    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [December 3, 1993]
    [Pages 2104-2110]
    [From the U.S. Government Publishing Office www.gpo.gov]

    [[Page 2104]]

    Remarks and a Question-and-Answer Session on Health Care in Bernalillo,
    New Mexico
    December 3, 1993

        The President. Thank you very much. He did a good job, didn't he?
    For a fellow that's not used to doing this, he did a great job.
        Well, first of all, Doctor, I want to thank you and all your
    colleagues for welcoming me into the clinic today. I enjoyed the tour. I
    enjoyed listening to you talk about what you've done. And I have to tell
    you that I saw something in that clinic today that no law can ever
    compensate for or require, and that is a level of constant commitment to
    the people of this area. That must be a priceless treasure, just the
    idea that you've committed your life here. And I thank you for that.
        I'd also like to thank Mayor Aguilar and Mrs. Aguilar for welcoming
    me here and--with their grandson back there. I enjoyed it, meeting them.
    And I appreciate the little--I'm about to fall in the hole here. This
    would make millions of people happy if I fell over--[laughter] I think
    I'm pretty well set now. They gave me a wonderful little proclamation
    declaring this day Bill Clinton Day in Bernalillo, which I am grateful
    for, and this wonderful piece of art. Thank you.
        I brought a number of people out here with me. But I want to
    recognize some of them because they will have a major say in what we
    ultimately do as a nation on the health care issue. First, members of
    your congressional delegation: Senator Bingaman and his wife, Anne,
    who's in our administration in the Justice Department. Senator Domenici,
    thank you for coming, sir. My good friend Congressman Richardson, who
    fought so hard for NAFTA, and his wife, Barbara, thank you for being
    here. Congressman Steve Schiff and Congressman Joe Skeen are here. Thank
    you for coming. We have a lot of State officials, but I do want to
    introduce my good friend Governor Bruce King here and his wife, Alice.
    Thank you, Bruce. Alice, are you there? Thank you, Alice. And your
    Lieutenant Governor, Casey Luna, flew back with me. Is he here in the
    audience somewhere? He wrote me a good letter endorsing our efforts in
    health care, which I really appreciated, as a Lieutenant Governor and as
    a small business person.
        I want to talk just a few moments today about what we're trying to
    do with this health reform effort, how the plan that I have presented to
    Congress would, in my view, help things for this doctor and this clinic
    and all of you who are served here and, perhaps more importantly, how it
    would help to provide these kind of services to other people in New
    Mexico and throughout the United States.
        Let me begin by saying that I think most of you know that before I
    became President, I was for 12 years the Governor of Arkansas, and there
    are thousands of people from my State now living in New Mexico. I see
    them every time I come out here. It is also a very rural State. I spent
    a lot of time as a boy in communities that make this place look like a
    thriving large metropolis, in little small towns in country crossroads.
    All my mother's people come from a place that now only has about 50
    people in it. I spent a lot of time as Governor trying to keep open
    rural health clinics, keep open rural hospitals, develop clinic services
    or primary care or emergency services for people who live in isolated
    rural areas. So I have a certain familiarity with a lot of the kinds of
    problems that you have. I've also seen a lot of those problems get worse
    and some get better over the last 15 years. And Doctor, I think you've
    been here 17 years, is that right? So about the same timeframe of your
    service, I have been involved in public service dealing with health care
    in another way.
        I came here today to listen, to learn, and to try to explain what
    we're trying to do. Let me just briefly summarize how this health care
    plan would affect you and your families and your community.
        First of all, it would provide for the first time in our history a
    system of universal coverage. Every family and every person in every
    family would have a comprehensive package of benefits which would
    include primary care, the kind of care you get here, and preventive care
    services that you would always have even if you changed jobs, even if
    you lost a job, even if someone in your family got sick so you had what
    the insurance companies now call a preexisting condition.

    [[Page 2105]]

