A talk with presidential candidate Howard Dean. (View on Washington).

When Howard Dean, MD, announced his campaign for the 2004 Democratic nomination for President, almost no one in Washington viewed him as a serious contender. After all, there are four U.S. senators, one former senator, two congressmen, and the Reverend Al Sharpton competing for the same honor (at press time). Most of them are better known and have access to more money than Dean. What's more, Dean's political base is Vermont--one of the least populated, more rural states in the Union.

Since he retired in December 2002, after five two-year terms as governor of Vermont, Dean has been surprising a lot of political analysts. He has emerged as one of the most successful fund-raisers among the Democratic candidates. He has also proven to be a tireless campaigner. His opponents can't claim that he's inexperienced, when he's won 10 consecutive elections, slashed his state's public debt, and enacted universal health insurance for all Vermont youth.

Above all, Dean is attracting interest because, like Sen. John McCain (R-Ariz.), he resists classification as a liberal, moderate, or conservative. For example. Dean was one of the most outspoken opponents of the U.S. attack on Iraq, because he thought it diverted world attention from the more immediately dangerous threats of Al Qaeda and a nuclear-armed North Korea. He chides Democratic congressmen for rigidly pursuing their version of a "health consumer Bill of Rights" at the expense of addressing the more urgent issues of underfunded health systems and unaffordable insurance.

Nursing Homes/Long Term Care Management caught up with the hard-traveling Dean recently. The only physician seriously contending for the White House was happy to briefly discuss his interests in medicine and his views on long-term care with Nursing Homes' Washington Editor Michael J. Stoil.

Stoil: Governor, you received a medical degree in 1978. By 1983, you were already serving in the Vermont state legislature. Did your experience as a healthcare professional have anything to do with your decision to enter politics?

Dean: I don't really think so, although it certainly has had a big influence on what I've done in politics. I've found that my skills as a physician sometimes have been transferable to politics.

I was always very interested in healthcare. [President] Jimmy Garter tried to put in universal healthcare, but it didn't work. I followed that effort closely, when I was in medical school, and I even spent a month in Washington working on the issue.

Stoil: Did you practice medicine during the time you were in the state legislature?

Dean: I did, and I also practiced during the time when I was lieutenant governor. I'm an internist and my wife, who also is an internist, was my partner when I was practicing medicine.

Stoil: So it was only when you became governor that you retired from active practice?

Dean: Right, I stopped in 1991.

Stoil: Several of the achievements that your campaign cites about your record as governor concern healthcare coverage. How have healthcare providers fared in Vermont under your policies?

Dean: I think reasonably well. The pediatricians now have a large number of patients covered under Medicaid, and there's been an increase in reimbursement for the pediatricians because of that. I think they're pleased that virtually every child under 18 has health insurance.

The rest of the record has been mixed, I would say. Certainly, every provider, and particularly the hospitals, wants more money. Money is hard to come by, so I think you'll find some dissatisfaction, but the healthcare system is a very strong one in Vermont.

As far as nursing homes go, I think we've been quite successful. We have a case-mix reimbursement method so that nursing homes with more difficult cases get reimbursed more to take care of them. That's been very helpful because we've tended toward more home healthcare and less nursing home care over the last decade. We're paying nursing homes for the work that only they can do, and that work is increasing.

Stoil: Have there been nursing home closures because of bankruptcy in Vermont?

Dean: There definitely have been closures. One of the things that's happening in the industry nationally is that small, family-owned homes are finding it more and more difficult to continue. The larger institutions that are either associated with hospitals or with national chains are more able to compete in the difficult environment that nursing homes find themselves in. So some of our smaller nursing homes have closed.

We're also making all kinds of efforts to take care of more people in their own homes because it costs the state about half of what taking care of them in an institution would cost.

Stoil: At the American Public Health Association annual meeting in Philadelphia last year, when you outlined a proposal for health financing reform, you didn't mention long-term care.

Dean: The principal problem with long-term care is underfunding by Medicaid and Medicare. I would add $3.6 billion to the budget of Medicare and Medicaid--pincipally to the budget of Medicaid--to cover the shortfall for nursing homes throughout the country.

Stoil: Would you support any changes in the tax code for long-term care insurance?

Dean: I'm interested, but frankly the Bush administration has made such a mess of the federal budget that it could be a long time before we can look at tax credits for anything. Ultimately, though, that is the way to do it: make it easier to buy long-term care insurance. We want people to be responsible when they can afford insurance.

Basically, the long-term care system in this country is not broken, and we have this saying, "If it ain't broke, don't fix it." I think that the industry just needs about $3.6 billion of additional money and, of course, for people to be encouraged to buy long-term care insurance. At some future date, I would be willing to look at tax credits to do that. Again, though, the President's tax cuts have hurt the federal budget so much that I don't see how that's going to be possible in the short term.

Stoil: The Bush administration has maintained what many providers see as a very heavy regulatory burden on nursing homes and, in fact, there is talk about extending federal regulation to assisted living. Without going into specifics, what's your view of the regulatory burden in healthcare?

Dean: In general, the regulatory burden is grossly excessive. It's a huge problem. It's a problem for small physician offices practicing alone and it's a problem for big institutions, including hospitals and nursing homes.

I favor the states regulating [healthcare] rather than federal regulation. States are more flexible and, in general, are going to do a better job than the federal government in protecting patients. I am inclined to avoid enormous amounts of federal regulation and instead let the states continue their regulation of healthcare quality. It makes it easier for everybody, and the protections for patients are frankly better than they are through federal intervention. The federal government is very well-intentioned, but it rarely gets regulation right.

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