Interview with Kevin Sack of The New York Times

SACK: So much of the narrative of your campaign, and really of your life recently, has to do with health care, given your wife's very public illness. So I am wondering how your own experiences with her illness, and with the medical system generally, have molded your views about changing the system, and try to be as detailed as possible?

EDWARDS: Well, they played a role. We have, through Elizabeth's health care problems, we've had a great deal of experience with the health care system and the difficulties that — and we have great health insurance — but even the difficulties that people with insurance have, which are far less than the people who have no health coverage. And I would add to that, that we've had, because of Elizabeth's experience, we have lots of people who come to us with their personal health care stories. So I think those two things in combination have given us an insight into how — how much the health care — the dysfunction of the health care system dominates people's lives in a way that it's overwhelming, in many cases. For example, single mothers who come to us say they've been diagnosed with breast cancer, they don't have health care and they have no idea what to do. I've seen how difficult going through Elizabeth's breast cancer treatment is for us with good health care coverage. I mean it's almost hard to imagine how hard it is for women going through the similar circumstance. And then also just the work I have done on the ground, on poverty, has put me in contact with lots of people around the country, who, because I go to a lot of community action centers, shelters, places that take care of and help the poor, puts me in contact with a lot of people with no health coverage. And so I think all those things in combination have had a significant impact.

SACK: Has there been anything specifically in her treatment that has given you a firsthand look at that dysfunction, whether it's from insurance companies, with payments being refused, kicked back, paperwork, medical errors or anything like that?

EDWARDS: Yes, I mean when you get the statements by the providers and the insurance companies about what's covered and what's not covered, even for two people who are well versed in the law and experienced with the health care system, it seems completely arbitrary in many cases. It doesn't make any sense.

And if it's hard for us to understand, number one, probably that's because many times it's nonsensical and not based on anything legitimate. And secondly it's just, I can just imagine what it's like for people who have no legal training or any reason to understand. I mean, I think there's so many, even if you have health coverage, there are so many barriers set up to actually getting payment for the services, the health care services people need, that I am sure it's just overwhelming.

SACK: You boast along the campaign trail about being the first to produce a health care plan, and I guess I am curious about why voters should care about that. What does that tell them about you, relative to the other candidates? Isn't the more relevant question whose plan is best? Seems like some people could argue that, yeah you have the first plan, but you've also been running the longest so that wouldn't necessarily be a surprise. Tell voters why it's important that you were first.

EDWARDS: Well, I think they're both important. I think coming first is an indication of how you prioritize health care. How important it is to what you want to do as president. I came out with my plan — you should check this, but I think it was February. And I know Senator Obama came out a few months later — I don't have the, you probably know, but I don't have the dates in my head. And Senator Clinton came out with hers this fall, this past fall, so months later.

And I think what it means is — number one — that I knew what I wanted to do with health care. Number two — that I think by getting out and being specific, about universal, about the substance of the plan, it also has the effect of driving the debate. It makes it very difficult for other candidates to float through on rhetoric. I mean Senator Clinton spent months saying she was for universal health care without having to make any choices. So I think it means something, number one — I think it means how I am prepared to lead on this issue as president. Number two — I wasn't waiting to see what others said to figure out what the politics were. I knew what I wanted to do. And number three — I think it helped drive the debate in the presidential race. So I think it is important, but that's not to downplay the importance of the substance of the plan.

SACK: The plan you're proposing is far more expensive than the one you proposed four years ago. Talk a little about the evolution of your thinking — what was it, if anything, about your personal experience or the experience of the country, changed conditions, increase in the number of the uninsured, that made you take a more aggressive approach to universal health care this time?

