The Heart of Power: Health and Politics in the Oval Office

GUEST: Dr. David Blumenthal
AIR DATE: 12/21/2013
VTR: 11/07/13

I’m Richard Heffner, your host on The Open Mind, where once again we concern ourselves with healthcare in America…as we have so many times since this century began.

Indeed, when my guest today, Dr. David Blumenthal, first joined me here a dozen years ago as a distinguished Harvard Medical School Professor of Medicine and Professor of Healthcare Policy, he discussed with me “Medical Scientists and the Marketplace” as well as the then seemingly much needed professional injunction, “Physician … Prepare Thyself”.

Well, now Dr. Blumenthal is President of the world renowned Commonwealth Fund, a major national philanthropy heavily engaged in independent research on health and social issues … and in this first of two programs I want to discuss with him his and historian James A. Morone’s quite extraordinary new book on The Heart of Power … Health and Politics In The Oval Office.

Clearly, other than war and peace, few issues have commanded our recent Presidents’ attention more than healthcare … their families’, their own, most importantly, their fellow Americans’.

And I’m more than intrigued to learn that Presidential scholar Richard Neustadt, my own late friend and colleague – indeed, one of Open Mind’s first guests when I began it nearly sixty years ago – played such an important role in focusing Dr. Blumenthal’s attention on health and politics in the Oval Office.

So that I would ask Dr. Blumenthal whether Dick Neustadt’s expertise in the nuances of Presidential power did indeed give him any particular insight into health policy and the Oval Office.

BLUMENTHAL: Thank you. Delighted to be here. Dick Neustadt was a towering figure in the history of understanding the US Presidency and I was a good friend and admired him enormously. And his interest in the Presidency directly influenced my sense that there was a story to be told about how Presidents lead at the national level in healthcare politics and policy.

And it was that story that I and my colleague Jim Morone set about to tell. And we were pleased to find that there was a story. One of the things that we were able to do because I’m trained as a physician is to incorporate … thread into the story … the personal health histories of Presidents and their families to try to see whether that was one special theme that was pertinent to this subject matter that might … might or might not be pertinent to many other issues that come before Presidents.

HEFFNER: And your answer was “Yes”, of course.

BLUMENTHAL: Of course.

HEFFNER: And how did that work out? What did you see?

BLUMENTHAL: Well, we saw that, of course, Presidents vary enormously, but there were critical times in Presidents decision making where they clearly were influenced by a personal experience.

And one thing that’s common to every human … whether they are poor and homeless or whether they sit at the height of power in the, in the known world. They all share a vulnerability to health problems and disease. And they all share families who have that vulnerability. And in a very personal way Presidents, just as anyone else feels that vulnerability.

So there were a couple of places where it clearly … played a role. And, I remember, for example, very clearly an archivist at the Eisenhower Library asking me if I’d read a particular oral history of a conversation between President Eisenhower and his then Secretary of Health, Education and Welfare.

And it was about his wife Mamie’s parent … who … mother who lived with them in the White House and was chronically and seriously ill.

And there when I … when the archivist brought it out was a story about President Eisenhower reflecting on the pain and difficulty of his mother-in-law and the cost of illness associated with that kind of a long-term chronic illness.

And after that he actually turned to his Secretary of Health, Education and Welfare and said, “I’d like to do something for the elderly.”

Now this part of Eisenhower’s tenure is rarely discussed, but in fact, there was an effort, toward the end of his Presidency to do something like Medicare and he made that effort. He got badly beaten up by the American Medical Association and by the Republican opposition to that kind of work. And he backed away from it. But it gave me a different insight into him as a man.

Now, Edward … Ted … not Ted Kennedy, but John Kennedy … had a similar experience after his father had a stroke. After Joseph Kennedy, Sr. had a stroke.

And this energized him to bring Medicare … health insurance for the elderly before the Congress. Unsuccessfully, as it turned out. But it energized him and he reflected on that in conversations with his aide, Lawrence O’Brien and in both those cases, there was a very direct relationship between a family illness and a Presidential proclivity … a tendency … a decision that leaned in one direction as it …. when it might have leaned in another direction.

HEFFNER: Of course I saw that so much in the … your chapter on Richard Nixon.

BLUMENTHAL: Yes, of course. That … that’s another very, very important … relatively untold story.

