


			 THE WHITE HOUSE

		  Office of the Press Secretary
		   (Charlotte, North Carolina)
_________________________________________________________________
For Immediate Release                               April 5, 1994

	     
		     REMARKS BY THE PRESIDENT
	     TO THE CITIZENS OF TROY, NORTH CAROLINA

	     
		      Troy Elementary School
		       Troy, North Carolina
	     

11:38 A.M. EDT
	     
	     THE PRESIDENT:  Thank you very much.  Kerry, you did 
a terrific job on the tour and just now with the introduction.  I 
do want to say, since a lot of you made comments about the 
basketball game, if it had come out the other way, I probably 
would have been in the Montgomery County Hospital as a patient 
today -- (laughter) -- rather than just someone trying to learn.
	     
	     I want to thank my good friend, Bob Jordan, for what 
he said and for his long friendship and support for me.  And I 
thank Congressman Hefner for representing you so well and 
faithfully, as well as for being fairly restrained last night.  
(Laughter.)  I brought all my North Carolina staff members and 
all the people that work at the White House who went to Duke to 
the game last night.  And so in our little box there were more 
people agin me than for me -- (laughter) -- which is -- but it 
was a wonderful occasion.
	     
	     This morning before we came here I met with Kerry 
and some other folks who are here who helped to talk to me a 
little bit about some of the medical problems that you face here 
in this county and in similar places throughout our country.  I'd 
just like to ask them to stand and be recognized, because I want 
you to know that I was with them before I came here, and a lot of 
what I have to say responds to what they said.  
	     
	     Jim Bernstein, the Director of the North Carolina 
Office of Rural Health and the President-elect of the National 
Rural Health Care Association; Dr. Hugh Craft is the Chief of the 
Pediatrics at Community Hospital in Roanoke, Virginia; Beth 
Howell, the Director of Nursing at your local hospital; Dr. 
Deborah McRoberts, who is one of your local family physicians; 
the Chairman of the Board of the Memorial Hospital, Hal Scott, 
who kind of emceed our event; and Dr. Tom Townsend, who is now at 
East Tennessee State University and has been a family 
practitioner for many years.  And just by coincidence, his father 
is probably the dean of pediatric practice in our state.  And I 
looked at him today, and I said, I knew a Tom Townsend who was a 
doctor once; and he said, he was my father.  (Laughter.)  But I 
didn't organize that.  I get accused of bringing Arkansas into 
everything.  I didn't do that.  (Laughter.)
	     
	     I'd also like to thank the people here at this fine 
school for taking us in.  Your principal and your superintendent 
and the mayor of Troy.  
	     
	     And I also know that these benches were constructed 
especially for this event by Jerry Holders, so I don't know 
what's going to happen to them, but I want to thank Jerry for 
making the benches available to us.  (Laughter.)  He did a fine 
job.
	     
	     I've been working on the issues that we talked about 
today and the things that you heard about today from the previous 
speakers for nearly 20 years now since I was first elected 
attorney general of my state in 1983, or -- excuse me -- in '79 

when I served as governor for the first time.  My wife and I 
started a rural health initiative, trying to connect our 
children's hospital to all of the rural hospitals in the state, 
and deal with a lot of the issues that you've done so well with 
here in North Carolina.
	     
	     In 1990, after years of dealing with the headaches 
of the Medicaid program as a governor, I agreed to work with the 
then-Republican Governor of Delaware, who is now a congressman 
from Delaware, on a Governors Association project, trying to 
figure out what we could do at the state level to deal with some 
of the terrible problems of health care -- the rising costs, the 
strain on state budgets, the lack of reimbursement, the high 
infant mortality rates in a lot of rural areas, all the -- and 
the lack of doctors.  And after I worked on this for sometime, 
and after I had been involved in this issue for a very long time, 
I came to the conclusion that a lot of the problems of the 
American health care system simply could not be addressed in the 
absence of a national effort to reform the way -- primarily the 
way we finance health care and the way we provide health care 
professionals in America.
	     
