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�THE WHITE HOUSE
Office of the Press Secretary
For Internal Use Only
November 2-2, 1993
AN INTERVIEW OF THE FIRST LADY
CONDUCTED BY EDITORIAL BOARD OF rHE
ATLANTA JOURNAL - CONSTITUTION
ATLANTA, GEORGIA
MRS. CLINTON: -- so many of the issues about
.(inaudible) and practice styles that (inaudible) familiar
from our own situation in Arkansas. And it is a leap of
faith to try to env:ision what different kinds of systems will
look like, which I recognize, but everything we're doing is
aimed at overcoming the concerns and objections that
physicians have to the present system and the trends that
we're going to be living with if we don't do anything.
So I thought it was a very productive session and I
was glad that they asked very specific, pointed, challenging
questions.
.Q
Do you think the doctors will be the biggest
obstacle?
MRS. CLINTON: No, I really don't. Because if you
look at what's happened, a lot of the big physician
.organizations, like the pediatricians and the family
physicians and the internists and the emergency physicians,
and you can go down the list-~ in the specialty areas are
very supportive of what we're doing.
And if you look even at the concerns of the more
traditional organized·medical groups, they have much more in
common with us than they do really (inaudible). So I think
we can narr.ow those areas of concern and work those through.
I'm pretty optimistic about that.
There will always be physicians who are against any
change, and there will be physicians who don't see the trends
the way the rest of us see them and will be very resistant
because they don't think that we're describing reality as
they know it. But I think the majority of physicians
understand that the status quo .isvery threatening to what we
view as traditional medical practice.
I mean, we do have opposition, but I think it'll be
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more narrow (inaudible).
Q What about the (inaudible)? A few weeks ago you
seemed very annoyed with the ads that they (inaudible)?
MRS. CLINTON: Well; it depends upon the --:- upon
the particular insurance company. Those ads were run by the
independent companies and agencies, through their umbrella
organization, and they we~e disclaimed by other insurance
companies, who disagre~d with (inaudible) and the.substance.
But it really depends upon how the particular
company ~s positioned as to what they think is going on with
health care. And there isn't any doubt that if we eliminate
the right of insurance companies to experience-rate their
insurance policies, force all insuran~e to be community
rated, and if we prohibit elimination of coverage for more
expensive coverage on the basis of preexisting conditions,
and if we eliminate lifetime limits, then we're going to
eliminate a lot of the business that some insurance companies
do. And that's a big threat.
But we can't get to where"we need to go, which is a
community-rated insurance system, with guaranteed health
dI:ha:tr.ac;1JD flIha 'tEf!.mlSihem:ertiI:mrr,ea.Ai1SmI.tt cdb ~o I og i caI struggIe,
if you will, probably will occur. That -- some of the .
insurance companies, the underwriters who make their living
on determining who is and who is not high-risk and marketing
policies to fit into the niches. So that.'s where I think the
real opposition will be.
Q What sort of timetabl~ are you hoping for?
You've got NAFTA b~hind you now. Now you're spending a
couple of weeks on this.
MRS. CLINTON: " We've had a busy year, when you
think about it. I hope that we will have health care reform
by the summer, certainly by the August recess is what we
hope.
Q
Did the NAFTA debate interrupt your momentum
much?
MRS. CLINTON: Sure. Yes, because it's very hard
to have the Congress concentrate on more than one huge issue
at a time. It's just -- I mean, they've got all the work
.that they need to do going on that is not very visible and
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doesn't get a lot of headline~ but which is important, all
going on.
..
.
The entire appropriations process was going on at
the same time, you know, plus other major initiatives like
the crime bill and the education bill and some other things.
But NAFTA dominated the landscape, just like the budget
debate .dominated it all the way up to the August recess.
So now I think health care will dominate the agenda
when the Congress comes back after the recess.
Q Did the NAFTA issue, though, really undermine
your support from labor? Do you think you'll be able to put
them back on your side and working with you, or is this
something that's going to take more than a few weeks or
months?
MRS. CLINTON: Oh, I absolutely think that they'll
be working with us. And don'.t forget, we had a lot of
Democrats who,· for a variety of reasons, did not vote for
NAFTA, but I think that most Democrats will support health
care reform.
Q I want to ask a question about the employer
mandate and the Budget Act. (Inaudible.) There are a lot of
things in common. You're encouraging (inaudible), but the
employer mandate and the budget (inaudible) cost control are
not there, and it seems like in order to prevent (inaudible)
focus on your plan, (inaudible), that you've got to
compromise in one of those areas.
Is that true or not true?
sort of (inaudible)?
And (inaudible), some
MRS. CLINTON: Well, you know, I don't know how you
get to universal coverage unless you do one· o·f three things.
You either have a single-payer system with a broad tax that
replaces private investment, or you have an individual
mandate, which is the Chafee approach, that requires people
to go out into the insurance markets, assuming it's been
reformed, in some form, and, like auto insurance in some
states, bear responsibility for th·eir own health insurance.
