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THE WHITE HOUSE

                  Office of the Press Secretary
                    (Albuquerque, New Mexico)
_________________________________________________________________
For Immediate Release                            December 3, 1993

                     REMARKS BY THE PRESIDENT
           IN DISCUSSION ON HEALTH CARE IN RURAL AREAS
              WITH PEOPLE OF THE BERNALILLO AREA AND

HEALTH CARE PROVIDERS OF THE EL PUEBLO HEALTH SERVICES CLINIC

                 El Pueblo Health Services Clinic
                      Bernalillo, New Mexico

4:04 P.M. MST

THE PRESIDENT: He did a good job, didn't he? For a fellow that's not used to doing this, he did a great job. (Applause.)

Well, first of all, Doctor, I want to thank you and all your colleagues for welcoming me into the Clinic today. I enjoyed the tour. I enjoyed listening to you talk about what you've done. And I have to tell you that I saw something in that clinic today that no law can ever compensate for or require --and that is a level of constant commitment to the people of this area. That must be a priceless treasure -- just the idea that you've committed your life here. And I thank you for that. (Applause.)

I'd also like to thank Mayor Aguilar and Mrs. Aguilar for welcoming me here and with their grandson back there. I enjoyed it -- meeting them. And I appreciate the little -- I'm about to fall in the hole here. (Laughter.) This would make millions of people happy if I fell over -- (laughter). I think I'm pretty well set now. (Laughter.) They gave me a wonderful little proclamation declaring this day Bill Clinton Day in Bernalillo, which I am grateful for and this wonderful piece of art. Thank you. (Applause.)

I brought a number of people out here with me. But I want to recognize some of them because they will have a major say in what we ultimately do as a nation on the health care issue. First, members of your congressional delegation --Senator Bingaman and his wife, Ann, who's in our administration in the Justice Department. (Applause.) Senator Domenici, thank you for coming, sir. (Applause.) My good friend Congressman Richardson, who fought so hard for NAFTA, and his wife Barbara, thank you for being here. (Applause.) Congress Steve Schiff and Congressman Joe Skeen are here. Thank you for coming. (Applause.)

We have a lot of state officials, but I do want to introduce my good friend, Governor Bruce King here and his wife Alice. (Applause.) Thank you, Bruce. (Applause.) Alice, are you there -- thank you, Alice. (Applause.) And your Lieutenant Governor Casey Luna flew back with me. Is he here in the audience somewhere? He wrote me a good letter endorsing our efforts in health care, which I really appreciated, as a Lieutenant Governor and as a small business person.

I want to talk just a few moments today about what we're trying to do with this health reform effort; how the plan that I have presented to Congress would, in my view, help things for this doctor and this clinic and all of you who are served here; and perhaps more importantly how it would help to provide these kind of services to other people in New Mexico and throughout the United States.

Let me begin by saying that I think most of you know that before I became President, I was for twelve years the governor of Arkansas and there are thousands of people from my state now living in New Mexico. I see them every time I come out here. It is also a very rural state. I spent a lot of time as a boy in communities that make this place look like a thriving large metropolis, and little small towns in country crossroads -- all my mother's people come from a place that now only has about 50 people in it. I spent a lot of time as governor trying to keep open rural health clinic, keep open rural hospitals, develop clinic services or primary care, or emergency services for people who live in isolated rural areas. So I have a certain familiarity with a lot of the kinds of problems that you have. I've also seen a lot of those problems get worse and some get better over the last 15 years -- and Dr., I think you've been 17 years, is that right? -- so about the same time frame of your service I have been involved in public service dealing with health care in another way.

I came here today to listen, to learn and to try to explain what we're trying to do. Let me just briefly summarize how this health care plan would affect you and your families and your community.

First of all, it would provide for the first time in our history a system of universal coverage. Every family and every person in every family would have a comprehensive package of benefits which would include primary care -- the kind of care you get here -- and preventive care services that you would always have even if you changed jobs, even if you lost a job, even if someone in your family got sick so you had what the insurance companies now call a pre-existing condition.