        In addition to that, it would recognize that in rural areas there
    are 21 million Americans today who don't have access to primary care
    physicians or have inadequate access to primary care physicians. So that
    even if you gave an American family a health insurance card and there
    was no doctor to see, you would have coverage that would be meaningless.
    So this plan makes a real effort to increase people's access to health
    care in rural areas by doing two or three things: first of all, by
    guaranteeing funding to rural health clinics that are publicly funded;
    by increasing the funding stream to clinics like this one--rural doctors
    are the most likely to have to do uncompensated care--to make sure there
    will be some payment coming in for all the people who get care within
    any clinic; by taking steps to remedy the doctor shortage. You heard the
    doctor say that he didn't leave here in part because there was no
    national health corps facility or physician to come in behind him.
    Today, we're only providing funds for about 1,100 doctors a year in the
    National Health Service Corps. Under our plan, we go from 1,100 to 3,000
    doctors a year by just after the turn of the decade and the century. So
    we would be, in other words, every year providing enough extra doctors
    to serve another couple of million patients in America at a reasonable
    ratio of doctors to patients. So that would make a huge difference in
    the quality of rural health care.
        Now, there are a lot of things we do to try to get doctors to come
    to rural areas. But the National Health Service Corps is one, providing
    more scholarship funds; providing more access to partnerships with
    people in health care centers like the ones that you mentioned is
    another. The other thing I want to emphasize is that a lot of people who
    have health insurance policies, in rural areas especially, tend to be
    underinsured. And one of the things that we've learned is: As Americans,
    we spend a huge amount of money on health care that we wouldn't spend if
    people had primary and preventive health care and if people had access
    to adequate medication. There are a lot of people who have all kinds of
    physical problems that could be adequately treated and their conditions
    could be maintained if they had adequate medication. A lot of people who
    have mental health problems that could be better managed and treated if
    they had access to a steady amount of appropriate medication.
        So one of the good things about our health care plan is that under
    the bill we presented, in the comprehensive benefit coverage, all
    families, whether they get care from the Medicare or Medicaid programs
    or through private health care programs, would have access to
    prescription drugs. There would be a copay, you'd have to put some money
    up front in it, but everybody would have access to those drugs. We
    believe that will lower the incidence of hospitalization and, over the
    long run, really lower the cost of health care by helping people to stay
    healthy and to maintain their own health conditions.
        How do we pay for this? The program would be paid for by a
    combination of sources. First of all we would require employers who
    don't cover their employees at all to cover their employees. And if
    their employees are not covered at all now, the employees would have to
    pay up to 20 percent of the premium themselves. The employer's
    contribution would be capped at 7.9 percent of payroll. But small
    businesses, which dominate rural areas, would be eligible for discounts
    on their guaranteed private insurance plan, which would dramatically
    lower in many cases the percent of payroll they would have to pay.
        Is this fair? I think it is. In every other country with which we
    compete, everybody makes a contribution directly or indirectly to the
    health care system. Today, everybody gets health care, but often when
    it's emergency care, when it's too late, and then their costs are paid
    by somebody else. They're either shifted back to the taxpayers or
    shifted onto other employers through higher insurance premiums. But by
    giving discounts to people who are smaller employers, we think that's a
    fair thing to do.
        How will the discounts be paid for, and how will the extra services
    be paid for that the Government's going to provide? By lowering the rate
    at which we're seeing medical inflation explode Medicare and Medicaid
    programs. Today the Government programs are increasing at 3 times the
    rate of inflation. Under our system, which would put more people on
    Medicare and Medicaid in the larger competitive bidding blocks with
    self-employed people and small businesses and others, we think we can
    cut the rate of increase in these costs at least to twice the rate of
    inflation and take the difference that we've already budgeted to pay for
    some of these other programs.
        There are no general taxes in this program.

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    We do seek to raise the cigarette tax. And we ask the biggest companies,
    that can opt out of our system to provide their own health care plan--
    they will get a huge drop in their premiums as a result of our system--
    we ask them to make a modest contribution, trying to help pay for those
    that are uninsured and may need subsidies. That's how we pay for it. And
    we think it will work.
        There will also be a lot more competition in the system than there
    is now. That will drive costs down. But we don't take that into account
    in figuring out what it costs. So we think the system will not cost even
    as much as we say it will, once you take account of the increased
    competition.
        If you're a small business person or a self-employed person, the
    best thing about this program is that you'll be able to have access to a
    better health insurance policy at a lower price because for the first
    time, small business people and self-employed people will be able to
    have access to less costly premiums and will have the same sort of
    bargaining power in health care, particularly those who live in the
    bigger areas, that only big businesses and governments do today. Small
    business and individuals are at a terrible disadvantage today.
        So that's how the system works briefly. There are a lot of other
    specific questions I'm sure you'll want to ask me. I'm here, and I also
    brought a couple of my staff folks here who helped to work on putting
    this program together and especially spent a lot of time on rural health
    care. I personally spent one full day in the White House talking about
    rural health care to make sure that before we sent this plan up to
    Congress we would have a program that was very sensitive to the needs of
    rural health care, to the needs of Native Americans, to the needs of
    people that are underinsured as well as those that are uninsured.
        So, we'll try to answer your questions, but now I'd like to hear
    from the folks you brought here, Doctor, and to thank you very much for
    that.