Or you have what we think is the best alternative.
You build on the existing employer-employee system. You've
got do something like one of those three to get to universal
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coverage. There isn't any other way to get to universal
coverage. And at least a vast majority of the Congress is
supportive, or seems to be supportive, of universal coverage,
so at some point they're going to have to confront the
financing of universal coverage •
.And I think when that discussion gets serious,
although the single-payer folks have a strong block in the
House particularly, I don't think that they 'will dominate
that conversation.
The conversation will be between those who
genuinely believe we've got to get to universal coverage. And
I think that includes the President and certainly John Chafee
has said that repeatedly and his plan seems to reflect that.
And those who say, "Well, we'll get there some day, but we
don't have to have a mechanism for getting there."
.
So that's the first kind of hurdle we've got to
overcome. And,the President has said very clearly he's not
going to sign anything that doesn't achieve univ.ersal
coverage. So we think that the debate really is between how
you design an employer-employee mandate or you figure out
some way to provide an individual mandate that overcomes our
concerns with it, so that you can achieve universal coverage.
And I think that's going to be the most SUbstantive
and difficult part of the debate because there are arguments,
I suppose, in favor and against both approaches, but we've
run the numbers on ours. We know how much our subsidies for
low-income people will cost. We know how much the small
business discount will cost.
And now that Senator Chafee has gotten his' bill in,
we're going to have to do the same -- run the numbers on all
of his stuff, so then we can start having a conversation.
Q It seems as early as the campaign, the President
was not even thinking or talking about a single-payer system.
What led you and the President to decide not to even
seriously consider that proposal?
MRS. CLINTON: Well, I think we seriously have'
considered it and have adopted its major goals, which are
universal coverage and a much simplified paperwork system, to
try to streamline the process of patients getting their
health care and physicians being paid for it. But we had
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some issues with single-payer, one sUbstantive and one
political, that were hard to overcome.
Substantively, we have a lot of built-in
in our system right now. And we spend more
money than any other country, 'by a long shot. And even if
'you. hold constant for all the demographic factors you could
imagine, and you factor out our rate of violence and our rate
ot AIDS and our rate of teenage pregnancy and all of that,
there still is very little explanation as to why we spend so
much more than we spend.
.
ineffic~ency
And you can see that most clearly in the Medicare
system, which is, after all, a government system. I'm always
amused when some member of congress. tells me they'd never
support a government systeJ.ll. I say, "Well, do you support
Medicare?" And they say, "Well, of course." So I say,
"Well, you know, that is a government system. It's paid for
with a tax." I mean, that's how it operates.
And you can see in the Medicare system, it has been
. very hard, in the absence of organized ways of delivering
health care and providing some public/private kind of
incentive to deliver health care more efficiently, to get the
u~necessary costs out of the Medicare system.
And our fear is that ,if you look at single-payer
systems around the country -- take Canada, for example
their rate of growth in health care expenditures, even though
they're a very low base, is rather significant because it's
hard, if you don't have competing delivery systems, to really
continually get the quality .improvements at the lowest
possible price that you would like to see.
And then, politically, it seems rather hard to
imagine that the Congress, in today's environment, would vote
for about a $500 billion tax increase, even though you could
tell people they would be, if they were insured, saving
themselves money. There would be just a very hard sell to
make on that, and many:people would not trust the government
to do it right and would not believe that it would work, and
so we'd have all of those arguments to contend with.
So I think the single-payer advocates have done a
great service by pushing the cause of universal coverage as
hard as they have, and also pointing out how much money we
waste in our system, to no discernible benefit. But we
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didn't see how we could take that concept and replace what we
currently have with it.
So that's why we opted to build on the
public/private model that we've got and to try to continually
increase the incentives for delivering health care at a high
quality and cost-effective way, which we don't think single
payer necessarily does.
Q I've heard some doctors say that you, in
speaking with them, maybe riot privately, but you've 'said
(inaudible) you really would prefer single-payer plan.
MRS. CLINTON:
I've never said that.
Q Somebody in some position with ~he national
health care said that. Maybe he interpreted i t wrong.
MRS. CLINTON:
No-
Q What I'm curious about is if you ever see the
managed competition being a link between what we have now and
eventually going to (inaudible).·
MRS.'CLINTON: Well, let me tell you what we've
done in the legislation. This may be where they got the
idea. To be fair to them, this might very well be what they
inferred.
We have a single-payer option in our plan. What we
have said to the single-payer community is, "If you really
think you can sell this to people, then we will give you the
option of selling it on the state basis."
So if New York wants to go single-payer under this
plan, they can go single-payer. And then you will have a
period of time where people can watch the results. You know,
that's how, if you think about how we're going to move from
where we are, we've got some models around that we can watch
deve~op, which is one of the reasons why we want to have a
lot of state flexibility, so that individual states can do
things a little bit differently within the federal framework.
I've said, "Look; if you can do that, that's
terrific, you know, but you're going to'have to do it on a
state basis because we're not going to move·towards single
payer on a national basis." Idon't.know that any state will
.
