An Address by the First Lady
at Washington University
St. Louis, MO
March 15, 1994

Thank you. Thank you very much. I am just
thrilled to be here. Some of you may remember that this is
where one of the debates during the presidential campaign was
held, and I can remember walking in the door I walked in a
few minutes ago, filled with a lot of anxiety and trepidation
over that upcoming debate. And I am so glad to be back, with
only a little less anxiety and trepidation, never dreaming we
would have so many people here.

I was frankly relieved when the invitation came and
they said, "But, you know it is during spring break." So I
thought, "Well, gee, you know, I could sit down and talk with
a few people about health care here at Washington University,
in St. Louis."

But it is a real pleasure to be here and to have
this opportunity, because this university and this community,
and particularly the health care center that I just visited,
is a symbol of excellence around the country. And I want to
salute one of the people who has made that possible over the
last years, your Chancellor, Chancellor Danforth.

I know that you will miss him as he retires. I
only wish I could have been one of the lucky people who heard
him read a bedtime story over the past years. It is such a
good idea I am going to suggest that maybe the President try
it with some people in Washington. (Applause.)

I also want to thank Dean Peck for opening up his
campus, for giving me the tour, and for having some of the
representatives of this extraordinary medical system spend
about an hour with me as we talked through issues of concern
and importance to academic health centers.

I want to thank the representatives of the students
who made the presentation. You will see the sweatshirt, if
not on the front page of the newspaper at least on either me
or my husband as we attempt to get the exercise that I now
know for sure, having been to the rehab unit, will make me
live longer if I really do it. (Applause.)

And I want to join all of you in wishing the Bears
great luck in this upcoming championship game. And I will be
rooting for you and watching you as you go forward.

I am also grateful to know that the Hot Docs are
not a group of angry physicians (Laughter), but instead a
jazz band, and I only heard a little bit because we were
waiting to come in, but I want to thank them especially for
being here and playing, and for the CDs, which I will take
home and give with great delight to my husband.

It is exciting for me to have a chance to visit
with you for a few minutes about what is happening with
health care reform, and what the real attempt that the
President is making would mean to you and the various
constituencies of people represented here. Because, this is
an historic opportunity.

You know health care reform in our country goes
back a number of decades. Some have argued that the very
first proposal actually was made by Theodore Roosevelt, as
part of his platform when he first ran for President and then
renewed it when he ran again. But we certainly know that
Franklin Roosevelt talked about it being the other part of
social security. And your own President Harry Truman was one
of the most passionate advocates on behalf of health care

I have gone back and read the speeches that
President Truman gave in 1945, and 1946, and 1974. They
could be made today. He identified the problem which, as the
Chancellor has said, is how do we provide high quality health
care to all Americans at an affordable cost. And Truman
argued passionately, but unsuccessfully, that the country
should move toward providing guaranteed health coverage to
all of our people.

And then, of course, we had the changes in the
1960s, to provide Medicare for Americans over 65, and to
provide Medicaid for people who were too poor to provide for
themselves. And then President Nixon recommended
comprehensive health care that was built on the employer
based system, the system by which most of us who are insured
receive our insurance benefits.

We have tried to address this issue many times in
the past under presidential leadership of both Democrats and
Republicans, but we have never been able finally to resolve
what has to be one of the most important questions for any
society: How do we fairly allocate our health care resources
so that every citizen is guaranteed that their health care
needs will be met?

This time this historic opportunity is calling us.
How can we, as the richest country in the world, be the only
one of our industrialized competitors who have not figured
out how to provide health care to every one of its citizens?

This time we have enough support in the medical
community which recognizes what the needs are; enough support
in the business community which primarily pays the bills;
enough support from leaders like your mayor who is here with
us, and state governments around the country who also bear a
huge part of the economic burden; and enough support in
Congress and a President who wants to get the job done. So
this could not be a more timely meeting for me to give you
some sense of exactly what the President's approach would
mean in your lives.

There are five major features to the President's
proposal for health care reform. The first is guaranteed
private insurance for every American, with comprehensive
benefits that stress primary and preventive health care, as
well as care for our most acute medical needs.

The President has not proposed a government health
care system. He has proposed building on the public private
system we have in our country today, but making sure that we
guarantee private health insurance to all of us.

The second major point is to eliminate insurance
practices that discriminate against Americans. And there are
a number of those. Some Americans are unable to obtain
insurance at any price, because of what are called pre-
existing conditions.

