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Health check (Part 4): All the presidents' plans

This article first appeared in the St. Louis Beacon, Oct. 14, 2009 - By making the case for a health-care overhaul, Barack Obama joins the ranks of seven other American presidents who grappled with the issue.

Of the seven earlier presidents, only one carried the day -- and only with Medicare and Medicaid, which restricted reform to the aged and the penniless.

The other presidents came away with empty hands -- and, in Harry Truman's case, a bad taste in his mouth. In his memoirs, he wrote:

"I had no patience with the reactionary selfish people and politicians who fought year after year every proposal we made to improve the people's health. I have had some bitter disappointments as president, but the one that has troubled me most, in a personal way, has been the failure to defeat the organized opposition to a national compulsory health-insurance program."

Still, Truman added that the opposition "has only delayed and cannot stop the adoption of an indispensable federal health-insurance plan."

Today, many might quarrel with the word "indispensable" and with Truman's tone of inevitability. But nobody can deny the delay -- almost a century's worth of it.

The Roosevelts: Non-Starters

Health care first cropped up as an American political issue 97 years ago this fall, in the 1912 presidential campaign.

That contest pitted incumbent Republican William Howard Taft against Democrat Woodrow Wilson and a third-party maverick, ex-President Theodore Roosevelt, leading the Progressive (or "Bull Moose") Party.

The Bull Moose platform called for compulsory health insurance for factory workers, like the system Germany started in 1883.

But on election day, ex-Republican Roosevelt split the Republican vote with Taft, giving Wilson the White House. And before long, Wilson was facing an issue much bigger than health care -- World War I, which began in 1914 with the Germans as the bad guys. That put a bad odor on anything German, like compulsory health insurance.

The war also did in America's Progressive Movement, which had been leading the charge for remaking the health-care system. Even the unions opposed a health-care plan. In 1916, Samuel Gompers of the AFL insisted that when it came to benefits, workers had to rely on their own economic power, not on the government.

In 1918, as the war drew to a close, Californians voted on a state plan for mandatory health insurance. Seventy percent said no. After the war, a Red Scare in the United States left Americans cool toward Bolshevik socialism -- toward "socialized medicine."

The ailing Wilson left the White House after the 1920 election. The Republicans who succeeded him in the Roaring '20s had no interest in growing government's reach into medicine.

Then, in 1929, the stock market crashed, dragging down with it a lot of the longstanding leeriness toward big government.

Democrat Franklin D. Roosevelt took office in 1933, at the depth of the Depression. His New Deal grew government at a breathtaking rate, to the cheers of most Americans.

They especially cheered Social Security, enacted in 1935. At the time, some of Roosevelt's advisers called the Social Security bill the perfect vehicle for a health-insurance plan. But the president shied away, fearing a fight with the American Medical Association. "Later," he said.

Later never came. Instead, WW II came, pushing any overhaul of health care way to the back of the priority line.

Truman: Twice Trumped

Roosevelt's death in 1945 put Truman in the White House. And in November of that year, two months after the war's end, Truman put health care before Congress. He called on Congress to approve a "public option" insurance plan. The government would run an insurance fund open to all, but optional. Those who opted in would pay monthly fees to the plan, which would cover all medical expenses.

The call by Truman fell flat. In their recent book, "The Heart of Power: Health and Politics in the Oval Office," authors David Blumenthal (a doctor) and James A. Morone (a political scientist) put some of the blame on the president. Despite Truman's give-'em-hell ways, they say, he stayed oddly silent on health insurance.

A year after Truman gave his plan to Congress, voters gave Congress to the Republicans. The new Republican majorities brushed health care off the table.

Truman and the Democrats bounced back in the 1948 elections, and Truman tried again in 1949 with another health-care call. But again, say Blumenthal and Morone (to whom this writer is indebted), the conservative Southern Democrats who chaired so many key committees took a dim view.

Health care drifted off into the shadows. True, Truman's successor, Republican Dwight D. Eisenhower, spoke out late in his second term in favor of what we know today as Medicare, health insurance for the elderly.

But when the AMA protested loudly, Ike quickly backed away.

Kennedy, Johnson: A Foot in the Door

When the Democrats retook the presidency in 1960, they rethought health care. John F. Kennedy decided that rather than marching uphill for mandatory national insurance, he'd settle for half a loaf -- Medicare, limited to elderly Americans.

Kennedy broached the notion in his State of the Union speech in 1962. He got nowhere. But when a sniper's bullet took Kennedy's life in 1963, Medicare -- like civil rights -- became part of his unfinished business.

Lyndon B. Johnson made it his business to finish JFK's. In those heady first years of his presidency, Johnson pushed for his Great Society, a new version of the New Deal. But this New Deal would include health care, or at least Medicare.

Florida Sen. George Smathers was dubious. As Johnson headed into the '64 campaign, Smathers warned him that Medicare "is a hell of a lot better issue than it is a fact on the book."