.
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choose to do that, but some states, particularly states with
a small population in a big area, might think it was an
important alternative.
Q' There are some leaders here in Georgia that
argue that Georgia should not forge ahead on the state level
(inaudible) simply because they should wait until the federal
government (inaudible) in Washington (inaudible).
Do you agree that states who are now considering
reforms would be prudent to hold up?
MRS. CLINTON: No, . and I'll tell you why. This is
going to be such an intense discussion, the more that we can
talk about alternatives at every level -- local, state,
federal -- and the more people can be engaged and really
having to learn the problems, so they're not just talking
from anecdotal experience and their own particular point of
view, I think the better off we/ll be.
And secondly, those states that have moved ahead,
many of them are much better positioned to take advantage of
reform than others, and I think that's a real net plus.
The State of Washington adopted a comprehensive
health care reform with an employer mandate, with a lot of
the features that we're adopting. Because of that debate at
the state level, their level of awareness among the medical
community, the business community, general citizens, is so
much higher than it is, say, in Arkansas or probably Georgia,
because they've had to get in there and really talk about
what we're going to do.
Florida, I would think, is better positioned than
some states because they've already created what would be the
alliance areas. They've got the voluntary purchasing
cooperatives already going. They're beginning to save money
and show that it will save money.
.
So I think states, even if they don't get a piece
of legislation, the effort of trying is a really good
educational tool for all the players, and I would really urge
them to go forward with it.
Q So what specifically should states do, any
state, right now?
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appointed.
MRS. CLINTON: I know there was a commission
Has it made its report?
Q
It's made some recommendations to the governor.
MRS. CLINTON: I think the process of making those
recommendations and trying to draft legislation around those
recommendations: Here's what Georgia would do. Here's how
Georgia would try to reform its insurance market. Here's hpw
Georgia would try to organize the buyers of insurance better .
so that they could be positioned to take advantage of
insurance market reform. And I think moving on some of those
issues right now is a very positive thing to do.
If you look at the states, they're at varying
levels of development, and I think even having the Georgia
legislature bring down for testimony legislators and
insurance commissioners and doctors and others from around
the country who,at the state level, have wrestled with these
problems could be a big plus, because even when the federal
legislation is passed, it's got to be implemented at the
state level.
.
And the framework of it is well known, and so the
more that a state can begin to talk about these problems now,
the quicker they'll be able to implement whatever we finally
end up with.
I would urge folks here to move forward.
I urge
the Georgia Medical Association and Society representatives
with whom I met to really educate themselves about what's
going on in the health care market around the country, so
that they, too, can know what they can do to be better
positioned.
Q Something that we saw in the past month or so,
as journalists, I think is that most Americans were
incredibly confused about NAFTA, and it wasn't until just
about the final week before the vote that people really
stopped and thought about it and really sort of had some grip
on what the issues were.
Both·the pro-NAFTA and anti-NAFTA sides had
corporate money or some kind of backing to run ads on
television, to explain their point of view, to put out press
packets for us. Who's going to push the advertising for
health care reform? Where is the corpprate money going to
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come from?
Who can you rely on to help put out the message,
so that we're not waiting until the last day or two before
the vote to have the American public actually understand what
the debate is?
.
.
Q And so that the issue isn't (inaudible) -
Q
-~
who do have the. money.
MRS. CLINTON: Well, this is one of my biggest
concerns, as you might guess. I went back and looked at
Harry Truman's efforts. He introduced comprehensive health
care reform in 1945, got beaten back, called a socialist, all
of that. He introduced it again in '47. The best estimates
are that the opponents of his health care plan $pent $60
million in 1947 (inaudible). I mean, that was real money
back then. We're talking big dollars.
So I'm very concerned about it because unlike a
political campaign, where you can raise the money to pay, to
run a repetitive message, I don't know that we're going to be
able to match them. I mean, I'm not sure.we're even going to
come close. And when I say "we," I mean the generic "we,"
everybody who favors reform, and there are lots of groups out
there.
.
But when the health insurance agents have already
spent $10.5 million and apparently are going to spend two or
three times that,· and that's just one group of opponents.,
we're 90ing to be outspent by a huge ratio.
And part of my problem, as I think about this,is
that what we need is repetition of the same things over and
over again. And what you all do is print something new every
day, because otherwise it's old news.
And I don't know how to reconcile those two things
because there isn't an issue that is of more personal
importance to people than health care, but it's going to take
weeks and weeks and months for people, like with the NAFTA,
(inaudible) to finally kind of begin to form an opinion, and
that can only be done if they get the same information over
and over and over again.
So there will be groups who are supporting the
President's plan who will raise the money and try to get out
there with the message, but we're not going to be any match
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for the other side. I can tell you that right now, from what
they're already planning.
unions?
Q Who are your potential allies?
