[Public Papers of the Presidents of the United States: William J. Clinton (1994, Book I)]
[April 5, 1994]
[Pages 571-575]
[From the U.S. Government Publishing Office www.gpo.gov]



Remarks in a Health Care Roundtable and an Exchange With Reporters in 
Troy, North Carolina
April 5, 1994

    The President. We just completed kind of a brief tour of the 
hospital, and I met some of the nurses and patients and people who work 
here. We talked a little bit about the physician shortage in this 
county, a little about the problems with delivery of babies and the high 
rate

[[Page 572]]

of teen pregnancies, low-birth-weight babies, relatively low number of 
prenatal visits. We talked about some of the reimbursement problems of 
Medicare and Medicaid and the problem that this hospital has at the 
emergency room because they take everybody whether they have insurance 
or not. And I think that's a fair summary--and I met the wonderful, 
dedicated people. So why don't you lead off.
    Harold Scott. Thank you, sir. I want to let Mr. Bernstein give us an 
overview of Montgomery County medicine and how it relates to the rural 
problems overall.
    The President. I think it would help for the press that are here, 
just the first time you speak, if you would say your name and why you're 
here.

[At this point, Jim Bernstein, director, North Carolina Office of Rural 
Health, and president-elect, National Rural Health Association, 
discussed the development of a community corporation within Montgomery 
County to provide rural health care and stressed that health care reform 
must address the urban-rural discrepancy.]

    The President. Thank you very much. I also think--I was reminded on 
the tour that North Carolina actually has a program to provide subsidies 
for the malpractice premiums of practitioners who deliver babies and do 
things in rural areas that they normally wouldn't do in urban areas. Is 
that right?
    Jim Bernstein. Yes. We have a lot of incentives in place in the 
State; one is that one. Another one--State hasn't done which is really 
good--Arkansas might do it, I understand--is that we pay our residents 
more money if they'll go into rural areas and give them higher salaries. 
And then we do the usual things like loan repayments, things like that. 
And we have, also, a statewide area health education center program 
trying to bring continuing education to keep people current in Troy and 
places like that.
    The President. That's very important. In this plan--I just wanted to 
mention this, because I think it's important--as the Congress debates 
this whole health care issue, the things which get the largest amount of 
attention, as they would expect, are how to provide universal coverage 
and whether you can maintain choice and quality with universal coverage, 
and a lot of these big questions. But what a lot of people don't know is 
that in rural America, even if you cover everybody, a lot of folks still 
don't have adequate access to health care, and there's a real doctor 
shortage out there. And no matter what happens, I hope the Congress will 
leave in the provisions of our plan, which have--one, would expand the 
National Health Service Corps by 7,000 doctors over the next 8 years; 
two, would give physicians who go into underserved rural areas tax 
credits of $1,000 a month, 5 years, which is a huge incentive; and 
three, would allow a much bigger, faster writeoff of equipment, medical 
equipment that doctors might bring into rural areas. So I think those 
three things will really help to reinforce what you're doing.
    Mr. Scott. Mr. President, Dr. McRoberts is one of our three 
practicing family physicians in the county. Our ratio of family practice 
physicians to population is almost one to 8,000.
    The President. One to 8,000, and what's the recommended ratio?
    Dr. Deborah McRoberts. Well, to qualify as a health profession 
shortage area, it would have to be about one to 3,000, correct?
    Mr. Bernstein. But you want to be at one to 2,000.
    The President. One to 2,000 is what you should have, right?
    Dr. Hugh Craft. Yes.
    Dr. McRoberts. What we should have. And I have 8,000 active patients 
in my practice right now.
    The President. Eight thousand?
    Dr. McRoberts. I have over 8,000.
    The President. When was the last time you slept?

[Dr. McRoberts described working an average of 100 to 110 hours a week 
during flu season and 80 hours a week normally while always facing 
unfinished paperwork, but affirmed her dedication to practicing rural 
medicine.]

    The President. What's the most important thing that could be done to 
make your life easier? More doctors?
    Dr. McRoberts. More doctors. I mean, definitely. We are at such a 
critical shortage of doctors right now, with only three family 
practitioners. And our draw area, the population that we draw from, is 
about 28,000 people.
    The President. And what would be more likely than anything else to 
generate more doctors in this area? What could be done by the county or 
by----

[[Page 573]]

