A sit-down with Dean
Howard Dean was in town today, for a lunchtime gathering at Powell's. It was ostensibly a book signing, but it was obviously a political mission. Dean was here to pitch President Obama's health insurance plan -- a "public option" plan designed to let people who currently have private health insurance keep what they have, but to give them and everyone else the option to be covered by a government plan akin to Medicare.
Dean, who led the Democratic Party to amazing success in the 2006 congressional elections and has been a stalwart asset to the party since then as well, is trying to hold his fellow Democrats' feet to the fire on the medical finance issue. Part of his strategy is to mobilize public support -- to get rank-and-file voters to twist their representatives' arms to do something substantial about the nation's expensive health insurance system, which leaves large segments of the population out in the cold. Hence the book, and the session at Powell's.
It was pretty much a lovefest for Dean, with 200 to 300 people in the crowd in the Pearl Room. A couple of hecklers who disrupted the first few minutes of the event were shown the door, by general acclamation, and then Dean, former governor of Vermont, one-time physician, and current spouse of a primary care doctor, got down to his stump speech and some question-and-answer. Among those asking questions were doctors, long-time activists in the health care wars, dedicated Dean fans (right), and folks who had obviously spent large chunks of time in the clutches of the health care system. After he signed copies of his modest $12.95 paperback for everyone who asked for an autograph, Dean sat down with some Portland bloggers and answered a few more questions. He was a most gracious guest.
We noted earlier today, live from Powell's, that Dean took a soft poke at Sen. Ron Wyden, who has been dragging his feet on the "public option" plan: Dean urged Oregonians to e-mail Wyden to tell him to get with the party program. Here, in no particular order, are some things that Dean added that we found revealing:
· Although pharmaceutical companies are clearly a villain in the piece, Dean & Co. find the health insurance companies to be more harmful agents in the system. Part of the professed goal of the "public option" is to put the government in competition with the private insurers, to make the latter less wasteful and less predatory.
· A pure "single payer" system, which would eliminate the insurance companies entirely, will never fly politically. Although Americans are critical of the health care system, those who have good private insurance now will fight to retain it. As people dislike Congress but always re-elect their own congressional representatives, many people dislike the current health care system but think their own insurance is pretty good. A brilliant aspect of the Obama plan is that it doesn't take private insurance away from anyone lucky enough to be able to get it.
· Private insurance co-ops, which some have proposed, will never survive in competition with the larger health insurance companies. "They'll be crushed," Dean said.
· Imposing stricter governmental regulations on health insurance companies is a good idea -- Dean cited as an example his own state's rules that require the insurers to adopt "guaranteed issue" and "community rating" -- but without government competition against the insurers, reforms are likely to have at most a limited benefit.
· Reforming the finance, or insurance, side of health care is just the first battle. Thereafter will come a fight over needed changes to the health care delivery system itself -- moving away from the traditional fee-for-service model and over to something more akin to the Kaiser model. As long as health care providers make more money on treating you when you're sick than on keeping you healthy, the system is going to produce inferior results. Acknowledging that he's heard some horror stories about Kaiser, Dean still thinks their model of integrated care, from the primary to the tertiary levels, keeps the focus where it should be, on wellness.
· A nice feature of the Obama plan is its endorsement of "comparative effectiveness research," which would eventually lead to making coverage decisions based on which medical procedures work, rather than on practice traditions and biases. This could help nontraditional treatments such as chiropractic and naturopathy to get covered by insurance plans, where they aren't now.
· Although specialist doctors do quite well financially in the current U.S. system, primary care physicians don't make out like bandits. The average primary care doctor in Britain makes more than the average primary care physician in the United States.
· It is highly unlikely that Dean will ever run for President again.
In the private time with the bloggers, Dean predicted that under the current timetable, the health care reform bill will probably be voted on during "budget reconciliation" in mid-October. If I understand it correctly, this is crunch time on the federal budget, when Congress has to pass something or close the government. At that juncture, if a measure can get tied into the budget package, its proponents can force an up-or-down vote. Dean said he was "looking forward to reconciliation," because he thinks the President's plan will have the 51 votes in the Senate that it needs for passage.
Dean also stressed to the bloggers that although the media hasn't covered it much, the past week has been a particularly good one for the Obama plan. The American Medical Association -- the nation's most powerful league of doctors -- endorsed the leading House bill on health care, which includes a "public option." And a state government panel in Massachusetts -- which already requires that everyone have medical insurance, with premium subsidies for low-income residents -- recommended that the state stop paying doctors and hospitals on a fee-for-service basis, but rather make payments to providers on a per capita basis, without regard to how many or which services are provided to any patient.
When my turn came to ask a question, I threw Dean one that a reader had sent along in response to my call a few days ago: Why is this so hard? The Democrats have comfortable control of the House, they have 60 votes in the Senate, and they have the White House -- why can't the Democratic Party just get this done?
For a fleeting instant there, it appeared that this wasn't a question that Dean was anticipating. He answered it by pretty much repeating the question. We've worked so hard over the last four years to bring the party to this point, he said. If we can't get real health care reform done, then perhaps it wasn't worth all the effort.
I came away energized and inspired to follow this issue more closely, but I haven't shaken the impression I had before I went down there. This perception was shared by a person in the audience, who complained about it to Dean during the Q&A: The media is big on reporting the daily drama of the politics involved, but they're doing a terrible job of actually presenting to the public the details of the competing health care plans. It's hard to get the public mobilized when the public doesn't even know what the issues are.
Dean had several explanations for this. One is that the mainstream media is on the decline. Another is that the topic is complex, and difficult to squeeze into sound bites for radio and television, and small news holes in hard-copy publications. And finally, the details of the various proposals keep changing so rapidly that it's hard to keep up with them on a daily basis.
Sounds like a job for the blogosphere.
In the meantime, Dean recommended this writer in The New Yorker. And of course, there's the very book that he was in Portland to promote: