[Public Papers of the Presidents of the United States: William J. Clinton (1994, Book I)]
[May 10, 1994]
[Pages 889-894]
[From the U.S. Government Publishing Office www.gpo.gov]



Remarks to the American Nurses Association
May 10, 1994

    Thank you so much. Thank you for your warm welcome. And thank you, 
Ginna, for that award.
    I arrived a few moments ago, and I remember the first time I ever 
heard your president speak. I knew that she had worked for Vice 
President Gore, and I thought it was so interesting to hear the head of 
a national association who was speaking without an accent. [Laughter]
    I want to say a special word of appreciation to your first vice 
president, Ellen Sanders, who's participated in White House and 
congressional meetings on health reform, and to Diane Weaver, the 
president of the Association of Nurse Executives, who cosponsored this 
breakfast.
    I am very proud to share the stage today with all the fine nurses in 
the executive and the legislative branches whom you have honored. And I 
thank you for doing that. And I thank them for their service. I also 
want to say a special word of thanks to all of you and to the ANA for 
the courage and the vision you have demonstrated by fighting for health 
care reform, and the right kind of health care reform, long before it 
was a hot issue. As you know, the position paper you put out on national 
health reform probably more closely parallels the recommendations that 
our administration has made than that of any other professional health 
care group in the country. And I thank you for that very much.
    I want to thank you, too, for recognizing my mother, who worked for 
30 years and then some as a nurse and was deeply proud of what she did. 
I remember when I was a little boy watching her get up in the middle of 
the night, always starting work by 7 or 7:30 in the morning, always 
telling me stories that indicated that there was literally nothing in 
the world more important to her than dealing with a person frightened, 
in pain, with a caring and effective manner. This award will help to 
expand the frontiers of nursing in the areas of women's health, some-


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thing that she would have been very proud to be a part of.
    My mother, as all of you now know, completed her memoirs, which 
became her autobiography, shortly before she died. She went over about 
half of it and was able to do the final editing. And it was my privilege 
after she passed away to work with the author and just try to make sure 
all the facts were right. I got very stern instructions from her. She 
said, ``Now, if you have to do this, do not change one word I said about 
you''--[laughter]--``especially the part about your manners not always 
being great.'' [Laughter] ``And make sure you get the facts straight. 
Otherwise leave it alone.''
    But I was very pleased with the two book reviews that her book got 
yesterday, one by the great American author Joyce Carol Oates in the New 
York Times and then another one here in the Washington Post. But it 
tickled me, the one in the Washington Post said that if you read this 
book, you would understand why I perplexed people in Washington. I was 
actually brought up by real people, and occasionally I still acted like 
one. [Laughter] I didn't know what that--[laughter]--I'm trying to get 
over it, but it's hard even here.
    Anyway, here's something my mother said about her work, which would 
apply to all of you and those whom you represent. But it meant a lot to 
me. It was just her words: ``Nurse anesthetist work is all-consuming. 
You don't do it halfway. You don't daydream. You don't let your emotions 
wander. You're the person responsible for putting another human being 
into a state of unconsciousness, somewhere between life and death. For 
30 years, from the minute that I would walk into the operating room and 
start talking to the patient and begin putting him to sleep, until I got 
him safely back to the recovery room, nothing in the world could have 
crossed my mind. I don't care what problems were on the outside. I don't 
care what problems I might have been having at home. I never thought of 
my life beyond the moment.''
    I remember when I was also a child, things were somewhat more 
informal. My mother used to take me to the hospital and let me meet the 
other nurses and the doctors and watch the emergency room and watch 
people go into the operating room. It was utterly fascinating. And the 
work you do has always sort of captured my imagination.
    My own wife had never been in a hospital before in her entire life 
until our daughter was born, never been in a hospital for any kind of 
sickness, and learned only a few moments before the happy event that she 
was going to have to have a C-section. And we had gone through Lamaze, 
and we had done all this stuff, and I was supposed to be in the 
operating room. And our hospital at that time had never before let a 
father into the delivery room if it wasn't a natural birth. It was a big 
deal. So I said, ``Look, I've been watching people get cut on and bleed 
since I was a little boy. I'll do fine.'' [Laughter] ``But she had never 
been here before, and she may not--you better let me come in.'' 
