    [Public Papers of the Presidents of the United States: William J. Clinton (1995, Book II)]
    [October 12, 1995]
    [Pages 1572-1581]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Teleconference Remarks With Rural Hospital Administrators and an
    Exchange With Reporters
    October 12, 1995

        The President. First of all, let me thank you very much for
    participating in this conference call to discuss the importance of
    continuing to invest in health care in rural America.
        As you all know, we are involved here in a serious attempt to
    balance the budget. I want to balance the budget. I have offered the
    Congress a proposal to do it. I think it will help to lift the burden of
    debt off our children, it

    [[Page 1573]]

    will help to strengthen our economy if we do it in a way that is
    consistent with our values and our interests.
        And one of the most important values we have is the obligation we
    have to strengthen our families and preserve the health care of our
    children and our parents. And the balanced budget I presented to the
    Congress does call for slowing the rate of growth in the Medicare and
    Medicaid programs, and it does secure the Medicare Trust Fund. But it
    strengthens rather than guts our Medicare program, and it recognizes
    that Medicaid is the principal source of funding not only for health
    care for poor children but for a lot of our seniors and for an enormous
    number of our hospitals in rural areas and in urban areas.
        And I believe that the Medicare/Medicaid budget that the Republicans
    in Congress are pushing violates both our basic values and our interests
    and it is not necessary, not necessary, to balance the budget. The level
    of Medicare cuts are more than twice what I propose. The level of
    Medicaid cuts are 3 times what I propose. And I believe it will force
    American families to choose between educating their children and making
    sure their families have the health care that they need.
        And as all of you know--and I want to hear from you in a moment--
    these cuts will be especially devastating to rural communities and to
    rural families because Medicare and Medicaid are the backbone of the
    health care system in so many rural areas. Hospitals in rural areas
    already are struggling to make ends meet and are closing at far more
    rapid rates than hospitals in urban areas and tend to depend a lot more
    on Medicare and Medicaid than urban hospitals do.
        Therefore, if this budget passes that the Congress has proposed, it
    can mean, I think, devastating consequences for rural health care. And
    of course, we want to hear what it will mean for your local hospitals.
    And if more of them close, they won't be there for families in
    emergencies or for families with a child that needs to be immunized or
    for people who need longer term care.
        And let me say, having been a Governor for 12 years in a rural State
    and having presided over a lot of hospital closings in the 1980's and
    having spent hours and hours and hours inside rural hospitals in all
    different kinds of communities, I think I have a good feel for this. But
    I wanted to hear from you because I want America to know what the real
    consequences are.
        This budget debate should not be a matter of abstract ideologies. We
    know we have to slow the rate of medical inflation. We know we have to
    deal with entitlements. We know we have to balance the budget. But we
    have to do it in a way that is prudent, humane, and decent and that is
    consistent with our values. So that's my objective, that's what I'm
    fighting for, and I need your help.
        Now, before I close, I'd like to say one more word about the
    Republican Medicare plan because it affects hospitals directly. Two days
    ago, we saw further evidence that the Congress is prepared to walk away
    from the impact of this plan on people. In the dark of night, the
    Republican leadership cut a deal with the AMA that put--once again--put
    their interests ahead of the interests of the patients.
        It may help the Republicans to pass their plan, but the rest of
    America needs to know who's going to pay for the payoff to the AMA to
    get them to support it. Older Americans who rely on Medicare are going
    to pay for it. Rural hospitals are going to pay for it. They took $3
    billion more in cuts and they shifted them to patients, which means they
    shifted them also to rural hospitals. They give less protection for
    laboratory results in doctor's offices. And worst of all, it's another
    hidden tax on elderly people who rely on Medicare.
        Under their plan, seniors can be forced into managed care networks
    which then can impose new fees on top of new premium increases. Under
    the Medicare program we have today, as all of you know, doctors can
    charge the Medicare-approved fee and no more. The new Republican plan
    would give doctors the power to charge any amount of additional out-of-
    pocket costs they want to older Americans every time they go to the
    doctor, whether or not they can afford the plan. And if you look at that
    and you add to that the fact that they cut out the Medicaid payments to
    low-income elderly people to help them pay their copays under the
    Medicare program, one group has estimated that as many as a million
    seniors may actually drop out of the Medicare system. And of course,
    that's going to make it even more difficult for rural hospitals.
        So I'm very disappointed that the AMA supported this plan. It may
    look better to doctors

