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A RECORD OF HEALTHCARE REFORM

March 1, 2007
by MICHAEL J. STOIL, PHD, WASHINGTON EDITOR
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Tom Vilsack has personal and political experience with behavioral healthcare, but he didn't last long in the presidential race

Each presidential election cycle, at least one candidate steps up to the podiums across America to remind us of our unmet healthcare needs. U.S. Sen. Bill Bradley (D-N.J.) in 2000 and Gov. Howard Dean (D-Vt.) in 2004 succeeded in raising awareness of important health policy issues but failed to win their party's nomination. However, the two most recent occupants of the White House also were persistent advocates of healthcare reform in their campaigns for the presidency.

In 2007, the mantle of being the “healthcare” candidate seemed to fall on one of the less well-known members of the crowded field of Democratic presidential contenders: former Iowa Gov. Tom Vilsack. Vilsack declared his candidacy in November, but ended it in February. In political terms, he already had achieved a remarkable feat: Elected as Iowa's first Democratic governor in three decades in 1998, he led his party to control of both chambers of the state legislature in November. Failure to gain press attention and to raise campaign funds comparable to rivals with briefer résumés apparently led him to quickly end his presidential bid.

Vilsack's most important legacy may be the reform of Iowa's healthcare policies. Aided by an energetic state Medicaid director and his close ally, Lt. Gov. Sally Pederson, Vilsack's administration crafted a major Medicaid package with Republican House Speaker Danny Carroll. The bipartisan legislation greatly reduced state costs for Medicaid, included incentives for businesses to contribute to health insurance for employees in Medicaid-eligible families, and gave performance awards to healthcare providers. Its greatest impact, however, was to expand eligibility for Medicaid. As a result of these efforts, more than 90% of the state's residents now are covered by health insurance, and Iowa ranks second among all states in overall health coverage.

The redesign of Iowa's Medicaid program was accompanied by major legislation to ensure that behavioral healthcare benefited from the changes. Vilsack and Pederson championed a successful effort to legislate mental health parity and a restructuring of the mental health system. At the beginning of his final year as governor, Vilsack proudly announced that “more of our children, more of our seniors, more of our veterans, more of those struggling to make ends meet and more of those coping with mental illness receive health care as their right and not as a result of privilege.” Improving access to quality mental healthcare is an issue that he cares about deeply.

In an exclusive interview with Behavioral Healthcare on January 31, Vilsack explained that the problems he found in his state's mental healthcare system “are not, unfortunately, unique to Iowa. There are many reasons why policies throughout the United States should be more comprehensive.” Vilsack first identified the human toll on people and their families, citing estimates that approximately one in four Americans are affected directly by mental health problems. He also identified multiple economic costs: the loss of productivity by people challenged by mental illness, the impact of delayed treatment on both mental and physical healthcare costs, and the enormous additional costs, such as “converting our prison system into a mental healthcare system.”

For Vilsack, the costs of unmet mental health needs are not mere abstractions. Bud and Dolly Vilsack, who adopted Tom from an orphanage in 1951, struggled with Dolly's dependence on alcohol and prescription drugs during his childhood. “I remember my father taking me as a young boy to a street corner in Pittsburgh where there was a big building—I suppose all buildings seem big at that age—and I counted the barred windows to find the room where my mother was staying,” he recalls.

His adoptive mother eventually achieved recovery from these problems, but mental illness again played a pivotal role in his life after he joined his father-in-law's law practice in Mount Pleasant, Iowa. In 1987, a former American prisoner-of-war who had unsuccessfully sought municipal services assassinated the town's mayor; Vilsack's victory in the subsequent special election was the start of his political career. Vilsack's close relationship with his lieutenant governor provided a third, less tragic contact with behavioral healthcare as he watched Pederson's family raise a child affected by autism.

These experiences helped to shape his views on the roles of behavioral healthcare professionals, which contrast sharply with those of members of the current administration: “It's a bit naïve to believe that family members alone have the capacity to bring people safely through severe mental illness. They can be supportive, but family members lack the expertise to make important diagnosis and treatment decisions.

“Everyone has a role—and no one alone can guarantee success. You can have great family support, but if you don’t have the expertise to provide appropriate diagnosis—and medication, if needed—you won’t achieve success. In Iowa, our mental health system has been reformed to provide basic care from professionals. We do not rely unduly on nonprofessionals and do not call on families to carry too heavy a load.”

The theme of guaranteeing basic care for everyone while dividing the responsibility for costs among consumers and other payers appears repeatedly in Vilsack's remarks. His final address as governor of Iowa included a challenge to his successor to complete the process of healthcare reform:

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