HIV AIDS Resource Guide/HIV-AIDS Resource Guide.iso/STAT/PROP_FED/HSAREPO2.ASC

Text File | 1993-01-14 | 88KB | 2,061 lines

Chapter 7 -- QUALITY
     "I am a first grade teacher in a very poor neighborhood
in North Philadelphia...Many of [my students] have never
seen a family physician; many have never even been inside a
public health clinic.  I was shocked to find that eight out
of ten of their absence notes are written by doctors in the
emergency room of nearby hospitals...I feel bad for my
students who have never had an ounce of preventive medicine,
but I feel angry, as do many of my middle-income peers, who
are ultimately footing the bill for the emergency treatment
these children are driven to."

J.G.
Philadelphia, PA
________________________


     In many parts of our nation, for many patients, the
quality of health care is unparalleled anywhere in the
world.  The United
States boasts the best technology, the most advanced
research, and the greatest number of medical breakthroughs
of any advanced nation.  When it comes to quality, we have a
great deal to be proud of. The Health Security Act protects
and improves the high standards we have set for American
medicine.

     But the quality of our health care is uneven, and
threatened
by serious flaws in the way we measure and report on which
health
care treatments should be used and which work best.  No
clear standards define what is the best medical practice;
lack of information compromises the care people get; and
inadequate attention to preventive care reduces the
effectiveness of treatment and services.

   The Health Security Act includes specific provisions to
make
sure that the high-quality health care delivered in some
parts of
our country spreads to other areas, and becomes the standard
nationwide.

     This Act takes steps to arm doctors, hospitals, and
health plans with the latest information on state-of-the art
treatments and their effectiveness, and arm consumers with
information to help them compare the quality of plans.

     It measures quality and accountability, focusing on
results rather than micromanagement and filling out forms.

     It increases funding for health care research to keep
American health care and technology state-of-the-art;  and
it improves health and wellness through unprecedented
coverage of preventive care and steps to build a better
health care workforce.

BETTER INFORMATION FOR JUDGING QUALITY
     Without the information they need to reward high-
quality plans with their business, consumers are powerless
to force health plans to compete.

     Researchers and panels of health professionals have
developed new ways to measure the results of different
treatments
and what type of care and treatment works best. A number of
medical professional groups have participated in extensive
efforts to develop guidelines for effective medical care for
specific conditions and illnesses.   The Health Security Act
will
promote greater sharing and use of information, helping more
practitioners benefit from the results.

  Many programs around the country have begun using the new
approaches to quality, building on better and more available
information.  Business groups are now joining with doctors,
hospitals and health plans to publish information about
comparative quality and price.  In communities from
Nashville, Tennessee to Rochester, New York, and in the
state of Pennsylvania, major employers, local hospitals and
state governments have begun collecting information that
allows businesses and consumers to make valid comparisons
among hospitals and physicians.

     Under the Health Security Act, American consumers will
benefit from greater access to information, which in turn
will further improve quality.  They will exercise not only
the right to choose doctors, other health providers and
health plans, but also the right to make informed choices
based on meaningful information about how health plans,
health professionals and hospitals perform.

   Annual performance reports provided by health alliances
will
survey consumers and measure how their health plans, doctors
and hospitals perform on a set of  four critical indicators:

*  Access:  whether care is readily and quickly available;
*  Appropriateness:  whether care fits the condition;
*  Outcome:  whether treatments produce good results; and
*  Consumer satisfaction.

     These information "report cards" will compare health
plans and providers,  reporting how various plans performed
on carefully selected indicators.  Researchers know that
certain medical indicators provide clues about overall
performance: How many children with asthma in this plan
ended up in the hospital last year?  How many older people
who suffered a fall didn't recover their ability to walk?
How many patients who suffered heart attacks survived?  On
the simplest level: How many patients
didn't like this plan and chose another?

     Performance reports based on these types of indicators
will prove valuable to consumers and health professionals.
When choosing a plan or providers within a plan, consumers
will be able to judge whether they can expect prompt access
to treatment,
how the care stacks up against competitors, and what other
consumers think about the plan.  Merely making this
information available will force plans and providers to
focus on quality.

     A reformed health care system that emphasizes
accountability
can improve the quality of health care, improve safeguards
for patients and reduce bureaucratic regulation.

  The Health Security Act will replace the outmoded system
for
measuring quality in practice today, where government
bureaucrats
and insurance companies second-guess decisions made by
doctors and their patients.  In its place will be a quality
measurement system focusing on results:  Was the treatment
the right one? Did it achieve the intended effect?  What can
we learn from the case?   Focusing on results will reduce
the paperwork and micromanagement that strangle doctors,
nurses, hospitals and clinics.  It frees health
professionals from intrusive insurance companies and
bureaucrats, improves morale, and creates an environment
that supports what health professionals are there to do --
care for patients.

     Under reform, doctors, clinics and hospitals will have
to examine ways to make their delivery of care more
efficient while improving quality.  "Business as usual" will
no longer be profitable.  Leading hospitals across the
country are already moving in this direction.  For example,
when doctors at the Hospital of Latter Day Saints in Salt
Lake City, Utah realized that post-operative wound
infections were causing excessive hospital stays, they
experimented with changing the timing of administering
antibiotics before surgery.  Patients got fewer infections,
left the hospital earlier, and saved $450,000 in the first
year.


INVESTING IN RESEARCH

     Under the Health Security Act, there will be
significant initiatives to increase research.  Advances in
medical science, new medications and technology, and
innovations in health care delivery will improve the quality
of life for all Americans.

     Research related to health promotion and prevention of
disease will focus on many common illnesses and other
priority areas:  heart disease, bone and joint disease,
Alzheimer's disease, cancer, AIDS, birth defects, mental
disorders, substance
abuse, nutrition, and health and wellness programs.

     Research regarding clinical practice will increase with
an emphasis on quality and effectiveness, as well as access
and financing. There will be an emphasis on "outcomes
research," to help answer questions about what treatment
works best for which conditions, so that doctors can provide
the highest quality care for their patients. Expanded
research will also measure consumer awareness, decision-
making and satisfaction so that the best information is made
available to the public.  This will ensure that people can
make well-informed decisions about their health care.

EMPHASIZING PREVENTIVE AND PRIMARY CARE

     Prevention is the cornerstone of the Health Security
Act. Incentives for patients and doctors alike to use and
prescribe preventive methods are woven throughout.  From
free coverage of a
wide range of preventive services to wellness education and
increased research funding, the plan offers unprecedented
focus on prevention.

************************************************************
**** **

Sidebar - Pg 65

Academic Health Centers
__________________________________________________

     Academic health centers are the sites of the basic
research that ushers in modern medical advances -- new
treatments and cures for human illnesses.  They pioneer
advanced techniques and procedures, from heart-lung
transplants to laser surgery for brain aneurysms.

     Under the Health Security Act, academic health centers
will continue to train physicians and provide state-of-the-
art care. The Act sets aside a portion of all health
insurance premiums specifically for academic health centers.
Resources will be channeled to centers by a formula that
recognizes each center's contributions to education,
research, and patient care.

     While most Americans will not obtain regular care at an
academic health center, the Health Security Act requires
that everyone has access to specialized care if needed.

************************************************************
**** **


  The comprehensive benefits package includes a broad array
of
preventive services not covered by the vast majority of
insurance
plans -- immunizations, mammograms, well-baby care, and
other screenings and early detection techniques to solve
health problems before they become serious illnesses.  The
Health Security Act covers a wide range of preventive
services with no coinsurance or co-pay, no matter which plan
you join.

     The Health Security Act will fundamentally restructure
incentives in the health care system.  For the first time,
every doctor, nurse and health provider will know that they
can provide
the services they believe are necessary -- and know they
will be reimbursed.

________________________

     "The plan recognizes that successful disease prevention
and health promotion must address the health plan of both
individuals
and communities.  It provides for universal coverage of
clinical preventive services that have been shown to be
effective in preventing disease and prolonging life.  All
these aspects constitute an approach to prevention that is
uniquely comprehensive in scope and long overdue."

