    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [October 28, 1993]
    [Pages 1840-1846]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Remarks to the Medical Community at Johns Hopkins University in
    Baltimore, Maryland
    October 28, 1993

        Thank you very much. You have just seen the most stunning example of
    one of Clinton's laws of politics, which is whenever possible be
    introduced by someone you've given a good position to.
        I want to thank Hillary--[applause]--think about that. [Laughter] I
    want to thank Hillary for the absolutely wonderful work that she and the
    health care group have done. This has been an unprecedented effort,
    really, involving thousands of Americans from all walks of life. I don't
    know how many doctors from around America have told me it's the first
    time any kind of health care reform has started by asking people who are
    actually providing health care what they thought about it. I want to
    thank all the groups that were involved in it, the Nurses Association,
    countless groups. This group just met with 1,500 separate groups in
    trying to put this plan together.
        And I want to say a special word of thanks to President Richardson
    and Dr. Block and to

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    Dean Johns and to Dean Gray and to Dean Sommer and all the people here
    at Johns Hopkins. This university has played a truly unique role in this
    process because so many have been involved; Hillary said over 20 faculty
    members, a few students, many administrators. We are very, very grateful
    to you. And I thank you.
        You know, when a President gives a speech there's always a little
    meeting, a hurried little meeting that occurs beforehand, a couple of
    days beforehand, and the staff gets together and they say, ``Well, what
    do we want to achieve?'' And it goes something like this. ``Well, you're
    going to Johns Hopkins. Be sure and tell them that it would be very hard
    for us to have done this without Ben Cardin because we can't really pass
    it unless he really wants to help us pass it on the Ways and Means
    Committee.'' So they say brag on Congressman Cardin, and that's in the
    note. So I'm doing that, and that's true. [Laughter] And then they say,
    ``Here are the points you're supposed to make.'' And so I wrote it down.
    Instead of all these notes, I just wrote down, they say, ``The purpose
    of this speech is to remind the American people that we actually have a
    plan, that it is written, that it is universal, that it is
    comprehensive, and that we actually asked people in health care to help
    us put it together.'' Now, I should just sit down. That's it. [Laughter]
        And that is what I want to do today. I want Americans all over this
    country, who look to the Johns Hopkins Medical School, who know that
    this medical center is a shining beacon of everything that is best about
    our health care, to know that this plan is real; it is specific; it is
    concrete--within the next couple of weeks every American will be able to
    read it at a library, or buy it in bookstores or other places where
    paperback books are sold--that it is specific, that it is universal and
    comprehensive, and that people who actually know something about giving
    care to people, healing the sick and taking care of people to help them
    stay well, had a big role in this; that we listened and incorporated
    those suggestions.
        And I want to talk a little bit today about what has already been
    said: What do we mean by keeping what's right and fixing what's wrong?
    But in the beginning let me say something that doesn't have anything to
    do with my notes because I think it's important about how we all came
    here. All of you came here because you had a personal history. You might
    wonder what two lawyers who met in law school and got married like
    Hillary and me are doing, being obsessed with health care. [Laughter]
    It's an interesting and long story. My mother was a nurse anesthetist. I
    was permitted as a young man to go into hospital rooms, to go into
    emergency rooms, to go into even surgery, to watch surgery when I was a
    young person. And I didn't faint.
        I can remember in a simpler time before there was Medicare or before
    there was Medicaid, when poor working people would pay my mother for
    performing the anesthesia in kind; when fruit pickers would come to
    Arkansas in the peak season and literally bring bushel baskets full of
    peaches to our door to pay for the service she had provided for some
    member of their family in the operating room.
        I can remember when I met Hillary in law school, she took an extra
    year in law school to work with the Yale Medical School on the problems
    of children and the relationships of children's health and developmental
    problems to the law, or at that time, the relative lack of relationship
    of children's health and medical problems to the law.
        In 1979, when I became the Governor of my State, and it was obvious
    we had a lot of serious problems both in terms of quality care and the
    availability of care, Hillary headed a task force in our State on rural
    health care to try to figure out what we could do to bring health care
    to more places in our State that didn't have it. And we set up and
    funded for the first time with State funds a tertiary care center at the
    Arkansas Children's Hospital, now the seventh largest in the country,
    I'm proud to say.
        When I was a Governor, we went many times to the Mississippi Delta
    where Robbye McNair is from. And I want to thank her not only for what
    she's become--this is a long way from Belzoni, Mississippi, folks--but
    for the fact that she wants to go back there to take care of the people.
