The MacNeil/Lehrer NewsHour

MS. WARNER: Good evening. I'm Margaret Warner in Washington.

MR. MacNeil: I'm Robert MacNeil in New York. After tonight's News Summary, Charlayne Hunter-Gault has a Newsmaker interview with Egyptian President Hosni Mubarak in Cairo. Then we begin a week- long look at how health care reform will affect different groups. Tonight, the consumer, individual Americans seeking care. We look at six different cases and discuss them with four experts and Judy Feather of the White House Task Force. NEWS SUMMARY

MR. MacNeil: President Clinton today told the United Nations it must reassess its peacekeeping message. In his first speech before the world body he also called on nations with nuclear weapons to stop testing them and said the United States would push for a ban on the production of nuclear materials. The President warned against isolationism and protectionism. He said the United States would remain engaged in world events and continue to be a leader in the effort to expand market-based democracies. Mr. Clinton praised the work of U.N. troops in Bosnia, Somalia, Cambodia, and elsewhere, but he said new thought must be given to future operations. He spoke to the opening session of the U.N. General Assembly in New York.

PRESIDENT CLINTON: In recent weeks in the Security Council our nation has begun asking harder questions about proposals for new peacekeeping missions. Is there a real threat to international peace? Does the proposed mission have clear objectives? Can an end point be identified for those who will be asked to participate? How much will the mission cost? From now on, the United Nations should address these and other hard questions for every deposed mission before we vote, and before the mission begins. The United States simply cannot become engaged in every one of the world's conflicts. If the American people are to say yes to U.N. peacekeepers, the United Nations must know when to say no.

MR. MacNeil: Mr. Clinton also said the U.S. is paying more than its share for the cost of peacekeeping operations, and it was time for that to change. He said other countries should assume more of the financial burden. The Mogadishu office and the head of U.N. operations in Somalia came under attack today. Somali gunmen fired three rocket-propelled grenades at the office. Gunmen also fired at U.N. officials opening Mogadishu's first court of law to operate since the 1991 civil war. No one was injured in either attack. Over the weekend, three American soldiers in the U.N. peacekeeping force were killed when gunmen shot down their helicopter over Mogadishu. Attacks on the U.N. force escalated last week after U.S. Army rangers captured a top aide to fugitive warlord Mohamed Farrah Aidid. Margaret.

MS. WARNER: In Russia today, Boris Yeltsin rejected a proposed compromise with its hard-line opponents saying he won't accept simultaneous presidential and parliamentary elections. Yeltsin sparked the current crisis last week by dissolving the conservative parliaments and ordering new legislative elections for December. He proposed holding presidential elections next June. Earlier today, scuffling broke out briefly outside the parliament building between Yeltsin opponents and interior ministry troops. Inside, lawmakers broke out gas masks amid rumors of an imminent attack by Yeltsin forces. There was no attack. Yeltsin has said repeatedly he will not use force. Rebels in the former Soviet republic of Georgia seized the city of Sukhumi today after a 12-day offensive. The Black Seaport was the last stronghold of Georgian government troops in the breakaway region of Abkhazia. Georgian President Eduard Shevardnadze, who had rushed to Sukhumi to make a last stand with his troops, reportedly escaped to a hideout south of the city just before it fell. Julian Manyon of Independent Television News filed this report.

JULIAN MANYON: After days of savage street fighting in the former Communist holiday resort, rebel Abkhazian troops today broke through the Georgian army's defenses and are now in control of the city. The Georgian leader, the former Soviet foreign minister, Eduard Shevardnadze, has been forced to flee. The city's fate was sealed from the moment that the Abkhazians started to shell the airport last week. At least two planes were destroyed on the ground and two more were shot down by heat-seeking missiles, their helpless passengers plunging to their deaths in the sea. Well over a hundred p died in this ruthless attack on Sukhumi's last air link. In the city's dying days, Russian ships came to evacuate some of the desperate civilians. A mother passed her child to safety as people struggled to climb on board. Some waded out to the ship, while others tried to row to them. With only one artillery piece in the city, the Georgian army was simply outgunned by the Abkhazian rebels who want to make Sukhumi the capital of their new state. Tonight there are fears for how the victors will treat the Georgian civilians who have been left behind in this city that was once a Communist playground.

MS. WARNER: Shevardnadze blamed Russia for the city's fall. In a statement issued by his office, he said Russia could have saved it. He asked Moscow to do it. In the past, Georgia's government had accused the Russian military of helping Abkhazia rebels.

MR. MacNeil: A Texas grand jury today indicted Sen. Kay Bailey Hutchison on felony charges of official misconduct and tampering with government records and evidence. The charges stem from her two and a half years as Texas state treasurer. The Senator is a Republican who was elected earlier this year. She denies any wrongdoing and is accused the Democratic district attorney in Austin of conducting a political witch hunt. A New York city man as killed last night in a drive-by shooting in Miami. He was the third tourist murdered in Florida this month. Police said the shooting appeared to be random. Forty-year-old Miguel Sanchez was riding in a car owned by his cousins who live in Miami when another car drove up alongside. A man fired once, hitting Sanchez in the head. The incident occurred on a well-traveled highway shortly after 8 PM.

