fresh voices from the front lines of change







Sara Robinson liveblogs Howard Dean's talk at Netroots Nation, starting at 9am ET Friday morning. Come on by and join the chat!

There are a lot of people here, considering we were all up drinking past 1 am at vodka reception given at the nearby Andy Warhol museum by an associated gaggle of gay groups. (It was totally fabulous.) Dean can turn out progressives, even at this unholy hour among this many people with hangovers.

A spirited introduction by the co-author (sorry, he said his name fast and I didn't catch it, but he's a Think Progress editor) of Howard Dean's Health Care Prescription for Real Health Care Reform. Mike Lux and Tanya Tarr will be moderating -- this should be good. I saw Tanya in a panel yesterday afternoon and found her very impressive.

Here's Dr. Dean.

The people in this room will be carrying the ball over the next 10 weeks or so: in the face of the lies, the net is the only real resource to get the truth out.

The public option cannot be compromised. We have already compromised from single payer -- this IS the compromise. We can't back off from this, because we won't get universal care without it. If people have the choice, they'll reform the system on their own.

Fifty percent of Republicans want a public option.

Tanya asks: How do we make plain English argument to people who aren't tracking this issue day by day?

Dean says: We need to control costs, without rationing. We spent 70% more than Canada or Germany, the next most expensive systems.

Eliminate fee for service medicine. They're doing this in Massachusetts. Primary care doctors here make less than they do in the UK. The public option allows for the market to reform itself.

Control costs. Medicare is structurally able to do this in a way that private medicine can't. Costs have gone up at 2.5x the rate of inflation on the private side, which strains businesses' competitiveness. Medicare, on the other hand, goes up 2% a year. It's much better controlled.

Mike asks a funny pseudo-question from a "death panel" grognard. Dean says: These meetings are not about health care. He says he gets smart questions from conservatives at book signings, and they're not shouting. But the teabaggers have been running on anger for 30 years-- Karl Rove used to talk about polling for anger points, looking for ways to incite activism around race and other issues.

He also notes that this group skews older -- these are not the generation that voted for Obama, and they're threatened and angry by the younger uprising. They are contentious and polarized (and have always done politics that way); but the younger generation does it differently. They are aging, losing power, and getting smaller. And they have a president "who's not accustomed to what they're seeing in the White House." Dean notes that he saw people like this when he signed Vermont's civil union bill, which got a lot of pushback from moderates who had supported him. He needed police protection for a while after that. That's what's going on: people are resisting change.

People don't know what's in the bill. They don't even want to know. This isn't about health care; it's about a generational transition.

Tanya asks: What happens to reproductive choice in this bill? How do we ensure choice is protected?

Dean replies: we're really discussing what the public option will cover; whatever's in the bill won't dictate to private insurers what they'll cover.

And the actual benefit package hasn't been determined yet. That comes later. So anybody who says that this issue has been settled simply doesn't know what's going on.

In the end, we need to let the as-yet unnamed benefits panel, which will be made up of fairly distinguished health care providers, decide. He doubts they'll "break new ground" in changing abortion access.

Mike asks: How has the politics around this changed?

Dean says: It's changed a lot. The fact that the other side is reduced to making things up and acting out tells how how done and over this really is. He also thinks the Blue Dogs contributed to the conversation, holding up the conservative arguments when the Republicans themselves would not. The Blue Dogs insisted on protections for small businesses under half a million bucks, which Dean supports. (He doesn't discuss what happens to their employees. People in the room are shaking their heads.)

He predicts that the bill will be settled in reconciliation and get passed. It'll be ugly, but it'll pass.

Mike asks about single payer, which has a lot of supporters in the room. Why didn't the Democrats start with that as an opening position, and then retreat to public option as a compromise point?

Dean: This was a mistake, and was a holdover from the old way of Democratic politics. "Single payer" was seen as a bad word, and taking it off the table was seen as necessary to "reasonable" debate. But the other side isn't interest in debate. The public option is the compromise -- it's OK, but we can't back off of it.

The fact about single-payer is that it's more efficient -- only about 4% goes to overhead, versus non-profit private at 12% and for-profit at 20%. We should have gone that route.

Tanya: How do we involve more health care professionals in this debate? She's heard from people whose doctors are telling them scare stories.

Dean: The polling on this is interesting. When the AMA endorses Henry Waxman's bill, that's a remarkable moment. For 15 years, the insurers have treated both doctors and patients so badly that the majority of physicians now favor single-payer. They've figured out they stand to make more money, or at least have better working conditions and the ability to provide better care.

Mike: He was recently in Oregon, doing a panel. A medical student asked him about the way new doctors are incentivized to go into specialties, and forego family practice.

Dean: Medicare rates are too low, and this has a lot to do with it. In Vermont, they raised those rates -- and some insurers left, which was fine, because they didn't need those companies anyway. If you make under $66K a year in Vermont, the kids in your family (up to age 18) are covered for $480 a year. They raised pediatricians' reimbursement rates at the same time.

Doctors go into specialties because they've got massive education debt that's hard to pay off if you're in primary care.

Also: A well-qualified nurse practitioner can do about 60% of what doctor can do. We should be relying more on NPs. The best quality of an NP is how well they know what they don't know, and how willing they are to refer up to the doctor. He advocates independent NP practices, especially in rural areas; helping primary care doctors pay off their debts; and federally-qualified health centers -- clinics where people can get low-cost primary care.

Some of these things are in the health care bill as it stands now.

Tanya: A local candidate from NY asks: How to frame the health care conversation for a local campaign?

Dean: The American people have made it clear this is what they want. Are you going to represent your donors, or your constituents? We'll find out and talk about it during the election campaign.

