REMARKS BY THE FIRST LADY
INSTITUTE OF MEDICINE ANNUAL MEETING
October 19, 1993
|DR. KOOP: Good morning. Before I introduce
Hillary Rodham Clinton to you, I want to express my personal
admiration and my gratitude to her for her leadership of the
President's health care reform effort.
She has brought to this assignment exemplary
energy, unfailing diligence, breath of vision, attention to
detail, care, and compassion. I'm sure that these words are
not new to her at all. Ever since the Clinton Health Care
Plan became public, and especially since her highly lauded
testimony before congressional committees, accolades have
come her way.
And although the compliments for her accomplishment
in producing a comprehensive reform plan are well deserved, I
must say that the tenor of much of the praise bothered me.
There was too much oohing and aahing about how no first lady
had never done such a thing before. I think these folks
missed the point. They indeed missed the person.
It is my understanding that Hillary Rodham Clinton
has presented this health care reform plan to the nation not
as the First Lady, but as the American citizen whom the
President decided he could best entrust with that task that
he placed on top of his domestic agenda. Now, I'm not saying
that being a friend of Bill hurt her chances at all.
After all, Presidents have always turned to trusted
friends to fill important positions. But I imagine in this
case that Mrs. Clinton received the assignment as much in
spite of her being First Lady as because of it.
A highly educated woman, an accomplished attorney,
a proven manager, a thoughtful analyst, a champion of
children and the disenfranchised in our society -- Hillary
Clinton did not surprise anyone who knew her by producing a
reform plan of such breadth and such depth. The kind of
accomplishment was simply to be expected from her.
I also admire her, and the President, for their
repeated statements that the plan they have offered is open
to debate and amendment, that they welcome suggestions to
improve upon it. And although the plan is complex, even
complicated, I especially admire its breadth, and I thank
you, Mrs. Clinton, for raising all of the issues, so that no
matter what finally emerges from the national debate and the
legislative process, you have forced us to deal with all of
these issues: medical, financial, legal, public and private,
as well as those of our personal responsibility for our own
No matter what any of us here today thinks about
some of the plan's particular points, we all owe our
gratitude and our admiration for placing the issues and the
ethical imperative for health care reform so clearly before
us. Hillary Rodham Clinton. (Applause)
MRS. CLINTON: Thank you. Thank you very much.
Thank you very much, Dr. Koop. And thank you for your advice
throughout this process, starting last spring, and your
willingness to serve in this role as a facilitator of
discussions moving forward, particularly with the medical and
And thank you, too, Dr. Shine, for your personal
involvement and commitment to health care reform, and to all
of you in the Institute of Medicine and associated with the
National Academy that have been great supporters, but also
excellent critics, as we have moved forward in this process.
And I hope for both roles to continue in the months ahead.
When Dr. Koop and I first talked about what we
hoped we could achieve, and what he is now referring to as
our road show here, it was with the idea that I would do much
less talking than listening and trying to answer questions
that were on your minds, because I assume that, with an
audience such as this, not only have many of you been
personally involved in some way with the reform process, but
most of you have avidly read what has been written, and have
questions about the nature of the reform and particular
issues that are of concern to you.
I would like, therefore, just to make a few minutes
of opening remarks. I have looked at the program that you
will have for the rest of the day, and I am very pleased to
see the time you will spend looking at particular issues.
I am delighted that many of the people who have
helped in this process, particularly Dr. Phil Lee, will be
addressing you, and you will have further opportunities to
ask questions during today, and, I hope, into the future.
I am very excited by what lies ahead of us. And I
am excited because, as Dr. Koop has said, we have tried very
hard to lay out the full range of issues that have to be
addressed. These issues are ones that overlap, and certainly
one cannot easily rank them in any importance because so many
of them bear one on the other.
But what is exciting to me is the willingness of so
many in the medical profession and the scientific community
to begin to talk more often in public, with colleagues and
with citizens, about the interrelationships of the pieces of
health care reform.
It is a complex undertaking that we are about to
begin in our country. I know no way to attempt what we are
doing: to achieve universal coverage; to guarantee a
comprehensive benefits package; to begin to simplify a system
that has become much too cumbersome, bureaucratic, and
overregulated; to attempt to begin to achieve savings and
eliminate inefficiencies; but at the same time, to enhance
quality through better outcomes research and reporting of
those outcomes; to guarantee choice -- in fact, to enhance
choice -- for both the citizen/consumer and the provider/
practitioner; and to inject more responsibility into the
system at every level.
And one of the questions that I'm often asked is
how one expects to be able to do all of this in the face of
complexity. And I always ask the one who questions me to
please describe to me the way our current system works -- to
take a few minutes, describe how people get into the system,
whether or not they carry with them financial reimbursement,
what are the conditions that either eliminate them from
coverage or in some way limit their coverage, who provides
health care, who holds it accountable, who pays for it, and
on down the line.
I think it would be extraordinarily difficult to
design a more complex system than the one we currently have.
So what I hope we will do as we move forward is not only to
question where we are going, but to have a very clear idea of
where we are now and what the options are available to us and
the costs of staying with our current system -- or non-
system, as some are more appropriately calling it -- or
making only marginal changes that will, inevitably, have just
as many unintended consequences as any attempt at
There are a few issues that I wanted to highlight
in these opening comments, because of your concerns and the
concerns of many in the professions.
First, the problems that physicians and patients
face in the current system are such that we know care is
being rationed every single day. We know that choice is
being limited every single day -- two issues that are often
discussed in the context of reform that we know are having a
bad effect in many settings already in the current systems.
Contrary to the way the system currently operates,
we have made some fundamental changes. Although we have
built on the employer/employee system, individuals will
choose their health plans -- not employers, and not the
government. This is a sea-change.
What is currently happening in our current system
is that employers, in their effort to control costs, are
pushing more and more of their employees into limited choice
options. That goes along with the trend that many of you
have observed, in which providers -- whether they be
physicians or others in hospitals and the like -- are being
also forced into situations where their practice is being
What we are trying to do is to take back that power
from insurers and from the federal government. Right now
insurers have the ability to grant and deny coverage. They
do it with a vengeance, because it has become the way in
which they make money.
We believe that taking that power away from
insurers is fundamental to any kind of health care reform.
And so, from our perspective, putting the authority back in
the hands of physicians and their patients will be absolutely
essential to what we achieve.
Now, how will that work? Individuals will have
choices among plans and providers. We will require that in
every region there will have to be a fee-for-service network.
It is absolutely not true that every physician will be forced
into HMOs. That is not part of the plan. It is not going to
occur, because we will guarantee a fee-for-service network.
We will also require that HMOs offer a point-of-
service option. This is a very important feature, in part
because we want to maximize choice as a principle, but also
because we want academic health centers and other centers of
medical excellence to be available for referral, even to
patients within HMOs.
We also want physicians to have an option as to
being able to join more than one plan. The fact that you
might be in a closed-panel HMO would not prohibit you from
also being in the fee-for-service network. The fee-for-
service network will be open to all willing providers.
