Former Mass. Governor Michael Dukakis: Views on Effective Governing

MONICA BHAREL: Hi, and good afternoon, everybody My name is Monica Bharel, and I’m a Commonwealth Fund fellow in Minority Health Policy It is my great pleasure today to introduce our speaker, Governor Michael Dukakis Governor Dukakis is a distinguished professor of political science at Northeastern University He was the governor of Massachusetts from 1974 to 1978 and then again from 1982 to 1990 Governor Dukakis is a native of Brookline, Massachusetts He’s a graduate of Swarthmore College and Harvard Law School, and he served two years in the United States Army Governor Dukakis began his political career in local government and then served in state government as a legislator for four years He was the Massachusetts Democratic Party’s nominee for lieutenant governor in 1970 As governor, he is credited with digging Massachusetts out of one of its worst financial and economic crises in history At the time, the Massachusetts unemployment rate was 11.2% By 1988, it was down to 2.9% In 1986, his colleagues in the National Governors Association voted him the most effective governor in the nation Governor Dukakis was the Democratic nominee for president in 1988 In addition to being a professor at Northeastern, he’s a visiting professor at the School of Public Policy at UCLA His research focuses on national health care policy reform and the lessons that national policy makers can learn from state reform efforts Recently he co-authored a book entitled How to Get into Politics and Why, which is designed to encourage young people to think seriously about politics and public service as a career Some interesting facts that you may not know about the governor– he has lived and worked in both Hawaii and Australia He was the only state government employee to go to work during the blizzard of 1978 He rode the subway to work every day while governor And, most importantly to me, he leads by example My children know him as the neighbor who cares so much about our neighborhood that he picks up the trash along the way while he goes to work Please join me in welcoming Governor Dukakis I’ll now hand the program over to Professor Blendon Thank you ROBERT BLENDON: Just a minute before we turn it over to the governor This is a very special series at the school, and the aim of the series is to have people understand the critical way people who make major decisions that shape the future think about them, their experiences, how they really listen and learn And when it’s your turn, and the reason why people come to Harvard, is that we have a dream that sometime we can change the course of that river What do I do? How do I think about it? How did others do that? So it’s a privilege of having the governor here And for many of us, he was the presidential candidate He was the governor He was the leader of so many advisory groups for presidents and governors And what we want today, and the format will be, is he’ll have some opening remarks I will ask just one question to make it relaxed for you to ask the rest And then we’re really going to follow his thinking about how you can be an effective leader in the next generation Governor, again, it’s a privilege to be here with you MICHAEL DUKAKIS: Thanks It’s good to be with you Thank you for being so close to Northeastern It’s just a quick stroll up the street I owe you all an apology If I’d have beaten Bush I, you’d have never heard of Bush 2, and we wouldn’t be in this mess So it’s all my fault I feel that personally every day And there’s a lot to be said for riding the streetcar when you’re governor It’s amazing what you learn on the streetcar You don’t learn it in a limousine You learn it– streetcar Not only that, but I think we dramatically improve the quality of the transit system at the same time There’s something about the governor riding it that inspires people to do well And very special– Bob, of course, and I are old friends and colleagues– and great to see John McDonough here, who knows a lot about how you get things done on the public sector, believe me And you’re likely to have him as a member of the faculty Betty said to me, before you finish up, I want you to leave folks with a couple of takeaways I’m going to start with a takeaway And if you remember nothing else about this session, I hope you remember this

You can’t divorce public policy from politics I want to repeat that You cannot divorce public policy from politics When I was governor, I interviewed lots and lots of people who wanted to work for me Somebody said to me, I’m a policy person, not a political person I’d say to them, thank you, but you can’t work for me Now, what do I mean, folks? I mean that, if you’re going to be effective in the public sector, and I assume– how many of you have worked in public service? Some How many of you want to work in public service? Public or nonprofit, I mean These days it’s– You’ve got to develop a set of what I call political skills Now, this doesn’t necessarily mean organizing precincts, although there’s a lot to be said for that Elizabeth Warren had better organize every one of the 2,157 precincts in this state if she’s going to beat Brown She can beat him, but she’s got to organize those precincts A precinct [? cap ?] and a six-block [? cap ?] in every precinct, making personal contact with every single voting household That’s one set of political skills And I’m all for you guys developing that as citizens But I’m talking about the kinds of political skills one needs if one is going to be effective in the public sector And it’s not that we’re born with them Every once in awhile, somebody comes along I mean, Bill Clinton has it in his DNA I don’t know where it came from I mean, he just has it But most of us don’t We may like to talk We may like people We may care deeply about the state of the world and want to do something about And, frankly, most of us who go into the public service sector, as I suspect you do, are here because you want to make a difference in the lives of your fellow citizens, and you can Of course, there are two basic rules which I repeat to my students all the time I mean, if you want to do work in the public sector, plan to live moderately If you want to make a lot of money, don’t go into the public sector, and have a good but conventional sex life If you’re into the other stuff, good luck to you, but don’t go into public service [LAUGHTER] MICHAEL DUKAKIS: But what do I mean by political skills? First, you’ve got to have passion for the job You’ve got to care deeply about what you’re doing If you don’t have that, then forget it But secondly, you’ve got to be able to master, as best one can, this very complicated political environment in which you find yourself One of the reasons that business people don’t do well in the public sector, for the most part, with rare exceptions, is that, while they’re very good at what they do in the business world, they just don’t understand this much more interesting, much