The MacNeil/Lehrer NewsHour

MR. MacNeil: Good evening. I'm Robert MacNeil in New York.

MR. LEHRER: And I'm Jim Lehrer in Washington. After our summary of the news this Thursday, we examine President Bush's health insurance plan announced today, Fred De Sam Lazaro reports financially strapped trauma centers, Presidential Candidate Bill Clinton delivers a stump speech, and essayist Jim Fisher talks about hard times. NEWS SUMMARY

MR. MacNeil: President Bush offered a prescription for the ailing health care delivery system today. He unveiled his long awaited proposal for what he described as comprehensive market- based reforms. The plan offers tax credits and reductions to help lower and middle income Americans buy health insurance. It would cost $100 billion in the first five years. Mr. Bush explained the principles behind it in a speech to the Cleveland, Ohio Growth Association.

PRES. BUSH: My plan puts the emphasis on expanding access while preserving the choice people now have over the type of health care coverage and health care they receive. My plan will give Americans a greater sense of security, changing the system to ensure people that they'll always have access to health insurance no matter where they work. And finally my plan will cut costs. It helps us make health insurance more affordable and more affordable means more accessible. And my plan will preserve what works and reform what doesn't. And above all, it will ensure every American universal access to affordable health insurance.

MR. MacNeil: Mr. Bush condemned other proposals which he said would create a new government bureaucracy to administer health care. He criticized a Democratic proposal called "Play Or Pay," which requires employers to provide insurance or pay into a national fund. He said that was a back door route to nationalization, but Democratic lawmakers had equally strong words for the President's plan.

SEN. TOM DASCHLE, [D] South Dakota: I can't believe that we've waited this long for this little. If this were the final test on controlling costs, I think that George Bush deserves an "F." It is the most expensive bandaid ever offered to the American people.

SEN. JAY ROCKEFELLER, [D] West Virginia: The actions that the President outlined today are at best hesitant and tentative, at worst they are deliberate subterfuge. They will not get coverage for tens of millions of un- or under-insured Americans. They will not lessen the anxiety of those who may lose their insurance at any time and they won't lower our health care costs. Indeed, they'll increase them.

REP. DAVID BONIOR, [D] Michigan: There's nothing in the plan that the President suggests that deals with taking care of our parents and our grandparents and long-term care. It's totally inadequate. It's deficient.

MR. MacNeil: We'll have more on the story right after the News Summary. The infant mortality rate in the United States fell to its lowest level ever in 1989. But this country remained well behind other developed nations and continued to slip. The Centers For Disease Control said the U.S. rate was 9.8 deaths by age one for every one thousand live births. The CDC said black babies in the United States are more than twice as likely to die as whites. They said prenatal care was the most important factor in reducing deaths. Jim.

MR. LEHRER: Sixteen people were killed today when a military plane crashed into a restaurant and motel in Evansville, Indiana. The C-130 transport was performing touch and go training maneuvers at a nearby airport when it crashed. All five crew members and eleven people on the ground were killed. At least 11 others were injured. Witnesses said the plane's wing clipped the side of the motel. It exploded into a fireball, with flames shooting fifty to sixty feet into the air. The aircraft was from a National Guard unit in Louisville, Kentucky.

MR. MacNeil: The Commerce Department reported orders to the nation's factories fell in December after three monthly increases. The 3.8 percent drop was the steepest in more than a year. For all of 1991, orders fell 2.6 percent, the biggest decline since the 1982 recession. Chrysler Corporation reported it lost $30 million in the fourth quarter and 665 million for all of 1991. GM and Ford report their results later this month. Analysts predict losses for the big three of nearly $7 billion. The Internal Revenue Service today admitted it goofed and many banks around the country could pay for the mistake. The IRS said it erroneously told 36,000 taxpayers filing electronic returns they were getting refunds estimated to total $40 million. Many people use that information to borrow from a bank until the refund is made. The IRS then sends the refund directly to the bank. The agency apologized for the mistake but said it was not a party to such loans.

MR. LEHRER: A bomb exploded in Madrid, Spain today, killing five people. Four of them were soldiers. Officials blamed the attack on a Basque separatist group known by the acronym ETA. We have a report narrated by Louise Bates of Worldwide Television News.

MS. BATES: According to Spanish police, Basque separatists used a remote control device to detonate 88 pounds of explosive packed into a stolen car. The four soldiers and the civilian traveling in an army minibus caught the whole impact of the blast. It left many in the area shocked and dazed. The bomb exploded during the Connecticut morning rush hour when the center of Madrid was bound to be at its busiest. Seven innocent bystanders were injured, one of them seriously. The attack has drawn unprecedented condemnation from the Spanish government which said it won't be blackmailed by ETA's violent campaign. The bombing comes at a sensitive time. Madrid is currently the cultural capital of Europe. In the summer, Barcelona hosts the Olympics and Expo '92 takes place in Seville. Thousands of visitors are expected to flock into the country but already this year ETA attacks have killed 10 people. The Basques are demanding a separate, independent homeland, a cause that's cost 700 lives since ETA took up arms 24 years ago.

MR. LEHRER: A bomb also exploded in Northern Ireland. It happened at a bus depot in a mostly Catholic part of Belfast. One person was injured. There was no immediate claim of responsibility. It came one day after Protestant extremists killed five Catholics in a Belfast betting parlor. And that's it for the News Summary tonight. Now it's on to the Bush health care plan, problems for emergency trauma centers, a Clinton stump speech and a Jim Fisher essay.

