    [Weekly Compilation of Presidential Documents Volume 30, Number 19 (Monday, May 16, 1994)]
    [Pages 1044-1050]
    [Online from the Government Publishing Office, www.gpo.gov]

    <R04>
    Remarks to the American Nurses Association Conference

    May 10, 1994

        Thank you so much. Thank you for your warm welcome. And thank you,
    Ginna, for that award.
        I arrived a few moments ago, and I remember the first time I ever
    heard your president speak. I knew that she had worked for Vice
    President Gore, and I thought it was so interesting to hear the head of
    a national association who was speaking without an accent. [Laughter]
        I want to say a special word of appreciation to your first vice
    president, Ellen Sanders, who's participated in White House and
    congressional meetings on health reform, and to Diane Weaver, the
    president of the Association of Nurse Executives, who cosponsored this
    breakfast.
        I am very proud to share the stage today with all the fine nurses in
    the executive and the legislative branches whom you have honored. And I
    thank you for doing that. And I thank them for their service. I also
    want to say a special word of thanks to all of you and to the ANA for
    the courage and the vi-

    [[Page 1045]]

    sion you have demonstrated by fighting for health care reform, and the
    right kind of health care reform, long before it was a hot issue. As you
    know, the position paper you put out on national health reform probably
    more closely parallels the recommendations that our administration has
    made than that of any other professional health care group in the
    country. And I thank you for that very much.
        I want to thank you, too, for recognizing my mother, who worked for
    30 years and then some as a nurse and was deeply proud of what she did.
    I remember when I was little boy watching her get up in the middle of
    the night always starting work by 7 a.m. or 7:30 a.m. in the morning,
    always telling me stories that indicated that there was literally
    nothing in the world more important to her than dealing with a person
    frightened, in pain, with a caring and effective manner. This award will
    help to expand the frontiers of nursing in the areas of women's health,
    something that she would have been very proud to be a part of.
        My mother, as all of you now know, completed her memoirs, which
    became her autobiography shortly before she died. She went over about
    half of it and was able to do the final editing. And it was my privilege
    after she passed away to work with the author and just try to make sure
    all the facts were right. I got very stern instructions from her. She
    said, ``Now if you have to do this do not change one word I said about
    you''--[laughter]--``especially the part about your manners not always
    being great.'' [Laughter] ``And make sure you get the facts straight.
    Otherwise leave it alone.''
        But I was very pleased with the two book reviews that her book got
    yesterday. One by the great American author, Joyce Carol Oaks in the New
    York Times, and then another one here in the Washington Post. But it
    tickled me, the one in the Washington Post said that if you read this
    book, you would understand why I perplexed people in Washington. I was
    actually brought up by real people, and occasionally I still acted like
    one. [Laughter] I didn't know what that--[laughter]--I'm trying to get
    over it, but it's hard even here.
        Anyway, here's something my mother said about her work, which would
    apply to all of you and those whom you represent. But it meant a lot to
    me. It was just her words. ``Nurse anesthetist work is all-consuming.
    You don't do it halfway. You don't daydream. You don't let your emotions
    wander. You're the person responsible for putting another human being
    into a state of unconsciousness, somewhere between life and death. For
    30 years, from the minute that I would walk into the operating room and
    start talking to the patient and begin putting him to sleep, until I got
    him safely back to the recovery room, nothing in the world could have
    crossed my mind. I don't care what problems were on the outside. I don't
    care what problems I might have been having at home. I never thought of
    my life beyond the moment.''
        I remember when I was also a child, things were somewhat more
    informal. My mother used to take me to the hospital and let me meet the
    other nurses and the doctors and watch the emergency room and watch
    people go into the operating room. It was utterly fascinating. And the
    work you do has always sort of captured my imagination.
        My own wife had never been in a hospital before in her entire life
    until our daughter was born, never been in a hospital for any kind of
    sickness. And learned only a few moments before the happy event that she
    was going to have to have a C-section. And we had gone through Lamaze,
    and we had done all this stuff, and I was supposed to be in the
    operating room. And our hospital at that time had never before let a
    father into the delivery room if it wasn't a natural birth. It was a big
    deal. So I said, ``Look, I've been watching people get cut on and bleed
    since I was a little boy. I'll do fine.'' [Laughter] ``But she had never
    been here before, and she may not--you better let me come in.''
    [Laughter] So they did and actually changed the policy so that if
    fathers had been through the Lamaze course and then the mothers
    eventually had to have a C-section, they got to go. So I felt--that's my
    one contribution to medical advances. [Laughter]
        But I owe all that to my mother, who was a remarkably determined
    woman in the face of often excruciating adversity. I think one of the
    reasons that the Nurses Association has been so forthright about this
    health care reform issue is that you see it from the grass-

