Healthy America Initiative
Address to the Markle Foundation
The following are prepared remarks given by Governor Howard Dean, M.D. at the National Press Club in Washington, DC on June 5, 2003:
Health care is a subject I've been passionate about for my entire adult life, so I'm very pleased that the Markle Foundation invited me here on the day it's unveiling the findings of their Connecting for Health Collaborative. I'm certain that Connecting for Health will play a crucial role in improving America's malfunctioning health care system.
The fact that our health care system needs major improvement, the fact that the quality of our care is often too low and the costs too high - these things are hardly news. Just listen to this message Harry Truman sent to Congress over a half century ago. President Truman wrote:
"The real cost of our present inadequate medical care is not measured merely by doctors' bills and hospital bills. The real cost to society is in unnecessary human suffering and the yearly loss of hundreds of millions of productive working days. To the individual, the real costs are the shattering of family budgets, the disruption of family life, the suffering and disabilities, the permanent physical impairments left by crippling diseases, and the deaths each year of tens of thousands of persons who might have lived. This is the price we are now paying for inadequate health care."
Truman wrote those words in 1949. Since then, several generations of Americans have been born, far too many Americans have died before their time - and we are still paying the price for a terribly inadequate health care system.
When I graduated from medical school twenty-five years ago, I swore an oath along with my classmates. In that oath, my classmates and I pledged, "the health of my patient will be my first consideration."
The health of my patients was indeed my first consideration when I was practicing medicine. As my wife Judy and I embarked on our residencies in Vermont and then joined a private practice, we saw clearly the human costs of America's flawed health care system - the uninsured women with late-stage breast cancer because they couldn't afford to pay for a diagnostic mammogram. Seniors with chronic but treatable conditions who had to decide every month between buying their medicine and buying food.
I saw these things, and I had to come to terms with the fact that if I were really serious that "the health of my patient will be my first consideration" - I had to do more than just treat my patients. Because the truth is, the health care system in this country is the sickest patient of all. And until we heal the system, we're not doing our best for our patients who rely on it.
So, it was precisely because the health of my patients was my "first consideration" that I decided to enter public service. And that's why I persevered as Governor of Vermont to get as close to universal health insurance for the people of my state as I could. My Administration offered health insurance to every child under 18 - and we made it a middle-class entitlement for families earning up to $52,000 a year. A few weeks ago, I unveiled an even broader universal health insurance plan for the nation.
But giving uninsured people access to health coverage is only one part of the solution. The second part is making sure that the health care we offer is the highest-quality care possible. The third is making better use of prevention - because preventing disease rather than curing it is a better outcome all around. (And in most cases, it's cheaper, too.)
Fourth is making sure that our health care choices are centered on patients and what's best for them, not on corporations and what's best for their shareholders. But while our health care system may not be accountable to shareholders, it should be accountable to taxpayers. And throughout the health care system, we have to make sure that we make cost-effective choices, to get the best, and the most, care possible for the least amount of money. That's the opposite of the system we have today, which often seems designed to provide the least care possible for the most amount of money.
We must, of course, deal with the problem of spiraling health costs, but HOW we do it is critical. There are some important steps we can take in the short run to restrain health care costs, and I will address these in a moment. But, over the long run, bureaucrats and insurance companies can't assure we will get good value for our health care dollar, only doctors and patients can do that. Therefore, our efforts should focus on educating, motivating and empowering doctors and their patients to do the right things.
I call my plan the Healthy America Initiative. I've already outlined one of its main components - universal health coverage. Over the next few weeks, I'll be discussing the details of my plans for preventive care and patient-centered care, all focused on cost-effective measures.
But today, I want to focus on a part of my health care program that will be greatly enhanced by the work of Connecting for Health. I want to talk about how we can improve the quality of the care we provide in this country, while simultaneously enhancing its cost-effectiveness.
I don't think anybody here doubts that the quality of our health care needs improving. A benchmark 1999 study by the Institute of Medicine found that anywhere between 44,000 and 98,000 people die each year because of medical error. Medical errors add $70 to $100 billion dollars annually to our national health spending. As a doctor and as a political leader, I have to agree with the Institute of Medicine that beyond the economic cost of these errors - and I quote - "It is simply not acceptable for patients to be harmed by the same health care system that is supposed to offer healing and comfort."
The Institute of Medicine's study also found that invasive procedures, such as hysterectomies, were often performed when they weren't necessary and that patients requiring crucial diagnostic tests, like coronary angiograms, often had to wait months to be tested.
