Weekly Compilation of Presidential Documents Volume 30 Issue 15 (Monday, April 18, 1994)

[Weekly Compilation of Presidential Documents Volume 30, Number 15 (Monday, April 18, 1994)]
[Pages 754-768]
[Online from the Government Publishing Office, www.gpo.gov]

<R04>
Remarks in a Town Meeting in Minneapolis

April 8, 1994

Angela Astore. Welcome to the Twin Cities and our town hall meeting.
And thank you for this unique opportunity to answer questions about your
health care program.
The President. Well, thank you for giving me the chance to do it.
And I want to thank the people who are joining us from Milwaukee and
Detroit and Sioux Falls, too.
Ms. Astore. We'd like you to start off the program perhaps with some
opening remarks.
The President. I'll do that.
Randy Meier. We turn it over to you.
The President. Thank you.
First, let me say, I came here to Minneapolis late last night, and I
started the day off with a rally for health care sponsored by the Nurses
Association of Minnesota. Over 2 million nurses in the American Nurses
Association have endorsed our health care plan. And that's especially
important to me because I started out my interest in health care because
my mother was a nurse. And then many years ago when I started out in
public life, I was an attorney general, and one of my jobs was to try to
ensure good care within our nursing home system in my State. Then as a
Governor, I had to worry about health care for the poor through the
Medicaid program, something Minnesota and every other State has wrestled
with.
About 4 years ago, a long time before I even thought I'd be running
for President, I agreed to take a look at the health care system for the
Nation's Governors to see what we could do about it. And at that time, I
talked to literally 900 health care providers, doctors, nurses, hospital
administrators, paramedical workers of all kinds, and a lot of business
people and health care consumers, people in every kind of medical
problem you can imagine. I became convinced then that unless we had a
national solution to a lot of our health care problems, we wouldn't be
able to solve them; that no State, even the most progressive State,
could solve all the problems of the health care system without a
national solution.
And let me just briefly say what I think the issues are, and a lot
of them will be represented by people who are in our four audiences
tonight. First of all, 39 million Americans don't have health insurance
at all, ever, during the year. And about another 100,000 a month are
losing their health insurance permanently. Secondly, at any given time
in this Nation of about 260 million people, 58 million people won't have
health insurance at some time during the year. Third--and it gets worse
as we go along here--about 81 million of us live in families with so-
called preexisting conditions, a child with diabetes, a mother with
cancer, a father who had a heart attack early but still had to go back
to work. Those families either can't get insurance, pay very high rates,
or can never change their jobs because if they change jobs, they won't
be able to get insurance in their new jobs. Fourth, small business
people and self-employed people who have health insur-

[[Page 755]]

ance pay on the average 35 percent more than those of us who are insured
who are Government workers or who work for bigger business. And 133
million of us have health insurance policies with lifetime limits, which
means that if someone in our family should get real sick, we could run
out of our insurance just at the time we need it the most.
In addition to that, we're spending 40 to 50 percent more of our
national income on health care than any other country in the world. The
cost of health care to State government and to the Federal Government is
exploding at 2 and 3 times the rate of inflation. All the things I'd
like to do for you as President, in terms of investing more in education
and training and new technologies for the 21st century, are limited by
how much we have to put into health care every year to pay more for the
same health care.
There are lots of other problems. We have tens of millions of
Americans with disabilities--some of them are here--who could work, who
could be self-supporting, who get no help for long-term care in their
homes and who can't get health insurance if they go to work. We have
older people on Medicare who need help with their medical bills. And if
they could get medicine, they could stay out of hospitals and save us
money and have a better quality of life, but that's not covered. So the
question is, what are we going to do about this? Let me very briefly
tell you what I think we should do; then we'll open the floor to
questions.
First of all, I'm convinced that we can't solve any of our problems
until we deal with the basic one. We can no longer be the only advanced
country in the world that doesn't provide health care security to all of
our citizens all of the time. If you want to do that, there are only two
ways to do it. You either have to have a system where you get rid of
insurance all together and have the Government fund it, the way Canada
does, or you have to have a system of guaranteed insurance, the way
Germany does and several other countries. I advocate--and I'll explain
why later--I think we should have a system of guaranteed private
insurance with comprehensive benefits, including primary and preventive
care which saves a lot of money in the long run, with no lifetime
limits, and insurance that you can't lose.
I believe that our system should maintain something that's very
important to Americans, which is the choice of doctors and health care
plans. More and more Americans are insured in plans that deprive them of
any choice of their doctors, and that can be a serious problem. I
believe there are ways to control costs and protect choice. Our plan
would guarantee you at least three choices every year.
Third, we have to change insurance practices. We have to make it
illegal for people to have their coverage dropped or benefits cut, for
rates to be increased just because there's someone in the family with a
preexisting condition who's been sick, for lifetime limits to cut off
benefits, or for people who are older to be charged more. This is a big
deal. The average person's going to change jobs eight times in a
lifetime. A lot of people are losing their jobs in their fifties and
sixties and have to get new jobs and can't get jobs because no one will
give them insurance because their rates are higher.
Fourth, I want to preserve Medicare, which keeps the choice of
doctors. But I also want to have Medicare begin to cover prescription
drugs, which it doesn't now, and phase in a long-term care program not
only for the elderly but for Americans with disabilities.
Finally, I think these health benefits should be guaranteed in
private insurance at work. Why? Because it's the simplest way to get to
universal coverage from where we are now. Nine out of ten Americans with
private health insurance are insured through the workplace. Eight out of
ten Americans who don't have any insurance at all are in working
families. So the simplest way to cover this is to say the employed
uninsured should have their insurance paid for by the employers and the
employees. The Government should pay for the unemployed uninsured and
should raise a pool of money to provide discounts to small businesses
who otherwise couldn't afford health insurance. That's essentially our
plan: guarantee private insurance, choice of the doctor, reform
insurance procedures, preserve Medicare, have health benefits guaranteed
at work.

