Saturday, May 8, 2010

The Heart of Power: Conclusions

The Heart of Power: Health and Politics in the Oval Office, David Blumenthal and James A. Morone. University of California Press (420pp).

I've read many books that expanded my store of knowledge, but few that changed my perspective. The Heart of Power changed the way I view health care policy and the ongoing debate about it.

Although the book covers the policies of each presidential administration from Franklin Roosevelt to George W. Bush (Gerald Ford excepted), it lays a foundation for an historical understanding of why Barack Obama made the critical decision to endorse a plan based on a public-private partnership. Blumenthal and Morone show convincingly that while liberals promoted and sustained the idea of universal health care access, conservatives were, over time, able to define the terms of the debate.

Obama took office with a commitment to health care reform, and immediately disappointed many of his supporters (including me) by not pursuing a single-payer plan. But Blumenthal and Morone demonstrate that progressives were never able to develop a constituency for single-payer outside of themselves. Pursuit of single-payer in 2010 meant overcoming a number of obstacles:
  • redefining a debate that had been in place since the early 70s;
  • attacking the insurance industry head-on;
  • persuading the moderate Democrats to support single-payer.
As brilliant a politician as Lyndon Johnson barely succeeded in passing Medicare during one of liberalism's peak years; a major offensive for single-payer in this day and age was simply not going to succeed, and the price of failure would have set the possibility for any health care reform back for a generation. Like it or not, Obama acted pragmatically in pursuing and passing the new law.

In their summary, Blumenthal and Morone outline eight principles of success for any president striving for health care legislation (Jeff Goldsmith of Health Affairs Blog evaluates Obama on each principle here; I've included his letter grade below):
  1. Passion. A president must care about health reform deeply enough to be willing to risk his presidency on it. (A+)
  2. Speed. The longer a president waits, the more his popularity erodes and the more difficult the task becomes. The more drawn out the process becomes, the more difficult passing legislation becomes. (C+)
  3. Bring a plan with you. Work on health care reform ideally begins with the transition to office or even before. (B-)
  4. Hush the economists. It's counterintuitive, but critical. More than one administration economist has strangled health care reform in the cradle. (A)
  5. Go public. Only the president can sell his plan to the electorate and to politicians. Visibility is critical. (B+)
  6. Manage Congress. Despite diametrically opposed styles, Lyndon Johnson and Ronald Reagan excelled at this. Lesser presidents must understand the system and install an effective staff with experience at working with Congress. (A-)
  7. Forget the PSROs. Jimmy Carters and Bill Clinton ran aground by immersing themselves in policy detail instead of tending politics. The president's job is to sell the plan and focus on the votes. (A)
  8. Learn how to lose. If you lose, try to leave something in place for your successor. Roosevelt cultivated the idea; Nixon left subsequent Republican presidents with a framework. (F, although NA seems more appropriate to me.)
I have two criticisms of The Heart of Power. First, the copy editing is execrable -- I'd estimate an error in punctuation, spelling, or conjugation every 10-15 pages. For example, President Obama's name is "Barack," not "Barak," and Bob Dole is from "KS," not "KA."

Second, The Heart of Power would have been even stronger had it consistently considered the state of American health care in the context of each presidency. Sometimes, it's a little difficult to figure out exactly what problem a president is attempting to address and why. For example, was Bush I's disinterest in health policy a matter of inclination or philosophy, or did he believe that there was no problem? How and when did the health insurance industry become so powerful? Why and when did the medical establishment become divided over health care reform?

Overall, though, this is one of the few books that, without reading it, the individual citizen has an incomplete picture of an issue. We need more books that, like The Heart of Power, cover the history of a policy from its inception through the tumult of changing times. Highly recommended...

The power of yes...

Do corporations like BP lie to save money? Is a bear Catholic? Does the pope s*** in the woods?...

Class Act Dept: Now, why would anyone think that the party of David Vitter, Mark Foley, and Voyeur would resort to pornography?...

Wake up, little Susie (and you, too, Lindsay and Holy Joe)...

Brownie, now doing a heckuva job as the Fox News disaster expert...

Using every trick he accuses Obama of (including, incredibly, sophistry), the Rasher gets especially upset by race-baiting, then launches into a race-baiting tirade of his own and recommends solving our problems with "corrective action." Who sounds like a Nazi now, Rash?...

Conservatives can't stop lying about the health care law. I wonder if their insurance policies cover treatment for addictions?...

Holy Joe, Tailgunner Joe -- what's the diff?...


Anonymous said...

Very enlightening, thank you.
I think the big winners in the health care bill are the insurance companies. They have too many politicians in their pocket and have proven they are not above lying to influence the public. Oh, gee, are their mouths moving? Now, with the supreme court giving corporations unlimited spending power for political ads, they are going to take over the country outright, not just behind the scenes.

Roy said...

