[Public Papers of the Presidents of the United States: William J. Clinton (1994, Book I)]
[March 8, 1994]
[Pages 395-401]
[From the U.S. Government Publishing Office www.gpo.gov]



Remarks to the American Society of Association Executives
March 8, 1994

    Thank you very much, Bob, for that fine introduction. Thank you, 
ladies and gentlemen, for the warm welcome. This is the biggest stage 
I've been on in quite a while. I'm told it's so big because you're 
having the Oak Ridge Boys tonight. That made me wish I'd been invited 
later instead of earlier. [Laughter] I want to thank your president, 
Bill Taylor, for the invitation to come here and Bob Elsner for that 
fine introduction, especially what he said about health care. I guess if 
it were easy, it would have been done a long time ago. I look out in 
this crowd and see many friends of mine from across the country. I saw 
my good friend Neil Offen, the president of the Direct Selling 
Association, a minute ago. And I've already spotted five or six people 
in the audience that I've known for years. I thank you all for inviting 
me here and for giving me a chance to talk about health care today.
    I'd like to just begin by trying to put this very briefly in the 
context in which I view it as your President. I think my job is to do 
everything I can to help every American reach his or her God-given 
potential and to try to bring the American people together to make our 
country stronger. In other words, even though you often don't read about 
it in these terms, the real purpose of our political system, when it's 
working properly, is to get people together and to get things done.
    In the last year, we have been able to bring the deficit down, keep 
interest rates down, see economic growth come back into this country.

[[Page 396]]

In the last 3 months of last year we had the highest growth rate in a 
decade, the biggest increase in productivity from American workers in 8 
years. If our budget is adopted, the one I have presented to the 
Congress, we'll have 3 years of decline in the Federal deficit for the 
first time since Harry Truman was President and the first real reduction 
in discretionary nondefense spending since 1969, if this budget is 
adopted. At the same time, we're moving the money around so we'll be 
investing more in Head Start, more in medical research, more in new 
technologies to support defense conversion and to rebuild the American 
economy. We are beginning to turn this situation around and to make this 
Government work for the American people.
    But this year we have a lot of other challenges we are facing. The 
Congress is working on a very important crime bill to put more police 
officers on the street, to stiffen penalties appropriately, to provide 
alternative punishments to first-time youthful offenders, to provide 
some ways for kids to stay out of jail, to take assault weapons off the 
street. They're doing a lot of important things. That's a big issue. And 
the Congress is dealing with that as we speak.
    The Congress will take up welfare reform, a subject on which I have 
worked for well over a decade now. And I hope they finally will make 
welfare a second chance, not a way of life, for all Americans and enable 
us to bring children up in a better fashion. The Congress is going to 
have a chance now to finally pass a campaign finance reform bill, which 
will increase the confidence of the American people in the way we do our 
business here, and a lobby reform bill.
    There are a lot of issues out there. But I can tell you that if over 
the long run we expect the American people to be a stronger community, 
if we expect our economy to have the funds necessary to invest in the 
growth opportunities of the 21st century, and if you want your Federal 
Government to be able to respond to the challenges of today and 
tomorrow, we must address the health care crisis. It is not just a 
problem for individual American workers and families, it is a problem 
for the Federal budget and for the national investment patterns.
    I can tell you, just to give you two examples, in addition to the 
fact that almost every American, at least those who don't work for 
larger businesses or for the Government, is at some risk of losing his 
or her health insurance or of having the inability to change jobs 
because someone in the family got sick, and almost every small business 
is at risk of having their premiums explode or their deductibles and 
copays explode, you also should know that this is a serious competitive 
problem for us. We are spending 14.5 percent of our income on health 
care. The Germans are just a little bit over 8 percent of their income. 
That's about where the Japanese are. Only the Canadians are at 10 
percent of their income. If you think about spotting our competitors 
5\1/2\ cents on every dollar spent, that is a significant issue. And 
almost all of you represent a group of business people who have 
personally experienced that. And as this economy becomes more global, 
that will become more relevant.
    Now, should we spend more money than other countries on health care? 
I would argue we should and we must, because we invest more in medical 
research and technology. And we lead the world in that, and that 
generates jobs, opportunities, and incomes. We have these great academic 
health centers. Every American, just about, would be happy to pay a 
premium for that. Must we spend more? The answer to that is, yes, we 
must; as long as we have higher rates of violence and AIDS and teen 
pregnancy than other countries, we'll have higher bills. Does that 
account for all of the difference? Not even close. Not even close. A lot 
of it is directly related to the way we finance health care.
    The second big problem you should know is this: In the budget we are 
adopting, we are cutting defense this year for the first time since 
1969. If my budget's adopted, we'll cut nondefense spending. Social 
Security will go up, but only by the rate of inflation, and it's paid 
for by the Social Security taxes, which are in surplus. We'll have to 
pay more on interest on the debt as it accumulates, although not as much 
as we would if interest rates weren't low. The only thing in this whole 
budget that is really going up by more than the rate of inflation in the 
Federal budget is health care costs, 2 and 3 times the rate of 
inflation. And if we don't do something about it, then the rising cost 
of Medicare and Medicaid will mean that 2 or 3 or 4 years from now, none 
of you, no matter whom you represent, will be able to come to Washington 
and say, ``How about a new airport, how about a new port, how about a 
new highway program? How about a new technology investment? How are you 
going to

