[Weekly Compilation of Presidential Documents Volume 29, Number 49 (Monday, December 13, 1993)]
[Pages 2511-2517]
[Online from the Government Publishing Office, www.gpo.gov]

<R04>
Remarks and a Question-and-Answer Session on Health Care in Bernalillo, 
New Mexico

 December 3, 1993

    The President. Thank you very much. He did a good job, didn't he? 
For a fellow that's not used to doing this, he did a great job.
    Well, first of all, Doctor, I want to thank you and all your 
colleagues for welcoming me into the clinic today. I enjoyed the tour. I 
enjoyed listening to you talk about what you've done. And I have to tell 
you that I saw something in that clinic today that no law can ever 
compensate for or require, and that is a level of constant commitment to 
the people of this area. That must be a priceless treasure, just the 
idea that you've committed your life here. And I thank you for that.
    I'd also like to thank Mayor Aguilar and Mrs. Aguilar for welcoming 
me here and--with their grandson back there. I enjoyed it, meeting them. 
And I appreciate the little--I'm about to fall in the hole here. This 
would make millions of people happy if I fell over--[laughter] I think 
I'm pretty well set now. They gave me a wonderful little proclamation 
declaring this day Bill Clinton Day in Bernalillo, which I am grateful 
for, and this wonderful piece of art. Thank you.
    I brought a number of people out here with me. But I want to 
recognize some of them because they will have a major say in what we 
ultimately do as a nation on the health care issue. First, members of 
your congressional delegation: Senator Bingaman and his wife, Anne, 
who's in our administration in the Justice Department. Senator Domenici, 
thank you for coming, sir. My good friend Congressman Richardson, who 
fought so hard for NAFTA, and his wife, Barbara, thank you for being 
here. Congressman Steve Schiff and Congressman Joe Skeen are here. Thank 
you for coming. We have a lot of State officials, but I do want to 
introduce my good friend Governor Bruce King here and his wife, Alice. 
Thank you, Bruce. Alice, are you there? Thank you, Alice. And your 
Lieutenant Governor, Casey Luna, flew back with me. Is he here in the 
audience somewhere? He wrote me a good letter endorsing our efforts in 
health care, which I really appreciated, as a Lieutenant Governor and as 
a small business person.
    I want to talk just a few moments today about what we're trying to 
do with this health reform effort, how the plan that I have presented to 
Congress would, in my view, help things for this doctor and this clinic 
and all of you who are served here and, perhaps more importantly, how it 
would help to provide these kind of services to other people in New 
Mexico and throughout the United States.
    Let me begin by saying that I think most of you know that before I 
became President, I was for 12 years the Governor of Arkansas, and there 
are thousands of people from my State now living in New Mexico. I see 
them every time I come out here. It is also a very rural State. I spent 
a lot of time as a boy in communities that make this place look like a 
thriving large metropolis, in little small towns in country crossroads. 
All my mother's people come from a place that now only has about 50 
people in it. I spent a lot of time as Governor trying to keep open 
rural health clinics, keep open rural hospitals, develop clinic services 
or primary care or emergency services for people who live in isolated 
rural areas. So I have a certain familiarity with a lot of the kinds of 
problems that you have. I've also seen a lot of those problems get worse 
and some get better over the last 15 years. And Doctor, I think you've 
been here 17 years, is that right? So about the same timeframe of your 
service, I have been involved in public service dealing with health care 
in another way.
    I came here today to listen, to learn, and to try to explain what 
we're trying to do. Let me just briefly summarize how this health

