Read more about the Oct. 4 Intelligence Squared U.S. debate on whether "Grandma's benefits imperil Junior's future," buy tickets, and see who else is debating.
Howard Dean was a doctor before he was governor of Vermont, a presidential candidate, or chairman of the Democratic National Committee. Now, he draws on his medical experience to argue that Medicare and Medicaid don't need radical surgery to remain solvent. And he'll draw on his 2004 presidential campaign experience to persuade the live audience at the Oct.4 Slate/Intelligence Squared U.S. debate to vote against the proposition "Grandma's benefits imperil Junior's future." (He's already proved he has the oratory prowess to rev up a crowd.) Dean, who now works as a consultant, says it's unnecessary to slash the benefits of Social Security, Medicare, and Medicaid in order to preserve the programs for future generations. I caught up with Dean earlier this week for a conversation about why America should avoid significant entitlement reform; what changes we can make to protect Social Security, Medicare, and Medicaid for posterity; and how his perspective on the health care system has changed since he stopped practicing medicine. Excerpts from the interview are below.
Slate: What question or issue will be at the core of this debate?
Howard Dean: The core question that people are interested in is, are we stealing from the next generation with our benefits structure? Of course, I'm going to be on the no side.
Slate: Can you give us a sneak peek of what you'll argue?
Dean: First of all, the Medicare problem, which is the biggest spending problem between Social Security and Medicare, is not a Medicare problem at all. It's a health care problem. The entire health care system does not control costs in any way. So the question is, how do you fix that? And the answer is, you have to fix the whole system. You can't just blame it on the beneficiaries. Everyone who uses the system is part of the problem. On Social Security, there's some minimal tweaking that needs to be done. It really is pretty solid. But I think this argument [to cut benefits] is essentially by the right wing to undo the notion of the social safety net. They're pitting generations against each other, and it's not necessary to do that. You can control the expenditures in these programs. But again, you can't focus just on these programs because it's a systemic problem. And, again, the right wing doesn't want to do anything about health care cost, but that's where the real problem is.
Slate: So how do we reform health care?
Dean: We have to stop using fee-for-service medicine. Right now, doctors get paid by the amount of things they do to people, which makes no sense at all. The more you do to people, the more you get paid, whether it does any good or not. You've gotta change that system and give people a budget for every patient. Then the physician needs to live within that budget. You should also give individuals the power to choose which plan they want to have. You have to fundamentally alter the way we pay for medicine in this country, otherwise it's going to continue to be out of control.
Slate: There have been attempts in the past through pilot programs and panels to reform Medicare, and to inspire collaboration and care coordination between hospitals and doctors. But those attempts haven't worked so well. What will be the mechanism this time around to make those kinds of changes stick?
Dean: Congress has been disgustingly irresponsible in the last two years, partly because the Republicans have decided that they're going to have it their way or no way. Probably what has to happen is [something like] this joint committee that they put together for deficit reduction: We need to take it out of the hands of Congress and just give Congress an up or down vote on a plan.
Slate: And how do we get rid of the "fee-for-service" system, or begin to encourage quality care over quantity of procedures?
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.