    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [September 20, 1993]
    [Pages 1539-1543]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Remarks to Physicians and Supporters on Health Care Reform
    September 20, 1993

        Good morning. I thank you for coming here, and I thank Dr. Koop for
    his stirring remarks. He always makes a lot of sense, doesn't he? And
    the Nation is in his debt for his work as Surgeon General and now, for
    the work he is about to undertake in behalf of the cause of health care
    reform.
        I also want to thank the many physicians from all across America,
    from all walks of medical life who have made a contribution to the
    debate as it has progressed thus far. I got very interested in this
    subject years ago when, as the Governor of my State, I noticed I kept
    spending more and more for the same Medicaid and had less and less to
    spend on the education of our children or on preventive practices or
    other things which might make a profound difference in the future.
        In 1990 I agreed to undertake a task force for the National
    Governors' Association, and I started by interviewing 900 people in my
    State who were involved in the delivery of medical care, including
    several hundred doctors. Some of them are in this room today. I thank
    them for their contributions, and I absolve them of anything I do which
    is unpopular with the rest of you. [Laughter]
        I'm glad to see my dear friend and often my daughter's doctor, Dr.
    Betty Lowe, the incoming President of the American Academy of
    Pediatrics; my cardiologist, Dr. Drew Kumpuris, who pulls me off a
    treadmill once a year and tells me I'm trying to be 25 when I'm not--
    [laughter]--and Dr. Morriss Henry from Fayetteville, Arkansas, back
    here, an ophthalmologist who hosted the wedding reception that Hillary
    and I had in Morriss and Anne's home almost 18 years ago next month; Dr.
    Jim Weber, formerly president of the Arkansas Medical Society. We
    started a conversation with doctors long before I ever thought of
    running for President, much less knew I would have an opportunity to do
    this.
        This is really an historic opportunity. It is terribly important for
    me. One of the central reasons that I ran for President of the United
    States was to try to resolve this issue, because I see this at the core
    of our absolute imperative in this sweeping time of change to both give
    the American people a greater sense of security in the health care that
    they have, and call forth from our people--all of our people, including
    the consumers of health care--a renewed sense of responsibility for
    doing what we all ought to do to make this country work again.
        I am determined to pursue this in a completely bipartisan fashion.
    And I have reached out to both Republicans and Democrats, as well as the
    thoughtful independents to help. There is one person in the audience I
    want to introduce, a longtime friend of mine who has agreed to help
    mobilize support for this approach among the Democrats of the country,
    the distinguished former Governor of Ohio, my friend Dick Celeste, who's
    here. Thank you for being here.
        When Dr. Koop talked about the ethical basis of this endeavor, he
    made perhaps the most important point. If I have learned anything in
    these years of public endeavors, or anything in the last several months
    of serving as your President, it is that once people decide to do
    something, they can figure out how to do it.
        When, one week ago today, on the South Lawn of the White House,
    Yitzhak Rabin and Yasser Arafat signed that peace accord, they did not
    even know what the ultimate map-drawing of the city of Jericho would be,
    or how all the elections would be held, or how the Palestinians'
    candidates would advertise on the radio since the radio stations don't
    belong to the Palestinians. I could give you a hundred things they did
    not know the answer to. They knew one thing, they couldn't keep going in
    the direction