I guess that's one way to save on health care costs - if you live long enough to go for your coronary angiogram, then we can assume you weren't really sick enough to need one. But I have this strange, old-fashioned notion that we should actually diagnose and treat people who have potentially life-threatening illnesses, not stall and wait for them to drop dead so we can save ourselves the trouble.
Another way our system is failing is that we're not providing proper care-management for people with chronic medical conditions. Six out of ten people in this country - and 88 percent of our seniors - have at least one chronic medical condition. And one-quarter of the seniors in this country suffer from not one, not two, but four chronic medical conditions. Some of these people get the help they need to manage their conditions but they're in the distinct minority.
In this country, according to a study of chronic conditions published in the "Journal of the American Medical Association" last summer, three out of four people with hypertension are not receiving adequate treatment; some 86 percent of patients with coronary heart disease have higher cholesterol levels than they should; and more than half of diabetics have difficulty controlling their blood sugar. Without proper care-management, they all risk grave consequences, including heart attack, stroke, kidney failure, blindness and even death.
If compassion isn't reason enough to properly fund care-management programs for them, then maybe economics will provide the rationale: We ought to recognize that making medications affordable enough to be taken regularly (and teaching people at risk to pass up the French fries) is a lot cheaper than angioplasty or years of kidney dialysis.
Our failure to help people manage their chronic illnesses does not just mean that Americans are living in pain unnecessarily. It also means that some people - who are otherwise fully capable of working and who would love to be productive, if they could find a respite from their pain and illness - these people are compelled by their chronic conditions to stay out of the workforce. Instead, they end up on public assistance, living pain-wracked lives on the taxpayer's dollar.
Now, some people really are too ill to work. Nothing medicine can do will change that, and we should support them appropriately. But some people with chronic illnesses could be productive and self-supporting - if we provided some resources up front to teach them how to manage their conditions. It's a win-win proposition: They get freedom from needless suffering and we get a lifetime of taxpaying productivity not to mention saving ourselves millions of dollars in public assistance.
Our health care system and our welfare system have been incredibly shortsighted in not making these proactive investments. We can do better - for our chronically ill neighbors and for ourselves.
The health care system in the United States has the potential to be the best in the world. We have the scientific knowledge to prevent, diagnose, treat and cure many conditions. But one survey found that more than a quarter of adults with health problems could not get the care they needed in a timely fashion. And these are people with insurance. For those without health coverage, accessing care is even more problematic.
We have a cadre of well-educated, trained medical professionals - doctors, nurses and technicians - highly motivated to do their best and who go to extraordinary lengths to help their patients. Their job is hard enough, but we make it immeasurably harder by drowning them in a sea of paperwork.
As many as two-thirds of the physicians in this country say they don't have enough time to spend with patients. One of the main reasons they don't is that with constant pressure on their reimbursement rates, they have to squeeze as many patients into a day as they can. They're simply not being adequately compensated for the care they give and the time they invest. And regulatory and payments policies require levels of letter-writing and other documentation that consume too much valuable physician time.
I have a confession to make here. The reimbursement rate is one thing we didn't get quite right in Vermont. We pegged it to Medicaid's reimbursement rate, and that's just too low. We're aiming to fix that now in our national plan. But you know, when you're talking about reimbursement, the level is not the only thing that's screwy. The rules for what procedures are and aren't reimbursable provide no incentive whatsoever for doctors to emphasize preventive strategies or proper management of chronic conditions. For example, doctor's offices that try to closely monitor and assist diabetic patients in managing their blood sugar either by telephone or on-line computer services cannot be paid for these services unless the patient comes into the office. Similarly, home nurse visits to new mothers have been shown to improve infant health, reduce abuse, and help mothers through what can be a difficult time; but these services are rarely reimbursed.
The bottom line is this: Keeping Americans healthy is one of the most important jobs in our society, yet we do not give nearly enough help to the professionals who do this essential work.
One thing everyone in the medical profession needs help with these days is keeping up with new discoveries in science and medicine. Our medical knowledge is growing by leaps and bounds: It took ten years to map the human genome, but only six days to decode the SARS virus. No individual can assimilate all of the complex information being produced and keep up a full-time practice. The federal government can help here, and it must.
We need a central repository for medical information, and fortunately we don't have to start from scratch to build one. The Agency for Healthcare Research and Quality examines what works and what doesn't in the health care arena. But, honestly, I don't know how they can focus on keeping Americans healthy when the agency is so often at death's door itself.
Being a part of the Department of Health and Human Services, it has to endure constant threats of funding cuts and the shifting winds of politics. I want to protect it from all that by moving it to the National Institutes of Health. And I want to make it more responsive to the needs of our health care system by having it focus on implementation as well as on research.