[[Page 397]]

keep up with our foreign competitors in the seven, eight areas of new 
technology that will control the future?'' because we will be spending 
all of the money you give us in revenues on health care, while we cut 
everything else.
    This is a huge problem. And I believe that after 60 years of false 
starts, we actually have an opportunity to do the right thing, that is, 
to give every American and every American family health security and 
have it be the right thing for the American economy and for the future 
of the United States.
    For individuals, health security means freedom from fear and the 
freedom to prosper and the freedom to make choices that now are becoming 
narrower and narrower for most Americans in health care. For the Nation, 
it means the ability to bring health care costs within inflation, to 
have the chance finally to control the deficit, and to allow many 
businesses now struggling with this problem to be able to invest, to 
become more productive without having to make the decision to basically 
terrify their own employees by cutting back health care so much. Is this 
an easy problem? No. Does anybody have all the answers? No. If it were 
easy and someone had all of the answers, it would have been done before.
    You represent more than 22,000 members who serve millions of 
Americans, tens of millions of Americans, engineers and teachers, 
pharmacists and farmers and bankers and Red Cross volunteers. Those are 
the kind of people served by the American Society of Association 
Executives. Next year you will turn 75, and for three-quarters of a 
century you have shown the importance of representation, of what can be 
done when people honestly seek to represent the genuine interest and 
feelings of their members and come together in a spirit of fairness and 
openness and try to achieve a common goal.
    Well, I feel that I almost ought to be a member of this group. I 
could have a little tag that said the ``Association of All the American 
People.'' [Laughter] And the members of my group want us to deal with 
the health care problem, and we're trying to do it. The American people 
want health care to be there when they need it, and they want it to be 
there at a reasonable price. That's what health insurance used to mean, 
what it can mean again.
    I know that because of the opposition of various interest groups and 
because some of them have changed their position under withering 
political heat, there are some who have already said, ``Well, we won't 
get health care reform; yet again, the people against it will prevail.'' 
Well, I say to the naysayers and the pessimists that, not quite so fast. 
I have seen a lot of endeavors in which I was involved over the last 15 
years given up for dead, including my own endeavors, political 
endeavors. But it's a funny thing about our system here in America. The 
American people and their representatives, in the end, more than half 
the time, do the right thing when given the chance. Congress is starting 
today. I don't know how many Members of the Congress I've had tell me 
privately in the last week that they are actually becoming more 
optimistic that we will get a genuine health reform bill out that will 
provide health security to all Americans.
    The reality is, and everyone knows this, that while we have the best 
health care in the world, people who have health insurance today might 
not have it tomorrow. People who can afford it today might not be able 
to afford it tomorrow. People who have choices with which they are 
satisfied today might lose all those choices tomorrow. Preexisting 
conditions today leave 81 million Americans at risk. It means they can 
be denied coverage or their rates can be raised or they can't leave the 
job they've got for a new one because they won't be able to carry 
insurance with them.
    A lot of you represent small businesses. A lot of people would like 
to leave a bigger business and start their own business or might want to 
seek a better career opportunity that is in a smaller business than the 
one in which they are in. But if they have some member of their family 
that's been sick, they're literally trapped where they are, and they 
cannot do that. Three out of four Americans have lifetime limits on 
their policies which means that, for many of them, they can lose their 
coverage just when they need it the most. Two million families lose 
their health insurance every month, 100,000 of them permanently. We've 
seen an increase in the number of Americans without health insurance 
from 37 to 39 million just in the last 2 years.
    The health care we have is good, if we can get it. But the health 
care financing system does not serve the American people well. It is 
broken. It is unfair. It leads to massive cost-shifting. It leads to, by 
far, the biggest paperwork burden of any health care system in the 
world. And

