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Robert B. ReichThis timely and insightful book puts Barack Obama's current quest for universal health insurance in historical context and gives new meaning to the audacity of hope.
—The New York Times
Even the most powerful men in the world are human—they get sick, take dubious drugs, drink too much, contemplate suicide, fret about ailing parents, and bury people they love. Young Richard Nixon watched two brothers die of tuberculosis, even while doctors monitored a suspicious shadow on his own lungs. John Kennedy received last rites four times as an adult, and Lyndon Johnson suffered a "belly buster" of a heart attack. David Blumenthal and James A. Morone explore how modern presidents have wrestled with their own mortality—and how they have taken this most human experience to heart as they faced the difficult politics of health care. Drawing on a trove of newly released White House tapes, on extensive interviews with White House staff, and on dramatic archival material that has only recently come to light, The Heart of Power explores the hidden ways in which presidents shape our destinies through their own experiences. Taking a close look at Franklin D. Roosevelt, Harry S. Truman, Dwight Eisenhower, John Kennedy, Lyndon B. Johnson, Richard Nixon, Jimmy Carter, Ronald Reagan, George Herbert Walker Bush, Bill Clinton, and George W. Bush, the book shows what history can teach us as we confront the health care challenges of the twenty-first century.
In this engrossing text, the history of American health-care policy, from the New Deal to the Medicare Modernization Act of George W. Bush, becomes a frame through which the authors illuminate the leadership qualities of late-20th-century presidents in the arena of domestic affairs. The authors present biographies of presidents from FDR on, investigating potential influences (e.g., heart attacks, abusive parents, deceased siblings) on their attitudes toward health policy. Blumenthal, a Harvard Medical School professor, and Brown University political scientist Morone (The Democratic Wish) draw on White House telephone tapes and memos in a laudatory chapter on Johnson's role in passing Medicare, and reserve their harshest criticism for Jimmy Carter, whose administration unwittingly "killed the late effort at health reform." The authors offer evenhanded critiques and conclude with lessons for future chief executives about the importance of political savvy, economic flexibility and popular appeal in determining the success of health-care initiatives. More than an excellent primer on American health policy, the book offers a thorough, incisive look at the presidency as an institution and the men who have occupied the office. (Aug.)Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.
Franklin Delano Roosevelt
The Enigmatic Angler
After four ballots, the Democratic Party Convention of 1932 finally brushed aside Governor Al Smith and nominated Franklin Delano Roosevelt for president. Tradition dictated that a committee would travel—not too quickly—to New York and proffer the nomination to Governor Roosevelt. But with the country in the grip of the Great Depression, this nominee chose something more dramatic. As soon as the California delegation put him over the top, Roosevelt chartered a small trimotor airplane from American Airlines and made the rough nine-hour flight to the convention in Chicago, battling strong head winds all the way. He landed in the midst of a brawl between advisors about the speech that Columbia professor Samuel Rosenman had helped write for him. Serene and unflappable, Roosevelt took the hasty edits and electrified the convention—and the country. "This appearance before a National Convention," he told the delegates, "is unprecedented and unusual, but these are unprecedented and unusual times.... I broke traditions," he continued. "Let it be from now on the task of our party to break foolish traditions." And break tradition they did.
More than eight months later, on Saturday March 4, 1933, Roosevelt took the oath of office. The entire banking system teetered on the edge of complete collapse—four thousand banks had already gone under. On Sunday, Roosevelt called Congress into extraordinary session. On Monday, he snatched up a World War I measure, the Trading with the Enemy Act, and used its (questionable) authority to shut the nation's banks. On Wednesday he held his first press conference and promised "delightful family conferences" without the old stuffiness or written questions—the press loved it and the transcript, even in that parlous moment, repeatedly notes laughter. On Thursday, the Emergency Banking Bill, which put all the resources of the Federal Reserve behind the nation's banks, flashed through a frightened Congress in eight hours—the president signed it forty-five minutes later before a phalanx of news cameras. On Sunday, FDR went on the radio and gave a warm, calm talk—the first Fireside Chat—explaining in plain language why the system had failed and what he had done to fix it. "Let me make clear that the banks will take care of all needs," he assured the nation, smoothly adding, "[I]t is my belief that hoarding during the past week has become an exceedingly unfashionable pasttime." When the banks opened the next day, a reassured nation poured its cash back into the institutions—$1.25 billion went back into American banks in March alone. The first 100 days of the Roosevelt administration had begun with a bang. The inspired, frantic, chaotic jumble of proclamations, programs, and public statements (stretching from March 9 to June 15, 1933) would become the unreachable star of every subsequent administration.
