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Office of the Press Secretary

For Immediate Release September 20, 1993
                      REMARKS BY THE PRESIDENT,
                           THE FIRST LADY,
                         THE VICE PRESIDENT,
                              MRS. GORE
                         DR. C. EVERETT KOOP
                            The East Room

8:45 A.M. EDT

MRS. CLINTON: Good morning, and thank you all -- please be seated -- for joining us. We were talking so much with Dr. Koop in the back, none of us heard our names. (Laughter.) And so that's one of the reasons we were a little bit slow getting here.

I want to welcome you to the White House. I want to thank you for coming and being part of this process that we believe will lead to the kind of reforms in our health care system that many of you have talked about, have spoken about, and have actually done in the practices you have, in the centers in which you practice, at the medical schools that you direct. And it is a particularly exciting moment for all of us to be on the brink of what we hope will be the kind of changes that will assure health security to every American and give opportunities, again, to physicians and nurses and those on the front lines of health care to make the decisions about what needs to be done for the patients in our country.

I want to acknowledge Secretary Donna Shalala who is here. (Applause.) She's not only doing an excellent job at HHS, there are some who will argue that she may be the best golfer in the administration. (Laughter.) She played with the President last weekend.

Also Dr. Joycelyn Elders, our newly confirmed Surgeon General is back there. (Applause.) I think when it comes to prevention and communicating with large groups of Americans who have not been part of the health care system but need to be for their own and their families well-being, Dr. Elders will be an extraordinary voice.

Dr. Phil Lee, the longtime advocate for -- (applause) -- for better health care for Americans. We enticed him out of his position, which I think he thought was a position he would not move from in California to come back. And I personally have been very grateful for Dr. Lee's counsel and advice throughout this process.

Ira Magaziner, Dr. Judy Feder, others who are here. Judy and Ira, if you would stand. (Applause.) The team that they have put together, thanks to many of your institutions, which as several of the deans of the medical schools have told me, have meant you've lost people for long periods of time to be part of this process. We are very grateful.

I also want to thank the chairs of the Health Professions Review Group, Dr. Steve Gleason and Dr. Irwin Redlener, if you would stand please. (Applause.)

And there are many others who are in this room who have been such great helps to us and will continue to be as we move forward. I'm particularly pleased that an old friend of mine, Dr. Terry Brazelton would be here. Dr. Brazelton, who gives the kind of -- (applause) -- gives the kind of confidence to young mothers that Dr. Spock used to give to mine and that many of you have given. And we're very grateful for that.

We want to spend a few minutes this morning talking about where we go and how we get there and how we hope all of you will be involved in this process. And I would like to introduce the Vice President to say a few words about the way this relates to what we're doing across the board in the administration.

Vice President Al Gore. (Applause.)

THE VICE PRESIDENT: Thank you very much. Distinguished guests, ladies and gentlemen. I want to thank the First Lady for her introduction and leadership in this whole initiative. This is the week that was, as they say. And it's wonderful to see so many physicians who are here and who are so strongly supportive of the President's efforts to reform our health care system.

I might say that it's a special honor to be with Dr. Koop. I look forward to his comments later. He and I had a chance to work together on a number of projects in the last several years. And it is always refreshing to hear his views.

It's very interesting to take stock of how much things have changed in so short a period of time. The debate on health care is now dominating our national debate about where we go as a country. No one any longer doubts that we are going to reform our nation's health care system. Now the debate is about exactly how and what kinds of changes. It's very refreshing.

I heard kind of a throwback in the last couple of days from someone who is resisting change who made a point that I haven't heard in quite a while. He said, we have the finest health care system in the world. And in many ways, of course we do. But he said, we have to resist tinkering with it because it's just -- it's great. Well, when I heard that I thought about an event last week when the President and I went over to Children's Hospital. The First Lady was out at Mayo Clinic and leading a number of events in Minnesota that day. Tipper was talking with mental health care groups. The President and I went over to Children's Hospital and talked with doctors and nurses there about the current system and what it means to them just in terms of the sheer paperwork and bureaucracy and red tape.