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    they were going, and so they decided to take a different direction.
        When President Kennedy's administration challenged this country to
    go to the Moon, they didn't have a clue about how they were going to go.
    The Vice President knows more about science than I, so he can tell it in
    a funnier way about they didn't understand what kind of rocket they were
    going on and what their uniforms would be like and on and on and on. But
    the ethical imperative is perhaps the most important thing. We have to
    decide that the costs, not just the financial costs but the human costs,
    the social costs of all of us continuing to conduct ourselves within the
    framework in which we are now operating is far higher than the risk of
    responsible change.
        We have certainly tried to do this in a responsible way. I want to
    thank the First Lady and all the people who work with her. I want to
    thank Tipper and Ira and Judy and everybody who was involved in this. We
    have really worked hard to reach out to, literally, to thousands and
    thousands of people in this great medical drama that unfolds in America
    every day.
        I want to thank Donna Shalala and the Department of Human Services
    for the terrific work they have done. We have really tried to do this in
    an embracing and a different way, almost a nonpolitical way. If you look
    around this room, we have doctors from Maine to Washington, from
    Minnesota to Florida. Some of you see patients in rural Virginia, some
    in public hospitals, others of you devote your lives to training the
    next generation of physicians.
        But I think every one of you is committed to seeing that we provide
    the finest health care in the world. That means as we undertake this
    journey of change, we clearly must preserve what's right with our health
    care system: the close patient-doctor relationship, the best doctors and
    nurses, the best academic research, the best advanced technology in the
    world. We can do that and still fix what's wrong. In fact, we can
    enhance what's right by fixing what's wrong.
        If we reduce the amount of unnecessary paperwork and governmental
    regulation and bureaucracy, that will by definition enhance the doctor-
    patient relationship. If we spend less money on paying more for the same
    health care and the incentives to churn the system, we will have some
    more money, for example, to invest more in medical research and advanced
    technology and breaking down the barriers which still limit our ability
    to solve the remaining problems before us. We need a discussion. We need
    constructive criticism. We need constructive disagreement on some
    points. This is a very complex issue.
        I worked at this for over a year and realized when I was a Governor
    I was just beginning to come to grips with it. When we started this
    great enterprise and I asked Hillary to undertake this task and she
    looked at me as if I had slipped a gasket--[laughter]--I knew more about
    it than she did. Now, she knows a lot more about it than I do.
        This is a learning effort. We are going to start today, as many of
    you know, this health care university, we call it, for Members of
    Congress, and about 400 Members of Congress have signed up for 2
    intensive days of learning. That is an astonishing thing. I have never
    seen anything like it: these Members, without regard to their party and
    completely without respect to the committees they are on, since most of
    them are on committees that would not have direct jurisdiction over
    this, hungering to know what you go through every day, hungering to
    learn, wanting to avoid making an irresponsible decision but determined
    that they should make some decisions to change this system. I think that
    is a terrific cause for hope.
        For patients, the reform we seek will mean more choices. Today,
    employers are too often forced by rising health care costs to decide
    which plans to offer their employees, and often they are inadequate or
    too costly. The decision is usually based on the bottom line, and is a
    moving bottom line as more and more Americans every month actually lose
    their health insurance for good. Our plans give consumers the power to
    choose between a broad range of plans within their region, giving them
    more freedom to find and to stay with a doctor they like.
        For doctors, reform will mean the flexibility to choose which
    networks or providers you want to join. If you want to be involved with
    one, that's fine. If you want to be involved with more than one, that's
    fine. So that whatever you want to do to continue to see the patients
    you see today, you will be able to do it. It's your choice.
        We intend to see a reform that drastically simplifies this system,
    freeing you from paperwork and bureaucratic nightmares that have already
    been well discussed. I cannot tell you how moved I was when we were at
    the Washington Children's Hospital the other day and

