e r
insurance t h a n t h e y can a f f o r d now.
So those a r e t h e p r i n c i p l e s , and as I s a i d , we b e l i e v e f a i r
f i n a n c i n g t h a t leads t o r e s p o n s i b i l i t y , we can work o u t d e t a i l s
but i t has t o make sure we g e t t o u n i v e r s a l coverage and t h e r e
has t o be these o t h e r p r i n c i p l e s f u l f i l l e d along t h e way.
F i n a l l y , l e t me j u s t say t h a t t h e k i n d o f i s s u e s t h a t you a r e
b r i n g i n g t o us a r e e x a c t l y what v/e want t o hear. I have been up
on t h e H i l l i n t h e l a s t week ever s i n c e t h e p o l i c y g o t o u t , and I
wish we c o u l d t a k e c r e d i t f o r t h e f a c t t h a t i t i s now b e t t e r read
t h a n i t ever would have been i f we had j u s t handed i t o u t .
There's n o t h i n g l i k e p l a y i n g s e c r e t o r p r o l o n g i n g you people t o
read i t .
I ' d l i k e t o say t h a t was our s t r a t e g y . But now t h a t
we've been up here t a l k i n g t o b o t h Republican and Democrats, t h e
c o n s t r u c t i v e a d v i c e about how we a l l meet these p r i n c i p l e s has
been v e r y h e l p f u l and we have a l r e a d y made adjustments on t h e
p l a n based on what you have t o l d us. And t h a t process, we i n t e n d
t o c o n t i n u e . So w i t h t h a t Mr. Speaker and Mr. Leader, I ' d be
happy t o answer q u e s t i o n s t h a t any o f t h e members may have.
END
�4
MEDIA PREP MEETING TRANSCRIPT
9/13/93
Q Nice t o see you today, Mrs. C l i n t o n .
MRS.
CLINTON:
Nice t o see you, t o o .
Q
So what t h e American people r e a l l y want t o know
about t h i s h e a l t h p l a n t h a t you've cooked up i s , what's i n i t f o r me?
MRS. CLINTON: W e l l , t h e r e i s a l o t i n i t f o r everybody,
s t a r t i n g w i t h t h e g u a r a n t e e o f h e a l t h s e c u r i t y f o r every American,
r e g a r d l e s s o f whether you work o r who you work f o r , o r where you
l i v e , o r whether you've ever been s i c k b e f o r e . I t h i n k t h a t i s t h e
most i m p o r t a n t f e a t u r e o f t h i s .
And i t c e r t a i n l y i s what people have
t o l d me a l l over t h e c o u n t r y , t h a t i f we can guarantee every American
a l i s t o f comprehensive h e a l t h b e n e f i t s t h a t w i l l be a v a i l a b l e t o
them no m a t t e r who t h e y a r e , t h a t ' s what Americans want.
Q
And you t h i n k Americans are w i l l i n g t o pay more f o r
that?
MRS. CLINTON: They won't have t o pay more.
Most
Americans are p a y i n g t o o much now f o r t h e h e a l t h care coverage t h a t
t h e y have access t o . Some Americans, as you know, don't pay a n y t h i n g
and t h e r e s t o f us pay f o r them e i t h e r t h r o u g h h i g h e r i n s u r a n c e
premiums o r t h r o u g h h i g h e r t a x e s . But what we've t r i e d t o do i s t o
d e s i g n a s e t o f b e n e f i t s t h a t w i l l be e q u i v a l e n t t o what a good
i n s u r a n c e p o l i c y p r o v i d e s t o d a y w i t h t h e a d d i t i o n o f p r i m a r y and
p r e v e n t i v e h e a l t h care i n c l u d e d so t h a t i t w i l l n o t c o s t Americans
more.
I n f a c t , many Americans w i l l f i n d t h a t t h e y are b e i n g asked t o
pay l e s s f o r b e t t e r b e n e f i t s when t h i s program i s implemented.
Q
How many?
MRS. CLINTON: M i l l i o n s and m i l l i o n s . More t h a n — you
know, by f a r a m a j o r i t y , a v a s t m a j o r i t y are g o i n g t o be p a y i n g no
more t h a n o r l e s s f o r b e t t e r b e n e f i t s .
Q
A l lright.
I'm t h e average f a m i l y o f f o u r i n Des
Moines and r i g h t now I pay $5,000 a year w i t h my company. What does
t h i s p o l i c y mean t o me?
Am I g o i n g t o pay more o r am I g o i n g t o pay
less?
4
MRS. CLINTON: You w i l l pay l e s s because you are a l r e a d y
insured.
Your company i s p r o v i d i n g t h o s e b e n e f i t s .
I assume t h a t
t h e package o f b e n e f i t s t h a t you have i s a good one, and t h a t ' s what
we're o f f e r i n g i s a good package o f b e n e f i t s .
And we t h i n k t h a t
under t h e p l a n as t h e P r e s i d e n t w i l l propose i t , you w i l l pay l e s s
t h a n what you and your company c u r r e n t l y are p a y i n g f o r what you
�4
have, and you w i l l have as good o r b e t t e r b e n e f i t s .
Q
A l l right.
But my company r i g h t now i s c o v e r i n g
a l l o f my h e a l t h i n s u r a n c e .
They cover e v e r y t h i n g . And from what I
understand t h e p l a n says t h a t employers o n l y have t o cover 80
percent.
So won't t h e y j u s t make t h e i n d i v i d u a l , me, pay f o r more o f
my h e a l t h care?
MRS. CLINTON: W e l l , t h e p l a n w i l l r e q u i r e a l l employers
t o c o n t r i b u t e 80 p e r c e n t toward t h e i r employees h e a l t h insurance, b u t
i t does n o t i n any way p r e v e n t your employer from c o n t i n u i n g t o
p r o v i d e 100 p e r c e n t i f t h a t ' s what your employer decides t o do.
Q
And what do your s t u d i e s show, t h a t employers a r e
g o i n g t o do t h i s o r not?
4
MRS. CLINTON: Many employers have t o l d us t h e y w i l l
c o n t i n u e t o do i t f o r a c o m p e t i t i v e advantage. I t ' s what t h e y have
a l r e a d y done i n o r d e r t o g e t people t o work f o r them and t o be l o y a l
and p r o d u c t i v e employees. And w i t h t h e decrease i n p r i c e s t h a t most
companies t h a t c u r r e n t l y i n s u r e w e l l w i l l see, many companies have
s a i d t h a t t h e y w i l l c o n t i n u e t o p r o v i d e even more coverage i n terms
of t h e amount r e q u i r e d t h a n we w i l l r e q u i r e t h e average employer t o
make a p a r t o f t h e c o n t r i b u t i o n .
Q
W e l l , l e t ' s t a l k about t h i s employer mandate i f we
c o u l d f o r a few m i n u t e s .
There's been a l o t o f c o n t r o v e r s y i n t h e
press and t h e N a t i o n a l F e d e r a t i o n o f Independent Businesses and o t h e r
groups a r e s a y i n g t h a t what you a r e r e a l l y g o i n g t o do i s j u s t k i l l
o f f a l o t o f s m a l l businesses.
The r e s t a u r a n t e u r s say you a r e g o i n g
t o k i l l o f 3.1 m i l l i o n j o b s .
MRS. CLINTON: W e l l , I know what people a r e s a y i n g and I
understand why some would be s a y i n g those t h i n g s because we a r e
a s k i n g t h a t every employer and employee, t h i s i s a mutual
r e s p o n s i b i l i t y , c o n t r i b u t e t o t h e i r h e a l t h i n s u r a n c e . We do n o t
b e l i e v e these f i g u r e s t h a t a r e b e i n g thrown around as scare t a c t i c s .
When you t a k e companies t h a t c u r r e n t l y i n s u r e and lower t h e i r
payments f o r i n s u r a n c e , as we w i l l be d o i n g f o r l i t e r a l l y m i l l i o n s o f
companies, you a r e g o i n g t o see an i n c r e a s e i n money a v a i l a b l e f o r
employing p e o p l e , f o r p a y i n g h i g h e r wages, f o r making investments.
4
Now, t h e r e a r e , i t i s a b s o l u t e l y t r u e , companies t h a t
have never c o n t r i b u t e d t o t h e i r employees h e a l t h care and t h e y , i n
e f f e c t , have been g i v e n a f r e e r i d e . They have not taken
r e s p o n s i b i l i t y f o r themselves and f o r t h e i r employees t h e way many,
many o t h e r s , t h e m a j o r i t y o f employers have. They w i l l have t o t a k e
t h a t r e s p o n s i b i l i t y now, b u t we t h i n k t h a t w i l l be good f o r t h e
companies, good f o r t h e employees and good f o r t h e economy because we
w i l l b e g i n t o decrease t h e amount o f money t h a t we have t o spend on
h e a l t h c a r e t h a t we c o u l d b e t t e r spend on i n c r e a s i n g wages and o t h e r
t h i n g s t h a t would h e l p t h e economy.
Q
But I t h i n k t h a t t h e i r argument would be t h a t what
�4
good does i t do t o have h e a l t h b e n e f i t s i f you don't have a job? I
mean, t h e s e a r e companies t h a t a r e o p e r a t i n g on t h e margin.
Some o f
them have almost no p r o f i t .
MRS. CLINTON: W e l l , t h e r e a r e many companies t h a t a r e
o p e r a t i n g on t h e margin t h a t bear r e s p o n s i b i l i t i e s f o r workers'
compensation, which we i n t e n d t o c o n t i n u e t o decrease by f o l d i n g t h e
w o r k e r s ' compensation system over time i n t o t h e h e a l t h care system,
t h a t have t o pay f o r t h e h e a l t h p a r t o f auto insurance which we a l s o
i n t e n d t o f o l d i n over t i m e . But more i m p o r t a n t l y than t h a t , t h e
employees and employers o f companies t h a t do n o t p a r t i c i p a t e i n t h e
h e a l t h c a r e system w i l l f i n d t h a t we a r e p r o v i d i n g d i s c o u n t s t o them,
i n e f f e c t , so t h a t i f t h e y a r e small employers t h a t have low wage
employees, they w i l l be g e t t i n g h e a l t h i n s u r a n c e f o r a very low
p r i c e , f a r lower t h a n a n y t h i n g t h a t i s i n t h e marketplace today.
4
And once we p r o v i d e t h a t d i s c o u n t and o f f e r t h a t k i n d o f
o p p o r t u n i t y f o r f i n a n c i n g h e a l t h care t h a t w i l l be phased i n and we
cap t h e amount o f money t h a t t h e employer and t h e employee have t o
pay, t h e r e w i l l be v e r y , v e r y few businesses t h a t w i l l not be able t o
a f f o r d t h a t . And as I s a i d , many o t h e r businesses w i l l f i n d t h a t
t h e i r investment i n h e a l t h care w i l l decrease which w i l l be a j o b
creator.
So I don't t h i n k any person w i l l h o n e s t l y be able t o say
t h a t as we implement t h i s p l a n t h a t t h e r e w i l l be a s i g n i f i c a n t j o b
loss.
I n s t e a d we b e l i e v e we w i l l be c r e a t i n g j o b s through d o i n g
this.
Q
A l l r i g h t . Let's t u r n t o one o t h e r t o p i c , and t h a t
i s whether o r n o t people a r e s t i l l going t o be a b l e t o choose t h e i r
d o c t o r s . The New York Times r e p o r t s today t h a t under t h i s program
everybody i s going t o go i n t o managed c a r e , and t h a t ' s going t o mean
t h e end o f people and t h e i r r e l a t i o n s h i p w i t h t h e i r d o c t o r s . Are t h e
d o c t o r s wrong about t h i s ?
MRS. CLINTON: W e l l , I don't know i f t h e d o c t o r s a r e
wrong, b u t some o f t h e r e p o r t i n g has been wrong because t h e r e w i l l
not be a requirement t h a t people go i n t o managed care. There w i l l be
d i f f e r e n t k i n d s o f h e a l t h p l a n s a v a i l a b l e f o r i n d i v i d u a l s t o choose
from. We a r e making a b i g change. We a r e r e q u i r i n g t h a t t h e
i n d i v i d u a l make t h e c h o i c e , n o t t h e employer. And among those ranges
of h e a l t h p l a n s t h a t w i l l be o u t t h e r e , some w i l l be HMOs o r PPOs,
b u t we w i l l a l s o r e q u i r e t h a t i n every area, d o c t o r s s t i l l be able t o
o f f e r t h e i r s e r v i c e s i n a network o f what's c a l l e d f e e f o r s e r v i c e ,
w h i c h i s g o i n g i n t o any d o c t o r whom you choose and p r o v i d i n g — and
g e t t i n g t h e care p r o v i d e d t h e r e and then r e i m b u r s i n g t h a t p a r t i c u l a r
d o c t o r . So t h a t c h o i c e w i l l always be a v a i l a b l e t o consumers.
Q
Mrs. C l i n t o n , I t h i n k most people have now had a
chance t o read about your p l a n .
4
MRS. CLINTON:
I hope so.
Q
You're o f f e r i n g — you're p r o m i s i n g t o guarantee
coverage f o r everyone, t o lower t h e c o s t s f o r most people and t o do
�4
i t w i t h no broad-based t a x e s . How a r e you going t o do t h a t ?
t h i s j u s t Reaganomics a l l over again?
Isn't
MRS. CLINTON: No. T h i s i s a h e a l t h s e c u r i t y p r o p o s a l
t h a t guarantees every American w i l l have h e a l t h insurance no m a t t e r
who o r he i s , o r who he works f o r , o r whether he's ever been s i c k
b e f o r e . And we're d o i n g t h a t by i n s u r i n g s e c u r i t y and by c r e a t i n g
s a v i n g s i n t h e system where we a l r e a d y spend $900 b i l l i o n on h e a l t h
c a r e and we t h i n k t h e r e i s money i n t h e r e t h a t c o u l d be b e t t e r spent
t o p r o v i d e t h a t h e a l t h s e c u r i t y . And by s i m p l i f y i n g t h e system so
t h a t we b e g i n t o e l i m i n a t e t h e r e d tape and a l l o f t h e problems t h a t
d r i v e up t h e c o s t s i n our system when we r e a l l y should be spending
the money on t a k i n g care o f people. We've looked a t these numbers
v e r y c l o s e l y . We've analyzed them. We've had a l o t o f people
w o r k i n g v e r y hard over many, many months, and we t h i n k we can do what
o t h e r c o u n t r i e s have done and t h a t i s g i v e everybody i n t h e c o u n t r y
h e a l t h s e c u r i t y , do i t by s a v i n g money and making our system s i m p l e r .
Q
And d o i n g i t a c c o r d i n g t o most o f t h e press r e p o r t s
w i t h a v e r y heavy hand o f government. I mean, when i n American
h i s t o r y has government ever touched something and s i m p l i f i e d i t o r
cut o u t waste?
4
MRS. CLINTON: W e l l , you know, I t h i n k t h a t you have t o
u n d e r s t a n d t h a t what we're p r o p o s i n g i s t h a t t h e f e d e r a l government
l a y down t h e ground r u l e s , h e a l t h s e c u r i t y f o r every American,
s a v i n g s i n t h e system, a comprehensive b e n e f i t s package l i k e most b i g
businesses o f f e r Americans today who work f o r them, and then t o g e t
o u t o f t h e way. T h i s i s a system t h a t w i l l depend upon p r i v a t e
b u s i n e s s , t h e p r i v a t e s e c t o r and s t a t e and l o c a l government r e a l l y t o
work. But t h e r e has t o be a n a t i o n a l guarantee f o r what every
American, no m a t t e r where t h a t American l i v e s , i s e n t i t l e d t o . And
t h a t ' s what t h e n a t i o n a l government w i l l do.
Q
How do you pay f o r t h a t ? Somebody who i s
g u a r a n t e e i n g you something u l t i m a t e l y has t o bear f i n a n c i a l
r e s p o n s i b i l i t y i f a l l else f a i l s .
Where does t h e money come from,
Mrs. C l i n t o n ?
4
MRS. CLINTON: The money i s g o i n g t o come from s e v e r a l
sources.
F i r s t i t w i l l come from people who a r e c u r r e n t l y n o t p a y i n g
t h e i r f a i r share, n o t t a k i n g r e s p o n s i b i l i t y . You know, most
Americans a r e i n s u r e d t h r o u g h t h e i r businesses and t h e i r employer
pays something, t h e y u s u a l l y make some k i n d o f c o n t r i b u t i o n . But you
can walk down any s t r e e t i n America and you can go t o t h e d r y
c l e a n e r s and t h e n you can go t o t h e garage o r t h e c a r wash, and two
of t h o s e t h r e e businesses a r e p r o v i d i n g some k i n d o f i n s u r a n c e , b u t
the t h i r d i s n ' t .
But when t h e employees a t t h a t t h i r d get s i c k , t h e y
go t o t h e same h o s p i t a l and t h e n t h e r e s t o f us p i c k up t h e t a b .
W e l l , we want everybody t o be r e s p o n s i b l e , so t h e r e w i l l be money
coming from a l l employers and employees. A t t h e same time we w i l l be
l o w e r i n g t h e c o s t a f o r many employers and employees who c u r r e n t l y
t a k e care o f themselves t h r o u g h having i n s u r a n c e . They w i l l be
g e t t i n g a b e t t e r d e a l because everybody w i l l be i n t h e system.
�We a l s o b e l i e v e t h a t t h e r e can be savings i n t h e
n a t i o n a l programs.
We t h i n k we can reduce t h e r a t e o f g r o w t h and
p r o v i d e b e t t e r b e n e f i t s by d o i n g t h a t i n t h e Medicare and M e d i c a i d
systems.
I f we t a k e t h e money t h a t would be f r e e d up from n o t h a v i n g
t o spend i t anymore on p r o p p i n g up h o s p i t a l s by p r o v i d i n g money t o
make up f o r t h e f a c t t h a t so many people don't pay t h e i r f a i r share
and t a k e r e s p o n s i b i l i t y f o r t h e i r h e a l t h care c o s t s , t h a t t h e
c o m b i n a t i o n o f t h e new money coming i n , b e t t e r spending t h e f e d e r a l
money, and p r o v i d i n g some s m a l l amount o f i n c r e a s e and t h e s o - c a l l e d
s i n t a x e s w i l l be enough t o p r o v i d e t h e k i n d o f h e a l t h coverage we
t h i n k e v e r y American w i l l make so l o n g t h a t we g e t t h e s a v i n g s t h a t
we know a r e i n t h a t system.
Q
4
How does your p l a n c o n t r o l costs?
MRS. CLINTON: Through a v a r i e t y o f ways. We do i t by
s a y i n g t h a t America w i l l no l o n g e r be t h e b l a n k check w r i t e r o f t h e
e n t i r e w o r l d when i t comes t o h e a l t h care. We spend more money t h a n
any o t h e r c o u n t r y and we don't even make sure a l l o f o u r people a r e
i n s u r e d . So we w i l l begin t o impose some d i s c i p l i n e i n t h e p u b l i c
and t h e p r i v a t e systems.
We w i l l p r o v i d e some d i f f e r e n t i n c e n t i v e s .
There w i l l no longer be i n c e n t i v e s f o r b e i n g p a i d i n t h e h e a l t h care
system on t h e number o f t e s t s you do, i n s t e a d people w i l l be p a i d on
t a k i n g c a r e o f people based on what a f a i r r a t e o f r e t u r n i s f o r
t r e a t i n g a l l o f t h e people who a r e i n t h e system.
We a l s o w i l l be squeezing o u t those m i l l i o n s o f forms
t h a t t a k e m i l l i o n s o f hours f o r people t o f i l l o u t , which j u s t adds
t o t h e c o s t . D i d you know t h a t i n t h e average h o s p i t a l we have been
h i r i n g f o u r c l e r i c a l workers f o r every d o c t o r . Why? Because we keep
adding on t h e forms t h a t t h e y have t o f i l l o u t . So as we squeeze o u t
these c o s t s , as we get tougher on t h e f r a u d and abuse t h a t
u n f o r t u n a t e l y i s s t i l l i n t h e system, t h a t e a t s up b i l l i o n s o f
d o l l a r s , we w i l l f i n d t h a t we w i l l have t h e money a v a i l a b l e t o t a k e
care o f a l l o f o u r people and do i t i n a more e f f i c i e n t way.
Q
So you're g o i n g t o squeeze and squeeze, and every
evidence has shown — people a r e f a m i l i a r w i t h HMOs, t h e y ' v e been
around f o r a l o n g t i m e , and e v e r y evidence has shown t h a t when you
s t a r t p u t t i n g t h e squeeze on t h e h e a l t h care system what you wind up
w i t h i s r a t i o n i n g , care i s c u r t a i l e d . When your HMO i s t i g h t t h e y
say, w e l l , a l l m a t e r n i t y cases now a r e g o i n g t o be o u t o f t h e
h o s p i t a l i n 36 hours, i n s t e a d o f 48 hours, a r e n ' t we j u s t l e t t i n g t h e
whole n a t i o n i n f o r a round o f r a t i o n i n g ?
4
MRS. CLINTON: Oh, n o t a t a l l . I mean, t h e r e i s n ' t any
evidence on t h e g e n e r a l b a s i s on any o f t h a t .
I n f a c t , t h e evidence
i s j u s t t o t h e c o n t r a r y . The r e a l evidence shows t h a t i n a s t a t e
l i k e P e n n s y l v a n i a , where t h e y have f o r a number o f years c a r e f u l l y
t r a c k e d m e d i c a l c o s t s , t h e same o p e r a t i o n i n one h o s p i t a l m i g h t c o s t
$20,000, w h i l e i n t h e h o s p i t a l down t h e road i t might c o s t $80,000
-- w i t h no d i f f e r e n c e i n q u a l i t y o r outcome.
What we a r e concerned about i s t h a t w i t h o u t some k i n d o f
�q u a l i t y outcome study and some i n c e n t i v e f o r h o s p i t a l s , d o c t o r s , and
o t h e r s t o engage i n making sure we've g o t h i g h q u a l i t y c a r e , what
you're d e s c r i b i n g c o u l d happen i f we do n o t h i n g r i g h t now. I f we
s t a y r i g h t where we a r e so t h a t t h e money g e t s b i g g e r and b i g g e r , and
the c o s t s g e t h i g h e r and h i g h e r , and t h e r e i s no e f f o r t made t o t r y
t o say what are q u a l i t y outcomes t h a t we have t o meet. And why does
a coronary bypass i n one h o s p i t a l i n Pennsylvania c o s t $80,000 and i n
another h o s p i t a l cost $20,000, when t h e r e i s no b e t t e r outcome shown
f o r t h e p a t i e n t who p a i d $80,000?
What we want i s f o r people t o t a k e charge o f t h e i r own
h e a l t h care d e s t i n i e s . We want i n d i v i d u a l s t o choose t h e h e a l t h care
p l a n t h e y want t o j o i n . And i f t h e y ' r e not s a t i s f i e d i n t h e next
y e a r , t h e y go j o i n another p l a n . I t ' s through t h a t k i n d o f market
c o m p e t i t i o n t h a t we t h i n k q u a l i t y w i l l a c t u a l l y have a chance t o
f l o u r i s h , i n s t e a d o f t h i s micromanagement, h i g h c o s t k i n d o f w a s t e f u l
approach t h a t we've t a k e n so f a r .
Q
4
How does t h a t add up?
MRS. CLINTON: I t adds up because we're s t a r t i n g from a
h e a l t h care system t h a t a l r e a d y has a l o t o f money i n i t , n e a r l y $900
billion.
Where most people a r e p a y i n g t o o much f o r t h e h e a l t h care
t h a t t h e y have, and some people a r e paying n o t h i n g . And we're g o i n g
t o make sure t h a t everybody t a k e s r e s p o n s i b i l i t y and everybody
c o n t r i b u t e s t o t h e i r own h e a l t h c a r e . And we're g o i n g t o b e g i n
g e t t i n g savings o u t o f t h e system, b o t h i n t h e p u b l i c and i n t h e
p r i v a t e p a r t s o f t h a t system, so t h a t we can do away w i t h t h e
paperwork and t h e r e d tape and t h e waste and t h e f r a u d and t h e abuse
t h a t ' s a l r e a d y i n t h e system and use t h e money t h a t w i l l be f r e e d up
t o cover every American so t h a t everyone has h e a l t h s e c u r i t y .
Q
What do you mean by h e a l t h s e c u r i t y ? I mean, 75
p e r c e n t o f t h e people i n t h i s c o u n t r y l i k e what t h e y have.
MRS. CLINTON: What I mean by h e a l t h s e c u r i t y i s t h a t
e v e r y American w i l l be guaranteed a comprehensive s e t o f h e a l t h
b e n e f i t s , and i t w i l l n o t m a t t e r who they work f o r o r even whether
t h e y ' r e employed, o r whether t h e y ' v e ever been s i c k b e f o r e . Because
t h e y ' r e an American t h e y w i l l have t h a t guarantee o f h e a l t h b e n e f i t s .
That can't be s a i d i n our c o u n t r y today, u n f o r t u n a t e l y . Even f o r
t h o s e o f us who a r e l u c k y enough t o be i n s u r e d and s a t i s f i e d , we
c a n ' t even t e l l f o r sure whether w e ' l l have t h e same h e a l t h care
b e n e f i t s next year t h a t we have t h i s year. Or, u n f o r t u n a t e l y , i n
t h e s e days, whether t h e people we work f o r w i l l even be i n business
t o h e l p pay f o r t h a t h e a l t h c a r e next year.
So what we're a b s o l u t e l y committed t o i s making sure
t h a t h e a l t h s e c u r i t y becomes t h e r i g h t o f every American.
*
Q
The Republicans have s a i d t h a t t h i s i s n o t h i n g b u t
a b i g government program and t h a t , you know, you're t r y i n g t o p u t t h e
heavy hand o f government a l l over a system t h a t ' s p r i v a t e and t h a t
works v e r y w e l l . Why would you add government t o t h i s system a t t h i s
�4
point?
MRS. CLINTON: Government i s i n t h i s system. Government
i s making many o f t h e d e c i s i o n s r i g h t now t h a t we t h i n k should be
changed. Government, o f course, runs Medicaid and Medicare and many
o t h e r government programs. S t a t e governments, l o c a l governments
c o n t r i b u t e t h e i r t a x money t o h e a l t h c a r e , r e g u l a t e h e a l t h care i n
many r e s p e c t s . So government i s a l r e a d y i n v o l v e d . That's n o t t h e
i s s u e . The i s s u e i s w i l l government be i n v o l v e d i n a way t h a t works?
And what we want t o do i s t o have a n a t i o n a l system t h a t guarantees
h e a l t h s e c u r i t y f o r every American, and t h e n we want t o g e t o u t o f
t h e way and l e t t h e p r i v a t e s e c t o r and s t a t e and l o c a l government
make t h e d e c i s i o n s on a day-to-day b a s i s as t o how t h a t w i l l be done.
t h i s system.
4
Q
You know, people have t r i e d f o r 50 years t o f i x
Why i s i t g o i n g t o work t h i s time?
What i s d i f f e r e n t ?
MRS. CLINTON: Because I t h i n k people have t r i e d f o r 50
y e a r s , and t h e y know t h a t i f we don't g e t i t f i x e d now t h a t we w i l l
c o n t i n u e t o have a system t h a t s p i n s o u t o f c o n t r o l , t h a t covers
fewer and fewer people and c o s t s more and more. And I t h i n k a l s o
what i s d i f f e r e n t now i s t h a t we have a b i p a r t i s a n , c o o p e r a t i v e
e f f o r t , l e d by t h i s P r e s i d e n t , t h a t r e a l l y i n t e n d s t o succeed. And
we've worked v e r y c l o s e l y w i t h people from a l l d i f f e r e n t walks o f
l i f e , w i t h d i f f e r e n t k i n d s o f e x p e r i e n c e s , r a n g i n g from p a t i e n t s who
can't a f f o r d i n s u r a n c e , t o d o c t o r s who p r o v i d e c a r e , t o i n s u r a n c e
companies t h a t a r e i n t h e marketplace, t o businesses and everywhere
e l s e we l o o k . We've heard s t o r i e s about what w i l l make t h i s system
work b e t t e r , and we have a P r e s i d e n t committed t o making i t happen.
Q
But I don't g e t i t s t i l l .
You're g o i n g t o t a k e
e v e r y t h i n g and you're going t o add on t o i t 37 m i l l i o n - 4 0 m i l l i o n new
people, and y o u ' r e not going t o charge people more f o r t h e i r h e a l t h
care. How does t h a t work?
MRS. CLINTON: I t works because when you add those 40
m i l l i o n p e o p l e who a r e n o t i n s u r e d r i g h t now, t h e y c o n t r i b u t e t o
t h e i r own h e a l t h care. You know, what happens i n America,
u n f o r t u n a t e l y , i s t h a t people do end up g e t t i n g h e a l t h c a r e , b u t i t
u s u a l l y happens a t t h e l a s t p o s s i b l e moment i n t h e most expensive
way.
You know, we a r e a c o u n t r y o f compassion and c a r i n g , thank
goodness, so we don't leave t h e a c c i d e n t v i c t i m s l y i n g on t h e s i d e o f
t h e r o a d , we don't t u r n away t h e person i n g r e a t need.
4
But when i t comes t i m e t o pay t h e b i l l those 40 m i l l i o n
people who don't b r i n g w i t h them any resources o f t e n can't pay i t
themselves, t h e y can't a f f o r d i n s u r a n c e , and so t h e r e s t o f us pay
it.
E i t h e r o u r t a x e s go up o r o u r i n s u r a n c e premium r a t e s go up. So
when t h o s e p e o p l e have t o make some c o n t r i b u t i o n t o t h e i r own h e a l t h
i n s u r a n c e , t h a t b r i n g s i n about $50 b i l l i o n new d o l l a r s i n t o t h e
system.
At t h e same t i m e , we're g o i n g t o be squeezing o u t t h e
waste and t h e f r a u d and t h e abuse t h a t s t i l l e x i s t s i n t h e system so
�4
t h a t we can b e t t e r u t i l i z e t h e money t h a t i s a l r e a d y i n t h e r e and
make b e t t e r use o f i t t o h e l p more people.
So when you l o o k a t a l l
of t h e numbers as t o what we a r e c u r r e n t l y spending, what we are
g o i n g t o spend i f we don't change our e x i s t i n g system, t h e way t h a t
t h i s p l a n proposes w i l l i n s u r e h e a l t h s e c u r i t y and do i t i n an
a f f o r d a b l e way.
Q
But you t a l k about squeezing o u t waste and f r a u d
and abuse and i n t h i s 240-page tome t h a t you guys have produced t h e r e
i s t h i s N a t i o n a l H e a l t h Board, and t h e r e a r e these a l l i a n c e s , and
t h e r e i s a l l t h i s new bureaucracy.
How does t h i s new bureaucracy
squeeze o u t waste and abuse?
MRS. CLINTON: Because i t ' s n o t g o i n g t o be any k i n d o f
b i g bureaucracy.
I n f a c t , t h e reason t h a t we're p u r s u i n g t h i s
approach i s t o begin e l i m i n a t i n g t h e bureaucracy i n b o t h t h e
government and t h e i n s u r a n c e i n d u s t r y and our h o s p i t a l s , t h a t has
b u i l t up over t h e years t o t a k e care o f t h e m i l l i o n s o f forms t h a t
people have t o f i l l o u t .
4
You know, one o f t h e b i g s u r p r i s e s t o me when I s t a r t e d
w o r k i n g on t h i s i s how many hours nurses and d o c t o r s spend f i l l i n g
out forms i n s t e a d o f t a k i n g c a r e o f p a t i e n t s . And t h e n I l e a r n e d
t h a t h o s p i t a l s have i n r e c e n t years h i r e d f o u r c l e r i c a l workers f o r
every d o c t o r they c o u l d a f f o r d t o h i r e .
I don't t h i n k t h a t i s a good
e x p e n d i t u r e o f our h e a l t h care d o l l a r .
I ' d r a t h e r have t h a t nurse by
my bedside when I'm t h e r e , n o t o u t i n t h e h a l l f i l l i n g o u t t h e form
f o r t h e i n s u r a n c e company o r t h e government system.
So a c t u a l l y , we t h i n k t h a t by s e t t i n g up l a r g e
p u r c h a s i n g c o o p e r a t i v e s t h a t w i l l d e a l w i t h people who are going t o
be b u y i n g i n s u r a n c e , we're g o i n g t o be s a v i n g money by e l i m i n a t i n g
the m i l l i o n s o f forms now t r y i n g t o g e t t o a s i n g l e form system. And
I t h i n k t h a t w i l l be good, n o t o n l y f o r our economy, b u t f o r p a t i e n t
care i n our h o s p i t a l s .
Q
cooperative?
health care.
4
I don't understand.
A large purchasing
I mean, i t sounds l i k e some k i n d o f S o v i e t idea f o r
MRS. CLINTON: W e l l , t h a t ' s because you're n o t from a
p l a c e l i k e Arkansas where we have l o t s o f p u r c h a s i n g c o o p e r a t i v e s
where f a r m e r s and o t h e r s g e t t o g e t h e r and p o o l t h e i r resources, and
t h e n t h e y go o u t and g e t t h e b e s t d e a l t h e y can g e t t o s e l l t h e i r
crops.
I t ' s a r e a l American i d e a and u n f o r t u n a t e l y i t hasn't ever
been a p p l i e d t o t h e h e a l t h i n s u r a n c e i n d u s t r y . And so what t h e
r e s u l t i s i s t h a t v e r y l a r g e businesses over t h e l a s t s e v e r a l years
have g o t t e n k i n d o f smart about how t o d e a l w i t h t h e h e a l t h insurance
i n d u s t r y , and been a b l e t o b e g i n t o g e t some c o n t r o l over t h e i r
prices.
But t h e r e s t o f us, e i t h e r as s m a l l businesses, o r s e l f
employed f a r m e r s , o r i n d i v i d u a l s , we don't have t h a t k i n d o f
p u r c h a s i n g power. Which i s why, i f we cooperate t o g e t h e r , where
�4
we're a l l i n i t t o g e t h e r , w e ' l l a l l be a b l e t o , f r a n k l y , g e t a b e t t e r
d e a l from t h e i n s u r a n c e companies i n b e i n g a b l e t o push those p r i c e s
down and be a b l e t o p r o v i d e h e a l t h care more cheaply than we can now.
(Gap
i n tape.)
MRS. CLINTON: — Medicare and Medicaid.
I f e e l so
s t r o n g l y about t h a t t h a t I wish I c o u l d repeat i t 100 t i m e s , because
I don't t h i n k i t ' s f a i r f o r anybody t o be upset o r concerned.
What has happened w i t h Medicaid and Medicare i s t h a t
t h e y have grown v e r y f a s t i n t h e l a s t s e v e r a l y e a r s . And i n f a c t ,
are c o n t i n u i n g t o grow v e r y f a s t . We t h i n k t h a t t h e money t h a t i s
g o i n g i n t o t h e c u r r e n t Medicare system c o u l d be b e t t e r u t i l i z e d by
p r o v i d i n g , w i t h o u t r a i s i n g t h e amount g o i n g i n , a drug b e n e f i t f o r
s e n i o r s , so t h a t we don't have t o hear t h e s t o r i e s I've heard a l l
over t h i s c o u n t r y where o l d e r p a r e n t s o f f r i e n d s o f mine,
grandmothers and g r a n d f a t h e r s have t o choose between f i l l i n g t h e i r
p r e s c r i p t i o n s o r e a t i n g . That's wrong.
4
And a l s o , we have t o b e g i n t a k i n g care o f our o l d e r
Americans when i t comes t o l o n g t e r m c a r e by p r o v i d i n g home-based
care and community-based c a r e . And t h e r e d u c t i o n s i n t h e r a t e o f
growth o f Medicare, not c u t s , w i l l be used t o do j u s t t h a t , p r o v i d i n g
p r e s c r i p t i o n d r u g b e n e f i t s and b e g i n n i n g a commitment on l o n g - t e r m
c a r e . Those a r e two v e r y i m p o r t a n t f e a t u r e s o f t h i s p l a n t h a t I want
my mother and o l d e r Americans t o know about because i t ' s going t o
make l i f e a l o t b e t t e r f o r m i l l i o n s o f them.
Q
When i s a l l t h i s g o i n g t o happen, Mrs. C l i n t o n ?
MRS. CLINTON: W e l l , i t depends upon how soon we can
reach an agreement i n t h e Congress as t o t h e d i r e c t i o n f o r h e a l t h
care r e f o r m we're going t o head and g e t a b i l l t o t h e P r e s i d e n t t o
s i g n . As soon as t h a t happens, t h e n we can begin implementing i t .
O b v i o u s l y , I would l i k e t o see us move as qnaickly as p o s s i b l e ,
because I would l i k e t o see us b e g i n t o p r o v i d e h e a l t h s e c u r i t y t o
e v e r y American w i t h i n t h e next s e v e r a l years, so t h a t i n a few y e a r s
e v e r y American would be guaranteed a comprehensive s e t o f b e n e f i t s ,
the system would b e g i n s a v i n g money and we would b e g i n s i m p l i f y i n g
it.
And a l l t h a t can o n l y b e g i n once t h e Congress backs and t h e
President signs t h e b i l l .
Q
I f t h e Congress were t o pass something
s u b s t a n t i a l l y s i m i l a r t o what you propose sometime next year, when
would a l l Americans f i n a l l y be covered?
MRS. CLINTON:
4
I n 1997.
Q
A r e n ' t you j u s t a s k i n g us t o once again t r u s t u s ,
t r u s t government? We've been burned so many t i m e s . I'm from
Washington; I'm here t o h e l p you. And t h e r e ' s a l o t o f change h e r e .
Convince me t h a t we should once a g a i n t r u s t Washington t o t e l l us
what's b e s t .
�4
MRS. CLINTON: I don't t h i n k we should t r u s t Washington.
I don't t h i n k we should t r u s t b i g insurance companies o r any o t h e r
g r e a t b i g bureaucracy.
We ought t o t r u s t o u r s e l v e s . And what we're
t r y i n g t o do i s t o c r e a t e a system t h a t I can f e e l very c o m f o r t a b l e
w i t h and so can you. W e ' l l s t i l l s i g n up f o r h e a l t h insurance a t t h e
workplace.
I n s t e a d o f h a v i n g an employer t e l l us what insurance we
have t o use and, t h e r e f o r e , what d o c t o r s we can use, w e ' l l g e t t o
choose t h e h e a l t h p l a n t h a t we l i k e b e s t . And i f we don't l i k e i t ,
we w i l l change i t . We w i l l be d e t e r m i n i n g our own r e s p o n s i b i l i t y .
We w i l l have access t o p r i m a r y and p r e v e n t i v e h e a l t h care t h a t we can
use t o t a k e b e t t e r care o f o u r s e l v e s .
What t h e f e d e r a l government should do i s t o p r o v i d e a
framework. I t should guarantee h e a l t h s e c u r i t y t o every American,
s h o u l d make sure t h a t e v e r y American has a comprehensive s e t o f
b e n e f i t s and should g e t o u t o f t h e way and should l e t t h e
m a r k e t p l a c e , t h e s t a t e and l o c a l governments t h a t a r e c l o s e r t o t h e
people make a l o t o f t h e s e d e c i s i o n s t h a t r i g h t now a r e being made by
d e f a u l t i n a system t h a t doesn't work w e l l f o r most people and which
doesn't appear t o be a b l e t o r e f o r m i t s e l f .
4
So what I'm hoping f o r i s t h a t we e l i m i n a t e t h e k i n d o f
micromanagement we've had t o o much o f from Washington i n t h e l a s t few
y e a r s , we e l i m i n a t e t h e k i n d s o f u n f o r t u n a t e d e c i s i o n s t h a t insurance
companies have made t o c u t people o u t o f insurance because t h e y were
s i c k once o r they had a s i c k c h i l d , make i t c l e a r everybody's i n t h i s
system. Everybody's r e s p o n s i b l e . And i f t h e system w i l l work best
because i n d i v i d u a l s w i l l be making t h e choices about what k i n d o f
h e a l t h care t h e y choose f o r themselves.
Q
L e t ' s t a l k about these r a b b i t - o u t - o f - t h e - h a t
numbers t h a t we've been r e a d i n g about here.
T h i s sounds a w f u l l y a
l o t l i k e b e i n g a b l e t o c u t t a x e s , r a i s e t h e defense budget and
balance t h e budget a l l a t t h e same t i m e , promises t h a t we heard about
t e n o r t w e l v e years ago.
MRS. CLINTON: But u n l i k e those k i n d s o f promises, we're
not a s k i n g t h e American p u b l i c t o r a i s e a l o t o f t a x e s o r t o r a i s e
b i g p a r t s o f t h e f e d e r a l budget w i t h o u t r a i s i n g t a x e s , where t h e
a r i t h m e t i c doesn't add up. What we're a s k i n g i s t a k e a system where
we're spending a l r e a d y n e a r l y $900 b i l l i o n , r e c o g n i z e t h a t we can g e t
s a v i n g s o u t o f t h a t system, and b e g i n t o b e t t e r u t i l i z e o u r money by
g e t t i n g savings and by e l i m i n a t i n g waste and f r a u d and abuse, by
p r o v i d i n g i n c e n t i v e s f o r p h y s i c i a n s and nurses t o t a k e care o f
p a t i e n t s i n s t e a d o f f i l l i n g o u t a l l those m i l l i o n s o f forms t h e y have
t o f i l l o u t . We t h i n k t h a t t h e r e i s money i n t h e system a l r e a d y t h a t
can be used and so we're n o t a s k i n g f o r t h a t k i n d o f new money t o
come i n t o i t .
4
Q
What happens i f we buy i n t o t h i s and i t t u r n s o u t
as i t d i d 12 years ago t h a t a l l o f those p r o j e c t i o n s were dead wrong?
MRS. CLINTON:
W e l l , we're not a s k i n g anybody t o buy
�4
i n t o i t w i t h o u t l o o k i n g very c a r e f u l l y a t t h e numbers and a t t h e
p r o j e c t i o n s . You know, when I f i r s t g o t i n v o l v e d i n t h i s , I was j u s t
stunned t o r e a l i z e t h a t most government agencies had never t a l k e d t o
each o t h e r about h e a l t h care. You had f o u r o r f i v e d i f f e r e n t f e d e r a l
government agencies t h a t never g o t i n t h e same room t o f i g u r e o u t how
t o compare t h e i r numbers. They d i d n ' t t a l k v e r y much t o t h e p r i v a t e
s e c t o r t h a t pays a l o t o f t h e b i l l .
We've g o t t e n a l l those people i n
t h e same room, they've a l l worked t o g e t h e r , t h e numbers t h a t u n d e r l i e
t h i s p l a n a r e s o l i d , c r e d i b l e numbers.
Now we can d i s a g r e e about t h e p o l i c y and I have a v e r y
h i g h r e s p e c t f o r a number o f people who say g i v e n those numbers we
ought t o do i t a l i t t l e b i t d i f f e r e n t l y , t h a t ' s what t h e l e g i s l a t i v e
process w i l l be about.
But t h e numbers a r e r e a l . We a r e a l r e a d y
spending more money on a per person b a s i s t h a n any o t h e r c o u n t r y i n
t h e w o r l d and we don't even p r o v i d e h e a l t h s e c u r i t y t o a l l o f o u r
people.
We can do b e t t e r than t h a t .
Q
You've sure r a t t l e d o f f a l o t o f winners
a f t e r n o o n , Mrs. C l i n t o n . T e l l me, who loses?
4
here t h i s
MRS. CLINTON: W e l l , I t h i n k America wins. And,
t h e r e f o r e , I t h i n k every American w i l l w i n i n t h i s . There r e a l l y i n
t h e l o n g r u n s h o u l d n ' t be many l o s e r s . Now i n t h e s h o r t r u n , some
people who make t h e i r l i v i n g by t r y i n g t o e l i m i n a t e people from
i n s u r a n c e coverage, by saying w e l l , you were s i c k once so you're n o t
g o i n g t o g e t an insurance p o l i c y , t h e y ' r e n o t g o i n g t o have t h a t k i n d
of b u s i n e s s anymore. They're going t o have t o go o u t and have a
d i f f e r e n t k i n d o f business.
But I have enough confidence i n t h e i r
a b i l i t y t h a t t h e y w i l l be able t o f i g u r e t h a t o u t .
Most people are going t o be winners because America w i l l
be a w i n n e r .
We w i l l g e t t h e heavy micromanaging hand o f government
o f f o u r backs. We w i l l g e t t h e o u t - o f - c o n t r o l p r i v a t e s e c t o r c o s t s
out o f t h e system so t h a t businesses can s t a r t making d e c i s i o n s about
how much t o pay workers i n s t e a d o f how f a r t o squeeze down h e a l t h
care c o s t s . There's g o i n g t o be a l o t o f winners and t h e r e should
be.
America deserves t o w i n on h e a l t h care f o r a change.
END
4
�FIRST LADY HILLARY RODHAM CLINTON
REMARKS TO THE AMERICAN HOSPITAL ASSOCIATION
ORLANDO, FLORIDA
AUGUST 9, 1993
DRAFT
I t i s a p r i v i l e g e t o be here w i t h you today t o address a
s u b j e c t we a l l care deeply about. I know h e a l t h care r e f o r m i s on
your minds, and i t i s a l s o on mine.
Let me say from t h e o u t s e t t h a t t h e p r e s i d e n t sends h i s
thanks f o r your o r g a n i z a t i o n ' s f i r m s u p p o r t o f Dr. J o y c e l y n
E l d e r s , t h e nominee f o r U.S. Surgeon General. I t h i n k we a l l know
t h a t she has t h e c o n v i c t i o n and backbone t o be a g r e a t l e a d e r i n
p r o m o t i n g b e t t e r h e a l t h f o r a l l Americans.
And l e t me a l s o say t h a t t h e C l i n t o n A d m i n i s t r a t i o n i s
deeply g r a t e f u l f o r t h e American H o s p i t a l A s s o c i a t i o n ' s
unwavering commitment t o i m p r o v i n g o u r h e a l t h care system. For
decades, your o r g a n i z a t i o n has shown a s p i r i t o f c a r i n g and
community t h a t i s a l l t o o r a r e today.
•
That s p i r i t was i n f u l l view a g a i n l a s t week. I know t h e
r e c e n t budget r e c o n c i l i a t i o n process i n Congress d i d n o t s a t i s f y
a l l your g o a l s . I know you're unhappy about t h e l e v e l o f Medicare
c u t s t h a t emerged from t h e House-Senate conference. But even so,
you u n d e r s t o o d t h a t p a s s i n g t h e budget was e s s e n t i a l t o o u r
n a t i o n ' s economic f u t u r e . You understood t h a t i t was e s s e n t i a l t o
h e a l t h c a r e r e f o r m . And f o r t h a t and more, t h e p r e s i d e n t sends
his s i n c e r e thanks.
I n 1988, when I j o i n e d t h e board o f t h e Arkansas C h i l d r e n ' s
H o s p i t a l , I t h o u g h t I had a w o r k i n g knowledge o f t h e c h a l l e n g e s
American h o s p i t a l s f a c e day i n and day o u t . I had l e a r n e d about
Dish payments and DRGs, u t i l i z a t i o n r e v i e w e r s and upcoders. I had
even f i g u r e d o u t what PROs and PPOs and HMOs were.
[ i n s e r t p e r s o n a l e x p e r i e n c e about ACH i f you want]
But, l i k e most n o n - h e a l t h care people, I d i d n ' t f u l l y
a p p r e c i a t e t h e complex u n d e r t a k i n g s o f h o s p i t a l s l i k e y o u r s . Now,
f i v e y e a r s l a t e r , I understand much more. And I am t h a t much more
g r a t e f u l f o r t h e thousands o f d e d i c a t e d h o s p i t a l managers around
the c o u n t r y who g r a p p l e w i t h v e x i n g h e a l t h care i s s u e s every day.
I don't need t o t e l l you t h a t w a l l s o f f e a r and stubbornness
s t a n d between us and h e a l t h care r e f o r m . But t h e s e w a l l s must be
�s c a l e d i f we want our n a t i o n t o t h r i v e and prosper
c o m p e t i t i v e 21st c e n t u r y .
in a
So much i s a t s t a k e . Because u l t i m a t e l y h e a l t h care r e f o r m
i s n o t j u s t about c o n t r o l l i n g c o s t s and r e d u c i n g paperwork and
l o w e r i n g p r e s c r i p t i o n drug p r i c e s . I t ' s n o t j u s t about t h e r a t i o
o f p r i m a r y care p h y s i c i a n s and s p e c i a l i s t s . I t ' s n o t j u s t about
d e v i s i n g more e f f i c i e n t ways o f d e l i v e r i n g h e a l t h care s e r v i c e s .
I t ' s about a l l o f these t h i n g s —
and more.
A t i t s c o r e , h e a l t h care r e f o r m i s about i n d i v i d u a l
o p p o r t u n i t y and r e s p o n s i b i l i t y . As t h e p r e s i d e n t s a i d i n h i s
address t o t h e n a t i o n l a s t week, we must ground our most e n d u r i n g
v a l u e s i n a p h i l o s o p h y t h a t says America owes a l l o f us an
o p p o r t u n i t y i f we assume r e s p o n s i b i l i t y f o r o u r s e l v e s , our
communities and our c o u n t r y . I n o t h e r words, no more something
for nothing.
Those of us w o r k i n g f o r r e f o r m may n o t agree w i t h a l l t h e
f i n e p r i n t i n t h e h e a l t h care p l a n . But we must remember t h a t ,
whatever our d i f f e r e n c e s , we are u n i t e d by common concerns and
common g o a l s . We a l l share a v i s i o n o f America i n which hope and
optimism t r i u m p h over apathy and c y n i c i s m . We a l l share a v i s i o n
o f a w o r l d t h a t i s s a f e and h e a l t h y f o r our c h i l d r e n . We a l l
share a b e l i e f t h a t every American should have access t o q u a l i t y ,
a f f o r d a b l e h e a l t h care.
These shared i d e a l s are t h e reason
and reshape — t o g e t h e r — our n a t i o n ' s
p r i m a r y r e s p o n s i b i l i t y t o each o t h e r as
p r i m a r y r e s p o n s i b i l i t y as a government.
care r e f o r m i s r e a l l y about.
So how
we must s e i z e t h i s moment
f u t u r e . That i s our
i n d i v i d u a l s . I t i s our
And i t i s what h e a l t h
do we g e t t h e r e ?
F o r t u n a t e l y , we have a l r e a d y made g r e a t s t r i d e s , thanks t o
o r g a n i z a t i o n s l i k e t h e AHA. While some have r e s o r t e d t o l o u d
e x h o r t a t i o n s and u l t i m a t u m s about r e f o r m , t h e AHA has
c o n s i s t e n t l y provided the A d m i n i s t r a t i o n w i t h t h o u g h t f u l —
c o n s t r u c t i v e — c o u n s e l . And your ideas have n o t f a l l e n on deaf
ears.
You were among t h e f i r s t t o promote community care networks
— a concept t h a t l i e s a t t h e h e a r t of r e v i t a l i z i n g our h e a l t h
care system. You have l o n g been proponents o f u n i v e r s a l coverage
— a fundamental c o n d i t i o n o f h e a l t h care r e f o r m . You are
committed advocates o f p r e v e n t i v e and p r i m a r y c a r e . You are
l i v i n g , b r e a t h i n g examples o f why we must reduce paperwork and
micromanagement and a l l o w h o s p i t a l s t o spend t h e i r t i m e t r e a t i n g
p a t i e n t s i n s t e a d o f w r e s t l i n g w i t h b u r e a u c r a t i c beadledom.
�E v e r y t h i n g t h a t i s wrong w i t h our h e a l t h care system i s
t h r e a t e n i n g e v e r y t h i n g t h a t ' s r i g h t w i t h American h e a l t h care —
and we need t o p r e s e r v e what's r i g h t . We have t h e f i n e s t
h o s p i t a l s i n t h e w o r l d . We have t h e b e s t - t r a i n e d d o c t o r s and
nurses anywhere. We have t h e most s o p h i s t i c a t e d t e c h n o l o g y and
t h e most modern equipment. These s t r e n g t h s make us t h e envy o f
every o t h e r n a t i o n — and we want t o s t a y t h a t way.
At t h e same t i m e , when m i l l i o n s o f Americans a r e haunted by
t h e f e a r o f l o s i n g t h e i r b e n e f i t s a t any moment, we know we can
do b e t t e r . When i t ' s e a s i e r t o g e t coverage f o r a bypass
o p e r a t i o n t h a n f o r a c h i l d ' s immunization, we know we can do
better.
When h o s p i t a l s must h i r e f o u r new a d m i n i s t r a t o r s f o r every
new d o c t o r s i m p l y t o handle t h e avalanche o f i n s u r a n c e forms and
paperwork, we know we can do b e t t e r . I spoke t o one nurse
r e c e n t l y who summed up t h e maze o f r e d tape t h i s way: she s a i d
she went i n t o n u r s i n g t o care f o r people. I f she had wanted t o be
an a c c o u n t a n t , she s a i d , she would have gone t o work f o r an
accounting f i r m .
R e t o o l i n g a h e a l t h care system t h a t accounts f o r 14 p e r c e n t
of our n a t i o n a l income and i s f u e l i n g our economic c r i s i s i s n o t
a t a s k f o r t h e w e a k - w i l l e d . Not every s t e p w i l l be smooth and
painless.
And we c a n ' t expect t o agree on every d e t a i l . As we l e a r n e d
from t h e r e c e n t budget w r a n g l i n g i n Congress, compromise
sometimes i s necessary i n o r d e r t o achieve t h e g r e a t e r good o f a
p r o g r e s s i v e economic p l a n .
L e t me j u s t say t h a t budget c u t s i n Medicare are a reminder
of why we c a n ' t address h e a l t h care p i e c e by p i e c e . I f we
c o n t i n u e t o p u t p r e s s u r e on t h e p u b l i c system w h i l e d o i n g n o t h i n g
t o c o n t r o l p r i v a t e c o s t s , t h e p r i v a t e s e c t o r w i l l be burdened
w i t h even h i g h e r p r i c e s .
I'm c o n f i d e n t t h a t , when t h e d u s t c l e a r s and h e a l t h care
r e f o r m i s etched i n t o law, a new system w i l l emerge t h a t embraces
your most v i t a l concerns.
Why am I so c o n f i d e n t ? Because so many o f t h e
A d m i n i s t r a t i o n ' s a m b i t i o n s f o r h e a l t h care r e f o r m m i r r o r your
a m b i t i o n s f o r h e a l t h care r e f o r m .
The p r e s i d e n t ' s p l a n w i l l s t a r t from a s i m p l e premise: t h a t
Americans who work f o r a l i v i n g , who pay t h e b i l l s t o t a k e care
of t h e i r f a m i l i e s , should have t h e s e c u r i t y o f knowing t h e y w i l l
never l o s e t h e i r h e a l t h coverage — even i f t h e y s w i t c h j o b s ,
l o s e a j o b , g e t s i c k , move t o a new c i t y or s t a r t a s m a l l
business.
�S e c u r i t y must be t h e h e a r t and s o u l o f our system. To t h a t
end, we w i l l p r o v i d e every American w i t h a h e a l t h s e c u r i t y c a r d
t h a t w i l l guarantee a comprehensive package o f b e n e f i t s , no
m a t t e r where a person works, where a person l i v e s or whether he
or she has ever been s i c k b e f o r e .
H e a l t h s e c u r i t y f o r our c i t i z e n s i s c r i t i c a l n o t o n l y f o r
t h e 40 m i l l i o n Americans who l a c k i n s u r a n c e , b u t a l s o f o r you,
who end up p r o v i d i n g s e r v i c e s t o them.
Too o f t e n , people assume t h a t h o s p i t a l s are p r o f i t - d r i v e n
businesses t h a t view p a t i e n t s as anonymous s t a t i s t i c s on a
f i n a n c i a l l e d g e r . I know i t ' s not t h a t s i m p l e . I know t h a t , w h i l e
t h e r e are o c c a s i o n a l i n s t a n c e s o f p r i c e - g o u g i n g and f r a u d , t h e
v a s t m a j o r i t y o f h o s p i t a l s t r e a t every i n d i g e n t p a t i e n t who walks
t h r o u g h t h e i r doors. And I know your w i l l i n g n e s s t o absorb
u n i n s u r e d p a t i e n t s can j e o p a r d i z e your f a c i l i t y ' s f i n a n c i a l
future.