You talk about
The labor
MRS. CLINTON: Labor unions, consumer groups, some
of the physician groups, the senior citizen groups. We have
some very powerful, strong allies, but very. few of them are
able to spend a ton of money and are able to do it over a
long period of time. So I don't know what the outcome will,
be.
But I know that a lot of these groups feel strongly
about it and they're going to try to do their best,' but I
can't predict right now what the breakdown is going to be. I
just know you're absolutely on target. That's going to be
one of our biggest problems, is to try to continue
persistently.
I mean, I brought my brochures and my book for each
one of you, and I hope you will read it. I mean, we're going
to continuing and try to get our message out. But it's going
to be tough. But we have some good allies. A lot of people
can get the word out, but we have to rely ori folks like you
to keep this alive and talk about it and hold everybody to
some level of scrutiny about what their real agenda is and
why they're coming from where they're coming.
Q There's·been some suggestion over the past
couple of weeks that the administration will greatly step up
its attention towards crime and come out with a crime package
and that you would be very much involved in that. Is that
true? And if that's true, isn't that taking on a great deal?
MRS. CLINTON: Well, we came out with a crime
package and it passed both hous'es.
Q That there would be a stepped-up crime package.
in the next
MRS. CLINTON: Not that I'm aware of. I think
you'll see -- there are two things I think that will have to
be done. Apparently we're not going to get the final crime
legislation until they come back after the recess and after
(inaudible) and all that. There will be a real effort made
to try to make sure that it can be implemented as effectively'
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and expeditiously as possible so people can start seeing some
evidence of the 100,000 new police and some of the other
features that are in the crime bill.
And I think the President will continue to speak
out about it. And I will, too. I think all of us will. And
I've been pleased that the President has sort of drawn the
linkage between violence and'health care on a number of
occasions, and we're going to keep on doing that.
But I think that we have to get the crime bill
finally passed, and then begin to get it implemented and
highlight its implementation, but it's not going to be a new
legislative (inaudible), except for maybe some gun-
whatever we don't get in the conference, we're going to keep
pushing on the gun control front.
Q Following what you said about the (inaudible),
the people in Florida seem to indicate that (inaudible) their
health alliances (inaudible) voluntary (inaudible) insurance
industry (inaudible) pharmaceuticals and whatever, including
(inaudible), and that the employers (inaudible) voluntary
situation •
. Who are the employers and the business folks
(inaudible) of that battle, the give and take? . If it'. like
80 percent, 100 percent, how do you see that getting past
that obstacle?
MRS. CLINTON: Well, I see it a couple of ways. I
mean, if you talk to the folks in Florida who designed the
system, they tried to get an employer (inaudible), and they
couldn't because of what you're describing. But they will be.
the first to tell you that their system won't work unless
everybody is in it. I mean, it'll work a little bit to help
certain folks, but it's not going to work and· stabilize the
whole system.
And I think we're going to have a· lot of employer
support. We do have a lot of employer support. Once .
employers really put the pencil to it, and especially
employers who are currently insuring, will~ in the vast
majority, save money. Their costs will be capped, which
there's no way they can predict now. Small businesses who
currently insure will be the most advantaged because they're
currently the most discriminated against.
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And so as we begin to demonstrate to these
businesses that we're out there working with.how much money
they're going to save, that, I think, is a huge incentive.
And if you're capping your employers at 7.9 percent if
they're above a certain level, above 75 on a sliding scale,
and you have a huge number of businesses in this country who
are currently paying more than 8 percent of payroll for
health care, and you've got a lot of businesses that are
paying between 11 and 15 percent, and you've got some very
big companies spending between 15 and 20 -- don't you all
have a big car plant down here? You do, don't you?
Q
Ford and GM.
MRS. CLINTON: You know, GM spends 20 percent of
payroll on health care. Now, if you relieve GM of that level
of burden, that's a huge boon·to th,e economy, to say nothing
of their bottom line. So there are a lot of businesses that
are going to be ,big, big winners and others which are going
to be winners but not to that extent. And there's going to
be a lot of small .businesses that are in the winner category.
And if you cap small businesses at 75 or fewer
employers at 3.9 percent of payroll and less than that, if
they're real small and you subsidize low-wage workers, most
businesses, when they stop and think about it, and don't get
carried away with either ideology or anxiety, are going to
end up saving money.
And what I've been telling small businesses is that
most of them have survived minimum wage increases in the last
16 years.
I think we've had three, if I'm not mistaken -
Kennedy, Reagan and Bush. We had three of them. There i~ no
evidence that a minimum wage increase costs jobs. There just
isn't. I mean, despite what the NFIBor other people might
say, there is no hard evidence.'
.
And if you believe th~t you can provide health
security for yourselves and your family, plus your employees,
for less than it would cost to raise the minimum wage" and if
you're a small employer, for probably like a dollar ~ day,
it's very hard to argue that businesses cannot ,afford th~t.
And if you're going to be folding in over time, if
we move to comprehensive health care, the workers' comp part
of your small business obligations, that's a real incentive.
