[Public Papers of the Presidents of the United States: William J. Clinton (1994, Book I)]
[April 5, 1994]
[Pages 575-581]
[From the U.S. Government Publishing Office www.gpo.gov]



Remarks to the Community in Troy
April 5, 1994

    Thank you very much. Kerry, you did a terrific job on the tour and 
just now with the introduction. I do want to say, since a lot of you 
made comments about the basketball game, if it had come out the other 
way, I probably would have been in the Montgomery County Hospital as a 
patient today--[laughter]--rather than just someone trying to learn. I 
want to

[[Page 576]]

thank my good friend Bob Jordan for what he said and for his long 
friendship and support for me. And I thank Congressman Hefner for 
representing you so well and faithfully, as well as for being fairly 
restrained last night. [Laughter] I brought all my North Carolina staff 
members and all the people that work at the White House who went to Duke 
to the game last night. And so in our little box there were more people 
``agin'' me than for me--[laughter]--but it was a wonderful occasion.
    This morning before we came here, I met with Kerry and some other 
folks who are here who helped to talk to me a little bit about some of 
the medical problems that you face here in this county and in similar 
places throughout our country. I'd just like to ask them to stand and be 
recognized, because I want you to know that I was with them before I 
came here, and a lot of what I have to say responds to what they said: 
Jim Bernstein, the director of the North Carolina Office of Rural Health 
and the president-elect of the National Rural Health Care Association; 
Dr. Hugh Craft is the chief of the pediatrics at Community Hospital in 
Roanoke, Virginia; Beth Howell, the director of nursing at your local 
hospital; Dr. Deborah McRoberts, who is one of your local family 
physicians; the chairman of the board of the Memorial Hospital, Hal 
Scott, who kind of emceed our event; and Dr. Tom Townsend, who is now at 
East Tennessee State University and has been a family practitioner for 
many years. And just by coincidence, his father is probably the dean of 
pediatric practice in our State. And I looked at him today, and I said, 
``I knew a Tom Townsend who was a doctor once,'' and he said, ``He was 
my father.'' But I didn't organize that. I get accused of bringing 
Arkansas into everything. I didn't do that. [Laughter] I'd also like to 
thank the people here at this fine school for taking us in, your 
principal and your superintendent and the mayor of Troy. And I also know 
that these benches were constructed especially for this event by Jerry 
Holders, so I don't know what's going to happen to them, but I want to 
thank Jerry for making the benches available to us. He did a fine job.
    I've been working on the issues that we talked about today and the 
things that you heard about today from the previous speakers for nearly 
20 years now, since I was first elected attorney general of my State in 
1983, or--excuse me--in '79 when I served as Governor for the first 
time. My wife and I started a rural health initiative, trying to connect 
our children's hospital to all of the rural hospitals in the State and 
deal with a lot of the issues that you've done so well with here in 
North Carolina.
    In 1990, after years of dealing with the headaches of the Medicaid 
program as a Governor, I agreed to work with the then-Republican 
Governor of Delaware, who is now a Congressman from Delaware, on a 
Governors Association project, trying to figure out what we could do at 
the State level to deal with some of the terrible problems of health 
care: the rising costs, the strain on State budgets, the lack of 
reimbursement, the high infant mortality rates in a lot of rural areas, 
all the--and the lack of doctors. And after I worked on this for some 
time, and after I had been involved in this issue for a very long time, 
I came to the conclusion that a lot of the problems of the American 
health care system simply could not be addressed in the absence of a 
national effort to reform the way--primarily the way we finance health 
care and the way we provide health care professionals in America.
    There's so much that's good about our health care system, and that 
which is good is the best in the world. So the trick is how to fix 
what's wrong and keep what's right. And that has been the great debate 
in which we have been engaged.
    Over the last year or so, through the First Lady's task force, we 
have asked for the help of literally thousands and thousands of doctors 
and nurses and other health care providers and consumer groups to try to 
give us some sort of insights into what we should do. But the main point 
I want to make in the beginning is that my roots are in a county a lot 
like this one. And I sometimes think in Washington we lose track of the 
human face of America's problems and America's promise. And I'm deeply 
grateful to be here today to see both of those things.
    First, let me say that rural America has a lot of folks who either 
don't have health insurance or who have very limited health insurance. 
There are a lot of small business people, there are a lot of farmers, 
there are a lot of self-employed people who have enormous difficulty 
with insurance policies that often have lifetime limits, very high 
deductibles, big copays, and premiums that go up every year. A lot of 
citizens I have met around this country have really told

