Lessons of and for Presidential Health Care Leadership

David Blumenthal MD, MPP

Institute for Health Policy

Massachusetts General Hospital

January 30, 2009

Agenda

Background Lessons Conclusions

Background

Book on health care policy making in the White House from FDR through GWB.

Focused on one major issue/decision/thrust relating to coverage/cost/system reform from each Presidency.

Co-author James Morone, Professor of Political Science, Brown University.

Background (cont)

The Heart of Power: Health Politics in the

Oval Office. University of California Press, June, 2009.

Some uber lessons:

Health care is a profoundly personal presidential issue. Risks are high, prospects of success often bleak. Personal and family experience with illness can

significantly affect presidential willingness to push health care issues.

Health care cannot be avoided. Even Presidents with no particular inclination to deal with

health policy end up spending time and political capital on health issues. Carter, GHWB.

This can only be expected to grow over time. Every president needs a health care policy and a health

care strategy.

Tactical lessons:

Campaign on it.

Do it early.

Use the transition.

Manage the economics (and the economists).

Go public.

Delegate.

Manage the Congress

Campaign

Political legitimacy.

Public support.

Hold Presidential feet to the fire when going

gets tough.

Carter

GWB

Do it early! LBJ in February, 1965 (from recollections of Wilbur

Cohen):

‘Now look. I’ve just been reelected by the overwhelming majority.

And I just want to tell you that every day while I’m in office, I’m

going to lose votes. I’m going to alienate somebody.’ And then he

took about twenty minutes and traced the history of other

Presidents . . And he says, ‘The President begins to lose power

fast once he has been reelected . . It’s going to be something. . . .

We’ve got to get this legislation fast. You’ve got to get it during my

honeymoon.’

More of LBJ on speed:

Talking with Wilbur Mills, Speaker McCormack, and Majority Leader Albert after Ways and Means reports Medicare/Medicaid, March, 1965:

“For God sakes, don’t let dead cats stand on your porch. Mr.

Rayburn used to say: ‘they stunk and they stunk and they stunk.’

When you get one [of your bills] out of your committee, you call

that son of a bitch up before they [the opposition] can get their

letters written.”

Use the Transition:

To do it early, you need to be ready. That means using the transition.

Not having a strategy on inauguration day severely reduces chances of success for a President serious about significant health care change (exception, Medicare expansion).

Does health care presidency really begin in July of election year?

Carter and Clinton examples of transition disasters. LBJ and GWB may be examples of success.

Manage economics: Virtually every coverage expansion sends chills up the spine of

economists in Treasury, OMB, NEC, CBO Unbroken track record of opposition, with very few exceptions.

Could LBJ have passed Medicare in the CBO era? Nixon, Reagan eventually overrode their objections. Clinton inserted premium caps to placate CBO (though his own

economists never bought it) Did Robert Byrd balk at doing Clinton health reform as part of

reconciliation in part because administration economists were whispering in his ear?

Every President who wants to expand coverage will have to be prepared to go over or around their own economic advisers, not just deal with CBO.

Go Public:

Anything meaningful will encounter strong political opposition.

Problem for health care change has usually been lack of support. This is why Medicare is different.

Health care is the acid test of domestic presidential leadership: can he/she create a constituency for change? One of Clinton’s most significant failures.

Delegate details and credit:

LBJ to Wilbur Mills June, 1964:

“The single most important popular thing is the bill you

are working with.” If Mills reported out a health bill,

said Johnson, we would all “applaud you.” Over and

over, he repeated, “I am not trying to go into details.”

Delegate (cont):

GWB:Decision in July 2001, reaffirmed June, 2003, to

issue principles concerning Medicare Modernization Act, not detailed legislation.

Counter-examples:CarterClinton.

Manage the Congress:

Single party control may be necessary, though not sufficient, to achieve meaningful health care change. LBJ 1965. GWB 2003.

But even then, Presidents need superb legislative skills, excellent staffs and preferably both. Will there ever be another LBJ? Do we need one?

Medicare exceptionalism:

The initial enactment of Medicare and Medicaid fits the rules.

But subsequent expansions have not.Reagan catastrophic (last year in office).GWB MMA (third year in office).

Why:The elderly are a unique constituency.And in any case, GWB acted quickly when he

won back the Senate in November, 2002.

Conclusions: Every President will have to deal with health care.

But to lead for change will require consummate

presidential skill and a great deal of luck.

History provides some guidance.

But there is no cookbook for leadership, political will

and political genius.