Howard Dean, M.D., recently stepped down as governor of Vermont after more than 11 years in office. Before that, he was a partner in a small internal medicine practice.
Now, Dean wants to be the ultimate physician executive: president of the United States.
As the longest-serving governor in Vermont history, Dean relied on his unique qualifications as a physician to enact programs to expand health coverage across the state. When he left office in January, more than 96% of Vermont children and teens had insurance.
Dean did not seek re-election last November so he could pursue the 2004 Democratic nomination for president. Since forming a presidential exploratory committee in May 2002, Dean has been a frequent traveler, traversing the country to preach his messages of fiscal responsibility, states' rights, a multilateral approach to foreign policy and a subject near and dear to him as a physician, universal access to health insurance.
During a Feb. 4 campaign and fundraising stop in Chicago, Dean sat down for a roundtable discussion of his candidacy with Modern Physician and Modern Healthcare editorial staff.
Following is a transcript of that meeting:
Gov. Howard Dean, M.D.: I'm fiscally conservative. I don't believe in the borrow-and-spend, borrow-and-spend supply-side stuff and I'm thoroughly driven by pragmatism.
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?
Dean: I hope so. They need one desperately. The campaign is going very well. When you start out from zero and get to where we are, that's pretty good. But we've got a long way to go.
(Editor's note: Dean's campaign had $156,812 on hand at the end of 2002, according to Federal Election Commission disclosures. He formed his presidential exploratory committee last May.)
I think we really do need a physician in the White House. I think you know why I'm running. It's because of the deficits, and I do want healthcare for all Americans. I think you can have that in a sensible system. And I want a foreign policy that is really going to not be unilateralist. I think it's important for us to cooperate with other countries, and the president never seems to quite do that, except when he's forced into it, and that's a problem.
I don't think we're doing our best with terrorism. I think the fact that we have no oil policy makes it impossible for us to tell the Saudis to stop giving money to Hamas and to stop funding madrassas, which essentially are training the next generation of terrorists.
I think that the war on terrorism is deeply flawed because of the fact that we have no policy that's going to allow us to become more independent from the very people who are funding the folks that want to blow us up.
But, more specifically, since this is probably going to focus mainly on healthcare, I'll give a perfect example of why we need a doctor in the White House. I thought the president's State of the Union speech was deceptive. For him to talk about putting more money into AIDS, having three weeks before at the population conference in Bangkok, trying to get any mention of or discussion of condoms off the table or removed from the resolution is not only hypocritical but disingenuous.
You're not serious about AIDS if you don't permit people to discuss condoms because AIDS is the largest public health problem in the world--the most dangerous. It's certainly not the largest in terms of cases--malaria would be larger--but certainly the most dangerous, and this administration, despite its lip service, is not the least bit interested in dealing with the problem.
This morning I found out when I looked at the president's budget that there is no new money for AIDS. It's all money that's transferred out of other amounts that was going to be going to foreign countries in any case.
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. As you position yourself to try to get higher in the polls and the nomination ...
Dean: We don't know what they are going to propose on healthcare. I'm the first one out with a healthcare plan, which you have covered in here (Feb. 3 issue of Modern Healthcare).
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 reimbursement rates. And I think the American Academy of Pediatrics essentially has endorsed everything that I have proposed.
Versel: Well, you've focused on children, specifically, in Vermont.
Dean: But we do a lot of other things for people in Vermont. If you're under 150% of poverty, you have health insurance in Vermont even if you don't qualify for Medicaid.
Versel: Would that work on a national scale, given that Vermont's per-capita income tends to be below the national average? Would that work on a national scale, in a big city like Chicago, for example?
Dean: It would be perfect for Chicago. Everybody under 23 has healthcare through Medicaid. Those are people who are mostly uninsured right now. That's a very high percentage of the uninsured, particularly between the ages of 18 and 23. They're not going to buy health insurance. If you give them a voucher, they'll buy a Harley-Davidson. And then they will need healthcare. A lot of it.
So, those folks ought to be insured. It's dirt cheap, as we discovered. You do need to raise Medicaid reimbursement rates significantly, otherwise every pediatrician in the place will go out of business. We did do that, and the pediatricians don't seem to have a big problem with what we did in Vermont.