MS. WARNER: An environmental group raised new questions today about the safety of the nation's tap water. The Natural Resources Defense Council said local utilities routinely let water quality slide. The Center for Disease Control in Atlanta estimates that nearly one million Americans get sick from water-borne bacteria each year. The EPA today promised tougher enforcement but said America's water drinking water remained among the safest in the world.

MR. MacNeil: That's it for the News Summary. Just ahead is the president of Egypt and a prescription for change. NEWSMAKER

MS. WARNER: First tonight, a Newsmaker interview with Egyptian President Hosni Mubarak. In Alexandria, Egypt, this morning, he talked to Charlayne Hunter-Gault about change in his country and the revitalized Middle East peace process. Charlayne asked him to describe the mind set of Syrian President Hafas Al-Asad, who has given a cool reception to the Israeli-PLO Accord.

PRESIDENT HOSNI MUBARAK: President Assad, in my point of view, is a very good man. This man want peace also. There are so new ones that he doesn't want to solve the problem in the Middle East, or he doesn't want to reach a peace solution in his occupied territories. On the contrary, the man -- every now and then is very sincere peace.

MS. HUNTER-GAULT: By why do we hear these almost conflicting things? I mean, he says he's for the peace -- he won't stand in the way. He won't be an obstacle. And yet, his public utterances each day are, you know, are utterances that make you wonder. When he says, for example, that Israel is assuming peace for peace sake, not peace for land, Israel is getting everything, the Arabs are getting nothing, is he wrong?

PRESIDENT MUBARAK: Sometimes some heads of state are not speaking about Hafas or Rabin. They have to make some statements for local consumption. Everywhere in the world, certain times to -- we have - - whenever we want to deal with some problems, we have to have in the back mind what are the needs of the people. Sometimes you cannot go quickly through problems to be solved in a very short period of time. It may be shock to the people. So you have to take it on a gradual basis, but my concept of President Hafas Assad that the man is sincere with peace.

MS. HUNTER-GAULT: In your own view, would you say that he is prepared, whether he says it or not, to open full diplomatic relations and have relatively free borders with Israel?

PRESIDENT MUBARAK: I could tell you he understands this very well, and on that, but just see openly and so quickly to the people who are not used to such diplomatic relations with Israel, staying for over 40 years with Israel as an enemy, it is preparing the people to accept such a new format.

MS. HUNTER-GAULT: But did you encourage him to move more quickly, or do you think he's doing it the right way in terms of his --

PRESIDENT MUBARAK: No. We are encouraging him to move much more quickly now, and the man is sincere, and I think he is moving in the right direction.

MS. HUNTER-GAULT: What do you think is at stake now if each country, Syria and Israel, don't move on these two tracks? Could their failure to, to take advantage of this momentum wreck the deal, or make it more difficult?

PRESIDENT MUBARAK: No. I think if they didn't move with the Syrians it will be a big problem.

MS. HUNTER-GAULT: Meaning?

PRESIDENT MUBARAK: A big problem.

MS. HUNTER-GAULT: In what way?

PRESIDENT MUBARAK: In the area, even problem with the Palestinians, with the Arabs. Of course, Syria is one of the countries in the area. We have very good contact with them, but to move on the Palestinian problem and to make it much more easier than for the Palestinian problem to proceed forward, we have to solve also with the Syrians, otherwise, after signing the accord in Washington, still a long way in -- for negotiating the western bank area. It's still difficult, complicated. It needs the support of all the Arab countries.

MS. HUNTER-GAULT: And what can the U.S. do at this point, the United States, to nudge this process along? I mean, for example, would taking Syria off the terrorist list help, or inviting Assad to the United States, or what could it do vis-a-vis Israel? Is there any role for the US?

PRESIDENT MUBARAK: Look, the US has a very important role. We consider the United States as a full partner in the peace process. Without the help of the United States, I don't think that we could achieve or reach a comprehensive settlement. It's a very important element and the partner in the peace process, so I think the United States should urge and persuade the Syrians, the Israelis, to continue negotiating with the Syrians to put an end to the problem between Assad and Syria.

MS. HUNTER-GAULT: Would taking Syria off the terrorist list help? I mean, would that enable President Assad to say that, well, look, I've gotten this and, you know, would that be a sweetener?

PRESIDENT MUBARAK: I think this is one of the points which should be discussed between the United States and Syria, but believe me, I think whenever they reach a settlement, the problem of Golan, reach an agreement, the United States look after its decision that Syria is a terrorist country.

MS. HUNTER-GAULT: On the other hand, the thing that preoccupies the Israelis the most is security vis-a-vis the Golan, and you, I think, have proposed a compromise that, that there be a gradual withdrawal over a four-month period. Is that kind of compromise the kind of thing you think the US should be pushing?

PRESIDENT MUBARAK: I think the US has dwelled on this point, and I think having multinational forces even like the Egyptian front - - we have multinational forces -- may serve and make both sides feel secure.

MS. HUNTER-GAULT: As a buffer.

PRESIDENT MUBARAK: Yes, as a buffer also. And we did in Egypt.

