    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [September 23, 1993]
    [Pages 1568-1586]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Remarks in the ABC News ``Nightline'' Town Meeting on Health Care Reform
    in Tampa, Florida
    September 23, 1993

        Ted Koppel. Welcome. A standing ovation. It's got to be downhill
    from here on in. [Laughter]
        The President. A lot of the work is still to be done.
        Mr. Koppel. Indeed. I'm going to begin with what may seem like a
    rather trivial thing, although I'll tell you it wasn't trivial to you
    yesterday. There you were. You were in front of the joint session of
    Congress. You had the Joint Chiefs of Staff there. You had your Cabinet
    there. You were talking to tens of millions of people. And you step up
    to the podium, and if you'd be good enough to take a look at one of
    those monitors out there, we're going to run--[applause].

    [At this point, the audience watched television monitors which showed
    videotape from the previous evening.]

        The President. You can see the teleprompters there. You can see
    them. I am telling the Vice President, ``Al, they've got the wrong
    speech on the teleprompter.'' He said, ``That's impossible.'' I said,
    ``You're not reading it. Read it.'' That's what I said. [Laughter]
        So it turned out that the people with our communications department
    had typed in the speech for the teleprompter on the disk that also had
    my State of the Union speech in February. And when the disk was called
    up, it started at the State of the Union instead of at the health care
    speech. And I thought to myself, that was a pretty good speech but not
    good enough to give twice. [Laughter] So that's what happened.
        Mr. Koppel. When I was looking at the First Lady there--you must
    have talked to her later on--it was almost as though she was telepathic.
    She looked worried. She knew there was something wrong.
        The President. She knew there was something wrong. My daughter,
    actually, watching at home,

    [[Page 1569]]

    told me she also sensed that there was something wrong. And I just
    decided to go on and give the talk. I mean, I had, you know, I'd
    internalized it. I'd worked hard on writing it with our folks. The only
    problem is when you have to go through a lot of points, and you can't
    just read it. So I would just look at the first line and try to recall
    from memory. I didn't want to miss anything.
        And the other problem is if the teleprompter goes off, that's one
    thing; you just look at the audience just like I'm looking at you. But
    imagine if I've got these teleprompters here, and I'm trying to speak to
    you, and the wrong words are going up on the screen, which is what we
    started out to do.
        So I had to ignore all these words and try to look through the words
    to the people. But about 8, 9 minutes into the speech, the fellow
    figured out what was wrong, pulled up the right speech and then whizzed
    through it to figure out where I was. And from then on in it was
    reasonably normal.
        Mr. Koppel. Well, I've got to tell you, Mr. President, as a
    communications specialist--and it may be the last nice thing I say to
    you or for you this evening--you have my admiration. I can't tell you
    how tough that is when you've got the wrong speech going by. You did an
    extraordinary job.
        Let us take at look at how the speech played. We've got some phone
    numbers there. Before the speech you can see, we took a poll and 43-
    percent approval of your health care plan, 41-percent disapproval. Let's
    take a look at after the speech: up to 56-percent approval; 24-percent
    disapproval. You're too good a political pro to put too much faith in
    that sort of kick that you get right after a speech. How tough is it
    going to be to hold onto that?
        The President. I think it depends upon how good a line of
    communication we can maintain with the American people and how open we
    can be in working this process through Congress. There will be a lot of
    people who will honestly disagree with certain things I have
    recommended. There will be a lot of other people who will not want it to
    happen because they will make less money out of the system that we
    propose or because it will require them to change. And they will all be
    heard. So the important thing is that everyone understand that this is
    an extremely complicated thing. You interviewed me before, and I saw you
    showed it out here. I've been working on this issue seriously for 3\1/2\
    years, and I've been dealing with health care as a Governor and attorney
    general and a citizen for a long time, but really working on the
    systematic problems for 3\1/2\ years and talking to hundreds of doctors,
    of other experts all around the country. It's a complex thing.
        But I think if the American people know that Hillary and I and our
    administration, that we're listening to people and that we're really
    shooting them straight, then I think we can maintain support for change.
    Because the reason there's so much support for change among Republicans
    and Democrats and all the people in the health care system is that those
    who know the most, know we cannot afford to continue with the system we
    have. It's bankrupting the country and not helping people.
        Mr. Koppel. Mr. President, we've got an awful lot of people here who
    I know want to ask questions. I just want to show you one more poll
    result. Take a look. ``I worry my future health care costs won't be
    taken care of.'' Now, look at how many people agree----
        The President. They should worry.
        Mr. Koppel. ----with that statement. That's after hearing your
    speech.
        The President. They should worry about that.
        Mr. Koppel. Why do you think it's still so high? Two-thirds of the
    American public still worry that their future health care costs won't be
    taken care of.
        The President. Because health care costs have been going up at twice
    the rate of inflation, or more. For people insured in small businesses,
    more than twice the rate of inflation. Because in any given 2-year
    period, almost one in four Americans don't have any health insurance,
    because about 100,000 Americans a month lose their health insurance
    permanently. So how could people not? And even if that hasn't happened
    to you, almost every one of us knows someone that it's happened to.
        Mr. Koppel. Let me ask you a favor, Mr. President. I've already
    talked to the audience out here and asked them the same favor. They're
    going to introduce themselves to you, tell you their names and who they
    are. We've got so many people who want to talk to you, to the degree
    that we can, let's zip through as many questions and answers as we can.

    [A homemaker said that she and her husband

    [[Page 1570]]

    had the best insurance coverage available to cover the costs of weekly
    treatment for her son, who had nearly drowned, and asked if that
    coverage would be lost under the new health care plan.]

        The President. Well, first of all, it won't get any worse. That is,
    if you're paying for it now and you have coverage that covers that,
    there's nothing to prevent that from continuing in our system. Anybody,
    for example, who's got a situation at work where your employer is paying
    100 percent of your premiums, that can continue. So you shouldn't worry
    about that.
        But in all probability, because of the changes in our plan, you will
    have more secure coverage. That is, if this plan passes, you will know
    that the coverage you have can never be taken away from you and that we
    will cover primary and preventive services, and those kinds of long-term
    care services for children are very important.
        Also what we want to do--it's very important, especially in the
    event your husband has to change jobs--we're going to rate all families
    in America under a broad-based community rating system so that people go
    into big pools. Insurance companies make money like grocery stores do, a
    little bit of money on a lot of people, instead of a lot on a few, and
    we all share the risks in ways that will guarantee that you'll always be
    able to get insurance at lower rates than would otherwise be the case.
        Mr. Koppel. All right, let me move right on. And forgive me, I know
    that none of you is going to be completely satisfied and would like to
    ask follow-up questions, but we are going to try and move around.
        Go ahead, sir.

    [A psychiatrist asked about coverage for mental health out-patient
    services.]

        The President. It depends. The reimbursement rate will depend upon
    what plan the person joins who wants the mental health care. For
    example, each individual will choose what health plan they belong to. If
    you choose, for example, a preferred provider organization where a lot
    of doctors get together and offer to give services, they will prescribe
    what the reimbursement rate will be and what the cost of the plan will
    be.
        If a person joins a fee-for-service plan, then the reimbursement
    rate will be published on the front end, and it will be agreed to by the
    doctors in the beginning. But the Government won't set the rate. So
    there will be some more flexibility there.
        And let me also say, because I don't want to overpromise in this
    thing, I really believe it's important for us to cover mental health
    benefits. But we're not going to be able to cover the full range of
    mental health benefits because we don't know how to cost them out very
    well, as much as I think we should, until the year 2000. So there won't
    be unlimited visits, for example, until the year 2000. But we'll start
    with some hospitalization that's significant and a number of visits per
    year and then build up to full coverage over the rest of the decade.
        Mr. Koppel. Mr. President, we also have our financing plan here. We
    have to take some commercial breaks. We're going to take the first of
    them right now. We'll be back with President Clinton and our audience
    here in Tampa in just a moment.

    [At this point, the network took a commercial break. ]

        Mr. Koppel. If you take a look at the poll--I don't know if you can
    read--your eyes are probably better than mine. I can't read those
    results from here. Can we put it up on the big screen? Can we see the
    poll up there?
        The President. Yes, I see it.
        Mr. Koppel. Can you read it? Well, will you be good--there we go.
    They think your plan versus the present system: 64 percent think it's
    better; 17 percent think it's worse; 3 percent think it's the same.
    Again, that's pretty good. I mean, you can't expect it to do much
    better.
        The President. Sixty-four percent are right. [Laughter] They're
    right.
        Mr. Koppel. Just to keep things from getting too dull, let's see if
    we can get a question from one of the 17 percent. Go ahead.