Over 65, you need a prescription benefit plan. It can't be the Republican plan, which doesn't work because it privatizes it.
Versel: You're talking about the drug card or something beyond the drug card?
Dean: What the Republicans proposed and passed in the House was to privatize with insurance.
And it can't be the Democratic plan either, because it was too expensive. You can't have an $850 billion plan. That's just not going to work. 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. It has to be a medium.
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, that kind of thing.
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. If you want to opt out, go ahead. If you want to buy supplemental insurance or "concierge" medicine or whatever it is, you know, be my guest.
Charles S. Lauer, publisher, Modern Healthcare: Boutique. Boutique medicine.
Dean: But, I think everybody needs the same benefit package.
Todd Sloane, assistant managing editor, op-ed, Modern Healthcare: What about drug price controls, using the federal government's power?
Dean: I'm not in favor of drug price controls because there is a much better way to do it, and that's through the market.
The reason that drug prices are outrageous is because the drug companies have managed to exempt themselves from the competitive forces of the marketplace by using their political power to influence legislation and to influence rulemaking.
I'll give you examples: With NAFTA, you can go buy an automobile from Canada but you can't buy your drugs. Now the notion that somehow Canadians pay less attention to safety issues than Americans is ridiculous on its face. Anybody who knows anything about Canada knows that that's absurd. So the safety arguments are nonsense. It's simply anti-competitive.
Secondly, (pharmaceutical companies) are suing Michigan and HHS, and we are part of this, for having the Medicaid program try to go out for bid. We've said we will put on the preferred drug list drugs from those companies that give us the best price. They claim that's against the Medicaid rules.
Thirdly, they have a deal on patent protection that nobody else in the world has. That is, they can get their patents automatically extended simply by claiming somebody is violating them. Nobody else has that kind of patent/intellectual-property protection.
Fourthly, they don't advertise on price. You see lots of advertisements for cars, but you've never seen a car advertisement without either a dollar figure in it or an APR price-interest rate. You've never seen a drug ad with a dollar figure or an APR drug rate. You've never seen a number in a drug ad.
Versel: In many ways, that's because the public just thinks that the $10 co-pay they make is just what the drug costs.
Dean: That's right. That's part of it. And that's a problem.
So, I think simply making drug companies comply with the same rules that everybody else has to, that when they (have competition) to their products, it will be enough to lower the price of drugs.
I don't, to my knowledge, even believe--and I could be wrong about this--that Bristol-Myers (Squibb Co.) is being prosecuted for essentially bribing a company not to make competitive products. Are you familiar with that case? Bristol-Myers (allegedly) was paying $55 million to--I forgot who it was--so they wouldn't make a generic equivalent. If ever there was an anti-competitive practice, that's it.
(Editor's note: In January, Bristol-Myers Squibb settled antitrust suits brought by several state attorneys general for a total of $670 million.)
So you don't need price regulation. You simply need to subject the drug companies to the same competitive pressures that everybody else has to deal with and prices, I think, will come down.
Joseph Conn, editor, Modern Physician: Is that program that you had there in Vermont, where you basically had a group there sending people with prescriptions across the border and coming back, is that still running there?
Dean: We do it over the Internet now. We do it over the 'Net so people don't actually have to go.
Versel: Being a border state, how many people in Vermont actually buy their drugs from Canada?
Dean: I don't know. It's not a large number because it works fine for chronic problems but not for acute, first of all. Secondly, it tends to put the local pharmacist out of business. What I want is to be able to have the wholesalers buy their drugs from Canada. What would put the local pharmacy out of business, what's the point of doing that?
Lyle Berkowitz, M.D., Modern Physician editorial advisory board: So you just want the pharmaceutical companies to lower the price so they can sell . . .
Dean: If we were able to get rid of all the anti-competitive regulations and laws, that's what you could have.
Bell: But going back to staking out your position, 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. And I'm not interested in reform because we've tried reform three times: Truman, Carter and Clinton. It failed all three times.
What we need is to get everybody in and then let's have a big fight about how to reform the system. But if we have that fight beforehand, the interest groups will cut each other up and there will be no addition of the 42 million (uninsured) people to the system.