MS. HUNTER-GAULT: And you're prepared to do that.

PRESIDENT MUBARAK: Yes.

MS. HUNTER-GAULT: And speaking of terrorism, how do you assess the capacity of groups like Hamas and Hezbollah and Iran's -- factions that Iran supports to wreck this deal?

PRESIDENT MUBARAK: In Iran, they said 500 million are prepared to be spent on this terroristic action, Hezbollah and this, and any problem, and persuading the, the so-called Islamic groups that we have problem in this part of the world, so it is very clear that Iran is doing that.

MS. HUNTER-GAULT: But do they have the capacity to wreck this deal?

PRESIDENT MUBARAK: No, they are trying, but I don't think that they could conclude something like that.

MS. HUNTER-GAULT: What has to happen in this process to have the peace process predominate over the terrorists? I mean, does, for example, the PLO have to quickly deliver something tangible in Gaza and in Jericho?

PRESIDENT MUBARAK: No. 1 issue is very important that you make the people feel that is very important to them what happened in Washington, it raised the standard of living of the people, economic reforms, helping these people to make the infrastructure there, and the people could feel there is something after they agreed to sign that accord.

MS. HUNTER-GAULT: Mr. President, in that regard, Egypt, itself, is facing some tough, economic challenges, violent challenges from radical groups within the society. How worried are you that resources and attention and everything else will be diverted to the Palestinians at Egypt's expense?

PRESIDENT MUBARAK: Look, I think the United States shouldn't, as far as they could evaluate, whenever looking after the Palestinian problem of financing the infrastructure there, it shouldn't reduce Egyptian aid now because it's very important. We are on different programs, economic reforms, which will take another two to three years. I think the aid should stay as it is. I'm not asking to keep the aid forever, it's impossible, but until we finish all these reforms and we are on right track, I think we need the aid for some important reasons. The stability of this part of the world cannot be maintained without Egypt.

MS. HUNTER-GAULT: Why is that?

PRESIDENT MUBARAK: Because Egypt is the biggest country, pivotal country in the area, so you have good economic reform, stability. Without this I don't think that it will be in the interest of the West or the United States that Egypt will be unstable. Peace without Egypt isn't possible. War without Egypt in this area is impossible. So keeping or helping or supporting Egypt to be stable vis-a-vis a state will continue for some time until we reach the end of our economic reform.

MS. HUNTER-GAULT: But some analysts of Egyptian affairs and Middle East affairs --

PRESIDENT MUBARAK: In the United States, American analysts.

MS. HUNTER-GAULT: -- in the United States, American analysts, have said that Egypt is on the edge like Lebanon before 1975, on the edge, i.e., about to fall off the cliff, that Egypt is the Achilles Heel of the Middle East. Are they just seeing things wrong? I mean, is that not a fair assessment of Egypt's position?

PRESIDENT MUBARAK: Egypt is in better form now. We made difficulties, so many difficulties four or five years ago, but we are going through economic reforms. We are dealing toughly and strictly accordingly with the terroristic group in this country. I don't think Egypt is on the edge at all.

MS. HUNTER-GAULT: MC International says that you are violating international law by the way you are treating the people who are opposed to your regime, that people are being tortured, detained, tried before military authorities, even though they are civilians. But by my question is: Are they just wrong about this?

PRESIDENT MUBARAK: I have to put it before a military court so as to finish as quickly as possible because the normal courts have lots of cases. It will take a very long time, which may make everything much more complicated. But we are not --

MS. HUNTER-GAULT: So this is --

PRESIDENT MUBARAK: -- violating the law of the constitution under any circumstance.

MS. HUNTER-GAULT: Let me just change the subject slightly, Mr. President. You are facing an election next week. Let me ask you about that. You are unopposed, and presumably you will win and be President again. How does the future of democracy look here in Egypt, as well as in the rest of the Arab world at this time?

PRESIDENT MUBARAK: We are very keen on democracy. But democracy is about 12 years old, or 14 years. So don't expect that we have full democracy overnight. It needs generations. I'd like to tell you a few -- the West, if it tries to push democracy in countries, third world countries that don't use democracy at all, if you push it fast, which the western democracy, it may have negative reaction. It may turn in the end to dictatorship. For example, having this open democracy in the West, some elements will use atmosphere of democracy to throw away regimes and take over, which is very dangerous. So we have to -- democracy should be taken on gradual basis, until the people understand and swallow each step and they adjust it.

MS. HUNTER-GAULT: Well, Mr. President, thank you for giving so much of your time during this very busy period. SERIES - CLINTON CHECKUP

MR. MacNeil: The Clinton health plan is next tonight. Each night this week we'll examine the President's plan to overhaul the health care system from the perspective of a different key group. Tonight we see it from the patient's point of view. We start with a sampling of the problems currently facing patients. Medical Correspondent Fred De Sam Lazaro has this backgrounder.

MR. LAZARO: There are some 37 million Americans without any form of health insurance. Gladys Healy spent substantial time as one of them.