EDWARDS: Well, I concluded that something bolder was needed, that the health care system had become increasingly dysfunctional, and my contact with a lot of uninsured Americans, who were not children, made it clear to me that the plan had to be universal, that it had to cover everybody. So I think it's a combination of what I saw as an increasing dysfunction, an increasing number of uninsured, health insurance premiums continuing to skyrocket, plus my personal contact with so many people telling me their stories. I mean, if I can be a little more specific about this, I mean, one of the things I did in the interim between 2004 and announcing for president a few years later, was traveling around the country to lots of places, lots of states and going into centers that were helping low-income families, and that put me in a position of constantly talking to single moms, to the uninsured, about the problems that they were faced with and what impact it was having on their lives, and that also had an effect on me.

SACK: Did you notice a change in the country's attitude towards health insurance between '04 and '08?

EDWARDS: Yes, but I wouldn't want to overstate the case. I think there has been a significant change in the country's attitude since the '90s, so I think it's gone over a period of time. I think it's become more intense since 2003, 2004. And the problems have become increasingly worse, have become worse, but I think it's been on a continuum.

SACK: The insurance companies are prominent on your list of villains, along with the pharmaceutical companies, the oil companies. What makes them such baddies?

EDWARDS: Well, what I'm referring to is the fact that they stand as obstacles to change. I'll give you an example. When we were doing the Medicare prescription drug law in the Senate.

And those of us who were working on it — again, it was not just me, there were many people working on it — it became clear that there were certain things that needed to happen. We should have been using the power of the government to negotiate the best price, we should be allowing prescription drugs to be reimported from Canada, we should be using the power we have to try to regulate drug company advertising on television, those kind of things. And the drug company lobby was a powerful force in preventing those things. And, the same thing happened more recently with the effort by Congress to do something about reverse payments, these payments that are being made by drug companies to generics to keep cheaper drugs, generic drugs, off the market. Congress took up the issue and planned to do something about it and the drug company lobby effectively killed it. I think these are just examples. I encountered the insurance company lobby directly when John McCain, Senator Kennedy and I got the Patients' Bill of Rights passed in the Senate. It later got killed, but it got passed in the Senate. I know how effective they are and I know how much money they spend to prevent the kind of reform that, in my judgment, this country needs.

SACK: In shaping your plan why did you decide against single-payer that would guarantee universal coverage? If you hate the insurance companies so much why not put them out of business with one swift blow?

EDWARDS: Completely fair question. I looked hard at single-payer. Proponents of single-payer have some very strong arguments, particularly the elimination of profit motive in a health care system. Medicare, for example, runs at 3 to 4 percent overhead compared to some insurance companies charging 30 to 40 percent profit and overhead, so I thought that there was a legitimate and strong argument for it.

But I also believed that there are an awful lot of Americans who like the health care they have and are nervous about entirely government-controlled health care. So I heard both sides, and by the way throughout this campaign I've heard both sides. I'll never forget, I had an event in Concord, N.H., not long ago where a guy stood up and said, "I don't understand why you are not proposing single-payer. The Canadian system is a good system." Not 15 minutes later a woman on the other side of the room said, "I just want to say, I like the idea of universal health care but my" — she had a relative, I've forgotten what — "living in Canada and she has to wait six months to get the tests that I can get in a week."

So I think people are very divided over that issue. So what I intentionally did was construct a system where the American people would effectively make that decision for themselves, so that they could choose in a health care market between either a private insurer or essentially Medicare-plus. And so that they would have to compete with one another.

SACK: You've said in the past the plan could gravitate either way. Because you are introducing the Medicare-plus as you describe it, a federal plan that people would have the option to choose, that the plan could gravitate in either direction. Which seems in some way to sort of acknowledge in some way what the Republicans contend, which is that the Democratic plans are sort of a back door to single-payer. Do you think that's right? And is it O.K. by you if does eventually morph into a single-payer system?

EDWARDS: There is nothing backdoor about it. It's right through the front door. We're going to let America decide what health care system works for them. I'm not deciding that for them. America's going to decide it. American health consumers will decide which works best. It could continue to be divided. But it could go in one direction or the other and one of the directions is obviously government or single payer. And I'm not opposed to that, as I've said many times. I think that if we're doing what needs to be done to seriously and comprehensively reform the system — cover everybody, dramatically reduce costs — I think there are roughly $120-125 billion of savings each year in this proposal that I have made. You're probably going to ask me about that in a minute — if we're doing what we need to do to create efficiencies, drive down costs, get everybody covered and leaving open to America what system makes the most sense to them, to me that's a sensible approach to this issue.

