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�THE WHITE HOUSE '
Office Of the
Pres~
secretary
For Internal Use Only
February 4, 1994
AN I~TERVIEW OF THE FIRST LADY', "
ACCOMPANIED 'BY' 5ENATORHARRIS WOFFORD AND
DR. "C. EVERETT ,KOOP
,
CONDUCTED BY' EDI'l:'ORIAL,BOARD"OF THE
PHILADELPHIA I~QUIRER,
Q -~ how. you plan to reposition, or regain the
moment:u.m or perhaps reposition the~:plan to (inaudible.)
MRS. CLINTON: Well, Idon.'t: think in general, but
as a foot soldier I'll teli you llowit fells. I don't :know
if, I'm on a high enough hill or not to be aware of everybody
is positioned.
'.'
I think we"re justgoirig th~ough a, natural kind of
five and take, 'but I would not Iread too' muqh into it.
There's a lot of jqckeying going on; which is understandable
'and will'continue fora while because w~'re trying to move
the action· into tile congressional (inaudible). And there's a
natural concern on the part of all' these interest groups
about how to get their strongest ne,gotiating position going
into that congressional (inaudible> ..
50 you look"at some~hing' like theBRT thing you
referred to, 'I mean,if you talk to every o"ne of those guys
and say to them, "Do you rea·llysupport a' health plan that
removes your tax dedUctibility <and forces your workers into
the lowest cost plan?" they'd' say,.·'!Of course not, but we
want to be in a negotiating positi6ri,' and we think we'll have
more leverage, both on the.~dministration and the Congress,
if. we do this. ','
That's th~ir choice., but'that doesn't particularly
concern me. That's kind of .their decision.about how they're
going to position themselves ..
From my perspective, I think that, based on
everything ~ see out there, all the polls and focus groups
and everything I'm looking at; there has been a steady'
support in the mid :to' high 50s for the plan~ without any real
description, and there's overwhelming support for the key
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features of the plan,. Any t~me you ask people whether they
feature getting rid of lifeti'me limits or wh~~her, they
approve of the feature of having a shared responsibility
between employers and employees, therang~ of support is 'from
60 on up.
So this battle is ju'st beginning and the one thing
I guess I've learned, watching legislative processes, is not
to overreact, and waituJ')tilt.he s.ltuationgels'a little and
continue' to marshall support for.the basi,C parts of what
we're trying to achieve. Andthat"s what .we're doing.
So I'm not at all concerned about~here, we are.
We're about where I thought we. would be at this point.
Q One of the things that. I hear a lot from either
my doctors or people., doct.orsl like., like my husband, is
there's a real concern on .thepart. -of those practic;::ing
medicine and, to some degree, their' patients, that a new kind
of health care system (inaudible) is going. t.o really affect
the time that they can spend.withtheir patients, that heal,th
care providers are feeling .very· forced to see more and more
people.
How. do you respond to those kinds of concerns?
",
MRS. CLINTON: . 'Well, that's exactlyw~at's
happening right now. I mean,. the s~atus quo is forcing more
and more physicians into·managed· c.are systems. More'
employers; are choosing·suchsystemsand eliminating choices
for their employees. And if we do nothing, the outcome will
be more and more closed panel HM0~,. fewer choices. for either
the patient or the physician, and.le$s time, with no increase
·in reimbursement for the clinical time you· spend with
somebody in your off ice" ·but· a ccm:tinuing downward pressure
on the' price pzlid for tp~ pr6cedur~, for the test, that is
the way we p'ay physicians;, on apie,.cework basis. .
So I say to physicians, if you're really unhappy
with what youE;lee 'hapPEming in medicine right now, if you're
tired of patients calling you up .and saying.; "Do,etor, I'm
sorry, but my employer just ehanged policies and I can't come
to ycm anymore," then you have ·a lqt to gain' from· 'changing
the status quo, where the ~hoic$s ¢f your' patients would be
theirs·, not their empleyers', where we will increase the
reimbursement for primary care . physi'cians because we know
that they're underreimbur:sedcompared tosp.~cia,lists, and
where you will have incentives in n,tanaged care to provide
preventive care as part of the basic benefits package, which
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will increase doctor-patient' ,Contact:, not.; decrease it.