When a l l Americans have a comprehensive package o f b e n e f i t s ,
h o s p i t a l s l i k e King/Drew H o s p i t a l i n Los Angeles and St. Agnes i n
P h i l a d e l p h i a , which t r e a t l a r g e p o p u l a t i o n s o f i n d i g e n t s , w i l l be
a b l e t o serve t h e needy people i n t h e i r communities knowing t h e y
w i l l be compensated f o r t h e care t h e y g i v e .
S t i l l , t h e r e a l t r i c k t o h e a l t h s e c u r i t y and comprehensive
b e n e f i t s l i e s i n broadening our approach t o h e a l t h c a r e . We need
a new approach t h a t encourages p r i m a r y and p r e v e n t i v e c a r e , so
t h a t we keep people h e a l t h y i n s t e a d o f w a i t i n g t o t r e a t them when
t h e y ' r e s i c k . We need a new approach t h a t encourages d o c t o r s t o
p r a c t i c e where t h e y are most needed. We need a new approach t h a t
encourages h o s p i t a l s and employers and d o c t o r s and nurses t o j o i n
t o g e t h e r t o d e v i s e i n n o v a t i v e ways o f s e r v i n g t h e i r communities.
Community care networks, l i k e ones i n W e l l s b o r o ,
Pennsylvania and r u r a l southwest Georgia, are examples o f t h e new
approach I'm t a l k i n g about. I n a 10-county r e g i o n o f Georgia
where people's l i v e s are r o u t i n e l y s c a r r e d by p o v e r t y , poor
n u t r i t i o n , l a c k o f medical care and c h r o n i c d i s e a s e , a p u b l i c p r i v a t e p a r t n e r s h i p of h e a l t h care p r o v i d e r s around Columbus i s
s h i f t i n g t h e emphasis from c u r a t i v e t r e a t m e n t s t o p r e v e n t i v e care
— w i t h promising r e s u l t s .
The Community H e a l t h Care Network has s e t up p r i m a r y care
c l i n i c s i n r u r a l areas and i s w o r k i n g t o c o n s o l i d a t e t h e r e g i o n ' s
p e d i a t r i c s e r v i c e s i n one f a c i l i t y . A 4 0 - f o o t van, equipped w i t h
two e x a m i n a t i o n rooms, a mammography s u i t e and a s t a f f o f f o u r
h e a l t h care p r o f e s s i o n a l s o f f e r s mobile m e d i c a l s e r v i c e s t o
r e s i d e n t s i n t h e r e g i o n ' s o u t e r reaches.
The p r e s i d e n t ' s p l a n w i l l b o l s t e r such e f f o r t s by
s t r e n g t h e n i n g h e a l t h care i n areas h i s t o r i c a l l y i g n o r e d . Funds
�w i l l be t a r g e t e d t o promote i n t e g r a t e d d e l i v e r y networks t h a t
l i n k community-based c e n t e r s w i t h o t h e r h o s p i t a l s and p r o v i d e r s .
The A d m i n i s t r a t i o n w i l l a l s o t a k e a hard l o o k a t r e d u c i n g
b a r r i e r s t o c o m p e t i t i o n and e f f i c i e n c y . R i g h t now, t h e J u s t i c e
Department i s e x p l o r i n g g u i d e l i n e s f o r mergers, networks, j o i n t
v e n t u r e s , p u r c h a s i n g c o o p e r a t i v e s and i n f o r m a t i o n exchanges so
t h a t h o s p i t a l s do n o t have t o f i l e hundreds o f forms and w a i t
y e a r s and y e a r s t o share an MRI machine or p o o l advanced
u l t r a s o u n d equipment.
The A d m i n i s t r a t i o n ' s p l a n a l s o w i l l p r o v i d e i n c e n t i v e s f o r
t h e n a t i o n a l h e a l t h s e r v i c e corps t o encourage d o c t o r s t o
p r a c t i c e i n remote and c h a l l e n g i n g p a r t s o f our c o u n t r y — where
many o f your h o s p i t a l s are l o c a t e d .
Everywhere I go I hear about t h e p a u c i t y o f d o c t o r s i n
underserved areas. R i g h t i n t h e n a t i o n ' s c a p i t a l , n o t f a r from
The White House, i s a s t u n n i n g example o f t h e imbalances p l a g u i n g
our system: The p o o r e s t s e c t i o n o f Washington, D.C. — Ward 8 —
i s home t o 25 p e r c e n t of t h e c i t y ' s c h i l d r e n , t h e h i g h e s t
p r o p o r t i o n of premature babies i n t h e c i t y , t h e most c h i l d r e n
w i t h AIDS and t h e l a r g e s t number of i n f a n t s who d i e b e f o r e t h e i r
f i r s t b i r t h d a y s . Yet Ward 8 has o n l y 6 p e r c e n t o f t h e c i t y ' s
p e d i a t r i c i a n s and o n l y one o f 15 c i t y - r u n c l i n i c s .
•
As a r e s u l t , t h e o n l y h o s p i t a l i n t h a t p a r t o f t h e c i t y ,
Greater Southeast Community H o s p i t a l , has been t r a n s f o r m e d i n t o a
g i a n t r e c e i v i n g dock f o r every s i c k person i n t h e s u r r o u n d i n g
neighborhood — r a n g i n g from t h e c h i l d w i t h a runny nose t o t h e
s e n i o r c i t i z e n s u f f e r i n g from a s t r o k e . By t r e a t i n g a l l o f those
p a t i e n t s — 11 p e r c e n t of whom were u n i n s u r e d — t h e h o s p i t a l
gave away more t h a n $11 m i l l i o n i n f r e e s e r v i c e s and was n e a r l y
f o r c e d i n t o i n s o l v e n c y a few years ago.
The good news i s t h a t h o s p i t a l o f f i c i a l s a t Greater
Southeast broke f r e e from t h e c o n v e n t i o n a l t h i n k i n g about h e a l t h
care and d e v i s e d i m a g i n a t i v e ways t o b r i n g p r e v e n t i v e and p r i m a r y
care t o t h e i r communities — w h i l e a l s o s a v i n g money.
Greater Southeast opened a school-based c l i n i c , launched
ambulatory care programs, and o r g a n i z e d v o l u n t e e r s t o p e r f o r m
b l o o d p r e s s u r e s c r e e n i n g s a t Sunday church s e r v i c e s . The h o s p i t a l
made j u d i c i o u s investments i n t e c h n o l o g y based on t h e needs o f
i t s community — o p t i n g , f o r example, f o r a s t a t e - o f - t h e - a r t
k i d n e y d i a l y s i s machine r a t h e r t h a n equipment t o p e r f o r m open
h e a r t s u r g e r i e s . And f i n a l l y , t h e h o s p i t a l a t t a c k e d t h e
u n d e r l y i n g s o c i a l r o o t s o f poor h e a l t h : inadequate housing, l a c k
of e d u c a t i o n , p o v e r t y , v i o l e n c e and drugs.
These i n v e n t i v e , compassionate, c o s t - s a v i n g e f f o r t s are n o t
g o i n g u n n o t i c e d . The p r e s i d e n t ' s h e a l t h care p l a n w i l l make sure
�every American has a d o c t o r and a h e a l t h care f a c i l i t y w i t h i n
reach and w i l l r e s t o r e c a r i n g and conscience t o o u r h e a l t h care
system.
S i m i l a r t o your community care networks, t h e p r e s i d e n t ' s
plan w i l l create h e a l t h a l l i a n c e s t h a t o f f e r a v a r i e t y o f plans
t o consumers and businesses i n a g i v e n geographic area.
I t w i l l harness runaway c o s t s and s t r e a m l i n e o u r system i n
ways t h a t i n j e c t new d i g n i t y and p r i d e i n t o t h e h e a l t h care
professions.
We w i l l s t a r t by u n t a n g l i n g t h e web o f paperwork and
r e g u l a t i o n so p a t i e n t s and h e a l t h care p r o v i d e r s a r e c o n f r o n t e d
w i t h one s t a n d a r d i n s u r a n c e form — n o t hundreds and hundreds. We
w i l l do away w i t h i n t r u s i v e micromanagement so t h a t h o s p i t a l
a d m i n i s t r a t o r s , d o c t o r s and nurses can make d e c i s i o n s based on
sound m e d i c a l judgment r a t h e r t h a n on reimbursement schedules. We
w i l l a l s o s i m p l i f y w e l l - i n t e n t i o n e d r e g u l a t i o n s l i k e CLIA t h a t
c u r r e n t l y burden t h e system.
The p r e s i d e n t ' s p l a n w i l l a l s o a p p l y more v i g i l a n c e t o t h e
s p e c i a l problems o f o l d e r Americans, many o f whom now seek
t r e a t m e n t i n your f a c i l i t i e s . There w i l l be i n c r e a s e d o p t i o n s f o r
home and community-based care s e r v i c e s and g r e a t e r p r o t e c t i o n s
f o r n u r s i n g home r e s i d e n t s . There w i l l be a new f e d e r a l home care
program f o r d i s a b l e d c i t i z e n s , r e g a r d l e s s o f income.
F i n a l l y , we w i l l i n s i s t t h a t , f o r t h e f i r s t t i m e ever,
everyone t a k e r e s p o n s i b i l i t y f o r g e t t i n g coverage and c o n t r o l l i n g
costs.
A f t e r a l l , why should i n d i v i d u a l s who t h i n k i n s u r a n c e i s
unnecessary f o r c e t h e r e s t o f us t o p i c k up t h e t a b when t h e y
have a s e r i o u s a c c i d e n t o r an unforeseen i l l n e s s and end up i n
the emergency room o r t h e ICU?
Why s h o u l d employers who don't p r o v i d e coverage f o r t h e i r
workers be a l l o w e d t o d r i v e up c o s t s f o r businesses who do?
And why s h o u l d drug companies charge t w i c e o r t h r e e t i m e s i n
America what t h e y charge overseas f o r p r e s c r i p t i o n drugs?
We must e s t a b l i s h new p r i o r i t i e s , new i n c e n t i v e s , and new
p a r t n e r s h i p s . We must a l l t a k e r e s p o n s i b i l i t y . We must a l l
contribute.
O b v i o u s l y , r e a c h i n g a consensus on h e a l t h care r e f o r m and
d r a f t i n g i t as l e g i s l a t i o n and n a v i g a t i n g i t t h r o u g h Congress
w i l l n o t be easy. There w i l l be s k e p t i c s and naysayers and
s p e c i a l i n t e r e s t s who r e s i s t change o f any s o r t . There w i l l be
�some who a r e u n c o m f o r t a b l e w i t h p o r t i o n s o f t h e p l a n and w i l l
n i b b l e around i t s edges. There w i l l be o t h e r s who — i n s t e a d o f
acting — prefer t a l k i n g , dissecting, analyzing.
Too many t i m e s , i n d i v i d u a l s , i n t e r e s t groups and t h e
government have marched t o t h e edge o f h e a l t h care r e f o r m , o n l y
t o cower i n f e a r and walk away.
Too many t i m e s , we have h e l d meetings and read brochures and
debated p l a n s — and t h e n walked away.
Too many t i m e s , we have watched as one p o l i t i c a l p a r t y
blamed t h e o t h e r f o r a system gone awry — and w h i l e t h e y were
a l l p o i n t i n g f i n g e r s , t h e problems g o t worse and we walked away.
Now, a f t e r w a s t i n g so many o p p o r t u n i t i e s , a f t e r w i t n e s s i n g
two decades o f r i s i n g h e a l t h care c o s t s and w a t c h i n g our problems
grow more i n t r a c t a b l e , we have reached a c r i s i s p o i n t where
change i s o u r o n l y o p t i o n .
How many more meetings do we need? How many more plans? How
many more d o l l a r s p i l i n g on t o our n a t i o n a l debt b e f o r e we show
t h e courage t o s t e p up and t a k e r e s p o n s i b i l i t y ?
With
w i t h your
chance t o
depending
your r e c o r d o f p r o g r e s s i v e t h i n k i n g on m e d i c a l c a r e ,
courage as h e a l t h care i n n o v a t o r s , we have one more
make a d i f f e r e n c e f o r a g e n e r a t i o n o f Americans who a r e
on us t o a c t .
I f we a r e brave enough . . . i f we a r e b o l d enough . . .
can j o i n t o g e t h e r now — n o t as Democrats o r Republicans o r
l i b e r a l s o r c o n s e r v a t i v e s — b u t as Americans committed t o
s a f e g u a r d i n g our n a t i o n ' s f u t u r e h e a l t h and w e l l - b e i n g .
T h i s t i m e , l e t ' s n o t walk away. T h i s t i m e , l e t ' s l e a d t h e
way.
Thank you a l l v e r y much.
###
we
�THE
WHITE HOUSE
O f f i c e o f t h e Press S e c r e t a r y
For Inunediate Release
J u l y 19, 1993
REMARKS BY THE FIRST LADY
AT CHARLES DREW UNIVERSITY OF MEDICINE AND SCIENCE
Los Angeles,
California
MRS. CLINTON: Thank you. Thank you very much. Thank
you, Vincenzo, and thank you a l l who are f a c u l t y and s t u d e n t s and
supporters of t h i s u n i v e r s i t y .
I t i s a g r e a t p r i v i l e g e f o r me t o be
here today, because you do r e p r e s e n t t h e k i n d o f p a r t n e r s h i p between
h e a l t h care and our communities t h a t has t o be t h e h a l l m a r k o f what
we are moving toward i n t h i s c o u n t r y .
•
I was p r i v i l e g e d , b e f o r e a d d r e s s i n g you t h i s morning, t o
v i s i t some o f t h e programs t h a t t h i s u n i v e r s i t y s u p p o r t s i n
encouraging young people l i k e those who are here on t h e stage w i t h
me, h i g h school s t u d e n t s , and c o l l e g e s t u d e n t s t o c o n s i d e r c a r e e r s i n
medicine and s c i e n c e t h r o u g h t h e i r exposure t o c l i n i c a l work and
l a b o r a t o r y work.
I t was very e x c i t i n g , because I t a l k e d with young people
who are committed to f i n d i n g cures for cancer, who are committed to
doing what they can to t r y to turn around the conditions t h a t they
see i n the h e a l t h care system today.
And t h e n , coming here, and h a v i n g an o p p o r t u n i t y t o
address you, j u s t p u l l s t h e whole morning t o g e t h e r f o r me, because I
see i n f r o n t o f me young people, and those n o t so young, who w i l l be
t a k i n g t h e i r p l a c e s i n t h i s community and o t h e r communities a t a time
of v e r y e x c i t i n g change i n our c o u n t r y .
I t i s no s e c r e t to any of you t h a t we are engaged now i n
an e f f o r t t o cafnrm our nation's h e a l t h care system. Those of you
who are here a t t h i s U n i v e r s i t y , perhaps more than most Americans,
see on an everyday b a s i s the reasons why the President i s committed
to making these changes^
system.
You see the people who are shut out of the health care
(Applause.) You see the i n s t i t u t i o n s t h a t are over-burdened
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to t h e p o i n t o f b r e a k i n g because o f t h e i r i n c a p a c i t y t o care f o r
those who come f l o o d i n g through t h e i r doors.
You see t h e wasted
l i v e s and t h e broken dreams o f people whose h e a l t h doesn't p e r m i t
them t o go on t o g a i n f u l employment o r t o make o u t o f themselves
whatever God intended them t o be. You are here on t h e f r o n t l i n e s .
What I would l i k e t o do f o r j u s t a few minutes i s t o
t a l k w i t h you about what we see as a v i s i o n f o r h e a l t h care i n our
c o u n t r y . We w i l l need your h e l p , n o t j u s t those o f you who i n t e n d t o
become p r o f e s s i o n a l s i n h e a l t h care, b u t a l l o f you -- community
members, j o u r n a l i s t s , business l e a d e r s , p o l i t i c a l l e a d e r s . A l l o f us
w i l l have t o be committed t o making t h e changes r e q u i r e d .
You know t h a t i n our c o u n t r y we have, probably, t h e
f i n e s t h e a l t h care a v a i l a b l e anywhere i n t h e w o r l d , i f you can get
it.
(Applause.)
We are a t t h e t o p o f t h e curve when i t comes
to r e s e a r c h .
We can do procedures and t h e k i n d s o f e x t r a o r d i n a r y
i n t e r v e n t i o n s t h a t were o n l y dreamed o f a few years ago. You are
s t u d y i n g i t . You can watch i t happen.
I read o f a graduate o f t h i s U n i v e r s i t y , a Dr. Clayton,
who performed an e x t r a o r d i n a r y o p e r a t i o n when a young g i r l , t h e
v i c t i m o f a s t r a y b u l l e t i n t h e k i n d o f mad and crazy v i o l e n c e t h a t
a f f l i c t s t o o many o f our c i t i e s , i n c l u d i n g t h i s one, came i n t o t h e
h o s p i t a l , a b u l l e t i n her h e a r t .
•
And what Dr. C l a y t o n was a b l e t o do was, through
e x t r a o r d i n a r y i n t e r v e n t i o n , keep t h a t young g i r l a l i v e and,
h o p e f u l l y , p u t her on t h e p a t h t o r e c o v e r y .
That c o u l d n o t have been
done w i t h o u t t h e advances t h a t have o c c u r r e d and w i t h o u t t h e t r a i n i n g
t h a t d o c t o r r e c e i v e d here.
(Applause.)
So we do have t h e best t h a t can be a v a i l a b l e i n medical
care anywhere i n t h e w o r l d , and we must never, ever l e t t h a t h i g h
standard f a l l .
We must always m a i n t a i n q u a l i t y i n our h e a l t h care
system. We must always p r o v i d e t h e s t a t e - o f - t h e - a r t k i n d s o f h e a l t h
care t h a t our people deserve.
But t h a t i s o n l y p a r t o f t h e s t o r y we have t o t e l l ,
because we have t o o many people who do n o t have access even t o b a s i c
c a r e . They d C Yi6t have t h e k i n d o f p r i m a r y and p r e v e n t i v e h e a l t h
care t h a t w i l l - enable them t o remain and s t a y h e a l t h y .
They t o o bfcten use t h e emergency room a t King and o t h e r
h o s p i t a l s as t h e i r p r i m a r y care p h y s i c i a n . They walk i n t h e r e t o o
l a t e t o r e a l l y g e t h e l p , t a k i n g up space t h a t s h o u l d be r e s e r v e d f o r
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the b u l l e t wounds i n the h e a r t t h a t are t r u e emergencies,
they have nowhere e l s e t o go.
(Applause.)
because
So we have t o t a k e our system and make i t a v a i l a b l e t o
everyone, w i t h an emphasis on p r i m a r y and p r e v e n t i v e h e a l t h c a r e ,
d e l i v e r e d i n a community s e t t i n g t h a t w i l l reach every American when
t h a t person needs h e a l t h care.
(Applause.)
Now, some people t h i n k t h a t t h i s r e f o r m e f f o r t t h a t the
P r e s i d e n t put i n motion by c r e a t i n g a t a s k f o r c e committed t o
s t u d y i n g what needed t o be done, t h a t Dr. Tuckson ( p h o n e t i c ) and John
Garamendi ( p h o n e t i c ) and o t h e r l e a d e r s i n t h i s community and t h i s
s t a t e have helped w i t h , was r e a l l y o n l y aimed a t making sure t h a t we
c o u l d p r o v i d e access t o those who d i d not have access now, the 37 t o
40 m i l l i o n Americans who are n o t i n s u r e d .
But, you know, i n today's w o r l d , t h e r e i s nobody here i n
t h i s audience who w i l l r e a l l y be a b l e t o say w i t h any c e r t a i n t y t h a t
you w i l l be i n s u r e d y o u r s e l f next year. You know, i t ' s r e a l l y
u n c l e a r a t a l l , g i v e n t h e changes i n t h e economy, g i v e n what i s
happening around t h e c o u n t r y w i t h i n c r e a s i n g h e a l t h c o s t s , t h a t even
those o f us who have insurance today w i l l have i t t h i s t i m e next
year .
I o f t e n t h i n k , as my f a t h e r used t o t e l l me, t h a t i n
most i n s t a n c e s , i f you s t o p f o r a minute and l o o k a t somebody and
say, "There, b u t f o r t h e grace o f God, go I , " you g e t a p r e t t y c l e a r
idea o f where you s t a n d i n l i f e , because so much o f what we have
today may not be a v a i l a b l e u n l e s s we work t o keep i t , and t h a t i s
t r u e w i t h h e a l t h care.
•
So t h i s i s n o t j u s t about making sure t h e m i l l i o n s who
do n o t have i n s u r a n c e r e c e i v e h e a l t h care coverage, t h i s i s making
the case t h a t , f o r every American i n s u r e d today o r u n i n s u r e d today,
we want t o guarantee h e a l t h s e c u r i t y so t h a t no one ever needs t o be
a f r a i d a g a i n t h e y w i l l n o t have access t o q u a l i t y h e a l t h c a r e .
(Applause.)
In order to do that, we have to make everybody part of
the same community, so t h a t everybody gets h e a l t h care. I n order to
achieve t h a t , we have to have a package of b e n e f i t s t h a t i s a v a i l a b l e
to every American, no matter where you work and no matter whether or
not you've ever been s i c k before.
You know, one of the great i r o n i e s today i s , i f you've
ever been s i c k b e f o r e / ^ o u ' r e l e s s l i k e l y to get h e a l t h insurance
than somebody who has never been s i c k . I t always s t r u c k me as a
l i t t l e b i t odd that you would get the kind of h e a l t h care that would
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p r o t e c t you i f you had shown over t h e years you d i d n ' t need i t , but
you c o u l d n ' t g e t i t i f you had ever been s i c k and might need i t .
We need t o e l i m i n a t e what a r e c a l l e d p r e e x i s t i n g
c o n d i t i o n s t h a t p r e v e n t people from g e t t i n g h e a l t h care insurance.
(Applause.)
So we need u n i v e r s a l access f o r every American. We need
a package o f b e n e f i t s t h a t i s guaranteed t o every American, no matter
who you a r e o r where you work o r whether you have had an i l l n e s s or a
problem i n t h e p a s t , and t h e package o f b e n e f i t s needs t o emphasize
p r i m a r y and p r e v e n t i v e h e a l t h care.
We have g o t t e n o u r s e l v e s i n t o a s i t u a t i o n where you can
get coverage f o r a h e a r t bypass, b u t you don't g e t coverage f o r
immunizing your c h i l d .
You can g e t coverage i f you have a s t r o k e ,
but you don't g e t immunized f o r t h e k i n d o f g e n e r a l t e s t s t h a t might
t e l l you whether o r n o t you're a c a n d i d a t e f o r a s t r o k e . You can g e t
coverage i f you have b r e a s t cancer, b u t you may n o t have coverage f o r
a mammogram. We need t o emphasize p r i m a r y and p r e v e n t i v e h e a l t h care
and d i a g n o s t i c t e s t s t h a t w i l l enable us t o t a k e b e t t e r care o f
people e a r l i e r .
(Applause.)
We a l s o need t o be sure t o i n s u r e c h o i c e , so t h a t
i n d i v i d u a l s w i l l have c h o i c e s among t h e h e a l t h p l a n s t h a t a r e
a v a i l a b l e t o them. Very o f t e n today, i f you do have i n s u r a n c e
t h r o u g h an employer, you a r e f i n d i n g your c h o i c e s more and more
limited.
You a r e t o l d who you can go see, what p l a n you can choose,
and how you can g e t h e a l t h care d e l i v e r e d .
•
We want to r e t a i n choice, so t h a t you can choose among
d i f f e r e n t kinds of plans and choose among the doctors and other
h e a l t h p r o f e s s i o n a l s that you would l i k e to have take care of you.
We think choice i s an important part of what an American h e a l t h care
plan should look l i k e , and so we want to i n s u r e t h a t .
We a l s o want to guarantee that i t i s simpler than what
we c u r r e n t l y have, p a r t i c u l a r l y f o r those of you who w i l l be the
p r o f e s s i o n a l s of the future. The average nurse and doctor now spend
an extraordinary amount of t h e i r time and often t h e i r income f i l l i n g
out the forms t h a t have to be f i l l e d out to s a t i s f y the government
and p r i v a t e insurance companies that r e q u i r e a l l those forms.
(Applause.)
Wfe want t o s i m p l i f y t h e paperwork, reduce t h e
bureaucracy, enable those o f you who w i l l be h e a l t h care
p r o f e s s i o n a l s t o spend i^our t i m e t a k i n g care o f p a t i e n t s i n s t e a d o f
f i l l i n g o u t forms. We t h i n k t h a t ' s a much b e t t e r use o f your
t r a i n i n g and e d u c a t i o n .
(Applause.)
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I f you had wanted t o be a bookkeeper o r an accountant,
you c o u l d have g o t t e n a d i f f e r e n t k i n d o f e d u c a t i o n than t r y i n g t o be
a d o c t o r o r a nurse o r o t h e r h e a l t h care p r o f e s s i o n a l . (Applause.)
We a l s o a r e going t o r e q u i r e everybody t o c o n t r i b u t e and
p a r t i c i p a t e i n t h i s h e a l t h care system. For most people, t h a t w i l l
mean some k i n d o f f i n a n c i a l c o n t r i b u t i o n .
Everybody w i l l have t o be
r e s p o n s i b l e i n some way.
But i t w i l l a l s o r e q u i r e , even from those who cannot
n e c e s s a r i l y make a s i g n i f i c a n t f i n a n c i a l c o n t r i b u t i o n o f any k i n d ,
t h a t a l l o f us be more r e s p o n s i b l e f o r our own h e a l t h care. Each of
us i s g o i n g t o be asked t o s t a r t t a k i n g b e t t e r care o f ourselves and
the people around us.
(Applause.)
That operates on two l e v e l s . That operates, c e r t a i n l y ,
on t h e i n d i v i d u a l l e v e l . P e r s o n a l l y , we should a l l e a t b e t t e r ,
e x e r c i s e a l i t t l e more, t r y t o reduce t h a t s t r e s s as much as
p o s s i b l e . We a r e l e a r n i n g a l o t about what those simple k i n d s o f
changes i n l i f e s t y l e can do t o improve your h e a l t h .
•
I r e c e n t l y was i n Hawaii.
Some o f you may know t h a t
Hawaii i s t h e o n l y one o f our s t a t e s t h a t comes anywhere c l o s e t o
n e a r - u n i v e r s a l coverage. About 98 p e r c e n t o f a l l o f t h e people o f
Hawaii a r e covered by h e a l t h care i n s u r a n c e . They have an employeremployee-based p l a n i n which people p a r t i c i p a t e w i t h t h e employers
and t h e employees making c o n t r i b u t i o n s .
Because they have everybody i n t h e i r system, they a l l
are a b l e t o p r o v i d e b e t t e r h e a l t h care, because t h e y g e t people t o
the d o c t o r sooner t h a n we do i n t h e r e s t o f t h e c o u n t r y . So they
l i v e l o n g e r , and i t ' s n o t j u s t because i t ' s a b e a u t i f u l i s l a n d s t a t e .
They l i v e l o n g e r because t h e y g e t b e t t e r p r i m a r y and p r e v e n t i v e
h e a l t h care.
But, even t h e r e i n Hawaii, they a r e l e a r n i n g t h a t j u s t
going t o t h e d o c t o r i s n o t enough. You have t o h e l p t a k e care o f
y o u r s e l f . H i p p o c r a t e s s a i d t h a t , t h a t t h e p h y s i c i a n and t h e p a t i e n t
are r e s p o n s i b l e f o r h e a l t h care.
So, i n Hawaii, one o f t h e t h i n g s t h a t I l e a r n e d i s t h a t
n a t i v e Hawaiians nave t h e h i g h e s t r a t e o f d i a b e t e s i n t h e w o r l d ,
because t h e y changed t h e i r d i e t so d r a m a t i c a l l y i n t h e l a s t 200
years.
So, now, what are we t r y i n g to do i n a place l i k e Hawaii
that has u n i v e r s a l coverage, we don't have the people f a l l i n g between
the c r a c k s , as we do here i n C a l i f o r n i a and elsewhere?
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Now, we are a t t e m p t i n g t o t a k e these people who are
paying l e s s per c a p i t a f o r h e a l t h care than t h e r e s t of us, who are
l i v i n g l o n g e r , and doing even more by changing how they themselves
make p e r s o n a l d e c i s i o n s .
So t h a t , f o r example, n a t i v e Hawaiians who
go back t o t h e d i e t of t h e i r a n c e s t o r s — f i s h and the k i n d s of
f r u i t s and v e g e t a b l e s t h a t t r a d i t i o n a l l y were eaten — have
d r a m a t i c a l l y improved h e a l t h outcomes when i t comes t o c a r d i o v a s c u l a r
disease and d i a b e t e s .
Research i s being done i n t h i s s t a t e which shows t h a t
you not o n l y can s t a b i l i z e h e a r t d i s e a s e , but r e v e r s e i t s e f f e c t s , by
changes i n d i e t and i n c r e a s e s i n moderate e x e r c i s e .
Those are the
k i n d s of t h i n g s t h a t people are going t o have t o do i n a d d i t i o n t o
the obvious, which i s t o q u i t smoking, don't d r i n k t o excess, and
s t a y away from drugs.
(Applause.) Those are some of the t h i n g s we
a l l are g o i n g t o have t o be committed t o d o i n g . R e s p o n s i b i l i t y a l s o
o p e r a t e s on a community l e v e l .
You know, i t i s a p u b l i c h e a l t h problem t h a t we have the
l e v e l of v i o l e n c e we do i n a community l i k e t h i s . That i s not j u s t a
c r i m i n a l law enforcement problem, i t i s a p u b l i c h e a l t h problem.
When t h e s i n g l e l e a d i n g h i g h e s t cause of death f o r young A f r i c a n American men between t h e ages of 18 and 30 i s homicide, t h a t i s a
p u b l i c h e a l t h problem.
(Applause.)
So, i n p a r t , what we have t o do i s n o t o n l y commit t o
t a k i n g b e t t e r care o f o u r s e l v e s , we have t o commit t o t a k i n g b e t t e r
care of each o t h e r and making i t p o s s i b l e f o r our c h i l d r e n t o grow t o
a d u l t h o o d w i t h t h e k i n d o f l i v e s we want them t o have. H e a l t h care
i s a p a r t o f t h a t , but so i s making sure our communities are good and
safe and n u r t u r i n g environments f o r c h i l d r e n and a d u l t s t o l i v e i n
together.
So, p a r t o f what h e a l t h care r e f o r m i s about i s not j u s t
changing b u r e a u c r a c i e s , not j u s t p r o v i d i n g access t o p e o p l e , not j u s t
emphasizing p r i m a r y and p r e v e n t i v e h e a l t h care t h r o u g h your t r a i n i n g ,
but i t i s making sure we a l l become more r e s p o n s i b l e .
I have a v i s i o n , not j u s t o f a h e a l t h care system t h a t
f i n a l l y works b e t t e r f o r a l l Americans, and not o n l y one t h a t makes
i t p o s s i b l e f o r a l l o f us t o be more r e s p o n s i b l e , c o n t r i b u t i n g t o our
own h e a l t h aneh t h e h e a l t h o f o t h e r s , but f o r t h a t k i n d o f p r i n c i p l e
t o spread t h r o u g h our l a r g e r s o c i e t y , so t h a t once a g a i n we can see,
not j u s t i n s i n g l e l o c a t i o n s l i k e Drew U n i v e r s i t y , t h e k i n d o f
c o o p e r a t i o n and i n s p i r a t - i o n t h a t I sense here, b u t t h a t w i l l spread
out i n t o our e n t i r e community, our s t a t e and our c o u n t r y .
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�THE
WHITE HOUSE
O f f i c e o f t h e Press S e c r e t a r y
( H o n o l u l u , Hawaii)
Internal Transcript
J u l y 13, 1993
REMARKS BY THE FIRST LADY
IN HEALTH CARE ROUNDTABLE
A l a Moana H o t e l
Honolulu, Hawaii
9:00
A.M. AHT
GOVERNOR WAIHEE: Good morning and aloha.
It's a
p l e a s u r e t o be a b l e t o welcome a l l o f you t o t h i s h e a l t h care
forum. We had a v e r y e x c i t i n g and i n t e r e s t i n g morning.
Russell
Watanabe from Watanabe F l o r i s t s was k i n d enough t o i n v i t e t h e
F i r s t Lady and myself t o h i s business so she can g e t a chance t o
see what 97 p e r c e n t o f Hawaii's businesses l o o k l i k e .
We wanted
an o p p o r t u n i t y b e f o r e coming t o t h i s forum t o t a l k t o some s m a l l
b u s i n e s s employers about what i t ' s l i k e t o be under t h e Hawaii
p r e p a i d h e a l t h care p l a n . And t h e y were v e r y i n f o r m a t i v e . And
we want t o thank them f o r t h e i r p a r t i c i p a t i o n .
We are v e r y f o r t u n a t e , o b v i o u s l y , t o have our
n a t i o n ' s dynamic F i r s t Lady, H i l l a r y Rodham C l i n t o n , w i t h us. As
you know, Mrs. C l i n t o n has been a t t h e f o r e f r o n t o f t h e
P r e s i d e n t ' s i n i t i a t i v e t o look i n t o h e a l t h care r e f o r m so t h a t
a f f o r d a b l e q u a l i t y h e a l t h care s e r v i c e s can be made a v a i l a b l e t o
a l l c i t i z e n s o f t h i s n a t i o n . As t h e P r e s i d e n t mentioned i n h i s
comments on Sunday a t t h e Great Aloha C e l e b r a t i o n on t h e beach o f
W a i k i k i , s p i r a l i n g h e a l t h care c o s t s i s t h e number one d r a i n on
our n a t i o n ' s economy. P r o v i d i n g u n i v e r s a l coverage and
c o n t a i n i n g h e a l t h care c o s t s are among t h e t o p p r i o r i t i e s f o r h i s
administration.
I n Hawaii, we found a way t o o f f e r more people
g r e a t e r access t o p r i m a r y care t h a n any o t h e r s t a t e . And we've
done i t by b u i l d i n g p a r t n e r s h i p s between t h e s t a t e , i n s u r a n c e
companies, d o c t o r s and h o s p i t a l s — a l l who share i n t h e c o s t s —
and by p i o n e e r i n g i n n o v a t i v e concepts l i k e s h o r t h o s p i t a l s t a y s ,
o u t - p a t i e n t s u r g e r y and p r e v e n t i v e h e a l t h programs.
But we haven't done i t o v e r n i g h t . The most
s i g n i f i c a n t f a c t o r i n Hawaii's success s t o r y i s e x p e r i e n c e .
We've been w o r k i n g t o be t h e h e a l t h s t a t e f o r 2 0 y e a r s , and t h i s
forum a l l o w s us t o share our experience w i t h t h e r e s t o f America.
The keystone o f Hawaii's system i s i t s employer mandate which
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r e q u i r e s employers t o p r o v i d e h e a l t h care coverage f o r most
workers. And w h i l e c o n t r o v e r s i a l n a t i o n a l l y , we have found t h i s
program t o be a success, e n s u r i n g a h i g h l e v e l o f coverage f o r
Hawaii's people and s t r e n g t h e n i n g our a b i l i t y t o c o n t r o l c o s t s .
And, f r a n k l y , a f t e r n e a r l y 20 y e a r s as, as i n d i c a t e d
t h i s morning, employers i n Hawaii r e c o g n i z e t h a t p r o v i d i n g h e a l t h
care i s good b u s i n e s s . And so, f o r t h i s morning's forum, we have
a l s o p r o v i d e d more o f Hawaii's business owners t o d i s c u s s t h i s
i s s u e w i t h us, as w e l l as e x p e r t s on h e a l t h c a r e .
A s i g n i f i c a n t c o s t c o n t r o l r e s u l t i n g from u n i v e r s a l
access t o coverage has been t h e a b i l i t y o f people i n Hawaii t o
make use o f p r e v e n t i v e and p r i m a r y c a r e , and t h u s , reduce
Hawaii's need f o r expensive emergency room and h o s p i t a l c a r e .
U n i v e r s a l access, t h e n , has been Hawaii's most e f f e c t i v e c o s t
c o n t r o l mechanism. And w h i l e Hawaii's successes i n s o l v i n g
access and c o s t containment have been n o t a b l e , t h e y a r e n o t
complete. Costs c o n t i n u e t o surge b o t h i n Hawaii and t h r o u g h o u t
the n a t i o n .
That i s why a s t r o n g p a r t n e r s h i p w i t h o u r f e d e r a l
government i s j u s t as c r u c i a l as t h e l o c a l p a r t n e r s h i p s — we a r e
f o r g e d w i t h t h e p r i v a t e s e c t o r here i n H a w a i i . And t h a t i s why I
and my f e l l o w g o v e r n o r s were so p l e a s e d t o hear t h e P r e s i d e n t on
the eve o f h i s i n a u g u r a t i o n promise t o l o o k t o t h e s t a t e s as
l a b o r a t o r i e s f o r i n n o v a t i o n and c r e a t i v i t y i n r e s o l v i n g t h e
n a t i o n ' s c u r r e n t h e a l t h care c r i s i s .
I n h i s i n i t i a l months as P r e s i d e n t , P r e s i d e n t
C l i n t o n has been t r u e t o h i s word. Through t h e F i r s t Lady's work
on t h e H e a l t h Care Task Force, h i s a d m i n i s t r a t i o n has sought t h e
i n p u t and s u g g e s t i o n s from a broad range o f c i t i z e n s and
p r o f e s s i o n a l s . And t h a t i s why she i s here t o d a y — t o l e a r n
more about Hawaii's h e a l t h care system.
And so, on b e h a l f o f a l l o f t h e p a r t i c i p a n t s , we
want t o , f i r s t o f a l l , thank Mrs. C l i n t o n f o r j o i n i n g us h e r e ,
t a k i n g t i m e o u t from h e r busy schedule, what s h o u l d , i n f a c t , be
a v a c a t i o n , t o be w i t h us here today. And t h e second t h i n g I
want t o do i s ask a l l o f you t o j o i n me i n welcoming H i l l a r y
Rodham C l i n t o n t o our h e a l t h c a r e forum t h i s morning. Thank you.
(Applause.)
MRS. CLINTON: Thank you v e r y much. W e l l , I am
d e l i g h t e d t o be h e r e . And I a p p r e c i a t e d t h e i n v i t a t i o n from t h e
Governor t o have some t i m e t o l e a r n more about how t h e Hawaiian
h e a l t h c a r e system works, t o l e a r n what c o u l d be done t o improve
i t , and t o p r o v i d e a forum f o r those o f you who a r e f i n a n c i n g i t
and d e l i v e r i n g c a r e i n i t and r e c e i v i n g c a r e from i t , t o share
your e x p e r i e n c e s w i t h t h e r e s t o f t h e c o u n t r y .
Because, o f t e n t i m e s , as I have t r a v e l e d around t h e
c o u n t r y t a l k i n g about h e a l t h c a r e , people have asked me about
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what i s g o i n g on i n Hawaii. And I have t r i e d t o educate m y s e l f
so t h a t I c o u l d g i v e answers t h a t were a t l e a s t c l o s e t o t h e
mark. But I t h i n k t h e r e i s no s u b s t i t u t e f o r g o i n g t o t h e people
as we d i d t h i s morning a t Mr. Watanabe's F l o r i s t t o shop, f o r
which I am v e r y g r a t e f u l t o him and h i s f a m i l y , and t h e n coming
here t h i s morning t o hear from a broad c r o s s - s e c t i o n o f Hawaiians
who a r e on t h e f r o n t l i n e s .
I r e a l l y b e l i e v e t h a t t h e r e s t o f t h e c o u n t r y has a
l o t t o l e a r n from what you have done over t h e l a s t 20 y e a r s . And
I am l o o k i n g f o r w a r d t o h a v i n g t h a t chance t h i s morning.
So I am
here t o l i s t e n and ask q u e s t i o n s and n o t o n l y enhance my own
awareness, b u t t o t a k e back w i t h me t o Washington s p e c i f i c
s u g g e s t i o n s from you as t o how t h e n a t i o n a l system s h o u l d be
implemented and what you would expect i t t o be a b l e t o do based
on your e x p e r i e n c e .
GOVERNOR WAIHEE:
Thank you, H i l l a r y .
I t h o u g h t a t t h i s t i m e i t might be b e n e f i c i a l i f we
have Dr. Jack Lewin, who i s our D i r e c t o r o f t h e Department o f
H e a l t h here i n H a w a i i , g i v e us a b r i e f w a l k - t h r o u g h on what t h e
Hawaii h o a l t h car© systam i s a l l about, how i t f u n c t i o n s , aoma o f
l ^ a l ^ ^ a r t ^ ' y ^ h r i p ^
"
•
•
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the
So, Jack, why don't you say a few words.
D R
, E W I N :
T
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.
y ' Governor. Welcome, Mro.
C l i n t o n . And good morning, everybody.
i-r,
i
t l
P
g once a g a i n t o have a chance
t o t a l k a l i t t l e b i t about t h e successes t h a t we have e n j o y e d
here i n Hawaii and how those successes may be r e l e v a n t t o t h e
r e s t o f t h e c o u n t r y i n terms o f h e a l t h care r e f o r m and t h e
c h a l l e n g e t h a t o u r F i r s t Lady has t a k e n on on b e h a l f o f t h e
President.
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t h a n t h e mainland
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n a t i o n does. We have c u l t u r a l groups — our n a t i v e Hawaiians who
need s p e c i a l access c o n s i d e r a t i o n s t a k e n i n t o account.
We need
p r i m a r y care p r o v i d e r s i n some o f our r u r a l areas where t h e y ' r e
hard t o a c q u i r e . We need t o d e a l w i t h l o n g - t e r m c a r e , t h e c o s t
of l o n g - t e r m c a r e , and address t h a t i s s u e s q u a r e l y . And we
c e r t a i n l y can accomplish even more i n Hawaii w i t h p r e v e n t i o n and
w i t h w e l l n e s s and w i t h approaches toward p u b l i c h e a l t h
intervention.
So t h e r e ' s a l o t more s t i l l t o be done.
But 98 p e r c e n t o f Hawaii's p u b l i c c u r r e n t l y has
access t o h i g h - q u a l i t y , e x c e l l e n t , h i g h - t e c h m e d i c a l c a r e . And
t h a t i n c l u d e s a f u l l a r r a y o f s e r v i c e s . The outcomes i n Hawaii
f o r t h e p u b l i c a r e v e r y , v e r y good. We have t h e g r e a t e s t
l o n g e v i t y i n t h e n a t i o n ; some would say t h a t ' s j u s t so we can
l i v e l o n g enough t o pay o f f our mortgages. (Laughter.) B u t ,
f r a n k l y , we have g r e a t l o n g e v i t y . We have t h e l o w e s t m o r b i d i t y
and m o r t a l i t y r a t e s f o r c a r d i o v a s c u l a r d i s e a s e , f o r cancer, f o r
emphysema. We a r e t i e d w i t h one o r two s t a t e s w i t h t h e lowest
i n f a n t m o r t a l i t y r a t e s i n t h e n a t i o n , and we have e x c e l l e n t
outcomes f o r our people.
And t h a t ' s w i t h a p o p u l a t i o n t h a t
s t a r t s o u t w i t h many o f t h e same a d v e r s i t i e s and h e a l t h problems
that e x i s t i n the other states of the nation.
We have a H a r r i s P o l l and a K a i s e r Family Foundation
Survey t h a t d i d consumer s a t i s f a c t i o n r e c e n t l y , and i t showed
t h a t Hawaii had t h e h i g h e s t amount o f consumer s a t i s f a c t i o n o f
any o f t h e s t a t e s , and even more t h a n Canada. So, w h i l e we have
some problems, we have a tremendous amount o f s u p p o r t f o r what
has happened here from our people.
And t h e b i g i s s u e i s t h i s :
t h a t t h e c o s t s i n Hawaii
are 35 t o 40 p e r c e n t lower t h a n t h e r e s t o f t h e c o u n t r y . While
t h e n a t i o n i s a t 14 p e r c e n t o f gross n a t i o n a l p r o d u c t f o r h e a l t h
care c o s t s , Hawaii i s between 8 and 9 p e r c e n t o f o u r gross s t a t e
p r o d u c t . And t h a t i s , i n f a c t , v e r y , v e r y remarkable when you
c o n s i d e r t h e good outcomes.
Now, our d o u b t e r s around t h e c o u n t r y a r e g o i n g t o
say, t h a t ' s f i n e , t h a t ' s dandy, t h a t ' s Hawaii, b u t how does t h a t
r e l a t e t o a l l o f us on t h e mainland o f t h e U n i t e d States? And
t h e r e a r e a l o t o f myths t h a t I'm sure t h e F i r s t Lady has heard,
t h a t i t ' s t h e g r e a t weather, t h a t i t ' s s u p e r i o r g e n e t i c s , t h e
l i f e s t y l e s here a r e so much b e t t e r , t h a t t h e r e ' s a m y s t e r i o u s
i s l a n d f a c t o r t h a t somehow doesn't work f o r t h e i s l a n d s i n t h e
Caribbean and so f o r t h b u t i t does here. And we need t o debunk
those myths because we've g a t h e r e d data u s i n g Center f o r Disease
C o n t r o l t o l o o k a t l i f e s t y l e s and g e n e t i c s and so f o r t h . And
those do n o t e x p l a i n 40 p e r c e n t lower c o s t s . We s i m p l y c a n ' t
e x p l a i n those c o s t s on t h e b a s i s o f those myths and we have t o
l o o k f u r t h e r , and t h a t ' s what t h i s meeting i s about.
P a r t o f debunking t h e mystery about H a w a i i i s t o
understand our employer mandate, t h e Prepaid H e a l t h Care A c t .
And I t h i n k i f we l o o k over here a t some o f these banners t h a t
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are o u t h e r e , you can see t h a t we have a number o f f a c t o r s g o i n g
i n t o p l a y . But, f i r s t o f a l l , w i t h o u t t h e Prepaid H e a l t h Care
A c t , we would n o t have been a b l e t o do t h e SHIP* program, t o move
ahead and p r o v i d e i n s u r a n c e f o r t h e people i n t h e gap.
We would
n o t have been a b l e , Mrs. C l i n t o n , t o go ahead w i t h p r e v e n t i o n
programs i n AIDS, i n e a r l y i n t e r v e n t i o n , i n c h i l d abuse
p r e v e n t i o n , and emergency m e d i c a l s e r v i c e s , i n t r a i n i n g p r i m a r y
care and some o f t h e o t h e r t h i n g s t h a t our s t a t e i s d o i n g .
None o f t h a t c o u l d happen i f we d i d n ' t have t h e
e f f i c i e n c i e s o f our system. The P r e p a i d H e a l t h Care A c t reaches
84 p e r c e n t o f Hawaii's p o p u l a t i o n . That's a l l t h e work f o r c e and
t h a t ' s t h e dependents o f t h e work f o r c e . I t ' s been here f o r 20
y e a r s . I t does not have a l a r g e government i n v o l v e m e n t .
I t is
n o t a bureaucracy, i t i s n o t — come under t h e g u i s e o f
s o c i a l i s m . Instead, i t i s a p a r t n e r s h i p of business, o f
government and o f h e a l t h c a r e p r o v i d e r s t o g e t h e r , w o r k i n g i n a
m a r k e t p l a c e w i t h a l o t o f consumer-driven c h o i c e t h a t makes t h e
system work. So, i n a way, Hawaii i s c l o s e r t o managed
c o m p e t i t i o n t h a n , f r a n k l y , anyplace i n t h e n a t i o n can p u r p o r t t o
be.
People have s a i d on t h e mainland t h a t we're f o r c i n g
people i n t o HMOs and i n t o managed c a r e . Now, we have some o f
b e s t HMOs and managed care as t h e n a t i o n can o f f e r . And we're
v e r y proud o f them. But on t h e o t h e r hand, t w o - t h i r d s o f t h e
people i n Hawaii s t i l l seek f e e - f o r - s e r v i c e medicine i n t h e v e r y
t y p i c a l freedom o f c h o i c e approach t h a t i s so p r e v a l e n t and
p o p u l a r elsewhere i n t h e c o u n t r y as w e l l as HMOs.
How does i t work? W e l l , i t ' s a d m i n i s t r a t i v e l y
s i m p l e . Employers and employees s p l i t c o s t s and pay t h e i r f a i r
share, a l t h o u g h , as y o u ' l l hear today, when t h e law was passed i t
s a i d t h a t 1.5 p e r c e n t o f employees' wages was t h e maximum t h e
employee c o u l d pay.
Wages have i n c r e a s e d more s l o w l y t h a n h e a l t h
care c o s t s . And today t h a t would need t o be somewhere between
t h r e e and s i x p e r c e n t o f wages i f we were r e a l l y g o i n g t o be
e q u i t a b l e w i t h t h e g o a l we had back t h e n o f a 50-50 c o s t s p l i t .
So businesses would l i k e t o see some m o d i f i c a t i o n i n t h a t area.
But f o r 20 y e a r s , today even, t h e c o s t s p l i t i s
p r o b a b l y 75 p e r c e n t c o s t share f o r t h e employer and 2 5 p e r c e n t
f o r t h e employee across t h e board.
For example, f o r s t a t e
government w o r k e r s , t h e government pays 60 p e r c e n t and t h e
employees pay 40 p e r c e n t o f c o s t .
The b e n e f i t package i n t h i s law i s v e r y c r i t i c a l t o
i t s success.
I t i s v e r y broad.
I t ' s prevention t o catastrophic
c a r e . I t i n c l u d e s 120 days i n t h e h o s p i t a l and major m e d i c a l ,
l a b , X r a y , o u t p a t i e n t , emphasis on p r i m a r y c a r e and o u t - p a t i e n t
s u r g e r y . The law d i d n ' t i n c l u d e p h a r m a c e u t i c a l drug coverage.
I t d i d n ' t i n c l u d e d e n t a l coverage.
And i t d i d n ' t i n c l u d e mental
h e a l t h and substance abuse.
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Now, we have k i n d o f g o t t e n mental h e a l t h and
substance abuse i n t h r o u g h t h e back door, and now more t h a n 9 5
p e r c e n t o f our people do have mental h e a l t h and substance abuse
in limited benefits.
D e n t a l and drug has been handled d i f f e r e n t l y .
A
supplemental package has been o f f e r e d t o a l l workers and t h e i r
f a m i l i e s . And, i n f a c t , t h a t supplemental has been t a k e n up by
more 80 p e r c e n t o f t h e people. So we a c t u a l l y have achieved t h a t
k i n d o f coverage f o r t h e most p a r t by consumer c h o i c e .
The dependent coverage i s n o t mandated i n t h e law,
but i t , de f a c t o , i s u n i v e r s a l . And t h e r e are s e v e r a l f e a t u r e s
of our law t h a t you need t o understand when we t h i n k o f a
n a t i o n a l employer mandate t h a t we would recommend. Our law
doesn't a b s o l u t e l y r e q u i r e community r a t i n g by i n s u r a n c e
companies. But t h a t has r e s u l t e d because t h e law says t h a t a l l
workers and t h e i r f a m i l i e s must be accepted w i t h o u t r e g a r d t o
p r e e x i s t i n g medical disease.
Because o f t h a t , our i n s u r a n c e companies have
l e a r n e d how t o manage medical care r a t h e r t h a n r e j e c t and e j e c t
people from c a r e . And t h a t p u t s us i n a v e r y d i f f e r e n t game
plan.
So i n s u r a n c e r e f o r m , dependent coverage, mandatory
p a r t i c i p a t i o n , w i t h a s t a n d a r d b e n e f i t package t h a t cannot be
u n d e r c u t , t h e s e are t h e c r i t i c a l f a c t o r s o f success i n t h i s law.
And t h e r e s u l t s o f i t are q u i t e s i m p l y t h e s e : t h a t we have more
p r i m a r y c a r e and p r e v e n t i o n because o f t h e s e t h i n g s ; and i n s t e a d
of g e n e t i c s , i n s t e a d o f l i f e s t y l e , i n s t e a d o f weather, here i s
where we achieve our success v e r y c l e a r l y — we reduce emergency
room use and h i g h - t e c h use by 35 p e r c e n t compared t o our mainland
c o u n t e r p a r t s . And we reduce per c a p i t a use o f h o s p i t a l beds by
3 5 t o 4 0 p e r c e n t i n t h i s s t a t e . And i t s because we p r o v i d e
b e t t e r u p - f r o n t and p r i m a r y care w i t h o u t copayment and d e d u c t i o n
b a r r i e r s and w i t h a r e a l emphasis on t h a t c a r e .
There's where Hawaii's success comes. And t h a t ' s
why our system r e a l l y works.
I t h i n k t h a t ' s i m p o r t a n t f o r people
t o u n d e r s t a n d and t o debunk t h e myths, because t h e r e ' s t h e
success.
The o t h e r r e a l i m p o r t a n t success t h a t i s c r i t i c a l t o
you and t h e P r e s i d e n t i s t h a t when Hawaii's law was passed, 17
p e r c e n t o f our employees, m o s t l y s m a l l b u s i n e s s p e o p l e , were
u n i n s u r e d . The law t o o k t h a t gap group down t o t h r e e t o f i v e
p e r c e n t . And t h a t would happen i n any mainland s t a t e because, as
you w e l l know, t h a t t w o - t h i r d s t o t h r e e - f o u r t h s o f our u n i n s u r e d
people i n America a r e , f r a n k l y , people who a r e w o r k i n g o r a r e t h e
dependents o f w o r k e r s .
or
I n Hawaii t h a t i s n o t a problem.
I f you're w o r k i n g
you're t h e dependent o f a worker, you're covered. I t doesn't
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m a t t e r i f you have cancer, i f you have h e a r t disease — you come
i n and you pay t h e same r a t e as anybody e l s e . And those a r e
i n c r e d i b l e r e s u l t s t h a t we need t o share w i t h t h e n a t i o n .
I n terms o f business, we do have some e f f e c t s t h a t
we need t o go i n t o i n t h e d i s c u s s i o n and t h e r e a r e people here
t h a t w i l l r e a l l y e n t e r t a i n t h a t . But i n essence, our program i s
not a bureaucracy, i t was implemented q u i c k l y . We can show you
t h a t i n terms o f new business c r e a t i o n , s i n c e '74 t o now, we do
b e t t e r t h a n t h e n a t i o n a l average. I n terms o f business f a i l u r e s
and b a n k r u p t c i e s , we do b e t t e r t h a n t h e n a t i o n a l average.
Some can say, b u t what about t h i s year and l a s t
year? And, y e s , on Kauai, we l o s t a l o t o f businesses t h i s year.
But, f r a n k l y , Mr. C l i n t o n , t h e y w i l l be back n e x t year as t h e
h o t e l s open. And Hawaii has been a v e r y h e a l t h y environment f o r
s m a l l b u s i n e s s , even though s m a l l businesses a r e always g o i n g t o
say t h a t t h e y don't a p p r e c i a t e worker's compensation, d i s a b i l i t y
i n s u r a n c e , f a m i l y leave mandates, h e a l t h i n s u r a n c e mandates.
I t ' s worked, and we've had 20 years o f g r e a t success w i t h i t .
So I t h i n k t h e one key f a c t o r t h a t t h e Governor and
I l i k e t o emphasize i s t h a t s a t i s f a c t i o n o f people on t h e j o b ,
s a t i s f a c t i o n o f employees and t h e i r f a m i l i e s knowing t h e y have
coverage — s a t i s f a c t i o n i s r e a l l y an i m p o r t a n t f a c t o r which i s
v e r y much u n d e r r a t e d i n our s o c i e t y .
I t h i n k t h a t we wrap t h i s up i n t h i s d i s c u s s i o n by
making a v e r y i m p o r t a n t p o i n t t o you: Yes, Hawaii has a t e r r i f i c
system g o i n g here, b u t we need what you're d o i n g . We need
n a t i o n a l h e a l t h care r e f o r m v e r y , v e r y much. A l o t o f t h e c o s t
i n c r e a s e s t o s m a l l businesses i n t h i s s t a t e have come from
Medicare and Medicaid i n c r e a s i n g c o s t s , which s h i f t back t o
business and i n s u r a n c e r a t e s . A l o t o f t h e c o s t i n c r e a s e s come
from d r u g c o s t i n c r e a s e s and medical supply i n c r e a s e s . We need a
n a t i o n a l program t o g e t those k i n d o f t h i n g s under c o n t r o l . We
need a n a t i o n a l program f o r t o r t r e f o r m and m a l p r a c t i c e , f o r a
common data system f o r emphasis on t r a i n i n g and p r i m a r y c a r e .