[Laughter] So they did and actually changed the policy so that if 
fathers had been through the Lamaze course and then the mothers 
eventually had to have a C-section, they got to go. So I felt--that's my 
one contribution to medical advances. [Laughter]
    But I owe all that to my mother, who was a remarkably determined 
woman in the face of often excruciating adversity. I think one of the 
reasons that the Nurses Association has been so forthright about this 
health care reform issue is that you see it from the grassroots up in 
human terms and you don't get so hung up as some people do on all the 
political rhetoric and the positioning and the characterizations that 
have, frankly, put a lot of Members of Congress at a severe disadvantage 
because they haven't had the chance to spend the time and make the 
effort to deal with this issue that you have. It is, after all, a mind-
bendingly complex problem. It's 14.5 percent of our income, and for 
people who don't live in it every day, it can be a very difficult thing.
    But I just wanted to thank you because I believe that the personal 
experiences you have shared, so many of you, common to the ones that my 
own mother shared, really animated the Nurses Association to take the 
position that you have taken.
    I want to emphasize today that what I seek, contrary to the attacks, 
and what you have sought, is not a Government-run health system, it's a 
private insurance health system that covers everybody, where the health 
care professionals run it and not the insurance companies. That's what 
we seek.
    We seek private insurance that can never be taken away. It's wrong 
to treat seriously ill children in an emergency room who could have

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been treated more easily and more inexpensively if their parents had 
just had the coverage. With our reforms, every family will have that 
kind of quality insurance. We ought to reform the insurance system that 
today often only covers the healthiest people and even then will deny 
them coverage for anything they've been sick with before.
    When you go to a patient's bedside, you ask, ``Why does it hurt? 
Where does it hurt? How can I help?'' You don't ask whether this is a 
preexisting condition you're looking at. [Laughter] It's a very 
important issue.
    If you think about all this preexisting condition business, there 
are 81 million Americans who live in families where there's been a child 
with diabetes or a mother that had cancer prematurely or a father that 
had an early heart attack or some other problem. I see these people 
everywhere. This is no small number. Now, we get action lickety-split up 
here all the time when a million people or 2 million people are 
adversely affected by something if they are well organized. But these 81 
million people, they're professionals and blue-collar workers; they're 
old folks and young folks; they're all different kinds of people; and 
they are by definition disorganized. There is no national association of 
people with preexisting conditions. [Laughter] You think about it; if 
there were, and 10 million of them showed up here, we'd have health care 
reform so fast you couldn't blink.
    You must be their voice in an organized way. And you can be. So we 
ought to cover everybody with private insurance, and we ought to have 
insurance reforms that deal with preexisting conditions and don't 
discriminate against people based on age. This is somewhat 
controversial. I know that. But I believe if we went back to health 
insurance the way it originally was when Blue Cross first started 
writing it, where everybody was put in a large group, risk was broadly 
spread, and people paid a fee against the day when they would be sick, 
it would be fairer for all Americans. And our economy would work better, 
our society would have a stronger sense of community, our families would 
function better. People would be free of a lot of the anxiety that comes 
to them.
    Hillary and I have received about a million letters. And whenever I 
go somewhere now, they arrange for some of the letter writers to come 
see me. And it's just gripping to see people just over and over and over 
and stunning to see how they really do come from all walks of life and 
how they have been broken by the things which have happened.
    The third thing I think we should do is to preserve the Medicare 
program. It's interesting, the people who criticize our program say this 
is Government-run health care which, of course, it isn't. And if you 
tried to take away Medicare, which is a Government-funded health care, 
well, they would be up in a tree somewhere screaming about it.
