A Platform for Policy
Photographs by Jon Gilbert Fox
Back when the weather was turning cold . . . and the political season was heating up . . . DHMC invited all the major presidential candidates to share their health-care proposals with a Dartmouth audience. Now the weather is turning warm again . . . and many candidates are out of the race. But the DHMC series focused on policy, not politics, so its substance is still sparking discussion. Here's a report from the (snowy) trenches of the nation's first-primary state.
Pictured above is our intrepid political correspondent-cum-medical student, California-born Katrina Mitchell, for whom home is now the snowy Granite State.
HOW THE SERIES WAS STRUCTURED
During the past few months, along with my usual reports to California-based friends and family members about the deepening snow and plunging temperatures, I was able to share the excitement of DHMC's "Health Policy Grand Rounds" series. Although many Californians I knowliberals and conservatives alikeshare an inexplicable wariness of native New England candidates, they all were eager to hear about my up-close observation of these DHMC-based discussions about health-care policy.
And the question almost everyone asked was: "Tell me againhow exactly did most of the front-runners end up at your hospital in New Hampshire?"
As I explained in a flurry of e-mails to these inquisitive westerners, DHMC wanted to capitalize on the fact that it's located in the nation's first-primary state but avoid politicking within its walls. So the Medical Center, in collaboration with Dartmouth College's Rockefeller Center, extended invitations back in the fall to all nine of the major Democratic candidates as well as to President Bush. The series was structured as part of DHMC's ongoing program of grand rounds lectures sessions whose topic is usually some new surgical technique or pharmacological finding. The planners hoped to elicit presentations and exchanges more substantial than the usual campaign sound bite.
The candidates were asked to speak on health-care policyeither broadly or on a specific topic of their choiceand to avoid overt campaigning (though a few quips did slip out). Most of the candidates talked for about 15 minutes, then led a question-and-answer session for the remainder of the hour.
Dean was the first candidate to accept the invitation and led off the series in September. A couple of candidates never responded, and many others didn't commit until shortly before a proposed speaking date; several cancelled and then reconfirmed. Thanks to persistence and a lot of coordination (pinning down dates wasn't the only hurdlethere was also a lot of last-minute scrambling to find free auditoriums), DHMC ultimately hosted Kerry, Lieberman, and Kucinich later in the fall. Clark visited in mid-January, and Senator Bill Frist spoke on behalf of President Bush shortly afterwards. To the disappointment of those who'd followed the series closely, Edwards cancelled his January 22 presentation the day before he was scheduled to speak, and by then it was too close to the New Hampshire primary to try again.
Attendance at the Health Policy Grand Rounds sessions was limited to individuals with a Dartmouth connection. A few constituencies got automatic entree (such as the eight medical students who are this year's Schweitzer Fellowsa group that I'm lucky enough to be part of). Some reporters were also present (in addition to yours truly, who wore two hats), though they were prohibited from asking questions during the presentations.
Mitchell is a second-year Dartmouth medical student, as well as a regular contributor to Dartmouth Medicine magazine. She wrote the cover feature for our Fall 2003 issue, about DMS's Patient Partnership Program, and has written a number of articles for the "Vital Signs" section over the past two years; she is also a member of the magazine's Editorial Board. She was the editor of her high school newspaper and an intern in the news office at her undergraduate alma mater, Bowdoin. She'll be taking a break from her reportorial sideline for the next few monthsto prepare for her third-year clinical rotations and to study for the national boards that all U.S. medical students take at the end of their second year.
I grew up in sunny southern California, watching TV coverage every four years of presidential candidates frozen against a snowy New Hampshire landscape. I never imagined that I would live in the nation's first-primary statemuch less be a medical student here at a time when health-care policy is a more pressing domestic issue than ever before. But now that the Granite State is home for me (and 300 other Dartmouth medical students), the proximity of the primary action to our lecture halls and our hospital has given us an opportunity to experience firsthand the intersection of politics and health care.
Some students even had a chance to meet many of the candidates as part of a series called "Health Policy Grand Rounds," a unique extension of DHMC's clinical grand rounds. Many of my fellow students were eager to attend the series, but none of them were quite sure how it originated.