    Dr. McRoberts. I don't know. That's the big question mark. What will 
it take to get doctors to come here? I think you have to look for things 
like loan forgiveness, certainly, or low repayment programs for the 
residents that are coming out, because that way you can get fresh, young 
blood, you know, people that aren't tired yet.
    The President. It doesn't take long to get that way.
    Mr. Bernstein. This sounds a little trite, because it's a big 
question. But for 30 years we've rewarded high-tech people and health 
professional people and basically didn't pay primary care people. And I 
know money is not the single most important thing, but it is important. 
And so, if the reform plan could move to reverse that, somehow the 
incentives would be not only loan repayment and stuff like that, but 
somebody who worked here could make as much money as somebody who 
worked--even if it had to be paid more to get to that level than in 
Charlotte--we would be in a better position, because our physicians get 
paid a whole lot less out here, a whole lot less, than they do in 
Charlotte.
    The President. Well I think, for one thing, you know, let me just 
mention, if you start in medical school, under our plan we would shift 
the allocation of internships and slots more toward primary care 
physicians, so you'll have more people in that business, and they don't 
have to go where the market is.
    Secondly, I think, we know the National Health Service works; it 
just got cut way back. So if you put another 7,000 doctors out there, it 
will make a difference, because that's a way to pay your medical school. 
And then the way the tax credit works is that it will, in effect, 
increase the income of every doctor in the underserved areas by $12,000 
a year. That's what a $1,000-a-month tax credit is. And even though--you 
know, if people just come in here in 5-year cycles, that's a significant 
amount; that's a big commitment of your professional life. You can keep 
going that way.

[Mr. Scott described the Montgomery County not-for-profit corporation 
designed to recruit six to eight family physicians to reduce the 
workload of county physicians. He then introduced Beth Howell, director 
of nursing, Montgomery Memorial Hospital, who discussed recruitment and 
retention of nurses in rural areas.]

    The President. How many more nurses do you need? I mean, just for 
example.
    Beth Howell. I would like to have five additional registered nurses.
    The President. And where are most of them trained, most of the RN's 
you get here?
    Ms. Howell. In the local community colleges.
    The President. And is there one--where's the nearest one?
    Ms. Howell. We actually have two that are within 20 miles and 
another one that's within 40 miles.
    The President. So that's not a real problem--[inaudible].
    Ms. Howell. Right.
    Dr. McRoberts. Retention is the problem. The nursing staff turns 
over a lot, just like she was saying.
    The President. I'd be interested in your feedback on this. The only 
thing that I know of that's in our bill that would help is there's 
also--as I say, we felt that the quickest way we could deal with the 
income disparity--I mean, we can't go in and sort of change the 
economics of every community in the country, but you could give a 
Federal tax credit. And a credit is not like a deduction; it's a dollar-
for-dollar deal. And so there's a $500-a-month tax credit for 5 years 
for nurses, too. And I think that will almost close most of the gaps. I 
mean, that's $6,000 a year. That's probably about what the gap is early 
on.
    Dr. McRoberts. Is that just for health profession shortage areas?
    The President. Yes. For shortage areas. But you could qualify.
    Dr. McRoberts. Thanks. [Laughter]
    The President. I mean, nobody can work 80 hours or 100 hours a week 
forever. You burn out. You can't do it.
    Dr. McRoberts. That's right. [Laughter]
    The President. That's what I tell all of the young people at the 
White House with their boundless energy. At some point, you stop working 
smart and you start working stupid. When you work hard, you just can't--
there's a limit to how much anybody can do.

[Mr. Scott introduced Dr. Hugh Craft, chief of pediatrics, Community 
Hospital of Roanoke Valley, VA, who discussed the importance of primary 
and preventive care for children and continuing education efforts for 
staff in smaller hos-


[[Page 574]]

pitals and then expressed support for the President's plan.]

    The President. One of the things--you mentioned the area health 
education concept, which I think has really done wonders in rural 
America, all over the country. But one of the things that we have tried 
to do in this plan which we haven't talked about this morning is to 
provide some funds for electronic hookups with really great access to 
technology so you can have almost instantaneous and continuous contact 
with medical centers around the country. I think it isn't quite like 
being there, but it will go a long way toward bridging the gap that 
exists now.

[Dr. McRoberts described an electronic system which linked Montgomery 
Memorial Hospital to the University of North Carolina for instant 
consultation but was discontinued for lack of support. Dr. Tom Townsend, 
East Tennessee State Medical School, discussed training and emphasized 
that medical schools must be reoriented to the needs of rural 
communities.]

