[Weekly Compilation of Presidential Documents Volume 29, Number 38 (Monday, September 27, 1993)]
[Pages 1850-1870]
[Online from the Government Publishing Office, www.gpo.gov]

<R04>
Remarks in the ABC News Nightline Town Meeting in Tampa, Florida

 September 23, 1993

    Ted Koppel. Welcome. A standing ovation. It's got to be downhill 
from here on in. [Laughter]
    The President. A lot of the work is still to be done.
    Mr. Koppel. Indeed. I'm going to begin with what may seem like a 
rather trivial thing, although I'll tell you it wasn't trivial to you 
yesterday. There you were. You were in front of the joint session of 
Congress. You had the Joint Chiefs of Staff there. You had your Cabinet 
there. You were talking to tens of millions of people. And you step up 
to the po- 

[[Page 1851]]

dium, and if you'd be good enough to take a look at one of those 
monitors out there, we're going to run--[applause].

[At this point, the audience watched television monitors which showed 
videotape from the previous evening.]

    The President. You can see the teleprompters there. You can see 
them. I am telling the Vice President, ``Al, they've got the wrong 
speech on the teleprompter.'' He said, ``That's impossible.'' I said, 
``You're not reading it. Read it.'' That's what I said. [Laughter]
    So it turned out that the people with our communications department 
had typed in the speech for the teleprompter on the disk that also had 
my State of the Union speech in February. And when the disk was called 
up, it started at the State of the Union instead of at the health care 
speech. And I thought to myself, that was a pretty good speech but not 
good enough to give twice. [Laughter] So that's what happened.
    Mr. Koppel. When I was looking at the First Lady there--you must 
have talked to her later on--it was almost as though she was telepathic. 
She looked worried. She knew there was something wrong.
    The President. She knew there was something wrong. My daughter, 
actually, watching at home, told me she also sensed that there was 
something wrong. And I just decided to go on and give the talk. I mean, 
I had, you know, I'd internalized it. I'd worked hard on writing it with 
our folks. The only problem is when you have to go through a lot of 
points, and you can't just read it. So I would just look at the first 
line and try to recall from memory. I didn't want to miss anything.
    And the other problem is if the teleprompter goes off, that's one 
thing. You just look at the audience just like I'm looking at you. But 
imagine if I've got these teleprompters here, and I'm trying to speak to 
you, and the wrong words are going up on the screen which is what we 
started out to do.
    So I had to ignore all these words and try to look through the words 
to the people. But about 8, 9 minutes into the speech, the fellow 
figured out what was wrong, pulled up the right speech and then whizzed 
through it to figure out where I was. And from then on in it was 
reasonably normal.
    Mr. Koppel. Well, I've got to tell you, Mr. President, as a 
communications specialist--and it may be the last nice thing I say to 
you or for you this evening--you have my admiration. I can't tell you 
how tough that is when you've got the wrong speech going by. You did an 
extraordinary job.
    Let us take at look at how the speech played. We've got some phone 
numbers there. Before the speech you can see, we took a poll and 43-
percent approval of your health care plan, 41-percent disapproval. Let's 
take a look at after the speech: up to 56-percent approval; 24-percent 
disapproval. You're too good a political pro to put too much faith in 
that sort of kick that you get right after a speech. How tough is it 
going to be to hold onto that?
    The President. I think it depends upon how good a line of 
communication we can maintain with the American people and how open we 
can be in working this process through Congress. There will be a lot of 
people who will honestly disagree with certain things I have 
recommended. There will be a lot of other people who will not want it to 
happen because they will make less money out of the system that we 
propose or because it will require them to change. And they will all be 
heard. So the important thing is that everyone understand that this is 
an extremely complicated thing. You interviewed me before, and I saw you 
showed it out here. I've been working on this issue seriously for 3\1/2\ 
years, and I've been dealing with health care as a Governor and attorney 
general and a citizen for a long time, but really working on the 
systematic problems for 3\1/2\ years and talking to hundreds of doctors, 
of other experts all around the country. It's a complex thing.
    But I think if the American people know that Hillary and I and our 
administration, that we're listening to people and that we're really 
shooting them straight, then I think we can maintain support for change. 
Because the reason there's so much support for change among Republicans 
and Democrats and all the people in the health care system is that those 
who know the most, know we cannot afford to continue with the system we

[[Page 1852]]

have. It's bankrupting the country and not helping people.
    Mr. Koppel. Mr. President, we've got an awful lot of people here who 
I know want to ask questions. I just want to show you one more poll 
result. Take a look. ``I worry my future health care costs won't be 
taken care of.'' Now, look at how many people agree----
    The President. They should worry.
    Mr. Koppel.----with that statement. That's after hearing your 
speech.
    The President. They should worry about that.
    Mr. Koppel. Why do you think it's still so high? Two-thirds of the 
American public still worry that their future health care costs won't be 
taken care of.
    The President. Because health care costs have been going up at twice 
the rate of inflation, or more. For people insured in small businesses, 
more than twice the rate of inflation. Because in any given 2-year 
period, almost one in four Americans don't have any health insurance, 
because about 100,000 Americans a month lose their health insurance 
permanently. So how could people not? And even if that hasn't happened 
to you, almost every one of us know someone that it's happened to.
    Mr. Koppel. Let me ask you a favor, Mr. President. I've already 
talked to the audience out here and asked them the same favor. They're 
going to introduce themselves to you, tell you their names and who they 
are. We've got so many people who want to talk to you, to the degree 
that we can, let's zip through as many questions and answers as we can.

[A homemaker indicated that her son had nearly drowned and that she and 
her husband had the best insurance coverage available to cover the costs 
of weekly treatment. She asked if her coverage would be lost under the 
new health care plan.]

    The President. Well, first of all, it won't get any worse. That is, 
if you're paying for it now and you have coverage that covers that, 
there's nothing to prevent that from continuing in our system. Anybody, 
for example, who's got a situation at work where your employer is paying 
100 percent of your premiums, that can continue. So you shouldn't worry 
about that.
    But in all probability, because of the changes in our plan, you will 
have more secure coverage. That is, if this plan passes, you will know 
that the coverage you have can never be taken away from you and that we 
will cover the primary and preventive services, and those kinds of long-
term care services for children are very important.
    Also what we want to do--it's very important, especially in the 
event your husband has to change jobs--we're going to rate all families 
in America under a broad-based community rating system so that people go 
into big pools. Insurance companies make money like grocery stores do, a 
little bit of money on a lot of people, instead of a lot on a few, and 
we all share the risks in ways that will guarantee that you'll always be 
able to get insurance at lower rates than would otherwise be the case.
    Mr. Koppel. All right, let me move right on. And forgive me, I know 
that none of you is going to be completely satisfied and would like to 
ask follow-up questions, but we are going to try and move around.
    Go ahead, sir.

[A psychiatrist asked if mental health out-patient services would be 
paid at a cost equal to other medical illnesses or paid at a lesser 
rate.]

    The President. It depends. The reimbursement rate will depend upon 
what plan the person joins who wants the mental health care. For 
example, each individual will choose what health plan they belong to. If 
you choose, for example, a preferred provider organization where a lot 
of doctors get together and offer to give services, they will prescribe 
what the reimbursement rate will be and what the cost of the plan will 
be.
    If a person joins a fee-for-service plan, then the reimbursement 
rate will be published on the front end, and it will be agreed to by the 
doctors in the beginning. But the Government won't set the rate. So 
there will be some more flexibility there.
    And let me also say, because I don't want to overpromise in this 
thing, I really believe it's important for us to cover mental health 
benefits. But we're not going to be able to

[[Page 1853]]

cover the full range of mental health benefits because we don't know how 
to cost them out very well, as much as I think we should, until the year 
2000. So there won't be unlimited visits, for example, until the year 
2000. But we'll start with some hospitalization that's significant and a 
number of visits per year and then build up to full coverage over the 
rest of the decade.
    Mr. Koppel. Mr. President, we also have our financing plan here. We 
have to take some commercial breaks. We're going to take the first of 
them right now. We'll be back with President Clinton and our audience 
here in Tampa in just a moment.

[At this point, the network took a commercial break. ]

    Mr. Koppel. If you take a look at the poll--I don't know if you can 
read--your eyes are probably better than mine. I can't read those 
results from here. Can we put it up on the big screen? Can we see the 
poll up there?
    The President. Yes, I see it.
    Mr. Koppel. Can you read it? Well, will you be good--there we go. 
They think your plan versus the present system: 64 percent think it's 
better; 17 percent think it's worse; 3 percent think it's the same. 
Again, that's pretty good. I mean, you can't expect it to do much 
better.
    The President. Sixty-four percent are right. [Laughter] They're 
right.
    Mr. Koppel. Just to keep things from getting too dull, let's see if 
we can get a question from one of the 17 percent. Go ahead.