So I sat down with DHMC's director of governmental relations, Frank McDougall, to get a little background. Over the years, he said, many presidential candidates had expressed an interest in speaking at DHMC. Yet the Medical Center wanted to avoid being just another campaign stop. So this election season, he collaborated with Dartmouth College's Rockefeller Center to create a forum that would be both politically neutral and educational.
"We realized that we had a terrific opportunity to inject ourselves into a national discussion about health care," McDougall explained. "We wanted to get in an exchange with the candidates and ask questions about policy."
During each Policy Grand Rounds presentation, the candidates were asked either to speak broadly on health-care issues or to focus on a specific health-care topic of their choice. There were some consistent themes across all the candidates' platforms: decrease the number of Americans without health-care coverage, increase the investment in nursing recruitment and education, and control the skyrocketing price of prescription drugs. But there were some clear differences among the platforms as well.
While speaking to a medical audience was clearly old business for Dr. Howard Dean, the other candidates appeared to be delighted by the novelty of presenting at a hospital grand rounds. Most of them opened their remarks with some joke about being relieved that they were the speaker rather than the subject of some clinical pathology. John Kerry noted with a smile, for example, that "it's amazing to get to do this without having to go to medical school!"
The reaction to the series was overwhelmingly positive. Students, faculty, and staff were grateful for the unique opportunity to see so many candidates speak, in person and on a sophisticated level, about health policy and research. We also got to hear them answer questions off the cuff before a small, intimate audience. Many people mentioned that as a result, the candidates could not sidestep questions the way they might at a large press conference and thus seemed more accountable for their answers.
Here's a summary of what transpired at each of the presentations, in the order in which they occurred. Most of these candidates are now out of the race, but their ideas still offer food for thought.
Howard Dean: Dean used the visit to DHMC to unveil his mental-health-care proposal, arguing for an "integrated treatment approach that would respect the rights of individuals and families." He said that his main goals were to push for better insurance coverage of mental-health conditions, to establish programs emphasizing early detection of mental- health problems, and to integrate mental- health treatment with job- and housing-placement services.
Dean noted the economic practicality of establishing a more comprehensive mental-health program, saying that "too many working people are pushed into poverty by mental- health conditions." Many mental-health patients depend on Social Security disability payments for their income, and Dean said he wants to end rules that discourage such individuals from working as well. He also suggested that the federal government employ individuals who are in alcohol and drug recovery as counselors for others seeking such care.
Aside from preventive and integrative strategies, another major component of Dean's mental-health plan was substance-abuse treatment. "We need to think about substance abuse as a public-health problem and a mental-health problem and not as a criminal problem," Dean said, a statement that received resounding applause from his audience. "These people need to be put into rehab, not prison. Putting them in the general prison population is expensive and unlikely to solve the problem."
During the question-and-answer period, Dean offered an unusual response to a question posed by Dartmouth's chair of psychiatry, Dr. Alan Green. Green wondered how Dean would eliminate the stigma of mental illness, and Dean pointed to Hollywood. "Wouldn't it be fantastic if Hollywood had a show with a sympathetic figure who is mentally ill?" Dean asked the audience.
"People bash Hollywood," he went on, "but Hollywood does make rules for pop culture. If Hollywood started a discussion on this topic, it would get people interested and would relate to personal experiences that people have with their families."
In closing, Dean demonstrated his comfort as an insider in medicine by acknowledging the tension between specialization and technology on the one hand, and the personal touch on the other. He emphasized that he wanted to find a way to reconnect doctors and patients, to honor the spiritual side of medical practice, and to eliminate the dominance of a bureaucratic, corporate reimbursement system.
John Kerry: Speaking shortly after Dean, Kerry adapted well to the challenge of addressing a group of health-care providers just across the Connecticut River from the former Vermont governor's home turf. Kerry opened by reflecting both on the fact that he's the parent of a medical student and on his recent experience as a patient undergoing surgery for prostate cancer. "I realized that any family's health care in America should be as important as any politician's," Kerry said. "I was luckyI can say that I was cured, that I am cancer-free. But not all are lucky. But having had this experience, I have opened a window to suffering that I didn't know before."
