[Public Papers of the Presidents of the United States: William J. Clinton (1993, Book II)]
[September 20, 1993]
[Pages 1539-1543]
[From the U.S. Government Publishing Office www.gpo.gov]



Remarks to Physicians and Supporters on Health Care Reform
September 20, 1993

    Good morning. I thank you for coming here, and I thank Dr. Koop for 
his stirring remarks. He always makes a lot of sense, doesn't he? And 
the Nation is in his debt for his work as Surgeon General and now, for 
the work he is about to undertake in behalf of the cause of health care 
reform.
    I also want to thank the many physicians from all across America, 
from all walks of medical life who have made a contribution to the 
debate as it has progressed thus far. I got very interested in this 
subject years ago when, as the Governor of my State, I noticed I kept 
spending more and more for the same Medicaid and had less and less to 
spend on the education of our children or on preventive practices or 
other things which might make a profound difference in the future.
    In 1990 I agreed to undertake a task force for the National 
Governors' Association, and I started by interviewing 900 people in my 
State who were involved in the delivery of medical care, including 
several hundred doctors. Some of them are in this room today. I thank 
them for their contributions, and I absolve them of anything I do which 
is unpopular with the rest of you. [Laughter]
    I'm glad to see my dear friend and often my daughter's doctor, Dr. 
Betty Lowe, the incoming President of the American Academy of 
Pediatrics; my cardiologist, Dr. Drew Kumpuris, who pulls me off a 
treadmill once a year and tells me I'm trying to be 25 when I'm not--
[laughter]--and Dr. Morriss Henry from Fayetteville, Arkansas, back 
here, an ophthalmologist who hosted the wedding reception that Hillary 
and I had in Morriss and Anne's home almost 18 years ago next month; Dr. 
Jim Weber, formerly president of the Arkansas Medical Society. We 
started a conversation with doctors long before I ever thought of 
running for President, much less knew I would have an opportunity to do 
this.
    This is really an historic opportunity. It is terribly important for 
me. One of the central reasons that I ran for President of the United 
States was to try to resolve this issue, because I see this at the core 
of our absolute imperative in this sweeping time of change to both give 
the American people a greater sense of security in the health care that 
they have, and call forth from our people--all of our people, including 
the consumers of health care--a renewed sense of responsibility for 
doing what we all ought to do to make this country work again.
    I am determined to pursue this in a completely bipartisan fashion. 
And I have reached out to both Republicans and Democrats, as well as the 
thoughtful independents to help. There is one person in the audience I 
want to introduce, a longtime friend of mine who has agreed to help 
mobilize support for this approach among the Democrats of the country, 
the distinguished former Governor of Ohio, my friend Dick Celeste, who's 
here. Thank you for being here.
    When Dr. Koop talked about the ethical basis of this endeavor, he 
made perhaps the most important point. If I have learned anything in 
these years of public endeavors, or anything in the last several months 
of serving as your President, it is that once people decide to do 
something, they can figure out how to do it.
    When, one week ago today, on the South Lawn of the White House, 
Yitzhak Rabin and Yasser Arafat signed that peace accord, they did not 
even know what the ultimate map-drawing of the city of Jericho would be, 
or how all the elections would be held, or how the Palestinians' 
candidates would advertise on the radio since the radio stations don't 
belong to the Palestinians. I could give you a hundred things they did 
not know the answer to. They knew one thing, they couldn't keep going in 
the direction

[[Page 1540]]

