MANAGED CARE June 2003. ©MediMedia USA
The former Vermont governor at first greeted managed care with good will. Now, however, he thinks it is shortsighted in its dealing with doctors. Unlike President Bush, he wouldn't call on it to rescue Medicare.
Howard Dean's presidential campaign opened for business with a catchy marketing slogan: The doctor is in.
The former governor of Vermont is hoping his background in family medicine — his wife still carries on the practice — will evoke the kind of caring image that can resonate with voters across the land. It's also being portrayed as one of his chief qualifications for his presidential bid — and sometimes used as a rueful explanation for his single-mindedness at pursuing objectives.
He once told a reporter that being a doctor probably made it harder for him to get along with the state Legislature "because doctors do have a tendency toward deciding what they think ought to be done and insisting that's the right thing to do. We're not very process-oriented people."
But he has been very determined. Dean graduated from Yale University in 1971 and went on to get his medical degree from Albert Einstein College of Medicine in New York City in 1978. A few years later he launched his first campaign, getting elected to the Vermont House in 1982. He was elected lieutenant governor in 1986 and suddenly became governor in 1991 when then-Governor Richard Snelling died.
Whether an underdog like Dean can survive the grueling primary schedule ahead and emerge at the top of the Democratic pack for next year's showdown with George W. Bush will have a lot to do with whether he can connect with people on exactly what he means about doing the right thing on health care reform. And he'll get a run for his money from every major candidate to hit the Democratic campaign trail.
Richard Gephardt recently stole the headlines as the candidate with the biggest ideas for offering universal health coverage. John Kerry from Massachusetts has unveiled plans to cut the number of uninsured Americans by making insurance more affordable through federal subsidies for catastrophic health care costs and new federal regulations designed to rein in drug and malpractice insurance costs. John Edwards and Joe Lieberman are close behind. And four more candidates are all eager to pick up the standard of health care reform and charge ahead.
Just how many voters will follow has yet to be determined. But when looking for chinks in Bush's heavy armor, Democrats find it in health care, where the president receives his lowest marks from an electorate that has shown deep ambivalence toward his domestic policies, even as it cheers him in support of his war on Iraq and all things regarding national security.
In a recent ABC News/Washington Post poll only 34 percent gave Bush good marks for his work on the availability, cost, and coverage of health care insurance. Democratic pollster Stanley Greenberg has suggested that if Democrats can successfully accuse Bush of playing to big money interests such as the pharmaceutical and insurance industries and pin the administration for failing to adopt significant new health care initiatives — even though Republicans control both chambers of Congress and the White House — they may have an issue that will strike home with voters already grumbling over a sputtering economy.
Writing for Democracy Corps, a not-for-profit political strategy group formed by Greenberg and the Democratic Party attack dog James Carville, analyst Karl Agne took a close look at Bush's poll numbers in late April.
"Continuing doubts about Bush and the Republicans on some of the most important issues facing the country have kept Democrats in a competitive position," Agne wrote. He said that in a Wall Street Journal survey, "Bush and congressional Republicans are favored by 52 points on the war on terrorism (71 to 19 percent) and 14 points on taxes (52 to 38 percent) but by only 4 points on the economy (46 to 42 percent). And Democrats still hold the upper hand on Social Security (45 to 41 percent); government spending for education, health, and environmental programs (51 to 39 percent); and prescription drugs for the elderly (46 to 38 percent). The public waits to hear a consistent Democratic message on the economy, tax cuts, and spending priorities that addresses the doubts they have about the Bush economic plan."
At least for now, though, consistency is in short supply as the candidates angle for the lead in a frantic race to next year's primary showdown.
"Right now, Gephardt seems to have won a little bit of a head start," says Drew Altman, president of the Kaiser Family Foundation, shortly after the candidate had unveiled a plan to aggressively push employers to make coverage available. "And certainly Governor Dean is strongly associated with health care — particularly on the issue of children's access to health care."