[[Page 756]]

One last thing--you have to find a way if you want to reform the
insurance practices to make it possible for insurance companies to do
these things, which means they have to insure all of us in very large
pools. And we have to let small business people and self-employed people
band together in co-ops so they can bargain for the same good prices
that those of us who are insured through big businesses or Government
get. That's essentially what we're trying to do in the Congress this
year.
Ms. Astore. Mr. President, we're going to start with a couple of
questions from our Twin Cities audience.

[Mr. Meier introduced a participant who asked for the philosophical
arguments in support of the President's plan.]

The President. Well, compassion is part of my philosophy. But
anyway, philosophically, I don't believe the Government can solve all
the problems for people, and I don't think you should rob people of
their personal responsibilities or their personal choice. That's why I
don't have a Government-run plan. It's private insurance. And people who
don't have insurance have the responsibility to provide it for
themselves.
But I believe philosophically it is wrong for people not to assume
responsibilities for themselves and let other people do it. And what's
happening today--let me just give you two examples. Self-employed person
X decides, ``Well, I'm not going to have any insurance.'' Then they get
in a wreck; they show up at the emergency room; they can't pay. They
could have had insurance, but they didn't do it. That's fine for them,
except they get the care. Nobody lets them die, and nobody thinks they
should. And then the rest of us pay for it. And that is irresponsible.
Another example: Restaurant X and restaurant Y next together; one covers
the employees, the other doesn't. One is fulfilling a responsibility not
only to himself and the employees but to the rest of society by not
asking us to bear the risk of anybody getting sick; the other isn't. The
other has a competitive advantage in business. I don't think that's
right.
And the system we have is not an individual responsibility system,
it's an irresponsibility system. I don't plan to take over the health
care system. I don't want the Government to run it. I think the
Government should help to organize the markets so that small business
people and self-employed people can afford to have insurance and so that
they are not disadvantaged as compared with big business and Government.
And I think it is irresponsible for people not to provide for their own
health care and irresponsible for the Government not to make it possible
for people to do it no matter what their station in life.

[Ms. Astore introduced a participant who asked if the plan was really
about control of health care rather than better service.]

The President. Well, let me try to answer 2 or 3 of those questions;
you asked me 10 at once so--[laughter]. The only real tax we have in
this plan--we have to raise funds to pay for the unemployed uninsured,
which we're all paying for anyway, folks. When they get sick, they wait
until it's too late, it's too expensive. They show up at the emergency
room, and we pay. Under our plan we would raise a fund to pay for them
and to pay for the discounts on small business from two sources, one, a
tax on cigarettes, and the other, a modest assessment on the biggest
American companies that will get the biggest windfall from this. That
is, most big companies are paying way too much in insurance now to
subsidize the rest of us. They'll get a windfall. We ask for a portion
of that back to create a fund for discounts for small business and for
the unemployed uninsured.
There will be more choice under our plan. This idea that every
American today has a choice of doctors is a myth. More than half the
American people who are insured in the workplace today don't have a
choice. They get one plan and that's it. Ninety percent of the American
people who are insured in small businesses with 25 or fewer employees
have no choice. Under our plan there will be more choices. That's one of
the reasons why so many medical groups have endorsed this plan, not just
the nurses but the family practitioners, the pediatricians. Any number
of other medical groups have endorsed our plan because they know it
guarantees more choice.

[[Page 757]]

Now, if you have a plan today that is better than the one in our
bill, you can keep it. In other words, if you have a plan today where
your employer pays 100 percent of your health insurance, not 80 percent,
and you continue to do that, that's perfectly alright. We don't change
that at all.
Q. [Inaudible]--individual when you go for universal coverage. If I
already have a policy, isn't it true that it will cost people that now
pay for insurance more?
The President. No, if you don't pay your premium, if your employer
pays all of your insurance now----
Q. They don't pay all of my insurance; I carry family coverage.
The President. Well, the question is whether it will cost you more.
It depends on a lot of factors. In all probability, you won't. Not our
studies but all the nonpartisan studies that have been done show that
more than half the people will get the same or better insurance for the
same or lower cost.
By and large, the people who will pay more are people who aren't
paying anything now, people who have only very bare-bones coverage now.
And young single workers will pay more so that older people can pay less
and we can have a large community rating. Otherwise, most other people
will pay the same or less.
But if you have a better plan than we require, what this does is put
a floor under you. We've got--keep in mind--I don't know where--you
know, I understand; I saw those ads putting out all that propaganda,
``This is just politics, this is just a power play,'' and all that. Tell
that to these people who are disabled who can't get insurance. Tell that
to these old people who choose between medicine and food every month.
Tell that to the 100,000 Americans a month who lose their health
insurance. Tell that to the farmers and the small business people who
insure at 35 and 40 percent higher rates. I mean, this is a bunch of
hooey. If people don't agree with me, let them come forward and contest
me with their ideas. But I am sick and I think a lot of you must be sick
of all this hot air rhetoric and all these pay television ads and all
these hit jobs from people who are making a killing from the insurance
business that we have today. It is wrong, and we should change it.
Let me just tell you something, I don't go around--I don't mind
doing this; I'll do this all night. But it never gets--one of the things
I've learned in 20 years of public life is you don't get very far
questioning other people's motives. Most people I've met--contrary to
what you read, most of the people I've met in public life are honest,
well-meaning. They're not crooks, and they're trying to do the right
thing. We have differences of opinion. But this health care debate, in
my judgment, has really been retarded, in more ways than one--
[laughter]--by all this motive throwing around we've had. If I had
wanted to take on a tough issue, I could have found something else to do
with my time. I believe we have to do this. And if we don't do it,
you're going to have more people without insurance, more people that
can't afford what they've got, and a terrible situation in this country.
And that's why I did it. That doesn't mean I'm right, but let's argue
about what should or shouldn't be done and not talk about other people's
motives. I've even tried to convince the insurance industry I don't want
to attack their motives. I just want us to argue about what we should
do.
Mr. Meier. Mr. President, I want to direct you to this side of the
floor where you can look at that large monitor. I want to give our live
satellite audiences a chance to join in. Let's go first to WDIV-TV in
Detroit and Carmen Harlan.
Carmen Harlan. Thank you, Randy. They were living the American
dream. The Bertolones had two healthy children, a nice home, and their
own business. But in a matter of months, their dream life changed.

