THE WHITE HOUSE
                      Office of the Press Secretary

For Release                                 September 17, 1993
 
                        REMARKS BY THE FIRST LADY
                           AT TOWNHALL MEETING
 
                          Minneapolis, Minnesota
 
 
        MRS. CLINTON:  Thank you very much. I am delighted to be back in
Minnesota, honored to be at this university of excellence on this
occasion to address this most important subject facing our country. I
want to thank Congressman Sable, in particular, for inviting me to this
health care conference and for his dedication over the years to health
care issues and his skillful leadership on the budget committee, both of
which have made him a very welcome presence in Washington over a long
period of time, but particularly in these last few months.
 
        I am also delighted to be here with my friends, Senators
Wellstone and Durenburger, whom I have gotten to know since moving to
Washington, and appreciate greatly their advice and counsel. I don't
think any state has two Senators with whom I have spent more time talking
about health care. And it has always been a very important exchange for
me. (Applause.)  And I also want to thank Congressmen Vento, and
Ramstead and Grahams for joining me here and also for being part of the
many consultations that I have been privileged to take place in the
Congress that I have been participating in in which they have attended.
 
        We are on the brink of a great national discussion about the
direction of health care in our country. And it is particularly
appropriate that I would have the opportunity to discuss those issues
here in this state, a state whose rich contributions to American culture
are undeniable and too numerous to mention.
 
        There are few states, if any, that can lay claim to the kind of
pioneering work that Minnesota has done repeatedly over the decades,
breaking new ground on the social issues that faced our country. And
there is no place in America that can lay claim both to the Mall of
America and the Mayo Clinic -- (laughter) -- or the Metrodome and the
Copperdome or the Cathedral of St. Paul. And I always believe that
everybody in Minnesota is above average, anyway. So, I'm just delighted
to be here. (Applause.)
  
        There is no area of leadership more important than what you have
already done here in this state in health care. We see it from one end
of the state to the other. We see it, certainly, at the Mayo Clinic,
sometimes called the most innovative doctor's office in the world. We
see it at the University of Minnesota, which has historically paved the
way in all kinds of new breakthroughs, including cardiovascular surgery,
the training of primary care physicians for rural areas. And I
particularly want to compliment the program at Duluth which has turned
out more rural health care family physicians and trained more --
(applause) -- Native American physicians than anyplace in the country.
(Applause.)  And I always ask myself:  If one medical school can do it
why can't others?  And we need to ask ourselves about that with respect
to many of the programs we see here in Minnesota.
 
        In Henopen County, for example, we have a program to provide
coverage for uninsured residents. And today when I visited a community
health clinic, I heard about the patients whose uninsured care is picked
up through the combination of programs -- Minnesota Care, county
contributions, local contributions -- that is rather unique in many parts
of the country. And, certainly, this legislature's courageous bipartisan
efforts to establish a program of health care, to begin to implement it,
to set budget targets and encourage integration of the health delivery
system stands far and above what has been able to be accomplished in many
other states. So, given this impressive history, it is not surprising
that we are here in this state to talk about the future of health care.
 
        In just a few days, the President will outline the principles
underlying the National Health Security Act. This initiative marks the
first time in years that the Congress will have before it a comprehensive
measure to provide health security for all Americans. This is an issue
that has been considered in Congresses many times before. Many
legislators have come forward with proposals ever since the 1930s. Other
presidents, starting with Franklin Roosevelt and including Harry Truman
and Lyndon Johnson and Richard Nixon, have come forward with
comprehensive health care legislation. But there was always some reason,
some timing, some excuse why we could not move forward.
 
        When this process began many months ago, the President's goal was
to design a program that would fulfill the American promise of
affordable, high quality health care for every citizen. That promise is
founded on a fundamental belief:  that good health is every American's
most cherished possession, a source of collective strength and prosperity
for our nation. It is also founded on a conviction that every American
should have the right to necessary health care. This is not a new idea,
nor a revolutionary concept. We have talked about it for years. But
while we have talked, the problems, the challenges, the bureaucracy, the
red tape, the costs of health care have continued to
 
accumulate. So it is time to move beyond talk, time to move out of the
auditoriums and the clinic offices, the water cooler discussions, into
the halls of Congress to establish the basic principle that every
individual is entitled to health care security. (Applause.)
 
        The process of drafting the plan that the President will propose
has involved literally thousands and thousands of people from all walks
of life and from every corner of every state. We have listened to those
who tend to the sick, the doctors, the nurses, the technicians, the
employees in hospitals and hospices. And we have listened to those who
receive care. The patients who know firsthand the benefits and pitfalls
of our current system.
 