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So what we've been finding, as we've gone around,
and Erskine Bowles, who is the head of the Small Business
Administration, has done a terrific job. He actually got a
computer program set up so that small businesses, regionally,
can go in and do their spread sheets and see how much it
would cost them and how much they would save and all that.
And what he basically argues is that the more small
businesses find out about this and kind of cut through the
arguments that the professional lobbyists are (inaudible) at
the small businesses, many of them will see that it's in
their long-term interest.
.
NOw, are they
course. Are they still
kill health care reform
But we're just going to
here?
still going to be hostile? Of
going to do everything they can to
on the employer mandates? Of course.
have to make that argument.
Q What do you envision is the transition period
How long will this phase in, and won't that be a mess?
MRS. CLINTON: Well, I'm sure it'll be something of
a mess. I'd be surprised if it weren't a mess to some
extent, but I don't think it's going to be a big mess because
we're phasing in on a state by state basis. And if the
legislation is passed this summer, next summer, '94, then
states are going to start coming in '95 and '96 and '97.
.
And there are some stat~s, like Vermont and
Washington and Minnesota and Hawaii and maybe California
even, that are extremely positioned to get into this system.
So we're going to start having states coming in within a year
of the enactmen~ of legislation and taking advantage of a lot
of the savings that will come from that, and then everybody
will be in by the end of '97.
And there will. be technical assistance provided to
states because some states are not very far along in thinking
about reform, compared to their neighbors. But I don't think
that -- I don't think it's going to be an overwhelming
challenge to do it right because so much of the .
responsibility is going to be shared between the federal
government and the state and local government and the private
sector. So there's a lot of pieces that· can move each other
along, asI envision it.·
Q.
But would a company's headquarters -- I mean,
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for example, would GM plants in Georgia be affected by what
the Michigan legislature decides, or will it be -
MRS. CLINTON: No. If a company's larger than
5,000 employees, a. company can decide it's going to remain
self-insured, basically, and it can run its own health plan.
And then it is governed under the federal ERISA provisions.
It's not governed by the states.
But if you look at GM and some of the very
expensively insured companies, it may be to their advantage
to fold their workers in on a state by state basis because
they get the cap on the contribution right away, and they
don't have to have a benefits department any more and they
don't have to worry about a lot of stuff they'd have to worry
about if they stay self-insured, even though they think they
can save money.
So I would think that a lot of companies will put
their employees in. The employees in Michigan will be part
of the Michigan alliance, and that doesn't really -
(End of side 1.)
MRS. CLINTON:
.Q
(Inaudible.)
(Inaudible.)
Where does the money come from
(inaudible)?
MRS. CLINTON: Well, they're going to come down on
a slope. They're not going to come down immediately. But
much of the money comes from those employers and employees
who basically use the health care system (inaudible) GM has
paid for all these years, but they've not paid their fair
share.
We're talking about increasing national expenditure
on health care by around $50 billion over the next five
years, so that if you take the 37 uninsured, plus all the
compa~ies that that they work for, who will all be making a
contribution, that's a huge infusion of new money.
.
And so from our perspective, the money that is in
the system can be decreased without any loss of services or
quality, as long as it's reallocated. And that's going to be
one of our objectives in this, is to change the incentive as
to how the system pays for services, so that we get to a more
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cost-effective kind of payment structure.
Take GM as an example. GM has basically subsidized
not only the spouses and families of'tneir employees, but all
of their competitors, who either insured at a lesser level or
didn't insure at all, but who used the facilities that the
premiums from GM paid for.' As GM lowers its payroll total,
we are taking off of GM the obligations of retirees. That's
going to be federalized.
People between 55 and 65 are no longer going to be
the responsibility of those few companies that decided to pay
for it, because that has been one of .the real inequities that
we've had. Oftentimes those people are the most vulnerable.
They're pre-Medicare, and often if they're not able to keep a
job because of an illness or their company doesn't provide
any benefits after retirement, they become a real burden on
society and on their families.
So we're trying to
federalize the retiree benefits, so there will be some money
coming in from that.
NoW, other sources of money, in addition to the
employer-employee mandate and what it will create, we have
the tobacco tax. We have a reallocation of money that is
currently in the federal system. There is something called
disproportionate share, which goes to hospita~s that have a
lot of uncompensated care.
We're not going to have a lot of uncompensated care
anymore, with everybody having to pay something. That money
is going to be used to help subsidize low-wage workers, and
they can contribute and be in the system, as well.
So we've got all of the money kind of reallocated
but not necessarily pulled out. .And we also have a 1 percent
payroll assessment on companies that decide to be self
insured that will go into the overall system.
Q
Do you remain very confident of your numbers?
MRS.'CLINTON:
Absolutely.
Q People point out that both the predictions on
Medicare and Medicaid were woefully low.
MRS. CLINTON:
Right.
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Q What makes you believe so strongly that your
numbers are right?
