[Weekly Compilation of Presidential Documents Volume 29, Number 38 (Monday, September 27, 1993)]
[Pages 1827-1832]
[Online from the Government Publishing Office, www.gpo.gov]
<R04>
Interview With Radio Talk Show Hosts
September 21, 1993
The President. Thank you very much and welcome to the Executive
Office Building and to the White House, and thank you for coming today.
I--what did you say, nice tie? [Laughter] That's a Save the Children
tie.
Audience member. All right!
The President. I wore it for the national service signing today.
It's interesting, we just had a lunch with a number of columnists--
--
Audience members. Lunch? Lunch? [Laughter]
The President. Lunch? I'm sorry. I'm sorry. Would it make you feel
better if I said I didn't enjoy it? I mean--[laughter]--anyway, and they
knew you were all here, and we had 700 or 800 people out on the lawn for
the national service signing. And four or five of these folks that have
been covering Washington for 20 years said they had never seen the White
House so busy. I didn't know if they were happy or sad about it, but
anyway, it's busy.
I thank you for coming today. I hope this will be the first of a
number of opportunities we have to provide people who have radio talk
shows and who communicate with millions of Americans on an intimate
basis, daily, to come to the White House to have these kinds of
briefings. You've already heard all the basic approaches that the
administration is going to take on health care and that will be
hopefully crystallized in a compelling way in my address to the Congress
and to the country tomorrow evening.
So, I thought what I would do is make a general statement about how
this fits into the overall approach the administration is taking and
then answer your questions. I'd rather spend time just answering your
questions.
But let me just make a general comment, that I think you can--that
runs through the thread of debate that we had on the economic program,
on the health care issue, on NAFTA, on the crime bill that's coming up,
on the welfare reform issue, on all the major things we're trying to
come to grips with.
It is now commonplace to say that we are living through a time of
profound change, not only in our country but around the world. People
are trying to come to grips with a rate and nature of change that comes
along less frequently than once a generation.
You may know that just since you've been sitting here, Boris Yeltsin
has dissolved the Russian Parliament and called elections for that
Parliament in December, and his major opponent has apparently declared
himself President. I mean, they are going through these things, trying
to come to grips with what it means to be a democracy and what it means
to try to change the economy.
In our country, if we're going to continue to be the leading power
of the world, not just militarily but economically, socially, the
shining light of the world, this has to be a good place for most
Americans to live. Most people have to know that if they work hard and
play by the rules that they can make the changes that are sweeping
through this country and the world their friends and not their enemies.
They have to believe that as citizens they can work together and trust
the major institutions of our society to function well, to meet these
changes, to respond to them.
We confront this bewildering array of challenges: the size of the
deficit, the fact that we have an investment deficit, too, in many
critical areas, the health care crisis, at a time when most people are
quite insecure in their
[[Page 1828]]
own lives and most Americans have worked harder for stagnant or lower
wages for the last 10 to 20 years, when they're paying more for the
basics in life, when they have lost faith in the fundamental capacity of
political institutions to represent them and to solve problems.
I think you can see that in the 700,000 letters we got on health
care. The number of people who would say, you know, ``What's wrong with
me? I worked hard all my life, and I lost my health insurance,'' or ``My
child got sick, and now I can never change my job,'' or ``My wife and I
spend 60 hours a week running our business. And our health insurance was
$200 a month 4 years ago, and it's over $900 a month today,'' you know
that things are out of control. I say that because I believe providing
security in the health care area and in meeting the other objectives we
talked about, quality and choice and cost controls and all, is a
necessary precondition, not only to improve the health care of the
American people but to help root the American people again in this
moment, to make them freer to face the other challenges that we face. I
see in this debate over NAFTA--which I have wrestled with in my own
mind, that is, the whole nature of our trade relations with Mexico and
other countries and where we are going for far longer than I've been
President, I had to deal with it when I was a Governor. I see people,
some of them looking ahead with confidence in the future that we can
triumph in the world of the 21st century, that we can compete and win,
that we can create tomorrow's jobs, and others so uncertain about it,
just trying to hold on to today and to yesterday's jobs.
So, what I am trying to do is to give the American people a greater
sense of security over those things that are basic to their lives that
they can control and at the same time challenge our people to assume
responsibility for dealing with our problems and for marching
confidently into the future. That's what this national service issue is
all about that we celebrated today on the White House lawn.
And therefore, the health care issue is about more than health care.