In the pantheon of American presidents, Franklin Roosevelt ranks alongside George Washington and Abraham Lincoln. Each of these greats redefined the relationship between government and the people. Franklin Roosevelt described his own contribution as "a long overdue political and economic reconstruction" that took the Constitution's negative rights—government may not interfere with the people's rights to speak freely, practice religion, own guns, or enjoy equal protection under the laws—and appended positive economic rights. Government would now guarantee the people's basic economic needs. "Necessitous men," said Roosevelt in a speech, paying homage to Abraham Lincoln, "are not free men." The government must "benefit the great mass of our farmers, workers, and businessmen." His philosophy, Roosevelt would say at different times, could be summed up as "human security," "social justice," or—when talking to church groups—"Christianity." By the time Roosevelt was through, the government's role extended to protecting economic security. FDR repeatedly cast his innovation in the resonant tones of the American founding: the "four freedoms" and the new "economic bill of rights."
Taking responsibility for the economy was part of an even larger political project. The presidency replaced the parties, the Congress, and the states at the heart of American politics. From now on, the person in the Oval Office would represent the people and their aspirations. In negotiating this change, Franklin Roosevelt birthed the modern presidency and transformed American government. Throughout his tempestuous thirteen years in the White House, he relished his role—perhaps more than any other president. Roosevelt had a love affair with power in that place, wrote political scientist Richard Neustadt: "It was an early romance and it lasted all his life."
Beneath the great transformation of national government lay the famous multitude of New Deal promises and programs. None had a more curious passage through Roosevelt's three-plus terms than national health insurance—the New Deal's lost reform. Health care dropped out of the Social Security package (in 1935), almost became an issue in the 1938 midterm campaign, and seemed to gather momentum again in 1944, when Roosevelt tasked a trusted advisor—the same Samuel Rosenman who had drafted his dramatic acceptance speech twelve years earlier—to prepare a health plan and a strategy for winning it. But by the time the plan was ready, President Roosevelt had died. The elusive reform passed into Harry Truman's hands and, from him, down through the decades, tantalizing generation after generation of Democrats who would chase Roosevelt's great unfulfilled social policy.
It is an odd legacy. President Roosevelt not only failed to win health insurance but also barely tried. And therein lies one of the great mysteries in the history of American health care policy. At its center sits a man of extraordinary power and political skill, deeply familiar with illness. He was a president during extraordinary times, with extraordinary opportunities. But when it came to health care, Roosevelt always disappointed his liberal advisors and chose not to fight. Why did he keep ducking? Understanding those choices illuminates FDR's persona and administration, as well as the health care experiences of every modern president.
There are many metaphors for Roosevelt's management style, but the one that best captures his health care policies is that of the expert angler. Roosevelt loved to fish, and according to his Labor Secretary and admirer, Frances Perkins, he had an almost "childish vanity about his skill." Fishing was one sport that FDR could master with his powerful upper torso and atrophied legs. Early in his presidency, FDR took long cruises during which he would angle for big game in warm Caribbean waters. (Once, when Roosevelt docked in Galveston, a young Congressman named Lyndon Johnson clambered aboard and charmed the president with a heavy load of bull about fishing and boating.) FDR's management style reflected his passion for fishing. He skillfully let out many lines, pulling in some, lengthening others, constantly changing lures, sometimes sitting patiently, and always knowing instinctively when to set the hook and when to cut bait. Naturally, all the lines led right back to Roosevelt.
MISTREATED AND OVERCHARGED
Roosevelt grew up gifted and charmed. He was handsome, wealthy, well educated (Groton, Harvard, Columbia Law), well traveled (he always had that vaguely European accent), and much fussed over, especially by his mother. He also enjoyed the most famous family name in politics. Franklin knew and admired his distant cousin, Theodore Roosevelt; he adopted Theodore's pince-nez spectacles as well as his habit of calling things "bully"—as in the "bully pulpit" that they would both so effectively stand on. In 1905, President Roosevelt became "Uncle Ted" when Franklin married the president's niece, Eleanor Roosevelt.
