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David Blumenthal and James A. Morone, The Heart of Power: Health and Politics in the Oval Office, Berkeley, Los Angeles, London, University of California Press, 2009, 484p

Éveline Thévenard

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1Written before the launch of Barack Obama’s reform campaign, this history of presidential leadership in health policy making is a timely addition to the large and growing number of publications about the evolution of the U.S. health care debate, and puts the current initiative in historical perspective. James Morone is the former editor of the Journal of Health Politics Policy and Law, the author of numerous articles on health care politics and policy, and editor, with Lawrence Jacobs, of Healthy, Wealthy and Fair, an acclaimed analysis of the inequities that plague the American health care system and their consequences. David Blumenthal, a Professor of Medicine and Health Care Policy at Harvard Medical School, was one of the main advisers to the Obama campaign. He was named National Coordinator for Health Information Technology in March 2009 to oversee the implementation of what the new administration sees as a crucial tool to improve efficiency and reduce costs within an overhauled health care system.

2Based on recently released presidential archives and tapes, as well as interviews with key players in health care policymaking, The Heart of Power provides a fresh angle from which to view the American presidency, American institutions, and the evolution of health care policy. If Roosevelt’s struggle with polio, Nixon’s psychological problems, and Reagan’s age-related problems are well-known, Eisenhower’s stroke and Johnson’s heart problems have attracted less public attention but still deserve the interest shown by Morone and Blumenthal in their masterful analysis of the unique role of the president in health care policy. The authors’ original approach links the personal and the political by showing how the presidents’ medical histories and their relations to illness and medicine (through their occasional battles with ill health or the suffering or death of a loved one) shaped their relationships with one of the most intractable domestic policy issues. Morone and Blumenthal thus succeed in lending a human touch to conservative figures such as Nixon, Reagan, or George W. Bush. They revisit the role of Republican presidents whose health policy approaches are explained and were softened, and sometimes corrected, by their personal histories.

3The Heart of Power also provides fascinating insights into the changing political, institutional, and societal environment in which presidents have exercised their function, one which has seen the rise of conservatism, Congress’ increasing polarization, the ascendancy of economists, and the growing importance of the media.

4“No president can escape the issue and almost none can successful manage it.”(130). Health care reform is a test of the president’s skill and determination to produce bold ideas and translate them into legislation by playing the insider game, navigating the pitfalls of the American system of government and using the bully pulpit to rally the nation behind his vision. In the area of domestic policy, more than any other issue, it has become the standard by which a successful, modern presidency is measured. The book also demonstrates the courage it takes for a president to commit political capital to an issue that carries enormous political risks for uncertain rewards, and it throws into stark relief the magnitude of the task upon which Barack Obama has staked his presidency.

5This history of presidential health policy making, which spans the seven decades and eleven presidents from Franklin D. Roosevelt to George W. Bush, takes us through successive cycles of social policy, from the New-Deal Era with its faith in the power of government to act for the public good, to the last decade of the 20th century, which saw the Democrats abandon the Social Security model and shift to market-based reforms. In their quest for the keys to success, the authors debunk a few myths, and in their conclusion they draw the lessons of presidential successes and failures by means of a list of eight principles that might serve as a toolbox to help the next president handle the unfinished business of the New Deal.

6Most of their suggestions are inspired by the true story of Medicare they claim to reveal, as well as by the successful way Lyndon Johnson manoeuvred Congress into passing legislation he was passionately committed to. In one of the book’s most enthralling chapters, which illustrates Johnson’s preference for domestic policy issues and his superior efficiency in dealing with them, the authors pay a vibrant tribute to “the most important health care president the U.S. has ever had.” Based on information unearthed from White-House tapes and interviews, they give Johnson his due as the main player behind the passage of Medicare. The chapter offers a fascinating account of a clash of titans: Johnson, the fervent New Dealer and arch progressive, was determined to cajole Wilbur Mills, the powerful conservative chair of the House Ways and Means Committee, into adopting a bill that would fulfil Kennedy’s unfinished agenda. Although historians generally agree that Mills was the architect of the legislation, Morone and Blumenthal demonstrate that it was Johnson who masterminded it and pushed it through Congress through an adroit combination of coaxing, threatening, and above all, relentless persistence. The chapter reads like a textbook illustration of what it takes for groundbreaking, divisive legislation to be passed: presidential passion and commitment, speed, the ability to manage Congress and give it credit for success, and a willingness to put political goals ahead of economic concerns. In the rest of the book, the authors keep hammering home this formula for legislative victory.

7This enthusiastic account of Johnson’s health policy skills sidesteps a conundrum that has bedevilled historians for decades: why didn’t he use his tremendous political gifts to push for national health insurance? If the 1965 amendments to the Social Security Act represented “the single most important piece of health care legislation in American history,” they also undercut later efforts at achieving the liberals’ dream of universal coverage, pushing it into the realm of the politically unfeasible.

8Although the issue is in theory owned by the Democrats, another lesson of this analysis of presidential leadership in health care policy is that Republicans have also significantly contributed to shaping the system and inspiring reforms which sometimes expanded, or aimed at expanding, a welfare state that they excoriated. Democrats won the most spectacular success with the passage of Medicare and Medicaid, but they also experienced the most resounding failure (Clinton's health Security Act). One unexpected conclusion of this remarkable series of portraits is that Republican presidents were, for political but also deeply personal reasons, interested in health care policy issues and quite effective at handling them, sometimes in opposition to their own party’s line. Thus the Eisenhower presidency firmly established the foundations of America’s public/private health care system with the tax exemption of employer and employee contributions to health insurance premiums. It was under Reagan, a president who blamed government for society’s problems and was a fervent free-marketer, that Medicare’s prospective payment system for hospitals was adopted, an unprecedented government intrusion in the health care sector, potentially opening a wedge in the alliance between Republicans and the medical lobby.

