The Heart of Power: The Republicans Take Command

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







"The time is at hand -- this year -- to bring comprehensive, high-quality health care within the reach of every American."

Richard Nixon, January 30, 1974

Richard Nixon grew up poor in household headed by a harsh and abusive father. Although he revered his mother, she appears to have been an emotionally aloof, if responsible, parent. A loner in school, Nixon became even more so when two brothers took ill and died from tuberculosis. The presidential personality that emerged from this traumatic childhood was secretive, ruthless, alcoholic, mistrustful, and paranoid. It was also capable of remarkable foresight and visionary strategic thinking. Although remembered for his foreign policy and the stain of Watergate, Nixon also changed the terms of the health care debate.

No doubt Nixon's boyhood experience informed his commitment to health care reform. The last Republican president to think of himself as a government man, Nixon shared Dwight Eisenhower's antipathy to Democratic health proposals based on comprehensive federal government programs. His health policy encouraged the development of HMOs, and late in his administration he proposed health care legislation based on broad insurance via an employer mandate backed by the government. Crippled politically by Watergate and lacking Lyndon Johnson's skills and inclination to work with Congress, Nixon was unable to make headway with his plan to insure all Americans. But the careful policy work of his White House combined with shifting political tides altered the policy discussion. After the Nixon presidency, the health care debate centered on a public-private partnership, not a single-payer government program.

In what served as a harbinger of the future, Jimmy Carter narrowly defeated a weakened Gerald Ford in the 1976 presidential election. An avowed centrist, Carter was the first Democratic nominee since John W. Davis in 1924 to run for president something other than a liberal. Carter grew up in relative luxury in backward rural Georgia, the son of a prominent peanut farmer. He assumed the presidency with no great interest in health policy, other than a conviction based on his upbringing that hospitals overcharged significantly and delivered little. Carter believed that overall public health would improve if more Americans lived as he did, foregoing tobacco and alcohol and maintaining physical condition.

But Carter had made a commitment to the United Auto Workers that he would pursue some sort of health care reform as president. And to Jimmy Carter, a promise was a promise. So, he dutifully assembled a health care task force from within his administration and carefully reviewed the precise details of each proposal, most of which concerned cost containment. Carter's personal attention to detail was prodigious, but he ignored the politics of health care: His White House offered a number of small government cost-cutting proposals that had no appeal to the critical liberal wing of the party. Eventually, differences in health policy helped motivate Senator Edward Kennedy's (D-MA) primary challenge Carter, a challenge Carter beat back only to lose badly to Republican Ronald Reagan in the 1980 general election.

Reagan's election signaled what Blumenthal and Morone call a "tectonic change" in American politics. Until Reagan, the debate between Republicans and Democrats had been over the extent of government's role in the economy, health care, civil rights, and all of the other issues of the day. Reagan questioned whether government should be involved at all, and millions of Americans agreed with him. American life, Reagan argued, had embodied the Puritan vision of the shining city on the hill until government ruined everything by taking people's tax dollars and providing nothing in return other than (he claimed) failed liberal programs.

The son of an alcoholic, a man who let only his wife behind the affable psychological facade he constructed around himself, Reagan had a burning desire to be liked and loved. Late in his administration, the Iran-Contra scandal eroded his popularity and caused many Americans -- especially the elderly -- to question both Reagan's competence and honesty. In part to regain his standing and in part because of genuine concern, Reagan acted against the advice of almost everyone in his administration and proposed a major extension of Medicare that offered catastrophic health insurance funded by a surcharge on Medicare beneficiaries. The Congressional Democratic majority added a prescription drug benefit, and legislation as antithetical to the Reagan Revolution as can be imagined passed into law.

But the new law was never popular with seniors, many of whom already had catastrophic insurance and who resented (or couldn't afford) the surcharge. Congress quietly repealed the bill during the first Bush Administration, an administration headed by a president with a distinct disinterest in health policy. But the growing number of uninsured Americans appeared certain to make health care reform an issue in the 1992 election, and the Bush Administration covered its bases by proposing a plan based on tax deductions for purchasing private insurances; market reform that would address issues of portability and pre-existing conditions; efficiencies achieved by, among other things, use of advanced health information technology (an important part of President Obama's plan); and greater state flexibility (which contained the genesis of the SCHIP plan of the 1990s). Hemmed in by the Reagan deficits, an uncooperative Democratic majority, and his own lack of commitment, George H. W. Bush allowed health policy to drift even as his administration developed ideas that some Democrats took careful note of.