Roy L. DeHart, MD, MPH
President, American College of Preventive Medicine
________________________

     As the American health care system has become more
complex, specialized, and technical, it has neglected some
simpler and, ironically, less costly needs.  The cost of
treatment for acute illness has soared, but we continue to
spend relatively little on
preventive and public health services.

     Good primary and preventive care is one of medicine's
essential responsibilities.  Meeting that need represents
one of the essential requirements under health care reform.
If the
American health care system is to provide high-quality care
at affordable prices, it must strike a better balance
between physicians, nurses and other professionals who take
care of basic
needs and those who provide the most sophisticated and
specialized treatment for serious illness.

************************************************************
**** *

Sidebar - Pg 67

Public Health

     Not all health problems can be addressed by providing
individual health care coverage alone.  Greater public
health strategies are necessary to improve public health
awareness, quality of care, and the prevention of future
epidemics.

    Public health protects communities against infectious
diseases, such as tuberculosis and measles, and helps
communities
discover how to control chronic disease, such as diabetes
and heart disease.  It also works to protect the environment
and educate about health and related issues.

  For too long, public health funds have been sapped to pay
for individual care.  Under the Health Security Act, public
health dollars will reach their intended destination -
targeting
issues that plague entire populations rather than
individuals first.  These efforts promise long-term savings
in lives and dollars.

************************************************************
**** *

     Primary care doctors and nurses work on medicine's
front line.  They diagnose and treat routine medical
problems, refer patients when necessary, and coordinate
specialist care.  Family physicians, general internists and
pediatricians are the principal primary care practitioners
among physicians, and many women also consistently see
obstetricians and gynecologists. Advance-practice nurses and
physician's assistants provide essential primary care as
well.

     But the number of doctors providing basic, routine care
has declined and many states have prevented advance-practice
nurses and other health professionals from taking on as
significant a role as they might.

************************************************************
***

Sidebar - Pg 68

PUGET SOUND
A Model for Reform

     Chances are that if you live in the Pacific Northwest,
and you belong to a health maintenance organization (HMO),
you belong
to Group Health Cooperative of Puget Sound. Founded in 1947
and located in Seattle, Washington, Group Health is the
single largest provider of health care in the Pacific
Northwest, serving
500,000 members. It offers convincing proof of the fact that
emphasizing primary and preventive care can mean high-
quality care, low costs, and satisfied, healthy patients.
  Like the Health Security Act, Group Health covers a wide
range of preventive services not covered by most insurance
plans.
Its efforts have brought results. In fact, Group Health
formed the basis for a Rand Corporation study that concluded
that providing high-quality care can go hand in hand with
controlling health care costs. Another important feature of
Group Health is its attention to customer satisfaction,
which it measures through
regular consumer surveys -- much like the surveys proposed
in the
Health Security Act for all health plans.


************************************************************
***

  For decades federal policy has reinforced the trend away
from training primary care doctors and toward training more
specialists.  Federal funding of graduate medical education
averaged $70,000 for each resident in 1992, with nearly all
of the money going toward training in hospitals.  Little
went to other health care institutions in local communities
that provide more basic care.  Between 1980 and 1993,
American hospitals increased the number of residents in
training from 82,000 to 97,000, with 94 percent of the new
positions devoted to training in specialty fields of
medicine.
   Health care reform will increase the demand for primary
care
physicians, nurses and other health professionals,
correcting the
long-standing incentives that discouraged medical students
from becoming family doctors.  But change won't happen
quickly.  To encourage American teaching hospitals to switch
some residency positions from specialist to primary care,
the federal government
must make it more worthwhile to train them.

     Consequently, rather than pay for graduate medical
education
without regard to specialty, public and private investment
will redistribute the balance between residency slots
devoted to primary care and those devoted to specialty
training. Other federal programs, including an expanded
National Health Service Corps, will support students
studying primary care and locating in underserved areas,
such as rural and urban communities.  Loan forgiveness
programs for medical students who are trained in primary
care, and re-training programs for mid-career specialists
who want to work as primary care physicians will further
boost the number of primary care doctors.

        The Health Security Act also proposes several
important
steps to remove barriers to practice that currently limit
the role of advanced-practice nurses.  It enables qualified
health professionals who participate in health plans to
fully use their expertise and ability to provide care.  In
addition, federal funds will provide additional resources
for training nurses, doubling the number of annual
graduates. Support will also be provided for training in
mental health and substance abuse treatment.

Chapter 8 -- CHOICE


     "The President's proposal guarantees stable and secure
health coverage for all Americans, regardless of employment
or health status.  Patients can stay with the same doctor
over time because patients, not employers, control their
coverage choices. Patients, not their employers, choose
their health plans and their physicians."
American College of Physicians
________________________


     Americans value the right to decide how and where they
get health care.  It is a key measure and protector of
quality.  Yet thousands of Americans are losing that right
each year, as rising
health care costs force employers to cut back on the number
of health plans and doctors they'll cover.

    Americans will gain a new level of control over their
health
care choices through the Health Security Act.  For many, no
element of reform will be more important than the right to
choose
their own doctor, hospital or health plan.


CHOOSING A DOCTOR

  A fundamental flaw in today's health care system is that
employers -- rather than employees -- have the power to
choose health plans and, consequently, the doctors,
hospitals and others
who provide care.

************************************************************
**** ***

Sidebar - Pg 71

Choice of Doctors
_____________________________________________________

   Choice is the basis of the doctor-patient relationship.
For
patients, the ability to keep seeing their own doctor --
someone who knows them and their family -- who knows their
medical history, who knows how to care for them when they
are ill, someone whom patients trust, can mean the
difference between a good experience and a frightening one,
between a successful outcome and a poor one.

  The Health Security Act ensures that consumers can follow
their doctor and his or her team to any plan they might
join. The Act requires every health alliance to have a point-
ofservice
option, which gives patients the opportunity to see a doctor
outside of their plan, although some plans will require
extra payment for that option.

     If they choose, physicians and other health providers
will be able to join more than one health plan.  These
health care providers may also decide to remain in private
practice rather than join a health plan.  Patients will
still have the opportunity to see their doctor even if he or
she is in private
practice.

************************************************************
**** ***


     The Health Security Act corrects that flaw.  Through
comprehensive reform, it transfers the power to choose back
to individual Americans and their families.  It requires
both regional and corporate alliances to offer a broad
choice of health plans, including at least one plan
organized around the traditional fee-for-service style,
where consumers visit any doctor they choose, and their
health insurer pays the bill.

     For patients who choose certain types of health plans,
exercising the right to see a doctor who does not
participate in the plan will cost more, as it does today.
But that right -known as a "point-of-service" option -- will
always be there, even in HMOs.  It reserves for every
American the right to seek the care of doctors and hospitals
on the leading edge of treatment if they ever confront an
illness in which even specialized care available through
their regular doctors and hospital is inadequate.  So, if
you join a plan that includes your obstetrician, your son's
pediatrician, but not your daughter's dermatologist, it will
cost more, but you can continue
to see them all.

     Health reform will also make it easier for patients to
follow their doctors, even if their doctors decide to switch
health plans.  Because an increasing number of employers
restrict
the choice of plans available to employees, a patient whose
doctor leaves one plan probably has little choice but to
find another doctor.  Under the Health Security Act, the
patient will always have the option of switching plans each
year, something that most people can't do today.

     For doctors and other health providers, health reform
also expands choice -- the choice of health plans in which
they practice. Under the Health Security Act, physicians and
other health professionals may participate in as many, or as
few, competing health plans as they wish. And because
patients are guaranteed a point-of-service option in every
plan, physicians will know that patients will be able to
seek them out.


CHOOSING A HEALTH PLAN

     Millions of Americans choose physicians and other
health care providers and pay for their services one at a
time through traditional indemnity insurance, a style of
coverage usually described as fee-for-service.  Over the
last two decades, millions of other Americans have moved
into so-called "managed care" health plans, including
preferred provider organizations (PPOs) or Health
Maintenance Organizations (HMOs).

