[Public Papers of the Presidents of the United States: William J. Clinton (1994, Book I)]
[February 1, 1994]
[Pages 150-154]
[From the U.S. Government Publishing Office www.gpo.gov]

Remarks to the American Hospital Association
February 1, 1994

    Thank you very much. Thank you, Dick, and thank you, Carolyn. And 
thank you also for bringing my tea out here. The Hospital Association is 
giving care to the President for his sick voice today. [Laughter] I 
thank you.

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    I appreciate so much what both Dick and Carolyn said, and I want to 
begin by thanking all of you here who have ever had me in your 
hospitals--[laughter]--which is a large number of people. Especially all 
the people who represent my native State and who have done so much to 
help educate me on these issues over the years.
    The time that I have spent in hospitals since I was a small boy has 
made a very big impression on me. I always learn something. I always 
leave with a sense of inspiration about the dedication of the people who 
work there. And I want to say a special word of thanks to this 
association for the work that you have done with our administration over 
the last year, in a very constructive way, in helping us to try to 
develop an approach which would solve the problems of the American 
health care system and protect and enhance what is good about it.
    I know that there will still be some issues on which there will be 
disagreement as we go forward, but I think it's important that we 
clarify today, as Dick did so well in his introduction, that we agree on 
the most important issue: We have to preserve what is right; we have to 
fix what is wrong; we have to guarantee private insurance to every 
American so that everybody will be covered. That is the only way to stop 
cost shifting, the only way to be fair, the only way to solve this 
    The problem with the health care system in this country did not just 
happen overnight. It happened because of the way this system is 
organized. Anybody who thinks there are no serious problems, no crisis 
in the health care system, I would say go visit your local hospital.
    Over the years, because of the insurance system we have in America, 
which is unlike any in the world and which, I will say, is irrelevant to 
the fact that we have the highest quality care in the world for the 
people who can afford it and access it, we have created a system which 
often makes it impossible for hospitals to do their jobs. While 
insurance companies have set up a system which enables them to slam the 
door on people who aren't healthy enough to get covered, hospitals open 
the door to everyone, whether they're covered or not.
    We have created in this country, through the systems of hundreds of 
different insurance companies writing thousands of different policies, a 
giant bureaucracy which on the insurance side sorts the healthy from the 
sick, the old from the young, the geographically desirable from the 
undesirable. And as more and more insurance companies sell more and more 
customized insurance policies to smaller and smaller groups, each of 
them has created its own set of forms and different sets of what would 
cover, spelled out in endless fine print. The result, as all of you 
know, has been a bureaucratic nightmare.
    And what about the hospitals? You have had to create your own 
bureaucracy to deal with the insurance bureaucracy and the Government's 
as well, to fight redtape, close loopholes, and to try to get reimbursed 
somehow. And that only covers the patients who have good insurance. For 
those without insurance or with barebone coverage, you're forced to jump 
through a whole lot of other hoops. And you probably still often don't 
get any reimbursement.
    Hospitals did not invent this system. You didn't choose a system 
which has resulted in hospitals hiring clerical workers at 4 times the 
rate of doctors being added to hospital staffs in the last 10 years. You 
did it because of the redtape of the present system, the insurance 
redtape and the Government program redtape.
    Meanwhile, your mission didn't change, it's still to treat the 
people who are sick who need to be in the hospital. Regardless of their 
age or medical history, of what may or may not be covered, you have to 
deal with the people that the insurance industry decides are not 
profitable. You can't ask whether an illness was a preexisting 
condition, it's still an illness.
    So what are we left with today? A system where we're ruled by forms 
and have less time to make people healthy. A system that forces doctors 
and nurses and clerical workers in hospitals to write out the same 
information six times in six different ways just to satisfy some distant 
company or agency. It doesn't make sense, and you shouldn't have to put 
up with it anymore.
    Just listen to Joan Brown, a registered nurse who works at a 
teaching hospital in Chapel Hill, North Carolina. She wrote to the First 
Lady that she spends, and I quote, ``more time with paperwork than with 
any other aspect of health care.'' They've got a joke at her hospital, 
she said, ``We'll do the patient care after we finish the paperwork, if 
we have time.'' It's not just a joke; it's a sign of a crisis and one 
we've got to do something about.
    I visited Children's Hospital here in Washington last year. The 
pediatrician, who is from this community and who has dedicated her life 