But at this stage, he adds, it's unlikely that voters have tuned in enough to be able to distinguish who wants what. Looking at Kaiser's polling data, though, it's clear that people closely associate their concerns about health care with their worries about a weak economy, says Altman. "People are very worried about the rising cost of health care and whether they can afford it if benefits are cut," says Altman. "It's caught up in the overall concern about the economy, which is critical."
If the Democratic candidate, whoever it is, fails to make a compelling case for health care reform and sharply distinguish it from Republican initiatives, he adds, all voters will be left with is the impression that "the president talks about health and cares, the Democrats are concerned about health and care."
To make sure voters see some stark distinctions, one increasingly popular tactic among the Democrats is to offer up Bush's schedule of tax cuts to pay for any new reforms. And Dean was one of the first to offer a tradeoff between future cuts and wider coverage.
In an interview with Managed Care contributing editor John Carroll, Dean talks about his attitude toward managed care and what kind of health system he wants to see in America.
Q&A with Howard Dean, M.D.
MC: As a physician, you must have heard every kind of criticism there is of managed care. Do you see managed care as part of the problem or part of the solution to a better health care system?
HD: It originally started out as part of a great solution. I actually enjoyed practicing under managed care 12 years ago because you got paid and you didn't have to worry about billing people and so forth and so on. But as time went on, managed care companies began to squeeze the little people a lot. They began to make it more and more difficult for internists, general practitioners, family practitioners, and pediatricians to make a living. And right now it's a huge problem, simply because of the way large companies squeeze small physicians. They squeeze where it's easiest to squeeze rather than where the most money is and that's the problem."
MC: President Bush has made it an important part of his Medicare reform package to use drug benefits to attract people into private Medicare health plans. Does managed care have a role to play in Medicare?
HD: No. The president, of course, doesn't know anything about health care and neither do his people. This plan was actually tried in Nevada. Gov. Kenny Guinn actually signed a bill that would get people into the private sector with drug insurance. And of course not one insurance company signed up for it. No insurance company, whether it's a managed care company or not, would sign up for a program to insure a commodity that is going up at five times the rate of inflation. Because you get the blame for these cost increases rather than letting the pharmaceutical industry get the blame. So I don't think that managed care would want to touch Medicare with a 10-foot pole and I wouldn't either if I were running one of these companies.
MC: Can Medicare survive intact as the baby boomer generation heads for retirement in seven years, or do you anticipate major changes in order to afford coverage?
HD: If you get a president who understands social services in general and health care in particular, of course Medicare can survive. There will have to be changes. But this president's major interest is dismantling Medicare and Social Security and privatization is the first part of that. I don't think the American people will put up with that. So I think it will be left up to the American people to sort out a Medicare system that works.
MC: You've said that you want states to guarantee coverage for everyone under 23.
HD: Twenty-five. I did post 23 but it's likely to be 25.
MC: And there are a number of states working very hard to make any budget cuts they can, including making cuts in Medicaid.
HD: The way it would work is that if the states would guarantee health insurance for everyone under 25 through Medicaid, the federal government in return would pick up all Medicaid expenses for seniors other than nursing homes. So ultimately the states would make out very well financially, because they wouldn't have any drug expenses for seniors nor would they have any additional expenses for acute care for seniors below the poverty line. Or any seniors other than those in nursing homes. The only reason I want to leave the nursing homes as a state responsibility is because I don't think the federal government will do a good job in inspecting nursing homes and protecting consumers.
MC: How much would that cost the government?
HD: The whole thing is about half the president's tax cut. We don't have an exact number yet, but we're working on it. [Dean later estimated his reform package would cost $88 billion annually.]
MC: Richard Gephardt said the number of uninsured Americans "is the most important problem facing the country." And he's offering a plan that would cost $200 billion to fund the credits behind a system that would require companies currently not providing a plan to pass on a 60-percent credit to employees to make insurance affordable. Your response?
