Hofstra University John F. English Health Care Symposium
Remarks by First Lady Hillary Rodham Clinton

Long Island, New York
April 20, 1999

(The audiotape of the First Lady’s speech was very difficult to hear. The following may not accurately represent Mrs. Clinton’s remarks. Please check with the First Lady’s Press Office if you plan to quote directly from this transcript.)

Thank you very much. That was an extraordinary, generous, lovely introduction. It seems also the longest I have ever heard Harold Ickes speak without any type of (inaudible).

Someone actually asked, “Why are you going to Hofstra?” And we were talking about health care, and the short answer is because Harold asked me. I did, though—for those of us who are fortunate enough to know him, call him a friend, work with him—extract a promise from him. And that was if I came to talk about health care, he would get a hearing aid. So that we would no longer have him say, “Well, you talked to me on the wrong side,” and he couldn’t hear a word you said.

This is my second trip to Hofstra, and I want to thank the president, the faculty, the staff, and the students for hosting this important symposium. I am very impressed by what I know about what goes on here at Hofstra and the work that you do, the preparation that you provide for people in the world beyond (inaudible).

I want to thank Jim Tallon for moderating this important discussion year after year. And I want to thank Bill Cunningham for organizing it and everyone from the law firm [Meyer, Suozzi, English and Klein] for making this event possible. And it is a special honor to participate in something dedicated to and carrying on the memory and the work of John English. He gave so much of himself to his firm, to his state, and to his country.

And when people talk about Jack English, they often still remember—as vividly as though they had just seen him—his passion for life, his generous spirit, his commitment to his family and community. And they all remark on the way he practiced law. In his office was a big circular table. Whenever there was a challenge to confront or a problem to solve, he would bring to that table a group of people from all sides of the issue. And he would sometimes, I am told, sit there all night until that roundtable or group (inaudible).

He would certainly have approved of this symposium because it is that kind of roundtable. It brings together many people (inaudible), but more than that it brings together extraordinary citizens who have different experiences and different interests, and the importance of them is discussed.

We have represented here labor leaders and health care leaders in the public and the private sector. We have political leaders on both sides of the aisle and health care (inaudible) young and old and everyone in between. And that is as it should be, because all of us have a stake in and must have a role in deciding how Americans prepare for the next century.

There is no more appropriate place for that kind of discussion than here in a community and a state that have long been at the forefront of trying to work out the complexities of providing quality health care to all citizens—particularly the most vulnerable among us. Programs like the Child Health Plus Program. Or New York’s program to implement the Children’s Health Insurance Program that passed by the President and the Congress in 1997. Supporting the finest academic health centers in the world. Learning how to spread the benefit, lessening the burden of trying to insure people. These are the issues that New York has struggled with, and has made great progress in meeting over the years.

We meet at a time when I sometimes am amused by what I hear in the voices of people talking about health care and medicine—a kind of nostalgia for a Golden Age that they think once existed back in the 50s and 60s or even in the 70s. Many of us here lived through that time, or at least we watched it on television. We could turn on our TV set where we could see doctors like Marcus Welby, M.D. Somehow he made a good living from his solo practice, seeing as it appeared to be about one patient a week. He never missed a diagnosis. He always had time to talk to his patients and get involved in their lives. And he never left home without that black bag.

But we know that away from the cameras, the full story of that time is that care varied greatly from place to place. And that black bag wasn’t enough often to save a patient’s life, prevent a deadly disease, or provide the comprehensive care that we all take for granted today.

I like to imagine Marcus Welby being transported through time and finding himself on the set of “ER” or “L.A. Doctors” or “Chicago Hope.” He—or today, maybe she—would have access to new treatments undreamed of for strokes and cancers. That doctor would find computers that allow us to share lifesaving information in real time. And the mapping of the human genome that is revealing extraordinary secrets that we didn’t even know were there—linking genes to breast cancer, colon cancer, and Parkinson’s disease.

If Marcus Welby brought that black bag with him into today’s world of medicine, he’d be surprised by the dramatic changes that we see giving rise to new promises—and new perils. We do see people living longer and with less disability, but we now have new questions: How we are going to care for ourselves as we age? We see people who are very active consumers of health care information—surfing the Internet, reading every health article in their paper—but often without the means, the experience, the guidance to sort out the bad information from the good. And we see the lines among payers, providers and insurers blur in our health care delivery system—giving us more opportunities to measure results and fight diseases, but raising new concerns about privacy and trust in the care we are receiving.

