Howard Dean: "This Is Ridiculous. We're 60 Years Behind the Times" on Fixing Health Care

During the 2004 presidential primaries, the conventional wisdom among Howard Dean's energized supporters was that the over-the-top conservative attacks on the Vermont governor reflected the degree to which the right feared his nomination. With his blunt, plainspoken populism, the argument went at the time, Dean represented a threat to the Bush administration's prospects for re-election that his more polished Democratic opponents lacked.

Five years later, and it may be the "disease care" industry -- now spending $1.4 million each and every day to lobby lawmakers against implementing significant health reforms -- that may be sweating Dean's simple, but uncompromising, brand of politics.

In his new book, Howard Dean's Prescription for Real Health Care Reform, the physician and former candidate explains what makes the American health care system the most expensive in the world but nowhere near the best. He calmly destroys the industry's arguments against substantial change and offers a plan to give everyone access to quality health care at a price that won't break the bank.

AlterNet caught up with Dean to discuss the book and the larger political landscape in which the debate over health care is taking place.

Joshua Holland: In your new book, you offer a prescription for fixing our ailing health care system. You lay out the scope of the crisis really well, both in human terms and in terms of the costs -- the financial burdens our system places on households and firms. And like the plan that Obama has laid out, like the Hacker Plan, your prescription revolves around a robust public health insurance option. Can you explain in a nutshell what that is -- what that looks like?

Howard Dean: In a nutshell, it looks like Medicare. We've had a single-payer in this country for 45 years, and the Republicans have used the same language today that they were using in 1965 to denounce it. And it works really well.

It has its faults like every system, but it is cheaper, it is more efficient and a far smaller percentage of dollars that goes into it is spent on non-health-care items. It's about five times as expensive to insure yourself with a private health insurance than it is with Medicare. So that's what the public option looks like. It's what we've had -- and your grandparents, and your parents have had -- for years.

JH: Now, you note that the debate has shifted over the years, from "how do we cover the uninsured?" to "how do we contain out-of-control costs?" So, in terms of this public insurance option, it'll result in a very large insurance pool, which will give it the ability to negotiate better prices and cut down on overhead. Can you just give me a little bit more on other ways that it might help contain costs?

HD: Well, there are two ways it contains costs. The first is that, of course, it's a huge pool. The second is, in terms of containing costs for ordinary Americans, [Medicare] can't and won't engage in the kinds of things that private insurance companies do. They don't have bureaucrats who second-guess doctors and make bad medical decisions. They don't pay extraordinary amounts of money for repeat procedures -- at least they do that less than the private sector does. They don't pay chief executives in the seven-, eight- or nine-figure range for their salaries. They don't have to advertise.

So it's much cheaper and more effective and efficient to control costs if you have a large public option. And the other thing about this is that the American people get to choose. You know, the Republicans are screaming and yelling about socialized medicine. Well, let the American people choose -- if they don't like it they won't choose it.

JH: Okay, that brings me right to my next question. You don't pull any punches when you describe insurance companies' practices. You say that they have mutually exclusive goals in protecting their shareholders and maximizing profits and their responsibility to give their customers good service. Now, in the book you cite an estimate that around 115 million people would remain with their employer-based insurance if a public option were added to the mix. Can you help me understand how the addition of a public insurance program with, say, 80 million people in it would change the behaviors of the insurance companies as it relates to the 115 million who will remain with their current insurance?

HD: Well, ultimately what's going to happen -- first of all, employer-based insurance with large companies is better than the individual market because it's already community rated with guaranteed issue -- that is, you cannot kick people out of their health insurance once they get sick, which many of these companies do, and you have to accept all comers.

Second, if the companies don't do their job in the employer-based system, there will be a lot of public clamor to change their insurance over to the public option. Now that is, of course, what the Republicans are terrified of. But in my view, and in the president's view as well, why not keep the insurance companies operating in a more consumer-friendly way and give the people a choice? That's what competition is all about -- it's giving people choices to do what's in their best interest.

JH: Let me go back one step. You were talking about the Republicans' scaremongering over socialized medicine. Just to be clear so my readers have a good grasp on this -- private insurers would also be able to participate in this large, federally managed insurance pool as well, is that right?

HD: Yeah, they do. They absolutely -- that is something that exists [for federal employees] today. The Federal Employee Benefit Health Plan is an exchange, essentially. The only thing the president wants to do is add a public option to that exchange. And you know, just while we're talking about this, the thing that I get such a chuckle out of, all these conservatives getting so upset about socialized medicine -- that's what they have is socialized medicine. They have government-sponsored medicine.

JH: I remember a Rand study a couple of years ago that showed that vets, who have truly a single-payer, British-style system are the most satisfied with their health care.

HD: This is a ridiculous debate. We are alone, we stand alone among industrial democracies in having a health care system that is 70 percent more expensive and much less effective than every other industrial democracy. This is ridiculous. We're 60 years behind the times. We need to fix this problem, it should be fixed now, and it should be fixed right.

JH: Now, in the book, you talk about single-payer advocates. You say that they are most likely "correct in terms of the inefficiency of the system, but they fail to understand the American psyche." Do I understand correctly that if you were, say, a benevolent monarch, King Howard the First, and you didn't have to worry about Congress, and the bobbleheads on Fox News, and you were starting from scratch, you would institute a single-payer system?

HD: No, because of where we are, no. And Obama totally gets this. You have to start from where people are. And it's not just Congress and the Fox News talking heads, and all that kind of stuff. The American people -- you know, health care is awfully personal -- even more personal than taxes.