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    in the short run, but it's going to be a lot tougher on their patients
    and a lot tougher on the hospitals in which they practice, especially
    the rural hospitals. They will be dealing with this.
        And I'd like to ask Secretary Shalala to say a few words and talk
    about this from her perspective. And then I'd just like to hear from all
    of you, and we'll have a little conversation about it.

    [At this point, Secretary of Health and Human Services Donna Shalala
    stated that the Republican health care proposals would have a negative
    impact on rural health care affordability, security, and quality.]

        The President. The only other point I'd like to make, and then I'll
    call on you, is that when I served as Governor of my State, I worked
    from the late seventies through the early nineties to try to provide all
    kinds of incentives for doctors to go out and practice in rural areas,
    to try to keep the quality of health care up in rural areas. And a lot
    of States have done that. And I know a lot of rural hospitals have done
    things like have really sophisticated interconnections with urban
    hospitals and with teaching hospitals. And a big portion of these
    efforts are going to be undermined by this budget.
        And again I will say, this should not be a matter of ideology. We
    should just practically look at the consequences. We do not have to slow
    this train down so fast we cause the train to run off the tracks. The
    health care system of America is too important.
        But I'd like to hear from you now to talk about what you think you
    will be personally experiencing. Let's start with Don Sipes, who's the
    CEO of St. Luke's Northland Hospital, a hospital with 92 beds and 150
    employees in Smithville, Missouri, which is a community of 2,500.
        Mr. Sipes.

    [Mr. Sipes described the potentially devastating impact of the proposed
    Medicare cuts on rural Missouri hospitals as health care providers and
    employers, noting that many of them were already struggling
    financially.]

        The President. I'd like to just emphasize two things here that kind
    of came out of your remarks. Number one, the 1980's were tough on rural
    hospitals. Rural hospitals--about 17 percent of our rural hospitals
    closed in the decade of the eighties, and only about 2 percent of our
    nonrural hospitals did. And we knew that some of that consolidation had
    to occur. But the important thing for the people of the United States to
    understand is that rural hospitals have undergone significant changes in
    management and the way they allocate their resources, and they have
    achieved enormous efficiencies, and their ability to do more is
    constrained by the remarkable progress that was made in the eighties and
    the enormous changes that were made.
        The second point I'd like to make is that no one has an answer to
    what happens to these folks if you close. I mean, who's going to be--how
    are these people going to be taken care of?
        What is the percentage of your Medicare--what percentage of your
    revenue comes from Medicare and Medicaid?
        Mr. Sipes. At the Smithville campus, 71 percent.
        Secretary Shalala. And you're going to lose at least $1 million
    under the Senate plan, I think. I think that's our calculation.
        The President. A year.

    [Secretary Shalala noted that other businesses in the community would be
    adversely affected by the closing of a major rural health care
    employer.]

        The President. That's right. The other point I want to make is that
    in this debate you will frequently hear the congressional leaders say,
    ``Look, we're not giving anybody less money; we're giving everybody more
    money.'' And that is true. But the real issue is, is the more money
    sufficient to deal with more patients and the cost of inflation?
        The real answer here is to bring medical costs per patient, per
    treatment closer to the general rate of inflation. And we're working on
    that. This year, premium costs for insurance were at or below the rate
    of inflation for the first time in a decade. But these numbers, the
    budget numbers, will not permit many of our health care providers to
    deal with increased case loads plus inflation.
        So even though it may look like more money 7 years from now than
    we're spending today, the real question is, in real dollar terms will it
    be more? And the answer is, for many, many of you, no. And I think
    that's really important because just to say we're giving more money

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    obscures the question of whether you'll really be able to deal with your
    patient loads, with the cost of health care, and with inflation.
        I'd like to call on Mr. Cannington now. H.D. Cannington is the
    administrator of the Jay Hospital, which has 55 beds and 110 employees
    in Jay, Florida.
        Mr. Cannington.

