The noontime rally in Chicago was a tough one for Democratic presidential hopeful Howard Dean, M.D. It was the second-to-last stop on his four-day, 10-city Sleepless Summer campaign tour and a typically sweltering late August afternoon on Lake Michigan.
Dean took the stage on a blazing, shadeless rooftop at the end of Navy Pier.
The 54-year-old former governor of Vermont was hoarse and coming off the high of an especially rowdy and responsive crowd in Bush country the night before. Campaign staffers and media correspondents alike remarked on Dean's special connection with his San Antonio followers, who cheered at every red-meat applause line.
But in Chicago, Dean was running late from a speech to the Communications Workers of America convention a few buildings away, keeping the anxious supporters sweating in the sun. When he finally took the stage, he just couldn't find his rhythm or his voice. After missing too many of his own cues, he launched the stump standby.
"Surely, the most wealthy and powerful society on the face of the earth can join the British and the Germans and the Japanese, and the French. The Italians, the Irish, the Israelis, the Canadians, the Norwegians, the Swedes--even the Costa Ricans--have health insurance for all their people."
It's just what the crowd was waiting for, and Dean's words were drowned in the cheers.
Dean insists on rescinding the Bush tax cuts to finance an incremental expansion of government healthcare programs and employer incentives to provide all Americans with health insurance.
Healthcare for all, while a natural cornerstone of the internist-turned-politician's platform, takes varying slots in his stump lineup, which includes jobs, the economy, foreign relations, the war in Iraq and a hearty helping of Bush-bashing.
Whenever universal coverage comes up, Dean touts his successes in Vermont and saves the details for later.
"We'll have the big fight about how to reform the system after everyone is covered," Dean said at a community center meeting in Spokane, Wash.
Even though Dean's tendency is to be wonkish, his healthcare policies seem to lack concrete particulars. That's because the bulk of his energy now is directed toward winning the nomination, aides say.
But he is indeed laying the groundwork for the "big fight." For this, Dean has tapped into a brain trust of notable physician executives, industry analysts and experienced government staffers.
The three tiers
The health policy quarterback of the Dean team is Peter Van Vranken, who joined the governor's staff in Vermont three and a half years ago to serve as his eyes and ears on health policy in the statehouse. He continues to work for Dean's presidential campaign, technically as an outside consultant. He coordinates the drafting of national health policy and the work of Dean's inner circle of health policy advisers.
Van Vranken brings experience and contacts to the process from Washington, D.C., where he worked for Sens. Paul Simon (D-Ill.) and Herb Kohl (D-Wis.).
Among those in the center of that circle is volunteer Larry Lewin, whom Dean called on for help in February. Lewin is the semi-retired founder of The Lewin Group, a healthcare and human resources consulting firm based in Falls Church, Va., that performed the cost analysis for Dean's $88 billion-per-year health insurance plan.
By mining the formidable relationships with healthcare luminaries that Lewin has built over three decades and Van Vranken's understanding of Dean's political thought processes, the two have developed a three-tier method for expert vetting of his ideas for healthcare reform.
According to Lewin, joining him and Van Vranken in the inner group are the unabashed Howard Dean supporters who are not afraid to say so publicly, the people with whom policy drafts are shared and improved. They include:
- Gilbert Omenn, M.D., former CEO of the University of Michigan Health System and a professor of internal medicine, human genetics and public health at the University of Michigan, Ann Arbor;
- Donald Berwick, M.D., president and CEO of the Institute for Healthcare Improvement in Boston;
- Nicole Lurie, M.D., principal deputy assistant secretary of HHS under President Clinton; and
- Jeffrey Koplan, M.D., former director of the Centers for Disease Control and Prevention and currently vice president for academic health affairs at Emory University, Atlanta.
"We thought it was important to organize a team of advisers before the good people got gobbled up by other campaigns," Lewin says. "These people have a lot of experience. They're not a bunch of kids."
The third tier, the "public utility" group, as Lewin calls it, is a "vast" number of people who are not prepared to say Dean is their man but who are willing to share their expertise with anyone willing to ask for it.
"When an idea comes up for a talk or position, Peter and I work to see who will draft it," Lewin explains. For example, drafting Dean's recently released policy on mental healthcare, Van Vranken calls recent Hill staffers in Washington who spread the word among experts in the mental health community. When the right person offers to help, Van Vranken asks him or her to draft a policy using a "short and sweet" template.