So I would just ask them \\fhere they heard that it
was going to do all th.'esethings~. They: .probably heard it
from the advertisements by the insurance companies, which
don't want any change.
.
.Q
So you think the administration will have to
make "Mr. Smith Goes to Washington" call to energize and .
counteract the lobbying grpups that are trying to serve their
best interests? I have'n' t seen an appeal from you or the .
White House -- I guess that's you~too -- for the man in the
street to come out and ',demand that .their interests be served
rather than the (inaudible).
MRS. CLINTON,: Yes, I think that will happen but
see,' unti 1. -- here's the posttion we're in now, which is why
I answered the firstquestion·the way I did. We don't have a
bill yet because when w.E! sent that up, we knew that it was
going to be changed in thecoinmittee process.
.
We've got 5 dif·ferentpommittees that ".il:re the major
committees, and I guess -probably ,about 10 more£:hat are minor
committees on these issue!i;;· i-n .both "hous~sr, th~:£, are ." in the
process now of marking up abil~.L And there are going to be
variations in how they put together, the piecesj which is why
we've created kind of a bottom-U;n:e mentality., -which is
what's. overwhelmingly support~d by the American public. They
want'guaranteed private insurance. without ·the kj.ng of
limitations and cO,sts that are assOciated with insurance now,
and a c9Inprehensive benefits package.
But Ways and Means .may 'have. a different approach
than Ed and Labor., whieh will have ad'ifferent appro~ch than
. the Senate Finance committee., and ·soJ··forth. It's very hard
to enlist people in tbe abst;ract.
This is the way we see what's.. happening. The sort
of leadersh~p ·of both. ~ouses, including the committee chairs,
want us to continue doing what I'm doing -- coming to
Philadelp~ia, talking about what:we think the plan is about,
positioning us in a way .that is sllPportive of the best health
care system in the world against the stupidest financing
system 'in the world, .which .lswhat I said earlier, and to
continue to build public support for changing the :status quo
in a certain direction.
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Once there. is a bill, once we know what we can
actually expect to get.out·of. these committees, there will be
.t~emendous public support.
But rigllt now, even th~ .groups
.that represerit large segments of the public are still
'
jockeying. You know" .the seniors group want to .know the best
deal they can get on prescz:iption dru:gs. They think .we've
got the b.est deal 'but they' restill ' shopping. That's all
part of this legislative effort that's. going on.
But I ..think that you can count on intense public
pressure being generated once we ¢ari say., "write your member
and tell him to support Bill XYZ." .. We can"·t do that right
now, and if we were trying to gin up that kind of support
arouild the president"s.plan, wheri we know there will be
changes in it, and we welcome thos.e' chal1ges because we want
there to be strong congress·ional owriersh;ip of, i 1:: ,. we'd have
to go through it allover again.
'
So the timing is
Q
~-
So you're ultimately pl'anning to do that?
MRS. CLINTON:
Yes, absolutely.
Q
(Inaudible): Don' s ' q~estion,' the situation now is
tha·t the people who have the· mQst toga,in by health care
reform are the sick and the .poor -- no money, no
organization. Th.ose w1:lb have the mQst to lose by that are
well organized and well funded. NOWi that's ·got to be
shifted. It's going to ta·k~ something to enlighten the
public.to get hold of their congressmen and senators and talk
about this.
.
But I think the kinds of things that .happened
today, with the First;. Lady.presenting the 'issues and showing
what the stakes are is.(inaudib1ieJ.
Q . What is your :response to 'theSpecte;r, chart, that '
threatens, suggests that your preliminary proposals would
create this monster burea\,lcracy that would be. impenetrable
and create all kinds of a p~esuma'bly patron~ge hires and take
it away from the private ,enterprise? . What .do you say to
that? .
MRS. CLINTON: We'll, we' vegot a couple. of
alternative charts, i·f we 'want to g~t. into a duel of charts.
I have one big chart wtlich'says "Republican Health Plan" with
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a total blank,on it that I'liice a lot. And, I hav~ another
chart which tries to shc;>w the e~isting system, which is mind
boggling~ "
And then I have ail accu:r::ate chart, which starts
with real. people,andllow they wou:idnavigate,the new system,
which is much simpler than the ,exis~ing system.