Those a r e t h i n g s you have been t a l k i n g about and we're v e r y
grateful for that.
We a l s o need a n a t i o n a l system t o g e t worker's
compensation, d i s a b i l i t y i n s u r a n c e , auto i n s u r a n c e , and t h o s e
t h i n g s c o n t r a c t e d and compacted down f o r businesses back i n t o a
h e a l t h package t h a t i s more e f f i c i e n t . And I t h i n k t h e s e a r e a l l
g r e a t areas t h a t g i v e us a c h a l l e n g e t o go ahead w i t h n a t i o n a l
reform.
We want t o say Hawaii's n o t p e r f e c t . We're n o t a
blueprint.
But we have p o w e r f u l lessons f o r t h e f u t u r e . We're
n o t t h e o r e t i c a l . We're r e a l ; we've been up and r u n n i n g f o r 2 0
years w i t h an employer mandate. And we know t h a t a w e l l - d e s i g n e d
employer mandate w i t h i n s u r a n c e r e f o r m , w i t h i r r e d u c i b l e b e n e f i t s
t h a t a r e broad and generous, and w i t h mandatory p a r t i c i p a t i o n
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w i l l reduce America's h e a l t h care c o s t s and w i l l i n c r e a s e access
s i g n i f i c a n t l y , so we can g e t on w i t h s o l v i n g t h e problems f o r t h e
o t h e r s t h r o u g h d i f f e r e n t mechanisms — t h e unemployed, t h e
e l d e r s , t h e s p e c i a l p o p u l a t i o n s t h a t need equal a t t e n t i o n t o
national reform.
I t h i n k we want t o j u s t say on b e h a l f o f a l l o f us
here, t h e r e a r e a l o t o f d i f f e r e n t views around t h i s room. And
y o u ' l l hear from many d i f f e r e n t vantage p o i n t s . But I am
convinced t h a t everybody w i l l come t o g e t h e r around t h e i s s u e t h a t
we need n a t i o n a l r e f o r m and t o back you and t h e P r e s i d e n t up w i t h
t h i s bold e f f o r t .
The most b e a u t i f u l p a r t about t h i s moment i n h i s t o r y
i s t h a t we have l i v e d f o r s e v e r a l decades w i t h apathy from t h e
White House about t h i s c r i t i c a l i s s u e t h a t ' s d r a g g i n g our
economy. Now, we have l e a d e r s h i p . I n o r d e r t o move ahead and
s o l v e t h e problem, we don't need t o n e c e s s a r i l y w a i t u n t i l t h e
p e r f e c t s o l u t i o n comes. I t w i l l never r e a l l y be t h e r e . We need
t o move ahead w i t h p r o g r e s s toward t h e good. And we r e a l l y
applaud you f o r t a k i n g t h e l e a d e r s h i p i n t h a t r e g a r d .
process.
Hawaii wants t o h e l p . We want t o be p a r t o f t h a t
And thank you v e r y much f o r coming.
(Applause.)
GOVERNOR WAIHEE: Mrs. C l i n t o n , you can now
understand why I send Jack t o Washington t o t e l l people about
Hawaii's h e a l t h care system. And I want t o thank him v e r y much
f o r g i v i n g us t h a t overview.
We a l s o have w i t h us t h i s morning a wide c r o s s s e c t i o n o f Hawaii's community. Employers i n s m a l l businesses,
business owners, s m a l l business owners, o t h e r employers, as w e l l
as t h e c r o s s - s e c t i o n o f e x p e r t s , I guess t h e y would be c a l l e d ,
i n d i v i d u a l s t h a t a r e i n v o l v e d i n our h e a l t h care p l a n . And I
t h o u g h t b e f o r e we went any f u r t h e r , we ought t o g i v e you a sense
of t h e knowledge, e x p e r t i s e and p a r t i c i p a t i o n t h a t we w i l l have
here a t t h e forum t h i s morning by a s k i n g people t o i n t r o d u c e
themselves.
( I n t r o d u c t i o n s o f a l l p a r t i c i p a n t s a r e made.)
GOVERNOR WAIHEE: That g i v e s you some sense o f t h e
d i v e r s i t y i n t h e room. Despite t h e setup here t h i s morning, I
t h o u g h t i t would be most p r o f i t a b l e i f we c o u l d have a sense o f
f r e e exchange and r e a l l y g i v e Mrs. C l i n t o n an o p p o r t u n i t y t o
i n t e r a c t w i t h members o f t h e t a b l e here and w i t h t h e p a n e l t h e r e
on any concerns she may have o r answer any s u g g e s t i o n s she may
g i v e o r response any s u g g e s t i o n s we may g i v e . And so don't f e e l
r e s t r i c t e d . We need t o g e t r i g h t down t h e r e and p a r t i c i p a t e .
So, H i l l a r y , I t h o u g h t I would ask maybe Ray Susaki*
t o g i v e us some idea o f what i t ' s l i k e t o be a s m a l l business
owner i n Hawaii under o u r h e a l t h care p l a n and j u s t l e t t h i n g s go
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from t h e r e . And i f a t any time you want t o g e t a q u e s t i o n i n or
c a r r y on a d i s c u s s i o n more e x t e n s i v e l y , please f e e l f r e e t o do
so.
So, Ray,
i f you c o u l d g e t us s t a r t e d t h i s
morning.
Q
Certainly.
I'm sure no employer, whether i n
Hawaii o r anywhere welcomes r i s i n g c o s t s such as i n s u r a n c e o r
h i g h e r expenses, r e n t s and so f o r t h , even w i t h m e d i c a l . But a
m e d i c a l program f o r t h e employees and t h e employer b e i n g
r e s p o n s i b l e I t h i n k i s one o f t h e t h i n g s t h a t goes w i t h the.
territory.
I t i s the r e s p o n s i b i l i t y of being i n business.
We
a l l have t h e c h o i c e and here i n American w i t h f r e e e n t e r p r i s e
i t ' s c o n s i d e r e d — t h i s i s an a d d i t i o n and a g o a l we a l l s e t t o
have our own b u s i n e s s . W e l l , p a r t o f t h a t comes a r e s p o n s i b i l i t y
t o a community, t o t h e employees e t c e t e r a . We don't want them
t a x e s , b u t these go towards improvements o f e d u c a t i o n , s e c u r i t y
of t h e c o u n t r y , o f our own community.
And my f a t h e r p u t i t i n a v e r y n i c e way:
although
we grumble about t a x e s and r i s i n g c o s t s such as m e d i c a l
i n s u r a n c e , i t i s a c t u a l l y n o t a burden, b u t a c t u a l l y , i n America,
l i v i n g here, a p r i v i l e g e .
Q
I n response t o what Mr. S u s a k i * j u s t s a i d , I
f e e l t h a t i t i s a p r i v i l e g e t o have h e a l t h care and a r i g h t .
And
w i t h every r i g h t , we a l s o have some r e s p o n s i b i l i t i e s as consumers
f o r those r i g h t s .
I t h i n k that, i t ' s r e a l l y i m p o r t a n t f o r
consumers t o be p r o p e r l y educated so t h e y can make a p p r o p r i a t e
h e a l t h care c h o i c e s f o r themselves.
So t h a t t h e y don't have a
h e a l t h c a r e system t e l l i n g them what t h e y need, t h e y have an
i n t e r n a l mechanism and I t h i n k t h a t i n o r d e r t o do t h a t , managed
care s h o u l d be p a r t o f t h e h e a l t h care system.
Managed care where. — and, a c t u a l l y , I t h i n k nurses
e x c e l i n managed care — b u t managed care where t h e r e i s a
pathway t o t r e a t i l l n e s s , a pathway t h a t i s d e c i d e d upon by t h e
consumer, by t h e p h y s i c i a n , by t h e h e a l t h care team. A pathway
t h a t w i l l g i v e people good outcome and reasonable outcome when
t h e y seek m e d i c a l a t t e n t i o n . And I t h i n k as consumer — i t i s
our r e s p o n s i b i l i t y as consumers t o t a k e some r e s p o n s i b i l i t y , and
i t i s t h e r e s p o n s i b i l i t y o f t h e h e a l t h care system t o p r o v i d e t h e
mechanisms, t h e managed care mechanisms f o r t h o s e k i n d s o f
d e c i s i o n s t o be a b l e t o happen.
MRS. CLINTON: Could I ask you, because I agree w i t h
t h a t v e r y s t r o n g l y about t h e need f o r g r e a t e r r e s p o n s i b i l i t y
w i t h i n t h e system from a l l p a r t s o f i t , b u t i n p a r t i c u l a r from
t h e consumers o f h e a l t h c a r e . What do you t h i n k e x i s t s w i t h i n
t h e Hawaiian system t o promote r e s p o n s i b i l i t y and what o t h e r
s p e c i f i c s u g g e s t i o n s would you have n a t i o n a l l y t o t r y t o i n c r e a s e
r e s p o n s i b i l i t y among consumers?
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�- 10 -
Q
One o f t h e t h i n g s i n t h e Hawaii system, I
t h i n k , t h e r e a r e s e v e r a l areas where I t h i n k t h a t t h e Hawaii
system p r o v i d e s t h e o p p o r t u n i t y f o r r e s p o n s i b i l i t y . One o f those
i s t h e c h o i c e o f p h y s i c i a n . I t h i n k t h a t b e i n g a b l e t o choose
t h e most c o s t - e f f e c t i v e — t h e p h y s i c i a n t h a t w i l l p r o v i d e t h e
p a t i e n t w i t h managed care c h o i c e s ; t h a t has t h e o p p o r t u n i t y t o
work w i t h t h e whole system; p h y s i c i a n s t h a t a r e w i l l i n g t o
i n c l u d e a l l h e a l t h care p r o f e s s i o n a l s t o decide what i s t h e b e s t
way f o r any t r e a t m e n t t o t a k e p l a c e . I a l s o t h i n k i t ' s v e r y
i m p o r t a n t f o r people t o choose p h y s i c i a n s t h a t i n c l u d e people i n
t h e i r own c a r e .
The o t h e r t h i n g t h a t I know t h a t i s a v a i l a b l e i n
many aspects o f s t a t e i n s u r a n c e here i s f o r people t o make
c h o i c e s about e x a c t l y what k i n d o f coverage t h e y a r e i n t e r e s t e d
i n h a v i n g . Do t h e y want more c a t a s t r o p h i c care coverage and l e s s
p r i m a r y care coverage? Do t h e y want more p r i m a r y care coverage?
Things t h a t a l l o w consumers t o s o r t o f s e t t h e i r own h e a l t h care
needs and g e t t h e k i n d o f i n s u r a n c e t h e y need t o meet t h o s e
p a r t i c u l a r needs.
Thank you.
GOVERNOR WAIHEE: H i l l a r y , Ann's a p r e t t y unique
i n d i v i d u a l , because n o t o n l y i s she a p r a c t i c i n g nurse r i g h t now
w i t h one o f our l e a d i n g m e d i c a l c e n t e r s , b u t she was a l s o a s m a l l
business owner t h a t had t o go o u t t h e r e and buy h e a l t h i n s u r a n c e
f o r h e r employees as w e l l . And, so, I t h o u g h t you m i g h t want t o
know t h a t —
MRS. CLINTON:
She's been on b o t h ends o f t h i s
stuff.
GOVERNOR WAIHEE:
—
b o t h ends o f t h a t e q u a t i o n .
Q
P r i o r t o g o i n g i n t o my own business i n 1972, I
worked f o r a l a r g e business concern, and we were covered by a
w o n d e r f u l h e a l t h c a r e program. And our f a m i l y was w e l l t a k e n
care o f and t h e c o s t t o me, p e r s o n a l l y , was m i n i m a l . So, t h e r e
was no q u e s t i o n when I s t a r t e d my business over 20 y e a r s ago t h a t
h e a l t h c a r e i s so i m p o r t a n t t h a t our employees would have t h i s
benefit.
I n f a c t , we s t a r t e d w i t h about f o u r employees and even
today we s t i l l have t h r e e o f them on our p a y r o l l .
And I b e l i e v e t h a t our h e a l t h care program had much
t o do w i t h t h e r e t e n t i o n o f these employees, i n c l u d i n g many
o t h e r s who a r e w o r k i n g w i t h us today. I t has h e l p e d our
employees i n t h e i r w e l l - b e i n g and good h e a l t h and, no doubt, o u r
company g a i n e d i n terms o f b e t t e r p r o d u c t i v i t y .
As f a r as c o s t s t o employees a r e concerned, we
r e a l l y have n o t charged them v e r y much. I n f a c t , we j u s t made a
t o k e n d e d u c t i o n about two years ago b u t w i t h a w a r n i n g t h a t i f
c o s t s keep on g o i n g up s u b s t a n t i a l l y , we may have t o make more
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deductions.
So, t h i s — ( i n a u d i b l e ) — c o s t i s a g r e a t concern
t o s m a l l businesses; I imagine w i t h b i g businesses, a l s o . And I
hope t o g e t h e r we can s o l v e t h i s dilemma i n t h e near f u t u r e .
MRS. CLINTON: George, c o u l d I ask you i f you have
any s p e c i f i c ideas based on your experience as t o how a n a t i o n a l
system w o r k i n g w i t h Hawaii and employers c o u l d b e t t e r c o n t r o l
costs? Are t h e r e t h i n g s t h a t you t h i n k should be done t h a t a r e
not b e i n g o r c o u l d be done b e t t e r ?
Q
I r e a l l y am n o t v e r y good so f a r as t h e
n a t i o n a l program i s concerned. You know, you hear a l l k i n d s o f
programs — t h e r e ' s a program I read about — medical s a v i n g s
account, I t h i n k you must have heard about t h a t , t o o — b u t t h e r e
i s so much i n v o l v e d t h a t would r e q u i r e a l o t o f study and
r e s e a r c h t o see i f i t makes sense.
MRS. CLINTON: Do you t h i n k i f you were p a r t o f a
l a r g e r group so t h a t i t wasn't your business n e g o t i a t i n g alone
f o r i n s u r a n c e b u t you were p a r t o f a v e r y l a r g e group t h a t c o u l d
be c o m p e t i t i v e , do you t h i n k t h a t would h e l p b r i n g your c o s t s
down?
Q
C e r t a i n l y i t would h e l p . Because every t i m e ,
you know, when t h e r e i s an i n c r e a s e i n medical h e a l t h c o s t s ,
t h e r e ' s always a l i n e i n t h e announcement t h a t t h e l a r g e r
companies w i l l n o t be a f f e c t e d , o n l y t h e s m a l l e r companies g o i n g
t o be p u t up so much.
MRS. CLINTON:
How many employees do you have,
George?
Q
Sixty.
MRS. CLINTON:
Q
Sixty?
Six-zero, s i x t y .
MRS. CLINTON:
Thank you.
GOVERNOR WAIHEE: Okay, May. Mae's w i t h Zippy. I
t h o u g h t I would mention t h a t as we g e t c l o s e r t o t h e c o f f e e break
t ime.
(Laughter.)
Q
Mrs. C l i n t o n , I d i d n ' t know what t o say as f a r
as b e i n g an employer because I don't own t h e — ( i n a u d i b l e ) —
b u t I can o n l y speak t o you as someone a f f e c t e d by h e a l t h c a r e .
I was t h i n k i n g Saturday about my f a t h e r who, r i g h t a f t e r t h e war,
he had h i s own b u s i n e s s .
He was a mechanic and he d i d n o t have
h e a l t h i n s u r a n c e . I don't t h i n k we a l l had i t i n t h o s e days. He
was j u s t t r y i n g t o earn a l i v i n g and he had d i a b e t e s .
He was n o t , I guess, a b l e t o go t o t h e d o c t o r i n
t i m e o r p r o b a b l y d i d n o t f o l l o w t h r o u g h w i t h t h e d o c t o r b u t what
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happened was t h a t he amputated h i s l e g . I was t h i n k i n g about
t h a t because I t h o u g h t i f t h i s was now t h e p r e v e n t i v e measures
t h a t c o u l d have been t a k e n would have d e f i n i t e l y changed t h e
q u a l i t y o f h i s l i f e as he g o t o l d e r . Then I t h o u g h t o f myself
because I d i d n ' t know t h a t i f you had a p r e - e x i s t a n t c o n d i t i o n i n
t h e mainland you c o u l d be t u r n e d down f o r h e a l t h i n s u r a n c e .
When I came t o Zippy's, I have a c h r o n i c c o n d i t i o n
t h a t i f t h i s was somewhere e l s e I c o u l d have been t u r n e d down f o r
i n s u r a n c e and t h e n i t would have been a burden on me because my
m e d i c a t i o n c o s t s and my ongoing c o s t s , you know, would have been
r e a l l y hard f o r me.
T h i s coming t o g e t h e r w i t h everybody e l s e has r e a l l y
helped me a p p r e c i a t e what we have here i n Hawaii.
I also s t i l l
s t r o n g l y b e l i e v e , though, t h a t as a consumer we have a l o t o f
r e s p o n s i b i l i t y i n p r e v e n t i o n . You know, p r e v e n t i o n o f g e t t i n g
s i c k , p r e v e n t i o n o f k i n d o f h e l p i n g keep t h e c o s t down, you know.
And I t h i n k t h a t ' s what we need t o do as employees.
MRS. CLINTON: Mae, I'm r e a l l y g l a d you mentioned
t h e p r e - e x i s t i n g c o n d i t i o n because I ' v e l o s t t r a c k o f how many
s t a t e s I ' v e v i s i t e d and how many people I ' v e t a l k e d w i t h , b u t
t h a t i s t h e s i n g l e c o m p l a i n t I hear everywhere. I t doesn't
m a t t e r what a t t i t u d e people have o r who t h e y a r e , t h e f a c t t h a t ,
i n t h e mainland, as you p o i n t o u t , t h e r e a r e many people i n your
c o n d i t i o n who e i t h e r a r e u n i n s u r a b l e o r whose i n s u r a n c e i s so
c o s t l y t h e y might as w e l l be u n i n s u r a b l e .
And i t i s a p a r t i c u l a r l y d i f f i c u l t s i t u a t i o n f o r
people who want t o change j o b s on t h e mainland b u t c a n ' t because
i f t h e y have i n s u r a n c e t h e y would have t o g i v e i t up i n o r d e r t o
go t o a b e t t e r j o b o p p o r t u n i t y t o maybe make more money, b u t i t
would be a n e t l o s s f o r them. So, t h i s whole i s s u e o f p r e e x i s t i n g c o n d i t i o n s , which I don't hear about i n Hawaii because
you have t a k e n care o f t h a t , i s a major problem i n t h e r e s t o f
the country.
Q
I t h i n k t h a t , w e l l , as Mae and I were
d i s c u s s i n g t h i s , I r e c a l l e d t h a t i n M i s s o u r i i n t h e Midwest when
I was growing up, we d i d n ' t r e a l l y — we d i d n ' t go t o t h e d o c t o r
v e r y o f t e n ; we o n l y went when we had t o go. And I r e c a l l an
e x p e r i e n c e where I had i n j u r e d my f i n g e r and I was up a l l n i g h t
i n e x c r u c i a t i n g p a i n . So, when t h e same t h i n g happened t o my
son, Matthew, I d i d n ' t t h i n k t w i c e about i t .
I t wasn't even — I
mean, w i t h i n a few minutes we were a l r e a d y on o u r way t o t h e
d o c t o r and we had i t t a k e n care o f .
And, a g a i n , my son, John, when he came down w i t h
pneumonia we caught t h a t v e r y e a r l y so i t was an inconvenience
r a t h e r t h a n a major problem f o r my f a m i l y . So, I t h i n k t h a t we
t a k e t h e system f o r g r a n t e d and I t h i n k t h a t ' s an i m p o r t a n t p a r t
because o f t h e c o o p e r a t i o n t h a t you mentioned. Governor. We
don't have t o be concerned about t h e paperwork o r who's g o i n g t o
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pay.
We don't g e t e m b r o i l e d i n a l l o f t h a t . The system works
f o r us and we r e a l l y l o v e i t . And, now t h a t I'm i n v o l v e d w i t h
t h i s I hope I can go back tomorrow and a g a i n t a k e i t f o r g r a n t e d .
(Laughter.)
MRS. CLINTON: One o f t h e p o i n t s we were t a l k i n g
about e a r l i e r a t t h e f l o r i s t was t h a t i n H a w a i i , I been
t o l d — and Jack you p r o b a b l y know t h i s s t a t i s t i c — b u t a c t u a l l y
people i n Hawaii may even see a d o c t o r o r go t o a c l i n i c more
f r e q u e n t l y t h a n people i n t h e mainland and t h e r e f o r e g e t problems
t a k e n care o f sooner a t l e s s c o s t . Because what Mae was t a l k i n g
about w i t h her f a t h e r and d i a b e t e s i s s t i l l a l l t o o common i n
p l a c e s where people e i t h e r c a n ' t a f f o r d t o , o r don't t h i n k t h e y
can, o r t h e y c a n ' t keep up w i t h t h e m e d i c a t i o n , o r t h e y don't
have t h e k i n d o f access t o the. system. And i t ' s always s t r u c k me
t h a t i t ' s a v e r y backwards way t o go about p r o v i d i n g h e a l t h c a r e ,
t o w a i t u n t i l people g e t r e a l l y s i c k which t h e n c o s t s us more i n
human c o s t s and i n d o l l a r c o s t s . So your example about t h e
d i f f e r e n c e between you and — your experience and your son's i s
j u s t r i g h t on t a r g e t .
GOVERNOR WAIHEE: Why don't we d e v i a t e a l i t t l e b i t
a g a i n . W e ' l l go t o R u s s e l l . We've been t a l k i n g about t h i s
morning so much, R u s s e l l , I t h o u g h t you ought t o t e l l us a l i t t l e
b i t about i t .
Q
We're a family-owned business — s m a l l
b u s i n e s s , and I t h i n k as most s m a l l businesses a r e o r g a n i z e d ,
workers who are n o t members o f t h e immediate f a m i l y a r e almost an
e x t e n s i o n o f t h e f a m i l y i n a s m a l l business.
And so i t ' s a g r e a t
concern o f ours t o p r o v i d e q u a l i t y h e a l t h b e n e f i t s t o our
employees.
I t h i n k one o f t h e s t r e n g t h s o f t h e Hawaii h e a l t h
p l a n t h a t has made i t a f f o r d a b l e f o r Hawaiian employees i s t h a t
t h e r e ' s a reasonable amount o f c o m p e t i t i o n by t h e h e a l t h care
p r o v i d e r s . And t h e l a s t t h i n g I would l i k e t o see, i n a l l due
r e s p e c t , Governor, i s t o have t h e s t a t e government t o t a l l y t a k e
over t h a t and r u n t h e program. I t h i n k h a v i n g a good i n p u t from
the p r i v a t e s e c t o r i s v e r y i m p o r t a n t i n keeping c o s t s down and
q u a l i t y s e r v i c e up.
spoken.
GOVERNOR WAIHEE: Okay, I t h o u g h t t h a t was v e r y w e l l
Now we w i l l go t o R i c h a r d , a man w i t h t h e bank.
Q
I ' d l i k e t o t a l k a l i t t l e about employer
mandate and how t h e employers views t h a t and c e r t a i n l y I come
from a p e r s p e c t i v e o f a l a r g e employer w i t h about 4,000 employees
i n t h e S t a t e o f Hawaii, b u t I a l s o g e t t o d e a l from t h e
s t a n d p o i n t o f a s m a l l employer i n t h a t I've g o t about 800
employees i n 17 d i f f e r e n t c o u n t r i e s and two d i f f e r e n t s t a t e s .
And I can t e l l you from a s m a l l employer s t a n d p o i n t which you've
heard from b e f o r e , b u t on t h e U.S. mainland i t ' s t e r r i b l e t o t r y
t o g e t h e a l t h i n s u r a n c e i n New York C i t y . I t ' s c o s t l y , i t c o s t s
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about t h r e e t i m e s as much as i t c o s t s here i f you can g e t a
c a r r i e r who wants t o do i t . I n A r i z o n a i t ' s a l i t t l e b e t t e r , i t
c o s t s about t w i c e as much and t h e r e ' s p l e n t y o f people who w i l l
do i t . And c e r t a i n l y t h e people who do i t i n some o f these
p l a c e s have had f a i r amount o f f i n a n c i a l problems themselves, so
i t ' s always a l i t t l e scary whether you're p r o m i s i n g t h e employee
you're g o i n g t o g i v e them some and doesn't come t r u e .
So I guess I come a t i t from a couple o f d i f f e r e n t
handles.
A l s o i n t h e c o u n t r i e s t h a t we do business i n , many o f
them p r o v i d e h e a l t h care s e r v i c e s f r e e t o everybody. But I t e l l
you i n about, l e t ' s see, 12 o f those c o u n t r i e s we buy a
supplemental p o l i c y f o r them so t h e y can come t o Hawaii t o g e t
h e a l t h care coverage. And i t ' s t h e b i g g e s t t h i n g on t h e i r agenda
t o have, much more t h a n an i n c r e a s e i n pay.
The P r e p a i d H e a l t h Care A c t , when i t came i n , I
t h i n k from our s t a n d p o i n t as a l o c a l l a r g e employer, p r o b a b l y
d i d n ' t have a s i g n i f i c a n t event because we were p r o b a b l y a l l
ready — we were a l r e a d y c o v e r i n g employees. I t h i n k t h e
s i g n i f i c a n c e came i n f o r us l a t e r — p a s t 7 4 , p r o b a b l y i n t o t h e
e a r l y 80s when t h e economy was s u f f e r i n g v e r y h i g h i n f l a t i o n
r a t e s , 2 1 , 22 p e r c e n t as w e l l as h e a l t h care i n excess o f t h a t .
And we saw many employers and c e r t a i n l y c o n s i d e r e d o u r s e l v e s what
we c o u l d do t o reduce those c o s t s o r leave t h a t b e n e f i t b e h i n d .
C e r t a i n l y w i t h t h e P r e p a i d H e a l t h Care A c t t h a t r e a l l y was n o t an
o p t i o n f o r us. We had t o s t a y ; we had t o f i g u r e how we c o u l d
manage those c o s t s and s t i l l p r o v i d e t h a t b e n e f i t . And yes, we
t o o k some o p t i o n s o f a l l o c a t i n g some t o t h e employees who had
r e a l l y n o t i n c u r r e d much o f t h a t expense themselves.
And t o our
d e l i g h t , most o f t h e employees I t h i n k r e a l l y u n d e r s t o o d why we
had t o do i t , and I t h i n k became much more educated as t o what
h e a l t h care c o s t s them.
x
x
And p r e s e n t l y our employees c a r r y about 25 p e r c e n t
of t h e premium c o s t s f o r h e a l t h c a r e . Any s u g g e s t i o n s f o r
something on t h e mainland, I t h i n k i t would be advantageous t o
have t h e k i n d o f programs t h a t we have here f o r t h e U.S.
mainland.
I would encourage you t o have t h e k i n d o f f l e x i b i l i t y
t h a t ' s b u i l t i n t o these programs. Our employees do have c h o i c e s
of HMOs o r f e e - f o r - s e r v i c e . We a r e f o r t u n a t e i n t h i s s t a t e i n
t h a t we a r e l a r g e enough so t h a t we can e f f e c t i v e l y s e l f - i n s u r e
and t h e P r e p a i d H e a l t h Care A c t a l l o w s t h a t t o be done. And we
t e l l o u r employees t h a t t h a t ' s what we're d o i n g . And when we
have good success, when t h e y have low c l a i m s , when t h e y t h i n k
about t h e i r h e a l t h care s e r v i c e s — ( i n a u d i b l e ) — f o r t u n a t e i n
t h i s s t a t e i n t h a t we're l a r g e enough so t h a t we can e f f e c t i v e l y
s e l f - i n s u r e , and t h e P r e p a i d H e a l t h Care A c t a l l o w s t h a t t o be
done. And we t e l l our employees t h a t t h a t ' s what we're d o i n g .
And when we have good success, when t h e y have low c l a i m s , when
t h e y t h i n k about t h e i r h e a l t h care s e r v i c e s , t h a t reduces o u r
c o s t s . And we've had two h o l i d a y s now, b o t h o f them two months
a p i e c e , where t h e employee and t h e employer have had t o pay no
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h e a l t h care c o s t s o r no premium f o r those months. I f t h e y keep
i t up, we're p r o b a b l y g o i n g t o have another one i n 1994.
So I t h i n k f l e x i b i l i t y i s a b i g key i n any program.
I t s h o u l d n ' t be so r i g i d t h a t t h e r e i s n ' t a way —
MRS. CLINTON: I s t h e r e a p a r t i c u l a r p l a n o r
p r o v i d e r t h a t t h e y have t o belong t o , o r how much c h o i c e can you
g i v e them as a s e l f - e m p l o y e d company?
Q
We g i v e them f r e e c h o i c e between HMO programs
or f e e - f o r - s e r v i c e . We can r e a l l y o n l y s e l f - i n s u r e t h e f e e - f o r s e r v i c e . They make t h e i r c h o i c e . I f t h e y l i k e g o i n g t o t h e i r
own p h y s i c i a n , f i n e . And t h e y can p a r t i c i p a t e i n t h e s e l f i n s u r e d p o o l and p a r t i c i p a t e i n any premium h o l i d a y s t h a t may
come about.
I f t h a t p o o l g e t s t o o s m a l l , o b v i o u s l y , t h e n we
would have t o s t o p s e l f - i n s u r a n c e . But t h a t would be t h e c h o i c e
t h a t t h e employees a r e making. We do n o t t r y and i n f l u e n c e them
one way o r t h e o t h e r .
We c e r t a i n l y a d v e r t i s e , and t h e c a r r i e r s we have
a c t i v e l y s o l i c i t t h e employee group as t o programs and what
advantages they've g o t and so on. But we l e t t h a t t a k e i t ' s
course.
MRS. CLINTON: What do you t h i n k has been t h e
b i g g e s t reason f o r your success i n r e d u c i n g costs?
Q
The a t t e n t i o n — as a l a r g e employer, we've g o t
the l u x u r y o f h a v i n g people t h a t can devote a t t e n t i o n t o how you
reduce c o s t s . And we've a l s o had t h e l u x u r y o f b e i n g a b l e t o
c r e a t e w e l l n e s s programs, smoking programs, a l c o h o l i s m programs,
d r u g - f r e e programs. And so we've u s u a l l y t a k e n those s a v i n g s and
plowed them back i n t o what we f e l t would be ways o f r e d u c i n g i t .
But a l s o , t h e employee has a good u n d e r s t a n d i n g o f where we're
i n c u r r i n g our costs.
And so i f t o o many people a r e g o i n g t o t h e emergency
c e n t e r s , we don't go o u t and, say, t o o many people a r e g o i n g t o
the emergency c e n t e r s . We're s a y i n g : do you know what i t c o s t s
t o go t o an emergency c e n t e r ? Do you know t h a t you c o u l d go t o
someplace e l s e ? Have you c o n s i d e r e d something e l s e ? They a l l
understand how much an AIDS p a t i e n t c o s t s . They a l l understand
how much cancer p a t i e n t s c o s t s . A l l t h a t may i n f l u e n c e h e a l t h i e r
lifestyles.
That's an i n t a n g i b l e — I mean, I c a n ' t q u a n t i f y i t .
But we do d e f i n i t e l y f e e l as though i t ' s come back t o us as a
positive.
GOVERNOR WAIHEE: I n a d d i t i o n t o b e i n g a banker,
R i c h a r d was a l s o t h e c h a i r o f t h e Governor's Blue Ribbon Panel on
the F u t u r e o f H e a l t h Care i n H a w a i i . And as we d i s c u s s e d t h i s
morning, H i l l a r y , one o f t h e problems — one o f t h e problems w i t h
the Hawaii P r e p a i d H e a l t h Care A c t i s t h a t i t i s f r o z e n i n t h e
1974 mode. Our a c t e x i s t s because we a r e t h e o n l y s t a t e i n t h e
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n a t i o n t h a t was a l l o w e d a c o n g r e s s i o n a l exemption t o t h e ERISA
l e g i s l a t i o n . And one o f t h e c o n d i t i o n s o f t h a t was t h a t we would
not change our p l a n from t h e o r i g i n a l p r o p o s a l i n 1974.
Now, o b v i o u s l y , s i n c e t h a t t i m e we have gained a l o t
of e x p e r i e n c e and have d i s c o v e r e d t h i n g s t h a t experience and
p r o b a b l y have — and have d i s c o v e r e d t h i n g s t h a t we might want t o
improve. So I t h o u g h t I ' d ask R i c h a r d as t h e c h a i r o f t h e
Governor's Blue Ribbon Panel i f he had some t h o u g h t s about how we
c o u l d improve t h e Hawaii h e a l t h care p l a n i f we had t h e a b i l i t y
t o r e f o r m our l e g i s l a t i o n .
That's s o r t o f known as a curve and a s l i d e r .
(Laughter.)
Q
W e l l , I d i d b r i n g t h e Blue Ribbon Panel's
report.
GOVERNOR WAIHEE:
I t j u s t so happens —
(laughter)
Q
J u s t so happen t o have t h a t . But I t h i n k i t
would be n i c e — and one o f our recommendations was t o be a b l e t o
reopen t h e P r e p a i d H e a l t h Care A c t . I t h i n k t h a t i t ' s something
t h a t i s 20 years o l d . N o t h i n g can j u s t s t a y c a s t i n c o n c r e t e
f o r e v e r . And we need t o reopen i t , t a k e a l o o k and see what a
b a s i c package i s a g a i n . There have been some a d d i t i o n s t o t h e
b a s i c package, which, q u i t e c a n d i d l y a r e v e r y good, and, q u i t e
c a n d i d l y , b e n e f i t r e l a t i v e few.
And I t h i n k t h a t t h e r e has t o be some mechanism
where we can c o n s t a n t l y go back and r e v i e w what t h a t b a s i c
package i s — w i t h a g o a l , r e a l l y , o f h o l d i n g t h e c o s t s i d e down
because everybody's concern w i l l always be what i t c o s t s t o
p r o v i d e t h i s b e n e f i t . And I t h i n k we have t o s t a y t h e r e and
t h i n k what t r u l y i s a b a s i c package i n 1993 i s n o t n e c e s s a r i l y
what i t was back i n 1994.
That process w i l l c e r t a i n l y h e l p us p r i o r i t i z e what
t h e b a s i c package i s . I t w i l l a l s o a l l o w us t o focus on i f t h e r e
are a d d i t i o n a l t h i n g s t h a t people d e s i r e , how do you a l l o w t h o s e
o u t s i d e o f a b a s i c package. I f t h e y want t o pay f o r them, f i n e ,
a l l o w them t o pay f o r them. And t h e n t h r o u g h t h e c o l l e c t i v e
b a r g a i n i n g process o r t h r o u g h t h e employer process o r whatever,
t h e y d e c i d e t h a t i t ' s p i c k e d up as an employer o r a u n i o n i s s u e ,
f i n e , l e t t h a t t a k e i t s course, b u t n o t damage t h e b a s i c package
which c o u l d u l t i m a t e l y damage our good access program.
I t h i n k we a l l agree — and t h e Blue Ribbon Panel
was v e r y adamant about i t — access i s t h e most i m p o r t a n t t h i n g
t h a t we've g o t i n t h i s s t a t e . The P r e p a i d H e a l t h Care A c t has
i n f l u e n c e d i t and d r i v e n i t f o r 20 y e a r s , b u t i t s c o s t c o u l d
d i s m a n t l e i t i f we a r e n ' t d i l i g e n t i n d o i n g t h a t .
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MRS. CLINTON: I wanted t o ask something, and maybe
Jack c o u l d answer as w e l l , because when you were t a l k i n g . Jack,
you s a i d t h a t you have t r i e d t o p r o v i d e access w i t h o u t copay and
d e d u c t i b l e b a r r i e r s . What i s t h e r o l e , i f you c o u l d c l a r i f y f o r
me, o f copayments and d e d u c t i b l e s w i t h i n t h e average p o l i c y i n
Hawaii?
Q
Okay, w e l l , we have — our r a t e s o f copayment,
we have c a l c u l a t e d some comparison w i t h o t h e r s t a t e s . And we do
have a lower o u t - o f - p o c k e t and copay t h a n our neighbor s t a t e s
anywhere on t h e West Coast — i n f a c t , much g r e a t e r — a
d i f f e r e n c e i n c r e a s e i n t h e East Coast when you l o o k a t copays and
out o f pocket.
But what's r e a l s i g n i f i c a n t about Hawaii t h a t we
t a k e f o r g r a n t e d i s t h a t our p o l i c i e s t o our employees and
employers don't come w i t h a $200, $300, or $500 d e d u c t i b l e up
f r o n t t h a t says you pay t h i s much f i r s t and t h e n we s t a r t
c o v e r i n g you.
That u p - f r o n t k i n d of major d e d u c t i b l e , which i s
v e r y commonplace — i n f a c t , t h e normal on t h e mainland — i s
what d i s c o u r a g e s women from g o i n g f o r p r e n a t a l care and f o r
immunizing t h e i r k i d s and f o r g o i n g i n t o t r e a t t h a t h y p e r t e n s i o n
t h a t w i l l reduce t h e r i s k o f s t r o k e , e t c e t e r a .
Hawaii has made i t t h e norm t o g i v e f i r s t d o l l a r
coverage and l e t people, as soon as t h e y ' r e covered, t h e y can
immediately go g e t c a r e . I f t h e y choose t h e t r a d i t i o n a l f e e - f o r s e r v i c e p l a n , t h e y w i l l pay a 20 p e r c e n t copayment f o r each v i s i t
w i t h a c e r t a i n cap on those c o s t s .
MRS.
CLINTON:
Q
Marvin H a l l can p r o b a b l y g i v e us a b e t t e r
Q
Twenty p e r c e n t , i t says r i g h t t h e r e .
Q
—
MRS.
CLINTON:
Q
—
Q
About $1,000 a n n u a l l y .
average
Do you know what t h e average cap i s ?
—
—
Annually?
a n n u a l l y per
person.
MRS. CLINTON: So t h e a d d i t i o n a l o u t - o f - p o c k e t c o s t s
added onto whatever t h e employee c o n t r i b u t i o n i s about $1,000 on
average?
Q
No, n o t average, b u t t h a t would be t h e maximum
t h a t somebody would pay on t h e average. So f o r most p e o p l e t h e y
have l i t t l e t h a t would n o t be covered.
These might be —
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MRS. CLINTON: T h i s i s a r e a l l y i m p o r t a n t p o i n t . I t
may sound k i n d o f obscure t o some people, b u t t h i s i s a
s i g n i f i c a n t i s s u e because, i n making c o s t p r o j e c t i o n s about what
a n a t i o n a l h e a l t h care p l a n would c o s t t h e c o u n t r y , t h e r e i s a
r e a l s p l i t o f o p i n i o n among those who c o s t o u t h e a l t h care as t o
whether you have t o have d e d u c t i b l e s i n o r d e r t o save money and
d i s c o u r a g e unnecessary u t i l i z a t i o n , because i n t h e absence o f
d e d u c t i b l e s , t h e t h e o r y i s you w i l l d r i v e up c o s t s , because you
w i l l i n c r e a s e u t i l i z a t i o n f o r t h e v e r y reason t h a t Jack was
t a l k i n g about how people w i l l a c t u a l l y go t o t h e d o c t o r t o g e t
t h e i r c a r e . I t ' s v e r y i m p o r t a n t t h a t we know as much as we can
about t h e experience i n Hawaii because, i f your e x p e r i e n c e has
been t h a t w i t h f i r s t d o l l a r coverage so t h a t you have no f r o n t
end d e d u c t i b l e t h a t serves as a b a r r i e r t o access, you've n o t had
t h a t k i n d o f increased cost, t h a t increase u t i l i z a t i o n but i t
s o r t o f p l a y s i t s e l f o u t i n t h e whole system as b e i n g a b l e t o
prevent g r e a t e r cost.
Q
I t h i n k , Mrs. C l i n t o n , we would say t h a t i n t h e
d e s i g n o f — you know, i n recommending t h e f u t u r e , t h a t we would
c e r t a i n l y take a l l b a r r i e r s o f f c l i n i c a l preventive services.
We'd p u t no b a r r i e r s o r c o s t b a r r i e r s on those s e r v i c e s a t a l l
because those a r e t h i n g s we want people — we want t o b r i n g them
in.
We almost need t o p u t i n c e n t i v e s t o g e t them i n t h e r e
somehow. And t h e n we p r o b a b l y need t o l o o k a t a c e r t a i n number
of o u t p a t i e n t v i s i t s , a few a t l e a s t , t h a t would g i v e people t h e
chance t o go t o t h e i r p h y s i c i a n o r p r o v i d e r and make sure t h a t
t h e y ' r e w e l l each year b e f o r e we s t a r t t h r o w i n g copayments i n t h e
way.
Because, f r a n k l y , we want people t o g e t care a t t h e
d o c t o r ' s o f f i c e , n o t i n t h e emergency room and n o t i n t h e
hospital.
So we've g o t t o open t h e door f o r t h a t . There may be
some p l a c e where we have t o b r i n g i n t o p l a y f o r people t h a t
choose more expensive programs, copays.
Q
W e l l , I t h i n k i t ' s been s t a t e d by Jack, a
r e a l l y b a s i c f o u n d a t i o n o f t h e h e a l t h c a r e , b o t h coverage and
system i n Hawaii i s t o cover f i r s t d o l l a r coverage and
w i t h o u t — w i t h no c o i n s u r a n c e , even on many o f t h e p r e v e n t i v e
s e r v i c e s . So I t h i n k as some o f t h e p r e v i o u s speakers have
commented, people seek o u t care e a r l y on, which we would c o n s i d e r
t o be p a r t o f p r e v e n t i v e . I t ' s n o t j u s t immunizations and t h a t
t y p e o f t h i n g , i t a l s o goes t o seeking care e a r l y i n i l l n e s s .
We have n o t found t h a t coverage o f these t h i n g s has
overwhelmed t h e c o s t o r v i s i t s ; p h y s i c i a n v i s i t s i n Hawaii i s
something near t h e n a t i o n a l average. So we're c e r t a i n l y n o t
t r a d i n g o f f one k i n d o f c o s t f o r another.
So c e r t a i n l y i t has b u i l t a system o f people s e e k i n g
c a r e , l o w - c o s t . There a r e e s s e n t i a l l y no d e d u c t i b l e programs i n
Hawaii i n t h e i n s u r a n c e market. Only a v e r y l i m i t e d number o f
people have any k i n d o f a d e d u c t i b l e program.
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MRS. CLINTON: Could I j u s t be sure I understand,
because I have read t h a t t h e r e was a h i g h e r t h a n t h e n a t i o n a l
average p h y s i c i a n v i s i t p e r p a t i e n t i n Hawaii.
But your
i n f o r m a t i o n i s t h a t ' s n o t accurate?
Q
No, I don't know where anyone e l s e g e t s t h e
numbers, b u t we're aware o f t h e p h y s i c i a n v i s i t s t h r o u g h o u t t h e
U n i t e d S t a t e s . And Hawaii numbers f o r b o t h f e e - f o r - s e r v i c e
programs and f o r HMO programs a r e s i m i l a r t o anyplace i n t h e
United States.
Q
That's i n t e r e s t i n g .
MRS. CLINTON:
Yes.
I t was no my
—
Q
What we do see, though, i s t h e p r o p o r t i o n o f
o u t p a t i e n t c a r e , t h e d o l l a r s g o i n g t o o u t p a t i e n t and n o n h o s p i t a l
care i s g r e a t e r i n Hawaii.
And so t h e t o t a l p r o p o r t i o n o f care
ends up g r e a t e r i n t h e o u t p a t i e n t s i d e .
Q
Yes, I t h i n k Jack has a r t i c u l a t e d t h e i s s u e
very w e l l .
I t e n d t o agree t h a t t h e l e s s o f a b a r r i e r we have
f o r seeking m e d i c a l c a r e , t h e b e t t e r o f f we a r e . I know t h a t
many o f t h e businesses a r e i n t e r e s t i n g i n i n c r e a s e d c l i n i c v i s i t
fees as a m a t t e r o f u t i l i z a t i o n c o n t r o l .
I p e r s o n a l l y worry t h e
most about t h e f o l k s who would have t h e most d i f f i c u l t t i m e
p a y i n g those f e e s . They would a l s o be t h e ones t h a t would be t h e
most l i k e l y t o g e t i n t o t r o u b l e f o r u n t r e a t e d o r i n a d e q u a t e l y
t r e a t e d i l l n e s s u n t i l t h e y w a i t e d t o a p o i n t a t which t h e y were
f o r c e d t o seek m e d i c a l c a r e .
Our experience i n K a i s e r i s , h a v i n g j u s t looked a t
t h e s t a t i s t i c s r e c e n t l y — i n f a c t , i n Hawaii — and why t h i s i s
d i f f e r e n t f o r K a i s e r i n Hawaii, our o u t p a t i e n t v i s i t s a r e t h e
h i g h e s t o f any K a i s e r i n t h e c o u n t r y p e r year.
I tend t o l i k e
Jack's e x p l a n a t i o n t h a t i t ' s because we do more as o u t p a t i e n t s ;
a l t h o u g h , across t h e c o u n t r y , K a i s e r i s a v e r y e f f e c t i v e
o u t p a t i e n t u t i l i z a t i o n program.,
But I share Jack's concern t h a t s i g n i f i c a n t copays
up f r o n t , s i g n i f i c a n t b a r r i e r s t o c a r e , r e a l l y a r e g o i n g t o h u r t
t h e people t h a t can a f f o r d i t t h e l e a s t and need t h e care t h e
most.
Q
I would l i k e t o mention, I was born and r a i s e d
here.
And I a l s o went t o s c h o o l i n Albuquerque, New Mexico. And
when I was l i v i n g here, I k i n d o f t o o k f o r g r a n t e d o u r h e a l t h
i n s u r a n c e . And when I went away t o s c h o o l , my husband g o t a
h e a l t h p l a n r i g h t away, and I n o t i c e d t h e expense (unmatched)
my husband g o t a h e a l t h p l a n r i g h t away and I n o t i c e d , you know,
t h e expense o f i t .
But what I r e a l l y n o t i c e d i s we had t o f i l e a l l our
i n s u r a n c e forms — t h a t wasn't t h e b i g i s s u e — t h e b i g i s s u e was
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t h a t we had t o pay our p r o v i d e r f i r s t and t h e n t h e i n s u r a n c e
company would pay us i n r e t u r n . So, we would have t o f i l e our
i n s u r a n c e and pay t h e p r o v i d e r and t h e n a l s o meet a h i g h
d e d u c t i b l e . T h i s was r e a l t a x i n g on our f a m i l y income and when
he came home, I immediately t h o u g h t , w e l l , w e ' l l have h e a l t h
i n s u r a n c e and I was r e a l pleased.
But i t ' s j u s t a way o f l i f e i n
Hawaii t h a t we t a k e f o r g r a n t e d so o f t e n .
Another experience I would l i k e t o share w i t h you i s
I have a s m a l l son who broke h i s arm about s i x weeks ago.
And,
my husband has v e r y good h e a l t h coverage and I t o o k him t o t h e
d o c t o r — excuse me, I t o o k him t o t h e h o s p i t a l because i t was a
compound f r a c t u r e — I d i d n ' t h e s i t a t e . I j u s t t o o k him i n r i g h t
away and s a i d , w e l l , w e ' l l be covered.
I d i d know t h a t t h e p l a n
d i d cover a c c i d e n t s w i t h i n 24 hours.
So, I t o o k him i n r i g h t
away and t h e a c c i d e n t was p a i d f o r , t h e s e r v i c e s were p a i d f o r a t
100 p e r c e n t .
Now, i f we d i d n ' t have t h a t t y p e o f coverage, i f we
had t h e coverage on t h e mainland, we would p r o b a b l y be p a y i n g f o r
t h a t today.
I t was something t h a t I t o o o f t e n t a k e f o r g r a n t e d .
So, I t h i n k i t ' s a v e r y good system. I would l i k e
t o see i t happen t h r o u g h o u t t h e U n i t e d S t a t e s . Thank you.
Q
Thank you, Governor and Mrs. C l i n t o n .
I'm
t h r i l l e d , e l a t e d t o have you here t h i s morning t o f o l l o w our —
t o t a k e a l o o k a t our h e a l t h care system. I t h i n k we have a
w o n d e r f u l system. I hate t o brag about i t , b u t I have t o p u t a
p l u g i n f o r t h e p h y s i c i a n s o f Hawaii.
I t h i n k we p r a c t i c e
e x c e l l e n t medicine here. And n o t o n l y do we p r a c t i c e e x c e l l e n t
medicine b u t our c o s t containment and e v e r y t h i n g l i k e t h i s i s
r e a l l y i n place.
We have t h e l o w e s t i n s u r a n c e premiums here and we
have t h e b e s t coverage I t h i n k . — t h e r e s t o f t h e n a t i o n c o u l d
f o l l o w our example v e r y e a s i l y . And I t h i n k , however, t h e i r
d o c t o r s have t o g i v e a l i t t l e because our d o c t o r s don't r e a l l y
g e t p a i d what we r e a l l y f e e l we deserve.
We g e t 80 p e r c e n t o f
our e l i g i b l e charges, whatever t h e y want t o s e t f o r us, t h e n t h e
p a t i e n t pays t h e 20 p e r c e n t . So, we t a k e a b e a t i n g . I ' d be
l y i n g i f I s a i d we g e t p a i d what we t h i n k we deserve.
We d o n ' t .
But t h e n you have t o g i v e up something t o g e t
something b e t t e r . I t s t i l l beats t h e s i n g l e - p a y o r system.
We
g e t freedom o f c h o i c e o f p h y s i c i a n s , freedom o f c h o i c e o f
i n s u r a n c e p l a n s t h a t you want. I f you want a d e l u x e p l a n , you
pay a l i t t l e b i t more f o r i t . I f you want a bare-bones, you pay
a l o t l e s s . So, you r e a l l y g e t what you want, and I t h i n k t h a t
t h a t ' s America. Freedom o f c h o i c e , and I hope t h a t you w i l l l o o k
i n t o a l l these p a r t s .
tremendously
I'm a p e d i a t r i c i a n and I f e e l p r e v e n t i v e medicine i s
i m p o r t a n t . For every d o l l a r t h a t you spend on
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p r e v e n t i v e m e d i c i n e , you're s a v i n g $10 i n t h e f u t u r e , because
h e a l t h y c h i l d r e n become h e a l t h a d u l t s someday. So, i f we t a k e
care o f them young, you don't have a l l t h e h y p e r t e n s i o n and a l l
the t e r m i n a l i l l n e s s e s , t h a t ' s where t h e b i g money comes i n .
The l a s t two weeks o f l i f e i s p r o b a b l y — t h a t ' s
where you spend most o f your money — n o t i n p r e v e n t i o n . So, I
hope w e ' l l c o n t i n u e t o have t h e w o n d e r f u l programs t h a t you have
g i v e n t o c h i l d r e n — EPSDT, t h e h e a l t h y s t a r t . And you're r e a l l y
v e r y wise f o r spending money t h e r e because you're g o i n g t o save a
l o t o f money i n t h e f u t u r e .
As a p e d i a t r i c i a n I f e e l I would l i k e more t i m e t o
p r a c t i c e medicine l i k e t h e good o l d days b e f o r e a l l t h i s
government r e g u l a t i o n s come i n . I want t o g e t r i d o f some o f
t h i s paperwork.
We have t o n s o f paperwork t h a t I would r a t h e r
spend t i m e p r a c t i c i n g medicine t h a n f i l l i n g o u t forms t h a t a r e so
a g g r a v a t i n g . You s i t t h e r e , and n o t o n l y i s i t expensive i n my
t i m e , b u t i t c o s t s a l o t o f money f o r these forms t h a t p a t i e n t s
r e a l l y g l a n c e a t , says, t h e y read i t , t h e y s i g n t h e i r i n f o r m e d
consent and throw i t away.
And I j u s t had t o g e t a whole b a t c h because I ' v e
been u s i n g some o f t h e s t a t e h e a l t h department forms, and t h e y ' r e
r u n n i n g o u t so we have t o o r d e r our own. Saw t h i s l i t t l e , t i n y
l i t t l e phone number a t t h e bottom o f t h e p r i n t t h a t says you can
have t h e s e p r i n t e d f o r a p r i c e . Saw what t h e p r i c e —
1,000
forms c o s t me $400 f o r paper t h a t t h e p a t i e n t ' s g o i n g t o t h r o w
away. And t h e y don't even l o o k a t i t .
So, she s a i d w e l l i f you buy 10,000 i t w i l l be much
cheaper.
I don't have 10,000 p a t i e n t s .
(Laughter.) I s a i d a l l
I want i s 2,000 o f them — $800. T h i s i s a f a c t . And I s a i d ,
w e l l , l e t me t h i n k about i t . For something people a r e g o i n g t o
d i s c a r d , I t h i n k t h i s i s a waste o f money. So, I want you t o
look i n t o t h a t .
I want a s i n g l e c l a i m f o r a l l i n s u r a n c e and n o t
10,000 forms t h a t we have t o l o o k a t — am I f i l l i n g o u t t h e
r i g h t form. T h i s i s nonsense. I want e l e c t r o n i c b i l l i n g where
everybody g e t s , you know, we save a l o t o f money. That's where
you're g o i n g t o have c o s t containment n o t i n t h e n i t t y - g r i t t y .
D o c t o r s a r e n ' t p r o f i t e e r i n g d o c t o r s and t h e y do n o t
make t h a t much money. I f I wanted t o make money, I ' d go i n t o
business l i k e own Zippy's o r whatever.
( L a u g h t e r . ) I'm s o r r y ,
but t h i s i s where you g e t t h e b i g bucks, n o t i n m e d i c i n e . We go
i n t o medicine because we l o v e t o h e l p people t o g e t w e l l and i t ' s
not a money-making t h i n g , b e l i e v e me.
I ' d be much r i c h e r i f I
went i n t o b u s i n e s s .
So, I t h i n k t h a t these are t h e p o i n t s I want you t o
t h i n k about. There a r e a couple o f o t h e r t h i n g s I would l i k e f o r
you t o r e a l l y l o o k i n t o — l i a b i l i t y r e f o r m . D o c t o r s a r e
spending a l o t o f money o r d e r i n g MRIs and u l t r a s o u n d and a l o t o f
t h i n g s t o r e a l l y defend — you g e t on t h a t s t a n d someday and d i d
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�- 22 -
you do an MRI on t h a t p a t i e n t ; no, because I d i d n ' t suspect a
b r a i n tumor o r whatever.
But you know we do i t — a l o t o f money
spent t h e r e t h a t ' s unnecessary.
So, I t h i n k i f we have l i a b i l i t y r e f o r m I t h i n k we
w i l l r e s t a l o t e a s i e r , p r a c t i c e medicine, use our c l i n i c a l
judgment a l o t more. Many t i m e s I'm t a k i n g X-rays n o t because I
f e e l i t ' s necessary, b u t because mothers say a r e n ' t you g o i n g t o
t a k e an X-ray.
I say, w e l l , I r e a l l y don't t h i n k i t ' s necessary
because t h e c h i l d ' s f a l l was n o t t h a t bad.
I can't f i n d
a n y t h i n g . Why don't we s i t and watch.
I f t h e y ' r e r e a l l y your
p a t i e n t s , t h e y w i l l say, okay, Doc, I ' l l do whatever you say.
But l o t s o f t i m e s you don't know t h i s p a t i e n t and, so, you t a k e
i t n o t because I'm g o i n g t o f i n d something.
I t ' s t o r e a l l y save
your neck someday.
So, I t h i n k these are t h i n g s I would l i k e you t o
l o o k a t . And a l s o I would l i k e you t o l o o k a t a n t i t r u s t s .
Doctors are so a f r a i d o f t a l k i n g t o each o t h e r anymore because
you're g o i n g t o g e t sued someday. And I t h i n k t o p r a c t i c e i n
t h i s k i n d o f a c l i m a t e i s r e a l l y nonsense. I want more t i m e t o
p r a c t i c e medicine and do i t t h e good o l d way where you have t h e
good r a p p o r t , a d o c t o r - p a t i e n t r e l a t i o n . You t r u s t each o t h e r .
You don't have t o w o r r y about l a w s u i t s . But now you g e t sued f o r
everything.
So, I t h i n k t h a t these are t h e p o i n t s I ' d l i k e t o
make.