In addition to that, it would recognize that in rural areas there are 21 million Americans today who don't have access to primary care physicians, or have inadequate access to primary care physicians. So that even if you gave an American family a health insurance card and there was no doctor to see, you would have coverage that would be meaningless. So this plan makes a real effort to increase peoples' access to health care in rural areas by doing two or three things. First of all, by guaranteeing funding to rural health clinics that are publicly funded; by increasing the funding stream to clinics like this one -- rural doctors are the most likely to have to do uncompensated care -- to make sure there will be some payment coming in for all the people who get care within any clinic; by taking steps to remedy the doctor shortage. You heard the doctor say that he didn't leave here in part because there was no national health corps facility or physician to come in behind him. Today we're only providing funds for about 1,100 doctors a year in the National Health Service Corps. Under our plan, we go from 1,100 to 3,000 doctors a year by just after the turn of the decade and the century. So we would be, in other words, every year providing enough extra doctors to serve another couple of million patients in America at a reasonable ratio of doctors to patients. So that would make a huge difference in the quality of rural health care. (Applause.)

Now, there are a lot of things we do to try to get doctors to come to rural areas. But the National Health Service Corps is one, providing more scholarship funds, providing more access to partnerships with people in health care centers like the ones that you mentioned is another. The other thing I want to emphasize is that a lot of people who have health insurance policies in rural areas, especially, tend to be underinsured. And one of the things that we've learned is as America, we spend a huge amount of money on health care that we wouldn't spend if people had primary and preventive health care; and if people had access to adequate medication. There are a lot of people who have all kinds of physical problems that could be adequately treated and their conditions could be maintained if they had adequate medication. A lot of people who have mental health problems could be better managed and treated if they had access to a steady amount of appropriate medication.

So one of the good things about our health care plan is that under the bill we presented in the comprehensive benefit coverage all families, whether they get care from the Medicare or Medicaid programs or through private health care programs, would have access to prescription drugs. There would be a co-pay, you'd have to put some money up front in it. But everybody would have access to those drugs. We believe that that would lower the incidence of hospitalization and, over the long run, really lower the cost of health care by helping people to stay healthy and to maintain their own health conditions.

How do we pay for this? The program would be paid for by a combination of sources. First of all, we would require employers who don't cover their employees at all to cover their employees. And if their employees are not covered at all now, the employees would have to pay up to 20 percent of the premium themselves. The employer's contribution would be capped at 7.9 percent of payroll. But small businesses, which dominate rural areas, would be eligible for discounts on their guaranteed private insurance plan which would dramatically lower in many cases the percent of payroll they would have to pay.

Is this fair? I think it is. In every other country with which we compete everybody makes a contribution directly or indirectly to the health care system. Today, everybody gets health care but often when it's emergency care, when it's too late, and then their costs are paid by somebody else. They're either shifted back to the taxpayers or shifted on to other employers through higher insurance premiums. But by giving discounts to people who are smaller employers, we think that's a fair thing to do. How will the discounts be paid for and how will the extra services be paid for that the government's going to provide? By lowering the rate at which we're seeing medical inflation explode -- Medicare and Medicaid programs. Today the government programs are increasing at three times the rate of inflation. Under our system, which would put more people on Medicare and Medicaid in the larger competitive bidding blocks with self-employed people and small businesses and others, we think we can cut the rate of increase in these costs at least to twice the rate of inflation and take the difference that we've already budgeted to pay for some of these other programs.

There are no general taxes in this program. We do seek to raise the cigarette tax and we ask the biggest companies that can opt out of our system to provide their own health care plan. They will get a huge drop in their premiums as a result of our system. We ask them to make a modest contribution, trying to help pay for those that are uninsured and may need subsidies. That's how we pay for it. And we think it will work.

There will also be a lot more competition in the system than there is now. That will drive costs down. But we don't take that into account in figuring it out what it costs. So we think the system will not cost even as much as we say it will, once you take account of the increased competition.

If you're a small business person or a self-employed person, the best thing about this program is that you'll be able to have access to a better health insurance policy at a lower price because for the first time, small business people and selfemployed people will be able to have access to less costly premiums and will have the same part of bargaining power in health care, particularly those who live in the bigger areas, that only big businesses and governments do today. Small business and individuals are at a terrible disadvantage today.

So that's how the system works briefly. There are a lot of other specific questions I'm sure you'll want to ask me. We have -- I'm here and I also brought a couple of my staff folks here who helped to work on putting this program together, and especially spent a lot of time on rural health care. We spent -- I personally spent one full day in the White House talking about rural health care to make sure that before we sent this plan up to Congress we would have a program that was very sensitive to the needs of rural health care, to the needs of native Americans, to the needs of people that are underinsured as well as those that are uninsured.

So, we'll try to answer your questions, but now I'd like to hear from the folks you brought here, Doctor, and to thank you very much for that. (Applause.)

DR. FIRESTONE: I've got a list of several people who were invited. And let me just go down the list very quickly --

THE PRESIDENT: Is his turned off? His is not working, is it?