[[Page 2512]]

care plan would affect you and your families and your community.
    First of all, it would provide for the first time in our history a 
system of universal coverage. Every family and every person in every 
family would have a comprehensive package of benefits which would 
include primary care, the kind of care you get here, and preventive care 
services that you would always have even if you changed jobs, even if 
you lost a job, even if someone in your family got sick so you had what 
the insurance companies now call a preexisting condition.
    In addition to that, it would recognize that in rural areas there 
are 21 million Americans today who don't have access to primary care 
physicians or have inadequate access to primary care physicians. So that 
even if you gave an American family a health insurance card and there 
was no doctor to see, you would have coverage that would be meaningless. 
So this plan makes a real effort to increase people's access to health 
care in rural areas by doing two or three things: first of all, by 
guaranteeing funding to rural health clinics that are publicly funded; 
by increasing the funding stream to clinics like this one--rural doctors 
are the most likely to have to do uncompensated care--to make sure there 
will be some payment coming in for all the people who get care within 
any clinic; by taking steps to remedy the doctor shortage. You heard the 
doctor say that he didn't leave here in part because there was no 
national health corps facility or physician to come in behind him. 
Today, we're only providing funds for about 1,100 doctors a year in the 
National Health Service Corps. Under our plan, we go from 1,100 to 3,000 
doctors a year by just after the turn of the decade and the century. So 
we would be, in other words, every year providing enough extra doctors 
to serve another couple of million patients in America at a reasonable 
ratio of doctors to patients. So that would make a huge difference in 
the quality of rural health care.
    Now, there are a lot of things we do to try to get doctors to come 
to rural areas. But the National Health Service Corps is one, providing 
more scholarship funds; providing more access to partnerships with 
people in health care centers like the ones that you mentioned is 
another. The other thing I want to emphasize is that a lot of people who 
have health insurance policies, in rural areas especially, tend to be 
underinsured. And one of the things that we've learned is: As Americans, 
we spend a huge amount of money on health care that we wouldn't spend if 
people had primary and preventive health care and if people had access 
to adequate medication. There are a lot of people who have all kinds of 
physical problems that could be adequately treated and their conditions 
could be maintained if they had adequate medication. A lot of people who 
have mental health problems that could be better managed and treated if 
they had access to a steady amount of appropriate medication.
    So one of the good things about our health care plan is that under 
the bill we presented, in the comprehensive benefit coverage, all 
families, whether they get care from the Medicare or Medicaid programs 
or through private health care programs, would have access to 
prescription drugs. There would be a copay, you'd have to put some money 
up front in it, but everybody would have access to those drugs. We 
believe that will lower the incidence of hospitalization and, over the 
long run, really lower the cost of health care by helping people to stay 
healthy and to maintain their own health conditions.
    How do we pay for this? The program would be paid for by a 
combination of sources. First of all we would require employers who 
don't cover their employees at all to cover their employees. And if 
their employees are not covered at all now, the employees would have to 
pay up to 20 percent of the premium themselves. The employer's 
contribution would be capped at 7.9 percent of payroll. But small 
businesses, which dominate rural areas, would be eligible for discounts 
on their guaranteed private insurance plan, which would dramatically 
lower in many cases the percent of payroll they would have to pay.
    Is this fair? I think it is. In every other country with which we 
compete, everybody makes a contribution directly or indirectly to the 
health care system. Today, everybody gets health care, but often when 
it's emergency care, when it's too late, and then their costs are paid 
by somebody else. They're either shifted back to the taxpayers or 
shifted

[[Page 2513]]