Kerry emphasized the importance of continuing the nation's advancement of scientific research as part of any reform of the health-care system. He said, for example, that he would promote increased funding for organizations such as the National Science Foundation. And, he added, he would push especially hard for more research into Alzheimer's disease and Parkinson's disease because of their increasing incidence in America's aging population. He also said he sees great promise in stem-cell research.
"I want to make sure research is benefiting everyone, not just a few," Kerry explained. "You shouldn't have to be lucky, fortunate, or rebellious to receive cutting-edge care. We are the only industrialized nation in the world where health care is a privilege and not a right, and we need to change this. The best medical breakthrough is not a breakthrough if it doesn't get through to everyone."
Kerry spent some time outlining the specifics of his plan for health-care reform. He said he would like to model a national health-care program after the federal employee program, which allows beneficiaries to choose their own health-care providers. He said that his goal would be to achieve 97% coverage of all citizens within three years, then work to cover the remaining 3%.
During the question-and-answer period, Kerry was asked about the proper level of funding for research. In his response, he noted that his daughter, a third-year student at Harvard Medical School, had lobbied him regarding the benefits of early intervention and the importance of putting money into research about preventive medicine.
Another question concerned the challenge of encouraging medical students to pursue careers in academic medicine and research. He used the opportunity to mention his plan to offer debt-forgiveness for students who choose to do scientific research, as well as those who pursue careers in what Kerry calls "socially critical job categories."
Joe Lieberman: Lieberman opened his speech by noting his long friendship with several doctors at Yale and praising the fact that they are "great citizens of community and great citizens of care."
But because so many Americans have such limited access to doctors like those at an academic medical center, Lieberman asserted that "the American health-care system is a study in contradictions. People fly here from all over the world to receive care, yet more than 43 million of our own citizens don't have health insurance. They don't get the best health care in the world until they reach such an extreme state that they have to go to the emergency room."
Like Kerry, Lieberman expressed interest in modeling a national health plan on the current federal employee plan. He sees insurance reform as the first step, because the current setup "strains our system, drives up costs, and does a deep injustice to the best humanitarian values of our society."
He said he envisions this reform as ultimately improving the way physicians are able to deliver health care to their patients. "If we begin to adequately fund the system, then the pressure will be off medical professionals," he said.
Lieberman also proposed limiting health-care profits and not allowing Americans to lose their health coverage if they lose their jobs. His plan calls for those laid off from work to be covered for two months by their employers and after that to have access to a national health-insurance pool. Lieberman also focused on two specifics: his "Medikids" plan and his "Center for Cures." Medikids would cover all children from the day they're born and would create more school-based health clinics. The Center for Cures would focus on research aimed at curing chronic diseases, using stem-cell research and increased NIH funding to achieve its goal.
In addition, Lieberman echoed Dean in expressing an interest in dealing with the stigma of mental illness by "confronting it," although he said he believes the problem now is less one of stigma than of monetary limitations. He concluded by stating that prescription-drug costs need to be capped and expressed the hope that the dangers associated with the increase in drug purchases over the Internet might ultimately pressure drug companies to lower their costs.
Dennis Kucinich: Like Kerry, Kucinich began with a personal anecdotereferring to his days as an orderly at St. Alexis Hospital in Cleveland. "And so," he said, "for an orderly to have a presentation at grand rounds is no small matter."
He mentioned that he had seriously considered a career in medicine and got a laugh from the audience when he said that although he'd turned to politics instead, "when you learn how to clean bedpans, you never know what you're preparing yourself for." He also drew a laugh when he observed that he'd decided against medicine after seeing the effect of doctors' long hours on a normal lifestyleand had chosen a career in politics instead.
Kucinich said that in his role as cochair of the Congressional Caucus on Complementary and Alternative Medicine, he'd come to see health-care reform as the number-one domestic issue. Preventive medicine and changing the system from for-profit to non-profit are two tenets of Kucinich's plan to "overhaul," not simply reform, the U.S. health-care system.
"Think of how good a system it would be if people were encouraged to access it," Kucinich proposed. "They wouldn't wait until they had a health crisis to see a doctor. That's our first step in changing health care we need to make it accessible before it becomes a crisis."
Kucinich also promoted his "Medicare for All" program, intended to "make health care better for physicians who provide the services and for the people who use the services." He said that hospitals and health-care organizations would have more control over the care they deliver and could negotiate for monthly lump sums from the national system to run their hospitals. "When health care is based on the ability to pay," he added, "then it becomes a moral crisis as well as a health-care crisis."
