An Address by the First Lady
St. Louis, MO
March 15, 1994
Thank you. Thank you very much. I am just thrilled to be here.
Some of you may remember that this is where one of the debates during the
presidential campaign was held, and I can remember walking in the door I
walked in a few minutes ago, filled with a lot of anxiety and
trepidation over that upcoming debate. And I am so glad to be back,
with only a little less anxiety and trepidation, never dreaming we
would have so many people here.
I was frankly relieved when the
invitation came and they said, "But, you know it is during spring break."
So I thought, "Well, gee, you know, I could sit down and talk with a
few people about health care here at Washington University, in St.
But it is a real pleasure to be here and to have this
opportunity, because this university and this community, and particularly
the health care center that I just visited, is a symbol of excellence
around the country. And I want to salute one of the people who has made
that possible over the last years, your Chancellor, Chancellor Danforth.
I know that you will miss him as he retires. I
only wish I could have been one of the lucky people who heard him read a
bedtime story over the past years. It is such a good idea I am going to
suggest that maybe the President try it with some people in Washington.
I also want to thank Dean Peck for opening up his
campus, for giving me the tour, and for having some of the representatives
of this extraordinary medical system spend about an hour with me as we
talked through issues of concern and importance to academic health centers.
I want to thank the representatives of the students who made the
presentation. You will see the sweatshirt, if not on the front page of the
newspaper at least on either me or my husband as we attempt to get the
exercise that I now know for sure, having been to the rehab unit, will make
me live longer if I really do it. (Applause.)
And I want to join
all of you in wishing the Bears great luck in this upcoming championship
game. And I will be rooting for you and watching you as you go forward.
I am also grateful to know that the Hot Docs are
not a group of angry physicians (Laughter), but instead a jazz band, and I
only heard a little bit because we were waiting to come in, but I want to
thank them especially for being here and playing, and for the CDs, which I
will take home and give with great delight to my husband.
exciting for me to have a chance to visit with you for a few minutes about
what is happening with health care reform, and what the real attempt that
the President is making would mean to you and the various
constituencies of people represented here. Because, this is an historic
You know health care reform in our country goes back
a number of decades. Some have argued that the very first proposal actually
was made by Theodore Roosevelt, as part of his platform when he first ran
for President and then renewed it when he ran again. But we certainly know
that Franklin Roosevelt talked about it being the other part of social
security. And your own President Harry Truman was one of the most
passionate advocates on behalf of health care reform.
I have gone
back and read the speeches that President Truman gave in 1945, and 1946,
and 1974. They could be made today. He identified the problem which, as
the Chancellor has said, is how do we provide high quality health care
to all Americans at an affordable cost. And Truman argued passionately, but
unsuccessfully, that the country should move toward providing guaranteed
health coverage to all of our people.
And then, of course, we had
the changes in the 1960s, to provide Medicare for Americans over 65, and
to provide Medicaid for people who were too poor to provide for
themselves. And then President Nixon recommended comprehensive health care
that was built on the employer based system, the system by which most of us
who are insured receive our insurance benefits.
We have tried to
address this issue many times in the past under presidential leadership of
both Democrats and Republicans, but we have never been able finally to
resolve what has to be one of the most important questions for any
society: How do we fairly allocate our health care resources so that every
citizen is guaranteed that their health care needs will be met?
This time this historic opportunity is calling us. How can we, as the
richest country in the world, be the only one of our industrialized
competitors who have not figured out how to provide health care to every
one of its citizens?
This time we have enough support in the
medical community which recognizes what the needs are; enough support
in the business community which primarily pays the bills; enough support
from leaders like your mayor who is here with us, and state governments
around the country who also bear a huge part of the economic burden; and
enough support in Congress and a President who wants to get the job done.
So this could not be a more timely meeting for me to give you some
sense of exactly what the President's approach would mean in your
There are five major features to the President's proposal
for health care reform. The first is guaranteed private insurance for every
American, with comprehensive benefits that stress primary and preventive
health care, as well as care for our most acute medical needs.
President has not proposed a government health care system. He has proposed
building on the public private system we have in our country today, but
making sure that we guarantee private health insurance to all of us.
The second major point is to eliminate insurance practices that
discriminate against Americans. And there are a number of those. Some
Americans are unable to obtain insurance at any price, because of what are
called pre- existing conditions.