        I have been in schools in the delta, which is the poorest part of
    America--the Mississippi Delta from Memphis to New Orleans is still
    America's poorest region--where as many as 30 percent of the kids have
    serious dental problems because even in their teen years they've never
    seen a dentist, they never had anybody give them any primary care
    advice, and where they're asked to stay in school and learn under very

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    adverse circumstances, when they're literally in pain all day every day
    because they never saw a dentist.
        So there are a lot of things that all sort of put these threads
    together that brought us to this point. And in 1990, I was asked on
    behalf of all the Governors to join the then Republican Governor of
    Delaware, now a Congressman from Delaware, Mike Castle, in trying to
    come up with some bipartisan Governors' approach to this because we all
    had millions of people who didn't have any health insurance, many others
    who didn't have any access to health care, and yet the Medicaid budget
    was breaking every State government in the country, taking money away
    from what we wanted to spend on education and on economic development
    and trying to offer opportunity to our people. So by the time I decided
    to run for President, I had been living with this for a very long time.
        I just couldn't see how America would ever get where we needed to be
    by the dawn of the 21st century without dealing with the health care
    crisis. I didn't believe it. That's why we decided to do this. That's
    why we devoted so much of the last 9 months to developing this plan, to
    presenting it, to giving it to Congress.
        And if I might, I would just like to say a couple of words about
    that. This is a deep human problem for every American who's ever lost
    health insurance, for every American who never had it, for every
    American who can't change jobs because someone in their family's been
    sick, for every nurse or doctor who tears their hair out because they
    spend so much time filling out useless forms, or because they have to
    get on the phone and call some bureaucrat and get permission to do
    something that anybody with a lick of sense would know they ought to do
    anyway.
        This is a human problem. But you must understand that it has
    enormous ramifications for all the other aspects of your Nation's life,
    because as we spend more and more and more and more money on health
    care, and yet more and more and more people don't have access to it, and
    more and more others are afraid they're going to lose it, and more and
    more small businesses make the decision every year to get rid of their
    health insurance or to raise the deductible to $2,500 or $3,000 or
    whatever, that chips away in millions of little human stories at the
    collective security we need as a country to face the challenges of the
    present day.
        We have been 20 years now when most hourly wage-earners in America
    are working harder for the same or lower wages, longer hours at work,
    less time with kids. We see a global economy full of both hope and fear;
    full of challenges there to be seized that offer opportunities for
    people and full of great pressures on people who aren't very well
    prepared for this global economy.
        We have to face as a nation what it's going to take for us to enter
    that next century just a few years away now--the world's strongest
    country with the American dream alive and well for everybody who's
    willing to do what it takes to seize it. That means we have to
    dramatically change our economic approach, our education system, our
    commitment to invest and grow, the way we relate to one another. We have
    to make a full-scale assault on the problems that are destroying the
    quality of life for millions of our young people and preventing them
    from growing up to be what God meant them to be. And in order to have
    the courage to change, we're going to have to have a much higher level
    of certainty that if we do the right things as a people, we will at
    least be rewarded with the basic things of life. And it begins with the
    health care issue.
        So I say to you that this is a very important thing on its own
    merits. It ought to be done. In any age in time with this set of
    problems and this set of opportunities in health care, somebody should
    be willing to act. At this time, it is critical for America to get in
    the shape we need to be in by the beginning of the next century so we
    can do what we have to do as a country.
        Now, very briefly, let me say how we seek to fix what's wrong with
    the system and keep what's right in terms of the six principles that I
    laid out when I addressed Congress on this issue last month:
        Number one, and most important of all, security. Some things are
    right with this system. A lot of people have good health insurance. Some
    people have health insurance that is paid for 100 percent by their
    employers even, that is very good, that has comprehensive benefits. We
    want them to be able to keep that. But we want to put a floor under what
    they can lose, because, keep in mind, nobody has absolute certainty
    today. Somebody can have a great health insurance policy, but if their
    company lays them off or if they decide to go try to start a small

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    business or they change jobs, they can lose it.
        So 100 percent of the people benefit from this plan, because all
    those with great policies now have a floor under them if this plan
    passes. There will be something they cannot lose. Their employer may
    require them to pay more than they now pay because of economic
    pressures, but there's a limit to how much they can be required to pay.
    And they can never lose coverage.