more complicated, by no means impossible, but far more complex, environment Why do I say that? Well, because, if you’re the governor, your board of directors is the legislature Now, in the private sector, boards of directors, for the most part, are hand picked by the CEO That is not the case The good people of Jamaica Plain elected this guy Fortunately, he’s a terrific guy and was a terrific guy and a terrific lawmaker But your board of directors is the legislature or the Congress or the city council And working effectively with these folks is a major challenge and once you have to master, whether you happen to be in the governor’s office or whether you happen to be running an agency or whatever I didn’t do that very well in my first term, despite the fact that I’d been in the legislature for eight years Why? Well, it was a whole different kind of ball game And one of the things you have to do is involve your legislators in policy making from the beginning If you see a policy area that you think needs work, the first thing you do is pick up the phone and call– John and I worked very closely on the health care thing– you’ve got to involve key legislators who have a strong, deep interest and considerable knowledge about health policy from the get go As I teach my students all the time, you’ve got to make a list of whom– or what I call the key players I hate this word “stakeholder.” It’s like somebody comes along and sticks a stake But who are we talking about? Talking about people in the executive branch that you’re going to have to work with? Including the budget agency, almost invariably You’re talking about legislators You’re talking about legislators at a variety of levels, because in a federal system, this is at least a three-level– and in many states, a four-level– system And there are very few domestic issues these days, folks, where the federal government is not involved, where the local governments are not involved If you’re operating at the state level, or if you’re operating at the local level, where those folks above you, if you will, must be involved And they want to be involved And they can be enormously helpful, but they’ve got to be part of the process from the beginning You’ve got to reach out to constituencies and advocacy

groups and the leaders of those advocacy groups You’ve got to work with them And they’re not easy I mean, they’re in the business of making demands That’s what they do Nothing the matter with that But how do you handle a situation where you want to go home for supper? And I had this thing about– Kitty and I have had two basic rules and still have them No politics on Sunday, with three exceptions– Saint Patrick’s Day parade in South Boston, Greek Independence Day and Combined Jewish Philanthropy’s Super Sunday, in which case I took Saturday off and dinner at home No kidding Dinner at home at 6 o’clock at night I’m was a fanatic, still am And there’s something to it My wife and I celebrated our 40th wedding anniversary, so I recommend this strongly to you And by the way, how you deal with your personal life is an important part of this I can tell you But what do you do when there are a bunch of advocates? You’re the governor You want to go home on the T, as I did, for supper before I went out to where I was going that night And you’ve got a bunch of folks sitting in your office They didn’t know that I had a secret escape route, up to the fourth floor, down the hall, down the stairs, out on to the common, and down the– and these poor folks would be sitting there waiting for me Where’s he going? But, in any event, constituencies are important And they must be involved in policy making from the beginning because they know a lot Sometimes they know a lot more than you do or the folks that are working for you Because they are out there You’ve got to be able to deal with the press, folks Dealing with the media and communicating through the media, particularly these days when you’ve got all this social media, as well as the more traditional media, is an essential part of your job Now, I’m the last guy in the world to advise the President of the United States these days– and for that matter, the Democrats in Congress– on how to communicate on the subject of health care But, quite frankly, I think they’ve done a lousy job And given my track record nationally when it comes to communicating, I’m very humble about this But I think they just missed this And a congressional and presidential achievement, which is history making, turns out to be, at best, neutral and maybe a negative Why? Because they didn’t frame a message, in my judgment, that connected with people Now, you may disagree with this Feel free to do so But I don’t think this is about pre-existing conditions or insurance reform or any of this jazz It’s about whether or not working people and their families of the United States of America will have decent, affordable health care Because all of– we’ve got 54 million uninsured people– overwhelmingly, they’re working members– working families They’re not loafing They’re not sitting around They’re not on public assistance If you’re on public assistance, you get Medicaid These are working folks No health care And John will tell you that when we were working together on the Massachusetts effort, and the bill that I signed in 1988, which, quite frankly, was a hell of lot better than the one we got, even though I’ll take the one we got in contrast to nothing In fact, it was the old Nixon plan translated into state policy And there is one state in the country that did that many years ago What is it? Nobody knows Just you and me, [? Jim. ?] ROBERT BLENDON: Somebody said it AUDIENCE: [? Dwight? ?] ROBERT BLENDON: Got it MICHAEL DUKAKIS: Takes an Australian to tell us that On the way over, he must have stopped and checked it out I must have had 200 press events We never had one without a working person or a working family next to me That was the theme Working folks and their families in Massachusetts were going to have decent, affordable health care if it was the last thing we did I’m not hearing that Are you? I’ve never heard it, either from the White House or the congressional Democrats, who, quite frankly, have not done a particularly good job So how you frame your issue– and this is not talking about dumbing it down– and how you address it publicly– we all have our jargon professionally, right? We talk in acronyms People out there don’t know what we’re talking about Docs, who get up and tell you what was wrong with their patient at a press conference, and they’re using technical terms that– every once in a while, you find a doctor who can do this and do it effectively Lawyers– we had a big fight over no-fault auto insurance, and lawyers would get on these panels that I’d do, and people had no idea what they were talking about Litigation and torts– people thought torts were something you ate They don’t understand this stuff Being able to address the issue in English so it’s understandable is important and being comfortable with the media Understanding that a good media campaign can help you