Most American with pre-existing
conditions -- and there are over eighty million of us -- we can get
insurance but at a very high price. And so what the President wants to
do is eliminate pre-existing conditions so that all of us, no matter
whether we have ever been sick before or have any kind of ailment, will be
eligible for insurance at an affordable price. That is one of the keys of
the President's approach. (Applause.)
And I would add, in this
great university with its extraordinary medical system, that it is
especially important we do that sooner instead of later; because, I was
recently at the National Institutes of Health with the new head of that
institute, Dr. Harold Varmus -- who some of you may know is a Nobel Prize
winner in science, and he was explaining, along with his colleagues, that
at the rate by which we are learning about the human gene system every
year, we are discovering the genes that we believe are responsible for
a number of medical conditions, that pretty soon all of us will know we
have pre-existing conditions because of our genetic makeup. So if we do not
reform the insurance industry very soon none of us will be eligible for
insurance, because our gene makeup will make us ineligible. (Applause.)
There is another insurance practice that the President wants
eliminated, and that is what is called life- time limits. If you read the
fine print in most insurance policies you will discover that after you have
reached a certain level of insurance coverage you are no longer
eligible under your policy for further reimbursement.
have life-time limits as low as fifty-thousand dollars, others as high as a
million dollars, but those limits come into effect when you need your
insurance the most. I have sat and talked with families who often to their
surprise discover in the midst of a medical emergency their insurance has
run out because they have reached their limit.
The President wants
to eliminate life-time limits. There is no reason you should be worrying
about your coverage when you need it most in your lives. (Applause.)
And the third practice that the President's proposal eliminates is
discriminating against older people, in favor of younger people. Now if you
are young, as many of our students are today, that may seem like a good
deal, that insurance would be much cheaper for you at twenty-five than
at fifty-five. The problem is most of you will be fifty-five some day, and
in the present system the cost of caring for young people is so much less
that many insurance companies want only to insure healthy young people,
often leaving older people out of the insurance market all together. So
that is another discriminatory practice that the President's proposal
So we will do away with pre-existing conditions,
life time limits, and age discrimination. (Applause.) All of which will
make insurance more affordable for everyone. (Applause.)
third point is that the President's approach guarantees choice of doctor
and choice of health plan. This has been an issue that has probably
received more misinformation than any other. Because, in the current
market place, there is a lot of confusion about what kinds of choice will
be available to you as a consumer.
In fact, as we are here today,
choice is diminishing for most Americans. Americans are being told by
their employers, who buy their insurance for them, by their insurance
companies if they buy directly, what doctors they can see and what
hospitals they can use.
In my discussion earlier today, I talked with
a representative of the children's hospital here, because most
children's hospitals that I have visited throughout the country are finding
the same thing: that more and more insurance policies are eliminating them
from being available for use by patients. Why? Because the childrens'
hospitals, which see very sick children, chronically ill children, are
expensive. They have to be in order to have the concentration of
specialists and technology necessary. So many insurance policies are saying
you cannot choose to go to a childrens hospital, just as they are saying
you cannot choose to go to a university hospital, or an academic health
center because they are more expensive. They have to be more expensive
because of the services they offer.
But under the current way health
care is both being organized and developing, fewer and fewer Americans are
being given choice. That choice is made by somebody else, for you.
Under the President's approach you will choose your health plan. Not your
employer, not your insurance company, and not a government bureaucrat. It
will be your choice, and you will make it every year. And what will be
guaranteed is that in your area, all of the physicians will be able to join
the health plans that they choose to join, so you will be able to
choose among them.
Additionally, every health plan will be required
to offer what is called a "point of service" option. In other words, if
you are in a health plan and you develop a problem where the specialist is
in another health plan, you will be permitted to go to that other health
The real danger for choice is the status quo, because if we
do not reform our system more and more of you will be told you cannot use a
certain doctor, you cannot use a certain hospital. It is the President's
approach that guarantees your freedom of choice for a doctor and health
plan, and if you value that, you need to support this reform.
The fourth important point is that the President's
approach preserves and improves Medicare for Americans over the age of 65.
The Medicare program has been a godsend for older Americans, who when it
was passed in the 1960s they were often the poorest of all Americans, often
deprived opportunities for health care for financial reasons. Medicare
has provided a base level of medical care for our older Americans.
But there are two features that most people I talk with say are missing,
that will be included in the President's approach. The first is
prescription drug costs which are often much too high for older Americans,
on fixed incomes, to be able to afford. And what we find is that many
older Americans do not take their prescriptions, do not get them refilled,
often end up being hospitalized because they could not maintain themselves
on the medication. Medicare pays for the hospitalization; we think it is
time Medicare starts paying for prescription drug coverage for older
Americans too. (Applause.)