    But we don't want to do anything to the Medicare program, except to 
make it better. I do believe we should add a prescription drug benefit 
and phase in long-term care that is community-based or home-based for 
two simple reasons. One is, there are an awful lot of elderly people who 
aren't poor enough to be on Medicaid but aren't well off, who have 
significant medical bills. We know the elderly use 4 times the 
prescription drugs that the nonelderly do. And we know from study after 
study after study that a proper medication regime can keep people out of 
the hospital and can save money and that we now have--any number of 
elderly people every month--I was in a grocery store in New York 
yesterday called Pathmark, which also operates, as many do now, a 
drugstore. And it was gripping; the CEO was saying, ``My workers tell me 
that every day they watch older people come in this store and go from 
the drugstore, down the food aisle, and try to make up their mind what 
food they're going to give up to get their medicine, or whether they're 
going to give up their medicine to buy their food''--gripping. So I do 
believe we should do that. But the Medicare program works. It has low 
administrative overhead. We think it should be secured.
    The fourth thing we want to do is to bring greater choice to our 
people. I guess the thing that has made me the maddest in the relentless 
campaign against this plan are all those bogus ads where they say, 
``You're going to have to call some Government office to figure out 
where you go to the doctor.''
    There are two realities of modern life that you have to drive home 
to every Member of Congress, without regard to party or philosophy. 
Number one, Americans are rapidly losing their choices today. Already, 
of people who are insured at work, fewer than half have more than one 
choice of a health plan. That's a fact today. And they're rapidly losing 
their choices. Number

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two, medical professionals are increasingly losing their right to decide 
unilaterally, may have to have somebody get on the phone to an insurance 
company executive a long way away to ask for permission to do what 
anybody knows ought to be done under the circumstances.
    Now, most Americans, believe it or not, don't know either one of 
those things, even though they may be caught up in it, and I think it's 
very important. Our plan is designed, number one, to increase the 
choices that consumers have. We're moving to more managed care. There 
can be a lot of good things in it, but under our plan, every year, every 
person would have a choice between at least three plans, or among at 
least three plans but in all probability many more. And number two, 
under our plan, medical professionals would also be given more choices 
and would have to do less checking in with the insurance company in 
advance. Now, being treated by doctors and nurses, you know, is an 
American tradition. Every time I do one of these town meetings, like I 
did in Rhode Island last night, I talk to somebody that's just been 
forced to give up their doctor and just move away from the choices they 
made.
    We believe when all Americans can choose among several health plans, 
many Americans, many more Americans, will choose to stay with their own 
providers. And many more of these plans will be organized in such a way 
that all providers can participate if they'll do it for the agreed-upon 
fee. That's what we believe will happen. And if we don't do this, if we 
don't have some legal action to reorganize this, you're going to have 
less choice by consumers, less choice by providers.
    Time and again, we've also seen that the quality of care is directly 
related to the quality and the quantity of the nursing staff. One of the 
things that amazes me is how many nurses have been laid off in recent 
months and been told, well, this is because health care reform is 
coming. I'll tell you what, one of Clinton's unbending laws of politics 
is, whenever somebody who's got a tough decision to make can shift the 
heat from themselves to you, they'll do it every time. They will do it 
every time. That law never varies.
    Now, what is really going on? What's really going on is, a lot of 
these health care providers are under the gun. Right? More managed care; 
people bargaining tougher for prices; more and more people who are 
uncovered where there's uncompensated care that has to be provided; less 
and less ability to pass on the cost of uncompensated care to other 
people because they're in these managed care networks they're in: all 
this stuff is going to happen if we don't do anything. All of us could 
go on vacation for a year, and this same thing would go on. You know 
that. And don't let your Members fall for it.
    What's going to happen is we'll continue to see these trends occur 
unless we find a way to give health care providers reimbursement for all 
the people for whom they care, at an appropriate level in an appropriate 
way. More than a decade of research now shows that more and better 
trained nurses result in shorter hospital stays, better survival rates, 
fewer complications, whether you're dealing with low birthweight babies 
or older people.