        We have listened to those who thought they were secure, but lost
that health insurance and joined the 2.25 million Americans every month,
who for some period of time, lose their health insurance. We have
listened to the stories of job lock. We have listened to the
excruciating tales that come from people being denied insurance coverage
because of pre-existing conditions. And we have heard from businesses
large and small, and from insurance companies that provide health
insurance coverage.
 
        We have talked to governmental leaders at the local state levels
to talk to them about what challenges confronted them. And we have
especially enjoyed the counsel and advice of people from Minnesota --
people like Lois Kwan, who is here on the podium and others who are in
this audience who have given of their time away from their families, away
from their businesses, away from their practices, to spend countless days
in Washington helping us make sure we got it right.
 
        Now, what we are coming forward with out of this process is the
beginning of a planning effort that will involve, we hope, everybody in
this country. One of the first conclusions I reached is that there are
not just experts in health care who sit in medical schools or other
places around our country. There are 250 million of us who are experts
in health care. All of us have some experience that we will bring to
this national discussion. And what we want is a solution that solves the
problems we face and gives people the security they deserve and they
currently lack.
 
        But those of us who have worked on this plan don't think we have
all the answers or that the answers we come forward with are coming down
in tablet form. We think there's a great deal of opportunity for us to
work in a bipartisan fashion to hear the responses, to begin to make sure
we come with a plan that will get it right and will assure people that we
have listened.
 
        But there are some principles that we have to insist on. We may
be able to discuss the details together and come up with better ways of
 
accomplishing these principles than the ones that our process has
produced. But there are certain bedrock principles that I think all of
us should agree we need to meet.
 
        The first principle -- the most important -- is security. That
means we have to reach universal coverage as soon as possible.
(Applause.)  This is a principle founded not only in the human tragedies
that come too often to our attention because of the denial of health
care. But in the economic realities that until every American is insured
and does have health security, there cannot be the kind of cost-effective
approaches to providing health care that we expect to achieve savings so
that as we move through the system, we can begin to enhance quality
while, indeed, we provide security.
 
        When we talk about security, however, we are not just talking
about giving people a health security card, although that will be done.
We are talking about what that card will entitle a citizen to. We must
provide a comprehensive benefits package so that it is guaranteed to
every American. It is not enough to have coverage and access unless that
coverage and access takes care of your medical needs when they arise.
And it is our firm belief that the package of benefits should emphasize
primary and preventive health care.
 
        It has been for too long that we have had our system rewarding
the wrong kinds of behaviors. We have not encouraged people to seek well
child care. We have not encouraged people to seek the diagnostic tests
that could point out a problem early. We have not encouraged the
diabetic to be able to go and afford the kind of scans and tests that are
needed to make sure that her condition doesn't deteriorate. But we have
paid for the operation, we have paid for the chronic illness. It is time
we put primary and preventive health care at the head of the list of what
people need and deserve. (Applause.)
 
        The second absolute principle is, we have to simplify this
system. We cannot permit it to continue unchecked, spewing out more
forms and more regulations in both the private and the public sector
every year that goes by. This morning, I spent time visiting with a
nurse who helps patients eligible for assistance to fill out the forms
that those patients face. And she went through the list of forms that
"as a patient," in her words, "might confront without adequate education
or understanding, I was, as I always am, overwhelmed. Stack after stack
of paper came my way."  And I know that is the situation for so many
people, confronted by government programs with forms and confronted in
the private sector with insurance forms.
 
        But it is even worse in our hospitals and doctors' offices. In
the last 15 years, hospitals, on average, have hired four administrative
and clerical employees for every doctor. We have turned nurses who went
to nursing school to care for patients into bookkeepers. We have
 
watched as we have tangled our hospital administrators and those who work
in our hospitals in a web of paperwork that there is no relationship to
the care that you and I expect when we walk in the door. (Applause.)  We
have the opportunity now in reform to reverse and eliminate that
paperwork jungle that has beset our health care system.
 
        This morning in Washington, the President went to the Children's
Hospital there, along with Vice President Gore, to present the kind of
single form that we hope to be able to move toward so that all who
provide care will be spending their time doing that instead of hiring
people to fill out forms in the future.
 
        If we can begin to tackle and finally conquer this paperwork
complex system that we have created, we will save billions of dollars and
free up, literally, thousands and thousands of hours for doctors and
nurses and others to do what they were educated to do.
 
