History Holds Lessons for Present Reform Fight

Posted November 12, 2009 at 4:12pm

“I am not the first president to take up this cause,— President Barack Obama said to a joint session of Congress in September, “but I am determined to be the last.—

He was referring, of course, to the cause of giving all Americans health insurance coverage. If he succeeds, it will be the culmination of a long, long journey building on the successes — and failures — of practically all his recent predecessors.

As Obama said earlier, addressing a White House conference in March, “the problems we face today are a direct consequence of actions that we failed to take yesterday.

“Since Teddy Roosevelt first called for reform nearly a century ago, we have talked and we have tinkered. We have tried and fallen short. We’ve stalled for time and again we have failed to act because of Washington politics or industry lobbying.—

In 1912, President Theodore Roosevelt included national health insurance as the 11th item in the “Social and Industrial Justice— section of his Bull Moose Party platform.

It’s not exactly clear what model he had in mind, but during that unsuccessful campaign for the White House, Roosevelt referred to the universal, mandatory — and privately managed — insurance plan introduced in Germany by Otto von Bismarck in 1883 and said, in effect, “If the Germans can do it, why can’t we?—

It’s a good question even today, but Americans prefer to do it their own way. And it has been a gradual, incremental, fitful, contentious way marked by notable successes and colossal failures.

Congress Plays a Role

The history of health care reform in America is compellingly told in a new book, “The Heart of Power: Health and Politics in the Oval Office,— by David Blumenthal and James Morone, professors at Harvard and Brown universities, respectively.

They focus on presidents and their techniques — Lyndon B. Johnson is their model for success and Jimmy Carter for failure — but there are notable Members of Congress who played significant parts in the story, paving the way for the major players waging the current fight.

They include former Rep. John Dingell (D-Mich.), father of the current longest-serving House Member, both champions of universal coverage, and former Rep. Wilbur Mills (D-Ark.), the House Ways and Means chairman who resisted Medicare coverage for seniors and then was maneuvered by LBJ into championing it — and Medicaid for poor people, too.

There was also Senate Majority Leader Robert Taft (R-Ohio), who denounced the senior Dingell’s universal coverage bill as “the most socialistic measure this Congress has ever had before it— — a theme repeated today by Republicans against “Obamacare.—

And a major force in health care policy from Johnson’s time to Obama’s was the late Sen. Edward Kennedy (D-Mass.), who fought tirelessly for universal coverage but was willing to work for less when he had to, even with Republican presidents such as Richard Nixon.

Blumenthal and Morone identify three distinct approaches to health care reform that have dominated the policy debate over the past 80 years.

One is the Social Security model — government-run and mandatory — that has been the choice of liberals since President Franklin D. Roosevelt’s time, now billed as “single-payer— or “Medicare for all.—

The second, invented to combat liberals, was dubbed “the American way— by President Dwight Eisenhower. The design is insurance provided through private employers and private companies, with government subsidies and programs filling in gaps.

It’s the system that dominates American health care today. In fact, it’s so dominant, the authors write, that, post-Eisenhower, “no administration — in fact, no presidential nominee of either party — would again propose national health insurance provided directly by the government.—

(Of course, Republicans are convinced that Obama and the current Democratic Congress intend to create a slippery slope leading to a single-payer system and the elimination of private insurance.)

The third model, championed by Presidents Ronald Reagan and George W. Bush, would be based strictly on competition among private insurers. It is the design of Bush’s Medicare Part D, the prescription drug program, which is popular with seniors, costs less than anticipated — but is excoriated by liberals.

The history of health care reform contains some surprises. FDR, the author of so many New Deal reforms and Social Security, actually dropped medical coverage from his agenda — possibly because he was influenced by his White House physician.

President Harry Truman, the authors say, “embraced national health insurance with a fervor Roosevelt never showed. Yet … he never used the bully pulpit to try to rally the public.—

He was stymied by fierce opposition from the American Medical Association, which mounted a huge media campaign against “socialized medicine,— going so far — in the era of Joseph McCarthy — to cite Vladimir Lenin as saying that “socialized medicine is the keystone to the arch of the socialist state.—

“During the Truman years,— the authors observe, “conservatives refined the idea of a private insurance system with some provision for the poor who could not afford or find it— — the model that Eisenhower would advance.

In fact, the Eisenhower administration enshrined it with an Internal Revenue Service ruling waiving taxes on employer-provided health care benefits — “an enormous federal government tax expenditure,— the authors note, “which even today totals over $200 billion a year.—

Eisenhower “shifted the main burden of health insurance from the shoulders of government (where Truman thought it belonged) to the backs of business.—

President John F. Kennedy fought hard — but unsuccessfully — for a government-run Medicare system for seniors. He also achieved the signal success of facing down the AMA with the question: “Do you think Social Security is socialism?—

Giving LBJ His Due

Lyndon Johnson, the authors write, “was the most important health care president the United States has ever had— and his presidency “is nothing less than a primer on how to make it happen.—

Unlike Obama, who has largely let Congress write health care legislation, Johnson declared, “There is but one way for a president to deal with Congress and that is continuously, incessantly and without interruption.—

Through constant attention, stroking and bestowal of the credit, Johnson maneuvered Mills into combining a hospital benefit for seniors (now Medicare Part A), a physician-payment benefit (Part B) and state-based aid for the poor (Medicaid) into one package.

Johnson signed the bill in 1965 at the Truman Library — and, today, surviving LBJ aides wonder why Obama never credits Johnson with the single biggest achievement in health care in U.S. history. (The answer probably is Vietnam.)

Nixon started out by resisting Edward Kennedy’s efforts to enact universal health care coverage but ultimately embraced the idea of an employer mandate to extend coverage. The idea died “in the wreckage of Watergate,— however, according to the authors.

Blumenthal and Morone regard Carter’s approach to health care reform — or “hospital cost containment— — as a model of failure.

Carter failed to act fast, promote a vision, develop popular support or manage Congress. He was focused on micromanaging process, they say, and “the result was four years of policy paralysis.—

Reagan, the famous free-market advocate and foe of government expansion, had fiercely opposed Medicare but instituted its current policy of setting prices for every service.

He also endorsed “the largest expansion in Medicare’s history— — a government guarantee to cover catastrophic medical costs for seniors.

Unfortunately, that program proved deeply unpopular because it imposed a tax on seniors before the benefit kicked in. George H.W. Bush, Reagan’s successor, allowed Congress to repeal it. Bush, the authors write, wasn’t interested in health care policy and, like Carter, didn’t affect it.

President Bill Clinton, of course, was interested and did try to achieve full-scale reform based on an employer mandate and highly regulated use of health maintenance organizations.

But, of course, he failed, stymied by his (and first lady Hillary Rodham Clinton’s) refusal to compromise (“policy hubris—), opposition from most Republicans and Democratic Sen. Daniel Patrick Moynihan (N.Y.), and by devastating ads mounted by the health insurance industry.

Republicans get little credit for it, but under George W. Bush they produced “the largest expansion in Medicare history and the biggest new health care entitlement in almost four decades (not much thanks to the Democrats who, in the end, largely opposed it).—

Blumenthal and Morone credit the younger Bush — widely seen as a disinterested delegator — with significant leadership and management skills in the Medicare Modernization Act campaign.

Their book doesn’t cover Obama, whose success or failure has yet to be determined. But Obama seems to be following some of the lessons of the past — display passion, act swiftly and go public.

Obama hasn’t followed other lessons: Produce your own plan and manage Congress. And they have one other lesson: If you lose at first, don’t quit.