    [[Page 1046]]

    roots up in human terms and you don't get so hung up as some people do
    on all the political rhetoric and the positioning and the
    characterizations that have, frankly, put a lot of Members of Congress
    at a severe disadvantage because they haven't had the chance to spend
    the time and make the effort to deal with this issue that you have. It
    is, after all, a mind-bendingly complex problem. It's 14.5 percent of
    our income, and for people who don't live in it every day, it can be a
    very difficult thing.
        But I just wanted to thank you because I believe that the personal
    experiences you have shared, so many of you common to the ones that my
    own mother shared, really animated the Nurses Association to take the
    position that you have taken.
        I want to emphasize today that what I seek, contrary to the attacks,
    and what you have sought, is not a Government-run health system, it's a
    private insurance health system that covers everybody, where the health
    care professionals run it and not the insurance companies. That's what
    we seek.
        We seek private insurance that can never be taken away. It's wrong
    to treat seriously ill children in an emergency room who could have been
    treated more easily and more inexpensively if their parents had just had
    the coverage. With our reforms, every family will have that kind of
    quality insurance. We ought to reform the insurance system that today
    often only covers the healthiest people and even then will deny them
    coverage for anything they've been sick with before.
        When you go to a patient's bedside, you ask, ``Why does it hurt?
    Where does it hurt? How can I help?'' You don't ask whether this is a
    preexisting condition you're looking at. [Laughter] It's a very
    important issue.
        If you think about all this preexisting condition business, there
    are 81 million Americans who live in families where there's been a child
    with diabetes or a mother that had cancer prematurely or a father that
    had an early heart attack or some other problem. I see these people
    everywhere. This is no small number. Now, we get action lickety-split up
    here all the time when a million people or 2 million people are
    adversely affected by something if they are well organized. But these 81
    million people, they're professionals and blue-collar workers; they're
    old folks and young folks; they're all different kinds of people; and
    they are by definition disorganized. There is no national association of
    people with preexisting conditions. [Laughter] You think about it; if
    there were, and 10 million of them showed up here, we'd have health care
    reform so fast you couldn't blink.
        You must be their voice in an organized way. And you can be. So we
    ought to cover everybody with private insurance, and we ought to have
    insurance reforms that deal with preexisting conditions and don't
    discriminate people based on age. This is somewhat controversial. I know
    that. But I believe if we went back to health insurance the way it
    originally was when Blue Cross first started writing it, where everybody
    was put in a large group, risk was broadly spread, and people paid a fee
    against the day when they would be sick, it would be fairer for all
    Americans. And our economy would work better, our society would have a
    stronger sense of community, our families would function better. People
    would be free of a lot of the anxiety that comes----
        Hillary and I have received about a million letters. And whenever I
    go somewhere now, they arrange for some of the letter writers to come
    see me. And it's just gripping to see people just over and over and over
    and stunning to see how they do come from all walks of life and how they
    have been broken by the things which have happened.
        The third thing I think we should do is to preserve the Medicare
    program. It's interesting, the people who criticize our program say this
    is Government-run health care which, of course, it isn't. And if you
    tried to take away Medicare, which is a Government-funded health care,
    well, they would be up in a tree somewhere screaming about it.
        But we don't want to do anything to the Medicare program, except to
    make it better. I do believe we should add a prescription drug benefit
    and phase in long-term care that is community-based or home-based for
    two simple reasons. One is, there are an awful lot of elderly people who
    aren't poor enough to be on Medicaid but aren't well off, who have
    significant medical bills. We know the elderly use 4 times the
    prescription drugs

