    [Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
    [September 16, 1993]
    [Pages 1500-1504]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Remarks in Response to Letters on Health Care Reform
    September 16, 1993

        The President. Good morning. Please be seated. Welcome to the Rose
    Garden. I'm glad the rain has stopped, but we put up the tent just as a
    precaution.
        Nine months ago, when I asked the American people to write to us to
    send their thoughts about the health care system and the need to reform,
    I had no idea what I was doing to our already overworked correspondence
    staff. Today, more than 700,000 letters later, I am happy to be able to
    join Hillary and Al and Tipper in welcoming a few of you here who wrote
    to us.
        In the weeks and months ahead, health care will often be topic
    number one at dinner tables, at offices, at medical clinics, and in the
    Halls of Congress. But before we launch into the debate I wanted to
    invite you here to remind everyone that, as Hillary says, there are 250
    million health care experts in our Nation, and everyone has a different
    story.
        If you read some of these letters as I have, the picture very
    quickly becomes clear. Even the millions of Americans who enjoy health
    care coverage are afraid it won't be there for them next month or next
    year. They want us to take action to give them the security that all
    Americans deserve. Let's start then with four people whose stories speak
    volumes about our health care system.
        In order, they are Jermone Strong, Nelda Holley, Stacey Askew, and
    Margie Silverman.

    [[Page 1501]]

    [At this point, the participants read their letters.]

        The President. These letters are representative of tens of thousands
    that we received telling stories like the ones you've heard: people who
    can't go back to work, people who can't take job advancements, people
    who have no coverage because they're young and they're unemployed, all
    the other things that you have heard here.
        There is one particular problem in our health insurance system in
    America that I'd like to focus on by asking for two more people to read
    letters, something that's a part of the everyday vocabulary now of most
    working men and women in this country: the preexisting condition, the
    thing which if you have it you either can't get health insurance or you
    can never leave the job you're in. So I'd like to hear from two people
    from California and Illinois, Suzy Somers and Jean Kaczmareck.

    [The participants read their letters, and Hillary Clinton responded.]

        The President. Let me just say one thing about this to try to hammer
    home what I think is a very important point. All the stories you've
    heard today have nothing to do with the quality of American health care
    but everything to do with the system of insurance we have. And in the
    weeks and months ahead you may hear a lot of stories about that, but the
    bottom line is this: If you lived in any other advanced country in the
    world, you wouldn't have this problem, none of these problems. But it's
    not a reflection on our doctors, our nurses, our health care providers;
    it is the system by which we insure against risk. It can be different.
        I want to go on now to the next issue, because every time I say
    this, people say, ``Well, how are you going to pay for this? This is
    going to cost a fortune.'' I have an answer to that, but I want to hear
    from people who are talking already about the exploding costs of health
    care in this country. Next to the problem of security, we hear more
    about cost.
        And of course, Miss Holley talked a little bit about costs, and some
    of the rest of you did, too. But we have some people here who want to
    read letters. They're from Georgia, Pennsylvania, and California: Karen
    Nangle, Mary Catherine Flyte, and Brigitte Burdine. Would you please
    read your letters to us, or say what you'd like to say?

    [The participants read their letters, and Tipper Gore responded.]

        The President. I wish I could say something to each of you, but I
    want to hear the other letters. But let me just say one thing to you,
    Karen. One of the things that really has upset me now that I am at least
    nominally in charge of the Federal Government--I say nominally--is how
    many programs, like the Supplemental Security Income program, were
    designed with the best of intentions, but because we have this crazy
    little patchwork health care system with a little done here, a little
    done there, a little done the other place, a system that was designed to
    help your family is actually wrecking your health care plan--and one
    that works--and costing the taxpayers more money to boot. That's one of
    the things that we think, just by rationalizing the system, we can
    handle.
        One other thing I want to say to you, Brigitte. I want to make it
    clear, there will be some difficult choices in this decision. But let's
    not kid ourselves: There's a lot of waste in this system which we can
    squeeze out. But there will be some difficult choices, and your family
    represents one. And I want to just try to describe this to you.
        Most countries that insure people either directly by tax dollars or
    indirectly, as in Germany, through employers--and more and more American
    States that are looking at this are looking at something called
    community rating. Hawaii has had it since 1974, where 98 percent of the
    people in the work force are covered and they have lower than average
    overall premiums. But it's because they put all people in big, big
    insurance pools.
        Now consider this, in the case of your family, how much better off
    your family would have been if your sister could never lose her
    insurance, certainly as long as she was at work, and then if she wasn't
    she'd be picked up under a general system. Even though she got sick her
    employer would not have to worry about going broke by covering her under
    the insurance package because he or she and all the employees would be
    in a big, big pool, say, a couple of hundred thousand people. So if one
    person gets AIDS, it only adds marginally to the cost of this big pool.
    Same thing with you.
        Now, I just want to tell you what the tough choice is. The tough
    choice is that someone like you in the same pool, because you're young
    and healthy and strong and unlikely to get sick,

