Sunday, June 28, 2020

Ten Things We Should Learn from COVID-19 and the Failed Trump Administration

1. COVID-19 is not the last virus we will see.  A new, even more, deadly virus could emerge any year.  We will probably not go five years without a pandemic.  We must be prepared to meet the economic and health challenges we will face from the next pandemic and the one after that.

 

2.  There is no place for racist or racism in this country.  

 

3. The debate is over.  The United States MUST have universal, free healthcare.

 

4. Traditional law-enforcement no longer works.  We must invest less in aggressively enforcing low-level, non-violent violations of the law and more in community-led support and public safety delivered by mental health providers, social workers, and victim's advocates.  Public safety should be about maintaining peace and reducing the social conditions that lead to crime.

 

5. Touchless and distance commerce is the norm.  Amazon is the future.  Shopping malls are the past.  Telemedicine is the future.  In-office doctor's appointments are the past.  Streaming movies is the future.  Movie theaters are the past.  Meals to go, takeout, and cook at home is the future.  Sit down restaurants are the past.

 

6.  The Gig Economy is here.  The days of a full-time, lifetime or near life-time employment are over.  The average person will have 100's, if not 1,000's of jobs during their career.

 

7. We should have a guaranteed minimum income for all Americans of working age pegged to the cost of living and above the poverty line.

 

8. Sixteen years of free public education.  A High School education is no longer sufficient to prepare students for good jobs in today’s economy much less tomorrow’s.  All current student debt should be forgiven.  

 

9. The Federal government should fully fund the expansion of 5G networks throughout the country.  Every American should have free and reliable internet access regardless of where they live.  Rural America cannot compete for jobs without reliable access to the internet.  

 

10. The American system of government no longer works.  We must write a new Constitution for the 21st Century that, among other things, provides for: 

 

a. Popular election of the executive for a single six-year term.  Candidates for the executive should be required to disclose their financial assets and place their assets in a blind trust during their term of office.  Candidates should be required to take general intelligence; physical and psychological tests and the results of the tests should be publicly disclosed at least six weeks before the first vote is cast in an election.  These tests must be repeated every two years with the results publicly disclosed.

b. Abolishment of the Senate.  

c. A single legislature elected for a four-year term from non-gerrymandered districts.  Districts should reflect contiguous geographical areas small enough that voters in the districts have a common community interest.  Terms should be staggered so that 25% of the legislature is elected each year.

d. 12-year single terms for Supreme Court and other federal judges appointed by a 2/3rd vote of the legislature.

e. Formal provisions for recall of the executive, members of Congress, and federal judges upon petition of 10% of registered voters.

f. Strict and effective legislative oversight of the military and Justice Department.

g. Federal funding of all national elections ban on corporate/group contributions to candidates, maximum limits on individual contributions to candidates, strict limits on campaign spending, and full disclosure by candidates on campaign contributions.

h. Online voting and/or vote-by-mail for all elections.

i. Automatic, simple, and easy voter registration to ensure that every American who is qualified to vote can vote.

j. Tax and other incentives for voting.

 

Please feel free to critique each of these and add new lessons.  We need a national dialogue concerning where we go from here.

Saturday, May 2, 2020

Why You Should Never, Ever Vote for a 3rd Party Candidate

You don’t like either Trump or Biden?  Thinking about voting for a 3rd Party?  Don’t.  If you vote for a 3rd Party candidate, you won’t just be throwing your vote away, you very likely will be helping elect the major party candidate you like the LEAST.  Here is why.

First, 3rd Party candidates can’t win.  The system is designed to prevent them from doing so.  NO 3rd Party candidate has ever been elected.  Former Republican Theodore Roosevelt running on the Progressive Party banner in 1912 had the best showing and he managed to get only 88 of the 531 electoral votes.  No other 3rd Party candidate has come close to matching Roosevelt.  Note: Roosevelt split the Republican Party handed a landslide victory to the Democratic Party candidate Woodrow Wilson.