[A homemaker indicated that she provides care to her mother and husband 
both of whom suffer from Alzheimer's disease, and she asked what the new 
health care plan would do for caregivers.]

    The President. It will do three things. First of all, for people 
with Alzheimer's and other problems that require institutional care, we 
will continue to cover that. And we will cover it at least as well or 
better as now.
    But secondly, over a period of years--now, we can't do all this at 
once, because we have to phase-in the coverage as we realize more 
savings from the waste in the existing system. But over a period of 
years, we will also reimburse people for in-home care, because often 
times it's less expensive to maintain people in homes than in nursing 
homes. So we will, for the first time, have a system by which people can 
actually have coverage for in-home care. And that will include respite 
care, too. If, for example, you are taking care of a parent or a spouse, 
you're doing an incredible service for a society. You're keeping your 
family together, and you're saving money for the system, but you're 
entitled to a little time off. And so under this system, over a period 
of years we'd actually set up a reimbursement system so you could be 
reimbursed or covered to bring in a nurse, for example, if you wanted to 
take a 4-day weekend or something just to get away from the pressure of 
your duties.
    And over the long run, this will enable more people to keep their 
families together, lower the cost of care by keeping more people out of 
institutions and make for, I think, a better quality of life in our 
country.
    Mr. Koppel. To the degree that you can, Mr. President, can you give 
a sense of what the progression of years is going to be? In other words, 
you keep saying we're not going to be able to do all of this right away.
    The President. Sure. Yes. Let me say, first of all, we assume that 
it will take a period of several months for the Congress to work through 
this. But I must tell you, this is the best spirit I have ever seen in 
the Congress, at least in modern times, among Democrats and Republicans, 
first to learn everything they can and second, to work together. We're 
in Florida tonight. We have six members of the Florida delegation up 
here, three Democrats and three Republicans who came down here with me 
tonight, and that's sort of the attitude that's going on.
    So, let's assume we pass a bill sometime next year. The first and 
most important thing we have to do is to lock in basic security for 
everyone; so we want to get that done by 1996. That is, everybody's 
covered with comprehensive benefits. And then, between 1996 and the year 
2000, we want to phase in each year more of these long-term care 
benefits. So it'll be about a 5-year period after the basic benefits 
come out.
    Mr. Koppel. You have got to be concerned, because I mean, there's a 
little thing called ``reelection'' that has to kick in before

[[Page 1854]]

you can be sure that you're going to be able to continue doing these 
things into a second term. You must feel tremendous pressure to get a 
lot of this done by the end of your first term.
    The President. What I feel the pressure to do is to at least pass 
the legislation and get the security in. I want everybody to have their 
health security card so I know they'll have comprehensive benefits that 
can't be taken away, that they can't lose. If that happens, I believe 
that the public feeling for this will sweep across America without 
regard to party, to region, to age, and that the American people will 
see this as a decent, humane thing that we have waited too long to do, 
and that it will then be a tide that no one can turn back, and no one 
will really want to turn back.
    Mr. Koppel. Let me ask you to swivel around. And I know you wanted 
to acknowledge the Attorney General, who is sitting up there. If we can 
just do that.
    The President. Say hello to Attorney General Reno. [Applause] She 
wanted to come home with me--you know, Janet Reno is from Florida--for 
two reasons. First of all, we're going to do an event tomorrow dealing 
with young people and crime and the costs that that imposes on our 
health care system, and because she also is deeply concerned about what 
she can do to help deal with some of the issues here. The Attorney 
General must enforce the Americans With Disabilities Act, for example. 
The Attorney General has the power to reach and deal with our young 
people in ways that can have a direct impact on the quality of their 
lives and health care in this country. So she came down here, and I'm 
glad she's here.
    Mr. Koppel. Swivel your attention over to the left, the gentleman up 
there at the microphone. Go ahead, sir.
    The President. Yes. sir.
    Q. Good evening, Mr. President.
    The President. Good evening, sir.

[A retired educator with AIDS indicated that some AIDS victims cannot 
get treatment because of the limitations of Medicaid.]

    Mr. Koppel. Do me a favor, if----
    The President. I know what you're--can I get to the--I know the 
question. First of all, there are a lot of doctors who don't treat 
Medicaid patients because it's an incredible paperwork hassle fooling 
with the Federal Government, and because often the reimbursement rates 
are so much below regular insurance reimbursement rates for Medicaid. 
People with AIDS at some point have to quit working, and often times 
don't have insurance on the job, so they quit working just so they can 
get Medicaid.
    Two things will happen under this system that will really help you 
and people like you all over America. There are one million Americans 
that are HIV or AIDS today:
    Number one, because you will be covered with health insurance while 
you're able to work, including a drug benefit that will make you able to 
work longer, along with everybody else, you will always have health 
insurance, and it won't break your employer because you'll be part of a 
big community pool. So your rates will be the same as everybody else. So 
the first thing is, more people with HIV positive will be able to work 
longer without bankrupting their employers.
    Number two, if you do have to quit work and you go onto what we 
now--now the Medicaid program, it won't be a separate Medicaid program. 
Medicaid patients will be in these big health alliances with self-
employed people, small business people, the employees of big 
corporations, everybody will be in there together. Everybody will pick 
their plans together. And the plan will treat you just like everybody 
else, because the reimbursement for you will be just like everybody 
else, and there will be one form to fill out for you, just like 
everybody else. So there will no longer be an incentive or the option to 
turn you down. They won't even know, for all practical purposes, whether 
you're Medicaid or not, because you'll just be in the plan with everyone 
else.
    That's a huge thing. It's a very important thing.
    Mr. Koppel. I told our audience before we went on the air, let me 
take this opportunity to tell our audience at home, we have three panels 
of experts: One in Boston; they're experts on public finance from 
Harvard's Kennedy School of Government group. In Chicago, they're 
practicing physicians; they're professors of medicine at the

[[Page 1855]]

University of Chicago. And I'd like to turn now to a panel in Los 
Angeles. They're three experts on public health policy at UCLA.
    Only one of them, if you would be kind enough, gentlemen, but I know 
you have some thoughts on what we've discussed thus far. And I need all 
the help I can get, please.

[Dr. Robert Brook asked about flexibility to have different family 
members receive care from different medical sources.]

    The President. We will basically have, I think, two assurances of 
quality of care. First of all, the plans that will be provided and the 
prices that will be offered in these plans will be influenced heavily by 
the physicians and the other caregivers. But there will be a lot of 
incentive to lower cost, because your administrative cost would be so 
much lower.
    Secondly, the National Government, as happens now with the 
Government in different ways, will prescribe certain quality standards, 
and then each State will offer information to people in these plans 
about not only the price of services but the outcomes.
    For example, as you probably know, Pennsylvania now has a program in 
which they presently publicize the price of certain services and the 
outcomes. And it enables people to make judgments about both quality and 
price that they couldn't otherwise make. So we're going to give 
consumers more information, we're going to give professionals more 
capacity to figure out how to manage the system while maintaining 
quality, and we will have ultimately, Government standards as the 
guarantor of quality practice.
    Mr. Koppel. Go ahead, Doctor, if you want to make one more quick 
comment. Then we've got to go to a break.

[Dr. Brook expressed gratitude that the new health care plan called for 
universal coverage and asked how the plan will assure quality care.]

    The President. That's a good question. Let me try to answer it. 
First of all, every person will have at least three choices. Most people 
will have more choices, but every person will have at least three. And 
so let me try to say what they would be.
    You can choose to stay in a traditional fee-for-service medicine. 
That is, you pick your doctor, and they charge you by the service. That 
may be more expensive, but it may not be if big networks of doctors get 
together to offer these services together. In that case, you would have 
a cardiologist and a pediatrician working together.
    Secondly, you could go into what's called a ``preferred provider 
organization'' which is normally an organization that is organized by 
health care managers but that have all kinds of specialists in them.
    Thirdly, you can go into an HMO which will have a range of 
specialists, but it'll be a closed panel. That is, the people that work 
there will be on salary. So you may not have the specialists you want.
    In the first two cases, you'll probably be able to do exactly what 
you want for the price that you pay up front. In the third case, if 
you're in an HMO, you'll still be able--if you say, ``Look, my child is 
really sick, and I want this child to see a pediatrician who is not in 
this HMO who is in another State,'' you'll still be able to go to that 
other State, but that pediatrician will be reimbursed by your insurance 
plan only at the rate that the HMO pediatrician will be reimbursed, then 
you would pay the difference. But that plan will be the cheapest, so 
you'll come out about the same, no matter what.
    Mr. Koppel. We're going to take another short break.
    The President. Least expensive. I don't like that word ``cheap.''

