Remarks in a Health Care Roundtable and an Exchange With Reporters in Troy, North Carolina

The President. We just completed kind of a here. We talked a little bit about the physician brief tour of the hospital, and I met some of shortage in this county, a little about the probthe nurses and patients and people who work lems with delivery of babies and the high rate of teen pregnancies, low-birth-weight babies, relatively low number of prenatal visits. We talked about some of the reimbursement problems of Medicare and Medicaid and the problem that this hospital has at the emergency room because they take everybody whether they have insurance or not. And I think that's a fair summary— and I met the wonderful, dedicated people. So why don't you lead off.

Harold Scott. Thank you, sir. I want to let Mr. Bernstein give us an overview of Montgomery County medicine and how it relates to the rural problems overall.

The President. I think it would help for the press that are here, just the first time you speak, if you would say your name and why you're here.

[At this point, Jim Bernstein, director, North Carolina Office of Rural Health, and presidentelect, National Rural Health Association, discussed the development of a community corporation within Montgomery County to provide rural health care and stressed that health care reform must address the urban-rural discrepancy.]

The President. Thank you very much. I also think—I was reminded on the tour that North Carolina actually has a program to provide subsidies for the malpractice premiums of practitioners who deliver babies and do things in rural areas that they normally wouldn't do in urban areas. Is that right?

Jim Bernstein. Yes. We have a lot of incentives in place in the State; one is that one. Another one—State hasn't done which is really good—Arkansas might do it, I understand—is that we pay our residents more money if they'll go into rural areas and give them higher salaries. And then we do the usual things like loan repayments, things like that. And we have, also, a statewide area health education center program trying to bring continuing education to keep people current in Troy and places like that.

The President. That's very important. In this plan—I just wanted to mention this, because I think it's important—as the Congress debates this whole health care issue, the things which get the largest amount of attention, as they would expect, are how to provide universal coverage and whether you can maintain choice and quality with universal coverage, and a lot of these big questions. But what a lot of people don't know is that in rural America, even if you cover everybody, a lot of folks still don't have adequate access to health care, and there's a real doctor shortage out there. And no matter what happens, I hope the Congress will leave in the provisions of our plan, which have—one, would expand the National Health Service Corps by 7,000 doctors over the next 8 years; two, would give physicians who go into underserved rural areas tax credits of $1,000 a month, 5 years, which is a huge incentive; and three, would allow a much bigger, faster writeoff of equipment, medical equipment that doctors might bring into rural areas. So I think those three things will really help to reinforce what you're doing.

Mr. Scott. Mr. President, Dr. McRoberts is one of our three practicing family physicians in the county. Our ratio of family practice physicians to population is almost one to 8,000.

The President. One to 8,000, and what's the recommended ratio?

Dr. Deborah McRoberts. Well, to qualify as a health profession shortage area, it would have to be about one to 3,000, correct?

Mr. Bernstein. But you want to be at one to 2,000.

The President. One to 2,000 is what you should have, right?

Dr. Hugh Craft. Yes.

Dr. McRoberts. What we should have. And I have 8,000 active patients in my practice right now.

The President. Eight thousand?

Dr. McRoberts. I have over 8,000.

The President. When was the last time you slept?

[Dr. McRoberts described working an average of 100 to 110 hours a week during flu season and 80 hours a week normally while always facing unfinished paperwork, but affirmed her dedication to practicing rural medicine.]

The President. What's the most important thing that could be done to make your life easier? More doctors?

Dr. McRoberts. More doctors. I mean, definitely. We are at such a critical shortage of doctors right now, with only three family practitioners. And our draw area, the population that we draw from, is about 28,000 people.

The President. And what would be more likely than anything else to generate more doctors in this area? What could be done by the county or by——

Dr. McRoberts. I don't know. That's the big question mark. What will it take to get doctors to come here? I think you have to look for things like loan forgiveness, certainly, or low repayment programs for the residents that are coming out, because that way you can get fresh, young blood, you know, people that aren't tired yet.

The President. It doesn't take long to get that way.