    [A homemaker said that she provides care to her mother and husband, who
    both have Alzheimer's disease, and asked what the new plan would do for
    caregivers.]

        The President. It will do three things. First of all, for people
    with Alzheimer's and other problems that require institutional care, we
    will continue to cover that. And we will cover it at least as well or
    better as now.
        But secondly, over a period of years--now, we can't do all this at
    once, because we have to phase-in the coverage as we realize more

    [[Page 1571]]

    savings from the waste in the existing system. But over a period of
    years, we will also reimburse people for in-home care, because often
    times it's less expensive to maintain people in homes than in nursing
    homes. So we will, for the first time, have a system by which people can
    actually have coverage for in-home care. And that will include respite
    care, too. If, for example, you are taking care of a parent or a spouse,
    you're doing an incredible service for a society. You're keeping your
    family together, and you're saving money for the system, but you're
    entitled to a little time off. And so under this system, over a period
    of years we'd actually set up a reimbursement system so you could be
    reimbursed or covered to bring in a nurse, for example, if you wanted to
    take a 4-day weekend or something just to get away from the pressure of
    your duties.
        And over the long run, this will enable more people to keep their
    families together, lower the cost of care by keeping more people out of
    institutions and make for, I think, a better quality of life in our
    country.
        Mr. Koppel. To the degree that you can, Mr. President, can you give
    a sense of what the progression of years is going to be? In other words,
    you keep saying we're not going to be able to do all of this right away.
        The President. Sure. Yes. Let me say, first of all, we assume that
    it will take a period of several months for the Congress to work through
    this. But I must tell you, this is the best spirit I have ever seen in
    the Congress, at least in modern times, among Democrats and Republicans,
    first to learn everything they can and second, to work together. We're
    in Florida tonight. We have six members of the Florida delegation up
    here, three Democrats and three Republicans who came down here with me
    tonight, and that's sort of the attitude that's going on.
        So, let's assume we pass a bill sometime next year. The first and
    most important thing we have to do is to lock in basic security for
    everyone; so we want to get that done by 1996. That is, everybody's
    covered with comprehensive benefits. And then, between 1996 and the year
    2000, we want to phase in each year more of these long-term care
    benefits. So it'll be about a 5-year period after the basic benefits
    come out.
        Mr. Koppel. You have got to be concerned, because I mean, there's a
    little thing called ``reelection'' that has to kick in before you can be
    sure that you're going to be able to continue doing these things into a
    second term. You must feel tremendous pressure to get a lot of this done
    by the end of your first term.
        The President. What I feel the pressure to do is to at least pass
    the legislation and get the security in. I want everybody to have their
    health security card so I know they'll have comprehensive benefits that
    can't be taken away, that they can't lose. If that happens, I believe
    that the public feeling for this will sweep across America without
    regard to party, to region, to age, and that the American people will
    see this as a decent, humane thing that we have waited too long to do,
    and that it will then be a tide that no one can turn back, and no one
    will really want to turn back.
        Mr. Koppel. Let me ask you to swivel around. And I know you wanted
    to acknowledge the Attorney General, who is sitting up there. If we can
    just do that.
        The President. Say hello to Attorney General Reno. [Applause] She
    wanted to come home with me--you know, Janet Reno is from Florida--for
    two reasons. First of all, we're going to do an event tomorrow dealing
    with young people and crime and the costs that that imposes on our
    health care system, and because she also is deeply concerned about what
    she can do to help deal with some of the issues here. The Attorney
    General must enforce the Americans With Disabilities Act, for example.
    The Attorney General has the power to reach and deal with our young
    people in ways that can have a direct impact on the quality of their
    lives and health care in this country. So she came down here, and I'm
    glad she's here.
        Mr. Koppel. Swivel your attention over to the left, the gentleman up
    there at the microphone. Go ahead, sir.
        The President. Yes. sir.
        Q. Good evening, Mr. President.
        The President. Good evening, sir.

    [A retired educator with AIDS discussed the difficulty of getting
    treatment under Medicaid.]

        Mr. Koppel. Do me a favor, if----
        The President. I know what you're--can I get to the--I know the
    question. First of all, there are a lot of doctors who don't treat
    Medicaid patients because it's an incredible paperwork hassle fooling
    with the Federal Government, and because often the reimbursement rates
    are so

    [[Page 1572]]

    much below regular insurance reimbursement rates for Medicaid. People
    with AIDS at some point have to quit working, and often times don't have
    insurance on the job, so they quit working just so they can get
    Medicaid.
        Two things will happen under this system that will really help you
    and people like you all over America. There are one million Americans
    that are HIV or AIDS today:
        Number one, because you will be covered with health insurance while
    you're able to work, including a drug benefit that will make you able to
    work longer, along with everybody else, you will always have health
    insurance, and it won't break your employer because you'll be part of a
    big community pool. So your rates will be the same as everybody else. So
    the first thing is, more people with HIV positive will be able to work
    longer without bankrupting their employers.
        Number two, if you do have to quit work and you go onto what we
    now--now the Medicaid program, it won't be a separate Medicaid program.
    Medicaid patients will be in these big health alliances with self-
    employed people, small business people, the employees of big
    corporations, everybody will be in there together. Everybody will pick
    their plans together. And the plan will treat you just like everybody
    else, because the reimbursement for you will be just like everybody
    else, and there will be one form to fill out for you, just like
    everybody else. So there will no longer be an incentive or the option to
    turn you down. They won't even know, for all practical purposes, whether
    you're Medicaid or not, because you'll just be in the plan with everyone
    else.
        That's a huge thing. It's a very important thing.
        Mr. Koppel. I told our audience before we went on the air, let me
    take this opportunity to tell our audience at home, we have three panels
    of experts: One in Boston; they're experts on public finance from
    Harvard's Kennedy School of Government group. In Chicago, they're
    practicing physicians; they're professors of medicine at the University
    of Chicago. And I'd like to turn now to a panel in Los Angeles. They're
    three experts on public health policy at UCLA.
        Only one of them, if you would be kind enough, gentlemen, but I know
    you have some thoughts on what we've discussed thus far. And I need all
    the help I can get, please.

    [Dr. Robert Brook praised the new health care plan's universal coverage
    but asked how the plan would assure quality care.]

        The President. We will basically have, I think, two assurances of
    quality of care. First of all, the plans that will be provided and the
    prices that will be offered in these plans will be influenced heavily by
    the physicians and the other caregivers. But there will be a lot of
    incentive to lower cost, because your administrative cost would be so
    much lower.
        Secondly, the National Government, as happens now with the
    Government in different ways, will prescribe certain quality standards,
    and then each State will offer information to people in these plans
    about not only the price of services but the outcomes.
        For example, as you probably know, Pennsylvania now has a program in
    which they presently publicize the price of certain services and the
    outcomes. And it enables people to make judgments about both quality and
    price that they couldn't otherwise make. So we're going to give
    consumers more information, we're going to give professionals more
    capacity to figure out how to manage the system while maintaining
    quality, and we will have ultimately, Government standards as the
    guarantor of quality practice.
        Mr. Koppel. Go ahead, Doctor, if you want to make one more quick
    comment. Then we've got to go to a break.

    [Dr. Brook asked about flexibility to allow different family members to
    receive care from different medical sources.]

        The President. That's a good question. Let me try to answer it.
    First of all, every person will have at least three choices. Most people
    will have more choices, but every person will have at least three. And
    so let me try to say what they would be.
        You can choose to stay in a traditional fee-for-service medicine.
    That is, you pick your doctor, and they charge you by the service. That
    may be more expensive, but it may not be if big networks of doctors get
    together to offer these services together. In that case, you would have
    a cardiologist and a pediatrician working together.
        Secondly, you could go into what's called a ``preferred provider
    organization'' which is normally an organization that is organized by
    health care managers but that have all kinds of special-

    [[Page 1573]]

    ists in them.
        Thirdly, you can go into an HMO which will have a range of
    specialists, but it'll be a closed panel. That is, the people that work
    there will be on salary. So you may not have the specialists you want.
        In the first two cases, you'll probably be able to do exactly what
    you want for the price that you pay up front. In the third case, if
    you're in an HMO, you'll still be able--if you say, ``Look, my child is
    really sick, and I want this child to see a pediatrician who is not in
    this HMO who is in another State,'' you'll still be able to go to that
    other State, but that pediatrician will be reimbursed by your insurance
    plan only at the rate that the HMO pediatrician will be reimbursed, then
    you would pay the difference. But that plan will be the cheapest, so
    you'll come out about the same, no matter what.
        Mr. Koppel. We're going to take another short break.
        The President. Least expensive. I don't like that word ``cheap.''
    [Laughter]

    [At this point, the network took a commercial break.]