Now the system that I am advocating supports the private sector. Instead of having all the interest groups in medicine fight the plan, the doctors should like it because they are going to see a lot more compensated care. The hospitals should like it for the same reason.
The insurance companies should like it because between (ages) 23 and 65, the government is actually making it easier for people to buy their product, although there have to be some limitations on the product. It can't be just (major corporations like) IBM or GE, otherwise IBM or GE would just dump all of their people into the government system. It doesn't work.
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. The purpose of the plan is not to make sure that nobody ever pays for healthcare, it's to make sure that no family ever goes bankrupt because they have big healthcare bills.
Bell: Is it funded through a payroll tax? I mean, what's the mechanism?
Dean: It wouldn't have to be. You could fund it right out of the Treasury if you get rid of the president's tax cut, or most of it, because the president's tax cut costs about twice what this costs.
Berkowitz: 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 a hypertension check and the sort of routine care that is internal medicine-based that's not common for well patients?
Versel: ... especially for pediatrics?
Dean: Well, pediatrics, of course, is not going to be a problem because everybody under 23 is going to have Medicaid, which we're not advocating changing. 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, acute care expenses--pharmacy and acute care." You can't take over the nursing home care because the federal government would do a terrible job regulating nursing homes. You're much better off having the states do it.
Berkowitz: So for the average adult, I understand the concept of wanting to cover catastrophic care, but you'd rather get them when they are hypertensive than when they have their MI (myocardial infarction) and need a CABG (coronary bypass surgery). How do you do that?
Dean: You'd have to structure the program so that they can come in, but if you give them the same package you're getting from IBM, you're going to end up with a huge government-run system, and I don't think you want to do that. Or maybe you do, I don't know. I don't think I want to do that.
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.
Versel: You're talking about privacy or the whole deal?
Dean: Well, it's the bureaucratic part that makes it difficult. My wife (Shelburne, Vt., internist Judith Steinberg, M.D.,) is more of an expert on this. My wife, as you know, is a physician. She's not a politician. She isn't going to campaign with me, although she will do interviews, because she's going to practice medicine. And if I win, she'll also practice medicine. She's just not a political person.
But I do hear about HIPAA. And like every other government program, HIPAA is always toughest--those kinds of programs are always toughest--on small offices.
And it's not just the government that does this, it's the private sector that does this, too. HMOs make it really difficult on small offices--small, rural offices with two or three or five or six people it them. And HIPAA has had a lot of unintended consequences that make it prohibitive and much more expensive to do business and much more bureaucratic.
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 toward making it work for small offices.
The other thing I can promise you is that if I get elected president of the United States, you're going to have a physician who's actually practiced medicine running HCFA or CMMS, or whatever it's called now.
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 to go after malpractice-related . . .
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: Pennsylvania, New Jersey now, Nevada, Mississippi, those are some others. So, the doctors have no choice. They can't practice if they can't make a living. So how could you blame them?
Bell: But is a strike a feasible way to achieve this?
Dean: (It's) the only way to get the legislatures' attention; they haven't paid any attention to this problem. How could you blame them?
And I don't think they're on strike anyway. What they're doing is, they're not refusing to treat patients under emergency situations. What they are saying is, "We can't practice under these situations." And they're right. It's why the trauma center in Las Vegas shut down. What other resort can there be?
Versel: Are you looking for a national fix, as far as tort reform, or state-level?
Dean: I hate it when the national government decides what's best for every state. It's why I oppose the president's education bill. It makes education worse rather than better. Ohio, for example, dumbed down their standards so that 200 schools would come off the failing list.
I hate it when the federal government goes in and tells the states how to run every last little thing. And they all do it, whether they are Republican or Democratic presidents. It's more annoying when the Republicans do it because they always promise not to do it when they get in, but they do it anyway.
So, I don't want a national tort reform. I mean, product liability may be a different issue because medical practice is controlled by the states. I think that's a good thing. I don't think you want a federal license for doctors. I think it's good to have it be a state issue, regulated by states.
