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EXECUTIVE OFFICE OF THE PRESIDENT 20-Jun-1995 05:55pm TO: Jennifer L. Klein FROM: Seth E. Masket Presidential Correspondence SUBJECT: Health letter revision [Jennifer: Here's a new draft based on your edits. Please let me know if it will work. Thanks. -Seth] Dear : Thank you for writing to me about health care reform. I appreciate your concern over this important topic. We recognize that too many Americans cannot get the high- quality, affordable health care they need. At the same time, skyrocketing costs continue to imperil our nation's economic future. If we are to ensure the long-term health of our country, we must enact meaningful reforms that protect people's coverage and reduce health care costs. by also I have proposed a Health Reform Initiative that will accomplish many of our important objectives This initiative helps working families; providing health security after job losses, promoting long-term care, and reforming the insurance market SO that lose their Americans won't lose their coverage if they change jobs or get job sick. My proposal will additionally make coverage more available and affordable for small businesses and the self-employed. I am also working to improve Medicare by expanding choice, offering helping new benefits, preventing new benefit çosts and' fundamentally strengthening the Medicare Trust Fund to ensure its solvency? who Finally, my plan will preserve Medicaid as a safety net while their jobs reforming it to make it work more efficiently. extending the solvency of insurance keep the The Health Reform Initiative will keep us firmly on a path toward long-term deficit reduction. It will also create a healthier nation, helping Americans obtain high-quality care in their moments of need. I look forward to working with the Congress to bring about these much needed reforms. Meanwhile, I am grateful for your input and am glad you took the time to write. Sincerely, without vonnor imposing new Cost increases on Medicare beneficiaries. HUMAN THE SECRETARY OF HEALTH AND HUMAN SERVICES SECURITY WASHINGTON. D.C. 2020) USA FEB 17 1995 Paul M. Ellwood Jr., M.D. President Jackson Hole Group P.O. Box 350 Teton Village, WY 83025 Dear Paul: Thank you for the opportunity to review the new draft proposal of "Responsible Choices." I am looking forward to meeting with you and others in Jackson Hole to discuss our respective ideas for improving the nation's health care system. I have appreciated the opportunity to work with the Jackson Hole Group in the past, in large part because we share a common commitment to improving both efficiency and fairness in the health care system. I think we all agree that health reform requires three elements to be effective - expanded coverage, lower costs and improved quality - and that a restructured marketplace is essential to achieving these elements. Our ultimate goal must be universal coverage in an efficiently operating marketplace. You and your colleagues have made a significant contribution to the health care debate in this country by recognizing the critical role that consumer choice and private innovation can play in our health care system. I think that we both agree that choice is a critical element in improving quality and efficiency. I was surprised, then, by the direction reflected in "Responsible Choices." The draft proposal seems to abandon your previous commitment to addressing the problems of the over 40 million uninsured in this nation. I understand that the political environment has changed, and that our strategies may need to change as a result. However, that does not alter the underlying fact that middle class people who lose their jobs, or working families struggling to get by, need some assistance to be able afford adequate health insurance. The Jackson Hole Group has recognized this fact in the past, and has advocated substantial subsidies to assist the uninsured in purchasing private insurance. It deeply troubles me that the "Responsible Choices" proposal fails even to mention the need to move towards universal coverage, let alone suggest policies (short or long-term) to do so. In fact, the arbitrary cap on funding for the Medicaid program proposed in "Responsible Choices" would actually decrease coverage. Over the past few years, enrollment in employer-based insurance has fallen by almost six percentage points (from around 66% to around 60% of the nonelderly population), while the percentage of the population covered by Medicaid has grown significantly. Between one-third