GLADYS HEALY: When I lost my job at Pan Am on December 4, 1991, I also lost my health insurance. I have in my family a history of various eye problems, and I've always been very, very cautious when it comes to my eye exams. And it makes me anxious to think that I've ignored this for well over a year now. It's very frustrating to know that someone may conceivably never have worked a day in their life and be receiving welfare benefits, and their health care is covered by Medicaid, and I don't begrudge anyone health care, but I think that someone should take a really hard look at the uninsured people today, aside from unemployed people, people who are working and just can't afford insurance when their health -- their employer doesn't provide it.

MR. LAZARO: Saverne Tompson tried to get off welfare, taking a low paying job with no benefits as a school bus monitor, but she quit when she realized the income disqualified her from continuing to receive Medicaid.

SAVERNE TOMPSON: They cut me off because I was working, and that's why, because I needed the Medicaid, because I couldn't afford to pay for doctors and like that.

MR. LAZARO: We met Tompson in the emergency room at the Westchester County Medical Center in suburban New York. She'd brought the youngest of her six children, eighteen-month-old Donald, for treatment of a burn. In addition to access, Tompson complained of rising out-of-pocket medical expenses like prescription drugs. So did Arnold Ring, a retired New York City police officer who has private insurance.

ARNOLD RING: It becomes quite a burden when seven children need checkups and various types of everyday health care like stitches here or a fracture here. It becomes quite a burdensome obstacle to overcome. The schedule doesn't cover today's rates, and, of course, there are deductibles and coinsurance costs that amount to quite a bit. And with my insurance it's quite a draw, especially the financial situation that we're in.

MR. LAZARO: Arnold and Maddy Ring had brought their daughter, Amanda, to Westchester for a tonsillectomy. They'd come 80 miles from their home in upstate New York where there's a very limited choice of doctors and hospitals covered by the family's insurance plan.

MADDY RING: Finding a physician sometimes is difficult just because we live in a more rural type area.

MR. LAZARO: It can also be difficult in the suburbs, according to Laura Unger. A few years ago, she had a lump on her right hand removed in a two-visit procedure at a hospital she selected, but then her employer adopted a new managed care plan that strictly limited her choices. Under this restricted plan, it took eight visits to various doctors, clinics, and hospitals to authorize surgery for a similar lump on her left wrist, costing her, all told, three days of work.

LAURA UNGER: And then I've had to go to several more visits with the orthopedist so he can look at the scar, which is the next thing I'm very unhappy about. This is a nightmare to take care of something that should have been simple and easy, and in the past would have been covered with no problem at all. I will be very, very sick again before I use this network.

BILL SENFELD: Getting every bill paid is a problem.

MR. LAZARO: Bill Senfeld had no problem with the quality of care he got for a ruptured aorta and subsequent complications, but he had a big grip with his insurer over the huge bills he faced.

BILL SENFELD: The paper work, the dealing with it is time consuming. It's frustrating, on top of whatever problems you have because you have not been well, because your life has been turned upsidedown by an extended illness -- it has completely changed everything about the way you conduct your everyday life -- you are now dealing with major bookkeeping problems.

MR. LAZARO: But Senfeld can't shop for a new insurer. With his medical history, chances are he wouldn't find one.

BILL SENFELD: Nothing is forever, except the fact that I have a preexisting condition. I am in constant fear of, one, that the premium will go so high that I cannot afford it, and if I can't afford it, I will never be able to get insurance or insurance that will be meaningful because they will, no matter what happens, they will say preexisting condition.

MR. LAZARO: Although problems abound, many are happy with the system just as it is. Florence Ehrlich, a retired nurse, is insured by her husband's employer. The plan is the old-fashioned "fee for service" kind, where the insurance company pays 80 percent of the bill of whatever doctor she chooses, in this case Dr. Jerry Edelman, who's been her internist for 30 years.

FLORENCE EHRLICH: I just don't want to make a change. I'm comfortable with what I have. The new program will not, will not affect my health care. I'm assuming it won't affect my health care, but I do feel that the people who do not have health care are entitled to some form of health care. I think we have to have preventive medicine in this country, much more of it.

MR. LAZARO: You're willing to pay your share?

FLORENCE EHRLICH: I'm willing to pay my share.

MR. LAZARO: Under President Clinton's health care plan, all of these people would be guaranteed coverage. Every American citizen and legal alien would become a card carrying member of a local health alliance and allowed to choose among various competing plans. Those who are now working and insured, like Laura Unger, Bill Senfeld, and Florence Ehrlich, would see little difference. Employers would be required to pay 80 percent of the premium. The employee would pay 20 percent. HMO plans would offer the cheapest coverage and limit patient choice to doctors and hospitals in the plan. Those who wanted unlimited choice would pay more, both in premiums and in higher costs, as they received care. People who lost their jobs, like Gladys Healy, would keep their insurance, paying on their own or helped by the government if their income falls below two and a half times the poverty level. Medicaid would be merged into the new program, with welfare recipients like Saverne Tompson choosing their health plans just like other alliance members. The government would pay the premium for the plan the individuals selected. And retirees too young for Medicare, like Arnold Ring, could get coverage through the alliance. They'd pay 20 percent of the premium as if they were still employed, with the former employer or pension plan, or the government, if necessary, paying the rest. The Medicare program would continue, though states would have the option of bringing its members into the alliances. As for concerns about rising costs, deductibles and coinsurance charges would be fixed, a new national health board would cap premium rates, and the alliances would try to bargain them down. Those with preexisting conditions could not be excluded or charged higher rates. Everyone in a given plan would pay the same. And to cut down on paper work, the President's plan offers a standard claim form and instant electronic processing.