As is often the case when a big change comes, people suddenly realize they have not allowed themselves to feel the weight of how bad things were until they can see the hope for change. Well, that's the message that we heard over there, as these doctors and nurses were saying. Since we sat down and really measured this, we didn't realize what we were doing. One patient comes in here under Medicare, and we have to fill out 26 different forms for that one patient.

We went to the file room, the stack of paperwork is growing six and a half feet per day -- just in one hospital. And one doctor said that in adding up the amount of time that he spent on paperwork, he could have seen an extra 500 patients per week -- I believe it was per week -- per year, I'm sorry. (Laughter.) I don't want to get carried away with this. No, I don't think it was per year. I think it was more than one per day.

MRS. CLINTON: It was one and a half per day.

THE VICE PRESIDENT: In any event, it was a lot. (Laughter and applause.) The main point is, the paperwork and the red tape and the bureaucracy is so overwhelming, when people now finally let themselves look at it and realize what they've been doing -- now, I believe I've got this statistic right. A pediatrician said that she was spending 25 hours -- believe it or not -- 25 hours per week just filling out forms for her patients. Is that right? Okay. (Laughter.) The heads are nodding yes on that one. (Laughter.) Well, that's crazy.

And we have been in the midst of this effort to reinvent government and we've been spotlighting the ways in which the system is very inefficient across the board. And there are so many similarities between what needs to be done government-wide and what needs to be done in the health care system.

This new approach is going to be simple -- one form per patient. It is going to be effective. It is going to extend health care coverage. And it's going to eliminate the waste and inefficiency. And we are all very excited about it and very pleased that you are here to help start this important week. Thank you. (Applause.)

MRS. CLINTON: I also now want to introduce someone who has been deeply involved in this. I know that there are representatives here from the American Psychiatric Association, other mental health professions, along with the APA, have worked very hard with Tipper Gore to come up with a proposal that would move our country forward on the treatment of mental health problems. And I'm very proud to introduce Tipper Gore. (Applause.)

MRS. GORE: Thank you. I want to add my voice in word of welcome to all of you and my deep gratitude for the work that you have given to the health care reform. And many of you have had direct input in the proposals on mental health. I see many people that I've worked so closely with and, as Mrs. Clinton said, when I addressed the American Psychiatric Association in the spring, it was really a wonderful event in which there was a meeting of the minds about the direction in which health care reform should go and the place that mental health care should have in it.

And I'm very proud to say that within this administration mental health, which has long been discriminated against, has been analyzed and debated along with all the other issues right from the very beginning. And that is a very revolutionary first step.

For those of you who have worked very hard on the proposal, thank you so very much for your input and your efforts. And just know that I will continue to work with you in the years ahead to make sure that American citizens have the very best mental health care that we can give them. Thank you. (Applause.)

MRS. CLINTON: One of the goals of the next weeks as we move forward is to be sure that all of the voices of those who are most involved in delivering health care will be heard. We believe that in coming forward with a plan that reflects what we have learned from listening and meeting with many of you and thousands of people around this country who are providing care that we have really sparked what will culminate in the final reform effort. But we cannot get there without all of your involvement.

Many of you in the last months have shown us why we can do what we think we can do in this country. You have through your practices shown how costs can be contained without in any way impacting quality. You have shown us how we can fairly finance a system if everybody is in it and everybody is responsible. You have convinced us of the importance of simplifying the system to get to the real problems that so many of you face.

We know there will be not only considerable discussion but probably even a very vigorous one in all kinds of settings around our country. And we welcome that, because we believe that this is an issue on which there are so many things to learn. And although we've tried to get it right, we are still getting it right.

As the Vice President said, I was in Minnesota on Friday talking with people from the university, from Mayo who have very specific suggestions about how to make it even better, which we are bringing back and incorporating.

In order to be sure that we continue to get that kind of involvement and feedback from the medical profession, we have scheduled a series of forums across the country that will bring together doctors and other local and national health care leaders to discuss various aspects of reform. It is our hope that these forums will serve as sounding boards for doctors who want to share their ideas about change, and as classrooms for ordinary citizens who want to learn more about our health care system.