   All of those options -- and other innovations that will
evolve -- will continue.  What the Health Security Act will
provide is the guarantee that a wide range of alternatives
will exist and that American consumers, not their employers,
will have
the opportunity to choose among them.

************************************************************
**** *

Sidebar - Pg 74

XEROX

A Model for Reform

  Most businesses pick their employees' health plan -- but
not
the Xerox Corporation. Xerox offers its employees a choice
of plans. Although it might sound like more trouble than
it's worth,
Xerox has managed to save money by offering choices.

Before changing the way it dealt with health benefits,
annual premium increases of 20% were not unknown at Xerox.
So the company started offering its employees a choice of
plans at its 250 sites across the country. Xerox would pay
based on the cost of the "benchmark" or average-cost plan.
If the employee picks a low-cost plan, he saves money. The
employee's job was to choose plans based on price and
quality -- and Xerox hoped that the competition among health
plans would drive down costs.

It worked.  Xerox's premiums have stopped spiraling higher
and higher every year. And Xerox's strategy -- using choice
and competition to drive down costs -- is central to the
Health Security Act.

************************************************************
**** *


INCREASING OPTIONS FOR LONG-TERM CARE

     Expanded choice must also mean a greater set of options
for Americans in need of long-term care.  Today, choices are
not only
limited, they are costly.  People either pay the full cost
of home care out-of pocket, pay the full cost of care in a
nursing home, or spend themselves into poverty in order to
qualify for government help, most often only for nursing
home care.

     Long-term care options are expanded and improved under
health care reform.  The Health Security Act provides a new
federal program to cover home and community-based care, an
option
that most people prefer, and that often costs less than a
nursing
home.

************************************************************
**** **

Sidebar - Pg 75

Americans with Disabilities
_____________________________________________________

  For Americans with disabilities, access to comprehensive
coverage without lifetime limits is the most important
achievement of The Health Security Act.  That guarantee will
allow many Americans with disabilities to work without fear
of losing health coverage.

     New tax incentives will remove obstacles preventing
people from seeking employment, opening the door to the
personal
freedom
that employment provides.  Employed individuals with
disabilities
who require personal assistance will be eligible for tax
credits covering 50 percent of their costs up to a maximum
of $15,000 each year.

     Home and community-based long-term care will be
provided to Americans of all ages with severe disabilities.
People who have cognitive and mental impairments qualify for
home or community-based care, as do children under the age
of six who depend on technology and would otherwise need
institutional care.

     States can design their own approaches to home and
community-based care.  Expansion of care may include
homemaker and chore services, respite services, assistive
technology, adult
day care, rehabilitation and supported employment.

************************************************************
**** **


  For those who plan ahead by purchasing private long-term
care insurance, reform will provide greater protection
against faulty or inadequate insurance, and tax breaks on
premiums.  For disabled Americans who want to work but need
assistance, the Health Security Act promises help.  The plan
not only offers personal assistance services at home, but
also personal care assistance tax credits to make working a
more viable option for people with disabilities.  Finally,
the plan increases financial protections for those on
Medicaid who receive care in nursing homes.

Chapter 9 -- RESPONSIBILITY



     "My husband and I are 59 and 63 years of age, so we are
not yet eligible for Medicare to help us...A brief summary
of our health insurance costs over the last 4 years are:

     1988- $3,578 with $500 deductible
     1990- $4,607 with $2,500 deductible
     1992- $10,500 with $2,000 deductible

"I have a pre-existing condition so I have to pay a penalty
on the rates.  Neither my husband nor myself, fortunately,
has ever had a claim of any kind...

"We do not want a 'free ride.'  We are more than willing to
pay our share, but these amounts are just too excessive."

M.M.
Joliet, Ill.
________________________

     Responsibility is central to every one of the
principles of the Health Security Act. As the President said
in his address to the Joint Session of Congress, "We need to
restore a sense that we're all in this together and that we
all have a responsibility to be a part of the solution."

  All those involved in providing health care will, for the
first time, share collective responsibility for the quality
of
care patients receive, and for keeping patients healthy, not
just
treating them once they're sick.  Health plans will have the
responsibility of keeping the costs of premiums reasonable -
there will be no more blank checks for health care. This
newfound
imperative for responsible health care will mean a change in
the way some currently do business.

   For insurance companies, responsibility means no longer
denying people coverage if they get sick. For unscrupulous

medical companies and laboratories, responsibility means an

end to fraudulent billing practices. For lawyers,

responsibility means no more filing of frivolous lawsuits.

"In short," as the President said, "responsibility should

apply to anybody who abuses this system and drives up the

cost for honest, hard-working citizens and  undermines

confidence in the honest, gifted health care providers we

have."

************************************************************

**** Sidebar - Pg 78-79

Medical Malpractice

     Responsibility means bringing common sense to our
medical malpractice system.  Although experts believe that
the direct cost of malpractice accounts for less than two
percent of our spending on health care, reform of our
existing system is badly needed. We must work to remove the
threat of lawsuits that leads to so much "defensive
medicine" and drives up costs for everyone.
We must free doctors to do what they do best -- care for
patients
-- while protecting consumers at the same time. And we must
take steps to let lawyers who profit from huge settlements
know that they can no longer take advantage of the system.

     In an effort to end frivolous lawsuits and protect
doctors, the Health Security Act will change tort laws and
develop new alternatives to resolve patients' claims against
providers before
they get to court. The Act will require those who believe
they have been the victims of malpractice to first submit
their claims
to an out-of-court panel to resolve the dispute. If the
patient is still unsatisfied with the resolution, the case
can be taken to court, but only after obtaining a
"certificate of merit," an affidavit from another doctor
stating that the patient has good cause to pursue a claim.

The Act will also:

*  Limit attorneys' fees to one-third of an award, and allow
   states to impose even lower limits;
*  Allow damages to be paid over a period of time rather
than
all
   at once;
*  Prevent injured patients from gaming the system and
getting
   paid twice for the same injury -- once by a doctor and a
second
   time by a health or disability insurance plan; and
*  Promote progressive ideas such as a program in Maine that
   frees doctors from malpractice liability if they can
demonstrate
 that they followed prescribed clinical practice guidelines.
     Taken together, these steps represent the first serious
national effort to take what has been learned in the states
and apply it on a national level. Once implemented, these
steps will help turn the incentives in our health care
system right side up.
By restoring responsibility to our medical malpractice
system, we
can also restore trust to the doctor-patient relationship
which lies at the heart of health care.

************************************************************
****


   For employers -- both large and small -- responsibility
means following the lead of our nation's most successful
businesses and helping contribute to the health security of
every
employee. For every American, responsibility means taking
care of
your health, rejecting behaviors that drive up health costs,
and making a contribution to health coverage.
"Responsibility," as the President said, "isn't just about
them. It's about you, it's about me, it's about each of us."

Paying for Health Security

     Even though our nation spends nearly one of every seven
dollars on health care, tens of millions of American lack
health security.  More than 37 million Americans have no
health insurance.  More than 25 million Americans have
inadequate insurance -- so-called "bare bones" coverage or
policies that don't cover them when they need it most. And
nearly every American family -- even those with health
insurance -- live with the fear and the hard fact that only
one pink slip, one seriously
ill relative, one misfortune could cost them a lifetime of
savings and even their independence and dignity.

    Providing all Americans health security will make our
nation
stronger and bring down health care costs. In the short
term, it will take new funds to cover the uninsured and
provide those who are now covered with rock solid security
and comprehensive benefits.  The question is how we will pay
and who will pay.

  The vast majority of funding for the Health Security Act
will continue to come from where it comes from today:
employer and employee contributions to the cost of health
insurance. New funding will be drawn from three primary
sources:

*  Asking all employers and the 30 million Americans who
work
for
 them but do not have health coverage to contribute to their
   health care;
*  Increasing excise taxes on tobacco and requiring small
   contributions from large corporations who choose to form
their
   own health alliance;
*  Limiting the growth in federal health care programs.