The fact is that if Marcus Welby were transported into 1999, he would hear from too many of those patients he’d find time to listen to their fear that they will not reap the benefits of these advances in medicine, especially when they need them most. “And what exactly,” he might ask them, “are you afraid of?” Well, if they don’t have insurance they worry about what will happen if they—or God forbid, their children—become sick or hurt. And if they do have insurance, they worry that it might not be worth the paper it’s printed on when it comes time to use.

Marcus Welby might have found himself in a movie theater or rented a video—something some of us know nothing about—to see the movie that some of you came and told me about. Remember in “As Good As It Gets” when Helen Hunt’s character said bluntly how she felt about an HMO denying her sick child care, people in theaters across America literally broke into applause. We should be concerned about our care in (inaudible). We should be concerned that people worry they don’t or can’t trust the care that they receive. And yet we also have to recognize the incredible advances that have taken place that make it possible for far more people than were able in Marcus Welby’s days to get the care they need.

A lot of attention is focused on managed care and HMOs today, and that is understandable. Since 1990, the number of people in managed care plans has grown from 94 million to over 160 million. What is the reason for that? There’s a reason why the federal government—people often don’t remember—in 1973, actually provided financial assistance to help foster the growth of HMOs. Because we knew as a people back in 1973 that managed care, when done right, can help us improve care and lower costs. And we know that most of us (inaudible). So we don’t want to turn the clock back—back to the day of blank checks and unchecked growth.

What we do want, and what I feel and I believe that people around the country feel, is that somehow we have to restore the balance back in the direction of reinforcing the relationship between the patient and the doctor or nurse. So we can embrace the progress we’ve made, while treasuring and valuing what we liked about the past. Because when people talk longingly about the Golden Age of medicine, they really do not want to take a trip back in time—with all the drawbacks that we can remember—but they do want to once again feel that sense of trust. Trust that life or death decisions are being made with their best interest in mind; trust that their doctors are equipped and enabled to make those decisions that really meet the needs of the individuals; trust that when they go into a hospital they will get the nursing care that they need and deserve.
Trust, in other words, that really binds us together as a people in any society. And you’ll need more trust when you face health care decisions than at any other point in our lives.

So how do we make sure that we have that trust and that what we do when we face the challenges of the health care system will help and not undermine those decisions? Well, we can start by making sure that whether someone chooses managed care or traditional pay-for-service care, they receive quality care. They receive what they are entitled to and what they trust they are getting when they pay for their insurance, when they visit their doctor, and when they are checked into their hospital. That means that they have the right to access a specialist when they need a specialist. They have a right to continuity of care with people who they trust to care for them. They have the right to some assistance to appeal a decision that their doctors have made that they believe breaks that bond of trust and denies them the care to which they should be entitled.

In the federal health care system, the President has ordered that fundamental consumer protection be extended to veterans, federal employees, and Medicare and Medicaid beneficiaries. But every American needs to have that kind of trust as well. Well, one of the ways to restore trust and create the conditions we need for ensuring that people feel that health care system is caring for them is to have what is commonly referred to as a Patients’ Bill of Rights.

There are many examples, and we can take a poll in this auditorium and find stories galore about people being diagnosed with cancer and making the difficult decisions they need—the surgery, the chemotherapy, the radiation. Growing to trust and depend on their doctors and nurses; putting their lives literally in the hands of these people. Being told that their employer is switching plans. Or a network drops their provider, that they have changed that care in the middle of what to them is the most challenging, difficult time in their lives.

We’ve heard countless stories like that. It is not the anecdotes or the stories that should guide our desire to make sure health care works well in the 21st century, instead it should be the trust that must underlie any health care system and any reforms that we propose.

I think about a woman named Mary Kuhl, whom you’ve met, whose husband died at the age of 45 after being forced to delay critical heart surgery. Doctor after doctor said he needed the surgery, but no one in his plan could perform it. The plan kept telling him that he couldn’t go out of the network. Well imagine what message that sends—not just to the family involved, but to everybody else in that network, everybody else in the health care system—when you have medical opinion on one side and the decision to deny that medical attention on the other. Eventually he was offered the opportunity, but it was too late. His heart had deteriorated so much that he could not withstand the strain of the operation. His only option was a heart transplant—but that did not come, so he died.