        The third principle is choice. More and more, the current system
is limiting choice for consumers. Employers who bear the cost for most
people's insurance who are insured make the choice as to what plans will
be available and increasingly limit that choice. With the health
security act, individuals will choose from among the plans in their area.
They will decide whether they want to join an HMO or a PPO or a fee for
service or, yet, some uncreated network that will deliver the care in the
way, at the price, at the quality that they want.
 
        If we preserve choice, what we have done is not only to give the
power for making that decision to the individual, we have given the
responsibility to the individual. We need better informed consumers in
health care. Most people know far more about the car they buy than the
health insurance plan they subscribe to. They don't know how to make
distinctions among the varying kinds of services that are offered. We
need to provide incentives for them to do so, and choice is the principle
that will lead them in that direction.
 
        Fourth, we have to realize savings in our new system. We now
spend, as many of you in this audience know, 14 percent of our national
income on health care. We spend as much money on health care in America
as the entire economy of the country of Italy. And if we do nothing, if
we do not insure one more person, we will be spending 20 percent of our
national income on health care.
 
        What that has meant is not only an extraordinary explosion of
commitment of resources to health care, but it has been a major factor in
slowing down and stagnating the wages of working people. Any of you who
work for a living, like most of us do, any of you who represent workers,
you know that the battles of the last decade have been over how much
money could be pushed into benefits as part of the total compensation,
taking it out of wages. This has not been good for our
 
economy, nor for our workers. It has particularly hit hard middle-class
families that have struggled to keep up with other costs in their
household expenses.
 
        Other countries in the world do a much better job than we do with
their health care expenditures. Canada is the next highest to us, at
about 9.4 percent. But our other major industrial competitors, like
Japan and Germany, are between eight and nine percent, and they cover
every one of their citizens with a more generous benefit package than we
do on average here at home.
 
        If we do not attempt to get savings out of this system as we
reform it, we will only be freezing in the inefficiencies and cost
structure that are such a problem for us now.
 
        There are some who say:  How can you ever get savings out of this
system which is so complicated, and how can you come with a reform that
will achieve savings when there is so much work to be done, like insuring
the uninsured?  We have studied this very closely, as many of you in this
audience who have been involved in the health care system know, there is
not anyone I have spoken
with -- doctor, nurse, hospital administrator, technician, patient,
advocate for patients -- who does not tell me stories about the
ridiculous decisions they confront because of costly bureaucracy and
regulations that affect how they can make decisions.
 
        I was home in Arkansas recently, and an ophthalmologist whom I
know came to see me. He said, "I've been following what you've been
doing, and I wanted to give you some evidence as to why I think you're on
the right track."  And he produced for me hospital bills from some of the
patients whom he serves. And he explained to me how he performed the
same procedures in various hospitals to the same kinds of patients, and
hospital charges would vary from $900 to $2300. We are caught in a
system that rewards those kinds of differences, because we have not been
willing to face up to how we could provide health care more cost-
effectively.
 
        There are some who will argue we can't get savings out of the
public system, out of Medicare or Medicaid, and we cannot get savings out
of the private system. And, to them, I ask:  Are we less efficient?  Are
we less able to deal with our health care problems than every other
country with whom we compete?  I don't think so. We may have to change
the way we think. We may have to let go of some cherished myths about
what care costs and start thinking about what it can or should cost. But
there is no way we can justify spending the amount of money we are
currently spending. And one of the President's goals is to set in motion
a process where we will begin to save money that can be better utilized
to provide real benefits to people who are left out of the system now.
 
        The fifth principle is, we have to preserve and enhance quality.
And we can accomplish a lot by collecting data and comparing standards
and outcomes, and then publishing what we know. If we are truly going to
have informed consumers, then we need to have what some of your health
care providers are now beginning to do:  report cards about quality, so
that consumers can make comparisons and make decisions.
 
        Without quality standards, we will continue to see wild
variations in prices, too many unnecessary procedures, too little
emphasis on primary and preventive care, and too little consensus about
the most appropriate treatments for many common illnesses.
 
        I go back to my friend, the ophthalmologist in Arkansas. He was
the one who performed the surgery on each patient. The outcomes were the
same. There was a relatively minor cataract surgery in those instances.
There was no difference in quality, only difference in price.
 