MRS. CLINTON: W e l l , Doctor, you a r e v e r y e l o q u e n t
i n making t h o s e p o i n t s . And t h e y are ones t h a t I have heard from
d o c t o r s a l l over t h e c o u n t r y . And p a r t i c u l a r l y from
p e d i a t r i c i a n s and f a m i l y p r a c t i c e d o c t o r s and i n t e r n i s t s , o t h e r s
who are on t h e k i n d o f c l i n i c a l f r o n t l i n e s o f p r i m a r y and
p r e v e n t i v e h e a l t h c a r e who f e e l t h a t t h e y do n o t have t h e t i m e t o
d e a l w i t h t h e i r p a t i e n t s i n t h e k i n d o f way t h a t t h e y t h i n k i s
o p t i m a l f o r t h e p a t i e n t s because o f t h e paperwork and t h e
bureaucracy and t h e i n t e r f e r e n c e . And a l s o because t h e y a r e n o t
u s u a l l y r e i m b u r s e d f o r s i t t i n g down and t a l k i n g t o somebody;
t h e y ' r e r e i m b u r s e d f o r o r d e r i n g t h a t t e s t . And t h a t i s one o f
t h e r e a l problems i s , we have s o r t o f p e r v e r t e d t h e i n c e n t i v e s i n
t h e m e d i c a l f i e l d by n o t r e w a r d i n g c l i n i c a l judgments and t i m e
w i t h people i n t h e same way t h a t we do reward t h e t e s t - t a k i n g .
So your p o i n t s are v e r y w e l l t a k e n and we're g o i n g
t o be t r y i n g t o do what we can t o answer t h o s e .
Q
Thank you v e r y much. And we want t o be o f h e l p
t o you. Any t i m e you need us we're here.
MRS.
CLINTON: Thank you v e r y much.
Q
Since Dr. Chang was so e l o q u e n t i n her
d i s c u s s i o n o f what p h y s i c i a n s need and want t o s e r v e , I t h o u g h t
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we ought t o g i v e Linda a chance t o say a l i t t l e b i t about nurses
i n H a w a i i . Linda B r i c h n e r ( p h o n e t i c ) , who i s t h e p r e s i d e n t o f
t h e Hawaiian Nurses A s s o c i a t i o n , and she happens t o be s i t t i n g
r i g h t up t h e r e . So why don't you — do you want t o make a few
comments about what n u r s i n g — nurses can c o n t r i b u t e t o t h e
dynamic o r a n y t h i n g e l s e you want t o say?
What's i n t e r e s t i n g about Linda i s t h a t she a c t u a l l y
spent a l o t o f t i m e i n Canada, so she has some sense o f t h e
Canadian system as w e l l .
Do you want t o j o i n i n , Linda?
Q
Thank you, Governor. I ' d c e r t a i n l y l i k e t o .
I've been a r e g i s t e r e d nurse f o r 2 0 years and I was b r o u g h t up i n
Canada and educated t h e r e . I've t a u g h t i n t h e n u r s i n g e d u c a t i o n
system i n Canada. And i n t h e p a s t n i n e y e a r s I ' v e been a
p r a c t i c i n g nurse and nurse educator i n H a w a i i .
For t h e p a s t s i x y e a r s , I've had a v e r y s u c c e s s f u l
business p r o v i d i n g s t a f f nurses from o t h e r c o u n t r i e s ,
p a r t i c u l a r l y Canada, f o r h o s p i t a l s i n Hawaii d u r i n g t h e c r i t i c a l
n u r s i n g s h o r t a g e t h a t we've had here. But I have a v e r y s t r o n g
f e e l i n g about where h e a l t h care i s g o i n g i n t h i s c o u n t r y , and my
c o n t r i b u t i o n i s g o i n g i n a p a r t i c u l a r d i r e c t i o n i n t h a t I have
now gone back t o t h e U n i v e r s i t y o f Hawaii and I'm w o r k i n g on my
nurse p r a c t i t i o n e r master's degree program t o p r a c t i c e i n p r i m a r y
care i n f a m i l y p r a c t i c e .
Nurses i n t h i s c o u n t r y are educated and
u n d e r u t i l i z e d i n t h e p r e s e n t system.
There are two m i l l i o n
nurses i n t h i s c o u n t r y , and we can p r o v i d e much o f t h e t e a c h i n g
and much o f t h e p r i m a r y care t h a t i s needed by t h e people o f our
country.
I remember i n Canada i n 1971 t h e r e was a r e p o r t from
t h e f e d e r a l government c a l l e d t h e LeLand(?) Report, and i t
t a r g e t e d p r e v e n t i v e h e a l t h care as t h e way t o c o n t r o l c o s t s and
t h e way t o p r o v i d e h e a l t h care t o t h e people o f Canada. That was
i n 1971. And t h a t r e p o r t g a t h e r e d d u s t , I guess, because i t was
never implemented i n Canada. And Canada i s i n t h e same s i t u a t i o n
as we a r e now i n t h e U n i t e d S t a t e s where we have s p i r a l i n g h e a l t h
care c o s t s .
Nurses see our r o l e i n t h i s system as p r o v i d i n g
s u p p o r t i n t h e system, s u p p o r t f o r t h e people o f t h i s c o u n t r y t o
m a i n t a i n t h e i r h e a l t h . We can t e a c h and educate, we can p r o v i d e
t h e k i n d o f c a r e t h a t f a m i l i e s need i n o r d e r t o s t a y h e a l t h y .
Nurses are n o t i n t e r e s t e d i n t r e a t i n g d i s e a s e ; we a r e i n t e r e s t e d
i n h e l p i n g people t o s t a y w e l l .
I'm l o o k i n g f o r w a r d t o b e i n g a p r i m a r y c a r e h e a l t h
p r o v i d e r as an advanced p r a c t i c e nurse and t o a s s i s t i n g people i n
t h e s t a t e o f Hawaii t o m a i n t a i n our h e a l t h y l i f e s t y l e .
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MRS. CLINTON: Linda, c o u l d I ask you i f you have
any comments about comparisons between t h e Canadian system and
what you have found here i n Hawaii?
Q
The Canadian system i s a s i n g l e - p a y o r system,
of course, whereas t h e r e ' s more c h o i c e o f t h e k i n d s o f coverage
t h a t you can ask f o r i n Hawaii.
I see nurses as u n d e r u t i l i z e d i n
t h e i r system as t h e y a r e here.
I don't t h i n k t h a t e i t h e r c o u n t r y
i s any f u r t h e r ahead i n t h a t r e g a r d , a l t h o u g h I do see t h e
f e d e r a l system here i n p u b l i c h e a l t h and i n Veterans'
A d m i n i s t r a t i o n u t i l i z i n g advanced p r a c t i c e nurses much b e t t e r
t h a n t h e p r i v a t e s e c t o r does. And I c e r t a i n l y see t h a t as a
c o s t - e f f e c t i v e measure and we're l o o k i n g t o t h e C l i n t o n
a d m i n i s t r a t i o n t o l e a d us i n t o b e t t e r u t i l i z a t i o n o f o t h e r
p r a c t i t i o n e r s t o keep our c o s t s down and p r o v i d e t h a t q u a l i t y
care t h r o u g h o u t t h e c o u n t r y .
MRS. CLINTON: I t ' s i n t e r e s t i n g you had mentioned
t h e VA, because i t i s t h e case t h a t i n b o t h t h e VA and i n t h e
Department o f Defense medical programs, nurses have a much
broader scope o f p r a c t i c e t h a n t h e y do i n t h e p r i v a t e s e c t o r .
Q
Since we a r e s o r t o f f l o a t i n g t o t h a t s i d e o f
t h e room, I see Rich Myers (?) s i t t i n g t h e r e . And we've heard
from t h e p h y s i c i a n s , we've heard from t h e nurses.
We ought t o
hear from t h e medical business — t h e h o s p i t a l s .
Q
Thank you v e r y much. Governor. Mrs. C l i n t o n ,
p r o b a b l y one o f t h e b i g advantages t h a t t h e h o s p i t a l s here have
enjoyed as a r e s u l t o f t h e P r e p a i d H e a l t h Care A c t compared t o
o t h e r h o s p i t a l s on t h e mainland, we r e a l l y have m i n i m i z e d o u r
uncompensated c a r e . And i f you t a l k t o t h e f o l k s on t h e mainland
— when I t a l k t o o t h e r h e a l t h care h o s p i t a l a d m i n i s t r a t o r s on
t h e mainland, t h a t i s a v e r y , v e r y b i g i s s u e . There i s s t i l l
some uncompensated c a r e ; I don't want t o m i s l e a d you. But t h e
P r e p a i d H e a l t h Care A c t has r e a l l y minimized t h a t .
I , t o o , am s o r t o f a s m a l l business.
I have n i n e
employees and I p a r t i c i p a t e i n t h i s program. And, p e r s o n a l l y , I
f e e l good i n knowing t h a t my employees, i f t h e i r f a m i l i e s g e t
s i c k , t h a t t h e y a r e g o i n g t o g e t t h e h e a l t h c a r e , t h a t I'm n o t
g o i n g t o w o r r y about o t h e r s p i n o f f s from t h e f a m i l i e s t h a t — you
know, t h e y would be w o r r i e d whether t h e i r f a m i l i e s a r e g o i n g t o
get h e a l t h care, e t cetera.
As f a r as o t h e r i s s u e s , we, o f course, a r e l o o k i n g
f o r some t o r t r e f o r m , as — t a l k e d about e a r l i e r . And c e r t a i n l y
t h e a n t i t r u s t i s e x t r e m e l y i m p o r t a n t t o us, because we, as
h o s p i t a l s , need t o t a l k t o each o t h e r . We need t o form t h e s e
networks.
And, you know, we have t o be v e r y , v e r y c a r e f u l i f we
s i t down and t r y t o do t h a t i n today's environment, because we
may f i n d o u r s e l v e s i n c o u r t . So i t i s e x t r e m e l y i m p o r t a n t t o us
t h a t we, o f course, do have some k i n d o f a n t i t r u s t l e g i s l a t i o n .
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And u n i v e r s a l access — I j u s t came from a meeting
y e s t e r d a y i n S e a t t l e — I g o t back l a t e l a s t evening — where a l l
the Western s t a t e s g a t h e r e d t o t a l k about t h i s whole p l a n .
And
t h e one i s s u e t h a t was v o t e d as t h e most i m p o r t a n t i s s u e by t h e
p r o v i d e r s from Colorado west t o Hawaii was t h e u n i v e r s a l access
t o coverage. And t h a t i s , q u i t e f r a n k l y , an i s s u e t h a t we f e l t
t h a t has t o s t a y i n t h e program.
That's j u s t one o f t h e key
elements t h a t we as an i n d u s t r y , so t o speak, f e e l has t o s t a y i n
the program.
MRS. CLINTON: R i c h a r d , c o u l d I ask you — when you
say you do have some uncompensated care s t i l l , can you d e s c r i b e
i n g e n e r a l who makes up t h a t p o p u l a t i o n t h a t i s uncompensated?
Q
Yes, t h e uncompensated care t h a t we would have
would perhaps come from t h e s h i p ( ? ) program, f o r example, w h i c h ,
you know, i s b a s i c a l l y an o u t p a t i e n t program w i t h l i m i t e d
s e r v i c e s . But sometimes those p a t i e n t s w i l l come i n t o t h e
h o s p i t a l and s t a y beyond what i s n o r m a l l y reimbursed.
But, a g a i n , here i n Hawaii t h a t ' s something t h a t
p r o v i d e r s have j u s t made up t h e i r mind t h a t t h e y w i l l a c c e p t , and
t h a t w i l l be t h e i r c o n t r i b u t i o n towards p r o v i d i n g h e a l t h c a r e —
good h e a l t h c a r e t o our c i t i z e n s . But t h a t would be an example.
Of course, w i t h t h e Hawaii quest program, which i s now
—
Q
I wondered when you were g o i n g t o g e t t o t h a t .
Put a p l u g i n t h e r e f o r t h e w a i v e r .
Q
Q
Yes.
Go ahead.
Q
W e l l , anyway, t h e Hawaii Quest program, which
the Governor b r o u g h t t o Washington a month o r so ago, w i l l
combine a l l o f t h e s e programs. And I don't want t o go i n t o a l o n g
e x p l a n a t i o n o f what t h e program i s . But s h o u l d combine a l l o f
t h e s e programs i n t o one program and, h o p e f u l l y , s h o u l d e l i m i n a t e
even t h o s e areas o f uncompensated c a r e . And perhaps Jack m i g h t
want t o say a l i t t l e b i t more —
Q
R i c h , why don't you — c o u l d you comment a
l i t t l e b i t about t h e uncompensated c a r e major areas i n terms o f
Medicare as w e l l and M e d i c a i d , t o o , i n terms — because I t h i n k
t h a t you've t a l k e d about t h a t b e f o r e .
Q
Yes.
T h i s p a s t year — i n j u s t t h e p a s t year
a l o n e — our h o s p i t a l s and l o n g - t e r m c a r e f a c i l i t i e s l o s t $38.8
m i l l i o n , even w i t h our own p l a n here. And t h a t was t h e
d i f f e r e n c e between t h e c o s t o f p r o v i d i n g care — n o t charges
—
t h e c o s t o f p r o v i d i n g c a r e , and t h e amount o f reimbursement.
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Now,
we t h i n k i t w i l l ,
the f u t u r e .
a g a i n , h o p e f u l l y i f t h i s program comes o u t as
we s h o u l d n ' t have those k i n d s o f problems i n
And what d i d t h a t cause? That caused us t o have t o
c o s t s h i f t , because t h e r e ' s no way you can s t a y i n business i f
you're l o s i n g $38.8 m i l l i o n t o $40 m i l l i o n a year.
You have t o
t a k e t h a t s h o r t f a l l , i f you w i l l , and c o s t s h i f t t o — t o
something e l s e . So t h a t ' s why we're hoping t h a t you a l l i n
Washington w i l l t a k e a c l o s e l o o k a t t h a t program.
A l s o , l o n g - t e r m care i s o f extreme importance t o us.
We have a s h o r t a g e o f l o n g - t e r m care beds here i n Hawaii, and
t h e r e are e f f o r t s , o f course, t o b u i l d a d d i t i o n a l beds.
We
a c t u a l l y have acute care beds b e i n g blocked r i g h t now, because we
have no p l a c e t o p u t l o n g - t e r m care p a t i e n t s t h a t are i n acute
care beds. So I know l o n g - t e r m care i s a v e r y expensive t o p u t
l o n g - t e r m care p a t i e n t s t h a t are i n acute care beds. So I know
l o n g - t e r m care i s a v e r y expensive program. I know i t ' s a l s o
g o i n g t o be down t h e road a l i t t l e b i t .
But we cannot f o r g e t
about l o n g - t e r m c a r e . Home care — v e r y , v e r y i m p o r t a n t .
Q
Thank you,
Rich.
We have w i t h us t h i s morning a l s o Dr. J u l i a
F r o e l i c h ( ? ) , who i s n o t o n l y t h e D i r e c t o r o f t h e Blood Bank, b u t
t h e c h a i r p e r s o n - e l e c t f o r t h e Hawaii Chamber o f Commerce. And so
she s o r t o f , a g a i n , i s a b l e n d i n g o f t h e m e d i c a l p r o f e s s i o n and
t h e sense o f business.
So, J u l i e , would you l i k e t o share some
t h o u g h t s w i t h us t h i s morning?
Q
Yes, thank you.
Perhaps I c o u l d j u s t p r o v i d e
some a d d i t i o n a l i n f o r m a t i o n t o t a k e back — and some o f i t i n t h e
area o f c o s t . You mentioned e a r l i e r reexamining o r opening up
t h e 1974 p r e p a i d h e a l t h p l a n might p r o v i d e some o p p o r t u n i t y t o
reexamine i n 199 3 terms what does t h e b a s i c package c o n t a i n .
Another t h i n g t h a t i t might a l s o p r o v i d e , w h i c h Jack
a l l u d e d t o e a r l i e r , i s who shares t h e c o s t o f t h e premium w h i c h
i s p a i d f o r t h e i n s u r a n c e , which we a l l s u p p o r t what i t does f o r
our community. And when t h e h e a l t h p l a n — 1974 p l a n was p u t i n ,
i t was meant t o be r o u g h l y a 50-50 c o s t - s h a r i n g .
W e l l , a r e c e n t survey done by our Hawaiian Employers
C o u n c i l o f about 250 companies r e p r e s e n t i n g a l l s i z e s —
50
p e r c e n t o f them had under 100 employees — showed t h a t i n a c t u a l
f a c t , 100 p e r c e n t o f t h e employee c o s t i s p a i d by about 80
p e r c e n t o f t h e companies t h a t were surveyed.
So I t h i n k when we
t a l k about j o i n t s h a r i n g o f t h e premiums, t h a t i s another way o f
h a v i n g t h e person who b e n e f i t s — a l l o f us workers — t a k e
r e s p o n s i b i l i t y f o r our r o l e i n u s i n g h e a l t h care s e r v i c e s i f we
are a l s o c o n t r i b u t i n g t o p a y i n g f o r i t i n t h a t way — n o t so much
as we t a l k e d about e a r l i e r as h i g h d e d u c t i b l e s , b u t a c t u a l l y
t a k i n g p a r t o f t h e n a t u r a l premium t o a l a r g e r degree t h a n i t i s
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r i g h t now i n t h e S t a t e s . So t h e r e may be b e n e f i t s i n l o o k i n g
back a t t h e p l a n beyond l o o k i n g a t a b a s i c package i n terms o f
1993, b u t a l s o a way t h a t b o t h t h e employer and employee once
a g a i n , c o n t r i b u t e and understand t h e y each have a r o l e i n
responsible h e a l t h care.
MRS. CLINTON: One t h i n g I want t o be s u r e t h a t I
u n d e r s t a n d c l e a r l y i s t h a t a l t h o u g h dependent coverage i s n o t
r e q u i r e d under t h e a c t , t h e r e i s a t r e n d t o w a r d employers
c o n t r i b u t i n g — now, do t h e y c o n t r i b u t e i n t h e same r a t i o as t h e y
do f o r t h e employee coverage, o r i s a d i f f e r e n t r a t i o ? And what
do we do w i t h c h i l d r e n who f a l l between t h e c r a c k s o r who a r e i n
f a m i l i e s o f d i v o r c e , o r , you know, some o f t h e p r a c t i c a l
a p p l i c a t i o n s o f n o t mandating dependent coverage i n terms o f
making s u r e a l l c h i l d r e n a r e covered? I r e a l l y need t o
u n d e r s t a n d how t h a t works.
Q
— as was s t a t e d by Dr. F r o e l i c h , p r o b a b l y 75
p e r c e n t o f employers pay 100 p e r c e n t o f t h e employee c o s t s . On
t h e dependents from our b e s t s t u d i e s i s t h a t t w o - t h i r d s o f
employers pay f o r p a r t o f t h e c o s t o f dependents — spouses,
c h i l d r e n — and t h a t c o n t r i b u t i o n i s a l l t h e way from some
nominal sum up t o 100 p e r c e n t . Probably h a l f o f employers pay
100 p e r c e n t o f a l l t h e c o s t s o f coverage f o r employees and
dependents.
Typically, divorces, children, p u t t i n g t h e
r e s p o n s i b i l i t y t o one o f t h e spouses, t h a t s o r t o f t h i n g , a r e
p r o v i d e d f o r and a r e covered based upon whatever t h e arrangement
t h a t t h a t f a m i l y has. So I t h i n k we f e e l t h a t t h e r e i s coverage,
i t i s provided f o r a l l o f these kinds o f s i t u a t i o n s .
MRS. CLINTON: That i s one o f t h e a r e a s , t h o u g h ,
t h a t I t h i n k t h e r e may w e l l be some d i f f e r e n c e s we have t o be
aware o f because t h e s o r t o f Hawaiian t r a d i t i o n , which s e v e r a l o f
you have a l l u d e d t o o f c o v e r i n g employees, even b e f o r e i t was
r e q u i r e d , o f h a v i n g f a m i l y businesses k i n d o f g r o w i n g up w i t h t h e
s t a t e ' s economy; perhaps a d i f f e r e n t s e t o f a t t i t u d e s m i g h t be i n
p l a c e here t h a t you w o u l d n ' t f i n d elsewhere.
And one o f t h e i s s u e s t h a t we have t o be e s p e c i a l l y
concerned about from t h e n a t i o n a l l e v e l i s , g i v e n m o b i l i t y and
g i v e n t h e needs o f c h i l d r e n , how t o make sure t h a t e v e r y c h i l d
needs o u r , no m a t t e r who t h a t c h i l d ' s p a r e n t s i s o r where t h a t
c h i l d i s employed.
So I would a p p r e c i a t e , maybe n o t now, b u t any
a d v i c e t h a t you would have based on your e x p e r i e n c e , because I
don't — I d o n ' t know t h a t we can count on t h e same l e v e l o f
v o l u n t a r y s u p p o r t f o r dependent coverage i n t h e r e s t o f t h e
c o u n t r y t h a t seems t o have developed here i n H a w a i i .
Q
I wanted, maybe j u s t t o add t o t h a t , when we
s t a r t e d t h e s h i p ( ? ) program, Mrs. C l i n t o n , we had t h e s i t u a t i o n
i n which any dependents t h a t weren't covered by t h e — because i f
t h e employee so chooses, t h e dependents would have t o be covered
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�- 28 -
and added i n t o t h e care p o o l and i n t h e community r a t i n g p o o l .
They cannot be r e j e c t e d , t h e y cannot be r i s k a d j u s t e d and so
forth.
But we weren't c e r t a i n how many o f those people
might be o u t t h e r e . And we were heartened t o l e a r n t h a t f r a n k l y
our dependent coverage has t u r n e d o u t t o be, de f a c t o , almost
universal.
And t h a t i s p a r t o f t h e g e n e r o s i t y t h a t ' s b u i l t i n t o
t h e p l a n and i t ' s become an e x p e c t a t i o n f o r employers t o have t o
deal w i t h t h a t .
We would recommend h e a r t i l y t h a t dependent coverage
be p a r t — a mandated, i n t e g r a l p a r t o f any employer mandate,
t h a t we n o t approach i t on t h e n a t i o n a l l e v e l , we need t o j u s t
p u t t h e c h i l d r e n , p u t t h e dependent spouses i n i f t h e y ' r e n o t
covered and have i t be a f a i r c o s t s p l i t w i t h t h e employer and
t h e employee. Because we c a n ' t a f f o r d t o have t h o s e people we
l e f t out.
We've been v e r y f o r t u n a t e
i n Hawaii.
GOVERNOR WAIHEE: Okay, one t h i n g , when we t a l k e d
about uncompensated care e a r l i e r , which — I d i d n ' t hear any
mention about t h e f a c t t h a t some o f our — a p o r t i o n o f our
uncompensated care came from t o u r i s t s and t h e P a c i f i c i s l a n d e r s
and a l i e n s and — do you have any s t a t i s t i c s on t h a t ?
Q
I d o n ' t , Governor, I don't have any s t a t i s t i c s
on t h o s e i s s u e s t h a t you mentioned o r t h o s e t y p e s o f p a t i e n t s
t h a t you mentioned.
But, yes, t h a t i s t r u e — whether t h e y ' r e
v i s i t o r s , whether t h e y ' r e homeless, whatever.
They a l l do f i t
i n t o t h a t compensated c a r e .
But h a v i n g s a i d a l l t h a t a g a i n , our problems as a
r e s u l t o f t h e P r e p a i d H e a l t h Care Act are nowhere near as g r e a t
as t h e y a r e on t h e mainland.
MRS. CLINTON: You mean, t h e t o t a l f o r Hawaii o f
uncompensated care i n t h e h o s p i t a l s i s o n l y $38 m i l l i o n ? I s t h a t
what I u n d e r s t o o d you t o say l a s t year?
Medicare
Q
T h i s p a s t year, we had a s h o r t a g e i n j u s t t h e
and M e d i c a i d what I understood you t o say l a s t y e a r .
Q
T h i s p a s t year we had a s h o r t a g e i n j u s t t h e
Medicare and M e d i c a i d f u n d i n g — o f a p p r o x i m a t e l y $38.8, $38.9
million.
GOVERNOR WAIHEE: Under compensated c a r e would be a
b e t t e r way o f s a y i n g i t .
(Laughter.) I t ' s not r e a l l y
uncompensated c a r e .
MRS. CLINTON: That i s p r e t t y remarkable, though,
because, you know, I ' v e been i n l o t s o f h o s p i t a l s on t h e mainland
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t h a t have, you know, a t h i r d o f t h a t i n one h o s p i t a l because o f
under compensated c a r e .
Q
—
a $3 b i l l i o n system t h a t ' s n o t v e r y good.
Q
Thank you. I n terms o f t h e Board o f H e a l t h ,
i t ' s an a d v i s o r y committee a p p o i n t e d by t h e Governor, and we have
r e p r e s e n t a t i o n from a l l t h e I s l a n d s t o be an a d v i s o r y t o t h e
Director of Health.
And some o f our i s s u e s — we have been w o r k i n g
t o g e t h e r now about two y e a r s , some o f us t h r e e y e a r s . And, I ,
p e r s o n a l l y , have been r e a p p o i n t e d f o r another term. And some o f
our c h a l l e n g e s have been t o understand our r o l e . And I t h i n k
w i t h t h e H e a l t h D i r e c t o r , h i s s t a f f , we a r e b e g i n n i n g t o f i n d o u r
n i c h e and how we can b e s t a d v i s e , q u a l i t y a d v i s i n g , I would say.
One o f t h e issues we t o o k up was Hawaiian h e a l t h ,
h e a l t h f o r Hawaii people, n a t i v e Hawaiians. And we were a b l e t o
b r i n g t h a t t o t h e f o r e f r o n t . We've had a minor setback, b u t I
b e l i e v e t h a t w o r k i n g w i t h our s t a t e l e g i s l a t u r e t h a t t h o s e
p h y s i c i a n s t h a t a r e needed i n o r d e r t o move t h a t program f o r w a r d
w i l l be c a r r i e d o u t w i t h i n t h e year. We're e x c i t e d about t h a t .
We went t o Kauai about t h r e e weeks ago t o hear some
of t h e problems t h a t even we were n o t aware o f t h a t a r e s t i l l
g o i n g on and t o see how w e l l t h e h e a l t h s t a f f and o t h e r community
workers have been w o r k i n g so h a r d , even w i t h t h e i r own p e r s o n a l
l o s s t h e y have been a b l e t o c a r r y on w h i l e t h e h o s p i t a l s
t h e r e — t h e y saved every p a t i e n t w i t h windows f l y i n g o u t , w a l l s
c a v i n g i n w i t h o u t l o s i n g a s i n g l e person.
And I p e r s o n a l l y
touched by t h a t woman who was a b l e t o d i r e c t t h a t k i n d o f
movement w i t h t h e storm happening.
So, we a r e here t o a b l e t o b r i n g departments
t o g e t h e r so t h a t we're w o r k i n g t o g e t h e r i n t e r d e p e n d e n t l y w i t h
i s s u e s , w i t h H e a l t h and Human S e r v i c e s — S t a t e H e a l t h Department
P l a n n i n g Agency and some o f t h e o t h e r departments t h a t w i l l be
w o r k i n g on some o f t h e same i s s u e s .
I n terms o f t h e g r a s s r o o t s , I'm i n v o l v e d i n
substance abuse — agency t h a t i s b u i l d i n g a r e s i d e n t i a l f a c i l i t y
f o r o u r people here t h a t don't have adequate funds t o g e t
t r e a t m e n t . And t h e problem i s a c h a l l e n g i n g one, b u t we f e e l
t h a t t h i s community has responded t h r o u g h i t s l e g i s l a t u r e i n
o r d e r t h a t t h o s e s e r v i c e s a r e a v a i l a b l e t o people t h a t need them
w i t h o u t r e g a r d t o a b i l i t y t o pay.
Q
I would share w i t h you t h a t I am your
neighbor because I l i v e i n C a l i f o r n i a .
next-door
I ' v e l o n g been impressed w i t h what you've been a b l e
t o accomplish here and have f e l t f o r many years t h a t t h e r e a r e
i m p o r t a n t lessons t h a t t h e r e s t o f t h e c o u n t r y c o u l d b e n e f i t
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�- 30
-
from. I want t o compliment t h e a d m i n i s t r a t i o n on i t s a c t i o n
today. T h i s i s t h e h i g h e s t l e v e l of any a d m i n i s t r a t i o n t h a t I
know of t h a t has expressed the k i n d of i n t e r e s t t h a t you've
expressed i n what i s g o i n g on here.
We b e l i e v e t h a t t h e a b i l i t y t o use t h e p r i v a t e
s e c t o r t o l e t market f o r c e s generate what s h o u l d occur t o p r o v i d e
h i g h q u a l i t y care a t a reasonable c o s t f o r t h e e n t i r e p o p u l a t i o n
i s e x e m p l i f i e d by what you see here. We t h i n k t h e c e r t a i n
p r i n c i p l e s t h a t I'm c e r t a i n you w i l l c a r r y away w i t h you — t h o s e
of h a v i n g a s t a n d a r d b e n e f i t package i s e x e m p l i f i e d by what you
see here.
We t h i n k t h e c e r t a i n p r i n c i p l e s t h a t I'm c e r t a i n you
w i l l c a r r y away w i t h you, those of h a v i n g a s t a n d a r d b e n e f i t
package, t h o s e of h a v i n g community r a t i n g , and t h o s e o f h a v i n g an
employer mandate are t h r e e of t h e e s s e n t i a l s .
There are some
o t h e r t h i n g s t h a t can be done t o enhance i t , b u t we g r e a t l y
admire what had o c c u r r e d here, and as I'm sure you're aware t h e
American M e d i c a l A s s o c i a t i o n ' s own p r o p o s a l , H e a l t h Access
America, which was developed i n 1990 was l a r g e l y based on what we
saw i n t h i s community. And we t h i n k t h a t t h e r e are many v a l u a b l e
lessons t h a t we are q u i t e c e r t a i n you w i l l t a k e away and we
applaud you f o r coming.
MRS.
CLINTON:
Thank you
v e r y much.
GOVERNOR WAIHEE: Thank you.
I t h i n k we're j u s t
about t o t h e end of our forum t h i s morning. I want t o t h a n k a l l
of you f o r p a r t i c i p a t i n g , but b e f o r e I do t h a t and end t h e forum,
I would l i k e t o i n v i t e Mrs. C l i n t o n t o ask any l a s t q u e s t i o n s she
may have o f any one here t h i s morning or t o make any s t a t e m e n t
t h a t she may want t o make a t t h i s t i m e .
MRS.
CLINTON: W e l l Governor, as you know, you and
Dr. L u i n ( ? ) and o t h e r members of your a d m i n i s t r a t i o n have been
i n v o l v e d i n our e f f o r t s i n Washington from t h e v e r y f i r s t day.
And we are v e r y g r a t e f u l f o r t h a t k i n d o f s u p p o r t and good
a d v i c e . But I have o f t e n found t h a t t h e r e i s no s u b s t i t u t e f o r
a c t u a l l y l i s t e n i n g t o and b e i n g w i t h people who are d e l i v e r i n g
what I r e a d about i n r e p o r t s or what I hear about from v i s i t o r s
from H a w a i i t o Washington. And t h a t ' s t h e way I f e e l t h i s
morning. I've t a k e n a whole page of n o t e s , I have some f o l l o w - u p
q u e s t i o n s t h a t we w i l l be coming back t o you w i t h .
I t i s v e r y e x c i t i n g f o r me, p e r s o n a l l y , t o be i n a
group of people who have worked t o g e t h e r t o h e l p s o l v e a problem
t h a t i s a n a t i o n a l one, b u t f o r which you d i d n ' t w a i t l i k e every
o t h e r s t a t e has t o t r y t o see what would happen coming o u t of
Washington. But, i n s t e a d , r e a l l y t o o k you own d e s t i n y i n hand 20
years ago.
And have b u i l t on t h a t i n a way t h a t does deserve a
l o t of c l o s e a t t e n t i o n from t h e r e s t of t h e c o u n t r y .
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�- 31 -
So we a r e g r a t e f u l f o r what you've done and as
s e v e r a l o f you, i n c l u d i n g t h e Governor, have r e f e r r e d t o e a r l i e r ,
a t t h i s moment i n Washington t h e Department o f H e a l t h and Human
S e r v i c e s , a t t h e d i r e c t i o n o f t h e P r e s i d e n t i s r e v i e w i n g your
l a t e s t p r o p o s a l i n o r d e r t o c o n t i n u e t h e k i n d o f improvements
t h a t Hawaii i s known f o r i n p r o v i d i n g h e a l t h c a r e .
So we're v e r y e x c i t e d by what you've done, what
you're d o i n g , and what you w i l l be d o i n g . And I'm so pleased
t h a t you're such a f u l l p a r t n e r i n what we're t r y i n g t o do f o r
the whole c o u n t r y .
GOVERNOR WAIHEE:
W e l l thank you v e r y much.
(Applause.)
Once a g a i n , on b e h a l f o f a l l t h e people h e r e , we
want t o thank our dynamic F i r s t Lady f o r t a k i n g t i m e o u t t o be
w i t h us t h i s morning.
I a l s o want t o thank a l l o f you f o r b e i n g
p r e s e n t and f o r p a r t i c i p a t i n g i n t h i s forum. Thank you v e r y
much.
(Applause.)
END
10:34 A.M. (AHT)
�THE WHITE HOUSE
O f f i c e of t h e Press S e c r e t a r y
For I n t e r n a l Use
June 23,
1993
REMARKS BY THE FIRST LADY
IN SPEECH TO CSIS CONFERENCE
Capitol
Hill
MRS. CLINTON: Senator Nunn and Senator Domenici and
l a d i e s and gentlemen, thank you f o r t h i s o p p o r t u n i t y . And, Senator,
because I know you're committed t o r e s p o n s i b l e d e f i c i t r e d u c t i o n -you j u s t go r i g h t back t o t h a t -- ( l a u g h t e r ) -- you're going t o t r y
t o move t h i s agenda forward so t h a t we can c o n t i n u e t o get the
c o u n t r y back on t h e r i g h t t r a c k t h a t w i l l lead t o t h e s t r e n g t h e n i n g
of America, which i s a commitment t h a t a l l of us share and which
Senator Nunn and a l l of you have been l e a d i n g spokespeople f o r and
f o r which I am v e r y g r a t e f u l .
I welcome t h i s o p p o r t u n i t y t o v i s i t w i t h you about
h e a l t h c a r e . And what I would l i k e t o do i s t o speak f o r a few
m i n u t e s , b u t m o s t l y t o have time t o answer any of your g u e s t i o n s o r ,
as Senator Domenici suggested, t o t a k e advantage of your suggestions
about how we proceed w i t h t h i s e x t r a o r d i n a r i l y i m p o r t a n t and very
complex m a t t e r .
I don't t h i n k t h a t I need t o remind t h i s group what i s
a t s t a k e i n h e a l t h care reform, because you have been l o o k i n g a t what
needs t o be done t o reverse the k i n d of economic s t a g n a t i o n and
u n d e r m i n i n g o f our f u t u r e t h a t has gone on because of d e c i s i o n s t h a t
we have f a i l e d t o make over the l a s t s e v e r a l decades.
But i t i s
c l e a r t h a t , i n t h e absence of s e r i o u s h e a l t h care r e f o r m t h a t
c o n t r o l s c o s t s and p u t s , f i n a l l y , some d i s c i p l i n e i n t o t h e h e a l t h
c a r e market, we are u n l i k e l y t o be a b l e t o d e a l w i t h t h e f e d e r a l
budget, t h e d e f i c i t , t h e debt, and we are g o i n g t o c o n t i n u e t o be
undermined i n t h e p r i v a t e s e c t o r w i t h r e s p e c t t o our c o m p e t i t i v e n e s s .
So t h e r e c o u l d n o t be a more t i m e l y issue f o r t h i s group t o address.
There are a number of competing p r o p o s a l s t h a t have been
a n a l y z e d and worked on f o r s e v e r a l years as t o how we best go about
r e f o r m i n g our h e a l t h care system t o assure s e c u r i t y t o every American
so t h a t we r e a c h u n i v e r s a l coverage t h a t w i l l enable us t o p r o v i d e a
comprehensive b e n e f i t s package a t a f f o r d a b l e c o s t , and w i l l c o n t r o l
c o s t s , t h e r e f o r e , w i t h i n both t h e p u b l i c and t h e p r i v a t e s e c t o r s .
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There has been an enormous amount of good and t h o u g h t f u l
work t h a t has gone on. And I was pleased t o r e c e i v e a d r a f t copy of
the " V i s i o n and P r i n c i p l e s " paper t h a t CSIS i s working on, and add
t h a t t o t h e l i s t o f o r g a n i z a t i o n s t h a t are t a k i n g a r e s p o n s i b l e
approach t o t h i s complex issue.
In t h e work t h a t we have been doing i n c o n j u n c t i o n w i t h
many groups i n both t h e p u b l i c and t h e p r i v a t e and t h e n o n p r o f i t
arenas, we have attempted t o analyze every s i n g l e proposal from a
v a r i e t y o f p e r s p e c t i v e s , and t o how w e l l i t reaches t h e p r i n c i p l e s
t h a t we t h i n k are e s s e n t i a l -- p r i n c i p l e s t h a t you, too, have adopted
i n your approach i n t h i s d r a f t paper.
I t became q u i c k l y apparent t h a t t h e r e were s t r e n g t h s and
weaknesses t o every one o f these independent approaches t h a t had t o
be t a k e n i n t o account, and t h a t what we would have t o do t o come up
w i t h a system t h a t we thought met t h e u n d e r l y i n g p r i n c i p l e s i n a
t i m e l y and a f f o r d a b l e manner, was t o c r e a t e an American s o l u t i o n t o
t h i s American problem. There was no model anywhere t h a t could be
adopted wholesale. And t h a t we needed t o b u i l d on t h e s t r e n g t h s of
our h e a l t h care system w h i l e we tended t o s h o r i n g up and e l i m i n a t i n g
where p o s s i b l e i t s weaknesses.
And what I would l i k e q u i c k l y t o do i s t o r u n through
your " V i s i o n s " paper so t h a t we can p u t t h e d i s c u s s i o n i n t o t h e terms
t h a t you have a l r e a d y been working on and p o i n t o u t t h e s i m i l a r i t i e s
and t h e approach we're t a k i n g and d i s c u s s areas where we need,
perhaps, t o c o n t i n u e c o n s u l t a t i o n s .
We b e l i e v e , along w i t h you, t h a t we need a market-based
approach t o t h e f i n a n c i n g and d e l i v e r y o f h e a l t h care t h a t w i l l
c r e a t e sound and e f f e c t i v e consumer d e c i s i o n - m a k i n g . T h i s i s an area
t h a t i n d i v i d u a l s l i k e i n which i n f o r m a t i o n t h a t i s r e a d i l y usable i s
rare.
I wouldn't embarrass anyone, i n c l u d i n g myself -- i f I wanted
t o , I c o u l d , though -- by asking each o f you t o t e l l me e x a c t l y what
your insurance coverage i s and a l l of t h e r e s t t h a t goes i n t o i t , and
how you shop t o make your choices, and i f you d i d n ' t , who made t h e
c h o i c e s f o r you and on what basis they d i d .
I t would be a r e l a t i v e l y s h o r t c o n v e r s a t i o n , because
I've done t h i s i n many groups w i t h many w e l l - e d u c a t e d people, and
t h e r e ' s been ambaxrassed s i l e n c e and then a s c r a m b l i n g t o say
something. I f _ I ' m c o n t r a c t , I would ask you why d i d you buy t h e car
you most r e c e n t l y bought, we could have a v e r y w e l l informed
c o n v e r s a t i o n and a good debate back and f o r t h , as Sam Nunn argued
w i t h J i m Cooper, who argued w i t h somebody e l s e about why they chose
whatever c a r they bought and what k i n d o f d e a l they g o t f o r i t and
how t h e y n e g o t i a t e d t h e best p r i c e .
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There i s n o t h i n g l i k e t h a t i n our c u r r e n t system. The
k i n d o f system we e n v i s i o n r e l i e s f u n d a m e n t a l l y on empowering and
i n f o r m i n g consumers t o make those k i n d s o f d e c i s i o n s . I n o r d e r t o do
t h a t , we need t o c r e a t e o p t i o n s among t h e choices t h a t are a v a i l a b l e
t o consumers, and we agreed w i t h your approach of p r o v i d i n g what we
c a l l "accountable h e a l t h p l a n s , " and you do as w e l l , t h a t w i l l
p r o v i d e a basic b e n e f i t package t h a t w i l l be r e q u i r e d by t h e f e d e r a l
government and t h e basic o p t i o n a v a i l a b l e t o every consumer.
Now, accountable h e a l t h p l a n s can d e l i v e r those b e n e f i t s
i n a v a r i e t y of ways
through an HMO, a PPO, a f e e - f o r - s e r v i c e
network, some as y e t undiscovered ways o f d e l i v e r i n g s e r v i c e s t h e
market w i l l h e l p t o generate. And we w i l l encourage t h a t k i n d o f
c o m p e t i t i o n and choice because we t h i n k t h e r e should be t h a t
a v a i l a b i l i t y o f o p t i o n s w i t h i n t h e d e l i v e r y o f h e a l t h care.
In order f o r t h a t system t o work e f f e c t i v e l y , we w i l l
have t o have adequate i n f o r m a t i o n , t h e use of r e p o r t cards -- a term
t h a t you use i n your d r a f t i s one t h a t we have a l s o used. We w i l l
go, i n a d d i t i o n t o r e p o r t i n g what i s c u r r e n t l y a v a i l a b l e i n t h e
market, we w i l l have t o c r e a t e new sources of i n f o r m a t i o n b e t t e r than
what we have c u r r e n t l y been able t o produce.
And we w i l l have t o
s t a r t comparing apples t o apples i n s t e a d o f apples t o oranges.
Because, as has been p o i n t e d o u t i n many o f t h e d i s c u s s i o n s I've had,
the p r i m i t i v e use o f i n f o r m a t i o n can be c o n t r a r y t o t h e outcome's
q u a l i t y measurements t h a t we are l o o k i n g f o r . So t h e r e w i l l have t o
be some r e a l thought g i v e n t o c r e a t i n g an e f f e c t i v e l y f u n c t i o n i n g
data c o l l e c t i o n system t h a t can be e a s i l y accessed and r e p o r t e d t o
consumers and p r o v i d e r s .
We c e r t a i n l y b e l i e v e that there has to be the
i n t e g r a t i o n of providers in the d e l i v e r y of s e r v i c e s . I t has been
very i n t e r e s t i n g and encouraging to me to watch other organizations
reach the same conclusions. C a t h o l i c Health Association, f o r
example, studying health care reform f o r two years, issued i t s report
before the President was inaugurated.
I t i s very much along the same
l i n e s as what we are proposing, what i s i n the CSIS d r a f t paper.
Because i f you look at our system, one of the c l e a r e s t needs i s for
i n c r e a s e d coordination and better integrated d e l i v e r y systems, which
we b e l i e v e w i l l be created by the kind of emphasis on i n c e n t i v e for
cooperation through the c r e a t i o n of these accountable h e a l t h plans.
P r e v e n t i v e h e a l t h care w i l l be a major p a r t o f t h e
b e n e f i t s package. T h i s i s a change i n d i r e c t i o n from where we have
come from. And i f one goes back and l o o k s a t t h e h i s t o r y o f how we
got i n t o t h e r a t h e r anomalous s i t u a t i o n o f i n s u r i n g a g a i n s t t h e
d i s e a s e o r t h e c h r o n i c c o n d i t i o n and n o t i n s u r i n g a g a i n s t t h e
p r e v e n t i v e measure, t h e w e l l c h i l d c a r e , t h e o t h e r k i n d o f d i a g n o s t i c
t e s t s t h a t lead t o d i s c o v e r y o f i l l n e s s , i t i s a n a t i o n a l o u t g r o w t h
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�of the e a r l y d e c i s i o n s t o i n s u r e a g a i n s t c a t a s t r o p h i c
which, of course, a l l of us would agree w i t h .
instances
But the r e s u l t of t h a t , going back t o the 1930s w i t h the
very f i r s t p r i v a t e h e a l t h insurance p l a n i s t h a t we worked our way
out of a market f o r p r i m a r y p r e v e n t i v e h e a l t h care. We have t o
c r e a t e t h a t market, we have t o mandate i t as p a r t of the b e n e f i t s
package. We s t r o n g l y agree w i t h you t h a t we must look a t ways of
p r o v i d i n g organized, c o o r d i n a t e d care w i t h i n a budget.
There are a number of laws a t both the s t a t e and f e d e r a l
l e v e l t h a t i n t e r f e r e with competition.
But, more i m p o r t a n t l y ,
i n t e r f e r e with coordination.
We have t o t h i n k about the k i n d of
arrangement of care we need and the best and h i g h e s t use of p r o v i d e r s
w i t h i n those arrangements. And so, l o o k i n g a t changing
a n t i c o m p e t i t i v e p r a c t i c e s or laws i s very i m p o r t a n t . Looking at the
f e d e r a l a n t i t r u s t laws so t h a t c o l l a b o r a t i o n w i l l be p e r m i t t e d
i n s t e a d of p r o h i b i t e d i s key.
•
We a l s o t h i n k , along w i t h you, t h a t once we e s t a b l i s h a
comprehensive b e n e f i t s package -- and we are l o o k i n g a t a package
t h a t i s a p p r o x i m a t e l y what one would expect from the good f e d e r a l l y
q u a l i f i e d HMO,
the Blue Cross-Blue S h i e l d package w i t h the primary
and p r e v e n t i v e care i n i t -- then we have t o be w i l l i n g t o remove tax
d e d u c t i b i l i t y f o r b e n e f i t s above t h a t l e v e l .
So t h a t we w i l l
c o n t i n u e t a x d e d u c t i o n t r e a t m e n t f o r what i s i n the comprehensive
b e n e f i t s package. But a f t e r - t a x d o l l a r s w i l l t h e n be used f o r any
b e n e f i t s or a n c i l l a r y s e r v i c e s beyond t h a t package.
T h i s i s a key p a r t of making i t p o s s i b l e t o extend such
a b e n e f i t s package t o the u n d e r i n s u r e d and the u n i n s u r e d and g i v e
those who are c u r r e n t l y i n s u r e d the s e c u r i t y t h a t even though they
are c u r r e n t l y i n s u r e d , none of us can p r e d i c t whether they w i l l even
be employed next year, l e t alone what t h e i r b e n e f i t s l e v e l w i l l be,
and t h a t they w i l l always have the s e c u r i t y t h a t t h i s l e v e l of
b e n e f i t s w i l l be a v a i l a b l e t o them. And t h a t i t w i l l be a f f o r d a b l e ,
i t w i l l remain w i t h them whether they are employed or unemployed,
because we t h i n k what we need t o do i s t o enhance the e x i s t i n g
employer-employee system by b r i n g i n g Medicaid r e c i p i e n t s i n t o the
same p u r c h a s i n g pools so t h a t t h e r e w i l l be both f e d e r a l and p r i v a t e
money, as w e l l as whatever s t a t e c o n t r i b u t i o n s are r e q u i r e d t o cover
the e n t i r e p o p u l a t i o n .
We, t o o , agree t h a t t h e r e need t o be p u r c h a s i n g
arrangements c r e a t e d t o empower the consumer and t b n e g o t i a t e w i t h
the accountable health plan.
We are r e f e r r i n g t o the e n t i t y t h a t ' s
h e a l t h a l l i a n c e s , because they b r i n g t o g e t h e r i n one e n t i t y consumers
and p r o v i d e r s , businesses, l a b o r -- a l l w i l l be a v a i l a b l e through
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t h a t a l l i a n c e t o n e g o t i a t e f o r the best p o s s i b l e h e a l t h plans
w i l l then be open f o r e n r o l l m e n t by any c i t i z e n .
which
Even i f one c o n t i n u e s t o f i n a n c e h e a l t h care through an
employer-based system, consumers w i l l be f r e e t o e n r o l l i n any
accountable h e a l t h p l a n -- not t h e o n l y one t h a t i s s e l e c t e d by t h e
employer.
C l e a r l y , one of t h e hopes behind our r e f o r m i s t o reduce
the c o s t s and redundancy of h e a l t h care a d m i n i s t r a t i o n , and t h e r e are
a number o f reforms t h a t we b e l i e v e w i l l b r i n g t h a t about.
Community
r a t i n g i s a key which w i l l e l i m i n a t e t h e expensive u n d e r w r i t i n g and
experience r a t i n g procedures c u r r e n t l y d r i v i n g much o f t h e c o s t s .
I f we a r e able t o b r i n g about these h e a l t h care reforms
i n t h e a d m i n i s t r a t i v e areas we w i l l be a b l e t o s t a b i l i z e t h e costs.
-- i t ' s a c h i c k e n and egg issue, how do we g e t t o u n i v e r s a l coverage
w i t h a f f o r d a b l e b e n e f i t s package w h i l e sweeping o u t t h e
a d m i n i s t r a t i v e c o s t s so t h a t those c o s t s can be r e c y c l e d through t h e
economy and even t h r o u g h t h e h e a l t h care system. We have t o proceed,
i n our view, on both f r o n t s a t once.
•
We a l s o b e l i e v e we have t o c r e a t e a framework, as you
have suggested, t o e l i m i n a t e excessive expenses a s s o c i a t e d w i t h
m a l p r a c t i c e l i t i g a t i o n and w i t h d e f e n s i v e medicine t h a t i s d r i v e n by
f e a r s o f such l i t i g a t i o n .
We are a l s o concerned, as you are, about
c r e a t i n g some k i n d o f consensus about t h e a p p r o p r i a t e t r e a t m e n t t h a t
i s a v a i l a b l e i n t h e l a s t months and days o f l i f e .
And Senator
Domenici has a l r e a d y l e f t , but he took a s t e p toward t h i s w i t h the
P a t i e n t S e l f - D e t e r m i n a t i o n Act, i n t h e l a s t Congress I b e l i e v e , and
we t h i n k i t i s a p p r o p r i a t e t o move as you do on encouraging consumers
when they s i g n up f o r h e a l t h plans t o complete a l i v i n g w i l l , or a t
the v e r y l e a s t , t o have t h e k i n d s o f i s s u e s t h a t t h e y may face i n an
emergency s i t u a t i o n e x p l a i n e d t o them so we have b e t t e r informed
d e c i s i o n s being made.
An absolute r e d - l i n e , bottom-line p r i n c i p l e for us i s
that a l l Americans have to be secure.
There should be no prohibition
of health insurance or access to health care to anyone. And the kind
of b e n e f i t s package and the d e l i v e r y of i t w i l l be key to that.
I . r n n l d not say better than what i s s a i d i n your paper
t h a t the p e r f e c t i s the enemy of the good. There i s no way we w i l l
c r e a t e a system e i t h e r that i s p e r f e c t or that w i l l s a t i s f y
everybody. I have thought for quite some time now, perhaps necessity
being the mother of invention, that i f everybody i s a l i t t l e b i t put
out we're probably doing the r i g h t t h i n g .
But we have to look for
the best p o s s i b l e system in order to d e l i v e r that s e c u r i t y which i s
the key to whether or not we w i l l have a s u c c e s s f u l reform.
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We agree t h a t b i o m e d i c a l i n n o v a t i o n and the a p p r o p r i a t e
use of technology and the c o n t i n u e d r o l e of medical research i s
e s s e n t i a l . , because, we t h i n k , i t i s one of the few ways open to us t o
a c t u a l l y improve p r o d u c t i v i t y i n the d e l i v e r y of h e a l t h care. And so
the s u g g e s t i o n s t h a t you i n c l u d e i n your paper about i n n o v a t i o n and
r e s e a r c h are ones t h a t we take very s e r i o u s l y and have had a number
of c o n v e r s a t i o n s w i t h medical research groups, academic medical
c e n t e r s and o t h e r s who are a t the f o r e f r o n t of a s s u r i n g t h a t the
American h e a l t h care system s t a y s on the c u t t i n g edge of the
development of t r e a t m e n t s t h a t w i l l enable us t o d e l i v e r care more
eff i c i e n t l y .
I t i s a l s o a b s o l u t e l y e s s e n t i a l t h a t we c o n t r o l the
growth of f e d e r a l spending f o r h e a l t h c a r e . But i t i s a l s o e s s e n t i a l
t h a t we c o n t r o l the growth of p r i v a t e spending f o r h e a l t h care
because one of the net e f f e c t s of r e d u c i n g f e d e r a l spending, as many
of you who are p r o v i d e r s around t h i s t a b l e know, i s t h a t i t knows up
i n the b i l l s t h a t you and I pay because we c a r r y insurance. And i t
p a r t i c u l a r l y becomes an a d d i t i o n a l burden on the l a r g e employers,
those who are p r o v i d i n g the b u l k of the p r i v a t e money t h a t i s funding
our h e a l t h insurance system. So, yes, we need t o weigh i n and budget
the f e d e r a l c o n t r i b u t i o n , but we a l s o need t o be sure we have some
d i s c i p l i n e t h a t i s imposed t h r o u g h the market on the p r i v a t e sector.
•
And l e t me say a word about t h i s because t h e r e has been
a g r e a t d e a l of c o n v e r s a t i o n about budget i n t h i s s i t u a t i o n and how
budgets do or do not c o r r e s p o n d w i t h c o m p e t i t i o n .
I t i s our view
t h a t we need t o s t a r t w i t h the idea of a budgeted system t h a t i s
based on the average w e i g h t e d premium c o s t t h a t w i l l be paid through
comprehensive b e n e f i t s package. That budget, we b e l i e v e , should
become redundant. I t i s a backstop, i f the market works as we expect
i t t o work. But i n the absence of budget t a r g e t s , of some k i n d of
d i s c i p l i n e as s t a t e s and accountable h e a l t h plans and p r o v i d e r s adapt
t o t h i s new system, we are a f r a i d t h a t the c o n t r o l l i n g of the costs
i n t h e f e d e r a l system w i t h o u t some k i n d of d i s c i p l i n e i n the p r i v a t e
system w i l l f u r t h e r d i s c o u r a g e the k i n d of steps toward more
e f f i c i e n t d e l i v e r y t h a n we have seen i n the l a s t years and put more
p r e s s u r e i n t u r n on the f e d e r a l system.
Fvp.ry t i m e you cap a f e d e r a l e n t i t l e m e n t program i n
h e a l t h c a r e , i n the absence of r e f o r m i n g the market i n the p r i v a t e
s e c t o r , you s h f f t c o s t t o the p r i v a t e s e c t o r , which has a r e s u l t of
e l i m i n a t i n g people from coverage e i t h e r because t h e i r employers no
l o n g e r can p r o v i d e i t , or the co-pay and d e d u c t i b l e become so high
t h e y no l o n g e r p a r t i c i p a t e i n i t , or t h e y get l a i d o f f , or something
e l s e happens t o them. They t h e n j o i n the 100,000 people a month who
l o s e t h e i r i n s u r a n c e . They t h e n f i n d t h e i r way on the p u b l i c r o l l s
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f o r some p e r i o d o f t i n e , which
system.
then busts t h e cap on t h e p u b l i c
T h i s i s a t o t a l system t h a t feeds on each p a r t of i t .
So from our p e r s p e c t i v e we have t o d e f i n e t h e costs w i t h i n t h e
f e d e r a l system a c c o r d i n g t o a formula t h a t i s paid t o what we b e l i e v e
should be t h e budget f o r t h e e n t i r e system, and t h a t we then have t o
do e v e r y t h i n g we can, as I s a i d b e f o r e , t o make t h a t budget w i t h
r e s p e c t t o t h e p r i v a t e s e c t o r l a r g e l y redundant.
I t would only apply
t o t h e comprehensive b e n e f i t s package premium c o s t s . Anything t h a t
i s bought w i t h a f t e r t a x . d o l l a r s would o b v i o u s l y be a v a i l a b l e f o r any
of us t o do whatever we chose t o do w i t h .
But w i t h respect t o how we
t r y t o g e t t h e whole system o p e r a t i n g under some k i n d o f d i s c i p l i n e
u n t i l we t h i n k these reforms can k i c k i n t h i s one o f those areas t h a t
we have t h o u g h t about very hard.
And one of t h e people w o r k i n g w i t h us s a i d , you know,
the t r a d i t i o n a l way of t r y i n g t o r e s t r a i n h e a l t h care costs has been
t o p u t a leash around every cow and t r y t o keep i t i n one spot and
not l e t them move. What we're t r y i n g t o do i s j u s t put a fence
around t h e whole system and l e t people decide w i t h i n i t how they can
a l l o c a t e t h e f e d e r a l l y mandated p a r t o f t h e e x p e n d i t u r e s and t h e
a c c o u n t a b l e h e a l t h plans marketing o f and d e l i v e r i n g o f t h e
comprehensive b e n e f i t s package.