MR. LEHRER: The President's health reform proposal is our lead story tonight. It aims to provide health coverage for 37 million uninsured Americans and to cut overall health costs. At the heart of the proposal are vouchers to poor families and tax breaks to middle class families for buying insurance. The plan drew immediate fire from Democrats and others who want a complete overhaul of the system. That debate follows this backgrounder on the President's plan by Kwame Holman. FOCUS - CURE OR COMPLICATION?

MR. HOLMAN: The President laid out his plan this morning in Cleveland. He described it as much needed, comprehensive health care reform that builds on the strength of the existing system.

PRES. BUSH: Reform is urgent for more reasons than one. Right now, far too many Americans are uninsured and those who are insured pay too much for health care. And we are going to do something about that.

MR. HOLMAN: The President's plan has four points.

PRES. BUSH: Point 1, we will make health care more accessible by making health insurance more affordable.

MR. HOLMAN: To create that accessibility, the President would provide tax credits or vouchers so that low income people could purchase health insurance. They would be worth $1250 a year for individuals, $2500 for couples, and $3,750 for families. The middle income uninsured would get tax deductions to help them buy health coverage. Self-employed people could deduct all the money they spend on health insurance.

PRES. BUSH: Point 2, we will cut the runaway costs of health care by making the system more efficient. Today I'm asking you to learn a new acronym, HIN, Health Insurance Networks.

MR. HOLMAN: The President says costs would be cut by such networks, companies would pool employee health plans, allowing them to purchase health insurance at lower cost than individual companies can.

PRES. BUSH: Point 3, we will wring out waste and excess in the present system.

MR. HOLMAN: According to the President, administrative reforms can substantially reduce the nation's health bill. His plan includes limiting the size of damage awards patients and their families receive from medical malpractice lawsuits, and urging the health insurance industry to simplify their forms and speed up the processing of health insurance claims.

PRES. BUSH: Fourth, and finally, we will get the growth in government health programs under control. Right now, government health care programs can claim a dubious distinction. They are the fastest growing parts in the federal budget.

MR. HOLMAN: The President's plan would be paid for in large part by capping spending increases in Medicaid and Medicare programs which already provide coverage for 74 million poor and elderly Americans. In Washington this afternoon, the advocacy group Families USA took particularly strong exception to that proposal to limit the reach of Medicaid and Medicare coverage.

RON POLLACK, Families USA: More and more doctors and hospitals are going to shut their doors to senior citizens, the disabled, and the poor because the amount of money they receive to treat them will be very low in comparison to what they receive from other payers. Second point, as Medicare and Medicaid ratchets down the amounts of money that will be paid to physicians and to hospitals, we are going to see an enormous cost shift onto the backs of middle income families. Doctors and hospitals are going to make up for the losses of income that they would otherwise be experiencing under Medicare and Medicaid by shifting costs onto the backs of other payers.

MR. HOLMAN: In his speech, the President seemed to anticipate such criticism. He defended his plan as providing the best access short of nationalized health insurance, which he strongly opposes.

PRES. BUSH: We don't need to put government between patients and their doctors. We don't need to create another wasteful federal bureaucracy. As President, I simply will not let that happen. We need common sense, comprehensive health care reform. And we need it now. And my plan I really believe is the right plan, a plan that meets our obligation to all Americans by putting hope and health within their reach.

MR. MacNeil: Joining us now to discuss the new plan are Kevin Moley, Assistant Secretary of Health & Human Services for Management & Budget, and Democratic Congressman Richard Gephardt of Missouri, and House Majority Leader. We also get reaction from two health care reform advocates with different views on what needs to be done. Stewart Butler is the director of domestic policy at the Heritage Foundation. Paul Starr is a Princeton University professor of sociology and the author of a Pulitzer Prize winning book titled "The Social Transformation of American Medicine." Sec. Moley, let's take a few of these issues, main problems in the health care system one at a time, so we can understand this. The uninsured, if you are one of the 35 million or so uninsured Americans, how do you get insurance under this plan?

SEC. MOLEY: Robin, 25 million Americans, most of whom are poor, will get a tax credit of $1250 a person, $3750 a family to pay for health insurance that they don't currently have. That goes a long way towards providing accessible, affordable health insurance that the President has talked about for our low income population.

MR. MacNeil: What if they don't pay any taxes?

SEC. MOLEY: Well, in fact, that's not a problem. This is going to operate as a voucher or certificate providing them with the ability to purchase that accessible and affordable health insurance made available at a state level through the state insurance commissioners providing a plan that will be basic health insurance, they will no longer be without health insurance; they will no longer have that insecurity of not having health care coverage for themselves and their families.

MR. MacNeil: So each state will set up a basic health care plan which a poor person can take his $3750 voucher, if he has a family, and buy a year's health insurance with it, is that right?

SEC. MOLEY: That's absolutely correct. We will make them available six months at a time. They'll have access to the system. And for the first time those people, Robin, will be coming in the front door of our health care system, much less expensive, being provided with preventive and primary care, than through the back door, the emergency room where they're currently coming for care, which is far more expensive and is a drain on the entire system.

MR. MacNeil: What kind of care will they get for that price and how will it compare with the Medicaid, with Medicaid now?

SEC. MOLEY: Well, in fact, we have at least seven examples in our, the President's White Paper of the kinds of plans that our actuaries and consultation with private actuaries have determined to be available. We expect that the marketplace will be able to provide these plans and they'll provide the kind of primary preventive care that all Americans should have and do need.

MR. MacNeil: For instance, we just heard the latest statistics on infant mortality. Is this the kind of system that would provide poor people like poor black women with adequate prenatal care?

SEC. MOLEY: Absolutely. And we have some examples already of case management, which is part of the coordinated care effort but is also part of the President's proposal dramatically decreasing infant mortality. For instance, in the state of Alabama, which is using case management for neonatal, prenatal care, we have had dramatic gains in the reduction of infant mortality, expect to have more so under the President's proposal.

MR. MacNeil: Congressman Gephardt, does that solve the problem of the uninsured?

REP. GEPHARDT: Well, I don't think it does and it doesn't solve the other major problem we have, which is the cost of this system.

MR. MacNeil: I'm going to come back to the cost question in a moment, but just what's wrong with what the President has proposed to insure the uninsured?

REP. GEPHARDT: Well, I think two things. First if we don't deal with cost, then everyone will be affected negatively. For instance, today for a family health care cost is at about $6,000 or even $6,500 a year, so a credit for $3750 for a family is hardly sufficient to be able to find a policy that would cover people and deal with their problems. Secondly, the President is proposing to pay for it by capping Medicaid and cutting Medicare benefits so we're going to be pushing in on one part of the balloon, trying to solve the problem for other people, and we're not even solving their problem. So I think it's a deficient proposal. It isn't going to help these families sufficiently and we're going to be asking other people who are already negatively affected to pay for these benefits for the people that do not have insurance today.

MR. MacNeil: Mr. Butler, does this solve the problem of the uninsured, which is the sort of most outstanding problem in the health care system?

MR. BUTLER: I think it's a big step in the right direction because the core problem of the uninsured are people who don't have company-based coverage or they move jobs and lose their benefits at one place and don't get them somewhere else. This solves that problem by giving them the kind of help either through a credit or a tax deduction that people have when they have company-based plans, so they'd be able to buy coverage and keep that same coverage when they move from place to place. It's important to understand that among the uninsured about 3/4 of the uninsured are working people or are dependents of working people. They don't have coverage because they work for a small firm, for example. This allows these people to buy into the kind of plan that typically people who do have company-based plans would have so I think it's a big step and it'll solve a lot of the problem.

MR. MacNeil: Is it a big step towards solving it, Mr. Starr?

MR. STARR: I really don't think so. Today we saw George Bush, the insurance salesman in Cleveland, and Robin, if you bought a policy from him today, you'd be on the phone with the Better Business Bureau tomorrow. I think a lot of people aren't really hearing what is going to be made available under this program. For people over the poverty line, it is a tax deduction, not a credit, and that deduction is worth for someone, for an individual in the 15 percent bracket $187 a year.

MR. MacNeil: Could we come back to those people in a moment? So we understand this, the uninsured people, people that have none which is the great scandal of American health coverage at the moment. Does this solve that problem by setting up the state system? Well, you just heard the description.

MR. STARR: I think it's just about the worst possible way to provide health coverage for them. Many of these people, most of them, are going to have to buy individual insurance policies and of every dollar that goes into an individual insurance premium, about 40 cents gets soaked up by administrative costs. So for every dollar they take out of Medicare and Medicaid to finance this program, 40 cents are going to be used up by administration in health insurance. This is the most wasteful, most inefficient way to buy health coverage known to man. It is, it is not a solution. Also, if we had had this program in place from the beginning of the Bush administration, it would have had to increase in cost by over 60 percent to keep up with health insurance premiums. But, of course, it probably wouldn't have increased to keep up with health insurance premiums and so people who had depended on it to buy health insurance would find themselves priced out of the market.

MR. MacNeil: Sec. Moley, back to the point Mr. Starr's just made, that this is the most wasteful way to buy health insurance because most of these poor people will have to buy individual policies and 40 cents on their dollar will go to administration?

SEC. MOLEY: Well, I can only wish that Paul had read the proposal. The fact of the matter is he's dead wrong. We are proposing to set up statewide pools, the most efficient way of providing health insurance, the least expensive, for these people under the poverty line. We think it's a very effective way. We've priced it out. We've gone to a lot of trouble to assure that we will be able to provide accessible, affordable health insurance to all Americans at or below the poverty line. We've looked at it; we've looked at it long and hard. Paul is just wrong on this point. As far as Congressman Gephardt goes, the fact is we are not capping Medicaid and we are not cutting Medicare benefits. This President wouldn't do it; he won't do it.

MR. MacNeil: Well, come back --

SEC. MOLEY: Maybe the Democrats will.

MR. MacNeil: Come back to that question in a moment. Just let's move on to the second point. How does this help people who havehad insurance but have been dropped from insurance, employed people, middle class people, this is one of the other great cries in the present system, who've had good insurance but they get dropped, or they can't buy insurance because they have a particular illness, how does this plan help them?

SEC. MOLEY: Well, we are going to eliminate the insecurity that comes from that problem, Robin. We are going to eliminate the problems of medical underwriting. We are no longer going to permit the insurance industry to pick and choose who they want to insure and who they don't. That's not what real insurance is all about. We are going to have insurance in this country that has everyone in that risk pool, the healthy, the unhealthy, the young, the old.

MR. MacNeil: You mean --

SEC. MOLEY: No longer are we going to permit medical underwriting to determine who should be covered and who can't be covered.

MR. MacNeil: You mean if you're in the insurance business, medical insurance business, you have to be willing to take anybody, whatever the risk?

SEC. MOLEY: That is going to be true under the President's proposal when enacted. And we are looking forward to the day. That is why we're calling this a bold and comprehensive approach.

MR. MacNeil: Is that a big improvement?

MR. STARR: Well, as I understand the plan, they are not eliminating what's called experience rating. They are imposing certain limitations on it, but they still provide opportunities for insurance companies to set rates according to the specific risks of employee groups.

MR. MacNeil: So if you had a higher risk, you pay a higher premium?

MR. STARR: Yes, and they have emphasized the idea of these new health insurance networks to bring small employers together, but those networks, themselves, have an interest in keeping unhealthy people out to keep their own rates down.

MR. MacNeil: Mr. Secretary.

SEC. MOLEY: We're going to limit the ability for insurance companies to increase rates. There have been several proposals on Capitol Hill. I can say we have borrowed from them, including Sen. Bentsen's bill, S1832, which has wide support on both sides of the aisle in order to, to create a circumstance where companies can maintain their insurance and are not faced by exorbitant rate increases.

MR. MacNeil: Yeah. Mr. Gephardt, how do you view that provision?

REP. GEPHARDT: I think it's insufficient. I think it is a little step in the right direction to try to make sure that people aren't dropped because they get very sick or that people who have an illness can get into a policy. But it is not experience rating, as Mr. Starr said, and therefore it won't solve the problem. I think the larger problem here is that this proposal does nothing to deal with the most important and fundamental challenge that we face and that is the problem of runaway costs. 1980 the costs of a family policy was about $2500. Today it's $6500. Dick Darman, the head of the Office of Management & Budget, has said by the year 2000 it'll be $14,000 a family. We have to deal with this problem of cost in a comprehensive way. We have to set a budget in this country for how much costs are going to be, and then we have to get physicians and hospitals and other suppliers of health care to negotiate how those costs are going to be allocated with the consumers of health care. The President's proposal does nothing in that are and that's why it's fundamentally deficient.

MR. MacNeil: Sec. Moley, it does nothing to control costs?

SEC. MOLEY: Well, I would ask the Congressman to read the 38 pages in the White Paper that it had voted to cost containment and controlling costs across-the-board, most particularly in our public system.

MR. MacNeil: Well, tell us very clearly what the plan does do to control costs.

SEC. MOLEY: Well, for instance, in Medicaid, where costs are as the Congressman indicated running out of control, 38 percent increase a year from last year to this year, as the President said today in Cleveland. We would suggest, recommend that the entire Medicaid program be in a capitated, coordinated care system. It's far better than the kind of care that is being received by Medicaid recipients today, when they're going to storefront, walk up, a fee for service, Medicaid mills, they'd be far better off in a managed care, coordinated care system. Medicare is available. The State of Arizona has proved it. The City of Philadelphia has proved it. The State of New York and the State of California are already moving in that direction. That's what the President's plan proposes. That's what we would like to enact.

MR. MacNeil: Congressman Gephardt.

REP. GEPHARDT: The problem with that is that as you tamp down on costs in one part of the system, say Medicaid or Medicare, what happens is the providers of health care try to pick up those lost costs on other people in the system. And so it's like a balloon. You push in in one place and it pops out somewhere else. It is not a solution to the problem. We've been through this debate now for a long time and I think anyone who has looked at what's happened in this market over the last 10 and 12 years, you have to conclude that as in the German system and other systems you finally have to set a limit beyond which health care costs will not go and get the providers and the consumers to negotiate out how those moneys will be spent. If we don't do that, don't face that fundamental decision, we will simply wind up spending a trillion and a half dollars by the year 2000 on health care.

MR. MacNeil: Mr. Butler, do you think this plan seriously addresses the runaway cost problem?

MR. BUTLER: I think it is a big step in the right direction because Congressman Gephardt has mentioned one way of trying to contain costs. That's to say we'll set a fixed budget or we'll clamp down on fees as we do in Medicare, for example. One result of that is that people get less care. Canadians come over here because of fixed budgets in Canada. I lived in Britain for 30 years. We have waiting lines in Britain. The other way is to introduce incentives for people to quite frankly shop around for the best deal in coverage. Now one thing, irony is that for federal workers, for Congressman Gephardt and his staff and Mr. Moley here and many others, they have the right every year to shop around for the plan that they think is best and they get a certain amount of government help towards that. The effect on costs is dramatic.

MR. MacNeil: But does this plan open those kind of incentives?

MR. BUTLER: Yes, it does, because essentially it allows individuals who have a credit or a deduction to look for a plan that they think, not the government, that they think is the best value for money. That is what federal workers do and typically, federal workers turn to managed care, they turn to union-sponsored plans. And I think we see the opportunity under this proposal for that kind of thing to be available not just for federal workers and for Congressmen, but for all Americans. And I think the record of bringing the cost down under that system is far better than the private system or other public systems.

MR. MacNeil: Do you see those incentives in this system that will really motivate people to go and look for more economical care?