  These are the fairest and most workable sources to yield
sufficient money and guarantee health security to every
American.
Expanding the Current Employer-Based System

     The principal way we pay to ensure health security for
all
Americans is by building on our current system and asking
all employers and employees to take responsibility for
paying for health coverage.
  Today, nine out of ten Americans who get health coverage
get
it through their employer. It's a system that works for the
vast majority of Americans. That's why the President
rejected any kind
of broad-based tax to pay for a government-run system -
deciding
instead to leave our health care system rooted in the
private sector.
     Today, most employers and employees contribute to the
cost of health coverage, but not all do.  Thirty million
Americans in working families go without health coverage
because they are not covered by their employers.
     But these workers still get health care when they need
it -
often the most expensive kind of health care in the most
expensive place: the emergency room. And the rest of us end
up paying the bills -- in higher premiums, higher taxes and
inflated
hospital charges.

  This phenomenon -- what academics call "cost shifting" --
contributes to the high health care costs we all are forced
to pay.  This "cost-shifting" happens on every street in
America where you'll find a supermarket, a dry cleaner, or a
gas station that doesn't insure its workers. On the next
block you'll find a supermarket, dry cleaner, or a gas
station that does insure its employees. The businesses that
insure pay higher premium costs because they are forced to
pick up the tab for their competitors who are not paying.

     The Health Security Act asks those who aren't paying to
pay their fair share, lowering costs for the vast majority
of companies and individuals, who will no longer see their
premiums rise to pay for those without insurance.  We'll
save $25 billion by providing coverage to everyone, because
the government will no
longer have to reimburse doctors and hospitals for the cost

of caring for the uninsured.

************************************************************

**** Sidebar - Pg 82

HAWAII

A Model for Reform

     Only one state in America has asked all employers to
contribute to the cost of their employees' health care:
Hawaii. And it has been able to achieve near-universal
coverage while maintaining a thriving economy.
    In many ways, the Health Security Act echoes Hawaii's
experience. Hawaii passed a health reform plan in 1974 that
required all employers to contribute to their workers health
care. As part of the reform, Hawaii included special
programs to ease the burden for small businesses. The
result? A greater percentage of Hawaiians have health
insurance, far more than in any other state in the country.
Health care costs are significantly lower in Hawaii than
elsewhere in the U.S. And only
2% of small firms have sought out a special program for
small businesses struggling to provide insurance.

     In fact, since Hawaii passed health reform, the
unemployment
rate there has dropped to one of the lowest in the nation
(2.8% in 1991). Meanwhile, small business creation rates
have remained high (the number of employers grew almost 200%
from 1970 to 1991).

************************************************************
****


    While building on our current system ensures that 30
million
working Americans will receive health coverage, requiring
responsibility from all employers and employees does not
alone provide true health security.  Additional funding is
needed to protect small businesses, provide long-term care
and prescription
drug coverage to older Americans, and ensure that no
American -including those who lose their jobs -- ever lose
their health coverage.

     To guarantee comprehensive benefits for all Americans,
the Health Security Act requires the second and third
primary sources
of funding: a cigarette tax and corporate assessment, and
savings
from slowing the growth of federal health care programs.


The Cigarette Tax and Corporate Assessment

     Cigarette taxes will increase by 75 cents a pack,
raising revenue for health reform, and ensuring that those
who smoke pay for the health costs that smoking causes.
Higher tobacco prices may also have a significant impact in
preventing teenagers from ever starting to smoke.

     In addition, large corporations that form their own
alliances will contribute to help support the backbone of
our health care system -- academic health centers, advanced
medical research, as well as other elements of our health
care infrastructure.  Asking large corporations to pay one
percent of their payroll will support those institutions
that benefit every American.


Slowing the Growth of Federal Health Care Programs

     The Health Security Act will also produce savings by
slowing the skyrocketing growth of government spending on
health care
programs.  Over time, the Health Security Act will slow the
rate of growth in Medicare (the government program for
seniors and the
disabled) and Medicaid (the program that provides health
care to the poor)  from three times the rate of inflation to
roughly two times the rate of inflation.

     Upper-income people who receive Medicare -- those
individuals who earn more than $100,000 per year -- will be
asked
to pay a higher percentage of the cost of coverage than they
do today.

     People covered by Medicare will see an increase in
their benefits under the Health Security Act. Elderly and
disabled Americans will receive the prescription drug
coverage they need, and a new  long-term care program will
provide options for home and community-based care.

     Most Americans who now receive health care through
Medicaid will be part of the same system as other Americans,
paying what they can for their care but benefitting from
discounts that make coverage affordable.

     By controlling costs in both the public and private
sector, these savings avoid hurting privately insured
people. Today, doctors and hospitals often charge more to
private patients to make up for shortfalls in what they are
paid to provide care to people covered by Medicare and
Medicaid.  The Health Security Act
slows the growth in federal health care programs as part of
fundamental reform that controls the cost of all health
care.

     These are the three primary sources of private and
government funding that will help pay for health security
for every American -- full responsibility from businesses
and individuals, cigarette taxes and a small corporate
assessment, and a slowdown in the growth of Medicare and
Medicaid.  This is a
conservative approach that doesn't count on the billions in
cost savings that can be achieved from the plan's new
emphasis on preventive care,  encouraging real competition
among health providers, and cracking down on health care
fraud.  It is an approach that asks responsibility of
everyone. In return, it guarantees every American
comprehensive health benefits that can never be taken away.


Conclusion






     For nearly a century, Americans have discussed and
debated how best to reform our national health care system.
Since the early 1900s, commissions, committees, groups and
organizations have put forth proposal after proposal to
overhaul the way our nation delivers and pays for medical
care.

  In 1915, a group calling for health reform concluded that
employers, employees and the government should contribute to
the cost of health care, and recommended that the system
focus on prevention.

   In 1932, a commission decided that we should encourage
doctors to form group practices and share responsibility for
high
quality, cost-effective care.

   In 1933, when President Franklin Roosevelt launched the
initiative that became the Social Security Act, he intended
to include national health insurance.

     In 1946, President Harry Truman proclaimed that health
care should be a right, not a privilege, and became the
first president to introduce a plan for national health
reform.

   And in 1972, President Richard Nixon told the American
people that the only way to insure health coverage for every
American was to ask employers to take responsibility and
contribute to their workers care.

     Now, in 1993, with one in four of us poised to lose
health insurance in the next two years and costs expected to
double by the year 2000, our nation stands ready for reform.
Since President Clinton took office, more than 260 members
of Congress have signed their names to some piece of
legislation proposing national health care reform. Democrats
and Republicans are teaming up to make history; for the
first time, members of both parties have agreed that every
American must be guaranteed health
care.

   The Health Security Act builds on whatUs best about the
American health care system. It maintains and strengthens
America's private health care. It extends the current system
of employer-based coverage that works well for so many. It
protects our cherished right to choose how we receive health
care. It invests in improving the quality of our care. It
establishes a national framework for reform, but leaves to
every state, every community, every doctor, nurse and
consumer the right to decide how to give and get health
care.

  The Health Security Act also reaches out to fix what has
gone wrong with our health care system.

     First and foremost, it guarantees health security for
every American - a comprehensive package of benefits that
can never be taken away. For those who have been victims of
today's health insurance lottery - those denied insurance
because of a pre-existing condition or those who have lost a
job and seen their coverage disappear - nothing could be
more important. And for those Americans who enjoy good
health coverage today, but go to bed at night worried what
might happen tomorrow, there could be no more reassuring
guarantee.

     The Health Security Act takes aggressive steps to bring
our runaway health care system under control. It reduces the
paperwork that chokes our system, the bureaucracy that
forces doctors and nurses to spend hour after hour  filling
out forms instead of caring for patients. It promotes true
competition in the health care marketplace - and reins in
skyrocketing costs, making sure insurance premiums no longer
rise uncontrollably. And
it turns upside down incentives right side up.

     The Health Security Act restores responsibility. It
requires
every employer and individual to pay for health coverage,
even if
that contribution is small. It recognizes that we can no
longer afford to allow some to squeeze excess profits from
health care consumers. And it promises swift and stiff
penalties to those who
take advantage of the system.