People from California and Illinois and New Jersey or New York may complain because they are big states with big bureaucracies, but 40 out of the 50 states are small. It's why I prefer to run my program for kids through Medicaid, not Medicare. I come from a small state. Most doctors in Vermont would far prefer to have to deal with Medicaid than Medicare. Medicaid is down the street. You can call the director. Even though the reimbursement level is lower, you get the check.
(Turning toward Berkowitz) You've all gotten those notices saying if you don't turn your whole office upside-down in six months, you're going to jail with a $20,000 fine. What is it called now? CMS? They've changed the name but the performance hasn't improved.
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 do something in this arena? It's becoming a national crisis, even though it's often brought up in certain states.
Dean: I'm not really sure it is a national crisis. I think it's about eight states, right?
Versel: The AMA says it's 12 states, I believe.
Dean: California has already acted. California has, what, a ($250,000) cap on pain and suffering and punitive damages?
Berkowitz: Well, there's tort reform and insurance reform.
Dean: Insurance reform is a different problem.
David May, assistant managing editor, features, Modern Healthcare: Right, and that I'd like to hear about.
Berkowitz: Tort reforms aren't going to work without insurance reforms.
Dean: 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. That does happen, and they are absolutely right about that.
What the trial lawyers are not right about is that's not the sole cause. (Another) cause is the dramatic increase in jury rewards gets masked at times when the stock market value is rising. And it all of a sudden is unmasked with a huge bang when the stock market falls because now they can't fix the problem by subsidizing the premium growth from the stock market increase.
What kind of insurance reform would you have in mind, though?
Berkowitz: That's not my job (laughs). I have read that there certainly are plans out there that may work, and, believe me, that is not my specialty.
Dean: Let me tell you what the issues are. I'm very leery to have the federal government do anything with insurance. Here's why: We (in Vermont) have community rating and guaranteed issue. The reason we do is that I once had a patient who had Golden Rule insurance. She was 35 years old, she was diagnosed with diabetes and as soon as they heard of that particular (condition), she was cut off.
After that, we had community rating and guaranteed issue. Golden Rule left the state and I was delighted. Those folks don't sell insurance, they sell security for the wealthy, I mean for the healthy. And the wealthy. For the healthy, when you get sick, you discover it's not really health insurance. We don't want that.
But there are a lot of states where the conservatives don't like community rating and guaranteed issue. Do I want a conservative president telling my state we can't have community rating and guaranteed issue? So we have to be very careful letting the federal government in the door to start regulating insurance companies.
Right now, the president has suggested basically a fancy version of something that used to be called MEWAs (multiemployer welfare associations) which is you can get insurance through a group, but the group doesn't have to have any reserves. Most states won't allow them to do that because they know that this is an insurance company that has no reserves and that they have losses that are higher than their premium income, they are out of business.
But the president thinks that's fine. Well, do we want to trust the president to regulate the insurance business if it's not really insurance business? So you have to be very careful when you say federal insurance reform, that's why I asked you what you meant.
Berkowitz: My question actually wasn't what should be done but do you think the federal government has a role to start looking at this?
Dean: We can always look into it, but the solutions from the federal point of view are going to be very difficult.
Bell: You've been on the trail now for a couple of months actively. What's your feel or take on just how important healthcare is going to be as an issue?
Dean: It's huge. The reason why it's huge is because the economy is such a huge issue and middle-class people are very insecure about losing their health insurance. The vast majority of Americans still have health insurance, but there is a big number of people that are scared they're going to lose it. And that's why it's a big issue.
Bell: Compared to the war, education, unemployment, where does it fit in the scale?
Dean: I think it fits just behind those three. I'd say it is the fourth-biggest issue.
Bell: What possesses you to run? You're a physician, from a small state.
Dean: I think the country is in enormous trouble. I call the president's fiscal policy Argentine fiscal policy: borrow and spend, borrow and spend, borrow and spend. It's a disaster for the country.
Lauer: (laughs) You and I disagree.
Bell: You disagree that it's OK to borrow and spend and borrow and spend?
Lauer: I don't see it that way.
Dean: What is it? The deficit is going to be a trillion dollars higher than it was in another three years, two years. I mean, can you imagine?