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    we heard not only the statistics that the hospital has calculated that
    they spend $2 million a year on paperwork unrelated to patient care and
    keeping up with the procedures, but the human stories. I mean, we had a
    nurse actually tell us about being pleaded with by a young child with
    cancer to play with the child, and she couldn't do it because she had to
    go to a little seminar on how to learn how to fill out a new set of
    forms that they were being confronted with, and she said, that really
    was a picture of what their life was like; an eloquent doctor who said
    she wanted to live in Washington, DC, she wanted to care for the poor
    children in the area. She did not go to medical school to spend her life
    poring over a piece of paper. And all of you have had that experience.
        We can do better than this. We also know we're going to have to trim
    back Government regulations that get in your way and do little to
    protect the patients or provide better care. If we simplify the system,
    we will reduce the apparently insatiable bureaucratic urge that runs
    through administrations of both parties and seems to be a permanent
    fixture of our national life to micromanage whatever aspect of tax
    dollars they have some jurisdiction over. We are determined to undo much
    of that. We want to respect your training, your judgment, and your
    knowledge and not unduly interfere with what you do.
        We also are determined to preserve the quality of health care that
    our people receive. Today, part of the reason we have the finest doctors
    in the world are the academic health centers. For years they have been
    the guardians, the guarantors of quality, training doctors and health
    care professionals and reaching into surrounding communities to provide
    help for those in need. In the coming years, these centers, if our plan
    passes, will have even greater responsibility to turn out high quality
    physicians, particularly primary care physicians who will work in
    underserved areas, and to create a system of lifelong learning for
    health care professionals. And they must continue to expand their
    partnerships with communities around them.
        The initiative I am offering offers the possibility of giving real
    building blocks to this Nation's health care system to fill in a lot of
    the gaps which exist for millions of Americans, not just universal
    coverage gaps but also organizational problems and the lack of adequate
    access.
        I want this plan to be fair, compassionate, and realistic, and I
    believe it is. Health security can be provided to the American people so
    that you don't lose your health care when you lose your job; you don't
    get frozen into a job because someone in your family has been sick and
    you're in the grip of the preexisting condition syndrome, which is
    literally undermining labor mobility in a world where the average 18-
    year-old American must change work eight times in a lifetime to be fully
    competitive, when security means the ability to continuously learn and
    find new and evermore challenging work, not to stick in the same rut
    you're in anymore. We don't have that option. We are literally rendering
    people insecure through job lock, undermining their potential, keeping
    them from moving on, and also keeping others from moving up into the
    positions they previously held. This is a serious economic problem.
        This plan will guarantee that every patient who walks in your door
    is covered. It will make sure you are paid to keep your patients healthy
    as well as to treat them when they're sick. It will give you the
    flexibility and freedom you need to do your jobs. In return, it must
    demand more responsibility from all of us. We must have a new generation
    of doctors which has a recommitment to primary care. We don't have
    enough primary care physicians in America, and I think we all know it.
    We have to care about family practice, pediatrics, and preventive
    medicine. And we all have to work together to get medical costs under
    control.
        But I'm convinced with your leadership we can do that. Without your
    help, we could not have covered as much ground as we have covered so
    far. I thank Dr. Koop for what he said. But the attention to detail by
    this project is the direct result of the painstaking effort and the
    hours that have been provided by physicians and other health care
    providers who have come to this town and spent day after day after day
    after day almost always at their own expense just to do something to
    help their country as well as to improve the quality of their own
    practice. We know that this will not be done overnight. We know that we
    will have to have a long-term commitment from individuals, from
    Government, from businesses, and from health care professionals. But we
    know that we have to begin now. This is a magic moment.
        Let me just say two things in closing. There are a lot of other
    things we haven't discussed, and I know that, but we didn't come here
    for