[At this point, the network took a commercial break.]

    Mr. Koppel. Now, you see the results of that poll. New taxes to pay 
for the health plan, you were being a little bit cagey in your speech 
last night. You were saying no broadbased taxes----
    The President. That's right.
    Mr. Koppel. You are going to have taxes on cigarettes. You haven't 
yet decided whether you're going to have taxes on alcohol, liquor.
    The President. But let me tell you what--[applause]. I know you all 
have a lot of questions. Let me just make some general points about 
this. Our analysis shows--and let me say, we have consulted with health 
care finance experts in Fortune 500 companies, in big accounting firms. 
We have talked to ev- 

[[Page 1856]]

erybody we can talk to who have dealt with the health system for years. 
They believe that if we can get the kind of savings we know are there--
keep in mind, in the American health care system, we spend 10 cents on 
the dollar more on paperwork. That's more than $80 billion a year more 
than any other country, a dime on the dollar more just on shuffling 
paper. If we can get the savings that I talked about last night, they 
believe that 63 percent of Americans that have health insurance will pay 
the same or less for the same or better coverage, that the people that 
have virtually no insurance but just a skeleton policy will pay a little 
more, and that young single workers, because they'll go into community 
ratings with people who are older and sicker, will pay about $6 more a 
month. Now, that's what they think. Why?
    With only a modest--I mean, a cigarette tax, not modest but a little 
under $1--and a fee on the big corporations who opt out of the system 
and continue to self-employ----
    Mr. Koppel. You haven't decided on alcohol yet----
    The President. Self-insured.
    Mr. Koppel. ----whether to put a tax on it.
    The President. No, I don't think it's necessary.
    Our numbers show that with a cigarette tax and if the big employers 
who opt out of the system because we let them self-insure, they should 
be asked to pay a little more, because they should pay for medical 
education, the health education centers, the preventive care networks, 
all the things that all the rest of us will pay for in our premiums.
    They still, by the way, will be big winners. Their premiums will 
drop a lot anyway, because big employers are paying way too much now 
because they're bearing the cost of the uninsured. That is, when people 
who are uninsured get real sick, they get health care, and then the rest 
of us pay the bill in higher hospital bills and higher insurance 
premiums. So we think that the larger employer fee plus the cigarette 
tax plus the savings, plus--keep in mind--requiring the people who are 
presently uninsured, but employed, and their employers to pay something, 
that those things will pay for it. I don't think we should raise a big 
general tax on people to pay for the uninsured when most people are 
paying too much for their insurance already. Keep in mind, 63 percent of 
the people under this plan will pay the same or less for the same or 
better coverage.
    Mr. Koppel. You know that much of the criticism is coming from small 
businessmen. I know because this gentleman came up and asked a question 
before the program started. Go ahead, sir, and ask it. If you'd be good 
enough to identify yourself, too.
    Q. Mr. President, I am a small business owner here in Tampa. I have 
10 employees. Right now my percentage of my payroll is 4 percent. Now, 
under our plan----
    Mr. Koppel. Your percentage that you spend on----
    Q. That we spend.
    Mr. Koppel. On health care?
    Q. Four percent of my payroll.
    Mr. Koppel. Right.

[At this point, the participant asked about paying insurance for 
dependents of his employees.]

    The President. First of all, let me ask you a question. How many of 
your employees have a spouse which also works?
    Q. Three.
    The President. Okay. Then, here's the short answer. The seven, you 
will have to provide a family plan under my--the three, which have 
spouses at work, they will be able to decide whether you or the other 
employer, they'll take the children's coverage, because they'll pay 
more, too, keep in mind.
    Now, because you are a small business person with under 50 
employees, you will be eligible for a discount that could take your 
premiums as low as 3.5 percent of payroll, even for the family coverage. 
So in all probability, you will be paying about what you're paying now, 
even though you will be covering seven families at a minimum, in 
addition to the seven employees. Because, the way we set this up--in 
other words, we understand, and let me go back a second--we went out and 
interviewed hundreds of small businesses. And my Small Business 
Administrator took the lead in this. He's from North Carolina, and he's 
spent the last 20 years of his life starting small businesses.

[[Page 1857]]

    So we were in a real dilemma here, because small businesses who 
cover their employees have premiums going up at roughly twice the rate 
that other people's premiums are going up. There's a 35-percent 
difference now between small business premiums and big business 
premiums. And I don't know what you cover, but basically that's the 
rule. One-third of the small businesses in America, according to a 
representative poll recently, said they were going to drop all their 
coverage if somebody didn't do something to stop the rate of cost 
increase.
    So the only way to stop the rate of cost increase is to get 
everybody covered, and then put them in these big groups, so you can 
have the same market forces working for you that big businesses do. But 
it's not fair for me to put you out of business, because small 
businesses are also creating most of the new jobs in America. So that's 
why we've got the discount system. Part of what we're going to do with 
the money we're going to raise is to fund a discount system for people 
with fewer than 50 employees, so you won't have to pay the 7.9 percent 
of payroll, and you may pay as little as 3.5 percent. In all 
probability, because you only have 10 employees, you'll pay almost 
exactly what you do now, and you'll get more coverage for it.
    Mr. Koppel. Let me just ask you quickly, though. Right now, paying 4 
percent on 10 people, you're saying 3.5 percent. He would than have to 
pay the 3.5 percent on all the dependents, other than the three who are 
working.
    The President. No, it's 3.5 percent of the payroll of his employees. 
So he would pay about----
    Mr. Koppel. Total?
    The President. Correct. He would pay about what he's paying now. 
Because he's a small business person, there would be a discount for his 
premiums.
    Mr. Koppel. Okay. Does that answer your question? We've got to take 
another break, we'll be back in a moment.

[The network took a commercial break.]

    Mr. Koppel. And let us get right to the questions again. Mr. 
President, if I could ask you to swivel around. We have a question back 
there also on money from a larger employer.

[An IBM employee asked what effect the new health care plan would have 
on large businesses which are self-insured.]

    The President. Well, actually, the biggest companies in the country 
are the ones most likely to benefit from this, because they are 
actually--even though they're self-insuring, when you self-insure, when 
you're big, the good news is that you acquire market power, and you can 
normally keep your rates from going up as fast as they otherwise would. 
The bad news is, you're still paying part of the costs of uncompensated 
care. That is, people are shifting the cost to you.
    We estimate that for a company like IBM that self-insures, you will 
save, the company will save on premiums, for whatever you're doing now, 
you'll save about $10 a month an employee under our system, which is a 
huge amount, simply by stopping the cost shifting to IBM, with no change 
in the benefits. No, you can keep on doing exactly what you're doing.
    Now, let me just give you an example of how it can get even bigger. 
For companies that have huge cost shifts and big retiree burdens like 
the big auto companies and the big steel companies, they will save even 
more.
    But the people that will be least affected by this are big companies 
with over 5,000 employees that choose to continue to self-insure. You 
will, however, benefit by the increased competition of the system. What 
I want everybody else to do is to have the benefits that IBM has. You 
won't lose anything. Xerox has cut their costs by $1,000 an employee a 
year through better managed care without taking anything away from the 
employees. And we think we can do that for all Americans.
    Mr. Koppel. Mr. President, let me be the doubting Thomas for a 
moment. Big companies are going to save money. The little businesses are 
going to save money. The 37 million people who you say are underinsured 
or uninsured right now----
    The President. They'll pay more.
    Mr. Koppel. They'll pay more, but they're going to be insured for 
the first time. Everybody's going to be better off----

[[Page 1858]]