Right now, the only choice people have is to sign a contract they can get kicked out of any time. The health care companies are Wall Street flim-flam; they're in the business to make money, not provide care. The public option will incentivize them to become more consumer friendly.

Mike: How do we make sure these new plans are affordable for everyone?

Dean: The public option, and the competition it provides, is the most important part of this. Primary care physicians don't like the way they're practicing now, which incentivizes them to practice bad medicine. The public option allows them to do things differently, and may actually allow them to innovate new kinds of cost controls that aren't possible in the current system.

Tanya: How do we maintain innovation?

Dean: There is a role for the private sector in medicine. We bash the pharmaceutical companies, but they're only 10% of our medical expenditures. Still, they drive innovation, and that should continue. (And they shouldn't be allowed to advertise.)

The public option will help us move from an illness model to a wellness model of medicine. The big innovators now are big co-op type companies like Kaiser. They change the incentives toward wellness. Some of the big companies that self-insure are also being pro-active: taking the crap out of the cafeteria, setting up health clubs for employees -- this is an investment in lower costs. They get that a wellness model works better for everyone.

A public option will allow us to bring that kind of thinking to national health care.

Mike: Should President Obama focus on bipartisanship when no Republicans are going to vote for this anyway?

Dean: Obama's playing this well. He's letting the Republicans speak for themselves, in saying they want this to fail so Obama will fail. He's forcing them to show their true colors.

Mike: About co-ops. Some senators from rural states are proposing this. Other people are pointing out that there are problems with this (using electric co-ops as a model). What about this?

Dean: Kent Conrad is a friend -- but he's wrong about this. It's a political compromise, not a policy one, and it won't work.

They're too small to do any good. And we already tried this: Blue Cross/Blue Shield was a non-profit co-op, and now it's a private insurance company just as bad as any of the rest. We don't want to make it easier for the insurance companies to come in and co-opt the co-ops. They're too small. The insurance companies will come in and undercut them and drive them out of business.

They will not work.

Q&As from the audience:

Jill from Ohio: How do we keep mental health parity as part of this discussion?

Dean: This was one of his first issues in the Vermont legistator. We have a national mental health bill now, but it's really up to the benefits panel when it's convened. They need to provide a benefit; but they'll settle the limits and other details.

We're also starting to realize the degree to which brain health is integrated into the rest of our health. We're moving closer to a medical model of mental illness, which means there's less reason to treat it differently. I hope the benefits panel will take that into account.

Another blogger: How do we talk about this in our work? How do we keep it simple?

Dean: This is not about refuting right-wing death panels and other lies.

This is about: Are we going to let the American people choose for themselves? Are we going to give them a full range of choices, or let Washington choose?

Whose side are you? The American people have spoken. Legislators need to choose who they work for -- and be prepared for the usual consequences that come to people who don't work in the best interests of their employers.

Another blogger: Won't the plan just stick us with the bill for high-risk people?

Dean: No. The bill eliminates restricting insurance on the basis of pre-existing conditions. There are a disproportionate people in the uninsured pool that are high-risk, but it's not overwhelmingly disproportionate. Also, the difference in overhead rates will give the public option more money to deal with increased risk. Finally: So what? These people are getting bad health care in emergency rooms, and we're paying for that now anyway via taxes. At the end of the day, we may end up paying less, because these people will be getting more rational and consistent care. It'll all work out pretty much evenly.

Mike: A questioner is skeptical of the small business exemption. In the Clinton plan, we tried to subsidize small business to the point where big businesses rebelled -- and we lost their support. Should small business have to pay into the pot, or exempted entirely?

Dean: Big business gets a lot of breaks from Congress and the taxpayers. It has no right to complain about the few subsidies small businesses get. These businesses create 80% of all new jobs in America. I'd say anybody with under a million dollars in revenue or fewer than 50 employees should be exempt from this.

I'm not pushing this (though it was part of my 2004 platform). I don't think we need a mandate. It won't be popular -- though Republicans are also mandating that we stick with the system we have now.

Also: We should give people under 30 the same Medicare we give people under 65. They're cheap to insure since they're generally healthy, they're not heavy users, they're hard to get signed up for anything, they're moving constantly and hard to keep insured. We did it for $480 a year in Vermont.

For the over 55s, I'd let them buy into Medicare. The public option advances that. This lets us do a lot of cost controls -- this is in the bill.

I wouldn't do away with employer-based insurance, though I argue for this in the book. People like it. They get good benefits, even though they're expensive. CEOs like it, for reasons that aren't quite reasonable. And America is a conservative country: we think we want change, but we won't always vote for it.

So we need to give Americans the choice, and Obama's bill does that.

We have failed to insure Americans -- not only because the insurance companies, but because 80% of us have insurance, and 60% have good insurance. They don't want to change. We need to let people experience an alternative, and let them make the choice. This allows the pace of reform to go at a pace people will be comfortable with.

Mike: Last question. What can we bloggers do to make health reform happen this year?

Dean: More than most people. Go to and find out what you can do. Bill Press's website list legislators we need to work on. E-mail them and ask what these Democrats are doing to pass the Democratic President's bill. Make sure they get contacted by people in their states.

This is even working on Max Baucus: he's going home to Montana and getting an earful. He knows he has to get a bill out of his committee with zero Republican votes, so he's got to work with the Democrats. In the end, I think we're going to get almost every Democrat in the Senate, because they know people want this.

For legislators, this is a choice between the insurance companies and the people who voted for them. We can be polite, but firm. We have made our compromise. There will be no more compromises. We expect them do what we elected them to do.

(And the crowd goes wild.)

Follow ups: Organizing for America is rounding up bloggers to do phone banking today for health care reform. (We're trying to get 10,000 calls out today.)

Dean's going out canvassing in Pittsburgh tomorrow with SEIU.

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