     The Health Security Act holds the promise of
strengthening our economy. It raises no new broad-based
taxes, but spends our health care dollars more wisely.  It
levels the playing field for
small businesses, making it possible for them to insure
their families and their employees. It eases the tremendous
burden of
rising health costs on big business, helping them compete
for global markets.  And it sets us in the right direction
of reducing our national debt.

     Finally, the Health Security Act restores common sense
to American health care. It protects older Americans and
gives them the health benefits they deserve when they need
them most. It is based on an approach that it is better to
keep people healthy rather than treating them only after
they get sick. It borrows from what works today, letting us
phase in change at a reasonable
pace and adjust our course if needed. It builds on what
works best - and makes it work for everyone.

  Our nation's health care system has reached a point where
change  is our only option. As President Clinton said in his
address to the Joint Session of Congress:


"Now it is our turn to strike a blow for freedom in this
country.
The freedom of Americans to live without fear that their own
nation's health care system won't be there for them when
they need it.

"It's hard to believe that there was once a time in this
century when that kind of fear gripped old age. When
retirement was nearly synonymous with poverty, and older
Americans died in the street. That's unthinkable today,
because over half a century ago
Americans had the courage to change - to create a Social
Security
system that ensures that no American will be forgotten in
their later years.
"Forty years from now, our grandchildren will also find it
unthinkable that there was a time in this country when
hardworking families lost their homes, their savings, their
businesses - lost everything simply because their children
got sick or because they had to change jobs. Our
grandchildren will find such things unthinkable tomorrow if
we have the courage to change today."


ADDRESS OF THE PRESIDENT TO THE JOINT SESSION OF CONGRESS

September 22, 1993
________________________


  My fellow Americans, tonight we come together to write a
new
chapter in the American story.  Our forebears enshrined the
American Dream - life, liberty, the pursuit of happiness.
Every generation of Americans has worked to strengthen that
legacy, to make our country a place of freedom and
opportunity, a place where people who work hard can rise to
their full potential, a place where their children can have
a better future.

     From the settling of the frontier to the landing on the
moon, ours has been a continuous story of challenges
defined, obstacles overcome, new horizons secured. That is
what makes America what it is and Americans what we are. Now
we are in a time of profound change and opportunity.  The
end of the Cold War, the Information Age, the global economy
have brought us both
opportunity and hope and strife and uncertainty.  Our
purpose in
this dynamic age must be to change - to make change our
friend and not our enemy.
          To achieve that goal, we must face all our
challenges with confidence, with faith, and with discipline
- whether we're reducing the deficit, creating tomorrow's
jobs and training our people to fill them, converting from a
high-tech defense to a high-tech domestic economy, expanding
trade, reinventing government, making our streets safer, or
rewarding work over idleness.  All these challenges require
us to change.
     If Americans are to have the courage to change in a
difficult time, we must first be secure in our most basic
needs. Tonight I want to talk to you about the most critical
thing we can do to build that security.  This health care
system of ours is badly broken and it is time to fix it.
     Despite the dedication of literally millions of
talented health care professionals, our health care is too
uncertain and too expensive, too bureaucratic and too
wasteful.  It has too much fraud and too much greed.
  At long last, after decades of false starts, we must make
this our most urgent priority, giving every American health
security; health care that can never be taken away, health
care that is always there.  That is what we must do tonight.

   On this journey, as on all others of true consequence,
there
will be rough spots in the road and honest disagreements
about how we should proceed.  After all, this is a
complicated issue. But every successful journey is guided by
fixed stars.  And if we
can agree on some basic values and principles we will reach
this destination, and we will reach it together.

     So tonight I want to talk to you about the principles
that I
believe must embody our efforts to reform America's health
care system - security, simplicity, savings, choice,
quality, and responsibility.

  When I launched our nation on this journey to reform the
health care system I knew we needed a talented navigator,
someone
with a rigorous mind, a steady compass, a caring heart.
Luckily for me and for our nation, I didn't have to look
very far.

     Over the last eight months, Hillary and those working
with her have talked to literally thousands of Americans to
understand
the strengths and the frailties of this system of ours.
They met
with over 1,100 health care organizations. They talked with
doctors and nurses, pharmacists and drug company
representatives,
hospital administrators, insurance company executives and
small and large businesses.  They spoke with self-employed
people. They
talked with people who had insurance and people who didn't.
They talked with union members and older Americans and
advocates for our children. The First Lady also consulted,
as all of you know, extensively with governmental leaders in
both parties in the states of our nation, and especially
here on Capitol Hill.

  Hillary and the Task Force received and read over 700,000
letters from ordinary citizens.  What they wrote and the
bravery with which they told their stories is really what
calls us all here tonight.

     Every one of us knows someone who's worked hard and
played by the rules and still been hurt by this system that
just doesn't
work for too many people.  But I'd like to tell you about
just one.

     Kerry Kennedy owns a small furniture store that employs
seven people in Titusville, Florida.  Like most small
business owners, he's poured his heart and soul, his sweat
and blood into that business for years.  But over the last
several years, again like most small business owners, he's
seen his health care premiums skyrocket, even in years when
no claims were made.  And last year, he painfully discovered
he could no longer afford to provide coverage for all his
workers because his insurance company told him that two of
his workers had become high risks because of their advanced
age. The problem was that those two people were his mother
and father, the people who founded the business and still
worked in the store.
     This story speaks for millions of others. And from them
we have learned a powerful truth. We have to preserve and
strengthen
what is right with the health care system, but we have got
to fix
what is wrong with it.

     Now, we all know what's right. We're blessed with the
best health care professionals on Earth, the finest health
care institutions, the best medical research, the most
sophisticated technology.  My mother is a nurse.  I grew up
around hospitals. Doctors and nurses were the first
professional people I ever knew
or learned to look up to. They are what is right with this
health
care system.  But we also know that we can no longer afford
to continue to ignore what is wrong.

     Millions of Americans are just a pink slip away from
losing their health insurance, and one serious illness away
from losing all their savings.  Millions more are locked
into the jobs they have now just because they or someone in
their family has once been sick and they have what is called
a preexisting condition. And on any given day, over 37
million Americans Q most of them working people and their
little children Q have no health insurance at all.
     And in spite of all this, our medical bills are growing
at over twice the rate of inflation, and the United States
spends over a third more of its income on health care than
any other nation on Earth. And the gap is growing, causing
many of our companies in global competition severe
disadvantage.  There is no
excuse for this kind of system. We know other people have
done better. We know people in our own country are doing
better.  We have no excuse.  My fellow Americans, we must
fix this system and
it has to begin with congressional action.
  I believe as strongly as I can say that we can reform the
costliest and most wasteful system on the face of the Earth
without enacting new broad-based taxes. I believe it because
of the conversations I have had with thousands of health
care professionals around the country; with people who are
outside this city, but are inside experts on the way this
system works and wastes money.

     The proposal that I describe tonight borrows many of
the principles and ideas that have been embraced in plans
introduced by both Republicans and Democrats in this
Congress.  For the first time in this century, leaders of
both political parties have joined together around the
principle of providing universal,
comprehensive health care.  It is a magic moment and we must
seize it.

     I want to say to all of you I have been deeply moved by
the spirit of this debate, by the openness of all people to
new ideas
and argument and information. The American people would be
proud to know that earlier this week when a health care
university was held for members of Congress just to try to
give everybody the same amount of information, over 320
Republicans and Democrats signed up and showed up for two
days just to learn the basic facts of the complicated
problem before us.
     Both sides are willing to say we have listened to the
people.  We know the cost of going forward with this system
is far greater than the cost of change.  Both sides, I
think, understand the literal ethical imperative of doing
something about the system we have now.  Rising above these
difficulties and our past differences to solve this problem
will go a long way
toward defining who we are and who we intend to be as a
people in
this difficult and challenging era. I believe we all
understand that.

     And so tonight, let me ask all of you - every member of
the House, every member of the Senate, each Republican and
each Democrat - let us keep this spirit and let us keep this
commitment until this job is done. We owe it to the American
people.

     Now, if I might, I would like to review the six
principles I
mentioned earlier and describe how we think we can best
fulfill those principles.