    The President. No, not everybody.
    Mr. Koppel. Who's not going to be better off?
    The President. Well, let me just say this. In the long run everybody 
will be better off if we bring health care inflation down to the regular 
rates of inflation.
    Mr. Koppel. Who is going to get hurt in the short term?
    The President. The following people will get less money, or will pay 
more: single, healthy workers who are insured in big plans now so they 
have low costs because they're at least risk, will pay more. They'll pay 
about $6 a month apiece more to help to cover that gentleman up there 
with AIDS or older people, just who get older, it costs more. They'll 
pay more. People who provide only the scantiest catastrophic illness--
for example, I met a man, a man came into my office in the White House 
today with a group of folks, who travels with an entertainment group. 
He's got a $5,000 deductible with a modest income. He might as well not 
have any insurance. Now, he'll have to pay a little more, but he'll have 
something when he pays it.
    People that don't pay anything now will have to pay more if they 
have jobs, and their employer will have to pay something, although we're 
going to try to keep the small businesses from being hurt too badly. All 
those people will pay more.
    Who will get less under this system? You've got to squeeze--
somebody's got to get less. Who will get less? The people who benefit 
from the paperwork explosion will get less. Hospitals in the future will 
hire fewer clerical workers, doctors' offices won't have to hire an 
extra person just to spend all day long calling insurance companies, 
beating up on them to pay the money that they owe anyway. Insurance 
companies will not grow as rapidly, and there may be fewer of them 
unless they can get in here and provide these plans at competitive 
costs. So that's the major squeeze in the management of the system.
    There will also be savings, frankly, in the provision of services. 
We had, in the Pennsylvania case I just cited, they published a heart 
procedure where the prices charged in the State of Pennsylvania varied 
from $21,000 to $84,000 for the same procedure, with no differences in 
health outcomes. When all of you get into big groups so that you have 
the power that the IBM employees do, you will take the $21,000 choice 
every time as long as there's no difference in the outcome.
    And so, everybody there, there will be some losers. But, on balance, 
most Americans will win, and the security is worth something. And then, 
over the long run, we'll all win if we can bring health costs closer to 
inflation.
    Mr. Koppel. Let me direct your attention to the balcony up there. Go 
ahead, sir.

[A participant asked about the effect on the tobacco industry of a tax 
on tobacco.]

    The President. Arguably, if we raise the tax, it will reduce 
consumption. But the answer to your question is, I don't think it's 
right to have a big, broad tax--I'll say again: tax everybody in 
America, most of whom are paying too much for what they've got to pay 
for those who haven't paid anything. I don't think that's right when 
there are savings. So, we didn't in the beginning know if there would be 
any tax. But we wound up with a gap in what we think the program will 
cost in the early years, for about 5 years before it starts to get big 
savings by the way, and what we had. And we had to figure out how best 
to make it up. And I thought that a tobacco tax and a tax on the biggest 
companies who will get big benefits out of this, a modest one just to 
make sure they contribute, as I said, to medical education, to medical 
research, and to preventive services like everybody else will, that 
those were the two fairest ways to get it.
    And the truth is, that smoking is one thing, unlike drinking for 
example, where it's a terrible thing if you do it to excess. We know 
that there is some risk in any level of it, and that it imposes enormous 
extra costs on the health care system which the rest of us have to pay. 
So it seemed to me that that was a fair way to get some money.
    Mr. Koppel. Mr. President, I want to take advantage of one of our 
experts again, this time in public finance up at the Kennedy School in 
Harvard. Mr. Forsythe, would you go ahead, please?

[Mr. Dell Forsythe expressed concern about job losses in the health 
industry.]


[[Page 1859]]


    The President. There will also be job gains in the health industry. 
There will be hundreds of thousands of new jobs in people providing home 
health care, in other kinds of preventive and primary care, so that we 
think even within the health industry, the job gains in direct health 
care providers will offset the job losses in clerical work.
    Secondly, there are bound to be job gains when you lower the payroll 
costs that a lot of major employers are paying today. You give them more 
money that they will either use to give their employees pay increases, 
and I might say millions of people in this country have foregone any pay 
increases for the last 4 or 5 years, because the pay increases have gone 
into higher medical costs. So you're either going to have more folks 
hired or pay increases going back to employees for the first time. So we 
believe there will be a net economic benefit by shifting the way this 
money is spent. I don't think that all investments are equal, and I 
think since you're going to shift the way money is spent, and we're not 
going to cut, keep in mind, we are not cutting spending on health care. 
America at the end of 5 years will still be spending 40 percent more 
than any other country, maybe even a little more. But we're going to 
spend the money differently in ways that we think will produce more 
jobs, not fewer jobs.
    Mr. Koppel. Let me just see if I can slip one more question in. 
We've only got about a minute and half left. Where is the lady who was 
at the microphone? You'll see--right over there. Go ahead.

[A participant asked whether the doctor or the insurance company would 
decide when to discharge a patient from the hospital.]

    Mr. Koppel. We've got 1 minute, Mr. President.
    The President. The doctor, the doctor will make the decision. The 
coverage will be comprehensive, and the doctor will make the decision.
    Can I say one thing real quick? I want to make a specific point 
here. A lot of people have coverage that have lifetime limits. That is, 
they look real generous, but if you run up to a certain dollar amount, 
it's gone. Another real benefit of this--and the only way you can 
guarantee real security is to say there are no lifetime limits, you just 
have the coverage--and again, I know it's counterintuitive--a lot of 
people just don't believe you can ever save money on anything. But all I 
can tell you is that every doctor and every health care expert that we 
have ever consulted who has really studied this believes that there are 
billions and billions of dollars of savings which can be made that will 
enhance the quality of care, not undermine it. And that's what I urge 
you--I don't ask you to just take my word for it, just watch the debate 
unfold and listen to the people who have spent their lives do it.
    Mr. Koppel. Mr. President, on that note, we've got to take one more 
quick break, and then I'll come back with a program note. This program 
is going to be going on but in another form. I'll tell you about that in 
a moment.

[The network took a commercial break.]

    Mr. Koppel. We're just about out of time in our prime time segment. 
But I do want to make a quick program note. First of all, the President 
has indicated he wants to amend one of the answers that he gave before. 
We don't have enough time to do that there and now, but we will be back 
after your local news. Most of the country will be taking it at 11:35 
p.m. Eastern Time. And the President has agreed to stay with us on an 
open-ended basis. Now, that means, I guess, until he gets tired or you 
get tired or we all get tired.

[The network took a commercial break.]

    Mr. Koppel. Good evening, ladies and gentlemen. Those of you who 
were with us in prime time know what we're up to. Those who are just 
joining you now in our regular Nightline slot, let me point out that 
this is a special open-ended edition of Nightline. Obviously, you 
recognize the gentleman to my immediate left, the President of the 
United States, who has been answering questions from a wide variety of 
the thousand-odd people or so that we have with us here in Tampa, 
Florida.
    And, Mr. President, if you don't mind, we'll get right back to the 
questions. There are a couple of things I know you want to

[[Page 1860]]

pick up from the last program. We'll do that in a couple of minutes. Go 
ahead, sir.

[A participant described his overwhelming medical bills from his 
daughter's surgery and asked what to do.]

    The President. Well, first of all, I don't think there can be a 
better case for changing the present system. What I think will happen 
before we have a change is that if your daughter has to have surgery 
next year, they'll probably do it, and do a good job, and that stack of 
bills will get higher and somehow the costs will just be spread among 
everybody else until we fix this system.
    But let me tell you what would happen if the proposal I have made 
were law now. First of all, as a self-employed person, you would be able 
to buy a health insurance policy for your family, even though your 
daughter has previously been sick, on the same terms as other self-
employed people. And instead of that policy being totally out of your 
reach, you would be able to buy it more or less on the same terms as 
other small business people, because we would put you and the farmers 
and the other self-employed people into a big pool like everybody else. 
So you would be able to take advantage of an economy of scale. So you'd 
be able to buy a more affordable policy.
    Secondly, because you're self-employed, you'd get 100-percent 
deduction on your taxes for it. Today, you only get a 25-percent 
reduction. So it would be lower costs, comprehensive benefits, you 
couldn't be denied coverage because your daughter had a terrible 
problem, and you'd have 100-percent deductibility. That's one of the 
reasons we ask single, young people to pay a little more. But all those 
single, young people will be in your situation, too, someday, if they're 
fortunate.
    I wish I had an answer for you right now. I don't. The answer right 
now is for the hospital to just step right up to the plate and the 
doctor and do what they did last time until we get this thing fixed. 
Once we get it fixed, then you won't be in this position again.
    Q. Her pediatrician, Dr. Augustine Martin, knows that he's not 
getting paid for this, and he knows it but he's taking care of her, and 
he's not even worried about that, which is great.
    The President. You know, I'm really glad you said that, because we 
heard a sad story here before about doctors who wouldn't take Medicaid 
patients, which leaves the patients out in the cold, although Medicaid 
is a real pain. But for every case like that, there's a case like this. 
And those doctors need our thanks.
    Q. Yes.
    Mr. Koppel. Mr. President, we've got so many people who want to talk 
to you here. We want to move over there to the wheelchair section. Go 
ahead, sir, please.