MRS. CLINTON: Two things. I guess the first is
that I don't think there's ever been a process that has
thoroughly vetted numbers before. My biggest surprise, when
we got to Washington, is how little cooperation and
communication there was among the federal government
agencies. I can't even describe how amazed I was, coming
from state government, where you've got people talking all
the time, you've got.the governor's office serving as the hub
and making sure everybody is related and having all of it
run
Q
(Inaudible. )
MRS. CLINTON: A very well run state, I might add.
But compared to what you find in .the federal government -
until we started health care reform, the actuaries who worked
for the federal government on health care had never been at
meetings (inaudible). They had never had the actuaries from
Treasury, OMB and HHS and HCFA and the VA and DOD and I don't
know how many other agencies who do health care cost
projections-- they had never been told to work together to
figure out what it was they wanted to communicate on a
uniform (inaudible).
'
I was just blown away. I could not believe that.
Part of the reason we've had all of these inaccurate
projections and why the 1990 budget deal fell apart is they
slaved over this budget deal and the budget got blown apart
by unexpected increases in health care costs.
Well, my belief was that the federal government,
until it could agree on a uniform economic set of assumptions
and the actuarial cross-projections based on those
assumptions, we weren't going to go anywhere with health
care. I mean, that has been the biggest task, and it's been
boring. You know, nobody has written any articles about it
because it's literally taken thousands of hours.
But the net result is we have subjected these
numbers to a higher degree of analysis than any had been
subjected to, and we have sort of backed up our analysis by
bringing in, those few private institutions that had models
that could model this, plus outside actuaries and benefit
package people and all the rest of that. So I have a high
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degree of confidence about the numbers.
NOW, there are policy implications for those
numbers that mayor may not be successful in the legislative
process. I mean, for example, we believe we can cut the rate
of growth in Medicare by $124 billion over the next five· .
years without in any way undermining the quality'of health
care.
Our plan depends upon being able to cut. that $124
billion, so if we can't persuade the Congress to cut it 124
and they only cut it 60 or whatever they'll cut it, we have
to make adjustments, but at least the pieces of our plan are
all accurate, so that we can begin to know what it is we have
to add to or subtract from if they begin to move policies
around.
And I guess the second thing I'd say about the
numbers, in addition to'our feeling confident about how they
were derived arid what kind of assumptions and work has gone
into them, is that when you take these numbers.in health care
and you make projections, like people say about Medicare,
"Gosh, they said it was going to cost $9 billion in '65 and
look what it costs now."
.
Part of the reason you couldn't get good health
care figures on Medicare or Medicaid is because they were
pieces of a system that were pulled out for individual
attention, as opposed to being dealt with in a comprehensive
package •. So that part of the reason you've got Medicaid
going up at 16 percent, even after the last budget, is
because you have a huge uninsured pool who keep falling onto
the Medicaid rolls.
So if you have a Medicaid system that is based on
what 1966 or '7 poverty figures were and you now have a
higher level of poverty than we had in many years, and the
cost of medical care has continued to inflate at three times
the rate of inflation, and you don't have all of the pieces
marching in unison so Medicaid gets way out of whack, there's
no way to have any kind of legitimate base for projections.
If you stop the cost shifting and you get everybody
into a universal system with some kind of cost containment,
you have a much higher degree of predictability than you do
if you're only focussing on this one program or this one
program and the rest of the system is going crazy. Because
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part of our program, with these people who want to continue to
reduce Medicare and Medicaid for deficit reduction is that
they keep forgetting if you squeeze the balloon in one place
in health care it pops out somewhere else.
So if you squeeze in Medicare, and Medicaid and you
pull the money out and you put it to deficit reduction -- you
don't put it for health care reform ~- then two things
happen. Providers don't want to take Medicare and Medicaid
anymore, because it doesn't cover their costs, or, they at
least don't want to' take it as their sole payment.
And in order to make up for whatever costs they
feel they're not getting from Medicare and Medicaid patients,
they shift the costs over to the private sector, onto
employer~driven health insurance.
costs then go up higher
and higher for employers, so employers adopt all kinds of
methods to c,ontrol costs, like $3,000 deductibles and the
kinds of co-pays that make health care very expensive.
So more and more people opt out of the employer
system, unable to be able to afford the insurance that is
offered to them. They fall into the ranks of the uninsured.
When they show up at the hospital, they finally get
uncompensated care, which then we pay for out of higher taxes
and out of increased premiums.
'
,So all these things just keep feeding on each
other. So we thihk if we get the universe here, we can have
much better predictability and control over the pieces than
we do alone.
Q Universal coverage is not the same as universal
access.
MRS. CLINTON:
No, it's not.
o And,that's an increasing part of the problem in
lots of the country. I realize that's a separate issue, but
they're kind of double first cousins. Is the administration
giving any thought to how to address that?
MRS. CLINTON: Yes. I want to say a couple of
things about that. A lot of people will tell you that their
bill will get you to universal access but be very careful
because that's not the same as coverage. We have universal
access now if you've got the money to access the health care
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system.
We don't have coverage.