Now when you think about this case, or any of the people picked from our common experiences, the care is eventually covered. The decision is eventually made for professional medical treatment. But you know in health care, like in justice, care delayed is often care denied. (Inaudible.) If we don’t trust the entire system in order to be making difficult decisions understandable to people—we have blatant examples that no one is able to explain or understand. So rebuilding trust means that when, in those rare instances—and they are rare—Mary Kuhl and her husband and others, when the system seemed to break down, then there does need to be some kind of accountability. Doctors are liable for medical malpractice; hospitals are liable; in fact, toy companies and automobile manufacturers are all liable; and unfortunately I believe that HMOs should be liable as well. It’s not a call for more litigation—which none of us would wish on anyone—it is instead a recognition that until we find a better way to make sure trust is at the center of that relationship, that accountability and the way we in our society define accountability, can I exempt any (inaudible).

We also have to make sure that when accountability occurs that there is some remedy. For example, if you were to need a mammogram, but your plan wouldn’t authorize one—maybe they take a cut-off that if you’re not 50 yet you don’t need one. (Inaudible.) And you wait. And six months later, finally you get a mammogram. And that lump that you felt but weren’t sure about—you find your worst expectations—is cancer, and if the screening had been done earlier, it might have changed the course of treatment.

Well if all that were to occur, what would you be entitled to from your health plan? Not the cost of lost wages or compensating the family you leave behind. But under the current law, only the cost of the original mammogram which you no longer need. Now most HMOs, (inaudible), will do the right thing. But in order to have trust in the system, we have to have an incentive so that every HMO, every health plan, understands what (inaudible).

And add to the cost—because we know that every decision in health care has some cost—a recent study by the Congressional Budget Office found that if we were to implement the full range of consumer protections under the most widely defined benefit protections of any patient’s bill of rights, you would find an increase in cost of about $2 per month. There may be ways of spreading that through the system, but indeed it would at least provide some level of trust and confidence.

But we can’t do that, or anything when it comes to health care, if we don’t build bridges among one another, if we don’t try to take the partisanship out of the health care debate. That’s one thing Jack English spent a lifetime doing: building bridges between Republicans and Democrats. He also built them between Democrats and Democrats, which based on my experience is sometimes even harder. But he never gave up in trying to bring people together behind that (inaudible). As you know, when you go into a hospital, there aren’t separate beds in wards for the Democrats and Republicans. And when you come to a symposium like this and listen to the distinguished panel, the problems that they see are very similar regardless of (inaudible).

(Tape briefly shuts off.)

No American should have to worry or not have trust in the system to compile and transmit information about medical records. And no American should have to worry that his or her medical records will be used to violate their privacy. Or that if they were to take some test that was medically necessary to them, that the results of that test could be used to discriminate against them in keeping and holding jobs for insurance.

We also need that level of trust and consensus to decide what we will do about the 43 million people in this country—including 3.1 million in New York alone—who have no health insurance. Now there are many reasons why people are not insured. And Carol reminded us in her remarks, some of you may recall, that I got an idea or two about this topic back in 1993. Now clearly that approach did not work. And we’re not going to try that again, that’s for sure. But none of us should give up on the effort to keep working together to find a way to provide insurance for all Americans. So when people ask me if I am discouraged about the defeat of health care reform, I say, “Yes, I was disappointed that we were not able to make more progress.” But when I learned—and all of us learned—about what is possible in the political environment, that there are maybe small steps we can take, I think it is an abdication of our responsibility not to continue to move forward.

So I come from the school of smaller steps now. The belief that making smaller changes, incremental changes, that will help some people is better than walking away and saying it’s an insoluble problem and there is nothing we can do about it. I feel that way particularly because of the groups of people in our society who find themselves uninsured.

Who are they? Well, about a quarter of them are children. Now these are children who, by and large, are in families that work for a living, but are not poor enough to be eligible for Medicaid. But they don’t have a working parent who either is given insurance at their place of employment or can afford insurance. These young children are less likely to receive care when they are injured and they are more likely to be sick as newborns.