[A participant described the fear disabled people have of losing 
Medicare and Medicaid benefits if they are employed.]

    The President. First of all, by providing insurance to everyone 
based on a community-based rating. We would never put an employer in the 
position of saying, I'd like to hire you, but you're disabled and 
something terrible might happen to you. And if I had to take care of it 
on my insurance, my premiums will go up 40 percent the next year, and 
I'd have to drop you anyway. So I can't do it, which is basically what 
happens now. A lot of disabled people are going basically to waste in 
our country because they could be gainfully employed, they could be 
making major contributions, and they're not hired because people either 
can't get insurance for them, or because they're afraid it will bankrupt 
them.
    Under our system, you'd be just like any other American citizen. You 
would pick a plan, you would go into it, and because of the community 
rating system, you would be insured. And therefore, there would never be 
a disincentive for an employer to hire you. And you would always have 
that insurance.
    And if you needed supporting services, even at work as we build in 
these long-term care services, we'll be able to have not only long-term 
care in the home, but some support services associated with people who 
work. That will save this country a lot of money over the long run, 
because you're going to have a lot of folks who don't work now working.

[[Page 1861]]

    But there are a lot of people who are disabled, as you know, who are 
on Medicaid only because they couldn't get private health insurance as 
workers. And just like this man who just talked to us over here about 
his daughter, there are people in this country who have quit their jobs 
and gone onto welfare and drawn Medicaid only because of the illness of 
their children. So that's something the disabled population has in 
common with people like him. That will never happen again. People will 
be able to keep working. It's very important.
    Mr. Koppel. Mr. President, we're going to have to take another quick 
break. When we come back, though, we've got a public policy expert up at 
Harvard who is just seething at some of the numbers. He wants to have at 
you. And I know you want to correct a couple of things or at least make 
an amendment to a couple of things that you said in our prime time 
segment. So we have all of that ahead of us when we come back in just a 
moment.

[The network took a commercial break.]

    Mr. Koppel. That's another one of our poll results, Mr. President: 
What will happen to your quality of health care? Twenty-seven percent 
think it's going to get better, 27 percent think it's going to get 
worse, and 42 percent think it's going to stay the same. You've 
obviously got some missionary work to do there. Do you want to comment 
on that poll and then get to the amendments, to what you wanted to 
correct?
    The President. Sure. I don't blame anybody for thinking that, 
because while Americans know more about their own health care than 
almost any other subject, most of us have never had a chance to learn 
anything about how the system as a whole works. So it's against our 
common experience to believe that you can get more and pay the same or 
less, or that if you control costs, you won't have to give up something 
really valuable for it. That's against our common experience. But if you 
study the system, you'll find that we have, literally--I'll say again--
just in paperwork alone, a dime on the dollar more waste in our system 
than any other system in the world, that we have more variations in 
prices with no differences in outcomes than any other system in the 
world, that there are all kinds of waste in this system that can be 
managed down.
    You don't have to take my word for it. I saw what those folks said, 
but let me just give you one example. The Mayo Clinic, we would all 
agree that they have pretty good health care, wouldn't we? I mean, their 
inflation is 3.9 percent this year; that's less than half the medical 
rate of inflation in the country. And I could give you lots of other 
examples of plans with very high consumer satisfaction where people are 
very happy with what they have and where they have squeezed out massive 
amounts of waste with no loss of quality. And so, that's what this 
debate ought to be about. I want that debate.
    Remember what I said last night? The first thing is security, 
simplicity, savings, choice, quality, and responsibility. If we give up 
quality, the rest of this stuff won't happen, because you can't have 
security without quality. So we'll debate it, but I'm telling you, the 
more you study this, the more you become convinced that we can achieve 
these savings.
    Mr. Koppel. President Clinton, we've got a public policy expert, 
John White, sitting up at the Kennedy School in Harvard. Am I misstating 
it, Mr. White, when I say that you don't think the figures add up?

[Mr. White asked why the President doesn't phase in benefits more slowly 
in the new health care plan.]

    The President. Let me answer that. First of all, the benefits that 
we don't phase in, basically the benefits that we start with in 1996 
that are new, are primarily two: First of all, the preventive and 
primary services, you know, the PAP smears, the mammograms, the well-
baby care, all those things, we believe that those achieve net savings 
fairly quickly, and almost all medical experts do. That is the 
relevantly low-cost, relatively quick benefits. The other major costs 
are the drug benefits. We provide prescription drug benefits in all 
health care plans, and for Medicare clients as well as Medicaid ones 
because there are so many older people who aren't poor enough to be on 
Medicaid but have huge drug bills. Now, that will cost more.
    We went around, John, to all the people we could find who knew 
something about

[[Page 1862]]

pharmaceutical costs and tried to pick a high figure. That is, we didn't 
try to lowball the cost of the drug benefit. And then, we believe that 
the money we're raising from cigarettes and from the fees on big 
corporations will cover that, and we believe that we have--all the other 
benefits will be phased from '96 forward over a 5- or 6-year period, and 
we believe during that time period, we'll be able to achieve these 
savings.
    Now, I believe this is another decision that the Congress will have 
to make. But I believe that having the universal coverage--that is, 
getting everybody insured by '96--is critical to the savings because 
that's what enables people to get basic care early rather than have care 
when it's too expensive only at the emergency room.
    Mr. Koppel. Let me just let John White come in one more time, 
please.

[Mr. White suggested that the system should ensure that cost savings are 
in place before the benefits are put in place.]

    The President. I agree with that, except for the two examples I 
mentioned. But let me make another comment. One of the things I've asked 
the Congress to do is to work with me to construct a system that, in 
effect, has to be monitored closely every year and adjusted if the money 
doesn't work out right. We cannot afford to aggravate the problems we 
already have. But if you look, John, at the cost estimates we have, even 
under our plan, even under our plan we project health care costs to go 
from 14 percent to over 17 percent of our income between now and the 
year 2000. We'll still be spending a lot more than any other country. I 
think we'll have more savings than we estimated. And I agree, and I want 
to just say this about the point he made. All of us have to be prepared 
to face the consequences if the cost savings don't materialize. And I 
don't want to sign a bill, and I don't have any intention of signing a 
bill that doesn't at least have the process built in that I recommended. 
If something happens and they don't materialize, then we're going to 
either have to slow down the benefits or raise more money. I don't think 
it will happen, but he's right. And that's why we've got to phase these 
things in carefully so it doesn't get away from us.
    Mr. Koppel. Mr. President, we've got to take another break. I 
promise, when we come back, the amendments to what you said an hour and 
a half ago, or whenever it was. We'll be right back.

[At this point, the network took a commercial break.]

    Mr. Koppel. Let me just explain two things to you. First of all, 
those of you who are watching Nightline, we just kept going after our 
10:00 p.m. show, which ended at 11:00 p.m. Eastern time, and began 
taping so that we could save time. So technically what you're seeing 
right now is on tape, but we are still here live talking and it's going 
to go on in an open-ended fashion now.
    At the end of our live segment, the prime time segment, there was a 
lady up there who asked you a question and you gave her a very quick 
answer. It was a question having to do with whether doctors or insurance 
companies were going to decide when you have received adequate care at a 
hospital.
    The President. That's correct.
    Q. You send them to your plan, the doctor would decide.
    The President. That's correct. There are two questions that were 
asked that I want to clarify. One is the lady said, ``Who decides when I 
leave the hospital, the doctor or the insurance company?'' And I said 
the doctor. That is right with one exception. Keep in mind what I said. 
Mental health benefits under this plan cover limited hospital stays 
until the year 2000. With that single exception, the doctor decides. The 
second point I want to make: You remember the gentleman who stood up 
over here and said he had 10 employees, and he paid 4 percent of 
payroll, and what was going to happen. And I said he'd pay about the 
same amount. I want to clarify that in a couple of ways.
    Number one, you're eligible for a subsidy if you have fewer than 50 
employees. But you don't get the subsidy on employees with incomes of 
over $24,000. Almost all small businesses have incomes less. So I want 
to make it clear. So we're actually trying--before the end of the show, 
we should be able to tell him exactly what his rate will be. But let's 
say, for example, he had to go up to 5 percent or 6 percent from 4--got 
more

[[Page 1863]]

generous benefits--two other things would happen which might make it a 
good deal for him anyway. Number one, we're going to fold in the health 
care costs of workers' comp into this system, and the health care costs 
of workers' comp have been going up even more than regular health care 
costs for most businesses.
    Number two, if you have a claim against you or against your employee 
as a small business, your rates can go up 20 percent in a year, or 25 
percent in a year just if you have a claim. Under our system, the small 
business would be protected from that. They'd be able to be basically on 
the same wavelength as some big company and would have a very marginal 
impact on rates because they'd be in a huge pool instead of just out 
there.
    Mr. Koppel. Let me ask you to swivel around again if you would. 
We've got a question from a medical student back there. Go ahead, 
please.