He edits it to be sure it corresponds with Dean's philosophy and vision for the future and gets the green light from Dean. Then Lewin's top health contacts get to work vetting.
The process is time-consuming but well-organized, Lewin says.
"I'm very respectful of (Dean's) instincts," Lewin says. "I give credit to the governor that he isn't just looking for sound bites.
"A, we have to be sure they're things he believes in--and he has some pretty strong beliefs--and B, he is willing to expose his views on health policy to people who have been around the track."
Lewin says the campaign is organized to give people freedom and room for creativity.
"Things get cleared quickly because the governor is so much on top of them."
Keeping it simple
When Van Vranken needs additional physician perspectives, he consults with members of Doctors for Dean, a network of physicians involved in fund-raising and recruiting more healthcare providers to support their candidate.
Of 400,000 people who have formally endorsed Dean, 4,037 donors had identified themselves as physicians as of Sept. 9, Van Vranken says.
Traditionally, most doctors have not been very political because they don't have the time, says Lyle Berkowitz, M.D., a member of the Doctors for Dean executive leadership committee. Berkowitz is an editorial advisory board member for Modern Physician. (See editor's note, below.)
"Physicians hopefully are realizing they do need to become politically active if they want a voice in shaping the future of America, within healthcare and without. This is a particularly great time for them to get involved, as I think it will be a while before we see another physician running for president of the United States with the background and knowledge he has," says Berkowitz. "My hope is that physicians become interested in Dr. Dean based on his strong healthcare record, and then are won over when they learn about his other strengths as well.
"Like all individuals, physicians have their own special interests, but hopefully they will understand that Howard Dean has a wide platform, much beyond healthcare," he continues. "So even though he does have a special insight into healthcare based on his years of primary care experience, it is by no means his only agenda, and I think most physicians will appreciate that fact."
Health policy counselor Omenn of the University of Michigan notes that it can be difficult enough getting mired in health policy minutiae in the White House (as the Clintons learned), let alone attempting it during a campaign.
"You have to have a set of principles and examples of how to make them practicable, enough so the Congressional Budget Office can do estimates, yet with room to work with interest groups, which include physicians," says Omenn.
"With every audience, people have particular interests," he says. "Things like proposed cuts in payment rates on federal programs and mandatory electronic prescribing are moving targets. You have to make negotiations and compromise. In every group that's interested, (Dean) is open and learning. He brings an unusual personal knowledge as a doctor and a governor. He says you can reject the notion that you can't balance a budget and make important health initiatives real. He's captured that in this plan."
Dean calls that plan the Healthy America Initiative, and it is more than simply universal coverage, although that component has garnered the attention.
Dean says he also plans to provide physicians with evidence-based information to improve healthcare and control costs. He says he'll add $300 million per year to turn the federal Agency for Healthcare Research and Quality into the Health Care Institute, an action-driven clearinghouse of best practices at the National Institutes of Health.
Integrated information technology and more government-sponsored research on quality will allow time for the provision of safe, effective care, Dean says.
"In the long run, insurance executives and federal bureaucrats can't make the system more cost-effective," says Lewin, who helped put the plan together. "Only doctors and patients can."
Van Vranken says Dean approaches policy issues as a doctor looking for solutions.
"If in fact it turns out we can't fix a problem entirely, he's going to at least make it better," Van Vranken says. "He is not proposing a complete rip-down of the healthcare system to try to rebuild. He bases his plans on what happened in Vermont, where he incrementally moved higher and higher."
Dean says he can be influenced by new information to change some of his positions, a trait shaped by his physician training, which he says makes him facts- driven rather than ideological.
For example, in a roundtable discussion in February with editorial staff from Modern Physician and its sister publication, Modern Healthcare, Dean said he was unfamiliar with the Leapfrog Group, the influential business healthcare coalition pushing computerized physician order entry systems, hospital intensivist programs and evidence-based referrals to improve quality and reduce employer costs.
Since then, however, Dean has addressed the Markle Foundation, a not-for-profit group advocating using healthcare IT to improve connectivity.
Dean is willing to talk to "everybody and anybody," Van Vranken says. "The whole thing is trying to do a public/private collaboration."