MR. MacNeil: We hear five perspectives on how the Clinton plan will affect these patients. Judy Feder is an adviser to President Clinton on health care. Richard Scoff is the chairman of the largest for profit hospital chain in the country. Cathy Hurwit is the legislative director for Citizen Action, one of the leading consumer groups campaigning for health reform. David Lawrence runs the nation's largest health maintenance organization, Kaiser Permanente, based in California. Thomas Chapman is the CEO of a community-based hospital in Washington, D.C. Let's go through, ladies and gentlemen, let's go through these cases, typical cases we've just posited here, and starting with you, Ms. Hurwit, ask in the case of Gladys Healy, the former Pan Am worker who's lost her job, who's unemployed, and uninsured, does the Clinton plan adequately look after her, in your view?

MS. HURWIT: Well, I think she will be guaranteed under the Clinton plan access to health care. She may have to change her source of health care. She may have to change what doctor she goes to, because she may not be able to afford anything other than the average cost plan or below, so while she's guaranteed that she gets benefits, she may have to change where she gets those benefits.

MR. MacNeil: Yeah. And how does -- Ms. Feder, how does a woman like Gladys Healy, she loses her job, she's unemployed, she's uninsured, how does she -- suppose she decides to go out of where she is right now and move to another state and look for a job because she's heard that another airline might have another job for her in another state -- how does she go about getting that, and who pays for it?

MS. FEDER: As long as she is uninsured and has no income from her job, she is not obligated to pay toward her premium. The part that her employer would have paid, she only paid her family share, her individual contribution, her 20 percent, if you will, based on the income and subsidies that toward it. If she goes to another state, she goes to the alliance, reports that she does not have coverage, and is unemployed, and signs up for a plan there, and subsidies will assist her with that coverage. It's really of enormous concern to us that people always have their coverage, even when they're not working, and that's the kind of system that we're trying to design.

MR. MacNeil: Thomas Chapman, do you see any problems under the new plan with a case like this, or do you think that will be adequately provided for?

MR. CHAPMAN: No. I think most of these cases that you presented will be generally and adequately provided for. It seems to me the backbone of this system is the comprehensiveness and the continuity that's offered, as well as the security in the types of insurance coverages that will cover people in a portable way from state to state. So I think everybody would be taken care of very well under these circumstances.

MR. MacNeil: Dr. Lawrence, what do you think about this case we've just given of the former Pan Am employee who's now unemployed and uninsured, that kind of person all right?

DR. LAWRENCE: This kind of person is exactly the person at whom the plan is directed, the Clinton plan is directed. That kind of portability, that kind of security is critical to this person's health, not only the immediate problems they face but over the long run having the kind of continuity that allows the plans, allows the person to have the benefit of prevention and ongoing education and development of capabilities to care for oneself and so forth. It's the lack of that continuity that has been a problem historically.

MR. MacNeil: Richard Scott, do you see any problems for this kind of patient with the new proposal?

MR. SCOTT: No. I think, I think these type of patients are going to be taken care of. My biggest concern though is the price controls through significant additional government regulation, through the $238 million Medicare and Medicaid cuts. We won't as a group of providers -- our employees won't have the opportunity to take care of these patients.

MR. MacNeil: Let's move on to the second case that we mentioned a while ago, Saverne Tompson, a welfare mother of several children who had a job as a school bus monitor but had to leave it in order to afford to get care for her kids under Medicare. Mr. Chapman, are people like Ms. Tompson going to be, going to be cared for in your view?

MR. CHAPMAN: Well, I think there's no question that Ms. Tompson will benefit from the program. The issue for people who have been on Medicaid as well as those who -- the under-insured who don't qualify for Medicaid -- is: What kind of a risk will they represent and bring to the qualified health plans that will provide care for them, and whether or not plans will experience a disproportionate amount of patients from those categories that they'll have to care for in an undetermined amount of risk that they'll have to be on the line for. I think that's an area that we're going to have to get a lot more detail on and understand better because the population of 37 million people who are uninsured represent a tremendous amount of risk that neither the insurance industry, nor the health plans have directly dealt with in the past.

MR. MacNeil: These are presumably would have cleared a lot of the sort of patients you are used to dealing with in Southeast Washington, is that right?

MR. CHAPMAN: That's correct.

MR. MacNeil: And how do you answer that, Ms. Feder?

