In her autobiography, Lillian Wald, the founder of the Henry Street Settlement, tells the story of how one morning in 1893, she was teaching a class in home nursing, when a trembling little girl tugged at her sleeve and said, "Come." Wald asked why. The little girl replied, "My mother. She's awful sick."
Wald followed the little girl through the narrow streets of the Lower East Side, occasionally tripping over the garbage that seemed to grow higher and ranker the closer she got to the girl's rickety tenement. The little girl escorted her upstairs to a small, sunless room where she and her six brothers and sisters lived. Her mother was on a crumpled bed stained with blood. Wald wondered how anyone could manage to be well in such circumstances. She cleaned the woman and ministered to her, and did what she could. But while there, Wald had a revelation. She thought that taking care of just one person in such circumstances was fruitless; the whole community needed to be looked after. Yes, you could treat an individual, and Lord knows that was necessary, but you needed to treat whole communities as well. Only then would families have a chance to be healthy. From that experience, Lillian Wald created the Henry Street Settlement, which was one of the first efforts in America to try to look after a whole community. Indeed, it was really what we think of today as a community center.
I confess that I've had no such revelation about heath care. But what I have come to is a commonsense vision of what must be done to improve the health of our nation, and a powerful sense that we must do so now.
People today talk about our unprecedented prosperity, and they are right. American ingenuity, free capital markets and hard work have created technological advances that put the U.S. far in front of any other country. But the question is, what are we doing with our prosperity?
I ask you, is it possible that the wealthiest nation on earth cannot afford health insurance for all its citizens?
Can we really say we are rich as a nation when 44 million Americans, most of them working people, 11 million of the children, do not have health insurance?
I say, if you're not for fixing this problem, what are you for?
And if not now, when?
It is not -- and never has been -- a question of money. It's a question of will.
I well know that you in the public health community have been at the forefront of this idea for decades. I am honored to join you in this quest.
In this campaign, I made a health care proposal six weeks ago. In my plan all children will be enrolled in a health care plan at birth. All adults will have additional choices of affordable, portable, and quality health care plans that are part of the Federal Employees Health Benefits Program, the same plan that insures your Member of Congress. Working families who can't afford health insurance will be given help. We will end the two-tiered system of health care in this country that stigmatizes the poor and gives them inadequate care. Every family in this country who has to pay for their own health insurance will get to exclude from their income what they pay in health premiums. And Medicare will provide the elderly with a drug benefit and an option for social services that will allow them to stay in their homes.
They say the best things in life are free, but health care is not. My plan will cost between $50 and $65 billion a year. The money will come from the budget surplus and from a dramatic cost reduction that will flow from the application of new information technology to billing, reimbursements, record-keeping, and treatment regimens.
This plan is only a first step in fulfilling the promise of a truly healthy America. It builds on what works now. It provides new choices for all Americans. It clarifies the federal and state roles. It treats both illness and the root causes of illness. It allows the private sector to do what it does best -- provide different insurance plans; the community to do what it does best -- promote prevention and early intervention; and the government to do what it does best -- spread the risk and help people in need. Ultimately, it creates a health care system that is sustainable, and one that over time yields better national health at a more affordable cost. Finally, it reflects my core belief that health care is a shared national responsibility.
This not a new idea. Bill Clinton and Al Gore had the right idea in 1993. After they took office, they looked around and diagnosed what they thought was the largest problem facing the country. They concluded that it was health care, and they were right. They agreed that it was a large problem that required a large solution. Right again.
I can't say that the solution they came up with was exactly right. It was too complicated and too top-heavy. It wasn't always clear to the American people. But they were on to the problem.
As so often happens in Washington, big ideas are brought down by a thousand cuts. It was savaged by special interests, it was caught up in the political opportunism of Newt Gingrich, it was at the mercy of the Republican penchant for putting congressional seats ahead of the national interest.
When the Clinton-Gore administration took office and proposed universal health care, we had $290 billion a year deficits, Medicare was six years from bankruptcy, and we were spending the Social Security trust fund just to keep government running. Yet Bill Clinton and Al Gore believed it was the time to have universal health care.
Now six years later we have a budget surplus, and Medicare is secure until 2015. Our economic circumstances are far better, and yet we have five million more people without health insurance -- one million more in the last year alone.
Again, I ask you, if now is not the time, when is?
The time is now.
Leadership is about having a big idea and then never losing sight of it. This is what Franklin Roosevelt did during the New Deal. He negotiated, he compromised, he horse-traded to get the main principles he wanted accomplished. He didn't abandon the principle if the details were not to his liking. He didn't walk away when people all around him told him it was a lost cause.