    You do not have to work for the Congressional Budget Office to 
understand that healthier patients and shorter stays means lower health 
care costs. Sometimes I think if you do work for the Congressional 
Budget Office you will never get that, but--[laughter]--we're working 
together pretty well on the whole. This is a big deal. This choice issue 
and maintaining an array of qualified people doing the things for which 
they are best qualified is terribly important.
    Finally, let me say--and this, I guess, is, except for this whole 
issue of whether this is a Government program, which it isn't, is the 
most controversial part of it--our reform is based on providing 
guaranteed benefits at work. Now the reason for that is simple, for the 
people in this country that have health insurance, 9 out of 10 of them 
have it at work where there is some shared responsibility between the 
employer and the employee. For the people who don't have insurance, 8 
out of 10 of them have someone in their family who is working.
    It seems to me that the fairest and simplest, and if you will, the 
most conservative way to achieve universal coverage, to have health care 
security for everybody, is to ask employers and employees who aren't 
doing anything or barely doing anything to do more so that they can 
fulfill their own responsibilities and then use tax funds to cover the 
unemployed, uninsured people for whom you could say, well, there's a 
general responsibility, just like Medicare and Medicaid, and then 
organize the market so that smaller businesses and self-employed people 
(a)

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get discounts if they need it and (b) are able to buy good insurance on 
the same terms that those of us who are insured by Government or larger 
businesses can.
    Now it seems to me that is a fair and simple and obvious way to do 
this. I think that any other way will sooner or later involve either a 
radical change, that is, getting rid of the whole health insurance 
market and substituting taxes for it, or involve people who are already 
paying too much for their own health care, having to pay something for 
people who won't do anything for themselves because they say they should 
be exempt.
    Now I think that this is a very important issue. You know, again, we 
lose sight of the fact that most small businesses are making an effort 
to cover their employees. We have brought hundreds and hundreds of small 
businesses to Washington to talk to the Congress, but they are not 
organized. There is no association called: small businesses who cover 
their employees and are mad their competitors don't and mad they can't 
get better insurance rates--[laughter]--and wish somebody would help 
them. So an association that may have a lot of folks in the insurance 
industry, along with other small businesses, says, ``Don't do this; the 
whole small business economy will break,'' says this, and there's no 
association on the other side. You have to be their voice.
    Had a car dealer from a town of 7,000 people in Arkansas up staying 
with me the other night, he and his wife, long-time friends of mine. 
She's a college teacher. He's a car dealer. He said to me the other 
night--it was funny--he said, ``You know, for 20 years I have been 
feeling sorry for myself because I've provided a good health plan for my 
employees, and none of my competitors did.'' So he said, ``I was so 
happy when you proposed this just because I thought I was going to get 
even.'' [Laughter] And then he said, ``But you know, then I remembered 
that in the last 20 years I put three of my competitors out of business. 
And I'm making more money than I ever have. And the reason is I still 
got the same folks working for me I had 20 years ago because I gave them 
health benefits.''
    And yesterday I went to New York and I visited this Pathmark store. 
They have 175 stores, 28,000 employees, the 10th biggest supermarket 
chain in the country. We're all told, ``Oh, if you do this, the 
retailing business will go to pieces.'' These people have put new stores 
in inner-city areas that other chains would not touch, fine new stores. 
They are making money, and they have always provided comprehensive 
health benefits to their employees. And they are now sacking their 
groceries in a bag that says they favor health care benefits to all 
Americans, guaranteed through the workplace.
    I say this to you because, as you know, there are a lot of nurses 
that don't have any health care coverage and a lot of nurses who are 
single parents who don't have health care coverage. And this is the 
other point I want to make that I did to all those young people working 
in that grocery store yesterday: Everybody now in Washington is for 
welfare reform, and I guess it means different things to different 
people. But I have basically a 3-point strategy to achieve what I think 
would end the welfare system as we know it: One was embodied in last 
year's economic plan, lower income taxes for working people who are 
hovering just above the poverty line with children. This year one in six 
American working families will be eligible for lower income taxes so 
they can succeed at work and can succeed as parents.