MS. FEDER: Well, I think it's an important concern, and we spent a lot of time working on mechanisms to see both that plans accept all people, regardless of the risk, and that they are paid appropriately and adequately to deliver quality care to high risk patients. Let me clarify. First, we -- by putting welfare recipients in the same plans as other Americans, we are seeing to it that plans will now be paid for an average risk patient the same for a Medicaid patient as they would for any other patient. That's holding risk aside for the moment. Right now, Medicaid pays far less to providers, and that's a problem in supporting adequate care. Then what we need to do for all patients, whether they are on welfare or not on welfare, is make certain that payments are adjusted to reflect high risk, so that if we have, for example, someone with AIDs, someone with a chronic condition, that there is an adjustment of the payments made to plans to cover those extra costs, and we, those -- developing those mechanisms will require additional research and work, although we already have a number of techniques available to us to provide those protections. And they have to be there. Let me just briefly comment also. When we look at the uninsured population and we focus on the welfare population, that's a misconception. About 85 percent of the population without insurance coverage are workers, or in families of workers, and many of them look very much like the people who are covered, and so let's not forget that as we move forward.

MR. MacNeil: Does that answer your anxieties, Mr. Chapman?

MR. CHAPMAN: Well, to a certain degree. It's true that 85 percent of the workers when you analyze the categories, the work that they do, you begin to develop a certain amount of cautiousness. Close to 40 percent of those people work in agriculture and are exposed to pesticides and certain other problems. The average income of many of those workers is far below $20,000 a year. That's pushing close to the poverty levels. And, of course, many are seasonal and part-time. The question here is not so much the coverage. The question is whether we can get under control the proper medical care management of the lives of these people as well as the other social and economic issues which impact their lives which drive the medical care demands in our system.

MR. MacNeil: Ms. Hurwit.

MR. CHAPMAN: That is really the question.

MR. MacNeil: I'm sorry. Ms. Hurwit, how do you feel about the category of people that Mr. Chapman's talking about, and how well - - his anxiety about it?

MS. HURWIT: Well, we havea slightly different concern in addition to the ones that Dr. Chapman has been raising, and that is the cost sharing requirement that will be placed on this woman. Right now in the plan as we've seen it she would have to pay $10 every time she goes to the doctor, $5 per prescription. That's more than Medicaid beneficiaries pay now. And that I think is going to end up being a financial obstacle to many people, so that while, as Dr. Feder was saying, there's some improvement in terms of the Medicaid population if those cost sharing requirements stay in place, they will be serious barriers to care.

MR. MacNeil: And people just wouldn't go.

MS. HURWIT: They won't go, and one of the -- while, in fact, there are no cost sharing requirements for prevention, one of the things we know is that many people get preventive services when they go to a doctor for a problem. They don't just go in for their physical, so we think that will keep them from getting preventive care as well.

MR. MacNeil: Ms. Feder, do you want to respond to that?

MS. FEDER: Sure. We think it's very important to recognize that what we are doing in many cases here -- and I'll come to the Medicaid -- the woman on Medicaid in a moment -- but we are providing coverage in a plan at a reasonable price that people have been lacking altogether. And I guess I'd take issue with the access to preventive services because we believe they will be available. They address some of the concerns that Dr. Chapman is raising with respect to caring for a population appropriately, immunizing our kids, providing mammograms, getting at diseases in advance. And the coverage there is without cost sharing, and that's important. And when you look at the woman who couldn't take a job because she lost her Medicaid coverage and got no coverage with employment, her circumstances would be totally changed because now any job she goes to will provide her coverage. She will be encouraged to work, not to stay on welfare and be in the position to contribute to the cost of her care.

MR. MacNeil: Well, what about the $10 a visit and the $5 per prescription which Ms. Hurwit saw as a disincentive?

MS. FEDER: There are cost sharing requirements we can discuss, and we'll continue to, to hear from groups that are concerned about the levels of cost sharing that are required in plans and continue to explore them, because we do want to provide assistance for low income people.

MR. MacNeil: Let's move on to the case of the retired New York City police officer, Mr. Ring, who is on a fixed income. He isn't old enough for Medicare yet, and he's privately insured, but Mr. Scott, he said he just found it much too expensive with all the costs he had to pay, the cost sharing parts of it. Is the Clinton plan going to look after a person like him all right?

MR. SCOTT: Well, I think there are a lot of things that are positive about the Clinton plan which will take care of those people, but if you think about what we're going to end up with is price controls, and price controls do one of two things: Either they create excess or create significant shortages. I think because of the deficit-driven issue, it's going to create shortages. I think we have not focused on the significant cost of government regulation that will be added. Again, that's going to drive up additional cost, which is what, the opposite of what we're trying to do, and finally, if we're going to cut $238 billion out of Medicare and Medicaid, and the health care providers in this country already lose money on both of those, there's going to continue to be cost shifting to the private sector, which will continue to drive up the cost to this type of individual.

MR. MacNeil: Ms. Feder, how do you respond to that, that the price controls are going to create excess or shortage?

MS. FEDER: Yes. I'm glad to respond to it. I let it go the first time, and I'm glad to come back to it. Providers, particularly those who are not serving the poor, will be talking about difficulties in terms of flowing cost growth in our health care system, but look at what that cost growth means. Health care costs are rising far faster than inflation. Essentially, providers, themselves, tell us how much waste there is in the system, how much more efficient we can be, and it is our commitment, and included in our proposal are many measures to simplify administrative costs throughout the system, to take malpractice pressures off providers, to make the system easier for them. And when that is done, we can expect them to offer care more affordably. And we do that not by micromanaging or setting their prices. What we are doing is saying to health plans, which it is our intent that increasingly doctors and hospitals will manage themselves, telling health plans to -- holding them accountable for delivering the guaranteed benefit package based on the premium that they bid in the marketplace. And we believe that in most areas of the country competition among plans will keep those premiums down but to guarantee a slowdown in cost growth we essentially say -- set a limit on how fast average premiums can rise, and then let the plan and the providers in those plans work to manage resources effectively, while holding them accountable for quality of care.