    [At this point, clinic physician Alan Firestone read a list of
    participating community members, patients, and clinic employees. He then
    introduced participant Miranda Sapien.]

        The President. Let me just say, if you can hear, these mikes aren't
    too strong, so you have to speak right into them so everybody can hear.
    Pretend you're singing to it. [Laughter]

    [Ms. Sapien began speaking but was interrupted by the noise of a passing
    train.]

        The President. At least it's not in the middle of the night, right?

    [Ms. Sapien then discussed caring for her elderly parents in her home
    and the need for affordable home health care and respite care for the
    elderly, especially in rural areas.]

        The President. No, as a matter of fact, this is a big problem
    everywhere in America, and the fastest growing group of our population
    in America are people over 80 years of age. And in general, I think we
    want to encourage families to stay together. The way the system works
    today, if you spend yourself into poverty you become eligible for
    Medicaid, and then you can go to a nursing home. There aren't very many
    Medicare certified nursing homes in the U.S. The older people are
    Medicare-eligible. So one of the things that our plan seeks to do,
    although I don't want to mislead anybody, we don't know how much it
    would cost. We can't know precisely how much it would cost if we started
    tomorrow covering everybody with this kind of long-term care. A lot of
    us believe that over the long run it would save money because more
    people would stay at home if there was some provision for in-home care
    and for respite care so that the families could have a break. But we do
    phase in long-term coverage over a period of several years as a part of
    this plan.
        And one of the things that we're also trying to do is to encourage
    some of the State reform efforts that are going on now where many States
    are looking at whether they can set aside some of the money that is
    presently allocated to nursing home care to also cover in-home care. I
    applaud you for doing it. I think since we know that the percentage of
    people who are quite old is going to increase and more and more people
    will be quite alert and will be able to function at a fairly high level
    but there may be some care needed and more as time goes on, I think it's
    quite important that we keep this long-term care part of our program,
    even though it's going to take us several years to get it fully phased-
    in.
        Lynn Mathes. Lynn was--I'll let her tell us. But I think--were you
    fully employed? And she was injured.
        Turn it on, will you, whoever's got the mike.

    [[Page 2107]]

    It worked great for her.

    [Ms. Mathes explained that she had been injured while employed as a
    horse trainer and her former employer would no longer pay for her
    therapy. She did not receive any help from insurance companies but was
    able to pay some of her expenses through her work as an artist.]

        The President. Unfortunately, the story you just told is all too
    typical. The reason I laughed is the doctor has a work of art on his
    wall inside that another artist gave him as an in-kind payment. And I
    can remember when my mother was a nurse anesthetist, I can remember when
    people, in the appropriate season, used to go pick fruit and pay her in
    return for her services. That works for a few people. I don't think it's
    a very good way to run a country.
        Let me just say, the way our system would work if we reformed the
    insurance system is that that simply would not happen because everybody
    would be covered, there would be a clear package of benefits, there
    would be a single form, you would just turn it in. And your employer
    would never--I'm glad your employer tried to get it covered, at least. A
    lot of small employers are terrified of a serious thing like this
    because they know that their insurance is already so much more expensive
    than larger employers or than Government insurance, and they're afraid
    they'll be priced right out of the market. Under our system, everybody
    would be able to buy insurance on equal terms, and the coverage would be
    uniform and consistent. So you wouldn't ever be putting an employer in a
    bind just because it was a small employer. Or if you were a self-
    employed artist and that was your only job, you'd have access to a
    really affordable policy.
        But you have to understand, this is the only country in the world
    with 1,500 separate health insurance companies writing thousands and
    thousands of different policies. And if they delay paying on you, then
    that in effect gives them time to earn interest on that money. So
    eventually, even if they pay, they've made a good deal out of it if they
    can delay payment for 2 or 3 or 4 or 5 or 6 months. But it may impair
    your ability to get certain care. This happens everywhere.
        You just heard what the doctor said. At the time when his caseload
    is doubled here--patientload--they have increased the number of people
    who devoted themselves to paperwork by sixfold. That's because this is
    the only country in the world that has literally 1,500 different
    companies writing thousands and thousands of different policies, where
    the doctors in the clinics have to hire people, trying to get payment
    when they're entitled anyway, and where the coverages are so complicated
    and different, when you put that with all the rules and regulations that
    the Government has, that you spend enormous amounts of time just trying
    to work out the transaction who's going to pay when. One of the primary
    benefits--perhaps the best benefit to doctors and clinics--of our plan
    is that we'd actually be able to have a single form for insurers, a
    single form for clinics, a single form for patients. And it would cut
    out a lot of this incredible paperwork and administrative cost.
        We spend about 10 cents on the dollar--let me tell you how much
    money that is. We're going to spend $900 billion on health care this
    year. So 10 cents on the dollar is $90 billion dollars a year. That's a
    lot of money. That's 1\1/2\ percent of our gross domestic product. We
    spend about that much more on administrative costs than any other
    country in the world spends on their health care system. That's how bad
    it is. And you get caught in it, in the delay.