MR. STARR: Well, I think providing for choice is a good thing in and of itself and we should look and the public proposals, the proposals that the Democrats are advocating, to provide for more choice. But I think it's a mistake to expect that these multiple choice arrangements will really generate the kinds of cost savings that we need. And one of the reasons for that is that it is easier for health plans to save money by seeking the best risks, by designing benefit packages that attract healthier people than it is to produce health care more efficiently. And what we have seen over time in the case of employers that have provided multiple choice is that the results overall have been very disappointing. There are examples of plans, particularly HMOs, that do provide health care more efficiently, but when you look at the whole picture and look at the many different so-called "managed care" plans that are now on the market, the results are disappointing.

MR. MacNeil: Sec. Moley, on paying for this, you said a moment ago it was wrong to say that President Bush would ever be cutting Medicare or Medicaid. Yet, that is how reducing the increase or something, taking money from Medicare and Medicaid is how you're going to pay the $35 million a year that this plan, if fully implemented, would cost, is it not?

SEC. MOLEY: No, it isn't, Robin. And let me be clear here. The fact is what the President is saying and what we're saying is we are not going to cut Medicare benefits, nor Medicaid benefits.

MR. MacNeil: But the money's coming from Medicare and Medicaid.

SEC. MOLEY: Some money may come from Medicare and Medicaid, and let me tell you how. Currently we make payments to hospitals under Medicare for our elderly on behalf of those hospitals that are paying for uncompensated care, people who are coming to their emergency rooms now, costing us tens of thousands of dollars, cumulatively billions of dollars, to the system, because they come to the emergency room door too late and too sick, and what we need to do and what the President is proposing to do is to provide those people with an insurance plan, $1250 an individual, $3750 a family. They will no longer be coming to the emergency room door without compensation to the hospital and those kind of patients to Medicare we clearly could reduce with absolutely no effect on benefits to Medicare beneficiaries.

MR. MacNeil: Congressman Gephardt.

REP. GEPHARDT: Well, I think there's some misleading advertising going on here. They say it pays for itself and it will all work. What if all the people that we anticipate are going to take these credits or deductions don't take them, aren't able to find the policies at that price, still show up in these emergency rooms and they're still cost shifting to the Medicare program, which I anticipate there will be? I think what you're really looking at here is what the Reagan and Bush administrations have done through the years and that's every time we need to find money in the budget, we cut Medicaid, they suggest we cut Medicare in order to take care of something else that's needed to be done in the system. It won't work, it's false advertising and I think we're going to wind up with a system, if we did this system, where we're once again cutting back on programs that have already been cut each and every year.

MR. MacNeil: Sec. Moley, come back to the cost control for a moment. It's been widely stated by people like GM and Chrysler that health care costs add about five or six hundred dollars to the cost of an American car. Is that going to go down to this plan? And explain how if it is.

SEC. MOLEY: I don't think necessarily it's going to go down, Robin, but I do think that the rate of increase can be sharply curtailed. We spend over $800 billion in our health care system, more per capita than any other nation on earth. There are certain inefficiencies, I might say in some areas gross inefficiencies, that need to be controlled. We need to look at the health care system in the same way many have looked at the Defense Department's budget in past years and see what excess administrative costs, unnecessary procedures can be eliminated from the system. We certainly believe that $35 billion, which is what the President's tax deduction and tax credit would cost when fully implemented, can be found in that $800 billion system. We've got 38 pages in the White Paper which give specific examples of how we can do that. Medical malpractice, $20 billion in defensive medicine a year is being spent not for the benefit of people in America, but to provide doctors cover from potential liability suits for medical malpractice. That has to be eliminated, it will be eliminated under the President's proposal.

MR. STARR: There really is nothing in the President's proposal that can reduce defensive medicine, but also we don't have any reliable estimates of the magnitude of defensive medicine. It's very hard to separate what defensive medicine is from --

MR. MacNeil: You mean whether the doctor orders a procedure to cover his behind, or whether he orders it for good medical reasons or whether he orders it to make money?

MR. STARR: Right. In fact, that's exactly the point. I think we all have to remember that the procedures that are called defensive medical procedures generate revenues for doctors and hospitals. They're not losses. And so what you have to ask yourself is this. Suppose tomorrow patients had no right at all to sue for medical malpractice. By how many billions of dollars would doctors and hospitals voluntarily reduce their revenues? Apparently, Sec. Moley thinks they'd cut their revenues by 20 to 30 billion dollars. I think that's a remarkable theory.

MR. MacNeil: I just want to ask Mr. Butler as we go around finally here, does this deserve the title "comprehensive health care reform?"

MR. BUTLER: Well, not exactly because I think one of the elements that is missing is really, in fact, addressing the escalating costs in those companies like Chrysler and GM that have coverage. The problem in those companies is that people have the illusion that somehow this is, the workers, themselves, that this is free care, it's the companies paying and so forth, so why should they economize. One of the advantages of, in fact, a more comprehensive proposal that would encourage and allow people to choose to get a plan separate from their place of work and take the money that they now have in health benefits at the place of work and use a portion of that to buy a better value for money plan somewhere else. If that was included in the proposal, then the people of GM and Chrysler would be finding a lot of their workers saying, I don't want $10,000 worth of coverage, I want a good lean plan, maybe five, six thousand dollars, I'll take the rest in cash, I'll shop around, and I will, in fact, force the hospitals to bring down costs by shopping around against those that don't --

MR. MacNeil: On that altruistic note, I think we'll leave it this evening. Thank you, gentlemen all. FOCUS - EMERGENCY

MR. LEHRER: There are all kinds of casualties of the health insurance crisis. One of them is the trauma center, the state of the art emergency hospital. Some 150,000 Americans are killed and another 80,000 maimed each year in accidents. Many of them taken to trauma centers have no insurance to cover their treatment, leaving some facilities struggling to survive. Fred De Sam Lazaro of public station KTCA-St. Paul-Minneapolis reports about a night at such a hospital in Detroit. Be forewarned that some of the pictures in the report are grisly and may be too much for some viewers.