DR. FIRESTONE: I've got a list of several people who were invited from various areas around the state as well as patients from our own practice. I'm just going to read through the list real quickly, and then start out things by calling on a couple of our patients and have them tell some of their stories, which may highlight a little bit better some of the problems which people have had.

First of all, Harriett Pancheco Brandstetter, who is the Executive Director of La Clinica de Familia, which is a privately and federally funded community migrant health center. She's got even more time in than I do. She's been 27 years of community health experience. And her clinic is part of a 17- year-old clinic system, which includes four medical clinics and dental clinic.

Christina Campos is community encourager for Guadalupe County, trying to activate the community to design a health care system which is affordable and acceptable to the citizens of the county.

Mrs. Blanche Ekdahl, is she here? Mrs. Ekdahl is 86 years old and lives in a trailer part in Abiquiu, which is northwest of Sante Fe. And with her arthritis and walking with a cane, she's been quite limited. And apparently -- you're going to be forced to move to Los Alamos or Sante Fe?

MRS. EKDAHL: No, we might have to if I can't find a nursing home --

DR. FIRESTONE: So she might have to move to a larger city if she's unable to find a nursing home.

Celestin Gachupin is the former Governor of the Zia Pueblo. And we'll be letting him go ahead and tell his story in a little bit.

Karen Lewis -- Karen, are you here -- is a patient from our office. And we may talk to her in a little bit, too. She is sort of three or four generations of problems, which I think represent a lot of the things that we see on a day-to-day basis.

Forrest William Mason has high blood pressure and diabetes, which we had talked about before as being as a fairly representative problem that we see all the time. And he has and interesting story about why he's doing well now.

Lynn Mathes is a patient of ours from Bernalillo, who again being uninsured demonstrates many of the problems that we see.

And Nedy Ogalez, Senor Ogalez -- I can't see with the lights -- is a patient of ours who was uninsured and had a quite serious illness necessitating hospitalization.

Miranda Sapien, who's in front of you, again a generational health problem. Fortunately she and her husband have been in excellent in health and their children have been in excellent health. But both parents reached a point where they were unable to be managed in coming into the clinic and needed home care.

And Angela Sosa. Angela's mother was a patient of ours, and again demonstrated what we were talking about as far as being afraid to go in for health care because of expense.

And Jack Vick -- Jack's over there. Jack is currently a resident at UNM and will be finishing up soon. And he's our future.

What I'd like to do is start with Miranda Sapien, have her tell us a little bit about the sequence of events and the care of her elderly parents.

THE PRESIDENT: Let me just say, if you can hear, that these mikes aren't too strong, so you have to speak right into them so everybody can hear. Pretend you're singing -- (laughter) --

MS. SAPIEN: This is terrible that I had to start, but I'll try my best. We live in Bernalillo, about, oh, I guess, about a couple of miles -- (train passed by ) -- (laughter) --

THE PRESIDENT: At least it's not in the middle of the night, right? (Laughter.)

MS. SAPIEN: My mother, who was completely blind and elderly lived with us after my dad died for about, I guess, about 11 and a half years. She passed away in May. Bill's dad lived with us also along with my mother for about eight months. We took care of both of them.

Dr. Firestone was very kind to visit the home whenever we needed someone to come in and check on them, although I don't think that this is available in all rural areas. I'm not sure. Anyway, Bill's dad passed away and we still had my mom. Gradually when I guess our care -- our problem mostly with respite care whenever we needed to, we tried to keep our family, you know, our lives, as normal as possible, which wasn't really real easy to do because my mom needed a lot of care.

Her Parkinson's got worse and she had to go on a wheelchair and she became bedridden. It was real difficult to find a sitter whenever we needed to go anywhere. I took care of her all day. Bill and the boys helped me at night. Whenever we needed to bring her to Dr. Firestone's, Bill would load her in the car and I would bring her in the wheelchair.

When she became this sick, it was hard to find anybody locally that could take care of her because she started needing specialized care. We also found that prescriptions and disposable diapers were more expensive here than in the metropolitan area.

Whenever we would go away, it was -- that was at the time that the boys where graduating from high school or going to high school and being involved in all kinds of activities, and went away to college and all -- and we were trying to keep up with them also. Whenever we would go away for a time, we would put mom in a nursing home. She didn't have insurance. Her only income was Social Security from my dad's earnings and a little bit of income from renting her home.