We think it is important to change the balance of
power that currently makes too many of the decisions in the
health care field. That's why having insurance reform is an
absolute precondition of everything else we are attempting to
We intend not only to achieve universal coverage,
but to eliminate preexisting conditions, to eliminate
lifetime limits -- two of the issues that have been the most
difficult for individuals, and for their physicians
confronted with some of the hard choices that individuals
with preexisting conditions or exhausted lifetime limits pose
when care has not been completed.
I heard Dr. Shine speak about the work that you did
yesterday with respect to genetics research. And it reminded
me of an extraordinary comment made to me at the Mary Lasker
Awards by Dr. Nancy Wexler, one of the recipients, whose
pioneering work on Huntington's Disease is, I'm sure, well
known to many of you.
She came up to me and said that, as a researcher in
the area of Huntington's Disease and as a member of the Human
Gene Project, she wanted me to be aware that, probably within
10 years, the state of our knowledge would demonstrate
unequivocally that we all have a preexisting condition of
some sort or another.
So we'd better hurry up and get reform or we're all
going to be out in the cold. (Laughter)
Secondly, we intend to change the balance of power
by moving forward with antitrust reforms. We believe that we
need to level the playing field and provide more freedom to
doctors and hospitals to work together to determine what is
the best and most efficient way to deliver high quality
Doctors and other health providers will be able,
under these antitrust reforms, to band together to form their
own community-based health networks in which doctors will be
able to negotiate to reduce interference with their practice.
They will also be able to negotiate collectively to
insure that they have a role in setting any fee-for-service
reimbursement rates, so long as they represent 20 percent or
fewer of the physicians in an area and share in the financial
Now, this is a request that had come to us from a
number of groups representing physicians. We think it is a
very important feature of what we are attempting to do,
because part of what we hope will occur is a real flowering
of networks of doctors and hospitals throughout the country
-- allied often, or maybe even begun, through academic health
centers as the center of excellence within a community.
But it was clear, in looking at the antitrust laws,
there were too many obstacles to being able to achieve that
realistically without the changes we are proposing.
We also believe that, if we reduce the bureaucracy
and the overregulation in the system, we will begin to free
physicians from the kind of sapping of resources -- time,
energy, financial -- that has occurred up until the present
time. And I want to say something specifically about this,
because it is not just rhetoric. It is a very important
commitment to what we are trying to achieve.
We have tried -- and I think it has been a very
good-faith effort in the past 20 years or so -- to perfect a
micromanaged approach toward the paying for health care. We
have done it in both the private and the public sector. We
have laid out innumerable lists of what certain procedures
should cost. We have gone to great lengths to check and
double-check how procedures are described and coded and
But again, going back to my original question about
describing our existing system -- if you take the time to
actually list what the procedures are for a bill being paid
by an insurance company or by Medicare or Medicaid, and you
put everything in there -- you put in the billing and the
coding departments, you put in the PROs and the fiscal
intermediaries and all of the other acronyms that are out
there -- you would be astonished to see where all of this
money that you know is being spent is actually going and the
kind of time that it is taking away from your practice.
The Children's Medical Center here in Washington
conducted such a study recently, which they reported to the
President. They actually went through and looked at every
form unrelated to patient care or quality reporting -- mostly
having to do with financing of the care -- and they
determined that if every physician on the staff of that
medical center, all 200 of them, were relieved of filling out
the forms that were irrelevant, in their professional
judgment, each physician would be able to see between one and
two more patients a day.
That added up to 10,000 more children who could be
seen by physicians in one hospital in one year, if we did
away with the kinds of forms that they had identified. So
this is a big issue. It's an issue not only for the
financial implications, but also for patient care as well.
I also want to emphasize our commitment to quality.
We believe very strongly, and have set aside in this plan,
funding for academic health centers and funding in outcomes
research and effectiveness research.
We believe, as strongly as I can express to you,
that expanded investments in health research and greater
support of academic health centers are critical not only to
insuring quality, but in controlling costs over the long run
and promoting a philosophy of prevention and wellness.
With reform, new funding will be available for
prevention research, outcomes research, and health services
research. We also want to continue the work that Dr. Koop
and Dr. Weinberg and others have been doing at Dartmouth,
that will focus on the kind of shared decision-making between
patients and doctors, exemplified by the prostate study that
has had so much notice in the last year.
Now, when we lay out these and the many other
features of the reform plan, people often say, "Well, how can
we afford this?" And, of course, my initial response is not
only how can we afford not to, but look at what we are
There is no way to justify our current expenditure
level, especially when we don't provide universal coverage,
and, especially when, even for millions who have some kind of
insurance coverage, their coverage does not cover preventive
services and the kind of intermediary services that are often
required and cost-effective.
So, certainly, we will in the next months have a
great debate about how we will finance this. There is no
real secret to our financing. We're going to require every
employer and employee to make a contribution. That will
amount to approximately $50 billion. That's a lot of money
-- new money going into the system.
With the new investments in health care, we will be
driving up our GDP percentage, from the approximate 14
percent that it is now to about 17 percent by the end of the
decade -- 2 percentage points below the projections if we do
nothing, but still twice as much, at least, of any other
industrialized country that is doing the job that needs to be
So anyone who says we will be rationing the system
or in any way constricting the system has not looked at the
amount of money going into the system that will be new.
In the meantime, though, we recognize that there
will be certain features of our existing system -- such as
academic health centers, such as public health facilities in
underserved urban and rural areas -- that will continue to
need additional resources, which we have provided.
Now, finally, let me say that our commitment to
basic research, our commitment to academic health centers,
cannot be successful if we do not have an ongoing,
consultative process with institutions, such as the institute
with the group of academic health centers that
Dr. Shine referred to, and that that kind of consultation be
built into the reform process.
As a layperson, one of the surprising discoveries
that I have made in the last month is that, here we are in a
country that has by far the best basic research and best
applied research in the medical sciences as any country -- or
all of them put together in comparison, yet, too often, what
you know in your academic health centers -- what this
institute proves on the basis of the kind of rigorous peer
review that it engages in -- does not penetrate into the
larger medical and health care community.
There are still too many decisions being made which
are being paid for -- not only made, but paid for -- that are
neither related to quality nor cost-effectiveness. And if
one looks at the pattern of expenditures and practice styles
throughout this country, it is shocking.
Some of you may have seen Uwe Reinhardt's piece in
-- I think it was the Times, over the last couple of days --
where he pointed out something that is obvious to a political
economist like himself, but which has not become clear to the
American public and even to many practitioners.
And that is that without sacrificing quality --
holding quality constant -- we have some areas of our country
that charge three times or two times more than other areas
for taking care of the very same kind of patients with the
very same kind of problems.
We have not put to good use the kind of research
that we know about what should make good decision making in
medicine. And we have not had any accountability system to
be able to compare that and to determine what should be
Our efforts up until now, although we have made
progress in the Medicare system, have not influenced the
entire health care system.
So these are the issues that we're going to have to
face with your help. We will need your constant constructive
criticism and advice. But I would close by just saying that
Dr. Shine is absolutely right. This institute is committed
to not only research, but health care. Most of you know,
very clearly better than I, the shortcomings of what we are
attempting to do now. Changing this system, no matter how
flawed, will be extremely difficult.
