Remarks by Vermont Governor Howard Dean at Iowa Health Care Forum

Des Moines, IA, August 14, 2003



GOV. VILSACK: Each of the last two speakers has indicated their background in medicine. I'm frank to say, all I've been is a patient and a payer. (Laughter.) Our next speaker to join us this afternoon is Governor Howard Dean from Vermont. (Applause.)

GOV. DEAN: Thank you. Tom told me that he almost introduced me as Governor Dean from Iowa. (Laughter.) And I've been here so often, I think I have a right to vote in the caucus, we're just trying to figure out which one. (Laughter.)

Let me say some thank yous before we start. Let me thank Tom Vilsack and his extraordinary staff for putting this together. This is a real service to the country, and we appreciate it. (Applause.) Let me thank all these incredible purple-and-yellow shirts who have been to every meeting I've been to in Iowa, anywhere I've been. And Andy Stern, the head of the SEIU is here and the SEIU for sponsoring this. Where is Andy? You're around somewhere. (Applause.) Let me thank AstraZeneca, who also is a cosponsor of this, and we'll try not to beat you up too bad. (Laughter.)

I have some advantage in this discussion of health care because I'm a physician as many of you know. I've been a former board member of a community health center, former staff physician of a community health center, had my own internal medicine practice for 10 years before I became governor. And for 20 years, I've wanted health insurance in America.

Let me tell you what we've done in Vermont and what I intend to do as president. In our state, everybody under 18 has health insurance. Ninety-nine percent are eligible; 96 percent have signed up. Everybody under 150 percent of poverty has health insurance. That means all our working lower-income people have health insurance in the state of Vermont. We have a prescription benefit assistance program for seniors up to 225 percent of poverty. And in a way that's not directly related to health care but very much indirectly related to health care, we have a program where we visit every newborn child in the hospital and follow-up in 91 percent of them with home visits. And we've dropped our child abuse rate by 90 -- excuse me, 43 percent in 10 years, and our child sexual abuse rate by 70 percent in 10 years. And the reason I mention that is because prevention is an essential part of health care and our kids are healthier not just because -- (applause) -- our kids are healthier not just because we have health insurance for all of them, but also because we take care of them at a very early age and find those families who are in serious trouble and support them early on.

Let me tell you why I put together the health care program that I'm about to tell you about. It's based on what we did in Vermont. And there are three words that will guide you in understanding why I've put this together. It can pass. I am tired of having the Democrats tilt at windmills. For 20 years we've tried to reform the system. And what happens is, the Democrats fight among each other about how to reform the system, and the special interests and the Republicans come in and kill the bill, and the people who are the victims are the 42 million people with no health insurance and the additional number that are uninsured because they can't pay the full freight.

So, what I offer Americans today and Iowans here today is a plan that will pass, a plan that's built on what we did in Vermont that I know will pass, and a plan that's built on the system that we have today. We simply expand the three mechanisms that we already have for paying for health care: Medicare, Medicaid, and the private insurance system.

Now I'm going to explain this, probably in two minutes or less, because it's a simple system to understand. First, everybody under 25 gets what essentially is SCHIP or Iowa Hawk-I, up to 300 percent of poverty. That means—we call it the family health insurance plan. People under 25 are dirt cheap to insure. They go to the physicians though more frequently, and we want that because our teen pregnancy had the biggest drop in the nation after we had universal insurance for teenagers.

Secondly, if you're under 185 percent of poverty, you get family health insurance plan, something like Iowa Hawk-I—everybody, adults and kids. Now, for those people who don't fall into that, we enable you to buy into a private insurance consortium, the same one that your congressman has. For 7 ˝ percent of your adjusted gross income, if you have no health insurance, you can buy the federal employee health benefits package. That means that if you make $40,000 a year in a family of four, you're self-employed, and you can't find a way or can't afford health insurance, for $3,000 a year, you can buy health insurance. Sounds like a lot of money. It's less than $300 a month. I think that's a pretty good deal for working people.

There's a prescription benefit for seniors that's a real prescription benefit for seniors, not what the president is suggesting, which clearly won't work and is aimed at November of 2004 with no thought of doing anything else past that. If I may make a partisan remark. (Laughter.)