I thought it was a very ,clE!ver ploy. I mean,
that's what they all are experts in, at clever ploys and
diversionary tactics so they'dori't have to meet the real
issues. ,The rea,l message of that night was there"s no health
care crisis, which is pat~n1Hya'l?s'!lrdand is not a tenable
political position. But ifthey'want to ,have a duel over
charts, we can come up wi~h charts, too •.
That's been, from,my p~rspectiv'e, one of their more
effective arguments, is to'scarepeople that the government
will takeover the system an~ ,that. the government will tell
you who you can go to and they'll takeawayy:our choice. And
we know we've got to counter that, and that has been
something that we are. working on. '
Q What are your coul"ite:r::points today? One can
adequately ,argue tbat ,you have.nit. :n'ailed in the balloon very
strongly today, that in oneot the'two major government':"run
programs, Medicaid, this proJ;?osalends gpvernl:l\ent-rl.I-n
medicine, and it puts Medh::ald 'constituents "in:pplvate sector
insurance, which is a huge' step away, f,romgovernment-run
medicine.
'.
MRS. CLINTON: You know, 'I think that I went back
and I looked at all the c::ampaignstnat were run against
he,alth care reform efforts, starting 'with Roosevelt,
including Truman" against Medicare andagains,t Medicaid,
until it kind of fell, of i,ts own w~ight against Nixon'~
proposal. And it's always t,he same argument -- the specter
of socialism, the specter'of.the government, it's the specter
of people getting in there and ta'king, over the system.
Arid this is I"iota gover:nIJlent system. We're keeping
private insura'nce. Some would argue, we shouldn't, that it
would be certainly more e,fficiehti,n 'many ways to eliminate '
,them. But we're keeping, ,priv:ate insurance and we are
building on the system ,that works, ,the employer system.,'
You know,a.ny time ,your 'opposition has,a lot of
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money, and. there was one estiina1:;Eft!)at the opposition against
Truman, w!)ich was primarily organ.ized medicine and the
commercial. insurers, spent $60 million, and that was real
money back in ' 47 and "48.
Any time they do. that, you've g.pt to counter it.
But I think we'll have more tha,n. enough ammunition to counter
it. Lots of groups are organizing, rais.ing, money to run
counter-ads and it's just going.. t!:otake awhile.
.
,
But most Americans";',":, YOll know~ the press engages
so fast and ·they watch the deals and they watch the nuance
and they try to figure out who'lS on f·irst -- most Americans
are still digesting the state Of the union. I mean, this
other.stuff hasn't made any impression on them. And the
support for health care reform has remained steady.
So most 'Americans are just kind.of waiting for
Congress and :the President to get it,done, and when it's'
appropriate', they're going .tobe called on to stand' up and
express their support.
. '
Q
When do. you think ,.'H: wiil g~t done?
MRS. eLINTON: Wheri do' I ·~t.hink hea,l:bh care wi'll' get
done? Well, I think we're goillgto'try to hav:ea bill by the
August recess,.. 'That' sthe .goal.
Q
(Inaudible. )
MRS. CLINTON:
Q
Yes.
(Inaudible. )
MRS. CLINTON: well, by the August recess, that we
could have a bill by the August r.ecess. That's' what our hope
is.
Q
bill on
t~e
Moyriihan said he expected t.he Senate. to have a
floor by the middle of the ¥.ear,·. which is ,June.
MRS. CLINTON: That's'what we're aiming for. It's
a very ambitious schedule., I mean i ·,part. of what we ' re
struggling wit!) is· there's heverbeen a piece of 'legislation
like that.· I ~ean, as~ hard as the budg~t ba,ttle was and as
hard as NAfTA was, there's ·otq.yonecommittee in each· house
responsible, and we only had tp deal and get it out of those
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one committees.
Now we've got a much more complicated situation,
and it is unprecedented. The las:t huge piece of legislation
they, tried was the energy Dill itithe 'TOsand they created a
superC011i11littee for it. TheY'wouldn't' do that th.is time
because everybody wanted their piece of it becau'se they see
it as their legacy, you know- So' every committee wants to
have their mark on it.
So I'm not in any way underestimating the process
difficulties of this, but I thiJ1k,w~ w.tn either way. We
either,get a bill by the August r~cess, which guarantees
private insurance and deals with\theproblems that people
have in their heads' abou~'hea,lth'Care, , 017 we have a 'midterm
election about health care. I mean, either way is good for
the country, in my view, and the, latter is good for Democrats
becaus~ if they filibuster,· if they ,won't come with the votes
to get this done irL 1:.he rl.ghtway, . there',s nothing' like a
, campaign to focus public, attention, much· more so than any
other way of doing it..