And I would argue that the people who are most
likely to have credible voices are people like those of you
in this room, that when the dust settles, the highly financed
advertising campaigns on behalf of special interests -- like
the one that the Independent Insurance Agents are running now
-- which goes to your expertise, which says, "You know, we're
going to ration care. We're going to take away choice."
When really, if they were held to any standard of
truth in advertising, it would be, "We won't be needed
anymore, because we won't be underwriting risks and
eliminating people from health care coverage." And that is
something that we're concerned about. (Applause)
So what we need are voices of experience and
expertise to join with us and to continue to improve what we
have struggled to put together, until finally -- before this
Congress adjourns next year -- we have passed fundamental
health care reform that guarantees every American a
comprehensive benefits package and fulfills the other
principles that the President talked about in his speech.
Thank you very much. (Applause)
DR. KOOP: Several weeks ago, on the 20th of
September, when all of these things began to become much more
publicly known, I spoke at the White House on behalf of this
plan. And the First Lady was about to go over to talk to a
number of people from both Houses of Congress on what they
called the university of health care reform."
And she suggested to me that I wait in the White
House while she went across town, and I could work the crowd.
(Laughter) And, whether you know it or not, yesterday I was
working this crowd. (Laughter) And, some of the things that
are of concern to you I have written down as questions that I
would like to pose to the First Lady, and I would like to
suggest the way that we would do it.
I would pose a question. Mrs. Clinton will answer
it. If one of you out there has a question pertinent to what
we're talking about at that moment, raise your hand and come
forward to the microphone, and we'll take one such question.
After I've done a few of these, then we will open the rest of
the day to questions from you at the microphone.
I remind you that you were given some housekeeping
rules yesterday by our President, (laughter) and be sure that
you don't violate that. I think you've only violated half of
them so far. (Laughter)
Mrs. Clinton, there was a very remarkable symposium
here yesterday on genetics. And toward the end of the
afternoon, a number of questions were raised. And I will
just phrase those all as one. And that is, how will the plan
deal with this exploding field of genetics? And just where
will genetic screening come into it?
MRS. CLINTON: Genetic screening is part of the
basic benefits package. And genetic screening and
developments in genetics will be evaluated as we currently
evaluate any new medical procedure or scientific
There will, obviously, continue to be clinical
trials and research protocols. And the health plans will
abide by those. But I think both with respect to inclusion
of genetics testing, but also with an emphasis on increased
investments in genetics research, I think this should be a
step forward from where we are today.
DR. KOOP: Genetics question, near the microphones.
DR. RIMOIN: I'm David Rimoin from Los Angeles.
With genetic diseases, many of them are extremely rare, and
there are only one or two places within the country that
currently have the expertise to deal with them. How will the
allied health plans be able to be forced to send their
patients for such expert help?
MRS. CLINTON: Well, I think just as many insurance
policies now provide for referral to specialists outside of
area or outside of plan, we're not leaving that to chance.
We are putting in a point-of-service option referral.
And, just as now, there probably will be some
disputes over specific referrals, but we will establish the
general principle that merely because one is an enrollee in a
health plan does not mean that one cannot be referred to the
highest and best treatment center that is available for
whatever the particular disease is. And that is something
that we intend to insist on, even with closed-panel HMOs.
DR. RIMOIN: Thank you.
DR. KOOP: I think the point-of-service option that
the First Lady referred to in her prepared remarks should
settle a lot of the questions that you people asked me
yesterday that are based on that exact same principle.
The next question that I would like to ask is, you
have said, Mrs. Clinton, that a person can follow his or her
doctor into an HMO, for example. But, by the age of 50, many
of us have several specialists. We may have accumulated a
cardiologist, a surgeon. We have physicians that we think
are our own. So how can these professional relationships be
MRS. CLINTON: Well, I think that, with respect to
the multitude of specialists that some patients have, there
will always be the fee-for-service network. That's another
one of the failsafe guarantees that we are putting into the
There will also, we believe, be an explosion of the
networks of physicians, again, which will not be able to
discriminate against physicians who wish to join them plus
Now, I cannot guarantee that you will be able to
follow every single one of your specialists, if you have a
multitude of them, if you do not go into the fee-for-service
network. But that's one of the reasons we're having the
fallback position on the fee-for-service network, so that
that will be able to be continued.
And for Medicare patients over 65, who certainly
have a tendency to have more specialists, that current system
will remain a fee-for-service network for most recipients.
DR. KOOP: Will physicians be permitted to join an
HMO or a PPO, for example, and maintain as well, a fee-for-
MRS. CLINTON: Yes. Yes.
DR. KOOP: That should answer a great many
questions that I heard here yesterday. (Laughter)
MRS. CLINTON: Now, you know, clearly the HMO will
be able -- if it's a closed-panel HMO -- to limit which
doctors it will have on the panel. But that is not going to
be a reciprocal limitation. The doctors will be free to
join, if they choose. This is not required. It is if they
choose to be, as well, in the fee-for-service network.
DR. KOOP: A question pertinent to this? Yes, sir.
A PARTICIPANT: Yesterday's Wall Street Journal
said that a provider -- under the plan proposed, the provider
may not charge or collect a fee in excess of the fee adopted
by an alliance. Is that a true statement as regards the
MRS. CLINTON: Yes, but there will be fee
reimbursement negotiations done within the health plans
within an alliance, not the alliance so much as at the health
plan level. But the alliance will be setting some kind of
And under those targets the physicians in the
various forms of health plans will be negotiating their own
reimbursement rates, so that, for example, a fee-for-service,
as I referred earlier, the physicians will be able to
participate in negotiating what their reimbursement level is.
The alliance won't be doing that. The alliance
will be setting out the big picture. You know, here is what
we intend to spend on health care in this region. And then
the individual health plans will be setting their own rates,
but within that budget target.
DR. KOOP: I think the concern brought forward was
that the fee-for-service network couldn't survive with that
MRS. CLINTON: You know, I don't believe that,
based on what we have looked at. We've looked at a number of
-- if you take, for example, those communities that I
referred to earlier, where you have a 3:2 or a 3:1 or 2:1
ratio of what it costs in Medicare compared to what it costs
in some other community, there are many communities where the
fee-for-service network, or the fee-for-service rates, are
very close to what you would find at an HMO or a PPO.
There will be some communities for whom this will
be a major change. I don't want to mislead you. I mean, if
you practice traditional fee-for-service medicine in some of
our regions -- and I'll just name names.
If you practice in Miami, where you charge, on
average, three times more than San Francisco, a city of
comparable cost, your fee-for-service charges may not be able
to be as high as they are now in competition with HMOs or
PPOs that will see a terrific market in that community.
So it's going to depend very much on what the level
of cost is now, what the practice style is now. And that's
one of the reasons we're trying to get out and talk about
this, so that physicians and others can begin to evaluate
where they stand right at this time.
