The Heart of Power

Health and Politics in the Oval Office

by David Blumenthal

and James Morone

California, 494 pp., $26.95

The Heart of Power begins with a story of how health policy expert and current Obama health IT czar David Blumenthal recruited the Brown political scientist James Morone to collaborate on a book on "how presidents deal with health care issues." By their own admission, they are writing the book with a political purpose--they express the hope that their book will "guide a new administration .  .  . toward winning social justice and the people's health"--but they have also produced a helpful history of both the health and health policies of almost all of the last 11 presidents, from FDR to Bush '43. "Almost all," that is, because they skip Gerald Ford, oddly whitewashing his health care policies and his presidency from their discussion.

Nevertheless, if you are interested in presidents and health care policy, this is the book for you. Of course, I'm not sure exactly how large that subpopulation is, but I'll leave that problem to the authors and to the University of California Press.

At its heart is an interesting idea, which is that presidents are most like real people in the realm of health care. Presidents don't go hungry or homeless, they don't schedule or drive themselves, but they do get sick and visit the doctor--er, have the doctor visit them. In addition, the Blumenthal/Morone analysis found presidents to be "distinctly unhealthy." Eleven of the 15 presidents who died in the 20th century died prematurely--"eight of them fell more than seven years short of the actuarial tables." We know a lot about the health of presidents, often more than we know about the health of friends or even some relatives: Ike's heart attacks, Kennedy's Addison's disease, Nixon's phlebitis. (Recall Jackie Mason's classic line on Nixon's painful and life-threatening swelling of the veins: "You don't screw 200 million people and get phlebitis. You get syphilis.")

Given their collective poor health, as well as the importance of the health issue to the American public, the authors describe how most of the presidents reviewed here made some kind of run at some kind of significant health care reform. One notable exception was George H.W. Bush, whom the authors claim could not be bothered with domestic trifles like health care while he had a world to fix. It was only in 1992, when worried about reelection, that Bush allowed his staff to come forward with a plan, and even then he had a hard time convincing voters he was serious about the issue.

According to Blumenthal/Morone, Bush would approach health care stakeholder meetings like a schoolboy trying to run out the clock in class to avoid a quiz. He would enter a room late, joke with the participants, talk about sports and world affairs, and only then, with a few minutes remaining, mumble something about his vision for health care reform. Even then, the authors claim (based on staff interviews) that Bush did not really understand, and could not fully articulate, that vision.

This is in stark contrast to George W. Bush, whom the authors credit mightily for his efforts in adding prescription drug coverage under Medicare. According to Blumenthal/Morone, on this issue President Bush was knowledgeable, skillful, and nimble throughout the deal-making process. In their words, "The details of an engaged, interested, and flexible President Bush surprised us." Another surprise for the authors was that, Lyndon Johnson aside, "Republicans have been far more successful at health reform than the Democrats." They do not, however, answer the obvious question their conclusion presents, which is why that is so. The furthest they go is to suggest that "Republicans get into [health reform] because of a president's personal bent, whether for systems reform (competition) or election-year insurance; Democrats go along for benefits they have invariably wanted for some time."

There is, of course, another possibility that the authors fail to suggest: Perhaps Republicans have tended to have more salable, or even better, ideas in this area.

One intriguing but apparently unsalable idea died in the Reagan administration, when White House staffers put forward perhaps the most conservative approach to health reform of any of our modern presidents. Beryl Sprinkel, Reagan's chairman of the Council of Economic Advisers, developed (with assistance from the Heritage Foundation) a plan to "voucherize" public health care assistance. When Sprinkel presented the plan to the president at a cabinet meeting, he ran into staunch opposition from Doc Bowen, Reagan's secretary of health and human services. Bowen, knowing how Reagan liked stark images or graphics to make a point, took out a pen and drew a complicated chart showing the various and intersecting lines the plan would require. Although, by Bowen's own admission, he exaggerated the complexity for effect, he soon had the whole room laughing, and the administration quietly shelved the voucher plan. A decade later, conservatives would use a similar tactic to defeat Bill Clinton's proposed health care plan.

Blumenthal and Morone have loads of similar stories, both fascinating and little known. Franklin Roosevelt's adult-onset poliomyelitis was initially misdiagnosed twice by the physician who made a house call to the Roosevelt vacation home at Campobello. The erring doctor then had the nerve to charge the family $8,000 for the double misdiagnosis. Fans of P. J. O'Rourke will be happy to learn that Harry Truman was both the most "hale" president studied in this volume, and yet the biggest drinker of the bunch. The hero, however, is Lyndon Johnson, who presided over the most eventful administration in history, from a health perspective. The authors show Johnson to have been a masterful behind-the-scenes presence during the creation of Medicare and Medicaid in 1965. Johnson worked secretly with the House Ways and Means Committee chairman, Wilbur Mills, on combining seemingly competing proposals to cover the elderly and the indigent into one giant, and still growing, system. It was a bold and risky move, but it worked--although the plan's passage was not always guaranteed. At one point, Johnson's chief health aide, Wilbur Cohen, warned LBJ about a new development that would increase the cost of the plan by $500 million in the first year.

Johnson's curious response: "Well, I guess I'll run and get my brother." He then proceeded to tell Cohen the story of a railroad switchman who was asked how to handle a pending and unstoppable train wreck: He said he'd get his sibling "because he hasn't ever seen a train wreck." Johnson was also quite good at convincing recalcitrant legislators to go along with him. Florida senator George Smathers told a reporter that he switched his vote on the Medicare bill from "against" to "for" because "Lyndon told me to."

While many of the stories told here are entertaining, and especially helpful during these health care-minded days for providing useful cocktail chatter, the stories do not necessarily create a narrative that explains the policies that presidents eventually pursued. If Truman was healthier than FDR, why did he seem to try harder to create a universal health program? Could it be that other factors than presidential health determine the approach to health policy? If anything, the number-one factor determining the level of presidential attention to health care appears to be electoral politics. In the current situation, Barack Obama is "all in" on health care reform, and it is not at all clear that his status as an occasional smoker, or as someone who works out twice a day, has led him to place that bet.

Perhaps this relates to the fact that Blumenthal and Morone are interested in something more than a work of history. This becomes clear in their appendix, which is a list of keys for successful presidents in the area of health care. Examples of their suggestions include "Passion," "Speed," "Bring a plan with you," and, amusingly, "Hush the economists," which will likely be necessary in the current administration because of the stratospheric scores the various proposals have been generating from the Congressional Budget Office.

Given Blumenthal's closeness to many top Democratic health strategists--he has been a Democratic health policy adviser for over three decades--it seems probable that he has pushed this book's argument with the Obama White House. So the Obama team has been closely following many of his lessons, particularly the point about a need for "speed." At the same time, Republicans are hoping that they get to demonstrate the last lesson the authors suggest, which is "Learn how to lose."


Tevi Troy, the author of Intellectuals and the American Presidency, and a former White House aide and deputy secretary of health and human services, is a senior fellow at the Hudson Institute.

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