        Mr. Koppel. Now, you see the results of that poll. New taxes to pay
    for the health plan, you were being a little bit cagey in your speech
    last night. You were saying no broad-based taxes----
        The President. That's right.
        Mr. Koppel. You are going to have taxes on cigarettes. You haven't
    yet decided whether you're going to have taxes on alcohol, liquor.
        The President. But let me tell you what--[applause]. I know you all
    have a lot of questions. Let me just make some general points about
    this. Our analysis shows--and let me say, we have consulted with health
    care finance experts in Fortune 500 companies, in big accounting firms.
    We have talked to everybody we can talk to who have dealt with the
    health system for years. They believe that if we can get the kind of
    savings we know are there--keep in mind, in the American health care
    system, we spend 10 cents on the dollar more on paperwork. That's more
    than $80 billion a year more than any other country, a dime on the
    dollar more just on shuffling paper. If we can get the savings that I
    talked about last night, they believe that 63 percent of Americans that
    have health insurance will pay the same or less for the same or better
    coverage, that the people that have virtually no insurance but just a
    skeleton policy will pay a little more, and that young single workers,
    because they'll go into community ratings with people who are older and
    sicker, will pay about $6 more a month. Now, that's what they think.
    Why?
        With only a modest--I mean, a cigarette tax, not modest but a little
    under $1--and a fee on the big corporations who opt out of the system
    and continue to self-employ----
        Mr. Koppel. You haven't decided on alcohol yet----
        The President. Self-insure.
        Mr. Koppel. ----whether to put a tax on it.
        The President. No, I don't think it's necessary.
        Our numbers show that with a cigarette tax and if the big employers
    who opt out of the system because we let them self-insure, they should
    be asked to pay a little more, because they should pay for medical
    education, the health education centers, the preventive care networks,
    all the things that all the rest of us will pay for in our premiums.
        They still, by the way, will be big winners. Their premiums will
    drop a lot anyway, because big employers are paying way too much now
    because they're bearing the cost of the uninsured. That is, when people
    who are uninsured get real sick, they get health care, and then the rest
    of us pay the bill in higher hospital bills and higher insurance
    premiums. So we think that the larger employer fee plus the cigarette
    tax plus the savings, plus--keep in mind--requiring the people who are
    presently uninsured, but employed, and their employers to pay something,
    that those things will pay for it. I don't think we should raise a big
    general tax on people to pay for the uninsured when most people are
    paying too much for their insurance already. Keep in mind, 63 percent of
    the people under this plan will pay the same or less for the same or
    better coverage.
        Mr. Koppel. You know that much of the criticism is coming from small
    businessmen. I know because this gentleman came up and asked a question
    before the program started. Go ahead, sir, and ask it. If you'd be good
    enough to identify yourself, too.

    [A small business owner paying 4 percent of payroll for health insurance
    asked about coverage for dependents of his 10 employees.]

        The President. First of all, let me ask you a question. How many of
    your employees have

    [[Page 1574]]

    a spouse which also works?
        Q. Three.
        The President. Okay. Then, here's the short answer. The seven, you
    will have to provide a family plan under mine; the three which have
    spouses at work, they will be able to decide whether you or the other
    employer, they'll take the children's coverage, because they'll pay
    more, too, keep in mind.
        Now, because you are a small business person with under 50
    employees, you will be eligible for a discount that could take your
    premiums as low as 3.5 percent of payroll, even for the family coverage.
    So in all probability, you will be paying about what you're paying now,
    even though you will be covering seven families at a minimum, in
    addition to the seven employees. Because, the way we set this up--in
    other words, we understand, and let me go back a second--we went out and
    interviewed hundreds of small businesses. And my Small Business
    Administrator took the lead in this. He's from North Carolina, and he's
    spent the last 20 years of his life starting small businesses.
        So we were in a real dilemma here, because small businesses who
    cover their employees have premiums going up at roughly twice the rate
    that other people's premiums are going up. There's a 35 percent
    difference now between small business premiums and big business
    premiums. And I don't know what you cover, but basically that's the
    rule. One-third of the small businesses in America, according to a
    representative poll recently, said they were going to drop all their
    coverage if somebody didn't do something to stop the rate of cost
    increase.
        So the only way to stop the rate of cost increase is to get
    everybody covered, and then put them in these big groups, so you can
    have the same market forces working for you that big businesses do. But
    it's not fair for me to put you out of business, because small
    businesses are also creating most of the new jobs in America. So that's
    why we've got the discount system. Part of what we're going to do with
    the money we're going to raise is to fund a discount system for people
    with fewer than 50 employees, so you won't have to pay the 7.9 percent
    of payroll, and you may pay as little as 3.5 percent. In all
    probability, because you only have 10 employees, you'll pay almost
    exactly what you do now, and you'll get more coverage for it.
        Mr. Koppel. Let me just ask you quickly, though. Right now, paying 4
    percent on 10 people, you're saying 3.5 percent. He would then have to
    pay the 3.5 percent on all the dependents, other than the three who are
    working.
        The President. No, it's 3.5 percent of the payroll of his employees.
    So he would pay about----
        Mr. Koppel. Total?
        The President. Correct. He would pay about what he's paying now.
    Because he's a small business person, there would be a discount for his
    premiums.
        Mr. Koppel. Okay. Does that answer your question? We've got to take
    another break; we'll be back in a moment.

    [The network took a commercial break.]

        Mr. Koppel. And let us get right to the questions again. Mr.
    President, if I could ask you to swivel around. We have a question back
    there also on money from a larger employer.

    [An IBM employee asked about the plan's effect on large businesses which
    self-insure.]

        The President. Well, actually, the biggest companies in the country
    are the ones most likely to benefit from this, because they are
    actually--even though they're self-insuring. When you self-insure, if
    you're big, the good news is that you acquire market power, and you can
    normally keep your rates from going up as fast as they otherwise would.
    The bad news is, you're still paying part of the costs of uncompensated
    care. That is, people are shifting the cost to you.
        We estimate that for a company like IBM that self-insures, you will
    save, the company will save on premiums, for whatever you're doing now,
    you'll save about $10 a month an employee under our system, which is a
    huge amount, simply by stopping the cost shifting to IBM, with no change
    in the benefits. No, you can keep on doing exactly what you're doing.
        Now, let me just give you an example of how it can get even bigger.
    For companies that have huge cost shifts and big retiree burdens like
    the big auto companies and the big steel companies, they will save even
    more.
        But the people that will be least affected by this are big companies
    with over 5,000 employees that choose to continue to self-insure. You
    will, however, benefit by the increased competition of the system. What
    I want everybody else to do is to have the benefits that IBM has. You
    won't lose anything. Xerox has cut their