	     There's so much that's good about our health care 
system, and that which is good is the best in the world.  So the 
trick is, how to fix what's wrong and keep what's right.  And 
that has been the great debate in which we have been engaged.  
	     
	     Over the last year or so, through the First Lady's 
task force, we have asked for the help of literally thousands and 
thousands of doctors and nurses and other health care providers 
and consumer groups to try to give us some sort of insights into 
what we should do. 
	     
	     But the main point I want to make in the beginning 
is that my roots are in a county a lot like this one.  And I 
sometimes think in Washington, we lose track of the human face of 
America's problems and America's promise.  And I'm deeply 
grateful to be here today to see both of those things.
	     
	     First, let me say that rural America has a lot of 
folks who either don't have health insurance, or who have very 
limited health insurance.  There are a lot of small 
businesspeople, there are a lot of farmers, there are a lot of 
self-employed people who have enormous difficulty with insurance 
policies that often have lifetime limits, very high deductibles, 
big copays, and premiums that go up every year. 
	     
	     A lot of citizens I have met around this country 
have really told me of the decisions that they make on an annual 
basis about whether they can even afford to insure their family.  
Seventeen percent of rural America has no health insurance at 
all.  The folks at the hospital today told me that half of all of 
the emergency room business they do in the hospital are with 
people who have no insurance, who show up at the emergency room 
when the care was too late, when it's too expensive, because they 
didn't have insurance to get it on a regular basis.
	     
	     Twenty-five percent of our farm families have no 
health insurance in America.  We have to do something about this.  
If you look at where we are, you can see here, at any given time 
in America our population is roughly 255 million people.  At any 
given time in a year there will be a total of 58 million every 
year who don't have health insurance at some time during the 
year.  And on any given day, we figure somewhere between 37 
million and 40 million who don't -- go uninsured.
	     
	     There are 81 million Americans who have preexisting 
conditions.  You heard Bob Jordon talking about someone who lost 
their job with IBM and had a preexisting condition.  Now, people 
with someone in their family with a preexisting condition 
normally find themselves in one of three positions.  Either they 
can't get insurance at all; or they're paying a whole lot more 

for it; or they're in a job where they got insurance before the 
preexisting condition that they had or their spouse or their 
child developed, and now they can't ever change their job because 
if they try to change jobs, they won't be able to get insured at 
a new job.  
	     
	     That is a huge deal in a country where the average 
18-year-old is going to change work eight times in a lifetime, 
and in which labor mobility is going to be the key to our future 
economic growth, when big companies are downsizing and small 
companies are expanding.  And we already know it's harder for 
small companies to get affordable insurance.  
	     
	     Then there are 133 million Americans who have, or a 
majority of our people, who have insurance but have lifetime 
limits on it, which means that if they have serious illnesses 
they could run out of a lifetime limit.  I met a family in 
Florida about 10 days ago that had written a letter to my wife 
about their problem -- they had two sons with rare forms of 
cancer that apparently had some sort of genetic connection 
because both their boys had it.  They had a daughter that at 
least to the present time had not developed this kind of cancer.  
They had a lifetime limit on their policy and they felt the 
lifetime limit would run before the first child was out of the 
house and eligible to be on Medicaid or something, and certainly 
would clearly run before the second child would.  They had no 
idea how they were going to get care for their children when that 
happened.
	     
	     So we have to decide whether we're going to do 
something about this.  No other advanced country with the kind of 
national economy as strong as ours has failed to provide for 
health care security for its people.  And there are basically 
only two ways to do that.  You can do what Canada does, which is 
just to abolish the whole private insurance industry and pay for 
it with a tax.  We do that with the Medicare program today.  
That's how we finance Medicare, that's how we finance Medicaid.  
You have low administrative costs, but there are all kinds of 
cost problems -- cost control problems there.
	     