Richard Nixon … his entire family was ravaged by tuberculosis. And Richard Nixon himself likely had tuberculosis as a child. There are tantalizing hints that, as a physician, I could kind of see in the …his description of his childhood.

But he lost a brother to tuberculosis … he wrote about it in very moving terms … in terms during his childhood. And he referred to his experience and his family’s experience with tuberculosis repetitively during his Presidency and as he resigned in disgrace … the morning he left the White House, flying away in the, in the White House helicopter, he stood and addressed his staff and recalled his mother and her care for his dying brother, who had tuberculosis and, ahh, while he was nearly weeping over his personal fate, his thoughts gravitated back to this personal healthcare experience.

Now that mattered because he was actually an incredible advocate of universal healthcare. Not commonly cited for that. But he put forward a Bill that was, in retrospect, more radical than President Obama’s proposal … now called “The Affordable Care Act”.

HEFFNER: As you look back … starting with Franklin Roosevelt … which of the Presidents, who … whose activities you recount … seemed to you to be most important in bringing us to where we are today … and later on … or in our next program I want to talk about (laugh) where …

BLUMENTHAL: (Laugh)

HEFFNER: … we are today.

BLUMENTHAL: MmmHmmm. Well, I came away most admiring, as a President, who could exert power and lead domestically … Lyndon Baines Johnson.

He was without parallel in his ability to execute on a agenda in the healthcare space. And it, it was assumed that the passage of Medicare and Medicaid, which occurred after his election in 1964, by a landslide … that it was a virtual inevitability and that Johnson was an almost passive observer of this process that was run mostly from the Congress.

And it turns out that that is the impression Johnson wanted to create. But behind the scenes, talking with his old colleagues in the Senate, talking with his colleague, Wilbur Mills on the House, that he was up to his ears in plotting and urging and strategizing about the passage of Medicare.

He was not a man who could leave anything he cared about alone. He had to be in every detail. And it never struck me that it was plausible that, that traditional history of Medicare, which is that Wilbur Mills kind of made it happen, could have … could have unfolded the way it was told. And the, the reason I was able to see … passed that appearance was because of the Johnson tapes.

HEFFNER: I wonder whether you feel that that’s an indication that one has to be, as President, up to his ears or her ears and in Johnson’s case they were so huge …

BLUMENTHAL: (Laughter)

HEFFNER: … to be successful and how that relates to the present scene.

BLUMENTHAL: I think the President has to lead. The President has to be involved and conscience and planning and in charge. There’s one thing that a President can do that no one else can do in the United States government or the United States as a whole. And that is communicate to the American people about healthcare and the policy needs to assure people access to healthcare.

HEFFNER: It’s so interesting. You make that point about FDR … that he told his …

BLUMENTHAL: MmmHmm.

HEFFNER: … disciples “I’m the one …

BLUMENTHAL: MmmHmm.

HEFFNER: … who has to speak to the people”.

BLUMENTHAL: That’s right.

HEFFNER: Why didn’t he then … sufficiently, as you indicate?

BLUMENTHAL: No. It’s a … FDR is a mysterious President in many dimension … that’s often commented on by the classic historians of Roosevelt. And his mystery is very apparent in the healthcare area.

Here was a man whose life was totally molded by personal illness. Actually a man who was very involved in his own cure …to the extent that cure was possible. He designed his own rehabilitation program for polio …

HEFFNER: Do you think that’s the key?

BLUMENTHAL: Yes.

HEFFNER: That he had to do it himself?

BLUMENTHAL: Ah, it’s part … it’s part of the story. The part of the story is, I think, that Roosevelt had a very ambivalent relationship with the medical profession.

I think he admired the medical profession, but he also had a healthy …

HEFFNER: No pun.

BLUMENTHAL: Yeah … a healthy skepticism, which was well earned because he was not well treated by the profession. Misdiagnosed when his polio was … first occurred. Misdiagnosed by multiple physicians. And then told that there was not possible way to rehabilitate himself and set about to prove that, that they were wrong. And was correct. He, he was in some … in, in a way the pioneer for what is now called “rehabilitative medicine”, which is a specialty … and well respected specialty of medicine.

I think that in Roosevelt’s case there were many … as in all, all of Roosevelt’s decisions, there were many streams feeding his ultimate decisions. He was very worried about passing Social Security at the time when it was most opportune for him to put healthcare in as part of the Social Security program.