MEDIC: 50 year old male stabbed in the left chest and the left arm.

HEALTH CARE WORKER: Any vitals at the scene?

MEDIC: No vitals.

MR. LAZARO: The report from incoming medics offered little hope for saving this patient, two deep stab wounds, no vital signs for at least 10 minutes, and a lot of lost blood.

EMERGENCY HEALTH CARE WORKER: Let's go for it.

MR. LAZARO: But go for it is the motto at Detroit Receiving Hospital. As a trauma center, it seems to almost specialize in patients with little hope. This beehive of MDs and technicians launched quickly into the patient's chest cavity, trying to resuscitate a heart barely beating. [TEAM WORKING ON VICTIM OF STABBING]

MR. LAZARO: Unlike typical emergency rooms, trauma centers have surgeons and other medical experts on hand, not just on call, 24 hours a day. Studies show this ability to take a patient from injury to surgery within minutes prevents death or serious disability in many cases. [TEAM WORKING ON VICTIM OF STABBING]

MR. LAZARO: This patient could not be revived. Thirty minutes of the very best emergency care ended only with a several thousand dollar medical bill and what's worrying hospital officials increasingly is there's a one in three chance that bill will never be paid.

LES BOWMAN, Hospital Administrator: The uncompensated care has been increasing significantly from maybe five years ago it was around $10 million uncompensated care to now it's $32 million.

MR. LAZARO: Administrator Les Bowman cites the major reason for the problem, a growing number of patients are not covered by any insurance and many of these belong to what doctors call "the knife and gun club."

DR. LEDGERWOOD: [talking to patient] I'm Dr. Ledgerwood. Tell me what happened to you.

MR. LAZARO: They are casualties in the city's raging drug wars. Their injuries are often severe, requiring extensive care by surgeons like Anna Ledgerwood.

DR. LEDGERWOOD: [examining patient] Does that hurt you?

PATIENT: Not there.

DR. LEDGERWOOD: [examining patient] Here?

PATIENT: No.

DR. LEDGERWOOD: [examining patient] Here?

MR. LAZARO: This young man was stabbed in the abdomen by a man he called his best friend. Unsure if the wound penetrated his stomach or other surrounding organs, Dr. Ledgerwood ordered him prepped for surgery.

DR. LEDGERWOOD: [talking to patient] Do you take any medicines? Does your doctor have you on any medicines?

PATIENT: No.

DR. LEDGERWOOD: Do you take drugs?

PATIENT: Yes.

DR. LEDGERWOOD: Cocaine?

PATIENT: Yes, I did.

DR. LEDGERWOOD: When's the last time you snorted cocaine?

PATIENT: Yesterday.

DR. LEDGERWOOD: Yesterday?

MR. LAZARO: It took about a half hour of exploration for Dr. Ledgerwood and her assistants to determine the patient was in the clear.

DR. ANNA LEDGERWOOD, Surgeon: And we looked at the large intestine there, we took it down and looked at all sides of it, and he never made a hole in it with the knife, and the small intestines are okayand the spleen is okay, so that's all we get to do. Pick up for me. This patient isn't going to be quite prepared for the discomfort he's going to have. Makes our job a little more difficult.

MR. LAZARO: As the patient endured the pain of his convalescence, Receiving Hospital likely absorbed its cost. An average trauma center admission costs $12,000, not counting the surgeon's fee. In this case, Dr. Ledgerwood, herself, was not counting on collecting her fee.

DR. ANNA LEDGERWOOD, Surgeon: I don't get paid for it; the hospital doesn't. No one pays me to stay here tonight.

MR. LAZARO: This hemorrhage of red ink is placing severe strains on Detroit Receiving and other trauma centers. Already 60 such facilities have gone out of business in the last six years, most in big cities. Trauma centers were established about two decades ago, most in the middle of urban population centers to be close and accessible to victims of trauma. But over the years, the neighborhood surrounding many of them have become drug blighted, violent, and impoverished.

DR. BROOKS BOCK, Medical Director: We have a population in this country of something in the range of 37 million people who are uninsured. At times, it seems like the majority of them live in the center city of Detroit.

MR. LAZARO: Receiving's Medical Director, Dr. Brooks Bock, says one of his biggest challenges is asking the staff to share in the hospital's financial woes. That's more easily done with higher paid professionals like Dr. Ledgerwood.

DR. LEDGERWOOD: I couldn't do this and not do anything else. I have other areas of my practice which allow me to pay for my overhead, my insurance, my billing. It's a job that needs to be done. Somebody needs to do it. I find it challenging. I find it very rewarding when patients do well and they leave.

MR. LAZARO: But nurses and other staff members say they can't afford to be so altruistic. Nursing Supervisor Rick Styz says for many the biggest reward for service here is a less dangerous, better paying job elsewhere.

RICK STYZ, Nursing Supervisor: If you have the Detroit Receiving name on your resume, people will, you know, they'll look at you twice because if you can work here, you can work anywhere.