    [[Page 1575]]

    costs by $1,000 an employee a year through better managed care without
    taking anything away from the employees. And we think we can do that for
    all Americans.
        Mr. Koppel. Mr. President, let me be the doubting Thomas for a
    moment. Big companies are going to save money. The little businesses are
    going to save money. The 37 million people who you say are underinsured
    or uninsured right now----
        The President. They'll pay more.
        Mr. Koppel. They'll pay more, but they're going to be insured for
    the first time. Everybody's going to be better off----
        The President. No, not everybody.
        Mr. Koppel. Who's not going to be better off?
        The President. Well, let me just say this. In the long run everybody
    will be better off if we bring health care inflation down to the regular
    rates of inflation.
        Mr. Koppel. Who is going to get hurt in the short term?
        The President. The following people will get less money, or will pay
    more: single, healthy workers who are insured in big plans now so they
    have low costs because they're at least risk, will pay more. They'll pay
    about $6 a month apiece more to help to cover that gentleman up there
    with AIDS or older people, just who get older, it costs more. They'll
    pay more. People who provide only the scantiest catastrophic illness--
    for example, I met a man, a man came into my office in the White House
    today with a group of folks, who travels with an entertainment group.
    He's got a $5,000 deductible with a modest income. He might as well not
    have any insurance. Now, he'll have to pay a little more, but he'll have
    something when he pays it.
        People that don't pay anything now will have to pay more if they
    have jobs, and their employer will have to pay something, although we're
    going to try to keep the small businesses from being hurt too badly. All
    those people will pay more.
        Who will get less under this system? You've got to squeeze--
    somebody's got to get less. Who will get less? The people who benefit
    from the paperwork explosion will get less. Hospitals in the future will
    hire fewer clerical workers, doctors' offices won't have to hire an
    extra person just to spend all day long calling insurance companies,
    beating up on them to pay the money that they owe anyway. Insurance
    companies will not grow as rapidly, and there may be fewer of them
    unless they can get in here and provide these plans at competitive
    costs. So that's the major squeeze in the management of the system.
        There will also be savings, frankly, in the provision of services.
    We had, in the Pennsylvania case I just cited, they published a heart
    procedure where the prices charged in the State of Pennsylvania varied
    from $21,000 to $84,000 for the same procedure, with no differences in
    health outcomes. When all of you get into big groups so that you have
    the power that the IBM employees do, you will take the $21,000 choice
    every time as long as there's no difference in the outcome.
        And so, everybody there, there will be some losers. But, on balance,
    most Americans will win, and the security is worth something. And then,
    over the long run, we'll all win if we can bring health costs closer to
    inflation.
        Mr. Koppel. Let me direct your attention to the balcony up there. Go
    ahead, sir.

    [A participant asked about the effect of a tobacco tax on the tobacco
    industry.]

        The President. Arguably, if we raise the tax, it will reduce
    consumption. But the answer to your question is, I don't think it's
    right to have a big, broad tax--I'll say again: tax everybody in
    America, most of whom are paying too much for what they've got to pay
    for those who haven't paid anything. I don't think that's right when
    there are savings. So, we didn't in the beginning know if there would be
    any tax. But we wound up with a gap in what we think the program will
    cost in the early years, for about 5 years before it starts to get big
    savings by the way, and what we had. And we had to figure out how best
    to make it up. And I thought that a tobacco tax and a tax on the biggest
    companies who will get big benefits out of this, a modest one just to
    make sure they contribute, as I said, to medical education, to medical
    research, and to preventive services like everybody else will, that
    those were the two fairest ways to get it.
        And the truth is that smoking is one thing--unlike drinking, for
    example, where it's a terrible thing if you do it to excess--we know
    that there is some risk in any level of it and that it imposes enormous
    extra costs on the health care system which the rest of us have to pay.
    So it seemed to me that that was a fair way to get some money.

    [[Page 1576]]

        Mr. Koppel. Mr. President, I want to take advantage of one of our
    experts again, this time in public finance up at the Kennedy School in
    Harvard. Mr. Forsythe, would you go ahead, please?

    [Dell Forsythe expressed concern about job losses in the health
    industry.]

        The President. There will also be job gains in the health industry.
    There will be hundreds of thousands of new jobs in people providing home
    health care, in other kinds of preventive and primary care, so that we
    think even within the health industry, the job gains in direct health
    care providers will offset the job losses in clerical work.
        Secondly, there are bound to be job gains when you lower the payroll
    costs that a lot of major employers are paying today. You give them more
    money that they will either use to give their employees pay increases,
    and I might say millions of people in this country have foregone any pay
    increases for the last 4 or 5 years, because the pay increases have gone
    into higher medical costs. So you're either going to have more folks
    hired or pay increases going back to employees for the first time. So we
    believe there will be a net economic benefit by shifting the way this
    money is spent. I don't think that all investments are equal, and I
    think since you're going to shift the way money is spent, and we're not
    going to cut, keep in mind, we are not cutting spending on health care.
    America at the end of 5 years will still be spending 40 percent more
    than any other country, maybe even a little more. But we're going to
    spend the money differently in ways that we think will produce more
    jobs, not fewer jobs.
        Mr. Koppel. Let me just see if I can slip one more question in.
    We've only got about a minute and half left. Where is the lady who was
    at the microphone? You'll see--right over there. Go ahead.

    [A participant asked whether a doctor or an insurance company would
    decide when to discharge a patient from the hospital.]

        Mr. Koppel. We've got 1 minute, Mr. President.
        The President. The doctor, the doctor will make the decision. The
    coverage will be comprehensive, and the doctor will make the decision.
        Can I say one thing real quick? I want to make a specific point
    here. A lot of people have coverage that have lifetime limits. That is,
    they look real generous, but if you run up to a certain dollar amount,
    it's gone. Another real benefit of this--and the only way you can
    guarantee real security is to say there are no lifetime limits, you just
    have the coverage--and again, I know it's counterintuitive--a lot of
    people just don't believe you can ever save money on anything. But all I
    can tell you is that every doctor and every health care expert that we
    have ever consulted who has really studied this believes that there are
    billions and billions of dollars of savings which can be made that will
    enhance the quality of care, not undermine it. And that's what I urge
    you--I don't ask you to just take my word for it, just watch the debate
    unfold and listen to the people who have spent their lives working at
    this do it.
        Mr. Koppel. Mr. President, on that note, we've got to take one more
    quick break, and then I'll come back with a program note. This program
    is going to be going on but in another form. I'll tell you about that in
    a moment.

    [The network took a commercial break.]

        Mr. Koppel. We're just about out of time now in our prime time
    segment. But I do want to make a quick program note. First of all, the
    President has indicated he wants to amend one of the answers that he
    gave before. We don't have enough time to do that here and now, but we
    will be back after your local news. Most of the country will be taking
    it at 11:35 p.m. Eastern Time. And the President has agreed to stay with
    us on an open-ended basis. Now, that means, I guess, until he gets tired
    or you get tired or we all get tired.

    [Following the 11 p.m. news, the town meeting broadcast resumed.]

        Mr. Koppel. Good evening, ladies and gentlemen. Those of you who
    were with us in prime time know what we're up to. Those who are just
    joining you now in our regular ``Nightline'' slot, let me point out that
    this is a special open-ended edition of ``Nightline.'' Obviously, you
    recognize the gentleman to my immediate left, the President of the
    United States, who has been answering questions from a wide variety of
    the thousand-odd people or so that we have with us here in Tampa,
    Florida.
        And, Mr. President, if you don't mind, we'll get right back to the
    questions. There are a

    [[Page 1577]]

    couple of things I know you want to pick up from the last program. We'll
    do that in a couple of minutes. Go ahead, sir.

    [A participant asked what to do about the overwhelming medical bills
    from his daughter's surgery.]

        The President. Well, first of all, I don't think there could be a
    better case for changing the present system. What I think will happen
    before we have a change is that if your daughter has to have surgery
    next year, they'll probably do it, and do a good job, and that stack of
    bills will get higher and somehow the costs will just be spread among
    everybody else until we fix this system.
        But let me tell you what would happen if the proposal that I have
    made were law now. First of all, as a self-employed person, you would be
    able to buy a health insurance policy for your family, even though your
    daughter has previously been sick, on the same terms as other self-
    employed people. And instead of that policy being totally out of your
    reach, you would be able to buy it more or less on the same terms as
    other small business people, because we would put you and the farmers
    and the other self-employed people into a big pool like everybody else.
    So you would be able to take advantage of an economy of scale. So you'd
    be able to buy a more affordable policy.
        Secondly, because you're self-employed, you'd get a 100 percent
    deduction on your taxes for it. Today, you only get a 25 percent
    reduction. So it would be lower costs, comprehensive benefits, you
    couldn't be denied coverage because your daughter had a terrible
    problem, and you'd have 100 percent deductibility. That's one of the
    reasons we ask single, young people to pay a little more. But all those
    single, young people will be in your situation, too, someday, if they're
    fortunate.
        I wish I had an answer for you right now. I don't. The answer right
    now is for the hospital to just step right up to the plate and the
    doctor and do what they did last time until we get this thing fixed.
    Once we get it fixed, then you won't be in this position again.
        Q. Her pediatrician, Dr. Augustine Martin, knows that he's not
    getting paid for this, and he knows it but he's taking care of her, and
    he's not even worried about that, which is great.
        The President. I'm really glad you said that, because we heard a sad
    story here before about doctors who wouldn't take Medicaid patients,
    which leaves the patients out in the cold, although Medicaid is a real
    pain. But for every case like that, there's a case like this. And those
    doctors need our thanks.
        Q. Yes.
        Mr. Koppel. Mr. President, we've got so many people who want to talk
    to you here. We want to move over there to the wheelchair section. Go
    ahead, sir, please.