Bell: But, so, you're giving up a lot of time. You have to raise money, all the hassles of being a candidate, when . . .
Dean: I care about what happens to the country. I have two things that I could do. I could have a lovely time reading the New York Times and be on some boards, or I could do something about it. I don't see the Democrats doing anything about it. The Democrats are all terrified. They hardly ever contradict the president, and when they do, they do it in meaningless ways. They're not going to touch healthcare. They're not going to do anything about healthcare.
Well, they will now, because I'm in the race and they all know that they have to do something about it.
May: Governor, what's your price tag on your plan?
Dean: My plan, half of the president's tax cut.
Sloane: So, $675 billion?
Dean: No, you might want to write $0.7 trillion over 10 years, although really you've got to look at over five years because, if I were to get into office, half of that tax cut would be spent already. So if you do a five-year spending curve, it's about half of the president's tax cut.
Lauer: 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. There's not one person in the race, Republican or Democrat, that's balanced a budget. . . .
There are no deficits in Vermont. It's the only state in the country without a requirement that you can't run a deficit and it's the only state that's not because we put a ton of money aside in a rainy-day fund and we paid down a quarter of the debt. . . .
Our accounting at the federal level--this is not just the president, although he's much worse than his predecessor--but our accounting at the federal level for many years has been far worse than Enron's. Far worse. I mean, it's just, "Cover it up." They do outrageous things, sliding money around. They have no idea how to manage money at the federal level.
Lauer: How about tax-and-spend. Do you know anybody that likes to tax, raise taxes and raise taxes?
Dean: I think taxes ought to be back to where they were when Bill Clinton left office. But I didn't raise taxes much when I was governor. We cut the income tax, we cut the marginal rate 30%, but that was because we had the highest marginal rate in the country. You can't get jobs to come into your state. I'm not a big tax cutter.
The second round, I wouldn't let them cut taxes much. We cut the income tax 4% and we cut the sales tax. We got rid of the sales tax on shoes and clothing. But then I saved the money and used it to pay down the debt because I knew that if you gave excessive tax cuts, someday the business cycle would come to an end and then we'd be in trouble.
So many governors have given huge tax cuts and the fiscal condition of the states is atrocious. It's not true in Vermont. We went from the worst bond rating in New England to the best.
I really think that if you want social justice, you have to have a balanced budget. Because what happens, 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 those people that need it the most, right when they can least afford to have them cut.
If you want to have social programs that make sense, first of all, you shouldn't build them up too fast. Second of all, you've got to limit spending in the good times so you'll have some money in the bad times. And every American family knows that, it's just the government that can't figure that out.
Conn: The healthcare industry is 20-some years behind in infrastructure for information technology. There has been talk about all sorts of different things: Marshall Plans, I think Lyle mentioned a new Hill-Burton plan for investment.
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. We definitely need a total infrastructure overhaul, there's no question about that. But you cannot justify a Hill-Burton Act for more infrastructure paid for by additional percentage of the budget.
Versel: Does the federal government, though, play a role in shaping what that infrastructure is? From my perspective, reporting on clinical information technology, one of the biggest gaping holes in all the HIPAA law and regulations is that it does not define what a medical record is.
Dean: I agree with that.
Versel: What role does the federal government play in shaping information technology infrastructure in healthcare?
Conn: And add to that, the latest IOM announcement that they thought there needed to be a role for the federal government in setting some standards for that.
Berkowitz: Most of the bills in discussion, part of it is standards. First thing is, does the federal government need to set national standards because you have all these competing information technology systems? A lot of money is being spent on IT now in healthcare, and a good 20% to 30% of it is in trying to integrate the systems.
The second part of it is funding of some sort that might be like the Hill-Burton Act, but some of it is just spending some money, and not a lot, on developing standards that we can start using because all my concerns about the plan that you are proposing are about putting money into universal healthcare coverage and then reforming later. We've got to start thinking about at least what are we thinking about to reform in information technology as we move forward: quality, efficiency, etc.