    [Mr. Cannington explained that the cuts would probably force his
    hospital to close, disrupting the entire health care system in that
    rural area.]

        The President. That's another thing I'd like to emphasize that's
    special about rural America. You just described the kind of services you
    provide. A lot of people say, ``Well, if we cut the budget this much and
    these hospitals close, it's no big deal; we'll just convert them into
    clinics, to primary care clinics. Then if they need a serious hospital,
    they can go to the nearest city somewhere.'' The problem is that a lot
    of these rural hospitals, most of the ones I know in my State, do just
    exactly what you said. They're running--they are the public health
    outreach. They are the home health outreach. They are doing these things
    that those who say, ``If we close the hospital, they'd be replaced by
    other people.'' There's just no reason to believe that.
        And we all know, anybody that's ever worked or lived in a rural area
    knows that one of the biggest problems in getting doctors to go to rural
    areas and stay there is having access to a decent hospital. And they
    just won't stay if all they have is their own clinics. We just see it
    over and over and over again in America.
        So I really appreciate your saying that very important point.

    [Mr. Cannington stated the importance of a hospital's proximity to its
    patients' homes.]

        The President. What percentage of your revenues come from Medicare
    and Medicaid?
        Mr. Cannington. About 69 percent of our revenue and about 71 percent
    of our patients are Medicare and Medicaid.
        The President. Thanks.
        Mr. Kelly, John Kelly, is the administrator of the Soldier and
    Sailors Memorial Hospital, which has 217 beds and 500 people on the
    staff in Penn Yan, New York, which has a population of 5,500.
        Mr. Kelly.
        Mr. Kelly. Yes, Mr. President. Some of our people up here wanted to
    wish you a happy anniversary, sir.
        The President. Thank you. I had a wonderful day. It was a great day.

    [Mr. Kelly described the services provided by his hospital as a result
    of changes in the previous decade and expressed concern about the
    systematic failure to address rural health care issues.]

        The President. First of all, let me emphasize something you said
    that Mr. Cannington also said, that typical rural hospitals, an awful
    lot of them now, are far more than traditional hospitals. They are long-
    term care centers; they offer psychiatric care; they perform home health
    functions; they perform public health clinic functions.
        When I started working on all these problems over a decade ago, our
    big struggle was to try to convince all these hospitals in rural areas
    in our home State, if they wanted to survive they had to diversify, they
    had to use their beds in the most efficient way, they had to provide all
    these services; that rural areas couldn't afford to have separate
    institutions for all these different things.
        That has now been done. We now have in so many rural communities in
    our country what we call hospitals, but they're basically comprehensive
    care centers. And they are now in a position to do what needs to be
    done. What we believe is that we have to lower the rate of medical
    inflation and that now you have the infrastructure and the organization
    to do that. But if you cut too much too fast, we're going to wind up
    wrecking the system that we built through a lot painstaking effort and
    often trial and error throughout the 1980's.
        I don't think most Americans--they wouldn't have any way to know--
    but I don't think they understand the dramatic, breathtaking changes
    that rural hospitals went through in the 1980's and how many rural
    hospitals are now the kind of flexible, entrepreneurial, comprehensive
    health care systems that we all could only imagine just a decade ago. So
    I really appreciate what you said, because we need to--the American
    people need to know that we're not dealing with some big, fat, bloated,
    outdated bureaucracy that's been living off the fat of the land for the
    last 20 years. That's not what happened

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    in rural America. But you are going to get a disproportionate hit out of
    this.
        I'd like to talk to Margo Arnold now--or hear from her. She is the
    CEO of the West Side District Hospital in Taft, California, which has a
    population of 5,900 and has 84 beds and 160 employees.
        Ms. Arnold.