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    might have to pay a little bit more in insurance premiums so that
    everybody in the big pool could always be covered and no one would be
    kicked out. I think most young, healthy, single Americans would be
    willing to do that to avoid the kind of horror stories we've heard
    today. Same thing would have helped you.
        But I do want to say, there are a lot of things that can be done to
    this system, but I don't want to kid you, the American people will have
    to be willing to make some changes. And this is one change that we think
    most young Americans would like to make, because they are all presumably
    going to be older some day or going to be sicker some day. And that is
    one thing that I think we've just got to do. If we were all in these big
    pools, then you wouldn't have had half the problems you had, and your
    family would be better off.
        Let's go to the next issue that nobody in America understands this,
    the crisis of American health care, more than small businesses. Small
    business owners often have the worst of both worlds. They want very much
    to cover their employees, but they can't afford the coverage, again
    because they can't buy into large pools. Their premiums are much, much
    more expensive. So you have this situation where a lot of small
    businesses don't cover their employees. Then when they get sick, they
    don't get care until they are real sick and they show up in the
    emergency room. Or they provide coverage, but the deductibles or the
    copays are astronomical, often as much as $2,500 a year.
        So I thought we should hear from a couple of people who can share
    their stories, Mabel Piley from Kansas and Karl Kregor from Texas.

    [The participants read their letters. Mr. Kregor concluded by thanking
    his wife for having the courage to support his career change.]

        The President. I feel the same way about my wife. [Laughter]
        First, let me thank both of you for coming. And let me say that this
    is another one of these areas where I think a change can offer enormous
    hope and deal with the problems that you have outlined, but where we'll
    also have to take some disciplined, different action that will require
    some people to do more. And let me describe that.
        Most small business people, both employers and employees and people
    who are self-employed, do have some kind of health insurance. But it
    often provides inadequate coverage or has astronomical deductibles or,
    in any case, costs a fortune. You said that your premiums, I think,
    quadrupled in 3 years, from '89 to '92. Now, during that time the cost
    of health care was going up at about 2\1/2\ times the rate of inflation.
    But that would not lead to the amount of increase you had. You had that
    increase because you owned your own business and you were probably in a
    very small pool of people, probably 100, 200, 300, something like that.
        Under our plan, two things would help you. You would be in a very
    large pool with a community rating--the same thing that would help your
    sister and family--and also as a self-employed person, because you'd
    still have to pay relatively more, you'd get 100 percent tax
    deductibility for your premiums instead of 25 percent today. So it is
    almost certain that your costs would go down. It is certain. Your costs
    would go down. Under our system, what would happen to you is if you
    developed your own consulting business, you would become like Mable.
    You'd have 100 percent deductibility for your premium, and you'd be able
    to buy into a very large pool, just as if you were an employee in a
    company that had 5,000 people insuring its own employees.
        Now, the flip side of that is, the only way we can make that work is
    for the small business people today who don't provide any insurance
    coverage at all to their employees to make some contribution to the
    health care system and for the employees to do it.
        Now, it will be better than the present system because we're going
    to lower premiums for small businesses by putting them in big pools. I
    just explained that. We also propose to provide a subsidy to keep the
    premiums even lower for several years for the employers that have low-
    wage employees and therefore are very low-margin businesses.
        So we're going to try to help there. But you have to understand that
    all the employers in the country who don't provide any insurance to
    their employees, they basically are getting a free ride in some ways
    from the rest of you because if their employees or they show up at the
    hospital, it's there. It's just like driving on the road without paying
    a gas tax. I mean, the infrastructure is there. The clinics are there.
    The hospitals are there. The tests are there. The nurses are there. And
    until everyone is willing to make some contribution to his or her own

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    health care, and until we get all the employers in the system even at a
    modest rate, we won't have a fair system where we can apportion the
    costs fairly, and we can keep everybody else from being overcharged.
        So that's one of the most controversial parts of this program. But
    it is true that a lot of small businesses simply could not afford to get
    into the insurance market today without going broke. That's absolutely
    true. And since most jobs are being created by people like you who are
    starting small businesses, we know we can't afford to do that. But it's
    also true that a lot of big businesses can't afford to hire anybody else
    and always work their people overtime or hire part-time workers because
    they can't afford health insurance premiums because they're paying too
    much. It's also true that a lot of people who work for employers that
    have health insurance never get a raise anymore because all of the money
    is going to the health insurance premiums.
        I don't want to pretend that this is all going to be easy, but it
    seems to me that it is a fair thing to say: Everyone in America should
    make some contribution to his or her own health insurance. And all
    employers should make some contribution, but if they have a very low
    margin, we're going to subsidize them for several years while we work
    into this system. And if we do that and give you 100 percent
    deductibility and you 100 percent deductibility and put you in great big
    pools, then more Americans will live without the kind of blackmail that
    you just outlined. I think it is the only fair way to work it. It's the
    only way any other country has solved this problem. And I don't think we
    can reinvent this wheel.
        You've heard a little about this already because of the so-called
    preexisting condition problem, but there are literally millions of
    Americans who are locked into the jobs they're in. This is a very tough
    thing in a country where job mobility is important, and the average
    young American going into the work force will change jobs eight times in
    a lifetime. To be locked into a job at a time when many people who've
    lost a job here can tell you, you don't get that same job back, you have
    to get a new job, is a very, very hazardous thing.
        Judy Dion and Shelly Cermak are here to tell us about this problem
    with our health care system that's come to be known as job lock. They're
    from Maine and Maryland. Judy and Shelly.