That's it. Now there's some technicalities. We tell companies if they're not giving health insurance and they should be, that they're senior executive salaries and pension benefits and so forth are not tax deductible because we think if Target is next to Wal Mart, and Target gives their insurance employees (sic) and Wal Mart doesn't, then Wal Mart ought not to have the same tax deductions that Target does. Tax deductions are gifts of the American taxpayer for socially responsible behavior. And if a company doesn't exhibit socially responsible behavior, then they don't get the same tax deductions. And I think that's fair. (Applause.)

There's some other things. The real number of uninsured people in this country is 60 million. There's 60 million people at some point during a year that don't have health insurance. The 42 million people number comes from the number of people at a particular time right now that don't have health insurance. So in order to dig into that number, we do require corporations to provide two months of free COBRA because an enormous number of people are uninsured in the short- term between jobs, between employers who do give insurance, so they will be guaranteed COBRA for two months, free. And that should put a big dent into the number of uninsured.

Let me close by saying this: There are those who argue that we ought to have a single payer. I have no problem with a single payer. If I'm the president of the United States and a single payer gets to my desk, I'll sign it. But I don't think that I can get it to my desk. Bill Clinton couldn't get it to his desk. Jimmy Carter couldn't get it to his desk. Harry Truman couldn't get it to his desk. And I'm not going to sacrifice the interests of the 42 million people with no health insurance for an ideological crusade. I just want a system that works. I'm not fussy about it. We have waited too long. The Japanese, the Germans, the French, the British, the Italians, the Israelis, the Irish, the Canadians, they all have health insurance for all their people. I'm tired of being a second class citizen in the industrial world. Thank you. (Applause.)

GOV. VILSACK: Have a seat. Governor, these folks are obviously very involved in this issue and have studied this issue, and one of the questions that was posed directly for me asking you is the following: Someone in this audience has calculated that your plan would cover approximately 31 million people that are currently not being covered with insurance, which would suggest that there are still some who are not yet covered. Tell us about what happens to those folks under a President Dean's administration.

GOV. DEAN: Actually the way our plan works is it covers all the people. If you have no insurance, you are automatically registered for our program. And you're automatically essentially billed through the IRS during your normal tax return season for the program. But it is not a mandatory program. So we estimate that as many as 10 million Americans will choose not to have health insurance. We could have made it mandatory. There are a lot of things we could do to make my plan better. The problem is, Americans hate mandates and it probably won't pass. I'm trying to get something passed here. This is from my experience. I tried to put in a big reform package in my first year as governor. I couldn't get it passed. This is designed to pass. So we do in fact insure everybody. But some people will say—let's suppose you make $100,000 a year, and there are people in this country that make $100,000 a year that work for themselves that have no health insurance. They choose not to have health insurance. Maybe somebody doesn't want to pay that $7,500, so they won't and they'll opt of the insurance. The gap between the 42 million people that have no insurance and the estimated 31 million people of the Lewen Group who wrote our plan gave is those people that we think will opt out.

GOV. VILSACK: Give us some specifics in terms of this issue of preventative medicine. You mentioned it in your comments. What can we expect to see in the form of initiatives or programs or ways in which this can become a greater part of our health care system?

GOV. DEAN: We have to, in this country, understand that what we're really talking about in our entire health care system—well, there's very small segment that this isn't true of, but for the most part it is—our system is based on illness control instead of wellness control. So we, all Americans, go to the doctor when something's the matter. We don't often go when we're just trying to make sure that nothing gets to be the matter. We don't reimburse nurses. We don't reimburse physicians for much wellness activity. We reimburse heavily for illness. This is one of the reasons that our health care costs are so high.

What I want to do, first, we need to get everybody in the system. That's the first thing we have to do, and we can't fool around with a lot of arguments about how to do it. Let's just do it. Secondly, when we get there, then we can have a big fight about how to reform the system and we can have a big fight about how to start to move the system away from illness control and move it towards prevention and wellness.

And there are a lot of doctors and nurses that are already doing this kind of work, but it's not considered mainstream because insurance companies don't pay for it, so therefore you've got to pay for it out of your own pocket. And that doesn't make any sense at all. And there's a lot of ways of doing this. And there's been a lot of work, especially at Dartmouth by Jack Wenberg, about how to do this, how to look at standardized medical practice to reduce costs and to improve results. And those are the kinds of things we need to look at. (Applause.)

GOV. VILSACK: We are a state as you well know as you traveled across the state of Iowa that has a significant number of senior citizens. And over the course of the last several years, we've been engaged in an effort to try to develop a continuum of care for those seniors so that they have as many options as possible. Give us your thoughts on the existence or non-existence of long-term care in the country, and what a Dean administration would do to insure all senior Americans that they would have a continuum of care.