It is about restoring self-confidence to America's families and
businesses. It's about restoring some discipline to our budget and
investment decisions, not only in the Government but in the private
sector. It's about giving us the sense that we actually can move forward
and win in the face of all these changes. I cannot under--or I guess I
cannot overstate how important I think it is, not only on its own terms
but also for what it might mean for America over the long run.
Yes.
Health Care Reform
Q. Does anybody really know whether this will work, from the
administration? Have you parsed the numbers that fine, that you can say
if this is passed in toto, it will indeed do what you say, cut costs,
maintain quality of care, cover everybody?
The President. We know it will do that, but that's not exactly what
you asked. That is, we know that if this plan is adopted, it will
provide universal coverage, that it will achieve substantial savings in
many areas where there is massive waste.
Dr. Koop, who was, you know, President Reagan's Surgeon General, who
was with us yesterday, and the doctors that we had, said that in his
judgment, there was at least $200 billion of waste, unnecessary
procedures, administrative waste, fraudulent churning of the system, at
least, in our system. So, we know that those things will achieve those
objectives? We do. Do we know that every last dollar is accurate, or
that there will be no unintended consequences, or that the timetable is
precisely right? No we don't know that because nobody can know that
exactly.
But I would like to make two points. Number one, our administration
has gone further to get good health care numbers than anyone ever has
before. Until I became President I didn't know this, but the various
Agencies in the Federal Government responsible for various parts of
health care financing and regulation had never had their experts sit
down in the same room together and agree on the same set of numbers and
the same methodologies for achieving them. So that's the first thing we
did. No wonder we had so much fight over what something was going to
cost and the deficit was going crazy. The Government had never gotten
its own act together.
[[Page 1829]]
Then the second thing we did was to go out and solicit outside
actuaries from private sector firms who made a living evaluating the
cost of health care and asked them to review our numbers. Now, that is
very important that you understand that, because there is going to be--
there should be a debate over whether the course I have recommended is
the best course to achieve the goals we all want to achieve, whether
there is a better course, whether we can achieve the Medicare and
Medicaid cuts that we say we can achieve without hurting the quality of
care. That's fine. But I want you to understand that we really have
killed ourselves at least to get the arithmetic right, to give people an
honest starting point, a common ground to start from, so that we can
have the arguments over policy.
Yes, sir.
Q. Do you feel that your plan places undue hardship on business with
the employer mandate versus an individual plan that has been proposed
with other proposals?
The President. No, and I'll say why. First of all, let's just look
at the employer mandate. Most employers cover their employees. I like
your question in the sense that the question assumes that we should have
universal coverage, and that's a good assumption. If you don't have
universal coverage, you can never really slow the rate of waste in cost,
because you'll always have a lot of cost shifting in the system. That
is, people who aren't covered will still get health care, but they'll
get it when it's too late, too expensive, somebody else will pay the
bill, and it will have real inefficiencies and distortions, as it does
today.
If you want to cover everybody, there are essentially three ways to
do it. You can do it the way Canada does. You can abolish all private
health insurance premiums, raise taxes to replace the health insurance
premiums, and have a single-payer system, just have the Government do
it. That's the most administratively efficient. That is, the Canadian
system has very low administrative costs, even lower than Germany and
Japan. The problem is, it's not very good for controlling costs in other
ways, because the Government makes all the cost decisions. The citizens
know they've already paid for this through government. So they make real
demands on the system. Whereas if you have a mixed system where
employers and employees are actually in there knowing what they're
spending on health care and lobbying for better management and to
control costs, like in Germany, you don't have costs go up as fast. So
the Canadian system, even though it's administratively the cheapest, is
the second most expensive in the world. We're spending 14 percent of our
income; they're spending 10 percent of theirs. Everybody else is under
9.
Now, the second system is the individual mandate. It's never been
tried anywhere. The problem with the individual mandate is that it
could--and again, I want a debate on this. I think the Republicans are
entitled to their day in court on this, and I want them to have it.
Really, I do. I mean, I want an honest, open discussion on this. I am so
impressed with the spirit that is pervading this health insurance--we
had 400 Members of Congress show up for 2 days at our health care
university just trying to get everybody to have enough information to be
singing out of the same hymnal when we talk to one another.
The dangers of the individual mandates are that it could cause the
present system we have for most Americans, which is working well for
most Americans, to disintegrate. That is, you have to have some
subsidies with an individual mandate. So will companies that now cover
their employees basically start covering their upper income employees or
not their lower income employees? Will they dump all their employees and
make them go under the individual mandate system? How are you going to
keep up with all these individuals when you realize who you've got to
subsidize or not? In other words, we believe it has significantly more
administrative burdens, and it has the potential to cause the present
system to come undone. But they deserve their day in court on it, and
we'll debate it.
