Ceci Connolly has an interesting profile of Howard Dean’s attempts to create universal health coverage while governor of Vermont. In addition to demonstrating the difficulties in a government solution to the problem, it’s a pretty good case study in Dean’s leadership style: He started with a plan that was far too grandiose, was handed a humiliating defeat, and then regrouped and got a workable if unsatisfactory program through.

Born in humiliating defeat, the seven-year odyssey established health care as Dean’s signature issue and created a banner he has carried proudly as a Democratic candidate in the 2004 presidential contest. His handling of the issue also provides a glimpse into his executive style — at times obstinate and combative; at others pragmatic.

His backers — and some independent analysts — said his Vermont record suggests Dean has the political savvy and persistence to drive a broad health care agenda for the nation and tackle other tough problems as well. Others in the health care industry said Dean simply took advantage of new federal dollars while shifting the burden of medical costs to doctors and private hospitals.

During Dean’s 11 years as chief executive, Vermont was frequently among the first states to enact innovative health legislation. It passed bills boosting child immunization rates, reducing prescription prices for senior citizens, cracking down on discriminatory insurance practices, requiring pharmaceutical companies to disclose gifts to physicians and putting mental health benefits on par with other coverage. Meantime, the state’s rates of smoking, child abuse and teen pregnancy fell sharply.


Dean’s tactics and style could inflame tensions, lawmakers said. On several occasions, he proposed trimming the very health benefits he instituted, including dental, foot and eye care for Vermont’s low- and moderate-income adults. He fiercely defends this approach.

“I promised the people of Vermont I would not take one person off the program,” he said. “So we did eliminate certain benefits. But that’s better than cutting people.”

The state budget plan that Dean submitted in 2002 contained &dol;27 million in Medicaid cuts and charged seniors higher co-payments and deductibles for medicine.

Initially, Dean said the legislature forced his hand by refusing to support his proposed cigarette tax increase in 2001.

Others said he cavalierly used services for the poor as a bargaining chip. “It’s a who-is-going-to-blink-first strategy,” Peter Youngbear, a lobbyist for the disabled, said at the time.

Dean said he proposed the cuts “to force the Republicans to adopt the cigarette tax. I got the damn program funded.”

Interesting. Clearly, Dean’s approach made few people happy, simultaneously alienating the business community and his own party’s base. Still, ruthless pragmatism is likely the only realistic approach to this issue. And, as government inexorably increases its role in the health sector, rationing and other hard choices will be inevitable consequences.

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James Joyner
About James Joyner
James Joyner is Professor and Department Head of Security Studies at Marine Corps University's Command and Staff College. He's a former Army officer and Desert Storm veteran. Views expressed here are his own. Follow James on Twitter @DrJJoyner.