    [[Page 1047]]

    that the nonelderly do. And we know from study after study after study
    that a proper medication regime can keep people out of the hospital and
    can save money and that we now have--any number of elderly people every
    month--I was in a grocery store in New York yesterday called Pathmark,
    which also operates, as many do now, a drugstore. And it was gripping;
    the CEO was saying, ``My workers tell me that every day they watch older
    people come in this store and go from the drugstore, down the food
    aisle, and try to make up their mind what food they're going to give up
    to get their medicine, or whether they're going to give up their
    medicine to buy their food''--gripping. So I do believe we should do
    that. But the Medicare program works. It has low administrative
    overhead. We think it should be secured.
        The fourth thing we want to do is to bring greater choice to our
    people. I guess the thing that has made me the maddest in the relentless
    campaign against this plan are all those bogus ads where they say,
    ``You're going to have to call some Government office to figure out
    where you go to the doctor.''
        There are two realities of modern life that you have to drive home
    to every Member of Congress, without regard to party or philosophy.
    Number one, Americans are rapidly losing their choices today. Already,
    of people who are insured at work, fewer than half have more than one
    choice of a health plan. That's a fact today. And they're rapidly losing
    their choices. Number two, medical professionals are increasingly losing
    their right to decide unilaterally, may have to have somebody get on the
    phone to an insurance company executive a long way away to ask for
    permission to do what anybody knows ought to be done under the
    circumstances.
        Now, most Americans, believe it or not, don't know either one of
    those things, even though they may be caught up in it, and I think it's
    very important. Our plan is designed, number one, to increase the
    choices that consumers have. We're moving to more managed care. There
    can be a lot of good things in it, but under our plan, every year, every
    person would have a choice between at least three plans, or among at
    least three plans but in all probability many more. And number two,
    under our plan, medical professionals would also be given more choices
    and would have to do less checking in with the insurance company in
    advance. Now, being treated by doctors and nurses, you know, is an
    American tradition. Every time I do one of these town meetings, like I
    did in Rhode Island last night, I talk to somebody that's just been
    forced to give up their doctor and just move away from the choices they
    made.
        We believe when all Americans can choose among several health plans,
    many Americans, many more Americans, will choose to stay with their own
    providers. And many more of these plans will be organized in such a way
    that all providers can participate if they'll do it for the agreed-upon
    fee. That's what we believe will happen. And if we don't do this, if we
    don't have some legal action to reorganize this, you're going to have
    less choice by consumers, less choice by providers.
        Time and again, we've also seen that the quality of care is directly
    related to the quality and the quantity of the nursing staff. One of the
    things that amazes me is how many nurses have been laid off in recent
    months and been told, well, this is because health care reform is
    coming. I'll tell you what, one of Clinton's unbending laws of politics
    is, whenever somebody who's got a tough decision to make can shift the
    heat from themselves to you, they'll do it every time. They will do it
    every time. That law never varies.
        Now, what is really going on? What's really going on is, a lot of
    these health care providers are under the gun. Right? More managed care;
    people bargaining tougher for prices; more and more people who are
    uncovered where there's uncompensated care that has to be provided; less
    and less ability to pass on the cost of uncompensated care to other
    people because they're in these managed care networks they're in: all
    this stuff is going to happen if we don't do anything. All of us could
    go on vacation for a year, and this same thing would go on. You know
    that. And don't let your Members fall for it.
        What's going to happen is we'll continue to see these trends occur
    unless we find a way to give health care providers reimbursement for all
    the people for whom they care, at an appropriate level in an appropriate
    way. More than a decade of research now shows