[At this point, a videotape was shown about the family's efforts to
obtain their insurance company's approval for treatment for Mrs.
Bertolone's breast cancer. Ms. Harlan made comments during the film and
then introduced Mr. Bertolone.]

Q. My wife had advanced breast cancer. She was told by a leading
bone marrow transplant unit in the country that they had a 25 percent
chance of prolonged life extension if she would receive the transplant.
Our insurance company deemed the procedure ex-

[[Page 758]]

perimental and would not cover the expense. Would women in a similar
situation be told the same under your health care plan?
The President. It's an issue I'm very familiar with. As you may
know, my mother had breast cancer, and so I've learned a lot about this
issue. What we would cover under this health care plan--transplants of
all kinds as long as the doctors thought it was an appropriate
procedure.
Now, there are some people who still believe bone marrow transplants
for breast cancer are experimental, although there's a lot of evidence
that it can prolong life among younger women, especially women 50 and
under. And the truth is that it will depend upon the doctor's belief
that it should be the appropriate course of medical care. But what we're
trying to do is to give these decisions back to doctors and their
patients who believe it's an appropriate course of medical care. And I
think that it is clear that we're moving to the point where most
physicians believe that there are circumstances under which it is an
appropriate thing to do to give women with breast cancer bone marrow
transplants.
But I'm not trying to give you an evasive answer, I'm trying to give
you the standard that will be used in the insurance policy, is it
appropriate medical care? Will the doctor believe that? I think that
more and more doctors do believe that, so in most cases I think you can
look forward to that kind of procedure being covered.
Thank you.
Ms. Astore. Let's bring the audience in Milwaukee into the
discussion now.

[The Milwaukee, WI, moderator introduced a participant who asked about
premium increases and the cost effectiveness of requiring a referral for
coverage of a visit to a specialist.]

The President. Well, first of all, let me say that a lot of that
referral business is probably because of requirements that the insurance
companies have put on the doctors treating this lady. If you talk to any
doctor, they'll tell you that more and more and more, they're having to
call insurance companies and get permission to practice medicine in
advance of doing what they think has to be done anyway. Last night I was
down in Kansas City, and I had three doctors in our group there, and
that's all they talked about was how much time they were spending
getting the approval of insurance companies to do what they knew to do
anyway.
You talked about how much your insurance had gone up. Let me say,
one of the best things about having a national reform is that you can
charge people the same price for an individual policy and a higher price
for a family policy, but you would pay that price even if you had to use
the doctor enough. That's what insurance used to be. I mean, when Blue
Cross first got organized, everybody was lumped in a great big pool,
everybody paid the same amount. Some people got sick, and the rest of us
paid for that as well, as a hedge against ourselves getting sick. Now we
have 1,500 separate insurance companies, thousands of different
policies, hundreds of thousands of people working in doctors' offices
and hospitals and insurance offices figuring out who's not covered for
what. So if you're in a little pool--and this lady, you heard what she
said, she has an illness--your rates can go way up. If we're all insured
in large pools, then your rates would not go up unduly--just more or
less at the rate of inflation--just because you had an illness. That's
one of the--this woman would be dramatically advantaged if we had
national insurance reform--health care reform.

[Mr. Meier introduced a participant who suggested combining the best
parts of the Canadian and German health care systems.]

The President. Well, that's kind of what we're trying to do. The
Canadian system--in Minnesota, for example, where you're close to
Canada, or in Michigan or any of the States that are in our program
tonight, there are a lot of people who would like to see the single-
payer system that the Canadians have.
The problem is twofold. One is, it would be very difficult to get
Congress to agree, in effect, to put all the health insurance business
in America out of business and substitute it with a tax. And a lot of
people like the lady who asked the second question here would wonder
what that would do to their

[[Page 759]]

health care plans. Secondly, the Canadian system, in my judgment, has
not had quite as much success at controlling costs as the German system
has, where all the people pay something, assume some responsibility
directly for their health care, and therefore negotiate more vigorously
on an ongoing basis to try to hold down the costs of health care.
But let me say from my point of view, sir, to you, there are lots of
people in America who are HIV positive who could be working, who could
be making a contribution and paying taxes, who have difficulty doing
that because they can't get health insurance. But if they were insured
in very large pools, they would be able to do so. So I think that one of
the most important beneficiaries of this policy will be people who have
very serious illnesses that still may permit them to work for long
periods of time and be active if they can provide for their own health
care needs.
Ms. Astore. Thank you, Milwaukee. We have one more live location to
bring into our town hall meeting tonight on health care.

[The Sioux Falls, SD, moderator introduced a participant who asked about
coverage for services by nontraditional medical practitioners.]