But he also had a very close relationship with his son’s father-in-law … a man by the name of Harvey Cushing. Harvey Cushing is a … one of the, the most eminent neurosurgeons ever to walk the earth. There are many … there are medical services named after him at leading universities, he was both at Harvard and Hopkins and Roosevelt put him as Chair of a critical advisory committee in the 1930’s, early 1930’s.

Cushing was quite conservative on issues of medical policy. And strongly advised Roosevelt against copying the socialist pattern that was then taking shape in Europe with regard to national health insurance and universal coverage.

I think that Roosevelt was, for his own personal reasons, unwilling to take on what was then the most powerful health care lobby and that was the American Medical Association. And Harvey Cushing reinforced that hesitance.

HEFFNER: What do you think about your colleagues in the profession and the role they have played in terms of the rest of us and our health.

BLUMENTHAL: Yes. Well, the, the medical profession of which I am proud to call myself a member has many, many fine attributes. And physicians go to work every day trying to do their best. When they get together collectively, they don’t always act as altruistically as they are capable of acting individually. And they have … from the time of Roosevelt and before Roosevelt until the present … and there’s been some modification in their current stances on healthcare policy issues.

But they have, by and large been a force for the status quo, whatever the status quo was. And they have, for the most part, defended their financial interests, rather than the interests of patients.

HEFFNER: And you feel that’s the key.

BLUMENTHAL: I think that has been a very, very important theme in their political stances. They do some wonderful things. They promote public health, they have now … they are important in the anti-smoking movement. They, they do have many public spirited endeavors. But when it comes to insurance coverage and payment, they tend to adopt self-interested and conservative stands.

HEFFNER: I am particularly interested in your chapter on the second Bush …

BLUMENTHAL: MmmHmm.

HEFFNER: President Bush … your enthusiasm for him sort of … for me … flew in the face of my perception of his participation in social legislation …

BLUMENTHAL: Yes.

HEFFNER: … I was wrong then.

BLUMENTHAL: Well, I, I think you’re wrong. From what we learned, talking to the people who worked around him and experienced his input directly on what was the most important expansion of Medicare in its history and that was the addition of the drug benefit for Medicare. So-called Medicare, part D.

President Bush decided early to champion that. He stayed with it, he carefully planned its … how to position himself around its passage and then lobbied vigorously and effectively for its passage. One of the things he did that Obama was later criticized for, but I think was a correct position to take, is he didn’t get too far into overt involvement in the passage. He laid out some principles, some guidelines and then he turned it over to the Congress to shape the actually legislation … the details.

Now that’s what Johnson did with Medicare and Medicaid. It’s what Clinton failed to do and it’s what Obama did with success.

My … one of the lessons we learned in watching Presidents work healthcare issues over time was how important it is for them to set direction, elaborate principles, set guardrails, but not try to write every line of a piece of what will turn out to be extraordinarily complicated and controversial legislation.

HEFFNER: In, in your Rules that you set down … in, in this wonderful book about the Heart of Power … I’m very much amused at your blanket statement “Don’t listen to the budget people”.

BLUMENTHAL: That’s right. (Laugh) That was … hmmm, as someone who trained at the Kennedy School of Government … in part and had a lot of economists who were my, my mentors and who I respected … we took that position with some, ahh, kind of circumspection, but it is true that starting with Lyndon Johnson … going through Clinton, going up through the Obama experience, there’s never been, as far as I can tell an organized economic force within the White House OMB, Treasury that has favored the extension of coverage to any part of the American public.

And the rationale is almost always, it can’t be afforded. There’s always a deficit to worry about … there’s always an expansion that might be undermined or a, a depression or a recession that makes it unwise to do it at any point in time.

And Johnson was able to get Medicare through because he ignored his economic advisors. Clinton ignored his economic advisors, otherwise he never would have advocated for healthcare. And Obama faced the same decision and also went forward with it.

Now Johnson was successful, Obama was successful. The other, the other proponents of healthcare, like Clinton … now Clinton actually made the decision to address the economy before he addressed healthcare and that was one of the reasons that he failed.

HEFFNER: Well, one of your rules is “Get in there quickly and you …

BLUMENTHAL: Yeah.

