[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

[[Page 1503]]

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

[[Page 1504]]

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.