    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [September 21, 1993]
    [Pages 1548-1553]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Interview With Radio Talk Show Hosts
    September 21, 1993

        The President. Thank you very much, and welcome to the Executive
    Office Building and to the White House, and thank you for coming today.
    I--what did you say, nice tie? [Laughter] That's a Save the Children
    tie.
        Audience member. All right!
        The President. I wore it for the national service signing today.
        It's interesting, we just had a lunch with a number of columnists--
    --
        Audience members. Lunch? Lunch? [Laughter]
        The President. Lunch? I'm sorry. I'm sorry. Would it make you feel
    better if I said I didn't enjoy it? I mean--[laughter]--anyway, and they
    knew you were all here, and we had 700 or 800 people out on the lawn for
    the national service signing. And four or five of these folks that have
    been covering Washington for 20 years said they had never seen the White
    House so busy. I didn't know if they were happy or sad about it, but
    anyway, it's busy.
        I thank you for coming today. I hope this will be the first of a
    number of opportunities we have to provide people who have radio talk
    shows and who communicate with millions of Americans on an intimate
    basis, daily, to come to the White House to have these kinds of
    briefings. You've already heard all the basic approaches that the
    administration is going to take on health care and that will be
    hopefully crystallized in a compelling way in my address to the Congress
    and to the country tomorrow evening.
        So, I thought what I would do is make a general statement about how
    this fits into the overall approach the administration is taking and
    then answer your questions. I'd rather spend time just answering your
    questions.
        But let me just make a general comment, that I think you can--that
    runs through the thread of debate that we had on the economic program,
    on the health care issue, on NAFTA, on the crime bill that's coming up,
    on the welfare reform issue, on all the major things we're trying to
    come to grips with.
        It is now commonplace to say that we are living through a time of
    profound change, not

    [[Page 1549]]

    only in our country but around the world. People are trying to come to
    grips with a rate and nature of change that comes along less frequently
    than once a generation.
        You may know that just since you've been sitting here, Boris Yeltsin
    has dissolved the Russian Parliament and called elections for that
    Parliament in December, and his major opponent has apparently declared
    himself President. I mean, they are going through these things, trying
    to come to grips with what it means to be a democracy and what it means
    to try to change the economy.
        In our country, if we're going to continue to be the leading power
    of the world, not just militarily but economically, socially, the
    shining light of the world, this has to be a good place for most
    Americans to live. Most people have to know that if they work hard and
    play by the rules that they can make the changes that are sweeping
    through this country and the world their friends and not their enemies.
    They have to believe that as citizens they can work together and trust
    the major institutions of our society to function well, to meet these
    changes, to respond to them.
        We confront this bewildering array of challenges: the size of the
    deficit, the fact that we have an investment deficit, too, in many
    critical areas, the health care crisis, at a time when most people are
    quite insecure in their own lives and most Americans have worked harder
    for stagnant or lower wages for the last 10 to 20 years, when they're
    paying more for the basics in life, when they have lost faith in the
    fundamental capacity of political institutions to represent them and to
    solve problems.
        I think you can see that in the 700,000 letters we got on health
    care. The number of people who would say, you know, ``What's wrong with
    me? I worked hard all my life, and I lost my health insurance,'' or ``My
    child got sick, and now I can never change my job,'' or ``My wife and I
    spend 60 hours a week running our business. And our health insurance was
    $200 a month 4 years ago, and it's over $900 a month today,'' you know
    that things are out of control. I say that because I believe providing
    security in the health care area and in meeting the other objectives we
    talked about, quality and choice and cost controls and all, is a
    necessary precondition, not only to improve the health care of the
    American people but to help root the American people again in this
    moment, to make them freer to face the other challenges that we face. I
    see in this debate over NAFTA--which I have wrestled with in my own
    mind, that is, the whole nature of our trade relations with Mexico and
    other countries and where we are going for far longer than I've been
    President, I had to deal with it when I was a Governor. I see people,
    some of them looking ahead with confidence in the future that we can
    triumph in the world of the 21st century, that we can compete and win,
    that we can create tomorrow's jobs, and others so uncertain about it,
    just trying to hold on to today and to yesterday's jobs.
        So, what I am trying to do is to give the American people a greater
    sense of security over those things that are basic to their lives that
    they can control and at the same time challenge our people to assume
    responsibility for dealing with our problems and for marching
    confidently into the future. That's what this national service issue is
    all about that we celebrated today on the White House lawn.
        And therefore, the health care issue is about more than health care.
    It is about restoring self-confidence to America's families and
    businesses. It's about restoring some discipline to our budget and
    investment decisions, not only in the Government but in the private
    sector. It's about giving us the sense that we actually can move forward
    and win in the face of all these changes. I cannot under--or I guess I
    cannot overstate how important I think it is, not only on its own terms
    but also for what it might mean for America over the long run.
        Yes.