We are starting at two different levels at one time. There are many, not only those in this room but in other positions around our country, who know a great deal about how the health care system works and how it could be reformed to work better.

There are others who are just beginning to focus their minds and attention on this. We want to be sure that the debate is as well informed as possible, because we believe that a well-informed debate will lead to the right solution for America.

It is our good fortune that Dr. C. Everett Koop has agreed to lead these panel discussions. He is one of the most thoughtful, courageous and independent health care leaders in the nation. During almost a decade as or nation's Surgeon General, he moved every American with his powerful messages about the AIDS crisis, the perils of smoking, and the murderous plague of urban violence.

For many years, Dr. Koop has campaigned to reform the health care system. He has been an passionate advocate of primary and preventive care, of universal coverage and cost containment. He has helped foster a new philosophy of medical education that emphasizes better communications between doctors and patients. And always he has stirred the consciences of all Americans by prodding each of us to be more responsible for our own health.

Dr. Koop's unwavering dedicating to improving our individual and collective health makes him uniquely qualified to moderate a national health care discussion in the months ahead. The work that he is doing at Dartmouth -- the work that demonstrates that very often there is no difference in quality between a coronary bypass priced at $20,000 and a coronary bypass priced at $80,000; the work that he is doing with courageous and forward-thinking leaders around our country who are already keeping costs below inflation without sacrificing one bit of patient care; the kind of work that he and his colleague, Dr. Wennberg, who is here, are doing to show that better allocation of our resources will result in no diminution of quality, but in fact, better quality in many instances because more people will be brought into the system in a more cost-effective, quality-driven way.

It was certainly influential to all of us, as we began to look for the kind of data that supports the sort of things and feelings and attitudes that many of you have expressed based on your own practice. If we can indeed take the physicians at Children's Hospital and relieve from them the Medicaid paperwork that is not related to patients records so that they could fulfill the promise that they made to themselves in front of the President and the Vice President, that for those 200 doctors on staff, each could then see approximately 500 more patients, that would be 10,000 more children just in Washington, DC, who could be taken care of. That's the promise of health care reform. And that is the hope we bring to this national discussion with all of you and why we're so pleased that Dr. Koop has been willing to take this leadership role.

Dr. C. Everett Koop. (Applause.)

DR. KOOP: Thank you very much. I know when people come to Washington, even sophisticated physicians, they like to go home having picked up some inside information. I'll let you in on a conversation that took place about two years ago when that grand old gentlemen Claude Pepper died and went directly to heaven. He had an audience with God and said, sir, just one question. Will there ever be health care reform in the United States? And the Lord answered and said, yes, Senator, there will be health care reform in the United States. That's the good news. The bad news -- not in my lifetime. (Laughter.)

Since I left office as your Surgeon General four years ago, I have really dedicated most of my time and energy to speaking out whenever and wherever I could all across the United States on the need for health care reform. At first mine seemed like a lonely voice out there. But now at long last, health care reform has moved to the top of the national agenda. And I thank President Clinton and the American people for placing it there.

A few weeks ago, I told the President that without passing a single law or issuing a single regulation, he had accomplished more in health care reform in the past four months than all of his living predecessors put together. (Applause.) And he did that with a special kind of leadership that is willing to take on an enormous task. This kind of leadership also takes courage because it's a daunting task to face runaway health care costs, the vexing issue of universal access, the malpractice mess, the mounting problems of Medicare and Medicaid, the application of outcomes research, a sweeping reassessment of medical ethics, to say nothing of rooting out fraud and waste and abuse and greed.

Like many of our big national problems, the health care crisis in America is a very complicated one. And that means it will call for a variety of solutions. They, of course, will be national, but that means regional and local. They will have to be a publicprivate partnership. And there is a way in which every citizen must make a personal contribution.

But the President knows that there is no panacea, there is no single magic bullet, and there are no easy answers, only a series of very difficult choices. The administration's health care reform initiative is comprehensive, it's complex, it's -- well, it's complicated. And that's because it is offered in the spirit of compromise.