GOV. DEAN: Well what we did in Vermont that's probably the most important thing that we could do, and is what I'd like to do in the country, we got a waiver from the Clinton administration and passed a bill that reduced the number of nursing home beds by 10 percent in our state and took the Medicaid money that we would have spent on those beds and spent them taking care of patients in their own homes. Seniors would much rather be taken care of in their own homes. You can take care of twice as many people in their own homes for the same amount of money. And a lot of times seniors end up in nursing homes, not because they're desperately ill and they can't be cared for anywhere else, but because they don't have the resources or the family support to be taken care in their own homes. So what we did is basically make home health care eligible for Medicaid dollars to take care of seniors in their own homes until they really did need nursing home care. And we found you could do that without increasing the budget dramatically other than the normal inflation, simply by transferring resources out of institutions and into the home. And there are lots of ways that we can do that.

One of the things that we should do, and I know my brethren in my profession won't like this, we should let independent nurse practitioners practice without the direct supervision of a physician because -- (applause) - what—I can tell you as an internist that probably between 50 and 75 percent of the things that I did in my office could have been done by a competent, qualified independent family nurse practitioner.

And so we need to extend that kind of approach to decentralize the medical care, try to get it as far from institutions as we can and start with your own home. And that's really part of what prevention's all about, because if you take care of seniors in their own home, they're happier, they're perhaps less likely, unless they're all by themselves, to have an accident where they fall down and break a hip, which is often the kind of thing in a senior that begins the sort of spiral to the end. So, again, the least restrictive, least institutional setting, is cheaper, we can take care of more people, and it's in the long run I think better for seniors.

GOV. VILSACK: You mentioned expanding opportunities for nurse practitioners, and I assume that that would also be true of other health care providers. Tell me a little bit about where you see the government's role in helping higher education and community colleges and other facilities to encourage more and more people to get into these professions given, you know, the low salaries that are paid in some cases or the tough working conditions.

GOV. DEAN: Well, not to be partisan or anything in a forum like this, but the president chose to give $3 trillion dollars worth of tax cuts to his friends like Ken Lay and pay for it in part by cutting PELL grants so people would have a harder time going to college. Most middle class people in this country are paying a lot more taxes, college tuition for their kids, local property taxes to fend off the cuts in schools from the president. And I think most Americans would much rather pay the same taxes they were paying when Bill Clinton was president if they could only have the same economy they had when Bill Clinton was president. (Laughter; applause.)

So, the first think I would do is get rid of the president's tax cuts, which mostly went to people who didn't need them, and help middle class people start to pay for college, restore PELL grants. I want AmeriCorps, not as the president promised it would be increased and then cut it, which is what he did. This is a president who has trouble keeping his word. (Laughter.) I want AmeriCorps to be 10 times bigger than it is today. Why? Because it's a great way to pay for college. And I want America's kids to come together and work together for the good of the country, and then go to college two years later and having some significant financial advantage when they do that.

We also need special programs for two categories of people: teachers and nurses. There's going to be a huge shortage of teachers. There already is a huge shortage of nurses. And we need special programs to alleviate school loans in return for practicing in particular geographic areas which really need help, both in the teaching area and the nursing area. (Applause.)

GOV. VILSACK: As I listen to your comments today about your plan, you talked about the amount of resources that would be required for those not covered under Medicaid, Medicare, and so forth. And I think you said 7 ˝ percent, somewhere along those lines. Some economists have suggested that it would be difficult for some American families to allocate that much of their resource to health care. Can you comment about that and whether or not there'd be any kind of graduated increase based on the ability to pay.

GOV. DEAN: It is graduated.

The program essentially covers everybody under 150 percent of poverty essentially for nothing but the co-payments and deductibles, which under Medicare are pretty low. The next 35 percent to 185 percent of poverty is limited to 5 percent of the patient's or the family's income. There's a reasonably low number, although these are reasonably low income people. But that's why it's at 5 percent. And finally above that, 7 ˝ percent.

We used the example of $40,000. I think most people who make $40,000 a year can afford a little less than $300 a month for their health insurance. Considering how many people there are today that are struggling paying $700 a month for their health insurance, I think that's a reasonable bargain.