	     The other thing you can do is to have the mix system 
that we have and extend it to everybody.  That is, employers can 
cover their employees; employees can pay part of their health 
care; employers can pay part of their health care.  And then if 
they are very small businesses with low payrolls, you can provide 
a discount for them.  But, in other words, you just extend the 
system we have now that we're most comfortable with.
	     
	     The third thing you can do is to keep on doing what 
we're doing -- just talk about it, say how terrible it is, and 
figure we're just not smart enough to figure out how to do it.  
Now, let me just say, if we keep on doing what we're doing, a lot 
of bad things will happen.  More and more hospitals like this one 
will either -- will go under or have to really cut back on what 
they do.  You won't be able -- because this hospital doesn't have 
full reimbursement, it restricts the income that can be paid to 
the nurses; it restricts whatever incentives you can offer to the 
doctors.  You get fewer doctors, and you get doctors like this 
doctor who told me she's, on a hard week, worked over 100 hours a 
week, and in a slow week worked an 80-hour week.  Pretty soon the 
doctors are going to need doctors if you do that.
	     
	     So I really don't think doing nothing is an option.  
Every year the number of Americans -- we lose about -- about 
100,000 Americans a month lose their health insurance 
permanently.  So the problem will get worse not better.  There is 
a perception today, I think in the nation's capital that maybe 
the problem won't get worse because there's so much managed care 
that inflation in medical costs overall has gone done.  Well, it 
has.  It always goes down when there's the threat of real health 
care reform.  But for small business people and farmers and a lot 
of individuals, health insurance has not gone down.  It's still 
going up quite rapidly.  And a lot of people are still losing 
their health insurance.
	     
	     So we have to deal with the fact that there is 
plainly a crisis.  I think that we ought to make the choice of 
guaranteed private insurance, because as a practical matter, I 
don't think we ought to just shut down all the health insurance 
companies in the country and figure out what all those people are 
going to do for a living; and the figure out how to substitute a 
tax for health insurance premiums when most people have health 
insurance; and you could make the health insurance work better 
for small business people.  People in government and big business 
today normally have pretty good health insurance systems, and 
their inflation rates have come down within inflation -- the 
inflation rate generally.
	     
	     So I think the simplest way is simply to guarantee 
private health insurance to all Americans.  That's what our plan 
does.  It says, every American should have health insurance that 
can never be taken away.  That if you work, employers and 
employees should make a contribution that health insurance plan.  
If you don't work, the government should pay.
	     
	     Now, we're paying anyway.  If somebody shows up at 
this emergency room and gets care, when it's too late and too 
expensive, you're going to pay one way or the other.  Either the 
hospital will have to find a way to pass the costs along to the 
other payers; or if the hospital can't do it, you pay for it in 
terms of reduced services, fewer doctors and terrible financial 
strain on the hospital.
	     
	     When everyone is covered, it reduces all this 
incentive to shift costs, and it provides the funds that you have 
in medically underserved areas that you need so desperately to 
hire more doctors and to keep the people that you have.  I think 
that is terribly important.  
	     
	     There's another thing that's important about it, and 
that is when everybody has health insurance, then you can use 
more preventive care and you can have more primary care.  Almost 
all of us were raised on that old adage that an ounce of 
prevention is worth a pound of cure.  We ignore that almost 
entirely in health care. 
	     
	     You have here -- the infant mortality rate in this 
country is well above the statewide average.  Why?  Because you 
have a whole lot of pregnant women who only have seven prenatal 
visits when they ought to have 12.  Who have low birth weight 
babies who have problems.  That has to be addressed.  Because we 
do not do enough in this country to do enough primary and 
preventive work in health care.  
	     
	     We have great high-tech medicine.  If you're really 
sick, we do more in medical research than any other country.  I 
don't propose to stop that; in fact, our plan would invest more 
in it.  But where our real shortcoming is, is in primary and 
preventive care.  So I think that is very important.
	     