MR. MacNeil: Dr. Lawrence, what do you think about Mr. Scott's point from, from the private hospital point of view, that these price controls as -- you heard what he said -- they're going to either create excess in the system, or shortages?

DR. LAWRENCE: Well, first of all, we don't know enough about how the price controls and the budget caps are going to work to make that kind of statement stick. We simply have to learn more about how they're going to work, how they're designed, to know whether or not that's the case. Certainly, the excess in the system of which Judy Feder has just spoken is substantial.

MR. MacNeil: The present excess?

DR. LAWRENCE: The present excess in the system is substantial. Moreover, we're already seeing the kinds of pressures brought to bear by purchasers that are encompassed in the Clinton plan, and many of the parts of the country this intense effort on the part of purchasers to, to rein in the cost, if you will, to try and encourage plans to be more efficient, is quite a force. So what I see happening with much of what's included in the Clinton plan is building on a series of forces that are already in play that, in fact, are reducing the cost of health care in the United States - - not reducing it but slowing the rate of increase in the cost of health care in the United States.

MS. FEDER: If I may.

MR. MacNeil: Ms. Feder.

MS. FEDER: Mr. Scott also was talking about changes in Medicare and savings that we're relying on. Let me be clear about that too. What we've seen over past years are efforts to cut Medicare spending without any changes in the private sector. And what that does is shift costs to private payers and threaten access for Medicare beneficiaries. We're not talking about that anymore. We're going to put an end to that. We're talking about slowing cost growth in the whole system, and as we do that, we can slow Medicare cost growth as well. And it is from that slowdown that we derive the substantial savings that contribute to financing the subsidies that we are including in this program.

MR. MacNeil: How do you feel about those explanations, Mr. Scott?

MR. SCOTT: Well, I still think if you at the other systems that have tried to control the -- through government regulations, through price controls health care, what we've ended up with is, you know, the Canadian system, which is clearly a system that has rationing. They're cutting way back on their system now, same thing in Britain. So I think that, you know, I'm not satisfied. I think there's going to be -- the price controls are going to -- they're clearly going to ration, reduce quality. We still -- there was no response to the significant increase in government regulation which would clearly drive up costs. And I mean, I think everyone out here is trying to do the best they can at taking care of Medicare patients, Medicaid patients, but constantly driving down what nurses, physicians, et cetera, pay is not going to solve the problem.

MR. MacNeil: Let me move on, because on other evenings this week we're going to talk about hospitals particularly, and go on to our next case that we chose, Laura Unger, the woman who had -- she was happy with the operation on one hand but very unhappy that the managed care plan she was in forced her through many visits, and she came out with an unhappy result. Dr. Lawrence, as somebody who knows a lot about managed care, why would she be happier under the new system?

DR. LAWRENCE: Well, first of all, I think we have to ask ourselves whether or not that managed care plan is typical of what we're shooting for, which certainly our program would want to see happen. The notion of bouncing from physician to physician or taking a fair amount of time, as she has, to, to obtain her surgery, and the outcome that she has obtained are certainly very difficult for, for me to understand. Looking at physicians very carefully, choosing them quite carefully to be part of a plan is part of what a plan has to do. Part of what we believe will happen with managed health care environments is that the, the consumer, the patient, will have far better information on which to make her choice in this case far better information about the nature of the plans, themselves, how well they're doing in terms of quality, and thereby make a far more informed choice about the kind of plan with which she wishes to associate. And within the plan, the physicians need to be well screened, well monitored over time by their peers to ensure that the quality of care that, that the patient is getting is, is superior.

MR. MacNeil: Are you -- excuse me -- are you, Ms. Hurwit, confident about this, that people who are going to be -- find themselves in plans where they will have -- that they will have choice and confidence of quality"

MS. HURWIT: Absolutely not. I think this is one of the biggest concerns we have with the President's plan, i.e., people are going to be forced into certain plans if they do not have the money to buy themselves up, to buy a better plan. Many of those plans --

MR. MacNeil: You're talking about the basic plan.

MS. HURWIT: The basic plan. Many of those plans will be managed care plans. Unfortunately, we hear complaints every day from people who are now in managed care plans either as patients or doctors who are, who are having insurance companies, the people who are running the HMO's, telling them what kind of care they can get, or how they can practice medicine. I think this is a very big concern that we have. There's got to be a way to get the, the insurance companies and the for profit HMO's out, out from between the relationship between doctors and patients so that people can really get health care. The other thing that we would propose is that people be given more choice to get something other than the managed care plan, if that's what they want, and that means we cannot charge people extra out of their own pocket to go into fee for service.