President Clinton has told me that he views these health care proposals not as a take it or leave it package, but as what they are -- proposals -- proposals that will lead to constructive debate and not just to constructive debate but then to constructive legislation. Some things, like universal access, are not negotiable. And that's exactly the way it should be. (Applause.) But they are proposals offered in trust that an honest congressional and public debate will bring out the best in health care reform for the American people.

Now, I don't imagine that any one of us will agree with everything, every single point in the proposed reforms. I imagine the President has his own reservation about some points.

When I read the first draft of the plan, I was impressed with the attention that had been given to detail: present situations that should be eliminated, needed additions that would be made. I was supportive of the plan, even if there was specific issues with which I disagreed.

Later, I was also pleased that suggestions I made in a critique of the plan did not fall on deaf ears. Whether there are pieces of the administration's health plan that you don't like or not, we have to move forward with dialogue seeking consensus. But our reservations, or even outright objections, to some provisions cannot give us the excuse to oppose everything.

My concerns about some issues will not stop me from fighting for the many reforms the American health care system so desperately needs. And I hope you'll approach the reform proposals in exactly that same spirit. It is in this spirit of dialogue and constructive debate that I have agreed, as the First Lady said, to moderate a dialogue between the medical profession and the administration a series of panel discussions scheduled this fall and winter in a number of cities across America.

Now, these forums could, for example, combine the views and expertise of national health care figures with those of local physicians and other health care workers so they can, together, thrash out the issues of the reform proposals before the profession as they relate to a local region.

Physicians have been noticeably absent from past efforts to reform the American health care system, even when it turned out that physicians proved to be among the major beneficiaries, as with Medicare. Indeed, all too often, past health care reform measures have been imposed upon physicians, often against their loudly voiced opposition. This time, doctors cannot allow themselves to be cast in the role of naysayers.

In one way or another, doctors' decisions for their patients and themselves drive the entire health care system. And, therefore, I call upon the medical profession in which I have served for over half a century to assume its rightful position of leadership to drive the health care system to the reformed excellence that it can deliver. (Applause.)

Our health care system may function with compassion, with competence, at times with sheer excellence. But not for enough Americans. For too many Americans, our health care system is a tyranny, and that means for them it is more a curse than it is a blessing. The next decade will force us to do some very hard thinking and deciding about the basic purpose of medicine. We haven't done much of that in days gone by. For most of human history, medicine really couldn't do very much, really couldn't cure anything. And so, at best, it offered some comfort, some relief of symptoms.

And, then, beginning in the 18th century -- and remember that modern medicine and the United States are about the same age -- with the application of science and technology to medicine, we saw the age when medicine could begin to cure many problems, and it could prolong the life for millions of people. And we entered the age of what we now call "our medical miracles." But a still other age may be dawning as we come to grips with the limits of curative and reparative medicine and surgery.

Today, in a strange way, hospitals and doctors -- in fact, the entire health care community -- are victims of their own success in curing disease and alleviating suffering. Increasingly, medicine decreases mortality while it increases morbidity. In other words, we have many more people living longer, but some of them are living sicker. And an increasing share of health care resources are allotted to those whom medicine cannot cure and we know about that at the start.

Too much, however, of the intensifying debate about health care focuses only on questions of how we finance it on the economic and political dimensions of health care reform. I think, for many of us, this puts the cart before the horse. More important, I think, than the economic and political pressures is the ethical imperative for health care reform.

Before we can enact the sweeping reform we need in health care, we must agree on the basic values and the ethics upon which our health care system, and, indeed, our society is based, and from which it draws its moral power.

If we could reach an ethical consensus, I think many of the economic and political problems of health care reform would fall rather easily in line. Physicians and allied health workers bring a broad field of vision to the health care reform effort. Physicians and nurses, other health care workers, have seen firsthand their fellow citizens' lack of health insurance go from being just an economic inconvenience to now being a medical risk factor.

Health workers know from experience that uninsured Americans are sicker than other patients when they finally enter the health care system, and their illnesses cost the system more to treat. And their lack of insurance results in a higher mortality rate than that of hospitalized Americans who do enjoy adequate health insurance.

Health care workers have also often seen patchwork efforts at cost control result merely in cost-shifting -- squeezing the balloon in one place, only to have it expand in another.

