One of my proudest moments, which was photographed — the photo is displayed in my office at the clinic — is the 1998 signing ceremony for the Healthy and Well Kids in Iowa (HAWK-I) program. I stood with representatives of several medical societies and an Iowa family that included a mom and three daughters while Governor Branstad signed into law a program that helped to make Iowa a leader in the nation in the percentage of insured children.

I worked long and hard with Democratic legislators, Republican Representative Brad Hansen, who also is in photo, and Republican Senator Nancy Boettger to create a program made possible by federal funding that created a public-private system to insure children. For my efforts, in 1999 I received a national Public Health Award from the American Academy of Family Physicians. During the negotiations for the HAWK-I bill, I clearly remember that then-Governor Branstad did not want a quasi-independent board to supervise the program.  He stated that in his administration he did not want to add “silos” that prevented him from overseeing the actions of state government.

Fast forward to 2013-2014.

I am struck by the contrast between then-Governor Branstad and current-Governor Branstad, who initially tried to thwart by lawsuit, then tried to delay some portions, and with other portions refused to fully use available resources of the Affordable Care Act (ACA) for the good of Iowans. Now, it appears that seemingly every department of Iowa state government is a near-independent silo, such that when the director of the Department of Public Health makes disparaging remarks regarding poor Iowans or the director of the Department of Administrative Services makes false claims before a legislative committee, it appears that Governor Branstad can remove them from office without taking any responsibility for their actions while in high-level state director positions. After 20 years as governor, he has developed a new and different style of “overseeing” the actions of state government.

I am proud of the HAWK-I program and its results. I am proud of the intent and much of the content of the ACA. I wish Iowa had utilized the ACA to its full capacity to benefit every Iowan.

I believe a Governor Hatch (Senator Jack Hatch is currently running for the governorship of Iowa) administration would have acted differently, and the effects on Iowans would have been both positive and profound. I would like to imagine what I believe a Governor Hatch administration would have done in 2013 and 2014 that would substantiate this claim.

Before starting this discussion, I make three provisions: 1) These actions that I propose are what I think a Governor Hatch should do and do not necessary mean a Governor Hatch would agree with each and every proposal, 2) what should have been done in 2013 does not necessarily predict what should be done in 2015 when a new administration will take office, as factors have and will continue to change, and finally, 3) I attended the first 2014 governor’s debate, held this month in a cattle barn at the Iowa State Fair. A replay was shown that evening on Iowa Public Television. I was chagrined to witness a total absence of questions and discussion regarding health care in Iowa. Senator Hatch, who is acknowledged by even those who might not agree with him as one of the most active, engaged, and informed legislators regarding health care, left some of his best, strongest positions unsaid during the debate.

So let us begin. The nexus of this blog is Senator Hatch’s responses to my health-care questions to candidates. Sadly, he was the only candidate to respond, despite personal promises from two other candidates. Senator Hatch’s responses were thorough and insightful. For his effort, I will contribute $1,000 to his campaign.

His answer to my question regarding a state-based health Exchange clearly shows not only his support but also his leadership on the issue. Having created a commission that produced a report recommending and detailing a proposed state-based health Exchange, he then used those recommendations to propose legislation in two different legislative sessions to create a state-based Exchange. Previous blog posts detail what I believe are the vital benefits of an Iowa-based Exchange. The value is even greater when one realizes that Iowa’s current hybrid Exchange ends, by federal mandate, in 2015 and will then force Iowans into a health Exchange run totally by the federal government in 2016. A federal court ruled recently that individuals on the federal Exchange are not eligible for federal subsidies for their health insurance premiums. For all these reasons, a Governor Hatch would have and should have had a state-based health Exchange ready for the 2013 ACA open-enrollment period.

I believe an Iowa state-based health Exchange should be a quasi-independent entity with its own board of directors. Furthermore, such an entity should be housed in a newly structured Department of Health, which would include the current Department of Public Health and the Medicaid Division currently operating within the Department of Human Services. Combining these state efforts — both which pertain to health care — would align common interests and give state government tighter focus on health care. Such a state-based health Exchange should mandate navigators in every Iowa county and work directly with hospitals and primary-care providers to have individuals such as health coaches in these institutions and offices who are able to enroll uninsured Iowa residents for health insurance or Medicaid. Only with efforts such as these will residents of rural Iowa be able to fully engage in making decisions regarding health-care coverage options and be able to meet the individual-mandate requirement of the ACA. I firmly believe a state-based Exchange utilizing local health-care provider offices would dramatically change the current negative connotations about the ACA found in many parts of rural Iowa. This new Department of Health should, in addition, have an Iowa surgeon general: a physician who would be charged with making informed recommendations regarding various state health programs and issues to both the Legislature and governor.

In a different venue of state government, an imagined Governor Hatch administration would have never allowed limited health-insurance policies to be grandfathered into the 2014 individual insurance market and for the upcoming 2015 market. This action by the Iowa insurance commissioner, which many insurance commissioners throughout the country did not allow, allowed for the potential for adverse selection. As a regulator, opening the door for adverse selection seems to me to be inappropriate and not in the best interest of Iowans. Additionally, many Iowa residents who maintained their grandfathered-in, limited policies would have met the criteria for federal subsidies. The loss of federal money to these individuals and the economy of Iowa is significant.

Finally, a Governor Hatch administration would have set a positive tone for the state’s actions and response to the ACA. Individuals who need health coverage and chose not to receive it due to the negative connotations of the ACA as portrayed by various groups and individuals might have reconsidered their positions and attitudes if the state had a positive approach to the ACA. Currently, these individuals are suffering and, in some cases, dying due to a lack of health coverage. That is an Iowa tragedy.

In summary, I began this blog referring to a photograph of the signing ceremony for HAWK-I. This photograph included a family with three daughters. My personal “poster” family for HAWK-I is currently in my medical practice. The family includes three daughters and one son. Sixteen years after the signing, two of the children are still on HAWK-I receiving necessary health services, while two older young women attend Iowa State University. The lives of all these children were measurably improved by the medical care they received under HAWK-I coverage. Their mother has thanked me many times for the existence of the program. This was a program then-Governor Branstad signed into law. I guarantee that there are thousands of Iowans who should now be receiving the benefits of the ACA but are not.

Contrary to the actions of the current-Governor Branstad administration, I believe the discussed actions of this imagined Governor Hatch administration would have allowed for them to obtain health-care coverage. In terms of health care, I believe the contrast between Governor Branstad and Senator Hatch is stark and telling and requires serious consideration by Iowans.