    Health Care Reform

        Q. Does anybody really know whether this will work, from the
    administration? Have you parsed the numbers that fine, that you can say
    if this is passed in toto, it will indeed do what you say, cut costs,
    maintain quality of care, cover everybody?
        The President. We know it will do that, but that's not exactly what
    you asked. That is, we know that if this plan is adopted, it will
    provide universal coverage, that it will achieve substantial savings in
    many areas where there is massive waste.
        Dr. Koop, who was, you know, President Reagan's Surgeon General, who
    was with us yesterday, and the doctors that we had, said that in his
    judgment, there was at least $200 billion

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    of waste, unnecessary procedures, administrative waste, fraudulent
    churning of the system, at least, in our system. So, we know that those
    things will achieve those objectives? We do. Do we know that every last
    dollar is accurate, or that there will be no unintended consequences, or
    that the timetable is precisely right? No we don't know that because
    nobody can know that exactly.
        But I would like to make two points. Number one, our administration
    has gone further to get good health care numbers than anyone ever has
    before. Until I became President I didn't know this, but the various
    Agencies in the Federal Government responsible for various parts of
    health care financing and regulation had never had their experts sit
    down in the same room together and agree on the same set of numbers and
    the same methodologies for achieving them. So that's the first thing we
    did. No wonder we had so much fight over what something was going to
    cost and the deficit was going crazy. The Government had never gotten
    its own act together.
        Then the second thing we did was to go out and solicit outside
    actuaries from private sector firms who made a living evaluating the
    cost of health care and asked them to review our numbers. Now, that is
    very important that you understand that, because there is going to be--
    there should be a debate over whether the course I have recommended is
    the best course to achieve the goals we all want to achieve, whether
    there is a better course, whether we can achieve the Medicare and
    Medicaid cuts that we say we can achieve without hurting the quality of
    care. That's fine. But I want you to understand that we really have
    killed ourselves at least to get the arithmetic right, to give people an
    honest starting point, a common ground to start from, so that we can
    have the arguments over policy.
        Yes, sir.
        Q. Do you feel that your plan places undue hardship on business with
    the employer mandate versus an individual plan that has been proposed
    with other proposals?
        The President. No, and I'll say why. First of all, let's just look
    at the employer mandate. Most employers cover their employees. I like
    your question in the sense that the question assumes that we should have
    universal coverage, and that's a good assumption. If you don't have
    universal coverage, you can never really slow the rate of waste in cost,
    because you'll always have a lot of cost shifting in the system. That
    is, people who aren't covered will still get health care, but they'll
    get it when it's too late, too expensive, somebody else will pay the
    bill, and it will have real inefficiencies and distortions, as it does
    today.
        If you want to cover everybody, there are essentially three ways to
    do it. You can do it the way Canada does. You can abolish all private
    health insurance premiums, raise taxes to replace the health insurance
    premiums, and have a single-payer system, just have the Government do
    it. That's the most administratively efficient. That is, the Canadian
    system has very low administrative costs, even lower than Germany and
    Japan. The problem is, it's not very good for controlling costs in other
    ways, because the Government makes all the cost decisions. The citizens
    know they've already paid for this through government. So they make real
    demands on the system. Whereas if you have a mixed system where
    employers and employees are actually in there knowing what they're
    spending on health care and lobbying for better management and to
    control costs, like in Germany, you don't have costs go up as fast. So
    the Canadian system, even though it's administratively the cheapest, is
    the second most expensive in the world. We're spending 14 percent of our
    income; they're spending 10 percent of theirs. Everybody else is under
    9.
        Now, the second system is the individual mandate. It's never been
    tried anywhere. The problem with the individual mandate is that it
    could--and again, I want a debate on this. I think the Republicans are
    entitled to their day in court on this, and I want them to have it.
    Really, I do. I mean, I want an honest, open discussion on this. I am so
    impressed with the spirit that is pervading this health insurance--we
    had 400 Members of Congress show up for 2 days at our health care
    university just trying to get everybody to have enough information to be
    singing out of the same hymnal when we talk to one another.
        The dangers of the individual mandates are that it could cause the
    present system we have for most Americans, which is working well for
    most Americans, to disintegrate. That is, you have to have some
    subsidies with an individual mandate. So will companies that now cover
    their employees basically start covering their upper income employees or
    not their lower income