Dean: Let me tell you where my great interest is in healthcare modernization. If we are going to standardize IT, I want some kind of a system where Wennberg's data (in the Dartmouth Atlas) comes up on the screen every time you open it up. I think what we do, or what we don't do, in this country in terms of saving the waste that goes on in medicine simply out of ignorance is appalling. And we've got to figure out a way so that Wennberg's stuff is known. It's just that knowing that alone will alter practice patterns, and it makes a difference. . . .
Berkowitz: The similar argument to healthcare coverage is that we have to get people using the systems before we can attempt to do a major change in quality.
Dean: You've got to have the information available.
Versel: Are you looking at quality or efficiency?
Dean: Both. Both. Now, I think the right way to do this is to do what the states are doing on a totally unrelated matter, which is Internet taxation.
What the states have done is to put together a group of, I think it's about 30 states now, for synchronizing an approach to the sales tax so that eventually when the issue of taxing the Internet really comes to the head, which is going to be soon, there is this uniform set of sales tax rules--not how much you can tax, but what falls into each category.
That's a better process than having Congress pass a standardized IT law. It's getting the states together for themselves and having them hash out for themselves what the best approach is.
Congress almost never does anything constructive when it passes national standards. Look at the president's education bill. It's a complete disaster, a huge unfunded mandate, and Ohio just dumbed down their standards to get more schools off the failing list, which means basically that the president's bill made things worse, not better.
That happens every time--and it really, frankly does not matter much whether it's a Democrat or Republican doing it--when the federal government gets in and starts to regulate. 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.
Versel:Still, though, the largest payer in America is Medicare, and some policy is going to have to come out of Washington.
Dean: Well, there was a policy, which apparently is roundly ignored. At one point there was a law that said that every insurance company in America had to use the same forms as Medicare. Now maybe it wasn't nationwide, but it certainly passed in Vermont. I don't think anybody has paid a bit of attention to it, because insurance forms are still not standardized.
Berkowitz: What do you think about going back to good old capitalism to make quality a priority? Are you familiar with the Leapfrog Group?
Berkowitz: They are a group of large employers who are going into cities and saying, "Look, you have to have computerized physician order entry."
Dean: I think that's great. I think that's terrific.
Berkowitz: Now, should the federal government become involved with a group like the Leapfrog Group?
Dean: I have a lot more faith in standards developed by people who are paying the bills than I do by the federal government. The federal government almost never gets it right in medicine. They just don't.
Berkowitz: It's not developing standards, it's just saying that if you show that you that practice at a higher level, however you want to do it, you will be reimbursed at a higher level.
Dean: I probably don't react as strongly to government intervention in any field except for medicine because I have had to live under it.
I'll tell you guys a great story. You will love this story (turning toward Lauer).
When I became governor, I had to give up my practice, obviously. I became governor because the (previous) governor died. I was lieutenant governor, which is a part-time job, and was actually doing a physical when it happened.
As you know, I practiced with my wife and another partner. So, a month or so after I became governor, I had to take a trip to the southern part of the state. So I get in the car and I'm being driven down. And the phone rings in the car. It's my wife, in a tone of voice that everybody who's married understands: What her problem is, is now my problem, and I'm responsible for fixing it.
The gist of this is that the bookkeeper is in tears. She's gotten a notice saying everybody in the office is going to go to jail for 20 years and get a $20,000 fine if such-and-such doesn't get fixed. Well, CMS, or that time it was HCFA, screwed everything up and it was a disaster. There was going to be an audit. You know how those notices are: They threaten you with everything but the guillotine.
So I said, "No problem. I know the person who runs Medicare in Vermont. I'll call them and we'll get this all straightened out." So I get on the phone. It was about an hour-and-a-half drive. So get on the phone and I call the Medicare office in Vermont, and I get a recording saying, "We're sorry, we're only open on Tuesdays and Thursdays. You have to call Maine."
So I call the number in Maine and I get a very nice person who says, "Excuse me, look, Doctor, I'm very busy. Can I put you on hold and I'll be right back to you?" It was a live person; I was stunned.
So 10 minutes goes by and the voice comes on again: "Well, I'm very sorry, but everybody's tied up. I'll be right back to you."
Finally, we make the turn around White River, we're now heading to Brattleboro and I've only got about 40 minutes left in the car ride, so I'm getting nervous that this isn't going to get fixed and I'm going to have a very difficult time of explaining this when I get home.