Now, f i n a l l y , I t h i n k i t i s a b s o l u t e l y e s s e n t i a l t h a t we
do e v e r y t h i n g we can t o come up w i t h a system t h a t i s understandable
and workable and i n t h e eyes o f t h e v a s t m a j o r i t y o f Americans, a
p o s i t i v e change from what they have now.
And what we hope to be able to do i s to come up with
such a plan that w i l l be as inexpensive as our e n t i r e economy can
manage to make i t i n terms of both new p r i v a t e sector contributions
and any new revenue. We b e l i e v e that an employer-based system, which
i s what we have now, that has a very wide range of contributions
w i t h i n i t from zero, as you a l l know, to a high -- employer high of
25 percent of p a y r o l l for health b e n e f i t s , but most s t a r t at the
eight to 15 range with the c o s t s going up a t 10 or 11 percent a year
and they're t r y i n g to keep cost i n c r e a s e s down to eight percent.
Most o f us a r e working o f f t h e premise t h a t we are n o t
g o i n g t o r e p l a c e our e x i s t i n g system, we a r e not going t o look f o r
p u b l i c p a s t monies t o r e p l a c e t h e e x i s t i n g k i n d o f c o n t r i b u t i o n t o
the h e a l t h care system. So t h e r e f o r e , how do we c r e a t e a system w i t h
the l e a s t amount o f d i s r u p t i o n and t h e l e a s t amount o f new revenues
r e q u i r e d . And what we are a t t e m p t i n g t o do i s t o c r e a t e a premium
t h a t i s p a i d t o t h i s b e n e f i t s package t h a t w i l l enable most employers
•no c u r r e n t l y p r o v i d e t h e comparable b e n e f i t s t o r e a l i z e c o n s i d e r a b l e
s a v i n g s over t h e next years and those employers who do n o t make any
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c o n t r i b u t i o n now or whose c o n t r i b u t i o n
comprehensive b e n e f i t s package --
i s inadequate
t o fund t h a t
(End Side 1)
(Begin Side 2, i n progress)
-- i n any way pay t h e i r f a i r share now,
ways burden the system t h a t t h e r e s t of us pay f o r .
but who
i n many
So, f i n a l l y , t h i s system i s not going t o be changed by
any wave of a magic wand or any s i l v e r b u l l e t .
I t i s , however, a
system t h a t we're convinced we need t o take a comprehensive approach
t o i n i t i a l l y even i f we choose t o phase i n t h a t approach; r a t h e r than
t a k i n g an i n c r e m e n t a l step now and then hoping f o r an incremental
step l a t e r .
Because t h e r e are t o o many i n t e r a c t i o n s among the
systems not t o t r y t o l a y out an approach t h a t w i l l a f f e c t the very
p i e c e s of i t so t h a t we can watch i t being phased i n , l a r g e l y by the
s t a t e s , through a m a r k e t - d r i v e n approach.
Q
Let's open the f l o o r t o q u e s t i o n s , so why
s t a r t around and whoever has a q u e s t i o n --
don't
we
Q
Thank you so very much f o r being here today.
The
statement t h a t we should not put anymore i n t o the system than we
a b s o l u t e l y have t o t h a t i s a l r e a d y t h e r e , I t h i n k i s what we r e a l l y
need t o do.
So how, when we c o n s i d e r the f a c t t h a t 14 percent of our
g r o s s domestic p r o d u c t now goes t o h e a l t h care, more than any other
i n d u s t r i a l i z e d n a t i o n , something t h a t we -- ( i n a u d i b l e ) -- how can we
j u s t i f y p u t t i n g a d d i t i o n a l money i n , which w i l l make t h a t percentage
even g r e a t e r ?
MRS. CLINTON: W e l l , Congressman, t h i s i s one of those
dilemmas t h a t we are s t u c k w i t h because of our c u r r e n t system. In
o r d e r t o c o n t r o l c o s t s , you have t o have everybody i n t h e system. In
o r d e r t o g e t everybody i n the system, everybody has t o bear t h e i r
f a i r share of t h e r e s p o n s i b i l i t y . At t h i s moment i n t i m e , you have
40 m i l l i o n Americans who do g e t h e a l t h care -- they show up a t our
emergency rooms, as you w e l l know. They get taken care o f , u s u a l l y
a t t h e h i g h e s t c o s t a t t h e l a s t p o s s i b l e moment.
We are unable, t h e r e f o r e , t o c o n t r o l t h e i r access and
usage of t h a t system. I n a d d i t i o n , we have a p u b l i c system t h a t goes
up and down based on p o l i t i c a l d e c i s i o n s as opposed t o being
i n c o r p o r a t e d w i t h i n t h e broader market system. And we see i t going
up and down depending upon d e c i s i o n s t h a t are made t h a t o f t e n impact
a d v e r s e l y on t h e c o s t s then i n the p r i v a t e system. So we t h i n k i t ' s
a chicken-and-egg k i n d of a problem.
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I f we can g e t everybody i n t o t h e system w i t h a r a t h e r
l i m i t e d new amount o f money t h a t comes p r i m a r i l y from t h e p r i v a t e
s e c t o r , which i s t h e primary funder now, b u t which f o r t h e f i r s t time
e x p e c t s everyone t o p a r t i c i p a t e , then we w i l l a c t u a l l y begin t o see
the k i n d s o f . c o s t s savings t h a t can come from a d m i n i s t r a t i v e savings
and from b e t t e r u t i l i z a t i o n of t h e e x i s t i n g system.
1
I t w i l l be a g r e a t accomplishment f o r our economy i f we
i n t h e f i r s t years f r e e z e our GDP percentage a t i t s c u r r e n t r a t e ,
because r i g h t now we are l o o k i n g a t moving t o 19 percent by t h e end
of t h i s decade. So i f we can f r e e z e and then move down, t h a t would
be t h e most l i k e l y and l e a s t d i s r u p t i v e way o f g e t t i n g t h i s s i t u a t i o n
under c o n t r o l .
•
Q
I'm w i t h an o r g a n i z a t i o n c a l l e d Georgia H e a l t h -( i n a u d i b l e ) -- i n a community-based e f f o r t i n understanding some of
the problems i n our s t a t e . One o f my f e a r s and one t h a t we hear over
and over again i s t h e lack of i n f r a s t r u c t u r e i n much o f t h e r u r a l
areas o f our c o u n t r y . I t ' s t r u e i n Georgia, and i t ' s t r u e across t h e
nation.
There's a l s o a major i n f r a s t r u c t u r e problem i n some o f our
i n n e r urban areas a l s o .
I t would seem t h a t even though I c e r t a i n l y
u n d e r s t a n d t h a t we a l l do t h e deed f o r f i s c a l r e s t r a i n t , t h e r e ' s
g o i n g t o need t o be some i n f u s i o n o f c a p i t a l from somewhere t o
p r o v i d e t h e b r i c k s , t h e m o r t a r , t h e b u i l d i n g s t o people t o go o u t and
d e l i v e r t h e care where i t j u s t simply i s n ' t r i g h t now. I wonder i f
you have any comment on t h a t .
MRS. CLINTON: Yes, s i r . We a b s o l u t e l y agree w i t h t h a t
-- t h a t t h e underserved urban and r u r a l areas have g o t t o be g i v e n a
h e a l t h care i n f r a s t r u c t u r e and personnel i n o r d e r f o r u n i v e r s a l
coverage and c o s t containment t o work. And we have s e v e r a l
approaches t o t h a t . We do t h i n k t h a t t h e f e d e r a l government w i l l
have t o r a i s e some funds i n o r d e r t o beef up t h e p u b l i c h e a l t h
infrastructure.
We a l s o b e l i e v e t h a t t h e accountable h e a l t h p l a n s w i l l
have t o u t i l i z e those e x i s t i n g s t r u c t u r e s i n o r d e r t o serve t h e
p o p u l a t i o n t h a t t h e y ' r e g o i n g t o be b i d d i n g on t o serve. And they
w i l l an i n c e n t i v e t o do t h a t , which they don't c u r r e n t l y have, which
i s a reimbursement stream, so t h a t t h e l e v e l o f uncompensated care
t h a t o f t e n burdens -inner c i t y and r u r a l p r o v i d e r s , w i l l be
dramatically l i f t e d .
I'm n o t going t o say i t w i l l be e l i m i n a t e d ,
because we won't know how t h i s a l l works u n t i l we g e t i n t o i t . But I
do know i t w i l l be d r a m a t i c a l l y reduced; so t h a t t h e r e w i l l be f o r
t h e f i r s t t i m e i n many years a much f a i r e r r e t u r n . f o r those people
who a r e a c t u a l l y w i l l i n g t o d e l i v e r t h e care i n those underserved
areas.
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A d d i t i o n a l l y , we have t o look f o r ways t o make i t
a t t r a c t i v e f o r p h y s i c i a n s , nurses and o t h e r medical personnel t o
p r o v i d e care i n those areas.
And our plans t h e r e range from
e v e r y t h i n g from p r o v i d i n g a much broader loan f o r g i v e n e s s and loan
program f o r people who are w i l l i n g t o serve i n those areas, t o a
h i g h e r reimbursement r a t e by encouraging plans t o be able t o provide
s e r v i c e s i n those areas and l o o k i n g a t some of t h e models t h a t have
worked, t o b e t t e r use of technology, because i t ' s n o t j u s t a q u e s t i o n
of pay, i t ' s a l s o a q u e s t i o n of p r o f e s s i o n a l i s o l a t i o n and the l i k e .
And we are very encouraged by how these k i n d s of
networks o f c o o p e r a t i o n i n which r u r a l and inner c i t y p r a c t i t i o n e r s
would become a p a r t would help t o c r e a t e a c l i m a t e i n which they were
much b e t t e r supported, could p r o v i d e b e t t e r care, i n which
reimbursements would f l o w t o them. So we've t h o u g h t very c a r e f u l l y
about t h a t and t h i n k we've g o t t o wade through t h e system t o fund i t
and t o c o n t i n u e t o p r o v i d e i t .
•
Q
I a p p r e c i a t e very much t h e l o g i c and care which
you've l a i d out t h e problem and p r i n c i p l e s .
I ' d l i k e t o ask a
g u e s t i o n about process.
And t h a t i s , by what process do you
a n t i c i p a t i n g i n d e t e r m i n i n g t h e coverage c o n t a i n e d i n t h e
comprehensive package, i n c l u d i n g d e d u c t i b l e s , copayments and so
f o r t h , s i n c e I would assume and I b e l i e v e t h a t t h a t w i l l s t r o n g l y
i n f l u e n c e t h e c o s t , even I hope t h e c a l c u l a t e d budget premiums and so
f o r t h i n such m a t t e r s as d e d u c t i b l e s , copayments, even i f t h e f e d e r a l
government takes care of. them o r reduces them f o r poor people --•
a c t u a l l y have been shown I t h i n k by t e s t s t o have a s u b s t a n t i a l
e f f e c t on t h e c o s t o f t h e program.
MRS. CLINTON: You're a b s o l u t e l y r i g h t about t h e
b e n e f i t s package and i t s cost being t h e key t o a l l o f t h i s . And i t
has been probably t h e most c o m p l i c a t e d t a s k we have faced among many.
J u s t as an a s i d e , which I t o l d s e v e r a l o f t h e s e n a t o r s -- Senator
Lieberman and o t h e r s here probably heard me say t h i s b e f o r e -- but
one o f t h e f i r s t t a s k s t h a t we d i d was t o g e t i n t o one room a l l the
f e d e r a l government a c t u a r i e s who d e a l t w i t h t h e c o s t p r o j e c t e d on
h e a l t h care programs t h a t were r u n by or funded by t h e f e d e r a l
government. They had never been a t a meeting b e f o r e ever.
And i f you wonder why we have problems i n America and i n
our government_4iis.t t h i n k about how d r i v i n g a f a c t o r h e a l t h care
c o s t s have been i n t h e l a s t 10 years i n every budget t h a t has ever
been p u t t o g e t h e r ; and t h e a c t u a r i e s have never met b e f o r e I g o t
t o g e t h e r i n a room. And they've been meeting c o n t i n u a l l y since then.
And t h e y , along w i t h an o u t s i d e panel o f a c t u a r i e s whom
we've convened, have worked very hard t o c o s t o u t t h e b e n e f i t s
package. I t w i l l i n c l u d e copays, and i t w i l l i n c l u d e d e d u c t i b l e s ,
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because most of t h e a c t u a r i a l matters and as a matter of personal
r e s p o n s i b i l i t i e s , we t h i n k t h a t t h e i m p o r t a n t p a r t o f t h e whole
approach t o r e f o r m i n g h e a l t h care. We are t r y i n g t o keep t h e c o s t s
as low a s . p o s s i b l e . So we are l o o k i n g very hard a t t h e b e n e f i t s and
i n t h e c o s t s of them.
But we have a problem, which I never knew was a problem
u n t i l I came t o Washington, and t h a t ' s c a l l e d something c a l l e d
s c o r a b i l i t y . And when one presents a budget t o t h e f e d e r a l
government, we end up w i t h these kinds o f arcane o r -- maybe t h e y ' r e
not arcane, t h e y ' r e j u s t r u l e s of budgeting I ' v e never encountered i n
my p r i o r l i f e b e f o r e -- i n which issues l i k e c o m p e t i t i o n and t h e
savings from c o m p e t i t i o n are not g i v i n g any weight whatsoever.
And so we have t r i e d very hard t o come up w i t h a
b e n e f i t s package t h a t i s a reasonable package t h a t most Americans who
are i n s u r e d w i l l f e e l good about, and which i s a f f o r d a b l e on
a c t u a r i a l t a b l e s and which i n a m a r k e t - d r i v e n system w i l l generate
savings t h a t are r e a l t h a t can be f i l e d back, t o go back t o Dr.
Roland's p o i n t , even i f . t h e y can't be scored i n t h e f e d e r a l budget.
•
So t h a t ' s t h e key t o t r y i n g t o keep -- t h i s i s t h e
c e n t e r p i e c e of making a l l t h i s happen, as Dr. Brown c l e a r l y p u t h i s
f i n g e r on. And we t h i n k we're going t o come up w i t h a b e n e f i t s
package t h a t i s comparable t o what a f e d e r a l l y q u a l i f i e d HMO would
o f f e r , an average Blue Cross-Blue S h i e l d p o l i c y , which we t h i n k i s
p r e t t y good t o be a v a i l a b l e t o t h e e n t i r e c o u n t r y . I t won't make
everybody happy, because some people, as you know, have f i r s t d o l l a r
coverage and a l o t more b e n e f i t s . But we t h i n k as a n a t i o n a l
guarantee package i s c e r t a i n l y one t h a t should be supported.
Q
You mentioned personal r e s p o n s i b i l i t y , and a l o t of
the h e a l t h problems and a l o t of -- (inaudible) -- r e s p o n s i b i l i t y .
I s there some way of incorporating in t h i s formulation a d i s i n c e n t i v e
for -- (inaudible) -- or an incentive for l i v i n g -- (inaudible.)
MRS. CLINTON: I joked t h e o t h e r day t h a t i f t h e r e were
a way t o do t h a t , i t would probably be a disadvantage, because t h e
a c t u a r i e s would then c l a i m people would l i v e longer and i t would cost
more. So, I mean, i t ' s l i k e -- t h i s i s l i k e a never-ending s e t o f
i s s u e s . But we do want t o discourage u n h e a l t h y b e h a v i o r . And one of
the reasons we,are l o o k i n g a t f u n d i n g t h e p u b l i c h e a l t h
i n f r a s t r u c t u r e t h r o u g h some o f t h e r e s e a r c h improvements t h a t we're
t h i n k i n g o f , t h r o u g h a combination o f tobacco and l i q u o r i s because
we do t h i n k t h a t ' s sends a d i s i n c e n t i v e .
Now, I'm a l s o h o p e f u l t h a t once we g e t t h i s system up
and r u n n i n g , we w i l l begin t o look a t some o f t h e o t h e r ways we could
provide i n c e n t i v e s f o r healthy kinds of behavior.
I t i s n o t easy t o
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b u i l d those i n t o the b e n e f i t s package or t o r e a l l y m o n i t o r them
carefully.
But I'm h o p e f u l t h a t once we are r u n n i n g , t h e accountable
h e a l t h p l a n , w e ' l l be able b e t t e r t o compete on t h e b a s i s o f what
k i n d s o f a d d i t i o n a l s e r v i c e s t h e y ' r e able t o a f f o r d because they get
t h e c o s t s o f t h e b e n e f i t s package down, which w i l l keep those people
who e n r o l l i n them cheaper, which w i l l have the b e n e f i t t h a t you're
t a l k i n g about.
But we do t h i n k t h a t c i g a r e t t e s and a l c o h o l are key
t o p r e v e n t a b l e h e a l t h care, and t h a t we need t o take a look a t those
f o r sources of funds.
Q
J u s t f o l l o w i n g up a q u e s t i o n , I wonder i f I could
suggest -- ( i n a u d i b l e ) -MRS. CLINTON: What you ask -- and I had a meeting
y e s t e r d a y w i t h 25 p h y s i c i a n s and o t h e r h e a l t h care p r o v i d e r s from
Houston w i t h Congressman Andrews. And Red Duke, t h e TV d o c t o r , was
t h e r e , and he s a i d t h a t he b e l i e v e s t h a t we c o u l d have a massive
p u b l i c e d u c a t i o n campaign on a c c i d e n t p r e v e n t i o n and o t h e r community
p u b l i c h e a l t h problems, i t would be one o f the q u i c k e s t ways t o c u t
our c o s t s . And he has some p r o p o s a l t h a t we're going t o t r y t o
implement through t h i s k i n d o f process of c r e a t i n g models and then
d i s t r i b u t i n g them t o s t a t e s t h r o u g h t h e i r a l l i a n c e s and t h e i r h e a l t h
p l a n s so t h a t we can a c t u a l l y do e x a c t l y what you're s a y i n g , because
t h a t i s where t h e r e are huge savings a v a i l a b l e i f we can change
community a c t i v i t i e s as w e l l as i n d i v i d u a l behavior.
•
Q
H i l l a r y , you haven't s a i d a n y t h i n g about t h e drug
i n d u s t r y y e t . Do you envisage i t being p a r t o f t h e b a s i c package?
And secondly, do you envisage i n t e r i m p r i c e c o n t r o l s f o r t h a t
industry?
MRS. CLINTON: W e l l , we do envisage t h e i r being a
p r e s c r i p t i o n drug b e n e f i t t h a t would be p a r t o f t h e b a s i c package as
w e l l as p a r t of Medicare. Again, i t would have a c o s t a t t a c h e d t o
i t , b u t we t h i n k a reasonable c o s t . That would p r o v i d e a s i g n i f i c a n t
i n c r e a s e i n t h e f u n d i n g a v a i l a b l e f o r p r e s c r i p t i o n drugs, i f we're
a b l e t o g e t t h i s a c t u a r i a l l y squared w i t h what we t h i n k our
a f f o r d a b l e costs are.
On t h e i s s u e o f p r i c e c o n t r o l s , t h i s i s one o f t h e more
e m o t i o n a l and t h o r n y issues t h a t c o n f r o n t us, because t h e r e are many
who, f r a n k l y , b e l i e v e t h a t i n t h e absence o f some k i n d o f p r i c e
r e s t r a i n t -- whether i t be f r e e z e s , c o n t r o l s , r a t e s e t t i n g s -- t h a t
t h e c o m p e t i t i v e " system alone i s inadequate, a t l e a s t i n t h e s h o r t
run, t o d e a l w i t h t h e k i n d s o f c o s t s t h a t are b u i l t i n t o t h e system.
And t h e r e o t h e r s -- and you know t h e arguments very w e l l
-- t h a t i t d i s t o r t s the.market, i t l e a k s , i t doesn't work -- I mean,
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t h e r e are arguments on both sides and I don't t h i n k i t w i l l ever be
f u l l y r e s o l v e d t o anybody's t o t a l s a t i s f a c t i o n .
But I do t h i n k t h a t i t would be very h e l p f u l f o r us t o
t r y t o c r e a t e an environment i n which v o l u n t a r y a c t i o n on the p a r t of
p r o v i d e r s was p a r t of our i n i t i a l p r e s e n t a t i o n of t h i s package. That
would i n c l u d e the drug manufacturers and everyone e l s e . I've had
c o n v e r s a t i o n s w i t h some of the manufacturers, I've had conversations
w i t h o t h e r e n t i t i e s who r e p r e s e n t major p a r t s of the h e a l t h care
system who seem t o be moving towards a w i l l i n g n e s s t o t a l k about
v o l u n t a r y r e s t r a i n t , some k i n d of f r e e z e , however i t could be
structured.
There might a l s o , though, need t o be i n the l e g i s l a t i o n
some k i n d of t r i g g e r f o r t h i s t r a n s i t i o n p e r i o d t h a t would help
e n f o r c e t h a t i n t h e event t h a t we were unable t o achieve the kinds of
i n i t i a l savings t h a t we t h i n k w i l l h e l p fund the whole system.
There's been no f i n a l d e c i s i o n on t h a t . T h i s i s something we welcome
everybody t o weigh i n on.
I t i s h i g h l y e m o t i o n a l . I t ' s hard t o k i n d
of c u t t h r o u g h t h e emotion t o get t o what a c t u a l l y would or would not
work. But i n any event, we would o n l y be l o o k i n g a t e i t h e r a
v o l u n t a r y system or a system w i t h a t r i g g e r f o r a very s h o r t
t r a n s i t i o n p e r i o d . We want t o s t a b i l i z e the system.
•
And one of the b i g problems we've g o t i s the huge
d i f f e r e n t i a l i n p r a c t i c e p a t t e r n s and c o s t s around the c o u n t r y . I
mean, i f you can p i c k an average and t r y t o say t h i s i s the average
h o s p i t a l c o s t , t h e i s the average p h y s i c i a n c o s t f o r t h i s k i n d o f
p r o c e d u r e , you l i t e r a l l y have a 100 p e r c e n t v a r i a t i o n on both sides
of t h a t average a t work r i g h t now.
And i t i s something t h a t you
cannot o v e r n i g h t change those p r a c t i c e p a t t e r n s and e l i m i n a t e the
excess c o s t s i n those systems i n many p a r t s o f t h i s c o u n t r y .
But
w i t h o u t some d i s c i p l i n e , i t w i l l take longer than we might have i n
o r d e r t o g e t ahead o f the curve. So those are t h e k i n d s of issues
we're s t r u g g l i n g w i t h .
Q
The q u e s t i o n I have i s t o a d m i n i s t r a t i v e c o s t s .
C u r r e n t l y , i n some s t a t e s , my h o s p i t a l s w i l l i n a year undergo a
Medicare i n s p e c t i o n , j o i n t -- ( i n a u d i b l e ) -- i n s p e c t i o n a Department
of H e a l t h i n s p e c t i o n , a Department of Mental H e a l t h i n s p e c t i o n and a
CHAMPUS i n s p e c t i o n . And a l o t of t i m e s , being i n s p e c t e d , w e ' l l spend
hundreds o f thousands of d o l l a r s and hours d e a l i n g w i t h those and
when we s h o u l d lie d e l i v e r i n g care. My q u e s t i o n t o you i s what are
the c e r t i f i c a t i o n f o r p r o v i d e r empowerments you e n v i s i o n from the
a l l i a n c e s and t h e h e a l t h p l a n s , or i s t h i s going t o be another l a y e r
of l i f e i n s u r a n c e c e r t i f i c a t i o n t h a t p r o v i d e r s have t o deal w i t h and
adds a d m i n i s t r a t i o n costs?
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.MRS. CLINTON: W e l l , the answer b e t t e r be no.
Otherwise, we won't have done our j o b . What we t h i n k i s t h a t much of
what you now are s u b j e c t e d t o i n terms of m o n i t o r i n g and checkers
checking checkers and u t i l i z a t i o n review and the l i k e , d e r i v e s from a
r e g u l a t o r y model t h a t attempted t o micromanage the d e l i v e r y of h e a l t h
care.
With a c a p i t a t e d model -- w i t h some k i n d of budget backup, so
t h a t people know when t h e y ' r e running up a g a i n s t the l i m i t s of what
we as a c o u n t r y or Georgia as a s t a t e i s w i l l i n g t o pay f o r h e a l t h
care, we t h i n k b e t t e r d e c i s i o n s w i l l be made and we a l s o b e l i e v e ,
f r a n k l y , q u a l i t y w i l l be enhanced. Because f o r every d o c t o r t h a t a
h o s p i t a l has been able t o h i r e i n the l a s t two years, they've had t o
h i r e f o u r a d m i n i s t r a t o r s i n order t o do e x a c t l y what you j u s t
described.
So c u t the d i f f e r e n c e -- g i v e us two d o c t o r s and another
t r a i n e d nurse and y o u ' l l get b e t t e r care a t l e s s c o s t and l e s s hassle
probably.
So, yes, we t h i n k t h a t t h i s c a p i t a t e d , market approach
w i l l e l i m i n a t e much of what you are now p u t t i n g up w i t h .
You w i l l
s t i l l have t o r e p o r t -- ( i n a u d i b l e ) -- compile the k i n d of r e p o r t
card mechanism t h a t w i l l enable the h e a l t h plan and then t h e consumer
t o make good d e c i s i o n s . But t h a t we t h i n k i s a minor burden t h a t
w i l l be much more e a s i l y borne compared t o what you're having t o do
now.
Q
I'm very i n t r i g u e d w i t h the proposals t h a t are
being made because tough c o m p e t i t i o n reduces c o s t s . And I a l s o
understand the n e c e s s i t y t o a l l o w the s t a t e s t o make i n d i v i d u a l
d e c i s i o n s about t h e i r own h e a l t h care programs. Having spent q u i t e a
b i t o f t i m e i n Canada, I'm very f a m i l i a r w i t h the s i n g l e payor
system. And I wonder about the c o m p a t i b i l i t y of s i n g l e payor system
w i t h t h e n o t i o n of c o m p e t i t i o n amongst t h e k i n d of h e a l t h plans.
And
I was j u s t wondering i f t h e r e ' s any way -- or i f you've thought about
t h a t problem and what your views on i t are.
MRS. CLINTON: I think that the s i n g l e payor system can
be viewed as e i t h e r a s i n g l e payor financing system or a s i n g l e payor
government-driven d e l i v e r y system. And what a number of governors
have s a i d to us, p a r t i c u l a r l y of smaller s t a t e s with very r u r a l
populations, i s they don't have any idea how they can generate the
kind of competition among accountable health plans that I presume
w i l l be a v a i l a b l e in Atlanta or Chicago or most of the l a r g e r areas.
So they are asking for the option of being able to
provide a system within t h i s plan that i s close to a d e l i v e r y system
that i n t e g r a t e s a l l of t h e i r e x i s t i n g providers.
So that, for
example, Montana, with a Republican governor, has j u s t passed a piece
of l e g i s l a t i o n s e t t i n g up a commission to determine whether my payor
should be a multi-payor or a s i n g l e payor system. They have 800,000
people i n that huge land mass. Their primary medical center i s
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Billings.
They b e l i e v e t h a t they c r e a t e a system t h a t creates
c o l l a b o r a t i o n i n B i l l i n g s among t h e i r t e r t i a r y and secondary care
f a c i l i t i e s , they w i l l then be able t o c o n t r a c t o u t , those f a c i l i t i e s
w i l l , out i n t o the areas t h a t are very r u r a l w i t h l o t s of need.
I don't know t h a t they would consider t h a t a s i n g l e
payor system under the Canadian model, but I t h i n k they would
c o n s i d e r i t , given t h e i r circumstances, the best they could probably
put t o g e t h e r i n one, maybe two, accountable h e a l t h p l a n s . But t h a t ' s
something we want t o l e t them have a choice i n making. I t w i l l not
change t h e amount of money t h a t goes i n t o the system. They w i l l
s t i l l have t o p r o v i d e the same b e n e f i t s package and consumers w i l l
s t i l l have some choice i n d e t e r m i n i n g what the outcome- i s . But we
don't b e l i e v e from the f e d e r a l government we're i n a p o s i t i o n t o say
t o Montana, you've got t o do e x a c t l y what Chicago does, and i f you
don't have c o m p e t i t i o n , get out t h e r e and c r e a t e i t somehow. We j u s t
don't t h i n k t h a t w i l l work.
So we're g o i n g t o t r y t o p r o v i d e enough f l e x i b i l i t y
t h a t s t a t e s can make some of those d e c i s i o n s on t h e i r own.
so
Q
We promised t o get Mrs. C l i n t o n out a t 3:00
p.m.,
and she's been very g r a c i o u s w i t h her time. Let me get two more
q u e s t i o n s . And then I t h i n k i f you have more t i m e , we w i l l respect
your schedule, and l e t t h a t be the end of the q u e s t i o n s .
•
Q
The q u e s t i o n I ' d l i k e t o ask g e t s back t o your
speech b e f o r e Johns Hopkins about a week or so -- two weeks ago, and
a f t e r t h a t -- ( i n a u d i b l e ) -- a l s o a major source of progress and -( i n a u d i b l e ) -- I n a w o r l d t h a t i s l a r g e l y composed of accountable
h e a l t h plans w i t h t h i s c o m p e t i t i o n , t h e r e ' s some q u e s t i o n as t o
whether or not academic h e a l t h c e n t e r s can s u r v i v e . As we now note,
t h e r e ' s a l s o some q u e s t i o n as t o whether they should s u r v i v e -(inaudible).
Are you c o n t e m p l a t i n g -- i s the t a s k f o r c e contemplating
a s e p a r a t e mechanism f o r f i n a n c i n g academic h e a l t h c e n t e r s t o some
s o r t o f a pooled fund or w i l l they be s u b j e c t t o t h e p r i c e s as
computed -- ( i n a u d i b l e . )
MRS. CLINTON: No.
We b e l i e v e t h a t academic h e a l t h
c e n t e r s and th«—comprehensive cancer c e n t e r s and some of the o t h e r
f r e e s t a n d i n g t e r t i a r y care f a c i l i t i e s t h a t are a t t h e h i g h end of the
system should be supported by the e n t i r e p o p u l a t i o n so t h a t t h e r e
w i l l be a p o o l i n g o f funds t o be able t o support those. Now, as you
w e l l know, academic h e a l t h c e n t e r s have a v a r i e t y o f missions. They
have a r e s e a r c h -- i m p o r t a n t research mission which w i l l have t o have
c o n t i n u e d h e l p from t h e f e d e r a l government, and I would argue,
i n c r e a s i n g our r e s e a r c h c a p a c i t y and commitment w i l l be a very good
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i n v e s t m e n t t h a t w i l l save us money i n t h e long run i f we're able t o
do t h a t .
So we want t o have a funding s t r a i n t h a t supports t h a t .
Secondly, they have an o b l i g a t i o n t o t r a i n medical
s t u d e n t s , and we do have t o make some changes t h e r e . The c u r r e n t
imbalance between s p e c i a l i s t s and g e n e r a l i s t s cannot c o n t i n u e i f we
expect t o have a h e a l t h care system t h a t puts an emphasis on primary
and p r e v e n t i v e h e a l t h care. So we have t o change some of t h e
i n c e n t i v e s t h a t go i n t o medical e d u c a t i o n .
And t h e n , t h i r d l y , most academic h e a l t h c e n t e r s take
c a r e o f p a t i e n t s . They run emergency rooms o f t e n and they c e r t a i n l y
t a k e c a r e o f p h y s i c i a n - r e f e r r e d p a t i e n t s as w e l l as, i n Johns Hopkins
case, s e r v i n g as t h e p r i m a r y care g i v e r f o r low income areas.
So i n our c o n v e r s a t i o n s w i t h them, they have taken t h e i r
r e s p e c t i v e mission and looked a t them as independents t o some e x t e n t
because i t very w e l l c o u l d be t h a t you might have a Johns Hopkins
a c c o u n t a b l e h e a l t h p l a n , j u s t as Mayo's i s now doing i n Minnesota.
So t h a t Johns Hopkins would be the t e r t i a r y care c e n t e r and might
even, t h r o u g h medical s t u d e n t s and o t h e r s , help t o s t a f f c l i n i c s , but
a l s o might c o n t r a c t w i t h l o c a l p h y s i c i a n s and even c o n t r a c t w i t h some
independent h o s p i t a l s .
I mean, t h a t i s an o p t i o n t h a t many o t h e r
m e d i c a l c e n t e r s are l o o k i n g a t .
•
Or they might be part of an integrated network that
somebody e l s e runs, but they would be the r e f e r r a l place. So there
are a number of a v a i l a b l e ways for the independent functions of the
academic health centers to be funded and to be delivered. And I'm
d e l i g h t e d at the r e s u l t of the conversations we've been having with
them because I think they're beginning to understand t h e i r
o p p o r t u n i t i e s and not j u s t the changes that they're facing.
Q
You mentioned the term -- (inaudible) — and
market-oriented health care on a number of occasions. Have you
thought about what would happen -- (inaudible) — but have Medicare,
which i s c l e a r l y not e i t h e r capitated or market-oriented, going on
for the over 65? I don't know whether you or members of the task
f o r c e have given thought about what i f anything to do with Medicare,
how soon i t would even need to be done, and f i n a l l y , whether the
types of changes you envision in the under 65 population would occur
-- ( i n a u d i b l e )
MRS. CLINTON: We've given l o t s of thought to that
because i t ' s one of the key phase-in i s s u e s . I personally favor the
eventual phase-in of Medicare into the e n t i r e system. And I think
t h a t t h a t w i l l happen. But in the short-run, while we're t r y i n g to
get the a l l i a n c e -- (inaudible) -- running, while we're t r y i n g to
deal with the problems of the insured and the uninsured, our
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p e r s p e c t i v e has been we need t o get t h i s system r u n n i n g . Because as
much as people complain about the Medicare system -- and I always get
two r e a c t i o n s when I speak t o groups of s e n i o r c i t i z e n s . I ask i f
they t h i n k i t c o u l d be done b e t t e r , and of course, they a l l y e l l and
c l a p and say i t can. And then I ask i f they want t o g i v e i t up
immediately and t r y something d i f f e r e n t , t h e r e ' s a r e l u c t a n c e t h e r e .
Because they've got i t and the r e s t of us don't, as we a l l know.
But I t h i n k t h a t i n the t r a n s i t i o n t o an a l l i a n c e - b a s e d
system t h a t d e l i v e r s care t o the under 65 -- and one t h i n g we're
c o n s i d e r i n g i s making the a l l i a n c e s a v a i l a b l e t o Medicare r e c i p i e n t s
who c o u l d choose t o go i n and purchase an a c c o u n t a b l e h e a l t h plan
w i t h some t r a n s f e r of funds from Medicare i n t o t h e a l l i a n c e ; and
depending upon where the b e n e f i t s package ends up, w i t h perhaps a
s u p p l e m e n t a l , i t would go i n t o the a l l i a n c e i n o r d e r t o pay f o r any
a d d i t i o n a l b e n e f i t s t h a t would be o t h e r w i s e u n a v a i l a b l e i n Medicare
-- we t h i n k we can prove over the .course of s e v e r a l years t h a t t h i s
system w i l l work. And we s t r o n g l y b e l i e v e t h a t Medicare ought t o be
a p a r t of i t .
We don't t h i n k we can b i t e t h a t a l l o f f a t once, which
i s why i t ' s very i m p o r t a n t t o continue t o do a l l we can t o c o n t r o l
e x p e n d i t u r e s w i t h i n t h e Medicare system and stop t h e c o s t s h i f t i n g so
t h a t we can g e t t o a p h a s i n g - i n of Medicare e v e n t u a l l y as w e l l .
(Lunch break.
End of tape.)
•
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�THE WHITE HOUSE
O f f i c e of t h e Press S e c r e t a r y
For Immediate Release
June 18,
1993
REMARKS BY THE FIRST LADY
Woodstock, Vermont
MRS. CLINTON: Thank you. (Applause.)
Thank you very
much. Thank you f o r t h a t k i n d i n t r o d u c t i o n and thank you f o r h o l d i n g
t h i s meeting i n Woodstock, Vermont. I t i s a g r e a t pleasure f o r me t o
be back i n Vermont and t o have a chance t o see some o f you. And I
hope l a t e r i n t h e a f t e r n o o n t o have a chance t o v i s i t w i t h some of
the c i t i z e n s here i n t h i s community.
•
I a l s o want t o thank Governor W a l t e r s , as t h e c h a i r of.
the Democratic Governors A s s o c i a t i o n , f o r i n v i t i n g me t o speak w i t h
you and w i t h t h e governors today. And i t i s p a r t i c u l a r l y f i t t i n g
t h a t t h i s meeting would be h e l d i n Vermont, because i t i s a s t a t e
t h a t has done more than j u s t t a l k about t h e importance o f h e a l t h care
r e f o r m . I t has been o u t f r o n t on t h i s i s s u e , and has p u t f o r w a r d
some o f t h e most f o r w a r d - t h i n k i n g p r o p o s a l s t h a t we have been able t o
review and analyze, t h a t would move our c o u n t r y toward expanding
coverage f o r a l l c i t i z e n s and l o w e r i n g c o s t s . And i t i s no s u r p r i s e
t h a t Vermont i s i n t h i s p o s i t i o n .
For years, Senator Leahy has been f i g h t i n g t o improve
h e a l t h c a r e , and has p a r t i c u l a r l y argued s t r o n g l y about t h e r o l e of
s t a t e s i n i m p r o v i n g h e a l t h care and how i m p e r a t i v e i t i s t o move on
r e f o r m i n g h e a l t h care now. And I p e r s o n a l l y have b e n e f i t t e d a g r e a t
d e a l from my r e l a t i o n s h i p w i t h Senator Leahy and t h e work t h a t he has
been w i l l i n g t o do w i t h me. And I am very g r a t e f u l f o r t h a t .
And a t t h e same t i m e , i t i s always a p l e a s u r e t o have a
governor l i k e your governor, Governor Dean, who f i g h t s hard from the
p e r s p e c t i v e n o t o n l y o f a governor and someone who has t o make these
hard d e c i s i o n s , b u t f o r him, h e a l t h care r e f o r m h i t s very c l o s e t o
home. As a p h y s i c i a n , he has l i v e d w i t h t h e problems o f today's
patchwork system.
He has seen t h e people who have been l e f t out. He
has d e a l t w i t h t h e problems o f a p r a c t i t i o n e r .
He and h i s w i f e ,
Judy, stand o u t as examples o f what t h e medical p r o f e s s i o n should be
about -- people d o i n g t h e i r best t o care f o r those i n need. And I've
l e a r n e d a g r e a t d e a l about t h i s issue from Governor Dean, and I am
very g r a t e f u l f o r t h a t .
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-
Before I go any f u r t h e r on h e a l t h care reform, however,
I want t o announce something of g r e a t importance t o the s t a t e of
Vermont. I was informed l a t e l a s t n i g h t by t h e Department of Labor
t h a t two emergency a p p l i c a t i o n s t o a s s i s t d i s l o c a t e d workers here i n
Vermont have been approved. And I wanted t o come and announce t h a t
today because t h e r e are hundreds of workers a t IBM and a t St.
Johnsbury who would o t h e r w i s e not know today t h a t they were going t o
get some a s s i s t a n c e when they have been l a i d o f f .
(Applause.)
The two g r a n t s t o t a l $1,225,000 and they w i l l a s s i s t
a p p r o x i m a t e l y 800 d i s l o c a t e d workers. And I t o l d Senator Leahy and
Senator J e f f o r d s and Congressman Sanders, a l l of whom I f l e w up w i t h
today from Washington, t h a t the a d m i n i s t r a t i o n was v e r y committed t o
c o n t i n u e t h e k i n d of economic e f f o r t s t h a t i t has s t a r t e d i n
Washington so t h a t we could i n the f u t u r e see fewer of these kinds of
a b r u p t changes t h a t throw people out of work who have been working
hard a l l o f t h e i r l i v e s .
And what we hope t o do i s t o have the kind
of p a r t n e r s h i p w i t h the s t a t e s and l o c a l communities, w i t h new
l e a d e r s h i p on t h e economic f r o n t i n Washington t h a t enables us not
j u s t t o h e l p d i s l o c a t e d workers, but t o l o c a t e more and more people
i n jobs t h a t w i l l not be d i s l o c a t e d i n t h e g l o b a l economy t h a t we are
confronting.
So I am d e l i g h t e d t o be of a s s i s t a n c e i n announcing
t h i s g r a n t t o make i t c l e a r t o Vermont t h a t Washington does know
where you a r e , Governor, and Washington cares about t h e people of
Vermont.
(Applause.)
•
Because, you know, our n a t i o n ' s c o m p e t i t i v e n e s s
u l t i m a t e l y r e s t s on t h e s k i l l s and t a l e n t s of our people. And i f we
do not have a work f o r c e t h a t i s w e l l - e q u i p p e d and ready t o go t o
work, t o be c o m p e t i t i v e , then a l l t h e r e s t t h a t we t a l k about cannot
come t o pass. And i t i s c l e a r t h a t h e a l t h care r e f o r m i s an economic
i s s u e as w e l l as a human one. We have t o be a b l e t o p r o v i d e t h e kind
of s e c u r i t y w i t h a good j o b and good h e a l t h care b e n e f i t s t h a t people
deserve t o have.
I t i s w i t h t h a t k i n d of s e c u r i t y on a p e r s o n a l
l e v e l t h a t w i l l enable people t o make t h e k i n d of commitments t o the
f u t u r e t h a t we need them t o make.
So t h i s i s an issue l i n k i n g economic s e c u r i t y and h e a l t h
care s e c u r i t y t h a t we have t o t a l k about now and i n t o t h e f u t u r e as
many t i m e s as we have the o p p o r t u n i t y t o do so, because we cannot
separate t h e h e a l t h care r e f o r m debate from t h e economic
c o m p e t i t i v e n e s s p o s i t i o n of our c o u n t r y , and we cannot l e t people
l i v e w i t h t h e k i n d of i n s e c u r i t y t h a t comes when t h e y can show up a t
work ond day and t o l d t h a t t h e i r company i s s h u t t i n g down t h a t
a f t e r n o o n , and t h a t whatever b e n e f i t s t h e y once t o o k f o r g r a n t e d w i l l
no l o n g e r be. t h e r e .
That has t o end i n America, and t h i s i s one of
the ways we can do t h a t .
(Applause.)
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�Which i s why i t i s so i m p o r t a n t t h a t governors l i k e
those whom you see before you s t a y i n t i m a t e l y i n v o l v e d i n t h e h e a l t h
care r e f o r m debate.
Because I know, from t h e 12 years of experience
t h a t my husband had as t h e governor o f a s t a t e , t h a t o f t e n t h a t i s
where we' f i n d o u t what i s r e a l l y meant by n a t i o n a l economic p o l i c y or
h e a l t h care p o l i c y , because b i l l s can be passed i n t h e Congress, but
they have t o be implemented a t t h e s t a t e and l o c a l l e v e l . And so i t
i s i m p e r a t i v e t h a t people w i t h t h e k i n d of experience you see before
you stand ready t o a d v i s e , t o experiment, t o come up w i t h t h e kinds
of ideas t h a t w i l l enable us t o have a n a t i o n a l h e a l t h care reform
system.
•
Because imagine, i f • y o u w i l l , seeing t h e h e a l t h care
r e f o r m i s s u e from t h e eyes of one o f these governors who i s s i t t i n g
here, j u s t as my husband was f o r 12 years. He remembers what i t was
l i k e t o see t h e number of u n i n s u r e d and u n d e r i n s u r e d people. He
remembers what i t was l i k e , d e s p i t e t h e best e f f o r t s of t h e s t a t e s t o
t r y t o c o n t r o l c o s t s , t o watch them c o n t i n u e t o a c c e l e r a t e i t . He
remembers what i t was l i k e t o t r y t o d e a l w i t h t h e budgetary
pressures t h a t were pushed upon t h e s t a t e s by t h e human need
u n d e r l y i n g t h e expaNsion o f Medicaid. He remembers what i t was l i k e
t o have businesses coming i n t o see him who were s a y i n g , we want t o
keep p r o v i d i n g b e n e f i t s because i t ' s t h e r i g h t t h i n g t o do, But i t
becomes harder and harder every year. And he remembers what i t was
l i k e , being on t h e r e c e i v i n g end o f a bureaucracy i n both t h e p u b l i c
and t h e p r i v a t e s e c t o r t h a t second-guessed d e c i s i o n s , t h a t peered
over s h o u l d e r s , t h a t employed people n o t t o d e l i v e r care b u t t o check
up on those who were. He remembers and he wants, t h e r e f o r e , t o take
t h a t experience and p u t i t t o work along w i t h these governors t o make
the changes he knows need t o be made.
Because t h e problems are f e l t most c l e a r l y a t t h e l o c a l
l e v e l , we need a n a t i o n a l p a r t n e r s h i p i n r e f o r m i n g h e a l t h care. I t
w i l l r e q u i r e n a t i o n a l s o l u t i o n s , but i t w i l l a b s o l u t e l y require
s t a t e s t o be i n v o l v e d i n implementing those s o l u t i o n s .
S t a t e s cannot
s o l v e t h e h e a l t h care c r i s i s on t h e i r own. No m a t t e r how i n n o v a t i v e
— and we have b e f o r e us today, t h e most i n n o v a t i v e among our
governors — But they cannot on t h e i r own d e a l w i t h what i s a
n a t i o n a l problem.
So I ' d l i k e t o take a few minutes t o t a l k about t h e
process we have undertaken t o improve t h e c o u n t r y ' s h e a l t h care
system and t o t a l k about t h e fundamental g o a l s o f our r e f o r m . F i r s t ,
as Governor Dean has a l r e a d y s a i d , we t r i e d t o p u l l t o g e t h e r from
across our c o u n t r y people from every walk o f l i f e , every k i n d of
e x p e r i e n c e , who knew what t h e problem was and had experienced i t
f i r s t h a n d . We f e l t s t r o n g l y t h a t s t a t e government had t o be
r e p r e s e n t e d i n t h a t process.
Many o f these governors and many others
sent s t a f f members t o work w i t h us, came i n themselves t o a t t e n d
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meetings, gave us t h e b e n e f i t of t h e i r d e l i b e r a t i o n s as they d r a f t e d
l e g i s l a t i o n , worked w i t h l e g i s l a t u r e s and w i t h groups i n t h e i r own
states.
We have been meeting on a r e g u l a r b a s i s , and we have
found, as you might guess, t h a t our process has been improved because
of t h e c o n t r i b u t i o n s from t h e s t a t e and l o c a l l e v e l .
We've held more
than 1,000 meetings w i t h people who have a p a r t i c u l a r p o i n t of view
on h e a l t h care r e f o r m ; because j u s t about everyone i n t h i s c o u n t r y
does have a stake i n making sure we do i t r i g h t .
And i t ' s been i n t e r e s t i n g t o me t o see how w i l l i n g
people have been t o p u t aside t h e i r own p a r t i c u l a r p o i n t o f view t o
t r y t o look a t t h e whole; because i t i s u n l i k e l y we w i l l or anyone
c o u l d come up w i t h a p r o p o s a l t h a t would s a t i s f y everybody.
Everybody w i l l have t o move a l i t t l e b i t i n o r d e r t o g e t t o a p o i n t
where t h e whole w i l l be b i g g e r than t h e sum o f i t s p a r t s . And many
people have been w i l l i n g t o do j u s t t h a t i n our e f f o r t s t o c r a f t t h i s
proposal.
We have a l s o been working hard t o educate o u r s e l v e s , t h e
American people, about what i s a t s t a k e . When people understand how
the h e a l t h care c r i s i s impacts on them p e r s o n a l l y , n o t j u s t i n terms
of whether o r n o t they have insurance, o r whether t h e i r insurance
t h i s year c o s t s t h e same as i t d i d l a s t year, o r whether they f e a r
l o s i n g insurance because o f something beyond t h e i r c o n t r o l l i k e a
p r e e x i s t i n g c o n d i t i o n or t h e i r i n a b i l i t y t o change j o b s , o r even
whether they stand scared on t h e p r e c i p i c e o f t h e next h e a l t h care
d i s a s t e r because they don't have insurance, b u t when they begin t o
see t h e i r p e r s o n a l s i t u a t i o n i n c o n t e x t w i t h what i s going on i n t h e
broader community, then we make r e a l progress so t h a t everyone
understands how t h e pieces o f t h i s f i t t o g e t h e r . That's t h e k i n d of
e d u c a t i o n a l process t h a t we are engaged i n now t h a t each o f you i s a
part of.
I t ' s i m p o r t a n t , as I walk down l a t e r t h i s a f t e r n o o n t h i s
b e a u t i f u l s t r e e t I rode up t o come t o t h i s meeting, t o know t h a t as I
w i l l pass s t o r e a f t e r s t o r e a f t e r s t o r e , some o f t h e people working
i n those s t o r e s w i l l have i n s u r a n c e ; down t h e b l o c k some w i l l n o t .
I f a medical emergency happens l a t e r t h i s a f t e r n o o n , t h e person w i l l
be taken t o t h e n e a r e s t h o s p i t a l w i t h o u t r e g a r d t o t h a t . The person
w i l l t h e n be g i v e n t h e care t h a t i s needed f o r t h a t emergency,
because i t i s n o t f a i r t o say t h a t people go c o m p l e t e l y w i t h o u t care
i n our country". They g e t care, b u t o f t e n o n l y i n an emergency, only
when i t ' s become more expensive than i t should have.
And r e g a r d l e s s o f whether t h a t person had t h e insurance
t o t a k e care o f t h a t emergency, i t w i l l be p a i d f o r by those o f us
who do -- those o f us who c a r r y p r i v a t e i n s u r a n c e ; those o f us who
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have employers who pay f o r i t ; those of us who have government
a s s i s t a n c e . That i s one of t h e reasons why when one looks a t a
h o s p i t a l b i l l you're sometimes s t r u c k by t h e f a c t t h a t a s p i r i n was
charged t o you f o r $20. I t ' s not because i t ' s w o r t h $20, i t ' s t o
take care o f those people who were taken of who d i d n ' t have
compensation.
Or when we t h i n k about what i t ' s l i k e f o r people who are
t r y i n g t o make j o b d e c i s i o n s , and they can't make them t o use t h e i r
best t a l e n t s t o be c o m p e t i t i v e because they can't leave a j o b where
they have b e n e f i t s .
And when people begin t o understand how we are a l l i n
t h i s t o g e t h e r , how today i s not a t a l l secure w i t h r e s p e c t t o what we
w i l l have tomorrow, then t h e e d u c a t i o n process r e a l l y takes h o l d -because t h e most i m p o r t a n t t h i n g t h a t I have found as I t r a v e l e d
around t h e c o u n t r y , no matter whom I have t a l k e d w i t h , i s s e c u r i t y .
That's what people want. Whether they t h i n k they have i t now or
whether they never have, they want t h e s e c u r i t y t o know t h a t t h e i r
p r i m a r y and p r e v e n t i v e h e a l t h care needs w i l l be taken care of and
t h a t t h e i r acute and c h r o n i c needs w i l l be taken care o f .
T h i s i s t h e key t o what k i n d o f h e a l t h care r e f o r m we
have t o o f f e r t o t h e American people, because what we have t o be able
t o say a t t h e end o f t h i s process i s t h a t i f we enact t h e P r e s i d e n t ' s
p r o p o s a l , those m i l l i o n s of Americans, n e a r l y 40 m i l l i o n now, who do
not have any insurance w i l l have h e a l t h s e c u r i t y .
Those m i l l i o n s
more who have some insurance but not enough i f t h e r e a l emergency
comes, w i l l have s e c u r i t y .
And most i m p o r t a n t l y , t h e m a j o r i t y of us
who do have some i n s u r a n c e , who f e e l t h a t we have taken care o f
o u r s e l v e s , t h r o u g h our own e f f o r t s or t h a t o f our employers, we can
r e s t assured we w i l l have i t next year and t h e year a f t e r and t h e
year a f t e r t h a t . No m a t t e r who we work f o r , no m a t t e r how s i c k we
might become, no m a t t e r who we marry or t h e s t a t e o f t h e h e a l t h of
the c h i l d we bear, we w i l l a l l be secure.
We have t o make i t p o s s i b l e f o r every American who works
f o r a l i v i n g , who pays t h e b i l l s , who takes care o f r a i s i n g t h e i r
f a m i l i e s , who pay t h e t a x e s , t h a t they do not have t o f e a r going
w i t h o u t insurance and h e a l t h s e c u r i t y .
(Applause.)
Yoii have b e f o r e you governors who have taken impressive
steps on t h e i r own i n t h e absence o f f e d e r a l a c t i o n , who have t r i e d
t o meet t h e needs as they saw them i n t h e i r own s t a t e s . Governor
C h i l e s from F l o r i d a has a h e a l t h care r e f o r m a c t t h a t w i l l b r i n g the
promise o f care t o many F l o r i d i a n s who have never had insurance. You
know here t h a t Governor Dean's Vermont H e a l t h Care A u t h o r i t y i s
w o r k i n g hard t o p r o v i d e u n i v e r s a l access i n a way t h a t makes t h e most
sense. Governor Jones and Governor McWherter have been f i g h t i n g f o r
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b e t t e r h e a l t h care i n t h e i r s t a t e s and have come f o r w a r d w i t h
comprehensive l e g i s l a t i v e p r o p o s a l s .
The n a t i o n a l r e f o r m e f f o r t v / i l l b o l s t e r these e f f o r t s ,
w i l l support them, w i l l enable them because we w i l l have a n a t i o n a l
framework w i t h i n which t h e r e s p o n s i b i l i t i e s of t h e f e d e r a l government
w i l l be s p e l l e d o u t and t h e r e s p o n s i b i l i t i e s o f t h e s t a t e government.
That i s an issue t h a t Senator Leahy has been w o r k i n g on f o r a number
of years w i t h my good f r i e n d , Senator Pryor from Arkansas -- t o b u i l d
up t h i s k i n d o f p a r t n e r s h i p between t h e n a t i o n a l and s t a t e
governments.
Once t h e new h e a l t h care system i s up and r u n n i n g , every
American c i t i z e n and those who are permanent r e s i d e n t s i n t h i s
c o u n t r y w i l l g e t a h e a l t h s e c u r i t y c a r d . That c a r d w i l l guarantee
a l l Americans a comprehensive package o f b e n e f i t s , no matter where
they work, were they l i v e , how o l d they a r e , o r whether they have
ever been s i c k .
The b e n e f i t s package w i l l emphasize primary and
p r e v e n t i v e h e a l t h care because v/e have t o begin t o redress t h e
imbalance t h a t has been a l l o w e d t o develop i n our h e a l t h care system
where we had t h e most h i g h l y s o p h i s t i c a t e d h e a l t h care a v a i l a b l e
anywhere i n t h e w o r l d ; so t h a t you c o u l d w i t h g r e a t ease and comfort
of mind know t h a t you c o u l d g e t a h e a r t bypass, b u t you c o u l d not be
sure t h a t you would be able t o g e t your c h i l d adequately immunized.
We need t o r e v e r s e t h a t . To n o t do a n y t h i n g t h a t endangers t h e
g u a l i t y o f t h e very t o p o f our h e a l t h care system, b u t t o b u i l d up
the base so t h a t we can p r o v i d e more s e r v i c e s and save more money,
because we w i l l a l l o c a t e our resources b e t t e r .
(Applause.)
Second, we are going t o make sure t h a t w i t h t h a t h e a l t h
card t h a t guarantees those b e n e f i t s packages, we w i l l be b r i n g i n g
c o s t s under c o n t r o l .
You see, every day what happens i s t h a t h e a l t h
care i s p r i c e d o u t o f reach o f many Americans. Many o f you have seen
your own p e r s o n a l c o s t s , your business's c o s t s , your s t a t e ' s costs
get d r i v e n o u t o f s i g h t .
I know t h a t F l o r i d a ' s h e a l t h care c o s t s ,
f o r example, have quadrupled i n t h e l a s t 12 y e a r s , and t h a t i s
happening a l l over t h e c o u n t r y .