And the second big problem for older
Americans in the Medicare program is there is not support for
alternatives to nursing home care. We do not help people who want to
keep their relatives in their own home. We want to start providing long
term care options, so that families will be able to take care of their own
relatives, they will not be forced to put their family members in nursing
homes if they can take care of them at home with a little bit of help.
It is the right thing to do, but it is also the economically smart
decision to make.
Nursing homes are very expensive. Providing a
home health aide, providing adult day care, giving some respite care to
the full-time caretaker of an Alzheimer's patient, that is all much cheaper
than putting the person in a nursing home. So let's start giving
alternatives that will enable older people to live with dignity, and not
make the nursing home the only place that we take care of older people
with medical problems. (Applause.)
And the fifth point that I want
to stress is that Americans will be guaranteed their health care
coverage through their place of employment, the way most of us get our
If you believe, as the President does and as I
do, that we need to guarantee health care coverage to every American,
because until every one is covered none of us is secure. And let me just
stress that. Every one of us in this room, with the exception of those of
you who already are eligible for Medicare, cannot know that this time next
month, or next year you will be insurable at the same rate, for the
same services that you are today. None of us under the age of 65 has that
If you believe, as we do, that all of us should there
are only three ways to pay for that. You can either have what is called a
single payer system, which means you eliminate private insurance and you
raise the tax to substitute for premiums, and you fund the health
insurance system that way. And there are many people who support that
approach. (Applause.) The single payer approach guarantees that every
American would have health care coverage.
The President rejected that
approach in its means, although he agrees with the goal, because he
believed we should keep the public/private mixture that has served our
country well. We should build on what works and fix what is broken, so we
should not eliminate private insurance, we should extend it to everyone.
And, if you believe that then there are only two ways to do that.
There is an approach called the "individual mandate," which, like auto
insurance, would require each of you to go into the market place and buy
your own insurance. That, at least, would on paper get us the universal
coverage, if you could enforce that individual obligation.
are several problems with that approach. One is we don't want to encourage
employers who currently provide insurance to stop doing so. And, if we pass
the law which said it is an individual responsibility there are employers
- - how many it would be difficult to predict -- who will say one of
two things to themselves, "Well then I no longer have to do this, because
the individual is required to do it." Or, they might say, "Well what I
will do is drop my low wage employees, because the government is going to
subsidize them on the individual responsibility and I will only provide
insurance for people of professional or managerial standing." Neither of
those would work very well.
What the President believes is we ought to
take our employer/employee system. This is what some Presidents who
have come before him have proposed. Each has looked at what works. Social
Security is an employer/employee based system. Medicare is paid for by an
employer/employee contribution. Let's extend health care to every one in
the work place, building on the employer/employee shared
Now how do we make sure that that is done fairly?
Well there are several considerations that we have looked at carefully.
First, for most businesses that currently insure your cost will go down,
because you will no longer be paying in your premium for businesses that do
not insure and for individuals who get taken care of at our hospitals but
cannot pay for themselves. Those costs have to be shifted to somebody,
and they usually are shifted to those of us with insurance.
Secondly, even if you are a small business and you currently insure you are
now being discriminated against in the insurance market. You pay anywhere
from thirty-five to forty percent more for your insurance than a big
business, or a government does when it buys insurance. So we can lower
the cost of even small business by making everybody share the cost more
Now if you have never paid for insurance for yourself, and
you have never contributed to your employees, yes, it is going to cost
something. But you have had a free ride in our medical system. Because, if
I go down any street in St. Louis or the surrounding towns here in the
county, we could point out the businesses that insure and the
businesses that don't. But when someone working at the business that
does not insure gets sick, they go to the same hospital, they get taken
care of. The doctors are there for them, but they don't pay for it. It is
being paid for by those who currently, and in the past, have insured.
So if we provide discounts to small businesses, and if we provide
subsidies to low wage workers then we can make insurance affordable for
even those who have never insured themselves in the past. Once everybody is
in the system then we can begin to get cost under control. Because, right
now trying to control cost in a system where everybody is not in it is
like holding on to the balloon in one part, it pops out somewhere else.
Everybody being in the system means the cost can be lowered for everyone,
because there will be no place to shift cost and make somebody else pay for
the health care of another person's employee or another individual.