    [Ms. Arnold stated that her hospital and others would face cuts at both
    Federal and State levels and expressed concern that the onslaught would
    continue.]

        The President. What percentage of your revenues come from Medicare
    and Medicaid?

    [Ms. Arnold stated that approximately 69 percent of revenues came from
    Medicare and Medicaid and reiterated her concern for the future of the
    facility and its clients.]

        The President. Thank you very much.
        Peter Hofstetter is the CEO at Northwestern Medical Center, with 70
    beds and 400 employees, in Saint Alban's, Vermont. Peter, would you like
    to comment?

    [Mr. Hofstetter expressed concern about the impact of the cuts on his
    hospital's efforts to maintain a high-quality staff and institute
    community health programs. Secretary Shalala then questioned Republican
    proposals that rural hospitals shift costs to their clients.]

        The President. Yes. I think of all the people we're talking to, Mr.
    Hofstetter's Medicare-Medicaid reliance is the smallest. And yours is
    what? What percentage of revenue--
        Mr. Hofstetter. Sixty percent.
        The President. And that's the smallest of anybody we're talking to,
    60 percent.
        It's important to emphasize that rural populations tend to be older
    and that their average incomes tend to be lower. It's also important to
    emphasize that what is rural in Washington, DC, may not be rural in
    Vermont. I mean, it's extraordinary to have 48 doctors in a town of
    7,300. But the reason is there's so many other many, many smaller towns
    in Vermont that you're probably serving near there. And of course, we
    don't have anybody on this telephone call today who's from one of the
    High Plains States or Intermountain States, a place like South Dakota or
    North Dakota or rural Colorado or some of those places where you're not
    talking about 30 miles, you're talking about 100 miles or 150 miles or
    200 miles to the nearest town of any size. We're talking about
    breathtaking distances in some of our rural States which are very
    sparsely populated.
        So I think it's an astonishing thing that you were able to go from
    17 to 48 doctors and to solve those--to do what you're doing in the
    1980's. I wish I had known you 10 years ago when I had a different job.
    That's an amazing achievement.
        Secretary Shalala. How critical are you to the economy of the area
    that you're in, with that large of a facility?
        Mr. Hofstetter. Saint Alban's?
        Secretary Shalala. Yes.
        Mr. Hofstetter. Oh, we're about the second- or third-largest
    employer in the county. We've got a couple of large manufacturers and
    some other industries. But we're consistently in the top two, three,
    four. And we put about, oh, $8 million and change, with payroll and
    stuff, back into the economy.
        The President. How many of those doctors are on the hospital
    payroll?
        Mr. Hofstetter. Well, just one primary care doctor and then
    pathologists, that kind of thing. But most of the physicians that came
    here in the eighties and early nineties, it was a quality of life thing,
    and they set up a traditional solo practice situation. And I have to
    tell you, honestly, they're all--not all of them but a number of them
    are starting to question that whole aspect of life as well, being sort
    of the lone cowboy out there practicing medicine.
        The President. And of course, a lot of them, in addition to their
    hospital practice, a lot of their patients who don't come into the
    hospital are probably Medicaid and Medicare patients as well.
        Mr. Hofstetter. Oh, sure. We still have a lot of docs that do home
    visits. It's textbook primary care.
        Secretary Shalala. Not much quality of life if you don't have good
    health care, though.
        Mr. Hofstetter. No.
        The President. Let's go on to Todd Linden, who is the president and
    CEO of the Grinnell Regional Medical Center in Grinnell, Iowa. He has 81
    beds and 350 employees in a community with a population of 8,900.
        Mr. Linden, would you like to talk?
        Mr. Linden. Good morning, Mr. President.
        The President. Good morning.