DR. KOOP: I asked a question a moment ago from the
patient's point of view. I'd like to turn it around through
the physician's concern. If, as we expect, the adoption of
the Clinton Plan leads to an increase in the number of HMOs,
PPOs, and so on, and if a large number of doctors in the
community move into such organizations, what will happen to
those physicians who are unable to find a slot in such an
MRS. CLINTON: They will be in the fee-for-service
network, or, I think, there is a -- unless we're dealing with
-- let's put aside people who, for professional reasons,
nobody wants. (Laughter) One of the things that we're going
to be asking all of you is to perhaps take a little stronger
stand against some of your colleagues that you have basically
let go by for years, because you weren't involved with them.
As everyone in this room knows, the stories that I
have heard over the last months about, you know, you don't
think the fill-in-the-X physician is doing what should be
done, but there's no real way, or no real incentive, to do
anything about inappropriate or unnecessary care -- or fill
in the blank.
So certainly there will be some who, for
professional reasons, people don't want. I don't think
that's all bad. There will, however, be protections against
discrimination that is not related to professional
competence, but is related to gender or race or minority
status of some kind.
But that does not guarantee that every physician
will have a place in every organized delivery network that is
going to be available. Again, that physician, though, will
have to be considered as a member of the fee-for-service
network. So there's going to be a sorting out.
But one of the things that I have been pleased by
in recent conversations is that a number of these ideas about
organizing delivery networks are certainly not new with the
For example, the Catholic Hospital Association had
adopted its reform proposal during the two years before my
husband was elected. It relies on networks. It relies on
willing physicians working with hospitals, working with other
providers to create organized networks of care.
Now, it may be that what is often said about
lawyers is true about doctors -- that trying to organize them
is like herding cats -- and I appreciate that. (Laughter)
But I think there is such an opportunity here to get ahead of
what is happening, and to not just wait to be purchased or to
be moved into some kind of large delivery system, but to take
And again, just sort of speaking out of school, I
think there is an incredible opportunity for academic health
centers, because you are the most respected institution in
most communities. You carry with you the validation and
credibility that would be impossible to buy by most others
who are going to be organizing networks. So I think there's
a real opportunity there.
DR. KOOP: Would it not also be possible for a
group of physicians who felt that they had not gotten into an
HMO in time, to themselves form?
MRS. CLINTON: Absolutely. And because individuals
are going to be making the decisions, individuals are going
to be looking at criteria that are not all related to bottom
I mean, it's going to be choices based on cost,
certainly, but quality, familiarity, and -- I just, again,
would stress that individual physicians, individual clinics,
individual hospitals, have such an opportunity now to join
together to figure out how best to do this, and that I would
urge that some thought be given to that.
DR. KOOP: Dr. Relman has a question on this issue.
DR. RELMAN: Mrs. Clinton, I'm delighted to hear
that you are concerned about making it possible for
physicians to form organizations of their own -- perhaps with
a community hospital -- to form a health plan.
Are you going to encourage not-for-profit plans?
Because, if you want to, it seems to me that you're going to
have to deal with the problem of start-up capital.
MRS. CLINTON: Yes.
DR. RELMAN: As you know very well, the investor-
owned insurance companies and many other businesses are now
actively shopping for group practices and HMOs and individual
practices that they're buying up all over the country. It's
a great wave of acquisitions of physicians' practices.
And if the administration wants, as I know it does,
to encourage independent physician organizations that will be
not-for-profit, you're going to have to think about some way
of giving them start-up capital that won't require such
terrible risks that not-for-profit, community-based
organizations are not able to assume. And I've suggested the
possibility of grants -- maybe reimbursable grants. I hope
you will consider that issue.
MRS. CLINTON: In fact, we have. And I appreciate
that recommendation. We are putting into the plan a
revolving loan fund and grants to do just exactly what you're
talking about, because we know there are capital barriers to
But don't sell yourselves and not-for-profits
short. There is a tremendous capacity for entrepreneurial
adjustments within the not-for-profit and the mission-driven
provider world that -- you know, again, as an outside
observer -- I think is not being fully appreciated.
One of my big fears is that too many physicians and
hospitals -- particularly community and not-for-profit --
will not realize their own potential and will sell out,
basically, to the investor-owned and the for-profit.
And so we're trying to provide incentives -- not
only financial, but also legal, with the anti-trust changes
and the like -- that would enable you to form your own
networks. But we have to hope that some discussions and
planning on that will begin immediately, and that those of
you in academic health centers affiliated with community and
not-for-profit hospitals in clinics will appreciate what you
have. I mean, you are big prizes as well as extraordinary
And there is a lot that you could get in terms of
technical assistance, and limited capital infusion from for-
profit and investor that would not amount to giving up
control or turning over your entire operation. So these are
some things that I hope the medical profession will be
DR. KOOP: You alluded to the failure of this
profession to police itself adequately, and I think there's
no question about that. But the track record of people who
have tried to do that altruistic task is not a good one.
They frequently have lost out in courts, and have
ended up not only without a job, without the policing effect
taking place, but also without money. Is there any plan to
provide some kind of protection -- some good samaritan
principle -- for such people?
MRS. CLINTON: That's an interesting idea. The way
we have approached it is along these lines. Part of the
reason that the policing or the accountability -- whatever
one calls it -- may not have been successful to date is
because of our system of reimbursing almost on a piecework
basis the work that you do, and treating all of you as
And that has not created any incentives for you to
hold each other accountable. And, in fact, there has been a
tradition of basically keeping separate your business from
others. And what I have hoped is that because -- if we form
these networks, each of you will have a stake in both the
quality and financial outcome, because every year citizens
The decision they make one year may not be the
decision they make another year, which is another reason why
I hope that doctor/provider groups and others form these
networks, because I predict there will be evolving decision
making and that it will, over time, trend toward the more
not-for-profit community-based systems, if they are there to
be taken advantage of.
If you, however, have this kind of joint
responsibility, then all of a sudden decisions that were no
matter to you become of consequence. And I'll just give you
one example that I have used before, because I was so struck
The hospital administrator of a large hospital in
Ohio told me that many of the people on his staff were
concerned about a particular surgeon admitting patients for
care which they didn't think was appropriate. But nobody
felt it was in their interest -- either professionally or
financially or any other way -- to say much about it.
And when confronted, the surgeon just basically
said, "I'm going to do what I want to do." And the net
result was the hospital administrator and a number of his
medical staff were feeling very frustrated because they had
no tools with which to carry on the conversation with this
In our system, there will be some kind of
accountability and sharing of responsibility that will enable
all of you to have more of a say in what your colleagues do
or don't do. So those are the kinds of approaches -- the
good samaritan idea is one that we will look at, Dr. Koop.
I'm not aware that we have included that.
(End of side 1)
DR. SHERDER (phonetic): -- Joe Sherder, family
physician in San Diego. As you talk about physician networks
and some doctors being left out, our problem is not
incompetence, but an oversupply of specialists. We find
that we have as many as twice as many specialists in a given
area as we need for our population. The overspecialization
has been described as the invisible driver of health care
How do you propose to reform medical education in
that area in terms of reimbursement for medical education to
correct the problem?