    [Dr. Firestone mentioned the concerns of a small business owner about
    the cost of providing health insurance and workers' compensation for her
    employees.]

        The President. The health care cost of workers' comp would be folded
    into the health care plan, which would save a lot of small business
    people a ton of money. Slightly more than half of the workers' comp
    premium is health care costs, that would be folded in. And that's a huge
    concern to small business people and also to people in certain targeted
    industries, like in my home State, the loggers and the people in the
    wood products industry. They have huge workers' comp bills. So that
    would really help.
        Again, I would have to know exactly how many employees the lady has
    and what the average income is of the employees, but they would be
    eligible for a discount rate. I can just tell from what you said to me,
    she would not pay the 7.9 percent. She would pay some lesser percentage
    of the payroll. But having been on the other side of it, she can
    understand what it's like if there is none.
        Let me say, there are a lot of part-time work-

    [[Page 2108]]

    ers in our country today and probably will be more. Under the way the
    bill has been presented to Congress, if you work 30 hours a week or
    more, you would be insured as a full-time worker and your employer would
    have to pay the full cost of the premium and you would have to pay your
    20 percent match. If you're under that, down to 10 hours a week, the
    employer could pay a proportionate amount of that, a smaller percentage,
    and therefore your premium would be less. And if you outran that in
    using the health care system because you're a part-time worker, and that
    would be eligible for the public subsidy. So we try not to bankrupt
    people who have part-time employees or discourage people from hiring
    part-time employees. But we think they ought to pay at least a portion
    of their benefits.

    [Dr. Firestone introduced Dr. Jack Vick, who discussed the difficulties
    of providing quality health care in rural areas but stated that he will
    continue his rural practice.]

        The President. I'm just glad you're going back.
        Let me just mention a couple of things you mentioned, because there
    are answers to some of them, and there aren't answers to some of them--
    at least if there are answers to some of them, I don't know what they
    are. But one of the best things, I think, from the point of view of the
    benefits package that we tried to do in this plan is to provide more
    coverage for primary and preventive services, pap smears, mammograms,
    cholesterol tests, important things that are early warning signals that
    may head off far more severe health care problems and actually save the
    system money.
        Secondly, I think part of the answer to the problems of doctor
    exhaustion and overcommitment, simply increasing the number of doctors
    in rural areas and trying to tie them more into partnerships with urban
    medical centers and with university health centers. Without going into
    all the details, I think we've got some good systems to do that.
        We also are working on one aspect of malpractice reform that will
    encourage more family practitioners to do things like deliver babies or
    set simple fractures where they are in rural areas. Based on an
    experiment that started in the State of Maine, where basically if you're
    a family practice doctor and you do these procedures out where people
    live, because you need to do it there, and you can prove that you've
    followed a set of guidelines approved not by the Government but by your
    national professional group, that raises a presumption that you were not
    negligent and sort of gets you out of this whole malpractice bind.
        Now, what I don't have an answer for, and I don't think there is one
    right now, is what you do with the problem pregnancy. I think if you
    think you've got a problem case, you still have to send it--whatever
    discomfort there is--to a place where you think the care will be
    appropriate. If there's an answer to that one, I don't know what it is.
    But I do think that we want more family doctors, and we want more family
    doctors out there in the rural areas doing things they know they can do
    but they're still afraid not to do because of the malpractice problem.
    And being able to prove that there's a set of nationally accepted
    guidelines for this kind of procedure in a rural area and that you've
    followed them, it seems to me will do a lot to alleviate both the cost
    of the malpractice insurance and the fear of the lawsuit.

    [Dr. Vick asked about coverage for mental illness.]