But Johnson connived with powerful Rep. Wilbur Mills, D-Ark. Early in 1965, Mills set out as his own plan what was actually Johnson's three-layered Medicare cake -- Medicare A (hospital care for the aged), Medicare B (optional doctor-bill insurance for the aged) and Medicaid (health care for the poorest of the poor).

The AMA wanted to limit Medicare to the elderly poor. But Johnson's plan proved popular with the voters, especially after Johnson lowballed cost projections.

Medicare sailed through Congress and on to Independence, Mo. There, on July 31, 1965, at the Truman Library, with Harry Truman looking on, Johnson signed the Medicare bill.

It took effect the following year. By now, it's as ingrained as Social Security.

Nixon: Reshaping the Issue

Few us think of Richard M. Nixon as a health-care reformer. But twice, Nixon dipped a toe into health care -- in part because Massachusetts Sen. Ted Kennedy was making a splash about it.

In 1969, Kennedy called, in effect, for broadening Medicare to cover everybody - so-called "cradle-to-grave" care.

Nixon had personal experience with health-care calamities during his hardscrabble upbringing in California. Tuberculosis killed two of his brothers and left its mark on Nixon. He spoke often and wistfully of his family's struggle to pay for care for his brothers.

After Kennedy's opening move, Nixon offered his own plan in 1971. Nixon called for an employer mandate -- a requirement that all employers offer private health insurance to their workers.

To keep costs down, Nixon would reach back again to his roots in California. The state was the birthplace of Kaiser Permanente, which hired doctors as employees and trained them to hold down costs by holding off on unnecessary and wasteful treatment. But the Kaiser idea had spread to only a few other parts of the country.

Nixon's inner circle coined a name for the Kaiser idea -- "health maintenance organization." His plan called for a national network of these efficient, cost-effective HMOs.

But the Democrats controlled Congress, and Nixon's plan went nowhere. Even so, he kept tweaking his idea. In February 1974, he told Congress that health-care reform was "an idea whose time has come."

This version of that idea kept the employer private-insurance mandate and the HMO base. It added something new: "public option" government insurance for Americans unable to get private insurance. And it called for more beady-eyed government oversight of private insurance.

Within months, the new plan ran head-on into the Watergate scandal, which ousted Nixon. Even so, he left behind some new ideas on the health-care table -- managed care through HMOs, the employer mandate, the public option and tighter regulation of private insurance.

As Blumenthal and Morone put it, "Nixon changed the health-care discussion in the United States. Today's reformers all stand in his shadow."

Clinton: Defeated by Harry and Louise

Gerald Ford had too little time as president to grapple with health care. Jimmy Carter had too many other balls to juggle -- the hostages in Iran, the inflation at home, the mood of malaise.

Then came the conservative surge, with Ronald Reagan and the senior George Bush. Neither put an overhaul of health care front and center.

But in 1992, Democrat Bill Clinton made a big deal out of health care. Candidate Clinton preached much of Nixon's gospel -- employer mandates for private insurance, plus hot competition for that private insurance among HMOs, with the federal government refereeing the game.

When Candidate Clinton became President Clinton, House Majority Leader Dick Gephardt of St. Louis offered a tip to Clinton: Don't wait for Congress to cobble together a bill from his ideas. Instead, move quickly to hand Congress a ready-made bill, detailed down to the last subsection.

Clinton nodded. Then, to write his bill, he turned to his wife, Hillary, and to a friend from their Rhodes scholar days, Ira Magaziner.

Magaziner and Mrs. Clinton mustered an army of 600-plus soldiers -- congressional aides, health-care analysts and industry reps, subdivided into eight "cluster teams" and 34 "working groups" -- and took it behind closed doors.

That September, Clinton himself stood before Congress to tout his plan. It centered on "managed competition" -- government pushing and prodding to fire up competition (and thus cut costs) among employers, doctors, hospitals and private insurers.

The bill itself arrived in Congress late in the year -- all 1,342 pages of it. It landed with a thud worthy of its weight. One presidential aide sighed that the measure was "a target the size of Philadelphia."

The shooting came quickly. Firing for a bulls-eye were Harry and Louise, stars of a clever TV commercial put together by an insurers' group. Over their kitchen table, Harry and Louise wondered whether Clinton's health plan would put their medical care at the mercy of federal bureaucrats.

In the Senate, Kansas Republican Bob Dole said he'd mow down the bill like so much wheat. He got help across the aisle from West Virginia Democrat Robert Byrd, who refused to allow any legislative shortcuts to foil Dole's minority Republicans.

In the end, Clinton's plan never made it to the Senate floor. In September 1994, a year after Clinton's health-care speech, Senate Majority Leader George Mitchell of Maine reluctantly pulled the plug and let the bill die. Clinton himself would later say, "We bit off more than we could chew."

Now, 15 years later, Obama has taken up the health-care cause.

If he prevails, he'll set a precedent.

And if he fails -- well, he'll fold into a precedent that was set almost a century ago.

Harry Levins is a freelance writer in St. Louis.