not only persuade people of the wisdom of your cause, but help you to implement the program Gordon Chase, who was a wonderful– do you guys read any of Gordon Chase’s stuff? Well, Chase was an interesting guy He’s the guy that taught me how to teach, frankly He was a kid from Worcester, went to Harvard, went into the Marines, came out, went into the Foreign Service Was discovered by McGeorge Bundy in the American Embassy in London, who was very impressed with this guy and brought him into the National Security Council when Bundy was Kennedy’s National Security Advisor Subsequently became the first Health Services Administrator in New York City ever to be a non-doc And [? the design of ?] the medical profession was very upset with Lindsay for appointing a superb public manager He was my Secretary of Health and Human Services for 13 days until I got beaten in the Democratic primary in 1978 And he ran back across the river to resume teaching at the Kennedy School And we ended up teaching together there And he was a remarkable guy And he makes this case in a little book, which– if you can get, get a hold of it It’s called Managing the Public Sector I still use it It’s the only thing, in my judgment, worth using when it comes to teaching this stuff And he talked about the importance of the media, which was kind of a discovery for him as well, because he wasn’t a natural communicator That’s not what he did He started on foreign service And how he discovered, among other things, that when it came to lead poisoning, the most important thing you could do was connect with mothers who could then make sure that their kids weren’t gnawing on window sills or ingesting this stuff And the way you did that was by using TV and radio And in his case, especially, radio, which kind of surprised him So being effective with the press isn’t just being able to handle the not-so-happy Happy Valley these days and what’s going on over there I married a Penn State graduate, so it’s been a certainly– a high degree of interest in what’s been going on at the State College, Pennsylvania, around the Dukakis house But it’s understanding that an effective media campaign can help you to implement policy, especially the kind of policy that you guys are interested in And that means you’ve got to be comfortable with it You’ve got to speak in ways that people can understand And you’ve got to take it seriously Building coalitions It won’t always work, but your chances of being successful are a hell of a lot better if you bring people into the process early, make them a part of the process, make them a part of the solution, and then go out there together to try to sell the program Nobody knows that better than John He did as well as anybody I could remember in the Massachusetts legislature But it took me a while to figure that out I was a reformer when I was in the legislature I was elected in 1962 at a time when this state was one of the three or four most corrupt states in the country, I kid you not As a matter of fact, when I was ringing doorbells for my first legislative campaign, people would say to me, you look honest I’ll vote for you I finally called my mother I said, Mom, thanks for producing a kid that looks honest It was that bad So I was the head of– of course, it used to give my Greek immigrant father heartburn to read that his son was the leader of the young Turks in the legislature, but in any event So I was kind of a reform guy I and 20, 25 of my younger Democratic colleagues were battling the system all the time Well, you become governor There’s nothing wrong with approaching your job with passion and with strong feelings and important issues, but you’ve got to be a coalition builder You have to develop those kinds of skills, folks And I’m talking about those of you who guys like me are looking for to recruit to come to work for them, as well as people that seek elective office Because if you’re running an agency or running a program, you’ve got to do that as well You’ve got to be comfortable with elected officials We don’t have 10 heads I mean, we put on our pants one leg at a time And, by the way, folks who run for elective office, with very few exceptions, do so for the same reasons all of us are here Because they care very deeply about their community and state and country, and they want to do something about it But I will say this to you There’s nothing more personally fulfilling and satisfying than being in a position where you can make a difference in the lives of your fellow citizens And don’t tell anybody you can’t do it Good people working together can make a difference And I’ll say one other thing There is nothing inherently corrupting

about public service That’s a lot of baloney That’s a lot of baloney You’ve got to set high standards for yourself and the people that work for you Every once in a while, somebody’s going to disappoint you by going off the reservation Happened to me twice in 12 years, and I was furious both times But setting high standards of integrity and living those standards is not difficult But you’ve got to plan to live moderately and have a good but conventional sex life Anyway, those are just a few thoughts about this whole public enterprise that we are actively involved with But don’t let anybody tell you that you cannot make a difference I walk around town these days, John, and I marvel at this city Look, I grew up at a time– both in this country and in this city– where we were racist, anti-Semitic All this talk about those wonderful schools we all went to and how schools are going to hell in a hand basket, and the United States is absolute nonsense Public schools in the United States these days are light years better than they were When Kitty and I graduated from Brookline High School, what do you think the dropout rate was in the United States? Any idea? Kids who didn’t finish high school, back in the day when schools were wonderful, and everybody behaved Nobody got pregnant All that wonderful stuff Over half the kids in this country never completed high school Over 70% of the minority kids– as a matter of fact, the African American completion high school completion rate in 1940, when I was seven years of age, was 12%, and most of those black kids were going to crappy, legally racially segregated schools, including the public schools of Washington, DC, the capital of the free world, as we called it Infant mortality was five times what is today This city itself was shabby, dirty, declining, angry And the fact that things are very different has a lot to do with people like yourself who decided they wanted something better and went out and worked like hell to do so But they had to develop these political skills, folks Don’t get me wrong A certain amount of intelligence and ability to deal with policy and shape policy is very important, but unless you develop this– what I call this set of political