	     Now, the second big issue that I think we have to 
face is this:  What kind of system are we going to have from the 
point of view of the patients?  And should you have or not have a 
choice of the doctor or a medical plan you buy into?
	     
	     This is a big issue.  I don't know how big an issue 
it is in Montgomery County, but I can tell you now that slightly 
less than half of the American people who are insured at work 
have a choice of more than one plan now.  More and more employees 
are being required to buy into whatever plan that the employers 
decide it's the only one that he or she can afford, and there's 
less and less choice in these plans of what doctor you visit, 
what hospital you visit, and what you do.  That is a big issue.
	     

	     So I think that one of the things that I would like 
to emphasize is the need to have choice -- not only insurance 
that can't be taken away, not only comprehensive benefits, not 
only no lifetime limits, but under our plan, if it passes, the 
way we have proposed it, people will be able to have a choice 
every year of at least three different plans.  You can join an 
HMO, you can have a fee-for-service practice.  And if you're in a 
rural area, that may be the only option you have, just to go 
through the same system that you have now.  Or there will be at 
least one other kind of plan offered; maybe a mix between the 
two.
	     
	     I think that's very important.  Most Americans 
believe that they should have some say over their own health 
care.  And most Americans believe that the quality of health care 
will be increased if their choices can be maintained.  And I can 
tell you that if we do nothing, if we do nothing for a couple of 
years, anyway, people who get their insurance through big 
businesses and through government, like I do, will continue to 
get good health care at reasonable prices. 
	     
	     The price of that will be, putting price squeeze on 
everybody else, which means that teaching hospitals, for example, 
which are very important in rural areas to support you, will find 
it harder and harder to get adequate money, and it means that 
people who are small businesses, and people who are self-employed 
will pay higher and higher premiums.
	     
	     One of the great raging debates we're having now is 
in the small business community, about whether it will be 
terrible for small business to have to insure their employees if 
the small businesses don't do it now.
	     
	     Well, the Director of the Small Business 
Administration, Erskine Bowles, from North Carolina is here with 
me today.  He spent 20 years helping to organize small 
businesses, get them started, help them expand, and he's one of 
the strongest advocates of our health care program, because he 
knows most small businesses already insure their employees; don't 
get the insurance that they want; pay higher premiums than they 
should; and that the small business sector is going to be in 
worse trouble if we don't do something than if we do.  So I think 
that this whole issue of having more choice is very, very 
important. 
	     
	     Let me also mention something else.  If you're going 
to have comprehensive benefits and the right to choose your own 
doctor, then it seems to me we also have to outlaw some insurance 
practices.  Let me just talk about this.  Today, insurance 
companies, as you just heard the story, can drop people for 
nearly any reason whatever.  Under our plan, insurance companies 
couldn't drop coverage or cut benefits, couldn't increase rates 
just because you've got somebody in your family who's been sick, 
who's got a preexisting condition, couldn't use lifetime limits, 
and couldn't charge older people more than younger people just 
because they get older.  
	     
	     Now, how are we going to do this and not bankrupt 
the insurance company?  The answer is you've got to cover 
everybody, and you've got to make it possible for insurance 
companies to make money the way grocery stores do -- to make a 
little money on a lot of people instead of a lot of money on a 
few people.  That's what community rating -- you hear this --when 
hear all this talk about community rating, you hear all these 
words that may not mean anything to you, that's all community 
rating means.  
	     
	     Why do you think people in government --if you 
belong to the federal employees health insurance plan, why do you 
think we have a good deal?  Because there's a whole bunch of us.  
It's as simple as that -- they're just a bunch of us.  And we can 
get a good deal.  And we can get a good deal whether we're the 
President in Washington or whether we are the Postmaster in Troy.  
If you buy into the federal health insurance plan, there's a lot 
of us.
	     