Mr. Bernstein. This sounds a little trite, because it's a big question. But for 30 years we've rewarded high-tech people and health professional people and basically didn't pay primary care people. And I know money is not the single most important thing, but it is important. And so, if the reform plan could move to reverse that, somehow the incentives would be not only loan repayment and stuff like that, but somebody who worked here could make as much money as somebody who worked—even if it had to be paid more to get to that level than in Charlotte—we would be in a better position, because our physicians get paid a whole lot less out here, a whole lot less, than they do in Charlotte.

The President. Well I think, for one thing, you know, let me just mention, if you start in medical school, under our plan we would shift the allocation of internships and slots more toward primary care physicians, so you'll have more people in that business, and they don't have to go where the market is.

Secondly, I think, we know the National Health Service works; it just got cut way back. So if you put another 7,000 doctors out there, it will make a difference, because that's a way to pay your medical school. And then the way the tax credit works is that it will, in effect, increase the income of every doctor in the underserved areas by $12,000 a year. That's what a $1,000-a-month tax credit is. And even though—you know, if people just come in here in 5-year cycles, that's a significant amount; that's a big commitment of your professional life. You can keep going that way.

[Mr. Scott described the Montgomery County not-for-profit corporation designed to recruit six to eight family physicians to reduce the workload of county physicians. He then introduced Beth Howell, director of nursing, Montgomery Memorial Hospital, who discussed recruitment and retention of nurses in rural areas.]

The President. How many more nurses do you need? I mean, just for example.

Beth Howell. I would like to have five additional registered nurses.

The President. And where are most of them trained, most of the RN's you get here?

Ms. Howell. In the local community colleges.

The President. And is there one—where's the nearest one?

Ms. Howell. We actually have two that are within 20 miles and another one that's within 40 miles.

The President. So that's not a real problem— [inaudible].

Ms. Howell. Right.

Dr. McRoberts. Retention is the problem. The nursing staff turns over a lot, just like she was saying.

The President. I'd be interested in your feedback on this. The only thing that I know of that's in our bill that would help is there's also— as I say, we felt that the quickest way we could deal with the income disparity—I mean, we can't go in and sort of change the economics of every community in the country, but you could give a Federal tax credit. And a credit is not like a deduction; it's a dollar-for-dollar deal. And so there's a $500-a-month tax credit for 5 years for nurses, too. And I think that will almost close most of the gaps. I mean, that's $6,000 a year. That's probably about what the gap is early on.

Dr. McRoberts. Is that just for health profession shortage areas?

The President. Yes. For shortage areas. But you could qualify.

Dr. McRoberts. Thanks. [Laughter]

The President. I mean, nobody can work 80 hours or 100 hours a week forever. You burn out. You can't do it.

Dr. McRoberts. That's right. [Laughter]

The President. That's what I tell all of the young people at the White House with their boundless energy. At some point, you stop working smart and you start working stupid. When you work hard, you just can't—there's a limit to how much anybody can do.

[Mr. Scott introduced Dr. Hugh Craft, chief of pediatrics, Community Hospital of Roanoke Valley, VA, who discussed the importance of primary and preventive care for children and continuing education efforts for staff in smaller hospitals and then expressed support for the President's plan.]

The President. One of the things—you mentioned the area health education concept, which I think has really done wonders in rural America, all over the country. But one of the things that we have tried to do in this plan which we haven't talked about this morning is to provide some funds for electronic hookups with really great access to technology so you can have almost instantaneous and continuous contact with medical centers around the country. I think it isn't quite like being there, but it will go a long way toward bridging the gap that exists now.

[Dr. McRoberts described an electronic system which linked Montgomery Memorial Hospital to the University of North Carolina for instant consultation but was discontinued for lack of support. Dr. Tom Townsend, East Tennessee State Medical School, discussed training and emphasized that medical schools must be reoriented to the needs of rural communities.]

The President. You know, this has been a source of real controversy, by the way, in the medical community, as you know, because we are only, of all of our graduates from medical school now, only about 15 percent are family practitioners. And in most other major nations, about half the doctors are family practitioners, maybe slightly over half.

So in our bill, we propose over a 5-year period to change the mix of medical school slots that the Federal Government subsidizes, and as you know, they're heavily subsidized, to get to a point where about 55 percent have to be in family and general practice. And I met the other night with all the teaching hospitals in the Boston area to talk about how quickly that can be done, because as you pointed out, they're all sort of geared up and wired to their specialties and subspecialties and all that, and that's sort of where the money is. But I just think that we have a very compelling obligation to spend the taxpayers' money at the national level to try to remedy what is a blooming horrible crisis.