    [[Page 1048]]

    that more and better trained nurses result in shorter hospital stays,
    better survival rates, fewer complications, whether you're dealing with
    low birthweight babies or older people.
        You do not have to work for the Congressional Budget Office to
    understand that healthier patients and shorter stays means lower health
    care costs. Sometimes I think if you do work for the Congressional
    Budget Office you will never get that, but--[laughter]--we're working
    pretty well on the whole. This is a big deal. This choice issue and
    maintaining an array of qualified people doing the things for which they
    are best qualified is terribly important.
        Finally, let me say--and this, I guess, is, except for this whole
    issue of whether this is a Government program, which it isn't, is the
    most controversial part of it--our reform is based on providing
    guaranteed benefits at work. Now the reason for that is simple, for the
    people in this country that have health insurance, 9 out of 10 of them
    have it at work where there is some shared responsibility between the
    employer and the employee. For the people who don't have insurance, 8
    out of 10 of them have someone in their family who is working.
        It seems to me that the fairest and simplest, and if you will, the
    most conservative way to achieve universal coverage, to have health care
    security for everybody, is to ask employers and employees who aren't
    doing anything or barely doing anything to do more so that they can
    fulfill their own responsibilities and then use tax funds to cover the
    unemployed, uninsured people for whom you could say, ``Well, there's a
    general responsibility just like Medicare and Medicaid'' and then
    organize the market so that smaller businesses and self-employed people,
    (a) get discounts if they need it and (b) are able to buy good insurance
    on the same terms that those of us who are insured by Government or
    larger businesses can.
        Now it seems to me that is a fair and simple and obvious way to do
    this. I think that any other way will sooner or later involve either a
    radical change, that is, getting rid of the whole health insurance
    market and substituting taxes for it, or involve people who are already
    paying too much for their own health care, having to pay something for
    people who won't do anything for themselves because they say they should
    be exempt.
        Now I think that this is a very important issue. You know, again, we
    lose sight of the fact that most small businesses are making an effort
    to cover their employees. We have brought hundreds and hundreds of small
    businesses to Washington to talk to the Congress, but they are not
    organized. There is no association called: small businesses who cover
    their employees and are mad their competitors don't and mad they can't
    get better insurance rates--[laughter]--and wish somebody would help
    them. So an association that may have a lot of folks in the insurance
    industry, along with other small businesses, says, ``Don't do this; the
    whole small business economy will break,'' says this, and there's no
    association on the other side. You have to be their voice.
        Had a car dealer from a town of 7,000 people in Arkansas up staying
    with me the other night, he and his wife, long-time friends of mine.
    She's a college teacher. He's a car dealer. He said to me the other
    night--it was funny--he said, ``You know, for 20 years I have been
    feeling sorry for myself because I've provided a good health plan for my
    employees, and none of my competitors did.'' So he said, ``I was so
    happy when you proposed this just because I thought I was going to get
    even.'' [Laughter] And then he said, ``But you know, then I remembered
    that in the last 20 years I put three of my competitors out of business.
    And I'm making more money than I ever have. And the reason is I still
    got the same folks working for me I had 20 years ago because I gave them
    health benefits.''
        And yesterday I went to New York and I visited this Pathmark store.
    They have 175 stores, 28,000 employees, the 10th biggest supermarket
    chain in the country. We're all told, ``Oh, if you do this, the
    retailing business will go to pieces.'' These people have put new stores
    in inner-city areas that other chains would not touch, fine new stores.
    They are making money, and they have always provided comprehensive
    health benefits to their employees. And they are now sacking their
    groceries in a bag that says they favor health care benefits to all
    Americans, guaranteed through the workplace.

    [[Page 1049]]

