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Presidents and health care: a detailed history

By Hillel Italie Associated Press

NEW YORK — As Congress takes on President Barack Obama's call to overhaul health care, the desire for change will be tested — by the expense, by politics, by resistance from doctors and private insurers, and by the 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 failed to get it passed or never tried. Meanwhile, presidents otherwise deeply suspicious of government programs — Dwight Eisenhower, Ronald Reagan, George W. Bush — have successfully backed expansion of health care.

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 déjà 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: Health and Politics in the Oval Office, a newly released history of health care and the presidency.

The book, published by the University of California Press, also was 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 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.

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 it was first taken seriously in the White House by Roosevelt, when the Great Depression led to 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 that 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," historian and Truman biographer Robert Dallek said.

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 employers 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 to 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. 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, chairman of the powerful House Ways and Means Committee, to give Mills credit for legislation that was essentially Johnson's idea.