The President. Well, what we do in the health care plan is to
require certain kinds of care to be covered. And then that care can be
provided in a variety of different ways by anybody who is qualified to
provide it. What will happen is that the people who band together in
these purchasing alliances will be given any number of choices from
which the consumers of health care can choose what kind of health care
plan they want. So all consumers will have the option, if they wish, to
choose plans that have different kinds of providers, including
alternative providers, as you mentioned, to provide various health
services. We have to have--everybody by law has a right to have three
different kinds of plans, kinds of plans. But what you'll have in most
places is the kind of choices that now, for example, Federal employees
have. You know, a lot of Federal employees can choose between two dozen
different plans. It's amazing. And as a consequence of that you have all
different kinds of options, and a lot of providers, including
chiropractors, have a chance to provide services to people. That's the
way ours would be set up.
Let me go right to the heart of the question because I've got a lot
of friends who are chiropractors who have asked me this. We do not
specify in the bill as it is presently drawn the services of
chiropractors, osteopaths, nurse practitioners, or neurosurgeons for
that matter. What we do instead is say, here are the kinds of health
care services that have to be offered, let people organize themselves
and offer them to the consumers of America.

[Mr. Meier introduced a participant who asked how the plan would address
increased costs related to malpractice.]

The President. Our plan does that in two ways. Let me also mention,
since we're talking to South Dakota and you've got a lot of rural
population, although we do here in Minnesota, too, and in Michigan, the
other States that are represented and in Wisconsin, another big problem
that we have in my rural State where I'm from is that more and more
general practitioners out in the country are reluctant to do things like
deliver babies and set simple fractures because of the malpractice
problems.
Our bill does two things. One is it sets a limit on the percentage
of a malpractice judgment that can be taken by a lawyer, a percentage of
the contingency fee. The second thing it does, which I am convinced will
have a far more positive impact on insurance rates, is it sets up a
system in which the professional associations set up medical practice
guidelines for various kinds of cases. And then if the physicians can
demonstrate that they follow the guidelines, there is a presumption that
the physician was not negligent.
Now, that presumption can be overcome, but it is much harder. And if
that happens, we believe that there will be a substantial reduction in
the number of frivolous cases in the malpractice area and therefore
malpractice insurance rates will go down.
That's been tried in a rural State, Maine, with some considerable
success. And I think that it's the best way to go to guarantee lower
malpractice fees and still give people a right

[[Page 760]]

to go into court when they've genuinely got a gripe.

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

Ms. Astore. Welcome back everyone to ``Health Care in the
Heartland,'' our town hall meeting in the Twin Cities with the
President.

[Mr. Meier introduced a videotape about a person's loss of health
insurance. A participant then asked about insurance portability and the
effect of economic changes and profitability of companies on the funding
of the plan.]

The President. Thank you very much. You know, this is so
interesting. Of all these forums that I've done, you're the first person
that's asked me that question. And let me try to explain how it would
work.
First of all, under our plan, companies would be free to self-insure
if they were above a certain size. We now have 5,000 and above. There
are some in Congress who think it should be smaller. But what we have is
complete portability of benefits so that no family can ever be without
benefits. So that if your company goes down and you don't have another
job, you just carry your benefits. And for the period in which you're
between jobs, this reserve fund that I talked about that we'll set up--
the Government basically would provide the reserve to guarantee that
your coverage would continue just as if you were still working at the
other company. So you would not have been put in the position that
you're in now. And it's very important. In addition to people who are in
the position that you're in, where your company went broke and you got
left with all those bills, there are an awful lot of people who just
want to change jobs, but they have to wait for months and months and
months, even after they change jobs, before they actually get coverage.
So this is a big issue. We need to guarantee--the term of art is
portability--complete portability of policies through jobs and through
employers. And our system would provide that.
Thank you.

[Ms. Astore introduced a participant who asked about health benefits for
immigrants.]

The President. Most of those folks, even with very limited English
capacity, have jobs. So they would get at the job site a card, a health
care card, just like everyone else, which they then would be able to
present to their doctor. They would have the opportunity either at work
or at a local health clinic to have explained to them what their choices
are of the health care plan, and then they would just--they wouldn't
have to keep up with a lot of paper or anything, just one card for the
family that they could present at the health care clinic when they
needed it or at the hospital. So I think that's the way it will work.
Now, in many places where there are a very large number of people
whose first language is not English, we will have to expand the outreach
activities of the public health clinics for people who are not employed
and where there's no one in the family who is employed. And we
understand that we're going to have to do that and make some provision
for doing that.
Thank you.
Mr. Meier. Mr. President, we're going to join our satellite audience
one more time in Detroit and station WDIV.

[The Detroit, MI, moderator introduced a participant who asked about
prescription drug coverage outside of Medicare.]

The President. Under our plan, every health policy would have to
have a prescription drug component which would have the following
characteristics. There would be a $250 deductible. In other words, you
have to spend up to $250 of your own money on medicine before it would
trigger in. And then after that, every prescription would require a 20
percent co-pay. But there would be a ceiling beyond which you could not
spend; it's about $1,000. If your expenditures were over $1,000 a year,
then the insurance policy would cover all the prescription drugs that
your doctor would require and that your health would require.
So it's a pretty good policy because--now, if you have a better
policy now, you can keep it. Keep in mind, if the coverage is better
now, you can keep it. But almost no one has coverage that good today in
their health care policy for prescription drugs. And there are

[[Page 761]]

a lot of national studies which show that the adequate provision of
prescription medicine can actually save money by reducing hospital stays
and emergency room visits.

[Ms. Astore introduced a participant who asked if the President knew
about the community health center system in Ontario, Canada.]