9But it is Nixon who here emerges as a visionary president, a health care innovator whose reform principles would be – in some form or other – part and parcel of all health care reform proposals, both Democratic and Republican, for the next three decades. The chapter on Nixon highlights two major initiatives with long-ranging consequences: the Health Maintenance Organization Act (the name “HMO” was forged by the Nixon Administration), which encouraged the creation of health care networks on the model of Kaiser Permanente, one of the first prepaid group practices, and the enrollment of Medicare and Medicaid beneficiaries in HMOs. Variations on this model of health care financing and delivery were the keystone of health reform efforts in the late 80s and the linchpin of Clinton’s ill-fated plan. They are now firmly entrenched in the U.S. health care landscape. Even more surprising, Nixon was also the first president to support a detailed policy proposal aimed at providing universal coverage (the Family Health Insurance Plan of 1971 and its successor, the Comprehensive Health Insurance Plan), to be based on a combination of public and private financing, through public programs and a requirement that (for the first time) employers insure their workers. Although Nixon’s plan went nowhere because of Democratic opposition and the Watergate scandal, it was eventually to be recognized as a missed opportunity by many health policy experts, as well as by Ted Kennedy, one of its fiercest opponents at the time. Nixon solidified the public/private structure of the American health care system that two later Democratic presidents, Bill Clinton and Barack Obama (who also embraced the employer mandate) would recognize as “the American way.”

10The bills which emerged from committee in 2009 included several features of the Nixon plan, among them the obligation of employers to contribute to their workers’ insurance, an expansion of Medicaid, and federal subsidies for the low-income.

11Less convincing is the authors’ presentation of Reagan’s determination to pass a catastrophic health insurance act as a case study of how to win a legislative battle. They set out to understand why a politician who, at the start of his political career, had warned Americans of the threat Medicare would present to the very essence of freedom would, almost obsessively, back a huge and costly expansion of the program to cover catastrophic costs, a highly controversial proposal opposed by most members of his administration. Although they recognize it was intended for political gain during one of the most difficult periods of the Reagan presidency, Morone and Blumenthal also attribute it to the psychological consequences of the president’s traumatic childhood and an assassination attempt, as well as to his battle with illness and aging. But if the success of legislation is measured by its longevity, the Medicare Catastrophic Coverage Act of 1988 clearly fails to pass the test: the very principle which had allowed the bill to squeak through Congress (it would pay for itself through higher beneficiary contributions) would spell its demise a year later, when a backlash against the law and loud protests from the elderly led to its repeal by Congress.

12The last chapter of the book, one of the few surveys to date of G.W. Bush’s health care presidency, sheds light on the political paradox of the Medicare Modernization Act of 2003: it was promoted by a conservative president actively engaged in passing the most expansive entitlement reform since 1965. While the details of the horse trading over the bill’s specifics are not new, the authors provide an unexpectedly warm and appreciative analysis of Bush’s policymaking skills, showing him actively engaged in pushing a popular bill for political but also personal reasons (among them the traumatic loss of his younger sister Robin to leukaemia when he was a child), and laying out a blueprint for success: speed, flexibility, leadership. Bush’s veto of the State Children's Health Insurance Program expansion for purely ideological reasons at the end of his second term probably deserves more than the few lines they give it, and this would have mitigated their empathetic portrayal of a president who repeatedly denied the urgency of the health crisis (he once said, “I mean, people have access to health care in America. After all, you just go to an emergency room.”). Although not the definitive account of Bush's health care policy, this one nevertheless does justice to his success in enacting a reform that had eluded the Democrats since 1965.

13No health care presidency has influenced Barack Obama more than Clinton’s. The much studied failure of Clinton’s reform effort, promoted by a charismatic president who put policy ahead of politics, designed a hugely complex plan, but neglected Congress, traumatized a generation of reformers, but also provided a lesson on what not to do. In their conclusion, Morone and Blumenthal take us back to the rules that remain crucial to making headway on an issue that will not go away. In late 2009, it looked as if Obama’s approach was at least partly following the script given in The Heart of Power: he had acted fast, outlined broad principles, left the details to Congress, had an effective chief of staff, was ready to build on what existed, and had shown a willingness to compromise. He also had great communication skills which he had used to convey a sense of urgency to the nation. For the first time in the history of health reform, bills had been reported out of committees and a floor debate was being held in Congress.

14But where Obama and his advisers sharply diverged from the authors’ recipe for success was on the role of economists and on competing priorities: coverage or costs. The authors clearly favor coverage, deploring that, since the 1960s, with the creation of the Office of Management and Budget and the Congressional Budget Office, the increasing power of economists has hampered and limited the presidential scope of action. The hard realities of budget constraints are difficult to reconcile with the grand vision that would be needed to achieve meaningful reform. Johnson would never have succeeded in passing Medicare if economists had forecast the financial burden it would create (and did create) for the federal government. But instead of playing down the warnings of his economic advisors, Obama has consistently tied coverage to a reduction in spending growth and framed health care reform as a fiscal imperative vital to the nation’s economic future. If eventually the prize eludes a president who has, more than any other, relentlessly pursued the goal he set for himself and the nation, he might still secure his place in history by following one more piece of the authors’ advice: if you lose, define the terms of the debate and keep it alive, don’t let your opponents bury the issue for another generation – be a Harry Truman, not a Bill Clinton.

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Éveline Thévenard, « David Blumenthal and James A. Morone, The Heart of Power: Health and Politics in the Oval Office, Berkeley, Los Angeles, London, University of California Press, 2009, 484p »Transatlantica [En ligne], 2 | 2009, mis en ligne le 01 février 2010, consulté le 27 mai 2024. URL : ; DOI :

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