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the children of this community, told me she spends up to 25 hours a week 
filling out forms instead of tending sick children. ``It's not what we 
trained all these years to do,'' she said. ``Reducing paperwork would 
enable me to practice medicine again. It would free me,'' she said, 
``free me from the shackles and the burdens of the paperwork maze.''
    Let's be honest. In his wildest dreams, Rube Goldberg could never 
have designed a system more complex than the present health care system. 
You in this room understand this better than anyone else in the world 
today. You see the crisis when people without insurance come to 
emergency rooms with serious injuries or illnesses. Many of those 
illnesses could have been prevented if only they had been covered and 
had access to a doctor, to primary and preventive care. The emergency 
room is the most expensive place to treat people. It should be reserved 
for emergencies. I know you believe that, and you can make sure it 
happened if everybody had access to health care coverage.
    You see the crisis when people come in who aren't fully insured, and 
you become loaded up with what's called uncompensated care. The smallest 
estimate of that is $25 billion a year. It either comes out of your 
budgets, which hurts your ability to provide health care at a high 
quality, or you have to shift the cost on to the bills of those who can 
pay them.
    A lot of people who complain about hospitals overcharging, about 
inflated bills, have no idea how much of this cost shifting occurs 
simply because of the insurance setup that we have in the United States. 
No other country in the world is burdened with it. And we should not 
tolerate it any longer.
    You also see it because a lot of the people who come to you, either 
before they come or sometime during their treatment, deal with the 
problems of preexisting conditions or lifetime limits on insurance 
policies. Three out of four policies have such lifetime limits. I know a 
lot of times you wind up having to send a collection company after a 
patient that you know is not going to be able to pay the bill anyway 
because of these problems.
    You see this crisis when a doctor prescribes prescription drugs, but 
then a person comes back to the hospital 3 or 4 weeks later because she 
couldn't afford to fill the prescription. So the illness got worse. One 
study says that problems related to the lack of appropriate medication 
lie at the root of up to 25 percent of all hospitalizations and cost 
over $21 billion a year. Our plan is the only one that takes account of 
this and covers prescription drugs along with other medical services.
    You see it with the crisis of violence in the emergency room. We 
have to learn to treat violence as a public health problem. Billions of 
dollars a year again are loaded onto the health care system because we 
are the most violent country in the world. Many people in health care 
supported the Brady bill, support our attempts to restrict assault 
weapons, to put more police officers on the street. That also will help 
alleviate the health care problem. So I hope you'll be out there after 
we deal with this the best we can, also supporting what the 
administration is trying to do on crime.
    I came here today once again to thank you for the work you have done 
with us and to appeal once again for your support, for the real battle 
is now being joined in Congress. And though we may disagree about the 
details, we all agree the time has come to do something. We have to do 
it now. And what we have to do includes providing guaranteed private 
insurance to every single American. That is what I need your help to do.
    I implore you to go to Capitol Hill and tell your Members of 
Congress again what is going on in your hospitals. Go home and talk to 
your friends and neighbors about it and the people who come in to your 
hospitals. Talk to business leaders in your communities and local media 
    One of the biggest problems we have in this fight today is that this 
issue is so complex and people are naturally enough so concerned that 
they don't want to lose anything good that they have now, that it is 
easy to confuse people about what the real issues and the real facts 
    I love having a discussion with your representatives, even if there 
is some disagreement around the edges of policy. We come to the table 
with an accumulated knowledge of how the world really works. Our biggest 
problem in passing this is that there are too many people even in the 
Congress who have not had the opportunity to study this program in all 
of its complexity. This is a tough, tough issue. And as I could tell 
from your applause, you know that the most complex system that could 
ever be designed is not the one in the administra-