The President. I think that one of the things that will happen if we
pass this bill is that you will have more and more health care provided
in that way by community-based clinics or comprehensive health centers
that have salaried professionals, including doctors. Interestingly
enough, we're here in Minneapolis; that's what you have at the Mayo
Clinic, right? Everybody concedes that there is no finer health care in
the world. And yet I have many people who have been patients at the Mayo
Clinic tell me that it is less expensive than what they paid back home
for other kinds of care.
So I think that you will see a lot more of that in this country once
the health insurance market is organized so that people know they will
always be reimbursed for the services they provide. That then permits
people to organize these kinds of associations and know that they'll be
able to run them without going broke, because they know they'll always
have reimbursement.

[The Milwaukee moderator introduced a doctor and showed a videotape
about his clinic. The doctor then asked if the President supported
community health centers.]

The President. Yes, I do, not only for the reasons we just saw in
the fine practice that you have but because the community health centers
are increasingly providing services to large numbers of people who used
to not use them at all. For example, in many of the southern States of
this country, including mine, over 80 percent of all the children in the
States get their immunizations through community health centers, because
a lot of regular doctor's offices don't do it anymore because of the
malpractice problems that were mentioned earlier. So I think it's very
important. And our plan has a special provision for funding community
health centers at a higher level to try to make sure that these kind of
comprehensive services can be provided.
And let me emphasize, too, that in the inner city and in rural
areas--we've got South Dakota here, remember, on this television
program--if it weren't for community health centers there would be no
access to health care, so that people might have insurance but they
still wouldn't have any place to go with their insurance. So it's very
important.
Thank you for practicing there.

[Mr. Meier introduced a participant who questioned the cigarette tax.]

The President. Well, as I said, first of all, let me say if I could
figure out how to get enough savings out of this program to pay for it
without any tax, that's what I would do. We are going to get dramatic
savings out of this program, mostly by having a single form, simpler
administration, which will save the taxpayers a lot of money, and those
of you who aren't taxpayers who have private insurance, by drastically
cutting the amount of administrative overhead in the system.
We cannot, however, provide enough money to do the things that we've
been discussing without raising some money. Obviously, I think it is
fair to ask the companies that will have the biggest drop in their
insurance premiums to give a small portion of that to the fund for small
business discounts and for unemployed people.
The reason I think that the cigarette tax is a legitimate place to
get funds is that cigarette smoking is the only activity we know of in
our society that there is no known safe margin for doing. That is, it's
not like alcoholic consumption where, if you're not prone to be an
alcoholic, there are safe margins of consumption. We know of no safe
measure of smoking. And we also know that several thousand people a year
get lung cancer from subsidiary exposure to smoke, when they don't do it
themselves. We also know that our society bears a health care burden and
cost as a result of the health care consequences of smoking far in
excess of the money raised from the cigarette tax. So for all those
reasons, I thought since we had to raise some money, that was the
fairest way to do it.

[[Page 762]]

[Following a commercial break, the Sioux Falls, SD, moderator presented
a videotape on rural health issues and then introduced a farmer who
asked about organ transplants.]

The President. Yes, sir. We support transplants, as I said, let me
restate--particularly organ transplants. We support transplants when
they are the recommended medical procedure, and we try to provide ways
to make sure that we facilitate that.
Now, let me also say to you since you were introduced in a slightly
different way--as a farmer who's self-employed, who has already had a
medical problem, who has folks working for you on the farm--farmers, in
my opinion, may be the biggest winner in the proposed reform we have
because today, believe it or not, self-employed people who buy health
insurance, number one, pay exorbitant rates anyway because they're not
in big pools. If they've been sick, they pay lots more. And if you're
self-employed, you can only deduct 25 percent of your cost of the
premium from your income taxes, whereas a business can deduct 100
percent.
Under our plan, you'd be able to buy on an equal basis with others
in a much bigger pool, and you would be able to deduct 100 percent of
your self-employed premium. Which means in almost every case in the
country, farmers would be able to insure their farm hands for the time
they work for them and their families for less than they're paying just
for family insurance today. And you certainly would, because of your
preexisting condition.
But let me just say this, I will try to get some more information on
the specific question you asked me about encouraging and organizing the
whole market for transplants. And I will make sure that we get back to
you in the next day or two with a more specific answer to your question.

[The Sioux Falls moderator introduced a participant who asked about the
development of a small town infrastructure.]

The President. Yes, I'd like to talk about that a little bit. And
I'd like to say, first of all, my wife had a wonderful time out there.
And I want to thank Senator Daschle for doing such a good job and
working on this rural health care issue.
Let me try to explain how this would work, and let me say for the
rest of you, a lot of people who live in small towns in rural areas
don't even have a doctor in their town anymore. I met in rural North
Carolina earlier this week a doctor who told me she was working 110
hours a week and had been for several weeks, but she had just come to
her slow season when she could work 80 hours a week. Now, that's a
doctor who's going to need a doctor pretty soon, right? [Laughter]
Here's what we try to do. Let me briefly run through the things that
are in this plan for rural areas: Number one, revive the national health
service corps where young doctors can pay for their medical education,
which normally leaves them with a big debt, by serving in underserved
areas; 7,000 doctors over the next few years doing that. Number two,
give doctors and other health care providers who go into underserved
areas significant income tax credits as incentives to do it, $1,000 a
month for doctors, $500 a month for nurses and other medical
professionals for up to 5 years; that's a huge incentive. Number three,
give doctors faster write-offs, tax write-offs, when they buy modern
equipment to put into their clinics in rural areas. And number four,
make sure that we've got the technology, the computer technology to
connect rural clinics with urban medical centers, so doctors can feel
good about the quality of their practice when they're out there and feel
like they're giving their patients the kind of care they need. Those are
the things that we think will get a lot more doctors and nurses and
others into rural America and make a big difference.