The American system is designed to make it impossible for 3rd Party candidates to win.  

First, the system is rigged to keep 3rd Parties off the ballot.  Most states place a nearly impossible requirement that a 3rd Party candidate must get signatures from 1% of the voters in the state who voted in the last presidential election AND these signatures must be obtained and verified by August and in some states as early as June of the election year.  Candidates who obtain the necessary signatures can expect to be sued by one or both major parties challenging each and every signature.  

Second, running for President is expensive.  Hilary Clinton spent $768 million in 2016 and Trump spent $440 million.  In 2020, Trump and Biden will probably have to come up with $1 billion each.  Most 3rd Party candidates can’t come close to raising that amount of money and, without it, they can’t get their message out.

Third, like them or not the Presidential Debates still, matter.  To get invited to participate in the all-important debates, any 3rd Party candidate must be picked by 15% or more of voters in at least 5 national polls.  Most people vote for their party identification and there are very few true independents.  Pew Research says that while 38% of Americans say they are Independents, 17% of those Lean Democrat and 13% Lean Republican.  Only 7% of Americans truly don’t lean toward one of the major parties.  Getting 15% or better in one national poll given the fact that even self-proclaimed Independents have a Republican/Democratic Party preference  is next to impossible if you are not running as a Republican or Democrat.  Getting 15% or better in five polls is impossible if you are a third-party candidate.

Bottom Line:  3rd Parties Can’t Win….EVER

VOTING FOR A THIRD-PARTY CANDIDATE IS THE SAME AS VOTING FOR THE CANDIDATE YOU LIKE LEAST

You are not just throwing your vote away on a guaranteed loser when you vote for a 3rd Party candidate.  You are actually helping the major party candidate you like the LEAST.  Why is that?

You are considering voting for a 3rd party candidate because you don’t like either of the two major-party candidates.  You don’t like Trump and you don’t like Biden.  Okay, but do you dislike them equally?  Let’s say, you had no 3rd party candidate to choose.  Let’s further say, just for the sake of this illustration, that write-in votes aren’t allowed.  You are stuck with picking Trump or Biden.  There is no other option if you vote.  You say you don’t like either candidate.  But, do you dislike Trump and Biden EQUALLY?  One is going to become President.  Will you be EQUALLY happy or unhappy with Trump or Biden? My guess is that you DO have a preference, even if it is a weak preference.  It is likely that you really, really don’t like one guy but only really dislike the other.  Unless you can honestly say that it makes absolutely NO difference to you whether Trump or Biden is President, then when you vote for a 3rd party candidate, you are voting FOR the candidate you would LEAST like to see as President.  Why?
Let’s say, you don’t like Trump or Biden.  However, if forced to pick between the two, you would pick Biden, not because you like him but because you DISLIKE Trump more.  You vote for a 3rd party candidate who cannot win.  Since you would have otherwise reluctantly voted for Biden, you are taking a vote away from him.  In a close election like 2020 is going to be, the loss of one vote could make a huge difference whether Biden beats Trump since in close elections EVERY vote counts.  If you are a “Biden is the lessor of two evils” voter and you vote for a 3rd party candidate, your best hope is that a “Trump is the lesser of two evils” voter votes for a 3rd party candidate, thereby canceling out your vote.  That’s the best you can hope to achieve, and that’s not a very good bet.  

What about not voting at all?  Here again, it depends upon whether you absolutely don’t have a  preference for one candidate over another.  Not voting when you have some degree of preference, even if it is very small, is the same as voting for a 3rd party candidate.  When you don’t vote, you take your vote AWAY FROM the candidate that you would have selected, although reluctantly.  That’s the same as voting for the guy you like least.

Bottom Line:  Hold your nose and cast a vote for the Democratic Party candidate or Republican Party candidate.  If nothing else, you avoid voting FOR the candidate you like LEAST.