Now we can say, “Well, that is the luck of the draw.” But we all know that nobody acts in a vacuum; some of us are stronger and healthier and others are not. I don’t think that’s what we believe in around here. I think part of our credo as Americans is the belief that we want to give people a chance to be all they can be. And what is more important than one’s health in the very beginning of one’s life?

Now we’ve made some progress on this. In 1997, the President proposed and the Congress passed a program that was funded with tobacco taxes of $24 billion called CHIP—the Children’s Health Insurance Program. And it represents the largest expansion of children’s health care since Medicaid was enacted. It includes a major public-private campaign to reach parents and everyone else who is in contact with children so that they can tell a family that doesn’t have insurance that they now may be eligible.

I’ve met so many of these parents. So many parents who both, or one or both of them, are working or maybe a single parent working as hard as he or she knows and they just can’t insure their children. One woman I met I thought summed it up best. She had two boys who wanted to play sports. She didn’t want to say no because they loved sports, but she didn’t want to say yes because she didn’t know what would happen if they got hurt. She felt like she was walking on eggshells the whole time. So since 1997 we’ve had in place the funding for and the states are putting into operation the programs that translate that funding into outreach for these families and children. And I am pleased to be able to announce today that, after its first full year, almost one million more children in America have health insurance thanks to the new CHIP program.

But that leaves about 9 million uninsured. Some of those children are eligible for Medicaid and should be encouraged to apply if they are eligible. Others should be reached through the CHIP program. I am very pleased that here in New York, these initiatives include messages in a number of languages that are playing on the radio. Everything from Greek to Russian to Albanian to Creole to Chinese.

And in other states and cities, they are developing ways of reaching out to hard-to-reach parents. I was in Chicago last week with the Mayor. Every time they have a yearly kick-off for report cards, they are registering kids. In Florida, they now have easy to understand sheets to give out at immigration offices and other places where people who might not know what their rights are meet. So there is a lot of creativity, but we have a long way to go before we meet the needs of all of our children.

I’m also concerned that the Medicaid program is not being given the support that it needs in many areas where it should be. Because for everyone who is eligible for Medicaid, they should be told that they are. We’ve heard some disturbing stories recently about people who are automatically dropped by the computer from Medicaid when they go off welfare. Now that is a catch 22. One of the reasons that I supported welfare reform is because I believed it would encourage people to be responsible for themselves, to get the opportunities, education and training they needed to be self-sufficient.

But I conditioned my support on the continuation of Medicaid for people who were making that difficult transition into the world of work and independence. Because it is a terrible dilemma if you have child—as many children on welfare have—with various diseases and ailments, often chronic like asthma. And all of a sudden you’re feeling good about yourself because you’ve got that job, you’ve held it for months, maybe you even got a raise and some encouragement to go forward. And suddenly you’re dropped from Medicaid, which means your children can no longer get the health care that they need. People who are told they must search for work to get their health benefits are left to believe they are no longer eligible and are otherwise discouraged from finding Medicaid—they will not be the kind of independent, self-sufficient citizens that we want in this country.

If these stories are true, they violate the provisions and purpose of the welfare law. And I believe that, in the last week or two, the Administration has written statements clarifying the welfare law, saying in its letters that the spirit must be followed. It would make no sense if we start with around 10 million uninsured children, and you make progress insuring them through the new CHIP program, and then drop them from the Medicaid roles. So in a year or two, we end up with more uninsured children. So I think all of us need to be diligent about how we are going to insure and keep insured our children from working families.

Now who are the rest of the uninsured? Well, the fastest growing group are people between the ages of 55 and 65. They are the ones more likely to have health problems than young people. They fall into all kinds of categories. Think of the woman who is covered because of her husband’s employment. And if he is older, he reaches 65 and is eligible for Medicare before she does. So she no longer has health insurance, yet he has Medicare; she’s in a real bind. Or think about the person who thought he would have retiree coverage, but all of a sudden the company he worked for his entire working life drops retiree coverage after he retired at 52 or 55 or 58, and he no longer has it. Or all of the older Americans who are increasingly losing their jobs—often because of plant closings or downsizing—just when they need it most.