I do something I just hate to do and I'm still embarrassed to talk about to this day. I almost never have done anything like this when I was governor. The lady comes back on and starts to say, "Excuse me, it will be another 10 minutes," but I said, "Wait! Wait a minute! I'm not just some doctor. I'm the governor."
Lauer: All right!
Dean: And she says, "Well, it will be 10 more minutes." (laughter) That's a true story.
I don't have a lot of faith in the federal government to regulate much in medicine. It's important. They have to do it, but if we ran our offices the way they run HCFA or CMS, none of us would be in business ever again.
Berkowitz: I wondered about your opinion on another successful physician executive in politics, Sen. Bill Frist (M.D., the new Senate majority leader).
Dean: You know, I don't know him, I don't think I've ever met him, and I don't know much about his politics, so I guess I don't have an opinion.
Sloane: I wanted to talk a little about Medicaid. One of your successes was insuring children in Vermont. Obviously, a lot of what happened with Medicaid was that they expanded the program and they cut taxes. Now they are in a situation where the states can't afford Medicaid and a lot of the expanded services.
The president in his budget now cuts SCHIP (State Children's Health Insurance Program), as I understand it. How are you going to expand coverage in this fiscal climate we are in now?
Dean: Well, you're going to get rid of the president. (laughter)
I don't think for a moment that President Bush is interested in helping children get healthcare. You need a presidential change when you have this deficit. It won't be fixed under this president. Imagine, the president would cut healthcare and then go spend $50 billion on a war in Iraq. Healthcare for kids. Imagine that.
Conn: You have a reputation for speaking in a rather blunt sort of way. I just noticed a couple of William Tannerisms: "Here's why, here's how," that sort of thing. Do you think someone like that could get elected president of the United States, and if so, why?
Dean: Because I think people are sick and tired of . . .
Conn: You (angered) the Saudis already. I know they're going to wrench off the oil spigot on you as soon as you get elected.
Dean: Well, if we could conserve oil, we wouldn't care. We'd be able to tell them to stop misbehaving themselves.
Look, I think that people are tired of politicians who put their fingers in the wind and see what the polls show.
Lauer: Let me ask you this: When I first heard you speak, I was very impressed. You're the first guy I've ever heard, really, in years, make sense about healthcare and I thought your priorities were right there. I don't know where it was that I saw you speak, but it either was on C-SPAN or something. The fact that you are a Democrat normally would usually turn me off.
Dean: Maybe I have.
Lauer: No you haven't. But as I listen to you, you were definitive, you said it with great passion. You seemed to waffle a little bit when we asked about the single-payer system this time. That time I heard you speak, you said definitely no single-payer system. It wouldn't work. This time, you meandered a little bit. You said, well, maybe if we didn't have anything else, maybe we would do the single-payer system.
Dean: Here's why I meandered a little bit on that one: I'm not a fan of the single-payers, I think I said.
Dean: But I have promised and I have told--you know, there is a big division in opinion in the Democratic Party.
Versel: You know, (Rep.) John Conyers (D-Mich.) today (Feb. 4) proposed a single-payer plan?
Dean: I respect John Conyers, but here's the deal on the single-payer: What I have said is that we cannot allow a fight over how to reform the system to stop us from getting everybody access. So if I say completely no way, no how to single-payer, it makes it impossible for me. I need the single-payer advocates to vote for whatever we're gonna get.
What happened in 1993 is I had a program to help everybody get insurance and the single-payer people killed it. It wasn't the Republicans who killed it, it was the left wing of my own party. So I've got to get the single-payer advocates.
Everybody knows the single-payer is not going to pass in Congress. If anybody doesn't know that, then they need a political re-education course. So I've got to get people all the way from the left to the center to vote for something.
As I said before, we're not going to have every interest group in health fight this thing. Most of the interest groups are going to be a net beneficiary. Even General Motors and the UAW (United Auto Workers union) are going to be beneficiaries, because there is going to be less uncompensated care and less cost-shift; so even though they're not going to get any direct subsidies to buy health insurance, they aren't going to have to pay the cost-shift portion of their premium increases.