They are double first cousins. Universal coverage
will increase access fpr those who are the most underserved
because once everybody has a payment guaranteed that they
carry with them, then all of a sudden they become attractive
patients.
You know, the big question I was asked at Grady
this morning? If you have universal coverage, how are we
.going to compete effectively if suburban hospitals and
private hospitals start opening up satellite clinics
downtown?
And my response was, "You're going to have to
compete. But isn't it· wonderful that somebody else wants'
'your patients, for the first time?" And I believe that a
hospital like Grady will have first claim on a lot of people
because they took care of them when nobody else would. But
that's what this new system is going to do.
All of a sudden, poor people, uninsured people,
Medicaid recipients, are going to be attractive because they
have guaranteed funding, and therefore there's going to be
more access for them.
Q
How will rural people become attractive?
MRS. CLINTON:. The same way, but you have to work a
little harder at it. So we're doing several additional
things in rural areas, too. We are providing incentives,
through loan programs, loan forgiveness programs, facility
development kinds of grants, so that providers in both
underserved urban and underserved rural areas have some
incentives to stay in those regions.
We are beginning to alter the Medicare-Medicaid
disparity that has disadvantaged rural areas. ~ural people,
doctors and hospitals have been paid much less than urban
areas under those programs. It's been very unfair to them.
We are increasing the use of telemedicine and
technology so that practitioners in rural areas don't feel so
isolated, and I've seen some incredible things. I mean, I've
seen x-rays in doctors' offices held up to screens and being
read 400 miles away at the medical school.
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Q Th~ Medical College of Georgia in Augusta is
doing that (inaudible).
MRS. CLINTON: Unbelievable.. So all of a sudden,
if you're a general internist· in South Georgia and you like
the lifestyle, you love to go hunting and fishing on the
weekends, but you're feeling isolated and you're worried that
you can't serve your patients, all of a sudden you not only
have firmer financial footing, which maybe you can hire a
young doctor to help you out with, but you've got much more
support.
And it'·s also likely that you will find it to your
benefit not to be in solo practice, but instead to be a
practicing· physician who is networking with hospitals and
doctors up the line. So you might be part of the Georgia
Baptist or the Atlanta Health Plan or something like that.
And that's what we're seeing happening in
Minnesota, which has a high degree of organized delivery
care. We're seeing Mayo's, for example, going out into the
community and asking local practice physicians if they want
to be on contract. You know, for $125,000, $130,000 a year,
which is pretty good for a rural physician in Minnesota, as
well as in Georgia, they're being put on contract and they
then serve those patients who are enrolled in the Mayo health
plan, and they're referred to Mayo's for tertiary care.
So that's the kind of thing that we see happening
that will extend out into the rural areas, too.
Q Where do undocumented immigrants fit into this
health care plan?
MRS. CLINTON: They do not receive a health
security card. They are not entitled to the comprehensive
health benefit. They will receive emergency care, as they do
now, and they will receive public health services, as they do
now. And we have funding for hospitals that have a larger
than usual share of illegal aliens, and we do have beefed up
public health dollars to take care of tuberculosis
immunization, things like that that we need to deal with.
But weare pretty much keeping the status quo in
the sense that they are entitled to those services, but we
are trying to do nothing that increases illegal immigration.
So that's the line we've tried to draw.
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Kind of high on the list of priorities for
according to the surveys, is to be able to choose
their own physician, which I know it's true in a lot of
states (inaudible). It seems to me there's some confusion
about whether or not, in your plan, you guarantee there would
be at least one option that th~y could choose their
physician. (Inaudible) might be required·to go through
(inaudible). Which (inaudible) is that?·
Q
~eorgians,
1
MRS. CLINTON: .No, it is settled. We think we're
actually going to be increasing choice. If you look at
what's happened in medicine today, more and more employers
are dictating who employees can go see.
I don't know if that's happened with your health
insurance plan yet, but I've been with a couple of editorial
boards when lots of heads started nodding because what has
come down from on high is, you know., we'll pay X amount if
you join the HMO, we'll pay X 'minus a lot if you don't.
.
And so that's part of what's happening right now.
And we're actually decreasing choice for both patients and
physicians right now because at the same time as we're saying
to patients, "You can't have a choice any longer because of
who you work for, and they're determining where you will get
. your medical care," we're saying to· physicians, through
insurance companies and these plans,· "If you don't belong to
our plan, you can never be referred to. And we're also
saying to hospitals -- a lot of hospitals are being told the
same.
Under this plan., we are guaranteeing choice ·because
in every region there will be at least three choices. There
will be an HMO, a PPO, and a fee-for-service network. And
the setting of the prices will be left to the marketplace in
terms of what they're going to be bidding for the services
that they will charge the people who join their plan.
We are mandating· a point of service option for
every plan, so that no plan can tell you you can't go outside
of the plan for a specialist. And I think that some of the
confusion is, particularly in some parts of the country, like
the Southeast, where you .don't have a lot of organized health
care yet, they don't know what that means, and they're scared
about what they think it ·means, ·and they're very
apprehensive •..