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me of the decisions that they make on an annual basis about whether they 
can even afford to insure their family. Seventeen percent of rural 
America has no health insurance at all. The folks at the hospital today 
told me that half of all of the emergency room business they do in the 
hospital are with people who have no insurance, who show up at the 
emergency room when the care is too late, when it's too expensive, 
because they didn't have insurance to get it on a regular basis. Twenty-
five percent of our farm families have no health insurance in America. 
We have to do something about this. If you look at where we are, you can 
see here, at any given time in America our population is roughly 255 
million people. At any given time in a year there will be a total of 58 
million people every year who don't have health insurance at some time 
during the year. And on any given day, the figure is somewhere between 
37 million and 40 million who don't--go uninsured.
    There are 81 million Americans who have preexisting conditions. You 
heard Bob Jordan talking about someone who lost their job with IBM and 
had a preexisting condition. Now, people with someone in their family 
with a preexisting condition normally find themselves in one of three 
positions. Either they can't get insurance at all, or they're paying a 
whole lot more for it, or they're in a job where they got insurance 
before the preexisting condition that they had or their spouse or their 
child developed, and now they can't ever change their job because if 
they try to change jobs, they won't be able to get insured at a new job.
    That is a huge deal in a country where the average 18-year-old is 
now going to change work eight times in a lifetime and in which labor 
mobility is going to be the key to our future economic growth, when big 
companies are downsizing and small companies are expanding. And we 
already know it's harder for small companies to get affordable 
insurance.
    Then there are 133 million Americans, or a majority of our people, 
who have insurance but have lifetime limits on it, which means if they 
have serious illnesses they could run out of the lifetime limits. I met 
a family in Florida about 10 days ago that had written a letter to my 
wife about their problem. They had two sons with rare forms of cancer 
that apparently had some sort of genetic connection because both their 
boys had it. They had a daughter that at least to the present time had 
not developed this kind of cancer. They had a lifetime limit on their 
policy, and they felt the lifetime limit would run out before the first 
child was out of the house and eligible to be on Medicaid or something 
and certainly would clearly run out before the second child would. They 
had no idea how they were going to get care for their children when that 
happened.
    So we have to decide whether we're going to do something about this. 
No other advanced country with the kind of national economy as strong as 
ours has failed to provide for health care security for its people. And 
there are basically only two ways to do that. You can do what Canada 
does, which is just to abolish the whole private insurance industry and 
pay for it with a tax. We do that with the Medicare program today. 
That's how we finance Medicare; that's how we finance Medicaid. You have 
low administrative costs, but there are all kinds of cost problems--cost 
control problems there.
    The other thing you can do is to have the mixed system that we have 
and extend it to everybody. That is, employers can cover their 
employees; employees can pay part of their health care; employers can 
pay part of their health care. And then if they are very small 
businesses with low payrolls, you can provide a discount for them. But 
in other words, you just extend the system we have now that we're most 
comfortable with.
    The third thing you can do is to keep on doing what we're doing, 
just talk about it, say how terrible it is, and figure we're just not 
smart enough to figure out how to do it. Now, let me just say, if we 
keep on doing what we're doing, a lot of bad things will happen. More 
and more hospitals like this one will either--will go under or have to 
really cut back on what they do. You won't be able--because this 
hospital doesn't have full reimbursement, it restricts the income that 
can be paid to the nurses; it restricts whatever incentives you can 
offer to the doctors. You get fewer doctors, and you get doctors like 
this doctor who told me she's, on a hard week, worked over 100 hours a 
week, and in a slow week worked an 80-hour week. Pretty soon the doctors 
are going to need doctors if you do that.
    So I really don't think doing nothing is an option. Every year the 
number of Americans--we lose about--about 100,000 Americans a month lose 
their health insurance permanently. So the problem will get worse, not 
better. There

