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In Sickness and in Health

In this interview, James A. Morone speaks about how presidents' personal experiences shaped their health care policy.

By and large, our modern presidents have not been a healthy bunch. Franklin Delano Roosevelt, a victim of polio, could barely walk with assistance. Dwight D. Eisenhower had two heart attacks, a stroke and suffered from Crohn’s disease. John F. Kennedy medicated himself with 26 different drugs to combat severe intestinal problems, back pain, osteoporosis and Addison’s disease—and had the last rites of the Catholic Church read to him four times as an adult.

But how much does a president’s personal experiences shape his health care policy? David Blumenthal, M.D., a Harvard Medical School professor and a health care adviser to the Obama administration, and James A. Morone, chair of political science at Brown University, tapped into newly released White House tapes and undisclosed archival material and conducted extensive interviews with former White House staffers to learn the answers.

What they uncovered for their new book,The Heart of Power: Health and Politics in the Oval Office, allows us to understand not only the modern presidents’ positions in the great health care debate that has been part of the political landscape since the 1930s, but the individuals themselves. In the process, the authors gleaned a few insights into what might make health care reform possible today. In a conversation with AARP Bulletin Today, James A. Morone explains.

Q. Why did you write about the presidents from the health angle?

A. There’s not one book that really gets into the fascinating details of the presidents’ lives and connects that to their policies. Presidents have no direct experience with many policy areas they wrestle with. They’re not homeless, they don’t go to jail, they’re not hungry. But here’s one policy area that every president experiences personally, and it’s the most human of policy areas.

Q. You write early in the book: “Deep personal hurts are what move these men to commit themselves to a reform that they know is a long shot even in the best of times.”

A. Health care reform is so hard. Unless deep in your gut you’re willing to risk a lot to win the reform, it’s just not going to happen. We found that in presidency after presidency.

Q. FDR was plagued with “deep personal hurts.” Why didn’t he get health care on the docket?

A. Here’s a guy who took the world’s most difficult job and really couldn’t walk. He was always faking it, always hiding it. When he contracted polio, he was badly treated. One physician misdiagnoses him. Another famous one not only misdiagnoses him but charges him $8,000 (about $85,000 today) for a useless house call. FDR had every reason to be skeptical of the medical profession, but he never took it on. His advisers pleaded, but for him health care was a purely political calculation, and he decided it was not worth the fight.

Q. So what kind of “deep personal hurts” do you mean?

A. There’s a corollary we weren’t expecting. President after president, we found that the presidents’ loved ones’ illnesses really shook them up. To our surprise, their own personal stories had no influence on them. Not one of them.

Q. For example?

A. John F. Kennedy was the sickest man on earth, practically, from the time he was 2 when he got scarlet fever, an often fatal disease before antibiotics. As a kid, he caught everything—bronchitis, pneumonia, diphtheria, you name it. He spent months in the Mayo Clinic during his high school and college years. Some of his problems came from doctors who injected him with powerful hormones that caused all kinds of trouble, including crippling back pain. Even in the White House, he was getting pretty dubious health care. One doctor—Dr. Feelgood as he was known—shot him full of very dicey concoctions. His brother Robert warned Jack about this and worried about his long-term addictions. But JFK paid no mind. “I don’t care if it’s horse piss. It works,” he told his brother.

Q. That must have had a huge impact on him.

A: His illnesses never touched him in terms of advocating national health insurance. But when his father had a stroke in 1961, he was devastated. From that moment on, he was definitely committed to Medicare. He’d say, “I just don’t know how regular people do it.” His father was rich and it was costing the family a fortune.

Q. Talk about the health of JFK and Richard Nixon during their famous televised presidential debate.

A. So JFK was this incredibly sickly guy. He was pumped up with drugs directly into his back up to five times a day. So the ruddy good health that he displayed was really chemical. Despite his incredible sickness, he was manic about seeming young and strong. Richard Nixon had terrible psychological problems, but physically he was a very strong and healthy guy. But on the campaign, he had gotten a knee infection. And on the day of the debate, he banged his knee on the door of the car and it caused him great pain. So on TV we had an essentially healthy man sweating profusely due to pain, appearing quite ill at ease. And the other man looked robust and healthy, who was actually very sick.

Q. Why did Nixon care so much about health care?

A. This was one of the shocks. We discovered a man deeply affected by the death of his two brothers. Every moment of great tension in Nixon’s life, he immediately started talking about his mother who left him in the hands of his incredibly abusive father and took one of his brothers, who had contracted tuberculosis, to Arizona. She then took in boarders—other boys with TB—and watched them die one by one as she tried desperately to keep Richard’s brother alive. It didn’t work. He died. And another brother also died of TB. So that’s the backstory. (Read more of Nixon’s story.)