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    employees? Will they dump all their employees and make them go under the
    individual mandate system? How are you going to keep up with all these
    individuals when you realize who you've got to subsidize or not? In
    other words, we believe it has significantly more administrative
    burdens, and it has the potential to cause the present system to come
    undone. But they deserve their day in court on it, and we'll debate it.
        Let me just say this. Our system for small businesses, I'd like to
    make the following points: We propose to keep lower the premiums of
    small businesses with fewer than 50 employees, including all those that
    are just starting up. And they get more if their wages of their
    employees are low, and low-wage workers also get a subsidy to try to
    make sure nobody goes out of business. But the point I want to make is,
    most small businesses who do cover their employees, and that's the
    majority of them, are paying too much for their health insurance. They
    are being burdened by it. That's one reason 100,000 Americans a month
    permanently lose their health insurance, as well as at any given time in
    a year, as many as one in four may be without it.
        So what we propose to do will actually help more small businesses
    than it will hurt. And over the long run, they'll all be better off,
    because if you put everybody under this system, then the rate of
    increase in health care costs will be much lower. And it's just not
    fair, at some point, for anybody who can pay something to get a free
    ride, because keep in mind, we all get health care in this country. But
    if we're not insured, we get it when it's too late, too expensive.
    Usually we show up at the emergency room, the most expensive of all, and
    then somebody else pays the bill. That's one of the things that's
    driving these costs out of sight.
        Yes, sir.
        Q. We've heard a lot about every group today, except for the
    doctors. And from the doctors that I'm hearing from, they're saying that
    this is going to hit them in their pockets. In my experience before in
    being in operating rooms and seeing doctors after the diagnostic related
    groups started setting some prices of procedures back in the eighties, a
    lot of doctors that went into business for themselves were either multi-
    using single-use items or resterilizing items that were made for single-
    use so that they wouldn't lose any of the money that was going to be
    coming to them, so they wouldn't take a personal hit out of it. How does
    your plan guarantee us an uncompromised medical plan?
        The President. Well, for one thing, the quality standards that
    govern medical care today will still be in effect. That is, most of them
    are professional standards, and they're not enforced by the Government
    today.
        Q. They're talking about doing more procedures to make up the money.
    They're saying, ``Well, I'm going to have to see more patients and spend
    less time with them.''
        The President. Yes, but that's what's happening today. I mean, the
    truth is that as we've tried to control the costs of Medicare and
    Medicaid, particularly Medicare, by holding down costs, you see
    dramatically increased numbers of procedures. What we want to do is to
    remove the incentive for having large numbers of procedures by having
    big blocks of consumers pay for their annual health care needs in a
    block, so that you won't have so much fee-for-service.
        I would also point out to you that one of the big problems we've had
    with doctor costs going up is that doctors are having to negotiate their
    way through the mine field of 1,500 separate health insurance companies
    writing thousands of different policies, having to keep up with it in
    ways that no doctors anywhere in the world but our doctors have to deal
    with.
        We've already had the American Academy of Family Practice and a lot
    of other doctors groups have endorsed our plan. The AMA has been quite
    interestingly supportive in general terms. They say they want to see all
    the details. They believe there ought to be universal coverage. Dr. Koop
    has agreed to come in and sort of moderate this discussion. But we had a
    couple hundred doctors here yesterday, most of whom were extremely
    supportive. And let me just give you one big reason why. This is the
    flip side of the argument you made.
        In 1980, the average doctor was taking home 75 percent of the money
    generated by a clinic. In 1990, the average doctor was taking home 52
    cents on the dollar, 52 percent of the money generated by a clinic.
    Twenty-three cents on the dollar increase in the amount of money the
    doctor was having to spend on people, basically to do clerical work in
    the clinics.
        The Children's Hospital at Washington told us last week that the 200
    doctors on staff there spent enough time in non-health-care-related
    paperwork every year because of the administrative cost of this system--
    a dime on the dollar