MRS. CLINTON: Well, we are as concerned about that
as you are. And what we have proposed is that we begin to
fund at a higher level medical education for primary and
preventive care physicians -- including internists,
pediatricians, family practice physicians, and others -- and
that we de-link some of the reimbursement patterns that have
funded medical education over the last 20 years from
providing only funding for subspecialists.
We have gotten the system we paid for. Every time
somebody tells me that we're going to impinge upon the right
of young medical students to go into subspecialty X, my
response is, "Why do you think, over these years, this young
medical student chooses to do that?"
Medicare, for years, has been funding that
subspecialist. You all have been able to hire terrific
people, exciting new ideas, more money coming into that area
-- which is very attractive to these young medical students.
We have turned our back on primary and preventive
health care. We've done it not only in medical education,
but in the reimbursement system and Medicare. We have said
to internists, or to pediatricians, "You're not going to get
paid what you should get paid for clinical time with
patients, which we know is important for your diagnostic
needs. Unless you can figure out something to bill for, it's
I mean, we have just done this backwards. So it is
absolutely clear, we have got to begin to bring more primary
care physicians into our system, both through changing the
incentives in medical education, changing the reimbursement
patterns, and trying to provide incentives like loan
repayment and the like.
And for those who will say that's unfair to
specialists, please take a look at the overall system. It is
not unfair to specialists to try to right a balance that is
undermining our capacity to deliver quality health care so
that specialists are not providing both primary care and
specialty care, which too often is the case.
DR. KOOP: I have many more questions that you
asked me yesterday. But, in fairness, we wanted to spend
half the time taking questions from the floor. I would like
to do that now, and would turn to Dr. Jonathan Rhodes
DR. RHODES: Mrs. Clinton, I find broad support for
your program, but lingering doubts as to the financial
viability of it. Those of us who are older remember, in the
'60s, projections of the costs of Medicare and of Medicaid,
which were shown later to be far too low.
In the event that the projections of this program
should not be as favorable as they have been predicted to be,
would the funds which will be raised under the deficit
reduction legislation be available to bridge the gap?
MRS. CLINTON: Well, Doctor, let me just say a few
words about the financing, because you raise a very important
question, and it will be at the key -- it will be at the
center, and one of the keys of what we do.
We know that there are going to be some evolving
assessments of what any of this will cost, no matter what
plan we were to choose, no matter how we were to design it.
We know that. And we've watched other countries with
different kinds of plans, whose costs have gone up faster
than anticipated in some respects, as well.
But what we believe is that there is sufficient
funding in the plan to do what we are talking about, but
that, clearly, one can always go back to the Congress, in the
event of shortages or needs that aren't being met, and
increase whatever the amount of money needed would be.
We do not want to extend that invitation without
some very careful planning, because part of the reason we are
in the situation we are today is, as you rightly point out,
starting in the 1960s we created a program in the Medicare
and Medicaid public sector that far exceeded any cost
projections. And at the same time, we had an explosion of
costs in the private sector.
Our attempt to bring down the rate of growth in
both of those, we believe, will succeed. But in the event
they do not, yes, there is deficit reduction projections in
this plan that certainly could be altered in the event of the
need for more money.
DR. KOOP: Over here now, please.
A PARTICIPANT: Madam Chairman, I commend your
wisdom and commitment. I'm concerned about the possibility
under managed care, managed competition plans -- both notable
oxymorons -- for exclusion of special populations -- special
populations in terms of their historical, social, and health
I'm speaking about the persons in the inner city
whose physicians traditionally have not been associated with
medical associations, or on medical staffs. I'm talking
about the community clinics. What will happen there?
And I'm particularly concerned about what I hear --
that this plan will not embrace people in correctional
institutions, which should be a matter of some concern, as
they are imminent incubators of tuberculosis, which may be
MRS. CLINTON: Thank you, sir. Let me answer your
last question and then go on to your more general point. The
plan does not include incarcerated persons. Even though
every citizen will have a health security card and be
entitled to the comprehensive benefits package, during their
term of incarceration they will be treated by whatever the
correctional systems health care plan is.
The reasons for that have to do with everything
from security, transportation, access -- there's a long list
of reasons. We struggled with that very hard.
But, based on advice from both city and state
governments that actually run these institutions, we
determined it was not in either the institutions' nor the
patients' interests during incarceration for them to continue
as a member of whatever health plan.
They certainly would renew their membership once
they were out. Now, that does not relieve the state, nor the
health care system, from dealing with their health care
problems, and particularly for any public health problems
like tuberculosis and some of the things that we're dealing
with right now.
I am particularly concerned about the points you
make concerning underserved populations and minority
providers. And we've done several things to try to protect
against either the populations or the providers being
discriminated against or being excluded.
For one thing, we are taking the Medicaid system
and integrating it into the alliance and health plan system.
We will no longer identify Medicaid recipients. When someone
shows up at your clinic or your emergency room, they will not
be identified as someone whose reimbursement is being
provided through a government stream.
We will also have requirements for treating entire
populations by the health plans if they choose to bid on the
services that a population defined in an alliance will need.
We anticipate -- and there was an article recently
that went in and talked to some minority providers in some of
our inner cities -- that there will be linkages created that
have never been created before between both private
practitioners, community health centers, and other community
clinics, because, for the first time, there will be
reimbursement available. There will be an incentive for
large institutions who aren't in that downtown area to want
to take care of those patients.
And then finally, with respect to managed care, I
really view managed care in much more basic terms. I view it
as making sure everybody has a doctor. And it has gotten a
bad name in some circles because of, frankly, some of the
unsavory and inappropriate techniques tried in order to wring
costs out of the system at the expense of the patient.
But last week I visited probably the poorest
congressional district in America -- in the south Bronx. And
I visited a satellite clinic that is part of a managed care
system for Medicaid recipients.
The patients I talked to were thrilled because,
when left on their own in a fee-for-service network where
there were no providers in the south Bronx, where they
couldn't get transportation to anybody else, they used the
emergency room. They did not have a doctor.
Now they come to the clinic under managed care in
the Medicaid system there. They get more -- from their
perspective -- more visits, more access, a 24-hour telephone
line where they can always get a doctor on the line.
So if we just take a step back and look at it from
a ground up perspective, it has great potential to enhance
services to underserved populations.
DR. KOOP: I would like to add one word in support
of what the First Lady said about correctional institutions.
Judging by my eight years' experience as Surgeon General,
with the Federal Bureau of Prisons that's the way to go. And
experiments have been done in the past which were disastrous
when you moved outside that system.
DR. WARSHAW: Mrs. Clinton, I'm Joseph Warshaw, a
pediatrician from New Haven. There are certain groups in the
population -- children with special needs, the mentally
retarded, the handicapped -- for whom the competition model
in the health alliances may not provide the most appropriate
What assurances will the plan have within it that
will assure those populations the kinds of care that would
provide the highest quality of service, not necessarily the
MRS. CLINTON: Well, we are not only going to
provide a comprehensive benefits package to which every child
is entitled, but we are going to continue some of the special
services that children need -- both those who are Medicaid
eligible and those who are not but who have been receiving
what are sometimes referred to as "wraparound services"
because of mental retardation or physical disability of some
So we have worked very hard on this with a number
of advocates and experts in this area. And we think we can
hold the health plans accountable. Again, I would ask you to
look at the system now.