[[Page 398]]

I would like to say in simple terms what I believe we should do to fix 
it.
    First, we should guarantee private insurance to every American. 
Second, we should guard the right to choose a doctor and improve the 
quality of health care plans. Third, we should limit how much insurance 
companies can raise rates based on whether your business is large or 
small or you work for the government, whether you're older or younger or 
whether someone in your family has been sick. And we should make it 
illegal for people to drop others. But we must set up a system in which 
insurance companies themselves will not be forced into bankruptcy if we 
make it illegal to drop them, which is why it is important for people to 
be able to be insured in large pools. Third, we want to protect and 
improve Medicare and health care for older Americans. Fourth, we want to 
provide benefits through the workplace, because that's where 9 of 10 
Americans who have insurance already get it.
    Now, that's the approach. It's not complicated, although millions 
have been spent to make people think it is complicated; it is not all 
that complicated. It uses what works today to fix what's wrong today.
    I know that a lot of people have seen this health security card. 
Don't leave home without it. [Laughter] But if you know how to use a 
credit card or a bank card or a Social Security card, people can figure 
this out. Under the system we have proposed, every American would get a 
card which stands for not a Government program but guaranteed private 
insurance and private health providers. The card would permit every 
American to choose a health care plan, to choose a doctor, to fill out 
one simple form, and to get health care for a whole year. And at the end 
of the year, Americans would be able to pick another plan or stay with 
the same plan or make a different decision. It would not stop any 
American, over and above that, from paying another private physician for 
some other service if that was desired. It would, in other words, give 
more choice than half the American work force has today in their health 
care plan.
    Beginning by guaranteeing private insurance for all means that 
everyone must be covered. That's not only the only way to guarantee 
security, it's the only way to stop cost-shifting. As long as an 
insurance company can deny coverage or drop from coverage, then no one 
is really secure, and some Americans will have to pay the price for 
other Americans' health care because those who don't have insurance will 
eventually get health care when it is too late and too expensive, often 
at an emergency room. And then the cost will be passed on to all the 
rest of you who are paying for your health care right now in the usual 
way.
    That is why I have said that I cannot sign and, indeed, would have 
to veto a bill that pretended to reform the health care system without 
providing a system by which everyone is covered. Because unless everyone 
is covered, there is no cost control, there is no end to cost-shifting, 
there is no real security, and there is no balance in the system. We are 
the only country in the world that hasn't figured out how to do this 
with an advanced economy, and we ought to be smart enough to do it. I 
mean, basically when I see all these ads that say we can't do it, I say, 
these people are telling me my country is dumber than these other 
countries. I don't believe that. Or they are telling me that the price 
of having great health care and great teaching hospitals and great 
medical research and extraordinary technology is that you have to have 
some people who don't have anything and all the rest of us have to pay 
for that besides. I don't believe that. That cannot be true.
    The benefits package ought to be comprehensive enough to encourage 
primary and preventive health care because that saves money over the 
long run. That's a very important part of this. You think about it: 
Immunizations, mammograms, physicals, prescription drugs, all those 
things actually avert our health care costs when properly done and keep 
us healthier. We spend too much time in America treating people when 
they are sick and not enough time keeping people healthy in the first 
place.
    Secondly, we want to preserve and enhance choice as the best 
guarantee that the quality of American medicine will remain the best in 
the world. People should be able to choose on their doctors and their 
health care plans; it guarantees quality. Under our proposal now, 
everyone would have a chance to make at least one from among three 
choices, at a minimum, every year. You could choose traditional fee-for-
service medicine; you could choose an HMO, for example; you could choose 
a preferred provider organization that physicians and others organized 
themselves. But every year you would be given the chance, once again, to 
make that choice under our proposal. This is important. More and