[A medical student asked if the plan would defer the debt incurred by 
the cost of medical school, implement malpractice reform, dictate 
specialties, and reallocate health care funds, especially those spent on 
care at the beginning and end of life.]

    The President. Let me try to remember them all. First of all, on 
your debt--and medical school is very costly--we propose to do two 
things. Number one, we have already passed a sweeping reform of the 
student loan program, which will enable people to borrow money without 
regard to their incomes at lower interest rates than have been available 
in the past, and then pay those loans off, not based just on the amount 
that you had to borrow but as a percentage of your income, which will 
make it easier for all people to pay their college loans off. I wouldn't 
call this a catch, but I have to say we're also going to be much tougher 
on collecting the loans than we have in the past, but they'll be easier 
to pay back.
    Secondly, we're going to expand the health service corps concept 
that will enable physicians to practice in underserved areas and pay 
their medical loans off. And that's been constricted in the last several 
years. We want to expand that. That's the first question.
    The second question you asked was malpractice, right?
    Q. Yes, sir.
    The President. We propose to do a couple of things in malpractice 
to--and let me just say, malpractice not only affects doctors with 
higher premiums but a lot of people believe it adds to the cost of the 
system, because doctors practice what is called defensive medicine and 
order procedures they otherwise wouldn't just to keep from being sued.
    We propose to do three things: number one, develop more alternative-
dispute-resolution mechanisms to lawsuits; number two, limit the amount 
of contingency fees lawyers can get in those lawsuits to one-third of 
the fees, not more, and number three, and I think most important, 
develop working with the medical specialists as well as GP's, general 
practitioners, a set of accepted medical practice guidelines that 
doctors can have that operate--to oversimplify it, almost like the 
checklist that you see a private pilot check off before they--if you've 
ever ridden in a private plane. So if you follow the medical practice 
guideline for whatever you're doing in your area, that will raise a 
presumption that you were not negligent. That can do more than anything 
else. This was pioneered for rural doctors in Maine, this whole theory. 
We believe it can do more than anything else to reduce the number of 
malpractice suits.
    The third thing you asked was what about the Government trying to 
force you into certain specialties.
    Q. Yes, sir.
    The President. The truth is, if you look at how the Government 
spends its money, it's heavily weighted towards specialties now. What we 
propose to do is to change the formula by which the Federal Government 
funds medical schools now to favor more--not to say you can't be a 
specialist but to slightly tilt more in the favor of general practice, 
because only 15 percent of the doctors coming out of medical school 
today are general practitioners. The average nation has--you know, like 
Germany or Japan or Canada--half the doctors will be general 
practitioners. We can't do what we need to do in medically underserved 
areas without more family doctors.
    And the fourth question you asked was?

[[Page 1864]]

    Q. The reallocation of funds.
    The President. Yes. Perhaps the most important thing, long-term, in 
this package is that we pay for things like pregnancy visits, well-baby 
care visits. We pay for immunizations for all children. In other words, 
we try to pay for a lot of preventive and primary services starting very 
early, and dental care for children although not for adults, as a 
mandated service.
    Mr. Koppel. We've got to take a short break again, but we will be 
back, live from--no, not live, on tape--from Tampa in just a moment.

[The network took a commercial break.]

    Mr. Koppel. In case you're wondering what happens during the 
commercial breaks while you're gone, don't feel badly. The same thing 
happens as when you're here. People keep asking questions, and the 
President keeps answering them. Let's get on the microphone over there.
    Go ahead, sir.

[A dentist asked about dental benefits under the new health care plan.]

    The President. Let me just mention the dental issue first. Under our 
proposal, the comprehensive benefit package would include dental 
benefits for children up to 18, but not mandates for adults. That 
doesn't mean any employer plan that now covers dental benefits is 
perfectly free to keep doing so. And since they'll have all kinds of 
economic incentives to keep their costs down, they'll probably keep 
doing it. But we don't think we can, again, recognizing the costs of 
this, afford to do more than this at this time. But there's nothing to 
prohibit that.
    Most people, as you know now, who have dental benefits through their 
employers actually buy the benefits in an override policy, and that will 
all still be available. The problem with the present insurance system, 
let me say again is that, first of all, too many people are uninsured, 
and the complexity of it is so great. But we are the only country in the 
world that has 1,500 different companies writing thousands of different 
policies, requiring every hospital and doctor's office to keep up with 
hundreds of different forms, so that we literally add about a dime to 
every dollar of health care cost on paperwork that has nothing to do 
with keeping people well.
    So what we're trying to do is get down to one form, and this health 
security card, so that, number one, your life will be a lot simpler. The 
time you have to spend on forms and the time you have to hire people to 
spend on forms will be less; the time you spend practicing dentistry 
will be greater. And the time all of our medical professionals spend 
doing what they hired out to do in the first place will be greater. 
That's what we're trying to do.
    Mr. Koppel. How detailed is that form going to be? I mean, that one 
form is going to have to be a killer form to--[laugther].
    The President. Well, not necessarily. The form--actually I should 
have brought it tonight--but there will be basically a model form for 
the doctors and one for the hospitals and one for consumers, because 
they'll have slightly different information needed, and they'll have 
some variations because of the differences in plans. Everybody will have 
some choice in plans, but once you have comprehensive benefits and 
uniform insurance schemes, you won't have to have a lot of variations.
    Let me just say this. I want to hasten to say this does not mean 
that physicians will stop keeping patient records on patient care. In 
fact, one of the ways we're going to reduce the amount of problems with 
malpractice, as I said, is by establishing uniform guidelines and then 
enabling physicians to demonstrate that they follow the guidelines and, 
therefore, to raise the presumption that they were not negligent.
    So we're talking about paperwork over and above what is required for 
the basic practice of medicine. Washington Children's Hospital, where I 
visited last week with the Vice President, says they spend $2 million a 
year in that one hospital over and above the recordkeeping necessary for 
patient care.
    Mr. Koppel. You saw that devastating study a few weeks ago that 
indicated there were roughly 60 million Americans are--I guess the only 
fair word is ``semi-literate,'' all but illiterate. You know, you're 
doing a terrific job here trying to explain what is obviously a terribly 
complex plan. How do you reach those people? Because my assumption

[[Page 1865]]

is that the 37 million people you're talking about who are uninsured, 
underinsured, probably many of them will fall into that same category, 
and that is people who have a very hard time understanding any forms, 
let alone something as complex as a medical form.
    The President. First, let me say that if you go back to that study, 
it also says that people are more literate now than they ever have been, 
but there are more challenges for them now than ever before. All of the 
research indicates that one of the things people know a lot about is the 
health care benefits they have and the problems with it. As a matter of 
fact, one of the problems that I'm having convincing you that we can 
save money in this system is that you know an enormous amount about your 
own health situation or that of your employees, and you know it costs 
more every year. But you've never had a chance to know about how the 
system itself operates; so it's hard for you to imagine that we can 
actually save any money--especially where the Government's involved, 
right?
    But when you come back to the basic thing, I believe if you simplify 
the system and you tell everybody you get three different plans at least 
and here's what the plans do, I think people have had enough experience 
negotiating their way through the mine field of the American health care 
system that most of them will do quite well.
    Mr. Koppel. A question over here on microphone B. Yes, ma'am?

[A participant asked if abortion would be covered under the new health 
plan.]