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is a perception today, I think, in the Nation's Capital that maybe the 
problem won't get worse because there's so much managed care, that 
inflation in medical costs overall has gone down. Well, it has. It 
always goes down when there's the threat of real health care reform. But 
for small business people and farmers and a lot of individuals, health 
insurance has not gone down. It's still going up quite rapidly. And a 
lot of people are still losing their health insurance.
    So we have to deal with the fact that there is plainly a crisis. I 
think that we ought to make the choice of guaranteed private insurance 
because, as a practical matter, I don't think we ought to just shut down 
all the health insurance companies in the country and figure out what 
all those people are going to do for a living and then figure out how to 
substitute a tax for a health insurance premium, when most people have 
health insurance and you could make the health insurance work better for 
small business people. People in Government and big business today 
normally have pretty good health insurance systems, and their inflation 
rates have come down within inflation, the inflation rate generally.
    So I think the simplest way is simply to guarantee private health 
insurance to all Americans. That's what our plan does. It says every 
American should have health insurance that can never be taken away; that 
if you work, employers and employees should make a contribution to that 
health insurance plan. If you don't work, the Government should pay.
    Now we're paying anyway. If somebody shows up at this emergency room 
and gets care when it's too late and too expensive, you're going to pay 
one way or the other. Either the hospital will have to find a way to 
pass the costs along to the other payers, or if the hospital can't do 
it, you pay for it in terms of reduced services, fewer doctors, and 
terrible financial strain on the hospital.
    When everyone is covered, it reduces all this incentive to shift 
costs, and it provides the funds that you have in medically underserved 
areas that you need so desperately to hire more doctors and to keep the 
people that you have. I think that is terribly important.
    There's another thing that's important about it, and that is when 
everybody has health insurance, then you can use more preventive care 
and you can have more primary care. Almost all of us were raised on that 
old adage that an ounce of prevention is worth a pound of cure. We 
ignore that almost entirely in health care.
    You have here--the infant mortality rate in this country is well 
above the statewide average. Why? Because you have a whole lot of 
pregnant women who only have 7 prenatal visits when they ought to have 
12, who have low birth weight babies who have problems. That has to be 
addressed. Because we do not do enough in this country to do enough 
primary and preventive work in health care. We have great high-tech 
medicine. If you're really sick, we do more in medical research than any 
other country. I don't propose to stop that; in fact, our plan would 
invest more in it. But where our real shortcoming is, is in primary and 
preventive care. So I think that is very important.
    Now, the second big issue that I think we have to face is this: What 
kind of system are we going to have from the point of view of the 
patients? And should you have or not have a choice of the doctor or a 
medical plan you buy into? This is a big issue. I don't know how big an 
issue it is in Montgomery County, but I can tell you now that slightly 
less than half of the American people who are insured at work have a 
choice of more than one plan now. More and more employees are being 
required to buy into whatever plan that the employers decide it's the 
only one that he or she can afford, and there's less and less choice in 
these plans of what doctor you visit, what hospital you visit, and what 
you do. That is a big issue.
    So I think that one of the things that I would like to emphasize is 
the need to have choice: not only insurance that can't be taken away, 
not only comprehensive benefits, not only no lifetime limits, but under 
our plan, if it passes the way we have proposed it, people will be able 
to have a choice every year of at least three different plans. You can 
join an HMO. You can have a fee-for-service practice--and if you're in a 
rural area, that may be the only option you have, just to go through the 
same system that you have now. Or there will be at least one other kind 
of plan offered, maybe a mix between the two. I think that's very 
important. Most Americans believe that they should have some say over 
their own health care. And most Americans believe that the quality of 
health care will be increased if their choices can be maintained.

