The Heart of Power: Stirrings

The Heart of Power: Health and Politics in the Oval Office. David Blumenthal and James A. Morone. University of California Press (420pp).
When Franklin Roosevelt became president in March, 1933, he led a nation that was, as he later said, one-third "ill-housed, ill-housed, ill-nourished." He might well have added ill-cared for, as the nation's health infrastructure was skeletal to say the least. Nascent efforts at health insurance had begun four years earlier with the first Blue Cross organizations, public hospitals were few and often segregated, and widespread treatment of illness via pharmaceutics remained well into the future. Indeed, so little was known about the treatment of serious illness that Roosevelt himself had devised rehabilitation for his polio based on the natural hydrotherapy of Warm Springs, Georgia.

It was against this backdrop that members of Roosevelt's early New Deal made the first serious proposals for national health insurance, and it's here that The Heart of Power: Health and Politics in the Oval Office, David Blumenthal's and James A. Morone's essential book about the politics and development of American health care policy, begins. Because of the scope and impact of an issue such as health care, the momentum to achieve reform must come from the Oval Office. Blumenthal and Morone cover the approaches of eleven administrations from Roosevelt to the second Bush with an unexpected twist: They examine the health history of each president for clues to his health policy.

In the course of their research, the pair uncovered a number of surprises. These include the extent of Lyndon Johnson's involvement in Medicare, which was much greater than previously thought, and the policy grasp and political skill brought by George W. Bush to the enactment of Medicare, Part D. Further, they demonstrate that while the Democratic party successfully kept the issue alive across several political generations, the Republicans eventually defined the terms of the debate so effectively that Barack Obama had little choice but to adopt what had once been the lynchpin of conservative thought about health care. That today's Republicans fought him so ferociously only proves the extent to which they moved the debate to the right, a process started by Ronald Reagan and consummated by George W. Bush.

Roosevelt inherited a nation on its knees. He came into office determined to use government as a vehicle for economic recovery, and he was visionary enough to seek ways of cementing economic security into place. The most lasting of these is, of course, Social Security, which he signed into law in 1935. Three times, members of his administration presented FDR with proposals to extend his legacy by way of universal health care, and three times he demurred. In 1934-35, Social Security and the many New Deal programs for economic recovery took priority: Roosevelt would not be the first president to determine that health care reform, while an important need, was not the most important.

His staff tried again in 1937, but by then Roosevelt's court packing plan had eroded his political standing. Moreover, the southern conservative Democrats who comprised a key part of the New Deal coalition sensed that universal health care meant integrated hospitals and objected to government-based program, as did the American Medical Association (AMA), which at the time was a powerful lobby. The AMA's cry of "socialized medicine" became a familiar refrain adopted by one opponent of health care reform after another.

During World War II, a shockingly high number of draft rejections on health grounds prompted administration health care experts to once again recommend health care reform, this time as matter of national security. Roosevelt included the "right to adequate medical care" as part of the economic bill of rights that formed the core of his 1944 reelection campaign, and a bill even made its way to Congress. But Roosevelt himself put his finger on the fundamental problem: "The only person who can explain this medical thing is myself," he said. And conducting World War II consumed all of the ailing president's energies. For a third time, Roosevelt passed.

In the end, circumstance and a lack of engagement with a complex issue conspired to prevent Franklin Roosevelt from pursuing health care reform. But the issue had been raised and raised persistently enough to gain a foothold in the Democratic party. And the failure of the New Dealers to persuade their own president to push seriously for health reform revealed a significant principle for future success: The absolute necessity of the president's prolonged and public commitment to the issue.

Harry Truman, FDR's successor, was an obscure Missouri politician who had been a compromise choice for vice-president. Though personally likable,  Truman seemed ill-prepared for the job of replacing the most iconic president since Abraham Lincoln, a man trusted and beloved by the American people. Most expected a caretaker presidency; Truman surprised the country by turning out to be a fiery liberal with a penchant for quick, intelligent assessment and willing decision-making. He  lead the country through the tumultuous post-war period with partisan fearlessness, developing a major presidency that, among many other things, exposed health care as a potent political issue.

Truman's passion for health care, for that's what it was, drew from his experience in the rough-and-tumble of Missouri politics. He saw a system that took care of the very wealthy and the very poor while leaving the middle class to its own devices. Moreover, he, too, had been shocked by the physical unreadiness of many men for military duty in a time of national crisis. Truman spoke to Congress of the idea of national health insurance immediately after the end of World War II, and became the centerpiece of his extraordinary 1948 campaign:

What did the Republicans do with my proposal for health insurance? You can guess that one. They did nothing. All they said was-- "Sorry, we can't do that. The medical lobby says it's un-American." And they listened to the medical lobbies in Congress.

I put it to you. Is it un-American to visit the sick, aid the affected, or comfort the dying? I thought that was simple Christianity. Does cancer care about political parties? Does infantile paralysis concern itself with income?

Never had a president spoken so passionately about health care; it resonated with voters, and helped return Truman to office in an election that no one other than Harry Truman thought he would win.

But once back in office, Truman never pushed seriously for national health insurance, and the reasons remain elusive. Certainly, any chance of serious reform disappeared in 1950 when the Democrats lost their Congressional majority for the first time since the Depression. Other events bedeviled the Truman Administration, including labor troubles at home and foreign policy crises in Greece, the Middle East, and Korea. Reorganizing the presidency itself, which the Depression and the war had transformed into a sprawling bureaucracy at the heart of American politics, proved difficult and time-consuming. And Truman was, by his own admission, often maladroit in public appearances, when championing this issue called for near perfection.

Harry Truman believed that the gravitational force of history created a progressive tide of events that would inevitably include health care insurance coverage for all Americans. He did not anticipate the direction from which it would come, but his passion on the stump cemented health care as a signature Democratic party issue, proved its political power, provoked the Republican opposition to developing an alternative, and ensured that health care reform would not disappear from the public consciousness....

Next: Part 2 (Momentum and Medicare)

Day of Reckoning: Demographic trends indicate that by 2050, whites will make up a plurality of less than half of American citizens, about 47% of the population. Moreover, whites will be older than other Americans, meaning that young minority workers will support aging whites with payroll taxes. I only wish that I could be here to see the s*** hit the fan...