We have good plans and bad plans. We have good
insurance policies and bad insurance policies. We have good
doctors and bad doctors. I mean, we have the full range of
everything out there now. We are not going to change human
It is going to be very important to hold these
health plans accountable, and for consumer groups and
advocacy groups with particular concerns to make sure that
people are getting those services. So we are providing them.
And we're going to make sure they're available. But we're
going to have to make sure they actually get delivered. And
that will be one of the roles of the alliance, which will be
to monitor such groups.
A PARTICIPANT: Mrs. Clinton, I compliment you on
your availability to the American Public to tell them, from
yourself, about the health care reform proposal, and your
willingness to access to the public so that they may ask
questions and bring to you their concerns.
I'm a medical educator, and I'm concerned about
preparing physicians and other health care providers to serve
in the areas of this nation that not only is there an
economic disincentive to enter practice, but also, there is a
You've traveled this great nation, and you know
that there are areas that are not very densely populated
where services are hard to get. And you've also traveled the
inner cities, such as the south Bronx. And you know the
scarcity of physicians who want to enter that area.
And I guess my question is -- as a medical
educator, as dean of one of the finest medical schools in
this country -- I would like to know what your message to me
is about how to lead our young people into these areas.
MRS. CLINTON: I thank you for your concern and
commitment on these issues. We are trying to build in
incentives to do just what you're talking about, ranging from
loan forgiveness, and additional funds for supporting
facilities in underserved areas -- both rural and urban -- so
that we can honestly tell young physicians that there's going
to be support out there.
We are working very hard to set up a series of
investments in informatics -- something Dr. Koop is very
interested in -- and in technological advances, so that it's
not just the financial disincentives that often keep
physicians from these areas; it is also the sense of
isolation from professional colleagues.
And we know we have to do better in order to
provide those kinds of linkages. And that's something that
Dr. Koop may want to comment on, because he has done a lot of
work on that.
We also believe that, with respect to most
underserved areas, we are going to have to rely on allied
professionals as well. It may not be possible to staff every
emergency clinic in rural Montana.
And Montana, for example, has adopted a law that
permits EMTs and physician assistants to staff emergency
rooms, because their view is that's a whole lot better than
nothing when somebody is brought to one of those emergency
rooms, and that it has actually proven very beneficial.
So we're going to ask for some changes in practice
parameters for some allied professionals, because we share
your concern that not only do we have barriers to overcome,
but the sheer numbers -- especially with the specialist/
primary ratio being what it is -- will make it very difficult
for the next years, until we get this thing up and going and
get the right incentives in it to be able fully to answer the
question the way I would like to. But I think we're on the
right road to it.
PARTICIPANT: Well, as an educator, if I can be of
any help, I'm offering my assistance.
MRS. CLINTON: Thank you very much. Would you tell
me what that great medical school is so that I can find you.
PARTICIPANT: Yes. I'm proud to say it's the
Uniformed Services University of the Health Sciences.
MRS. CLINTON: I know where it is. (Laughter and
PARTICIPANT: The B.F. Edward-Aberr (phonetic)
School of Medicine. And Mrs. Clinton, you might also like to
know that I am the only woman dean of a medical school in
this country -- the fourth ever.
MRS. CLINTON: You know, one thing about practice
in the military services which has been very interesting to
me is that both physicians and nurses have testified on
numerous occasions that their range of practice parameter was
so much broader in the military than it was once they got
into civilian practice.
Not just nurses, but physicians as well have told
me that all of a sudden they find themselves being restrained
by hospital or staff rules. And certainly nurses feel
terribly constrained after having gone from being very
responsible in the military system to becoming much less able
to make decisions. So I -- there's a lot we can learn there.
I appreciate that.
PARTICIPANT: We also train physicians for the
Public Health Service and graduate nurse practitioners, and
our students have a tradition of going to some places where
they are desperately needed that aren't very popular.
MRS. CLINTON: Thank you.
DR. KOOP: I'm not going to speak about
informatics, as the First Lady suggested I might. But I
don't think anybody in this room travels more than I do. And
in those travels I try to meet as many medical students as I
can. And I'm constantly pleased and amazed at how many more
altruistic youngsters are coming into medicine.
And what I find that they see in this plan is that,
having had the desire to go to a previously underserved area,
but feeling they couldn't do it because they couldn't be paid
enough, they now see an economic return that makes that kind
of a life possible. Dr. Abdellah --
DR. ABDELLAH: I represent the Graduate School of
Nursing at the University of the Health Sciences -- the
President's own university. (Laughter) Mrs. Clinton, I am a
nurse. We are preparing nurse practitioners to function in
primary care centers, and also in underserved populations.
We know -- and this has been well documented --
that nurses can provide quality care and in an economic way.
We are pleased that the health care report does recognize the
importance of the contribution of nurse practitioners.
My question is, Mrs. Clinton, can you assure us
that the support for the education of nurse practitioners
will be forthcoming, and that the practice barriers at the
state level can be removed? Thank you.
MRS. CLINTON: Well, that is certainly the
intention of the plan. I will say that we're going to have
to fight for that. That is not going to be easy to maintain
for both, what I would consider, unfair reasons, and for some
And this is an area where the Institute might very
well help us, because we need some unbiased opinion out
there, because we're going to have quite an argument, I would
predict, as to how far we should preempt state practice
barriers and whether nurses will be able to perform the full
range of functions for which many of them are now being
trained. But we intend to pursue that vigorously.
DR. KOOP: I would like to put some statistics in
here. I think the backbone of the plan that the First Lady
is talking about is really primary care physicians. And we
are woefully understaffed in those on a national basis.
And if we were to turn out from our medical schools
50 percent of each class as primary care physicians from here
on, it would take us 22 years until half of the physicians in
the country were practicing primary care. And that means
that what Dr. Abdellah has said requires some kind of stopgap
mechanism for people like nurse practitioners, physician
assistants, and so on.
But I have one warning. If both of these groups
are striving to take care of the entire problem, we have to
be able to reassess this about 10 years down the pike so we
don't end up with an oversupply of both and one of the worst
turf battles we could ever have. (Laughter)
DR. HERDER (phonetic): I'm Dr. Larry Herder of New
York and Florida, and a member of another health profession,
the dental profession, and we applaud you for your interest
in this total picture, and what a great job in communication.
Your lovely smile indicates the fact that the axiom that you
cannot have total health without good dental health.
DR. KOOP: You might tell them who coined that
DR. HERDER: You betcha. Our concern is, what was
the rationale of not having in the basic benefits package
dental care for adults. We've been struggling for 30 years
to help a whole segment of the population -- let's say under
Medicare, and Medicaid, really -- to achieve good dental
health. Can you help me with that?
MRS. CLINTON: Yes. And it is something that we
are planning to add to the package within the next eight
years -- or seven years, by the year 2000. It was largely a
question of cost.
We were able to fund children's dental care, which
we thought was very important. As you know, dentists were
not included in Medicare originally. And so the costing on
extending dental care to everyone prevented us from including
it for everyone from the very beginning.