Read more about this topic here:



Thursday, April 30, 2020

How should we address an economic downturn caused by social distancing during a pandemic?

Dennis Snower , a Senior Fellow at the Brookings Institution has produced an excellent paper on the unique economic policy challenges raised by a pandemic such as the COVID-19 crisis.
Snower begins with a summary of traditional Keynesian economics and government pump-priming during an economic crisis.  The basic model goes like this.  
Economies operate based upon Supply and Demand.  An increase in Demand for goods and/or services creates a need for more Supply to meet that Demand.  When companies cannot produce enough goods or services to meet the increased Demand, they have to hire more people or increase working hours that put more money in the hands of consumers who spend that money and create even more demand.  Demand leads to a need for increased Supply which leads to increased Employment/Wages which leads to increased Demand.
When a non-pandemic economic crisis occurs, such as in 2008, there is a drop in Demand which leads to less need for Supply which leads to Unemployment that leads to even less Demand.  The economy goes into a vicious downward spiral.  Governments can break that downward spiral in two ways.  First, governments can spend directly to create Demand by buying things like bridges, military equipment, and so on.  Second, governments can put more money in the hands of consumers through tax cuts or direct payments.  Consumers spend that money to create Demand.  It is called Keynesian Pump Priming.
Keynesian Pump Priming doesn’t work as well during a pandemic where people have to engage in Social Distancing.
Snower explains that the economy consists of two distinct kinds of production and consumption activities—Physically Interactive activities and Physically Distant Activities.  For example, waiters and customers in restaurants engage in Physically Interactive Activities—they have close physical contact.  Contrast that with Food Delivery such as Pizza Delivery.  Participants in Food Delivery are engaged in Physically Distant Activities.  Consumers and delivery people have limited physical contact.  Snower calls the Physically Interactive activities I-Chains and Physically Distant Activities D-Chains. 
In a normal economic downturn, I-Chains and D-Chains respond equally to a typical Keynesian response to getting the economy going again.  That’s not true when the economic downturn is caused by a pandemic such as the COVID-19 pandemic during which people have to engage in social distancing.  I-Chains collapse.  Keynesian pump-priming can’t bring them back to life as long a social distancing is in place.  
Snower says during a pandemic we can, and usually do, end up with a Great Economic Mismatch regardless of the pump-priming governments provide.  I-Chain jobs don’t come back while the demand for jobs in the D-Chain explode.  For example, restaurants can’t reopen and re-hire waiters, food preparers, and so on because people are voluntarily engaging in social distancing or being required to do so.  At the same time, demand for food delivery explodes and companies in that D-Chain struggle to meet demand since, for example, they don’t have sufficient production or delivery capability.  Some I-Chain companies can switch to D-Chain but, for many, it isn’t that easy.  For example, some restaurants can adapt easier to takeout, drive-through and delivery while others can’t simply because of the way their business is designed—they don’t have drive-through windows, delivery vehicles and drives, menu items that are well-suited for takeout or delivery and so on.  Food producers that are set up to serve the I-Chain restaurants having packaging and delivery systems that can’t easily be converted to meeting the needs of D-Chain grocery stores.  Food grown or packaged for the I-Chain may go unsold or may have to be discarded while D-chains grocery stores are unable to obtain sufficient supplies to meet a sudden increase in demand.  Grocery store shelves sit empty while warehouses are overflowing with food packages in large containers for delivery to restaurants.  Vegetables intended for the I-Chain rot in fields or are plowed under while grocery stores sell out of produce.  Employees who work in the I-Chain may find it hard to transition to working in the D-Chain because they lack the necessary skills or tools to match the skills they have with the vacancies that exist in the D-Chain due to the explosion in demand.  Additionally, D-Chain may be reluctant to invest in training out-of-work I-Chain workers for fear that they will lose these workers and their training investment as soon as Social Distancing ends and the I-Chain reopens.
If pandemics are rare and short-lived, the Great Economic Mismatch that Snower discusses may not matter that much.  As soon as the crisis ends, I-Chains open back up and over-stressed D-Chains go back to normal.  But, what if we experience more frequent and long-term pandemics in the future?  Some research suggests that is exactly what is happening.