[The Sioux Falls moderator introduced a participant who asked about
reimbursement for rural providers under Medicare and Medicaid.]

The President. Well, for one thing, Medicare and Medicaid are going
up right now at 2 and 3 times the rate of inflation, by far more than
inflation and population growth, because primarily of the way the
Medicaid program is organized. Under our plan, Medicaid recipients would
be put into big insurance pools along with small business people, self-
employed people, and larger business people. In other words, they'd be
put in these

[[Page 763]]

big community pools. And doctors, for the first time, would be
reimbursed at the same rate, whether or not they had a Medicaid patient
or someone who was privately insured. It would be exactly the same
reimbursement. And that would make a huge difference to the physicians.
And how would we do that and still save money? Because you'll have
competition, you'll have managed competition, which we've seen already
in Minnesota with the work that's been done here. You've had dramatic
drop-off in the increase in medical costs here as people have organized
themselves into larger groups.
Secondly, under Medicare, we leave it the way it is because so many
of the people that I have talked to at AARP and the other groups believe
Medicare works and want it left alone. But we do add a prescription drug
benefit, and we add a long-term care benefit.
How will rural doctors be able to deal with this? They won't have
any more uncompensated care. One of the things that makes Medicare and
Medicaid a bigger burden in rural areas is there are an awful lot of
uncompensated care in rural areas. Now doctors will be paid something by
everybody they treat. And I believe that that will make a big difference
to the quality and rewards of the practice of medicine in rural areas.
We can save this money, to go back to your question, by the way we
organize the health care markets and by making sure that everybody is
reimbursed for all the services that are provided. Then we'll be able to
lower the rate of inflation.
Keep in mind, we don't propose to cut Medicare and Medicaid, ma'am.
Medicare and Medicaid under our proposal would go up at twice the rate
of inflation, instead of 3 times the rate of inflation, which it's going
to do if we don't pass national health care reform.

[Ms. Astore introduced a participant who asked about coverage for mental
health care.]

The President. Yes, it is a very important part of health care
reform. Under our plan, some mental health benefits would be included
from the beginning of national health reform. That is, whenever--all the
States would have until the end of '97 to provide universal coverage.
Each State would have that time. From the beginning of the time
everybody was covered, there would be significant mental health
benefits, much more than most people have under their policies today,
both inpatient and outpatient care.
There would not, however, be complete parity. And if you're
interested in mental health, you know--parity between the mental health
benefits and the physical health benefits until the year 2000. And
that's because we don't have accurate cost estimates on how much it will
cost, and we have to phase it in. To go back to what some other people
had said earlier, we have to know that when we put these things in, that
we can pay for them and we're not going to cost the Treasury more than
we have.
But there will be quite a significant mental health benefit from the
very beginning and much more than most people have today. I think it's
very important. I think it's one of the best things about our plan, and
I personally believe it will make us a healthier country and will cut
down on long-term medical costs if we have proper kind of mental health.

[Mr. Meier introduced a participant who asked about the plan's effect on
the present Minnesota Care health plan.]

The President. No, you won't lose money because--and I commend what
you've done; I think it's important. But you won't lose money. We
estimate that both private insurers and the Government will save money
if we go on with national health care reform. And what will happen is if
we have the national plan, we'll be able to do some things that at least
you're not now doing.
First, everybody will be able to be insured. And secondly, in
addition to holding costs down, we'll be able to hold costs down with
more choices for health care consumers than you're going to be able to
provide unless we have a national plan which reorganizes the insurance
markets. So my judgment is you'd be--I would urge you to keep going with
your reforms here, to do the best you can and go full out until the
Congress acts. But I believe you'd be much better off when the Congress
acts.

[Ms. Astore introduced a participant who asked about coverage for
substance abuse treatment.]

[[Page 764]]

The President. I don't know if I can do a better job of defending
it. Some days I don't think I do such a hot job. [Laughter] I did my
best when we started tonight, but I'm going to try. Let me say--I think
you may know this, but I have a brother who is an addict, who is a
recovering addict. I know the treatment works. And we have done two
things in our administration. One is to require that drug treatment be a
part of the benefits, as a part of a general approach to preventive
health care. I believe in preventive health care, folks. We spend a ton
of money after the cow's already out of the barn door in our health care
system. And I like--I mean, I like the fact that we have the best
technology in the world. I like the fact that we can get it. But we can
save so much money if we just invest in prevention generally, whether
it's mammograms for women or cholesterol tests for people or substance
abuse treatment.
In addition to that, although I just presented a budget to the
Congress that cuts defense and cuts discretionary domestic spending--
that is, not Medicare, Medicaid, or Social Security--for the first time
since 1969, we increase in our regular budget drug treatment funds by,
oh, about 8 or 10 percent, just because I think it is so important. And
I will fight very hard for it. I think it would be a big mistake for us
to back off of this. There's still an awful lot of people who have
alcohol and drug abuse, substance abuse problems in this country. And we
can save a bunch of money and a lot of people, more importantly, if we
stay with it.

[The Detroit moderator introduced a participant who asked about
prescription drug coverage for senior citizens.]