    Strategy number two, give people education and training and then 
give them a certain amount of time to find a job. And if they don't, 
require them to take it. And if they can't, provide some public subsidy 
in the private sector or some publicly funded job so that work is 
preferable to welfare.
    Strategy number three has got to be cover the people with health 
insurance. Consider this: All these people on welfare in this country 
who are dying to get off--and by the way, that's most of them--who are 
dying to get off, most of them have limited education. Suppose they go 
through a little training program and they get a job that pays a modest 
wage but is still more than the welfare benefits. But they go to work 
for an employer who does not provide for health care.
    Think about this: You are a mother with two children. You give up 
being on welfare to take a job that pays more than the welfare check, 
but you lose health care coverage for your kids. What are you going to 
do if your kid has to go to the dentist? What are you going to do if 
your child is desperately ill? How are you going to feel every week, 
every 2 weeks or every month when you get your paycheck and you see 
what's taken out of it in taxes and you real-


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ize those taxes are going to pay for the health care benefits of people 
who decided to stay on welfare instead of going to work? You don't have 
to be as bright as a tree full of owls to figure out that this doesn't 
make a lot of sense. [Laughter]
    Now a lot of American nurses are in this situation today, getting up 
every day, slaving away, trying to take care of people who have children 
without insurance, caring for people who come into their office who are 
on public assistance who have children with insurance because of the 
Medicaid program. It is not fair. It is not right. It is not smart.
    And you could say, well, all this inability to cover everybody, if 
this were fueling some enormous American economic expansion because we 
were saving so much money on health care, maybe you could deal with 
that. But the truth is we're spending over 40 percent more of our income 
on health care than any other country in the world. Oh yes, some of it 
because we're more violent, and that's something we pay for. Some of it 
because we have better medical research and technology, and that's worth 
paying for. But a whole lot of it, as you well know, is because of the 
way we have financed health care, which has employed hundreds of 
thousands of people in doctors' offices, in clinics, in hospitals, and 
in insurance companies to read the fine print on thousands and thousands 
of policies to see who and what is not covered. And it has rifled 
inefficiencies through this system that we are all paying for.
    We can fix this. We can fix it by having a law which fixes what's 
wrong, keeps what's right, provides health care security to everybody 
through a private system, increases the choices consumers have, and 
increases the decisions that doctors and nurses and other qualified 
providers make without oversight by others. We can do it.
    In order to do it, we have to recognize we have to go through a fog 
of misinformation, a torrent of labels which aren't right, and 
recognize, too, that you have to lobby and stand up for, in an organized 
and very personal way, that great association that doesn't exist, the 
association of 81 million Americans in families with preexisting 
conditions, the association of hundreds of thousands of small businesses 
who are doing the right thing and being punished for it, the association 
of all the poor women in this country who are out there working their 
hearts out and their fingers to the bone to do right by their kids 
without health insurance and paying taxes for people on public 
assistance who have it for their children. All of those associations are 
disorganized.
    You have devoted your lives to providing health care to all 
Americans. You have honored my favorite nurse today. You have given me a 
chance to hope that my mother and my grandmother are looking down on me 
thinking I was the first generation in three that didn't produce anybody 
that was caring for other people in health care. So they think at least 
I walked off with the award today. [Laughter] It means more to me than I 
can say.
    But the determination that my mother showed in getting up off the 
pavement many times in her life is the same sort of determination you 
have to show for us to get health care reform this year. And remember, 
most of these Members of Congress want to do the right thing. But they 
don't know what you know; they haven't spent the time that you've spent; 
they haven't had the experiences you have had. You have to help them. 
And the people in their districts that really need their help are not in 
those great national associations.
    You keep them in your mind and keep that example in your mind. Don't 
let this year go by. We can do this this year with your help and your 
leadership.
    Thank you, and God bless you all.

Note: The President spoke at 9:56 a.m. in the Regency A Ballroom at the 
Hyatt Regency. In his remarks, he referred to Virginia Trotter Betts, 
president, American Nurses Association.