Franklin entered politics in 1910 and glided into a seat in the New York state Senate. Three years later, when Democrat Woodrow Wilson won the White House—thanks to a split in the Republican ranks between President William Howard Taft and Uncle Ted—Franklin became assistant secretary of the Navy. He served until the end of the Wilson administration (with time out for a failed run for the U.S. Senate in 1914) and became the Democratic nominee for vice president in 1920. He was only thirty-eight years old when he ran with Governor James Cox of Ohio and got thumped. The Republican candidate, Warren G. Harding, didn't even bother to campaign—and crushed the Democrats, 16 million (and 404 electoral votes) to 9 million (and 127). But Franklin cut a fine figure on the campaign trail and the political wreckage did not seem to mar his own image. Franklin Roosevelt faced a bright, and apparently easy, future.
The following August, the charmed life came to a terrible end. While the family was vacationing at its retreat on Campobello, an island off Northern Maine, Franklin began to complain about feeling tired and "logy." That did not change his robust exercise routine; Franklin and two sons went sailing, leaped ashore to stamp out a brush fire, jogged to a favorite swimming lake, jogged back, and plunged into the icy ocean water. Franklin returned to the house, exhausted and chilled. By the next morning, he felt sharp pains in one leg. Over the next three days, an acute paralysis spread over his entire lower body all the way up his chest. Roosevelt had contracted poliomyelitis—polio.
Medical follies came next. The local GP arrived and declared the problem a heavy cold. As Roosevelt's condition deteriorated, family friends called up and down the Maine coast before locating Dr. W. W. Keen, a celebrated physician—now in his eighties—who had performed one of the most dramatic operations in presidential history when he removed a cancer from Grover Cleveland's upper mouth (secretly, on the presidential yacht) in 1893. Now Keen arrived, misdiagnosed a blood clot in the spinal column, later changing that misdiagnosis into another—an intractable spinal lesion—and charged the family the astounding sum of $8,000 for the less-than-helpful consultation.
Finally, the family located an expert in "infantile paralysis," Dr. Robert Lovett of Children's Hospital in Boston, to become Roosevelt's physician. Lovett gloomily insisted that there was nothing anyone could do to improve Franklin's muscular control, a judgment Roosevelt rejected. After that, Roosevelt directed his own rehabilitation with a vigorous exercise program. He grittily stuck to his routine and cheerfully minimized the problem. Almost everyone around him commented on his sheer determination. Eventually, Roosevelt bought and managed a hotel in Warm Springs, Georgia, where geothermal waters enabled him and other people with polio to exercise in a warm pool. "The water put me where I am," said Roosevelt, "[and] the water will bring me back."
The hotel became the 1920s equivalent of a modern rehabilitation hospital, where FDR designed exercise regimens for the polio victims who flocked to the facility. He wrote a letter describing how he managed his own rehabilitation from polio and his observations on how to treat the effects of the illness, "judging from my own experience and that of hundreds of other cases which I have studied." It was published in the Journal of the South Carolina Medical Association. Roosevelt asked to present his work at a meeting of the American Orthopedic Association in 1926. When the Association refused, he and Eleanor crashed the meeting and secured a commitment from the orthopedists to evaluate the Warm Springs program. The association made good on its promise and confirmed the program's positive effects. Speaking to his fellow Warm Springs patients at a 1934 reunion in the White House, FDR said: "During that first year, I was doctor and physiotherapist rolled into one." Roosevelt's work at Warm Springs is now the province of an entire medical specialty called physiatry. No president has ever come closer to practicing medicine without a license than Franklin Delano Roosevelt did in the 1920s in rural Georgia.
Frances Perkins claimed that the illness remade the man. "The pain and suffering had purged the slightly arrogant attitude" of the young Roosevelt. Now, she wrote, the "lack of humility" and "the streak of self righteousness" were replaced by a more serious, more warmhearted, more deeply empathetic man. "He had a firmer grip on life and ... he had become conscious of other people, of weak people, of human frailty." Not everyone agreed with Perkins; Franklin's son James claimed that his father remained his father and would have been a great man, polio or no. But every observer was impressed at Roosevelt's courage, grit, and spirit in the face of the illness.