they were going, and so they decided to take a different direction.
    When President Kennedy's administration challenged this country to 
go to the Moon, they didn't have a clue about how they were going to go. 
The Vice President knows more about science than I, so he can tell it in 
a funnier way about they didn't understand what kind of rocket they were 
going on and what their uniforms would be like and on and on and on. But 
the ethical imperative is perhaps the most important thing. We have to 
decide that the costs, not just the financial costs but the human costs, 
the social costs of all of us continuing to conduct ourselves within the 
framework in which we are now operating is far higher than the risk of 
responsible change.
    We have certainly tried to do this in a responsible way. I want to 
thank the First Lady and all the people who work with her. I want to 
thank Tipper and Ira and Judy and everybody who was involved in this. We 
have really worked hard to reach out to, literally, to thousands and 
thousands of people in this great medical drama that unfolds in America 
every day.
    I want to thank Donna Shalala and the Department of Human Services 
for the terrific work they have done. We have really tried to do this in 
an embracing and a different way, almost a nonpolitical way. If you look 
around this room, we have doctors from Maine to Washington, from 
Minnesota to Florida. Some of you see patients in rural Virginia, some 
in public hospitals, others of you devote your lives to training the 
next generation of physicians.
    But I think every one of you is committed to seeing that we provide 
the finest health care in the world. That means as we undertake this 
journey of change, we clearly must preserve what's right with our health 
care system: the close patient-doctor relationship, the best doctors and 
nurses, the best academic research, the best advanced technology in the 
world. We can do that and still fix what's wrong. In fact, we can 
enhance what's right by fixing what's wrong.
    If we reduce the amount of unnecessary paperwork and governmental 
regulation and bureaucracy, that will by definition enhance the doctor-
patient relationship. If we spend less money on paying more for the same 
health care and the incentives to churn the system, we will have some 
more money, for example, to invest more in medical research and advanced 
technology and breaking down the barriers which still limit our ability 
to solve the remaining problems before us. We need a discussion. We need 
constructive criticism. We need constructive disagreement on some 
points. This is a very complex issue.
    I worked at this for over a year and realized when I was a Governor 
I was just beginning to come to grips with it. When we started this 
great enterprise and I asked Hillary to undertake this task and she 
looked at me as if I had slipped a gasket--[laughter]--I knew more about 
it than she did. Now, she knows a lot more about it than I do.
    This is a learning effort. We are going to start today, as many of 
you know, this health care university, we call it, for Members of 
Congress, and about 400 Members of Congress have signed up for 2 
intensive days of learning. That is an astonishing thing. I have never 
seen anything like it: these Members, without regard to their party and 
completely without respect to the committees they are on, since most of 
them are on committees that would not have direct jurisdiction over 
this, hungering to know what you go through every day, hungering to 
learn, wanting to avoid making an irresponsible decision but determined 
that they should make some decisions to change this system. I think that 
is a terrific cause for hope.
    For patients, the reform we seek will mean more choices. Today, 
employers are too often forced by rising health care costs to decide 
which plans to offer their employees, and often they are inadequate or 
too costly. The decision is usually based on the bottom line, and is a 
moving bottom line as more and more Americans every month actually lose 
their health insurance for good. Our plans give consumers the power to 
choose between a broad range of plans within their region, giving them 
more freedom to find and to stay with a doctor they like.
    For doctors, reform will mean the flexibility to choose which 
networks or providers you want to join. If you want to be involved with 
one, that's fine. If you want to be involved with more than one, that's 
fine. So that whatever you want to do to continue to see the patients 
you see today, you will be able to do it. It's your choice.
    We intend to see a reform that drastically simplifies this system, 
freeing you from paperwork and bureaucratic nightmares that have already 
been well discussed. I cannot tell you how moved I was when we were at 
the Washington Children's Hospital the other day and

[[Page 1541]]