SACK: Do you think it will be a problem in the fall, your openness to that option? Will that just be red meat to the Republicans, socialized medicine and all that?

EDWARDS: No, my argument is really very simple to America. If you believe that what you are paying for health care and how the health care system operates today is satisfactory, you should vote for the Republican candidate. If you think we need serious, comprehensive reform, you should vote for me.

SACK: Let's talk about whether Americans should be required to have insurance. You and Senator Clinton say that you have to have a mandate to reach universal coverage. Senator Obama respectfully disagrees. He'd only mandate coverage for children. A lot of commentators say that in the larger context of Democratic versus Republican positioning on health care that this difference is so small as to be insignificant. Are they wrong? Do you think that Obama's position is a serious shortcoming? Or is this sort of a minor disagreement that's being magnified to play to certain constituencies in the primaries?

EDWARDS: The threshold question of any health care plan is 'Is it universal?' and his plan is not universal. So I don't think it's a minor thing. I think it's a serious thing. He's to be applauded for coming out with a serious plan, let's be fair. But his plan is not universal, and to argue that it's universal is not the truth.

I believe that his argument against mandates, which he made Monday night — did you watch the debate Monday night — which he made Monday night and I made the comparison then to Social Security. To me, it's like arguing that you should be able to opt out of Social Security. No, we've decided that as a nation this is a comprehensive plan for all seniors and everyone's going to be part of it. The same is true of a universal health care plan. So I think there is a fundamental divide between my plan and Senator Clinton's plan and his, because ours are universal and his is not. And I think we need universal care.

SACK: Define the term for me. How universal is universal? What we're learning from the experience in Massachusetts is they can't really cover everybody even though they've got a mandate. They're offering exceptions for people who can't afford it even in a heavily subsidized system and while their enrollment is doing pretty well, it's clear to them that there are going to be some people who just calculate the penalty as preferable to the mandate. The Schwarzenegger plan that's being considered in California would also leave some people out. So, is universal near-universal or is there really a way to cover every American?

EDWARDS: First let's distinguish between what I'm proposing and what Senator Obama is proposing. His plan has no mandate. I have seen some calculations that indicate there could be as many as 12-15 million people could be left uncovered. What you're asking about now are people that may fall in the cracks. We will do everything in our power to cover everybody. Basically what happens is — and I actually haven't heard Senator Clinton say how she would enforce her mandate, so I'm not sure what she would do — I've heard some talk from some of the people who work for her but I haven't heard her say it. What our mandate would do is anytime people come into contact with the system, whether it's in the hospital or paying their taxes etc., and they're not enrolled in something — Medicaid, S-CHIP, private insurance, Medicare plus — then they will be enrolled. Let's go to the next step, you can play this out. If they then refuse to pay their premiums, it will be our responsibility as a nation to go collect the premiums.

SACK: Thru what mechanisms?

EDWARDS: Through the normal collection mechanisms...

SACK: Through garnishment? Through taxes?

EDWARDS: Whatever collection mechanisms would be most effective.

SACK: What are some options?

EDWARDS: The ones you just mentioned are some.

SACK: Under your plan will some people be exempt? Will there be a need for some kind of hardship exemption, or will the subsidies be adequate to lure everybody in?

EDWARDS: I have not proposed a hardship exemption. Realistically, we know as we put this plan into place, as we start implementation, there may be some tinkering that needs to be done to it. Maybe in some cases the subsidy needs to be raised. Maybe we need to make certain that it covers a certain small group of people that aren't getting what they need. There are a variety of things that we may need to tinker with on the edges to make sure it works the way it needs to work. But the fundamentals won't change and the plan is to cover everybody.