We would have to pay for that nursing home out of our own pocket. I tried later, when she was not able to -- when she was not able to -- when we were not able to move her, to find someone to come to the house to take of here. And it was -- the expense was too much for us. It would cost us -- like, for example, if we were going out just for the night or if we were going out for the weekend or whatever, I would have preferred to have someone come to the house, but the expense was too much. We just couldn't afford it.

And something else I was going to say -- when she was doing a little better, when we were able to take her out, I tried to find a place that I could take her, like for day care, so that I could go shopping. It was really difficult for me. We would have to wait until the boys came at night to have someone stay with her so that Bill and I could go shopping for whatever we needed, because we couldn't find anyone who would take care of her. I left her with a sitter one time, and when I came back -- we have a stairs in our house -- with her Parkinson's, she would shake so badly that the sitter couldn't move her. And so I found them sitting -- they had sat all day on the stairs and the sitter couldn't move her. So she needed more specialized care, which we couldn't afford.

I think that if care -- affordable home health care could be made available with our increasing older population, perhaps a lot of us would be able to take care of our parents at home and not cost the government so much money putting them in nursing homes and so forth.

I also think that if we could have perhaps a place where we could make arrangements just to be able to bring our parents at the spur of the moment, so that we could do whatever needed to be done, it would kind of ease our emotional frustrations or whatever. It was very hard for me whenever we wanted to go anywhere. I would have to get my mother ready, feed her. She needed total care, she couldn't feed herself. The sitter could feed her, but they couldn't pick her up from the wheelchair to put her in the bed. Those were the problems that we encountered. So I don't know that this is only a problem in rural areas. But that was the problem that we encountered.

THE PRESIDENT: No, as a matter of fact, this is a big problem everywhere in America, and the fastest growing group of our population in America are people over 80 years of age. And in general, I think we want to encourage families to stay together. The way the system works today, if you spend yourself into poverty you can get -- you become eligible for Medicaid and then you can go to a nursing home. There aren't very many Medicare certified nursing homes in the U.S. The older people are Medicare eligible. So one of the things that our plan seeks to do, although I don't want to over -- I don't want to mislead anybody, we don't know how much it would cost. We can't know precisely how much it would cost if we started tomorrow covering everybody with this kind of long-term care. A lot of us believe that over the long run it would save money because more people would stay at home if there was some provision for in-home care and for respite care so that the families could have a break. But we do phase in long-term coverage over a period of several years as a part of this plan.

And one of the things that we're also trying to do is to try to encourage some of the state reform efforts that are going on now where many states are looking at whether they can set aside some of the money that is presently allocated to nursing home care to also cover in-home care. I applaud you for doing it. I think since we know that the percentage of people who are quite old is going to increase and more and more people will be quite alert and will be able to function at a fairly high level. But there may be some care needed, and more as time goes on. I think it's quite important that we keep this long-term care part of our program, even though it's going to take us several years to get it fully phased in.

Lynn Mathes. Lynn was -- I'll let her tell us. But I think -- were you fully employed? And she was injured.

Turn it on, will you, whoever's got the mike. It worked great for her.

MS. MATHES: Hello. Yes, I was fully employed with two jobs. I was a horse trainer, I'm an artist and I sold bridal gowns. I had a very severe horse injury. I consequently lost both of my jobs due to this injury. The employer where I was training the horses had insurance for me. He took me to the hospital, gave his insurance policy so I could have treatment because I didn't have my own insurance. He paid for the first three prescriptions. I went home to recuperate. I'm still in therapy now. And then he wouldn't pay anymore.

I had to hire an attorney for my -- to get compensated, which I have not got compensated yet for either job. I almost lost my home. I could not fill the prescriptions that Dr. Firestone gave me. One was $140 for swimming therapy which I really needed desperately. I then went to -- I still am under Dr. Firestone's care. I had to see two specialists. One, I'm still under his care. I could not pay him so I said, " Can we barter? Can I trade you some of my artwork because I have got to heal?" And this is how a lot of people in the rural areas -- there are a lot of us that are artists and we live out in the boonies. I'm not so much in the boonies now. But we depend on our art and our education. If we don't have money, we do barter. That's how I'm getting one of my treatments now.

The insurance -- they ignore me. They say, well we're going to treat you really good as soon as we figure out if you were an employee or a guest. Well, I got a paycheck. What does that make me? I was an employee. And I still have not got a lot of my prescriptions filled. And I don't know where it's going to lead to. But I am concerned about the insurance that people do pay for their employees and then we don't receive the benefits of it, and it's really hard on the family. My insurance now are my family and friends. That's the insurance in a lot of these rural areas. And I see a lot of elders walk around -- because I couldn't walk, hardly -- and I watch them. And I think it's because they didn't have the initiative, maybe, to barter. They didn't have the insurance. They couldn't heal and then their injuries then became a major handicap for them and it still is. So that's what I have to say.