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    a seminar on the details of it. We are trying some innovative approaches
    to the malpractice problem, which I think will find broad favor. We are
    going to do some things that will increase public health clinics'
    ability to access people who are otherwise left out of the system and
    try to deal with these horrible statistics on immunization and the
    absence of prenatal care. There are a lot of those things that are going
    to be dealt with.
        But I want to make two points in closing. First of all, there are a
    lot of disconnects as you might imagine between Washington, DC, and the
    rest of America, which everybody loves to talk about when they get
    alienated from the Federal Government. But one of the most amazing in
    this has been the following thing: I don't talk to any doctor or any
    hospital administrator or any nurse with any seniority in nursing who
    doesn't believe that there's a huge amount of waste in this system, that
    has nothing to do with caring for people, which can be gotten rid of. I
    don't talk to anybody in Washington who thinks you can do it. [Laughter]
        Our friends in the press are laughing because you know I'll finish
    this talk, then they'll go talk to somebody on the Hill who will say,
    ``Aahh, they can't save that money in Medicare and Medicaid. It's got to
    be that way. We really need a room under the garage in the Children's
    Hospital in Washington, DC, which is piling up paper 6\1/2\ feet a day.
    We've got to have that. How would we function?''
        Hillary goes to the Mayo Clinic; they've already got their annual
    average cost increases now down under 4 percent. And we talk about, you
    know, maybe getting it down over the next 3 or 4 years to inflation plus
    population plus 2 percent, and they talk about how we are slashing
    Medicare and Medicaid, when what we really want to do is take the same
    money and not take it out of health care, but use it to cover the
    uninsured, unemployed, use it to cover some new services to do more
    preventive primary health care. So this is an interesting thing. Dr.
    Koop said: In the past, reform has been imposed on the doctors. You
    might have to come up here and impose it on the politicians and the
    bureaucrats. You may have to do that.
        I say that not to be critical of the Congress. We are all--all of us
    see the world--[laughter]--no, no, no, I don't--all of us see the world
    through the prism of our own experience, don't we? You do. I do. We all
    do that. And they are so used to believing that the only way they can be
    decent stewards of the public trust, to take care of the poor on
    Medicaid and the elderly on Medicare, they are so used to believing that
    the only way they can do it is just to write out a check to pay more for
    the same health care, never mind if it's 2 or 3 or 4 times the rate of
    inflation; never mind if there's a 16-percent increase in the Medicaid
    budget for the coming year, when we estimate no more than a 2-percent
    increase in the enrollments in Medicaid.
        We're just so used to believing that in this town that we have to
    have your help to believe that it can be different, and you can enhance
    the care people get, not undermine it. I don't want to minimize that.
    Yes, we need your critical scrutiny of the specific plan the
    administration will propose. Yes, we do. But we also need for you to
    convince the people who live here, who believe we are trapped in this
    system, that it can be different. And you are the ones who have
    responsibility for caring for people. If you can believe it can be
    different, you can convince the Congress that it can be different, that
    they are not going to hurt, they are going to help by making some of
    these changes.
        The second point I want to make in closing is this: This is really a
    part of a great national discussion we have to have about what kind of
    people we are and what kind of country we're going to be. And Dr. Koop
    said it better than I could, but we can't really get the kind of health
    care system we need until there is a real renewed sense of
    responsibility on the part of everyone in this system. It is terribly
    important to recognize that we have certain group behaviors in this
    country that, unless they are changed, we will never get health care
    costs down to the level that our competitors have.
        It's not just high rates of AIDS and excessive smoking; it's high
    rates of teen pregnancy, of low birth weight, of poor immunization of
    children. It's outrageous rates of violence that we willfully refuse to
    deal with by taking away the main cause of it, which is the unrestricted
    access that young people in our most violent areas have to guns that
    give them better weapons than the police.
        Yes, within the health care system, doctors shouldn't perform
    unnecessary procedures, patients shouldn't bring frivolous malpractice
    suits, people who use the health care system now, who aren't in it now,
    are going to have to pay

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    a little for their health care, so they realize there is a price for
    everything instead of when all of the money just comes from a third-
    party source they don't know. There needs to be more responsibility
    within this system but we also have got to remember that if we can plant
    the ethical roots that Dr. Koop talked about, we may then be able not
    only to change this system but to use this success to try to change some
    of the destructive group behavior that is tearing this country apart.
        But believe me, it all begins here. If we can give the security of
    decent health care to every American family, it will be the most
    important thing that the Government has done with--not for but with--the
    American people in a generation. And it can only happen if people like
    you lead the way.
        Thank you very much.

    [At this point, Hillary Clinton invited participants to breakfast.]

        Q. Mr. President, is Senator Moynihan wrong?
        The President. [Inaudible]--you heard what he said yesterday? What
    he said was absolutely right. I mean, based on the experience of the
    last decade, you can't get the cost down to zero, but that's not what we
    proposed. We proposed working over a 5-year period to move the
    Government's cost to inflation plus population growth. And in the
    beginning--we have inflation plus population growth plus another 2 or 3
    percent. Where this group care is working well, like at the Mayo Clinic,
    they now are down to less than inflation plus population growth. So I
    believe that if you give us 5 years to do it, we can get there. But it
    will require some substantial changes.
        What I said was true. People in Washington can't imagine that it can
    be different because of the experiences they've had over the last 5
    years. But to say we're trying to cut Medicare and Medicaid, it's not
    true. We propose never to take it below inflation plus population
    growth.

    Note: The President spoke at 8:45 a.m. in the East Room at the White
    House. In his remarks, he referred to C. Everett Koop, former Surgeon
    General; Ira Magaziner, Senior Adviser to the President for Policy
    Development; and Judith Feder, Principal Deputy Assistant Secretary for
    Planning and Evaluation at the Health and Human Services Department. The
    exchange portion of this item could not be verified because the tape was
    incomplete.