and one-half of the projected annual growth in Medicaid spending results from projected growth in enrollment. Page 2 - Paul M. Ellwood Jr., M.D. Furthermore, I am perplexed and disturbed that you would propose an arbitrary cap on the Medicare program. Like Social Security, Medicare is an inter-generational compact. Placing an arbitrary, pre-determined cap on Medicare spending, while at the same time eliminating its status as an entitlement, would put services to the elderly at risk and would violate that compact. A cap on Medicare puts the elderly and disabled at risk. The vast majority of Medicare beneficiaries have modest incomes. Over 75% of beneficiaries have incomes below $25,000; 30% of beneficiaries get 80% or more of their income from Social Security. So while a voucher program like that proposed in "Responsible Choices" may expand choice for some beneficiaries, it would in fact diminish choice for many by effectively forcing them into a low-cost plan and away from the providers of their choice. This does not mean that we oppose improving Medicare - quite the contrary. We are pleased that, during the Clinton Administration, projections for the average annual rate of growth for Medicare spending for the period 1996 - 2000 have decreased - by more than a percentage point a year - just in the period between the Mid-Session Review last spring and the President's Fiscal Year 1996 Budget. We are pressing ahead with improvements in Medicare management, data processing, contractor oversight, and program integrity activities. Among the other improvements we are making in Medicare, I believe that we share a commitment to expanding and improving the managed care choices available to Medicare beneficiaries. Today, about 74 percent of Medicare beneficiaries have access to a managed care plan, and 9% of beneficiaries have enrolled in one. Enrollment is increasing rapidly - by over 1% per month. We also are working on ways to make our existing managed care program work better. Examples include our work with the industry to improve quality measures and the AAPCC methodology for the Medicare risk contracting program, and our collaboration with Alain Enthoven to design a competitive bidding demonstration. And, as we have testified in recent weeks, we are in the process of developing new managed care options under Medicare, including a PPO option. While managed care appears now to be reaching a critical mass in private sector health programs, at least in some areas, it has taken many years to achieve this state. Many employers that have embraced managed care have moved cautiously to avoid disruption, by maintaining a fee-for-service option at affordable levels or by offering out-of-network options through point-of-service plans or PPOs. Most Medicare beneficiaries - and particularly the most elderly among them - have not had the benefit of a gradual exposure to managed care. I am strongly committed to expanding the managed care options available in Medicare, but the emphasis must be on choice. We should learn from the private sector and recognize that we need to move prudently if we are to foster understanding and acceptance of managed care approaches among beneficiaries. Page 3 - Paul M. Ellwood Jr., M.D. I look forward to the upcoming discussions at Jackson Hole. We need to focus on how we can improve both the private insurance market and public programs. And we must discuss ways to expand coverage for vulnerable populations. I believe that there are many points on which we can agree. To me, making responsible choices means finding ways to improve what we have, not making arbitrary cuts in important programs that can leave the elderly, disabled, and poor at risk. I hope that we can work together over the coming months to accomplish meaningful health care reform. Sincerely, Donn 98hlole Donna E. Shalala EXECUTIVE OFFICE OF THE PRESIDENT 11-Jan-1995 04:56pm TO: Jennifer L. Klein FROM: Barbara D. Woolley Public Liaison SUBJECT: RE: Letter to Supporters As we begin a new year, I want to thank you personally for your tremendous support for our efforts to achieve meaningful health care reform. I hope you share my pride in the progress we have made. Because of the active involvement of people like you, our nation has moved further than ever before toward addressing the critical need to ensure high-quality, affordable care for Americans. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and governments. In the 104th Congress, we can and should work together to take important first steps toward achieving these goals. With your continuing support, we can improve the health and well-being of all American families. THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Tom: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, Bris The Honorable Thomas A. Daschle United States Senate Washington, D.C. 20510 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Bob: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, Brin Brincuiture The Honorable Robert Dole United States Senate Washington, D.C. 20510 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Dick: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, Brinciuten The Honorable Richard A. Gephardt House of Representatives Washington, D.C. 20515 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Newt: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, Buicane The Honorable Newt Gingrich House of Representatives Washington, D.C. 20515 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Newt: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, The Honorable Newt Gingrich House of Representatives Washington, D.C. 20515 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Tom: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, The Honorable Thomas A. Daschle United States Senate Washington, D.C. 20510 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Bob: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, Brins Cuiter The Honorable Robert Dole United States Senate Washington, D.C. 20510 THE WHITE HOUSE WASHINGTON December 27, 1994 Dear Dick: While we could not achieve broad-based agreement on a health reform initiative last year, there can be little disagreement that we still face the enormous problems of increasing health care costs and decreasing coverage. We need to confront these problems on a bipartisan basis and address the insecurities that too many Americans have about their health care. I am writing to reiterate my strong desire to work with you in this regard. I remain firmly committed to providing insurance coverage for every American and containing health care costs for families, businesses, and Federal, State, and local governments. In the upcoming session of Congress, we can and should work together to take the first steps toward achieving these goals. We can pass legislation that includes measures to address the unfairness in the insurance market, make coverage more affordable for working families and children, assure quality and efficiency in the Medicare and Medicaid programs, and reduce the long-term Federal deficit. We look forward to talking with you in the upcoming weeks about a bipartisan effort to deliver health care reform to the American public. Hillary and I send our best wishes for a safe and happy holiday season. Sincerely, Brincrimen The Honorable Richard A. Gephardt House of Representatives Washington, D.C. 20515 copy: Jen 12/20/94 updated language December 25, 1994 approved by of.k. Mr. Santa Claus Four Calling Birds Three French Hens Two Turtle Doves North Pole 00000 Dear Santa: Thank you for writing to share your thoughts on health care reform. As head of the Domestic Policy Council, I share your belief that reforming our health care system should be one of our highest national priorities. Although our health care system is among the world's finest, its problems threaten our country's economic future and the security of hardworking Americans. We are working hard to get health care costs under control and guarantee Americans health insurance that is always there when they need it. Thank you again for your letter. 1) *I am forwarding it to our health policy staff for further review (if the writer sent along materials) OR *It is very important that those of us working on health care reform hear the valuable insights of concerned individuals like you. 2) *I hope that we may continue to count on your support when we return next year to fight for meaningful health care reform. OR *We are committed to working with the new Congress to achieve meaningful health care reform. Sincerely, Carol H. Rasco Assistant to the President for Domestic Policy TO: Roz FROM: Jen RE: Tickler File Prepare on for letterhead my signature Attached please find a draft of the Brandt/Kammer letter. Please note that I choose not to mention anything about Medicaid waivers (Dr. Brandt and Mr. Kammer are from Ohio). Does Carol agree with this approach? yes I forwarded the Kevin Kearns letter to Marilyn since it was a request for a meeting. She did not recommend that Carol meet fine with the Business Coalition for Affordable