THE PRESIDENT: Unfortunately, the story you just told is all too typical. The reason I laughed is the Dr. has a work of art on his wall inside that another artist gave him as an in-king payment. And I can remember when my mother was a nurse anesthetist. I can remember when people in the appropriate season used to go pick fruit and pay here in return for her services. That works for a few people. I don't think it's a very good way to run a country.

Let me just say, the way our system would work if we reformed the insurance system is that that simply would not happen. Because everybody would be covered, there would be a clear package of benefits, there would be a single form -- you would just turn it in. And your employer would never -- I'm glad your employer tried to get it covered, at least. A lot of small employers are terrified of a serious thing like this because they know that their insurance is already so much more expensive than larger employers or than government insurance, and they're afraid they'll be priced right out of the market. Under our system, everybody would be able to buy insurance on equal terms and the coverage would be uniform and consistent. So you wouldn't ever be putting your -- an employer in a bind just because it was a small employer. Or if you were a self-employed artist, and that was your only job, you'd have access to a really affordable policy.

But you have to understand, this is the only country in the world with 1,500 separate health insurance companies writing thousands and thousands of different policies. And if they delay paying on you, then that in effect gives them time to earn interest on that money. So eventually, even if they pay, they've made a good deal if they can delay payment for two or three or four or five or six months. But it may impair your ability to get certain care. This happens everywhere.

You just heard what the doctor said. At the time when his caseload is doubled here -- patient-load -- they have increased the number of people who devoted themselves to paperwork by six-fold. That's because this is the only country in the world that has literally 1,500 different companies writing thousands and thousands of different policies; where the doctors in the clinics have to hire people trying to get payment when they're entitled anyway; and where the coverages are so complicated and different -- when you put that with all the rules and regulations that the government has -- that you spend enormous amount of time just trying to work out the transaction who's going to pay when. One of the primary benefits -- perhaps the best benefit to doctors and to clinics --of our plan, is that we'd actually be able to have a single form for insurers, a single form for clinics, a single form for patients. And it would cut out a lot of this incredible paperwork and administrative cost.

We spend about ten cents on the dollar. Let me tell you how much money that is. We're going to spend $900 billion on health care this year. So ten cents on the dollar is $90 billion dollars a year. That's a lot of money. That's 1.5 percent of our gross domestic product. We spend about that much more on administrative costs than any other country in the world spends on their health care system. That's how bad it is. And you get caught in it -- in the delay.

DR. FIRESTONE: That brought up another point. One of the other patients I contacted was concerned about she had been on the receiving end of the problems of no insurance with working 30 hours a week. She was employed by a physician, had no insurance and had an extremely complicated pregnancy and tremendous medical expenses that were absolutely not covered. Now she's on the other end and she's a small employer and is terrified about the cost to her for buying health insurance for all of her employees. And was concerned, that in addition, if she had to also pay for workman's compensation insurance that that would be an unmanageable situation for her. Would the workman's compensation then go by the wayside and just be included in the other insurance?

THE PRESIDENT: The health care cost of worker's comp would be folded into the health care plan, which would save a lot of small business people a ton of money. Because that's about -- slightly more than half of the worker's comp premium is health care costs. So that would be folded in. And that's a huge concern to small business people and also to people in certain targeted industries -- like in my home state, the loggers and the people in the wood products industry. They have huge worker's comp bills. So that would really help.

Again, I would have to know exactly how many employees the lady has and what the average income is of the employees, but they would be eligible for a discount rate. So it's almost -- I can just tell from what you said to me, she would not pay the 7.9 percent. She would pay some lesser percentage of the payroll. But having been on the other side of it, she can understand what it's like if there is none.

There's also -- let me say, there are a lot of parttime workers in our country today, and probably will be more. Under the way the bill has been presented to Congress, if you work 30 hours a week or more, you would be insured as a full-time worker and your employer would have to pay the full cost of the premium and you would have to pay your 20 percent match. If you're under that, down to 10 hours a week, the employer could pay a proportionate amount of that -- a smaller percentage, and therefore your premium would be less. And if you outran that in using the health care system because you're a part-time worker, and then that would be eligible for the public subsidy.

So we're trying not to bankrupt people who have part-time employees or discourage people from hiring part-time employees. But we think they ought to pay at least a portion of their benefits.