But it will be part of the legislation, that adult
dental care will be available, as well as additional mental
health benefits, by the year 2000. And that's the way we
were -- those are some decisions we had to make based on
actuarial decision making. It's been interesting dealing
with actuaries on health care. (Laughter)
They don't believe in prevention. They think if
you let people go to the doctors early, they'll just keep
going to the doctors, even if they solve problems that might
be more expensive in the -- the only data we've got, which is
not really good, is that Hawaii, with its universal coverage
system, has a higher per capita doctor/visit ratio than the
rest of us, and lower costs.
But that's not convincing because everybody knows
Hawaii doesn't count for comparisons because it's an island.
You know, so there's all kinds of -- (laughter) -- and the
dental issue got caught up in there somewhere, so --
DR. HERDER: Well, wait just for one more second.
We appreciate your interest in the fee-for-service system as
a potential part. I come from a little county in New York
called Broome County, where we have something called Medmax
and Dentmax, which, utilizing the best capabilities of the
fee-for-service system, is now delivering care for Medicaid
We have saved, among 1,200 Medicaid patients, $1
million in prevented fees from them going to the emergency
room for what we can handle in our own office.
MRS. CLINTON: That's what will happen all over the
country if we can get this done right. Thank you.
DR. KOOP: There's one aspect of this that I think
we haven't talked about. And, in the exclusion for the next
seven or eight years of dental problems in adults, we have to
remember that there are dental complications of diseases such
as diabetes that do have to be covered meanwhile.
MRS. CLINTON: Right. And I believe those are
covered. Medically necessary -- what's the -- there's a
phrase for that. I'll check on that, Dr. Koop. But I think
that there is a coverage for those kinds of dental problems.
DR. HERDER: Yes. It is covered, but it can get
lost in the shuffle because of dentistry.
MRS. CLINTON: Right.
DR. WATTS-LUBEK (phonetic): My name is Ruth Watts-
Lubek. I'm from another island called Manhattan. (Laughter)
I'm a nurse-midwife, and we met last week, Mrs. Clinton, at
the fundraiser for Mayor Dinkins (phonetic).
But I've been involved for 18 years in giving birth
back to families, primarily through free-standing birth
centers, which we have proven works at all socioeconomic
levels, including in the south Bronx, where we have done a
demonstration which Dr. Lee will be seeing next month, and
also with rural, low-income families, as well as among the
There is a birth center here in Bethesda which
serves middle-class families. But, if utilized by only 50
percent of child-bearing families in this country, such
centers could save $4 billion annually, because the birth
center care for normal childbirth comes in at about half of
the costs of in-hospital normal childbirth.
Expansion of such community-based services will
require both construction and training monies. How will the
plan accommodate to needs like this?
MRS. CLINTON: Well, we think that there will be a
demand for birth centers. Again, this is related to how your
services will be fit in with broader networks, and the role
that nurse-midwives are permitted and encouraged to play in
I don't know, though. I don't know the answer to
whether there, specifically, is any funding available. I
don't think there is. I think that is something that is
probably not available in the plan at this time. I will look
DR. WATTS-LUBEK: Thank you.
MRS. CLINTON: Oh, Dr. Lee just corrected me. It
is in the plan. Thank you, Dr. Lee. Okay. Nurse-midwifery
training and some funding for capacity expansion.
DR. KOOP: Over here.
A PARTICIPANT: Mrs. Clinton, although budgetary
restraints will not allow, as you said, comprehensive dental
care for adult patients at this time, I think I beseech you
to reconsider at least giving emergency dental care for adult
patients, because we feel that the greatest amount of
suffering and dissemination of disease come from the
underprivileged, who cannot receive emergency care at this
time -- dental care.
MRS. CLINTON: I will check on that. I think we do
have emergency care covered. I will check on that again.
PARTICIPANT: Thank you.
DR. BOWMAN (phonetic): I'm Dr. Marjorie Bowman
from Winston-Salem, North Carolina. I'm a family physician.
And I thank you first of all for tackling this difficult
subject. And I have multiple questions, but I'll limit
myself to one.
And that is that, as you recognize, the bureaucracy
of our current system is great. The paperwork is great. But
I also note that in the new plan there are new bureaucracies
built into the plan. And I would like to hear what you think
about whether or not we would really be simplifying or if
we'll be moving from one bureaucracy to others.
MRS. CLINTON: Well, from my perspective, we're
going to be eliminating a number of the bureaucracies that we
currently have to contend with. The 1,500 insurance
companies will not survive. There will be some, but most
will not. That will save an enormous amount of time, effort,
and money in paperwork and bureaucracy.
The way we have tried to structure this is to take
away from both private and public sector bureaucracies the
need and right to micromanage independent decision making by
physicians, hospitals, and other providers. Now, the trade-
off is that we set some kind of boundaries. Namely, that we
set some kind of budget.
And some have said, "Well, you know, that's a very
uncertain prospect, to be working within a budget." But your
hospitals work within budgets, and you bust them all the time
because you can't realistically predict what you're going to
be spending on uncompensated care and other things that will
no longer be part of the day-to-day worries that you will
The health alliances are consumer- and employer-
driven organizations that are largely going to be collecting
the funds and then, at your individual direction by the
consumer, transmitting those to the health alliance that you
choose. And that can change from year to year.
So I think that there is certainly an argument that
what we're doing will be limiting bureaucracy. And it's one
of our goals to continue to be extremely vigilant about that
-- to limit it as much as possible. And it's just something
that we're going to have to be watching all the time. But
there is no doubt in my mind, we will significantly
streamline the system over what we currently have.
DR. BOWMAN: But there will be a new national
health board, a new graduate medical education board, a new
board related to academic health centers, et cetera. And I
perceive that those will engender bureaucracies related to
them as well.
MRS. CLINTON: Well, that may be. But, you know,
if we have a benefits package that's guaranteed, there has to
be some entity that will make the decision about what
benefits will be upgraded and included in years to come.
Now, we could leave that to the Congress. I don't think
that's a good idea. (Laughter)
This will take the politics out of it. But think
now. We are replacing with one board, literally, hundreds of
decision-making boards, all of them staffed, called insurance
company executives and claims agents. I mean, we are
replacing this huge infrastructure.
And it is a little bewildering to think that when
we look out at how decisions are made now, that we will not
be limiting bureaucracy. And yes, we do want some kind of
advisory board for academic health centers to get together to
make some decisions about quality and to make some decisions
about the direction of graduate medical education.
That seems to me to be a very cheap and
unbureaucratic way to help organize decision making. So
we'll watch it, and we'll see how it develops, and we want as
many of you to take a hard look at it as possible. But we've
tried to be as focused as we can about the missions that
these entities are to preform.
DR. KOOP: If you ask short questions, you might
get as many as two in. (Laughter)
A PARTICIPANT: Mrs. Clinton, your leadership is
simply inspiring. Thank you very much. I wanted to focus
for a moment on one other aspect of education. I'm the dean
of the medical school at Columbia University. One of the
things that's enabled us to educate medical students, and I
would submit that one of the -- American medicine at its
finest is the finest. The thing is to get it to everybody.