MR. MacNeil: I'll come back to that in a moment. Just first on the general point, Ms. Feder. The observation that people like Ms. Hurwit are worried, that people are going to be forced into plans with a basic coverage and, and not very much choice or guarantee of quality.

MS. FEDER: Let's be very clear. First of all, we're talking about comprehensive benefits in all the plans. This is not -- there's not an issue of basic or otherwise. Everybody is guaranteed a comprehensive set of benefits. What Ms. Hurwit is appropriately concerned about is whether we are going to hold plans accountable for delivering those benefits in a quality manner. What we're seeing right now, and you can see it from the case you showed, that people are -- choices are being restricted, and plans are not being held accountable for quality care. You heard Dr. Lawrence talk about what a good managed care plan is and about building a system of information for practitioners and for consumers to hold plans accountable. And that is a critical element of our plan, providing information on outcomes like complications from surgery or waiting time for appointments or adequacy of referrals or satisfaction with surgery. All of those pieces of information are needed so that doctors, as well as consumers, can make the system work.

MR. MacNeil: Mr. Chapman, how confident are you about this area of the plan?

MR. CHAPMAN: Well, I'm extremely confident. I think it's realistic to understand that wherever we move from this point forward we have to improve upon a system that we currently have. It's easy to criticize at the edges, and this plan will have some impact on almost everybody in the system. But fundamentally, we're moving in the right direction. You know, if you're insured privately and if you have a job and if you're not ill, you're probably in very good shape. But fool around with any of those variables, and you begin to experience a lot of insecurity. So I think it's important. And on the other issue, just going back for a moment, of price caps, it seems to me what we're trying to do here is to rationally adjust the kinds of dollars that we're spending in this system so that everybody has a fear and equal opportunity to receive an excess comprehensive health care. We have always had rationing in the system. It's just been disproportionate. And now we're trying to approach it on a logical basis so that we can eliminate it and provide everybody with their fair share of reasonable and quality health care. So I don't think the providers, and especially the hospitals, have a lot to fear in that regard.

MR. MacNeil: Let me go on to the case of Mr. Senfeld, who had the ruptured aorta. He was satisfied with the treatment he got for it, but absolutely bowled over by the paper work, and now lives with a preexisting condition. Ms. Hurwit, is his -- are his worries going to completely disappear in the, in the new system?

MS. HURWIT: In terms of problems with preexisting conditions absolutely. I think this is a very important step in the Clinton plan. But I too want to go back to the price cap issuebecause I think it underlines whether people are actually going to be able to get care. It is extremely important to have government guaranteeing that prices cannot continue to go up the way they have under a totally free market. We are very supportive of the premium limits that are in the President's plan. In fact, we think he needs to go further by limiting administrative waste and drug prices and all that. But I do think that in terms of this gentleman, he will be able to get access to care. He will not be barred because of his preexisting condition. The other part though and the other side of it that I think President Clinton is looking at, and we're looking at, is how to ensure it's affordable to him.

MR. MacNeil: And Dr. Scott -- Mr. Scott, do you see any problems with the case of this man who's adequately insured at the moment, had good treatment, but was driven crazy by paper work and now might lose -- and -- and could not get new insurance with his preexisting condition?

MR. SCOTT: I think this is one of the great things about the Clinton plan, elimination of preexisting conditions as a criteria for eliminating coverage. I think there's a lot of things that Clinton has proposed under the insurance reform that will ensure that people that do have preexisting conditions will have care, and hopefully affordable care. You know, just to go back, one additional point on the price controls, if you look at what -- what I don't understand about this system is the fact that we're complaining about Russia today, about all this centralized planning, that they should not be trying to decide price, supply, demand, all those things, and we're saying now that our federal government can do those things. I don't think the American people trust our government enough to say that they can set price. They know exactly what supply is needed. They know what the demand is, et cetera. It cannot happen. The free market system has to work.

MR. MacNeil: Let's ask Ms. Feder about that finally.

MS. FEDER: Well, it's just got -- I don't think raising those kind of symbols will work anymore. We are building on a private system, a premium-based system, in which plans are required to provide the guaranteed benefit package, and then with these new rules for plans, they have to take everyone, preexisting condition or not, we allow them to compete. So this is not a regulatory system. Essentially what we've done is change the balance of power in the insurance market, put consumers in the driver's seat, and create a system in which the market does have a chance to work.

MR. MacNeil: Well, Ms. Feder, Ms. Hurwit, and gentlemen, thank you all. As we go on this week, we will continue with different aspects of the Clinton plan. RECAP

MS. WARNER: Again, the major stories this Monday, President Clinton told the United Nations it must reassess its peacekeeping operations. Rebels in the former Soviet republic of Georgia have seized the capital of the breakaway Abkhazia region, and in this country, Texas Republican Sen. Kay Bailey Hutchison was indicted on felony charges of abusing her former office as state treasurer. She has denied the charges. Good night, Robin.

MR. MacNeil: Good night, Margaret. That's the NewsHour for tonight. Tomorrow night we'll have extended excerpts from First Lady Hillary Rodham Clinton's Senate Committee testimony on health care and the Lebanese view of the Middle East peace process. I'm Robert MacNeil. Good night.