Q. And we rarely hear of Nixon’s health care legacy.

A. He recast the entire concept of national health insurance, creating a new model that kept employer health care in place, covered the poor and the old and gave people who weren’t covered national health insurance. Before that, most people who wanted national health insurance wanted a single-payer Medicare system for all. But this mixed model has been embraced by Carter, Clinton, Obama and all the Democratic hopefuls who ran on health care—Kerry, Dukakis, Mondale. They’ve all borrowed from Nixon,who wrote up this idea on his yellow legal pads.

Q. Yellow legal pads?

A. He would hide in his secret office across the street from the White House in the middle of the summer with the air conditioner going full blast and a fire in the fireplace and fill yellow pads with ideas. Here he brilliantly rethought national health insurance. He conceived the plan of the future, the one we’re still pursuing. He came close to concluding a deal with the Democrats, but the Republicans balked and ultimately, Watergate consumed the presidency.

Q. Another Republican who wanted to expand government health care coverage was Ronald Reagan.

A. This was another shock. Reagan has an image of being totally out of it. At the low point of his presidency—the Iran-Contra scandal, the Republicans just lost the midterm elections and Reagan had suffered a serious cancer episode—he decided to go forward with catastrophic coverage for Medicare recipients. Ronald Reagan, Mr. Government-is-not-the-Solution, added the single largest expansion of Medicare of all time. [Ultimately, the initiative didn’t survive Congress.]

Q. Bill Clinton certainly had the fire in the belly for health reform, yet ultimately nothing happened.

A. Clinton is all lessons about how not to go about health care reform. One, he waited. The plan didn’t go to Congress until the last day of the session when Congress was leaving. By then, everyone was focused on the midterms. Huge problem. Second, he spent way too much time on the details, not the big picture. But the big lesson here is learning how to lose. When national health insurance went down to defeat, Clinton simply walked away.

Q. Why was that a problem?

A. The Republicans were terrified of health care passing under Clinton. If it did, the Democrats would renegotiate their lost link to the middle class and the GOP would be out of power for a long time. But once Clinton walked away, the GOP controlled the spin, giving their party credit for saving America. Clinton did the exact opposite of Harry Truman. Truman lost his health care insurance fight but continued to campaign for his cause. “The do-nothing Congress, the American people need this!” he’d say.

Q. So Clinton walked away …

A.and health insurance drops out of the debate for a decade. And not coincidently, we believe, so did the Democratic majorities.

Q. George W. Bush had a different approach.

A. We came away pretty impressed with G.W. Bush on this issue. G.W. wanted to turn Medicare into a market-driven program and use prescription drugs to do it. His idea: You can have prescription drug coverage as long as you agree to let private insurance companies handle all your Medicare. Once he got a majority in Congress after the 2002 midterms, he turns to health care.

Q. And how’d he do?

A. He read the briefing book. He listened, asked intelligent questions. He kept the big picture in mind and sent a series of principles, not a detailed plan, to Congress. He was flexible, backing off on many of the components of his initial idea. He ran a very disciplined campaign to get the prescriptions drugs benefits through, which was considered a victory for him.

It’s a delicious irony of history. Look at the two greatest expansions of Medicare. The first comes under Reagan, the most conservative president of our story, and the next comes under G.W. Bush, the second most conservative.

Q. How’s Obama’s health care campaign going?

A. He’s doing remarkably well. FDR, Truman, Kennedy, Clinton, Carter—all tried major health reform and all failed somewhere in the process. Not one of them even got it through a single House committee. [Lyndon] Johnson is the great Democratic exception, getting Medicare passed. Obama has gotten four out of five congressional committees and he seems to have a plan before the House. He’s learned the lesson of speed. He’s managed Congress reasonably well. And he understands he has to sell it and use his credibility with the public.

Q. He also seems to have the passion. In a radio town hall at AARP, the president mentioned that while his mother was battling cancer, she was also battling her insurance company—and she’d already paid her premiums. He was a little riled up when he said this, whereas the rest of his comments were much more measured.

A. This is what we look for in presidential biographies. Every now and then you see what makes them tick. What you saw in that meeting was exactly what we’ve seen from other presidents—there’s Barack’s heart under that measured exterior—the reason he goes messing around in the weeds of health care reform.

Q. Will his efforts be rewarded?

A. All you have to do is watch the conversation. If the public seems to be terrified of reform, it will fail. This is now in the hands of the public … the public of those swing states, who are now really going to let their congressmen hear it during the recess. There are no holds barred in this debate. You are not limited to the truth. There’s going to lying, cheating and stealing. And like always in great democratic debates, when Congress comes back in session we’ll know.

Q. Handicap Obama’s chances.

A. He’ll actually succeed. It will be a heavily compromised plan. But if I had to make a bet, I would give it 51-49 percent that this time they’ll actually do it.

Carol Kaufmann is a contributing editor at the AARP Bulletin.