T h i s f o r c e s us as i n d i v i d u a l s , as businesses, as s t a t e s ,
and as t h e f e d e r a l government t o absorb more and more r e d i n k . And
i t f o r c e s many segments o f t h e h e a l t h care system t o s h i f t c o s t s
wherever they can f i n d those d o l l a r s . That's what leads t o t h e $20
a s p i r i n . A l l o f us bear t h e burden and i f l e f t unchecked, h e a l t h
care c o s t s w i l l c o n t i n u e t o h u r t our f a m i l i e s , bankrupt our
businesses, and our s t a t e budgets, and d r i v e t h e f e d e r a l d e f i c i t ever
and ever h i g h e r .
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�But t h e r e has been some i n n o v a t i v e e f f o r t s a t t h e s t a t e
l e v e l t o t r y t o g e t a h o l d o f c o s t s . Governor Romer's program,
Colorado Care, f o r example, c o n f r o n t s t h e c o s t problem head on,
something t h e f e d e r a l government f o r t h e l a s t 12 years has never been
able t o do. We w i l l l e a r n from t h e e f f o r t s o f Colorado and o t h e r
s t a t e s how best t o c o n t r o l p r i c e s w i t h i n t h e h e a l t h care system, b u t
i t w i l l be a b s o l u t e l y necessary as v/e move t o a r e f o r m system t o
r e a l i z e t h a t i f we do not c o n t r o l t h e c o s t s , we cannot reach
u n i v e r s a l coverage and we cannot p r o v i d e t h e k i n d o f broad-based
b e n e f i t s packages t h a t Americans deserve t o have.
So we w i l l have t h e r e i n i n h e a l t h care c o s t s i n s e v e r a l
ways. We w i l l have t o g e t r i d o f i n c e n t i v e s f o r d o c t o r s who do more
t e s t s and procedures.
I n s t e a d , we w i l l c r e a t e a system t h a t
encourages c o s t - e f f e c t i v e , h i g h q u a l i t y care where d o c t o r s and
p a t i e n t s can again be a t t h e c e n t e r o f t h e r e l a t i o n s h i p , and where
d e c i s i o n s can be made n o t on how something w i l l be reimbursed, but on
whether a d o c t o r b e l i e v e s i t i s best f o r a p a t i e n t .
We w i l l have t o reduce t h e bureaucracy and m i c r o management t h a t absorbs b i l l i o n s o f d o l l a r s o u t o f our h e a l t h care
system, and t h a t so many of you have complained about because i t adds
unnecessary c o s t s . And we w i l l have t o t e l l h e a l t h care i n s t i t u t i o n s
and p r o v i d e r s t h a t v/e a l l must l e a r n t o l i v e w i t h i n a budget. We can
no l o n g e r w r i t e a blank check f o r h e a l t h care i n t h i s c o u n t r y .
(Applause.)
We w i l l have t o ask everyone -- workers, employers,
d o c t o r s , nurses, o t h e r h e a l t h care p r o v i d e r s , h o s p i t a l s -- t o do
t h e i r p a r t . We'll have t o t e l l every o t h e r aspect o f t h e h e a l t h care
i n d u s t r y t h a t i t can no longer expect t o be r a i s i n g i t s p r i c e s and
p r o f i t s growing a t two t o t h r e e t o f o u r t o f i v e t o e i g h t times t h e
rate of i n f l a t i o n .
We're going t o t e l l workers t h a t i f they do not
do t h e i r p a r t t o be r e s p o n s i b l e users o f h e a l t h c a r e , then we w i l l
never be a b l e adequately t o r e i n i n c o s t s . But we w i l l a l s o have t o
t e l l companies t h a t do n o t cover t h e i r workers today and, t h e r e f o r e ,
d r i v e up t h e c o s t s f o r a l l those o t h e r companies t h a t do, i t i s time,
f i n a l l y , f o r everybody i n America t o take r e s p o n s i b i l i t y .
That has
t o be one o f t h e keys t o our f u t u r e .
(Applause.)
There c a n ' t be any more f r e e l u n c h . There can't be any
more f r e e h e a l t h care t o which people f e e l they a r e e n t i t l e d .
There
cannot be any more people who take advantage o f t h e system and
b a s i c a l l y take" a f r e e r i d e .
I t i s o n l y f a i r t h a t we a l l pay our
share.
Now, Governor Roberts from Oregon knows t h a t t h i s i s no
easy t a s k . But Oregon took t h i s issue on anyway by a s k i n g employers
t o c o n t r i b u t e f o r t h e i r workers' h e a l t h c a r e . And i t means t h a t
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�everyone w i l l share the burden.
I t w i l l - b e , t h e r e f o r e , spread more
evenly across more people, which w i l l enable a l l of us t o have more
s e c u r i t y , a b e t t e r f u n c t i o n i n g h e a l t h care system, and lower c o s t s .
And we're going t o t e l l i n d i v i d u a l s who t h i n k they can
get by w i t h o u t coverage because t h e y ' r e 25 and b e l i e v e t h e y ' r e
i m m o r t a l , t h a t when they have t h a t t e r r i b l e a c c i d e n t or u n p r e d i c t e d
i l l n e s s and end up i n t h e emergency room or i n t h e ICU and s t i c k us
w i t h t h e b i l l , t h a t we're not going t o l e t t h a t go on any longer.
Everybody w i l l have t o c o n t r i b u t e t o t h e h e a l t h care system, j u s t
l i k e i n many s t a t e s they have t o have auto insurance -- because
nobody can p r e d i c t when you're going t o have t h a t a c c i d e n t or you're
going t o have t h a t i l l n e s s , and i t ' s t i m e t h a t everybody bears t h e i r
f a i r share o f t h e r e s p o n s i b i l i t y f o r t a k i n g care o f those a c c i d e n t s
and i l l n e s s e s when they occur.
(Applause.)
I t i s an a b s o l u t e l y c r i t i c a l p a r t of t h i s p l a n t h a t
people become r e s p o n s i b l e . Many of t h e problems t h a t we are d e a l i n g
w i t h i n Washington today have been made a l l t h e much harder because
of years o f i r r e s p o n s i b i l i t y a t t h e f e d e r a l l e v e l .
I t i s time f o r us
t o go beyond p a r t i s a n p o l i t i c s , t o go beyond i d e o l o g y and t o say,
r e s p o n s i b i l i t y i s not a Republican or a Democratic or a l i b e r a l or a
c o n s e r v a t i v e concept.
I t i s a t t h e r o o t of what i t means t o be an
American, and we're going t o s t a r t i n s i s t i n g upon i t being present
once again i n t h i s c o u n t r y .
(Applause.)
T h i r d l y , we are p r o p o s i n g a wholesale r e d u c t i o n of the
f r u s t r a t i n g and w a s t e f u l paperwork t h a t e a t s up t h e h e a l t h care
system.
When you look, as I r a and I have, a t t h e volumes o f
r e g u l a t i o n s t h a t have been put i n t o e f f e c t over t h e y e a r s , t h e stacks
and s t a c k s o f forms, you ask y o u r s e l f : Where d i d a l l t h i s
bureaucracy come from? And t h e s h o r t answer i s , i t came from
everywhere.
I t comes from p r i v a t e i n s u r e r s , i t comes from t h e
government. Forms were c r e a t e d t o make sure forms were f i l l e d out
p r o p e r l y . And i t makes i t i m p o s s i b l e , o f t e n , f o r t h e most v u l n e r a b l e
people t o g e t t h e care t h a t they need. And i t a l s o has undercut the
d e l i v e r y of care. Because as t h e number of h e a l t h insurance
companies grew -- and today t h e r e are more than 1500 -- so d i d the
number o f forms. And t h e r e s u l t i s t h a t , i n s t e a d o f a system i n
which p a t i e n t care and d o c t o r d e c i s i o n - m a k i n g and nurse c a r i n g d r i v e
the system, paperwork does.
Most "nurses now spend n e a r l y h a l f o f t h e i r t i m e f i l l i n g
out forms. MtfSt p h y s i c i a n s now spend an e x t r a o r d i n a r y percentage of
t h e i r income c o n t r i b u t i n g t o t h e bookkeeping and a c c o u n t i n g necessary
t o f i l l o u t forms. P a t i e n t s don't know how t o read these b i l l s .
They don't understand these forms. Those o f us who have gone t o
school l o n g e r than we'd l i k e t o admit can't understand these forms.
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�And, y e t , we are c o n t i n u e d t o be deluged by them because t h a t i s t h e
excuse f o r n o t g e t t i n g t o t h e h e a r t of t h e problem.
We now need t o make i t c l e a r t h a t what i s going t o count
i s q u a l i t y outcomes, not paperwork p r o c e s s i n g . And i f we do t h a t -(applause) -- i f we do t h a t , then consumers w i l l see a h e a l t h care
system made understandable and easy. One insurance form f o r
everybody; a r e p o r t card f o r q u a l i t y t h a t i s understandable so t h a t
choices can be made; no hidden f i n e p r i n t .
And d o c t o r s and nurses
w i l l f i n a l l y be able t o do what they were t r a i n e d and educated t o do:
keeping people h e a l t h y , not f i l l i n g o u t forms.
And a g a i n , t h e s t a t e s are paving t h e way. Governor
Sundlund's "Right Track" program holds o u t t h e promise of coverage
f o r a l l Rhode I s l a n d ' s c h i l d r e n by s t r e a m l i n i n g so many o f t h e
programs t h a t a f f e c t c h i l d r e n . Governor Carnahan recognizes t h a t
p r o v i d i n g r e s p o n s i v e p r i m a r y and p r e v e n t i v e care can mean more than
b r i n g i n g c h i l d r e n t o h e a l t h care p r o v i d e r s , i t means b r i n g i n g t h e
h e a l t h care p r o v i d e r s t o t h e c h i l d r e n . And M i s s o u r i ' s i n i t i a t i v e t o
p r o v i d e h e a l t h care t o c h i l d r e n i n schools w i l l focus on making t h e
s t a t e a p r i m a r y c a r e - g i v e r f o r many c h i l d r e n and e l i m i n a t e a l o t of
the unnecessary b u r e a u c r a t i c maneuvering and c a t a l o g i n g o f k i d s t h a t
goes on now.
L e t ' s t a k e a c h i l d as a whole person, f i g u r e o u t how t o
take care o f t h a t c h i l d .
Don't d i v i d e them up i n t o l i t t l e pieces
t h a t f i t i n t o t h e w e l f a r e bureaucracy, t h e h e a l t h bureaucracy, t h e
c h i l d s u p p o r t bureaucracy, t h e e d u c a t i o n bureaucracy.
That's what
M i s s o u r i i s t r y i n g t o do. That's what t h i s c o u n t r y needs t o do.
Because i f we focus on p r e v e n t i v e care and e l i m i n a t e t h e
a d m i n i s t r a t i v e hassles t h a t now e x i s t , our r e f o r m e f f o r t s w i l l work,
and more c h i l d r e n w i l l be h e a l t h i e r .
F o u r t h l y , t h i s r e f o r m w i l l focus on addressing long-term
care. T h i s i s a problem t h a t we need t o g e t ahead o f t h e aging curve
on as soon as we can. S t a t e s have a l a r g e stake i n p r o v i d i n g and
paying f o r t h i s c o u n t r y ' s growing need f o r l o n g - t e r m care.
Now, many w i l l t e l l us t o p u t o f f c o n s i d e r a t i o n o f t h i s
i s s u e and n o t t o do a n y t h i n g . That's t h e way we g o t i n t o a l l of
these problems.
Don't t a k e on any hard i s s u e s . Don't expend any
political capital.
Don't make -- (gap i n tape) -- and maybe t h e
v o t e r s w i l l j u s t t h i n k you're doing a good j o b . We've g o t t o p u t
those days behind us. I f we don't begin t o address long-term care
now, i n f o u r o r e i g h t years we w i l l be so much f u r t h e r behind i t w i l l
be an e x t r a o r d i n a r y f i n a n c i a l and human d r a i n f o r us t o begin then.
We have t o make a s t a r t .
And we need t o do t h a t by b u i l d i n g up t h e
i n f r a s t r u c t u r e i n t h e s t a t e s so t h a t people who wish t o s t a y i n t h e i r
homes and o u t o f i n s t i t u t i o n s w i l l have t h a t o p t i o n . And people who
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need i n t e r m e d i a r y care, whether i t i s a d u l t day care or congregate
housing, w i l l have t h a t o p t i o n .
As you know, i n d i v i d u a l s and f a m i l i e s are too o f t e n
bankrupt by long-term care. And i t i s not f a i r t o make them make
t h a t choice between money or d i g n i t y . We need a system i n which we
g i v e r e a l choices t o the e l d e r l y and t h e d i s a b l e d . And i f we have an
a d m i n i s t r a t i o n and we have s t a t e s t h a t are w i l l i n g t o embark on t h i s
p a r t n e r s h i p t o g e t h e r , we w i l l c r e a t e more o p t i o n s f o r community-based
care, which i s not o n l y what people t e l l us they want, but i s less
expensive and w i l l enable us t o cover more people. So we w i l l expand
home and community-based care i n t h i s r e f o r m p r o p o s a l so t h a t people
w i t h severe d i s a b i l i t i e s w i l l have access t o a broad a r r a y of
s e r v i c e s , c o o r d i n a t e d by a case manager, t a i l o r e d t o i n d i v i d u a l
needs. And by expanding t h i s a v a i l a b i l i t y of c a r e , s e n i o r s and
d i s a b l e d c i t i z e n s who can't manage on t h e i r own w i l l remain i n t h e i r
own home or t h e i r own community as long as p o s s i b l e .
(Applause.)
F i n a l l y , we w i l l improve t h e a v a i l a b i l i t y of h e a l t h care
i n underserved urban and underserved r u r a l areas. I t w i l l not do us
any good t o have a h e a l t h care r e f o r m system t h a t holds out t h e
promise of h e a l t h s e c u r i t y i f i t does not d e l i v e r . There are many
p a r t s of our c o u n t r y t h a t have t r a d i t i o n a l l y not had adequate access
t o h e a l t h c a r e . I don't need t o t e l l Governor W a l t e r s or Governor
King t h a t a h e a l t h s e c u r i t y card alone w i l l mean l i t t l e t o people
u n l e s s we guarantee t h a t the s e r v i c e s they need w i l l be a v a i l a b l e f o r
them i n even t h e most remote p a r t s of America.
The P r e s i d e n t ' s p l a n w i l l b o l s t e r these e f f o r t s by
t a r g e t i n g funds f o r areas t h a t are now underserved.
I t will
s t r e n g t h e n t h e h e a l t h care i n f r a s t r u c t u r e i n these areas by l i n k i n g
community-based c e n t e r s t o o t h e r h o s p i t a l s and p r o v i d e r s , and w i l l
o f f e r i n c e n t i v e s f o r t h e N a t i o n a l H e a l t h S e r v i c e Corps and o t h e r
programs t o encourage d o c t o r s t o p r a c t i c e i n remote p a r t s of our
c o u n t r y . That i s one of t h e most c o s t - e f f e c t i v e t h i n g s we can do t o
encourage d o c t o r s and nurses and o t h e r s t o pay o f f t h e i r loans, t o be
f o r g i v e n f o r t h e i r loans, i f they w i l l go i n t o areas t h a t need t h e i r
h e l p . There i s h a r d l y a program t h a t i s more worthy of c o n s i d e r a t i o n
than t h a t , and i t w i l l be r e i n v i g o r a t e d a f t e r being a l l o w e d b a s i c a l l y
t o d i e on t h e v i n e over t h e l a s t 12 years.
I f we make sure t h a t a l l of our people are covered by
i n t e g r a t e d d e l i v e r y networks, l i k e Governor Dean and o t h e r s are
t a l k i n g a b o u t , " t h e n nobody, no m a t t e r where t h e y l i v e , w i l l be
w i t h o u t access t o decent care.
For 12 y e a r s , these governors and those who served w i t h
them and b e f o r e them have taken t h e lead i n keeping h e a l t h care on
the agenda. Before my husband was e l e c t e d P r e s i d e n t he worked w i t h
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the N a t i o n a l Governors A s s o c i a t i o n t o c r a f t a b i p a r t i s a n approach
toward h e a l t h care r e f o r m .
I t i s t h a t k i n d of a t t i t u d e we need t o
encourage not j u s t a t the s t a t e l e v e l , but i n Washington as w e l l .
We need t o end the p a r t i s a n s h i p . We need t o recognize
the f e d e r a l government does not have a l l the answers, t h a t i t needs
t o work w i t h the s t a t e s t o s o l v e the h e a l t h care c r i s i s .
I n order t o
do t h a t , we need r e a l l e a d e r s h i p from the t o p . And t h a t ' s what t h i s
President i s w i l l i n g to o f f e r .
The f e d e r a l government w i l l e s t a b l i s h the framework and
set t h e standards, but i t w i l l be us t o the s t a t e s t o t a i l o r the
program t o meet those standards and o f f e r the guaranteed b e n e f i t s i n
ways t h a t each s t a t e t h i n k s w i l l work best f o r t h a t s t a t e . We cannot
do t h i s w i t h o u t t h a t k i n d of p a r t n e r s h i p . And we need t h a t
p a r t n e r s h i p t o c o n t i n u e t h a t has a l r e a d y s t a r t e d so t h a t we have the
b e n e f i t of your advice and counsel.
There i s no way t h a t we can wave a magic wand or even
pass a piece of l e g i s l a t i o n t h a t w i l l o v e r n i g h t s o l v e a l l of our
h e a l t h care problems. Too many changes i n a t t i t u d e s and behavior are
going t o be needed. But we do know we have t o take a comprehensive
approach so t h a t we look a t a l l these problems a t one t i m e .
The P r e s i d e n t has a p p r e c i a t e d the advice and help from
t h e governors.
We look forward t o working w i t h t h e governors i n the
weeks and months ahead, because we b e l i e v e t h a t w i t h a h e a l t h care
r e f o r m p l a n t h a t t r u l y p r o v i d e s s e c u r i t y f o r every American we w i l l
be on t h e way toward making i t p o s s i b l e f o r t h i s c o u n t r y t o r e g a i n
i t s economic l e a d e r s h i p and i t ' s c o m p e t i t i v e p o s i t i o n because h e a l t h
care r e f o r m i s p a r t of the economic p l a n t h a t the P r e s i d e n t has f o r
America. One can not proceed w i t h o u t t h e o t h e r . Both t o g e t h e r w i l l
not o n l y secure s e c u r i t y f o r each of us, but w i l l ensure s e c u r i t y and
l e a d e r s h i p f o r t h i s c o u n t r y t h a t we a l l l o v e .
Thank you very much.
(Applause.)
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�THE WHITE HOUSE
O f f i c e o f t h e Press Secretary
For Immediate Release
REMARKS BY THE FIRST LADY
TO THE AMERICAN MEDICAL ASSOCIATION
June 13, 1993
Chicago, I l l i n o i s
MRS. CLINTON: Thank you very much, Mr. Speaker; a l l o f
the members o f t h e House o f Delegates, t h e o f f i c e r s and t r u s t e e s of
t h e AMA, and a l l whom you r e p r e s e n t . I t i s an honor f o r me t o be
w i t h you a t t h i s meeting and t o have t h e o p p o r t u n i t y t o p a r t i c i p a t e
w i t h you i n an ongoing c o n v e r s a t i o n about our h e a l t h care system and
t h e k i n d s o f c o n s t r u c t i v e changes t h a t we a l l wish t o see brought t o
it.
I know t h a t you have, through H e a l t h Access America, and
through o t h e r a c t i v i t i e s and programs o f t h e AMA been deeply i n v o l v e d
i n t h i s c o n v e r s a t i o n a l r e a d y , and a l l o f us are g r a t e f u l f o r your
contribution.
I'm a l s o pleased t h a t you i n v i t e d s t u d e n t s from t h e
Nathan Davis Elementary School t o j o i n us here t h i s a f t e r n o o n .
(Applause.) I know t h a t t h e AMA has a s p e c i a l r e l a t i o n s h i p w i t h t h i s
s c h o o l , named as i t i s f o r t h e founder o f t h e AMA, and t h a t t h e AMA
p a r t i c i p a t e s i n i t s c o r p o r a t e c a p a c i t y i n t h e Adopt a School program
here i n Chicago. You have made a r e a l c o n t r i b u t i o n t o these young
men and women. And not only have you p r o v i d e d f r e e immunizations and
p h y s i c a l s and l e c t u r e s and h e l p about h e a l t h and r e l a t e d m a t t e r s , but
you have served as r o l e models and mentors. I t i s very i m p o r t a n t
t h a t a l l o f us as a d u l t s do what we can t o g i v e young people t h e
s k i l l s they w i l l need t o become r e s p o n s i b l e and s u c c e s s f u l a d u l t s .
And I c o n g r a t u l a t e you f o r your e f f o r t s and welcome t h e s t u d e n t s here
today.
A l l of us respond to c h i l d r e n . We want to nurture them
so they can dream the dreams that free and healthy c h i l d r e n should
have. This i s our primary r e s p o n s i b i l i t y as a d u l t s . And i t i s our
primary r e s p o n s i b i l i t y as a government. We should stand behind
f a m i l i e s , teachers and others who work with the young, so that we can
enable them to meet t h e i r own needs by becoming s e l f - s u f f i c i e n t and
responsible so-*hat they, i n turn, w i l l be able to meet t h e i r
f a m i l i e s and tfceir own c h i l d r e n ' s needs.
When I was growing up, n o t f a r from where we a r e today,
t h i s seemed an e a s i e r t a s k . There seemed t o be more s t r o n g f a m i l i e s .
There seemed t o be s a f e r neighborhoods. There seemed t o be an
o u t l o o k o f c a r i n g and c o o p e r a t i o n among a d u l t s t h a t stood f o r and
behind c h i l d r e n .
I remember so w e l l my f a t h e r s a y i n g t o me t h a t i f
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you g e t i n t r o u b l e a t s c h o o l , you g e t i n t r o u b l e a t home -- no
g u e s t i o n s asked -- because t h e r e was t h i s sense among t h e a d u l t
community t h a t a l l o f them, from my c h i l d ' s p e r s p e c t i v e , were
i n v o l v e d i n h e l p i n g t h e i r own and o t h e r s ' c h i l d r e n .
Much has changed s i n c e those days. We have l o s t some of
the hope and optimism of t h a t e a r l i e r time. Today, we t o o o f t e n meet
our g r e a t e s t c h a l l e n g e s , whether i t i s t h e r a i s i n g of c h i l d r e n o r
r e f o r m i n g t h e h e a l t h care system, w i t h a sense t h a t our problems have
grown t o o l a r g e and unmanageable. And I don't need t o t e l l you t h a t
k i n d o f a t t i t u d e begins t o undermine one's sense of hope, optimism,
and even competence.
We know now -- and you know b e t t e r than I -- t h a t over
the l a s t decade our h e a l t h care system has been under e x t r a o r d i n a r y
stress.
I t i s one o f t h e many i n s t i t u t i o n s i n our s o c i e t y t h a t has
experienced such s t r e s s . That s t r e s s has begun t o break down many of
the r e l a t i o n s h i p s t h a t should stand a t t h e core of t h e h e a l t h care
system. That breakdown has, i n t u r n , undermined your p r o f e s s i o n i n
many ways, changing t h e n a t u r e of and t h e rewards of p r a c t i c i n g
medic ine.
Most d o c t o r s and o t h e r h e a l t h care p r o f e s s i o n a l s choose
c a r e e r s i n h e a l t h and medicine because they want t o h e l p people. But
too o f t e n because our system i s n ' t working and we haven't taken f u l l
r e s p o n s i b i l i t y f o r f i x i n g i t , t h a t motive i s clouded by p e r c e p t i o n s
t h a t d o c t o r s a r e n ' t t h e same as they used t o be. They're n o t r e a l l y
doing what they used t o do. They don't r e a l l y care l i k e they once
did.
•
You know and I know t h a t we have t o work harder t o renew
a t r u s t i n who d o c t o r s a r e and what d o c t o r s do. That i s a l s o n o t
unique t o t h e medical community. J u s t as our i n s t i t u t i o n s across
s o c i e t y a r e under attack, and s t r e s s , a l l elements o f those
i n s t i t u t i o n s a r e f i n d i n g t h a t they no longer can command t h e t r u s t
and r e s p e c t , whether we t a l k o f p a r e n t s o r government o f f i c i a l s or
o t h e r p r o f e s s i o n a l s -- p o l i c e o f f i c e r s , t e a c h e r s
t h a t should come
w i t h g i v i n g o f themselves and doing a j o b w e l l t h a t needs t o be done.
But f o c u s i n g t h i s a f t e r n o o n on those concerns t h a t are
yours — what has happened w i t h medicine, what i s l i k e l y t o happen -we need t o s t a r t w i t h a fundamental commitment t o making t h e p r a c t i c e
of medicine a g a i n a v i s i b l e , honored l i n k i n our e f f o r t s t o promote
the common good. And t h e way t o do t h a t i s t o improve t h e e n t i r e
system o f which you a r e a p a r t . We cannot c r e a t e t h e atmosphere o f
t r u s t and r e s p e c t and p r o f e s s i o n a l i s m t h a t you deserve t o have, and
t h a t many o f you who a r e i n t h i s room remember from e a r l i e r years,
w i t h o u t changing t h e i n c e n t i v e s and t h e way t h e e n t i r e system
o p e r a t e s . That has t o be our p r i m a r y commitment. I f we do n o t p u t
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medicine and those who operate w i t h i n medicine i n t h e f o r e f r o n t of
the r e s p e c t they deserve t o have, no matter what we do t o the system
on t h e margins w i l l not make the d i f f e r e n c e s t h a t i t should.
(Applause.)
As you know, the P r e s i d e n t i s i n the process of
f i n a l i z i n g h i s proposal f o r h e a l t h care reform, and I am g r a t e f u l t o
speak w i t h you about t h a t process and where i t i s today and where i t
i s g o i n g . I had o r i g i n a l l y hoped t o j o i n you a t your meeting i n
March i n Washington, D.C.
And I , again, want t o a p o l o g i z e f o r my
absence. I very much a p p r e c i a t e d Vice P r e s i d e n t Gore a t t e n d i n g f o r
me, and I a l s o a p p r e c i a t e d the k i n d words from your e x e c u t i v e
o f f i c i a l s on b e h a l f of the e n t i r e a s s o c i a t i o n because of my absence.
My f a t h e r was i l l and I spent s e v e r a l weeks w i t h him i n
the h o s p i t a l b e f o r e he d i e d . During h i s h o s p i t a l i z a t i o n a t St.
V i n c e n t ' s H o s p i t a l i n L i t t l e Rock, Arkansas, I witnessed f i r s t h a n d
the courage and commitment of h e a l t h care p r o f e s s i o n a l s , both
d i r e c t l y and i n d i r e c t l y .
I w i l l always a p p r e c i a t e the s e n s i t i v i t y
and the s k i l l s they showed, not j u s t i n c a r i n g f o r my f a t h e r , not
j u s t i n c a r i n g f o r h i s f a m i l y -- which, as you know, o f t e n needs as
much care as the p a t i e n t , but i n c a r i n g f o r the many o t h e r s whose
names I w i l l never know. I know t h a t some of you worry about what
the impact of h e a l t h care r e f o r m w i l l be on your p r o f e s s i o n and on
your p r a c t i c e .
Let me say from the s t a r t , i f I read o n l y what the
newspapers have s a i d about what we are doing i n our p l a n , I ' d
p r o b a b l y be a l i t t l e a f r a i d myself, t o o , because i t i s very d i f f i c u l t
t o get out what i s going on i n such a complex process.
•
But the simple f a c t i s t h i s : The President has asked
a l l of us, r e p r e s e n t a t i v e s of the AMA, of every other element of the
health care system, as w e l l as the administration, to work on making
changes where they are needed, to keeping and improving those things
that work, and to preserving and conserving the best parts of our
system as we t r y to improve and change those that are not.
This system i s not working as w e l l as i t did, or as well
as i t could — for you, for the p r i v a t e sector, for the public or for
the nation.
The one area that i s so important to be understood on a
macronational l e v e l i s how our f a i l u r e to deal with the health care
system and i t s f i n a n c i a l demands i s at the center of our problems
f i n a n c i a l l y i n Washington. Because we cannot c o n t r o l health care
c o s t s and becoftife r u r t h e r and further behind in our e f f o r t s to do so,
we f i n d our economy, and p a r t i c u l a r l y the f e d e r a l budget, under
i n c r e a s i n g pressure.
J u s t as i t would be i r r e s p o n s i b l e , t h e r e f o r e , t o change
what i s w o r k i n g i n t h e h e a l t h care system, i t i s e q u a l l y
i r r e s p o n s i b l e f o r us not t o f i x what we know i s no l o n g e r working.
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And t h a t i s a p o i n t t h a t you understand t h a t you have t o
h e l p the r e s t of the c o u n t r y understand -- t h a t u n t i l we do p r o v i d e
s e c u r i t y f o r every American when i t comes t o h e a l t h care, we cannot
f i x what i s wrong w i t h the h e a l t h care system. Secondly, we do have
t o c o n t r o l c o s t s . How we do t h a t i s one of the g r e a t challenges i n
t h i s system, but one t h i n g we can a l l agree on i s t h a t we have t o cut
down on the paperwork and reduce the bureaucracy i n both the p u b l i c
and p r i v a t e s e c t o r s .
(Applause.)
We a l s o have t o be sure t h a t when we look a t c o s t s , we
look a t i t not j u s t from a f i n a n c i a l p e r s p e c t i v e , but a l s o from a
human p e r s p e c t i v e . I remember s i t t i n g i n the f a m i l y w a i t i n g area of
St. V i n c e n t ' s , t a l k i n g t o a number of my p h y s i c i a n f r i e n d s t o stop by
t o see how we were doing. And one day, one of my f r i e n d s t o l d me
t h a t , every day, he discharges p a t i e n t s who need m e d i c a t i o n t o
s t a b i l i z e a condition.
And a t l e a s t once a day, he knows t h e r e i s a
p a t i e n t who w i l l not be able t o a f f o r d the p r e s c r i p t i o n drugs he has
p r e s c r i b e d , w i t h the r e s u l t t h a t t h a t p a t i e n t may decide not t o f i l l
the p r e s c r i p t i o n when the h o s p i t a l supply runs o u t . Or t h a t p a t i e n t
may decide t h a t even though the d o c t o r t o l d him t o t a k e t h r e e p i l l s a
day, h e ' l l j u s t take one a day so i t can be s t r e t c h e d f u r t h e r .
And even though St. Vincent's has created a fund to try
to help support the needs of p a t i e n t s who cannot a f f o r d
p r e s c r i p t i o n s , there's not enough to go around, and so every day
there i s someone who my f r i e n d knows and you know w i l l be back in the
h o s p i t a l because of t h e i r i n a b i l i t y e i t h e r to a f f o r d the care that i s
required a f t e r they leave, or because they t r y to cut the corners on
i t , with the net r e s u l t that then you and I w i l l pay more for that
person who i s back in the h o s p i t a l than we would have i f we had taken
a s e n s i b l e approach toward what the r e a l c o s t s in the medical system
are. That i s why we w i l l t r y , for example, to include p r e s c r i p t i o n
drugs i n the comprehensive benefit package for a l l Americans,
i n c l u d i n g those over 65, through Medicare.
(Applause.)
We b e l i e v e t h a t i f we h e l p c o n t r o l c o s t s up f r o n t , we
w i l l save c o s t s on t h e back end.
That i s a p r i n c i p l e t h a t runs
t h r o u g h our p r o p o s a l and which each of you knows from f i r s t h a n d
e x p e r i e n c e i s more l i k e l y t o be e f f i c i e n t i n both human and f i n a n c i a l
terms.
We w i l l a l s o preserve what i s best i n t h e American h e a l t h
care system today.
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We have looked a t every o t h e r system i n the w o r l d .
We
have t r i e d t o t a l k t o every expert.whom we can f i n d t o describe how
any otfter c o u n t r y t r i e s t o p r o v i d e h e a l t h care. And we have
concluded t h a t what i s needed i s an American s o l u t i o n f o r an American
problem by c r e a t i n g an American h e a l t h care system t h a t works f o r
America.
(Applause.)
And two of the p r i n c i p l e s t h a t u n d e r l i e t h a t
American s o l u t i o n are q u a l i t y and choice.
(Applause.)
We want t o ensure and enhance q u a l i t y . And i n order t o
do t h a t , we're going t o have t o make some changes, and you know t h a t .
We cannot, f o r example, promise t o r e a l l y achieve u n i v e r s a l access i f
we do not expand our supply of primary care p h y s i c i a n s , and we must
do t h a t .
(Applause.)
And you w i l l have t o help us determine the
best way t o go about a c h i e v i n g t h a t g o a l .
I've spoken w i t h r e p r e s e n t a t i v e s of our medical schools,
and we have t a l k e d about how the f u n d i n g of graduate medical
e d u c a t i o n w i l l have t o be changed t o p r o v i d e i n c e n t i v e s f o r the
t r a i n i n g of more p r i m a r y care p h y s i c i a n s . (Applause.)
I have t a l k e d
w i t h r e p r e s e n t a t i v e s of many of the a s s o c i a t i o n s , such as t h i s one,
about how c o n t i n u i n g e d u c a t i o n a l o p p o r t u n i t i e s c o u l d h e l p even midc a r e e r p h y s i c i a n s , once we have a r e a l supply of p r i m a r y care
p h y s i c i a n s who are adequately reimbursed and adequately supported,
how they might even go back i n t o primary care.
(Applause.)
We have a l s o very much put choice i n t h e c e n t e r of our
system so t h a t we w i l l have not j u s t choice f o r p a t i e n t s as t o which
p l a n they choose t o j o i n , but choice f o r p h y s i c i a n s as t o which plan
they choose t o p r a c t i c e w i t h , i n c l u d i n g the o p t i o n of being p a r t of
more than one p l a n a t the same t i m e .
(Applause.)
•
Now, as we work out a l l of the d e t a i l s in the many
proposals and i t s p a r t s that must come together, I am not suggesting
that you w i l l agree with every recommendation the President makes. I
don't expect any group to do that.
In f a c t , I suppose that i f
everybody's not a l i t t l e put out that means we probably haven't done .
i t r i g h t . But I do hope and expect that t h i s group, as with other
groups representing p h y s i c i a n s and nurses and other health care
p r o f e s s i o n a l s w i l l find in t h i s plan much to be applauded and
supported. And I a l s o b e l i e v e that given the complexities of the
problem we face, i t would be d i f f i c u l t to a r r i v e a t a s o l u t i o n that
was u n i v e r s a l l y accepted.
But t h e reason I have confidence t h a t t h i s house, the
AMA, and o t h e r s w i l l be s u p p o r t i v e of the P r e s i d e n t ' s p r o p o s a l i s
because we have b e n e f i t e d so much from what you have a l r e a d y done and
from t h e involvement of many of you and o t h e r s around t h e c o u n t r y .
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Again, c o n t r a r y t o what you may have heard scores of
p r a c t i c i n g p h y s i c i a n s served on the working groups t h a t were s t u d y i n g
h e a l t h care r e f o r m . I am deeply g r a t e f u l on a p e r s o n a l l e v e l t h a t
members o f t h e AMA's l e a d e r s h i p spent i n v a l u a b l e time coming t o
meeting a f t e r meeting, day a f t e r day s h a r i n g t h e i r ideas, r e a c t i n g t o
ideas a t the White House. And, of course, i n the course of t h a t we
learned we had many common goals and o b j e c t i v e s .
We w i l l not o n l y stand f o r u n i v e r s a l coverage, but i n
a d d i t i o n the f o l l o w i n g : community r a t i n g so t h a t we can assure a l l
Americans they w i l l be taken care of -- ( a p p l a u s e ) ; e l i m i n a t i n g
r e s t r i c t i o n s based on p r e e x i s t i n g c o n d i t i o n s so t h a t every American
w i l l be e l i g i b l e -- ( a p p l a u s e ) ; a n a t i o n a l l y guaranteed comprehensive
b e n e f i t s package t h a t w i l l emphasize primary and p r e v e n t i v e h e a l t h
care as w e l l as h o s p i t a l i z a t i o n and o t h e r care -- ( a p p l a u s e ) ; the
k i n d of choice and q u a l i t y assurances t h a t we w i l l need t o have t o
make sure t h i s new system not o n l y operates w e l l d u r i n g the
t r a n s i t i o n but gets a f i r m f o o t i n g as i t moves i n t o the f u t u r e and we
w i l l t h e r e f o r e be emphasizing more on p r a c t i c e parameters and
outcomes research so t h a t you, t o o , can know b e t t e r what works.
One of the g r e a t i n t e r e s t i n g experiences I have had
d u r i n g the past months i s as I've t r a v e l e d around from s t a t e t o s t a t e
i s having d o c t o r s coming up t o me and t e l l i n g me t h a t they need more
i n f o r m a t i o n ; t h a t a l l too o f t e n the i n f o r m a t i o n they r e c e i v e doesn't
come t o them i n forms t h a t they b e l i e v e are p r a c t i c a l i n t h e i r
p a r t i c u l a r c o n t e x t . And what we want t o do i s by working w i t h
o r g a n i z a t i o n s l i k e yours i s be sure t h a t the q u a l i t y outcomes and the
k i n d o f r e s e a r c h t h a t w i l l done w i l l be r e a d i l y a v a i l a b l e t o every
p r a c t i c i n g p h y s i c i a n i n the c o u n t r y .
•
We a l s o b e l i e v e t h a t i t w i l l be e s s e n t i a l t o c o n t i n u e
medical r e s e a r c h and t o use t h e breakthroughs i n medical r e s e a r c h ,
a g a i n , not j u s t t o a l l e v i a t e human s u f f e r i n g but t o save money,
because you know b e t t e r t h a n I t h a t o f t e n times a b r e a k t h r o u g h i n
r e s e a r c h , a new d r u g , a new procedure i s t h e q u i c k e s t way t o take
care of t h e most people i n a c o s t - e f f e c t i v e manner. So we w i l l
c o n t i n u e t o s u p p o r t medical r e s e a r c h .
(Applause.)
A l l of these p r i n c i p l e s a r i s e from t h e same common
assumption — t h a t t h e s t a t u s quo i s unacceptable. And i t i s not
r e a l l y even a n y l o n g e r a s t a t u s guo because we do not stand s t i l l , we
d r i f t backwards-. Every month people lose t h e i r i n s u r a n c e ; every
month you have more micromanagement and r e g u l a t i o n t o p u t up w i t h ;
every month our h e a l t h care system becomes more expensive t o f i x .
I know t h a t many of you f e e l t h a t as d o c t o r s you are
under s i e g e i n the c u r r e n t . system.
And I t h i n k t h e r e i s cause f o r
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�you t o b e l i e v e t h a t , because we are w i t n e s s i n g a d i s t u r b i n g a s s a u l t
on the d o c t o r / p a t i e n t r e l a t i o n s h i p . More and more employers are
buying i n t o managed care plans t h a t f o r c e employees t o choose from a
s p e c i f i c p o o l of d o c t o r s . And t o o o f t e n , even when a d o c t o r i s
w i l l i h g t o j o i n a new p l a n t o m a i n t a i n h i s r e l a t i o n s h i p w i t h
p a t i e n t s , he, or she I should say, i s f r o z e n o u t .
What we want t o see i s a system i n which the employer
does not make the choice as t o what p l a n i s a v a i l a b l e f o r the
employee, the employee makes t h a t choice f o r him or h e r s e l f .
(Applause.)
But i f we do not change and i f the present p a t t e r n
c o n t i n u e s , as i t w i l l i f we do not a c t q u i c k l y , the a r t of p r a c t i c i n g
medicine w i l l be f o r e v e r t r a n s f o r m e d . Gone w i l l be the p a t i e n t s
t r e a s u r e d p r i v i l e g e t o choose h i s or her d o c t o r . Gone w i l l be the
c l o s e t r u s t i n g bonds b u i l t up between p h y s i c i a n s and p a t i e n t s over
the years. Gone w i l l be the s e c u r i t y of knowing you can s w i t c h jobs
and s t i l l v i s i t your longtime i n t e r n i s t or p e d i a t r i c i a n or OB/GYN.
We cannot a f f o r d t o l e t t h a t happen. But the e r o s i o n of
the d o c t o r / p a t i e n t r e l a t i o n s h i p i s o n l y one piece of the problem.
Another p i e c e i s the r o l e t h a t insurance companies have come t o play
and the r o l e t h a t the government has come t o p l a y along w i t h them i n
second-guessing medical d e c i s i o n s .
I can understand how many of you must f e e l .
When
i n s t e a d of being t r u s t e d f o r your e x p e r t i s e , you're expected t o c a l l
an 800 number and get a p p r o v a l f o r even b a s i c medical procedures from
a t o t a l stranger.
(Applause.)
•
Frankly, despite my best e f f o r t s of the l a s t month to
understand every aspect of the health care system, i t i s and remains
a mystery to me how a person s i t t i n g at a computer in some a i r conditioned o f f i c e thousands of miles away can make a judgment about
what should or shouldn't happen at a p a t i e n t ' s bedside in I l l i n o i s or
Georgia or C a l i f o r n i a . The r e s u l t of t h i s e x c e s s i v e oversight, t h i s
peering over a l l of your shoulder's i s a system of backward
i n c e n t i v e s . I t rewards providers for over p r e s c r i b i n g , overtesting,
and g e n e r a l l y overdoing. And. worse, i t punishes doctors who show
proper r e s t r a i n t and e x e r c i s e t h e i r p r o f e s s i o n a l judgment in ways
that those s i t t i n g at the computers disagree with.
(Applause.)
Dr. Bob B a r r i n s o n , one of the p r a c t i c i n g p h y s i c i a n s who
spent hours and hours working w i t h us w h i l e a l s o m a i n t a i n i n g h i s
p r a c t i c e , t o l d - u s r e c e n t l y of an experience t h a t he had as one of
many. He a d m i t t e d an emergency room p a t i e n t named J e f f .
Jeff
s u f f e r e d from c i r r h o s i s o f the l i v e r and — .
Dr. B a r r i n s o n put him
i n t h e h o s p i t a l and w i t h i n 24 hours r e c e i v e d a c a l l from J e f f ' s
insurance company. The insurance company wanted t o know e x a c t l y how
many days J e f f would be i n t h e h o s p i t a l and why.
Dr. B a r r i n s o n
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r e p l i e d t h a t he c o u l d n ' t p r e d i c t t h e p r e c i s e l e n g t h of stay. A few
days l a t e r t h e insurance company c a l l e d back and questioned whether
J e f f would need surgery. Again, Dr. B a r r i n s o n s a i d he wasn't y e t
sure.
And what was Dr. Barrinson's reward f o r h i s honesty and
h i s p r o f e s s i o n a l i s m ? He was placed on the insurance company's
"special exceptions" l i s t .
You know, t h a t ' s a l i s t of troublesome
d o c t o r s who make t h e insurance company w a i t a few days or a few weeks
t o determine t h e bottom l i n e on a p a r t i c u l a r p a t i e n t .
From t h a t p o i n t on, t h e insurance company c a l l e d Dr.
B a r r i n s o n s i x times i n two weeks. Each time he had t o be summoned
away from t h e p a t i e n t t o take t h e c a l l .
Each time he spoke t o a
d i f f e r e n t insurance company r e p r e s e n t a t i v e . Each time he repeated
the same s t o r y .
Each time h i s r o l e as t h e p h y s i c i a n was subverted.
And each time t h e t r e a t m e n t of t h e p a t i e n t was impeded.
Dr. B a r r i n s o n and you know t h a t medicine, t h e a r t of
h e a l i n g , doesn't work l i k e t h a t . There i s no master c h e c k l i s t t h a t
can be a d m i n i s t e r e d by some f a c e l e s s b u r e a u c r a t t h a t can t e l l you
what you need t o do on an h o u r l y b a s i s t o take care of your p a t i e n t s ;
and, f r a n k l y , I wouldn't want t o be one of your p a t i e n t s i f t h e r e
were.
(Applause.)
Now, adding t o these d i f f i c u l t i e s d o c t o r s and h o s p i t a l s
and nurses, p a r t i c u l a r l y , are being b u r i e d under an avalanche o f
paperwork. There are mountains of forms, mountains o f r u l e s ,
mountains of hours spent on a d m i n i s t r a t i v e m i n u t i a e i n s t e a d of c a r i n g
f o r t h e s i c k . Where, you might ask y o u r s e l f , d i d a l l t h i s
bureaucracy come from? And t h e s h o r t answer i s , b a s i c a l l y ,
everywhere.
•
There are forms t o ensure a p p r o p r i a t e care f o r t h e s i c k
and t h e d y i n g ; forms t o guard a g a i n s t unnecessary t e s t s and
procedures.
And from each insurance company and government agency
t h e r e are forms t o r e c o r d t h e d e c i s i o n s of d o c t o r s and nurses. I
remember going t o Boston and having a p h y s i c i a n b r i n g i n t o a hearing
I h e l d t h e r e t h e stack of forms h i s o f f i c e i s r e q u i r e d t o f i l l o u t .
And he h e l d up a Medicare form and next t o i t he h e l d up an insurance
company form. And he s a i d t h a t they are t h e same forms t h a t ask t h e
same q u e s t i o n s , b u t t h e insurance company form w i l l n o t be accepted
by t h e government, and t h e government form w i l l n o t be accepted by
the insurance "Company. And t h e insurance company b a s i c a l l y took the
government form, changed t h e t i t l e t o c a l l i t by i t s own name and
r e q u i r e s them t o have i t f i l l e d o u t . That was t h e t i p of t h e
iceberg.
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one nurse t o l d me t h a t she entered the p r o f e s s i o n
because she wanted t o care f o r people. She s a i d t h a t i f she had
wanted t o be an accountant, she would have gone t o work f o r an
a c c o u n t i n g company i n s t e a d .
(Laughter.) But she, l i k e many o t h e r
nurses, and as you know so w e l l , many of the people i n your o f f i c e s
now, are r e g u i r e d t o be bookkeepers and a c c o u n t a n t s , not c l i n i c i a n s ,
not c a r e g i v e r s .
(Applause.)
The l a t e s t s t a t i s t i c I have seen i s t h a t f o r every
d o c t o r a h o s p i t a l h i r e s , four new a d m i n i s t r a t i v e s t a f f are h i r e d .
(Applause.) And t h a t i n the average d o c t o r ' s o f f i c e 30 hours a month
i s now spent on a d m i n i s t r a t i o n .
That i s not t i m e spent w i t h a
p a t i e n t r e c o v e r i n g from bypass surgery or w i t h a c h i l d or teenager
who needs a checkup and maybe a l i t t l e e x t r a TLC time of l i s t e n i n g
and c o u n s e l i n g , and c e r t a i n l y not spent w i t h a p a t i e n t who has t o run
i n q u i c k l y f o r some k i n d of an emergency.
B l a n k e t i n g an e n t i r e p r o f e s s i o n w i t h r u l e s aimed at
c a t c h i n g those who are not l i v i n g up t o t h e i r p r o f e s s i o n a l standards
does not improve q u a l i t y . What we need i s a new b a r g a i n . We need t o
remove"from the vast m a j o r i t y of p h y s i c i a n s these unnecessary,
r e p e t i t i v e , o f t e n uneven read forms and i n s t e a d s u b s t i t u t e f o r what'
they were a t t e m p t i n g t o do -- more d i s c i p l i n e , more peer review, more
c a r e f u l s c r u t i n y of your c o l l e a g u e s . You are the ones who can t e l l
b e t t e r than I or b e t t e r than some b u r e a u c r a t whether the q u a l i t y of
medicine t n a t i s being p r a c t i c e d i n your c l i n i c , i n your h o s p i t a l , i s
what you would want f o r y o u r s e l f and your f a m i l y .
(Applause.)
•
Let us remove the k i n d of micromanagement and r e g u l a t i o n
t h a t has not improved q u a l i t y and has wasted b i l l i o n s of d o l l a r s , but
then you have t o help us s u b s t i t u t e f o r i t , a system t h a t the
p a t i e n t s of t h i s c o u n t r y , the p u b l i c of t h i s c o u n t r y , the d e c i s i o n makers of t h i s c o u n t r y can have c o n f i d e n c e i n . Now, I know t h e r e are
l e g a l o b s t a c l e s f o r your being able t o do t h a t , and we are l o o k i n g
very c l o s e l y a t how we can remove those so t h a t you can be p a r t -(applause) -- of c r e a t i n g a new s o l u t i o n i n which everyone, i n c l u d i n g
y o u r s e l f , can b e l i e v e i n .
I n every p r i v a t e c o n v e r s a t i o n I've had w i t h a p h y s i c i a n ,
whether i t ' s someone I knew from St. V i n c e n t ' s or someone I had j u s t
met, I have asked: T e l l me, have you ever p r a c t i c e d w i t h or around
someone you d>d not t h i n k was l i v i n g up t o your standards?
And,
i n v a r i a b l y , the answer i s , w e l l , yes, I remember i n my t r a i n i n g ;
w e l l , yes, I remember t h i s emergency room work I used t o do; yes, I
remember i n the h o s p i t a l when so-and-so had t h a t problem. And I've
s a i d , do you b e l i e v e enough was done by the p r o f e s s i o n t o d e a l w i t h
t h a t problem and t o e l i m i n a t e i t ? And, i n v a r i a b l y , no m a t t e r who the
d o c t o r i s , I've been t o l d , no, I don't.
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We want you t o have t h e chance so t h a t i n t h e f u t u r e you
can say, yes, I do b e l i e v e we've been d e a l i n g w i t h our problems. I t
i s n o t something we should leave f o r t h e government, and, c e r t a i n l y ,
we cannot leave i t t o t h e p a t i e n t . That i s t h e new k i n d of
r e l a t i o n s h i p I t h i n k t h a t we need t o have.
F i n a l l y , i f we do n o t , as I s a i d e a r l i e r , p r o v i d e
u n i v e r s a l coverage, we cannot do any of what I have j u s t been
speaking about because we cannot f u l f i l l our basic commitment you as
p h y s i c i a n s , us as a s o c i e t y , t h a t we w i l l care f o r one another. I t
should no longer be l e f t t o t h e i n d i v i d u a l d o c t o r t o decide t o probe
h i s conscience before d e t e r m i n i n g whether t o t r e a t a needy p a t i e n t .
I cannot t e l l you what i t i s l i k e f o r me t o t r a v e l around t o hear
s t o r i e s from d o c t o r s and p a t i e n t s t h a t a r e r i g h t on p o i n t .
But t h e most p o i g n a n t t h a t I t e l l because i t s t r u c k me
so p e r s o n a l l y was of t h e woman w i t h no i n s u r a n c e ; working f o r a
company i n New Orleans; had worked t h e r e f o r a number o f y e a r s ; t r i e d
to t a k e good care of h e r s e l f ; went f o r t h e annual p h y s i c a l every
year; and I s a t w i t h her on a f o l d i n g c h a i r i n t h e l o a d i n g dock of
her company along w i t h o t h e r s -- a l l o f whom were u n i n s u r e d ; a l l of
whom had worked numbers of years -- w h i l e she t o l d me a t her l a s t
p h y s i c a l her d o c t o r had found a lump i n her b r e a s t and r e f e r r e d her
to a surgeon. And t h e surgeon t o l d her t h a t i f she had insurance, he
would have b i o p s i e d i t b u t because she d i d n o t he would watch i t .
•
I don't t h i n k you have t o be a woman t o f e e l what I f e l t
when t h a t woman t o l d me t h a t s t o r y . And I don't t h i n k you have t o be
a p h y s i c i a n t o f e e l what you f e l t when you heard t h a t s t o r y . We need
to c r e a t e a system i n which no one ever has t o say t h a t f o r good
cause o r bad, and no one has t o hear i t ever a g a i n .
(Applause.)
I f we move toward u n i v e r s a l coverage, so t h e r e f o r e
everyone has a payment stream behind them t o be a b l e t o come i n t o
your o f f i c e , t o be able t o come i n t o t h e h o s p i t a l , you w i l l again be
a b l e t o make d e c i s i o n s t h a t should be made w i t h c l i n i c a l autonomy,
w i t h p r o f e s s i o n a l judgment. And we i n t e n d t o t r y t o g i v e you t h e
time and f r e e you up from o t h e r c o n d i t i o n s t o be a b l e t o do t h a t .
One s p e c i f i c issue I want t o mention, because I f e e l
s t r o n g l y about i t — i f my husband had n o t asked me t o do t h i s , I
would have f o t t s t r o n g l y about i t because o f t h e impact i n my s t a t e
of Arkansas -- we have t o s i m p l i f y and e l i m i n a t e t h e burdensome
r e g u l a t i o n s c r e a t e d under *CLEA — (applause) — a w e l l - i n t e n t i o n e d
law w i t h many u n i n t e n d e d conseguences t h a t have a f f e c t e d n o t only
those o f you i n p r i v a t e p r a c t i c e b u t p u b l i c h e a l t h departments l i k e
ours i n Arkansas around t h e c o u n t r y .
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But again we need t h a t new b a r g a i n . Vou have t o help us
know what should be e l i m i n a t e d so t h a t we then can j u s t focus i n on a
very s m a l l p a r t o f t h i s whole s i t u a t i o n and e l i m i n a t e t h e r e s t of t h e
r e g u l a t i o n s t h a t were thrown on t o p .
So those are t h e k i n d s of issues i n which we t h i n k we
can make i t more p o s s i b l e f o r you t o p r a c t i c e i n a more e f f i c i e n t ,
humane, b e t t e r manner. We a l s o b e l i e v e s t r o n g l y t h a t we have t o
emphasize p r e v e n t i v e care. And we have t o p r o v i d e a basic p o l i c y of
p r e v e n t i v e care. And we have t o be sure t h a t a l l of you and those
who come a f t e r you i n t o medicine are t r a i n e d w e l l i n medical school
t o a p p r e c i a t e t h e importance of p r e v e n t i v e care.
(Applause.)
Much of what i s now considered o u t s i d e t h e scope of
mainstream medicine i s crowding i n . Many of us i n t h i s room I know
e x e r c i s e , t r y t o watch our d i e t s , do t h i n g s t o t r y t o remain
h e a l t h i e r . And y e t o f t e n medical e d u c a t i o n and medicine as i t ' s
p r a c t i c e d does not i n c l u d e those new k i n d of common-sense approaches
to h e a l t h . We need t o be a system t h a t does not take care of t h e
s i c k b u t i n s t e a d promotes h e a l t h wherever we can i n whatever way we
p o s s i b l y can do i t . (Applause.)
And f i n a l l y , l e t me say t h a t we w i l l o f f e r a s e r i o u s
p r o p o s a l t o curb m a l p r a c t i c e problems f o r a l l of you. (Applause.)
But l e t me add t h a t i t , t o o , must be p a r t o f t h i s new c o n t r a c t . I n
o r d e r t o do t h a t and t o do i t i n a way t h a t engenders t h e confidence
of t h e average American, we must have organized medicine s t a n d i n g
ready t o say we w i l l do a b e t t e r j o b of t a k i n g care of t h e problems
w i t h i n us. (Applause.)
•
I have read or t r i e d t o read e v e r y t h i n g I can f i n d about
a l l of t h i s .
And you know as w e l l as I do t h e r e a r e s t u d i e s a l l over
the f i e l d .
I t depends upon who w r i t e s i t and who i t ' s w r i t t e n f o r
and t h e l i k e .
But we know t h e r e ' s a problem. We know we're going t o
d e a l w i t h i t . But one o f t h e s t a r k s t a t i s t i c s from these s t u d i e s i s
t h a t a l l t o o o f t e n t h e l a r g e s t number of m a l p r a c t i c e s u i t s i s brought
a g a i n s t t h e same p h y s i c i a n s on a r e p e t i t i v e b a s i s .
Now, i t may be t h a t f o r some t h a t i s an u n f a i r
a c c u s a t i o n , and we need t o d e a l w i t h t h a t t h r o u g h r e f o r m . But f o r
o t h e r s , you need t o weed them o u t o f your p r o f e s s i o n i f they cannot
p r a c t i c e t o t l i e q u a l i t y t h a t you expect your f e l l o w c o l l e a g u e s t o
p r a c t i c e t o . .So we w i l l propose s e r i o u s m a l p r a c t i c e r e f o r m , and we
w i l l have t o look t o you t o h e l p us make sure t h a t t h e problems t h a t
w i l l s t i l l f l o w from people who should n o t be making d e c i s i o n s w i l l
be e l i m i n a t e d . That way we can g i v e c o n f i d e n c e back t o you as a
p r o f e s s i o n , t h a t you w i l l n o t be second-guessed o r u n f a i r l y c a l l e d
i n t o c o u r t . And we w i l l g i v e c o n f i d e n c e t o t h e p u b l i c t h a t they w i l l
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be p r o t e c t e d i n s o f a r as humanly p o s s i b l e . So t h a t i s what we w i l l
have t o look f o r when we come forward w i t h t h a t .