    [A participant described the fear disabled people have of losing
    Medicare and Medicaid benefits if they are employed.]

        The President. First of all, by providing insurance to everyone
    based on a community-based rating, we would never put an employer in the
    position of saying, ``I'd like to hire you, but you're disabled and
    something terrible might happen to you. And if I had to take care of it
    on my insurance, my premiums will go up 40 percent the next year, and
    I'd have to drop you anyway. So I can't do it,'' which is basically what
    happens now. A lot of disabled people are going basically to waste in
    our country because they could be gainfully employed, they could be
    making major contributions, and they're not hired because people either
    can't get insurance for them or because they're afraid it will bankrupt
    them.
        Under our system, you'd be just like any other American citizen. You
    would pick a plan, you would go into it, and because of the community
    rating system, you would be insured. And therefore, there would never be
    a disincentive for an employer to hire you. And you would always have
    that insurance.
        And if you needed supporting services, even at work as we build in
    these long-term care services, we'll be able to have not only long-term
    care in the home, but some support services associated with people who
    work. That will save this country a lot of money over the long run,
    because you're going to have a lot of folks who don't work now working.
        But there are a lot of people who are disabled, as you know, who are
    on Medicaid only because they couldn't get private health insurance as
    workers. And just like this man who just talked to us over here about
    his daughter, there are people in this country who have quit their jobs
    and gone onto welfare and drawn Medicaid only because of the illness of
    their children. So that's something the disabled popu-

    [[Page 1578]]

    lation has in common with people like him. That will never happen again.
    People will be able to keep working. It's very important.
        Mr. Koppel. Mr. President, we're going to have to take another quick
    break. When we come back, though, we've got a public policy expert up at
    Harvard who is just seething at some of the numbers. He wants to have at
    you. And I know you want to correct a couple of things or at least make
    an amendment to a couple of things that you said in our prime time
    segment. So we have all of that ahead of us when we come back in just a
    moment.

    [The network took a commercial break.]

        Mr. Koppel. That's another one of our poll results, Mr. President:
    What will happen to your quality of health care? Twenty-seven percent
    think it's going to get better, 27 percent think it's going to get
    worse, and 42 percent think it's going to stay the same. You've
    obviously got some missionary work to do there. Do you want to comment
    on that poll and then get to the amendments, to what you wanted to
    correct?
        The President. Sure. I don't blame anybody for thinking that,
    because while Americans know more about their own health care than
    almost any other subject, most of us have never had a chance to learn
    anything about how the system as a whole works. So it's against our
    common experience to believe that you can get more and pay the same or
    less, or that if you control costs, you won't have to give up something
    really valuable for it. That's against our common experience. But if you
    study the system, you'll find that we have, literally--I'll say again--
    just in paperwork alone, a dime on the dollar more waste in our system
    than any other system in the world, that we have more variations in
    prices with no differences in outcomes than any other system in the
    world, that there are all kinds of waste in this system that can be
    managed down.
        You don't have to take my word for it. I saw what those folks said,
    but let me just give you one example. The Mayo Clinic, we would all
    agree that they have pretty good health care, wouldn't we? I mean, their
    inflation is 3.9 percent this year; that's less than half the medical
    rate of inflation in the country. And I could give you lots of other
    examples of plans with very high consumer satisfaction where people are
    very happy with what they have and where they have squeezed out massive
    amounts of waste with no loss of quality. And so, that's what this
    debate ought to be about. I want that debate.
        Remember what I said last night? The first thing is security,
    simplicity, savings, choice, quality, and responsibility. If we give up
    quality, the rest of this stuff won't happen, because you can't have
    security without quality. So we'll debate it, but I'm telling you, the
    more you study this, the more you become convinced that we can achieve
    these savings.
        Mr. Koppel. President Clinton, we've got a public policy expert,
    John White, sitting up at the Kennedy School in Harvard. Am I misstating
    it, Mr. White, when I say that you don't think the figures add up?

    [John White asked why the plan did not phase in benefits more slowly.]

        The President. Let me answer that. First of all, the benefits that
    we don't phase in, basically the benefits that we start with in 1996
    that are new, are primarily two: First of all, the preventive and
    primary services, you know, the PAP smears, the mammograms, the well-
    baby care, all those things, we believe that those achieve net savings
    fairly quickly, and almost all medical experts do. That is the
    relevantly low-cost, relatively quick benefits. The other major costs
    are the drug benefits. We provide prescription drug benefits in all
    health care plans, and for Medicare clients as well as Medicaid ones
    because there are so many older people who aren't poor enough to be on
    Medicaid but have huge drug bills. Now, that will cost more.
        We went around, John, to all the people we could find who knew
    something about pharmaceutical costs and tried to pick a high figure.
    That is, we didn't try to lowball the cost of the drug benefit. And
    then, we believe that the money we're raising from cigarettes and from
    the fees on big corporations will cover that, and we believe that we
    have--all the other benefits will be phased from '96 forward over a 5-
    or 6-year period, and we believe during that time period, we'll be able
    to achieve these savings.
        Now, I believe this is another decision that the Congress will have
    to make. But I believe that having the universal coverage--that is,
    getting everybody insured by '96--is critical to the savings because
    that's what enables people to get basic care early rather than have care
    when it's too expensive only at the emergency room.

    [[Page 1579]]

    [Mr. White suggested that the system should ensure that cost savings
    were in place before benefits were put in place.]

        The President. I agree with that, except for the two examples I
    mentioned. But let me make another comment. One of the things I've asked
    the Congress to do is to work with me to construct a system that, in
    effect, has to be monitored closely every year and adjusted if the money
    doesn't work out right. We cannot afford to aggravate the problems we
    already have. But if you look, John, at the cost estimates we have, even
    under our plan, even under our plan we project health care costs to go
    from 14 percent to over 17 percent of our income between now and the
    year 2000. We'll still be spending a lot more than any other country. I
    think we'll have more savings than we estimated. But I agree, and I want
    to just say this about the point he made. All of us have to be prepared
    to face the consequences if the cost savings don't materialize. And I
    don't want to sign a bill, and I don't have any intention of signing a
    bill that doesn't at least have the process built in that I recommended.
    If something happens and they don't materialize, then we're going to
    either have to slow down the benefits or raise more money. I don't think
    it will happen, but he's right. And that's why we've got to phase these
    things in carefully so it doesn't get away from us.

    [The network took a commercial break.]

        Mr. Koppel. Let me just explain two things to you. First of all,
    those of you who are watching ``Nightline,'' we just kept going after
    our 10 o'clock show, which ended at 11 Eastern time, and began taping so
    that we could save time. So technically what you're seeing right now is
    on tape, but we are still here live talking and it's going to go on in
    an open-ended fashion now.
        At the end of our live segment, the prime time segment, there was a
    lady up there who asked you a question and you gave her a very quick
    answer. It was a question having to do with whether doctors or insurance
    companies were going to decide when you have received adequate care at a
    hospital.
        The President. That's correct.
        Q. You said under your plan, the doctor would decide.
        The President. That's correct. There are two questions that were
    asked that I want to clarify. One is the lady said, ``Who decides when I
    leave the hospital, the doctor or the insurance company?'' And I said
    the doctor. That is right with one exception. Keep in mind what I said.
    Mental health benefits under this plan cover limited hospital stays
    until the year 2000. With that single exception, the doctor decides.
        The second point I want to make: You remember the gentleman who
    stood up over here and said he had 10 employees and he paid 4 percent of
    payroll, and what was going to happen. And I said he'd pay about the
    same amount. I want to clarify that in a couple of ways.
        Number one, you're eligible for a subsidy if you have fewer than 50
    employees. But you don't get the subsidy on employees with incomes of
    over $24,000. Almost all small businesses have incomes less. So I want
    to make it clear. So we're actually trying--before the end of the show,
    we should be able to tell him exactly what his rate will be. But let's
    say, for example, he had to go up to 5 percent or 6 percent from 4--got
    more generous benefits--two other things would happen which might make
    it a good deal for him anyway. Number one, we're going to fold in the
    health care costs of workers' comp into this system, and the health care
    costs of workers' comp have been going up even more than regular health
    care costs for most businesses.
        Number two, if you have a claim against you or against your employee
    as a small business, your rates can go up 20 percent in a year, or 25
    percent in a year just if you have a claim. Under our system, the small
    business would be protected from that. They'd be able to be basically on
    the same wavelength as some big company and would have a very marginal
    impact on rates because they'd be in a huge pool instead of just out
    there.
        Mr. Koppel. Let me ask you to swivel around again if you would.
    We've got a question from a medical student back there. Go ahead,
    please.