If the economy, stupid, was the most instrumental issue in Bill Clintons's election, then health care, stupid, was a close second. After Clinton's victory, large-scale health care reform seemed such a certainty that Republicans began to develop their own plans based, ironically, on employer and individual mandates. Unfortunately, when it came to health care, Bill Clinton displayed none of the exceptional political skills that came to define his presidency as it matured.

Impressed by the early success of Health Maintenance Organizations in controlling costs, the policy wonk president placed two other policy wonks -- Hillary Clinton and Ira Magaziner -- in charge of writing health care legislation. (To be fair, House and Senate Democrats recommended to Clinton that he present Congress with a finished bill. A more experienced Washington hand might have recognized the folly of this approach, as anything submitted to Congress -- no matter how detailed or broad -- was certain to be publicly dissected and rewritten.)

While Hillary Clinton and Magaziner led hundreds of hours of policy discussion, no one appears to have paid much attention to political exigencies. The pair developed a bill so complex and so aimed at accommodating all interested parties that few understood it and even fewer were happy with the whole. The insurance industry's infamous "Harry and Louise" commercial (actually shown only in one market) went viral, interest groups used individual parts of the bill to attack its entirety, and Republicans moved from offering their own version to outright opposition. The bill collapsed under its own weight and an absence of political acumen. For the remainder of his presidency, Bill Clinton regarded health care reform as toxic and never raised the matter again.

The signal health care accomplishment of the 1990s was the State Children's Health Insurance Program (SCHIP), co-sponsored by Senators Edward Kennedy and Orrin Hatch (R-UT) and designed to cover the uninsured children of low-income families who did not qualify for Medicare. Clinton's successor, George W. Bush twice vetoed legislation extending SCHIP on ideological grounds.
Nonetheless, Bush not only approved other legislation that added a prescription drug benefit to Medicare, he actively pursued it.

History is likely to define the Bush presidency as failure headed by a cocky, overmatched, and incurious man who led the country into a disastrous and pointless war, who bears responsibility for the failed federal response to Hurricane Katrina, and whose ideological rigidness contributed to a near total collapse of the economy. His interest in health care stemmed from a complicated mix of a desire to remake Medicare in a conservative image, awareness of the price paid by his father for ignoring health care, and the childhood death from leukemia of his sister. (Why the latter did not influence Bush when he vetoed an extension of SCHIP is something only he can answer.)

Changes in the practice of medicine emphasized pharmaceutics, and Medicare did not address prescription coverage. Bush, who wanted to completely privatize Medicare, eventually proposed a plan in 2003 to offer prescription coverage to seniors, but only via purchase of private insurance. Nervous about senior reaction to this approach, the Republican Congressional leadership negotiated a compromise with AARP that limited privatization to four competitive demonstrations beginning in 2010, then quelled a conservative rebellion in their own ranks and passed what became Medicare, Part D largely along party lines. It is the largest expansion of Medicare to date.

On this one issue, at least, Bush proved an able and engaged politician. He understood the issue and, although forced to give ground on privatization, ensured passage of a bill that he thought would negate a key Democratic advantage in the 2004 election. And, yet, it did not: Health care reform was firmly established in the collective mind of the electorate as a Democratic issue. Save Jimmy Carter -- and he ran under unique circumstances -- every successful Democratic candidate for president included health care reform as a key part of their platform. In 2008, Barack Obama was no exception.

The Heart of Power concludes its history of health care policy with the second Bush presidency. As Blumenthal and Morone demonstrate, it took nearly 75 years of victory, defeat, and debate for a strategy of successful health care reform to emerge. In the final part of this review, I'll examine the elements of that strategy, its application to Barack Obama's success in passing health care reform, and the underlying political rationale to Obama's decision to work within the existing health care system.

(End Part 3. Next, Part 4: Rules for Success)

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