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Senator Hillary Clinton released her plan to achieve universal health coverage

A few days after Senator Hillary Clinton released her plan to achieve universal health coverage, I interviewed her by telephone for this article. Following is a transcript of that conversation:

When did you sit down and seriously start to think about a new health care plan?

I've been committed to universal health care for fifteen years. When we weren't successful after '93 and '94, I kept working to try to expand coverage and was the primary advocate for the S-CHIP [the State Children's Health Insurance Program] program inside the White House those years and did other work on expanding vaccine rates and making medicine safe for kids and the rest. But, when I ran for the Senate, I said that I would keep working on health care. I made a very big point of it. I think a lot of people were surprised that I would even talk about it. But it's a passion of mine. Obviously, in the Senate, I did what I could to keep making improvements, saving and protecting S-CHIP, and working on health care for veterans...

And I have been talking with people, and reading, and aware of arguments that many people have made ... over a lot of years, but I didn't really sit down and start intensely pulling people together until really this past year. Getting people to actually come in, and sit and talk, and trying out ideas, and looking at all the different pieces that would have to be put together. But it's really rooted in the last 16 years of effort.

There's been a lot of talk about how you've changed. How do you think everybody else has changed--in other words, how are the politics of today different from the politics of 1993 and 1994?

I think that's a great question, because, obviously, from my perspective, I learned a lot of lessons. This is a different plan that was proposed 15 years ago. And I think the country was different. We've had a much greater awareness of the cost of not doing anything. More people are uninsured, to be sure, but also the cost of premiums continues to rise by double digits, we have the competitive pressures on our employer sector. We are learning more about how our quality is not what we would expect it to be, given how much money we spend on health care, and starting about a year ago, there became all of these strange bedfellows. Andy Stern from SEIU standing there with Lee Scott from Wal-Mart, and a lot of other business groups getting into this, rolling up their sleeves, paying attention to it as they never have before. It suggested to me there was a growing consensus, number one, that we needed to address this again, and number two, the outlines of what might actually be politically and substantively possible. So I believe that the Democrats in this presidential campaign are reflecting a new real commitment to tackling universal care again.

But a lot of business groups supported reform last time, only to change their minds. Are they really a reliable partner?

I think experience is a great teacher. A lot of the CEOs, who were initially favorable to what was being proposed years ago, determined for political and ideological reasons that, yes, there was a problem, but they could handle it on their own, they could do more to lower costs, they could drive harder bargains, they would be able to at least control their small part of the health-care universe. And what they found was that no matter how they tried, it was a losing proposition. I've had so many CEOs who've come to me over the last number of years, and said, look, I'm running out of options. I've tried nearly everything I can. And I can't do this on my own.

So I think there's an awareness that the health-insurance industry is not working in a way that makes economic sense for the rest of the economy. And I think that's a revelation for them. Because businesses are not going to step outside of their comfort zone, they're not going to be pointing fingers at somebody in some other sector--that's really not their interest. But when it affects their bottom line, when you have companies that are struggling to contain costs and losing, then they lift their heads up and say there has to be a better way.

They still want to have control, which is one of the reasons why sticking with employer-based insurance makes sense for a lot of people. And it really leads my plan's structure. If you're happy with what you have, you will be able to keep it.

But we think we will make sufficient changes in the system, that you will be able to have more choices, at more affordable rates, that you will be able in this comprehensive health care system to control costs and improve quality.

If you're not happy, then we're going to have all of these options. And if you're uninsured, you're going to have options you don't have today. And I think that's appealing, because it builds on what people feel is still working for them, but not as well at they would like. But it also gives those who have tried everything, can't figure out how to make it work, or don't have it at all, the option of pursuing affordable alternatives with the health care tax credit that makes a lot of sense.

If Congress votes for a plan, it may look a lot different from the one you just unveiled. So you'll have to negotiate with them. Can you give me two or three core principles that you'd take into those negotiations?