     First and most important, security.  This principle
speaks to the human misery, to the costs, to the anxiety we
hear about every day - all of us - when people talk about
their problems with the present system.  Security means that
those who do not now have health care coverage will have it;
and for those who have it, it will never be taken away.  We
must achieve that security as soon as possible.

     Under our plan, every American would receive a health
care security card that will guarantee a comprehensive
package of benefits over the course of an entire lifetime,
roughly comparable to the benefit package offered by most
Fortune 500 companies.  This health care security card will
offer this package of benefits in a way that can never be
taken away.

     So let us agree on this: whatever else we disagree on,
before this Congress finishes its work next year, you will
pass and I will sign legislation to guarantee this security
to every citizen of this country.

     With this card, if you lose your job or you switch
jobs, you're covered. If you leave your job to start a small
business, you're covered.  If you're an early retiree,
you're covered.  If someone in your family has,
unfortunately, had an illness that
qualifies as a preexisting condition, you're still covered.
If you get sick or a member of your family gets sick, even
if it's a
life threatening illness, you're covered. And if an
insurance company tries to drop you for any reason, you will
still be covered, because that will be illegal.

  This card will give comprehensive coverage. It will cover
people for hospital care, doctor visits, emergency and lab
services, diagnostic services like Pap smears and mammograms
and cholesterol tests, substance abuse and mental health
treatment.
          And equally important, for both health care and
economic reasons, this program for the first time would
provide a
broad range of preventive services including regular
checkups and
well-baby visits.

  Now, it's just common sense. We know - any family doctor
will tell you that people will stay healthier and long-term
costs
of the health system will be lower if we have comprehensive
preventive services.  You know how all of our mothers told
us that an ounce of prevention was worth a pound of cure?
Our mothers were right.  And it's a lesson, like so many
lessons from
our mothers, that we have waited too long to live by.  It is
time
to start doing it.

     Health care security must also apply to older
Americans. This is something I imagine all of us in this
room feel very deeply about.  The first thing I want to say
about that is that we must maintain the Medicare program.
It works to provide that kind of security.   But this time
and for the first time, I believe Medicare should provide
coverage for the cost of prescription drugs.
     Yes, it will cost some more in the beginning.  But,
again, any physician who deals with the elderly will tell
you that there
are thousands of elderly people in every state who are not
poor enough to be on Medicaid, but just above that line and
on Medicare, who desperately need medicine, who make
decisions every
week between medicine and food.  Any doctor who deals with
the elderly will tell you that there are many elderly people
who don't get medicine, who get sicker and sicker and
eventually go to the doctor and wind up spending more money
and draining more money from the health care system than
they would if they had regular treatment in the way that
only adequate medicine can provide.

     I also believe that over time, we should phase in long-
term care for the disabled and the elderly on a
comprehensive basis.

    As we proceed with this health care reform, we cannot
forget
that the most rapidly growing percentage of Americans are
those over 80.  We cannot break faith with them.  We have to
do better by them.

     The second principle is simplicity.  Our health care
system must be simpler for the patients and simpler for
those who actually deliver health care - our doctors, our
nurses, our other
medical professionals. Today we have more than 1,500
insurers, with hundreds and hundreds of different forms. No
other nation has a system like this.  These forms are time
consuming for health care providers, they're expensive for
health care consumers, they're exasperating for anyone who's
ever tried to sit down around a table and wade through them
and figure them out.
     The medical care industry is literally drowning in
paperwork. In recent years, the number of administrators in
our hospitals has grown by four times the rate that the
number of doctors has grown.  A hospital ought to be a house
of healing, not a monument to paperwork and bureaucracy.

     Just a few days ago, the Vice President and I had the
honor of visiting the Children's Hospital here in Washington
where they
do wonderful, often miraculous things for very sick
children.  A nurse named Debbie Freiberg told us that she
was in the cancer and bone marrow unit. The other day a
little boy asked her just to stay at his side during his
chemotherapy.  And she had to walk
away from that child because she had been instructed to go
to yet
another class to learn how to fill out another form for
something
that didn't have a lick to do with the health care of the
children she was helping. That is wrong, and we can stop it,
and we ought to do it.

     We met a very compelling doctor named Lillian Beard, a
pediatrician, who said that she didn't get into her
profession to
spend hours and hours - some doctors up to 25 hours a week
just filling out forms.  She told us she became a doctor to
keep children well and to help save those who got sick. We
can relieve
people like her of this burden. We learned - the Vice
President and I did - that in the Washington Children's
Hospital alone, the
administrators told us they spend $2 million a year in one
hospital filling out forms that have nothing whatever to do
with keeping up with the treatment of the patients.

    And the doctors there applauded when I was told and I
related to them that they spend so much time filling out
paperwork, that if they only had to fill out those paperwork
requirements necessary to monitor the health of the
children, each doctor on that one hospital staff - 200 of
them - could see another 500 children a year. That is
100,000 children a year.  I think we can save money in this
system if we simplify it.  And we
can make the doctors and the nurses and the people that are
giving their lives to help us all be healthier a whole lot
happier, too,  on their jobs.
     Under our proposal there would be one standard
insurance form - not hundreds of them. We will simplify also
- and we must - the government's rules and regulations,
because they are a big part of this problem.  This is one of
those cases where the physician should heal thyself.  We
have to reinvent the way we relate to the health care
system, along with reinventing government.  A doctor should
not have to check with a bureaucrat in an office thousands
of miles away before ordering a simple blood test.  That's
not right, and we can change it.  And doctors, nurses and
consumers shouldn't have to worry about the fine print.  If
we have this one simple form, there won't be any fine print.
People will know what it means.

    The third principle is savings.  Reform must produce
savings
in this health care system. It has to. We're spending over
14 percent of our income on health care - Canada's at 10;
nobody else is over nine.  We're competing with all these
people for the
future.  And the other major countries, they cover everybody
and they cover them with services as generous as the best
company policies here in this country.

     Rampant medical inflation is eating away at our wages,
our savings, our investment capital, our ability to create
new jobs in the private sector and this public Treasury. You
know the budget we just adopted had steep cuts in defense, a
five-year freeze on the discretionary spending, so critical
to reeducating America and investing in jobs and helping us
to convert from a defense to a domestic economy.  But we
passed a budget which has Medicaid increases of between 16
and 11 percent a year over the next five years, and Medicare
increases of between 11 and 9 percent in an environment
where we assume inflation will be at 4 percent or less.

   We cannot continue to do this. Our competitiveness, our
whole economy, the integrity of the way the government works
and,
ultimately, our living standards depend upon our ability to
achieve savings without harming the quality of health care.

     Unless we do this, our workers will lose almost $600 in
income each year by the end of the decade. Small businesses
will continue to face skyrocketing premiums.  And a full
third of small businesses now covering their employees say
they will be forced to drop their insurance.  Large
corporations will bear vivid disadvantages in global
competition. And health care costs will devour more and more
and more of our budget.

  Pretty soon all of you or the people who succeed you will
be
showing up here, and writing out checks for health care and
interest on the debt and worrying about whether we've got
enough defense, and that will be it, unless we have the
courage to achieve the savings that are plainly there before
us. Every state
and local government will continue to cut back on everything
from
education to law enforcement to pay more and more for the
same health care.

  These rising costs are a special nightmare for our small
businesses - the engine of our entrepreneurship and our job
creation in America today.  Health care premiums for small
businesses are 35 percent higher than those of large
corporations
today. And they will keep rising at double-digit rates
unless we act.

     So how will we achieve these savings?  Rather than
looking at price control, or looking away as the price
spiral continues; rather than using the heavy hand of
government to try to control what's happening, or continuing
to ignore what's happening, we believe there is a third way
to achieve these savings.

     First, to give groups of consumers and small businesses
the same market bargaining power that large corporations and
large groups of public employees now have. We want to let
market
forces enable plans to compete. We want to force these plans
to compete
on the basis of price and quality, not simply to allow them
to continue making money by turning people away who are sick
or old or performing mountains of unnecessary procedures.
But we also believe we should back this system up with
limits on how much plans can raise their premiums year in
and year out, forcing people, again, to continue to pay more
for the same health care, without regard to inflation or the
rising population needs.