onto other employers through higher insurance premiums. But by giving 
discounts to people who are smaller employers, we think that's a fair 
thing to do.
    How will the discounts be paid for, and how will the extra services 
be paid for that the Government's going to provide? By lowering the rate 
at which we're seeing medical inflation explode Medicare and Medicaid 
programs. Today the Government programs are increasing at 3 times the 
rate of inflation. Under our system, which would put more people on 
Medicare and Medicaid in the larger competitive bidding blocks with 
self-employed people and small businesses and others, we think we can 
cut the rate of increase in these costs at least to twice the rate of 
inflation and take the difference that we've already budgeted to pay for 
some of these other programs.
    There are no general taxes in this program. We do seek to raise the 
cigarette tax. And we ask the biggest companies, that can opt out of our 
system to provide their own health care plan--they will get a huge drop 
in their premiums as a result of our system--we ask them to make a 
modest contribution, trying to help pay for those that are uninsured and 
may need subsidies. That's how we pay for it. And we think it will work.
    There will also be a lot more competition in the system than there 
is now. That will drive costs down. But we don't take that into account 
in figuring out what it costs. So we think the system will not cost even 
as much as we say it will, once you take account of the increased 
competition.
    If you're a small business person or a self-employed person, the 
best thing about this program is that you'll be able to have access to a 
better health insurance policy at a lower price because for the first 
time, small business people and self-employed people will be able to 
have access to less costly premiums and will have the same sort of 
bargaining power in health care, particularly those who live in the 
bigger areas, that only big businesses and governments do today. Small 
business and individuals are at a terrible disadvantage today.
    So that's how the system works briefly. There are a lot of other 
specific questions I'm sure you'll want to ask me. I'm here, and I also 
brought a couple of my staff folks here who helped to work on putting 
this program together and especially spent a lot of time on rural health 
care. I personally spent one full day in the White House talking about 
rural health care to make sure that before we sent this plan up to 
Congress we would have a program that was very sensitive to the needs of 
rural health care, to the needs of Native Americans, to the needs of 
people that are underinsured as well as those that are uninsured.
    So, we'll try to answer your questions, but now I'd like to hear 
from the folks you brought here, Doctor, and to thank you very much for 
that.
    Dr. Alan Firestone. I've got a list of several people who were 
invited. And let me just go down the list very quickly----
    The President. Is his turned off? His is not working, is it?

[At this point, Dr. Firestone read a list of members of the community, 
patients, and clinic employees who participated in the meeting. He then 
introduced participant Miranda Sapien.]

    The President. Let me just say, if you can hear, these mikes aren't 
too strong, so you have to speak right into them so everybody can hear. 
Pretend you're singing to it. [Laughter]
    Ms. Sapien. This is terrible that I had to start, but I'll try my 
best. We live in Bernalillo, about, oh, I guess, about a couple of 
miles----

[At this point, the noise of a passing train interrupted Ms. Sapien's 
remarks.]

    The President. At least it's not in the middle of the night, right?

[Ms. Sapien discussed the difficulty and expense of caring for her 
elderly parents in her home and the need for affordable home health care 
and respite care for the elderly, especially in rural areas.]

    The President. No, as a matter of fact, this is a big problem 
everywhere in America, and the fastest growing group of our population 
in America are people over 80 years of age. And in general, I think we 
want to encourage families to stay together. The way the system works 
today, if you spend yourself

[[Page 2514]]

into poverty you become eligible for Medicaid, and then you can go to a 
nursing home. There aren't very many Medicare certified nursing homes in 
the U.S. The older people are Medicare-eligible. So one of the things 
that our plan seeks to do, although I don't want to mislead anybody, we 
don't know how much it would cost. We can't know precisely how much it 
would cost if we started tomorrow covering everybody with this kind of 
long-term care. A lot of us believe that over the long run it would save 
money because more people would stay at home if there was some provision 
for in-home care and for respite care so that the families could have a 
break. But we do phase in long-term coverage over a period of several 
years as a part of this plan.
    And one of the things that we're also trying to do is to encourage 
some of the State reform efforts that are going on now where many States 
are looking at whether they can set aside some of the money that is 
presently allocated to nursing home care to also cover in-home care. I 
applaud you for doing it. I think since we know that the percentage of 
people who are quite old is going to increase and more and more people 
will be quite alert and will be able to function at a fairly high level 
but there may be some care needed and more as time goes on, I think it's 
quite important that we keep this long-term care part of our program, 
even though it's going to take us several years to get it fully phased-
in.
    Lynn Mathes. Lynn was--I'll let her tell us. But I think--were you 
fully employed? And she was injured.
    Turn it on, will you, whoever's got the mike. It worked great for 
her.

