Dean: There are some things in the president's health care plan that would actually help. And one is the ACO (Accountable Care Organizations). That is potentially the way of reorganizing medicine so that we can use what we call capitated care, care under a fixed budget. That exists now—Kaiser does this. It's not like it's a new concept that has never been done before. But that's the model that makes the most sense. You can't do it by doctors; you have to do it by systems, because it wouldn't work to do it doctor by doctor. You have to give an entire system that could take care of totally integrated care of a patient. Different patients have different needs. So the ACO is such an integrated system, and that's why I think it would work well.
Slate: You were originally a physician before you were a politician. How has medicine changed since you practiced?
Dean: It's gotten much more difficult. The insurance company bureaucracy is now worse than Medicare's bureaucracy. The malpractice situation is more difficult, the fee-for-service system has driven costs up three times the rate of inflation in the last 20 years, which is as long as I've been out of medicine, so it's an enormous problem. The level of care is good if you have insurance, in general. But the expenses are not commensurate with the level of care. We pay more than anybody else in the world [for medical care], and we're about 37th in the world in terms of indicators like infant mortality and so forth.
Slate: Has your perspective on how we should tackle these major systemic issues changed since then?
Dean: It has, actually. I've become a reluctant convert to single-payer. I was hoping that this could be straightened out in the private sector, but the private sector has been so irresponsible for so many years that I think you have to have more government involvement, simply because the private sector doesn't work in medicine. It can deliver care, but not efficiently. Of course, now the government is failing as well, so I don't know where that leaves us. The national government is simply incapable of dealing with this, and it's going to have to be done state by state. Massachusetts has actually done some things very similar to what the president is trying to do for the country. It really is true that Romneycare and Obamacare are the same thing, which isn't all bad. Massachusetts has something like a 98 percent insurance rate.
Slate: What finally converted you to being a single-payer supporter?
Dean: Seeing an increasing number of people with no insurance, the incredible waste of resources, and the fact that the current system just makes it difficult for the patients and for the physicians.
Slate: In a 1984 speech, Colorado Gov. Richard Lamm introduced the "duty to die," theidea that health care should be rationed at a certain age, that we can't afford to do everything to everyone. Essentially, he said we have to stop treating death as optional. What's your reaction to his manifesto?
Dean: It's not necessary to do that. We're paying 70 percent more than the next country in terms of our gross national product. You don't need to deny people care in order to make this work. What you need to do is have a sane system of reimbursement.
Slate: Say we can't get to a single-payer system before Medicare becomes insolvent in 2024. Are there last-resort entitlement reforms you would support?
Dean: A big step in the right direction would just be to say we're not going to pay for health care fee-for-service anymore. We're going to offer people cheaper plans with a fixed budget. Not a fixed budget per patient, but a fixed budget for a group of patients. Inside a large group of patients, some people will never need to see a doctor, someone else might need a heart transplant. All of a sudden prevention will actually really work. They'll do better financially if they focus on prevention than if they focus on lots of X-rays and procedures.