[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

[[Page 1550]]

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

[[Page 1551]]

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

[[Page 1552]]

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.