	     So to make it possible for us to cure these 
insurance abuses and have it really work in a town like troy, or 
for a small business person or a farm family, you have to be able 
to put folks in large pools.  That's what community rating means.  
That's all community rating means is you make money -- insurance 
would make money the way grocery stores do.  And just the way 
grocery stores have to allow for a certain amount of broken 
merchandise or stale bread or people making off with olives or 
whatever, if you've got a big enough base, then if you get a few 
people who are real sick, you can speak it over the base and 
people can still make a living doing it.  That's basically what 
we're trying to do.
	     
	     I want to come back to how this affects rural 
America in a minute.  One of the programs that does work in the 
government, I think, is Medicare.  Most people think it works.  
It's very important that the American people know and that the 
senior citizens in this county know that our plan preserves 
Medicare.  But it covers two things that are not covered in 
Medicare now.  One is the prescription drug benefit -- big 
problem.  A lot of older people wind up going to hospitals 
because they can't afford to buy medicine that they should take 
to stay out of the hospital under Medicare.  This will save money 
over the long run.  There have been a couple of studies showing 
that it will.  
	     
	     The second thing is, we begin to cover some long-
term care coverage through Medicare.  Today, basically what the 
government does is if old folks are real poor, they can get long-
term care under Medicaid, and mostly it's institutional care, 
nursing home care.  So we want to support in-home care and other 
community-based care.  
	     
	     I've already been over this -- we want to guarantee 
the benefit that work -- if small businesses have low payrolls 
and low profit margins and are strapped, we will provide 
discounts to those small businesses so that they might pay as 
little as four percent a payroll.
	     
	     People say, well, I can't even afford that.  But if 
all of the competitors have to pay, you can.  I want to point 
this out.  Seventy percent of the small businesses in America 
today provide some health insurance for their employees -- seven 
out of 10.  Almost 100 percent of the small businesses where jobs 
are growing in numbers provide health care benefits for their 
employees. 
	     
	     Health care costs of small business are 35 percent 
more than they are for big business for the same benefits -- 35 
percent more -- because they're small.  Under our plan, you won't 
ever be at a competitive disadvantage, because all of your 
competitors would also have to provide for health care coverage.  
You'd be able to get a better deal than you can now, and here's 
something else that has received almost no notice:  Our health 
care plan folds the health care costs of workers' compensation 
and automobile insurance health care cost into this.  So small 
businesses that are being killed by workers' compensation costs 
will have their workers' comp rates go down because the health 
care portion of it will be covered in the health care plan. 
	     
	     So health care -- the small business community of 
this country will come out a winner in this, not a loser, if we 
do it.  If we don't do it, what will happen is, more and more 
small businesses will lose their health insurance every year, or 
they'll have higher copays, higher deductibles, and less 
coverage.
	     
	     So let me just make one last comment about the rural 
areas.  The biggest problem I heard today here was there are not 
enough doctors.  You've got one doctor for nearly 8,000 people.  
That's not enough.  You need many more.  So do most folks in 
rural America.  Why does this happen?  Well, doctors make more 
money in cities, doctors have more support in cities, and, 
frankly, our medical schools are turning out too many specialists 
and too few general practitioners for the needs of not just 
people in rural areas, but all over the country. 
	     
	     What does our plan do about that?  Number one, it 
changes the incentives.  The federal government spends an 
enormous amount of money to subsidize the training of doctors, as 
expensive as it is.  We change our subsidy program over time to 
subsidize more family practitioners and fewer specialists.  It's 
important; we've got to produce more family practitioners.  If 
the doctors aren't there, no incentive will bring them here.
	     
	     Number two, we will dramatically increase the 
national health service corps, another 7,000 doctors over the 
next few years, to pay people's way through medical school, let 
them come out here and practice for a couple of years and pay 
their debts.  Number four, we give a $1,000 a month tax credit, 
or a $12,000 a year income subsidy to doctors who will go to 
medically underserved areas for five years, and a $500 a month 
credit to other
for five years and a $500 a month credit to other medical 
professions that will go to underserved areas.  That will make a 
huge difference.
	     