SACK: And on enforcement, the penalty would be that they have to buy a policy. There wouldn't be a financial penalty over and above that.

EDWARDS: That's right.

SACK: Your mandate would only kick in once insurance is deemed affordable. Talk about how that's going to be determined and it seems like that potentially could be a pretty big loophole. How long do you estimate that would take to kick in?

EDWARDS: Well, all these things are unknowable with certainty. I mean, first of all, let's live in the real world for a moment instead of just academia. The first thing we've got to do is we've got to get the health care plan passed into law. And there are a whole group of principles that I will never walk away from in my health care proposal. But the reality is as it goes through Congress, it will get tinkered with. I mean, that's just the way these things work, as everyone knows. So the first thing you've got to do is you've got to get it passed. Then you've got to start the process of implementation and bringing people into the system who have not been part of the health care system. So for me to try to sit here now and predict exactly how long that's going to take, I think is not realistic. I can't do that. We will do it aggressively, and we will try to get everyone covered as quickly as can possibly be accomplished, and as we find small areas where we need to make it work more effectively, we'll make those changes.

SACK: Well, how are you going to define affordable? If the notion is that the mandate only kicks in once insurance is affordable, can you give us some guidelines on that?

EDWARDS: Sure. If you are living at or near the poverty line, you're going to be essentially 100 percent subsidized. If you are up to about 250% of poverty, which is probably around $50,000 income for a family of four, you will have very low premiums, very low co-pays. And then, above that level, you'll continue to be subsidized up to about $100,000 of income.

SACK: Obama doesn't rule out mandates. He says that he'd consider one down the road if he finds that it's necessary to reach universality. So given that he's saying that and that you're saying that yours won't kick in immediately, aren't you guys really sort of in the same place?

EDWARDS: Absolutely not. If you start the process of trying to get a health care plan through Congress without it being universal, and without a mandate, then you're starting from a weak position. You have to begin with the principle of universal coverage. That is a principle that can not be conceded. We've already, you and I have talked today about there may be various mechanisms that people will suggest to do it more effectively. I have my own plan, I'm proud of it, but if people have other ideas that make sense I'm open to that. What I'm not open to is not covering everybody. Everyone has to be covered. And no I don't think we're the same.

SACK: If one of the enforcement mechanisms would catch people at the point that they're using the system, do you think that could be a disincentive at all for people to use the system?

EDWARDS: I'm not following you.

SACK: When you're talking about that the mandate — you said that when people access the system, if they're not insured, they would then be enrolled. So, if somebody's ill and doesn't have insurance, doesn't want to pay those premiums, might it be a disincentive for them to engage with the system?

EDWARDS: I don't, I think – My view is that's far-fetched. I think somebody who is sick enough to need health care they're going to go get it.

SACK: Are there any substantive differences between your plan and Clinton's plan?

EDWARDS: Yes.

SACK: Talk about them.

EDWARDS: Both of us have similar proposals for savings in Medicare. But because she funds her plan by rolling back Bush's tax cuts for those who earn $250,000 and above, and I fund mine by rolling back Bush's tax cuts for people who make $200,000 and above, that gap has to be made up somewhere. And so what she does is she takes the, and I'll be glad to go through them, but our proposals are very similar for savings in Medicare, she takes that savings out of Medicare and uses it help fund her universal plan. I keep the savings in Medicare, and the reason I'm, and everyone knows how intensely sick Medicare is financially, and the reason I'm able to do that is because I went lower on the tax cuts that would be rolled back.

SACK: Talk about S-CHIP a little bit. Would you be in favor of sort of unfettered expansion of the program to cover adults as it does in some states now, to raise the eligibility limits way high — some states have tried to do 350-400%?

EDWARDS: Well, what I just suggested is what I would do. When I'm talking S-CHIP being available to families you know of incomes of $50,000 for a family of four that applies to children and adults. I think that's about the place that makes sense.

SACK: Talk about what happens to illegal immigrants under your plan.