JH: Right.

HD: So you've got to -- you know, [Obama] is the first president, I think, that's really understood the American people and why we've struggled with health care reform for so long. You've got to give people choices. Let them choose. Don't have the politicians choose for them. Let them choose, and they'll choose what's best for them.

There are employer-based systems that work in other countries. Now what it means is you've got to treat the insurance companies as regulated utilities in order to make that work. But let the American people make their own choices. So I would not, if I were a benevolent despot, just force people into systems. Let them make their own choices about which system is best for them.

JH: Let me just push you on this a bit. As I was reading that -- first of all, I agree with you to a large degree -- but I kept thinking about Social Security. What is it about our political culture, or this moment in history, that is different from when FDR made everybody enter into a social insurance program for the first time, without a choice?

HD: The difference is that in those days, 80 percent of people struggled to survive retirement. And the people over 65 were the highest percentage of Americans who were below the poverty line. Nobody had anything, except for the very, very wealthy, and there weren't so many of them during the Depression. Furthermore, Social Security started in 12 states -- I think it was already in 12 states. Don't forget, for many Americans, the Depression started in 1926 not 1929. The Dust Belt was hit much earlier than the fallout from the Wall Street crash in 1929. So some states already had the rudiments of Social Security in place.

So first of all, Roosevelt had the advantage of having a system in place that already worked in some states, and second, the group of people that he was trying to help were catastrophically in trouble. On the contrary, even though health care is very expensive in this country, 80 percent of Americans have it. Now it's a scandal that 20 percent don't, but 80 percent in a democracy always trumps 20 percent.

So that's one of the reasons that the debate is not being run on the issue of the uninsured, it's being run on what's good for everybody in terms of the cost and the competitiveness. And the other reason is -- it's also the reason that you have to let people make their own choices. They have experience with a system that they like some aspects of, and they should be allowed to keep that system if they want it.

JH: OK, let me ask you a related question about the politics. In 2004, I was a volunteer for your campaign in Los Angeles.

HD: Thank you.

JH: Yeah, we almost rumbled with those [John] Kerry nerds. (Laughter). Anyway, you came out and you talked to a crowd at UCLA and really fired up the audience. And one thing that you said that stuck out for me was that the era where we start in the middle in terms of these legislative debates and move to the right has got to end.

What do you think about the argument that if we in the progressive movement had started basically pushing [Michigan Rep. John] Conyers' HR 676 [single-payer bill], we might not have a better chance of meeting in the middle with a hybrid plan such as the one that you've laid out.

HD: Well, I think that was a mistake made by the administration. I do not think we should have "taken single-payer off the table." I don't believe that the votes are there for single-payer, and I don't believe that the politics are right for single-payer, but single-payer has some good things to recommend it, and we should be discussing what those good things are. And the most important part of single-payer is its cost effectiveness. It is just incredibly cost effective relative to any other system.

And so, you know, I don't know about the positioning, because in some ways you're right -- because we started with the public option. The public option -- and people don't understand this in Congress -- the public option is the compromise.

JH: Right.

HD: If you give up the public option, then this is not worth doing. You can do some insurance reform, but you shouldn't put any money into it. Just force the insurance companies to behave differently by the law, but don't put a trillion dollars into the system we already have. It's already too expensive.

JH: OK, in the book you discussed the "black hats" standing in the way of reform. I just want to briefly discuss a couple of proposals that I think most people would agree are attempts to water down this public option. Can you tell me a little bit about what the talk of a "trigger mechanism" is about?

HD: Yeah, a trigger mechanism -- these are internal compromises in the United States Senate to try to get a bipartisan bill. Well, you know, I think a bipartisan bill is always a wonderful thing, but if it doesn't do anything and it's a lousy bill, then what's the point?

So a trigger mechanism is one version of what I call the fake public option -- it's been used before in different forms. It was used against the inflation fighting in the '80s where inflation was high, so they had a trigger mechanism that was going to force some wage and price control if corporate America didn't do the job itself.

And of course, the minute that the time period passes, the private sector goes back to the usual behavior. So a trigger mechanism is worthless. You'll get some concessions from the insurance companies in the short term, and we'll be right back where we are in the long term as soon as the deadline passes.

Another fake public option is the co-op proposal. They'll be crushed just like Blue Cross was crushed. Most Blue Cross chapters are now for-profit. They've been taken over by the insurance industry. Any reasonable-sized insurance company can crush a not-for-profit co-op.

So these are all what I call fake public options, and they're really not serious health care reforms. They're not aimed at reforming the health care system, they're aimed at getting a bipartisan vote in the Senate. That's just not going to happen. We should just give up on the bipartisan vote in the Senate and pass a decent bill.

JH: And the co-ops, of course, undermine the idea of having a very large insurance pool.

HD: Well, that's right. You can't do this without a large insurance pool, and the private insurance companies will just crush the co-ops.

JH: Our readers tend to be very activist oriented. My final question is this: How can ordinary people like the people who read your book or read this interview -- how can they get involved, and how can they make sure that they don't get screwed as health-reform legislation moves through Congress?

HD: Well, that's going to be tough. But the first rule is don't give up no matter what. Don't ... look, we just selected a president by an enormous grassroots effort, so keep going until the last vote happens. So they can go to, and there's a long list of things you can do.

Second, Bill Press' show has a Web site, and it has the names of, I think, 10 Democrats who haven't made up their mind on the public option. Contact them all. E-mail them if you're constituents. Call them. Let them know that you expect them to support a real health insurance bill. At a minimum that means having a real public option.


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