You know, we're here in a little rural area, but there is a shortage of family practice doctors in a lot of the major urban areas of the country. So I think it's not just the training setting; you actually have to get the med students into those slots, and we're going to have to change the subsidy ratio.

Now, again, this is something that almost never gets discussed in the larger debate about health care. But unless we're prepared to do what it takes to guarantee that we educate our young people in sufficient numbers to be family practitioners, all the economic subsidies in the world won't get them out there because they won't be there; people won't be there. And I think that's one thing that's very important, that the American people know that, that with all of the doctors we have, we actually have a shortage of family practitioners nationwide, and it's going to get worse unless we change the economic incentives for the next year.

Mr. Scott. Mr. President, this is a wonderful discussion, and I know that you have other commitments that you must attend to today, and we could sit here all day and all night——

The President. I'm having a good time.

[Mr. Scott thanked the President for visiting and reiterated the hospital's commitment to the community and the need for health care reform to resolve the problems it faces.]

The President. How much uncompensated care do you do here every year, do you know— just people who show up at the emergency room that are uninsured?

Ms. Howell. Fifty percent.

Dr. McRoberts. I would say it would be about 50 percent in the emergency room. Probably, what——

Ms. Howell. In emergency.

Q. Uncompensated care or less than total compensated care is better than 50 percent in our hospital.

Mr. Scott. That's true, our hospital, too.

The President. So that goes back to the first point you made, that universal coverage is a big deal and if people want medical care to continue in rural America and forget about the taxpayers and anything else, this hospital could pay more——

Mr. Scott. That's right.

The President. ——to pay the nurses more, to pay other people—to offer incentives to doctors to come directly if you had compensated care. And you'd have a—if you had a better array of services then because it was compensated, you could take better care of the pregnancies and everything else.

It all comes back to this universal care thing. We cannot be the only country in the world that can't figure out how to provide basic coverage to all its citizens. We can't justify this any longer.

Mr. Scott. Thank you very much, Mr. President.

The President. Thank you all. Dr. Townsend, I'm glad to see you. Your father has been educating me about these things for years and years.

Dr. Tom Townsend. He's tried to figure it out.

Health Care

Q. Mr. President, why is it worth it for you to come here and talk to just such a few people when you have already basically done this before? You asked a lot of these same questions before.

The President. Because it's obvious to me that these things come in waves. I mean, the American people are thinking about it again now, and it's very important that we deal with some of these horrible health problems. Most people lobbying on Capitol Hill will be lobbying against universal coverage in one way or the other. But these folks who are out here giving health care know we've got to have it.

I also think it's very important to emphasize a lot of the things that are in our health care program that are not controversial on their face, but they could get lost unless we emphasize them, for example, all the incentives for people to come out here and become family practitioners.

And so the debate, in a funny way, is just beginning. We're getting all this work in subcommittees; we're getting things going forward. All the surveys show an interesting dichotomy. They show that support for our plan goes up and down based on what they heard about it from interest groups or in paid ads, but that if you tell them what the details are in our plan, there are more than two-thirds of the American people support all the specifics.

So what I'm trying to do is to get out here and highlight these real-world experiences that these doctors and nurses and other health care providers have so that we can focus the attention of the American people and the Congress on solving the real problems, not the rhetorical problems.

Q. And get this on local television.

The President. Well, yes, that's the idea.

Q. Mr. President, are you losing the public relations battle, Mr. President?

The President. No, I think we're winning it again now. And we're getting real movement in Congress. But I think we don't have the ability to raise the kind of funds or do the kind of nationally organized advertising that has been done by some against the program. And inevitably, a lot of the national organizations may get more publicity than local ones do. But when you get out here and you go beyond the rhetoric and get down to the details and the real-life experiences of these folks that are out here trying to take care of America, then the compelling case for reform, for universal coverage, for guaranteeing health security for all Americans, and getting the funds in here to these rural hospitals and providing more family doctors is overwhelming. And so I think we just have to keep hammering this home, not just on local television—I'll be grateful if you put this story on national television tonight. [Laughter]

Mr. Scott. Thank you, Mr. President, we appreciate you being here. The President. Thank you.