I would suggest that you in this room can bring your experience and expertise to the debate on health care reform so that we can preserve what is right and correct what is wrong. In so many ways, the American health care system, in spite of its many flaws, offers the best health care in the world. Nevertheless, we must remember if it ain't broke, don't fix it; but, unfortunately, an increasingly large share of our system is breaking down. So let's be sure that we turn our attention to ways that we can fix that.

And so I do call up on the medical community to approach the health care reform proposals now being offered in the spirit of our high calling in the Hippocratic tradition that requires us to do nothing but the best for our patients. Let us make sure that physicians play their part in making sure that the health care system we reform offers the very best for the American people. The President has said he wants a dialogue. Let us accommodate him in the spirit of reform and of give-and-take.

Physicians are individualists to be sure, but they are also altruists. And we have come to a time when, for once, the medical profession and the government can work together to forge a health care system for all Americans by achieving a new American consensus. Let me reaffirm that I think the plan is headed and moving in the right direction. I look forward to lending my support as I moderate the forthcoming dialogue between the great profession of medicine and this administration. Thank you. (Applause.)

THE PRESIDENT: Good morning. I thank you for coming here, and I thank Dr. Koop for his stirring remarks. He always makes a lot of sense, doesn't he. And the nation is in his debt for his work as Surgeon General and now, for the work he is about to undertake in behalf of the cause of health care reform.

I also want to thank the many physicians from all across America, from all walks of medical life who have made a contribution to the debate as it has progressed thus far. I got very interested in this subject years ago when, as the governor of my state, I noticed I kept spending more and more for the same Medicaid and had less and less to spend on the education of our children or on preventive practices or other things which might make a profound difference in the future.

In 1990 I agreed to undertake a task force for the National Governors Association, and I started by interviewing 900 people in my state who were involved in the delivery of medical care, including several hundred doctors. Some of them are in this room today. I thank them for their contribution, and I absolve them of anything I do which is unpopular with the rest of you. (Laughter.)

I'm glad to see my dear friend and often my daughter's doctor, Dr. Betty Lowe, the incoming President of the American Academy of Pediatrics. (Applause.) My cardiologist, Dr. Drew Kumpuris, who pulls me off a treadmill once a year and tells me I'm trying to be 25 when I'm not. (Laughter.) And Dr. Morris Henry from Fayetteville, Arkansas, back here, an ophthalmologist who hosted the wedding reception that Hillary and I had in Morris and Anne's home almost 18 years ago next month. Dr. Jim Weber, formerly President of the Arkansas Medical Society. A lot of our doctors here -- we started a conversation with doctors long before I ever thought of running for President, much less knew I would have an opportunity to do this.

This is really an historic opportunity. It is terribly important for me. One of the central reasons that I ran for President of the United States was to try to resolve this issue, because I see this at the core of our absolute imperative in this sweeping time of change to both give the American people a greater sense of security in the health care that they have, and call forth from our people -- all of our people, including the consumers of health care -- a renewed sense of responsibility for doing what we all ought to do to make this country work again.

I am determined to pursue this in a completely bipartisan fashion. And I have reached out to both Republicans and Democrats, as well as the thoughtful Independents to help. There is one person in the audience I want to introduce, a longtime friend of mine who has agreed to help mobilize support for this approach among the Democrats of the country, the distinguished former governor of Ohio, my friend Dick Celeste, who's here. Thank you for being here. (Applause.)

When Dr. Koop talked about the ethical basis of this endeavour, he made perhaps the most important point. If I have learned anything in all these years of public endeavors, or anything in the last several months of serving as your President, it is that once people decide to do something they can figure out how to do it.

When, one week ago today, on the South Lawn of the White House, Yitzhak Rabin and Yassar Arafat signed that peace accord, they did not even know what the ultimate map drawing of the city of Jericho would be, or how all the elections would be held, or how the Palestinians candidates would advertise on the radio since the radio stations don't belong to the Palestinians -- I could give you a hundred things they did not know the answer to. They knew one thing, they couldn't keep going in the direction they were going and so they decided to take a different direction.

