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

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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-of-service
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.