Let me just say this. Our system for small businesses, I'd like to
make the following points: We propose to keep lower the premiums of
small businesses with fewer than 50 employees, including all those that
are just starting up. And they get more if their wages
[[Page 1830]]
of their employees are low, and low-wage workers also get a subsidy to
try to make sure nobody goes out of business. But the point I want to
make is, most small businesses who do cover their employees, and that's
the majority of them, are paying too much for their health insurance.
They are being burdened by it. That's one reason 100,000 Americans a
month permanently lose their health insurance, as well as at any given
time in a year, as many as one in four may be without it.
So what we propose to do will actually help more small businesses
than it will hurt. And over the long run, they'll all be better off,
because if you put everybody under this system, then the rate of
increase in health care costs will be much lower. And it's just not
fair, at some point, for anybody who can pay something to get a free
ride, because keep in mind, we all get health care in this country. But
if we're not insured, we get it when it's too late, too expensive.
Usually we show up at the emergency room, the most expensive of all, and
then somebody else pays the bill. That's one of the things that's
driving these costs out of sight.
Yes, sir.
Q. We've heard a lot about every group today, except for the
doctors. And from the doctors that I'm hearing from, they're saying that
this is going to hit them in their pockets. In my experience before in
being in operating rooms and seeing doctors after the diagnostic related
groups started setting some prices of procedures back in the eighties, a
lot of doctors that went into business for themselves were either multi-
using single-use items or resterilizing items that were made for single-
use so that they wouldn't lose any of the money that was going to be
coming to them, so they wouldn't take a personal hit out of it. How does
your plan guarantee us an uncompromised medical plan?
The President. Well, for one thing, the quality standards that
govern medical care today will still be in effect. That is, most of them
are professional standards, and they're not enforced by the Government
today.
Q. They're talking about doing more procedures to make up the money.
They're saying, ``Well, I'm going to have to see more patients and spend
less time with them.''
The President. Yes, but that's what's happening today. I mean, the
truth is that as we've tried to control the costs of Medicare and
Medicaid, particularly Medicare, by holding down costs, you see
dramatically increased numbers of procedures. What we want to do is to
remove the incentive for having large numbers of procedures by having
big blocks of consumers pay for their annual health care needs in a
block, so that you won't have so much fee-for-service.
I would also point out to you that one of the big problems we've had
with doctor costs going up is that doctors are having to negotiate their
way through the mine field of 1,500 separate health insurance companies
writing thousands of different policies, having to keep up with it in
ways that no doctors anywhere in the world but our doctors have to deal
with.
We've already had the American Academy of Family Practice and a lot
of other doctors groups have endorsed our plan. The AMA has been quite
interestingly supportive in general terms. They say they want to see all
the details. They believe there ought to be universal coverage. Dr. Koop
has agreed to come in and sort of moderate this discussion. But we had a
couple hundred doctors here yesterday, most of whom were extremely
supportive. And let me just give you one big reason why. This is the
flip side of the argument you made.
In 1980, the average doctor was taking home 75 percent of the money
generated by a clinic. In 1990, the average doctor was taking home 52
cents on the dollar, 52 percent of the money generated by a clinic.
Twenty-three cents on the dollar increase in the amount of money the
doctor was having to spend on people, basically to do clerical work in
the clinics.
The Children's Hospital at Washington told us last week that the 200
doctors on staff there spent enough time in non-health-care-related
paperwork every year because of the administrative cost of this system--
a dime on the dollar more than any other system in the world--to see
another 500 patients each a year, 10,000 more kids a year. So, a lot of
doctors are going to feel very liberated by this because they are going
to be freer to practice medicine, and the incentives to
[[Page 1831]]
churn the system just to pay for all their paperwork will be less.
Yes, sir.
Mr. Strauss. Time for one more question.
Q. I guess I have the opportunity, I'll make it a two-part question
because it's a rare opportunity, and I appreciate it. First of all, if
you receive everything that you want, that you're hoping for, and we
hear about the 37 million uninsured and the many underinsured people,
I'm wondering if there's anybody that will be disappointed with the new
system----
The President. Oh yeah.
Q. ----if you get everything you want, and who those people might
be? And secondly, I hear very little about medical fraud and medical
malpractice problems, as if it isn't a major problem, and we are led to
believe that it is.
The President. It is a big problem. Maybe I should answer that
question first, because it's a quicker one. Then let me try to tell you
how to sort through the winners and losers. Okay?