    [[Page 1577]]

    [Mr. Linden described his facility's task of dealing with one of the
    Nation's highest Medicare populations coupled with one of the lowest
    reimbursement rates, noting that the problem would increase as the baby
    boom generation became more of a senior boom.]

        The President. I wish you hadn't said that. [Laughter]

    [Mr. Linden then expressed his concern that Medicare reforms be achieved
    in the most responsible manner possible, avoiding regional inequities.]

        The President. I want to thank you for what you said. Let me--you
    made a point that I want to reemphasize that everybody who talked today
    did. No one questions the fact that we have to slow the rate of medical
    inflation. That is not an issue here. The issue is--and no one knows,
    frankly, how much more progress we might make with telemedicine, with
    HMO's. And all of us recognize that you need to have more options, like
    for providers to directly sponsor managed care plans. And I certainly
    agree with you, we need to constantly review the equity of the
    reimbursement system.
        There is--however, one thing has been--there has been a consensus on
    one thing in this entire debate, which is that the number selected by
    the majority in Congress for their medical cuts in Medicare and Medicaid
    had nothing to do with a study of what the system would bear and what it
    could accommodate over the next 7 years. It was a number picked out of
    the air arbitrarily to fit a certain set of economic assumptions which
    are questionable, a 7-year balanced budget and a tax cut of $250
    billion. So they said, ``Well, that leads us to these cuts, and so we're
    going to make them, even though we have no idea what the impact on the
    system will be.''
        The people I talk to all across America--I was with senior citizens
    in Florida the other day--everybody in America is willing to make an
    effort to do what it takes to bring medical inflation down. Everybody
    knows that we can't continue to have medical inflation go up at 3 times
    the rate of inflation. But enormous efforts have been made by health
    care providers, especially in rural areas, in the last several years.
    And there is a consensus among providers with whom I talk that no one
    knows how and no one believes that this volume of cuts can be just taken
    out of the system in the next 7 years without severe adverse impact.
        And so I think it's important again to say this is not about
    ideology and this is certainly not about irresponsibility. The health
    care providers, the seniors in this country, everybody is trying to
    respond to this situation in a responsible way, but nobody, nobody,
    believes that this arbitrary very high number can be reached, based on
    all the evidence and experience we have today. That is the important
    thing.
        We have to do this in a way that is consistent with what we believe
    the facts and evidence are. We have to be honest and we have to be
    concerned about our primary mission, which is to provide decent health
    care. We don't want to make it worse.
        There's one other point I want to make about Iowa that relates to a
    lot of other States. I have been a big proponent of managed care as an
    option for seniors. And I'm glad that the Congress--the congressional
    majority now supports that. But I think we have to go into this with our
    eyes wide open. If we sell this as an end-all and be-all, what's going
    to happen is a lot of these networks, if there's not some real
    discipline here in how we do it, will cream the healthiest seniors. And
    the oldest seniors that have the highest health care costs will be left
    not in managed care networks and will be back either dependent on the
    Government--which either means they won't get health care, or we'll wind
    up spending a lot more than we think we will on the system because of
    that. And because Iowa has the highest percentage of Americans over 80,
    I think that's worth focusing on.
        It depends on who sets up these networks and how they serve them,
    whether everybody really gets served. This thing could get out of hand,
    and a lot of older people could get--and less healthy seniors could get
    left in the dust by this managed care movement if we don't do it in a
    decent and humane way.

    [Mr. Linden concurred on the complexity of the issue and stressed the
    primary importance of preserving health over curing disease. Secretary
    Shalala then noted that the Trust Fund would be adequately secured by
    $90 billion in cuts rather than the $270 billion Republican proposal.]