In the case of health care, Al Gore decided it wasn't worth standing and fighting. He abandoned that fundamental Democratic principle of basic health care for all Americans he had talked about so much in the campaign of 1992 and during the first two years of his Administration. But health care is the kind of fundamental democratic principle I would expect Democrats to stand and fight for. It's a principle that Democratic presidential candidates should agree on -- the kind of obligation that all Democratic candidates should pledge themselves to. Maybe something happens when you listen to Washington voices, instead of the people's.
The Washington view of things says, "Don't propose anything bold in a campaign, because your opponent will surely pick it apart." The Beltway perspective says that if you try something once and fail, move on to another issue that polls better or is safer to talk about. The Washington reality says that it is easier to campaign against your opponent than for yourself -- that negative politics may not be pretty, but that it will always be successful because people in this country are so cynical about the political process they automatically believe the negative over the positive.
I don't think it has to be that way.
The lesson Al Gore learned from the health care defeat was that big bold things can't get done in Washington, so let's look to the small, symbolic things. But that was the wrong lesson. Indeed big rhetoric followed by small actions contributes to the disillusionment people have with politics.
Ultimately, it is the task of leadership to set the goal and point the way and then to get there come hell or high water. I think it is morally unacceptable that 44 million Americans, one out of four of them children, don't have health insurance. I have a destination. And I have a map to get there, but I need your help.
What I've talked about so far can be described as America's system of health care. A simpler way of saying that is that I've been talking about what we do for people when they get sick. What I will talk about now is something much broader and more inclusive. Call it America's approach to good health, and it involves not only how we prevent illness, but how we create a healthier society for all Americans.
Too often we associate health care with health. In fact, health care only determines 10 percent of health. Good health also depends on decisions we make as individuals and as communities.
But I don't have to tell you about how communities can work with the health care system to support and to produce good health. You in the public health community embody this very idea. You are all the inheritors of Lillian Wald's vision. It was that vision of public health that in this country helped wipe out the infectious diseases that once crippled us -- cholera, typhoid, smallpox, and tuberculosis. As a nation, we made a critical commitment to combat these diseases, and we succeeded. The contributions that the public health community has made to the 20th century are incalculable. I'm talking about vaccinations and control of infectious diseases and safer workplaces and prenatal care and healthier mothers and family planning. I'm talking about safer and healthier food and motor-vehicle safety and the recognition of something as simple as tobacco as a health hazard. Because of all of these things, we have extended our longevity this century from 47 years to 77 years old. It is a breathtaking achievement.
What do I mean by a healthy America?
I mean an America where every man, woman, and child has health care. An America where Medicare is a sacred national trust. An America where individual Americans take care of themselves. An America where the simple things like nutrition and exercise are followed by almost everyone and self-destructive behavior like smoking is followed by almost no one. An America that creates and protects a healthy environment so that national childhood epidemics like asthma and obesity are reversed, and no American lives next door to a health hazard. An America where child abuse is not at epidemic heights and where child poverty is a distant memory.
With health, everything connects.
Take handguns. Look at what happened just last week in Seattle and Honolulu. Handguns, as much as any infectious disease, are a menace to our health. A pack of cigarettes comes with the message, "Hazardous to your health," but there is no such message on handguns. The proliferation of millions of handguns in America is a profound hazard to our health as a society. And not just because they kill other people -- as they do -- but because they are the weapon of choice when people kill themselves. The combination of guns and suicide form a tragic nexus in this country. There are 40 percent more deaths from suicide in this country each year than from homicide. Among teenagers, firearms are used in 96 percent of suicides. Suicide is an epidemic aided and abetted by the free supply of handguns. When circumstances help a disease spread we try to change them. To that end, I have proposed -- among other things -- the registration and licensing of all handguns and the elimination of Saturday night specials. It is the toughest gun proposal of any candidate for the presidency.
Because everything connects with health, we must change our view of health and invest in new techniques of prevention and community care.
We must create a continuum for health -- from the targeted molecule that kills a microbe to the seat belt that protects us in a car to the effort to provide poor children a hot meal and help seniors stay vital. For only then will we have a truly healthy society. For just as illness begets illness, health begets health.
Health is begetting health in innovative community partnerships that are bringing both prevention and renewal to people. Such community partnerships are the essence of what we mean by civic engagement.
I'm talking about communities such as Flint, Michigan, which have reached out to improve the health of its citizens. The Flint Faith Access, founded by a group of faith community leaders, has grown from seven to thirty faith-based organizations in three years. They have started walking clubs and passed local tobacco control regulations. They are working to prevent lead poisoning and provide health education for their congregations. Their work has bridged gaps in culture and race. It has enhanced trust among people who knew little about each other.
