NEW YORK CITY New York — As Congress takes on President Obama’s call for overhauling health care, the desire for change will be tested — by the expense, by politics, by resistance from doctors and private insurers, and by the general fear by some of “socialized medicine.”
The terms of the debate are as old as the debate itself.
Since Franklin Roosevelt considered national health care in the 1930s, virtually every president has sought to expand or universalize medical coverage. Public support has been as consistent as the countering arguments: It costs too much, it doesn’t have the votes, it will ruin the free market system.
Presidents sympathetic to health care for all, from Roosevelt and Harry Truman to John F. Kennedy and Bill Clinton, have either failed to get it passed, or never tried. Meanwhile, presidents otherwise deeply suspicious of government programs — Dwight Eisenhower, Ronald Reagan, the second President Bush — have successfully backed expansion.
The political history of health care is equally simple and unpredictable.
“For people who know the boring details of health care, the debate is really deja vu all over again, although I’m not sure the general public picks up on all the echoes from previous debates,” says James A. Morone, co-author of “The Heart of Power,” a newly released history of health care and the presidency.
The book, published by the University of California Press, was also written by David Blumenthal, a Harvard Medical School professor who in March — after the manuscript was completed — was named the Obama administration’s national coordinator for health information technology. (He declined to be interviewed).
The Obama administration is advocating a government-sponsored health insurance plan that would compete with private companies, a proposal strongly opposed by insurers and many Republicans. Individuals and small businesses would get to pick either the public plan or a private one through a new kind of insurance purchasing pool called an exchange. Eventually, the exchanges could be opened to large companies as well.
The approach is the latest variation of a decades-long quest. Care for all has been advocated since the Progressive era before World War I, and was first taken seriously in the White House by Roosevelt, when the Great Depression led to the creation of Social Security and numerous other government programs.
Roosevelt was enormously popular and persuasive, and had large Democratic majorities in Congress, but no health care legislation was passed or submitted. Roosevelt would periodically raise the issue, commission studies, then drop it. When he died in office, in 1945, aides were still drafting a proposal.
“I don’t think his heart was in it,” Morone says, “and that’s ironic because since he had had polio and was in a wheelchair, he understood better than any president what it meant to be sick.”
Roosevelt’s successor, Truman, was openly committed to health care for all, mentioned it often and seemed in a good position to achieve it after his stunning victory over Republican Thomas E. Dewey in 1948. But after suggesting he would re-enact his fiery “whistlestop” train tours of the campaign, this time for medical legislation, Truman never made a serious effort, despite the urging of political allies and repeated questions from reporters.
“I just think he got caught up in the Cold War and foreign policy,” said historian and Truman biographer Robert Dallek.
Republicans, meanwhile, were surprisingly willing, and able, to extend coverage. Eisenhower was a free-market man and a determined budget cutter, but he made an exception for health care, successfully backing legislation that made coverage provided by employees tax free and granting medical coverage to federal employees.
His reasons were at least partly personal. His mother-in-law had fallen ill and required medical treatment for two years, an ordeal that was emotionally and financially devastating. His determination was such that when the American Medical Association helped block a plan that would have encouraged insurers to take on high-risk patients, he fumed and called the AMA “a little group of reactionary men dead set against change.”
Reagan was an even more unlikely backer. A committed conservative who in the 1960s attacked Medicare by saying, “We can’t socialize the doctors, without socializing the patients,” Reagan defied his economic advisers and in 1987 supported a bill expanding Medicare to offer catastrophic health coverage.
“That wasn’t unusual for conservatives in those days, including Reagan,” says Reagan biographer Lou Cannon. “They would make an exception for something catastrophic by saying, ‘That’s a special situation.”’ What they didn’t want was a cradle to grave system for the general public.”
But the health care champ was Democrat Lyndon Johnson, who pushed through — shoved might be a better word — the passage of Medicare and Medicaid. Tragically raised to the presidency by the assassination of Kennedy, who tried and failed to get Medicare approved, Johnson brought a historic sense of urgency and matchless gifts at working with Congress, illustrated by his secret connivance with Rep. Wilbur Mills, chair of the powerful House Ways and Means Committee, to give Mills the credit for legislation that was essentially Johnson’s idea.
Rule for success
Johnson’s success, say the authors of “The Heart of Power,” demonstrates a number of rules:
l Believe in it. Johnson did, so did Eisenhower. President Carter and the first President Bush didn’t.
• Educate the public: Health care legislation is easier to desire than to understand. “The only people who can explain this medical thing is myself,” said Roosevelt, who never did.
• Ignore the economists. Every president who has suggested adding to health care coverage has been resisted by his budget director and other members of the economic team. And the vaguer one is about the numbers the better. Morone says that Obama may have erred in saying his plan will cost $1 trillion, making it easier for opponents to say the proposed changes were too expensive, especially after a Congressional Budget Office estimate raised the price to $1.6 trillion.
• Act quickly. More time spent on drafting legislation gives opponents more time to organize, a lesson learned by Clinton in the 1990s when his health care package was brought down, in part, by the “Harry and Louise” ads funded by the Health Insurance Association of America.
• Communicate with Congress. Carter’s treatment of legislators was widely regarded as high-handed and insensitive. Roosevelt was hurt in part by his poor relations with the chair of the Senate Finance Committee, Walter George, a conservative Democrat from Georgia whom Roosevelt unsuccessfully tried to have defeated for re-election.
• And wish for luck. Robert Dallek tells the old story of a health care advocate who dies and goes to heaven, where he is granted an audience with God. Told he could ask any question, the man notes that he devoted himself to medical care, was accepted into heaven because of his good work and wants to know when the United States will fulfill his dream and have universal coverage.
Responds the Lord: “Not in my lifetime.”