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    more than any other system in the world--to see another 500 patients
    each a year, 10,000 more kids a year. So, a lot of doctors are going to
    feel very liberated by this because they are going to be freer to
    practice medicine, and the incentives to churn the system just to pay
    for all their paperwork will be less.
        Yes, sir.
        Mr. Strauss. Time for one more question.
        Q. I guess I have the opportunity, I'll make it a two-part question
    because it's a rare opportunity, and I appreciate it. First of all, if
    you receive everything that you want, that you're hoping for, and we
    hear about the 37 million uninsured and the many underinsured people,
    I'm wondering if there's anybody that will be disappointed with the new
    system----
        The President. Oh yeah.
        Q. ----if you get everything you want, and who those people might
    be? And secondly, I hear very little about medical fraud and medical
    malpractice problems, as if it isn't a major problem, and we are led to
    believe that it is.
        The President. It is a big problem. Maybe I should answer that
    question first, because it's a quicker one. Then let me try to tell you
    how to sort through the winners and losers. Okay?
        First of all, in this system if you put consumers of health care,
    employers and employees, particularly the small businesses, in large
    buying groups where they will have more market power and more oversight
    authority, you will inevitably--we are going to change the economic
    incentives as well as the private sector oversight to reduce fraud and
    abuse--we are definitely going to see big savings there.
        Secondly, what was the other thing you asked me?
        Q.  The medical malpractice.
        The President. Medical malpractice. Doctors----
        Q. Doctors spending--[inaudible]----
        The President. Well, doctors----
        Q. [Inaudible]
        The President. One of the things that we don't know is how much
    extra excess procedures and tests are done as defensive medicine or to
    churn the system, to go back to your other question. The economic
    incentives to churn the system will be dramatically reduced under these
    kind of payment plans.
        It will be more like the way the Rochester, New York, system works,
    the way the Mayo Clinic system works. More and more people will be in a
    system where they pay up front, and then they take what they need. And
    the doctors are going to get paid out of that.
        But the malpractice issue is a problem. We will propose some
    significant reforms, including limiting the percentage of income lawyers
    can get in contingency fees in lawsuits. But I have to tell you, what I
    think the most significant--and alternative dispute resolution
    mechanisms--but I think the most important one will be permitting the
    professional associations to draw up medical practice guidelines which,
    when approved, will protect the doctors to some extent, because if they
    follow the guidelines in any given case, it will raise a presumption
    that they weren't negligent. And that will be a real protection against
    just doing an extra procedure because you're trying to hedge against a
    lawsuit.
        The State of Maine pioneered this because they wanted more general
    practitioners in rural Maine to do more things for people like help
    deliver babies because they didn't have anybody else to do it. So, the
    idea of giving people practice guidelines I think is very good.
        Now, you asked who's going to win and who's going to lose. Can we
    talk through that?
        Q. Yes, sir.
        The President. I'll tell you who will have to pay more. You know,
    there will be some people who will have to pay more. The news magazines
    this week did a pretty good job of analyzing this.
        If we go to community rating, so that we can allow people, for
    example, who have had a sick child not to be bankrupt by their insurance
    costs and to move from job to job, and you put everybody in a broad
    community, it means young, single, super healthy people will pay more in
    the first year of this than they would have otherwise. Now, here's why I
    think that's a good deal for young, single, super healthy people. Number
    one, all young, single, super healthy people will get insured, and they
    aren't now. Number two, they'll all be middle-aged someday, too, and
    they'll win big. Number three, their cost will go up less every year. So
    even though they might pay more this year, within 5 to 8 years, if this
    plan goes through, everybody will be paying less than they would have.
    So, they would pay more.
        Secondly, there are some businesses who don't insure at all. They'll
    have to pay something. There are others who insure but only for
    catastrophic. They will have to pay more,

    [[Page 1553]]

    but they'll get much better benefits, and their rates will go up less.
    So, there will be some people who will pay more now than they were
    paying. But I believe that if we can--keep in mind, if we can stop the
    cost of health care from going up at 2 and 3 times the rate of
    inflation, if we can get it down where the rate of increase is much
    lower, by the end of the decade everybody will be way better off than
    they were.

    Russia

        Q. Mr. President do you approve of--Boris Yeltsin's announcement
    that he's going to dissolve the Parliament, and does the United States
    support him in his power struggle with his opponents?
        The President. Well, first of all, let me say I have had only a
    sketchy briefing about this, and I have not talked to President Yeltsin
    yet. I would like to reserve the right to issue a statement after I
    attempt to talk to President Yeltsin. In any case, I will issue a
    statement before the end of the day, but I think at least I should have
    a direct briefing.
        Yes sir, one more. Go ahead.

    Health Care Reform

        Q. President Clinton, tomorrow you'll be speaking before a joint
    session of Congress and there are 535 people, individuals, in Congress
    that will have their own specific plans of what they want----
        The President. Yes.
        Q. If you could say that you could put your name on one or two or
    three specific parts of this that you want to say, ``This is my health
    care plan,'' that you want to see no matter what 535 other people want
    to see, that you feel you want to be part of your Clinton health care
    program, what two or three items, specifically?
        The President. Number one, every American would have security in
    their health care system. You would be able to get health insurance,
    there would be adequate benefits, and you wouldn't lose them. Number
    two, the system would impose a far higher level of responsibility for
    managing costs than it does now on all the players, including the
    consumers. Number three, people would keep their choice of physicians
    and medical providers. And number four, we would guarantee adequate
    access to preventive and primary care so we could stop some of the big
    things that are happening to us before they get going. And five, we
    would have market incentives to bring costs down. Those are the things
    that I want to be the hallmark of our program.
        I wish I could stay all day. I'm sorry, but thank you very much.

    Note: The President spoke at 3:06 p.m. in Room 450 of the Old Executive
    Office Building. Richard Strauss was the White House radio services
    coordinator.