Is Dr. Dean's prescription a placebo?
The Washington Post
December 21, 2003
Dean’s Care For All, Built Part by Part
By Ceci Connolly
(In 1994, Vermont Governor Howard) Dean, a doctor by training, would be the nation’s first governor to guarantee health coverage to every state resident. And he would do it in a single legislative session, with one enormous bill.
It was ambitious, bold — and an utter failure.
But it wasn’t the end. Like a pragmatic physician who tries a new therapy when the first fails, Dean devoted much of the next decade to smaller, incremental changes aimed at filling the state’s health care gaps.
It was a slower strategy, but by the close of his tenure, Dean came very close to achieving universal health coverage. Vermont now has one of the nation’s highest rates of health insurance coverage, providing care to virtually every child and more than 90 percent of adults. The national average is 83.7 percent.
As some Democratic presidential rivals are quick to note, Dean’s embrace of
balanced budgets led him to flirt with the Medicare-reduction plans of then-U.S. House Speaker Newt Gingrich (R-Ga.), and Dean sometimes trimmed his own state health programs.
These opponents also said that his policies have exacerbated the financial problems for Vermont hospitals, and despite Dean’s efforts to expand health
care coverage, there remains a yawning insurance gap for residents ages 18
to 29. Most important, Dean’s heavy emphasis on government-run programs,
with their low reimbursement rates, has saddled the business community with
higher costs, according to some health care officials.
“Gov. Howard Dean has presided over a constant expansion in government health programs, without a commensurate increase in funding,” the Burlington Free Press editorialized in December 2000.
Another criticism of Dean’s health care record is that his heavy reliance on
government programs hurt the private sector. Because government reimbursement rates are so low, doctors and hospitals in Vermont have been forced to charge more to private clients — individuals and businesses — to make up the difference. As Dean encouraged families to enroll their children in Dr.Dynasaur, corporate insurance pools were left with a larger proportion of high-risk, more expensive adults.
Dean’s tactics and style could inflame tensions, lawmakers said. On several
occasions, he proposed trimming the very health benefits he instituted, including dental, foot and eye care for Vermont’s low- and moderate-income adults. He fiercely defends this approach.
“I promised the people of Vermont I would not take one person off the program,” he said. “So we did eliminate certain benefits. But that’s better than cutting people.”
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Comment: The current emphasis on reducing the numbers of uninsured has created an explosion in the rate of under-insurance. Reducing benefits, increasing cost sharing, inequitably funding risk pools, shifting public program costs to providers which drives up fees for private payers, concentrating high-cost patients in separate risk pools making the premiums unaffordable, are only a few of the problems exacerbated by implementing a policy of incremental expansions of program enrollment without ensuring adequate funding of those programs.
Being insured may not mean much if care remains unaffordable because necessary benefits are not covered or the out-of-pocket expenses are too high. But limited insurance is better than none at all. Is there an alternative? Of course. Comprehensive coverage can be provided for everyone at no significant increase in cost if we were to eliminate the administrative inefficiencies of our multi-payer and non-payer system, and establish a single, universal health program.
Dr. Dean initially supported single payer reform but found that it wasn’t politically feasible. He then demonstrated that a pragmatic, incremental approach was feasible, even though it falls short on many goals. Dr.Dean has said that, as president, he would sign a single payer bill if it made it to his desk. But whoever is president, a single payer bill will never pass Congress without overwhelming public support. That won’t happen until the public really understands the various options. We have a lot of work to do.
There is risk for us. We may discover that the real reason for the lack of reform is that the United States is a nation that does, in fact, uniquely reject egalitarianism. Are you prepared to accept that possibility?