Most American with pre-existing conditions -- and
there are over eighty million of us -- we can get insurance
but at a very high price. And so what the President wants to
do is eliminate pre-existing conditions so that all of us, no
matter whether we have ever been sick before or have any kind
of ailment, will be eligible for insurance at an affordable
price. That is one of the keys of the President's approach.

And I would add, in this great university with its
extraordinary medical system, that it is especially important
we do that sooner instead of later; because, I was recently
at the National Institutes of Health with the new head of
that institute, Dr. Harold Varmus -- who some of you may know
is a Nobel Prize winner in science, and he was explaining,
along with his colleagues, that at the rate by which we are
learning about the human gene system every year, we are
discovering the genes that we believe are responsible for a
number of medical conditions, that pretty soon all of us will
know we have pre-existing conditions because of our genetic
makeup. So if we do not reform the insurance industry very
soon none of us will be eligible for insurance, because our
gene makeup will make us ineligible. (Applause.)

There is another insurance practice that the
President wants eliminated, and that is what is called life-
time limits. If you read the fine print in most insurance
policies you will discover that after you have reached a
certain level of insurance coverage you are no longer
eligible under your policy for further reimbursement.

Some policies have life-time limits as low as
fifty-thousand dollars, others as high as a million dollars,
but those limits come into effect when you need your
insurance the most. I have sat and talked with families who
often to their surprise discover in the midst of a medical
emergency their insurance has run out because they have
reached their limit.

The President wants to eliminate life-time limits.
There is no reason you should be worrying about your coverage
when you need it most in your lives. (Applause.)

And the third practice that the President's
proposal eliminates is discriminating against older people,
in favor of younger people. Now if you are young, as many of
our students are today, that may seem like a good deal, that
insurance would be much cheaper for you at twenty-five than
at fifty-five. The problem is most of you will be fifty-five
some day, and in the present system the cost of caring for
young people is so much less that many insurance companies
want only to insure healthy young people, often leaving older
people out of the insurance market all together. So that is
another discriminatory practice that the President's proposal
would eliminate.

So we will do away with pre-existing conditions,
life time limits, and age discrimination. (Applause.) All
of which will make insurance more affordable for everyone.

The third point is that the President's approach
guarantees choice of doctor and choice of health plan. This
has been an issue that has probably received more
misinformation than any other. Because, in the current
market place, there is a lot of confusion about what kinds of
choice will be available to you as a consumer.

In fact, as we are here today, choice is
diminishing for most Americans. Americans are being told by
their employers, who buy their insurance for them, by their
insurance companies if they buy directly, what doctors they
can see and what hospitals they can use.

In my discussion earlier today, I talked with a
representative of the children's hospital here, because most
children's hospitals that I have visited throughout the
country are finding the same thing: that more and more
insurance policies are eliminating them from being available
for use by patients. Why? Because the childrens' hospitals,
which see very sick children, chronically ill children, are
expensive. They have to be in order to have the
concentration of specialists and technology necessary. So
many insurance policies are saying you cannot choose to go to
a childrens hospital, just as they are saying you cannot
choose to go to a university hospital, or an academic health
center because they are more expensive. They have to be more
expensive because of the services they offer.

But under the current way health care is both being
organized and developing, fewer and fewer Americans are being
given choice. That choice is made by somebody else, for you.
Under the President's approach you will choose your health
plan. Not your employer, not your insurance company, and not
a government bureaucrat. It will be your choice, and you
will make it every year. And what will be guaranteed is that
in your area, all of the physicians will be able to join the
health plans that they choose to join, so you will be able to
choose among them.

Additionally, every health plan will be required to
offer what is called a "point of service" option. In other
words, if you are in a health plan and you develop a problem
where the specialist is in another health plan, you will be
permitted to go to that other health plan.

The real danger for choice is the status quo,
because if we do not reform our system more and more of you
will be told you cannot use a certain doctor, you cannot use
a certain hospital. It is the President's approach that
guarantees your freedom of choice for a doctor and health
plan, and if you value that, you need to support this reform.

The fourth important point is that the President's
approach preserves and improves Medicare for Americans over
the age of 65. The Medicare program has been a godsend for
older Americans, who when it was passed in the 1960s they
were often the poorest of all Americans, often deprived
opportunities for health care for financial reasons.
Medicare has provided a base level of medical care for our
older Americans.

But there are two features that most people I talk
with say are missing, that will be included in the
President's approach. The first is prescription drug costs
which are often much too high for older Americans, on fixed
incomes, to be able to afford. And what we find is that many
older Americans do not take their prescriptions, do not get
them refilled, often end up being hospitalized because they
could not maintain themselves on the medication. Medicare
pays for the hospitalization; we think it is time Medicare
starts paying for prescription drug coverage for older
Americans too. (Applause.)