HD: I think it's twice as expensive as it needs to be. And I think that it'll never pass. Our health plan costs less than half of Dick's plan. And it's a plan that can get through Congress because we've already done a lot of what I'm proposing in Vermont. We have universal health insurance for everyone under 18 in Vermont. Most of the rest of the plan is just very, very expensive. I just don't know how we'd pay for Dick's plan. I know how we can pay for ours.
MC: You've talked about using tax credits and refunds to encourage companies to provide insurance for everyone between 25 and 65. How would that work and exactly how much would it cost?
HD: The whole entire plan costs about half of the president's tax cuts, which is about $850 billion over 10 years. The way it would work is to use Medicaid for everyone under 25, Medicare plus prescription benefits for everyone over 65, and then help small business and individuals who work for themselves buy health insurance.
MC: Is this something that would lead to universal care or would there be anyone left out?
HD: There would not be anyone left out. We'd have to help individuals who couldn't afford health insurance buy it. And you'd have to help individuals who are unemployed either buy a new COBRA or Medicare. But you could do it. People would have to pay something toward their own health insurance.
MC: You've called for Medicare to cover a drug benefit for seniors, but let's get into the nitty-gritty. There's a Democratic plan to provide the drugs for a $25 a month premium and a $100 annual deductible. Do you support it?
HD: I don't have that in front of me. We do have a health care plan and that will be in it, but I'm not in a position to pull that out and read it to you.
MC: But you anticipate a fee would be paid by Medicare members?
HD: Yes, but honestly we haven't closed on that. Will individuals be paying something? Definitely. Yes. Will they be paying big copayments and deductibles or will they be paying a fee to get into the program? We haven't settled on that.
MC: Realistically, how important an issue is health care for the Democrats in this election?
HD: It's the most important issue to me other than balancing the budget. The reason I got into this race was to bring fiscal sanity back to the country and have health insurance for every American so we're not the last industrialized country in the world without it.
MC: Is there any part of the Republican agenda — association health plans, malpractice reform, Medicare reform — that you like?
HD: Frankly, I haven't noticed a serious Republican health care agenda, so I don't pay much attention to what the Republicans are offering because I don't think they're in the least bit serious about doing anything for health care. This is a group of people moving further and further to the right. I think they're completely out of touch with what most Americans' needs are and I actually don't pay much attention to what they propose because I think that most of what they propose is political and not policy oriented. The president's prescription benefit is a joke — just ludicrous. And if it passes not a single American gets insurance from it. People aren't going to leave Medicare to join HMOs to get prescription benefits. And if they do, my guess is that the prescription benefits won't last long. Look what happened the last time the Republicans tried this. They got HMOs to sign up Medicare recipients and you tell me how fast these HMOs are getting out of the Medicare business. Why? Because the government under-reimburses it. It is not going to work, and the president knows it.
MC: So it's just a political ploy?
HD: Any interest that the Republicans have in health care is driven by Karl Rove and [Republican pollster] Frank Luntz. They're just talking about it because Americans are concerned about it. They have no intention of delivering anything.
MC: Al Gore a few months ago declared himself a "reluctant" convert to the single-payer cause. Any chance of a conversion ahead for Howard Dean?
HD: I'm not a big pusher for single payer but I'd sign one tomorrow. But it's never going to pass. I'm not driven by an antipathy for single payer. I'm driven by getting something that will take care of the 42 million people with no health insurance. Most Americans don't want the government to run the whole health care system. I don't find anything offensive about single payer and there are several good things about it. But I just don't think it'll ever pass.
MC: The Republicans have been pushing a federal cap on malpractice awards as a way to rein in health care costs. Is that appealing to you?
HD: I think it's unconstitutional, unfortunately. As a physician, of course, I'd like something done about malpractice. But I can't imagine the Supreme Court upholding the notion that Congress has the right to tell the state Legislatures what laws they can and cannot pass and state courts how they're going to enforce them. I think this is just another political move by the Bush administration. They're not serious about this. I have no doubt that if the Senate passed it then the president would sign it. And then it would quickly be declared unconstitutional.
MC: Thank you.