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Whereas if you go to the west Coast or Minnesota,
they're so much more comfortable with it and they like it, so
that it's not a big deal for them. So it's really where you
~re seeing this from.
And I started explaining to people who are
concerned, that what I'm trying to do is to give to every
American the same options that members of Congress has. And
if you think about what the members of Congress and all the
federal employees have, they have an employer-based system in
which the employer, namely the government, pays for 75
percent of .the health care and the employee pays for 25
percent.
.
The federal government, as. employer, does not
mandate who the employee has to go to. Instead, the federal
. government acts as a clearinghouse for every plan that wants
to be able to offer its services to federal employees. So
they do the framework check, the same way we're going. to have
the alliance do. You know, are they capitalized? Can they
deliver what they've said? But that's it. If they pass that
kind of qualification, they're in. There's not going to be
anybody telling them they can't offer their services.
And then every year, as a federal employee, you get
deluged with all this information, and you make up your mind,
and you choose. 00 you want an HMO? 00 you want a PPO? 00
you want a Blue Cross indemnity plan? Whatever you want.
And I'm trying to make the argument that a lot of
these members of Congress who are against what we're offering
are very happy to sign up for that every year themselves and
very happy to have their employer pay the vast majority of it
and very happy to have the choice that comes to them as
federal employees.
And'so one of the things we are doing is we're
going to fold the federal employee system obviously into
this, so that we're offering to everybody what they now have
and putting them into the same system. And that's the kind
of choice that we want to make available for everybody around
the country.
.
Q
will Congress itself be under the same system?
MRS. CLINTON: Absolutely. Because that's the
irony, that they have the system that we want for everybody
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basically right now, the system I just described •. And so for
them to say, "Well, you know, this is socialized medicine.
We don't believe we ought to do this. The government can't
run this," and that's what the federal government, through
the Office of Personnel Management, does for them every year.
And this will be done at the state level, at the
so-called alliance level, so it's not going to be government
run by the federal government at all, but the alliances -
now, I would suppose in Georgia you'd have three or four or
five. I don't know. how many you'll end up choosing to have,
but the alliance is the one that will basically say, "Okay,
everybody, offer your services to the people who are part of
our alliance and then each one of us individually will sign
up." And the government will· be -- you know, the people.who
are in the Congress who live in Maryland, they'll be in the
Maryland alliance. If they live in Virginia, they'll be in
the Virginia alliance. If they.live in the District, they'll
be in the District alliance. There's an incentive for them
to make sure it works well.
'
Q What do you think are the major flaws with the
House bipartisan plan?
MRS. CLINTON: Well, 'every time I answer this
question people accuse me o·f being critical, and I'm just
trying to be, you know, informative. So with that preface, I
guess you'r,e talking about the one that Jim Cooper has
introduced?
The two biggest problems are that it does not
achieve universal coverage, and it increases the deficit, and
I think those are two very serious problems.
Q
On that note we'll have to wrap up.
MRS.' CLINTON: Thank you all very much. Don't
forget your books and brochures. We're not a $10.5 million
ad campaign, but we'll keep you informed as best we can.
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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
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Lissa Muscatine - Press Office
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First Lady's Office
Press Office
Lissa Muscatine
Date
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1993 - 1997
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<a href="http://clinton.presidentiallibraries.us/items/show/36239" target="_blank">Collection Finding Aid</a>
<a href="http://catalog.archives.gov/id/7431941" target="_blank">National Archives Catalog Description</a>
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2011-0415-S
Description
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<p>Lissa Muscatine first served in the Clinton Administration as a speechwriter. Within the First Lady’s Office, she served as Communications Director to the First Lady.</p>
<p>Lissa Muscatine’s records consist of materials from First Lady Hillary Clinton’s Press Office, highlighting topics such as health care, women’s rights, the Millennium Council, Hillary Clinton’s 2000 Senate campaign, and deal extensively with press interviews given by the First Lady; her domestic and foreign travel; and speeches and remarks, on a wide variety of topics, given by her before and during her time as First Lady. The records include interview transcripts, press releases, speeches and speech transcripts.</p>
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Clinton Presidential Records: White House Staff and Office Files
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Clinton Presidential Library & Museum
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Adobe Acrobat Document
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1,324 folders in 27 boxes
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FLOTUS Press Office Interview Transcripts Volume II 10/93 - 01/28/94 [Binder]: [11/22/93 Atlanta Journal Constitution]
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Box 3
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/Systematic/2011-0415-S-Muscatine.pdf" target="_blank">Collection Finding Aid</a>
<a href="http://catalog.archives.gov/id/7431941" target="_blank">National Archives Catalog Description</a>
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First Lady's Office
Press Office
Lissa Muscatine
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2011-0415-S
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Clinton Presidential Records: White House Staff and Office Files
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11/26/2012
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2011-0415-S-flotus-press-office-interview-transcripts-volume-ii-10-93-01-28-94-binder-11-22-93-atlanta-journal-constitution
7431941