And the second big problem for older Americans in
the Medicare program is there is not support for alternatives
to nursing home care. We do not help people who want to keep
their relatives in their own home. We want to start
providing long term care options, so that families will be
able to take care of their own relatives, they will not be
forced to put their family members in nursing homes if they
can take care of them at home with a little bit of help. It
is the right thing to do, but it is also the economically
smart decision to make.

Nursing homes are very expensive. Providing a home
health aide, providing adult day care, giving some respite
care to the full-time caretaker of an Alzheimer's patient,
that is all much cheaper than putting the person in a nursing
home. So let's start giving alternatives that will enable
older people to live with dignity, and not make the nursing
home the only place that we take care of older people with
medical problems. (Applause.)

And the fifth point that I want to stress is that
Americans will be guaranteed their health care coverage
through their place of employment, the way most of us get our
insurance today.

If you believe, as the President does and as I do,
that we need to guarantee health care coverage to every
American, because until every one is covered none of us is
secure. And let me just stress that. Every one of us in
this room, with the exception of those of you who already are
eligible for Medicare, cannot know that this time next month,
or next year you will be insurable at the same rate, for the
same services that you are today. None of us under the age
of 65 has that security.

If you believe, as we do, that all of us should
there are only three ways to pay for that. You can either
have what is called a single payer system, which means you
eliminate private insurance and you raise the tax to
substitute for premiums, and you fund the health insurance
system that way. And there are many people who support that
approach. (Applause.) The single payer approach guarantees
that every American would have health care coverage.

The President rejected that approach in its means,
although he agrees with the goal, because he believed we
should keep the public/private mixture that has served our
country well. We should build on what works and fix what is
broken, so we should not eliminate private insurance, we
should extend it to everyone.

And, if you believe that then there are only two
ways to do that. There is an approach called the "individual
mandate," which, like auto insurance, would require each of
you to go into the market place and buy your own insurance.
That, at least, would on paper get us the universal coverage,
if you could enforce that individual obligation.

There are several problems with that approach. One
is we don't want to encourage employers who currently provide
insurance to stop doing so. And, if we pass the law which
said it is an individual responsibility there are employers -
- how many it would be difficult to predict -- who will say
one of two things to themselves, "Well then I no longer have
to do this, because the individual is required to do it."
Or, they might say, "Well what I will do is drop my low wage
employees, because the government is going to subsidize them
on the individual responsibility and I will only provide
insurance for people of professional or managerial standing."
Neither of those would work very well.

What the President believes is we ought to take our
employer/employee system. This is what some Presidents who
have come before him have proposed. Each has looked at what
works. Social Security is an employer/employee based system.
Medicare is paid for by an employer/employee contribution.
Let's extend health care to every one in the work place,
building on the employer/employee shared responsibility.

Now how do we make sure that that is done fairly?
Well there are several considerations that we have looked at
carefully. First, for most businesses that currently insure
your cost will go down, because you will no longer be paying
in your premium for businesses that do not insure and for
individuals who get taken care of at our hospitals but cannot
pay for themselves. Those costs have to be shifted to
somebody, and they usually are shifted to those of us with

Secondly, even if you are a small business and you
currently insure you are now being discriminated against in
the insurance market. You pay anywhere from thirty-five to
forty percent more for your insurance than a big business, or
a government does when it buys insurance. So we can lower
the cost of even small business by making everybody share the
cost more fairly.

Now if you have never paid for insurance for
yourself, and you have never contributed to your employees,
yes, it is going to cost something. But you have had a free
ride in our medical system. Because, if I go down any street
in St. Louis or the surrounding towns here in the county, we
could point out the businesses that insure and the businesses
that don't. But when someone working at the business that
does not insure gets sick, they go to the same hospital, they
get taken care of. The doctors are there for them, but they
don't pay for it. It is being paid for by those who
currently, and in the past, have insured.

So if we provide discounts to small businesses, and
if we provide subsidies to low wage workers then we can make
insurance affordable for even those who have never insured
themselves in the past. Once everybody is in the system then
we can begin to get cost under control. Because, right now
trying to control cost in a system where everybody is not in
it is like holding on to the balloon in one part, it pops out
somewhere else. Everybody being in the system means the cost
can be lowered for everyone, because there will be no place
to shift cost and make somebody else pay for the health care
of another person's employee or another individual.