     We want to create what has been missing in this system
for too long, and what every successful nation who has dealt
with this problem has already had to do:  to have a
combination of private market forces and a sound public
policy that will support
that competition, but limit the rate at which prices can
exceed the rate of inflation and population growth, if the
competition doesn't work, especially in the early going.

     The second thing I want to say is that unless everybody
is covered - and this is a very important thing - unless
everybody is covered, we will never be able to fully put the
breaks on health care inflation.  Why is that?  Because when
people don't have any health insurance, they still get
health care, but they get it when it's too late, when it's
too expensive, often from the most expensive place of all,
the emergency room.  Usually by the time they show up, their
illnesses are more severe and their mortality rates are much
higher in our hospitals than those who have insurance.  So
they cost us more.

     And what else happens?  Since they get the care but
they don't pay, who does pay?  All the rest of us.  We pay
in higher hospital bills and higher insurance premiums.
This cost shifting
is a major problem.

     The third thing we can do to save money is simply by
simplifying the system - what we've already discussed.
Freeing the health care providers from these costly and
unnecessary paperwork and administrative decisions will save
tens of billions
of dollars. We spend twice as much as any other major
country does on paperwork. We spend at least a dime on the
dollar more than any other major country.  That is a
stunning statistic.  It is something that every Republican
and every Democrat ought to be
able to say, we agree that we're going to squeeze this out.
We cannot tolerate this.  This has nothing to do with
keeping people
well or helping them when they're sick. We should invest the
money in something else.

    We also have to crack down on fraud and abuse in the
system.
That drains billions of dollars a year.  It is a very large
figure, according to every health care expert I've ever
spoken with.

  So I believe we can achieve large savings. And that large
savings can be used to cover the unemployed uninsured, and
will be used for people who realize those savings in the
private sector to increase their ability to invest and grow,
to hire new workers or to give their workers pay raises,
many of them for the
first time in years.

  Now, nobody has to take my word for this. You can ask Dr.
Koop.  He's up here with us tonight, and I thank him for
being here.  Since he left his distinguished tenure as our
Surgeon General, he has spent an enormous amount of time
studying our health care system, how it operates, what's
right and wrong with it. He says we could spend $200 billion
every year, more than 20 percent of the total budget,
without sacrificing the high quality
of American medicine.

     Ask the public employees in California, who have held
their own premiums down by adopting the same strategy that I
want every
American to be able to adopt - bargaining within the limits
of a strict budget.  Ask Xerox, which saved an estimated
$1,000 per worker on their health insurance premium. Ask the
staff of the Mayo Clinic, who we all agree provides some of
the finest health care in the world. They are holding their
cost increases to less than half the national average.  Ask
the people of Hawaii, the only state that covers virtually
all of their citizens and has still been able to keep costs
below the national average.
     People may disagree over the best way to fix this
     system.
We may all disagree about how quickly we can do what - the
thing that we have to do.  But we cannot disagree that we
can find tens
of billions of dollars in savings in what is clearly the
most costly and the most bureaucratic system in the entire
world. And we have to do something about that, and we have
to do it now.
     The fourth principle is choice. Americans believe they
ought
to be able to choose their own health care plan and keep
their own doctors.  And I think all of us agree. Under any
plan we pass, they ought to have that right.  But today,
under our broken
health care system, in spite of the rhetoric of choice, the
fact is that that power is slipping away for more and more
Americans.
     Of course, it is usually the employer, not the
     employee,
who
makes the initial choice of what health care plan the
employee will be in.  And if your employer offers only one
plan, as nearly
three-quarters of small or medium-sized firms do today,
you're stuck with that plan, and the doctors that it covers.
     We propose to give every American a choice among high-
quality plans. You can stay with your current doctor, join a
network of doctors and hospitals, or join a health
maintenance organization.  If you don't like your plan,
every year you'll have the chance to choose a new one.  The
choice will be left to the American citizen, the worker -
not the boss, and certainly not some government bureaucrat.
   We also believe that doctors should have a choice as to
what
plans they practice in.  Otherwise, citizens may have their
own choices limited. We want to end the discrimination that
is now growing against doctors, and to permit them to
practice in several different plans.  Choice is important
for doctors, and it
is absolutely critical for our consumers.  We've got to have
it in whatever plan we pass.

     The fifth principle is quality.  If we reformed
everything else in health care, but failed to preserve and
enhance the high quality of our medical care, we will have
taken a step backward, not forward.  Quality is something
that we simply can't leave to chance.  When you board an
airplane, you feel better knowing
that
the plane had to meet standards designed to protect your
safety. And we can't ask any less of our health care system.

  Our proposal will create report cards on health plans, so
that consumers can choose the highest quality health care
providers and reward them with their business. At the same
time, our plan will track quality indicators, so that
doctors can make better and smarter choices of the kind of
care they provide. We have evidence that more efficient
delivery of health care doesn't
decrease quality.  In fact, it may enhance it.

     Let me just give you one example of one commonly
performed procedure, the coronary bypass operation.
Pennsylvania discovered
that patients who were charged $21,000 for this surgery
received as good or better care as patients who were charged
$84,000 for the same procedure in the same state. High
prices simply don't always equal good quality.

     Our plan will guarantee that high quality information
is available in even the most remote areas of this country
so that we can have high-quality service, linking rural
doctors, for example, with hospitals with high-tech urban
medical centers. And our plan will ensure the quality of
continuing progress on a whole range of issues by speeding
the search on effective prevention and treatment measures
for cancer, for AIDS, for Alzheimer's, for heart disease,
and for other chronic diseases. We have to safeguard the
finest medical research establishment in
the entire world. And we will do that with this plan.
Indeed, we
will even make it better.

  The sixth and final principle is responsibility.  We need
to
restore a sense that we're all in this together and that we
all have a responsibility to be a part of the solution.
Responsibility has to start with those who profit from the
current system.  Responsibility means insurance companies
should no longer be allowed to cast people aside when they
get sick. It
should apply to laboratories that submit fraudulent bills,
to lawyers who abuse malpractice claims, to doctors who
order unnecessary procedures.  It means drug companies
should no longer
charge three times more for prescription drugs made in
America here in the United States than they charge for the
same drugs overseas.

     In short, responsibility should apply to anybody who
abuses this system and drives up the cost for honest, hard-
working citizens and undermines confidence in the honest,
gifted health care providers we have.

     Responsibility also means changing some behaviors in
this country that drive up our costs like crazy. And without
changing it we'll never have the system we ought to have.
We will never.
     Let me just mention a few and start with the most
     important
- the outrageous cost of violence in this country stem in
large measure from the fact that this is the only country in
the world where teenagers can rout the streets at random
with semi-automatic weapons and be better armed than the
police.
     But let's not kid ourselves, it's not that simple. We
     also
have higher rates of AIDS, of smoking and excessive
drinking, of
teen pregnancy, of low birth-weight babies.  And we have the
third worst immunization rate of any nation in the western
hemisphere. We have to change our ways if we ever really
want to be healthy as a people and have an affordable health
care system.
And no one can deny that.

    But let me say this - and I hope every American will
listen,
because this is not an easy thing to hear - responsibility
in our
health care system isn't just about them. It's about you,
it's about me, it's about each of us.

     Too many of us have not taken responsibility for our
own health care and for our own relations to the health care
system. Many of us who have had fully paid health care plans
have used the system whether we needed it or not without
thinking what the costs were.  Many people who use this
system don't pay a penny for their care even though they can
afford to. I think those who don't have any health insurance
should be responsible for paying a portion of their new
coverage. There can't be any something for
nothing, and we have to demonstrate that to people. This is
not a
free system.  Even small contributions, as small as the $10
co-payment when you visit a doctor, illustrates that this is
something of value. There is a cost to it.  It is not free.