[Ms. Mathes explained she was injured while employed as a horse trainer 
and her former employer will no longer pay for her therapy. She hasn't 
received any help from insurance companies but has been able to pay for 
some of her expenses through her work as an artist.]

    The President. Unfortunately, the story you just told is all too 
typical. The reason I laughed is the doctor has a work of art on his 
wall inside that another artist gave him as an in-kind payment. And I 
can remember when my mother was a nurse anesthetist, I can remember when 
people, in the appropriate season, used to go pick fruit and pay her in 
return for her services. That works for a few people. I don't think it's 
a very good way to run a country.
    Let me just say, the way our system would work if we reformed the 
insurance system is that that simply would not happen because everybody 
would be covered, there would be a clear package of benefits, there 
would be a single form, you would just turn it in. And your employer 
would never--I'm glad your employer tried to get it covered, at least. A 
lot of small employers are terrified of a serious thing like this 
because they know that their insurance is already so much more expensive 
than larger employers or than Government insurance, and they're afraid 
they'll be priced right out of the market. Under our system, everybody 
would be able to buy insurance on equal terms, and the coverage would be 
uniform and consistent. So you wouldn't ever be putting an employer in a 
bind just because it was a small employer. Or if you were a self-
employed artist and that was your only job, you'd have access to a 
really affordable policy.
    But you have to understand, this is the only country in the world 
with 1,500 separate health insurance companies writing thousands and 
thousands of different policies. And if they delay paying on you, then 
that in effect gives them time to earn interest on that money. So 
eventually, even if they pay, they've made a good deal out of it if they 
can delay payment for 2 or 3 or 4 or 5 or 6 months. But it may impair 
your ability to get certain care. This happens everywhere.
    You just heard what the doctor said. At the time when his caseload 
is doubled here--patientload--they have increased the number of people 
who devoted themselves to paperwork by sixfold. That's because this is 
the only country in the world that has literally 1,500 different 
companies writing thousands and thousands of different policies, where 
the doctors in the clinics have to hire people, trying to get payment 
when they're entitled anyway, and where the coverages are so complicated 
and different, when you put that with all the rules and regulations that 
the Government has, that you spend enormous

[[Page 2515]]

amounts of time just trying to work out the transaction who's going to 
pay when. One of the primary benefits--perhaps the best benefit to 
doctors and clinics--of our plan is that we'd actually be able to have a 
single form for insurers, a single form for clinics, a single form for 
patients. And it would cut out a lot of this incredible paperwork and 
administrative cost.
    We spend about 10 cents on the dollar--let me tell you how much 
money that is. We're going to spend $900 billion on health care this 
year. So 10 cents on the dollar is $90 billion dollars a year. That's a 
lot of money. That's 1\1/2\ percent of our gross domestic product. We 
spend about that much more on administrative costs than any other 
country in the world spends on their health care system. That's how bad 
it is. And you get caught in it, in the delay.

[Dr. Firestone mentioned that a former patient who owns a small business 
is very concerned about the cost of providing health insurance and 
workers' compensation for her employees.]

    The President. The health care cost of workers' comp would be folded 
into the health care plan, which would save a lot of small business 
people a ton of money. Slightly more than half of the workers' comp 
premium is health care costs, that would be folded in. And that's a huge 
concern to small business people and also to people in certain targeted 
industries, like in my home State, the loggers and the people in the 
wood products industry. They have huge workers' comp bills. So that 
would really help.
    Again, I would have to know exactly how many employees the lady has 
and what the average income is of the employees, but they would be 
eligible for a discount rate. I can just tell from what you said to me, 
she would not pay the 7.9 percent. She would pay some lesser percentage 
of the payroll. But having been on the other side of it, she can 
understand what it's like if there is none.
    Let me say, there are a lot of part-time workers in our country 
today and probably will be more. Under the way the bill has been 
presented to Congress, if you work 30 hours a week or more, you would be 
insured as a full-time worker and your employer would have to pay the 
full cost of the premium and you would have to pay your 20 percent 
match. If you're under that, down to 10 hours a week, the employer could 
pay a proportionate amount of that, a smaller percentage, and therefore 
your premium would be less. And if you outran that in using the health 
care system because you're a part-time worker, and that would be 
eligible for the public subsidy. So we try not to bankrupt people who 
have part-time employees or discourage people from hiring part-time 
employees. But we think they ought to pay at least a portion of their 
benefits.
    Dr. Firestone.  The next one we'd like to hear from is Jack Vick, 
who, again, is the future of rural health.