we heard not only the statistics that the hospital has calculated that 
they spend $2 million a year on paperwork unrelated to patient care and 
keeping up with the procedures, but the human stories. I mean, we had a 
nurse actually tell us about being pleaded with by a young child with 
cancer to play with the child, and she couldn't do it because she had to 
go to a little seminar on how to learn how to fill out a new set of 
forms that they were being confronted with, and she said, that really 
was a picture of what their life was like; an eloquent doctor who said 
she wanted to live in Washington, DC, she wanted to care for the poor 
children in the area. She did not go to medical school to spend her life 
poring over a piece of paper. And all of you have had that experience.
    We can do better than this. We also know we're going to have to trim 
back Government regulations that get in your way and do little to 
protect the patients or provide better care. If we simplify the system, 
we will reduce the apparently insatiable bureaucratic urge that runs 
through administrations of both parties and seems to be a permanent 
fixture of our national life to micromanage whatever aspect of tax 
dollars they have some jurisdiction over. We are determined to undo much 
of that. We want to respect your training, your judgment, and your 
knowledge and not unduly interfere with what you do.
    We also are determined to preserve the quality of health care that 
our people receive. Today, part of the reason we have the finest doctors 
in the world are the academic health centers. For years they have been 
the guardians, the guarantors of quality, training doctors and health 
care professionals and reaching into surrounding communities to provide 
help for those in need. In the coming years, these centers, if our plan 
passes, will have even greater responsibility to turn out high quality 
physicians, particularly primary care physicians who will work in 
underserved areas, and to create a system of lifelong learning for 
health care professionals. And they must continue to expand their 
partnerships with communities around them.
    The initiative I am offering offers the possibility of giving real 
building blocks to this Nation's health care system to fill in a lot of 
the gaps which exist for millions of Americans, not just universal 
coverage gaps but also organizational problems and the lack of adequate 
access.
    I want this plan to be fair, compassionate, and realistic, and I 
believe it is. Health security can be provided to the American people so 
that you don't lose your health care when you lose your job; you don't 
get frozen into a job because someone in your family has been sick and 
you're in the grip of the preexisting condition syndrome, which is 
literally undermining labor mobility in a world where the average 18-
year-old American must change work eight times in a lifetime to be fully 
competitive, when security means the ability to continuously learn and 
find new and evermore challenging work, not to stick in the same rut 
you're in anymore. We don't have that option. We are literally rendering 
people insecure through job lock, undermining their potential, keeping 
them from moving on, and also keeping others from moving up into the 
positions they previously held. This is a serious economic problem.
    This plan will guarantee that every patient who walks in your door 
is covered. It will make sure you are paid to keep your patients healthy 
as well as to treat them when they're sick. It will give you the 
flexibility and freedom you need to do your jobs. In return, it must 
demand more responsibility from all of us. We must have a new generation 
of doctors which has a recommitment to primary care. We don't have 
enough primary care physicians in America, and I think we all know it. 
We have to care about family practice, pediatrics, and preventive 
medicine. And we all have to work together to get medical costs under 
control.
    But I'm convinced with your leadership we can do that. Without your 
help, we could not have covered as much ground as we have covered so 
far. I thank Dr. Koop for what he said. But the attention to detail by 
this project is the direct result of the painstaking effort and the 
hours that have been provided by physicians and other health care 
providers who have come to this town and spent day after day after day 
after day almost always at their own expense just to do something to 
help their country as well as to improve the quality of their own 
practice. We know that this will not be done overnight. We know that we 
will have to have a long-term commitment from individuals, from 
Government, from businesses, and from health care professionals. But we 
know that we have to begin now. This is a magic moment.
    Let me just say two things in closing. There are a lot of other 
things we haven't discussed, and I know that, but we didn't come here 
for