(Applause.)
Now, r e a c h i n g consensus on a l l t h a t should be done and
p u t t i n g i t i n t o a piece of l e g i s l a t i o n and moving i t through the
Congress i s not going t o be easy. There w i l l be many groups t h a t
w i l l n i b b l e a t the edges of i t , not l i k e the whole idea of i t , want
t o c o n t i n u e t o the s t a t u s guo.
But i f we do not have the courage t o
change now, i f we do not move toward a system t h a t once again gives
you back your p r o f e s s i o n a l i s m t o p r a c t i c e prudent, p r a c t i c a l ,
i n t e l l i g e n t medicine again; i f we do not move toward r e s t o r i n g the
d i g n i t y again t o the d o c t o r - p a t i e n t r e l a t i o n s h i p , and t h a t encourages
young people t o become p h y s i c i a n s because they want t o p a r t i c i p a t e i n
t h a t w o n d e r f u l process of h e a l i n g and c a r i n g , then the e n t i r e
s o c i e t y , but most p a r t i c u l a r l y medicine, w i l l s u f f e r .
The reason we are doing any of t h i s i s because of
c h i l d r e n l i k e those who are here from Nathan Davis.
Most of us i n
t h i s room are a t l e a s t halfway through.
(Laughter.) And most of us
i n t h i s room have s a t i n dozens and dozens of meetings j u s t l i k e
this.
We've s a t and l i s t e n e d t o people t e l l us what was wrong w i t h
h e a l t h care or what medicine or w i t h whatever, and we've t a l k e d about,
t h e problems a t l e a s t s e r i o u s l y s i n c e the 1970s. And we've produced
p r o p o s a l s l i k e yours f o r H e a l t h Access America.
But w h i l e we have t a l k e d , our problems have g o t t e n
worse, and the f r u s t r a t i o n on the p a r t of a l l of you and o t h e r s has
i n c r e a s e d . Time and again, groups, i n d i v i d u a l s , and p a r t i c u l a r l y the
government, has walked up t o t r y i n g t o r e f o r m h e a l t h care and then
walked away.
There's enough blame t o go around, every k i n d of
p o l i t i c a l s t r i p e s can be i n c l u d e d , but t h e p o i n t now i s t h a t we could
have done something about h e a l t h care r e f o r m 20 years ago and solved
our problems f o r m i l l i o n s of d o l l a r s , and we walked away. L a t e r we
c o u l d have done something and solved our problems f o r hundreds of
m i l l i o n s , and we walked away.
A f t e r 20 years w i t h r a t e of medical i n f l a t i o n going up
and w i t h a l l o f t h e problems you know so w e l l , i t i s a harder and
more d i f f i c u l t s o l u t i o n t h a t c o n f r o n t s us.
But I b e l i e v e t h a t i f one
looks a t what i s a t s t a k e , we are not t a l k i n g j u s t about r e f o r m i n g
t h e way we f i n a n c e h e a l t h care, we are not t a l k i n g j u s t about the
p a r t i c u l a r s of "how we d e l i v e r h e a l t h care, we are t a l k i n g about
c r e a t i n g a new sense of community and c a r i n g i n t h i s c o u n t r y i n which
we once a g a i n v a l u e your c o n t r i b u t i o n , value t h e d i g n i t y of a l l
people.
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How many more meetings do we need? How many a l e r t s ?
How many more plans?
How many more brochures? The time has come f o r
a l l o f us, n o t j u s t w i t h respect t o h e a l t h care, b u t w i t h respect t o
a l l of t h e d i f f i c u l t i e s our c o u n t r y faces t o s t o p w a l k i n g away and t o
s t a r t s t e p p i n g up and t a k i n g r e s p o n s i b i l i t y .
We are supposed t o be
the ones t o lead f o r our c h i l d r e n and our g r a n d c h i l d r e n . And t h e way
we have behaved i n t h e l a s t years, we have run away and abdicated
that responsibility.
And a t t h e core of t h e human experience i s
r e s p o n s i b i l i t y f o r c h i l d r e n t o leave them a b e t t e r w o r l d than t h e one
we found.
We can do t h a t w i t h h e a l t h care. We can make a
d i f f e r e n c e now t h a t w i l l be a legacy f o r a l l o f you. We can once
again g i v e you t h e confidence t o say t o your grandsons and
granddaughters, yes, do go i n t o medicine; yes, i t i s t h e most
rewarding p r o f e s s i o n t h e r e i s .
So l e t ' s c e l e b r a t e your p r o f e s s i o n by improving h e a l t h
care. Let's c e l e b r a t e our c h i l d r e n by r e f o r m i n g t h i s system. Let's
come t o g e t h e r n o t as l i b e r a l s or c o n s e r v a t i v e s o r Republicans or
Democrats, but as Americans who want t h e best f o r t h e i r c o u n t r y and
know we can no longer w a i t t o g e t about t h e business o f p r o v i d i n g i t .
Thank you a l l very much.
END
•
t
(Applause.)
�THE
WHITE HOUSE
O f f i c e o f the Press Secretary
Internal Transcript
June 10, 1993
REMARKS BY THE FIRST LADY
AT THE SYMPOSIUM ON HEALTH CARE REFORM
Johns Hopkins U n i v e r s i t y
B a l t i m o r e , Maryland
11:30
•
A.M. EDT
MRS. CLINTON: Thank you very much. P r e s i d e n t
Richardson and Dean Johns, thank you f o r those very warm words of
welcome. And I am d e l i g h t e d , Dean Johns, t h a t you have made i t c l e a r
t h a t my predecessor, Mrs. H a r r i s o n , was here b e f o r e . and a l s o I
b e l i e v e Mrs. Cleveland served on the committee t h a t f i n a l l y got the
money t o g e t h e r t h a t enabled JohnS Hopkins t o open i t s doors. And I'm
a l s o pleased t h a t you r e i n f o r c e d the very s t r o n g a d m o n i t i o n t h a t both
Mrs. H a r r i s o n and Mrs. Cleveland gave 100 years ago t h a t women should
be a d m i t t e d t o the Johns Hopkins School.
I d i d not have t i m e t o go
back and read the c l i p p i n g s , but I'm sure they were r o u n d l y
c r i t i c i z e d f o r being so a g g r e s s i v e and a s s e r t i v e i n t h e i r views.
(Laughter.)
I'm a l s o very pleased t o be here w i t h Congressman Cardin
and Mayor Schmoke, two l e a d e r s not j u s t i n the Congress and not j u s t
i n B a l t i m o r e , but n a t i o n a l l y on a number o f i s s u e t h a t are very
i m p o r t a n t t o t h e w e l l - b e i n g o f our c o u n t r y . And I p a r t i c u l a r l y
enjoyed w o r k i n g w i t h Congressman Cardin, whose e x p e r t i s e on h e a l t h
care and what has been accomplished i n the s t a t e o f Maryland w i t h
r e s p e c t t o t h e changes t h a t have come about here and have r e a l l y
a p p r e c i a t e d h i s c o u n s e l . And I'm always pleased t o be w i t h Mayor
Schmoke i n h i s c i t y .
I a l s o wish t o extend my c o n g r a t u l a t i o n s t o a l l o f you
who are p a r t of - t h e Hopkins community -- t o t r u s t e e s , t o t h e
d i s t i n g u i s h e d members o f t h i s f a c u l t y , t o s t a f f , t o s t u d e n t s , t o
f r i e n d s o f t h i s i n s t i t u t i o n . There r e a l l y i s n ' t any o t h e r q u i t e l i k e
it.
And I am honored t o be p a r t o f i t s c e n t e n n i a l a n n i v e r s a r y .
One need not be a d o c t o r , a nurse, a medical s t u d e n t or
even i n v o l v e d w i t h h e a l t h care r e f o r m t o a p p r e c i a t e t h e magnitude o f
Johns Hopkins' c o n t r i b u t i o n s t o medicine and h e a l t h care i n the past
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�100 years. How many o t h e r i n s t i t u t i o n s can boast of r e v o l u t i o n i z i n g
t h e standards f o r medical school admission or c l a i m c r e d i t f o r being
among t h e f i r s t t o i n c l u d e women as students?
How many have so ably
served t h e poor and i n d i g e n t i n the i n n e r c i t y around them? And how
many have spawned so many i m p o r t a n t d i s c o v e r i e s i n medical treatment?
Indeed, Johns Hopkins, as you know, i s w i d e l y respected
f o r e x c e l l e n c e , progress, and v i s i o n i n h e a l t h care. And besides
t h a t , how many o t h e r schools of medicine are d i s t i n g u i s h e d enough t o
be i m m o r t a l i z e d as a q u e s t i o n on Jeopardy?
(Laughter.) As we a l l
know, when you make i t i n the popular c u l t u r e you r e a l l y make i t .
And so t h a t ought t o be one of the issues you d i s c u s s d u r i n g t h i s
centennial conversation.
But g i v e n your h i s t o r y as t r a i l b l a z e r s i n medical
e d u c a t i o n and r e s e a r c h , your t r a d i t i o n of s o c i a l l y r e s p o n s i b l e
medicine, your remarkable f a c u l t y and s t u d e n t s , you have much t o be
proud o f . And y e t , t h e r e i s a l s o much t o look forward t o i n the next
100 years.
You w i l l c o n t i n u e , I am sure, -the t r a d i t i o n of research
t h a t brought you t h e Nobel P r i z e s of Doctors D a n i e l Nathen and
Hamilton Smith, t o the medical advancements ^nd the t r e a t m e n t of
b l i n d n e s s , t o the i n n o v a t i v e research t h a t Hopkins d o c t o r s have
produced on b r a i n c h e m i s t r y . And, a l t h o u g h I cannot t e l l you what a
P53 gene i s , I do know t h a t Dr. V o g e l s t e i n ' s r e c e n t r e v e l a t i o n about
g e n e t i c c o n n e c t i o n s t o c o l o n cancer are a welcome breakthrough f o r
those thousands of Americans who s u f f e r from and d i e from t h a t
disease each year.
•
And yet I a l s o know that no matter how distinguished
your past and future in research i s , and no matter how great your
reputation as an academic medical center throughout the world i s , you
have a l s o s e t and changed the agenda for medical education.
Few
medical schools were as quick to understand the importance of
incorporating humanistic learning in the t r a i n i n g of doctors.
And
few others have even yet today a curriculum that so emphasizes
general p r a c t i c e and the r o l e of the physician in s o c i e t y .
And you have done a l l of t h i s while not neglecting to
t r e a t p a t i e n t s . You are a beacon in t h i s region and in the nation
when i t comes to c l i n i c a l and t e r t i a r y care, and most importantly,
you are an anchor i n East Baltimore, providing q u a l i t y treatment for
poor and needy _ c i t i z e n s who might otherwise go without.
Tttfere are many things that I could say and that w i l l be
s a i d during t h i s day and in days to come about the achievements of
this institution.
But what I would l i k e to do for a few minutes i s
look toward the future and share with you what I b e l i e v e w i l l be the
impact of the President's reform e f f o r t on academic medical centers
such as Hopkins. I b e l i e v e you w i l l be encouraged by our ideas and
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t h e assumptions we are o p e r a t i n g on. And y e t , I t h i n k we also have
t o understand f u l l y t h e c o n t e x t i n which t h i s r e f o r m e f f o r t i s
d e v e l o p i n g and moving f o r w a r d .
You know b e t t e r than most t h a t a l t h o u g h we do have much
t o be proud o f i n t h i s c o u n t r y when i t comes t o t h e q u a l i t y of our
p h y s i c i a n s , our nurses, our medical care, our technology, our
research, we are f a c i n g a c r i s i s .
I t i s not a c r i s i s t h a t i s evenly
d i s t r i b u t e d throughout our p o p u l a t i o n . There a r e many p a r t s of our
c o u n t r y t h a t s t i l l wake up every day not r e a l l y touched by what many
of you see day i n and day o u t here a t t h i s i n s t i t u t i o n . They do not
see t h e crowded emergency rooms. They do not see t h e hard choices
t h a t d o c t o r s now have t o make, s t r u g g l i n g w i t h t h e competing demands
of s o - c a l l e d managed care and t h e i r own consciences about what needs
t o be done.
And y e t , we can't t u r n back t h e c l o c k . We are not
l i k e l y t o go back t o t h e time when h e a l t h c a l l s were made r o u t i n e l y ,
a l t h o u g h t h e r e i s some c l i n i c a l work being done now which
demonstrates t h a t house c a l l s and even telephone c a l l s are very
c l i n i c a l l y efficacious.
So i t may be t h a t a r e t u r n t o t h a t would
h e l p us i n o t h e r ways.
But what we now are c o n f r o n t i n g , what you c o n f r o n t i s
o f t e n a n i g h t m a r i s h v i s i o n o f overcrowded emergency rooms, l a y e r s of
paperwork, c o n f u s i n g insurance p l a n s , and a l l t o o o f t e n , inadequate
t r e a t m e n t a t t h e end.
You have devoted your p r o f e s s i o n a l l i v e s t o improving
t h e h e a l t h and w e l l - b e i n g o f your f e l l o w c i t i z e n s .
You're t h e ones
who a r e on t h e - f r o n t l i n e s .
And you're t h e ones w i t h whom I have
spent many, many hours, both p e r s o n a l l y and i n my r o l e on t h e h e a l t h
care r e f o r m t a s k f o r c e , t a l k i n g about what has happened t o medicine;
what has happened t o t h e p a t i e n t - d o c t o r r e l a t i o n s h i p ; what has
happened t h a t has c r e a t e d a system t h a t no one w i l l t a k e c r e d i t f o r ,
which has spun o u t o f c o n t r o l , c r e a t i n g unintended consequences,
whether i t be i n mountains o f paperwork o r i n t h e k i n d s o f c o s t c u t t i n g p r a c t i c e s t h a t i n t e r f e r e w i t h t h e q u a l i t y o f care.
You're
t h e ones faced w i t h t h e e t h i c a l dilemmas about proper t r e a t m e n t f o r
people w i t h no h e a l t h i n s u r a n c e .
You see i t a l l f i r s t h a n d . And I
have come t h r o u g h t h e l a s t s e v e r a l months t o see many o f those same
issues w i t h you^
I t r i s very d i f f i c u l t f o r me, and I can imagine, even
more d i f f i c u l t f o r you t o experience what I see happening t o so many
people — d o c t o r s , nurses, o t h e r c a r e - g i v e r s , p a t i e n t s , h o s p i t a l
a d m i n i s t r a t o r s . When I go t o a h o s p i t a l , as I have i n t h e l a s t few
months, and v i s i t w i t h t h e medical d i r e c t o r , a man who had p r a c t i c e d
f o r 30 years, who looks a t me and says, "You know, t h e r e ' s t h a t o l d
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s a y i n g , ' i f i t a i n ' t broke, don't f i x i t . '
Well, t h i s system i s
broke and I don't know who's going t o f i x i t but somebody b e t t e r . "
And t h e n goes on t o say, "And nobody speaks f o r me or my p a t i e n t s .
Those f o l k s up i n Washington, they don't r e p r e s e n t me.
I don't know
who speaks f o r a person i n my p o s i t i o n , who has t o make the kinds of
choices I make every day."
And I know many of you have been i n s i t u a t i o n s where
you s i t and t a l k w i t h a f a m i l y or a p a t i e n t who doesn't have
i n s u r a n c e , doesn't q u a l i f y f o r Medicaid or any o t h e r k i n d of
a s s i s t a n c e , y e t , faces a medical c r i s i s .
I w i l l never f o r g e t s i t t i n g
i n a s m a l l business i n New Orleans, t a l k i n g t o workers t h e r e who had
worked, some of them f o r 30 years f o r the same company. They weren't
w e l l educated people, but they got up every day and went t o work.
They d i d n ' t have any medical insurance because they c o u l d n ' t a f f o r d
i t on the s a l a r i e s they made. And one woman who had been t h e r e about
15 years who was a bookkeeper, a s i n g l e mother, r a i s i n g a c h i l d , said
she t r i e d t o take good care of h e r s e l f . She g o t a p h y s i c a l exam
every year. But t h i s past year she'd gone t o her d o c t o r and he'd
found a lump i n her b r e a s t and he r e f e r r e d her t o a surgeon.
And the
surgeon had s a i d i t looked s u s p i c i o u s and i f she had insurance he
would have b i o p s i e d i t .
But because she d i d n ' t he would j u s t watch
it.
And I s a t t h e r e and I don't t h i n k you need t o be a woman
t o f e e l as I f e l t , t h a t why on e a r t h was t h a t c h o i c e f o r t h a t surgeon
made not on the b a s i s of a p r o f e s s i o n a l d e c i s i o n but on t h e b a s i s of
whether the k i n d of d e c i s i o n t h a t was the r i g h t one t o make was going
t o be p a i d f o r .
There are a m i l l i o n s t o r i e s l i k e t h i s a l l over the
country.
A l e v e l of f r u s t r a t i o n among those of you who work in
i n s t i t u t i o n s l i k e t h i s or who work in emergency rooms or in Indian
h e a l t h c l i n i c s and to p a t i e n t s who come in a l l s i z e s and shapes with
a l l kinds of problems. And as President Richardson and Dean Johns
s a i d , we need the help of people l i k e you who know f i r s t h a n d what
t h i s country i s up against. We need to s t a r t by being honest with
one another. We need to recognize that, as t h a t doctor in
P h i l a d e l p h i a t o l d me, the system i s broke and i t does need to be
fixed.
I have yet to find anyone who with a s t r a i g h t face who's
a c t u a l l y i n the business of d e l i v e r i n g health care who w i l l t e l l me
that everything i s f i n e .
AiTd our p r i n c i p a l g o a l i n t h i s e f f o r t has t o be t o f i n d
a way t o p r o v i d e qua 1 i t y a f f o r d a b l e h e a l t h care f o r a l l Americans.
The two g o a l s o f access t o q u a l i t y h e a l t h care f o r every American and
c o n t r o l l i n g c o s t s so t h a t we can a f f o r d t o have a system t h a t
p r o v i d e s q u a l i t y h e a l t h care f o r a l l Americans are i n separable.
We
cannot do one w i t h o u t the o t h e r .
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As you know so w e l l i n t h i s h o s p i t a l here a s s o c i a t e d
w i t h t h i s i n s t i t u t i o n , t h e more we t r y t o c u t around t h e edges, t o
jimmy people i n t h e systems and make t h e people f i t t h e systems
i n s t e a d o f t h e o t h e r way around, t h e more problems we cause o u r s e l f .
And t h e c o s t s c o n t i n u e t o go up. And t h i s i s n o t a problem any
longer p r i m a r i l y f o r t h e uninsured or t h e poor. T h i s i s a problem
now t h a t t h r e a t e n s t o undermine t h e s e c u r i t y o f every American.
There i s no one I know except t h e very r i c h e s t i n our country who can
be sure, g i v e n what i s happening i n our economy, g i v e n t h e changes i n
companies as they make d e c i s i o n s about b e n e f i t s o r l a y people o f f or
go o u t of business, t h a t even those among our c i t i z e n s w i t h t h e best
insurance w i l l have i t next year or even, i n some cases, next month.
Tens of thousands of Americans j o i n t h e ranks of t h e
uninsured each month. Workers and employers a r e g r a p p l i n g over who
should pay t h e e s c a l a t i n g p r i c e o f h e a l t h b e n e f i t s . American
c o r p o r a t i o n s are o f t e n a t a c o m p e t i t i v e disadvantage because t h e i r
f o r e i g n c o m p e t i t o r s u s u a l l y p r o v i d e h e a l t h care a t a cheaper c o s t ,
not l e s s h e a l t h care b u t more e f f e c t i v e l y d e l i v e r e d h e a l t h care. And
d o c t o r s a r e burdened w i t h more and more paperwork t h a t doesn't
n e c e s s a r i l y have a n y t h i n g t o do w i t h g u a l i t y and w i t h t h e specter of
l a w s u i t s hanging over t h e i r d e c i s i o n s .
Hundreds o f Americans have come t o g e t h e r i n t h i s e f f o r t
t o f i n d an answer. We have had t h e h e l p o f many people a s s o c i a t e d
w i t h Johns Hopkins and I c o u l d not name them a l l .
But they have been
t h e r e c o n s u l t i n g w i t h us, a d v i s i n g us, g i v i n g us guidance about what
w i l l be t h e best s o l u t i o n s . Those people who a r e members o f t h e
Johns Hopkins community have looked a t an e x t r a o r d i n a r y range o f
i s s u e s , along w i t h t h e o t h e r members o f t h e t a s k f o r c e . And i t i s
c l e a r t h a t we cannot j u s t a t t a c k one p a r t o f t h i s problem.
That i s p a r t o f why we are i n t h e s i t u a t i o n we are i n
today.
I f you t r y t o c o n t r o l t h e r i s i n g c o s t s i n h e a l t h care by
c o n t r o l l i n g p r i c e , volume goes up. I f you t r y t o c o n t r o l t h e r i s i n g
c o s t s by r e g u l a t i o n s you have more micromanagement w i t h checkers
checking t h e checkers, which has very l i t t l e t o do w i t h q u a l i t y .
So what we have t o do i s t o look comprehensively a t a l l
of t h e problems t h a t impact on t h e o v e r a l l issue t h a t c o n f r o n t s us i n
t h e h e a l t h care system today.
C l e a r l y , we b e l i e v e t h a t t h e r e are a
number o f p r i n c i p l e s t h a t have t o guide us i f we expect t h e system we
want t o see c r e a t e d t o be e f f e c t i v e .
F i r s t , i t has t o p r o v i d e
s e c u r i t y f o r every American. H e a l t h care has t o be a v a i l a b l e no
m a t t e r who you work f o r , no matter what your h e a l t h s t a t u s . I t has
t o be p o r t a b l e from j o b t o j o b and across t h e s t a t e l i n e s .
That
level of security i s absolutely essential.
I t does have t o c o n t r o l
c o s t s , b u t i t needs t o focus on e l i m i n a t i n g t h e unnecessary c o s t s i n
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the system f i r s t and be able t o r e a l l o c a t e those resources t o
a c t u a l l y p r o v i d i n g h e a l t h care.
I do n o t know now, I have l o s t count o f how many d o c t o r s
have t t i l d me t h e huge percentage they are c u r r e n t l y paying o u t of
t h e i r income, those who are i n p r i v a t e p r a c t i c e , t o pay f o r t h e
a d m i n i s t r a t i v e s i d e of t h e i r business; how many more people they have
had t o add; how many more hassles they have had t o contend w i t h .
There are c o s t s i n t h i s system t h a t need t o be e l i m i n a t e d . There i s
no excuse f o r t h e p r o l i f e r a t i o n of forms t h a t are o f a b s o l u t e l y no
use t o t h e p r o v i d e r or t h e p a t i e n t . There i s no excuse f o r t h e k i n d
of bureaucracy t h a t has been b u i l t up i n both t h e p r i v a t e insurance
w o r l d and i n t h e government i n order t o check people and double-check
t h e i r decisions.
We a l s o need t o be committed t o improving and r e t a i n i n g
q u a l i t y and by m a i n t a i n i n g choice on b e h a l f o f p a t i e n t s . And we need
t o have a system t h a t i s simple enough f o r t h e average person t o
understand and f e e l good about.
•
We are l o o k i n g f o r those k i n d s o f s o l u t i o n s and b e l i e v e
t h a t we a r e c l o s e t o being able t o present a p r o p o s a l t h a t w i l l
enable us t o achieve a system t h a t meets them. But t h e r e i s a
p a r t i c u l a r p i e c e o f t h i s t h a t I know i s o f g r e a t importance t o t h e
Johns Hopkins community, and t h a t i s t h e r o l e o f t h e Academic Medical
Center.
The k i n d o f i m p o r t a n t r o l e t h a t has been played by Johns
Hopkins and w i l l c o n t i n u e t o be played i s one t h a t we have spent a
g r e a t d e a l o f time working on, t o be sure t h a t we understand how best
t o p u t i n t o p l a c e an o v e r a l l r e f o r m system t h a t w i l l enable t h e Johns
Hopkins o f our c o u n t r y t o c o n t i n u e and even enhance t h e i m p o r t a n t
r o l e s c u r r e n t l y played.
There a r e a number o f issues t h a t come i n t o
c o n s i d e r a t i o n when we look a t t h e Academic Medical Center.
The f i r s t
i s t h e supply o f p h y s i c i a n s and t h e k i n d s o f p h y s i c i a n s i n t h a t
s u p p l y . There i s no way we can p r o v i d e t h e k i n d o f u n i v e r s a l access
t h a t i s r e q u i r e d , and r e q u i r e a b e n e f i t s package t o be a v a i l a b l e t o
a l l Americans t h a t emphasizes primary and p r e v e n t a t i v e h e a l t h care
w i t h o u t a l a r g e r supply o f p r i m a r y p h y s i c i a n s .
That i s a s i m p l i s t i c statement, b u t one which w i l l take
a g r e a t d e a l o f e f f o r t t o meet. How do we move from our c u r r e n t
imbalance o f trtfe number o f s p e c i a l i s t s f o r p r i m a r y care p h y s i c i a n s
and g e t t o a po-int where we can promise t h e r e w i l l be p r i m a r y care
p h y s i c i a n s , n o t j u s t i n t h e suburbs, b u t i n t h e i n n e r c i t y and i n
r u r a l areas so t h e r e w i l l be a t r u e network o f care t h a t w i l l f u l f i l l
the promise we a r e a t t e m p t i n g t o make t o Americans.
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As Dean Johns and others.have suggested, t h e success of
our h e a l t h care r e f o r m e f f o r t depends i n p a r t on our a b i l i t y t o put
d o c t o r s and h e a l t h care resources where they are most needed, not
s i m p l y where they are most p r o f i t a b l e .
But t h a t w i l l happen only i f
i n c e n t i v e s t h a t have t r a d i t i o n a l l y gone i n t o medical e d u c a t i o n t o
promote s p e c i a l i s t s now go i n t o medical e d u c a t i o n t o promote
generalists.
The b o l d c u r r i c u l a r changes undertaken a t Hopkins
r e f l e c t e x a c t l y t h e s o r t of c r e a t i v i t y and v i s i o n we need across the
board. U l t i m a t e l y we have t o recognize t h a t t h e r e are values i n our
h e a l t h care system t h a t we need t o promote and r e a s s e r t and even t o
i n t r o d u c e . And t h i s c u r r i c u l a r change t h a t w i l l lead t o t h e
p o s s i b i l i t y of more primary care p h y s i c i a n s i s one of those values.
I commend Hopkins and I suggest t o you t h a t our n a t i o n a l
h e a l t h care r e f o r m e f f o r t w i l l i n many ways have t o f o l l o w t h e model
t h a t Hopkins has s e t . Through t h e government p r o v i s i o n of resources
f o r medical e d u c a t i o n we w i l l have t o a l t e r t h e i n c e n t i v e s t h a t are
c u r r e n t l y t h e r e i f we are t o have an adeguate supply of p r i m a r y care
physicians.
•
We w i l l then have t o look f o r ways of a c t u a l l y p r o v i d i n g
r e a l loan repayment o p t i o n s and f o r g i v e n e s s of loans f o r s t u d e n t s who
are w i l l i n g t o go i n t o those area t h a t our c o u n t r y most d r a m a t i c a l l y
needs i n p r i m a r y care. We w i l l a l s o have to. be sure t h a t we have t h e
k i n d o f l i n k a g e s between p r i m a r y care p h y s i c i a n s and secondary and
t e r t i a r y care p r a c t i t i o n e r s and f a c i l i t i e s t h a t w i l l enable t h e
p r i m a r y care p h y s i c i a n t o be p a r t of a network o f c a r e .
Technology w i l l h e l p us i n t h a t r e g a r d . I'm sure many
of you, as I have, have watched now t h e k i n d o f t e c h n o l o g i c a l l i n k a g e
t h a t e x i s t s i n r u r a l areas w i t h academic medical c e n t e r s i n some
p a r t s o f our c o u n t r y . Where we are g e t t i n g t o t h e p o i n t where a
d o c t o r i n a r u r a l area can h o l d an X-ray up and i t can a c t u a l l y be
read 400 or 500 m i l e s away.
We need t h e k i n d of communication and c o o p e r a t i o n
between our academic medical c e n t e r s and these p r i m a r y care
p h y s i c i a n s once t h e i r s u p p l y i s increased t o ensure t h a t we have t h e
q u a l i t y o f care t h a t they w i l l expect t o be a b l e t o d e l i v e r y t o t h e i r
p a t i e n t s . We a l s o w i l l have t o be sure t h a t t h e academic medical
c e n t e r s do n o t i n any way f a l l down on t h e i r r e s p o n s i b i l i t y t o t r a i n
s p e c i a l i s t s and" s u b s p e c i a l i s t s , but a t l e a s t f o r t h e immediate
f u t u r e , t h e balance has t o be a l t e r e d .
I am p a r t i c u l a r l y g r a t e f u l t o Dean Johns and t o Dr. Jim
Block f o r t h e t i m e t h a t t h e y have spent w i t h us t a l k i n g t h r o u g h t h e
problems o f t h e academic medical c e n t e r s , how t o keep t h e missions of
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�these c e n t e r s a l i v e . And l e t me j u s t run through some a d d i t i o n a l
issues t h a t we t h i n k w i l l be p a r t i c u l a r l y h e l p f u l t o these c e n t e r s .
I n a d d i t i o n t o your o b l i g a t i o n t o h e l p us meet our
supply problem, we a n t i c i p a t e being able t o help c e n t e r s such as t h i s
d e a l w i t h t h e i r f i n a n c i a l problems. You c u r r e n t l y bear a
d i s p r o p o r t i o n a t e burden of t r e a t i n g p a t i e n t s who cannot a f f o r d t o
pay. Under a new h e a l t h care system, however, a l l p a t i e n t s w i l l be
e n t i t l e d t o h e a l t h care coverage and a l l p r o v i d e r s w i l l be f a i r l y
compensated f o r t h e i r s e r v i c e s . T h i s i s p a r t i c u l a r l y i m p o r t a n t f o r
the uncompensated care t h a t i s d e l i v e r e d by a h o s p i t a l such as the
one here and many o t h e r s l i k e i t around t h e c o u n t r y .
I have o f t e n e x p l a i n e d , or t r i e d t o e x p l a i n t o audiences
of c i t i z e n s what t h a t $20 b i l l f o r t h e T y l e n o l means on t h e h o s p i t a l
b i l l they r e c e i v e i n t r y i n g t o e x p l a i n t o them how uncompensated care
i s p a i d f o r . Because one of t h e sad, and perhaps u n f a i r , f a c t s t h a t
we c o n f r o n t i n t h e h e a l t h care reform debate i s t h a t most American
b e l i e v e t h e r e i s a very simple answer:
Don't charge as much f o r what
you do. That, t o them, i s t h e answer.
A l l t h e r e s t of these issues
t h a t we have looked a t and w o r r i e d about over t h e l a s t f i v e months
p a l e i n t o i n s i g n i f i c a n c e a g a i n s t t h e overwhelming p u b l i c p e r c e p t i o n
t h a t t h e r e a l problem i n h e a l t h care i s t h a t d o c t o r s charge t o o much,
h o s p i t a l s charge t o o much, insurance companies charge t o o much,
everybody charges t o o much so we j u s t c u t everybody's p r i c e s and
e v e r y t h i n g w i l l be f i n e .
You know t h a t i s not t h e case, and I know i t . But i t
w i l l be one o f our c h a l l e n g e s t o educate t h e p u b l i c and t h e more t h a t
you can t a l k about what i t means f o r an i n s t i t u t i o n l i k e Hopkins
H o s p i t a l t o t r y t o care f o r t h e people of East B a l t i m o r e , and t o t r y
t o fund t h a t care when so many p a t i e n t s are e i t h e r u n i n s u r e d or
u n d e r i n s u r e d w i l l enable us t o have a much b e t t e r educated audience
when we come f o r w a r d w i t h h e a l t h care r e f o r m .
So t h e r e w i l l be g r e a t o p p o r t u n i t i e s because t h e r e w i l l
be so l i t t l e uncompensated care l e f t when we a r e a b l e t o r e f o r m the
system. There w i l l a l s o be i n c e n t i v e s f o r h o s p i t a l s , such as t h e one
at Hopkins, t o be p a r t o f networks t h a t remove care away from t h e
emergency and t h e t e r t i a r y care f a c i l i t y o u t i n t o t h e community.
I h a v e v i s i t e d o t h e r h o s p i t a l s , much as what you're
t r y i n g t o do here, where you begin t o have a s c r e e n i n g system so t h a t
when people walk i n t h e door o f t h e emergency i t i s n o t assumed t h a t
t h e y w i l l s i t t h e r e and w a i t f o r s e v e r a l hours u n t i l t h e i r minor
problem can be d e a l t w i t h w h i l e you deal w i t h emergencies, b u t
i n s t e a d t h e y a r e i m m e d i a t e l y d e f l e c t e d o f f i n t o a d i f f e r e n t system,
maybe down t h e b l o c k , maybe across t h e s t r e e t , maybe i n t o a van where
[
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they a r e taken t o a f a m i l y c l i n i c where t h e problem t h a t they have
can be e f f e c t i v e l y and c o s t e f f e c t i v e l y d e a l t w i t h .
We a l s o w i l l c o n t i n u e t o do what we can t o support t h e
t r a d i t i o n a l research r o l e of t h e academic medical c e n t e r . We know
how i m p o r t a n t t h a t i s . I t i c k e d o f f e a r l i e r some of t h e many
advances t h a t have been and w i l l c o n t i n u e t o be made i n medical
research here a t t h i s i n s t i t u t i o n .
We w i l l look f o r ways t o support t h a t research.
We
b e l i e v e t h a t medical research i s a cost e f f e c t i v e investment, and we
w i l l be l o o k i n g f o r ways t o spread t h e burden more f a i r l y and t o
i n c r e a s e t h e resources a v a i l a b l e t o academic medical c e n t e r s so t h a t
you can look forward t o a steady stream of revenue, maybe even
i n c r e a s i n g i n some areas a p a r t i c u l a r need so t h a t we can continue
the k i n d of breakthrough research t h a t has been t h e hallmark of
Hopkins and o t h e r academic medical c e n t e r s .
We w i l l a l s o look f o r ways t o be sure t h a t t h a t
w o n d e r f u l phrase t h a t comes from one of your l e a d e r s , managed
cooperation, i s the r e a l i t y .
That i s what we a r e r e a l l y l o o k i n g f o r .
We a r e not l o o k i n g f o r an environment i n which t h e academic medical
c e n t e r competes w i t h any o t h e r i n s t i t u t i o n a t t h e lowest common
denominator. We a r e l o o k i n g f o r ways t o enhance t h e s p e c i a l r o l e s of
a l l k i n d s o f i n s t i t u t i o n s w i t h i n our h e a l t h care d e l i v e r y system.
That can o n l y come about through c o o p e r a t i o n .
•
And I had no idea before I g o t i n t o t h i s how d i f f i c u l t
c o o p e r a t i o n was. (Laughter.)
You know how d i f f i c u l t i t i s . But
i t ' s g o i n g t o r e g u i r e new a t t i t u d e s on t h e p a r t o f l o t s o f people.
S p e c i a l i s t s a r e going t o have t o cooperate w i t h n o n - s p e c i a l i s t s ;
d o c t o r s a r e going t o have t o cooperate w i t h nurses; h o s p i t a l s are
g o i n g t o have t o cooperate w i t h c l i n i c s .
A l l kinds of cooperative,
c o l l a b o r a t i v e arrangement should be seeded and n u r t u r e d i n a reformed
environment.
There w i l l be so many o p p o r t u n i t i e s f o r you as
p h y s i c i a n s or nurses or o t h e r s t a f f members t o have your r o l e s
enhanced and t o be g i v e n back a u t h o r i t y f o r making d e c i s i o n s again.
But t h a t w i l l then p u t t h e burden on you o f c o o p e r a t i n g .
We have, i n a d v e r t e n t l y over t h e y e a r s , c r e a t e d a system
i n which c o o p e r a t i o n was not n e c e s s a r i l y v a l u e d .
And i t has not
g o t t e n us what "We want . I t has i n s t e a d g o t t e n us a system i n which
people a r e p i t t e d a g a i n s t one another; i n which reimbursement i s
based o f t e n on d i a g n o s i s or t e s t s r a t h e r than q u a l i t y and outcome;
where teamwork i s valued because i t has t o be t h e r e when you're
a c t u a l l y on t h e f l o o r doing what needs t o be done; b u t i s n o t valued
w i t h i n t h e l a r g e r system.
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So we w i l l look t o you t o help us c r e a t e those new
r e l a t i o n s h i p s of c o o p e r a t i o n . And we w i l l look t o those who are not
p r o f e s s i o n a l s t o be more r e s p o n s i b l e f o r t h e i r own h e a l t h care; t o
take t h a t p r i m a r y or p r e v e n t i v e h e a l t h care o p t i o n t h a t we w i l l now
r e q u i r e t o be g i v e n t o them; t o be r e s p o n s i b l e f o r t h e i r own w e l l b e i n g ; t o g i v e you a l i t t l e help i n your e f f o r t s t o t r y t o be the
h e a l e r s . But you w i l l a l s o have t o perhaps go beyond the t r a d i t i o n a l
medical school o r i e n t a t i o n , t o t a l k more about t h i n g s l i k e n u t r i t i o n ,
d i e t , e x e r c i s e , s t r e s s r e d u c t i o n , the kinds of issues t h a t u n t i l
r e c e n t l y have not been considered p a r t of the mainstream medical
school c u r r i c u l u m but which many of us i n t h i s room p r a c t i c e
o u r s e l v e s , whether you t a l k t o your p a t i e n t s about them or not.
And so we w i l l have t o look t o you t o g i v e new
l e a d e r s h i p of a d i f f e r e n t k i n d , new meaning t o the words h e a l t h care.
Because of P r e s i d e n t Richardson s a i d , we o f t e n have a system t h a t i s
a sickness system, not a h e a l t h system. And we have t o p a r t i c i p a t e
i n changing the a t t i t u d e s of o u r s e l v e s and our f e l l o w c i t i z e n s i f
t h i s r e f o r m i s r e a l l y t o do what we hope i t w i l l do.
•
The k i n d of o p p o r t u n i t i e s a v a i l a b l e f o r an Academic
Medical Center are r e a l l y o n l y l i m i t e d by t h e scope of i m a g i n a t i o n
and v i s i o n .
I a n t i c i p a t e t h a t as we move f o r w a r d i n the next weeks
we w i l l engage i n a v i g o r o u s and, I hope, c o n s t r u c t i v e debate about
what d i r e c t i o n we need t o go and how the P r e s i d e n t ' s p o l i c i e s w i l l be
r e c e i v e d . That's what should take place as we embark on a g r e a t
e f f o r t t o r e f o r m t h i s system t o b e n e f i t everyone.
But I hope t h a t i t w i l l not be a debate j u s t about
narrow issues and t h a t each of us from whatever p e r s p e c t i v e we b r i n g
w i l l be a b l e t o s t e p o u t s i d e our own view and our own experience t o
t h i n k as b r o a d l y as p o s s i b l e . There i s no b e t t e r place t o get t h a t
k i n d of v i s i o n than a place l i k e t h i s one.
We w i l l need your
c o n t i n u i n g guidance as so many of you have a l r e a d y g i v e n t o us.
We
w i l l need your v o i c e s .
And f o r every q u e s t i o n you ask, suggest a p o s s i b l e
answer, because t h e r e i s n ' t any doubt, I don't t h i n k , t h a t we can do
b e t t e r . We can do b e t t e r as a n a t i o n because when one stops and
t h i n k s a minute about what i s a s t a k e , i t i s not j u s t about how we
finance h e a l t h care, although c e r t a i n l y i t i s t h a t .
I t i s not j u s t
about i n s u r i n g " t n a t we r i d o u r s e l v e s of t h e unnecessary bureaucracy
and paperwork, -and how we d e a l w i t h the t h r e a t of m a l p r a c t i c e t h a t
hangs over your heads, I t i s not j u s t about i n c r e a s i n g and enhancing
our r e s e a r c h agenda so t h a t we get b e t t e r r e s u l t s more q u i c k l y
d e l i v e r e d t o t h e maximum number of people.
I t i s not even j u s t about
how we cooperate w i t h one another among p r o f e s s i o n a l s . I t i s not
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even j u s t about how much r e s p o n s i b i l i t y i n d i v i d u a l s f i n a l l y are
w i l l i n g t o t a k e f o r themselves.
I t i s a l l of t h a t , but i t i s more.
I t i s about the
q u a l i t y o f our community t o g e t h e r .
I t i s about what k i n d of people
we are and i n t e n d t o be. I t i s about how we t r e a t one another, how
we care f o r a l l of us, but p a r t i c u l a r l y those who are l e a s t f o r t u n a t e
among us. T h i s h e a l t h care r e f o r m w i l l c e r t a i n l y say a l o t about
Johns Hopkins, about h o s p i t a l s , about medicine, but i t w i l l
u l t i m a t e l y say a l o t more about what k i n d of s o c i a l c o n t r a c t we have
w i t h one another, what k i n d of c o u n t r y we a r e , and what k i n d of
c o u n t r y we want t o be. Thank you a l l very much. (Applause.)
END
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�The F i r s t Lady
Johns Hopkins U n i v e r s i t y School of Medicine Centennial
June 10, 1993
Good afternoon, President Richardson, Dean Johns, t r u s t e e s ,
distinguished members of the f a c u l t y , students, alumni, and
friends.
I'm honored t o j o i n you here today t o celebrate the
centennial anniversary of the Johns Hopkins School of Medicine.
One need not be a doctor, a nurse, a medical student, or even a
p a r t i c i p a n t i n the health care reform movement t o appreciate the
magnitude of Johns Hopkins' c o n t r i b u t i o n s t o the medical f i e l d i n
the past hundred years.
How many other i n s t i t u t i o n s can boast of r e v o l u t i o n i z i n g the
standards f o r medical school admission? How many can claim c r e d i t
f o r being among the f i r s t t o include women as students? How many
have so ably served the poor and indigent i n the inner c i t y
around them? And how many have spawned so many important
discoveries i n medical treatment?
•
Indeed, Johns Hopkins i s widely respected f o r excellence,
progress, and v i s i o n i n health care. I mean, how many other
schools of medicine are d i s t i n g u i s h e d enough t o have been
immortalized as a question on Jeopardy?
In a l l seriousness, few i n s t i t u t i o n s can compare w i t h yours.
Given your h i s t o r y as t r a i l b l a z e r s i n medical education and
research, given your t r a d i t i o n of s o c i a l l y responsible medicine,
given your remarkable f a c u l t y and students, i t i s t r u l y a
p r i v i l e g e t o share t h i s occasion w i t h you.
You have much t o be proud of: From the Nobel Prizes of Drs.
Daniel Nathans and Hamilton Smith, t o medical advances i n the
treatment of blindness, t o the innovative research t h a t Hopkins
doctors have produced on b r a i n chemistry, t h i s school's
c o n t r i b u t i o n s t o medical science are v i r t u a l l y u n p a r a l l e l e d . I
can't e x p l a i n what a P53 gene i s , but I do know t h a t Dr. Bert
Vogelstein's rSCSTTt r e v e l a t i o n s about genetic connections t o
colon cancer are a welcome breakthrough f o r the 57,000 Americans
who d i e from t h a t dreaded disease each year.
p
I also know t h a t research i s only p a r t of what t h i s
i n s t i t u t i o n i s a l l about. As one of the foremost academic medical
centers i n the world, Hopkins also has been a pioneer i n s e t t i n g
the agenda f o r medical education. Few other schools were as quick
t o understand the importance of i n c o r p o r a t i n g humanistic l e a r n i n g
i n the t r a i n i n g of doctors. Few others have developed a
curriculum t h a t so emphasizes general p r a c t i c e and the r o l e of
the physician i n s o c i e t y .
�At the same t i m e , Hopkins has not n e g l e c t e d t h e most
e s s e n t i a l area o f h e a l t h care: t r e a t i n g p a t i e n t s . You are a
beacon i n t h i s r e g i o n , and even t h e n a t i o n , when i t comes t o
c l i n i c a l and t e r t i a r y care. And, perhaps most i m p o r t a n t , you are
an anchor i n East B a l t i m o r e , p r o v i d i n g q u a l i t y t r e a t m e n t f o r the
p o o r e s t and n e e d i e s t i n our s o c i e t y .
I wish I c o u l d spend a l l of my time t a l k i n g about t h i s
w o n d e r f u l p l a c e . But I know you are anxious t o hear about what
impact the P r e s i d e n t ' s r e f o r m e f f o r t w i l l have on academic
medical c e n t e r s . I hope you w i l l be encouraged by some o f our
ideas, which I w i l l o u t l i n e a l i t t l e l a t e r . F i r s t , though, I want
t o e x p l a i n why we so u r g e n t l y need r e f o r m .
Although our n a t i o n i s blessed w i t h t h e f i n e s t d o c t o r s , the
most s o p h i s t i c a t e d medical t e c h n o l o g y , and t h e most modern
h o s p i t a l s i n t h e w o r l d , we are c u r r e n t l y f a c i n g a n a t i o n a l h e a l t h
care emergency.
H e a l t h care i n t h i s c o u n t r y no longer c o n j u r e s up images of
f a m i l y d o c t o r s w i t h l i t t l e b l a c k bags who t r u d g e t h r o u g h t h e r a i n
and snow making house c a l l s . Nowadays, h e a l t h care t o o o f t e n i s a
n i g h t m a r i s h v i s i o n o f overcrowded emergency rooms, l a y e r s o f
paperwork, c o n f u s i n g insurance p l a n s , and, i n many cases,
inadequate or unnecessary t r e a t m e n t .
•
You i n t h i s audience, more than most, know what I'm t a l k i n g
about. You are d e v o t i n g your p r o f e s s i o n a l l i v e s t o i m p r o v i n g the
h e a l t h and w e l l - b e i n g o f your f e l l o w c i t i z e n s . You're t h e ones
who see t h e anguish and p a i n o f p a t i e n t s s u f f e r i n g from
d e b i l i t a t i n g i l l n e s s e s . You're t h e ones who are boxed i n by
paperwork and r e g u l a t i o n s you had no r o l e i n d e v i s i n g . You're t h e
ones faced w i t h e t h i c a l d e c i s i o n s about proper t r e a t m e n t s f o r
people w i t h no h e a l t h i n s u r a n c e . You're t h e h e a r t o f t h e system
and you know f i r s t - h a n d t h e d e v a s t a t i n g consequences t h a t
everyone — d o c t o r s , p a t i e n t s , h o s p i t a l s , businesses, o r d i n a r y
Americans — w i l l f a c e i f we do not s t r e a m l i n e our h e a l t h care
system.
T h i s i s a time of great urgency. And i t i s with t h a t i n mind
t h a t I ask for your help, your e x p e r t i s e , and your energy as we
attempt to s o l v e our current health care c r i s i s .
I have f a i t h t h a t you can help us meet the challenges ahead.
Johns Hopkins has always embodied a pioneering s p i r i t . And i t has
always appreciated the need to change with changing times.
At t h i s c r i t i c a l moment, we must be w i l l i n g to s t r i p away
years of papering over the problems i n our h e a l t h care system, of
avoiding the r e a l i t y t h a t was a l l around us. We have to be honest
with one another; we have to be w i l l i n g to put a s i d e our personal
i n t e r e s t s i n s o f a r as t h a t i s humanly p o s s i b l e .
�And we have t o remember t h a t t h e P r e s i d e n t ' s p r i n c i p l e goal
i n r e f o r m i n g t h e system i s one we a l l share: t o f i n d a way t o
p r o v i d e q u a l i t y , a f f o r d a b l e care f o r a l l Americans.
The reason t h a t we must a c t g u i c k l y i s because our n a t i o n i s
f a c i n g a f r i g h t e n i n g t r u t h : s k y r o c k e t i n g c o s t s are undermining
the f o u n d a t i o n of our h e a l t h care system. Middle c l a s s Americans
can no longer t a k e f o r g r a n t e d t h a t they w i l l be cared f o r i n
times of need. Tens o f thousands of Americans j o i n t h e ranks of
the u n i n s u r e d each month. Workers and employers are g r a p p l i n g
over who should pay f o r t h e e s c a l a t i n g p r i c e t a g on h e a l t h
b e n e f i t s . American c o r p o r a t i o n s are f e e l i n g pinched by f o r e i g n
c o m p e t i t o r s w i t h f a r lower h e a l t h care c o s t s . Doctors are
i n c r e a s i n g l y burdened by. r e g u l a t i o n s and paperwork and the
s p e c t e r of l a w s u i t s .
Hundreds of Americans — some o f them r e p r e s e n t i n g t h i s very
i n s t i t u t i o n -- have spent c o u n t l e s s hours t r y i n g t o f i n d ways t o
address these problems. I want t o pay s p e c i a l t r i b u t e t o t h r e e
members of t h e Johns Hopkins community who have been h e l p f u l i n
this effort:
o Diane Rowland, a s s o c i a t e p r o f e s s o r i n t h e School o f
Hygiene and P u b l i c H e a l t h P o l i c y and Management a t Johns
Hopkins;
•
o Dr. R i c h a r d Frank, economics p r o f e s s o r i n t h e School o f
Public Health;
o and Lu Zawaistowich, who got her d o c t o r a t e o f science i n
t h e School o f P u b l i c H e a l t h .
A f t e r months of looking at the extraordinary range of i s s u e s
we confront, one thing i s c l e a r : we cannot j u s t a t t a c k one part
of the problem. To do t h a t would be to i n v i t e an explosion of
c o s t s and continuing growth i n other parts of the system. So the
President has c a l l e d for a comprehensive approach to t r y to
reform the h e a l t h care system, put i t on a sound f i n a n c i a l
footing for the future, r e t a i n the q u a l i t i e s of choice and
opportunities t h a t c u r r e n t l y e x i s t , and be sure t h a t a l l
Americans have access to health care.
You, as h e a l t h care p r o f e s s i o n a l s , have a unique r o l e to
play as we attempt to make our system more e f f i c i e n t . With your
v a s t e x p e r t i s e on h e a l t h i s s u e s , with the moral oath you take to
m i n i s t e r to the s i c k , with your revered p r o f e s s i o n a l s t a t u s , you
must view your jobs NOT merely as p r a c t i t i o n e r s but as community
leaders who a l s o seek treatment for s o c i e t y ' s i l l s . J u s t as each
i n d i v i d u a l has a r e s p o n s i b i l i t y to the l a r g e r community, health
care p r o f e s s i o n a l s have d u t i e s t h a t extend beyond t h e i r
individual patients.
�Most p h y s i c i a n s and h e a l t h care p r o v i d e r s choose c a r e e r s i n
medicine because t h e y want t o h e l p people. But t o o o f t e n t h a t
noble m o t i v e i s clouded by p e r c e p t i o n s t h a t d o c t o r s are moneyhungry and l a z y , more i n t e r e s t e d i n a F r i d a y a f t e r n o o n g o l f game
than t e n d i n g t o a s i c k l y p a t i e n t . W e l l , i t ' s t i m e f o r us t o work
harder t o r e s t o r e a t r u s t i n who d o c t o r s are and what d o c t o r s do.
I t ' s t i m e t o make t h e p r a c t i c e of medicine a v i s i b l e , honored
l i n k i n our e f f o r t t o promote the common good.
Too much i s a t stake f o r us t o operate i n our own l i t t l e
w o r l d s . Now i s t h e time t o f i g u r e out how we might a l l prosper by
making our h e a l t h care system s t r o n g e r .
To begin w i t h , t h e medical p r o f e s s i o n as a whole must h e l p
revamp t h e system t o b e t t e r r e f l e c t t h e broad-based needs o f our
society.
•
A l r e a d y t h e r e are s i g n s o f p r o g r e s s . I am heartened by t h e
new f o u r - y e a r course of study t h a t Hopkins has c r e a t e d c a l l e d
"The P h y s i c i a n and S o c i e t y . " And I am e q u a l l y e x c i t e d by your
e f f o r t s t o encourage more s t u d e n t s t o embark on c a r e e r s as
g e n e r a l p r a c t i t i o n e r s . The s u r p l u s o f s p e c i a l i s t s and t h e p a u c i t y
of p r i m a r y care p h y s i c i a n s , p a r t i c u l a r l y i n urban and r u r a l
areas, i s an imbalance t h a t must be addressed. As Dean Michael
Johns and o t h e r s have suggested, t h e success o f h e a l t h c a r e
r e f o r m depends i n p a r t on our a b i l i t y t o p u t d o c t o r s and h e a l t h
care resources where t h e y are most needed, n o t s i m p l y where t h e y
are most p r o f i t a b l e . But t h a t w i l l o n l y happen i f i n c e n t i v e s t h a t
have t r a d i t i o n a l l y gone i n t o medical e d u c a t i o n t o promote
s p e c i a l i s t s now go i n t o medical e d u c a t i o n t o promote g e n e r a l i s t s .
The bold c u r r i c u l a r changes undertaken at Hopkins r e f l e c t
e x a c t l y the s o r t of c r e a t i v i t y and v i s i o n we need a c r o s s the
board. U l t i m a t e l y , we have to recognize that there are values in
our h e a l t h care system t h a t we need to promote, and r e a s s e r t , and
even to introduce. I n d i v i d u a l s w i l l have to be more responsible
for t h e i r own h e a l t h care.
So where do academic medical centers f i t i n t o a l l of t h i s ? I
know some of you worry about the impact of reform on i n s t i t u t i o n s
such as t h i s one, whose broad missions and p a t i e n t s with complex
i l l n e s s e s r e q u i r e c o s t l y expenditures. I'm glad the P r e s i d e n t ' s
task force h a s j i a d the opportunity to hear from some of you as we
formulate our proposals for reform. I n p a r t i c u l a r , I want to
thank Dean Michael Johns and Dr. Jim Block for some of t h e i r
valuable time with us i n Washington when we met with academic
medical c e n t e r s . They and the other r e p r e s e n t a t i v e s helped us
focus on how h e a l t h care reform must address the s p e c i a l
s i t u a t i o n of academic medical c e n t e r s , with t h e i r m u l t i p l e
missions: s e r v i n g as h e a l e r s of l a s t r e s o r t , pioneers i n
research, and teachers of tomorrow's doctors.
�We r e a l i z e t h a t your i n s t i t u t i o n and o t h e r s l i k e i t are
v i t a l channels i n p r o v i d i n g t r e a t m e n t and care f o r t h e uninsured
and underserved. C u r r e n t l y , c e n t e r s such as t h i s one bear t h e
burden' o f t r e a t i n g p a t i e n t s who can't a f f o r d t o pay. Under a new
h e a l t h system, however, a l l p a t i e n t s w i l l be e n t i t l e d t o h e a l t h
care coverage and a l l p r o v i d e r s w i l l be f a i r l y compensated f o r
their services.
On t h e research f r o n t , we b e l i e v e t h a t i m p r o v i n g our h e a l t h
care system w i l l r e q u i r e an a d d i t i o n a l investment, and we are
committed t o p r o v i d i n g i n c e n t i v e s and o t h e r resources t o f u r t h e r
medical research and advances.
Johns Hopkins a l s o i s a c l i n i c a l l a b o r a t o r y f o r s t a t e - o f t h e - a r t p a t i e n t care, and t h a t i s a r o l e t h a t must be p r o t e c t e d .
As p i o n e e r s o f new t r e a t m e n t s , Hopkins and o t h e r academic medical
c e n t e r s w i l l c o n t i n u e t o be t h e f i n e s t and most c o s t - e f f e c t i v e
p r o v i d e r s o f s o p h i s t i c a t e d procedures. We b e l i e v e t h a t these
s e r v i c e s b e n e f i t a l l Americans and must be m a i n t a i n e d and
supported. The new h e a l t h system w i l l e x p l i c i t l y r e c o g n i z e t h e
v a l u e o f t h i s t y p e o f advanced p a t i e n t care.
•
F i n a l l y , we a p p r e c i a t e t h e c r i t i c a l r o l e t h a t academic
medical c e n t e r s p l a y i n t r a i n i n g f u t u r e g e n e r a t i o n s o f h e a l t h
p r o f e s s i o n a l s . The new h e a l t h care system w i l l expand t r a d i t i o n a l
forms o f s u p p o r t t o r e c o g n i z e t h a t we a l l b e n e f i t from our
e d u c a t i o n a l system.