In addition, Kucinich addressed the needs of health-professions students, arguing for more nursing schools and easier debt repayment for medical students.
This point was highlighted by Kucinich's exchange with a retired DMS faculty member who offered his opinion on loan repayment during the question-and-answer period. Kucinich invited the doctor to join his campaign and help craft his medical-student loan-repayment plan.
More than the other candidates' visits, Kucinich's presentation was punctuated by exchanges with the audience. A medical student engaged him in a discussion on the influence exercised by insurance and pharmaceutical companies in Washington, while a surgeon requested that Kucinich work to "change the national vernacular" on health care. "Our country isn't experiencing a health-care crisis," said the surgeon, "it's experiencing an insurance and bureaucratic crisis." Kucinich said he agreed.
Wesley Clark: Echoing the surgeon who'd attended Kucinich's talk, Clark said the main problem facing the country is lack of universal access to health care. His remarks revolved around the theme of moving from the current system, a holdover from the 20th-century, to a system that meets the demands of a 21st-century populationeffecting change in a way that would maintain the system for years to come.
"Modernizing our health-care system is not about the next electionit's about the next generation," Clark said.
Like Dean, Clark emphasized the need for mental-health treatment that is "appropriate, with no strings and no stigma attached. That means making mental-health-benefits parity one of our highest priorities." But, he added, "parity is not enough." He said he would proactively screen for psychiatric problems in children as well as bolster social-service programs for the treatment of the mentally ill. During the question-and-answer period, he expressed his support for treatment and rehabilitation over criminalization of drug offenders.
Clark also devoted a significant portion of his presentation to nursing. He recounted his experience of being wounded in Vietnam and cared for by Army nurses, saying, "I know firsthand that nurses make the difference." He said he would like to improve compensation and working conditions for nurses, to give them more autonomy and authority in medical decision-making, and to increase funding for nurse education and recruitment.
The point Clark emphasized most force-fully was his personal experiences with military health care and the way in which that system could serve as a model of preventive medicine for the entire country. "They had a vested effort in keeping soldiers healthy and ready to fight," he said. "We had routine checkups, cholesterol checkups, and dental checkups. It was good and it was effective. The army understood that it was not just good medicine, it was good economics."
Clark added that appointments with Army doctors were like "coaching sessions" on how to stay healthy. "I want to see medicine move toward wellness, as opposed to always delivering bad news to people," he said.
Bill Frist: When Dr. Frist visited DHMC as the Bush administration's representative in mid-January five months after Dr. Dean's vis-it he exhibited the same insider's ease at speaking to a room full of health-care providers. Unlike any of the actual presidential candidates, Frist spoke without using prepared remarks. He also appeared especially comfortable during the question-and-answer period, even when he was challenged on several points.
Frist, who is majority leader of the Senate, outlined three major health-care goals of the Bush administration: improving Medicare further and solving the prescription drug problem; increasing funding for the NIH; and combating AIDS on a global level. To emphasize his point about AIDS, Frist, a surgeon, offered several anecdotes about visiting Africa, performing surgery there, and watching how different countries are battling the deadly virus. "The greatest moral and humanitarian challenge of our time is a medical one," he said.
In terms of achieving health-care reform, Frist joked that a surgeon like himself was an appropriate figure, because "we like to cut things out, fix stuff, and put it all back together."
Frist also devoted a significant portion of his talk to emphasizing the need for defense against biological terrorism. He sees research in this area as likely to contribute to major advances in medical science.
During the question-and-answer period, Frist acknowledged that the sale of unregulated drugs over the Internet is a growing problem, and he said work was under way to find a solution. He also suggested that pharmaceutical products should be included in trade agreements with other countries. But he worried that drastically cutting back on pharmaceutical profits could reduce the amount of research that drug companies are able to fund.
After responding to queries about AIDS funding, preventive health care, mental health, tax credit vouchers for health insurance purchases, and the benefits of community health centers, Frist wrapped up the question period by reflecting again on the intersection of his background as a physician with the policy issues surrounding health-care access. In particular, he mentioned that he has seen "some amazing doctors leave medicine" due to administrative hassles, insurance paperwork, and medical liability concerns. "The facilities are beautiful, but when you lose person-power, you lose experience and knowledge and you are hurting the American people."