	     Number five, we help to hook these doctors up with 
new medical technical, to the medical centers in urban areas far 
away, which is very important, and we give certain tax incentives 
to make it easier for physicians to buy the laboratory and other 
equipment they need to feel good about their practice in rural 
areas.
	     
	     Now, all these things will really help the terrible 
problems I heard about today.  I'll say again, I don't see how 
your hospital is functioning with doctors where a slow week is an 
80-hour week and a fast week is 110-hour week.  There is a limit 
to how long you can expect your physicians to do that and 
function at a high level of efficiency.  You cannot do it.  So we 
have to change that, and we're going to.   
	     
	     So, in summary, we've got a plan that would expand 
the system we've got, guaranteed private insurance; keep your 
choice of doctors; provide real insurance reform in a way that 
will permit the insurance companies to function in our free 
enterprise economy and still make a profit; preserve Medicare but 
add a prescription drug benefit and a long-term care benefit; and 
guarantee these health benefits at work.  And finally, there is a 
very special attention given to the problems of medically 
underserved areas, which are especially rural America, to get 
more doctors out there, more nurses out there and keep the 
connections that physicians and other health care providers feel 
they need to folks in the big medical center areas so they can 
get high-quality care.
	     
	     Now, we don't have to do any of this, but if we 
don't the problems of this hospital are going to keep getting 
worse.  You can organize a local community effort like you are, 
and it can make a real difference.  You can raise money, you can 
do things, you can get some more doctors in here.  And maybe you 
will escape the trend.  But if the number of family practice 
doctors continues to go down, then somebody in rural America is 
going to be hurt even if you aren't.  If you escape -- there are 
just only so many ways you can cut a pie that gets smaller.  
	     
	     And even if you do that, if you keep having people 
who don't have insurance not come in here for primary and 
preventive care, showing up when they're real sick at the 
emergency room, and half your emergency room load are people with 
uncompensated care, it's going to get worse.  
	     
	     So you're doing what you have to do to succeed, but 
your country is not doing what it should do to help you succeed.  
And that's what this health care reform issue is all about.  And 
what I want to ask you to do is to take the experience that you 
have -- this is the real world out here; that's what I heard 
these folks talking about -- and support Bill Hefner, and support 
the other members of the Congress, and say what Bill did.  This 
is not a political deal.  Everybody gets sick, regardless of 
their political party.  And this country needs a health care 
system where the financing is as good as the medical care.  
That's what we need.
	     
	     And if we don't do this we are going to pay a 
terrible economic and human price.  You know this.  And what 
happens is we get up there in Washington, we start going to work 
on this, and all we ever hear from are lobbyists.  Then the real 
world experience, what really is going on out here in the 
heartland of America gets lost in a cloud of hot air.
	     
	     I'm here today just to ask you to encourage this 
good congressman, and the other members of Congress, to deal with 
this issue and to deal with it now, and not to fool with it any 
more.  Sixty years ago we had a chance --60 years ago we had a 
chance -- to guarantee health care coverage for all Americans, 
and we passed it up.  Twenty years ago, under President Nixon, he 
proposed guaranteed private health insurance for all Americans 
with employers and employees paying their part; and we passed it.  
And every time we have passed it, we have let the problem get 
worse, we have put more of a burden on rural America, we've put 
more of a burden on small business people and farmers, and we 
have really played havoc with a significant percentage of the 
American people.  We can do better than that.
	     
	     So I'm asking you to take what you know in your 
heart, your mind, and your life as truth and say to the Congress 
of the United States, the time to act is now and we will support 
you.
	     
	     Thank you very much.  (Applause.)

			       END12:53 P.M. EDT