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tion's bill, it's the one you're living with right now.
    Our approach is not to tell you how to deliver health care, not to 
build barriers or bureaucracy. What we want to do is to establish a 
framework in which people are covered, provide the right incentives, 
help to remove the barriers to access, and get out of the way. We agree 
that local community-care networks must be the center of any reform 
system, groups of providers who see their mission as keeping people 
well, treating the sick when they are sick, and having the right 
incentives to do exactly that. We need to look no further than your own 
NOVA award winners for examples of providers who come together and make 
collaboration work.
    One example, the Health Partners of Philadelphia, where six urban 
teaching hospitals came together and worked together to deal with 
violence and drugs and teen pregnancy in one community--this is a very 
moving sort of thing. This can be done throughout America. And we could 
do more of it if we covered everybody. It would lower the cost to the 
overall health care system if we did it, because we could practice 
prevention, we could give more primary care. The system as a whole would 
be less burdened, and we could have more networks like the one in 
Philadelphia you have honored.
    I know that many of you are already finding incredibly creative ways 
to serve your community and are forming these networks. That approach 
will be quite consistent with the administration's approach. We helped 
to do that with clear incentives for people to join together in networks 
and guarantees that when they do there will be compensation there for 
the services that are provided. And we agree that reform must simplify 
the system for you by reducing the paperwork burden. There's no excuse 
for not having a single standard form to replace the thousands of forms 
that exist today. And we want to help you move forward; electronic 
billing, less regulation by the Government, and other ways to help get 
rid of some of this paperwork hassle. I am tired of trying to explain 
why we spend a dime on the dollar more on paperwork, regulation, and 
premiums than any other country in the world and we still don't even 
cover everybody. It cannot be explained, so it should be changed.
    And I want you to help me do something else, too, when you go up to 
Congress. Ask every Member of Congress, the next time somebody comes to 
them and says, ``What we really ought to do is tax the benefits, the 
health care benefits of middle class working people,'' say, ``Well, 
before you tax the benefits of working people whose wages have been 
stagnant for 20 years, why don't you ask how we can justify spending a 
dime on the dollar more on paperwork, regulation, and insurance premiums 
than anybody else?'' That is waste. Why take something away from hard-
working people before you squeeze the system and its unconscionable 
burdens on hospitals, doctors, nurses, and the American people 
themselves? That is where we ought to start.
    I also want to talk a little bit about the guarantee of private 
insurance. Most people, under our approach, would get insurance the same 
way they do today, through their employer. Each consumer, not an 
employer, not a bureaucrat, would have a choice of health care plans and 
    Let me point out something else on this choice. Today, 55 percent of 
the companies who insure their employees and 40 percent of the total 
work force insured through their employer have no choice today in 
doctors or health plans. They take the plan the employer has chosen. 
Under our plan, everybody would have at least three choices of plans, 
including the right to simply pick a doctor and have fee-for-service 
medicine. That is more choice than exists today, not less. Again, the 
rhetoric of people who have attacked change defies the reality of what 
people face and deal with in their daily lives in the health care system 
    Once someone has picked a plan, if they need to go to a doctor for a 
checkup or if they get sick, they'll simply take a health care security 
card, show it, and get the care they need. Then they'll fill out one 
standard form, and they're done. That way, we can go back to seeing 
hospitals as places of healing, not monuments to paperwork and 
    I have heard so many stories in so many hospitals, I could keep you 
here all day laughing, but it would be like preaching to the saved. The 
only thing I want you to do is to go tell the Congress about it and that 
we can do better.
    Last week when I spoke to Congress, I said that I would veto any 
legislation that did not cover every American with guaranteed insurance. 
Now, again I want to say that I did that because you know that unless we 
do that we can't have everybody playing by the same rules,

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using the same forms, ending the cost shifting, and getting people the 
preventive and primary care they need so they don't simply wind up in 
the emergency room. That is, all the systematic problems that the 
Hospital Association brought to the administration when we began this 
discussion will continue unless we provide coverage to everyone.
    Now again, I know there are issues to work out. There are 
differences about what level of Medicaid savings can be achieved. I'll 
tell you this: Our plan is the only one that takes the Medicare savings 
and puts it back into the health care system, which is very, very 
important. But the biggest thing you need to do, I would argue, to get a 
good health care bill out of Congress is make sure that the people in 
the Congress understand how the system works today and what these 
various approaches would do if they were passed.
    Yesterday, Families USA issued a very valuable document which I just 
received a copy of this morning which takes 10 different families, 10 
different health situations, and goes through in practical terms how 
they would be affected if each of the major plans now pending in the 
Congress were the law of the land. I would urge you to read it. But it 
won't surprise any of you because you know how the system works today.
    Again, I implore you to take this debate to Congress, get beyond the 
rhetoric, get beyond the ideology, talk to people in the Congress about 
the American people and how the American health care system affects 
them. That is the only way we can work through the real problems as 
opposed to the imagined one.
    One distinguished Member of the House of Representatives who 
represents a district with a wonderful teaching hospital and who has 
been required by virtue of his membership--his constituency--to become 
an expert on health policy over the years, read our plan the other day, 
and he said, ``It's the only one that really takes account of so many 
different problems that most people don't even know about. But I have no 
idea how to get my colleagues in the Congress to take this issue 
seriously and spend all the time it would take to absorb it all.''
    You can do that. Every Member of Congress has a lot of hospitals in 
his or her district. Every Member of Congress basically cares a lot 
about health care. And you can come to this debate with a perspective 
that is not ideological, not partisan, has no ax to grind, doesn't care 
who wins except the American people and the American health care system. 
That's what you can bring to this debate.
    So I would ask you, at a time when some say we just need a little 
tinkering and others say there are ideological barriers to changing it, 
I just want to say that Dick Davidson, your president, in my view, said 
it as well as it could be said last December. He said, ``Comprehensive 
reform is what the American people are asking us to do. To do nothing, 
or worse, to fall back on simplistic solutions, only postpones and 
complicates our task.'' And that's the truth.
    Let us stand together for the health care of the American people. We 
have a chance finally for the first time in decades to do this right. 
You know what needs to be done. I pledge to you an open door, a 
listening ear, a firm partnership. Let's go out there and solve this 
problem for the American people.
    Thank you very much, and God bless you.

Note: The President spoke at 10:18 a.m. at the Washington Hilton. In his 
remarks, he referred to Dick Davidson, president, American Hospital 
Association, and Carolyn Roberts, chairman-elect, American Hospital 
Association Board of Trustees.