        The State of Pennsylvania, as have other states, have been
collecting information about how much certain procedures cost and then
correlating that cost with quality. You can get a coronary bypass in
Pennsylvania in one hospital and pay $20,000, and you can get it in
another and pay $80,000. Based on careful analysis, comparing the same
kinds of patients at the same state of disease, there are no discernable
quality differences. But without that information that enables us all to
make informed decisions and enables those within the system to consider
alternative ways of performing medical services, we will not know whether
what we are getting is good quality or not.
 
        The sixth principle is responsibility. Responsibility should
permeate the system, and for too long it has not. Too many people have
not taken responsibility for their own health. And we need to insure for
the first time ever that everyone pays their fair share in the health
care system. Everybody must pay something, because everybody must assume
responsibility for their health care.
 
        The way the current system operates, some people pay a lot --some
employers, some individuals; some people pay some, and too many people
pay nothing. We have to put an end to the free rides in the medical
system. Everybody should be responsible to pay something. (Applause.)
 
        Individual citizens have to bear responsibility, and there are
only three ways that can be used to finance universal health care
coverage in this country. There is the way that many in Minnesota and
Senator Wellstone favor, which is a system which transfers away from the
private sector wholly onto the government the total costs for health care
through taxes; there would be ways to replace both business and
 
individual contributions in the form of insurance premiums. (Applause.)
 
        There is also the way that we've introduced just last week by a
number of Republican Senators, to require an individual mandate in which
individuals, much as we do now with auto insurance, would be responsible
for buying health insurance, and low-income individuals below a certain
level of income would be subsidized with vouchers. (Applause.)
 
        Now, both of these approaches would move us toward more
responsibility than we currently have. And we and the task force looked
very carefully at both of these and learned a lot from each. We
considered the single-payor approach. But the task of raising taxes to
replace all that private sector investment, plus other considerations,
seemed to us that we ought to focus instead of on the way a single payer
system is financed, on the qualities that it contains, namely universal
coverage, administrative simplification, and the like.
 
        So the strengths of the single-payor approach, including the
savings we believe will come, have been continued in the President's
approach.
 
        We also explored the possibility of requiring individuals to buy
health insurance, but we had a number of questions that we are still
exploring with Republicans in the Senate as to how that practically would
be done.
 
        How, for example, would we insure that individuals will really go
out and buy the insurance, and what system will we use to require that
they do so. How would we prevent employers from suspending or
eliminating coverage for employees, particularly low-wage employees who
would then fall into the subsidy pool that the government would pay for.
And that would require increasing subsidies that a growing number of
people that might be thrown into that pool, which would, in turn, raise
the government's involvement, both financially and administratively,
because to keep track of the amount of subsidy each individual would
require to track that person would, we believe, necessitate a rather
complex administrative structure. But we also believe as that approach
sets forth that the key is individual responsibility.
 
        What we would like to do is to build on the system we already
have. An employer-employee based system in which everyone is responsible
for contributing. That model allows us to achieve reform without
compromising the core principles that we believe in. If we do that, then
we know that for those employers who are currently insuring at the level
of benefits that we think should be the guaranteed level, there should be
savings -- and we believe there will be -- savings even in the first
year.
 
        That will represent savings to the vast majority of businesses,
 
both small and large, which currently insure. We also want to be
sensitive to businesses that are currently insuring but not at the level
of benefits that we think are necessary. And we have worked out a system
to subsidize businesses that would need some assistance financially to
meet those requirements.
 
        But of course, there are businesses that now do not provide any
health for their employees whatsoever. For many of those businesses the
idea that they would be required to do so poses grave problems to them.
But on the other hand, those businesses now are taking advantage of a
system both through their owners or through their employees that the rest
of us pay for.
 
        There is no easy answer as to how we finance a system that
includes every American. But we have, since World War II, used the
workplace as the location for assuming responsibility would be met. By
building on that, we do not dislodge what has become the accepted means
of thinking about insurance in America. You would get your insurance
through your workplace, if you are unemployed you would be subsidized by
the government.
 
        We also believe that the Medicaid program as we know it now
should be ended. (Applause.)  And Medicaid recipients should be eligible
for insurance along with their friends and neighbors through large
purchasing pools. And they should not be identified in the system as
being any different from you or me. (Applause.)  So that we will have,
we hope, a seamless system in which everyone, including those currently
on Medicaid who work, everyone who works will contribute something bases
on their ability to pay to their health insurance. And all businesses
will contribute something on behalf of their employees.
 
        Now, what will this initiative mean for Minnesota?  First, let me
say that many of your state innovations guided us in developing this
plan. We know from what you have done that this cannot happen overnight,
it must be built in stages, but that we must have goals and principles
that we do not detour from.
 
