President Obama proved last week that he is shrewder than Harry Truman, Dwight Eisenhower, Richard Nixon and Bill Clinton, two Republicans and two Democrats who were canny politicians but who in sunnier times couldn't deliver universal health coverage.
Obama approached the challenge differently anyway by talking with unusual frankness about the costs, taxes and tough Medicare reforms to bring it about and inviting a bipartisan Congress to work out the details for him, the last a marked contrast to Bill Clinton's strategy in 1994 of handing Congress a 1,300-page bill choked with the minutiae of healthcare administration.
Let's hope Obama's is the political formula that finally works.
Truman called for universal health insurance in 1949 but the American Medical Association, the amalgamation of pre-Medicare docs who hadn't yet discovered how much they liked guaranteed reimbursement, poured millions into a campaign to stop it in 1950 and defeated six senators and a number of representatives who supported the Truman plan. It was the first model for special interests using congressional elections to stop a policy initiative. The lesson was that you shouldn't let an election intervene.
Eisenhower repeatedly urged a federal initiative to encourage the insurance industry to cover all workers by offering federal coinsurance, but it was too socialistic for Republicans and too anemic for Democrats and labor.
Nixon, in his last state of the union speech in 1974, proposed a universal health program very similar to the plans outlined last year by Obama and Hillary Clinton. It would have built on the existing employment-based insurance system and provide government subsidies to the self-employed and small businesses. He introduced the bill a few days later but Watergate soon drove him from office.
Clinton enjoyed the support of 59 percent of Americans for his complicated health plan in 1993 but after the Health Insurance Association of America and other interests spent more than $100 million on the campaign against it and flooded members of the House and Senate finance committees with campaign gifts, public support fell to 44 percent and the bill was dead.
President Obama passed the first test by rejecting the notion that you can't undertake a big expensive reform when the country is in the worst slump since the 1930s. If that were true, we would never have got Social Security, which by the way should have included mandatory health insurance for everyone but the AMA discouraged Roosevelt from doing it.
Rather than presenting Congress with a finished bill, Obama did the tough part. He would put aside $634 billion over the next 10 years to get it started, half from restoring taxes on very high earners and the other half by lowering subsidies to insurance companies, drug companies, home health agencies and hospitals for Medicaid and Medicare and by otherwise stanching the exploding costs of medical care. By tightening the bidding on the wasteful Medicare private insurance plans, which add 14 percent to the cost of treating a Medicare patient, he would pick up a nifty $176 billion.
But you negotiate how precisely to extend coverage to 48 million Americans, he told the congressional finance committees.
The insurance industry began ramping up for the fight immediately, but Obama seems to have a better team than Clinton did. Kathleen Sibelius, the smart and tough governor of Republican Kansas, will run it from the president's end as secretary of Health and Human Services. As insurance commissioner and governor she took on the insurance companies. Obama's health-care czar is expected to be Nancy Ann DeParle, a Rhodes Scholar who administered the Centers for Medicare and Medicaid Services in Clinton's final years and who has been a director of several big health-care companies. She came up in the rough and tumble of Tennessee politics.
There should be none of the naivete that dogged Clinton's health campaign.
Still, the argument will be that the country must not now undertake an initiative so large. Wait for better times, opponents will say. But the opposite is true. Nothing will do more for the country's long-term fiscal health than controlling health care costs and putting everyone into the system. Bloated health expenditures account for a good share of the federal budget deficits and waste in the private health sector is a huge drag on the economy. The United States spends twice as much per person on health care as other wealthy nations but with far poorer results, measured by life expectancy and infant mortality.
Arkansas's congressional delegation ought to take note of what it would mean for their constituents. Although Arkansas spends nearly a fifth of its state budget on direct health-care benefits, conditions are getting steadily worse for families. Even for the declining number of workers who have private or work-based insurance, premiums rose by 65.8 percent between 2000 and 2007 while median earnings rose only 11.6 percent. The trend is projected to steepen. Arkansas's median wage in 2007 was $22,692 but the average health insurance premium for a family was $10,534. Medical debts are the largest factor in bankruptcies.
A national solution is required. We may have a leader at last who can master the nasty politics of health care and get it done.