When President Kennedy's administration challenged this country to go to the moon, they didn't have a clue about how they were going to go. The Vice President knows more about science than I, so he can tell it in a funnier way about they didn't understand what kind of rocket they were going on and what their uniforms would be like and on and on and on. But the ethical imperative is perhaps the most important thing. We have to decide that the costs, not just the financial costs, but the human costs, the social costs of all of us continuing to conduct ourselves within the framework in which we are now operating is far higher than the risk of responsible change.

We have certainly tried to do this in a responsible way. I want to thank the First Lady and all the people who work with her. I want to thank Tipper and Ira and Judy and everybody who was involved in this. We have really worked hard to reach out to literally to thousands and thousands of people in this great medical drama that unfolds in America every day.

I want to thank Donna Shalala and the Department of Human Services for the terrific work they have done. We have really tried to do this in an embracing and a different way -- almost a nonpolitical way. If you look around this room we have doctors from Maine to Washington, from Minnesota to Florida, some of you see patients in rural Virginia, some in public hospitals, others of you devote your lives to training the next generation of physicians.

But I think everyone of you is committed to seeing that we provide the finest health care in the world. That means that as we undertake this journey of change, we clearly must preserve what's right with our health care system -- the close patient-doctor relationship, the best doctors and nurses, the best academic research, the best advance technology in the world. We can do that and still fix what's wrong. In fact, we can enhance what's right by fixing what's wrong.

If we reduce the amount of unnecessary paperwork and governmental regulation and bureaucracy, that will by definition enhance the doctor-patient relationship. If we spend less money on paying more for the same health care and the incentives to churn the system, we will have some more money, for example, to invest more in medical research and advanced technology and breaking down the barriers which still limit our ability to solve the remaining problems before us.

We need a discussion, we need constructive criticism, we need constructive disagreement on some points. This is a very complex issue.

I worked at this for over a year and realized when I was a governor I was just beginning to come to grips with it. When we started this great enterprise and I asked Hillary to undertake this task and she looked at me as if I had slipped a gasket -- (laughter) -- I knew more about it than she did. Now, she knows a lot more about it than I do.

This is a learning effort. We are going to start today, as many of you know, this health care university we call it for members of Congress, and about 400 members of Congress have signed up for two intensive days of learning. That is an astonishing thing. I have never seen anything like it. These members, without regard to their party and completely without respect to the committees they are on, since most of them are on committees that would not have direct jurisdiction over this -- hungering to know what you go through everyday. Hungering to learn, wanting to avoid making an irresponsible decision but determined that they should make some decisions to change this system. I think that is a terrific cause for hope.

For patients, the reform we seek will mean more choices. Today employers are too often forced by rising health care costs to decide which plans to offer their employees, and often they are inadequate, or too costly. The decision is usually based on the bottom line and is a moving bottom line as more and more Americans every month actually lose their health insurance for good. Our plans give consumers the power to chose between a broad range of plans within their region, giving them more freedom to find and to stay with a doctor they like.

For doctors, reform will mean the flexibility to choose which networks or providers you want to join. If you want to be involved with one, that's fine. If you want to be involved with more than one, that's fine, so that whatever you want to do to continue to see the patients you see today, you will be able to do it -- it's your choice.

We intend to see a reform that drastically simplifies this system, freeing you from paperwork and bureaucratic nightmares that have already been well discussed.

I cannot tell you how moved I was when we were at the Washington Children's Hospital the other day and we heard not only the statistics that the hospital has calculated that they spend $2 million a year on paperwork unrelated to patient care and keeping up with the procedures. But the human stories -- I mean, we had a nurse actually tell us about being pleaded with by a young child with cancer to play with the child, and she couldn't do it because she had to go to a little seminar on how to learn how to fill out a new set of forms that they were being confronted with. And she said, that really was a picture of what their life was like -- an eloquent doctor who said she wanted to live in Washington, D.C., she wanted to care for the poor children in the area. She did not go to medical school to spend her life pouring over a piece of paper. And all of you have had that experience.