skills, you’re going to have a very tough time making things happen And most of us have to work at it We’re not Bill Clinton We’re not born with this stuff I mean, that guy’s just remarkable He’s got this new book out, Back to Work, and he was talking about it in DC a week ago And here we are with all this stuff flying around And he said– this is pure Clinton– he said, no great civilization in the history of humankind was anti-government Think about it Only Clinton, in seven words, could capture that When you think about it, give me one great civilization in the history of humankind that was anti-government But as I say, it’s in his DNA And he’s got a few other problems, as all of us know, and I love him dearly But you’ve got to work at these skills, folks You’ve got to develop them And if you do, then a combination of intelligence and passion and a concern for people can be translated into real results And that’s what I hope you’ll all be doing And believe me, we need you There’s lots to do out there, including lots to do internationally I was saying to somebody the other day that after my junior year at Swarthmore, I was able to get a scholarship to Peru for the summer I didn’t speak a word of Spanish I won’t even tell you how I got there But in any event, what I did discover is the Greek and Spanish accents are identical, even though the languages are different Don’t ask me why, but they are So if you speak Greek, then you speak perfectly accented Spanish and vice versa So at least I had an accent When I was in Peru in 1954, one out of every two Peruvian babies never reached its first birthday Now, I don’t know what the infant mortality rate is in Peru these days, but I’ll tell you, it’s a hell of a lot less than that And this is true all over the world And many of you and your colleagues are doing incredible work internationally as well as here

The one remaining question is, what the hell is the matter with the United States when we can’t provide decent, affordable health care for all of our people? And we’re spending twice per capita what everybody else is spending to do the same thing If you want to get into that in detail in our Q&A, I’d be happy to do it But, again, understanding the importance of mastering as best one can the political environment in which one develops and tries to implement public policy is absolutely critical to your success Even as you’re working on policy and academic stuff and so on and so forth, make sure that’s part of what you do around here Because without it, you just can’t do the kinds of things that we all expect you’re going to do Enough from me You have a question ROBERT BLENDON: Before we open to you, just one So, Governor, when I first saw you, you were speaking at a White House conference on urban development And I envisioned you’d be a presidential candidate, talking about the economy and fixing cities and everything And then I turned around and you were the leading spokesman, as a governor, for health care How did you get there, given– as you said, combine politics with policy This has not been a good issue for people in US elected politics, and you became a leader in that field and stayed with it and [? council people– ?] MICHAEL DUKAKIS: Why did it happen? ROBERT BLENDON: –why did it happen? MICHAEL DUKAKIS: Because I’m a failed pre-med My dad was a remarkable guy, Bob My mother was too, for that matter My father was born in a predominantly Greek town in Western Turkey There were a million and a half Greeks in Western Turkey prior to the forced exchange in 1923 And he was one of them His parents were islanders, but like a lot of the islanders, they’ gone to the mainland because there was more economic opportunity there And over the vile objection of his father, at the age of 15, he said, I’m leaving I’m going to the United States He had a couple of brothers working in the textile mills, in Lawrence and Lowell, to get an education, which was unusual, Bob, because in those days, Greeks came over here, like other immigrants, to get a job And he came here, and that young 15-year-old, who didn’t speak a word of English and didn’t have a nickel in his pocket, 12 years later was graduating from the medical school next door And don’t ask me how he did it It’s an incredible story And practiced medicine for 52 years across the Museum of Fine Arts at 454 Huntington Avenue Now, interestingly enough, Burstein Hall at Northeastern University And my brother was not particularly interested in medicine, so I was the heir apparent When kids get hurt in the neighborhood, I’d bring them in and put on the CureChrome, as we called it in those days, and the Band-Aids and all that kind of stuff And I’d been a good student at Brookline High I’d never had any problems I took biology and chemistry, and I figured, got to Swarthmore, I’ll start with physics There’s a piece of my brain, folks, marked physics, that’s missing I’d never had this problem before I just couldn’t get it The harder I worked, the worse I did I finally got a charitable D. I was having a wonderful time in political science, economics, and history Called my dad and said– he was very good about it– and I said, Dad, I just don’t think it’s going to be medicine But when you grow up in the household of a guy who works seven days a week, who has a heavily ethnic practice, but at the same time is a fellow of the American College of Surgeons, does his own surgery, and delivers about 3,000 babies, and brings you into the office to handle the patients on Saturday– he had office hours on Saturdays and Sundays– the notion that people would have to go without health care because you couldn’t afford it was just– and my dad was no radical In fact, he was a registered Republican, and the only way, John, I got him to vote for me was to tell them he couldn’t vote for me in the Democratic primary was if he got that darn R off his name So at least he was an Independent so he could take a Democratic ballot in the primary But a wonderful guy, and growing up in that household, I just had this sense that for this country not to make it possible for everybody to have decent, affordable health care was just a national disgrace And I wish I heard a little more of that rhetoric, frankly, these days, because I think it is a national disgrace that we have not been able to do that But that’s how I got interested in health care And then I remember Harry Truman I remember the Truman Plan And I remember the Nixon Plan And I remember the Clinton Plan We finally have a President and a Congress that were able to do it, and now we’re trying to figure out why people don’t like it And there, I think, the media piece and the message has not