So guaranteed private insurance, eliminating unfair
insurance practices, guaranteeing choice of doctor and health
plan, preserving and improving Medicare, and guaranteeing
insurance at the work place through shared responsibility by
employers and employees, those are the major points of the
President's plan.

An additional point, I would add because of where
we are, is the awareness that the President has, of the
important work done by the academic health centers; the
research that is done, the application of that research
through clinical practice; the education and training of
physicians, nurses, and other allied personnel.

This system that we have built up has features that
have to be strengthened and protected, and in the President's
approach there will be guaranteed funding for academic health
centers, because of the important functions they perform for
the entire system.

And there will be a requirement that health plans
contract with those health centers, so that those health
centers will not be eliminated from the provision of health
care in an effort to control costs, but will become the
centers of excellence so that we will have places in every
region where only the services that can be provided at that
level of complexity will be available. So we want to preserve
and strengthen our academic health centers.

Now this debate, as we move forward, will be filled
with all kinds of arguments, and many of them will be engaged
in in very good faith, by people who see the problem and know
that it has to be solved but have different points of view.
That is what the Congressional process is for. And I am very
encouraged when I see the kind of work that is going on now
in the Congress, often behind the scenes, in the Committees
and the Sub-Committees, where Republicans and Democrats of
good faith working toward solutions are coming together to
hammer out differences.

But there will always be extremes in these debates,
and there will always be interest groups who, frankly, have
profited from the status quo and do not want reform to occur.
It will be our task, as citizens, to keep the debate as
honest as possible, to ask the hard questions, to say how
will this affect me? Me as a mother, me as a patient, me as
a physician, me as a nurse. How will this change make our
health care system work better?

I am very optimistic about where we are in this
debate, because I do believe that there are enough people in
the country who understand what is at stake. But it has to
be a debate in which you are engaged. And I would ask you to
follow it closely, to ask what the motive or the agenda of
the person speaking is, so you can cut through the rhetoric
to try to find out what is really being advocated, to follow
it closely in the Congress, to stay in touch with your
members of Congress, to give them the benefit of your

Because, this is not just a debate about how we are
going to finance health care. It is bigger than that. It is
a debate about what kind of a country we are and intend to

In the meeting I was just in there was a medical
student who said she had worked in a clinic last summer,
where she had taken care of a lot of people who were falling
through the cracks, homeless people, runaway teenagers,
undocumented workers, the recently unemployed, and she wanted
to know what would happen to those people. That is one of
the right questions.

Yesterday in Denver, I visited a National Guard
unit that was set up in one of the poorest, toughest sections
of Denver. We are finally using our National Guard resources
for taking care of our own people in situations other than
disasters, and I wanted to see it firsthand. And I was led
through with a lot of very exciting news from the people who
were with me, the doctors and the nurses, about what they had
seen in just a week, the people who had flooded in seeking

And while I was there, I met a man who got a pair
of glasses for the first time in years. I met a young Downs
syndrome boy who is 10 years old. He was there with his
grandmother, they had just lost their Medicaid card, they
were no longer eligible under some change in rules, and she
had brought him to the only place that she thought he could
get medical care, a National Guard MASH unit.

I visited with the doctors and nurses who were so
pleased to be here answering the unmet health needs.

This is not just about those people, but it is
about how we treat them and how we think about them, and at
bottom, it is about us. If we move through this next year
and think about the people who you know, and who you see and
you hear about, and if you know that, fortunately, there, but
for the grace of God, often go any of us None of us can
predict the state of our health, no one knows when the
accident may occur. Then we will ask the right questions,
how will we take care of each other? How will be better use
our resources? How will we build on what is the finest
health care system in the world? By fixing the financing
system that is distorting it.

And what I hope is at the end of this debate I can
go back to the literally hundreds and hundreds of Americans
who have shared their stories with me, who have told me what
it feels like to be the mother of a chronically ill child
whose insurance runs out, or to be a small business owner who
can't afford insurance and has to tell her son not to go out
for sports this year because she is afraid he might get hurt,
or the woman whose husband could afford insurance for himself
and their four children but didn't insure her because he
couldn't afford it, and she got pregnant again and now she
wonders whether she can afford anesthetic when she gives
birth because it would be the equivalent of a house payment
for them. Or the woman who had a breast exam and they found
a lump, and she was referred to someone and was told that
because she didn't have insurance they wouldn't biopsy it,
they would just watch it.

I have so many stories, it is like a movie in my
head, the people who I see -- and I want to be able to go
back to them, I want to go back to this medical student I
talked to today, and tell her and tell them we have now
provided health care coverage for every American, and we have
taken a step toward becoming the nation we should be.

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