        I think this is very, very important because I hear a lot of people
    sort of slinging their arrows over at our plan, talking about, ``Well,
    they're going to all this trouble for the 15 percent of the people that
    don't have any health insurance.'' Well, you know, there are 15 percent
    that have nothing, another 100,000 a month that have nothing
    permanently. There are also a lot of people that have health insurance,
    but it doesn't amount to much. And there are people that have great
    policies, but they can lose it. So this puts a floor under it.
        Secondly, it provides coverage for people in and out of the
    workplace who don't have it now in the customary way we provide it. That
    is, we require employers and employees who don't have any coverage now
    to make a contribution and provide coverage for those in the workplace.
    For those who are in small business and have low-wage operations, we
    provide discounts. For those who are the uninsured unemployed, the
    Government will cover them in the way we cover Medicaid patients today.
    So we will have security for everybody, and everybody will be more
    secure than they are now. No one under our plan will lose benefits from
    what they have now by what we do. So we keep what's good about the
    system, but we fix what's wrong.
        Simplicity. I think when Robbye said the present system was simple,
    what she meant was it's good to maintain the transaction between the
    doctor and the patient. But make no mistake about it, when you get
    beyond that to the paperwork, our system is the most complex system in
    the world.
        Somebody said, ``Gosh, Clinton turned in a 1,360-page bill'' or
    however long it is. We reckon there will be more than 10 times that much
    legislation repealed if our bill passes. And it's a metaphor for what's
    going on now. Rube Goldberg in his wildest dream could not have designed
    a machine that's like the American paperwork machine in medicine today.
        So what do we want to do? By having a benefits package that is at
    least a basic comprehensive package, we will be able to have a single
    simple form for medical providers, a single simple form for insurers, a
    single simple form for people who access the system. We figure in total,
    maybe four or five forms, but one for each of the main aspects. That
    will dramatically simplify the paperwork burden.
        We also will be able to devolve more decisionmaking back to the
    providers themselves and hold people accountable for results instead of
    having the Government or an insurance company try to micromanage every
    decision on the front end. That will drastically simplify this
    decisionmaking process, drastically cut down on the paperwork, and free
    up all across America millions and millions and millions of hours every
    year for people to do what they train to do, which is to take care of
    patients. And it is very important.
        The third principle of this plan is savings; how do you keep what's
    right and fix what's wrong. What's right in the medical profession with
    regard to savings now, a lot of people are doing a good job, finally, in
    saving money. This institution has proved that you can provide high-
    quality care and still have economy. The Mayo Clinic had an inflation
    rate of 3.9 percent on their services last year. The Federal health
    insurance system has modest increases in most of its policies and
    decreases in some. The same is true for the California public employees
    system. So savings are being achieved.
        How do you permit those people to continue to do what is right and
    fix what's wrong, which is that the overall system is still going up at
    2 and 3 times the rate of inflation, that small business premiums are
    going up at 2 and 3 times the amount that nonsmall business premiums
    are? How do you effect those savings? Well, we believe the way to effect
    those savings, first of all, is to stop cost shifting by having
    everybody covered, which will save a lot of money, and secondly, to give
    the presently uninsured small businesses, self-employed people, and
    farmers the opportunity to have the same bargaining power that people in
    bigger units do. There's no reason that big business and Government
    should benefit from all the economies of scale in health care. The only
    reason they do today is because of the way the insurance market is
    organized.
        So under our plan, those savings will be fairly

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    spread across the whole area, and we will also put Medicaid into the
    kind of comprehensive care delivery system that we're asking for small
    business, and self-employed people. So you'll have the poor, small
    business, and self-employed in the same sort of buying units, larger
    ones, that only big business and Government have today. It will produce
    huge savings. It will not take away the savings that others are getting.
    And it will fix what's wrong and keep what's right. It's high time we
    did it.
        Three other things. Quality. How are you going to keep quality?
    Everybody says we've got the highest quality health care in the world,
    and we do. Is there something wrong there and something right? You bet
    there is. We always know, we know what's right, right? You're right;
    you're what's right about it. We know what's right about it.
        What's wrong about it? First of all, too many people don't have
    access to health care, and too many people, when they get health care,
    get it when it's too late and too expensive in an emergency room. And
    too many people even could be covered in theory--which is what Robbye
    was talking about--too many people could be covered in theory by this
    plan and still not be covered in fact because they might have access to
    insurance but not access to providers.