        The President. Well, we think the basic benefits package should
    include mental health benefits, pretty comprehensive mental health
    benefits, as well as medication for treatment of mental illness. I know
    this is a particular interest of Senator Domenici and a number of other
    Members of the Congress. But let me say this has been a big fight in our
    administration, essentially with the bookkeeping of health care. That
    is, we can't ask the Congress to pass, and the Congress cannot pass, any
    bill that they don't think they have a pretty good feel for how much it
    will cost and how it will be paid for.
        So, we have been through a lot of very tough sessions with the
    actuaries for health care, people who are supposed to be experts in
    health care costs, to figure out how much the mental health benefit will
    cost and how we have to phase it in over time. Right now we phase in
    mental health benefits, comprehensive mental health benefits, between
    now and the year 2000, although other health care costs would be covered
    by the beginning of 1997, the end of 1996, in all the States.
        So, I'm glad you said that. I'm glad you said it here in this rural
    setting because, again, as you know much better than I, there are a lot
    of mental health problems that can be treated,

    [[Page 2109]]

    that can be managed, that can allow people to be productive members of
    society, and that can therefore be a very cost-effective thing to do, as
    well as the humane thing to do. And we have to get these benefits in.
        Again, I believe that our actuaries have overestimated the cost and
    underestimated the benefits of including comprehensive mental health
    benefits. But nonetheless, we can't--again, I don't want to mislead the
    American people. I don't want to overpromise. And I don't want to pass a
    bill that breaks the bank. So right now we provide for the phasing-in of
    the mental health benefits, with the benefits to trigger in about the
    year 2000 to do what you say we should do.

    [Dr. Firestone introduced Cel Gachupin, who discussed health care
    concerns of Native Americans and then shared the tragic story of his
    son's death from asthma.]

        The President. Thank you for sharing it, and thank you for having
    the courage to share it. I don't know if I can give you an answer to the
    policy questions you raised. Thank you very much for what you said.
        The first thing you said was you often had to drive your son past
    hospitals to get to the Indian Health Service. Under our plan, if it
    passes the way we have presented it, American Indians will be able to
    get health care either through the Indian Health Service or through
    another network of health care at their own choice. So that if people,
    because of where they happen to live, have much better access to some
    other health care provider, they will be, at their own choice, they will
    be able to choose to use those facilities.
        But we feel that the United States has a solemn obligation to
    maintain the Indian Health Service. And as you probably know, the
    funding has dropped over years as the number of people using it has
    dropped. So one of the things that--after the leaders of tribes from all
    over America came to see us in Washington about this, one of the things
    we did was to go back and amend the plan to try to strengthen the
    financial support for the health care service so they would be able to
    provide particularly the kind of services to people who are out-patients
    like your son was. So I think in this case, we will give the American
    Indians more personal choice than many now have. You won't be forced to
    the health care service. You'll have the option of using something else.
    But if you do use it, it should be better funded than it now is.

    [At this point, Dr. Firestone asked about benefits for children with
    multiple disabilities and chronic illnesses and presented the President
    with a letter regarding their needs. He then thanked the President for
    visiting the clinic.]

        The President. I can't answer the question you just asked me. But
    I'll get an answer, and I'll get back to this lady who wrote you the
    letter--or to me--the letter. I'll do it.
        Let me just say before we close, and then I want to say hello to all
    of you and then go back around and see the kids who have been waiting so
    patiently, if they're still there. I don't know if they are. I hear some
    people chanting in the background.
        When the new year comes and the Congress comes back into session,
    there will be a few months of really intense debate on this. Just think
    about this town and the size of this town and the diversity of the
    things we've heard about already today, as well as all the things we
    haven't heard about. This is a very complicated matter. But in the end
    it comes down to something very simple. We are spending a much bigger
    percentage of our income on health care than any other country in the
    world, and yet we are the only major country who doesn't provide
    everybody health care coverage that is always there, that can never be
    taken away.
        And we have permitted a system to develop so that now, coming out of
    medical school, only about one in seven doctors are committed to do what
    this doctor has done and this doctor wishes to do. So we have to change
    that. And it is perfectly clear that it will not happen unless the
    Congress is prepared to go through the incredibly rigorous process of
    reviewing the bill that I presented, listening to anybody else's
    alternatives and hearing the human voices that we have heard today, and
    coming to grips with this problem and actually acting on it.

    [[Page 2110]]

        This is something we should have done a generation ago when we could
    have saved untold billions of dollars and no telling how many lives. But
    we can do it now, and we have to do it. And I would just implore you to
    work with us, make sure we don't make any mistakes we can possibly
    avoid, but give the Members of Congress from your State the courage to
    face this problem that our Nation has neglected for too long.
        Thank you very much.

    Note: The President spoke at 4:04 p.m. at the El Pueblo Health Services
    Clinic.