First of all, in this system if you put consumers of health care,
employers and employees, particularly the small businesses, in large
buying groups where they will have more market power and more oversight
authority, you will inevitably--we are going to change the economic
incentives as well as the private sector oversight to reduce fraud and
abuse--we are definitely going to see big savings there.
Secondly, what was the other thing you asked me?
Q. The medical malpractice.
The President. Medical malpractice. Doctors----
Q. Doctors spending--[inaudible]----
The President. Well, doctors----
Q. [Inaudible]
The President. One of the things that we don't know is how much
extra excess procedures and tests are done as defensive medicine or to
churn the system, to go back to your other question. The economic
incentives to churn the system will be dramatically reduced under these
kind of payment plans.
It will be more like the way the Rochester, New York, system works,
the way the Mayo Clinic system works. More and more people will be in a
system where they pay up front, and then they take what they need. And
the doctors are going to get paid out of that.
But the malpractice issue is a problem. We will propose some
significant reforms, including limiting the percentage of income lawyers
can get in contingency fees in lawsuits. But I have to tell you, what I
think the most significant--and alternative dispute resolution
mechanisms--but I think the most important one will be permitting the
professional associations to draw up medical practice guidelines which,
when approved, will protect the doctors to some extent, because if they
follow the guidelines in any given case, it will raise a presumption
that they weren't negligent. And that will be a real protection against
just doing an extra procedure because you're trying to hedge against a
lawsuit.
The State of Maine pioneered this because they wanted more general
practitioners in rural Maine to do more things for people like help
deliver babies because they didn't have anybody else to do it. So, the
idea of giving people practice guidelines I think is very good.
Now, you asked who's going to win and who's going to lose. Can we
talk through that?
Q. Yes, sir.
The President. I'll tell you who will have to pay more. You know,
there will be some people who will have to pay more. The news magazines
this week did a pretty good job of analyzing this.
If we go to community rating, so that we can allow people, for
example, who have had a sick child not to be bankrupt by their insurance
costs and to move from job to job, and you put everybody in a broad
community, it means young, single, super healthy people will pay more in
the first year of this than they would have otherwise. Now, here's why I
think that's a good deal for young, single, super healthy people. Number
one, all young, single, super healthy people will get insured, and they
aren't now. Number two, they'll all be middle-aged someday, too, and
they'll win big. Number three, their cost will go up less every year. So
even though they might pay more this year, within 5 to 8 years, if this
plan goes through, everybody will be
[[Page 1832]]
paying less than they would have. So, they would pay more.
Secondly, there are some businesses who don't insure at all. They'll
have to pay something. There are others who insure but only for
catastrophic. They will have to pay more, but they'll get much better
benefits, and their rates will go up less. So, there will be some people
who will pay more now than they were paying. But I believe that if we
can--keep in mind, if we can stop the cost of health care from going up
at 2 and 3 times the rate of inflation, if we can get it down where the
rate of increase is much lower, by the end of the decade everybody will
be way better off than they were.
Russia
Q. Mr. President do you approve of--Boris Yeltsin's announcement
that he's going to dissolve the Parliament, and does the United States
support him in his power struggle with his opponents?
The President. Well, first of all, let me say I have had only a
sketchy briefing about this, and I have not talked to President Yeltsin
yet. I would like to reserve the right to issue a statement after I
attempt to talk to President Yeltsin. In any case, I will issue a
statement before the end of the day, but I think at least I should have
a direct briefing.
Yes sir, one more. Go ahead.
Health Care Reform
Q. President Clinton, tomorrow you'll be speaking before a joint
session of Congress and there are 535 people, individuals, in Congress
that will have their own specific plans of what they want----
The President. Yes.
Q. If you could say that you could put your name on one or two or
three specific parts of this that you want to say, ``This is my health
care plan,'' that you want to see no matter what 535 other people want
to see, that you feel you want to be part of your Clinton health care
program, what two or three items, specifically?
The President. Number one, every American would have security in
their health care system. You would be able to get health insurance,
there would be adequate benefits, and you wouldn't lose them. Number
two, the system would impose a far higher level of responsibility for
managing costs than it does now on all the players, including the
consumers. Number three, people would keep their choice of physicians
and medical providers. And number four, we would guarantee adequate
access to preventive and primary care so we could stop some of the big
things that are happening to us before they get going. And five, we
would have market incentives to bring costs down. Those are the things
that I want to be the hallmark of our program.
I wish I could stay all day. I'm sorry, but thank you very much.
Note: The President spoke at 3:06 p.m. in Room 450 of the Old Executive
Office Building. Richard Strauss is the White House radio services
coordinator.