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Health and Politics in the Oval Office, Blumenthal and Morone

Blumenthal and Morone's most provocative finding is that presidents who have been most successful in moving the country toward universal health coverage have disregarded or overruled their economic advisers. Plans to expand coverage have consistently drawn cautions or condemnations from economic teams in every administration, from Harry Truman's down to George W. Bush's. An exasperated Lyndon Johnson groused to Ted Kennedy that "the fools had to go to projecting" Medicare costs "down the road five or six years." Such long-term projections meant political headaches. "The first thing, Senator Dick Russell comes running in, says, 'My God, you've got a one billion dollar [estimate] for next year on health. Therefore I'm against any of it now." Johnson rejected his advisers' estimates and intentionally lowballed the cost. "I'll spend the goddamn money." An honest economic forecast would most likely have sunk Medicare.


THE HEART OF POWER: Health and Politics in the Oval Office
By David Blumenthal and James A. Morone

Illustrated. 484 pp. University of California Press. $26.95

Books / Sunday Book Review
Critical Care
Published: September 6, 2009
This history of health policy and the Oval Office shows that the presidents who made the biggest steps in the direction of universal care have acted despite their economic advisers.

It's not so much that presidential economic advisers have been wrong -- in fact, Medicare is well on its way to bankrupting the nation -- but that they are typically in the business of thinking small and trying to minimize risk, while the herculean task of expanding health coverage entails great vision and large risk. Economic advice is important, but it's only one source of wisdom.

Yet since Johnson, presidents have found it increasingly difficult to keep their economists at bay, mainly as a result of the growth of Washington's economic policy infrastructure. Cost estimates and projections emanating from the White House's Office of Management and Budget and the Congressional Budget Office, both created during the Nixon administration, have bound presidents within webs of technical arguments, arcane rules and budget limits. To date, Democratic presidents have felt more constrained by this apparatus than Republicans, perhaps because they have felt more of a need to prove their cost-cutting chops.

The book was written before President Obama began his push for universal health care, but he seems to have anticipated many of its lessons. He's moved as quickly on the issue as this terrible economy has let him, and he has outlined his goals but left most details to Congress. Nor has he been too rattled by naysaying economists (although the cost estimates of the Congressional Budget Office set him back). The question remains whether, in the months ahead, he can knock Congressional heads together to clinch a meaningful deal, and overcome those who inevitably feed public fears about a "government takeover" of health care and of budget-busting future expenditures. "The Heart of Power" suggests that the odds are not in his favor.

But even if Obama fails, the authors offer one large consolation. There is an art to losing, too -- in a way that can tee up the issue for future presidents. Truman lost but nonetheless redefined the terms of debate, setting the stage for Medicare (which is why Johnson honored Truman when he signed it into law). Compare him with Clinton, who walked away from the wreckage of his health care plan and rarely mentioned the subject again. According to the authors, this allowed opponents to gain control over the spin and history, so that the Democrats' signature cause slipped out of political sight for a decade.

This fine book also contains a subplot with a supporting actor who, although he never became president, is repeatedly heard from offstage -- goading, pushing, threatening and pulling presidents of both parties toward universal coverage. Ted Kennedy first introduced his ambitious national health insurance proposal 40 years ago, and he never stopped promoting the cause. A deal he reached with President Nixon was the closest this country has ever come to universal care. Even before Kennedy's death last month, his illness had tragically sidelined him just when his powerful voice was most needed. Yet when and if America ever achieves universal coverage, it will be due in no small measure to the tenacity and perseverance of this one remarkable man.

Robert B. Reich, a former secretary of labor, is a professor of public policy at the University of California, Berkeley, and the author, most recently, of "Supercapitalism."
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A version of this article appeared in print on September 6, 2009, on page BR1 of the New York edition.


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