been done well Feel free to disagree Maybe there’s another way to describe this, but if you go out and take a poll, folks, tomorrow, and you ask the American people, should working people and their families have decent, affordable health care, what you think the numbers would look like? It’s about 95%, and the other 5% haven’t thought about it I’m serious It’s overwhelming Why are we saying that? I don’t know I don’t know ROBERT BLENDON: It’s your turn Questions? And tell us who you are MICHAEL DUKAKIS: I thought you told me this was a lively, verbal group here Don’t feel like– ROBERT BLENDON: Something must have been spread over the air, because they are MICHAEL DUKAKIS: OK Don’t let me intimidate you George H.W. Bush beat me for the presidency How could I be losing this guy? Have you seen that Saturday Night Live thing? I’ve been asking myself that question ever since Yeah Go ahead SHANICE CHRIS: Hello My name is Shanice Chris I’m a second-year doctoral student in Society, Human Development, and Health and very interested in public service MICHAEL DUKAKIS: Where from? SHANICE CHRIS: South Carolina MICHAEL DUKAKIS: Where in South Carolina? SHANICE CHRIS: Greenville, South Carolina MICHAEL DUKAKIS: Greenville I have kinfolk in Greenwood SHANICE CHRIS: Oh, cool Our way MICHAEL DUKAKIS: If you’ve ever eaten at the Star Cafe, you ate at a place where my Uncle Nick ran the place for about 67 years Anyway, go ahead SHANICE CHRIS: I’m very interested in media exposure, and I want to know, how do you balance positive messaging versus negative messaging when you’re doing these media campaigns? What’s more effective with the positive versus negative messaging? MICHAEL DUKAKIS: That’s a good question I mean, clearly, part of what you’ve got to do with the media is deal with the shots that people are taking at you– I don’t mean in a personal sense– or taking at your policy The biggest mistake– I made a lot of mistakes in the presidential campaign– the biggest mistake I made was in making a decision– it was my decision, nobody else– that I would not respond to the Bush attack campaign It just turned out to be a huge mistake What should I have done? I should have attempted to put together, to think through in advance a strategy for dealing with the Bush attack campaign which, preferably, turned his attack campaign into a character issue on him That’s easier said than done But I just made the decision It was just a huge mistake So you’ve got to try to anticipate what the opposition is going to say, and you’ve got to frame what you’re saying in ways that will deal with that That’s why I think the idea that this is all about– and I think I’m accurate in saying this– this is all about working people and their families It’s not only a powerful message, but what is the Republican leader in the Senate going to say if you turn to him and say, hey, Mitch You don’t believe that working people and their families ought to have decent, affordable health care? It seems to me, in framing the message, you are already setting up the opponents How would you do it if you don’t like our position? How would you make it possible for working people? Or don’t you think working people and their families ought to have decent, affordable health care? You get the point here But much of what you do on the media side, especially those of you in the field that you’re specializing in, really has to do with reaching out to folks, informing them, and helping them to try to care for themselves and their families, to follow good practices and so forth And that really has nothing to do with opposition to such It’s an attempt to reach out to people and communicate with them effectively about– what?– diet and substance abuse and a million other things that we’re all involved in as we try to help people live healthy lives So, yes, there is a negative thing that you’ve got to anticipate, typically if you’re in the middle of an important battle over major public policy But in so many cases, especially those of you in the field of public health, it’s all about informing people as effectively as Chase tried to do, that the most effective way to protect your kids from lead poisoning is to make sure they don’t ingest the stuff in the first place And that’s a very powerful message that the press can help you to get out I mean, John went at it with children’s health, just banged away and banged away and banged away Kids in this state are going to have decent, affordable health care By the time it was over, the only people who opposed him were the then governor, who then began taking credit for it later, remember? That was well And the tobacco industry, because it was going to be financed with the cigarette– everybody else was with him A lot I had to do with his particular skill, but a lot of it had to do with the message We’re going to make sure that children in this state have decent, affordable health care That’s a powerful message to attack, don’t you agree? Now, what did they attack? Well, they attacked an extra– what was it, a dime or something on the cigarette tax? A quarter

Should have been a half a buck, right? Why not? But notice, in framing the issue as he did, you’re already setting up your defenses against the attackers And it was attacked, mostly by the tobacco industry But, then again, consider the enemy They’re not the most popular people in the world And the cause was just so compelling And he made that case, folks, using the media AUDIENCE: My name is [INAUDIBLE], and I’m an MPH student from Serbia And I’m just the messenger at this moment I’m actually grateful to welcome you in front of the people who are in an overflow room and who are watching this over the internet And this is the first time we introduce this [? questionnaire ?] so people can ask questions, even if they’re not in the room So out of many interesting questions we got, we picked up one that I think is quite challenging And it’s coming from Elizabeth Chan She’s an MPH student here at HSPH And I’m going to read it so we’ll be sure that it’s [? reflected ?] properly So Massachusetts has been successful in reaching near universal health care insurance coverage As we move towards cost control, what needs to happen next? Which stakeholders do believe– or key players, like you said– do you believe need to step forward to take an effective lead, and how long we will need before we can see a bending curve in Massachusetts? MICHAEL DUKAKIS: How much time do we have? I may be off on a slightly different tangent from a lot of my friends who are working on this But I begin with a simple proposition The market does not work in health care It never has, and it never will And indulging ourselves in the notion that it will is just a colossal waste of time Now, it’s not a sin that the market doesn’t work I mean, I’m a market guy If you want to go out and buy a television set, they’re practically give them away I mean, go to Best Buy, go to here, go to there, and so on But the market doesn’t work in health care, for reasons that you’re all very familiar with And if the market doesn’t work, you have to regulate R-E-G-U-L-A-T-E. Thoughtfully, responsibly, and with the active involvement of all of the people who provide health care and who are very important to us Our health care community is very important to this state We’re not