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    And I can tell you that if we do nothing, if we do nothing for a 
couple of years anyway, people who get their insurance through big 
businesses and through Government, like I do, will continue to get good 
health care at reasonable prices. The price of that will be putting a 
price squeeze on everybody else, which means that teaching hospitals, 
for example, which are very important in rural areas to support you, 
will find it harder and harder to get adequate money. And it means that 
people who are small businesses and people who are self-employed will 
pay higher and higher premiums.
    One of the great raging debates we're having now is in the small 
business community about whether it will be terrible for small business 
to have to insure their employees if the small businesses don't do it 
now. Well, the Director of the Small Business Administration, Erskine 
Bowles, from North Carolina, is here with me today. He spent 20 years 
helping to organize small businesses, get them started, help them 
expand. And he's one of the strongest advocates of our health care 
program because he knows most small businesses already insure their 
employees, don't get the insurance that they want, pay higher premiums 
than they should, and that the small business sector is going to be in 
worse trouble if we don't do something than if we do. So I think that 
this whole issue of having more choices is very, very important.
    Let me also mention something else. If you're going to have 
comprehensive benefits and the right to choose your own doctor, then it 
seems to me we also have to outlaw some insurance practices. Let me just 
talk about this. Today insurance companies, as you just heard the story, 
can drop people for nearly any reason whatever. Under our plan, 
insurance companies couldn't drop coverage or cut benefits, couldn't 
increase rates just because you've got somebody in your family who's 
been sick, who's got a preexisting condition, couldn't use lifetime 
limits, and couldn't charge older people more than younger people just 
because they get older.
    Now, how are we going to do this and not bankrupt the insurance 
company? The answer is you've got to cover everybody, and you've got to 
make it possible for insurance companies to make money the way grocery 
stores do, to make a little money on a lot of people instead of a lot of 
money on a few people. That's what community rating--you hear this--when 
you hear all this talk about community rating, you hear all these words 
that may not mean anything to you, that's all community rating means.
    Why do you think people in Government--if you belong to the Federal 
employees health insurance plan, why do you think we have a good deal? 
Because there's a whole bunch of us. It's as simple as that. There are 
just a bunch of us, and we can get a good deal. And we can get a good 
deal whether we're the President in Washington or whether we are the 
postmaster in Troy. If you buy into the Federal health insurance plan, 
there's a lot of us.
    So to make it possible for us to cure these insurance abuses and 
have it really work in a town like Troy or for a small business person 
or a farm family, you have to be able to put folks in large pools. 
That's what community rating means. That's all community rating means is 
you make money--insurance would make money the way grocery stores do. 
And just the way grocery stores have to allow for a certain amount of 
broken merchandise or stale bread or people making off with olives or 
whatever, if you've got a big enough base, then if you get a few people 
who are real sick you can spread it over the base, and people can still 
make a living doing it. That's basically what we're trying to do. I want 
to come back to how this affects rural America in a minute.
    One of the programs that does work in the Government, I think, is 
Medicare. Most people think it works. It's very important that the 
American people know and that the senior citizens in this county know 
that our plan preserves Medicare. But it covers two things that are not 
covered in Medicare now. One is the prescription drug benefit--big 
problem. A lot of older people wind up going to hospitals because they 
can't afford to buy medicine that they should take to stay out of the 
hospital under Medicare. This will save money over the long run. There 
have been a couple of studies showing that it will. The second thing is, 
we begin to cover some long-term care coverage through Medicare. Today 
basically what the Government does is if old folks are real poor, they 
can get long-term care under Medicaid, and mostly it's institutional 
care, nursing home care. So we want to support in-home care and other 
community-based care.
    I've already been over this. We want to guarantee the benefits that 
work. If small businesses have low payrolls and low profit margins and 
are strapped, we will provide discounts to those