DR. FIRESTONE: The next one we'd like to hear from is Jack Vick, who again is the future of rural health.

DR. VICK: I am from rural New Mexico. About 13 or 14 years ago, I said there's a real problem here; I want to become a doctor and help with the problem. And I'm almost through. As a resident, I've been lucky to be involved, or maybe not lucky, to be involved in some of the developments at UNM to reach out into the rural areas. It was a good choice by their part to decide that we could do this.

I've served in three areas of the state that are rural areas, like you were talking about. There has been none or very minimal health care there. And I've seen some of the problems they've already alluded to here.

Childhood immunizations -- I think that's an education problem because we have three county health service clinics that these people can go to; but yet I still see sixmonth -old, eight-month-old, four-year-old kids who have not been immunized yet. We're working on that.

People living rurally -- pregnant women -- they get their prenatal care in these clinics. Some of them do; some of them don't. It's a big problem. But yet if they're getting their care in a clinic or a rural area, they still are not able to deliver their baby there. Family practice docs don't have the back-up or the facilities to do a complicated delivery, therefore people may have their care one place and then have to drive an hour, hour and a half, two hours when they're in labor for delivery.

I see women who are of child-bearing age not getting their pap smears; or a little older -- when was your last pap smear? Well, it was 12 years ago when I had my baby. I see women in their 50s, 60s, 70s, as the incidence of breast cancer increases with each decade, never having had a mammogram.

I see, as Dr. Firestone mentioned, hypertension and diabetes problems. They didn't renew their -- six months ago, so now they come in with problems or even longer.

Then I see the problems from the doctors' side. I've been on call two weeks in a row, 24 hours a day. And I'm a resident just covering for someone, where these doctors have been out there months with no cover. And, again, UNM has recently started addressing this with a -- tenants within the state. So some of them will be answered.

I've seen the doctors saying, is the check for Medicaid in yet? No, but we got this back -- we signed the wrong line. So, again, it's delayed weeks. I did learn in one of my months in the rural area, someone has to pay the electric bill for this place to stay open. And if you don't get paid from the insurance company or what -- the clinic closes.

And another perspective from the doctor is: I have some job offers in the rural areas for a very good salary for New Mexico. But then at the same time, I get a job offer to move to a more urban area or a larger town at twice the income -- and I don't have to cover nights; and I have call once every seven nights. Those are real problems. How do you keep people here?

And, of course, I am from the rural area, and I will go back in spite of that, but not everyone will. Those are a few things. And you've addressed most of them, I think.

THE PRESIDENT: I'm just glad you're going back.

Let me just mention a couple of things you mentioned, because there are answers to some of them and there aren't answers to some of them. At least if there are answers to some of them -- I don't know what they are -- but one of the best things, I think, from the point of view of the benefits package that we tried to do in this plan is to provide more coverage for primary and preventive services -- pap smears, mammograms, cholesterol tests -- important things that are early warning signals that may head off far more severe health care problems and actually save the system money.

Secondly, I think part of the answer to the problems of doctor exhaustion and overcommitment, simply increasing the number of doctors in rural areas and trying to tie them more into partnerships with urban medical centers and with university centers. And there is -- without going into all the details, I think we've got some good systems to do that.

We also are working on one aspect of malpractice reform that will encourage more family practitioners to do things like deliver babies or set simple fractures where they are in rural areas. Based on an experiment that started in the state of Maine, where basically if you're a family practice doctor and you do these procedures our where people live because you need to do it there, and you can prove that you've followed a set of guidelines approved not by the government but by your national professional group, that raises a presumption that you were not negligent and sort of gets you out of this whole malpractice bind.

Now, what I don't have an answer for, and I don't think there is one right now, is what you do with the problem pregnancy. I think if you think you've got a problem case, you still have to send it -- whatever discomfort there is -- to a place where you think the care will be appropriate. If there's an answer to that one, I don't know what it is. But I do think that we want family -- we want more family doctors and we want more family doctors out there in the rural areas doing things they know they can do but they're still afraid not to do because of the malpractice problem; and being able to prove that there's a set of generally-, nationally-accepted guidelines for this kind of procedure in a rural area, and that you've followed them, it seems to me will do a lot to alleviate both the cost of the malpractice insurance and the fear of the lawsuit.

DR. VICK: I have one more. One more that I had forgotten. I seem to see a fair number of people mentally ill, whether severely mentally ill where they need psychiatric care, and they are not getting it. They've been on this prescription years, and someone keeps refilling it, but they have not had any psychiatric care. What in the world are we going to do with the mentally ill people, because there are a lot of them?