     And I want to tell you that I believe that all of us
should have insurance. Why should the rest of us pick up the
tab when a guy who doesn't think he needs insurance or says
he can't afford it gets in an accident, winds up in an
emergency room, gets good care, and everybody else pays?
Why should the small businesspeople who are struggling to
keep afloat and take care of
their employees have to pay to maintain this wonderful
health care infrastructure for those who refuse to do
anything?

  If we're going to produce a better health care system for
every one of us, every one of us is going to have to do our
part.
There cannot be any such thing as a free ride. We have to
pay for
it. We have to pay for it.

   Tonight I want to say plainly how I think we should do
that.
Most of the money we will - will come under my way of
thinking, as it does today, from premiums paid by employers
and individuals.  That's the way it happens today. But under
this health care security plan, every employer and every
individual will be asked to contribute something to health
care.

     This concept was first conveyed to the Congress about
20 years ago by President Nixon. And today, a lot of people
agree with the concept of shared responsibility between
employers and employees, and that the best thing to do is to
ask every employer
and every employee to share that. The Chamber of Commerce
has said that, and they're not in the business of hurting
small business.  The American Medical Association has said
that.

     Some call it an employer mandate, but I think it's the
fairest way to achieve responsibility in the health care
system. And it's the easiest for ordinary Americans to
understand,
because it builds on what we already have and what already
works for so many Americans.  It is the reform that is not
only easiest
to understand, but easiest to implement in a way that is
fair to small business, because we can give a discount to
help struggling
small businesses meet the cost of covering their employees.
We should require the least bureaucracy or disruption, and
create the cooperation we need to make the system cost-
conscious, even as we expand coverage.  And we should do it
in a way that does not cripple small businesses and low-wage
workers.

     Every employer should provide coverage, just as three-
quarters do now. Those that pay are picking up the tab for
those who don't today.  I don't think that's right. To
finance the rest of reform, we can achieve new savings, as I
have outlined, in both the federal government and the
private sector, through better decision-making and increased
competition.  And we
will impose new taxes on tobacco.

     I don't think that should be the only source of
revenues. I believe we should also ask for a modest
contribution from big employers who opt out of the system to
make up for what those who
are in the system pay for medical research, for health
education center, for all the subsidies to small business,
for all the things that everyone else is contributing to.
But between those two things, we believe we can pay for this
package of benefits and universal coverage and a subsidy
program that will help small
business.

   These sources can cover the cost of the proposal that I
have
described tonight. We subjected the numbers in our proposal
to the scrutiny of not only all the major agencies in
government I
know a lot of people don't trust them, but it would be
interesting for the American people to know that this was
the first time that the financial experts on health care in
all of the different government agencies have ever been
required to sit in the room together and agree on numbers.
It had never happened before.

  But, obviously, that's not enough.  So then we gave these
numbers to actuaries from major accounting firms and major
Fortune 500 companies who have no stake in this other than
to see
that our efforts succeed. So I believe our numbers are good
and achievable.

     Now, what does this mean to an individual American
citizen? Some will be asked to pay more.  If you're an
employer and you aren't insuring your workers at all, you'll
have to pay more. But
if you're a small business with fewer than 50 employees,
you'll get a subsidy.  If you're a firm that provides only
very limited coverage, you may have to pay more.  But some
firms will pay the same or less for more coverage.

   If you're a young, single person in your 20s and you're
already insured, your rates may go up somewhat because
you're going to go into a big pool with middle-aged people
and older people, and we want to enable people to keep their
insurance even
when someone in their family gets sick. But I think that's
fair because when the young get older, they will benefit
from it, first, and secondly, even those who pay a little
more today will benefit four, five, six, seven years from
now by our bringing health care costs closer to inflation.

  Over the long run, we can all win.  But some will have to
pay more in the short run. Nevertheless, the vast majority
of the
Americans watching this tonight will pay the same or less
for health care coverage that will be the same or better
than the coverage they have tonight. That is the central
reality.

   If you currently get your health insurance through your
job,
under our plan you still will. And for the first time,
everybody will get to choose from among at least three plans
to belong to. If you're a small business owner who wants to
provide health insurance to you family and your employees,
but you can't afford it because the system is stacked
against you, this plan will give
you a discount that will finally make insurance affordable.
If you're already providing insurance, your rates may well
drop because we'll help you as a small business person join
thousands of others to get the same benefits big
corporations get at the same price they get those benefits.
If you're self-employed, you'll pay less; and you will get
to deduct from your taxes 100 percent of your health care
premiums.

     If you're a large employer, your health care costs
won't go up as fast, so that you will have more money to put
into higher wages and new jobs and to put into the work of
being competitive in this tough global economy.

   Now, these, my fellow Americans, are the principles on
which
I think we should base our efforts:  security, simplicity,
savings, choice, quality and responsibility. These are the
guiding stars that we should follow on our journey toward
health care reform.

     Over the coming months, you'll be bombarded with
information
from all kinds of sources. There will be some who will
stoutly disagree with what I have proposed - and with all
other plans in the Congress, for that matter. And some of
the arguments will be genuinely sincere and enlightening.
Others may simply be scare tactics by those who are
motivated by the self-interest they have
in the waste the system now generates, because that waste is
providing jobs, incomes and money for some people.
     I ask you only to think of this when you hear all of
these arguments:  Ask yourself whether the cost of staying
on this same
course isn't greater than the cost of change.  And ask
yourself when you hear the arguments whether the arguments
are in your interest or someone else's. This is something we
have got to try to do together.

     I want also to say to the representatives in Congress,
you have a special duty to look beyond these arguments. I
ask you instead to look into the eyes of the sick child who
needs care; to think of the face of the woman who's been
told not only that her condition is malignant, but not
covered by her  insurance. To
look at the bottom lines of the businesses driven to
bankruptcy
by health care costs. To look at the Rfor saleS signs in
front of
the homes of families who have lost everything because of
their health care costs.

   I ask you to remember the kind of people I met over the
last
year and a half - the elderly couple in New Hampshire that
broke down and cried because of their shame at having an
empty refrigerator to pay for their drugs; a woman who lost
a $50,000 job that she used to support her six children
because her youngest child was so ill that she couldn't keep
health insurance, and the only way to get care for the child
was to get public assistance; a young couple that had a sick
child and could
only get insurance from one of the parents' employers that
was a nonprofit corporation with 20 employees, and so they
had to face the question of whether to let this poor person
with a sick child
go or raise the premiums of every employee in the firm by
$200. And on and on and on.

   I know we have differences of opinion, but we are here
tonight in a spirit that is animated by the problems of
those people, and by the sheer knowledge that if we can look
into our heart, we will not be able to say that the greatest
nation in the
history of the world is powerless to confront this crisis.

     Our history and our heritage tell us that we can meet
this challenge.  Everything about America's past tells us we
will do it.  So I say to you, let us write that new chapter
in the American story. Let us guarantee every American
comprehensive health benefits that can never be taken away.

  In spite of all the work we've done together and all the
progress we've made, there's still a lot of people who say
it would be an outright miracle if we passed health care
reform. But
my fellow Americans, in a time of change, you have to have
miracles.

     And miracles do happen. I mean, just a few days ago we
saw a
simple handshake shatter decades of deadlock in the Middle
East. We've seen the walls crumble in Berlin and South
Africa. We see the ongoing brave struggle of the people of
Russia to seize freedom and democracy.
   And now, it is our turn to strike a blow for freedom in
this
country.  The freedom of Americans to live without fear that
their own nation's health care system won't be there for
them when they need it.

     It's hard to believe that there was once a time in this
century when that kind of fear gripped old age. When
retirement was nearly synonymous with poverty, and older
Americans died in the street. That's unthinkable today,
because over a half a century ago Americans had the courage
to change - to create a Social Security system that ensures
that no Americans will be forgotten in their later years.

  Forty years from now, our grandchildren will also find it
unthinkable that there was a time in this country when
hardworking families lost their homes, their savings, their
businesses, lost everything simply because their children
got
sick or because they had to change jobs.  Our grandchildren
will find such things unthinkable tomorrow if we have the
courage to change today.
     This is our chance. This is our journey. And when our
work is done, we will know that we have answered the call of
history and met the challenge of our time.
         Thank you very much. And God bless America.