So guaranteed private insurance, eliminating unfair insurance
practices, guaranteeing choice of doctor and health plan, preserving and
improving Medicare, and guaranteeing insurance at the work place through
shared responsibility by employers and employees, those are the major
points of the President's plan.
An additional point, I would add
because of where we are, is the awareness that the President has, of
the important work done by the academic health centers; the research
that is done, the application of that research through clinical practice;
the education and training of physicians, nurses, and other allied
This system that we have built up has features that
have to be strengthened and protected, and in the President's approach
there will be guaranteed funding for academic health centers, because of
the important functions they perform for the entire system.
there will be a requirement that health plans contract with those health
centers, so that those health centers will not be eliminated from the
provision of health care in an effort to control costs, but will become
the centers of excellence so that we will have places in every region
where only the services that can be provided at that level of complexity
will be available. So we want to preserve and strengthen our academic
Now this debate, as we move forward, will be
filled with all kinds of arguments, and many of them will be engaged in
in very good faith, by people who see the problem and know that it has to
be solved but have different points of view. That is what the
Congressional process is for. And I am very encouraged when I see the kind
of work that is going on now in the Congress, often behind the scenes, in
the Committees and the Sub-Committees, where Republicans and Democrats
of good faith working toward solutions are coming together to hammer
But there will always be extremes in these
debates, and there will always be interest groups who, frankly, have
profited from the status quo and do not want reform to occur. It will be
our task, as citizens, to keep the debate as honest as possible, to ask the
hard questions, to say how will this affect me? Me as a mother, me as a
patient, me as a physician, me as a nurse. How will this change make
our health care system work better?
I am very optimistic about
where we are in this debate, because I do believe that there are enough
people in the country who understand what is at stake. But it has to be
a debate in which you are engaged. And I would ask you to follow it
closely, to ask what the motive or the agenda of the person speaking is, so
you can cut through the rhetoric to try to find out what is really being
advocated, to follow it closely in the Congress, to stay in touch with
your members of Congress, to give them the benefit of your
Because, this is not just a debate about how we are
going to finance health care. It is bigger than that. It is a debate about
what kind of a country we are and intend to be.
In the meeting I
was just in there was a medical student who said she had worked in a clinic
last summer, where she had taken care of a lot of people who were
falling through the cracks, homeless people, runaway teenagers,
undocumented workers, the recently unemployed, and she wanted to know what
would happen to those people. That is one of the right questions.
Yesterday in Denver, I visited a National Guard unit that was set up in one
of the poorest, toughest sections of Denver. We are finally using our
National Guard resources for taking care of our own people in situations
other than disasters, and I wanted to see it firsthand. And I was led
through with a lot of very exciting news from the people who were with me,
the doctors and the nurses, about what they had seen in just a week, the
people who had flooded in seeking help.
And while I was there, I
met a man who got a pair of glasses for the first time in years. I met a
young Downs syndrome boy who is 10 years old. He was there with his
grandmother, they had just lost their Medicaid card, they were no longer
eligible under some change in rules, and she had brought him to the only
place that she thought he could get medical care, a National Guard MASH
I visited with the doctors and nurses who were so pleased to
be here answering the unmet health needs.
This is not just about
those people, but it is about how we treat them and how we think about
them, and at bottom, it is about us. If we move through this next year
and think about the people who you know, and who you see and you hear
about, and if you know that, fortunately, there, but for the grace of God,
often go any of us None of us can predict the state of our health, no one
knows when the accident may occur. Then we will ask the right
questions, how will we take care of each other? How will be better use
our resources? How will we build on what is the finest health care system
in the world? By fixing the financing system that is distorting it.
And what I hope is at the end of this debate I can go back to the
literally hundreds and hundreds of Americans who have shared their stories
with me, who have told me what it feels like to be the mother of a
chronically ill child whose insurance runs out, or to be a small business
owner who can't afford insurance and has to tell her son not to go out
for sports this year because she is afraid he might get hurt, or the woman
whose husband could afford insurance for himself and their four children
but didn't insure her because he couldn't afford it, and she got pregnant
again and now she wonders whether she can afford anesthetic when she
gives birth because it would be the equivalent of a house payment for
them. Or the woman who had a breast exam and they found a lump, and she was
referred to someone and was told that because she didn't have insurance
they wouldn't biopsy it, they would just watch it.
I have so many
stories, it is like a movie in my head, the people who I see -- and I want
to be able to go back to them, I want to go back to this medical student
I talked to today, and tell her and tell them we have now provided
health care coverage for every American, and we have taken a step toward
becoming the nation we should be.
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