DR. BOCK: If I were to look at our nursing budget right now, I think we have something in the range of 35 registered nurse positions; we're not able to fill them because we can't get the people to come to work for what we are able to pay them and the difficult conditions under which they work. [EMERGENCY VICTIM BEING BROUGHT INTO HOSPITAL]

MR. LAZARO: So far, there's little evidence the difficult conditions are affecting patient care. Detroit Receiving continues to serve some of the most severely injured patients in Southeastern Michigan. But with one of its every three bills going unpaid, hospital officials say it's only a matter of time before the quality of care will be compromised or worse, the hospital will have to close.

MR. MacNeil: Still ahead on the NewsHour, Gov. Clinton on the stump and essayist Jim Fisher on hard times. SERIES - '92 - MAKING HIS CASE

MR. LEHRER: Next, another in our series of extended excerpts from stump speeches of Presidential candidates. Tonight the speaker is Gov. Bill Clinton, Democrat of Arkansas. It is from his speech yesterday at Concord High School in Concord, New Hampshire.

GOV. BILL CLINTON, Democratic Presidential Candidate: I want to begin by saying that when the President was here a few days ago making his first trip to New Hampshire since, well, since forever, I guess, since you madehim President, he made a lot of interesting comments and little slogans that appeared to have been prepared for him by his advisers, things like "I care," and "Don't cry for me, Argentina." But I listened then and I've listened since and I listened to the State of the Union message. And I still haven't heard the awareness of a leader of the real conditions of this country. I come here to you from a long way away, having worked for 11 years at the real problems Americans face today. How do you get and keep good jobs? How do you educate people in a global environment in which what you earn depends on what you can learn? How do you provide health care and solve social problems? How do you bring people together, instead of letting them drift apart? How can people actually band together over a long period of time and make progress and solve their problems? These are the issues that are at the core of this election. I've done my best to put out a plan for America's future that deals not only with the short-term issues which are important but with the long-term, profoundly significant problems this country faces, including how do we have an economic policy that generates over a long period of time greater investment, greater cooperation between business and labor and government, greater competitive capacity in this economy to generate high wage, high growth jobs? How do we develop a system in which every American can have access to educational opportunities for a lifetime? How do we develop a system of affordable health care for all Americans which includes long-term care for the elderly and the disabled and which emphasizes more primary and preventive care so that we can be a healthier country at less cost? How do we have an environmental policy and an energy policy which not only preserves the environment but enhances our economy? These are the things that I have tried to talk about. And I think that they are central to your future. Those of you who are students here today have more riding on this election than I do, or than people of my generation do. For it is literally true that we are at risk of raising the first generation of Americans to do worse than their parents. That has never happened before. For 10 years a majority of Americans have worked harder for lower incomes and paid more for the necessities of life and felt greater insecurity. I have heard no more moving stories of the insecurity of American working families than the stories I've heard from the students of New Hampshire, telling me what it's like to go home at night to parents who've been out of work for a long time, parents who can't get health insurance coverage, parents whose businesses have failed with no help and no plan to do better. Every great nation in the world we are living in and the world you will grow up in must put people first. If you look at the nations that do well, they develop the capacities of their people and they make them as secure as they possibly can in their schooling and in their work and in their health care so they can deal with the rapid change of the world you're living in. We ought to have, in my opinion, preschool education in kindergarten for every child in this country who needs it, every child. We ought to have a national system of standards for what all our students should know and a meaningful examination system to test whether we're learning what we need to know for all students in the country. We ought to have a system of apprenticeships, comprehensive quality vocational programs for young people who do not want to go to college but who don't want to be in dead end jobs. The most stunning economic development of the 1980s perhaps was the sharply declining incomes of younger workers who had high school diplomas. At the end of the decade, a 25-year-old with a high school diploma was earning about 20 percent less than a high school graduate was at the beginning of the decade. That is a stunning, dramatic change. It's literally stripped the dignity out of blue collar work for millions of Americans. The reason that happened is that the world we live in -- I will say again -- pays people based on not only what they know but what they're capable of learning. Skill level is critical to value, to adding value to labor in our country. And what I have proposed to do is through a federal-state partnership set up training programs in all of our schools which will give people the opportunity to go to work for employers who will hire them when they get out of high school and who will also continue their training for two years after high school with help from government sources. All of our competitors, all of our competitors have a system for training high school graduates at higher skill levels. We don't. The next thing we need to do, in my opinion, is to make college education affordable for all Americans. The dropout rate from college is more than twice the high school dropout rate. That's a stunning statistic. And there are two reasons. One is too many people go to college without having taken the recommended preparatory courses. The second is too many people can't afford to stay. I have proposed trying to reverse the trend of the last 12 years where the national government has basically done everything it could to reduce the amount of aid going to middle class families. Instead, what I want to do is to scrap the present student loan program, which is costing us over $3 1/2 billion this year in unpaid loans and transaction costs, do away with that, and substitute for it a national service trust fund out of which any American can borrow the money to go to college, any of you, no questions asked, no income limitations. You would pay it back in one of two ways, either as a small percentage of your income over time, or with two years of service to your country here at home as a nurse, as a teacher, as a police officer, as a family service worker, doing something that is needed done here in Concord. Just think about it. If everybody here borrowed the money to go to college and paid it back with two years of service to this community think what you could do. The final thing I think we need to do is this. We need to have a workplace training program that guarantees that in the next five years everybody with a job in America learns to read at a high school level, everybody has a chance to get a GED, and then everybody has a chance to get constantly retrained throughout a lifetime. Now, this is a very important issue. In the United States today corporations spend over $200 billion a year training their employees. But in the U.S., 70 percent of the money is spent on the top 10 percent of the employees. In all of our competing nations, they spend the money up and down the line, they spend as much money on the front line workers because they know that's where the money is made. So I have proposed a system in which every company over a certain size could get a significant deduction for training its employees up and down the line, but if they don't spend at least one to one and a half percent of payroll training the employees uniformly, they will pay the difference into a training fund and the government would pay for it. Now, we can have all the economic policies in the world and if we don't put people first, if we don't lift up the capacities of all of you in this room and make a commitment to a lifetime system of education and training, we cannot recover our economic leadership, we cannot go back to an economy where incomes grow, where poverty declines, where the middle class expands and this country begins to live up to its potential again. So if there is any special contribution I have to make to this Presidential campaign, it may be that having worked for 11 years in these areas, I know how important education and training is, I've got a lifetime commitment to it, and I've outlined by far the most detailed program to achieve the kind of system we need in America so that you never have to worry about being part of the first generation of Americans to do worse than their parents. Instead, as the first generation of Americans to be adults in the post cold war era, you will have the most exciting life of any group of Americans in the whole history of our country. Thank you very much. [applause]