        I say this to you because, as you know, there are a lot of nurses
    that don't have any health care coverage and a lot of nurses who are
    single parents who don't have health care coverage. And this is the
    other point I want to make that I did to all those young people working
    in that grocery store yesterday: Everybody now in Washington is for
    welfare reform, and I guess it means different things to different
    people. But I have basically a 3-point strategy to achieve what I think
    would end the welfare system as we know it: One was embodied in last
    year's economic plan, lower income taxes for working people who are
    hovering just above the poverty line with children. This year one in six
    American working families will be eligible for lower income taxes so
    they can succeed at work and can succeed as parents.
        Strategy number two, give people education and training and then
    give them a certain amount of time to find a job. And if they don't,
    require them to take it. And if they can't, provide some public subsidy
    in the private sector or some publicly funded job so that work is
    preferable to welfare.
        Strategy number three has got to be cover the people with health
    insurance. Consider this: All these people on welfare in this country
    who are dying to get off--and by the way, that's most of them--who are
    dying to get off, most of them have limited education. Suppose they go
    through a little training program and they get a job that pays a modest
    wage but is still more than the welfare benefits. But they go to work
    for an employer who does not provide for health care.
        Think about this: You are a mother with two children. You give up
    being on welfare to take a job that pays more than the welfare check,
    but you lose health care coverage for your kids. What are you going to
    do if your kid has to go to the dentist? What are you going to do if
    your child is desperately ill? How are you going to feel every week,
    every 2 weeks or every month when you get your paycheck and you see
    what's taken out of it in taxes and you realize those taxes are going to
    pay for the health care benefits of people who decided to stay on
    welfare instead of going to work? You don't have to be as bright as a
    tree full of owls to figure out that this doesn't make a lot of sense.
    [Laughter]
        Now a lot of American nurses are in this situation today, getting up
    every day, slaving away, trying to take care of people who have children
    without insurance, caring for people who come into their office who are
    on public assistance who have children with insurance because of the
    Medicaid program. It is not fair. It is not right. It is not smart.
        And you could say, ``Well, all this inability to cover everybody, if
    this were fueling some enormous American economic expansion, because we
    were saving so much money on health care, maybe you could deal with
    that.'' But the truth is we're spending over 40 percent more of our
    income on health care than any other country in the world. Oh yes, some
    of it because we're more violent, and that's something we pay for. Some
    of it because we have better medical research and technology, and that's
    worth paying for. But a whole lot of it, as you well know, is because of
    the way we have financed health care, which has employed hundreds of
    thousands of people in doctors' offices, in clinics, in hospitals, and
    in insurance companies to read the fine print on thousands and thousands
    of policies to see who and what is not covered. And it has rifled
    inefficiencies through this system that we are all paying for.
        We can fix this. We can fix it by having a law which fixes what's
    wrong, keeps what's right, provides health care security to everybody
    through a private system, increases the choices consumers have, and
    increases the decisions that doctors and nurses and other qualified
    providers make without oversight by others. We can do it.
        In order to do it, we have to recognize we have to go through a fog
    of misinformation, a torrent of labels which aren't right, and
    recognize, too, that you have to lobby and stand up for, in an organized
    and very personal way, that great association that doesn't exist, the
    association of 81 million Americans and families with preexisting
    conditions, the association of hundreds of thousands of small businesses
    who are doing the right thing and being punished for it, the association
    of all the poor women in this country who are out there working their
    hearts out and their fingers to the bone to do right by their kids
    without health insurance and paying taxes for people on public
    assistance

    [[Page 1050]]

    who have it for their children. All of those associations are
    disorganized.
        You have devoted your lives to providing health care to all
    Americans. You have honored my favorite nurse today. You have given me a
    chance to hope that my mother and my grandmother are looking down on me
    thinking I was the first generation in three that didn't produce anybody
    that was caring for other people in health care. So they think at least
    I walked off with the award today. [Laughter] It means more to me than I
    can say.
        But the determination that my mother showed in getting up off the
    pavement many times in her life is the same sort of determination you
    have to show for us to get health care reform this year. And remember,
    most of these Members of Congress want to do the right thing. But they
    don't know what you know; they haven't spent the time that you've spent;
    they haven't had the experiences you have had. You have to help them.
    And the people in their districts that really need their help are not in
    those great national associations.
        You keep them in your mind and keep that example in your mind. Don't
    let this year go by. We can do this this year with your help and your
    leadership.
        Thank you, and God bless you all.

    Note: The President spoke at 9:56 a.m. in the Regency A Ballroom at the
    Hyatt Regency. In his remarks, he referred to Virginia Trotter Betts,
    president, American Nurses Association. A tape was not available for
    verification of the content of these remarks.