The President. Yes, ma'am. Let me explain this again for the benefit
of all of our participants here. Older people who are at or below the
poverty line are eligible for coverage under the Medicaid program, the
Government's program for poor folks. If you're under Medicaid, then you
have a prescription drug benefit. But if you're a senior citizen
eligible for Medicare, that is, the regular elderly person's health care
program, and you haven't spent yourself in poverty, you don't get any
prescription drug benefit. But we know that older people are 4 times as
likely to use medicine as younger people. And we also know that we save
money in our health care system if people who need medicine get it and
can therefore stay out of hospitals. I mean, you can spend a year's
worth of medicine in 3 days in a hospital.
So what our plan does is to add to Medicare a prescription drug
benefit which has a $250 deductible, a 20 percent co-pay, and I think, a
$1,000 ceiling; it has a ceiling, and I think it's $1,000. That is,
after you spend $1,000 out of pocket, your insurance then will cover all
your medicine from then on.

[Ms. Astore introduced a participant who asked about maintaining
competition in the health insurance market.]

The President. First, let me say, I think there has to be some
consolidation of the insurance market. To be fair, I've tried to say
this over and over again, and sometimes not so well, but I don't think
there are any bad people in this drama. We have the best health care in
the world. We have the best doctors, the best nurses, the best medical
technology, the best medical research. We have the worst health care
financing system in the world. It is the world's most expensive. It's
estimated by nearly everybody that studies it that we spend about $90
billion a year, which is pretty good money, in clerical work, simply
because of the way we're organized.
I think there should be and will be, inevitably, some sort of
insurance consolidation. How do we guarantee competition? By requiring
that in every group of buyers, every consumer in America have access to
at least three different kinds of plans, a fee-for-service plan, a
health maintenance organization, a professional provider organization.
They may have access to 24 different specific plans--as I said, the
way the Federal Government employees often do today--but we will
guarantee that every person always has access to at least three
different kinds of plans, including fee-for-service medicine in the old-
fashioned way. When you do that, you're going to ensure that there will
be more competition than there will be. If we do nothing, the move
toward competition, in my judgment, will be just exactly what you say,
there will be more and more concentra-

[[Page 765]]

tion, more and more managed care but less choice, less quality, and less
competition.

[Ms. Astore introduced a participant who asked if choice of physicians
would be limited.]

The President. No. But let me answer your question directly. First
of all, one option you will always have, ma'am, is to continue to pay
your doctors as you would now, on a fee-for-service basis. Your premiums
might be slightly higher, but they probably still would be as low, if
not lower, than they are today because of the way the markets are
organized.
In addition to that, you can also join a certain plan, like a
certain health plan, and maybe all your doctors aren't members of it;
let's say three are, but one of your specialists aren't. You can buy a
small premium, which would not be very expensive, which would give you
the right also to use that doctor, who would then get reimbursed from
your plan at the same rate other doctors in the same specialty or the
same area would.
So you would be able to keep all your doctors. That would be one of
the things you'd have to do. You might have to pay slightly more to do
it than you would otherwise pay, but you could keep them all and, in all
probability, based on our studies, it would be for the same or less
money than you're paying now, if you have a comprehensive plan.

[Ms. Astore called on the Milwaukee moderator, who introduced a
participant who asked about increasing employment opportunity for
welfare recipients, listing her education and job skills.]

The President. My guess is we've already done it. I'll bet you'll
have four job offers tomorrow since you've been on television.
[Laughter] I imagine we probably solved your problem. But let me give
you a more general answer. I hope somebody who's watching you will call
you and offer a job tomorrow.
First of all, quite apart from welfare, we have to create more jobs
in this country. In the last 15 months, our economy has produced 2\1/2\
million new jobs, 90 percent of them in the private sector, more than in
the previous 4 years. So we're creating more jobs. That's the first
thing.
Secondly, with regard to welfare, how do you move people from
welfare to work? You have to make work more attractive. We, this year,
starting in this calendar year, we are lowering income taxes for 16.6
percent, one-sixth, of American workers who make lower wages, to make
sure that work will always be more attractive than welfare by saying if
you work for modest wages, you'll get an income tax cut.
The third thing we are trying to do is to reform the welfare system
itself by helping to create jobs ultimately for people who have training
and are able to go to work, if necessary, with some sort of public
funding. But let me say, it doesn't apply to you.
But the biggest problem we've got with welfare for a lot of people
is that--remember, if you're poor, on Medicaid and on welfare, your
children get health care. If you take a minimum-wage job in a business
that doesn't have health insurance, you have to give up your kid's
health care to go to work. Then you work for a minimum wage and you pay
taxes so people on welfare can have health care. It doesn't make any
sense. So, the health care issue is an important part of welfare reform.
The answer to this lady's question is she should be able to get a
job in a healthy market economy. So we have to create more jobs.
Ultimately, for people on welfare who are willing to go to work, if they
can't find jobs within a certain specific time, in my judgment, the
Government is going to have to work with the private sector to give
extra incentives for people to go to work. It's better to have work than
be on welfare even if you have to give extra incentives to create the
jobs.

[The Milwaukee moderator introduced a participant who asked about the
plan's effect on the U.S. free enterprise system.]

The President. I think it will do much more good than harm. There
will be some job loss in some areas, and there will be some job gain in
some areas. And let me explain how and why I think it's the right thing
to do.

[[Page 766]]

First of all, the system is entirely private. We require people to
purchase insurance. We keep private insurance. We do not abolish
insurance and substitute taxes. Secondly, all the health care providers
that are now private will continue to be private. So we leave that
alone. But if you go to a comprehensive benefit program where you have a
single form that the doctor has to fill out, a single form that a
hospital has to fill out, a single form that a patient has to fill out,
and everybody is clearly covered by producing a card, then all those
people who are busily at work trying to figure out who's not covered
under what health insurance policy or why the health insurance policy
needs to be cut off or why a small pool can't anymore support a person
who's got a sick child, those jobs will go down in number dramatically.
But we'll have a big increase in jobs in health care providers, people
who work in home health, for example.
Some small businesses will pay more because they don't pay anything
now or they have very limited policies now. But on average, it will add
one to 2 percent to their cost of doing business, and all their
competitors will have to do the same thing. And within a few years
they'll all be saving so much more because medical inflation will be
less.
The Congressional Budget Office is a nonpartisan group that did a
study on this. They estimate that on average, within 5 years we'll be
creating many jobs in the small business sector because we'll lower
medical inflation and all small business people will be on equal
competitive terms.
So I think there will be some job loss, more job gain in the short
run in health care, and big job gains over the long run by bringing
health costs in line with inflation.