[[Page 399]]

more people under the pressures of the present system are living with 
shrinking choices. And a lot of people are quite properly worried that 
those shrinking choices will not only interfere with their choice but 
will interfere with the quality of health care.
    There have been a lot of articles written in thoughtful publications 
in the last few months pointing out that choice is a rapidly vanishing 
facet of American health care today, and that in fact the attack on our 
plan as limiting choice is simply not true; that by guaranteeing at 
least three choices and that you get to make a decision every year 
again, that we are building into this system a higher level of choice 
and therefore a guarantee of competition and quality that otherwise 
would not be the case.
    Now, the other thing that I want to say about this system is that 
affordable insurance should be there and should not be able to be taken 
away. That's why we want to make it illegal for rates to be raised 
unreasonably or for coverage to be dropped based on age or previous 
condition of illness. And we know that in order to do that and be fair 
to the private insurance companies, we have to let people be in large 
pools. That is, this is what all of you know as community rating. That's 
the only way you can guarantee that small businesses and self-employed 
people and farmers, for example, through some sort of cooperative 
system, can have access to the same good rates that people in big 
business and Government do, still have community rating, not 
discriminate against the old, not discriminate against the worker who's 
had a sick child or a spouse with cancer, and not bankrupt the insurance 
companies. If they're going to be able to be a part of this, you have to 
have some system of community rating.
    These steps are very important. They put the control of the health 
care system of America back into the hands of the American people on the 
one hand and health care providers on the other. Today, the control is 
determined by the financing, and it is in the hands of the insurance 
companies. And very often they do what they do because of the way we are 
all organized and divided, so that even if they don't want to do 
something that has a harmful effect, the economics of their business 
dictate it because of the way the system is set up.
    We can't permit that to go on anymore. The American people should 
have the power to choose. The American health care providers should have 
the power to deliver. There should be incentives to control cost through 
competition and requiring people to take some responsibility for their 
own health care. But it should not be organized the way it is now so 
that the people who are providing the financing in the middle have all 
the control and themselves are in a position not to make it fairer for 
many people. We cannot have the security of millions of our people in 
jeopardy, with a system that they are basically satisfied with when they 
have it but which could vanish overnight.
    Another thing I want to say, because there have been a lot of 
questions about this, is that there's another part of our system we 
shouldn't mess up: Medicare is one of the best things about American 
health care because it works and has very low administrative costs, 
providing health security for millions of older Americans. The question 
is, how do we keep Medicare healthy as our population gets older? The 
fastest growing group of Americans in percentage terms are people over 
80--hope to be one of them before long. [Laughter]
    But how are we going to do that? How are we going to take care of 
our own as health care costs keep rising? We believe that we have to 
keep Medicare but that we have to recognize that the present system is 
heavily tilted toward institutionalized care which will (a) not be 
necessary for some people and (b) which will be explosively expensive as 
the percentage of our people living in higher age brackets goes higher 
and higher and higher. So our system, number one, covers prescription 
medicine along with Medicare, which Medicare doesn't do now--because we 
believe there is ample evidence that that keeps people healthier and 
will save money over the long run; a year's worth of medicine might cost 
the same thing as a day or two in a hospital--and secondly, by beginning 
to phase-in a long-term care system where we give people some help for 
making noninstitutional choices, for keeping their parents at home or 
finding adult day care centers or having in-home care. Because 
otherwise, you're looking at a population, by the turn of the century 
and the end of the first decade of the next century, which we simply 
cannot afford to maintain and would be bad for our country, unless we 
have more different options to deal with this rapidly aging population.
    So under our proposal, if you get Medicare you keep it, which also 
includes the doctor of