EDWARDS: They're not, they're not included in it. By the way, best I can tell, they're not included in anybody's plan. But what I do is reinforce the public health safety net. And that public health safety net will continue to be available to undocumented workers. So that means more funding for public hospitals, more funding for public clinics, basically all the mechanisms by which we provide coverage for people through public health.

SACK: You have dollars attached to that? You know how much you would increase those by?

EDWARDS: I do, but I don't have those in my head right now.

SACK: And I guess one problem there is access, I mean those facilities don't necessarily exist where all the illegal immigrants are.

EDWARDS: I do know that we have proposed as part of this plan an expansion of not just funding for them, but an expansion of the number of facilities too.

SACK: Cost containment. Walk me through the keys to bringing down cost, and I guess start by talking a little bit by talking how your health markets plan would work. And I'm curious how you keep it from being a dumping ground for the sickest patients.

EDWARDS: Because everybody — let's start with the basics — every insurer, and the government, are required to take all comers. So, if you, if you're going to be in the business, this will be done by law, if you're going to be in the business of providing health care coverage, whether you're the government or a private insurer, you are required to cover everybody.

Second, you're required to set premiums based on large groups. In other words, if you have MS, even though they have to cover you, if you don't make clear in the law that the premiums will be set in large groups, they could single you out and say, "Well, we're going to charge you a fortune for your health insurance premiums."

Let me keep going, on the bigger question of how do you reduce costs. So, the big mechanisms for cost containment are, for the private insurers, they have to put 85 cents of every health care dollar into health care, which effectively caps profit and overhead at 15%. For the drug companies, they, we're going to reform the patent system. We're going to make it easier to get generics into the market more quickly. And take a very hard look at drugs that could have a real impact on low and moderate income families, whether instead of providing a patent, we pay a cash award. In other words, instead of creating essentially a monopoly for a period of time, we instead give them a cash award, get the drug on the market more quickly, more available, cheaper. Beyond that, required electronic record keeping. Excuse me, required use of technology, and electronic record keeping.

And then in a bigger-picture way, the whole concept of the system is cradle-to-grave coverage, but not just for when you get really sick. So that we — essentially the idea is this — that from the time children are very young, they're taught nutrition, health, well-being, exercise. When they develop a health care problem, since preventive care is 100% covered, we make sure we intervene, we're monitoring closely, we intervene as early as possible in their health care problem, so that whether they're young or old the patient does not get catastrophically sick. I mean, we know that one of the big problems in our health care system today is people that don't have coverage or who are worried about their coverage just put off getting care because they don't want to incur the expense, and as a result they get catastrophically sick. It's bad for them — bad for the patient — and bad for costs because it drives up costs. So I think the whole concept of preventive care is also an important cost-saving mechanism.

SACK: You've criticized your opponents for being too cozy with the drug and insurance companies, and have suggested that you won't let these big commercial interests in under the tent. So on an issue as complex as this and with such varied approaches, how do you envision putting a coalition together to pass health reform legislation in 2009? Who would your allies be? Could you do it without Republican support, because you're pretty much declaring war on interests that they are allied with?

EDWARDS: Well, I think that there are two things that have to be done simultaneously. One is you have to galvanize America behind the cause. And the most powerful tool the president has is the bully pulpit. And Americans are very receptive to the idea of comprehensive health care reform to begin with. And galvanizing America to create the political support for what needs to be done. That is done simultaneous with reaching out to the leadership of the Congress, both the Democrats and the Republicans, and I do believe there are — I'll give you an example — I had a debate with Newt Gingrich a couple of years ago in California, and the subject of health care came up, and he made a very comprehensive, and I wish I could remember, I believe it was universal, health care proposal. Now it was very different than mine, but he believed, clearly, that some sort of comprehensive health care was needed.