        The President. Let me say to all of you how much I appreciate the
    time you've given this,

    [[Page 1578]]

    and even more, how much I appreciate the work you've done with your
    lives. As I said, because of the job I had before I became President,
    because I lived in a rural State, I know how hard it's been for you in
    the last 10 years, and I know what dramatic advances have been made in
    the face of these difficulties and challenges.
        And we can do more, we can do better, and we will. But it is
    important that when we have this budget finalized that we don't have an
    arbitrary number, that we make an honest effort to discipline this
    system in a way that will save the Medicare Trust Fund, slow the rate of
    medical inflation, but do it in a way that will enable us to enhance the
    quality of medical care and the quality of life for seniors, for
    children, and for poor people, particularly those that are in more
    isolated areas and the rural areas.
        I'm going to do my best to take care of those concerns here and to
    defend them. And we will do our very, very best to achieve in the end a
    balanced budget that is decent and fair and based on our values when it
    comes to health care, and that's based on the evidence that you've given
    us. And I can't thank you enough.
        But if I could just say one thing in closing, I would implore you to
    personally contact the Members of the Congress in your area without
    regard to their party and say that you have done your part in the
    eighties, you are willing to do your part in the nineties, you
    understand why we want to balance the budget, but we have to do it in a
    prudent, disciplined way that does not wreck the health care system. We
    have worked so hard to reconstruct a comprehensive health care network
    in rural America, and there's still great difficulties in maintaining
    it. And to take it out now would be a tragedy. And it would be wrong,
    and it is not necessary to balance the budget.
        So I thank you from the bottom of my heart. And I just want to urge
    you to share your experiences and your knowledge with the Members of
    Congress, because many of them are having to vote on these issues
    without the experience base that you have--or that I have, frankly, or
    that any of us who have actually been through this and lived through it.
    So I would just close with that.
        There are a lot of good people up here trying to do the right thing,
    and we've got to just stick to our values, stick to the evidence, and do
    what is doable.
        And so--but, please, please, continue to reach out to the Congress
    in these next few weeks so that we can make the right kind of decisions
    for our country.
        Mr. Kelly. Mr. President?
        The President. Yes.
        Mr. Kelly. This is John Kelly up in Penn Yan. Could you just tell us
    what do you think the next step would be from your perspective in this
    process?
        The President. Well, I keep trying to engage the Congress in this.
    They're going to have to decide when and how they want to work with us
    to try to come to some agreement. But meanwhile, I think the next step
    is, that will either happen or they'll pass a budget that I find
    unacceptable and I will manifest that with a veto and then we'll talk
    about it then.
        And I don't know how this is going to unfold. But I do know this,
    that the more information, the more information you can get for the
    Members of Congress, based on what is real and what is going on in their
    districts and what their constituents are living with, the better chance
    we have to do the right thing on this budget.
        It is not clear to me yet exactly how the congressional leaders will
    determine they're going to proceed. But however it's going to proceed,
    in the end, I'm going to do my part in this process. And my
    responsibility is to basically advance the values and the interests of
    the American people and stand up for the people who I believe have been
    left behind in the process. That is what I'm going to do; that's my
    responsibility.
        But the mechanics of it are not yet clear because we're in somewhat
    of an unprecedented situation now. We're already past the time when the
    budgets are normally done. So I can't tell you that. But I can tell you
    this: It is never too late for you to contact them and explain your
    experiences and say, ``Look, this is just not doable; these numbers are
    arbitrary and they're not achievable. We're willing to help, we're
    willing to contribute, but we can't do that.'' And I urge you to do it.
        Thank you very much.
        Q. Thank you, Mr. President.
        The President. Goodbye.

    [At this point, the teleconference ended, and the President took
    questions from reporters.]