Research suggests that we can expect more pandemics like COVID-19, not fewer due to three major changes.  First, the globalization of travel.  In 1970 the world had 310 million air transport journeys.  In 2018, the number of air transport trips had grown to 4.2 billion.  People are traveling longer distances, more often, and taking infectious diseases with them.  It is increasingly difficult to isolate an outbreak of infectious disease before it has a chance to spread not just to a neighboring country but to the other side of the world.  Second, people are living closer together.  It is estimated that nearly 70% of the world’s population will live in urban areas by 2050.  Day-to-day social distance is becoming less and less possible for more and more people.  The closer we are packed together, the easier it is for a virus to spread.  Finally, there is climate change.  Recent research shows that global warming is exposing larger numbers of people to infectious diseases.  For example, the warming of the planet has been linked to the spread of viruses from bats to humans which is one likely source of COVID-19.
Snower argues that to avoid or minimize the Great Economic I-Chain/D-Chain Mismatch we need a Readaptation policy that provides incentives for people and companies to rapidly switch from I-Chain to D-Chain activities during a pandemic.  Snower proposed Readaptation Policies for Labor Markets, Investments, and Financial Markets.
Labor Markets: One way to encourage rapid Readaptation in labor markets, says Snower, would be to provide D-Chain incentives during a pandemic to hire and train out of work I-Chain employees and incentives for online job search and matching services to provide I-Chain to D-Chain matching.  These programs would be funded by providing out-of-work I-Chain employees with hiring and training credits that D-Chain employers would receive from hiring and training I-Chain employees.  The number of credits an I-Chain worker had to offer a perspective D-Chain employer would rise with the duration of unemployment, fall with the duration of employment, and be totally phased out after two years.
Investment:  During a pandemic, I-Chain company capital equipment sits idle while D-Chain companies can’t ramp up services to meet increased demand because they lack the same type of capital equipment.  For example, I-Chain trucks and delivery vans sit idle while D-Chain companies experience a shortage of the same trucks and vans.  Here Readaptation Policies would focus on providing incentives to I-Chain companies to convert or make available their excess I-Chain capital equipment for D-Chain use.  Again, the policy would require online services that matched D-Chain needs to available I-Chain equipment and supplies.  
Financial Markets-Here Snower is concerned about “debt overhang” or the overall indebtedness of governments, businesses, and individuals.  He notes that many, if not most, corporations are highly leveraged.  U.S. corporate debt reached $10 trillion in 2019 or 47% of the U.S. economy, a record high.  Corporate indebtedness has been driven by cheap interest rates since 2008.  Now we have a pandemic and the monetary and fiscal stimulus from the U.S. governments has come primarily in the form of loans that further increase corporate debt.  Once the pandemic ends, many corporations may be carrying so much debt that they cannot borrow funds they need to get back up and running, even if the economy and consumer confidence are improving.  Snower proposes two new instruments to mitigate the effects of debt overhang.  The first is corporate bonds and loans where interest rates and repayment options are tied to corporate earnings.  When corporate earnings fall below a certain loan, interest rates on these loans decline, and the corporation is allowed to postpone payment of principal and interest for a specified period.  Second, corporate bonds and loans could be automatically convertible to non-voting equity when the ratio of corporate equity to risk-weight assets drops below a certain level.  Such financial instruments would avoid bailouts for corporations “too big to fail”.
Would Snower’s proposals work?  We don’t know.  However, Snower is raising an important issue.  Traditional Keynesian pump-priming to address an economic downturn does not work when the downturn is caused by the response to a pandemic.  We need a different strategy to address pandemic-induced downturns which are likely to become more frequent in the future.
Read Snower’s paper here:
NOTE: Dennis J. Snower is President of the Global Solutions Initiative; Professor at the Hertie School of Governance, Berlin; Senior Research Fellow at the Blavatnik School of Government, Oxford University; Nonresident Senior Fellow at the Brookings Institution; and President-Emeritus of the Kiel Institute for the World Economy. 