an international life sciences center by accident, folks We’ve got terrific people around here, and they’re very important to us And as I’ve often said, if you want to get sick, get sick in Boston There’s no better place to do that And, by the way, they know the whole system is crazy, too Because they’re tell you so Now, it just so happens that the governor of the Commonwealth has all the authority he needs right now to regulate health insurance premiums in this state He doesn’t need additional legislation As a matter of fact, John will tell you that if a governor sends in a bill, it might come back with half of his authority stripped from him So you’ve got to watch this And the governor and I have had lots of conversations about this, and I’ve been urging him, and he has acted under that authority, to some extent But for reasons I don’t understand, what is it with us? This is a case of regulating And if we paid a little attention– it might be a good idea– to the experience of other countries around the world who are doing this, and for some reason, seem to be able to provide rather good health care to their people at half the cost we do Whatever the system, whether it’s Australian Medicare, or a multi-payer system in Germany, or an essentially privatized system in Switzerland, every one of them regulates costs, without exception What do we do? Come up with this ACO global payment thing If one more person says to me, what do you think about payment reform? This is not about payment reform It’s about regulating cost, folks We’ve done it ACOs and global payments What did we used to call them? HMOs and capitations We tried that, folks It didn’t work Why are we doing it again? Now, don’t get me wrong Nobody loves having to regulate We had something called a rate-setting commission when I was governor And by the way, it wasn’t my initiative It preceded me It happened under a Republican governor We treated hospitals as public utilities They couldn’t raise their rates a nickel unless they went to the rate-setting commission We certainly didn’t have these huge disparities between what [? Partners ?] gets and what the BI gets Wouldn’t allow it So we’ve got to get on with the business

of regulating costs And I think the least bureaucratic way to do it, rather than getting into setting elaborate fee schedules and so forth, is essentially to use the authority we have in this state under the state insurance statutes to regulate the rate of increase and the cost of premiums Now, let me also emphasize, however, that you just can’t– the governor can’t say, well, we’re just going to regulate premiums You’ve got to involve the key players– providers, consumers, legislators, and so forth– in a process of developing how we’re going to regulate, and then carefully monitoring it so that, in point of fact, it works and works effectively, and at the same time, make sure that we provide people with excellent health care, which we do in this state And what I’m worried about is that we’re futzing around with new institutional arrangements, accountable care organizations Look, I’m a member of Harvard Vanguard I get good health care It’s an ACO, isn’t it? More or less It’s the most expensive health care in the state ACOs, global payments We’re going to spend 10 years going through this, and we’re going to end up exactly where we ended up after a decade or two decades of HMOs and capitation And I was a member of one of the first HMOs in the state, the so-called Harvard Community Health Plan, which, unfortunately has morphed into this Harvard Vanguard thing, and we got great care And it was terrific There was a staff model HMO, and we didn’t get stars in our eyes and do all this kind of stuff and try to expand it and include an IPA and all those kind of things So that’s my view And my advice as the governor is to get on with it, frankly And don’t waste too much time futzing around with the legislative process, which has given us this year legislative redistricting That’s a good thing Casinos, that’s not a good thing And hasn’t given us cost control, which is far more important than either of those things If that doesn’t make sense to you, argue with me But what can I tell you? Yep AUDIENCE: Hi My name is [INAUDIBLE] I’m a doctoral student in epidemiology And you mentioned the importance of building coalitions So I was curious, when you had first proposed health care, who do you think were the strongest proponents– not necessarily just partisan-wise, so Democrats versus Republicans– but– MICHAEL DUKAKIS: With the universal health care bill that John and I worked on? AUDIENCE: –right So in terms of industry or private organizations, who do you think were the strongest proponents, and who do you think would still be the strongest proponents today? MICHAEL DUKAKIS: Well, I’ll [? move ?] your question a little bit and talk about who the opponents were Well, look, again, if you go out and ask people, should working people and their families have decent, affordable health care, it’s overwhelming, particularly if you emphasize working, right? And just about all of us have a stake in a good, comprehensive health plan, which covers everybody at reasonable cost On the other hand, within this health care community of ours, there are obviously a lot of people who are concerned about this Why? Because if you’re spending $2.5 trillion on health care, that’s $2.5 trillion worth of spending, but it’s also $2.5 trillion worth of income to somebody So the economic stakes are quite high That’s not unusual in politics You’ve got to deal with that And so the question is, can you bring people to the table who represent these interests in a way that gets them working together, collaborating together, so long as they agree that everybody should have decent, affordable health care And there are very few people– at least around my table– who didn’t believe that– who generally didn’t believe that Secondly, you’ve got to have a quarterback One of the problems these days, I think, is that I’m not quite sure who the quarterback is in the executive branch My quarterback was my Secretary of Health and Human Services It was a guy named Phil Johnston, who had been a legislator, had formidable political skills, and he was a guy that I looked to convene this working group And I think you were one of them, weren’t you, John? You were part of that group I remember John saying, you’re talking about Hawaii? That was a long time ago And then you’ve got to work with these folks to see if you can help them to understand why it is in their best interest– not their self interest– to do so