'
So Ithi,nk it's a win-wirisituation.
Q One of the opponents,' if. I can remember who, of
health care reform when it,was initi~ted, said a factor that
you don't hear in current debate is the cos,t (inaudible) cost
and the impact on the deficit t;:hat.lsleaning over us. I was
wondering, is it too early to refocus on that? I haven't
heard much conversation .about that, 'and what impact would it
have on reducing the deficit? .I unders,tand we don't which '
version is going tq come out, ·butwhat'; is y:ou;- hope fG)r that?
MRS. CLINTON: Well, we're doing a lot 'better with
the deficit than we'predicted. Ttle latest figures from the
Ol:fB are. considera,bly higher even, t.han w.e. thought they would
be. So we've made a loto·£' pz:oogress, ,thanks: to the budget
and econom~c package last summer. '
,
But there's no doubt ,that ,even though"":7-1 wish I
had all these charts; they're all' ·in cqlor because we did
them on our Macintosh and ,they're beaut;:irut -- but even with
the chartlS, which s;how discr.'etioriary .spendinggoing down for
the first time and where the deficit would have beert.and now
where it will be, all that stqff'" :werun into a brick wall in
about '98-'99 because of.heaith,.;care costs.
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If you do. not contror he~l:th care· costs, you do not
control the continuing re¢luction in 1:he deficit. And the
President has said 'that ,eve;r sinc.e. last. year.
What you've got is an interesting set of choices
for the congress. ourbill does reduce tQe deficit. There's
nQ doubt about that. Even an i~dependent study by Lewen
(phonetic) and Associates." which is.a health care analysis
firm, concluded it does reduce the def.icit, even though we're
putting more money into the s¥stem •.
The other plans that are out there either do not
reduce the deficit or try to reduce the deficit by decreasing
expenditures of Medicare alldM~dicaid without making
comparable changes in the pii va,te sector.
So they.reduce'the de:ficit· on paper in the short
run; they increase it in ,the ,long run because if you ~ust
J;educe Medicare and· Medicaid, . then . what··~ you' redoing ~s
throwing more uninsured into ·the sys:t,em,which increases the
costs 1:0 the priva:te sec.tor., because" of the cost~shifting,
which leads more employers to drop ,mqre .employees,which puts
them into the pool where tl1.ey're government-assisted. I
mean, all of this is part of the sa~e qnified system.
So the preside~t'sp'lan wo:iJld reduce the deficit
and it would reduce it considerably by 2.0.0.02, but more
important than that, because ,pe,ople .can 'a~gue, . "Well, would
it reduce it $5.0 billipp? Woul:d it·re.duce ·it $35 billion?"
There is no ~rgument that the t::oinprehensive approach we
proposed would avoid having the de:f;icit balloon ·back up.
Cooper's bill, the de·flcit gocasllp.The Republ, ica'ns, the
deficit goes up.
' .
So there isn't any 'other bill out there that can
say it will control f.ederal'expenditures •. ,.And one of the
great challenges for the Congress, as they deal with this, is
to be honestabout,these.other approaches. That's why I view
this kind of boomlet aro~ndsomeof these other .approaches as
a negotiating position. 'I mean, these are' being supported by
people whose· positions are mutually contradictory, and will
be show,n to be so as we ·move forward'in the debate.
Q I guess aquesti'on t have parrots something that
folks like (inaudible) all say.,. which is . that -- and we can
argue the merits of your ( inaudil:)~e,) . bottom line" is that.
you're not really talking-about the"critical savings that .
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need to l;>e m~de and probably notbeirig as 'straightforward as
you need to be with the.Amli!rican public, in terms of the kind
'of trade':'offs we'll have ,t'omake. You're basically saying
that we can, have more res,earch, we can have all of the new
technologies, allot the pew medicaiprocedures, and the
costs that "go along, with ib, ~Jld not: ha·ve to return something
over here..
'
,
I w,onder if you :can:z:espprtd to 'that, as a general
broadside against,the plan.