        We know from your forward thinking health plans that emphasizing
primary and preventive care leads to lower expenditures and significant
savings. We know from the Minnesota State Employees Group and from
AFSCME's leadership in this area, that families can get better, more
affordable health care by purchasing coverage through large groups. We
know from recent efforts in places like Willmar and Chisago City that
integrated health care services can be established in rural areas.
 
        And we know that if we put our minds to it, as I already
mentioned, with the University of Minnesota Medical School at Duluth,
with the right incentives, medical students will go into primary care and
practice in underserved areas so that we will have the manpower we
 
need to make good on the promise of universal coverage.
 
        We have seen what can happen here in Minnesota by the changes
that you have already accomplished. You have also showed us how the
federal government too often has been an impediment to reform. That is
not the way it should work.
 
        Let me assure you that the President's initiative will give
states more flexibility to move forward with reforms that are appropriate
for each state. For example, regional health alliances will create a
mechanism for covering all citizens, and will, therefore, eliminate the
need to get waivers or changes in ARISA. We hope that the kind of
flexibility that will be given to states will enable Minnesota to pursue
what is best for Minnesota and permit Texas to pursue what is best for
Texas.
 
        Reform will benefit Minnesota in other ways, as well. Because
you are further along than most states in organizing integrated delivery
systems and setting budget targets, you will move toward lower costs more
quickly. That puts you in a much more competitive situation than other
states could claim.
 
        If we begin the process of considering the President's plan now,
and move forward in the Congress with the assistance and help and
guidance of people in places like Minnesota, we should be able to reach
consensus on the kind of health care plan this country needs in time for
us to begin implementing it over the next
few years. Every year that we delay, we continue to increase the
problems we will face when we finally meet the challenge. Back in 1977
Hubert Humphrey sounded this prophetic alarm. He said we don't have any
health protection program in this country. We have a sickness program.
You have to get sick before you get anything. (Applause.)
 
        We need a program on how to prevent disease. Otherwise there
will be no end to the costs of health care. Hubert Humphrey was right
when he spoke those words 16 years ago, and unfortunately he would be
right if he were here with us today saying them again.
 
        Now, I don't want to underestimate how difficult the challenge
ahead of us will be. There are many who are already filling the airwaves
with scare tactics and fears about what reform might mean. There are a
lot of people who stand to make a lot of money if the system doesn't
change. And there are a lot of people who stand to lost a lot of money
if it does. One of my hopes as we move forward in this debate, is that
every time you hear a charge, every time you see an ad, every time you
listen to someone talking on the television about what reform will bring,
you ask yourself:  Am I hearing someone who is giving me his honest
opinion as objectively presented as he can?  Or am I hearing someone who
either is or represents some interest who is likely to suffer financially if we make the changes that need to be made?  If we insure every American, for example, there will no longer be need for people to sit furiously figuring out how to eliminate people from coverage so that we don't have to pay for them. (Applause.)
 
        This debate will require the best that America has to offer. But
if we can agree on the principles, then I am absolutely confident there
are enough people of good faith and of informed opinions and of
compassion and good sense in the United States Congress that we can work
out the details. That is my fervent desire. I just want, at the end of
the day, however we struggle over the technical parts of this, to know
that we are all moving in the same direction together, that we are not
giving up the goal of universal coverage or on the hope of choice and
enhanced quality.
And based on my experience over these months in the Congress, I have
every reason to believe that that will be the outcome of the efforts we
will undertake.
 
        And I have to confess, that as I sat on the White House lawn on
Monday watching representatives of two ancient enemies come together to
sign a Declaration of Principles of Peace, and then to shake hands, I
thought to myself: there were people all over the world who, every single
day, against dangers and obstacles we cannot even imagine, got up and
worked for peace, who believe that, someday, the leader of Israel and the
chairman of the PLO would have to meet and agree to end the war.
 
        But that would never have happened without people who believed it
would. Now, surely we in America, who have more blessings and more
security and a brighter future than has ever been dreamed of in most of
the world for most of history, can put aside the divisions that for too
many years now have kept us apart. Can get beyond part of the wrangling
and ideological name-calling and come together around what makes this
country what it is. And one of the most important challenges facing us
is to achieve a health care system that includes every American for which
we, then, can be proud to have done our part. That's what's going to
happen in the months to come -- but only if you all help make it so.
Thank you all very much. (Applause.)
 
                                   END