Thursday, March 5, 2020

Trump Economic Policies Leave Us Poorly Prepared to Fight an Economic Downturn

The U.S. economy goes through cycles of boom and bust.  For example, from April 1991 to February 2001 the U.S. had a booming economy driven largely by investments in the internet.  In March 2001 the economy went bust and we had the 2001 recession.  From 2002 to 2007 the economy boomed due to derivatives and the housing bubble then crashed leading to the 2008 bust and the great recession.  In 2009, the economy began responding to quantitative easing and the American Recovery and Reinvestment Act.  It has been in a boom cycle since then, the longest boom cycle ever.  We don’t know yet but the current correction in the stock market may be a sign that the economy is once again going from boom to bust.  No one should be surprised.  It is the nature of the economy to go boom, bust, boom, bust, etc.  If we don’t have a bust this year, one will come in the next few years.  That is certain.
When the economy goes bust, unemployment increases, the stock market tubes, and businesses stop expanding.  The U.S. government has three options to try to get the economy going again.  The Fed can cut interest rates to make it cheaper for companies and individuals to borrow and spend, thereby increasing demand.  The U.S. government can create demand directly by increasing spending on things like roads and bridges and other infrastructure improvements.  Congress can cut taxes in the hope that consumers will spend the retained dollars, thereby creating demand.  Tax cuts are most effective when they are targeted.  For example, when lower-income people receive tax cuts, they are more likely than rich people to increase their spending.
Two things affect the ability of the Fed to cut rates and Congress to increased spending and/or cut taxes.  The U.S. Government deficit and the Fed Funds Rate.  During a Bust, government revenues decline, and the deficit grows.  Tax cuts result in even less revenues.  The only way the government can increase spending is by borrowing money, thereby increasing the deficit. The Fed’s ability to cut the funds rate depends upon how high the funds' rate is when the bust begins.  Obviously, the Fed has more leverage if the funds' rate at the beginning of the bust cycle is 5% than if it is at 1% since the Fed cannot cut the rate to less than 0%.
During a Boom such as we have been experiencing since 2009, the smart thing to do is let the Fed Funds Rate slowly rise.  You lower it until the economy is gets going and then gradually raise the rate but not so fast that you slow the recovery.  Second, you avoid tax cuts and gradually raise taxes in order to pay down the deficit.  Again, you do this gradually to avoid slowing the recovery.  The objective is to get the Funds Rate back up, so the Fed has room to cut the rate during the next Bust and pay down the deficit so that there is room to engage in deficit spending or to adopt targeted tax cuts to create demand in a downturn.
Since 2016, the Trump Republicans have done just the opposite of what they should have been doing.
In 2008 at the beginning of the Great Recession, the Fed Funds rate was at 3.5%.  The Fed cut the rate all the way down to 0.25% before letting it gradually rise to 1.75%.  That’s much lower than you would want at the beginning of a Bust or deep recession since this time around the Fed will have less leverage in rate cuts.  We are fortunate that the current Fed Rate is not lower.  Trump and Republicans have been pressuring the Fed to cut the rate.  If they had their way, the Fed Rate would now probably be under 1%, a disastrously low level at the beginning of a Bust.