So I think that because of the will that exists today that didn't exist a decade or more ago, I think the public will, bringing America to the cause, and being able to work not just with Democrats but with Republicans, who are hearing the same thing from their constituents that I hear all over this country, I think there's an enormous opportunity. And I think what will ultimately control is first the power of a good idea, second, the political will in America to actually create reform, and third, I think the political leadership of Democratic and Republican, recognize that this is something that's time has come.

SACK: Small businesses are obviously very scared about these mandatory plans. What do you say to reassure them and do you have an idea in mind for the percent of payroll that small businesses should be putting toward health care for their employees?

EDWARDS: Well, what I would say to them is the two greatest beneficiaries of this universal health care proposal are the uninsured and small businesses. Small businesses who are struggling to pay their costs, most of the small businesses — and I've spoken to many all over the country — are terrified about health care costs. They have no market power, they can't negotiate a decent price. It's not just covering their employees, by the way, they can't cover themselves, so it's their own family that's being impacted by this dysfunctional health care system. And so what I say to them, and I've said it repeatedly, is you are an enormous beneficiary of this health care reform that we are proposing. Because what effectively do is give you the same kind of market power that General Motors or IBM or some large American employer has, and because of that you're going to be able to cover yourself, you'll going to be able to cover your employees, and the net result of it is both good for the people who work for you and good for you. So I actually think that small business are among the most — are among those who will benefit most from this proposal.

SACK: You've proposed limiting pharmaceutical advertising. Is that constitutional?

EDWARDS: Yes, if it's done the right way. It has to be done looking very closely at what the First Amendment provides, and what the limits of our authority is to regulate, but yes I think there are reasonable regulations that could be imposed that would, number one, help drive down the cost of some of this drug company advertising. They're spending twice as much on advertising as they are on research and development and, number two, require the disclosure of some information that's not prominently being disclosed today.

SACK: How could it be done constitutionally?

EDWARDS: It has to be done within the frame of what the First Amendment allows and doesn't allow. The First Amendment doesn't allow unfettered free speech. There are limitations on free speech, and we just have to do it within the confines of those limitations.

SACK: Talk a little bit about your malpractice proposal, which I know you have sort of a 3 strikes and you're out proposal for frivolous lawsuits. What would the federal government's ability be to impose those kinds of rules on state courts?

EDWARDS: Well, first of all, most of this is regulated at the state level, as you know, but I think as part of a comprehensive reform if, if, you're saying it like you understand it, but let me walk through it because I want to make sure that …

SACK: That's a good assumption on your part.

EDWARDS: [laughs] Let me walk through what I've actually said, what I have said is that I am not in favor of taking away the rights of patients who have been badly hurt to have their day in court and to have the jury decide their case. I believe in the jury system. What I am in favor of is keeping cases out of the system that don't belong there. And what I would do is say to any lawyer who's considering filing a malpractice case, you must first have the case reviewed by an independent expert, who determines that the case is both meritorious and serious, you have to certify that in order for the case to be filed in the court system, and now we get to the part you made reference to, if you fail to do that then the lawyer will be held financially responsible, and if you do it three times, there's a three-strikes-and-you're-out rule. That's basically what I'm proposing.

SACK: So what would your authority be to impose that in the states? Or is it a bully pulpit issue?

EDWARDS: It can be done either way. I think that actually you do have the constitutional authority to do it nationally. But there's also a good argument to be made that this is traditionally an area that's been left to the states and should be left to the states.

SACK: Last thing.

EDWARDS: And I might add, and I do think that the idea that this is a huge part of health care costs is a complete fantasy. I think it's way less than 1% of health care costs.

SACK: If someone was to know you only by your approach to health care, what would it tell them about your political philosophy on the roles of government and markets and individual rights?

EDWARDS: It would say to them first that I as President would believe we need bold solutions to the country's problems, not timid halfway measures. Secondly, that I believe in responsibility, and my proposal creates individual responsibility, employer responsibility and government responsibility and I think it's that marriage of responsibility that actually works and makes this proposal effective.

SACK: And you guys are insured by the campaign right, the current insurance?

EDWARDS: That's correct.

SACK: Thanks Senator.