Chronic Politics: Health Care Security from FDR to George W. Bush

by Philip J. Funigiello

Few domestic issues dominate today's headlines as much as the high cost of health care. Despite this media attention and a litany of election-year debates over health care funding, some 45 million Americans remain without adequate health insurance. Philip Funigiello chronicles the contentious political history behind this state of affairs, from the New Deal to the present.

Funigiello unlocks the puzzle of why the United States has never guaranteed its citizens health security comparable to that enjoyed by people of other first-world nations—and he tells what needs to happen for policy reform to take place. Examining specific episodes in the history of health care financing, he highlights the importance of key individuals in the legislative process, the political haggling involved in shaping a bill, the clash of personalities and agendas that determine its fate, and the extent to which American ideas about fairness are reflected in the result.

Beginning with the National Health Survey of the 1930s, Funigiello traces the long struggle to enact Medicare and explains how medical inflation adversely affected both public and private employment-based insurance systems. He then recounts how Medicare became a target in the Republicans' war on spending, assesses the ill-fated Clinton health plan, and brings everything up to date with the Bush administration's expansion of Medicare to include prescription drug coverage.

Throughout this history, Funigiello shows that both liberals and conservatives, Democrats and Republicans, share the blame for not providing every American with health security as a right of citizenship. He argues that ideological values such as rugged individualism and laissez-faire capitalism have continually overshadowed the spirit of pragmatism, cooperation, and community ethos that health security requires.

As the swelling ranks of the uninsured threaten to destabilize the entire health care system for those who can still afford it, this country is faced with growing health insecurity unless we learn to rise above political differences. Chronic Politics is an incisive look at how history has affected current policy and is required reading for all concerned with the politics of financing health care in America.

408 pages, Hardcover

First published September 21, 2005

Reviews

[Lobstergirl · Rating 4 out of 5]

This is an excellent, detailed, chronologically organized synthesis and analysis of every attempt to create national, universal (or near-universal) healthcare in the U.S. from FDR to George W. Bush. (No, not all presidents across the years tried. In the case of George W. Bush, for example, a Medicare reform law was passed.)

In the Roosevelt and Truman years, through the sixties at least, the biggest impediment to passage of any kind of law that would increase access to healthcare was the AMA (American Medical Association). The AMA was fiercely and pathologically protective of its turf and saw every potential reform as damaging to physicians, their incomes, and hospital profitability. Way to be a good citizen, AMA! The AMA created PR campaigns every time the issue of reform arose, helping ignorant Americans believe that all healthcare reform attempts were socialized medicine (during the Cold War, this was very easy) and that nothing should come between the sacrosanct relationship of a doctor and his patient. The AMA's bullshit ran thick.

Although we often think of FDR as far left politically, he was in many ways conservative and unwilling to extend himself to promote policies which were not guaranteed of success. FDR had achieved a huge victory with Social Security, but didn't want to press for a government universal health plan because he felt it would be a push too far. He had gotten into trouble and aroused ire with his Court-packing scheme. He pushed health reform off into the future. By the time the future arrived, he was dead.

Truman and Nixon made efforts at legislation, but failed. Johnson, battling the AMA and the paranoids who feared socialism, gave us Medicare. Reagan, in spite of himself, signed COBRA (Consolidated Omnibus Budget Reconciliation Act) into law, which enabled fired or laid off employees to continue the health coverage they got through their employer, but paying full cost. It didn't help all that many people because not all employers offer healthcare, and the premiums were too expensive for most people; still, it was better than nothing.

George H.W. Bush was utterly useless and made no attempts to improve the health care system.

Clinton was most ambitious when it came to reform, but his administration shot itself in the foot so many times that you can assign him a large proportion of the blame for his plan's failure. (Clinton, as a candiate, ruled out single-payer, the most liberal reform option. Many liberals resent him for this, just as they resent Obama for it, but there's no question that single-payer would be the most difficult type of legislation to get passed; given that this is America, probably impossible. As much as we would like to be Canada, or Britain, or Germany, or Japan when it comes to our healthcare system, these are pipe dreams that could only have been solved before the 1960s. By the 1960s, too many Americans got insurance benefits through their jobs for a dismantling of the employer-health benefits nexus to work. The American middle class has been addressed as consumers and taxpayers for so long that they no longer think of themselves as citizens - people with a stake not just in themselves, in their own financial situation and prospects, their own families and jobs, but humans in a collective society where it would behoove all of us to act for the common good.)

As a candidate Clinton was very slow to spell out what kind of health reform he favored, between managed care and "pay or play." Hillary Rodham Clinton and the Clintons' friend Ira Magaziner were put in charge of the health care task force, which quickly became huge, unwieldy, indecisive, and bogged down. Some agencies that felt they should have been part of the process (HHS under Donna Shalala, for example) were left out or deemphasized, and probably retaliated by leaking unfavorable tidbits to the press. The mainstream press did its part to doom the law, focusing more on the opposition to reform, taking on that viewpoint sometimes, and editorializing that the administration was biting off more than it could chew and that incremental reforms were preferable.

The task force took far too long, given Americans', the media's, and politicans' attention spans, to come up with legislation. When they finally did, it was more than 1,000 pages, Clinton had squandered a lot of political capital, people were impatient, the political climate was shifting from one where healthcare was seen as in crisis to one where reining in deficits was seen as more important (Gingrich and the GOP harped and fearmongered on the deficit endlessly), and the bill ultimately went nowhere.

The Clinton administration didn't try hard enough to woo Congress, in particular powerful Democrats in the House and Senate. It was bad enough to have all the Republicans against reform, but many Democrats either were against the particulars of reform, or just didn't care enough about it to prioritize it as policy. Daniel Patrick Moynihan, in charge of the Senate Finance Committee, didn't think there was a health care crisis and was unwilling to help move the legislation. When a president tries to get such a large law as this passed, the fracturing in Congress is a massive hindrance: the bill is debated and rewritten in multiple committees and subcommittees, each with different leaders who have different vested interests. Clinton had allies in his own party in Congress, but not enough of them, or they weren't powerful enough, or sitting in the right committee chairs.

Funigiello makes the very important point that the attempts at reform by Nixon and Clinton failed because their advocates, though united in the ends they wanted to achieve, disagreed over so many details of the plans that they were splintered, whereas the opponents of the reforms were unified in their opposition, well financed, and willing to commit the resources to defeat them.

The book stops mid-Bush, short of Obama. Obama studied history and learned from its mistakes. From the entire 20th century, he learned that single-payer was an impossibility. From the Clintons, he learned that if something is important to you, you have to stake your entire presidency on it. Half measures, the waxing and waning of enthusiasm, can kill your ambitions. Obama went whole hog. From Hillary Clinton and Ira Magaziner and the task force, which were criticized and even sued for conducting their operations in secret, he learned that you need to make your discussions public. He made sure C-span cameras were in the room when the law was being debated. From Bill Clinton's wan, half-hearted public relations push, Obama learned that you have to go on the stump and campaign like a maniac for your damn plan. You have to do this repeatedly, all across America, not just from the Oval Office. You have to connect with the People. Obama did everything right when it came to getting his law passed, and it still barely squeaked by.