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REMARKS BY THE FIRST LADY
INSTITUTE OF MEDICINE
ANNUAL MEETING
WASHINGTON, D.C.
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. (Laughter) 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 health. 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 scientific communities.
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 comprehensive reform.
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 limited. 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 achieve. 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 services. 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 risk. 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 billed for. 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 currently spending. 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 done. 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 reimbursed. 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
breakthrough. 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. Yes, sir. 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 continued?
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 plan. 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 something
else. 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- service
practice? 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 network? 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 budget
targets. 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 condition. 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 organization?
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 President's
proposal. 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 the initiative. 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 line. 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
formation. 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 resources. 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 thinking about.
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 individual entities.
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 will
choose. 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 by it. 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 particular surgeon. 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 costs." 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 lost time." 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 (phonetic). 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 care burdens. 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 resurgent. 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 services. 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 least expensive? 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
kind. 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 nature overnight. 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 geographic
disincentive. 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.
(Laughter) 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 applause) 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 legitimate questions. 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) Yes, sir.
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.
(Laughter) DR. KOOP: You might tell them who coined that phrase.
(Laughter) 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 -- (laughter). 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 patients. 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
affluent. 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 this system. 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 into that. 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 have.
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 schools themselves. 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 that? 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 play. 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 this. 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 mental illness. 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
bureaucracy. 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
well known. 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 this country.
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 quality. 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 appreciated. (Applause) 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 about. 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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