    The President. You know, this has been a source of real controversy, 
by the way, in the medical community, as you know, because we are only, 
of all of our graduates from medical school now, only about 15 percent 
are family practitioners. And in most other major nations, about half 
the doctors are family practitioners, maybe slightly over half.
    So in our bill, we propose over a 5-year period to change the mix of 
medical school slots that the Federal Government subsidizes, and as you 
know, they're heavily subsidized, to get to a point where about 55 
percent have to be in family and general practice. And I met the other 
night with all the teaching hospitals in the Boston area to talk about 
how quickly that can be done, because as you pointed out, they're all 
sort of geared up and wired to their specialties and subspecialties and 
all that, and that's sort of where the money is. But I just think that 
we have a very compelling obligation to spend the taxpayers' money at 
the national level to try to remedy what is a blooming horrible crisis.
    You know, we're here in a little rural area, but there is a shortage 
of family practice doctors in a lot of the major urban areas of the 
country. So I think it's not just the training setting; you actually 
have to get the med students into those slots, and we're going to have 
to change the subsidy ratio.
    Now, again, this is something that almost never gets discussed in 
the larger debate about health care. But unless we're prepared to do 
what it takes to guarantee that we educate our young people in 
sufficient numbers to be family practitioners, all the economic 
subsidies in the world won't get them out there because they won't be 
there; people won't be there. And I think that's one thing that's very 
important, that the American people know that, that with all of the 
doctors we have, we actually have a shortage of family practitioners 
nationwide, and it's going to get worse unless we change the economic 
incentives for the next year.
    Mr. Scott. Mr. President, this is a wonderful discussion, and I know 
that you have other commitments that you must attend to today, and we 
could sit here all day and all night----
    The President. I'm having a good time.

[Mr. Scott thanked the President for visiting and reiterated the 
hospital's commitment to the community and the need for health care 
reform to resolve the problems it faces.]

    The President. How much uncompensated care do you do here every 
year, do you know--just people who show up at the emergency room that 
are uninsured?
    Ms. Howell. Fifty percent.
    Dr. McRoberts. I would say it would be about 50 percent in the 
emergency room. Probably, what----
    Ms. Howell. In emergency.
    Q. Uncompensated care or less than total compensated care is better 
than 50 percent in our hospital.
    Mr. Scott. That's true, our hospital, too.
    The President. So that goes back to the first point you made, that 
universal coverage is a big deal and if people want medical care to 
continue in rural America and forget about the taxpayers and anything 
else, this hospital could pay more----
    Mr. Scott. That's right.
    The President. ----to pay the nurses more, to pay other people--to 
offer incentives to doctors to come directly if you had compensated 
care. And you'd have a--if you had a better array of services then 
because it was compensated, you could take better care of the 
pregnancies and everything else.

[[Page 575]]

    It all comes back to this universal care thing. We cannot be the 
only country in the world that can't figure out how to provide basic 
coverage to all its citizens. We can't justify this any longer.
    Mr. Scott. Thank you very much, Mr. President.
    The President. Thank you all. Dr. Townsend, I'm glad to see you. 
Your father has been educating me about these things for years and 
years.
    Dr. Tom Townsend. He's tried to figure it out.

Health Care

    Q. Mr. President, why is it worth it for you to come here and talk 
to just such a few people when you have already basically done this 
before? You asked a lot of these same questions before.
    The President. Because it's obvious to me that these things come in 
waves. I mean, the American people are thinking about it again now, and 
it's very important that we deal with some of these horrible health 
problems. Most people lobbying on Capitol Hill will be lobbying against 
universal coverage in one way or the other. But these folks who are out 
here giving health care know we've got to have it.
    I also think it's very important to emphasize a lot of the things 
that are in our health care program that are not controversial on their 
face, but they could get lost unless we emphasize them, for example, all 
the incentives for people to come out here and become family 
practitioners.
    And so the debate, in a funny way, is just beginning. We're getting 
all this work in subcommittees; we're getting things going forward. All 
the surveys show an interesting dichotomy. They show that support for 
our plan goes up and down based on what they heard about it from 
interest groups or in paid ads, but that if you tell them what the 
details are in our plan, there are more than two-thirds of the American 
people support all the specifics.
    So what I'm trying to do is to get out here and highlight these 
real-world experiences that these doctors and nurses and other health 
care providers have so that we can focus the attention of the American 
people and the Congress on solving the real problems, not the rhetorical 
problems.
    Q. And get this on local television.
    The President. Well, yes, that's the idea.
    Q. Mr. President, are you losing the public relations battle, Mr. 
President?
    The President. No, I think we're winning it again now. And we're 
getting real movement in Congress. But I think we don't have the ability 
to raise the kind of funds or do the kind of nationally organized 
advertising that has been done by some against the program. And 
inevitably, a lot of the national organizations may get more publicity 
than local ones do. But when you get out here and you go beyond the 
rhetoric and get down to the details and the real-life experiences of 
these folks that are out here trying to take care of America, then the 
compelling case for reform, for universal coverage, for guaranteeing 
health security for all Americans, and getting the funds in here to 
these rural hospitals and providing more family doctors is overwhelming. 
And so I think we just have to keep hammering this home, not just on 
local television--I'll be grateful if you put this story on national 
television tonight. [Laughter]
    Mr. Scott. Thank you, Mr. President, we appreciate you being here.
    The President. Thank you.

Note: The President spoke at 11:04 a.m. in the activity room of the 
nursing facility at Montgomery Memorial Hospital. Harold A. Scott, Jr., 
chairman of the board, Montgomery Memorial Hospital, served as 
moderator.