We can do better than this. We also know we're going to have to trim back government regulations that get in your way and do little to protect the patients or provide better care. If we simplify the system, we will reduce the apparently insatiable bureaucratic urge that runs through administrations of both parties and seems to be a permanent fixture of our national life to micromanage whatever aspect of tax dollars they have some jurisdiction over. We are determined to undo much of that. We want to respect your training, your judgment and your knowledge, and not unduly interfere with what you do.

We also are determined to preserve the quality of health care that our people receive. Today, part of the reason we have the finest doctors in the world are the academic health centers. For years they have been the guardians, the guarantors, of quality -- training doctors and health care professionals and reaching into surrounding communities to provide help for those in need.

In the coming years, these centers, if our plan passes, will have even greater responsibility to turn out high quality physicians, particularly primary care physicians who will work in underserved areas, and to create a system of lifelong learning for health care professionals. And they must continue to expand their partnerships with communities around them.

The initiative I am offering offers the possibility of giving real building blocks to this nation's health care system to fill in a lot of the gaps which exist for millions of Americans -- not just universal coverage gaps, but also organizational problems and the lack of adequate access.

I want this plan to be fair, compassionate and realistic, and I believe it is. Health security can be provided to the American people so that you don't lose your health care when you lose your job; you don't get frozen into a job because someone in your family has been sick and you're in the grip of the preexisting condition syndrome, which is literally undermining labor mobility in a world where the average 18-year-old American must change work eight times in a lifetime to be fully competitive. When security means the ability to continuously learn and find new and evermore challenging work, not to stick in the same rut you're in anymore, we don't have that option. We are literally rendering people insecure through job lock -- undermining their potential, keeping them from moving on, and also keeping others from moving up into the positions they previously held. This is a serious economic problem.

This plan will guarantee that every patient who walks in your door is covered. It will make sure you are paid to keep your patients healthy as well as to treat them when they're sick. It will give you the flexibility and freedom you need to do your jobs. In return, it must demand more responsibility from all of us. We must have a new generation of doctors which has a recommitment to primary care. We don't have enough primary care physicians in America, and I think we all know it. We have to care about family practice, pediatrics and preventive medicine. And we all have to work together to get medical costs under control.

But I'm convinced with your leadership we can do that. Without your help, we could not have covered as much ground as we have covered so far. I thank Dr. Koop for what he said. But the attention to detail by this project is the direct result of the painstaking effort and the hours that have been provided by physicians and other health care providers who have come to this town and spent day after day after day after day almost always at their own expense just to do something to help their country as well as to improve the quality of their own practice. We know that this will not be done overnight. We know that we will have to have a long-term commitment from individuals, from government, from businesses and from health care professionals. But we know that we have to begin now. This is a magic moment.

Let me just say two things in closing. There are a lot of other things we haven't discussed, and I know that, but we didn't come here for a seminar on the details of it. We are trying some innovative approaches to the malpractice problem, which I think will find broad favor. We are going to do some things that will increase public health clinics' ability to access people who are otherwise left out of the system, and try to deal with these horrible statistics on immunization and the absence of prenatal care. There are a lot of those things that are going to be dealt with.

But I want to make two points in closing. First of all, there are a lot of disconnects as you might imagine between Washington, DC, and the rest of America, which everybody loves to talk about when they get alienated from the federal government. But one of the most amazing in this has been the following thing. I don't talk to any doctor or any hospital administrator or any nurse with any seniority in nursing who doesn't believe that there's a huge amount of waste in this system that has nothing to do with caring for people which can be gotten rid of. I don't talk to anybody in Washington who thinks you can do it. (Laughter and applause.)

Our friends in the press are laughing because you know I'll finish this talk, then they'll go talk to somebody on the Hill who will say, aahh, they can't save that money in Medicare and Medicaid. It's got to be that way. We really need a room under the garage in the Children's Hospital in Washington, DC, which is piling up paper six and a half feet a day. We've got to have that. How would we function?