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small businesses so that they might pay as little as 4 percent of 
payroll. People say, ``Well, I can't even afford that.'' But if all of 
the competitors have to pay, you can. I want to point this out. Seventy 
percent of the small businesses in America today provide some health 
insurance for their employees, 7 out of 10. Almost 100 percent of the 
small businesses where jobs are growing in numbers provide health care 
benefits for their employees.
    Health care costs of small business are 35 percent more than they 
are for big business for the same benefits, 35 percent more, because 
they're small. Under our plan, you won't ever be at a competitive 
disadvantage because all of your competitors would also have to provide 
for health care coverage. You'd be able to get a better deal than you 
can now. And here's something else that has received almost no notice: 
Our health care plan folds the health care costs of workers' 
compensation and automobile insurance health care costs into this. So 
small businesses that are being killed by workers' compensation costs 
will have their workers' comp rates go down because the health care 
portion of it will be covered in the health care plan.
    So health care--the small business community of this country will 
come out a winner in this, not a loser, if we do it. If we don't do it, 
what will happen is more and more small businesses will lose their 
health insurance every year, or they'll have higher copays, higher 
deductibles, and less coverage.
    So let me just make one last comment about the rural areas. The 
biggest problem I heard today here was there are not enough doctors. 
You've got one doctor for nearly 8,000 people. That's not enough. You 
need many more. So do most folks in rural America. Why does this happen? 
Well, doctors make more money in cities, doctors have more support in 
cities, and frankly, our medical schools are turning out too many 
specialists and too few general practitioners for the needs of not just 
people in rural areas but all over the country. What does our plan do 
about that? Number one, it changes the incentives. The Federal 
Government spends an enormous amount of money to subsidize the training 
of doctors, as expensive as it is. We change our subsidy program over 
time to subsidize more family practitioners and fewer specialists. It's 
important; we've got to produce more family practitioners. If the 
doctors aren't there, no incentive will bring them here. Number two, we 
will dramatically increase the National Health Service Corps, another 
7,000 doctors over the next few years, to pay people's way through 
medical school. Let them come out here and practice for a couple of 
years and pay their debts off. Number four, we give a $1,000-a-month tax 
credit, or a $12,000-a-year income subsidy, to doctors who will go to 
medically underserved areas for 5 years and a $500-a-month credit to 
other medical professionals that will go to underserved areas. That will 
make a huge difference. Number five, we help to hook these doctors up 
with new medical technology--to the medical centers in urban areas far 
away, which is very important, and we give certain tax incentives to 
make it easier for physicians to buy the laboratory and other equipment 
they need to feel good about their practice in rural areas.
    Now, all these things will really help the terrible problems I heard 
about today. I'll say again, I don't see how your hospital is 
functioning with doctors where a slow week is an 80-hour week and a fast 
week is a 110-hour week. There is a limit to how long you can expect 
your physicians to do that and function at a high level of efficiency. 
You cannot do it. So we have to change that, and we're going to.
    So in summary, we've got a plan that would expand the system we've 
got: guaranteed private insurance, keep your choice of doctors, provide 
real insurance reform in a way that will permit the insurance companies 
to function in our free enterprise economy and still make a profit, 
preserve Medicare but add a prescription drug benefit and a long-term 
care benefit, and guarantee these health benefits at work. And finally, 
there is a very special attention given to the problems of medically 
underserved areas, which are especially rural America, to get more 
doctors out there, more nurses out there, and keep the connections that 
physicians and other health care providers feel they need to folks in 
the big medical center areas so they can give high-quality care.
    Now, we don't have to do any of this, but if we don't, the problems 
of this hospital are going to keep getting worse. You can organize a 
local community effort like you are, and it can make a real difference. 
You can raise money, you can do things, you can get some more doctors in 
here, and maybe you will escape the trend. But if the number of family 
practice doctors continues to go down, then

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somebody in rural America is going to be hurt even if you aren't. If you 
escape--there are just only so many ways you can cut a pie that gets 
smaller. And even if you do that, if you keep having people who don't 
have insurance not come in here for primary and preventive care, showing 
up when they're real sick at the emergency room and half your emergency 
room load are people with uncompensated care, it's going to get worse.
    So you're doing what you have to do to succeed, but your country is 
not doing what it should do to help you succeed. And that's what this 
health care reform issue is all about. And what I want to ask you to do 
is to take the experience that you have--this is the real world out 
here, that's what I heard these folks talking about--and support Bill 
Hefner and support the other Members of the Congress and say what Bill 
did. This is not a political deal. Everybody gets sick, regardless of 
their political party. And this country needs a health care system where 
the financing is as good as the medical care. That's what we need. And 
if we don't do this we are going to pay a terrible economic and human 
price. You know this. And what happens is we get up there in Washington, 
we start going to work on this, and all we ever hear from are lobbyists. 
Then the real world experience, what really is going on out here in the 
heartland of America, gets lost in a cloud of hot air.
    I'm here today just to ask you to encourage this good Congressman 
and the other Members of Congress to deal with this issue and to deal 
with it now and not to fool with it any more. Sixty years ago we had a 
chance to guarantee health care coverage for all Americans, and we 
passed it up. Twenty years ago, under President Nixon, he proposed 
guaranteed private health insurance for all Americans with employers and 
employees paying their part, and we passed it. And every time we have 
passed it, we have let the problem get worse, we have put more of a 
burden on rural America, we've put more of a burden on small business 
people and farmers, and we have really played havoc with a significant 
percentage of the American people. We can do better than that. So I'm 
asking you to take what you know in your heart, your mind, and your life 
is the truth and say to the Congress of the United States, ``The time to 
act is now, and we will support you.''
    Thank you very much.

Note: The President spoke at 11:38 a.m. at Troy Elementary School. In 
his remarks, he referred to Kerry Anderson, Montgomery Memorial Hospital 
administrator; Bob Jordan, former Lieutenant Governor of North Carolina; 
Larry Robinson, principal, and Dewey Jackson, superintendent, Troy 
Elementary School; and Mayor Roy Maness of Troy.