THE PRESIDENT: Well, we think the basic benefits package should include mental health benefits -- pretty comprehensive mental health benefits -- as well as medical for treatment of mental illness. I know this is a particular interest of Senator Domenici and a number of other members of the Congress. But let me say this has been a big fight in our administration with -- essentially with the bookkeeping of health care. That is, we can't ask the Congress to pass, and the Congress cannot pass, any bill that they don't think they have a pretty good feel for how much it will cost and how it will be paid for.

So, we have been through a lot of very tough sessions with the actuaries for health care -- people who are supposed to be experts in health care costs -- to figure out how much the mental health benefit will cost and how we have to phase it in over time. Right now we phase in mental health benefits -- comprehensive mental health benefits -- between now and the year 2000, although other health care costs would be covered by the beginning of 1997, the end of 1996, in all the states.

So, I'm glad you said that. I'm glad you said it here in this rural setting, because, again, as you know much better than I, there are a lot of mental health problems that can be treated, that can be managed, that can allow people to be productive members of society and that can therefore be a very cost-effective thing to do, as well as the humane thing to do. And we have to get these benefits in.

I believe -- again, I believe that our actuaries have overestimated the cost and underestimated the benefits of including comprehensive mental health benefits. But nonetheless, we can't -- again, I don't want to mislead the American people; I don't want to overpromise; and I don't want to pass a bill that breaks the bank. So right now we provide for the phasing in of the mental health benefits with the benefits to trigger in about the year 2000 to do what you say we should do.

DR. FIRESTONE: Mr. President, Cel Guchapin has a story to tell about difficulties with provision of emergency services in rural areas. And I think I'll just pass him my microphone rather than lug the other one all the way around.

MR. GACHUPIN: I don't go ahead and stand. My name is Cel Gachupin, and I'm from the Pueblo Zia, which is 18 miles northwest of here. And forgive me for shivering, but I'm not in awe of talking to the President, I'm just cold. (Laughter.) Somebody said that it would get a little warmer once the politicians get here, but I'm not sure it's working. (Laughter.) I was told to be informal, that's why I say that.

But, seriously, I'm here twofold -- one, I was asked to share a tragedy that my family experienced; and the other being the only Native American that's here on the panel. The Pueblos are concerned with the health care package. And maybe it's due to a lack of understanding, but they're concerned that maybe the United States government at this point is reneging on its responsibility to provide health care services. And it's something that -- there's a genuine concern in light of all the benefits that owed Native Americans because of all the real estate that they so voluntarily gave up a long time ago. But that's a concern that's the tribal governments have.

The other is that in light of the funding that most of the funding is going to start being channeled through the states. And historically the tribes and the states has not been on good terms. The states have continuously not wished to acknowledge the sovereignty of tribes, and therefore the relationships have been strained. So there is a concern there.

But on a personal note, my son was born June 1st, 1981. And at the age of two-and-a-half years old, he contracted asthma. And for the next six years, he was in and out of the hospital. We took him to the Indian health service. And some of the problems that we encountered there -- the referral system that they have, the nearest Indian Health Service is 50 miles away from the village. And in traveling that distance we bypass 5 hospitals. And in emergency situations we are required to take him to the Indian Health Service first or they will not pay for the services.

In an emergency situation there might be a hospital or a clinic, say here in Bernalillo that is 20 miles away, but we can't take him there. We have to drive him another 30 miles to get him to the Indian Health hospital where they check him and they determine whether they can provide the services or they refer him to another hospital.

If we take the patient directly to the hospital, and we go to inform Indian Health Service, then they say, I'm sorry, we didn't refer him, we can't pay for him.

Another concern or problem that we had is lack of equipment. Being asthmatic he needed some nebulizers that would permit him -- portable nebulizers -- that would permit him to go out into the mountains, go fishing, things that a normal boy should be doing, but because the Indian Health Service didn't have portable nebulizers to give him, he constantly had to stay within the proximity of the house. We got to a point where the family did fundraising and we went ahead and purchased some of these things for him.

To make a long story short, on July 1, 1989, we went on a family outing. We went fishing. And he caught 8 or so trout. Driving home he was sitting in the back seat of the car, he was singing away and telling us that that was the best day of his lift, he's never caught so much fish before, that -- he was asking when we could come back down again. I was telling him well, we will, son, we will.

That night in the middle of the night we -- he called my wife's name, mom. She went to him. He said, "I need my nebulizer. I need my neb." He used to call it neb. We gave it to him and after a few minutes then he told his mother, "I want dad to hold me."