First, we have to remain committed to the goal of quality affordable care for everyone. If you don't have that as a core principle, you'll never get there. That has to be one of those principles that we'd take in to whatever the negotiations are. There are a lot of ways of getting there. Working to lower costs, and being able to improve quality by the changes we make with respect to prevention and chronic care management, will meet a second goal, which is that it has to be affordable. We're going to have a system to include everybody, but it's going to be affordable for everybody.

Those are really principles you have to be willing to stick with, because there are a lot of details that we can work out with negotiation and compromise, but at the end of the day, we want to get to quality affordable health care for everybody. The details can be negotiated and there can be a lot of legislative give and take, because there are a lot of good ideas out there. But at the end of whatever the process is, that has to be the outcome.

John Edwards has said he would be willing to sacrifice at least some deficit reduction if that's what it takes to enact universal health coverage. Would you?

As you noticed, in my financial planning, I do not take all of the president's tax cuts that are expiring for health care. I think we've got to begin to make a down-payment on fiscal responsibility, but it has to come over time. That's what we saw in the '90s. The framework was enacted in '93, and the results were years later, but they were real and it began to reap benefits as time went on.

If you don't get ... quality affordable health care to everyone in the plan that you have, you can't realize a lot of the savings that will help you with deficit reduction, with Medicare, Medicaid, and other government programs.

As you might remember, one of the reasons why Bill was so determined to tackle health care was because he thought you could not get to the kind of fiscal responsibility for the long run--and shore up Medicare--if you didn't have everybody in the system and realize the savings that came from that.

A goal of your plan is to make for-profit insurers change a lot of their business practices, like excluding people with preexisting medical conditions. But will that work? Is it possible to make them act more like non-profits?

It wasn't so long ago that we had a lot of not-for-profit insurance companies, as you may recall. There may be a relationship here that may be worth exploring. [Laughs]

This is a new business model and it may be that some will go back to being non-profit. It may be that profit will be realized by competition, on the basis of cost and quality. Because, remember, this is an industry that spends $50 billion a year excluding people either altogether by denying them coverage, or by denying them care that they need.

$50 billion is no longer going to be an expense to them, so this could actually provide the opportunity of a new business model for for-profit insurance.

The insurance industry is not going to name me "woman of the year" any time soon. But I think this is a business opportunity that some may understand and see.

The other piece of this, which I've talked about many times before, is that with the advances in our understanding of the human genome, and individualized genetically-based treatments, the model of our system may be out of date anyway. If your whole model is based on excluding for preexisting conditions, and we will find out that nearly all of us have such a genetically-based preexisting conditions, how do you have an insurance model that really is going to last beyond the next 20, 25 years?

There's a lot going on here that is, I think, pushing for some recognition that the insurance industry's model, as they have allowed it to develop, with rejection of not-for-profit health care, the transformation of not-for profits to for-profits, the increasing money spent on underwriting, the double-digit profit margins--it may have provided short-term financial benefits for individual companies but it has been bad for the economy.

That is what the fight is going to be over. There are those ideologically who will cling to a for-profit model with no regulation. But, by doing so, they are really dooming millions more to both no insurance and underinsurance--and they are continuing to hobble the economy. And I think that's much more clearly understood today than it was 15 years ago.

Some Republican presidential contenders are already characterizing your plan as socialized medicine. And while they're clearly wrong, it's also clear that they'll keep doing so--and probably get a lot of people's attention. How do you fight back?

Well, I think we educate people about the plan, because what they're saying is not true. There is no new government bureaucracy, it's not government-run health care, and they can no longer make those claims once people look at it.

There is a clear distinction as to what they believe is important and what I believe. They believe neither the American economy nor political system is capable of solving a problem that has great human and economic cost. They have no answer. That's what the debate is going to be about and I look forward to that debate. I am anxious to engage with them on a factual, accurate basis on what the situation is now and what we need to do to remedy it.