Our new Health Care Institute will serve as a clearinghouse for vital information, giving patients, hospitals, and medical professionals the help they need to put our growing base of medical knowledge into practice. The additional cost, estimated at $300 million, will be far outweighed by the benefits to patients, as physicians incorporate applicable discoveries into their clinical practice.
New discoveries will inevitably include new medicines. Which means new patents. Which means new attempts by pharmaceutical companies to extend their patents in order to avoid competition from generic drugs.
Listen - I'm not the kind of guy who thinks "profit" is a dirty word. I recognize that pharmaceutical companies devote huge sums to their Research and Development budgets, often taking extraordinary financial risks. And in the market-based system we live by, when you take a risk and that risk proves successful, you deserve to be compensated appropriately. But let's be fair - pharmaceutical companies should only seek patents for new drugs, new formulations that are the product of new research.
When a company discovers a new use for a drug just as the lucrative patent it holds is about to expire, we should see through the ruse and deny the extension. Otherwise, the Patent Office is reduced to playing the role of enabler, allowing pharmaceutical companies to abuse the trust of patients and drain the savings of sick people, as well as the coffers of our public and private insurers.
Big R&D budgets aren't the only things that cause drug prices to rise big advertising budgets do, too. But why are companies advertising their drugs to the public in the first place? Consumers don't need to know about every new drug that comes down the pike. Doctors make the decision about what to prescribe based on the patient's condition and medical profile.
Warm-and-fuzzy images of grandma hugging her grandson again because of the latest miracle drug these images don't affect the doctor's clinical decision. Or at least, they shouldn't. The only reason most of these ads exist is to increase the amount that consumers and insurers spend on drugs. Limiting the advertising budget of pharmaceuticals should lower drug costs to consumers. I would personally direct the FDA to approve direct-to-consumer advertising for drugs, devices and procedures only where there is a compelling health benefit and where the product has demonstrated that it would be cost-effective if widely used.
Value-based purchasing, also known as "gain-sharing," has helped the federal Medicare program to reduce its costs and increase the quality of care by setting specific goals and rewarding those who achieve them. For example, insurers might provide a financial bonus to providers who succeed in lowering the excess blood sugar for their diabetics. These contracts are based on solid research and are usually administered as part of specific disease management programs.
Encourage competition and we can harness the power of the market to lower health care costs naturally. Developing drug formularies that compare with therapeutically equivalent drugs will help physicians choose the lowest-cost option for their patients. We will remove restrictions barring the importation of drugs from countries that have protections comparable to those in the U.S. And we'll allow states wide latitude to do what Vermont and Maine have already done - experiment with other ways of controlling drug costs. In addition, I would achieve greater transparency requiring disclosure of gifts and consulting relationships between the drug companies and physicians, as well as the rebates that pharmaceutical companies offer pharmacy benefit managers (PBMs).
You know, one of the commitments doctors make when they swear the Hippocratic Oath is - quote - "I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patients." That's certainly a rule that I followed when I was a physician. And I've never stopped following it.
I don't pretend to have all the answers I would be highly skeptical of anyone who said they did. So I've built "seeking the counsel of skilled physicians" - and others - into my health care plan. I will convene a White House Conference on Health Care Quality that reaches out across all disciplines of medicine and research, to bring together the best minds in the nation.
White House Conferences send a message of Presidential priorities and galvanize action. They demonstrate the focus and commitment of the country and its leaders on critical issues. I will ensure that there is such leadership as we seek to translate into action the new gains in evidence-based medicine and new preventive techniques, as they are developed.
In this country, our doctors have access to a range of cutting-edge medical technologies for diagnosing and treating disease. But, as many patients waiting for angiograms know all too well, we are not always able to use this technology efficiently. In fact, the United States is significantly behind other industrialized nations in the way we utilize information to manage medical technology. For example, only 17 % of General Practitioners in the US use electronic medical records compared to 48% in Germany, 58% in the UK, and 88% in the Netherlands.
In virtually every other American industry, technology is central to the exchange and analysis of information. When American banks adopted ATMs, they reduced transaction costs from one dollar, to three cents. Yet in the United States - the very birthplace of information technology - our health care system has not capitalized on most of the efficiencies that state-of-the-art technology has to offer.
There are some practical reasons for this lapse - we must be absolutely certain that confidential patient information will remain safe from the prying eyes of hackers - or anyone else who has no legitimate reason to view it.