Eleanor kept Franklin in the public eye—giving talks and meeting public officials. Although their marriage had foundered in 1918 when she discovered a stash of love letters between her husband and his elegant secretary, Lucy Mercer, Franklin and Eleanor stuck together and forged an extraordinary political partnership. In 1924, Franklin resumed his public role. He addressed the Democratic national convention and, in 1928, was elected governor of New York.
It was not easy for a man in a wheelchair to negotiate the political trail—especially in the 1920s, long before anything was "handicapped accessible." Franklin would arrive at the national convention and be lifted out of his car, dropped into a wheelchair, and wheeled down the service corridors of the convention hall. When he arrived near the stage, he would need help standing up, and someone would lock his stiff metal braces into place. Then, gripping his son James with one arm and his cane with the other, he would "walk" by swinging himself forward—always distracting observers with smiles, charm, and wit—until he reached a podium he could grip for support. He took some spectacular spills when his braces failed or a podium collapsed—but the falls never seemed to rattle him. Throughout, Roosevelt forbade any pictures of himself in a wheelchair or with his leg braces showing. The media conspired to keep the secret. Running for governor in 1928, FDR stopped just short of a brazen lie: "Seven years ago ... I came down with infant paralysis, a perfectly normal attack.... By personal good fortune, I was able to get the very best of care and the result of having the best of care is that today I am on my feet." On his feet, perhaps, but gripping the railing, the podium, or his son to keep from crashing down.
As governor, Roosevelt took an immediate and strong interest in health care. In his first annual message to the legislature, he declared it "the duty of the state to give the same care to removing physical handicaps of its citizens that it now gives to their mental development." Restoring to health those "who have the misfortune to be crippled" was "as important in a modern state as universal education." He made the same comparison to the New York Times: "Public health ... is a responsibility of the state.... The state educates its children. Why not also keep them well?" He formed a special committee of citizens and experts to "study a new health program for the state" and then tangled with the legislature when it "absolutely declined to pass the bill." In 1931, speaking at a governors' conference, Roosevelt pointed to health insurance, along with a more progressive tax system and unemployment insurance, as part of the remedy for the growing economic crisis.
Prepared by personal life to understand the consequences of illness, and by professional experience to understand its policy implications, FDR stepped into the White House with a brief but unparalleled freedom to act. But the story of President Roosevelt's health care policy is a story of baiting hook and encouraging supporters, then always pulling back.
Health and Politics in the Oval Office
Did Roosevelt's illness sensitize him to the illness of others? Search as one might for evidence of this, very little emerges. He rarely spoke about health care during his presidency—only two speeches focused on it during his entire tenure. Indeed, FDR's public life after polio focused on denying his illness.
A second question turns on Roosevelt's reaction to the profession that so abused him. Physicians misdiagnosed, overbilled, discouraged, and rebuffed him. He pursued his vigorous and largely self-designed rehabilitation program in the face of naysaying physicians who told him, between 1921 and 1924, that medicine had nothing to offer him. Nor did he find the exercise specialists or their regimens particularly helpful. Roosevelt might easily have entered the Oval Office with a big chip on his shoulder where doctors were concerned. And yet, just the opposite seems to have been the case during most of his administration. He deferred to, flattered, and retreated before organized medicine. He seriously weighed the views of the few medical professionals to whom he turned for advice about health policy. On the other hand, Roosevelt constantly stirred his liberal advisors—renewing their hopes for a good brawl with organized medicine. His last word on the subject seemed to promise—yet again—a battle with the American Medical Association once World War II had been won.
Excerpted from The Heart of Power by David Blumenthal, James A. Morone. Copyright © 2010 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Preface and Acknowledgments / vii
introduction / 1
1. franklin delano roosevelt
The Enigmatic Angler / 21
2. harry s. truman
We’ll Take the Starch Out of Them—Eventually / 57
3. dwight d. eisenhower
Compassionate Conservative / 99
4. john f. kennedy
The Charismatic with a Stricken Father / 131
5. lyndon b. johnson
The Secret History of Medicare / 163
6. richard nixon
A Flower That Bloomed Only in the Dark / 206
7. jimmy carter
The Righteous Engineer / 248
8. ronald reagan
Socialized Medicine and the Working Stiff / 283
9. george herbert walker bush
Stick to the Running Game / 319
10. bill clinton
Kicking the Can down the Road / 346
11. george w. bush
Bring It On—Reforming Medicare / 385
Eight Rules for the Heart of Power / 409
Notes / 421
Index / 471