[Dr. Vick explained the difficulties of providing quality health care in 
rural areas. He stated that he will continue to practice in rural New 
Mexico but feels that many doctors choose to leave and go to urban areas 
where salaries are higher and the work is less demanding.]

    The President. I'm just glad you're going back.
    Let me just mention a couple of things you mentioned, because there 
are answers to some of them, and there aren't answers to some of them--
at least if there are answers to some of them, I don't know what they 
are. But one of the best things, I think, from the point of view of the 
benefits package that we tried to do in this plan is to provide more 
coverage for primary and preventive services, pap smears, mammograms, 
cholesterol tests, important things that are early warning signals that 
may head off far more severe health care problems and actually save the 
system money.
    Secondly, I think part of the answer to the problems of doctor 
exhaustion and overcommitment, simply increasing the number of doctors 
in rural areas and trying to tie them more into partnerships with urban 
medical centers and with university health centers. Without going into 
all the details, I think we've got some good systems to do that.
    We also are working on one aspect of malpractice reform that will 
encourage more family practitioners to do things like deliver

[[Page 2516]]

babies or set simple fractures where they are in rural areas. Based on 
an experiment that started in the State of Maine, where basically if 
you're a family practice doctor and you do these procedures out where 
people live, because you need to do it there, and you can prove that 
you've followed a set of guidelines approved not by the Government but 
by your national professional group, that raises a presumption that you 
were not negligent and sort of gets you out of this whole malpractice 
bind.
    Now, what I don't have an answer for, and I don't think there is one 
right now, is what you do with the problem pregnancy. I think if you 
think you've got a problem case, you still have to send it--whatever 
discomfort there is--to a place where you think the care will be 
appropriate. If there's an answer to that one, I don't know what it is. 
But I do think that we want more family doctors, and we want more family 
doctors out there in the rural areas doing things they know they can do 
but they're still afraid not to do because of the malpractice problem. 
And being able to prove that there's a set of nationally accepted 
guidelines for this kind of procedure in a rural area and that you've 
followed them, it seems to me will do a lot to alleviate both the cost 
of the malpractice insurance and the fear of the lawsuit.

[Dr. Vick asked the President about coverage for mental illness.]

    The President. Well, we think the basic benefits package should 
include mental health benefits, pretty comprehensive mental health 
benefits, as well as medication for treatment of mental illness. I know 
this is a particular interest of Senator Domenici and a number of other 
Members of the Congress. But let me say this has been a big fight in our 
administration, essentially with the bookkeeping of health care. That 
is, we can't ask the Congress to pass, and the Congress cannot pass, any 
bill that they don't think they have a pretty good feel for how much it 
will cost and how it will be paid for.
    So, we have been through a lot of very tough sessions with the 
actuaries for health care, people who are supposed to be experts in 
health care costs, to figure out how much the mental health benefit will 
cost and how we have to phase it in over time. Right now we phase in 
mental health benefits, comprehensive mental health benefits, between 
now and the year 2000, although other health care costs would be covered 
by the beginning of 1997, the end of 1996, in all the States.
    So, I'm glad you said that. I'm glad you said it here in this rural 
setting because, again, as you know much better than I, there are a lot 
of mental health problems that can be treated, that can be managed, that 
can allow people to be productive members of society, and that can 
therefore be a very cost-effective thing to do, as well as the humane 
thing to do. And we have to get these benefits in.
    Again, I believe that our actuaries have overestimated the cost and 
underestimated the benefits of including comprehensive mental health 
benefits. But nonetheless, we can't--again, I don't want to mislead the 
American people. I don't want to overpromise. And I don't want to pass a 
bill that breaks the bank. So right now we provide for the phasing-in of 
the mental health benefits, with the benefits to trigger in about the 
year 2000 to do what you say we should do.
    Dr. Firestone. Mr. President, Cel Gachupin has a story to tell about 
difficulties with provision of emergency services in rural areas. And I 
think I'll just pass him my microphone rather than lug the other one all 
the way around.