[[Page 400]]

your choice and medical security. We achieve some savings in the 
Medicare program by bringing the rate of inflation in Medicare down to 
twice the rate of normal inflation. When you hear there are all these 
cuts in Medicare, don't believe it. We're just going to bring the rate 
of inflation down to twice the normal rate of inflation and take those 
savings to pay for prescription medicine and to pay for the beginnings 
of a new and more comprehensive long-term care system. This is, again, 
terribly important. We cannot do anything to mess up health care 
security for older people. But we must strengthen it.
    Finally, I think we should guarantee these benefits at work. And 
this is, after all, among the organized folks the most controversial 
decision of all. Nine out of ten Americans who have private insurance 
get it at work. Eight out of ten Americans who don't have any insurance 
have someone in their family who works. Expanding the present system 
lets us reach out to most of the uninsured and is based on shared 
responsibility. It is the easiest and simplest way to accomplish the 
goal. It's also the right thing to do. You can never stop cost-shifting 
until everybody's got insurance.
    Consider this--I just mentioned welfare reform earlier--if we take a 
welfare mother with two little kids who says, ``I hate welfare, and I 
want to get off of it, and I want to support my children,'' and you give 
that fine person job training, and then the woman finds a job. And she 
goes to work for a small business at an entry-level pay slot, because 
she got a very limited education, and no health care benefits at the 
office. And that woman goes from getting a welfare check to getting a 
paycheck; she begins to pay taxes. She is now paying taxes for someone 
who made a different decision, who stayed on welfare to keep getting 
Medicaid, the Government-funded health care program for poor people, 
which she has given up to go to work. That, by the way, is the central 
reason that we're having some difficulty moving people from welfare to 
work. People don't want to hurt their children. Again, this is a system 
that no other country has. So we have to find a way to do it.
    Now you say, well, but it's really tough on restaurants who have a 
lot of young people who are healthy and who don't want to pay for health 
insurance anyway. Or it's tough on people who have a lot of part-time 
workers. Some do and some don't; UPS has over 100,000 part-time workers 
and insures them all. But you say, it's tough on businesses with part-
time workers, and it's certainly tough on small businesses that are 
eking by. But that is why we reasoned that if we do this, we have to 
give substantial discounts for small businesses with low average 
payrolls, low profit margins, difficult times. There are big discounts 
written into this bill for just that purpose. And the self-employed, for 
the first time, under our bill, get 100 percent tax deductibility, not 
limited tax deductibility as they do now. These things will make this 
insurance more affordable, plus which, if small businesses and self-
employed people are in larger pools, they will not be paying higher 
rates as they do now.
    One reason small business people have to either not cover their 
folks or reduce coverage every year is that the average small business 
premium is 35 percent higher than the average government premium or big 
business premium. And you can't blame people for doing something in the 
face of those kinds of economics.
    Another reason is, as a restaurant owner told me--the other day I 
was in Columbus, Ohio, and this restaurant owner said to me, ``Look, I'm 
getting the worst of all worlds. I have 20 employees full-time and 20 
part-time. And I was sick 5 years ago, so our rates went up.'' It was an 
eating establishment. She says, ``I cover my 20 full-time employees. I 
don't cover the part-time employees. I feel guilty that I don't cover 
the part-time employees and mad that my competitors don't cover the 
full-time employees, and I'm having to pay higher rates because we had 
one person, me, in our group of 20 that was sick.'' So the rates go up, 
and the deductibles go up. She said, ``I'm getting the worst of all 
worlds, too high insurance, my competitors have an advantage because I'm 
covering my employees and they aren't covering theirs, and I feel just 
terrible that the part-timers don't get any insurance at all.'' She 
said, ``I would gladly do it all if everybody were treated the same way 
and we had access to competitive rates.''
    So I would argue that this is still the fairest and best way to make 
sure everyone is covered, discounts for smaller business, full 
deductibility for the self-employed, and a system which permits us to 
overcome the discrimination in rates that small business endures today.
    So again, this is a private health care system; it builds on what 
has worked; it is not more Government and more bureaucracy. It uses