But privacy isn't the only issue holding us back. Our health care system is so fragmented that the people who participate in it - physicians, researchers, administrators, insurers and patients - might as well be speaking different languages. And from a technological standpoint, they are. Technology can integrate the disparate parts of our health care system, but the system's size and fragmentation remain huge barriers.
Improving our technological infrastructure is central to the success of my health care plan. The Markle Foundation has done a great service to this nation and given us a great head start by funding the Connecting for Health collaborative.
The Connecting for Health working groups will create substantive models from which we can fashion a truly interconnected health care infrastructure. This is more important than ever because now, as the Institute of Medicine noted in a recent report, in addition to keeping people healthy, our health care infrastructure needs to address the threat of bioterrorism. Hopefully it will remain just a threat. But if it ever went farther, we would need a robust, technologically sophisticated health care infrastructure every bit as much as we would need a stockpile of Cipro or vaccines.
In this "fully wired" system, doctors will have access to all the information they need to treat a patient from data on clinical trials of experimental techniques or drugs, to the patient's lifelong medical records. Patients will no longer have to hunt for their medical records, or track down a doctor they saw ten years ago in another city whose name they can barely remember, because their entire medical history will be synthesized into one electronic form. Wherever people are in the world even if they're traveling far from home - any doctor treating them could be authorized to access their complete medical history.
Information will flow instantly and securely across the system, with medical records integrated into a uniform billing system that will radically reduce the amount of paperwork that health care generates today. That reduction in paperwork also, not incidentally, will save the system a great deal of money. And there's a great deal of money to be saved: On average, Americans spend over $1,000 dollars more per capita than economic formulas predict we should. And the vast majority of that $1,000 can be traced to the huge administrative overhead that American doctors and hospitals are required to support and American patients are required to pay for. A study by the McKinsey Global Institute found that in 1990, Americans consumed $390 less health care per capita than Germans but they spent over $600 more per capita. And what was the bulk of that $600 paying for? You guessed it administration.
As Princeton University economist Uwe Reinhardt wrote in a "Letter to the Editor" of The Wall Street Journal last month, "If one fed a dozen Princeton seniors six kegs of beer and then asked them to develop a health-care financing system for our country, they'd probably come up pretty much with the system we have." Needless to say, we can do better.
At my medical school graduation, my classmates and I pledged to uphold our profession according to the Physician's Oath of Geneva. Most of its provisions mirror the commitments in the ancient Hippocratic Oath, but one section does seem to be unique to the Oath of Geneva. We pledged: "I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient." As a physician, my duty to provide my patients with the best health care possible had to transcend all the traditional categories that all too often divide us. As an elected leader, my duty to provide my constituents with the best health care system possible also transcends those traditional divisions.
That's why to me, health care isn't a partisan issue. It's a moral imperative.
Since 1949, when Harry Truman made the assessment of our health care system that I read you at the beginning of this speech, we've had Democratic presidents and we've had Republican presidents. We've had Democratic-controlled Congresses and we've had Republican-controlled Congresses. Both sides of the aisle have had their opportunity to improve the health care system. And still, very little about our nation's health care infrastructure has changed since Harry Truman's day. That's unconscionable.
We cannot let this situation stand another 50 years. But ten years have passed since President Clinton tried to improve our health care system. And in the last eight years, the only health care debate in the United States Congress has been about whether to pass the Republican or the Democratic version of the Patients' Bill of Rights. The argument is about whether or not you can sue your HMO.
I get a kick out of politicians who thump the table and declare, "By God, we need a Patients' Bill of Rights." The truth is, it doesn't matter which bill passes - or if neither bill passes. The truth is, neither bill will extend health insurance coverage to even one more American, and neither bill will make health insurance even one nickel cheaper.
The truth is, what our health care system needs most is leadership. As I travel across the country in the coming year, I'll be making "House Calls" to discuss the problems with the health care system and some of my proposed solutions - with the American people. I bet you thought doctors didn't make house calls anymore. But let me tell you: They do if they're running for president.
And I'll be giving more speeches, in the two other main areas of my initiative - prevention and patient-centered care - to complement the ideas on high-quality care I outlined today and the plan for universal health insurance I unveiled last month. In all these discussions, I'll be focused on improving cost-effectiveness.
Through the Connecting for Health collaborative, all of you here today are displaying real leadership in identifying technology-based solutions to many of our health care system's thorniest problems.
You are proof that solutions are emerging. And to implement the solutions, we'll have to rely on Americans themselves to elect leaders with the backbone to create a more efficient, more effective health care system in this country. A system that really does offer "quality health care for all."