In January, Howard Dean, M.D., stepped down as governor of Vermont after more than 11 years in office. Now, Dean wants to be the ultimate physician executive-president of the United States. Since forming a presidential exploratory committee in May, Dean has traversed the country, preaching his messages of fiscal responsibility, states' rights and a subject near and dear to him as a physician: universal access to health insurance.
During a Feb. 4 campaign stop in Chicago, Dean sat down for a roundtable discussion with Modern Physician and Modern Healthcare editorial staff. Following are highlights of that meeting:
Clark W. Bell, publisher, Modern Physician: We called for this opportunity just to see what you are up to, see how the campaign is going, ask you a few questions . . .
Neil Versel, reporter, Modern Physician: And find out, is America ready for a physician in the White House?
Gov. Howard Dean, M.D.: I hope so. They need one desperately.
I think that we need a real commitment to health in this country. We don't have one. We don't have any method, for a plan to privatize Medicare is lunacy. And that's just more ideological nonsense from the Republicans. We've just got to stop this stuff.
Bell: You're a long way away from running against President Bush. You've got a whole field of Democrats to work your way through first.
Dean: We don't know what they are going to propose on healthcare. I'm the first one out with a healthcare plan. The thing about the healthcare plan that I'm proposing is that, as you may remember in 1993, "Harry and Louise" came out and said, well, people are going to give up their quality and they're going to give up their choice of physician.
All I'm doing is what we did in Vermont, which is to expand the existing system. We use Medicaid for everybody under 23. We raised Medicaid reimbursment rates. Over 65, you need a prescription benefit plan.
It can't be the Republican plan, which doesn't work because it privatizes it. And it can't be the Democratic plan either, because it was too expensive. It has to be a plan that makes sure that nobody goes broke but doesn't cover every last nickel of people's drug coverage.
Versel: How do you do that?
Dean: You make sure there are co-payments and deductibles and advantages for people who use generics over brand names.
Bell: How about means testing?
Dean: I don't support means testing because there is a fairly small percentage of people who would be means-tested out. I think this needs to be a program that is not about welfare or poor being poor. It needs to be a program for everybody.
Bell: I take it that a single-payer system is not necessarily what you advocate?
Dean: It's not what I advocate for two reasons. First of all, I don't happen to think that's the way to go, although if you had that or nothing, you're going to choose that. But I don't happen to think that's the best alternative. And the second is, you couldn't possibly get it passed. I'm only interested in something I can get passed. It has to be a catastrophic (coverage) plan. My idea is first-dollar coverage for things like Pap smears, mammograms, colonoscopies--all the things we all hate but that have clear preventive values. And then big deductibles.
Lyle Berkowitz, M.D., Modern Physician editorial advisory board member: I understand what you are talking about, preventive care procedures, but the idea that if you have a big deductible, is the patient going to go in for routine care?
Dean: The way you get to the states to do that is you don't make them, because I hate unfunded mandates. You say, "If you do this up to 23, we will take over your expenses for those over 65."
Versel: Speaking of unfunded mandates, that's what a lot of people are calling the HIPAA regulations.
Dean: I think the HIPAA regulations are ghastly and they have to be fixed. I don't want to get rid of all of HIPAA, no--we clearly have to protect patients' privacy--but I'd like to look through the whole thing with an eye towards making it work for small offices.
Bell: As a physician in a leadership role, what's your take on docs in New Jersey just being the latest state to go on strike?
Dean: I actually think it's a good thing. Here's why: I don't think that federal tort reform makes sense or is right, because the situation in New Jersey is not the same as it is in Montana. But I think the legislatures have to get the message that there is a huge problem in some states.
Bell: But is a strike a feasible way to achieve this?
Dean: (It is) the only way to get the legislatures' attention; they haven't paid any attention to this problem.
Berkowitz: When we talk malpractice reform, there's tort reform, insurance reform. Do you think the federal government has any role, perhaps to set some standards or to give states some monies to do something in this arena?
Dean: Insurance reform is a different problem.
Well, the question is, what do you do about insurance reform? And the basic mechanism is one thing the trial lawyers are right about.
The basic mechanism, other than the runaway juries and all that, that's causing this problem is that it is absolutely true that when market values go way down, they stop subsidizing the premiums with their proceeds from the stock market, and therefore they've got to, in order to stay in business, raise the premiums dramatically.
What the trial lawyers are not right about is that's not the sole cause. The (primary) cause is the dramatic increase in jury rewards gets masked at times when the stock market value is rising.
Charles S. Lauer, publisher, Modern Healthcare: So, the reason why you've gotten into the presidential race, is your highest priority healthcare?
Dean: My highest priority is a decent foreign policy and then somebody who knows how to balance a budget.
I really think that if you want social justice, you have to have a balanced budget. Because what's happening, as is happening all over the country, is, now that we've fallen off the cliff financially, what's getting cut? All the programs for the people that need it the most, right when they can least afford to have them cut.
Joseph Conn, editor, Modern Physician: The healthcare industry is 20-some years behind in infrastructure for information technology.
Berkowitz: Right, five or six key congressional bills have been bandied about, sort of like analogous to the Hill-Burton Act, to say that we need a national healthcare information infrastructure.
Dean: Let me just take a very hard line about this. We're at 15% of GNP (devoted to healthcare expenditures). If we're going to fix the infrastructure, we're going to find the IT money in existing money.
Versel: What role does the federal government play in shaping information technology infrastructure in healthcare?
Dean: Congress almost never does anything constructive when it passes national standards. So why not have the medical practice boards start to deal with this or the medical societies come forward and let them propose the kinds of IT standards that they need?
Click here for a transcript of the complete interview.