Hillary goes to the Mayo Clinic; they've already got their annual average cost increases now down under 4 percent. And we talk about maybe getting it down over the next three or four years to inflation plus population plus 2 percent, and they talk about how we are slashing Medicare and Medicaid, when what we really want to do is take the same money and not take it out of health care, but use it to cover the uninsured, unemployed; use it to cover some new services to do more preventive primary health care. So this is an interesting thing that Dr. Koop said in the past, reform has been imposed on the doctors. You might have to come up here and impose it on the politicians and the bureaucrats. (Applause.) You may have to do that.

I say that not to be critical of the Congress. We are all -- all of us see the world -- (laughter) -- no, no, no -- I don't -- all of us see the world through the prism of our own experience, don't we? You do, I do -- we all do that. And they are so used to believing that the only way they can be decent stewards of the public trust, to take care of the poor on Medicaid and the elderly on Medicare. They are so used to believing that the only way they can do it is just to write out a check to pay more for the same health care, never mind of it's two or three or four times the rate of inflation; never mind if there's a 16-percent increase in the Medicaid budget for the coming year, when we estimate no more than a two-percent increase in the enrollments in Medicaid.

We're just so used to believing that in this town that we have to have your help to believe that it can be different, and you can enhance the care people get, not undermine it. I don't want to minimize that. Yes, we need your critical scrutiny of the specific plan the administration will propose. Yes, we do. But we also need for you to convince the people who live here, who believe we are trapped in this system, that it can be different. And you are the ones who have responsibility for caring for people. If you can believe it can be different, you can convince the Congress that it can be different, that they are not going to hurt, they are going to help, by making some of these changes.

The second point I want to make in closing is this: This is really a part of a great national discussion we have to have about what kind of people we are and what kind of country we're going to be. And Dr. Koop said it better than I could, but we can't really get the kind of health care system we need until there is a real renewed sense of responsibility on the part of everyone in this system. It is terribly important to recognize that we have certain group behaviors in this country that, unless they are changed, we will never get health care costs down to the level that our competitors have.

It's not just high rates of AIDS and excessive smoking; it's high rates of teen pregnancy, of low birth weight, of poor immunization of children. It's outrageous rates of violence that we willfully refuse to deal with by taking away the main cause of it, which is the unrestricted access that young people in our most violent areas have to guns that give them better weapons -- (applause.)

Yes, within the health care system, doctors shouldn't perform unnecessary procedures, patients shouldn't bring frivolous malpractice suits, people who use the health care system now, who aren't in it now, are going to have to pay a little for their health care, so they realize there is a price for everything instead of when all of the money just comes from a third party source they don't know. There needs to be more responsibility within this system, but we also have got to remember that if we can plant the ethical roots that Dr. Koop talked about, we may then be able not only to change this system, but to use this success to try to change some of the destructive group behavior that is tearing this country apart.

But believe me, it all begins here. If we can give the security of decent health care to every American family, it will be the most important thing that the government has done with -- not for, but with -- the American people in a generation. And it can only happen if people like you lead the way.

Thank you very much. (Applause.)

MRS. CLINTON: We'd like to invite all of you now to join us for breakfast in the State Dining Room. And the President and the Vice President will be in the Red Room, and we hope people will come in and meet them. They'd like to meet all of you personally to thank you for being here. So, please, join us for breakfast.

Oh, and could I also -- we just -- I just learned Dr. Arthur Flemming is here. And talk about a reform advocate for many decades and a strong supporter of what this President is trying to do, Dr. Fleming(?), thank you very much. (Applause.)

Q Mr. President, is Senator Moynihan wrong?

THE PRESIDENT: -- you heard what he said yesterday? What he said was absolutely right. I mean, based on the experience of the last decade, you can't get the cost down to zero, but that's not what we proposed. We proposed working over a five-year period to move the government's cost to inflation plus population growth. And in the beginning -- we have inflation plus population growth plus another two or three percent. You do have -- where this group care is working well, like at the Mayo Clinic, they now are down to less than inflation plus population growth. So I believe that if you give us five years to do it, we can get there. But it will require some substantial changes.

What I said was true. People in Washington can't imagine that it can be different because of the experiences they've had over the last five years. But to say we're trying to cut Medicare and Medicaid -- it's not true. We propose never to take it below inflation plus population growth.

END9:35 A.M. EDT