    [A medical student asked about medical school debt deferral, malpractice
    reform, mandated specialties, and reallocation of funding, especially
    for care at the beginning and end of life.]

        The President. Let me try to remember them all. First of all, on
    your debt--and medical school is very costly--we propose to do two
    things. Number one, we have already passed

    [[Page 1580]]

    a sweeping reform of the student loan program, which will enable people
    to borrow money without regard to their incomes at lower interest rates
    than have been available in the past, and then pay those loans off, not
    based just on the amount that you had to borrow but as a percentage of
    your income, which will make it easier for all people to pay their
    college loans off. I wouldn't call this a catch, but I have to say we're
    also going to be much tougher on collecting the loans than we have in
    the past, but they'll be easier to pay back.
        Secondly, we're going to expand the health service corps concept
    that will enable physicians to practice in underserved areas and pay
    their medical loans off. And that's been constricted in the last several
    years. We want to expand that. That's the first question.
        The second question you asked was malpractice, right?
        Q. Yes, sir.
        The President. We propose to do a couple of things in malpractice
    to--and let me just say, malpractice not only affects doctors with
    higher premiums but a lot of people believe it adds to the cost of the
    system, because doctors practice what is called defensive medicine and
    order procedures they otherwise wouldn't just to keep from being sued.
        We propose to do three things: number one, develop more alternative-
    dispute-resolution mechanisms to lawsuits; number two, limit the amount
    of contingency fees lawyers can get in those lawsuits to one-third of
    the fees, not more, and number three, and I think most important,
    develop working with the medical specialists as well as GP's, general
    practitioners, a set of accepted medical practice guidelines that
    doctors can have that operate--to oversimplify it, almost like the
    checklist that you see a private pilot check off before they--if you've
    ever ridden in a private plane. So that if you follow the medical
    practice guidelines for whatever you're doing in your area, that will
    raise a presumption that you were not negligent. That can do more than
    anything else. This was pioneered for rural doctors in Maine, this whole
    theory. We believe it can do more than anything else to reduce the
    number of malpractice suits.
        The third thing you asked was what about the Government trying to
    force you into certain specialties.
        Q. Yes, sir.
        The President. The truth is, if you look at how the Government
    spends its money, it's heavily weighted towards specialties now. What we
    propose to do is to change the formula by which the Federal Government
    funds medical schools now to favor more--not to say you can't be a
    specialist but to slightly tilt more in the favor of general practice,
    because only 15 percent of the doctors coming out of medical school
    today are general practitioners. The average nation has--you know, like
    Germany or Japan or Canada--half the doctors will be general
    practitioners. We can't do what we need to do in medically underserved
    areas without more family doctors.
        And the fourth question you asked was?
        Q. The reallocation of funds.
        The President. Yes. Perhaps the most important thing, long-term, in
    this package is that we pay for things like pregnancy visits, well-baby
    care visits. We pay for immunizations for all children. In other words,
    we try to pay for a lot of preventive and primary services starting very
    early, and dental care for children although not for adults, as a
    mandated service.

    [Following a commercial break, a dentist asked about dental benefits
    under the new plan.]

        The President. Let me just mention the dental issue first. Under our
    proposal, the comprehensive benefit package would include dental
    benefits for children up to 18, but not mandates for adults. That
    doesn't mean any employer plan that now covers dental benefits is
    perfectly free to keep doing so. And since they'll have all kinds of
    economic incentives to keep their costs down, they'll probably keep
    doing it. But we don't think we can, again, recognizing the costs of
    this, afford to do more than this at this time. But there's nothing to
    prohibit that.
        Most people, as you know now, who have dental benefits through their
    employers actually buy the benefits in an override policy, and that will
    all still be available. The problem with the present insurance system,
    let me say again is that, first of all, too many people are uninsured,
    and the complexity of it is so great. But we are the only country in the
    world that has 1,500 different companies writing thousands of different
    policies, requiring every hospital and doctor's office to keep up with
    hundreds of different forms, so that we literally add about a dime to
    every dollar of health care cost on paperwork that has nothing to do
    with keeping people well.

    [[Page 1581]]

        So what we're trying to do is get down to one form, and this health
    security card, so that, number one, your life will be a lot simpler. The
    time you have to spend on forms, the time you have to hire people to
    spend on forms will be less; the time you spend practicing dentistry
    will be greater. And the time all of our medical professionals spend
    doing what they hired out to do in the first place will be greater.
    That's what we're trying to do.
        Mr. Koppel. How detailed is that form going to be? I mean, that one
    form is going to have to be a killer form to--[laughter].
        The President. Well, not necessarily. The form--actually I should
    have brought it tonight--but there will be basically a model form for
    the doctors and one for the hospitals and one for consumers, because
    they'll have slightly different information needed, and they'll have
    some variations because of the differences in plans. Everybody will have
    some choice in plans, but once you have comprehensive benefits and
    uniform insurance schemes, you won't have to have a lot of variations.
        Let me just say this. I want to hasten to say this does not mean
    that physicians will stop keeping patient records on patient care. In
    fact, one of the ways we're going to reduce the amount of problems with
    malpractice, as I said, is by establishing uniform guidelines and then
    enabling physicians to demonstrate that they follow the guidelines and,
    therefore, to raise the presumption that they were not negligent.
        So we're talking about paperwork over and above what is required for
    the basic practice of medicine. Washington Children's Hospital, where I
    visited last week with the Vice President, says they spend $2 million a
    year in that one hospital over and above the recordkeeping necessary for
    patient care.
        Mr. Koppel. You saw that devastating study a few weeks ago that
    indicated that roughly 60 million Americans are--I guess the only fair
    word is ``semi-literate,'' all but illiterate. You know, you're doing a
    terrific job here trying to explain what is obviously a terribly complex
    plan. How do you reach those people? Because my assumption is that the
    37 million people you're talking about who are uninsured, underinsured,
    probably many of them will fall into that same category, and that is
    people who have a very hard time understanding any forms, let alone
    something as complex as a medical form.
        The President. First, let me say that if you go back to that study,
    it also says that people are more literate now than they ever have been,
    but there are more challenges for them now than ever before. All of the
    research indicates that one of the things people know a lot about is the
    health care benefits they have and the problems with it. As a matter of
    fact, one of the problems that I'm having convincing you that we can
    save money in this system is that you know an enormous amount about your
    own health situation or that of your employees, and you know it costs
    more every year. But you've never had a chance to know about how the
    system itself operates; so it's hard for you to imagine that we can
    actually save any money--especially where the Government's involved,
    right?
        But when you come back to the basic thing, I believe if you simplify
    the system and you tell everybody you get three different plans at least
    and here's what the plans do, I think people have had enough experience
    negotiating their way through the mine field of the American health care
    system that most of them will do quite well.

    [A participant asked if abortion would be covered under the new plan.]

        The President. It will probably become a political football because
    so many people feel so strongly about it on both counts. But the answer
    is that we are trying to privatize this system, not make it more
    Government-dominated. And so the answer to your question is, it will be
    because it is now by private plans. And what we propose to do is to fold
    people who get their Government health care into the private plans. That
    is, keep in mind, if you're on Medicaid today, you show up at the
    hospital, you've got all your Medicaid forms--that's why the doctors
    don't like to treat Medicaid patients, a whole different set of forms--
    and you get a specific fee for a specific service. And today, if you're
    on Medicaid, abortions are not covered by the Federal Government unless
    the life of the mother is endangered. But they are covered in some
    States where the States pay for it.
        Under this system, people on Medicaid will join a health alliance
    just like other people. And then they will get to choose among plans.
    The plans will offer pregnancy-related services. Most private plans
    today that offer pregnancy-related services do offer abortions. They
    don't all.

