Sen. Clinton urges bigger role for nonphysicians.

WASHINGTON -- According to Sen. Hillary Rodham Clinton (D-N.Y.), primary care physicians don't get enough pay or respect, and there aren't enough of them. Her response to the problem? The federal government should try to help increase the supply of primary care doctors, but in the meantime nurses, pharmacists, and others should fill the gaps in care.

"I'm intrigued by the fact that a lot of states are permitting pharmacists to give vaccines," Sen. Clinton, a candidate for the Democratic presidential nomination, said at a health policy forum sponsored by Families USA and the Federation of American Hospitals. "What other functions can we delegate out, given appropriate oversight and training?"

For example, she said, "I think nurses have a great opportunity to do much more than they're doing. If we're not going to be able to quickly increase the number of primary care physicians, we need more advanced practice nurses, and they've got to be given the authority to make some of these [treatment] decisions, because otherwise people will go without care."

Sen. Clinton, who is in her second Senate term, said that health care would be her top domestic priority if she were elected president.

"This is, for me, a moral question and an economic one," she said. "Do we want to continue to be so unequal and unfair that, if you are uninsured and you go into the hospital with someone who is insured, you are more likely to die?"

Sen. Clinton said she learned a lot from her experience in her husband's first presidential term when she led his efforts to develop a universal health care plan.

"The fact that the White House took on the responsibility of writing the legislation turned out to be something of a mistake," she said at the forum, part of a series of presidential candidate health policy forums underwritten by the California Endowment and the Ewing Marion Kauffman Foundation. She said that now she sees the president's role on health care as "setting the goals and framework but not getting into the details."

Further, the Clinton plan of the early 1990s was just too complicated, she said. "It was a source of concern to a lot of Americans who didn't understand how it could work, and it certainly wasn't presented in the best way."

This time, Sen. Clinton has a different plan. The "American Health Choices Plan" would allow people to keep their current insurance coverage, but if they didn't like their current insurance or were uninsured, they could choose from a variety of plans similar to those offered to federal employees or a public plan similar to Medicare.

Sen. Clinton said coverage under her plan would be affordable and portable, and insurers would be barred from discriminating against enrollees with preexisting conditions. Large employers would be required to offer coverage or help pay for employee health care; small businesses would not be required to offer coverage, but would get tax credits to encourage them to do so.

She estimated the cost of her plan at $110 billion per year and said it would be paid for by rolling back tax breaks for Americans who make more than $250,000 annually.

Sen. Clinton said critics who called her plan a back door to a single-payer, government-run health care system were either misinformed or were misrepresenting her proposal. "I've included the public plan option because a lot of Americans want it," she said. "It will not create a new bureaucracy; it will not create a government-run system unless you think Medicare is government run. In Medicare, you choose your doctor, you choose your hospital--you have tremendous choice."

Sen. Clinton predicted that a lot of people would still choose a private plan because "if the private plans are competitive and smart, they'll offer a lot of new features. What are we afraid of? Let's see where competition leads us."

Sen. Clinton expressed support for the increased use of electronic health records to make the health care system more organized. "It's very hard to think about having a system when you don't have any way for people to move [their records with them] from place to place and job to job."

Paying providers based on their outcomes was another recent innovation mentioned by Sen. Clinton. She lauded the Bush Administration for announcing that the Medicare program would no longer pay for care occurring as a result of medical errors. "That kind of connection between pay and performance, quality and results ... makes sense. It's hard to do, but we have to experiment."

The recent increase in cases of nosocomial infections such as methicillin-resistant Staphylococcus aureus "should be a wake-up call for everybody," she said. "A couple of hospitals I'm aware of have changed their infection control policies; they have cut the rate of hospital-borne infections. Everybody should be expected to do that.

"When you look at some of the disparities and disorganization, it's because we don't have a good system to disseminate evidence-based clinically proven treatments," she continued. "It takes 17 years for something that is proven in the lab to be broadly disseminated. It should take 17 hours--17 seconds. With the Internet, why are we so far behind?"

BY JOYCE FRIEDEN

Senior Editor