So I went to his bedside and held him. He was looking at me; smiled at me; didn't say a word. He just closed his eyes, and I thought he fell asleep. One dream that he had was that we had bought him an Arabian horse. His name was Dark Moon. He wrote a book in class, a little story about how he would feed his horse alfalfa, apples and how his horse would be the fastest horse in the village, win all the horse races there, and that his dream would be to some day ride Dark Moon all by himself.

I'm sure that through the spirits he is doing that because that night my son died in my arms. I just wanted to share that story with you and I thank you for giving me the opportunity.

THE PRESIDENT: Thank you for sharing it and thank you for having the courage to share it.

You really -- and I hate to, I don't know if I can give you an answer to the policy questions you raised. Thank you very much for what you said.

The first thing you said was you often had to drive your son past hospitals to get to the Indian Health Service. Under our plan, if it passes the way we have presented it, American Indians will be able to get health care either through the Indian Health Service or through another network of health care at their own choice. So that if people, because of where they happen to live, have much better access to some other health care provider they will be -- at their own choice, they will be able to choose to use those facilities. But we feel that the United States has a solemn obligation to maintain the Indian Health Service. And, as you probably know, the funding has dropped over years as the number of people using it has dropped. So one of the things that -- after the leaders of tribes from all over America came to see us in Washington about this.

One of the things we did was to go back and amend the plan to try to strengthen the financial support for the Health Care Service so they would be able to provide the kind of -- particularly the kind of services to people who are outpatients like your son was. So I think in this case, we will give the American Indians more personal choice than many now have. You won't be forced to the Health Care Service. You'll have the option of using something else. But if you do use it, it should be better funded than it now is.

DR. FIRESTONE: There are thousands of stories that are similar to these, in my office, in this area and in other rural areas throughout the country. I want to take just about 30 seconds to raise one other point.

We have, in our practice, in many rural areas, there are children who are multiply handicapped, who have special requirements. And Polly Arrongo (phonetic), who's one of our board members, has a child Nick with multiple handicaps requiring medication, special therapy and an awful lot of support. And I have another child who is now five years old and has been on a ventilator her entire life, and is on home ventilator therapy in Bernalillo. So she is hooked up to a breathing machine probably about 70 percent of the day. There are concerns that the health care reform plan, although it does many things for rural communities and rural families, that it may put some of these children with chronic conditions and disabilities at some risk of losing some of the benefits, which if the families are wellinformed and the system is responsive, they've been able to receive it at this time.

I know Nick and having followed him over the years, we've been able to provide supportive care for him out here; but have frequently utilized many other services, as well as additional care through the schools and special care through the Carrie Tingley Hospital at the University of New Mexico. I'd just like to -- I'll pass this letter on to you to pass to staffers. But we would like to go ahead and see the needs of these children also especially attended to.

I know you've got a busy schedule and there's no way I can express my appreciation for you coming to Bernalillo and listening to our stories and visiting our clinic. It's been one of the more exciting weeks of my life. Thank you very much. (Applause.)

THE PRESIDENT: I can't answer the question you just asked me. But I'll get an answer and I'll get back to this lady who wrote you the letter -- or to me the letter. (Laughter.) I'll do it.

Let me just say before we close, and then I want to say hello to all of you and then go back around and see the kids who have been waiting so patiently, they are still there. I don't know if they are. I hear some people chanting in the background.

When the new year comes and the Congress comes back into session, there will be a few months of really intense debate on this. Just think about this town and the size of this town, and the diversity of the things we've heard about already today, as well as all the things we haven't heard about. This is a very complicated matter.

But in the end it comes down to something very simple. We are spending a much bigger percentage of our income on health care than any other country in the world and yet we are the only major country who doesn't provide everybody health care coverage that is always there that can never be taken away.

We have permitted a system to develop so that now coming out of medical school, only about one in seven doctors are committed to do what this doctor has done and this doctor wishes to do. So we have to change that. And it is perfectly clear that it will not happen unless the Congress is prepared to go through the incredibly rigorous process of reviewing the bill that I presented, listening to anybody else's alternatives, and hearing the human voices that we have heard today, and coming to grips with this problem and actually acting on it.

This is something we should have done a generation ago when we could have saved untold billions of dollars and no telling how many lives, but we can do it now, and we have to do it, and I would just implore you to work with us, make sure we don't make any mistakes we can possible avoid, but give the members of Congress from your state the courage to face this problem that our nation has neglected for too long.

Thank you very much. (Applause.)

END5:03 P.M. MST