Lessons of and for Presidential Health Care Leadership

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Lessons of and for Presidential Health Care
Leadership

• David Blumenthal MD, MPP
• Institute for Health Policy
• Massachusetts General Hospital
• January 30, 2009

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Agenda

• Background
• Lessons
• Conclusions

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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.

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Background (cont)

• The Heart of Power Health Politics in the Oval
  Office.
• University of California Press, June, 2009.

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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.

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Tactical lessons

• Campaign on it.
• Do it early.
• Use the transition.
• Manage the economics (and the economists).
• Go public.
• Delegate.
• Manage the Congress

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Campaign

• Political legitimacy.
• Public support.
• Hold Presidential feet to the fire when going
  gets tough.
• Carter
• GWB

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Do it early!

• LBJ in February, 1965 (from recollections of
  Wilbur Cohen)
• Now look. Ive just been reelected by the
  overwhelming majority. And I just want to tell
  you that every day while Im in office, Im going
  to lose votes. Im 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 . . Its going to be
  something. . . . Weve got to get this
  legislation fast. Youve got to get it during my
  honeymoon.

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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, dont 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.

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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.

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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.

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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 Clintons most significant failures.

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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.

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Delegate (cont)

• GWB
• Decision in July 2001, reaffirmed June, 2003, to
  issue principles concerning Medicare
  Modernization Act, not detailed legislation.
• Counter-examples
• Carter
• Clinton.

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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?

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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.

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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.