    [[Page 1582]]

        There is a conscience exemption for religious reasons that covers
    hospitals and doctors, and that will be covered again today. And people
    who want to join those plans will do it. By the way, there are no
    specific surgical procedures guaranteed here, not knee surgery, not
    abortions, not brain surgery, not heart surgery. They never are. The
    procedures are not prescribed. The problems are covered. So you have to
    cover pregnancy-related services.
        Let me say, since you're in Planned Parenthood, abortion under our
    Constitution is legal. But let me say, I also think there are too many
    every year, and I think this could be--[applause]--I think if you want
    it to be legal, safe, and rare, we have got to fund more preventive
    outreach.
        I want to make this very clear. This plan, for the first time ever,
    not only acknowledges the constitutional legality of abortion but funds
    preventive services in ways that will reduce the number of abortions by
    reducing the number of unwanted pregnancies. And I want to make that--
    that's very important. That's part of the preventive strategy of this
    plan. It will do both.

    [The network took a commercial break.]

        Mr. Koppel. And we are back, once again, from Tampa. The President
    shaking hands with a few well-wishers here. I figured if we didn't
    restart the program, we'd never get you back from there, Mr. President.
        The President. Tell the girls to come back later. Hey kids, I'll
    come back there. Later I'll be there. You wait here, and when we next
    take a break we'll shake hands, okay?
        Mr. Koppel. What are we--come on. Shake hands. Get it over with.
    Come on up. Now, while we're feeling good, you might as well tell the
    folks what the head of St. Vincent's Hospital told you when he----
        The President. St. Joseph's?
        Mr. Koppel. St. Joseph's. I beg your pardon.
        The President. This gentleman is the head of the hospital who took
    care of the daughter of the independent contractor with the $186,000
    worth of bills. He said, ``We took care of it before, and we'll take
    care of it again until we get this''--[applause]. But he also said we
    need to reform, because he's entitled to be reimbursed for it.
        Mr. Koppel. Yes. Now, you don't expect all the questions to be that
    easy, do you?
        The President. No.
        Mr. Koppel. Okay.
        The President. They've all been hard.

    [A participant expressed her disapproval of the use of taxes to fund
    abortion.]

        The President. Well, let me say again--let's talk about what the
    present law is. The present law is that there is a constitutional right
    to abortion, but the Supreme Court has never ruled that that meant that
    poor women had to have equal access to it. In other words, that if the
    Federal Government or a State government decided not to fund abortion
    services through the Medicaid program, that that was legal. So the
    Congress for many years has said we will not specifically fund abortions
    unless the life of the mother is at risk. Therefore, there's no public
    funding for poor women to get abortion services unless each State
    decides to do it. Some States decide to; a majority don't. That's the
    law today.
        I want to make clear to you what we are proposing. What we are
    proposing incidentally affects this: What we are trying to do is to stop
    the two-tiered system, to put the Medicaid patients in with the
    employees of small businesses and hospitals and others to provide for a
    common private system in which people join plans that provide services,
    including pregnancy-related services. Some of those plans won't cover
    abortion. Most of them do today. But I would just say to all of you
    who--if you're in a private health insurance plan today, your money is
    commingled with everybody else's. And if those services are covered, the
    money goes out from a central payment place, not necessarily for a
    specific service. But because people have enrolled in a plan--for
    example, somebody enrolls in an HMO, they don't pay for a specific thing
    at all necessarily on a fee-for-service basis. They pay a fee for
    whatever services are covered. So that is part of the limit. It would be
    a terrible price to pay just over this issue to keep segregating all the
    Medicaid patients and deny them the opportunity, and deny us the
    opportunity, to have the benefits of everybody being in large group
    health care without separating this out.
        In other words, the whole system will be changed if you put
    everybody in a private system. There will still be also hospitals and
    doctors who, for religious or other reasons, for moral reasons, will not
    participate in this and will not have to in any way, shape, or form.
        Mr. Koppel. Mr. President, this is a curious criticism to make, but
    sometimes I think you're

    [[Page 1583]]

    so specific in your answers or so detailed in your answers that it's a
    little hard to know what the answer to the question was.
        The President. The answer to the question is, if a person goes into
    a health care plan that provides pregnancy-related services, the person
    can ask, ``Does this include abortions, or not?''
        Mr. Koppel. If it doesn't, then you go to another plan?
        The President. If it doesn't, they can go to another plan. If it
    does and they're offended by it, they can go to another plan.
        Mr. Koppel. Are tax monies going to be used to support those
    abortions? That was----
        The President. The answer is, indirectly they will. Today, it's a
    direct question. You know, the Government writes a check for every
    Medicaid procedure. Under this system, people on Medicaid would be just
    like any other person. They'd join a health plan. They'd sign up for
    certain services. The funds, the public and the private funds, would all
    be mixed together. They would fund certain things and not fund others.
        But if our plan goes through, it will be impossible to separate out
    the public and the private funds, the Medicaid and the other people.
        Mr. Koppel. So, implicitly, the answer is yes. There will be----
        The President. That's right, they will be able to fund it. That's
    right. If it comes down on this issue, we keep all these Medicaid people
    from going into a revolutionary new system, then you're going to throw
    away a lot of the savings and deprive those people of a whole range of
    things that don't have anything to do with abortion, including higher
    quality care at lower cost.
        Mr. Koppel. But that's clearly one of the political mine fields.
        The President. That will be a big political mine field.

    [The participant reiterated her opposition to the use of her tax money
    to fund abortions.]

        The President. Well, let me ask you--we are also personally and
    morally improving preventive and primary health services, and we'll
    actually stop some abortions from occurring with the kind of preventive
    services that we're going to cover for the first time in the history of
    this country.
        This could be a subject for a whole other program. I have a
    difference of opinion from you about whether all abortions should be
    illegal. I do agree that there are way too many in the United States. I
    believe we need an aggressive, an aggressive plan to reduce teen
    pregnancy, to reduce unwanted pregnancies. One of the reasons I named
    the Surgeon General I did, my health department director, is because I'm
    committed to that. I believe we need an aggressive plan to promote
    adoptions in this country. If every pro-life advocate in America adopted
    a child, this world would be a better place.
        I want this issue to be debated, and I haven't hedged with you. Most
    people will get this service covered because most private plans do it.
    And we propose for the first time ever to put Medicaid people in the big
    private plans to get the economies of scale. Not for the purpose of
    doing that, but basically to end this two-tiered system we've had. So
    most will be covered. But some won't if they choose to join plans that
    don't cover them. Most plans do today.
        Mr. Koppel. I met the gentleman over there just before we went on
    the air. I know he wants to talk about the homeless. But we're going to
    take a quick break. When we come back----
        The President. He's been the most patient person here. We've got to
    hear from him.
        Mr. Koppel. We'll be back in a moment.

    [The network took a commercial break.]

        Mr. Koppel. There's another one of our poll results. Under Clinton's
    plan, will you pay more? Forty-nine percent think they will pay more; 10
    percent think they'll pay less; 33 percent, about the same. Again, as I
    said earlier, you've got some missionary work to do here.
        The President. But that's because people can't imagine how much
    waste there is in this system. Today, we spend over 14 percent of our
    income as a nation on health care. Canada spends 10; Germany is under 9;
    Japan is under 9. The German system, which is the most like what I
    propose, is a private system where large groups of employers and
    employees can work with health care providers to provide a wide range of
    services at low cost. But the administrative cost is much less than we
    have, although they cover more people and about the same number of
    services.
        Mr. Koppel. You also know, and you've heard your critics say, they
    look at the Canadian system, and they start counting the Canadians who
    cross the border and come over to Detroit, be-