    [[Page 1579]]

    Federal Budget

        Q. Mr. President, a short time ago, Speaker Gingrich said of you--
    and I quote--``If he plans to run for reelection, I think it's a very
    big step for him to say, `I'm going to veto the balanced budget, tax
    cuts, welfare reform, and save Medicare.' I'm not at all certain by the
    time we're done in early November that he is not going to sign these
    things.'' Could you react to that?
        The President. Well, those words sound good, but what stands behind
    them? What kind of balanced budget plan? What kind of tax cuts?
        My job is to protect the families of this country, the children of
    this country, and the future of this country, the elderly. The
    President's job is to stand up for the fundamental values of the
    country. Those are nothing more than slogans. There are ways--if what
    the Speaker wants to achieve is a balanced budget with a tax cut that
    secures the Medicare Trust Fund, well, I'm for that. I'm for that. And I
    will work with him to help him to achieve that. But underneath that very
    appealing slogan there are $148 billion in taxes and fee increases on
    the elderly and on working people with very low incomes.
        This budget would take people out of the middle class and put them
    back into poverty. This budget would jerk up the ladder that poor people
    are now using to work their own way into the middle class. This budget
    would say, ``We're going to cut taxes on the President if he has capital
    gains income, but we're going to raise taxes on working people with
    children living on 15,000 bucks a year.'' This budget would say, ``If
    you're a senior citizen now on Medicare and you're living on 300 bucks a
    month, we're no longer going to make your copay from the Medicaid
    program, we're going to raise your cost of living, even if you're living
    on $300 or $400 a month.'' This budget would say, ``If you're going to
    college, we're going to charge you more for your college loan and make
    it more expensive and make it more difficult for you to get. And we're
    going to give more money that we used to allocate to students and their
    loans to middlemen like banks and others in the middle of the process.''
    I don't believe that's consistent with American values. I just--and it
    is not necessary.
        And so, these goals sound very good, but how you achieve them is
    very important. And they have, apparently, very little confidence--much
    less confidence than I have--that a balanced budget would lead to a
    growth in the economy. I mean, they say they want to grow the economy,
    but they have given us a budget that says, ``If you adopt our budget
    just like we've given it to you, we're going to have a big tax cut
    including--that goes to some people that don't want it and don't need
    it, and we're going to have huge cuts in Medicare and Medicaid, and
    we're going to balance the budget, and it's going to give America the
    slowest economic growth it's had in 25 years.'' That's the message of
    their budget.
        You know, I'd be proud of it if I were them. Now, what I did to show
    fiscal prudence was to give them a budget which says that I am assuming
    only that we will grow as fast as we have for the last 25 years, when
    we've had some very, very bad years. I believe we're going to grow
    faster than that, but I wanted to be prudent. But they say, ``No, adopt
    our budget. Do all these really tough things to the middle class, to the
    elderly, to the children, and we will slow the economy down. That's your
    reward, America, for adopting our budget.'' I think that's a very
    curious message.
        So, you know, I don't want to get into a shouting match on this, but
    would I sign a budget like this because they would maybe hide some of
    the severe consequences in the election year just to get reelected? The
    answer is, no. I won't do that. Because whether I get reelected or not,
    I hope to live to be an old man, I hope to live to see my grandchildren
    grow up in the America of the 21st century, and I want it to be a
    country with opportunity for everybody, with strong families and strong
    communities leading the world, that's a place where the things that we
    all believe in are alive and well. And I would gladly, gladly terminate
    my tenure here if the price of continuing it was just shelving
    everything I believe in about this country.
        So we need to take this debate out of the politics of it and take it
    out of the ideology, and let's talk about the facts. You heard these
    people. They're running these rural hospitals. They've all slowed their
    cost of inflation down. They're all willing to do more. None of them
    believe they can make the numbers in the congressional budget. Let's get
    out of politics and ideology and personal gain and all this rhetoric,
    and let's talk about what the impact is going