Now, what you do with the employer community? Well, we have a relatively high percentage of our employers who do provide health insurance to their employees, about 73% It’s very high When I go out to California in the winter time– sorry about that, but somebody’s got to do it, folks It’s a terrible burden I don’t know what the California– they’re down to the high 50s now and dropping But that still means 27% of the employers in the state are not insuring, and the 73%, in effect, are paying for the 27%, right? Fortunately, there was a guy named Nelson Gifford that I had never met who ran the Dennison Company, back when there was a Dennison Company in Framingham Interesting guy I think he’s probably a moderate Republican But he understood this, that he and his fellow employers who were providing health insurance to their employees were paying for these guys who weren’t And he went to the business community, and he said, look, this is intolerable Everybody or nearly every employer in the state ought to be expected– and employees– to contribute to health care So he was an ally And he was very effective in convincing lots of employers to do so How about the folks in the health care community? Well, most of them tend to be quite reasonable And they’re doing it because they really want to help people That’s why they go into the profession in the first place And if you talk to them, as I said to you a few minutes ago, if you talk to people– I mean, I’ve had lots of conversations with Gary Gottlieb and other folks He knows the system is crazy Basically he said to me, just don’t drop it on us Involve us Let’s do it in a way that make sure that we don’t throw the baby out with the bath water ROBERT BLENDON: He’s the president of Partners, for those of you– MICHAEL DUKAKIS: Yeah President of Partners And a great guy Psychiatrist by profession Ran the Brigham before he went to Partners So I think you begin with considerable goodwill Now, what about the biotech industry, which is very nervous about regulation? Because they have to spend a lot of money to develop these products But the thing that’s unique about being governor in this situation is that when you ask people to come to the table, they come I never remember anybody– when I finally figured this, and it took me a long time to do so– this process stuff– I never remember anybody, when we’d invite them to be part of a working group on whatever the issue was– I never remember anybody saying, screw you, Governor, I’m not coming People don’t do that around here If you invite them, especially if it’s the governor or a key legislator or something, they come They want to be a part of the solution So I think you start with a lot of goodwill And then you’ve just got to work it through And we were able to do so in a variety of ways Did we have some problems? Yeah I mean, in some cases, we didn’t anticipate them Congress made a pretty substantial cut in Medicare, which is going to cost our hospitals $50 million I don’t know what they were spending, gross, at the time, John Something like $4 billion And basically said, if the state doesn’t replace the $50 million that Congress has cut out of Medicare with state money, we’ll oppose your bill And about 10,000 hospital employees who, quite frankly, did not understand the issue They had just been told to show up in front of the State House, come in and protesting my bill My friends I was working in a hospital Well, we worked it out And, in effect, told them we’d pay them the $50 million, and we never did But it was really pretty outrageous We were going to have to be a backstop for a federal cut? When it was last time that happened? So we had some issues along the way, but I’ve got to tell you, the process worked well So why didn’t our bill– John’s and mine and others– why wasn’t it fully implemented? Well, because I left office And we were able to implement some aspects of it, the student mandates– sorry about that, but that’s of the reasons you’ve got to be insured, you guys, because of this thing– the provision that provided that people that were involuntarily unemployed would have health insurance But I was succeeded by a guy named Weld, who was a smart guy but never understood health care Just never did He called it anti-business What is more anti-business than the current health care system? It forces responsible employers to pay for those who choose not to contribute But he never got it And he did everything he could to fight it John fought him back and finally, sadly, had to compromise by essentially giving up the employer-employee mandate in exchange for 25 cents on the cigarette tax, which Weld opposed, also, so that we could at least insure kids in the state And that was the precursor, folks, to the Children’s Health Insurance Program that was passed nationally with the leadership of Senator Kennedy and among others– Senator Hatch– and they followed John’s model Called them up, and I said, John, what are you doing? He said, look

He said, realistically– I’ll never forget our conversation– you said, you know unless we get a Democratic governor, this will never happen again I said, OK I understand So we got the Children’s Health Plan Then we get this guy Romney who comes along and at least has the good sense– it’s the only time I remember him actually acting like the son of George Romney– who, by the way, is dead Was a wonderful guy In fact, I don’t know if I’ve ever told you this, John, but I courted Kitty in a little yellow Rambler convertible You guys don’t even know what a Rambler is, because George Romney was the only guy in Detroit making a small, fuel-efficient car at the time Serious But Mitt, who– can I be subtle?– I mean, the guy’s a fraud I mean, he’s just a fraud He’s terrible Anyway Just wanted to drop that in there But the fact is that he deserves some credit getting the process going Now, in the end, he walked away from his own bill and had to be overridden by the legislature Even Scott Brown voted to override him But at least he had the good sense to start the process And it was a pretty good process, I thought And we ended up with something not as good as the ’88 bill, but pretty good So back to your– sorry, this was a windy answer– but you can bring people together And you can get a lot done And it’s very important to bring them together ROBERT BLENDON: Next question HUGO TORRES: Hi I’m Hugo Torres I’m an MPH student and a medical student at UC San Francisco My question is– MICHAEL DUKAKIS: Could you say again? HUGO TORRES: –I’m a medical student at UC San Francisco, and I’m a MPH student MICHAEL DUKAKIS: My son-in-law just ran for DA Unfortunately finished second in San Francisco Sorry about that HUGO TORRES: So my question is about prevention And something that we learned here in public health school is that there’s a lot to health besides health care And a lot of the policies that we implement affect health And that doesn’t really seem to permeate the national conversation about health reform at all What do you think can be done about that, and why do you think that is? MICHAEL DUKAKIS: About prevention? It’s hard It’s hard If you can tax the offending substance– or conduct, for that matter– as we were able to on the cigarette side What’s happened with tobacco use in this country is a big public health victory Why? Well, a lot of it was education, but a lot of it was cost I mean, you tell some kid it’s