Health Care at this time, and she has called Mr. Kearns to let him know that it is not possible to schedule the meeting now. Jen- please return tome- Thanks tristen 12/14/94 This president. He wrote note 10 Jeremy - letter was written to the Please respond." Carol For saying his signature or hers December 9, 1994 Robert L. Brandt, Jr., M.D. Michael T. Kammer, M.Div., LSW Health Care Interventions 51 E. Stewart Street Dayton, Ohio 45409 Dear Dr. Brandt and Mr. Kammer: The President shared with me your letter Thank you for writing to share your concerns about Medicaid spend down requirements in Ohio. The hardships and frustration that you described demonstrate why we must continue to work for health care reform. Our health care system is among the world's finest, but this is little comfort to the nearly 40 million Americans who have no health insurance, to the millions more who are one illness or pink slip away from losing coverage, and to people, like Jeff, who must impoverish themselves to get desperately needed health care services. the President The health care reform proposal that P sent to Congress would have eliminated spend down requirements by integrating Medicaid recipients into the private insurance market. As you know, Congress was unable to pass health care legislation this year. Nevertheless, I am pleased that my Administration put health reform on the national agenda and sparked a thoughtful, We are national debate about how to change our health care system. am committed to continuing to work for meaningful health care reform. the President is his Again, thank you for writing. I commend you for your vigorous efforts on behalf of chronically and terminally ill people and will keep your experiences in mind as we work with the new Congress. Sincerely, Carol H. Rasco Assistant to the President for Domestic Policy Jen Klein TO: NEC Staff FROM: Naomi Tinklepaugh DATE: December 5, 1994 RE: Outstanding Letters 2nd/ww As noted during the staff meeting on Monday, December 5th, please draft and submit to Sylvia a response to each of the outstanding letters that have been assigned to you by Monday, December 12th (which is precisely one week from today). Recall that after drafting a response, everyone should send to Sylvia a draft of the response on plain paper with the incoming letter attached (this is preferred to sending the document by E-Mail), along with a disk that has a copy of the response on it as well. Naomin LETTERS IN PROGRESS 12/2/94 Date of Date We Due Date Who's Letter From Subject of Letter Action Officer BC/BR Comments Letter Received to Resp. OTHER Letter 8/1 8/2 8/9/94 Agt, Andreas van ANS Elgie BR 9/19 9/22 9/29/94 Allvine, Fred C. improving the US Theo BR economy 8/15 8/23 8/30/94 Bachmann, Jon MBA Social security Theo BR 11/18 11/29 12/6/94 Ball, William L. aluminum Deich BR 9/23 9/27 10/5/95 Bradford, Martina global Kalil BR communications 10/18 10/24 11/2/94 Brown, Augustus O. Healthcare Benefits Jen Klein Trust Fund 9/28 10/24 10/31/94 Crandall, R.L. air transpo. in Deich BR Japan 11/15 11/23 11/30/94 Crandall, R.L. U.S. Airline growth Deich BR 10/18 10/26 11/2/94 Crosby, Jeffrey TRP Dorothy BR 10/21 11/23 11/30 Daschle, Thomas Farmers Peter POTUS 10/12 10/24 10/31/94 Eakeley, Douglas China '94/Infras. M. Goodman BR Tech. Dev. and Fin. 10/27 11/1 11/8/94 Edwardson, John US/Japan Airlines Deich BR 7/27 7/29 8/9/93 Evans IL NETO on WH Advisory Tom Kalil BR 8/1 8/9 8/16/94 Goldberg, Gary fuel - ethyl Heather BR tertiary butyl ether 9/28 10/3 10/10/94 Gwyn, Robert B. ethanol tax Heather BR subsidies 9/13 9/21 9/28/94 Hamburg, David A. Adolescent Devlmt Dimond, Paul BR 9/15 9/26 10/4/94 Hamburg, David A. children and youth Dimond BR in poor communities 9/25 10/24 10/31/94 Hamburg, David A. follow up to 9/13 Dimond BR ltr. 10/17 11/1 11/8/94 Hutchinson, Kay US/Japan airlines Deich POTUS Bailey 11/2 11/7 11/14/94 Hanway, H. Edward GATT M. Goodman 5/5 5/12 5/19 Hay, John China Froman BR 10/5 10/7 10/14/94 Jefferson, William Military Sealift Deich Command 6/1 6/7 6/14/94 Kennedy, Kenneth unemployment Peter BR c/o Derrick, Butler resolution 10/3 10/14 10/21/94 Kelleher, Herbert airline taxing Deich BR 11/15 11/23 11/30/94 Kickert, Ronald Healthcare & Klein BR Insurance Reform 11/24 11/30 12/7/94 Martin, Keith B. Healthcare Program 11/7 11/16 11/25 Matz, Marshall Medical Food & Jen Klein Healthcare Reform 11/8 11/23 11/30 Metsch, Jonathan Healthcare Reform Klein BR 11/4 11/8 11/15/94 Murkowski, Stevens, Nutuna Sea natural Elgie POTUS Young gas 9/28 10/7 10/14/94 Peppercorn, J.E. clean air act Heather BR 11/18 11/23 11/30/94 Phipps, Ronald U.S. China Goodman BR relations 11/7 11/9 11/16/94 Prestowitz, Clyde WTO/China Goodman BR 11/16 11/23 11/30/94 Odom, William grants to support Dimond BR the development of voluntary nat. curriculum. 