For Americans 55 and older, the President has proposed that you should be able to buy into Medicare. And if your company reneges on its commitment to provide you with retiree benefits, you should be able to get COBRA coverage until you’re 65. He proposed that in last year’s budget, and was proud to have Senator Moynihan as his lead sponsor. He proposed it again this year. And we hope that this year Congress will pass it.

Well, those are two big groups—children and 55-65 year olds. But we know that more than 50 percent of the uninsured are young people between the ages of 18 and 34. Now I vaguely remember when I was 25. And like most 25 year olds, I was not insured. I thought I’d live forever. And now, of course, being over twice that old, I wake up and know I’m alive only because I ache somewhere. And it’s very different from the way I felt all those years ago. This group of far too young and largely healthy people often do not think that a car accident will ever happen or a disease will ever strike. But indeed it does. And oftentimes, because they are uninsured, the hospitals represented here pick up the cost of taking care of them, and those costs then are uncompensated and spread to the rest of us. So thinking about some ways to try to entice such people to be insured is a good idea.

For example, a large number of this group work for small businesses which are much less likely to offer insurance. And so we’re proposing tax incentives to encourage the formation of voluntary purchasing coalitions that will help small businesses have access to affordable, quality insurance—and tax credits to help them join. And we want to extend coverage as far as we can to small businesses by making it affordable for them. There are also people, a very small group but a group that is, I think, particularly needing of our attention—a small group of people in this category who are aging out of foster care: 1,500 children in New York alone with, oftentimes, disabilities. And when they turn 18, they lose their health insurance and they lose their place to live; they’re out of the system and often on the streets.

So there are many ways that we can be imaginative about trying to really whittle down this incredibly large number of uninsured people. But if we are going to do that then we have to be sure that the health of our health care system remain strong. And that means ensuring that we take care of Medicare in the future. Again, if we were to go back to Dr. Welby’s time, it was not always a good story for older people; less than half had insurance. And Medicare literally transformed the way it is to grow older in America. Life expectancy has increased, and we’re so grateful for those additional years of good health. But we also know the problems—I don’t need to tell this audience. By the year 2035, the number of people enrolled in Medicare will double. And we have to act now if we are going to be ready for that challenge.

One thing we cannot do, I believe, is to look for further provider cuts to finance how we meet this huge demographic challenge. The growth rate of Medicare is already below that in the private sector. There is not much left to squeeze. We can do a better job, as we have done under the leadership of the President, Donna Shalala, and others in making sure that every dollar spent in Medicare is spent as well as it needs to be. But we have to be very thoughtful about how we rake in the costs so that we can afford the baby boomers’ retirement years. That’s why the President calls for us to dedicate 15 percent of the budget surplus to preserve Medicare. And in the upcoming weeks he will put forth his proposal to modernize and strengthen Medicare. One thing that it will include is a long overdue drug benefit, which is very important to millions of Americans who are still forced to make untenable decisions between the drugs they need and other necessities of life.

Another element that Medicare reform and the President will include is the continuation of the historic role of supporting our nation’s academic health centers. Our teaching hospitals are the crown jewels of America’s health care system. That’s where we train the next generation of specialists and where we conduct cutting-edge research. Often where we care for those who are the most vulnerable. No one understands that better than the people of New York who are fortunate enough to have within her borders so many of the best academic health centers.

We know that graduate medical education and teaching hospitals have been reimbursed by Medicare. And we also know that many of the health plans serving the Medicare population are not always passed on those payments. So in 1997 we made sure that Medicare payments for medical education will go directly to teaching hospitals, not indirectly through any other channel. We also are proposing this year a $40 million program to support graduate medical education at children’s hospitals so that we don’t disadvantage the training of our next generation of pediatricians.

Now, some have proposed that we separate the funding of Medicare from the funding of teaching hospitals, without any assurance whatsoever that there will be a safe and secure compensation screen. I disagree with that. If there were a better idea that would guarantee the funding that our academic health centers need, everyone would be willing to look at that. But it is imperative that if we don’t have a better idea that we continue to use what has worked.

I also want to say that it is only fair and appropriate for health insurance plans to help pay for the missions of our nation’s teaching hospitals. What is discovered in one teaching hospital can then be spread among all of us. The training of the specialist is something all of us can benefit from. Those goods which our teaching hospitals produce benefit all of us—and the cost for producing them should be borne by all of as well.