        So to fix what's wrong and keep what's right, we have tried to
    provide a special financial funding string for the medical research
    institutions, the people who do a lot of health education, for public
    health units in isolated urban and very sparsely populated rural areas
    to make sure that the access to health care as well as to insurance is
    there. And we have tried to emphasize primary and preventive services in
    this comprehensive package of benefits. Perhaps the single biggest
    deficiency across the board in American health care is the insufficient
    attention we have paid to primary and preventive services. And that is
    how we will improve quality and not undermine what is right.
        Choice. We got a lot of letters, including from doctors saying,
    ``You're going to make me be in an HMO, and I don't want to be.'' We got
    letters from people saying, ``You're going to make me join an HMO, and
    I'll lose Dr. Jones, and I hate you for doing that.''
        So, here's the issue: How can we preserve what's right and fix
    what's wrong? First of all, let's be realistic about this. Americans
    have been losing their choices of physicians by the millions for the
    last decade, right? Of all the people who are insured in the workplace,
    only one in three today have a choice of plans or options in what their
    employer has provided for them in the form of health care coverage, down
    from 50 percent just 7, 8 years ago.
        What does our plan do? It actually gives people more choices, both
    providers and insured people. Insured people under our plan would have
    three options, at least three. Their employer's premium would be the
    same regardless. They might have to pay a little more depending on what
    option they exercised. They might have an option to be in an HMO. They
    might have an option to be in a PPO, where professionals got together
    and managed their own health plan. There's a group of 700 doctors, for
    example, in Nevada, that have had their premiums collectively go up, or
    their costs, within a range of 2 or 3 percent over 6 years now. But
    there's a huge range of doctor choice because there are so many doctors
    in the group. Or it might be strict fee-for-service medicine at the
    election of the person with the insurance. But at least everybody will
    have a choice now, which is something they don't have.
        So under our plan there will be more choices. The same will be true
    for physicians and other health care providers--will have multiple
    choices about what kinds of things they can engage in because we've
    attempted to prohibit exclusive, mandated organized arrangements in our
    plans.
        So we believe as a practical matter, if you look at where American
    medicine is today as compared with 10 years ago, our plan will actually
    provide more choices for both the insured and for medical providers than
    they now have.
        And finally, responsibility. Let's be frank about this. This system
    lends itself to a lot of monkeying around. There's a lot of health care
    fraud. There is some abuse of the legal system, of malpractice. There is
    the ability of people to overutilize the system because there are no
    significant deterrences to it. Americans have a lot of habits which make
    us sicker and which cause us to use the health care system more, that we
    need to deal with. There is something to be said for the proposition
    that we will never really bring health care costs into line with what
    they ought to be until all of us are willing to assume a higher level of
    personal responsibility for the outcome of the health of the American

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    people.
        I want to make this last point, and I want you to think about it.
    Don't answer out loud, but everybody think of this in your mind. I don't
    know if you've thought of this, but this is the kind of thing I have to
    think about as President; it's my job. If I were to ask you what are the
    reasons that America spends 14.5 percent of its income on health care--
    Canada is at 10. Germany and Japan, our major competitors, are under 9;
    that means they spend under 9 cents on the dollar. We're spending 14.5
    cents on every dollar made in America on health care. Let me just give
    you an idea of what some of the practical consequences of that are.
    Every year they spend 3 cents on a dollar more than we do investing in
    their infrastructure. You know what that means? That means 10 years from
    now, they're going to have better airports; they're going to have faster
    trains; they're going to have better roads. They're going to have
    invested in those things that may be boring but may provide a much
    higher quality of life and a much higher income. But they had the money.
    It means that they can invest in all kinds of R&D in their economy,
    which may give them critical advantages 10, 20 years from now because we
    spend this money on health care now.
        So, if I ask you, why is that? How can they cover 100 percent of the
    people? And you can't just say they don't invest any money in medical
    research. It's plainly not true in Germany, one of the leading countries
    in the world, for example, for pharmaceutical companies. If I were to
    ask each of you, why is that? What's the difference in their 9 percent
    and our 14.5 percent? Is any of it good, from our point of view, and is
    some of it bad, and what can we do about it? And how much of it requires
    responsible decisions on the part of all of us?
        Here would be my answer. This is the best I can do, and I thought
    about this until my brain aches for years now. I believe first of all,
    we spend more money on some things that we intend to keep right on
    spending more money on. We spend more money on medical research and more
    money on technology, and we don't want to give it up. And it's an
    important part of our economy, and we're not going to. And make no
    mistake about it, that also creates high-tech, high-wage jobs. When
    pharmaceutical companies spend a lot of money on research, they put a
    lot of scientists to work. And that's a good thing for the economy.