11/2 11/7 11/14 Shook, Bill economic reforma in M. Goodman China 11/21 11/30 12/7/94 Phil Wheeler, & TRP Robyn BR Mark MacKenzie 11/21 11/30 12/7/94 Zarb, Frank imported crude oil Heather BR December 6, 1994 Mrs. Alan Delk Box 1223 Fort Benton, Montana 59442 Dear Mrs. Delk: I am SO sorry to hear about the loss of your husband, and I extend my heartfelt condolences to you and your family. I am grateful that you and your husband came to Washington for the ceremony for law enforcement officers, and I was moved by your description of its importance in his life. I know that you will find comfort in remembering the richness of Alan's life -- the joy and love he brought to you and your children, his courage, and his commitment to protecting the citizens of our nation. I sympathize with your family's experience with our health care system during this difficult time. No family should have to worry about financial disaster when a loved one is faced with a serious illness. Please know that I will continue to fight for much needed national health care reform for all Americans. You and your family are in my thoughts and prayers. Sincerely, BILL CLINTON BC/MHM/KM/DH/ws (Corres. #1936816) (11.delk.k) CC: Monica Mullens, 93 OEOB CC: JENNIFER KLEIN, 2ND 71. ww Xeroxed copy of personally signed original to NH through John Podesta SAMPLE standard letter Thank you for writing to share your thoughts on health care reform. Too many Americans cannot get high quality, affordable health care. At the same time, skyrocketing costs continue to imperil our nation's economic future. Our health care system is among the world's finest, but this is no comfort to the nearly 40 million Americans -- including close to 10 million children -- who have no health insurance and to the millions more who are in danger of losing their coverage. I am proud that we put health care reform on the national agenda and began a thoughtful discussion about how to change our health care system. I am committed to working with the new Congress to effect meaningful and lasting health care reform. Jen- I Here is a copy of the new languagefor health care Its. The Health Cave info unit may use slightly dief. lang le.g. "cold constort"v. "no comfort") Kav heartfelt letter Thank you for your thoughtful letter. I am deeply touched that you chose to share your personal story with me. The hardships and frustration you described illustrate why Americans need health care reform. Today, too many Americans cannot get high quality, affordable health care. At the same time, skyrocketing costs continue to imperil our nation's economic future. Our health care system is among the world's finest, but this is no comfort to the nearly 40 million Americans -- including close to 10 million children -- who have no health insurance and to the millions more who are in danger of losing their coverage. I am proud that we put health care reform on the national agenda and began a thoughtful discussion about how to change our health care system. I am committed to working with the new Congress to effect meaningful and lasting health care reform. I will keep your experiences in mind as we continue to work on this important issue. supporter letter Thank you for writing to share your views on health care reform. As you well know, today too many Americans cannot get the high quality, affordable health care they need. At the same time, skyrocketing costs continue to imperil our nation's economic future. Our health care system is among the world's finest, but this is no comfort to the nearly 40 million Americans -- including close to 10 million children -- who have no health insurance and to the millions more who are in danger of losing their coverage. Well-financed special interests have fought for sixty years to prevent health care reform, and this year they waged an unprecedented battle. Although the President and I are disappointed that Congress was unable to pass health care legislation this session, we are pleased that we put health care reform on the national agenda and began a thoughtful discussion about how to change our health care system. Thank you again for writing. The President and I hope that we may continue to count on your support when we return next year to fight for meaningful health care reform.