[Mr. Gachupin explained that it is often difficult for Native Americans 
to receive quality health care due to lack of funding and problems in 
the current Indian Health Service system. He then shared the tragic 
story of his son's death from asthma.]

    The President. Thank you for sharing it, and thank you for having 
the courage to share it. I don't know if I can give you an answer to the 
policy questions you raised. Thank you very much for what you said.
    The first thing you said was you often had to drive your son past 
hospitals to get to the Indian Health Service. Under our plan, if it 
passes the way we have presented it, American Indians will be able to 
get health care either through the Indian Health Service or through 
another network of health care at

[[Page 2517]]

their own choice. So that if people, because of where they happen to 
live, have much better access to some other health care provider, they 
will be, at their own choice, they will be able to choose to use those 
facilities. But we feel that the United States has a solemn obligation 
to maintain the Indian Health Service. And as you probably know, the 
funding has dropped over years as the number of people using it has 
dropped. So one of the things that--after the leaders of tribes from all 
over America came to see us in Washington about this.
    One of the things we did was to go back and amend the plan to try to 
strengthen the financial support for the health care service so they 
would be able to provide particularly the kind of services to people who 
are out-patients like your son was. So I think in this case, we will 
give the American Indians more personal choice than many now have. You 
won't be forced to the health care service. You'll have the option of 
using something else. But if you do use it, it should be better funded 
than it now is.

[At this point, Dr. Firestone expressed his concern that benefits for 
children with multiple disabilities and chronic illnesses might be 
reduced and presented the President with a letter regarding their needs. 
He then thanked the President for visiting the clinic.]

    The President. I can't answer the question you just asked me. But 
I'll get an answer, and I'll get back to this lady who wrote you the 
letter--or to me--the letter. I'll do it.
    Let me just say before we close, and then I want to say hello to all 
of you and then go back around and see the kids who have been waiting so 
patiently, if they're still there. I don't know if they are. I hear some 
people chanting in the background.
    When the new year comes and the Congress comes back into session, 
there will be a few months of really intense debate on this. Just think 
about this town and the size of this town and the diversity of the 
things we've heard about already today, as well as all the things we 
haven't heard about. This is a very complicated matter. But in the end 
it comes down to something very simple. We are spending a much bigger 
percentage of our income on health care than any other country in the 
world, and yet we are the only major country who doesn't provide 
everybody health care coverage that is always there, that can never be 
taken away.
    And we have permitted a system to develop so that now, coming out of 
medical school, only about one in seven doctors are committed to do what 
this doctor has done and this doctor wishes to do. So we have to change 
that. And it is perfectly clear that it will not happen unless the 
Congress is prepared to go through the incredibly rigorous process of 
reviewing the bill that I presented, listening to anybody else's 
alternatives and hearing the human voices that we have heard today, and 
coming to grips with this problem and actually acting on it.
    This is something we should have done a generation ago when we could 
have saved untold billions of dollars and no telling how many lives. But 
we can do it now, and we have to do it. And I would just implore you to 
work with us, make sure we don't make any mistakes we can possibly 
avoid, but give the Members of Congress from your State the courage to 
face this problem that our Nation has neglected for too long.
    Thank you very much.

Note: The President spoke at 4:04 p.m. at the El Pueblo Health Services 
Clinic. In his remarks, he referred to clinic physician Dr. Alan 
Firestone. This item was not received in time for publication in the 
appropriate issue.