SPARC (Sickness Prevention Achieved through Regional Collaboration) is another example. It is a new program in the Taconic Berkshire region, spanning four counties in New York, Massachusetts, and Connecticut. They have created 40 community committees that bring health services to the community. Doctors, nurses, public health workers, volunteers -- all meet in school houses or medical offices on a Saturday afternoon to immunize community residents and screen for the first signs of disease with mammograms and blood pressure screening. They explain how to deal with illness, to discuss ways to stay healthy. That is my vision for how we make America healthier.
These are examples that inspire. But inspiration is often no match for the threats that are out there. You know them well. Some of these are threats I have already talked about: the proliferation of handguns and the downward spiral of hopelessness that can lead to suicide. I am also talking about the growing numbers of our children who smoke cigarettes. I am also talking about new and re-emerging infectious diseases, such as tuberculosis and diseases that bring renewed threats to our public health system as trade and travel increase exposure and risk. I'm talking about new and mutated viral strains that become resistant to our antibiotics. These are not scenes from a movie thriller, but threats that are real and all around us.
We also have an array of public health problems that won't go away.
While our mothers and babies are healthier, we still have an infant mortality rate twice that of Japan. And, within our own nation, African American babies are 2.5 times more likely to die before their first birthday than are white babies.
Why is it that Latino kids in East Harlem have rates of asthma much higher than kids in middle-class communities? The answer is that our public health care system is just not able to do the job because it is not being supported either by the government or the private sector.
How do we remedy this?
First, we must paint a fuller picture of what we mean by health. We must understand its connection to behavior, lifestyle, and environmental factors. We must look at neighborhood characteristics and the impact of early childhood experiences on adult health status. We must research the ecology of stress, as well as the biology. We must treat mental health on parity with physical health. We must realize that there will never be a pill to cure poverty or racism or child abuse. Instead we must be our own doctors -- we must heal ourselves. To help accomplish all of these things I want to invest $2 billion more a year in public health and healthy communities.
We will use this money for three things. I want to increase the number of community health centers and expand their mission. Community health centers are today's Henry Street settlements. They are deeply imbued with the American values of democracy, and humanity, and respect for the individual, but they are also threatened by the growing conglomeration of health care delivery. There must be places where people are known and cared about over time, where local voices are dominant, culture is respected, outreach is a daily event, and prevention and early intervention become the watchwords. I have visited urban clinics in Boston and Los Angeles and rural clinics in Iowa. They serve populations which without them would be sicker and less productive. They and others like them become anchors in their communities.
Next, I want to strengthen the capacity of the Centers for Disease Control and Prevention to research the characteristics of healthy communities and how to achieve them. The CDC is the bridge between the science in the laboratory and the actual delivery of care. I look to the CDC to help communities increase physical fitness and reduce obesity, encourage better nutrition, and cut down the number of people smoking. It makes sense to target our young people -- when is it a better time to learn how to protect your own health?
I want to establish an Institute of Community-based Public Health Sciences at the National Institutes of Health. This is where we will explore what truly creates health and protects the public health, where we will try to learn the characteristics of neighborhoods that inspire health, where we will make the connections between social circumstances and health. This will be the premier public source of the science of health in America.
I want to strike a new balance between the best traditions of public health, new knowledge, and the potential of American communities to lead the way. Only when these three things are intertwined will we be able to achieve health as a nation.
Ultimately, we cannot look at just one dimension of health policy as some do, or try to improve the health of the nation through piecemeal efforts. For health is all of a piece, not just individual pieces. We must not only cure illness, but teach people how to be well. My goal with my health care proposal is to create a healthier nation. A healthier nation is also a more just nation. A healthier nation is also a stronger nation. For our sense of justice decrees that everyone has an inalienable right to decent health care. And our strength as a nation depends on everyone having that same hope and opportunity.
The ultimate goal is to create a health care system that is self-sustaining and self-healing, one where all the pieces work together to keep costs under control and improve health and personal security. This works on two levels. For when we insure all Americans, we protect them against the crippling fear of financial ruin. When we invest in the creation and sustaining of health, we engender a more productive nation, and we create a sense of national well-being.
When we do all of these things as a nation, we deliver on the promise of our Declaration.
It was Benjamin Franklin who first talked about being healthy, wealthy, and wise. I say we have the wealth to be healthy; all we need now is the commonsense wisdom to pursue it.