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a seminar on the details of it. We are trying some innovative approaches 
to the malpractice problem, which I think will find broad favor. We are 
going to do some things that will increase public health clinics' 
ability to access people who are otherwise left out of the system and 
try to deal with these horrible statistics on immunization and the 
absence of prenatal care. There are a lot of those things that are going 
to be dealt with.
    But I want to make two points in closing. First of all, there are a 
lot of disconnects as you might imagine between Washington, DC, and the 
rest of America, which everybody loves to talk about when they get 
alienated from the Federal Government. But one of the most amazing in 
this has been the following thing: I don't talk to any doctor or any 
hospital administrator or any nurse with any seniority in nursing who 
doesn't believe that there's a huge amount of waste in this system, that 
has nothing to do with caring for people, which can be gotten rid of. I 
don't talk to anybody in Washington who thinks you can do it. [Laughter]
    Our friends in the press are laughing because you know I'll finish 
this talk, then they'll go talk to somebody on the Hill who will say, 
``Aahh, they can't save that money in Medicare and Medicaid. It's got to 
be that way. We really need a room under the garage in the Children's 
Hospital in Washington, DC, which is piling up paper 6\1/2\ feet a day. 
We've got to have that. How would we function?''
    Hillary goes to the Mayo Clinic; they've already got their annual 
average cost increases now down under 4 percent. And we talk about, you 
know, maybe getting it down over the next 3 or 4 years to inflation plus 
population plus 2 percent, and they talk about how we are slashing 
Medicare and Medicaid, when what we really want to do is take the same 
money and not take it out of health care, but use it to cover the 
uninsured, unemployed, use it to cover some new services to do more 
preventive primary health care. So this is an interesting thing. Dr. 
Koop said: In the past, reform has been imposed on the doctors. You 
might have to come up here and impose it on the politicians and the 
bureaucrats. You may have to do that.
    I say that not to be critical of the Congress. We are all--all of us 
see the world--[laughter]--no, no, no, I don't--all of us see the world 
through the prism of our own experience, don't we? You do. I do. We all 
do that. And they are so used to believing that the only way they can be 
decent stewards of the public trust, to take care of the poor on 
Medicaid and the elderly on Medicare, they are so used to believing that 
the only way they can do it is just to write out a check to pay more for 
the same health care, never mind if it's 2 or 3 or 4 times the rate of 
inflation; never mind if there's a 16-percent increase in the Medicaid 
budget for the coming year, when we estimate no more than a 2-percent 
increase in the enrollments in Medicaid.
    We're just so used to believing that in this town that we have to 
have your help to believe that it can be different, and you can enhance 
the care people get, not undermine it. I don't want to minimize that. 
Yes, we need your critical scrutiny of the specific plan the 
administration will propose. Yes, we do. But we also need for you to 
convince the people who live here, who believe we are trapped in this 
system, that it can be different. And you are the ones who have 
responsibility for caring for people. If you can believe it can be 
different, you can convince the Congress that it can be different, that 
they are not going to hurt, they are going to help by making some of 
these changes.
    The second point I want to make in closing is this: This is really a 
part of a great national discussion we have to have about what kind of 
people we are and what kind of country we're going to be. And Dr. Koop 
said it better than I could, but we can't really get the kind of health 
care system we need until there is a real renewed sense of 
responsibility on the part of everyone in this system. It is terribly 
important to recognize that we have certain group behaviors in this 
country that, unless they are changed, we will never get health care 
costs down to the level that our competitors have.
    It's not just high rates of AIDS and excessive smoking; it's high 
rates of teen pregnancy, of low birth weight, of poor immunization of 
children. It's outrageous rates of violence that we willfully refuse to 
deal with by taking away the main cause of it, which is the unrestricted 
access that young people in our most violent areas have to guns that 
give them better weapons than the police.
    Yes, within the health care system, doctors shouldn't perform 
unnecessary procedures, patients shouldn't bring frivolous malpractice 
suits, people who use the health care system now, who aren't in it now, 
are going to have to pay

[[Page 1543]]

a little for their health care, so they realize there is a price for 
everything instead of when all of the money just comes from a third-
party source they don't know. There needs to be more responsibility 
within this system but we also have got to remember that if we can plant 
the ethical roots that Dr. Koop talked about, we may then be able not 
only to change this system but to use this success to try to change some 
of the destructive group behavior that is tearing this country apart.
    But believe me, it all begins here. If we can give the security of 
decent health care to every American family, it will be the most 
important thing that the Government has done with--not for but with--the 
American people in a generation. And it can only happen if people like 
you lead the way.
    Thank you very much.

[At this point, Hillary Clinton invited participants to breakfast.]

    Q. Mr. President, is Senator Moynihan wrong?
    The President. [Inaudible]--you heard what he said yesterday? What 
he said was absolutely right. I mean, based on the experience of the 
last decade, you can't get the cost down to zero, but that's not what we 
proposed. We proposed working over a 5-year period to move the 
Government's cost to inflation plus population growth. And in the 
beginning--we have inflation plus population growth plus another 2 or 3 
percent. Where this group care is working well, like at the Mayo Clinic, 
they now are down to less than inflation plus population growth. So I 
believe that if you give us 5 years to do it, we can get there. But it 
will require some substantial changes.
    What I said was true. People in Washington can't imagine that it can 
be different because of the experiences they've had over the last 5 
years. But to say we're trying to cut Medicare and Medicaid, it's not 
true. We propose never to take it below inflation plus population 
growth.

Note: The President spoke at 8:45 a.m. in the East Room at the White 
House. In his remarks, he referred to C. Everett Koop, former Surgeon 
General; Ira Magaziner, Senior Adviser to the President for Policy 
Development; and Judith Feder, Principal Deputy Assistant Secretary for 
Planning and Evaluation at the Health and Human Services Department. The 
exchange portion of this item could not be verified because the tape was 
incomplete.