Medicare Expansion

No ‘I told you so’ from Howard Dean—yet

Timothy Kelley
Senior Contributing Editor

Originally a New Yorker, he made his political career as a Democrat in Vermont. He didn’t win the presidential nomination, but sparked enduring energy on the left. And he’s long backed proposals to achieve universal health coverage by expanding Medicare.

Howard Dean

Howard Dean

Of course, we’re talking about Howard Dean, MD, who spent 10 years as a practicing family physician and another decade-plus as Vermont’s governor, ran for president in 2004, and later served as chairman of the Democratic National Committee. As you’ll recall, he balked at dropping the public option from the Affordable Care Act, which became necessary to squeak it through the Senate on Christmas Eve 2009. Dean called the revised bill an insurance industry bailout. And he’d said all along that expanding Medicare was a simpler way to get health care reform.

Now that the ACA’s individual mandate has been scuttled and “Medicare for All” is progressive Democrats’ rallying cry, Managed Care wondered if Dean felt he had an “I told you so” coming.

“Not yet,” he replied, proceeding to splash his fellow Dems with cold water.

“Medicare for All won’t work unless we get rid of fee-for-service medicine—period, end of sentence,” says Dean. “Otherwise you’re wasting your time.”

Dean would “outlaw” fee-for-service and require that medical services be paid for on a capitated basis—though he’d permit an opt-out provision. “If people want to use their money to buy something extra, fine,” he says. “Wealthy people always find their way around a system. But we ought to focus on the 95% who really need help and get to universal coverage.”

That can’t be achieved affordably, contends Dean, without reorienting medicine’s business model so that a hospital’s ICU or cardiac cath lab becomes a cost center rather than a profit center.

“You really need to do some cost control and practice wellness medicine instead of illness medicine,” he says. “And ideally, you do that at the same time you put in universal coverage.”

Some experts disagree—partly. While overutilization of services is indeed one problem driving up costs, says Matthew Fiedler, a fellow at the Brookings Institution’s Center for Health Policy, a separate problem is unit prices: “How much do we pay per hospital stay? Per office visit? Per diagnostic test?

“I think there is a strong policy case for moving away from fee-for-service payment,” says Fiedler. But today’s universal coverage proposals, he argues, are “not targeted at that problem—though there’s no reason they couldn’t be combined with changes to the underlying structure of provider payment.”

No reason, perhaps, except that it’s another hard one—as if St. Patrick, heading out to banish Ireland’s snakes, were suddenly asked: “Oh, could you get rid of the cockroaches, too?” Concedes Harold Pollack, a University of Chicago professor of public policy: “Many of the pathologies of fee-for-service are going to be difficult to dramatically address.”

But Dean sees hope—in a surprising place. He says the ACOs created under the ACA offer the potential—as long as there’s reinsurance—to make care vertically integrated, letting the consumer sign up with a particular health care system for all the care he or she needs. And he’d be happy with any coverage plan that can be enacted—“as long as it’s universal.”

Still, this political veteran warns that the political system will avoid tough choices as long as it can.

“Most people in politics always think of the easy thing everybody wants, which is universal care,” says Dean. “And no one likes to tell anybody how they’re gonna pay for any of it.”


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