Attendees' Reactions: As I finish writing this article, my review books for the first step of the medical licensing examwhich my classmates and I take in a few monthsare stacked ominously behind my computer. They remind me that despite our excitement about the primary, my fellow students and I don't have the time to follow politics as closely as we did before we entered medical school. Even the most political among us wish we understood more about the various health-care proposals being set forth during the campaign.
"It's a tragedy that we don't have more time to educate ourselves about what is going on," reflects AuTumn Davidson, a first-year student. "As future teachers and leaders, . . . it's paradoxical that we have such potential to affect people, but we don't always have the time to play out our role as activists." Nevertheless, she is encouraged by the fact that the American public is recognizing the importance of health care and forcing candidates to take it more seriously than they have in the past.
Second-year student Emily Walker found the grand rounds format especially conducive to thoughtful discussion. Even though nationally televised debates are intended to give voters insight into how candidates grapple with major policy issues, Walker felt that she didn't have a good feel for their personalities until she attended the DHMC sessions. She attributes this to the fact that the candidates could assume the audience had a certain level of knowledge, so they didn't have to spend as much time framing issues. "They could get to another layer in terms of their vision and policies," she says.
Christopher Jons, also a second-year student, says that besides learning something about each candidate's health-care platform, he appreciated the chance to get a "sense of the style and spirit of the candidates. It was neat to see them in an intimate setting." Jons also feels that some of the candidates' messages were more powerful than those he's heard them deliver nationally. He remembers being particularly impressed by Dean's knowledge of the intricacies of the physician- patient relationshipespecially by the fact that he touched on the spiritual and humanistic side of medicine rather than focusing solely on policy issues.
Dr. Alan Green, Dartmouth's chair of psychiatry (and one of my class's pharmacology professors last fall), believes the grand rounds formatby making the candidates address health issues before an audience of experts forced a high caliber of discussion. He feels the fact that the candidates were speaking at a top-flight academic medical center also impelled them to talk about research in more depth than they usually do.
In addition, Green is "pleased that many of the candidates addressed the need for proper mental-health care as well as addressed the related lack of substance-abuse treatment, both regionally and nationwide." But, he adds, "what did not come out was how this will work and where the money will come from and how we will get to the point where someone with mental illness or substance- abuse problems will be treated the same way as someone with a physical illness."
My classmate Emily Walker echoes this assessment. "I agreed with what many of them said about treating mental illness medically rather than relying on the criminal justice system," she says. "It's rare in politics that people talk about mental illness with compassion and vision."
While some people attended all six sessions in the series, others were drawn to specific candidates. Dr. Stephen Rous, a professor emeritus of surgery and a retired Army colonel, was particularly interested to come hear Clark's talk and likes his idea about using the military health system as a model. Having had extensive experience with the military system himself, Rous says that he was pleased to hear Clark endorse its approach to preventive care. The Policy Grand Rounds "were a wonderful thing," he adds. "They were a great opportunity to reach out and touch and feel these individuals and make them human."
Future Plans: Because of its resounding success, the Health Policy Grand Rounds concept is expected to continue long after the current election season. McDougall and his staff are already working to schedule a visit from U.S. Secretary of Health and Human Services Tommy Thompson. And during the summer, McDougall hopes to arrange a discussion between New Hampshire Governor Craig Benson and Vermont Governor Jim Douglas.
"We are going to try to weave this into our educational fabric," McDougall explains. "It won't always have the intensity of a primary year, but it hopefully will become a regular component of grand rounds throughout the year."
Although more of the visitors this season were Democrats, due to the nature of the 2004 primaries, McDougall emphasizes the nonpartisan nature of the series. The intent is to foster discussion about health-care policy, not to endorse a particular candidate or partyparticularly since health care is seen by many as the leading domestic issue, probably for many years to come.
And because DHMC told the politicians that no campaigning would be allowed on the stop, McDougall sees the series as "a great opportunity to get away from sound bites.
"We have been able to listen to them and ask questions," he concludes. "I think our folks have learned a lot from the candidates and the candidates from them."