There is going to be a very vigorous debate about how to reform Medicare. And certainly there will be many ideas put forward, and already have been. But I think all of us, as we sit around this sort of imaginary roundtable, we ought to be thinking about how we improve Medicare stability to insure older Americans without jeopardizing its capacity to do so and without eliminating its guarantee of benefits for tens of millions of Americans who would otherwise not be very attractive in the health care marketplace.

A healthy 66-year-old who still plays golf every week might be able to have his pick among health care plans out in the market place. But maybe five years after that, after he had a heart attack or found that he had some other disease, he might not be a very attractive risk. And what about the 88-year-old right now who has cancer or dementia? How do we even imagine taking care of this broad population of older people with so many different health challenges without making some defined floor of benefits?

I believe the burden must be on those who would change the system in ways that would jeopardize all it has accomplished. And so while there will be some tough choices and trade-offs, there are certain ideas that I think should come off our roundtable. We will not be reforming Medicare if we undermine its defined benefit. We will not be reforming Medicare if we reduce the viability of the traditional fee-for-service program. As we saw last year here in New York and across the country, HMOs are free to go or come in Medicare. And if they go, how do we then treat the vulnerable who are left without the care they have grown to trust and depend on?

And, finally, we will not be reforming Medicare if we raise the age of eligibility without providing for other affordable options. I remember at a health care forum back in 1994, meeting a woman who was 64 who had been diagnosed with breast cancer because she had gone to a free screening program. She was referred to a surgeon and, when she called to make the appointment, was asked what her insurance coverage was. She said she wasn’t currently insured, and they said, “Well, come back when you are eligible for Medicare.” And that is not an uncommon story. If we change Medicare, we have to be very conscious of the ripple effect that will have all the way down the line.

There is no better time for us to tackle this issue than now. We have a surplus; we can use that money to support the changes that will be needed. If we don’t, how will we explain our neglect or abdication of responsibility? How will we tell our children, how will we tell our future retirees—ourselves—that we thought we would just postpone that because we couldn’t get around that table (inaudible).

There are many challenges that we confront in America today, but there are also many blessings that we have that should enable us to meet those challenges. Yesterday morning I started my day talking about the crisis in Kosovo. Even in the best of times in that troubled region, people there do not even imagine health care that we take for granted here at home. And now with the incredible pressures caused by the vicious expulsion of hundreds of thousands of Kosovars, the health care crisis is one thing that is overwhelming the need of resources available in the countries that have taken the refugees in.

Today we’re talking about how to buy emergency care and try to help those people who need something that is more long term than what we can provide in a (inaudible). (Inaudible)… willing to reach out and open their hearts. Later yesterday I spoke to a group called the Children of Chernobyl. Once again Americans who weren’t living in Ukraine or Belarus when the Chernobyl nuclear tragedy occurred have learned about the terrible incidents of cancer in children and the birth defects, and opened their hearts and opened their wallets and began air lifts and talking with corporate sponsors to make sure we could do everything possible to reach out to those who were suffering. Just within the space of about 12 hours, I could see firsthand the generosity and commitment of Americans.

And there is no doubt that we have done an incredible job of providing health care to the vast majority of Americans. But as with any human enterprise, we have to be willing always to take a hard look at its pluses and it minuses and particularly the decisions that will enable us in 10 years, 20 years, and 50 years, at a symposium like this or likely a virtual symposium, be able to say we’re still doing it, we met our challenges, and we kept moving forward.

I hope that we’ll be able to say that, just as in the spirit of Jack English and the tradition of institutions like Hofstra that emphasize service as well as learning, we’ve been willing to tackle the hard choices of our times. And I personally hope that we will see the day in America, early in the next century, when no American will be without health insurance, when access to health care will never depend on the color of your skin or the neighborhood you live in or the amount of money in your wallet. And that truly that trust—because the most fundamental value of people in a democracy is they must have to get along with one another and make decisions with each other. You’ll still be the hallmark of (inaudible).

We can make that day happen if we’re willing to get around that table and roll up our sleeves and do the job that needs to be done.

Thank you very much.