    [The participants read their letters.]

        The President. We agree. And we don't think taking care of your
    beautiful, young daughter should keep you from ever taking a better job,
    either.
        The bottom line on this is that if we change the rules so that no
    one can be denied insurance coverage because of a preexisting condition,
    we also have to change the system so that no business goes broke for
    giving that insurance coverage. In other words, we can't afford to cut
    off our nose to spite our face. We have to make it possible.
        So again, what we hope to do is to give you the protection of
    knowing you can always have health insurance; that if you change your
    jobs, you'll be able to get it; that no one will be able to turn you
    down; but that your employer won't go broke, either, because they will
    be in these large pools so that the risk will be fairly spread across a
    significant percentage of the American citizenry. And it seems so
    simple. You must wonder why it hasn't been done before. But it's wrong
    not to do.
        And probably this and the cost issue will probably affect more
    Americans than any other single issue because a lot of you, even who
    have talked about other problems, are indirectly affected by this whole
    job lock issue. Also, it affects everybody in all kinds of different
    ways. So we must do this. We must do this.
        And let me also say that it's bad for the American economy. Every
    healthy person in America is disadvantaged if you two can't take a
    better job. Because when Americans with talents and gifts can't fulfill
    their God-given abilities to the maximum extent, then that makes our
    whole economy less productive, less competitive. It hurts everybody. So
    it's not just all the people who have your life stories. All the rest of
    us are really disadvantaged if you get locked into a job. Also, somebody
    coming along behind you who would get that job, and that's a better job
    than they have, those folks are disadvantaged, too.
        Let me just say in introducing the last set of letters that there
    are a lot of people in this system who are very frustrated by the
    incredible bureaucracy of the American system. It is the most
    bureaucratic health care system in the world of all the advanced
    countries. The expense is staggering. It probably costs at least a dime

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    on the dollar more in sheer paperwork than all competing systems. That
    not only has financial consequences; it has terrible personal
    consequences. We've found some people here who have been lost in that
    maze, and I wanted you to hear their stories.
        So let me ask now James Heffernan from Florida--I'm going to try to
    pronounce this right--Carol Oedegeest--close enough?--from California to
    read their letters, and the Vice President will respond.

    [The participants read their letters and Vice President Gore responded.]

        The President. Let me say that I hope all of you are familiar with--
    at least have heard about the Vice President's brilliant report on
    reinventing Government. And he's given us suggestions that will save the
    taxpayers $100 billion over the next 5 years, if we can implement them
    all, and free up that money to reduce the deficit or invest it in needed
    programs. But the health care system needs that, too. And our strongest
    allies in this, I think, will be doctors and nurses.
        To illustrate what he said, let me just give you two statistics with
    this nurse sitting here. The average hospital in America has hired
    clerical workers at 4 times the rate of health care providers in the
    last 10 years. Think about it. Another thing: In 1980, the average
    doctor took home 75 percent of the money that came into his or her
    clinic. They just took it home. By 1990, that figure had dropped from 75
    to 53 cents on the dollar, the rest of it going to paperwork. You wonder
    why the bills are going up? So this is a huge deal.
        I also want to thank publicly, I think--I've not had a chance to do
    this--I want to say a special word of thanks to Tipper Gore for being
    such an active member of the Health Care Task Force and being such a
    passionate advocate for the interests of the mentally ill and the
    interest that the rest of us have in dealing with it in a more sensible
    and humane fashion.
        And I'd also like to thank the First Lady for the work this task
    force has done, not only for receiving 700,000 letters but for meeting
    with literally 1,500 different interest groups and involving thousands
    and thousands of people in the health care system itself.
        In the months ahead, as we debate health care reform, you will hear
    numbers and arguments fly across America. I hope that this beginning
    will help us to remember that fundamentally this is about people, about
    all of you that have read your letters, about all of you who wrote us
    letters who are out here today whose letters couldn't be read. I invite
    all of you to speak to the members of the press who are here about your
    stories.
        I just want to thank you for coming and for having, particularly
    these people, for having the courage to tell us their personal story and
    to tell America their personal stories. We can do this. We can do this
    if we recognize that even though it's complicated, we can work through
    it, if we will listen to the voices of the real people who know it has
    to be better and different.
        Thank you very much.

    Note: The President spoke at 8:10 a.m. in the Rose Garden at the White
    House.