    The President. It will probably become a political football because 
so many people feel so strongly about it on both counts. But the answer 
is that we are trying to privatize this system, not make it more 
Government-dominated. And so the answer to your question is, it will be 
because it is now by private plans. And what we propose to do is to fold 
people who get their Government health care into the private plans. That 
is, keep in mind, if you're on Medicaid today, you show up at the 
hospital, you've got all your Medicaid forms--that's why the doctors 
don't like to treat Medicaid patients, a whole different set of forms--
and you get a specific fee for a specific service. And today, if you're 
on Medicaid, abortions are not covered by the Federal Government unless 
the life of the mother is endangered. But they are covered in some 
States where the States pay for it.
    Under this system, people on Medicaid will join a health alliance 
just like other people. And then they will get to choose among plans. 
The plans will offer pregnancy-related services. Most private plans 
today that offer pregnancy-related services do offer abortions. They 
don't all.
    There is a conscience exemption for religious reasons that covers 
hospitals and doctors, and that will be covered again today. And people 
who want to join those plans will do it. By the way, there are no 
specific surgical procedures guaranteed here, not knee surgery, not 
abortions, not brain surgery, not heart surgery. They never are. The 
procedures are not prescribed. The problems are covered. So you have to 
cover pregnancy-related services.
    Let me say, since you're in Planned Parenthood, abortion under our 
Constitution is legal. But let me say, I also think there are too many 
every year, and I think this could be--[applause]--I think if you want 
it to be legal, safe, and rare, we have got to fund more preventive 
outreach.
    I want to make this very clear. This plan, for the first time ever, 
not only acknowledges the constitutional legality of abortion but funds 
preventive services in ways that will reduce the number of abortions by 
reducing the number of unwanted pregnancies. And I want to make that--
that's very important. That's part of the preventive strategy of this 
plan. It will do both.
    Mr. Koppel. Let me ask you to hold on to that thought for a minute, 
Mr. President, because when we come back we're going to hear from 
someone who is prolife, as no doubt you expected. We'll be back in Tampa 
in just a moment.

[The network took a commercial break.]

    Mr. Koppel. And we are back, once again, from Tampa. The President 
shaking hands with a few well-wishers here. I figured if we didn't 
restart the program, we'd never get you back from there, Mr. President.

[[Page 1866]]

    The President. Tell the girls to come back later. Hey kids, I'll 
come back there. Later I'll be there. You wait here, and when we next 
take a break we'll shake hands, okay?
    Mr. Koppel. What are we--come on. Shake hands. Get it over with. 
Come on up. Now, while we're feeling good, you might as well tell the 
folks what the head of St. Vincent's Hospital told you when he----
    The President. St. Joseph's?
    Mr. Koppel. St. Joseph's. I beg your pardon.
    The President. This gentleman is the head of the hospital who took 
care of the daughter of the independent contractor with the $186,000 
worth of bills. He said, ``We took care of it before, and we'll take 
care of it again until we get this--[applause]. But he also said we need 
to reform, because he's entitled to be reimbursed for it.
    Mr. Koppel. Yes. Now, you don't expect all the questions to be that 
easy, do you?
    The President. No.
    Mr. Koppel. Okay.
    The President. They've all been hard.

[A participant expressed her disapproval of taxes being used to fund 
abortion.]

    The President. Well, let me say again--let's talk about what the 
present law is. The present law is that there is a constitutional right 
to abortion, but the Supreme Court has never ruled that that meant that 
poor women had to have equal access to it. In other words, that if the 
Federal Government or a State government decided not to fund abortion 
services through the Medicaid program, that that was legal. So the 
Congress for many years has said we will not specifically fund abortions 
unless the life of the mother is at risk. Therefore, there's no public 
funding for poor women to get abortion services unless each State 
decides to do it. Some States decide to; a majority don't. That's the 
law today.
    I want to make clear to you what we are proposing. What we are 
proposing incidentally affects this: What we are trying to do is to stop 
the two-tiered system, to put the Medicaid patients in with the 
employees of small businesses and hospitals and others to provide for a 
common private system in which people join plans that provide services, 
including pregnancy-related services. Some of those plans won't cover 
abortion. Most of them do today. But I would just say to all of you 
who--if you're in a private health insurance plan today, your money is 
commingled with everybody else's. And if those services are covered, the 
money goes out from a central payment place, not necessarily for a 
specific service. But because people have enrolled in a plan--for 
example, somebody enrolls in an HMO, they don't pay for a specific thing 
at all necessarily on a fee-for-service basis. They pay a fee for 
whatever services are covered. So that is part of the limit. It would be 
a terrible price to pay just over this issue to keep segregating all the 
Medicaid patients and deny them the opportunity, and deny us the 
opportunity, to have the benefits of everybody being in large group 
health care without separating this out.
    In other words, the whole system will be changed if you put 
everybody in a private system. There will still be also hospitals and 
doctors who, for religious or other reasons, for moral reasons, will not 
participate in this and will not have to in any way, shape, or form.
    Mr. Koppel. Mr. President, this is a curious criticism to make, but 
sometimes I think you're so specific in your answers or so detailed in 
your answers that it's a little hard to know what the answer to the 
question was.
    The President. The answer to the question is, if a person goes into 
a health care plan that provides pregnancy-related services, the person 
can ask, ``Does this include abortions, or not?''
    Mr. Koppel. If it doesn't, then you go to another plan?
    The President. If it doesn't, they can go to another plan. If it 
does and they're offended by it, they can go to another plan.
    Mr. Koppel. Are tax monies going to be used to support those 
abortions? That was----
    The President. The answer is, indirectly, they will. Today, it's a 
direct question. You know, the Government writes a check for every 
Medicaid procedure. Under this system, people on Medicaid would be just 
like any other person. They'd join a health plan. They'd sign up for 
certain services. The funds, the public and the private funds,

[[Page 1867]]

would all be mixed together. They would fund certain things and not fund 
others.
    But if our plan goes through, it will be impossible to separate out 
the public and the private funds, the Medicaid and the other people.
    Mr. Koppel. So, implicitly, the answer is yes. There will be----
    The President. That's right, they will be able to fund it. That's 
right. If it comes down on this issue, we keep all these Medicaid people 
from going into a revolutionary new system, then you're going to throw 
away a lot of the savings and deprive those people of a whole range of 
things that don't have anything to do with abortion, including higher 
quality care at lower cost.
    Mr. Koppel. Yet that's clearly one of the political mine fields.
    The President. That will be a big political mine field.

[The participant reiterated her opposition to having her tax money fund 
abortions.]

    The President. Well, let me ask you--we are also personally and 
morally improving preventive and primary health services, and we'll 
actually stop some abortions from occurring with the kind of preventive 
services that we're going to cover for the first time in the history of 
this country.
    This could be a subject for a whole other program. I have a 
difference of opinion from you about whether all abortions should be 
illegal. I do agree that there are way too many in the United States. I 
believe we need an aggressive plan to reduce teen pregnancy, to reduce 
unwanted pregnancies. One of the reasons I named the Surgeon General I 
did, my health department director, is because I'm committed to that. I 
believe we need an aggressive plan to promote adoptions in this country. 
If every prolife advocate in America adopted a child, this world would 
be a better place.
    I want this issue to be debated, and I haven't hedged with you. Most 
people will get this service covered because most private plans do it. 
And we propose for the first time ever to put Medicaid people in the big 
private plans to get the economies of scale. Not for the purpose of 
doing that, but basically to end this two-tiered system we've had. So 
most will be covered. But some won't if they choose to join plans that 
don't cover them. Most plans do today.
    Mr. Koppel. I met the gentleman over there just before we went on 
the air. I know he wants to talk about the homeless. But we're going to 
take a quick break. When we come back----
    The President. He's been the most patient person here. We've got to 
hear from him.
    Mr. Koppel. We'll be back in a moment.

[The network took a commercial break.]

    Mr. Koppel. There's another one of our poll results. Under Clinton's 
plan, will you pay more? Forty-nine percent think they will pay more; 10 
percent think they'll pay less; 33 percent, about the same. Again, as I 
said earlier, you've got some missionary work to do here.
    The President. But that's because people can't imagine how much 
waste there is in this system. Today, we spend over 14 percent of our 
income as a Nation on health care. Canada spends 10 percent. Germany is 
under 9 percent. Japan is under 9 percent. The German system, which is 
the most like what I propose, is a private system where large groups of 
employers and employees can work with health care providers to provide a 
wide range of services at low cost. But the administrative cost is much 
less than we have, although they cover more people and about the same 
number of services.
    Mr. Koppel. You also know, and you've heard your critics say, they 
look at the Canadian system, and they start counting the Canadians who 
cross the border and come over to Detroit, because when it comes to 
optional surgery, optional procedures, they have to wait 3 months, 6 
months, 9 months, a year. And they get so frenzied over this that rather 
than wait, they come over to the United States. Now, those people will 
tell you, ``Whatever you do, don't exchange what you've got for what 
we've got.''
    The President. But we don't do that. In other words, keep in mind, I 
am not proposing to bring our cost level down to the level of Canada, 
much less Germany. What I am proposing is to slow the rate of increase, 
which if we don't slow it, by the end of the