        So these are good things, and that will mean more. What's the rest,
    though? We have huge numbers of unnecessary procedures. We all know
    that. We don't do enough primary and preventive care. We all know that.
    We do have all kinds of fraud and abuse in this system. And we spend a
    dime on the dollar more in administrative costs than any other country
    in the world because of paperwork. That's the stuff we've got to fix.
        Finally, we have certain group behaviors that we have to deal with.
    In the 1980's, under great financial pressures, schools all over America
    virtually abandoned physical education at a time when poor children
    needed it worse than anything. They needed not only the exercise, but
    they needed education in dietary habits, in personal hygiene habits, in
    the kinds of things that ought to be a part of a physical education
    curriculum. You want to lower the cost of health care? Undo that. Fix
    it. Go back and do something differently so that people can deal with
    that.
        We'll never get the cost of health care down to where it is in other
    countries as long as we have higher rates of teen pregnancies and higher
    rates of low birth-weight births and higher rates of AIDS and, most
    important of all, higher rates of violence. We've got so many people cut
    up and shot in our emergency rooms, how in the world can we expect to
    lower our health care costs?
        That's why this responsibility is so important. We begin by asking
    people who are taking advantage of the system to pay something into it.
    This business that we're going to break small business if we require all
    employers to pay something who don't pay anything now is not very
    credible.
        My Small Business Administrator, Erskine Bowles, has spent 20 years
    creating small business. And he's perhaps the most ardent advocate for
    our plan. Why? Because he knows that 70 percent of the small businesses
    do provide some health insurance coverage. Most of them are paying too
    much for too little, and a lot of them are risking going broke because
    of the cost of the premiums. And one reason is that other people, who
    can access the system when they need it, don't pay anything even though
    they can afford to pay something. So that's the beginning of
    responsibility. If all of us are going to have access to this system,
    all of us should

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    make a contribution in accordance with our ability to pay.
        It goes way beyond that. We have certain group behaviors in this
    country that are imposing intolerable burdens on the health care system,
    which will never be remedies. And we must recognize every time another
    kid takes another assault weapon onto another dark street and commits
    another random drive-by shooting and sends another child into the Johns
    Hopkins emergency room, that adds to the cost of health care. It is a
    human tragedy. It is also the dumbest thing we can permit to continue to
    go on for our long-term economic health. Why do we continue to permit
    this to happen?
        And so we need to advocate those things, too. We need to put the
    physical education programs back in our schools. We need to favor those,
    not just the Friday night contests. We need to think about the kids who
    need it. And we need to challenge these group behaviors. We have got to
    reduce the number of low birth-weight births. It's great that we can
    keep all of those little babies, or so many of them, alive today. But it
    is an unnecessary cost. We can reduce those if we work at it.
        And most important of all, we have got to do something about the
    rising tide of violence in this country. There's a crime bill that the
    Congress can give you for a Christmas present that includes the Brady
    bill and more police officers on the street and alternatives for kids,
    and we ought to pass it. We ought to pass it before the Congress goes
    home.
        Let me close with this. We are beginning now the process that will
    lead to a vote sometime next year on the health care plan. It will begin
    with this, and the more people who know what's in this, the more people
    who make constructive suggestions about how it can be improved, the
    better off we're all going to be. So I ask you to think about this: This
    book will be in every library in the country. It will be available,
    widely available. And now that the Government Printing Office has
    printed it, any other publisher in the country can go out and try to
    print it for a lower cost. That's good. That means we'll have a little
    competition and these books will be everywhere. [Laughter]
        I want to implore all of you to get this and read it, to get as many
    of your friends and neighbors as possible to read it, and to create a
    climate in this country where we have an honest, nonpartisan American
    debate to have an American solution to this issue; and that you insist
    that these principles be observed--that we fix what's wrong, keep what's
    right--and that we act on this, that we act on it before Congress goes
    home next year. It begins with you knowing about it. Please help us.
        Thank you very much, and God bless you all.

    Note: The President spoke at 12:20 p.m. in the Newton White Athletic
    Center. In his remarks, he referred to university officials William C.
    Richardson, president, Michael E. Johns, dean, medical faculty, Carol J.
    Gray, dean, School of Nursing, and Alfred Sommer, dean, School of
    Hygiene and Public Health; Robbye NcNair, medical student at the
    university; and James A. Block, president, Johns Hopkins University
    Hospital.