HEFFNER: … quote Lyndon Johnson as saying to his staff people after his election, “I lose support every day …

BLUMENTHAL: Yup.

HEFFNER: … now that the election is over.”

BLUMENTHAL: So …

HEFFNER: Here we want him to rush into it.

BLUMENTHAL: Here was a man, Lyndon Johnson, who understood power better than … as well as any President has ever understood power. He … in 1964 he was elected over Goldwater by an historic margin … a huge landslide and if there was any time in American history when a President could have relaxed and, and planned carefully for the enactment of legislation he cared about … that was the time.

And what did Lyndon Johnson do? He got his staff together within a week and he said, “We have to act fast, we have to act now … every day I lose power. Every day I will make someone angry at me, every day I will lose a vote”.

And that was only another example of what I think we saw repeatedly … Clinton’s delay of the … of his healthcare legislation made it impossible to pass it. Obama’s … didn’t delay, but the waiting while Grassley and Baucus negotiated almost sunk the legislation because it enabled … it provided time for Senator Kennedy to pass away and Senator Brown to be elected in his place with the loss of that 60 vote margin that was so important to the Senate support.

So, it was … I think a lesson that stands the test of time. This is one issue … and in fact, almost any Presidential … real Presidential priority has to be acted on within months of the President’s first election.

HEFFNER: But now I want to go back to the, to the other observation that you make … stay away from the economists … don’t let them get their fingers into this pie.

Aren’t you saying that the kind of provision for the kind of medical care we need as a people is not affordable in terms of dollars and cents?

BLUMENTHAL: MmmHmm. I get … I’d make a somewhat more complicated statement. I think our ways of accounting for the costs and benefits of healthcare do not, do not figure effectively, the benefits.

So we look almost always at the expenditure side. We never looked …look at the revenue side. The revenue occurs in terms of a healthier work force. Less absenteeism, more productivity at work, a population that’s capable of learning in school with healthy children. Or learning as adults … a population that is more secure in their lives and in their work.

Let me give you an example from, from China. So the Chinese are very interesting because we think of them as a Socialist country, but they have fashioned a healthcare system that is pure capitalism, unfettered capitalism. People pay out of pocket, they’re now getting some insurance, but that’s only about a three or four year … only three or four years old at the time … that the Chinese have had a conscious effort to extend insurance to their population.

So why did they do this? Because there was no inclination to do it. The Chinese decided that they had to give everyone some protection against the cost of illness because people were saving so much money to deal with their healthcare expenses …

HEFFNER: Hmmm.

BLUMENTHAL: … that they weren’t buying other goods and services. They couldn’t build a domestic consumer economy as long as healthcare was not covered.

So I think that there are many calculations that go into the welfare that society reaps from universal coverage of healthcare that don’t come up in the Federal budget deficit calculations.

HEFFNER: Is that one of the calculations that the Commonwealth Fund can address itself to?

BLUMENTHAL: Well, we are very interested in creating a high performance health system. And in the policies that are required to do that. And we have had historically a deep interest in access to affordable insurance coverage and access to high quality health services, especially for vulnerable populations.

And we do believe, or we have in the past, valued the assurance that all people who need healthcare can get access to it. And we continue to pursue that.

We’re very interested, for example, in whether the Affordable Care Act can be effectively implemented and how it can be most effectively implemented and who will be left out.

Because we know with a certainty that at least undocumented Americans … currently undocumented … will be left out of the benefits of the Affordable Care Act … sometimes called Obamacare.

And we also expect that there will be individuals who, for economic or other reasons, will choose not to participate in … despite the penalties … that would be imposed, through the individual mandate.

So we want to be aware of who’s not included and who is included and to make sure that the promise of the Affordable Care Act is realized.

HEFFNER: Dr. Blumenthal that’s the point at which I have to say that our time is almost up and get you to promise to stay where you are and let us do another program in which we do deal with Obamacare.

BLUMENTHAL: Sure. Delighted.

HEFFNER: Thanks for coming here today. And thanks to you in the audience. I hope you join us again next time.

Meanwhile, as an old friend used to say, “Good night and good luck”.

And do visit the Open Mind Website at thirteen.org/openmind to reprise this program online right now or to draw upon our Archive of 1,500 or so other Open Mind and related programs. That’s thirteen.org/openmind.