going to cost– what does it cost for a pack of cigarettes these days? $8? $10? Is it that high? No, no It’s higher than that ROBERT BLENDON: I think it’s the wrong audience to ask MICHAEL DUKAKIS: I mean, when we were kids, it was $0.25 But for young people, particularly, you start hitting– I know in Canada it’s $12– but you start hitting them with that kind of price, and it has an effect It’s difficult to do that Taxing food, taxing soda, all this kind of stuff is very tough, folks So the alternative is to take the field of drug and alcohol use and abuse, which I happen to have spent a lot of time at And where we were quite successful with something– we called the Governor’s Alliance Against Drugs and Alcohol Unfortunately, my successors weren’t interested Weld wasn’t interested His successor wasn’t interested Romney finally killed the thing But it had a real impact What did it consist of? Early education and prevention beginning in the early elementary grades No joke You don’t want to wait until middle school Kids are already starting to get into this stuff And I would argue the same is true for comprehensive health care education generally As a matter of fact, do we have comprehensive health education in the public schools of this country? No Do we have it in Massachusetts? No Why don’t we? In my view, comprehensive health education ought to be every bit as much a part of the curriculum as math, science, or whatever People say, we don’t have enough time Extend the school day, for heaven’s sake Why are we sending kids home at 2 o’clock in the afternoon? What’s the answer to that question? Anybody know? Because in the 19th century, they had to go home and help their parents with the harvest I’m not kidding you Kids ought to be in school– start them at 8:30, send them home at 4:30, quarter of 5:00 Why not? Give them a rich, full school day We’re beginning to do that in Massachusetts, but where’s the rest of the country? It makes all kinds of sense But I think comprehensive health education has got to be a regular part of the curriculum And I’m not talking about some cop in the DARE program showing up three times in the fifth grade I mean, that is not comprehensive health care and health education And it ought to include nutrition It ought to include sex It ought to include substance abuse, all of this stuff,

beginning in the early elementary grades We’ve got plenty of age-appropriate curriculum right now that can be used And if we did that in every school system in America, trust me, we’d see some real results But I chaired a national task force on just substance and alcohol abuse in the States, and there was not a single governor in the United States of America that addressed that issue in his or her State of the State message [INAUDIBLE] Can’t get the National Governors Association interested I don’t get it I don’t understand it All this stuff going on in Mexico, folks, has everything to do with demand in the US of A, right? As some Latin American political figure once said, look, as long as there’s that giant vacuum cleaner to the north sucking up everything we produce down here, we’ll continue to grow it But where’s the demand reduction strategy? And it’s got to begin early Trust me It’s got to begin early So that’s my response Sure, there are other things, but you’ve got to start with these kids at a very early age, and it will have an impact There’s no question about that ROBERT BLENDON: One more quick question MICHAEL DUKAKIS: Let’s see if I can make it a quick answer Go ahead JIM KENNEDY: Thank you Good afternoon, Governor I’m Jim Kennedy from Oklahoma I’m an MPH student here, and I’m an [? emergency physician ?] by trade– MICHAEL DUKAKIS: Thank you for Elizabeth Warren JIM KENNEDY: –oh, you’re very welcome Thank you MICHAEL DUKAKIS: We’re going to put her in the Senate JIM KENNEDY: My question is– I’ve been dragged, kicking and screaming, into the whole thinking about politics even at all [? I’m not ?] a very political person, but I obviously came to the conclusion that you have to interface, like you said, with the political process The whole political process is very dirty and– there’s a lot of corruption going on, obviously, with the Jack Abramoff stuff we’ve heard about in the recent– [? Jack Pelosi ?] and the 60 Minutes stuff that’s been coming out recently Is it possible to go in and not get sucked up into the whole corruption thing? How you not sell your soul to the devil and get involved in all that? MICHAEL DUKAKIS: Let me try to keep this as brief as possible First, I’m not being defensive about this The overwhelming majority of people that guys like John and I work with are honest They’re willing to live moderately They go into politics because they care deeply Whether I happen to agree with them or not, they’re in it for the best reasons Yeah, there’s a tiny minority that do things that are inappropriate, unethical, and, at times, illegal But that’s true of every profession, including the medical profession, as we all know But don’t make the mistake of assuming that the something inherently corrupting about politics That’s nonsense That’s absolute nonsense And I will simply say this to you and everybody here If you are a health professional, folks, you cannot afford to be apolitical You don’t have the luxury to be apolitical Because whether you like it or not, the political system is going to be very much a part of your life, in the decisions you make, how you practice, whether or not we can simplify the system– by the way, I didn’t get into this– so that you don’t have to have three or four people on staff doing nothing but collecting because of this cockamamie insurance system we’ve got All those things involve public policy and politics And one of the best ways to do that is get involved in professional organizations and take leadership positions in them Guys like me need people like you to help us figure this out I’m a failed pre-med I never made it I have a lot of respect for those of you But a, most of the people in politics really are in there for the best reasons, and b, you’ve got to be deeply and actively involved– all of you– if we’re going to make this thing work MICHAEL DUKAKIS: And then in closing, just one quick observation I saw the governor– he was on a task force of governors that was supposed to address health care And he looked around at his co-governors and discovered they had no intention of discussing the issue at all And one hour later, they were right in the middle of this And so a style which said, you’re not going to come here and discuss anything else as long as I’m the governor and I’m at this table– it just shaped the way a whole group of people were just peripherally deal with the issue He was there They were not going to deal with it peripherally They took a lot of strong stands, and it’s something about what leadership is really about, and it’s incredibly [? admiring. ?] And thank the governor very much for joining us MICHAEL DUKAKIS: Thank you, Bob [APPLAUSE]