The Deficit as a % of GDP was at 3.1% in 2008, went up during the recession and was back down to 3.1% in 2016 and trending down.  Trump Republicans pushed through an unnecessary tax cut coupled with a massive increase in military spending.  As a result, the deficit as a % of GDP shot up to 5.1% in 2019, just what we would not want to happen.  The Debt to GDP Ratio, another measure of the deficit, was at 67.7 in 2008, a sustainable level.  The ratio increased to over 100 during the recession and recovery and was just beginning to decline when Trump took office.  Under Trump, the debt to GDP ratio has resumed its upper path and is now at 105.5 and climbing.  Most economists say a debt to GDP ratio around 60 is probably okay and but over 100 is not sustainable for more than a few years.  The World Bank says a debt to GDP ratio over 70 slows economic growth.  So, there is disagreement about when to worry.  There is no disagreement that a lower number is better than a higher one.  The highest in the U.S. was 120 at the end of World War II.
In summary, the U.S. Government needs the ability to step in to revive the U.S. economy when a downturn occurs, which always happens.  If the Fed Rate is relatively high and the U.S. Debt is low, then the Fed has a lot of room to cut the Fed interest rate to stimulate spending and increase demand.  Congress has a lot of room to increase government spending and to cut taxes to pump money into the economy without worrying about creating an unsustainable debt such as a debt to GDP ratio well over 100.
Instead of facing a possible economic downturn with a high Fed Rate and low debt, we currently have a relatively low Fed Rate and high and increasing debt to GDP ratio, just the opposite of what we would want.  
Trump Republicans are to blame for putting us in this difficult situation.  They cut taxes at the wrong time.  They failed to target the tax cuts, so they had little positive effect on the economy.  They dramatically increased military spending at a time when the stated goal of the Trump administration was to withdraw from conflicts and bring the troops home.  That policy should have called for less, not more, military spending.  Finally, Trump has consistently pressured the Fed to cut the Fed Rate at a time when the rate should have been gradually increased.  We don’t know if the Fed would have raised the Fed Rate faster without the pressure from Trump, but Trump’s pressure probably did have an impact.
It took the United States nearly 10 years to fully recover from the 2008 Recession, in spite of drastic cuts in the Fed Rate (down to almost 0%) and deficit spending that while massive was much less than required given the severity of the recession.  In fact, most economists would agree that the recovery could have been shortened with a larger stimulus.  
Thanks to Trump, the next time we have a downturn, the FED will have less room to cut interest rates than it did during the 2008 recession.  Congress will find it difficult, and perhaps impossible, to pass a stimulus the size of the stimulus it passed to combat the 2008 Recession because of the huge Trump deficit. 
It took 10 years for the U.S. economy to recover from the last major downturn.  Thanks to Trump’s economic policies we may face an even longer recovery the next time our economy goes bust.  The chance of the U.S. economy going bust someday, maybe someday soon, is 100%.  It is going to happen.