MRS. ',CLINTON:' ,You'r.e rigpt. We're not standing on
street corners saying that decision X is going to be
impossible to make in 10 'year.s compared to decision Y,
because the way we've tried ,to struc.ture this is to push a
lot of those decisions'down, to the local and regional and
state level. And I've had this conv,ersation with some of
tJ:lose people.
From6ur perspective, it is very difficult to
engage the American public ina disq\1ssipn about rationing
the services, for exampie"in: the absence of universal
coverage. I mean" Oregon is'always' ;talked about as this
great courageous state that: went forward on rationing. Yeah,
. they did it for the Me,dicaidpqpul:ation. They weren't trying
to ration for the non-Mediqaid population~
So people c~uldc(jme tog~t;herand very seriously in
their communities say, "Well, what should those people on
Medicaid qetor not get?", ',They were saying, "what should I
· get~r not get?'"
Until there isunive:rsal coverage, so that
everybody has a sense of security"you are not going to get
that kind of discussi0n gainqinthis countr.y. But the way
we've tried to set this up' is ,get unh'~rsal coverage and you
pr.o'vide services at the 'loca'I l'evel., within some kind of
budget discipline, whi'ch forces people', to make hard
decisions. Do they, need an, MRI or 'don't they need an MRI?
Well, they' should decide','not ,someb.ody sitting in Washington.
So I see this alias' an evolution in order to get
to the point where those ,conversations, can be had ,because
'right now ,when Dr. Koop and 190 to' medical groups, and I'
a'lways say or he says later, I a];ways say, "You know ~ right
now we ration. The uninsuredar~ three times more likely to
die from the same ailment as ' the insured.'"
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,
And'invariably, whellever'i: say that, I'm attacked
by doctors who tell me it's no,t true, that's not the way the
system works, and I must be, mist~ken. Or they say, "Well,
that's true until they get to the ,hospital, but then survival
is the same."
DR. KOOP:
It's worse in the hospital.
MRS. CLINTON: And it.ls,worse in the hospital. So
we ,can't have that coriversatton now a,bout the facts that are
existing~
So ,I 1;:hink we'ne~d,toget't6universal coverage
before we expect to have any sensible conversation.
Q How about'the other, aspect of what ,Gill was'
saying, about the fact that it would have a', chilling effect
on ,bringing around new d:r;ugs" a cu:z:e 'for AIDS" all that, on
the biotech industry?
'
,
MRS. CLINTON:
didn't.get that.
Were you
im~lyillg
that, because I
Q
I don'tth-ink, I,' was. If indeed, we had a tough
budget cap, it would force us make decisions (inaudible).
MRS.. CLINTON: 'Well, there is,' so :mUch money in the
system right now~that 1s misspent, poorly spent, that I don't
think anyone who has rea:lly 'stud:j;ed it" and I know Reinhardt
(phonetic) (inaudible) would-argue that we're going to
underm.ine research orpharmacetiticcq development in this
country if we try to have ~qme k4.nd 9f 'b:udgetary discipline.
I said earlier today at the civic Center that all
last year I was just hammered, day in and day out, by the
biotech groups. I mean, theyhadeveryhody in the world
calling me, saying, "You know, you're going to destroy
biotechnology. Venture capitalists won't' invest in us
anymore,. Wall Street's' turning ,their back' on us. We're
going to have to go offshore for our money.n 'Youknow, ,it
was,just, "The sky is falling," with,all these people rushing
,around.
'
End of '93, i: went. and got, the statistics.
Investments, in biotech firms were up 23 ,percent. Venture
capitalists were pour:i,.ng money into biotech firms.
So from my perspectIve,that fear, wh;ich in some
cases I think is legiti:ma:te and ,in other cases masks other
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interests, is rebutted, by th,e fo:+lowing,.
Number one, wea:r;epumping more money into the
health care system.' We are going from· 14.5 percent of ,GOP to
17.5 percent of GOP by the year 2002. And we are going to be
spending the mop.ey on more ,dlr.ect inedi~al services, like
research and pr~scription drugs and the iike, and far., less of
it on paperwork, bureaucracy" insurance' companies and the
like. So the net increase andrealiocation is huge for
medical care.
Secondly, we are goingtc) be ,putting at least $15
billion a year into prescriptiop drugs, which will go right
into the pockets of the drug~ompanies~
Thirdly, drug compan-ies 'have a' very hard
justifying, except by scare ~tactics,the.prices they charge.
