James Morone: What healthcare politics lays bare

From FDR to Barack Obama, James Morone’s revelatory history of presidents and healthcare policy lays out some basic rules — the conditions, in short, that Lyndon Johnson met to pass Medicare in 1965, but that asked too much of Jimmy Carter and Bill Clinton in the losing campaigns of 1977 and 1994 for universal insurance.

The bare essentials: Passion, personal and sustained. Speed in the legislative drive. Keep-it-simple engagement of the public. Suppression of economists, wonks and budget numbers. An opportunistic mix of muscle and deference with kingpins in Congress, who must inevitably write the final law. And the foresight, in case of defeat, to leave the issue in good shape for the next try, as Harry Truman did for Johnson, and Bill Clinton entirely failed to do for Barack Obama.

Obama hasn’t flunked any of the core tests so far, in Jim Morone’s judgment. But then, he’s a long way from a victory that would have been automatic in a parliamentary system and may actually be impossible in the American labyrinth of a special-interest Congress.

We will repair early and often to Jim Marone, a born color commentator on politics and chairman of the political science department at Brown, for reviews of the Obamacare scorecare. Meantime, Morone the story-teller is letting us in on some of the striking original themes of his new book, with David Blumenthal of the Harvard Medical School, The Heart of Power: Health and Politics in the Oval Office.

Health policy, Marone argues persuasively, lays bare the soul as well as the working temperament of presidents as almost nothing else does. Our presidents tend to be “sick men,” he writes, with complex medical histories and poorer health than American males in general. But in fact they all have two health stories: first of their own submerged afflictions (FDR’s polio, Eisenhower’s grave heart problems, Kennedy’s wrecked adrenal system and drug dependency) and then: the family memories of health and medicine (Ike’s agitation about his mother-in-law’s ruinous bills for years of round-the-clock nursing care, or JFK’s devastation by his father’s major stroke in 1962). Surprise: it’s not their own medical charts but rather the imprinted stories of near-and-dear exposure to medicine that drives our presidents on healthcare. It may not matter much that, on and off the basketball court, Barack Obama looks like the healthiest president we’ve ever had. The well of his passion is the tearful memory of his grandmother’s battles with insurance companies before she died of cancer just as he got elected.

“Every president changes the conversation about health care in America,” Morone and Blumenthal write in The Heart of Power. It’s a point that leaves me less impressed than Jim Morone is with the Obama drive so far. Obama’s opposition has made it a conversation about socialism and death panels. The media coverage has made it a conversation about Obama: will he bend, or be broken by, the lobbies? Can he dominate the Congress as Lyndon Johnson did? Can he win the big one? Even people who love Obama as I do have doubts that he has addressed the exclusions from care, the fee-for-service racket or the ruinous rise of costs to the whole economy. So we root more for him than for his plan, which is not the way it’s supposed to be.

This is the start of a continuing conversation with Jim Marone, about a battle just well begun:

If you talked to the Obama people ahead of time, they would have said “Oh, we’re girded, we’re ready, whatever they throw at us, we know it’s going to be ugly” — but not this ugly. Why is it so deep? That’s the interesting question here, really. What does this touch? I’ve got two answers…

One, this is the thing that Franklin Roosevelt never fought for in the New Deal. He gets unemployment compensation, he gets welfare, he gets Social Security, he gets the whole list of good welfare-state stuff, but he pulls back on healthcare. So for Democrats this is the lost reform that the New Deal never won. And for the Republicans, this is what distinguishes the United States from all those other welfare states, like Denmark, like Canada, like France. So that this is in the DNA, in the genetic code of each party. Ask a Democrat, and they’ll say, shamefully, “we are the only industrialized country without national health insurance.” Republicans: “We’re the only country without national health insurance!!” So this is a battle about America.

That’s one level. That’s bad enough. Add to that, this is the battle for the high ground in Washington. If Obama wins something significant — if he wins, if it’s significant, two very big ifs — he has done something that Truman, that Carter, that Kennedy, that Clinton couldn’t get done. He emerges from this a star. If the Republicans manage either to make this a very weak bill, or to defeat it, Obama becomes Carter. He’s defeated. This is Waterloo. James DeMint, Senator from South Carolina is absolutely right. But remember, Waterloo had both Wellington and Napoleon: there’s a winner that comes out of this, and the winner is dominating the Washington conversation for the next year. So we are met on the great battlefield. Of course it’s ugly. Of course it’s bloody. Control of our politics is at stake.