The disadvantaged people would be the people who make incomes over $300,000, which is where you would have to get the money because that's where the bulk of the tax cut went. And that's about it.
Those folks, that money, instead of going into the discretionary income of people who have lots of discretionary income and then didn't stimulate the economy by spending money, it goes to small businesses and improves their balance sheets and helps to build a more stable workforce, which I personally think is going to do more to stimulate the economy than giving it to individuals.
So this can pad and it can help the economy, and it makes sense to people; and it's existing systems, so nobody has to think they're going to lose their insurance or lose their quality or have the government run their plan or any of that kind of thing that people don't like.
So if I trash the single-payer system and say no way, no how, it makes it impossible for me to hope that someday John Conyers and (Rep.) Jim McDermott (D-Wash.) might vote for this as a second choice.
Lauer: Well, you started off by saying that you are a pragmatist.
Dean: I am a pragmatist. So the reason why I wasn't as tough on the single-payer as I was six months ago is not because I've changed my opinion, it's because I know that I have to build a coalition with those Democrats that want a single payer. Because if they take the position that we are single-payer or nothing, then 42 million people are going to be out of health insurance for another 10 years.
Lauer: I think the stars are lined up, and I think something significant in healthcare could happen in the next two years.
Dean: And this wouldn't wreck the system. And unlike some people, I think there is a system. It's basically three ways we finance healthcare: Medicaid, Medicare and the private sector. And I'd just leave all those intact. We can have a big fight about how to fix that later, but let's get the 42 million people who are not in the system in the system first.
Sloane: In a practical sense, at the end of the last campaign finance cycle, you had like 150-some thousand dollars and I think (Sen. John) Kerry (D-Mass.) had $3 million.
Dean: He's spending his faster than mine, and I've raised as much in this month as I raised in the previous year.
Sloane: So what is your fundraising approach? Kind of a toll-free number type of thing?
Dean: No, we're doing the Internet. We're raising a lot of money over the Internet. What's interesting is that there was poll, a New York Times online poll. I'm second in the poll now. Now it's not scientific at all, but people who cruise the Internet know about me and like me. There's a huge movement out there on the 'Net, which we're not encouraging. We haven't even e-mailed our people and said, "Oh please, go vote in the poll." I was shocked when I saw it.
I think there are a lot of ordinary people out there who are not all that in to politics who are interested in what I am saying, partly because of the way I say it. There's not many people who don't know where I stand on an issue when they get done. They may not like it, but most people in America would rather know where you stand than think that you are going to say this here and that there and this thing once and maybe I'll appeal to someone else the next time.
Bell: Well, there also are a lot of groups, organizations and companies that would benefit theoretically from your healthcare plan, if, in fact, there is a net gain for everybody out there. What about raising money through the associations and the companies? It's a double-edged sword, I realize, but it's also a deep-pocketed . . .
May: Well, you actually can't do that.
Dean: Well, you can, I guess. You cannot take corporate money in a presidential campaign, and I'm not going to take political action committee money.
Bell: OK, no PAC money, then.
Versel: You've got your own PAC (Fund for a Healthy America), though, don't you?
Dean: I do.
Versel: How is that going to affect you?
Dean: What that's for is supporting other candidates. Part of the deal is that when you go to Iowa, they expect you, basically, to pass out a little money, and that's what that is for.
Berkowitz: Any other thoughts on the lot of real working physicians out there? If they want to get more involved in politics or, you know, if they have things to say, what's the best way for the readers of Modern Physician, especially, to get out their thoughts and messages?
Dean: We're on the Internet: www.deanforamerica.com. They can even give if they want. There are two portals. One, they can e-mail us and get on our list and find out what we are doing, and the other, you can put in your credit card and give us anything up to $2,000.
Bell: What else brings you to Chicago?
Dean: Well, a meeting with the mayor (Richard M. Daley), which everybody has to do that's running for president, and I was happy to do it, and some fundraising tonight and some meetings during the day.
Bell: Well, on behalf of my colleagues at Modern Physician and Modern Healthcare, we appreciate your time. Thank you for giving us the opportunity.