And they keep saying the same thing: "Ifyo'u try to do
anything to us, we'll go, out of bU:si~ness and it'1l be
terrible for Americans."
'
Well, Amerfcan's:f2un,d ..most. dt~g research, directly
or indirectly. We fund i 1;: thr6ughthe NIH., We fund it
through academic he,alt.hcenterf?_ We fund it in all different
,kinds of ways. And some may ,be i'nd~pendentand,totally frees~anding, but that is the minority.
•
••
>
And yet Americans pay any'Whe:r;e from 2 to 15 times
for the same drugs that are sold overseas, to people who've
made no contrib4tion totbe research or:, the development
~ecause the prices are (;:antrolled.
',.,
'
We are not proposing" price: controls, although I·
have these arguments with the heads of all these drug
companies all the,time. We are p':t;'opo~ingthat we,get
information about their costs, ,which we, then can make
available to the maz-ketplace. They'",ilL not open their ,
books. They will not tel,l, you ,wha·t ,things have cost them.
They're all of "The sky isfalTing"schoQl, so that no matter
what you ask them, they say, "If you ma~e us do that, we'll
just have to leave.'"
,
' '
.
So what.we're trying to do, is ,to strike' a balance.
We're putting more money into'these guys, huge amounts of
. money, but we'd like not to 'corttrol,thE!ir prices"but we'c:i
like some better' information so consumers and providers can
make better decisionsbecause.if ·we,get that prescription
MO~E
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drug benefit in, Medicare wi,ll becom.e the largest drug
purchaser i~ the w.orld. .And.we think' we ought to get things
like discounts and we ought toget.sol'Jle other breaks that we
shou;Ld get for that kind'of trade-off.
. SENATOR WOFFORD: The R&D cushion that the
pharmaceutical houses (inaudible). I talked to a group of 11
pharmaceutical houses that'are very altruistically
(inaudible) concern'edabout health care in the Third World.
Those 11 companies have $30 mill~on (ina~dible).
So a lot can happen to (inaudible.)
Q You've l'Jladesome strong points on the
(inaudible)' 'budget issue coming 'up on the plane •
DR. KOOP: I'll tell you the facts of the matter,
because there are some personalities . . John Kitzhoffer,
(phonetic), who is president of the senat.e, put this thing
through in the beginning J·ina,tidible). So. am I and we have
people up there who were ver.y much interested in (inaudible).
.
,
'
And he invited us out and we ·looked at.it and we
found that if Oregon had reallocated i t:spresent resources,'
they could have given everything to the Medicai,d people
without taking .from the poor·to give :t.o tne poor. And I
tried to make this. point todaY-at the forum.
The medical,p:rofessi'on and tile .states have to
reallocate 'r~sources becaus.e ·the federa'i government can't
force them to do that. But the federal goyernme'nt eventually
will force them·, to stop doing things ,thatwotildback to
having necessary permits ·for planning and so forth, which you
don't have to have i·f people will take charge of their own
responsibilities. .
MR!3. CLINTON: I just want·t.o ~ollow-up because.
this isone.·of the key arguinentswe/.re gofng' to have in·
Congress.' Our plan calls' for premium: caps. We adopted that
approach, as opposed to either a to~al1.Y free market.
approach, which we b.eliev.e will' bust. the deficit and lead to
escalating,' costs, or toa heavily price-ccmtrolled approach,
.where you .have set the price ·fc:.r every treatment that ~nyone
gives ,becaus~ we wanted'n6tdd wha·t Dr. Koap was saying.
.
.
We wanted to be able to say 'to"a state or a region,
"Here are the budget paran'leters,:and they will be a very
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comfortable cushion in which Y9U will m~ke these decisions."
,'"
, You go make' the decisions. I mean, Philadelphia
,may decide, through its medicafi:pemmunity and whatever local
decision-makers are at: the bl'b1¢, that they want to limit the
number of MRIs and CAT scans in:,: ;philadelphia because they
have more than they need. Pittsburgh may decide they're
short, '. and so they want that :within their;. budget.
Q
Why~on't th~,caps~beqome
,
" , ' ,
ceilings?