MR. LEHRER: That was Gov. Bill Clinton of Arkansas. Tomorrow night we'll hear a speech by Sen. Tom Harkin of Iowa. FOCUS - HARD TIMES

MR. MacNeil: Finally tonight essayist Jim Fisher of the Kansas City Star looks at the recession through Midwestern eyes.

MR. FISHER: The words coming just before Christmas were riveted. GM, said its chairman, Robert Stemple, had news.

ROBERT STEMPLE: Despite the many steps we've taken throughout the year to improve our competitive situation, business conditions are not improving and we don't see significant change in the near future.

MR. FISHER: After Stemple came the video tape, workers leaving factories that might close, acres of unsold cars, empty new car showrooms. The free fall of one America's most powerful corporations half its size was added to the continuing recession, the paralysis of Washington, the layoffs of blue and white collar workers. Welcome to hard times. So why here in the middle of the country did a lot of people shake their heads, maybe shrug and go on about their business? Easy. We have been there. In fact, we're still there. In a lot of cases what the pundits and experts have been describing as the bleak future of this country has been roosting out here for nigh on a decade. Remember the 1980s, padlocked steel mills, banks that were belly up as far back as '85 and '86, the wave of car plants closed by the big three when they conceded the low end of the market to the imports, and farm auctions, ending not only a job but a way of life, and leaving all across the Midwest empty farmsteads, and that so-called backbone of America, the rural small town, looking like this. Recession out here is not a new word. Seventy-four thousand GM workers. How about 2.2 million people gone from their farms between 1980 and 1989, and gone too from the American consciousness? That recession scourged the Midwest. The Midwest in 1992 is a far different place than it was ten or twelve years ago and throughout those years when living between the coasts is like living in another, less affluent country. We watched and listened and read how a Cape Cod cottage turned over after a couple of years for a bargain basement $1/4 million, how Route 128, Massachusetts, was a high- tech miracle, ditto the rest of the East Coast, where people with basketfuls of money made by moving paper around were just wild to get a weekend place. The West Coast, a place basically immune from recession since the 1930s, didn't it have all those defense plants, surely as rock solid as the cold war? Three hundred grand for a house in Los Angeles, when essentially the same structure in Washington County Kansas sold for twenty thousand tops. Figures don't lie. That was money. There was a brief moment like that here in the late '70s. Wheat was $5 a bushel, beans closing in on 10. Some farmers started thinking they were the new Arabs, food would be a currency, just like a barrel of oil. Of course, the bottom fell out, a lot of those farmers lost it all. The tractor cage of the early 1980s now seem oddly akin to the 1990s demonstrations protesting welfare cuts and the lack of extended unemployment benefits. But did the world come to an end? No. Take farmers who still drive the economy out here. They stopped fooling around with paper, thinking that it in itself was wealth. Most paid down their debts, borrowed less, exerted considerable political muscle to get farm bills they wanted, embraced what new technology could make their pencils even sharper, and looked at the real wealth, the land, and survived, bigger, more flexible, more business-like. They adapted. And the farmers' urban and suburban brethren, like most Americans they work harder now, drive their cars longer, take shorter, closer to home vacations, watch their pennies. In essence, they have adapted too, reducing their expectations. So what if they haul grain or print greeting cards and manufacture crock pots? They sell. They're commerce. And new home starts in Kansas City are up 18 percent over this time last year. Unemployment is down a full point -- not that there aren't problems, but there's a feeling that maybe the worst is over. Out here, there's an old saying about life, one that a lot of people probably would have laughed at in the 1980s, when no one ever coupled the word "bust" with "boom." Life, it goes, why it's a hard fight with a short stick -- amen. I'm Jim Fisher. RECAP

MR. LEHRER: Again, the major stories of this Thursday, President Bush announced a plan to bring health insurance to 37 million Americans without any. Democrats and other critics said the plan was deficient and totally inadequate. And in Evansville, Indiana, 16 people died when a military transport plane crashed into a restaurant and motel. Good night, Robin.

MR. MacNeil: Good night, Jim. That's the NewsHour for tonight. I'm Robert MacNeil. We'll see you tomorrow night. Good night.