[[Page 1868]]

decade we'll be spending roughly 19 percent of our income on health 
care. Canada will be about 11 percent. And everybody else will be under 
10 percent. And that is a huge economic disadvantage in a global 
economy. It also means a lot of workers just give up all their pay 
increases. We are not proposing to cut spending on health care. We're 
proposing to increase spending on health care quite briskly but not as 
much as we're going to if we don't change the system.
    Mr. Koppel. So fundamentally, the people in that poll are right. 
Those who think that they're going to end up paying more, they will.
    The President. They'll pay more, the system, no.
    Mr. Koppel. They may get more, but they're going to pay more.
    The President. The system will cost more, but they will pay much 
less under my plan than if we do nothing. Keep in mind, of the 85 
percent of the people with health insurance, two-thirds of them will pay 
the same or less for the same or better benefits.
    Mr. Koppel. No, I hear you. But let me try and state it one more 
time. You tell me if I'm wrong. Under the existing system, you're going 
to end up paying more.
    The President. Much more.
    Mr. Koppel. Under your system, you're going to end up paying more. 
But you're saying under your system you're going to end up paying a 
smaller amount more than you would in the existing----
    The President. That's right. You'll pay over the next 5 years much 
less under my system, my proposal, much less than you'll pay if you stay 
with the system we've got. And you get better benefits and security. You 
will never lose your health care.
    Mr. Koppel. This gentleman has been standing there most of the 
night. Go ahead, sir.

[A participant asked if people who work with a temporary job service 
will be included in the new health care plan.]

    The President. The short answer to that is somebody will be held 
accountable to them. For people who are temporary workers, it depends 
upon how they're ultimately classified under the tax system. For 
example, if you're a temporary worker and you work for an employer, and 
you're on that employer's payroll for, let's say as much as 10 hours a 
week, then that employer would prorate his payments, or her payments, 
for the temporary worker. They'd have to pay a third the normal rate. If 
they're on the payroll for 20 hours a week, they pay two-thirds the 
normal rate. If the temporary employee is listed as being on the payroll 
of the temporary company, then they would pay. If the temporary employee 
is an independent contractor under the Tax Code, then the temporary 
employee would have to buy his or her own insurance, just like the paint 
contractor. But depending on the income, they'd be eligible for a 
discount, and they'd have 100-percent tax deductibility.
    So the answer is, the temporary employees will be covered. Who pays 
and how depends on how they are classified under the Tax Code. But 
either the temp company, the company for which they're working part-
time, or if they're independent contractors, they, themselves, they will 
get coverage at an affordable rate.
    Mr. Koppel. Mr. President, as I told you, we have three practicing 
physicians out at the University of Chicago. One of them, Dr. Mark 
Siegler, would like to either make a comment or ask a question.
    Go ahead, Dr. Siegler.

[Dr. Siegler asked the President if the quality of patient care will be 
affected by the new health care plan.]

    The President. If you look at the plan the way it operates, and I 
would urge you to read it carefully, we will actually provide more 
funding for medical research than we are now, more funding for health 
education centers than we are now. Each employee in the country will get 
at least three choices of plans. They might choose an HMO which, you're 
right, would then have a closed panel of doctors which would limit the 
number of doctors. But we know that there are a lot of HMO's that have 
very high patient satisfaction, the ones that are really well run. But 
they might also choose a provider organization, and under our rules, no 
PPO can deny interest to any doctor that wanted to be a part of it. So a 
doctor could join a lot of dif- 

[[Page 1869]]

ferent organizations so that the doctor could, in effect, be available 
to all his or her patients, even after this reform takes place. And 
finally, keep in mind, if you look at the package of comprehensive 
benefits here, virtually all Americans with insurance now would get the 
same benefits that Fortune 500 companies enjoy and much better than they 
have now. So we want to preserve choice; we want to preserve quality; we 
want to preserve a range of benefits.
    Also, one of these plans, every employee will have the option today, 
under this plan, to choose fee-for-service medicine. Today in America, 
only one-third of the insured employees in this country have an option 
of more than one plan.
    Mr. Koppel. Mr. President, let me jump in for just one moment. What 
I'm hearing in my ear is that some of those who have your best interest 
at heart, namely members of your staff, are very concerned that you not 
spend too much of this night with this, because you've got a big day 
tomorrow. So I want to let the audience know that we are in the process 
of winding down.
    I would like to have maybe two or three more questions. Would that 
be all right with you?
    The President. Sure.
    Mr. Koppel. And then we will bring this program to a close. I 
suppose it's also appropriate at this point to note that, believe me, 
this is not going to be the last you hear on this subject. Either pro or 
con, the President's plan, it is just the beginning of what promises to 
be a long national debate. But I think you've had an extraordinary 
opportunity here to at least hear from the man who is behind what is 
clearly one of the most ambitious health plans that this country has 
ever seen.

[A pharmacist asked if the health care plan will control discriminatory 
pricing by drug manufacturers so people can get their prescriptions at 
the pharmacy of their choice.]

    The President. You can, and that's why the Pharmaceutical 
Association of the United States--Association of Pharmacists has already 
endorsed our plan, and they were up until 2 a.m. last night sending out 
press releases around the country, saying that this is a good deal for 
your neighborhood pharmacy.
    Mr. Koppel. Okay. Let's see if we can just get some quick questions, 
quick answers. The lady on microphone A.

[A mother of a boy born with congenital heart defects asked if they will 
be denied access to quality service under the new health care plan.]

    The President. No.
    Q. Because we can't afford to pay 20-percent of a hospital bill that 
is in excess of $100,000, $200,000.
    The President. No, absolutely not. If you have a plan now that 
covers all your benefits, if anything your employer will have more 
incentive to continue to cover you, because their costs will go up less 
in the future than they would now.
    Keep in mind, this 20-percent requirement for the employee to pay is 
for all those who don't have any coverage now. And It's not a 
requirement on the employee; it's a limit on how much the employee can 
pay. The employee cannot be required to pay more than 20 percent. If the 
employer wants to pay more, they can. The truth is, it's largely going 
in the other direction today for most folks. So if you have a good 
health insurance plan and it pays more than 80 percent, nothing in this 
plan will change that. In fact, your employer should be more willing to 
do it, because in the aggregate their costs will go up less in the 
future than they will if we stay with the same system.
    I talked today to a half a dozen people who said that their 
contribution share was going up, up, up. And it was going to be over 20 
percent before long, and they were glad to know there was a ceiling on 
it. All we're trying to do is to put a ceiling on it, not a floor.
    Q. Thank you.
    Mr. Koppel. Mr. President, we've got one more question. And you, 
sir, have the last question. Go ahead.

[A participant asked if all insurance companies that are part of the new 
health care plan will be required to open their provider list to all 
qualified doctors.]

    The President. The short answer to that is yes. Keep in mind, we 
want to give the

[[Page 1870]]

employee the choice. What happened to your patients was the employer 
made the decision to go with another health plan that closed out certain 
doctors. We want to give the employee the right to go with a closed 
panel HMO if they think that's good--health maintenance organization--if 
they think they get better prices and they think they get adequate 
services. But we also want to give the employee other options, including 
to continue dealing with you as a fee-for-service doctor, or working 
with a group of doctors in which you have an absolute legal right to be 
a part.
    Now, if that happened today, the fee-for-service option might be a 
little more expensive. But what I think will happen is that you and 
other doctors--what I'm banking on is that the physicians of this 
country will get together and offer their services at reasonably 
competitive rates so that people will be able to maintain a maximum of 
individual choice. But it is legally mandated that every employee in the 
country will have the option to choose fee-for-service medicine or a 
panel of doctors, which has to remain open for any doctors who want to 
join so that doctors can be in multiple panels. And so we're going to 
increase choice of physicians, not decrease choice of physicians for 
most Americans. That's a very important value, and we have to pursue it.
    Mr. Koppel. Alright. President Clinton, please excuse my back. I 
just want to express a personal note of thanks to you for coming here 
this evening. I know there are an awful lot of people, possibly many in 
this audience, who wished they'd had the opportunity to pose questions 
to you or to criticize certain aspects of the plan, over the course of 
the next year. I'd also like to say to your adversaries out there who 
are watching us and who have criticisms that they too will have access 
to this program and many others.
    There is something wonderful, however, about being able to bring an 
American President and an audience of 1,000 of his constituents together 
for this kind of an exchange. And I know you'll want to express your 
gratitude to the President, as I do now. Thank you. [Applause]
    The President. Thank you, folks.

Note: The town meeting began at 10:10 p.m. in the Playhouse at the Tampa 
Bay Performing Arts Center. A tape was not available for verification of 
the content of these remarks.