MRS. CLINTON: Wel,l,Lthinkbecause we' v.e got the
competition under, the, caps,. -I me'an, part. of what we think
makes ,thisworkabte is thatyou'tve ,'g.ot competing health
plans, each of whom are going, to'try to get our business,
each of whom is going ,te 'llave.to"offer competition based on
both price'and quality fot; the fi·rst time", but each of whom
is going to have to price its services within some kind of
budget discipline.
And what we're (inding., il1what we consider to be
analogous s,ituations" is that jti$t as Dr. Kooppbinted out
about Oregon, there is so·muchfa't in the ,system that once
health pla'ns really have tocempete and nave to make the hard
decisions, they're 'coming in belbwwhat -the projected budgets
are, in places like Florida w:f:fi:ch:hav,e set o,f purchasing
,
plans. And we have no reason t(t>: bel,.,ieve that won i t happen in
:the entire oountry.
'
But as a backstop, these premium caps will be there
in the event that a hea'lth plan :exceeds what should be a
reasonable amount. They're not going to be, put out of
business but they're geing te be'told.,that they've got to, go
through and take a hard look again abeut how to. reallocate
their reseurces.
'
Q One .problem tha·t I''Veconte across, the whole
issue o·f cos·t-e'ffect:iveness (inaudible). And underlying the
whole issue is the 'question of: what Is, cost-effectiVe? And
most of the experts agree ~hatthe( inaudible)" and yet in
this plan you're relying heavily on someone determining cost
effectiveness, and generally that tel)dsto be,th,e companies,
who have the financial incentive to ·try to show cc;>st- '
effectiveness in favor of tneirown product.
How are you going to deal with that? You have one
small agency now 'that's trying ,'to learn something about costMORE
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effectiveness.
trade-offs? "
How do we trust the studies and what will be
MRS~ CLINTON:
Well, :that's where we agree
those who want to give a role,to,t;.hemarketplace. I
want ,this to be worked out 'through th~marketplace.
me just give you a couple of examples about where we
going.
with
mean, we
And let
see this
If you look at the way ,we reimburse physicians
today, it is largely done on, a ,piecework basis. I mean, we
stopped pay.ing people whomqde clothes that, way 50 years ago
in many instances, butthat'swh~t we still do with doctors.
There is, thertiafore, no incentive tp be cost
effective because you have 'to keep' gaming and building up
your services. to pe able to "get. paid.
,Now, that is j'ust a financinq cost-effectiveness
that we think, if properly changed through other incentives,
could make a huge differertce,and'that has nothing to do
necessarily directly, with quality,
(End of Side 1.) ,
,MRS. CLINTON:'
-- physician,s in thatposition
every day. Or integrated.delivery networks, thro~gh a model
like Mayo, which is a mul·tl-specHalty clinic, which, when it
started, was called socialism by the American Medical
Association, where physicians are on salary, very good
salaries, but they're riot paid: by the pr.ocedure.
You actually can 'b~.more cost-effective and
·quality-driven. That's oneot the ou~;..;growths that we think
will come from reorganizing·the, way we finance health care,
so that cost-effectiveness, then: through competing health
plans and people making sQme hard decisions, will be joined
with quality to give us a better outc::::ome.
.
Q I (inaudib~e)conc~rnedi at least from my
research, I think that there i:s~\a .grea,t gap .i,n our ability to
distinIDlif?h the studY' of what p~,GP:J.e seem to (inaudible).
You can take two drugs, and drug A will appear cost-effective
in one study and the company wil'l' go ahead and tout it that
way, and the,n drug B will be touted by ,the other company.
A perfect example has ."beenthe debate over TPA
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(inaudible) in the blbodclot arena. Arid I think that there
is great room there for' ~'iot of manipul~tion.
MRS. CLINTQN:B:ut let, Die' 'g,oback to what I said
about the drug companies, apd what we want from them, which
is'information. You said it exactly ,right .. Where do doctors
get their information abou:t'drtigs? 'Initially from the drug
companies, and often unrelateq to'cqst~,effective or quality,
but who put on the be~t seminar or g'cl:V~ the' best "brunch at
the medical society meeting:; ',all' of; which. is spoj:lsored by big
drug companies.
"
.