    [[Page 1584]]

    cause when it comes to optional surgery, optional procedures, they have
    to wait 3 months, 6 months, 9 months, a year. And they get so frenzied
    over this that rather than wait, they come over to the United States.
    Now, those people will tell you, ``Whatever you do, don't exchange what
    you've got for what we've got.''
        The President. But we don't do that. In other words, keep in mind, I
    am not proposing to bring our cost level down to the level of Canada,
    much less Germany. What I am proposing is to slow the rate of increase,
    which if we don't slow it, by the end of the decade we'll be spending
    roughly 19 percent of our income on health care. Canada will be about
    11, and everybody else will be under 10. And that is a huge economic
    disadvantage in a global economy. It also means a lot of workers just
    give up all their pay increases. We are not proposing to cut spending on
    health care. We're proposing to increase spending on health care quite
    briskly but not as much as we're going to if we don't change the system.
        Mr. Koppel. So fundamentally, the people in that poll are right.
    Those who think that they're going to end up paying more, they will.
        The President. They'll pay more, the system, no.
        Mr. Koppel. They may get more, but they're going to pay more.
        The President. The system will cost more, but they will pay much
    less under my plan than if we do nothing. Keep in mind, of the 85
    percent of the people with health insurance, two-thirds of them will pay
    the same or less for the same or better benefits.
        Mr. Koppel. No, I hear you. But let me try and state it one more
    time. You tell me if I'm wrong. Under the existing system, you're going
    to end up paying more.
        The President. Much more.
        Mr. Koppel. Under your system, you're going to end up paying more.
    But you're saying under your system you're going to end up paying a
    smaller amount more than you would in the existing----
        The President. That's right. You'll pay over the next 5 years much
    less under my system, my proposal, much less than you'll pay if you stay
    with the system we've got. And you get better benefits and security. You
    will never lose your health care.
        Mr. Koppel. This gentleman has been standing there most of the
    night. Go ahead, sir.

    [A participant asked if temporary workers would be included in the new
    plan.]

        The President. The short answer to that is somebody will be held
    accountable to them. For people who are temporary workers, it depends
    upon how they're ultimately classified under the tax system. For
    example, if you're a temporary worker and you work for an employer, and
    you're on that employer's payroll for, let's say as much as 10 hours a
    week, then that employer would prorate his payments, or her payments,
    for the temporary worker. They'd have to pay a third the normal rate. If
    they're on the payroll for 20 hours a week, they pay two-thirds the
    normal rate. If the temporary employee is listed as being on the payroll
    of the temporary company, then they would pay. If the temporary employee
    is an independent contractor under the Tax Code, then the temporary
    employee would have to buy his or her own insurance, just like the paint
    contractor. But depending on the income, they'd be eligible for a
    discount, and they'd have 100 percent tax deductibility.
        So the answer is, the temporary employees will be covered. Who pays
    and how depends on how they are classified under the Tax Code. But
    either the temp company, the company for which they're working part-
    time, or if they're independent contractors, they, themselves, they will
    get coverage at an affordable rate.
        Mr. Koppel. Mr. President, as I told you, we have three practicing
    physicians out at the University of Chicago. One of them, Dr. Mark
    Siegler, would like to either make a comment or ask a question.
        Go ahead, Dr. Siegler.

    [Dr. Mark Siegler asked about quality of patient care under the new
    plan.]

        The President. If you look at the plan the way it operates, and I
    would urge you to read it carefully, we will actually provide more
    funding for medical research than we are now, more funding for health
    education centers than we are now. Each employee in the country will get
    at least three choices of plans. They might choose an HMO which, you're
    right, would then have a closed panel of doctors which would limit the
    number of doctors. But we know that there are a lot of HMO's that have
    very high patient satisfaction, the ones that are really well run. But
    they might also choose a preferred provider organization, and under our
    rules, no PPO can

    [[Page 1585]]

    deny interest to any doctor that wanted to be a part of it. So a doctor
    could join a lot of different organizations so that the doctor could, in
    effect, be available to all his or her patients, even after this reform
    takes place. And finally, keep in mind, if you look at the package of
    comprehensive benefits here, virtually all Americans with insurance now
    would get the same benefits that Fortune 500 companies enjoy and much
    better than they have now. So we want to preserve choice; we want to
    preserve quality; we want to preserve a range of benefits.
        Also, one of these plans, every employee will have the option today,
    under this plan, to choose fee-for-service medicine. Today in America,
    only one-third of the insured employees in this country have an option
    of more than one plan.
        Mr. Koppel. Mr. President, let me jump in for just one moment. What
    I'm hearing in my ear is that some of those who have your best interest
    at heart, namely members of your staff, are very concerned that you not
    spend too much of this night with this, because you've got a big day
    tomorrow. So I want to let the audience know that we are in the process
    of winding down.
        I would like to have maybe two or three more questions. Would that
    be all right with you?
        The President. Sure.
        Mr. Koppel. And then we will bring this program to a close. I
    suppose it's also appropriate at this point to note that, believe me,
    this is not going to be the last you hear on this subject. Either pro or
    con, the President's plan, it is just the beginning of what promises to
    be a long national debate. But I think you've had an extraordinary
    opportunity here to at least hear from the man who is behind what is
    clearly one of the most ambitious health plans that this country has
    ever seen.

    [A pharmacist asked if patients would be able to get prescriptions at
    the pharmacy of their choice.]

        The President. Yes, sir, you can, and that's why the Pharmaceutical
    Association of the United States--Association of Pharmacists has already
    endorsed our plan, and they were up until 2 a.m. last night sending out
    press releases around the country, saying that this is a good deal for
    your neighborhood pharmacy.

    [The mother of a boy with congenital heart defects asked if they would
    be denied access to quality service under the new plan.]

        The President. No.
        Q. Because we can't afford to pay 20 percent of a hospital bill that
    is in excess of $100,000, $200,000.
        The President. No, absolutely not. If you have a plan now that
    covers all your benefits, if anything your employer will have more
    incentive to continue to cover you, because their costs will go up less
    in the future than they would now.
        Keep in mind, this 20 percent requirement for the employee to pay is
    for all those who don't have any coverage now. And It's not a
    requirement on the employee; it's a limit on how much the employee can
    pay. The employee cannot be required to pay more than 20 percent. If the
    employer wants to pay more, they can. The truth is, it's largely going
    in the other direction today for most folks. So if you have a good
    health insurance plan and it pays more than 80 percent, nothing in this
    plan will change that. In fact, your employer should be more willing to
    do it, because in the aggregate their costs will go up less in the
    future than they will if we stay with the same system.
        I talked today to a half a dozen people who said that their
    contribution share was going up, up, up. And it was going to be over 20
    percent before long, and they were glad to know there was a ceiling on
    it. All we're trying to do is to put a ceiling on it, not a floor.
        Q. Thank you.
        Mr. Koppel. Mr. President, we've got one more question. And you,
    sir, have the last question. Go ahead.

    [A participant asked if all insurance companies would be required to
    open their provider lists to all qualified doctors under the new plan.]

        The President. The short answer to that is yes. Keep in mind, we
    want to give the employee the choice. What happened to your patients was
    the employer made the decision to go with another health plan that
    closed out certain doctors. We want to give the employee the right to go
    with a closed panel HMO if they think that's good--health maintenance
    organization--if they think they get better prices and they think they
    get adequate services. But we also want to give the employee other
    options, including to continue dealing with you as a fee-for-service
    doctor, or working with a group of

    [[Page 1586]]

    doctors in which you have an absolute legal right to be a part.
        Now, if that happened today, the fee-for-service option might be a
    little more expensive. But what I think will happen is that you and
    other doctors--what I'm banking on is that the physicians of this
    country will get together and offer their services at reasonably
    competitive rates so that people will be able to maintain a maximum of
    individual choice. But it is legally mandated that every employee in the
    country will have the option to choose fee-for-service medicine or a
    panel of doctors, which has to remain open for any doctors who want to
    join so that doctors can be in multiple panels. And so we're going to
    increase choice of physicians, not decrease choice of physicians for
    most Americans. That's a very important value, and we have to pursue it.
        Mr. Koppel. All right. President Clinton, please excuse my back. I
    just want to express a personal note of thanks to you for coming here
    this evening. I know there are an awful lot of people, possibly many in
    this audience, who wished they'd had the opportunity to pose questions
    to you or to criticize certain aspects of the plan. Over the course of
    the next year, I'd also like to say to your adversaries out there who
    are watching us and who have criticisms that they too will have access
    to this program and many others.
        There is something wonderful, however, about being able to bring an
    American President and an audience of 1,000 of his constituents together
    for this kind of an exchange. And I know you'll want to express your
    gratitude to the President, as I do now. Thank you. [Applause]
        The President. Thank you, folks.

    Note: The town meeting began at 10:10 p.m. in the Playhouse at the Tampa
    Bay Performing Arts Center.