    [[Page 1580]]

    to be as a factual matter on the American people and how we can sign a
    credible budget that will grow the economy. Grow the economy, create
    jobs, raise incomes. We're going to be able to balance the budget quite
    easily, and we don't have to do all this.
        Q. What do you think about the AMA, Mr. President? What do you think
    about the AMA?
        Q. Mr. President, how do you suggest that the White House works with
    Republicans and vice versa? The two sides aren't even talking at this
    point.
        The President. I have a conversation with the Speaker every week
    about a lot of things. And we try to find ways that we can work
    together. But they have tensions within their own caucus, as you know.
    They have ideological tensions in the House and they have in the
    Senate--they have ideological tensions and political tensions that I
    can't reach or influence at this moment, because they're sort of encased
    in the way the Republican Party is today.
        A genuine discussion and negotiation about what we can do involving
    the leaders of the Republican Party--there are a lot of Democrats who
    want to vote for a balanced budget, a ton of them. You know, it's been
    largely ignored here, but the Democrats in the Congress took the lead in
    reducing the deficit. They took it without any support from the
    Republican Party. They took the deficit from $290 billion down to $160
    billion. So there are a whole bunch of Democrats that are literally
    yearning to vote for a bipartisan budget that reflects the best of the
    budget I put forward and the best of the budget they put forward and is
    better than both of them. We're not talking about a compromise that just
    splits the difference, we're talking about something that is better for
    America.
        So we can have these conversations before, during, and after they
    cast whatever votes they're going to take, but we have to get beyond
    this sort of line-in-the-sand rhetoric where--my door's been open since
    I gave my budget. That's why I gave them a balanced budget.
        Q. Will it take a budget summit, Mr. President?
        Q. Why don't you invite them over for a budget summit here? You're
    getting the Bosnians----
        Q. Will it take a budget summit?
        The President. I don't know. I don't know.
        Q. --for peace talks. Why don't you have peace talks with the
    Republicans?
        The President. Well, you know, like I said, I try to talk to as many
    of them as I can, all the time. I think, to be fair to them in terms of
    the timetable, to be fair to them, they have to--they're in a better
    position than we were 2 years ago, because 2 years ago, the week I got
    here, I was informed by the Republican leaders that there would be no
    votes for my budget. Whatever I did, there would be no votes. And so
    what we had to do was to work through our budget and figure out how to
    cut the deficit by $500 billion with Democrats only, which made it--
    which meant, compared to what I wished, there was a little more tax on
    upper income people and a little less cuts than I wanted. But we passed
    it. And it had a terrific impact. It drove down interest rates. It drove
    up the economy. It got us where we are today, with 7\1/2\ million jobs
    and 2\1/2\ million new homeowners and 2 million new small businesses.
        What they have to do--the timing on this will be, I think,
    determined as much by--will have to be determined by where they are
    within their own caucus. But they know something that we didn't know 2
    years ago. They know that we want to balance the budget, too--not just
    the President but a large number of Democrats in Congress in both Houses
    are willing to work with them. But they can't say working with us is,
    ``We're going to pass what we want, we're going to put it on your desk,
    and you will sign it or veto it.'' That's not my idea of working
    together.
        If their real objectives are a balanced budget, tax cuts that are
    reasonable, extending the life of the Medicare Trust Fund, we can
    achieve those objectives. But we cannot do it if the objective--or the
    real objective is to raise taxes on the lowest income working families
    of the country, to raise the cost of living to the poorest elderly
    people of America, do significant damage to the health care system, and
    to undermine the education investments of America and the environmental
    responsibilities of America, just because there's an ideological desire
    to wreck the Federal Government. And they have to work through that.
        But at some point, we'll all get together and work this out. I
    believe in the system and I wouldn't--and I don't think you all should
    over-react to this. I believe we're going to work this

    [[Page 1581]]

    out. But meanwhile, I'm going to do my best to take care of the American
    people.
        Q. Thank you, Mr. President.

    President's Wedding Anniversary

        Q. What did you get for your anniversary? [Laughter]
        The President. I got a number of things, but one of the most
    interesting things I got was from my wife. It was two old pictures of us
    together 20 years ago blown up.
        Q. Show us. [Laughter]
        The President. My daughter had unfavorable comments on men's styles
    in the 1970's. [Laughter]

    Note: The President spoke at 11:45 a.m. from the Roosevelt Room at the
    White House.