I n s h o r t , our r e f o r m w i l l assure t h a t academic medical
c e n t e r s s u r v i v e and prosper i n a w o r l d o f u n i v e r s a l coverage,
community-based s e r v i c e s , and c o s t c o n t r o l .
No c o m p e t i t i o n , no r e g u l a t i o n can be a l l o w e d t o undermine
our commitment t o h e l p i n g you accomplish your v i t a l m i s s i o n s .
As we g r a p p l e w i t h f i n d i n g t h e best ways t o o v e r h a u l t h e
system, we welcome your i n p u t and your i d e a s . We cannot promise
t o f i n d cures o v e r n i g h t . We cannot promise t o p l e a s e everyone
w i t h our p l a n .
But we can promise t o work f o r a f a i r and e f f i c i e n t system
t h a t n o t o n l y p r o v i d e s q u a l i t y a f f o r d a b l e care t o a l l Americans,
but a l s o r e i n f o r c e s t h e v a l u e s we share about t h e importance o f
b e i n g a member o f a community where people a r e j o i n e d t o g e t h e r i n
a common g o a l .
We a l l have a s t a k e i n t h i s e n t e r p r i s e . We a l l have a stake
i n t h e f u t u r e . And, t h r o u g h c o o p e r a t i o n , c a r i n g , and commitment,
we can b u i l d a h e a l t h care system t h a t f o s t e r s a s t r o n g e r ,
h e a l t h i e r , more compassionate n a t i o n .
0
Thank you v e r y much.
�Remarks by the F i r s t Lady
By S a t e l l i t e to Annual Meeting of
The C a t h o l i c Health Association
June 9, 1993
Good ^afternoon^ everyone. And thank you, S i s t e r Maryanna
Coyle, f o r t h a t w o n d e r f u l i n t r o d u c t i o n .
I t i s a r e a l p r i v i l e g e t o be able t o speak w i t h t h e Annual
Assembly o f t h e C a t h o l i c H e a l t h A s s o c i a t i o n . For t h a t , we can
thank t e c h n o l o g y t h a t g i v e s new meaning t o the s a y i n g , " I f I
c a n ' t be t h e r e i n person, I ' l l be t h e r e i n s p i r i t . "
Today, we are indeed connected by s p i r i t and by a v i s i o n . . .
the s p i r i t o f community... and t h e v i s i o n of an America where
every c i t i z e n has access t o a f f o r d a b l e h e a l t h c a r e .
My a d m i r a t i o n f o r t h e C a t h o l i c H e a l t h A s s o c i a t i o n runs deep.
Yours i s a l o n g , proud h i s t o r y o f p r o v i d i n g the h i g h e s t q u a l i t y
h e a l t h c a r e w i t h o u t r e g a r d t o r a c e , r e l i g i o n or c i r c u m s t a n c e .
Your c o n t r i b u t i o n t o t h e h e a l t h o f Americans i s immense,
e s s e n t i a l and i r r e p l a c e a b l e . I applaud t h e work o f each and every
one o f you.
S i s t e r Maryanna mentioned my v i s i t t o S a i n t Agnes H o s p i t a l
l a s t March. I w i l l always remember t h a t v i s i t . . . and a l l t h e
c a r i n g s t a f f devoted t o d o i n g t h e b e s t t h e y know how. There, from
p a t i e n t s and d o c t o r s , I heard what I ' d been h e a r i n g around t h e
c o u n t r y f o r a l o n g t i m e , b u t t h e impact o f t h e words had even
g r e a t e r meaning and urgency. I heard a growing sense o f
v u l n e r a b i l i t y and p e r s o n a l i n s e c u r i t y . . . a f e a r from people i n
need.
I remember i n p a r t i c u l a r one d o c t o r , who s a i d t o me:
"You
know t h e s a y i n g , ' I f i t a i n ' t b r o k e , don't f i x i t . ' W e l l , Mrs.
C l i n t o n , t h e system i s broke and i t ' s t i m e t o f i x i t . "
I t h i n k we can a l l agree w i t h t h a t .
You and C-H-A
have known t h i s system i s broken f o r some
t i m e . . . and have been h a r d a t work t r y i n g t o f i x i t . Your Working
P r o p o s a l f o r Systemic H e a l t h c a r e Reform i s as t h o u g h t f u l as i t i s
t h o r o u g h . And I s h o u l d say t h a t i t covers much o f t h e ground t h a t
our t a s k f o r c e i s c o v e r i n g as we prepare our recommendation f o r
the P r e s i d e n t . I t h i n k i t ' s amazing t h a t your group and my group
s t u d i e d such an enormous problem... and a r r i v e d a t so many
o v e r l a p p i n g c o n c l u s i o n s and s o l u t i o n s . That t e l l s me t h a t we're
b o t h on t h e r i g h t t r a c k .
t
�In the work you do at C a t h o l i c health-care f a c i l i t i e s across
America, you understand how important i t i s to f i x our nation's
h e a l t h c a r e system.
As you know, we've been w o r k i n g hard t o do j u s t t h a t .
Toward t h a t end... we have p u l l e d t o g e t h e r t h e people from
w i t h i n t h e government w i t h e x p e r t i s e i n h e a l t h c a r e . . . and we've
sought t h e advice from people o u t s i d e o f government who have
b r o u g h t p a r t i c u l a r p o i n t s of view t o bear.
There has been an e x t r a o r d i n a r y amount of c o n s u l t a t i o n .
Many o f you l i s t e n i n g t o me now have been i n meetings w i t h
m y s e l f , and w i t h I r a Magaziner and h i s team. We've h e l d more than
one-thousand meetings w i t h groups r e p r e s e n t i n g a l l sides of the
h e a l t h c a r e debate.
T h i s process w i l l n o t o n l y c o n t i n u e , but i n t e n s i f y as the
P r e s i d e n t moves toward f i n a l p o l i c y d e c i s i o n s .
Our group has begun a s u b s t a n t i a l p u b l i c e d u c a t i o n e f f o r t .
Many Americans s i m p l y do not have t h e f a c t s about what our h e a l t h
c a r e c h o i c e s have meant t o our economy, t o our q u a l i t y o f l i f e ,
t o our f u t u r e s t a b i l i t y . And so we're r e a c h i n g o u t , t o enable
people t o be p a r t i c i p a n t s i n a v e r y broad c o n v e r s a t i o n about t h e
s t a t e o f h e a l t h care t o d a y ; about i t s r e a l c o s t ; and about what
f u t u r e p o l i c y changes w i l l mean f o r them p e r s o n a l l y .
Now, I ' d l i k e t o t o u c h b r i e f l y on each of t h e fundamental
g o a l s o f our r e f o r m .
F i r s t , our primary goal i s to provide health s e c u r i t y for
a l l Americans.
You know the depth of t h i s problem better than most
because you see i t every day.
In a d d i t i o n to the 4 0 - m i l l i o n Americans without insurance,
m i l l i o n s of other Americans are gripped by fear t h a t a t any time,
they could l o s e t h e i r b e n e f i t s . . . and every year, two m i l l i o n
Americans do l o s e them. They may lose them for a month or two or
s i x months or a- year before they f i n d a way back on some
i n s u r a n c e r o l l s . And they u s u a l l y pay a l o t more to be insured
again.
S t i l l , every month 100-thousand Americans f a l l o f f the
h e a l t h insurance r o l l s . Others stay i n jobs that they want to
leave because they can't take the r i s k of being uninsured. And
many f a m i l i e s f i n d they can't get coverage for the very problem
they need c a r e for, because t h a t i l l n e s s i s stamped a — quote —
" p r e - e x i s t i n g condition."
t
�Americans who work f o r a l i v i n g , who pay the b i l l s and take
care o f r a i s i n g t h e i r f a m i l i e s should not be burdened by the
i n s e c u r i t y o f n o t knowing whether t h e y w i l l have h e a l t h
insurance.
S e c u r i t y i s what t h i s h e a l t h care debate i s a l l about.
Can
America's f a m i l i e s f i n d peace of mind? Can our c h i l d r e n or our
p a r e n t s g e t the q u a l i t y o f care when you need i t most? That's
what we have t o be f o c u s i n g on every s i n g l e day. We have enough
i n s e c u r i t i e s and s t r e s s i n our w o r l d today.
Once the new h e a l t h care p l a n i s up and r u n n i n g , everyone
w i l l g e t a h e a l t h s e c u r i t y c a r d . That card w i l l guarantee a l l
Americans access t o a comprehensive package of b e n e f i t s , no
m a t t e r where they work, where they l i v e , how o l d they are and
whether o r not they've ever been s i c k . S e c u r i t y . . . no matter
what.
Second... we're g o i n g t o work t o g e t h e r t o make sure t h a t
h e a l t h care c o s t s are b r o u g h t under c o n t r o l .
You see every day what happens when h e a l t h care i s p r i c e d
out o f t h e reach of many Americans. I t f o r c e s you t o absorb more
red i n k . . . and many o t h e r segments o f t h e h e a l t h care system t o
s h i f t c o s t s . . . and a l l o f us bear t h e burden. L e f t unchecked
h e a l t h care c o s t s w i l l c o n t i n u e t o h u r t our f a m i l i e s . . . bankrupt
b u s i n e s s e s . . . and d r i v e t h e d e f i c i t t o e v e r - g r e a t e r h e i g h t s .
Our reform w i l l r e i n i n h e a l t h care costs through s e v e r a l
measures. We w i l l s t r i p away the i n c e n t i v e s from rewarding
doctors who do more t e s t s and procedures and instead w i l l create
a competitive system t h a t encourages c o s t - e f f e c t i v e , h i g h - q u a l i t y
c a r e . We w i l l reduce the bureaucracy and micro-management t h a t
b l o a t s our health-care system and adds unnecessary c o s t . F i n a l l y ,
we w i l l say to h e a l t h care i n s t i t u t i o n s and providers: You must
l i v e w i t h i n a budget.
And we're going to ask everybody... workers, employers and
p r o v i d e r s a l i k e . . . to chip i n and do t h e i r part for h e a l t h care.
To t h e d r u g companies t h a t charge two and t h r e e t i m e s i n
America what t&ey charge overseas... we're going t o say: B r i n g
your p r i c e s down. I t ' s o n l y f a i r .
To the businesses who don't cover t h e i r workers today... and
d r i v e up the c o s t s f o r the businesses who do r i g h t by t h e i r
workers... we're going to say: I t ' s time for you to take
r e s p o n s i b i l i t y . I t ' s only f a i r .
t
To the i n d i v i d u a l s who think they can get by without coverage
and end up i n emergency rooms and s t i c k us with the b i l l . . . we're
�going t o say: You, too, must do your part. I f you can a f f o r d i t ,
you must c o n t r i b u t e . I t ' s only f a i r .
We w i l l a l l b e n e f i t i f we a l l take r e s p o n s i b i l i t y .
Third, our reform w i l l reduce the waste that eats up our
health care d o l l a r s . . . and so much of your time.
Another key component of our reform w i l l be a wholesale
reduction of the f r u s t r a t i n g and wasteful paperwork eating up our
h e a l t h care system.
Yes, you a l l know very well what the load i s l i k e . And when
you look at the number of rules, the volumes of regulations, the
stacks upon stacks of forms, you have t o ask yourself: Where did
a l l t h i s bureaucracy come from?
The short answer i s : I t comes from everywhere. Forms were
created t o make sure t h a t the most vulnerable people were getting
proper care. Then more forms were created t o make sure doctors
and h o s p i t a l s d i d n ' t perform unnecessary t e s t s and procedures.
•
Then, the insurance companies have t h e i r own sets of rules
for doctors and nurses t o f o l l o w , so they create t h e i r own forms.
And as the number of health insurance companies grew — today
t h e i r are more than fifteen-hundred of them -- so d i d the number
of forms.
The result? Instead of a system where forms enforce the
rules, we have a system ruled by the forms. Patients don't know
how to read their b i l l s or to make sense of their policy, and
worry that t h e y ' l l be l e f t hanging because they didn't understand
the fine print.
Doctors and nurses — especially nurses — spend as much
time dotting i ' s and crossing t's as they do taking temperatures.
One of the nurses we spoke with told us she entered nursing
because she wanted to care for people; she said that i f she
wanted to be an accountant, she'd have gone to work for Arthur
Anderson. For every new doctor an average hospital hires, i t
hires four new administrators. I t ' s a bad case of the t a i l
wagging the doqp*
We're going to take the mess and clean i t up. For the f i r s t
time, you'll see a health care system made easy: one insurance
form, a report card for quality, no hidden fine p r i n t . And we're
going to reduce the paperwork and streamline the regulations.
Doctors and nurses w i l l be able... f i n a l l y . . . to do what they
were trained to do. At the same time, we w i l l maintain and
enhance the quality of American health care by measuring quality
based on r e s u l t s . . . not based on micro-management.
t
�F o u r t h , t h i s r e f o r m w i l l make a s e r i o u s s t a r t a t addressing
the growing long-term care problems our c o u n t r y faces. Now, many
w i l l argue we should put o f f c o n s i d e r a t i o n of t h i s i s s u e . While
i t woUld.be too c o s t l y t o t r y t o meet a l l of America's long-term
care needs a t once, i t would i r r e s p o n s i b l e f o r us not t o make a
start.
Today, f r a i l and d i s a b l e d s e n i o r s who need help w i t h d a i l y
t a s k s o f t e n have o n l y one choice: move i n t o a n u r s i n g home. The
problem i s , most people would p r e f e r t o l i v e a t home, near
f a m i l y , f r i e n d s and f a m i l i a r s u r r o u n d i n g s , f o r as long as
possible.
There are t o o few o p t i o n s f o r people hoping t o stay a t home
and o u t o f i n s t i t u t i o n s , and t o o l i t t l e h e l p f o r f a m i l i e s doing
t h e i r best t o care f o r a i l i n g r e l a t i v e s .
I n d i v i d u a l s and t h e i r
f a m i l i e s are o f t e n bankrupted by t h e c o s t s o f long-terra c a r e , and
c a n ' t g e t h e l p u n t i l they have almost n o t h i n g l e f t . The system
i s complex and d i s j o i n t e d , and i t fragments the care people
receive.
I f the long-term care system i s l e f t unchanged, a l l
t h a t w i l l o n l y g e t worse.
Most of you know Monsignor Charles Fahey. Monsignor Fahey
served on pur working group on e t h i c s , the group charged with
making sure that the system we develop i s driven by fundamental
v a l u e s , l i k e f a i r n e s s , shared r e s p o n s i b i l i t y , and s o c i a l j u s t i c e .
Monsignor Fahey has confronted the fragmentation and backward
i n c e n t i v e s of our long-term care system f i r s t hand. He took a
month o f f t h i s year to care for h i s parents, both s e r i o u s l y i l l ,
in order to keep them out of a h o s p i t a l or nursing home. As he
struggled to nurse his-parents back to h e a l t h i n ways t h a t met
t h e i r needs and maintained t h e i r d i g n i t y , he took on a system
t h a t looked at the moving p a r t s , but never a t the whole person.
As the Monsignor put i t : "We've got a system that c a r e s f o r the
eye or the foot or the nose, but never f o r C h a r l i e or E l i z a b e t h . "
Our reform w i l l reverse the i n c e n t i v e s , expand the options
for c a r e a t home, and improve coordination of s e r v i c e s . We'll
make a s e r i o u s s t a r t on improving long-term care coverage for
e l d e r l y and d i s a b l e d Americans by expanding home and communitybased c a r e . People with severe d i s a b i l i t i e s w i l l have access to a
broad a r r a y o f . s e r v i c e s , coordinated by a case manager, t a i l o r e d
to i n d i v i d u a l needs. By expanding a v a i l a b i l i t y of home and
community-based care... we w i l l give s e n i o r s and d i s a b l e d
c i t i z e n s who can't manage on t h e i r own the opportunity to remain
in the community for as long as p o s s i b l e .
L a s t l y , we w i l l improve the a v a i l a b i l i t y of health care i n
the areas that have been t r a d i t i o n a l l y under-served: r u r a l
communities, urban centers and other p a r t s of the country where a
t
�h e a l t h care c a r d alone w i l l mean l i t t l e t o people u n l e s s
guarantee t h a t s e r v i c e s w i l l be t h e r e f o r them.
Americans everywhere need t o know t h e r e w i l l be a
h e a l t h f a c i l i t y a v a i l a b l e t o them. T h i s i s a problem
C a t h o l i c H e a l t h A s s o c i a t i o n knows v e r y w e l l , because
have helped t o address the problem i n many r u r a l and
areas.
we
d o c t o r and a
t h a t the
your members
urban poor
I can guarantee you t h i s : my husband b e l i e v e s very s t r o n g l y i n
making sure t h a t a l l of America i s adequately cared f o r . . . t h a t
i t s needs are taken i n t o account. We p l a n t o t a r g e t funds f o r
areas t h a t now are under-served. We w i l l s t r e n g t h e n t h e h e a l t h care i n f r a s t r u c t u r e i n these areas by l i n k i n g community-based
c e n t e r s t o o t h e r h o s p i t a l s and p r o v i d e r s . . . and by p r o v i d i n g
i n c e n t i v e s f o r the N a t i o n a l H e a l t h S e r v i c e Corps and o t h e r
programs f o r d o c t o r s t o p r a c t i c e i n remote p a r t s of t h i s c o u n t r y .
I should note here t h a t I was e s p e c i a l l y proud t h a t t h e work
of one o f t h e C a t h o l i c h e a l t h - c a r e p r o v i d e r s i n r u r a l Arkansas
was r e c o g n i z e d t h i s year f o r i t s w o n d e r f u l work i n c a r i n g f o r the
n e e d i e s t . St. E l i z a b e t h H e a l t h Center i n Gould, Arkansas, serves
a community t h a t o t h e r h e a l t h - c a r e p r o v i d e r s have abandoned. For
t h e 15-hundred r e s i d e n t s of Gould, t h e n e a r e s t d o c t o r was o u t of
r e a c h . . . more than 18 m i l e s away! But almost t h r e e years ago, St.
E l i z a b e t h ' s s e t i t s e l f up i n an o l d p o l i c e s t a t i o n and i t ' s been
f i l l i n g t h a t c r i t i c a l v o i d ever s i n c e .
C o n g r a t u l a t i o n s , St. E l i z a b e t h ' s , f o r your w e l l - d e s e r v e d
Achievement. C i t a t i o n . . . and f o r t h e example o f s e r v i c e t h a t you
set f o r r u r a l America.
As we go t h r o u g h t h i s process of r e f o r m i n g h e a l t h c a r e , I'm
c o u n t i n g on a new s p i r i t o f c o o p e r a t i o n and commitment i n our
c o u n t r y . I want again t o f e e l t h a t I'm l i v i n g i n t h e c o u n t r y
t h a t I t o o k f o r g r a n t e d and was r a i s e d i n . I know t h a t f o r some
people, t h a t sounds n o s t a l g i c and maybe u n r e a l i s t i c .
But I remember very w e l l i n t h e suburb I grew up i n . . .
everybody l o o k e d o u t f o r each o t h e r , n e i g h b o r s r e a l l y cared about
each o t h e r . Doctors made house c a l l s . A l l those k i n d s o f t h i n g s
may seem l i k e jaart of d i s t a n c e p a s t . But you know, t h e r e was a
c o n n e c t i o n among us then t h a t I would l i k e t o see r e i n s t i l l e d i n
America.
H e a l t h care touches us a t our most b a s i c human emotion...
t h e b i r t h o f a baby... t h e death o f a l o v e d one... w a l k i n g those
l o n g h o s p i t a l c o r r i d o r s . . . or seeing t h e j o y on a person's face
when you t e l l them t h a t e v e r y t h i n g i s g o i n g t o be a l l r i g h t .
t
�That's how, a t t h e very most basic l e v e l , we understand what
i t means t o be a human b e i n g ; t h a t ' s how we understand what i t i s
about l i f e t h a t connects us from g e n e r a t i o n t o g e n e r a t i o n ; t h a t ' s
what makes us r e l i a n t i n a most fundamental way upon each o t h e r .
We've g o t t e n away from t h a t . We've watched bureaucracies
and paperwork and r e d tape d i s t a n c e us from human c a r i n g t h a t
needs t o be a t t h e r o o t o f any h e a l t h care system. And we can't
wave a magic wand and r e v e r s e t i m e .
But we can t r y t o reconnect. I know t h a t C a t h o l i c Health
A s s o c i a t i o n members t r y every day t o i n j e c t t h a t e x t r a b i t o f
humanity i n t o t h e system. That's t h e k i n d o f e f f o r t t h a t can make
a l l t h e d i f f e r e n c e a t those moments when we f i n d ourselves
dependent on each o t h e r .
T h i s i s what I hope: t h a t i n a few years we w i l l n o t o n l y
have a s t r e a m l i n e d system; t h a t we w i l l n o t o n l y have a b e t t e r
d i s t r i b u t i o n o f h e a l t h care p r o f e s s i o n a l s , and have more primary
and p r e v e n t a t i v e h e a l t h care p h y s i c i a n s , and nurse p r a c t i t i o n e r s ,
and p h y s i c i a n a s s i s t a n t s ; t h a t we w i l l n o t o n l y have b e t t e r
access, b u t w e ' l l f e e l b e t t e r about o u r s e l v e s and about each
other.
We won't j u s t be h e a l t h i e r . . . a l t h o u g h t h a t ' s a tremendous
g o a l i n i t s e l f . . . b u t w e ' l l a l l be p a r t o f a community o f c a r i n g
a g a i n . And h e a l t h care can be t h e s t a r t o f t h a t i f we do i t
right.
Thank you very much.
t
�THE
WHITE HOUSE
O f f i c e of the Press Secretary
For Immediate Release
June 10, 1993
REMARKS BY THE FIRST LADY
TO CATHOLIC HEALTH ASSOCIATION
VIA SATELLITE
JUNE 9, 1993
MRS. CLINTON: ( I n progress) M i l l i o n s o f o t h e r
Americans are g r i p p e d by f e a r t h a t a t any time they c o u l d lose t h e i r
b e n e f i t s . And every year, two m i l l i o n Americans do lose them. They
may lose them f o r a month o r two o r s i x months o r a year before they
f i n d a way back on some insurance r o l l .
And they u s u a l l y pay a l o t
more t o be i n s u r e d a g a i n . S t i l l , every month, 100,000 Americans f a l l
o f f the h e a l t h insurance r o l l s .
Others s t a y i n j o b s t h a t they want
t o leave because they can't take the r i s k o f being u n i n s u r e d . And
many f a m i l i e s f i n d they can't get coverage f o r the very problem they
need care f o r , because t h a t i l l n e s s i s stamped a " p r e e x i s t i n g
condition.
11
Americans who work f o r a l i v i n g , who pay the b i l l s and
t a k e care o f r a i s i n g t h e i r f a m i l i e s should not be burdened by the
i n s e c u r i t y o f not knowing whether they w i l l have h e a l t h insurance.
S e c u r i t y i s what t h i s h e a l t h care debate i s a l l about.
Once the new h e a l t h care p l a n i s up and r u n n i n g ,
everyone w i l l g e t a h e a l t h s e c u r i t y c a r d which w i l l guarantee a l l
Americans access t o a comprehensive package o f b e n e f i t s , no matter
where t h e y work, where they l i v e , and whether o r n o t they've ever
been s i c k b e f o r e . S e c u r i t y , no m a t t e r what, i s t h e f i r s t c o n d i t i o n .
Second, we're g o i n g t o work t o g e t h e r t o make sure t h a t
h e a l t h care c o s t s are brought under c o n t r o l .
You see every day what
happens when h e a l t h care i s p r i c e d out o f t h e reach o f many
Americans. I t f o r c e s you t o absorb more red i n k , and many o t h e r
segments o f t h e h e a l t h care system t o s h i f t c o s t s , and a l l o f us bear
the burden.
L e f t unchecked, h e a l t h care c o s t s w i l l c o n t i n u e t o h u r t
our f a m i l i e s , bankrupt businesses, and d r i v e t h e f e d e r a l d e f i c i t t o
ever g r e a t e r h e i g h t s .
Our r e f o r m s w i l l r e i n i n h e a l t h care c o s t s t h r o u g h
s e v e r a l measures. We w i l l s t r i p away t h e i n c e n t i v e s from rewarding
d o c t o r s who do more t e s t s and procedures, and i n s t e a d w i l l c r e a t e a
system t h a t encourages c o s t - e f f e c t i v e , h i g h q u a l i t y care where a
d o c t o r and a p a t i e n t can again be a t the c e n t e r o f t h e r e l a t i o n s h i p
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�- 2 -
and where d e c i s i o n s can be made not on how something w i l l be
reimbursed, b u t what a d o c t o r b e l i e v e s i s best f o r a p a t i e n t .
We
w i l l reduce t h e bureaucracy and micromanagement t h a t b l o a t s our
h e a l t h care system and t h a t so many of you have complained about
because i t adds unnecessary c o s t s .
F i n a l l y , we w i l l say t o a l l h e a l t h care i n s t i t u t i o n s and
p r o v i d e r s , j u s t as you recommended i n your p r o p o s a l , we must l i v e
w i t h i n a budget, and we must r e a l l o c a t e our h e a l t h care resources
w i t h i n t h a t budget away from paperwork, a d m i n i s t r a t i o n , insurance
c o s t s , i n t o what m a t t e r s most, c a r i n g f o r people. We're going t o ask
everybody -- workers, employers, p r o v i d e r s , d o c t o r s , nurses,
h o s p i t a l s -- t o c h i p i n and do t h e i r p a r t f o r h e a l t h care. And t o
the drug companies t h a t charge two and t h r e e times i n America what
they charge overseas, we're going t o say, b r i n g your p r i c e s down.
I t ' s only f a i r .
I can remember so w e l l s i t t i n g i n t h e St. V i n c e n t ' s
w a i t i n g area and t a l k i n g w i t h a f r i e n d of mine who's a p h y s i c i a n
t h e r e who t o l d me t h a t every day he d i s c h a r g e s somebody from t h e
h o s p i t a l who needs c o n t i n u i n g p r e s c r i p t i o n m e d i c a t i o n t o s t a b i l i z e a
c o n d i t i o n . And every day t h e r e i s a t l e a s t one p a t i e n t whom he knows
cannot a f f o r d t h e drugs he p r e s c r i b e s . And so what o f t e n happens i s
t h a t p a t i e n t decides not t o take those expensive drugs, or t o s e l f medicate.
I n s t e a d o f t h e f o u r a day r e q u i r e d , maybe o n l y one t o
s t r e t c h them a l i t t l e f u r t h e r . And, sure enough, i t ' s not t o o long
b e f o r e t h a t p a t i e n t ends up back i n t h e h o s p i t a l , c o s t i n g a l l of us
even more.
To t h e businesses who don't cover t h e i r workers today,
yet t a k e advantage of your h o s p i t a l s and, t h e r e f o r e , d r i v e up t h e
c o s t s f o r t h e businesses who do cover t h e i r workers, we're going t o
say i t ' s t i m e f o r everyone i n America t o t a k e r e s p o n s i b i l i t y . I t ' s
o n l y f a i r t h a t we a l l pay our f a i r share.
To t h e i n d i v i d u a l s who t h i n k they can g e t by w i t h o u t
coverage and have t h a t t e r r i b l e a c c i d e n t or t h a t u n p r e d i c t e d i l l n e s s
and end up i n t h e emergency room or i n t h e ICU and, t h e r e f o r e , we a l l
pay t h e b i l l , we're g o i n g t o say, you, t o o , must do your p a r t . I f
you can a f f o r d i t , o r whatever you can a f f o r d , you must c o n t r i b u t e .
I t ' s only f a i r .
We w i l l a l l b e n e f i t i f we a l l t a k e r e s p o n s i b i l i t y
f o r our h e a l t h and f o r each o t h e r .
Th-ird, our r e f o r m w i l l reduce t h e waste t h a t eats up our
h e a l t h c a r e d o l l a r s now -- and so much o f your t i m e . Another key
component o f r e f o r m w i l l be a wholesale r e d u c t i o n i n t h e f r u s t r a t i n g
and w a s t e f u l paperwork t h a t e a t s up t h e h e a l t h care system.
You a l l
know v e r y w e l l what t h e load i s l i k e , and when you l o o k a t t h e number
of r u l e s , t h e volumes o f r e g u l a t i o n s , t h e s t a c k s upon s t a c k s o f
MORE
t
�- 3-
forms, you have t o ask y o u r s e l f , where d i d a l l t h i s bureaucracy
from?
come
The s h o r t answer i s i t comes from everywhere.
I t comes
from p r i v a t e i n s u r e r s , i t comes from government. Forms were c r e a t e d
t o make sure t h a t t h e most v u l n e r a b l e people were g e t t i n g proper
care. Then more forms were c r e a t e d t o make sure d o c t o r s and
h o s p i t a l s d i d n ' t perform unnecessary t e s t s and procedures.
Then t h e
insurance companies have t h e i r own s e t s o f r u l e s f o r d o c t o r s and
nurses t o f o l l o w , so they c r e a t e t h e i r own forms. And as t h e number
of h e a l t h insurance companies grew -- today t h e r e are more than 1,500
— so d i d t h e number o f forms. The r e s u l t :
I n s t e a d o f a system
where forms e n f o r c e t h e r u l e s , we have a system r u l e d by t h e forms.
P a t i e n t s don't know how t o read t h e i r b i l l s o r make
sense o f t h e i r insurance p o l i c i e s , and worry t h e y ' l l be l e f t hanging
because they d i d n ' t understand t h e f i n e p r i n t .
Doctors and nurses,
e s p e c i a l l y nurses, spend as much time d o t t i n g I s and c r o s s i n g Ts as
they do t a k i n g temperatures and c a r r y i n g f o r p a t i e n t s . One of t h e
nurses I spoke w i t h t o l d us she entered n u r s i n g because she wanted t o
care f o r people.
She s a i d t h a t i f she had wanted t o be an
accountant, she would have gone t o work f o r an a c c o u n t i n g f i r m .
And f o r every new d o c t o r an average h o s p i t a l h i r e s , i t
h i r e s f o u r new a d m i n i s t r a t o r s .
I t ' s a bad case o f t h e t a i l wagging
the dog. And we're going t o take t h a t a d m i n i s t r a t i v e mess we now
have and c l e a n i t up f o r you and f o r everyone.
W e ' l l see a h e a l t h
care system t h a t i s made easy. One insurance form f o r everybody.
A
q u a l i t y check form -- no hidden f i n e p r i n t .
And we're going t o
reduce t h e paperwork and s t r e a m l i n e t h e r e g u l a t i o n s . Doctors and
nurses w i l l be able f i n a l l y t o do what they were t r a i n e d t o do. At
the same t i m e , we w i l l m a i n t a i n and enhance t h e g u a l i t y o f American
h e a l t h care by measuring q u a l i t y based on r e s u l t s , n o t based on
micromanagement and forms.
F o u r t h , t h i s r e f o r m w i l l make a s e r i o u s s t a r t a t
a d d r e s s i n g t h e growing long-term care problems our c o u n t r y faces.
Now, many w i l l argue we should p u t o f f c o n s i d e r a t i o n o f t h i s issue.
While i t would be t o o c o s t l y t o t r y t o meet a l l o f America's l o n g term care needs a t once, i t would be i r r e s p o n s i b l e f o r us n o t t o make
a s t a r t , t o t r y t o g e t ahead o f t h e aging c u r v e . Today t h e r e a r e t o o
few o p t i o n s f o y people hoping t o s t a y a t home and o u t o f
i n s t i t u t i o n s , and t o o l i t t l e h e l p f o r f a m i l i e s d o i n g t h e i r best t o
care f o r a i l i n g r e l a t i v e s .
I n d i v i d u a l s and t h e i r f a m i l i e s , as you
know, a r e o f t e n bankrupted by t h e c o s t o f l o n g - t e r m c a r e , o r a t l e a s t
f o r c e d t o spend themselves i n t o p o v e r t y and t u r n t h e i r backs on t h e i r
older r e l a t i v e s .
They can't g e t h e l p u n t i l t h e y have almost n o t h i n g
left.
MORE
t
�_
A
—
The system i s complex and d i s j o i n t e d and i t fragments
the care people r e c e i v e . I f the long-term care system i s l e f t
unchanged a l l t h a t w i l l o n l y get worse.
Most of you know Monsignor Charles Fahey. Monsignor
Fahey served on our working group on e t h i c s , the group charged w i t h
making sure t h a t the system we develop i s d r i v e n by fundamental
v a l u e s , shared r e s p o n s i b i l i t i e s , s o c i a l j u s t i c e .
Monsignor Fahey has
c o n f r o n t e d the f r a g m e n t a t i o n and backward i n c e n t i v e s of our long-term
care system f i r s t h a n d . He took a month o f f t h i s year t o care f o r
both h i s p a r e n t s , s e r i o u s l y i l l , i n order t o keep them out of a
h o s p i t a l or a n u r s i n g home. As he s t r u g g l e d t o nurse h i s parents
back t o h e a l t h i n ways t h a t met t h e i r needs and maintained t h e i r
d i g n i t y , he took on a system t h a t looked a t t h e moving p a r t s but
never a t the whole person. As the Monsignor put i t , "We've got a
system t h a t cares f o r the eye or the f o o t or the nose, but never f o r
C h a r l i e or E l i z a b e t h . "
Our r e f o r m w i l l reverse the i n c e n t i v e s and expand the
o p t i o n s f o r care a t home and improve c o o r d i n a t i o n of s e r v i c e s .
Another example from my v i s i t t o St. Agnes: That h o s p i t a l , as many
of your does, runs an a d u l t day care c e n t e r . And what they found i s
t h a t t h e y c o u l d n ' t g e t reimbursed on even a s l i d i n g s c a l e t o h e l p
keep t h e i r p a t i e n t s and t h e i r f a m i l i e s from the neighborhood a t home.
And so what o f t e n happened i s t h a t , a l t h o u g h n u r s i n g home care was so
much more expensive, the $35 a day f o r a d u l t day care i n a h o s p i t a l
s e t t i n g was beyond the f i n a n c i a l reach of so many f a m i l i e s t h a t they
went ahead, met the Medicaid requirements and, very r e g r e t f u l l y , put
t h e i r r e l a t i v e i n a n u r s i n g home.
I t wasn't the choice they wanted and i t c o s t us more
money. How much more s e n s i b l e we w i l l be i f t h e St. Agneses and the
St. V i n c e n t s and t h e o t h e r h o s p i t a l s i n your a s s o c i a t i o n are able t o
reach o u t and h e l p f a m i l i e s make t h i s c o n n e c t i o n t o be a b l e t o serve
t h e i r older relatives.
We'll make a s e r i o u s s t a r t on i m p r o v i n g long-term care
coverage f o r t h e e l d e r l y and d i s a b l e d Americans by expanding home and
community-based c a r e . People w i t h severe d i s a b i l i t i e s w i l l have
access t o a broad a r r a y of s e r v i c e s , c o o r d i n a t e d by a case manager,
t a i l o r e d t o i n d i v i d u a l needs. By expanding t h e a v a i l a b i l i t y of home
and community-has^d c a r e , we w i l l g i v e s e n i o r s and d i s a b l e d c i t i z e n s
who c a n ' t manage on t h e i r own the o p p o r t u n i t y t o remain i n t h e i r
community f o r as long as p o s s i b l e .
L a s t l y , we w i l l improve the a v a i l a b i l i t y o f h e a l t h care
i n t h e areas t h a t have been t r a d i t i o n a l l y underserved -- r u r a l
communities, urban c e n t e r s and o t h e r p a r t s of t h e c o u n t r y where a
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h e a l t h care card alone w i l l mean l i t t l e
t h a t s e r v i c e s w i l l be t h e r e f o r them.
t o people u n l e s s we guarantee
Americans everywhere need t o know t h e r e w i l l be a d o c t o r
and a h e a l t h f a c i l i t y a v a i l a b l e t o them. This i s a problem t h a t t h e
C a t h o l i c H e a l t h A s s o c i a t i o n knows very w e l l because your members have
helped t o address t h e problem i n many r u r a l and urban poor areas. I
am e s p e c i a l l y proud t h a t one work o f t h e C a t h o l i c h e a l t h care
p r o v i d e r s i n Arkansas was recognized t h i s year, and I'm speaking
about t h e w o n d e r f u l work i n c a r i n g f o r t h e needy by t h e St. E l i z a b e t h
H e a l t h Center i n Gould, Arkansas, which serves a community t h a t o t h e r
h e a l t h care p r o v i d e r s have abandoned.
For t h e 1,500 r e s i d e n t s of a community l i k e Gould out i n
the c o u n t r y , t h e nearest d o c t o r was o u t o f reach. Many people d i d n ' t
have t r a n s p o r t a t i o n and c o u l d n ' t reach even t h e f a c i l i t i e s 18 m i l e s
away. But about t h r e e years ago S t . E l i z a b e t h ' s s e t i t s e l f up i n an
o l d p o l i c e s t a t i o n and i t ' s been f i l l i n g t h e c r i t i c a l h e a l t h v o i d i n
t h a t community ever s i n c e .
The President's plan w i l l b o l s t e r these e f f o r t s by
t a r g e t i n g funds for areas that are now undeserved. And the plan w i l l
strengthen the health care i n f r a s t r u c t u r e in these areas by l i n k i n g
community based centers to other h o s p i t a l s and providers and w i l l
provide i n c e n t i v e s for the n a t i o n a l health s e r v i c e corps and other
programs to encourage doctors to p r a c t i c e i n remote p a r t s of our
country.
This plan w i l l make sure that a l l America i s cared for,
j u s t as you've recommended, with integrated d e l i v e r y networks where
a l l of our providers, doctors and nurses and others w i l l be connecr
up to give care in areas that t r a d i t i o n a l l y have been overlooked.
We've gotten away from t h a t . We've watched bureaucracies and
paperwork and red tape d i s t a n c e us from the human c a r i n g that needs
to be a t the root of any health care system.
We can't wave a magic wand and r e v e r s e time, but we can
try to reconnect.
I know that CHA members t r y every day to i n j e c t
that e x t r a b i t of humanity and caring into the system. That's the
kind of e f f o r t t h a t can make a l l the d i f f e r e n c e a t those moments when
we f i n d o u r s e l v e s , as I have, dependent on each other.
Trtis i s what I hope: t h a t i n a few years we w i l l not
o n l y have a s t r e a m l i n e d more e f f i c i e n t system, t h a t we w i l l n o t only
have a b e t t e r d i s t r i b u t i o n o f h e a l t h care p r o f e s s i o n a l s and have more
p r i m a r y and p r e v e n t i v e h e a l t h care p h y s i c i a n s and nurse p r a c t i t i o n e r s
and p h y s i c i a n ' s a s s i s t a n t s , t h a t we w i l l n o t o n l y have b e t t e r access,
but w e ' l l f e e l b e t t e r about o u r s e l v e s and about each o t h e r . We won't
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j u s t be h e a l t h i e r , a l t h o u g h t h a t ' s a tremendous goal i n i t s e l f , but
w e ' l l a l l be p a r t o f a community of c a r i n g again.
Thank you very much f o r being p a r t of t h a t community
now, f o r ' t h i n k i n g hard about how we can expand i t t o every American,
and by standing behind the reforms that need to be made. Thank you
a l l again.
END
t
�THE WHITE HOUSE
O f f i c e o f t h e Press S e c r e t a r y
Internal Transcript
May 26, 1993
REMARKS BY THE FIRST LADY
AT SEIU
MRS. CLINTON: This must have been some c o n c e r t i n here
— (inaudible).
(Laughter.)
I'm j u s t probably g r a t e f u l I wasn't
here i n t h e b e g i n n i n g .
(Laughter.)
But I am very honored t o be here, and honored t o be
i n t r o d u c e d by P r e s i d e n t Sweeney. There i s n o t anyone whom I have met
i n t h e months t h a t I have worked on h e a l t h care r e f o r m who i s more
knowledgeable, more committed, and more c o n v i n c i n g about t h e needs of
change than P r e s i d e n t Sweeney.
I a l s o want t o thank a l l o f you, because i n t h i s room
are h e a l t h care workers and h e a l t h care l e a d e r s . And many o f you
know from t h e f r o n t l i n e why t h i s campaign f o r h e a l t h care r e f o r m i s
long overdue.
(Applause.) You see i t every day. And I remember so
w e l l d u r i n g t h e Democratic Convention t h e s i g n t h a t read " A f f o r d a b l e
H e a l t h Care For F a m i l i e s . " That was a good slogan then and i t ' s a
good slogan today.
(Applause.)
You have kept h e a l t h care r e f o r m on t h e n a t i o n a l agenda,
never wavering.
Everywhere I went d u r i n g t h e campaign and s i n c e , I
have seen s i g n s h e l d up by many o f you and your c o l l e a g u e s . The
h e a l t h a c t i o n teams have been t h e r e everywhere we have gone. And t h e
reason i t ' s been so s i g n i f i c a n t i s because your c o n s t a n t presence
speaks volumes about what i s a t s t a k e .
I f t h e people who are c a r i n g f o r our f e l l o w c i t i z e n s i n
h o s p i t a l s and n u r s i n g homes and so many o t h e r s e t t i n g s understand so
w e l l why we need r e f o r m , you can lead t h e way f o r so many o f our
o t h e r c i t i z e n s who understand what i s a t s t a k e . T h i s i s a debate not
j u s t about r e f o r m i n g our h e a l t h care system; i t i s a debate about
s e t t i n g t h e d i r e c t i o n f o r our c o u n t r y . We have t o change t h e way we
p r o v i d e h e a l t h care n o t j u s t because o f an economic i s s u e -- b u t i t
i s a v e r y b i g one; n o t j u s t because i t ' s an i n d i v i d u a l human issue —
but i t i s . You" see i t every day. But because a t t h i s p o i n t i n our
h i s t o r y , t h i s c o u n t r y can no longer stand alone among i t s major
c o m p e t i t o r s o f i n d u s t r i a l i z e d c o u n t r i e s i n t h e w o r l d and n o t p r o v i d e
health security — (inaudible).
(Applause.)
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You know b e t t e r than most t h e problems f a c i n g you and me
and every o t h e r American. You know t h a t one out o f every f o u r of you
i n t h i s room r i s k s l o s i n g t h e h e a l t h insurance you now have, i n t h e
next two y e a r s . J u s t stop and t h i n k about t h a t .
You are i n t h i s
room among t h e i n s u r e d , by and l a r g e . And y e t you can't be secure
t h a t you w i l l have your insurance. Every year, m i l l i o n s of Americans
are on t h e b r i n k o f l o s i n g t h e i r insurance and two m i l l i o n a year do.
They may lose i t f o r a month or two or s i x months o r a year b e f o r e
they f i n d a way back on t o some insurance r o l l s .
They may -- u s u a l l y
do — pay a l o t more t o be able t o g e t back t o being i n s u r e d . And
every month, 100,000 Americans don't make i t back on those h e a l t h
insurance r o l l s .
J u s t t h i n k o f how you w i l l f e e l because you have seen
t h i s i n your work. A l l of us know p e r s o n a l examples o f people who
are i n between i n s u r a n c e , were l a i d o f f , were l e t go, found t h e cost
too h i g h . And i t was j u s t a t t h a t moment i n t i m e t h a t f a t e s t r u c k .
I t was then t h a t t h e c h i l d g o t s i c k . I t was then t h a t t h e p a r e n t s
faced some t e r r i b l e t r a g e d y . I t was then t h a t they needed insurance,
and they d i d n ' t have i t anymore.
•
And t h e n , when they t r i e d t o go back t o g e t i t , maybe
t h e y g o t a new j o b , maybe they were brought back t o work a f t e r t h a t
l a y o f f , t h a t they found t h e employer's c o s t - c u t t i n g r u l e s had changed
p o l i c i e s on them. Not o n l y had c o s t s gone up, b u t now p r e e x i s t i n g
c o n d i t i o n s stood i n t h e way o f being i n s u r e d . That c h i l d was a
problem.
That spouse w i t h t h e i l l n e s s c o u l d n ' t even be covered, o r ,
i f covered, o n l y a t a very h i g h c o s t .
Think about what m i l l i o n s o f i n s u r e d Americans go
t h r o u g h every month. And t h i n k about how many more o f us a r e no
l o n g e r secure, we can no longer take f o r g r a n t e d t h a t we a r e employed
and our employer p r o v i d e s insurance, t h a t i t w i l l always be t h e r e f o r
us when we need i t . We a l s o no longer can count on insurance
c o v e r i n g us i n t h e event t h a t a w f u l a c c i d e n t s or u n p r e d i c t a b l e
i l l n e s s w i t h o u t grave f i n a n c i a l c o s t and even t h e p r o s p e c t o f
bankruptcy.
S e c u r i t y i s what t h i s h e a l t h care debate i s a l l about.
Can your f a m i l y f i n d peace o f mind? Can you, o r your c h i l d , or your
p a r e n t s g e t t h e q u a l i t y o f care when you need i t most? That's what
we have t o be f o c u s i n g on every s i n g l e day. We have enough
i n s e c u r i t i e s i n our w o r l d today. We see i t a l l around us. Americans
who work f o r a " l i v i n g , who pay t h e b i l l s , t a k e care o f r a i s i n g t h e i r
f a m i l i e s s h o u l d n o t be burdened by t h e i n s e c u r i t y o f now knowing
whether t h e y w i l l have h e a l t h insurance.
(Applause.)
workers
Those o f you who a r e on t h e f r o n t l i n e w i t h h e a l t h care
have a tremendous amount a t stake i n h e a l t h care r e f o r m . You
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know t h a t b e t t e r than I . You see i t every day -- your j o b , your
l i v e l i h o o d , t h e q u a l i t y o f your workplace. But you know more about
the problems i n our system than most o f your f e l l o w Americans.
And I
ask you t o t a l k about those problems w i t h t h e people you see. Talk
about i t a t t h e c o f f e e shop, a t t h e supermarket o r a t church or a t
d i n n e r . Make sure t h a t what you see every day i n a system t h a t i s
not a system any l o n g e r , i n which people f a l l t h r o u g h t h e cracks
t h r o u g h no f a u l t o f t h e i r own, make sure t h a t comes a l i v e f o r
everyone you reach.
Talk about t h e hard choices you see being made.
People
being d i s c h a r g e d from h o s p i t a l s w i t h p r e s c r i p t i o n s i n t h e i r hand t h a t
t h e y cannot a f f o r d t o f i l l .
(Applause.) How, when they t r y then t o
s e l f - p r e s c r i b e f o r themselves by s a y i n g , w e l l , I'm supposed t o take
f o u r o f t h e s e , b u t I can o n l y a f f o r d t o take one o f these, maybe t h a t
w i l l h e l p -- how they end up back i n t h e h o s p i t a l , which c o s t s us a l l
and t h e i n s u r e d more money.
(Applause.)
Talk about t h e t i m e you spend f i l l i n g o u t forms i n s t e a d
of t a k i n g care o f people — (applause.) You know b e t t e r than any
t h a t a paperwork h o s p i t a l and a paperwork n u r s i n g home and a
paperwork d o c t o r ' s o f f i c e i s growing f o u r times f a s t e r than a
h o s p i t a l -- ( i n a u d i b l e ) -- (applause.)
Make a l i t t l e experiment sometimes. C o l l e c t up blank
c o p i e s o f a l l t h e forms you have t o f i l l o u t . Okay? Take them and
show them t o your f r i e n d s and n e i g h b o r s . Hold them up and say, i f
you l o o k a t a l l these forms -- ( i n a u d i b l e ) -- 1,500 d i f f e r e n t
i n s u r e r s and t h e government, they a l l ask f o r about t h e same k i n d of
i n f o r m a t i o n , b u t you have t o f i l l them a l l o u t i n d i v i d u a l l y because
t h e y won't t a k e somebody e l s e ' s form. T a l k about t h e hours and waste
and i n e f f i c i e n c y t h a t causes t o you. I ' d r a t h e r have those o f you
who a r e f r o n t - l i n e h e a l t h care workers making sure t h a t I and my
f a m i l y and yours g e t b e t t e r i n s t e a d o f d o t t i n g every I and c r o s s i n g
every T.
(Applause.)
And one o f t h e promises o f h e a l t h care r e f o r m i s we're
g o i n g t o e l i m i n a t e t h e r i d i c u l o u s paperwork and a d m i n i s t r a t i v e —
( i n a u d i b l e ) — (applause.) T a l k t o your f r i e n d s and neighbors about
what you see every day i n terms o f p r i c e gouging, c o s t s h i f t i n g ,
u n c o n s c i o n a b l e p r o f i t e e r i n g . E x p l a i n how you see t h e system i s being
— ( i n a u d i b l e ) — and r i p p e d o f f because i t has no r e a l d i s c i p l i n e —
(inaudible) — ( a p p l a u s e . )
P a r t o f t h e reason we are i n t h i s s p i r a l i n g c o s t
e x p l o s i o n which makes i t i m p o s s i b l e f o r us t o f e e l secure t h a t we
w i l l be i n s u r e d even i f we c u r r e n t l y a r e , because t o o many -( i n a u d i b l e ) — people have made t o o much money o f f o f e l i m i n a t i n g
o p p o r t u n i t i e s f o r c a r i n g f o r people i n s t e a d o f expanding them. We
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need — (applause) -- t o g e t back t o a system t h a t values added -( i n a u d i b l e ) — t h e q u a l i t y o f care t h a t i s a v a i l a b l e t o every
American. And we need t o have a budget f o r our h e a l t h care system
j u s t l i k e we budget e v e r y t h i n g e l s e , so t h a t people w i l l know t h e i r
p r i m a r y r e s p o n s i b i l i t y i s t o take care o f people, not t o enhance the
p r o f i t s o f a l l — ( i n a u d i b l e ) -- (applause.)
You a r e a l s o , though, consumers o f h e a l t h care. And we
want t o make you b e t t e r informed consumers. We want you t o be able
t o choose your h e a l t h p l a n , not t o be r e q u i r e d t o choose o n l y t h e
h e a l t h p l a n o f f e r e d by your employer b u t t o make r e a l c h o i c e s . We
want t o g i v e you good i n f o r m a t i o n so t h a t you can make good consumer
c h o i c e s among h e a l t h p l a n s .
Most people have h e a l t h insurance t h a t they don't
understand as w e l l as t h e c a r they d r i v e .
(Applause.)
(Inaudible)
— c a r t h a n you do f o r your h e a l t h i n s u r a n c e . And I wouldn't want t o
embarrass myself o r any o f you, but I b e t we c o u l d n ' t r e a l l y e x p l a i n
e v e r y t h i n g about our h e a l t h insurance p o l i c y t o each o t h e r i f we
tried.
We don't g e t t h e i n f o r m a t i o n i n understandable forms. We
cannot comparison shop. We can't make good d e c i s i o n s t h a t may be
r i g h t f o r my f a m i l y b u t wouldn't f i t your f a m i l y . So we need a
system t h a t promotes consumer awareness, i n f o r m a t i o n and c h o i c e .
•
The system t h a t w i l l be proposed w i l l do a l l o f t h a t .
Because among t h e a b s o l u t e bedrock p r i n c i p l e s t h a t we want t o abide
by i s consumer c h o i c e as much as p o s s i b l e w i t h i n t h e h e a l t h care
system.
You know, t h e s u r e s t way t o g e t an i n s t i t u t i o n or an
i n d i v i d u a l t o change i n business i s t o walk away when you a r e -( i n a u d i b l e . ) R i g h t now, we can't do t h a t i n most i n s t a n c e s . I n a
new p l a n , every year y o u ' l l be a b l e t o comparison shop and j o i n t h e
p l a n t h a t you t h i n k i s best f o r you. And t h a t w i l l send a very good
messages t o those p l a n s you do n o t choose t o j o i n t h a t t h e y had
b e t t e r change t o g e t your business. An educated consumer i n a h e a l t h
care f i e l d i s one o f t h e s u r e s t ways o f c o n t r o l l i n g c o s t s and
m a i n t a i n i n g q u a l i t y . And we i n t e n d t o have Americans be educated
consumers and make good d e c i s i o n s f o r t h e i r own h e a l t h -- (applause.)
We want s e c u r i t y f o r every American. We want t o c o n t r o l
the c o s t s i n t h e system so t h a t we can r e a l l o c a t e t h e money t h a t i s
t h e r e so i t couLdLJie. used f o r t a k i n g care o f people. We want t o
ensure q u a l i t y and g i v e you good i n f o r m a t i o n so t h a t you can be
judges o f t h e q u a l i t y o f your h e a l t h c a r e . We want t o g i v e you
c h o i c e among h e a l t h care p l a n s so t h a t you can decide what i s best
f o r your f a m i l y based on t h e comprehensive b e n e f i t s package t h a t w i l l
be a v a i l a b l e t o every American. And then you can decide i f you want
fee f o r s e r v i c e l i k e you have now, i f you want an HMO l i k e you have
now. Do want a p a r t i c u l a r k i n d o f s e r v i c e t h a t may be a v a i l a b l e i n
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one p l a n b u t n o t i n another?
choices.
You w i l l be able t o make those k i n d s of
Now, i s t h i s going t o be easy? No. The s t a t u s quo
e x i s t s because t h e r e are people who b e n e f i t from i t . There are
i n t e r e s t s who see t h e same s t a t i s t i c s and hear t h e same s t o r i e s t h a t
we do; who meet people who are a f r a i d t h e y ' r e going t o lose t h e i r
insurance o r who t h r o u g h no f a u l t of t h e i r own a l r e a d y have, but they
-- ( i n a u d i b l e ) -- j u s t t h e p r i c e o f doing business.
We have t o be w i l l i n g t o commit o u r s e l v e s t o these
fundamental v a l u e s about what t h e American h e a l t h care system should
be founded on. We have t o be w i l l i n g t o take on every s p e c i a l
i n t e r e s t group. We have t o be w i l l i n g t o stand up and say we are
g o i n g t o p u t t h e American people and t h e i r h e a l t h f i r s t .
(Applause.)
We have t o be w i l l i n g -- ( i n a u d i b l e ) -- what w i l l be a very hardf o u g h t b a t t l e over changing t h i s -- ( i n a u d i b l e . )
And you know as w e l l as I do t h a t t h e r e w i l l be many
arguments m a r s h a l l e d a g a i n s t r e f o r m . The s t r o n g e s t w i l l be t h a t i f
we change i t c o u l d g e t worse. I t ' s s o r t of hard t o imagine t h e cost
going up $100 b i l l i o n a year, w i t h m i l l i o n s o f people a t r i s k of
l o s i n g t h e i r i n s u r a n c e and a 1.2 m i l l i o n every year l o s i n g i t , w i t h
i t c o s t i n g more and more and d e l i v e r i n g -less and l e s s ; i t ' s hard t o
imagine how these proponents o f t h e s t a t u s quo w i l l be s u c c e s s f u l
w i t h t h a t argument. But don't ever u n d e r e s t i m a t e t h e i r c a p a c i t y t o
confuse t h e i s s u e , t o scare people, t o use t a c t i c s t h a t w i l l be very
d i f f i c u l t t o -- ( i n a u d i b l e . )
But we have a l o t o f arguments on our s i d e . You know
you can be t h e l e a d e r i n g e t t i n g t h i s argument across, because we
know t h a t i f we do n o t h i n g , we w i l l n o t stand s t i l l , we w i l l go
backwards. We know i f we do n o t h i n g , t h e r e w i l l be people who w i l l
c o n t i n u e t o p r o f i t from our e x i s t i n g system — ( i n a u d i b l e ) — w i l l go
w i t h o u t c a r e , have t o postpone c a r e , be bankrupt by o b t a i n i n g care.
So I ask each o f you t o c o n t i n u e what you have begun.
Stand up f o r t h e k i n d o f h e a l t h care system t h a t makes sense, t h a t
w i l l save money, w i l l e l i m i n a t e f r a u d and abuse, w i l l focus on
g u a l i t y , w i l l p r o v i d e a c h o i c e , and w i l l i n t h e long r u n make t h i s
c o u n t r y and everyone i n i t more secure and h e a l t h i e r .
I f t h e debate
i s f o u g h t o u t on those terms, then by t h i s t i m e next year, I w i l l be
g e t t i n g ready f 6 r t n e c e l e b r a t i o n -- ( i n a u d i b l e ) -- P r e s i d e n t meeting
and s i g n i n g t h i s .
(Applause).
Thank you.
END
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[HRC Health Care Speeches] [Binder] [2]
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Simone Rueschemeyer
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092987" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12092987-20060885F-Seg2-037-003-2015
12092987