I can tell you one thing I'm not going to do in this race. I'm not going to do what so many politicians from Washington always do and that's promise you something I can't deliver. There is pain with this. You have a choice. You want the president's tax cut or you want health insurance? Some of my opponents are saying, “Oh well, you know, Dean's not really a Democrat because he wants to get rid of tax breaks for the middle class.” Well, we priced out our health care plan, which is the same as most of the other ones, except for Dick Gephardt's which is more expensive and it's a different plan. We priced out our health care plan. We came to the conclusion we couldn't pay for it without taking the whole tax cut and still try to balance the budget and fund special education.

So I put a fairly big premium on honesty in this race. I do not think we're going to win and beat George Bush by being the same old, same old, promise them everything and then forget what you've promised them after you get to election day because your numbers didn't add up. Our numbers add up. The price tag for my health care plan is about a half of the president's tax cut. You have a choice. You can have insurance for everybody and pay something for it, or you can have the president's tax cut. And since most Americans never really saw the president's tax cut, I think they'll be happy to make the choice. (Laughter, applause.)

GOV. VILSACK: I can assure you in this field, I'm not going to run out of questions, Governor. I've got plenty of questions. As a physician you probably are aware of some of the paperwork that's associated with the practice of medicine. What can we expect from a Dean administration in terms of reduction of paperwork and how would you go about doing that?

GOV. DEAN: I have not made many campaign promises, but I've made two to the medical profession. I promise that the person who's in charge of the Food and Drug Administration will have hands-on experience taking care of patients, and the person who's in charge of Medicaid and Medicare will have hands-on experience taking care of patients, because the bureaucracy is awful.

I remember one time I got a weeping phone call from our bookkeeper who had been sent a notice by the federal government they were going to get a $20,000 fine and six months in jail if they didn't fill out 9 zillion forms that were due three months ago that there was no paperwork for and no charts for, et cetera, et cetera, et cetera. There's a long story with this which is pretty funny, but we don't have time for it. But the bottom line is, there are a lot of things that we've been promised by the federal government that have never been delivered.

First of all, we should require in this country that there is one kind of insurance form and one kind of insurance form only. (Applause.) And we need to do the same thing with codes. Everybody ought to be required to use the same codes that Medicare uses so you never go through those books and all that stuff ever again. That's the beginning of the paperwork piece.

Now, how much time do we have?

GOV. VILSACK: You got just less than a minute and I've got one more question.

GOV. DEAN: Alright, we'll do the one more question. (Laughter.)

GOV. VILSACK: No, no, go ahead, go ahead, finish.

GOV. DEAN: Well, every politician will tell you of the five things that cost control has a problem with. They'll blame lawyers, doctors, hospitals, insurance companies, and pharmaceutical companies. They're right. Those are all the big problems. What they won't tell you is this: One of the biggest problems in medicine is us. My son had an emergency appendectomy last year. I was instantly transformed from the governor who wanted to do something about cost controls to the parent who wanted everything done for their child, and I expect the insurance company to pay for every last nickel of it. The reason politicians won't tell you that is because first, there is some kind of problem in Washington with actually treating voters as adults, and they don't like to admit that you have responsibility too. We all have responsibility.

Secondly, there's no easy solution. What we need to do is deal with the pharmaceutical problem because it's a huge problem and they're getting away with murder. But we also need to figure out what our own responsibility for health care is. It talks about wellness. It talks about prevention. We need to do what they did in Oregon, is to have state-wide meetings, in this case country-wide meetings for a year and a half and acknowledge that each of us has responsibility for health care costs too. We can't just blame the doctors, the hospitals, the lawyers, the insurance companies, and the pharmaceutical companies. It always makes us feel good to blame them, but nothing ever happens unless we acknowledge our own responsibility as well. (Applause.)

GOV. VILSACK: We have 15 seconds left. Dual eligibles. Federal responsibility? State responsibility?

GOV. DEAN: My deal is, you do universal health care, we take care of dual eligibles. (Applause.) The one thing we didn't talk about that was raised by the dual eligible question is this is a system that's going to be run by the states. We're going to pay the money. You're not going to have to pay five cents more to insure all your people. We're going to give you a bigger match rate. We're going to help take care of a lot of dual eligibles. But I want this system to be run by the states because most states will do a much better job than the federal government will running the health care system. (Applause.)

GOV. VILSACK: With that, Governor, we're going to let that be the final word from you today. Ladies and gentlemen, please join with me in thanking Governor Dean. Thank you.

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