An interesting book indeed. It's good to see the history of the health care debate through the administrations. I didn't know Nixon was a proponent; that was a surprise. And it's sad to watch the Republican side of the debate go from admitting the problem but offering an alternative approach to outright opposition and denying there's a problem at all. Thanks for the in-depth review of this book; it definitely added to my store of knowledge.

By the way, your link to "Holy Joe, Tailgunner Joe, what's the diff?" goes to the article about how conservatives can't stop lying about the health care law.

I've stopped following links to rants by Rushbo, Glenn Beck, Bill O'Reilly, etc. I like my digestive tract, and these only upset it.

K. said...

Greg: There's no doubt that this law represents a bargain with the insurance companies: In exchange for not opposing the bill and getting 32,000,000 new customers, they agree to cover pre-existing conditions, drop limits and rescission, extend the age at which parents can cover children, and make insurance available to everybody.

It curbs costs and reduces the deficit somewhat, but nothing like a single-payer plan would. After reading The Heart of Power, I'm convinced that it's the best that can be obtained under the circumstances, and that the alternative was nothing at all. To be against this law, you have to believe that it's worse than nothing.

Roy: I, too, was surprised by Nixon's influence and the overall historical impact Republicans have had as serious players. Overall, it was a response to the Democrats' success in raising the issue of health care, but Eisenhower and Nixon viewed government as an important player, and neither Reagan nor Bush II were reluctant to use government as an incident. In some respects, Medicare, Part D is a mirror image of the new law: In the case of Medicare, Democrats had established it as a government program; if Bush wanted to add prescription coverage, he had to do it in that context.

As recently as seven years ago, a Republican president put getting something done and compromised on ideology. I think we know what's more important now. Now, Republicans would rather let the system collapse than reform it any other way but their own.

Fixed the link!

Roy said...

Holy Hannah! I'd heard about the people complaining about reading Shahzad his Miranda rights, and that was stupid enough. But Holy Joe wants to strip Americans of their citizenship for associating with groups he doesn't like? What cave did he crawl out of? The more he opens his mouth, the more I'm convinced that he's not really a Jew; he's a plant by the American Nazi Party to sabotage the American Jewish community. Either that or he's a golem inhabited by the soul of Joseph Goebbels.

Foxessa said...

#8 -- F > Clinton. He left us with no infrastructure to work from. Instead he left the bushcheneyites a framework to move ever further toward de-regulation and erosion of civil rights, particularly for women.

IOW, it was all about HIM.

Love, C.

Foxessa said...

Michael Moore in Sicko laid out an awful lot of this, particularly Nixon's role.

Love, C.

Darlene said...

I will die cursing the day that this country failed to pass a single payer health care system. The power of the insurance/pharmaceutical complex matches that of the military industrial one. Pogo was right; the enemy is us.

K. said...

Roy: LOL.Don't get me started on Holy Joe. Limbaugh may be despicable, but at least he doesn't cloak it in sanctimony.

I get a guy like Charlie Crist. The Florida Republican party has moved to his right, but he looks at the numbers and state demographics and concludes that there's still a constituency for traditional Republicanism. He goes independent before the primary and sets up a campaign to appeal to that.

But Holy Joe? He moves to his party's right on the most critical issue of the day and Connecticut Democrats give him the boot. He refuses to go away and campaigns on vague principle that, when it comes time for cutting nuts, means that Joe Lieberman can't imagine life without the US Senate. Aaaaarrrrggghhh!

C: Blumenthal and Morone may be more critical of Clinton on the grounds you mention than of his handling of the legislation (and they're plenty critical of that). When Medicare went down to defeat in 1962, John Kennedy took it personally and planned to make it a centerpiece of his '64 campaign. He left that and some lessons learned to LBJ, who made fulfilling Kennedy's legacy the emotional core of passing Medicare. That along with Nixon's success in defining the future debate are the two best examples of the Learning How to Lose principle.

I haven't seen all of Moore's films, but of the the ones I have seen, Sicko! was the strongest from beginning to end. He's so effective with everyday people -- the Canadian conservative who thought single-payer was just fine, the British doctor who said that he made enough money, the American ex-pat marveling over the scope of the French system; those are the scenes I took away from the movie (like the unemployed black man in Fahrenheit 9/11 who observed that wartime Baghdad looked like Flint).

K. said...

Darlene: I thought a great deal about your point while reading the book. Regrettably, I've concluded that progressives bear some responsibility here. I'll write more in a later blog.

Everyone, I hope she doesn't mind my saying this, but Darlene has been around for every administration in this book, plus Hoover and Coolidge. Maybe someday the fact that I was born in the Eisenhower administration will amaze my grandchildren!

Foxessa said...

We are all fortunate for people like Darlene in our lives and can only hope to be so fortunate as be the same for others ourselves.

Love, C.