But one of the things that enables us to do it is
the fact that we've been able to educate medical students.
And as the needs change, we can change those needs. But
there has to be support of the education through the medical
I know you have streams of money. I guess one of
the concerns is that some of that money be designated for the
education of the medical students, which heretofore has been
done by cross-subsidization of clinical practice and also a
lot of voluntary teaching. I wonder if you could comment on
MRS. CLINTON: I believe that in the designated
streams, we do designate funding for medical education, as
well as for other roles we want academic health centers to
PARTICIPANT: I think one of the fine points to
make is that the educational part of an academic health
center -- the medical schools, the nursing schools -- have to
have those educational monies to make sure education gets
done in the ambulatory care setting or anywhere else we think
it should be done.
MRS. CLINTON: I absolutely agree with that. And
based on the many conversations we've had with you and others
who have been kind enough to share your time with us, we have
drafted legislation that we think will do that. And,
obviously, we want you to carefully read it and make sure
it's in accord with what we think we're doing together on
PARTICIPANT: Since Dr. Koop said I could have a
second question, I'll make it very quick. (Laughter)
DR. KOOP: Herb, I didn't say that.
PARTICIPANT: Thank you for helping destigmatize
DR. WOLHAMEL (phonetic): I'm Stephanie Wolhamel
from Cambridge, Massachusetts, and I'm not going to ask about
the details, which are really dazzling in their elegance, but
about your poor decision to embrace managed competition,
which at best -- at best -- is untried in terms of cost
containment, and also your decision to turn your back on the
single-payer system that many of us in the room have
advocated and has a proven track record not only in covering
the population, but in controlling costs and simplifying
MRS. CLINTON: Well, I appreciate that. And I also
appreciate greatly the extraordinary work you and your
colleagues have done over the past decade to raise a lot of
these issues that weren't raised before. And if it had not
been for your painstaking comparisons of Mass General and
Toronto General, a lot of these distinctions would not be
In the legislation, we are providing that any state
that wishes to be a single-payer state may choose to do so.
Now, this is a decision that I'm sure will be controversial
in some quarters. But it seems to us an appropriate role for
the states, who will be given a lot of decision making
authority in this area, to be able to choose.
And as the speaker has pointed out, there are a
number of physicians, the New England Journal, other very
distinguished observers of the medical scene, as well as
practitioners, who believe totally in the single-payer
system. There are many who believe it is totally wrong for
And we, in attempting to figure out how to create a
system that would build on what we have -- to preserve what
works and to fix what's broken with it -- have opted to
create a system which, in general, would provide accountable
health plans that would be competing on the basis of cost and
But we want to be sure that the legislation
provides for single-payer. And I anticipate, in going back
to Dr. Shine's remarks, that there will be some states that
will choose to have a single-payer system. And so, during
the next 10 years as this system evolves, we will be able to
make some legitimate comparisons.
We will have an opportunity to dispel myths, both
pro and con, of both approaches -- or all approaches,
because there will probably be more than two that you can
describe. And I think that is the realistic and appropriate
step for us to take at this time.
And I will look forward to seeing which states
choose to go in that direction, and to watch closely the kind
of support they engender and the kind of results they have.
This will be an area that we will have to fight
very hard to keep in the legislation. Those of you who are
single-payer advocates will really have to work hard to keep
this option in this legislation, because right now there is
not anywhere near a majority in either house to do anything
beyond that with single-payer. But we have to try to
preserve that option. And that's what we're going to do.
DR. KOOP: We'll take the last question from here.
DR. FRANK: I'm Ellen Frank (phonetic) from the
University of Pittsburgh School of Medicine, and I do
treatment outcomes research.
I would like to return to the last theme of your
prepared remarks, and that is to ask what provision there is
in the plan for shortening the time lag between the
publication of a treatment outcome finding and its adoption
in general practice. My understanding is that on average
now, that's about 10 years.
MRS. CLINTON: Well, we don't have any sort of
magic remedy for that. (Laughter) But you are absolutely
right, that it is a significant problem.
We think, though, that through devices such as
quality report cards, through the kind of peer accountability
we think that the networks will engender, through the kind of
small-scale, comparative research that Dr. Weinberg and Dr.
Koop have been doing -- we really think we will have better
mechanisms for getting information out, and there will be a
return to the physician or the provider for doing it.
Now, I'll just give you one example that was
brought to my attention in Minneapolis. One of the fine
clinics in Minnesota developed a procedure -- radiological
procedure for the detection of breast lumps, the mammo test.
They're having a difficult time beginning to
introduce it and utilize it, even within their area, because
there is, frankly, no incentive for surgeons to make
referrals to radiologists so that a noninvasive procedure can
be used, even in the numbers necessary to provide the kind of
information that you're talking about.
In better organized networks of care, we won't have
that kind of either/or situation in quite as stark a way as
there is now. So information coming from basic research and
applied research and clinical trials will have a more
receptive audience, because it will not be so clearly viewed
as a threat, very frankly, to the reimbursement patterns that
currently exist to continue what has been done.
And I think we're talking about big changes in
attitude to support big changes in practice styles. But
we've got some mechanisms that we hope will push that. Any
ideas you would have, we would certainly welcome to try to
enhance that transition period.
DR. FRANK: Well, thank you for that opportunity,
and thank you for all of your hard work. It's much
DR. KOOP: At the risk of being anticlimactic --
(laughter) -- there is one question that I would like the
First Lady to have the opportunity to answer, and it was
posed to me by a number of you last night, and I'd like to
put it to her just as bluntly as you put it to me.
The plan is so complicated. There is so much to
expect. There is so much possible opposition from Congress
and from lobbies. If you don't have a simple fall-back
position, isn't there a chance that we could lose it all?
MRS. CLINTON: Well, there's always that chance.
But my view is that we have to believe we're going to succeed
at this effort. The details will change. There will be a
lot of good advice -- from you in this room and others --
that will be legitimately aimed at improving what we are
trying to do, that we will be very open to.
But I don't think you bring about change in the
kind of atmosphere in which we live without enormous
persistence and commitment to the final outcome. And from my
perspective, there are certain absolutely nonnegotiable
conditions -- like universal coverage and comprehensive
benefits and enhanced quality and the things we've talked
And if we stick to those, and particularly if you
become partners in this reform effort -- and when I say that,
I don't mean that you will agree with everything that's in
it, but you will stand behind and support what we're doing,
and speak out for it -- I am very confident of the outcome.
And I wish we lived in an earlier time. I wish
that this were the Social Security instead of the Health
Security battle and that the legislation could be 32 pages
long and the President could just go around saying, "Here's
the deal. It's a new deal. You just put your money in and
we'll take care of you when you're old." (Laughter)
But we don't live in those times. We live in an
information overload time where everything is second-guessed
and skepticism abounds, and where, as a result, we do have to
present as many details as possible. But the details should
not obscure our fundamental goal, which is to secure health
security to every American, and to do it in a way that
enhances their access and quality of care.
And if we stick with that, I think we're going to
get it done. And, I don't think about fall-back positions.
I think about getting the job done. (Applause)
(End of tape.)
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