[[Page 401]]

what's right about the American system, the health care, and fixes what 
is wrong, the financing. It guarantees permanent private insurance, 
safeguards the right to choose a doctor and a plan, limits how much 
rates can be raised because of categories and makes it illegal for 
people to be dropped, protects and improves Medicare and the health care 
of senior citizens, and provides health benefits to the workplace.
    Now, the largest associations of America's family physicians, 
pediatricians, nurses, and pharmacists have supported this health care 
plan. Our approach was not designed to hurt anyone. It did have to make 
some difficult choices. It was designed for the American people. It was 
about giving life to our best values and dealing with one of our biggest 
problems. It was about giving families who work hard and do their best 
to raise their kids the security they deserve; stopping people from 
paying more because of the irresponsibility of others; stopping a 
situation in which 8 million older Americans, every month, who are not 
poor enough to be on the Medicaid program but are on Medicare and have 
to have medicine every month, 8 million, choosing between food and 
medicine. It was, in short, about dealing with a problem that is only 
going to get worse unless we fix it now and doing it in a way that does 
not interfere with what is finest about our health care system. It's 
about, ultimately, the freedom of the American people to be free from 
fear, the freedom to preserve choice, the freedom to preserve quality, 
and the freedom to grow and prosper into the 21st century, putting our 
values to work and believing that it is irrational to say that we can't 
do something that our competitors have figured out how to do.
    That's why I think this year we will give every American the freedom 
that only real health care security can mean. I would encourage you to 
participate in this outreach, to respond to your communities, the people 
you honorably represent, not to agree with every jot and tittle of 
everything in the plan we have presented. If we involve thousands of 
people and work for months and we know how complicated this is, but the 
basic things we have to do are fairly simple and straightforward. And we 
ought not to be in a great political campaign to maneuver symbols here. 
We ought to be involved in a great national debate of the American 
family to produce results that will genuinely solve this problem.
    And so, my fellow Americans, let me end where I began. You represent 
an awful lot of the American family. You know how the people you 
represent would be affected by certain changes that were made. The 
Congress is beginning to debate in earnest. I ask you to support health 
security for all Americans. I ask you to support doing it through the 
workplace. I ask you to support preserving Medicare and preserving 
choice and giving small business people and self-employed people a 
break. I ask you to support those things. I ask you to enter into this 
debate and help us to fashion a plan that will meet those objectives. I 
ask you to do it with a good spirit, with a fair heart, with a sense of 
commitment to this, because you cannot succeed over the long run with 
the particular objectives of your group and we cannot succeed over the 
long run as a whole people unless we face this.
    If we had done it earlier, it would have been less complex and 
easier. We'd still have problems with the health care system, the 
problems with this never go away in any country, but at least it would 
not have us by the throat, financially and emotionally. We can do this, 
we can do it this year, and we ought to do it. People like you will 
speak not with one voice on the details, but with one voice on the 
urgency of the mission.
    Thank you very much.

Note: The President spoke at 10:50 a.m. at the Washington Convention 
Center. In his remarks, he referred to Bob Elsner, chairman, American 
Society of Association Executives, and country music entertainers the 
Oak Ridge Boys.