We want more 'and better'information, and that can
come through clinical trials and through other kinds of
research, but a lot of that is done before the drug goes to'
market, but it's not,readily available exeept in the way the'
drug company wants to pres'ent .it initia,ily. And then you've
got to go through kind of real wor:l,d practical clinical
trials to acquire'a new b~se.
'
If drug companiefi' wer'e:reqUired, as we're asking
them to be, in the health care plan, to come to a health
board not to get their: price set',butto give information that
that then be made available" ',we will be 'further along towards
det:ermining cost-effeetivel'less than we a:t~ now, where we,
start basically'froIJl zero with competing propaga,nda from drug
companies.
'
So none of this is going tohapp~n ove~,night. I
mean, we have to change inibeddedattitudes' and practice
styles and behaviorso'f people. But right now, we need to
change the incent:iyes initl;.ally that ,will move us in that
direction and then watch i~:, carefully to ·make sure ,that it
unfolds correctly.
DR. KOOP:
(Inaud1:ble) is it sholildn,it even be
considered until you know wha,t w,orks and doesn't work, in the
theory and practice of ,medieine. We don't know that yet.
NOW, if you ,knew t~at,then you can say ,"Here a,re two things
that work. Which is cost":effective?"
"
, And one of 1ihe l'ittle-discus~ed things in the
President's plan is the pl?ovision for'professional'
,foundations, which ~re'totally profe~sionally operated, the
purpose of which is to study util,ization., informed
,
decisionmaking on the parto~ pa;t.ients" arid ,outcome i:esearch~
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And I would think 10 years from· now, that there's
no transaction a doctor will do in his office that doesn't
automatically become a .uni:t ofev'idence in outcome research,
so that what he can pull uponl:l,isdompute,r in January is
quite diffeJ;,"ent than he does, in March, but he. has contributed
to it all during that time.. It takes' ftcompletely out of
commercial hands.
MRS. cLniTON: I just want to make one last point,
which is that Dr. Koop, who's, been, extremely helpful during
this process-- he's given tis lots o:f good advise and
actually read early dra·f·ts,of the plan to advise us' -~ has
said over and over again that many f.eatur,es of this plan that
are .getting no attention whatsoever,' like the US,e of
technoiogy, like the.professiona.Ifoundations --'I'm never
asked about' them and people are not ,p(;lying 'attention to them
-- have, in the long run, the possibility' of huge pay-offs
for the entire system.
.
And what I worry about is that we will narrow the
d,ebate and we>will make ,marginai changes that are in the
absence of this kind of systemic reform, and we will
therefore lose a lot of whatls iri this ,plan that kind of' is
leading edge, like the technol~gy and some of these quality
Q~tcome things that' in the abse,nce of it, we' will not be able
to 'do effectively under the,buqget, as we currently have it
at the federal government, and we will lose an opportunity to
get ahead of both the priceahd:' the qu.a1it,y curve.
So that's why we went,wit.h·a comprehensive plan,
and people say it's long: and it" s· compl·ex,. but everything' IS
in there •. I mean, some of the .competing ,plans are 400 or 500
or 800 pages long and they don.lt,have anything except'the
financing and a few other features.
.
,
.
So we've tried to leok at, every issue and put it
out there. And what we hope is. that w,e can keep the focus on
comprehensive reform and ·nQt have it na,rrowed too soon.
But I wanted to say, before lim dragged out of
here, that you all have done a g~eat job. covering this. I
thin}{ that both therepQrtii1<j'(ind the editorials and the
cautioris and the encoul;."a.gemen:tsand all· that you've done in
your coverage has beenainong the best in. the entire 'country.
'So I'm grateful for wh~t ,yol:live already done and feel like
I'm preaching to the choIr ;i.nte,rms of what you (ill.know and
what you've already communicated •.
'";-
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But I can't stress"h9w~mportant that's going to be
for now, going forward •. And f ,wish I could get other papers
to' go iitit with the kind of depth and understanding that
you've brought to it because th;is his going to pe hard enough
to do, and not having (,lccurate· i:rl·form~tiqn will make our job
even harder.
Q
Just among the best?
(Laugl1ter.)
(The interview was concluded.)
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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
Creator
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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 III 02/02/94 - 05/31/94 [Binder]: [02/04/94 Philadelphia Inquirer Editorial Board]
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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-iii-02-02-94-05-31-94-binder-02-04-94-philadelphia-inquirer-editorial-board
7431941