[Mr. Meier called on the Sioux Falls moderator, who introduced a
participant who asked if businesses would still provide health insurance
to retirees under the new plan.]

The President. It would relieve them of some of their
responsibilities for paying for the early retirees. And they would be in
the retiree pool in our health care program. But I still believe it's
good economics because a lot of these companies are paying now 15, 16,
17, 18 percent of their payroll, as compared with the national average
of 8 to 8.5 percent of payroll, for health care. And that is undermining
their ability to reinvest money and to create more jobs and to make our
economy stronger.
Most of those companies that are severely affected by this are
companies like automobiles and steel, which had to have huge layoffs
through early retirement all during the 1980's to be competitive. In
other words, it wasn't a decision they made, it was necessity. And they
had contracts which required them to carry these health burdens.
We believe for relatively modest cost we can generate a huge amount
of money in these sectors, which are now prospering, to create more jobs
and help strengthen the American economy. So we think that it'll be
about a wash that we can well afford.
Let me say, sir, that we have had the cost of our plan evaluated by
any number of people, including groups that are composed largely of
folks that were active in the previous two Republican administrations.
And all of them say more or less the same thing, that over the 10-year
period our numbers are right. They differ from year to year sometimes,
but I think that the cost figures in my plan are good because we've bent
over backwards, we've contacted 10 different medical actuarial firms and
also had a lot of outsiders look at it. I think the numbers are right.
Ms. Astore. Thank you, Sioux Falls. Mr. President, we have time for
one final question here in the Twin Cities. And we'd like you to pick a
member of the audience to ask that final question.
The President. Go ahead.
Mr. Meier. Wait, wait, wait, wait. I've got to pull a Donahue here
and get up there. [Laughter]
The President. Maybe we'll do two if you can do it real quick.
Mr. Meier. Tell us your name and what your question is.

[A participant asked if the plan would include dental coverage.]

The President. Yes--we're running out of time. I can't give you the
whole details. But the short answer is yes. You'll have to pay some of
it, and I'll get you the details.

[[Page 767]]

Go ahead, what's your question? Thank you.

Ms. Astore. Hurry, Randy.

The President. We can do it. We can do it.

Mr. Meier. I'm getting there. Here we go. Your name and what your
question is.

[A participant asked about coverage for his adult handicapped daughter.]

The President. What's her handicap?

Q. Right now it's a form of scoliosis. She's got a severe curvature;
she's had a back spinal fusion amongst other things.

The President. Your daughter would be able to buy insurance as an
individual once she becomes an adult, on the same terms as anybody else.

Now, the only way we can do that is if we organize the insurance
markets and the buyers so that there are big insurance pools and large
numbers of buyers so we can spread the risk of some future illness or
problem of hers across a large number of people.

I do want to make full disclosure, because one of the first
questions I got was who would pay more under this plan. We would ask
young single workers to pay a little more per month than they would
otherwise pay so that we'd be able to insure people like your daughter
and older workers on affordable terms. I think, again, that's a fair
thing because young, single workers want to be older some day, number
one, and they're going to be married, they're going to have children,
and they might have children that have health problems.

So I think it's a fair thing to do. But that's the way it would
work. That's the way, by the way, other countries do it. And your
daughter would be able to get insurance.

Ms. Astore. President Clinton, we're coming to the end of our town
hall meeting. We'd like to give you this opportunity to offer some
closing remarks.

The President. I just want to make two points after I say thank you
to all of you. Thank you to those of you who asked questions and those
who couldn't get your questions asked. For those of you in the other
sites, if you had a question that didn't get answered, send it to us and
we'll answer it. And those of you that are here, I'll just gather them
up while I'm here.

I want to make two points if I might. We can differ about the
details of this, but the one thing we have to decide on as a people is,
are we going to continue to be the only advanced economy in the entire
world that can't figure out how to provide health insurance for all of
its people, so that we insure people and pay for them if they are on
welfare but we punish working people? Or are we going to solve this
problem after talking about it for 60 years now?

The second thing I want to say is this, to go back to a point I made
at the beginning. This is a complicated issue. I've tried to shoot
straight with you and tell you what the problems are with it. I respect
people who have differences of opinion with me on exactly how we should
do it.

But what I want to ask you to do is to try to communicate to your
Members of Congress, without regard to party, that Republicans and
independents and Democrats all get sick, all have kids, all have
parents, all have hopes, all have fears, and that it's okay for us to
disagree about this in terms of the details, but it is not okay to let
another year go by and not deal with it.

And what I ask you to do is not so much to say, ``Bill Clinton's
right about everything,'' but to say, ``This is a serious problem; we
have to deal with it. Please act now.'' We will not know any more about
this next year than we do this year. It's just going to be like an
ingrown toenail. It will get worse, not better, if we don't move. So
that is what I plead with you to do. Ask your Members of Congress to act
now and to work in the spirit of humanity, bipartisanship, and common
sense, and let's get this done.

Thank you very much.

Note: The town meeting began at 7 p.m. at the KSTP-TV studio. This item
was not received in time for publication in the appropriate issue.

[[Page 768]]