In recent debates, other candidates have characterized this quality as flip-flopping on issues--such as America's relationship with Israel (Sen. Joseph Lieberman, D-Conn.) and cutting Medicare spending (Rep. Dick Gephardt, D-Mo.).
"The scientific method is that you have a theory and you have a fact, and if the fact disputes the theory, you throw the theory out and start all over again," Dean says.
Steve McMahon, Dean's campaign media consultant, says Dean's pragmatism is evident in the lessons he took from helping the Clintons with their failed attempt to overhaul healthcare a decade ago.
"He says on the stump all the time, one of the things he learned from the Clinton experience was we have to do it incrementally," McMahon says. "The only way to get there is through the existing infrastructure, then we can get to the market inefficiencies that are out there."
One critic of this approach is John Kitzhaber, M.D., former Democratic governor of Oregon and a physician whose term of service coincided with part of Dean's.
"I don't believe you can solve the problems facing the American healthcare system unless you're willing to challenge some of the existing institutions, like the huge implicit subsidies that take resources from poor people to finance those who have plenty of money," says Kitzhaber, referring to the need for a discussion on means testing for Medicare.
Kitzhaber now serves as chair of health policy at the Foundation for Medical Excellence, a not-for-profit physician education center based in Portland, Ore. He calls Dean "a brilliant governor" and "an absolute straight-shooter."
"What he tells you, you can take to bank," he says. "He's not afraid of taking controversial positions."
Yet in March, soon after Dean had unveiled his plan to expand coverage, Kitzhaber told a group of healthcare journalists in San Francisco that the national debate was not focused on the right issues.
"Even Howard Dean, who I think knows more about healthcare than anybody in the race, has essentially proposed repealing the tax cut and just paying for the current system," Kitzhaber said. "That begs the question of, 'What's the value we're getting for these expenditures?"'
Kitzhaber admits that he hasn't examined Dean's platforms since spring. But not much has changed, according to Omenn. "This plan has been standing pretty solid for a while."
Kitzhaber says, "Dean has a well-thought-out approach. I just don't think it's going to work. He is trying to find enough money to cover everybody. But what are we going to cover them for? Everything? There is always something else we just have to have. If you don't challenge that, then you have to continue to finance it."
Is America ready for such a challenge from a presidential candidate? "We'll never know until we try," Kitzhaber says.
Dean has cautiously broached the subject of coverage limits, with an emphasis on consumer responsibility for appropriate healthcare utilization, particularly for end-of-life care.
"Every candidate will tell you there are five problems with healthcare--lawyers, doctors, pharmaceutical companies, insurance companies and healthcare bureaucracy--and talk about what to make them do to behave themselves," Dean said at a post-rally press conference in Kitzhaber's hometown of Portland. "What they never tell you about is the sixth thing. There's a sixth problem, and that's us. We've got to come to grips with our own responsibility."
Dean says most politicians don't talk about this because there is no easy solution and it requires voters to be responsible.
"We need to have a dialogue about how to improve our own accountability," he has said. "We have to be open about the connection between what we want and what we pay for."
Dean says the system too often provides "the works" whether the patient wants them or not. Dean blames the "corporatization of medicine" and the interference of lawyers and insurance companies for degrading the doctor-patient relationship. "The family doesn't know who to trust," he says.
Dean has let Van Vranken and Lewin guide the early stages of his policymaking directed at rebuilding that relationship.
"I tend to make decisions quickly and I'm very results-oriented. I'm not process-oriented. I have an impatience with process," Dean says.
His hurried nature may have been part of the reason Dean's lesser known ideas about system reform have not received much media attention.
Van Vranken says the Dean team may have attempted to unroll too much too fast when the candidate first delivered the details of his Healthy America Initiative in June at a Washington, D.C., speech to the Markle Foundation.
"That was a learning experience," Van Vranken says. "We can't be too wonkish. We need to do it in digestible pieces."
Lyle Berkowitz, M.D., a member of our editorial advisory board, participated in a roundtable discussion in February with Gov. Howard Dean, M.D., before Dean had officially declared his candidacy. Soon after that meeting, Berkowitz informed me of his intention to join Doctors for Dean and asked whether it was necessary to resign from the advisory board. I told him it wasn't. Subsequently, Berkowitz has had no influence on our decision to write about Dean or on our coverage. He is quoted in the following story as a leader of the Doctors for Dean organization.