Wednesday, February 26, 2020

Key States and Strategies to Win in 2020

I don’t know how I missed this when it first came out but back in October of last year, Ruy Teixeira and John Halpin at The Center for American Progress provided a detailed analysis of the 2016 election coupled with projections of changes in voter demographics in 2020 to show what it will take for Democrats to beat Trump this year.  See: https://www.americanprogress.org/issues/politics-and-elections/reports/2019/10/24/476315/path-270-2020/
Note: Voter demographics refer to changes in the age, racial and other characteristics of voters that occur as people move into and out of the state, come of voting age, get older, etc.  
I highly recommend you read this 60-page analysis.  It is excellent.
Teixeira and Halpin focus their analysis on what they believe 15 key states that will determine who wins the election in 2020 by getting 270+ electoral votes.
Pennsylvania
Ohio
Michigan
Minnesota
Wisconsin
Iowa
Texas
Arizona
Colorado
Nevada
New Mexico
Georgia
North Carolina
Virginia, and
Florida.
Teixeira and Halpin leave out states that are almost certain to go for one candidate or another such as California which will most likely be Democrat and Mississippi that almost certainly will go for Trump.
Here is a brief summary of their findings and predictions for each of these key states.
In 2016, Trump received 304 votes to Clinton’s 227.  Trump carried 10 of the 15 states in the Teixeira and Halpin analysis and Clinton won five.  We begin by deducting the electoral votes of the states in this analysis from the 2016 totals for both Trump and Clinton to get the following which represents the votes Trump and Clinton won in 2016 EXCLUDING  the states Teixeira and Halpin examined in their study.  We start with the following:
2016 Results States Not Examined Below: Trump 124   Clinton 192
ANALYSIS OF KEY BATTLEGROUND STATES
Now, we look at each battleground state in the Teixeira and Halpin study and award electoral votes based upon their analysis.  Pennsylvania is first.
Pennsylvania: 20 electoral votes
Trump won Pennsylvania in 2016 by just 0.7% of the vote.  Demographic changes in the voting population in Pennsylvania in 2020 are favorable to the Democrats and might just be enough to flip the state back to Democrats if turnout and voting patterns remain the same as 2016.  Democrats can improve their chances by increasing Black turnout, increasing their margin among white college-educated voters and cutting into Trump's 30-point 2016 lead among white non-college educated voters.  
Advantage: Democrats due to demographic changes
2020: Trump 124   Democrat 212  We award Pennsylvania’s 20 electoral votes to the Democrat.
Ohio: 18 electoral votes
Trump won Ohio by 8 points in 2016. Demographic changes in 2020 favor the Democrats but will not be enough to tip the election to Democrats.  Democrats need to increase Black turnout to 2012 levels and increase support from white, noncollege voters by concentrating on white women, college and noncollege.
Major Advantage: Trump
2020: Trump 142   Democrat 212
Michigan: 16 electoral votes
Trump won Michigan by just 0.2 points.  Demographic changes in 2020 favor Democrats and could give Democrats a win by 0.6 points.  If Democrats could get Black turnout back to 2012 levels, they would add to their margin.  The greatest opportunity for Democrats in Michigan is to increase their white, noncollege vote.  Getting the Democratic white, noncollege vote back to 2012 levels could give Democrats a 5-pt. margin of victory.  Teixeira and Halpin say Democrats have their best shot by focusing on white, noncollege women.
Advantage: Democrats
2020: Trump 142    Democrat 228
Minnesota: 10 electoral votes
Clinton won Minnesota but by only 2 points.  Demographic changes should be enough to give the Democrats another victory in 2020, possibly with a larger margin.  They could do even better if they got their support from white, noncollege voters back to 2012 levels.
Major Advantage:  Democrats
2020:  Trump 142  Democrat 238
Wisconsin:  10 electoral votes
Trump won Wisconsin by just 0.8 points.  Demographic changes may be just enough to give Wisconsin to Democrats in 2020 by a thin margin.  Democrats can increase their margin of victory by getting Black turnout back to 2012 levels and returning their support from white, noncollege voters, particularly women, to 2012 levels.  Those changes would give Democrats a comfortable margin of victory.
Major Advantage:   Democrats
2020:  Trump 142   Democrat 248
Iowa: 6 electoral votes
Trump won Iowa by 9 points.  Demographic changes favor the Democrats but Teixeira and Halpin say Trump will probably carry Iowa easily.  Democrats could pull off a win if they could get their white, noncollege vote back to the level Obama achieved in 2012.
Major Advantage:   Trump
2020:   Trump 148  Democrat 248
Texas: 38 electoral votes
Trump won Texas by 9 votes.  Demographic changes favor the Democrats but Teixeira and Halpin say Trump’s 76% to 21% lead over Clinton among white, noncollege voters will be difficult to overcome.
Major Advantage:   Trump
2020:   Trump 186  Democrat 248
Arizona: 11 electoral votes
Trump won Arizona by 3.5 votes.  Demographic changes favor the Democrats largely because of an expected decline white, noncollege voters which are Trump’s base.  Teixeira and Halpin say Trump may have difficulty holding Arizona if Democrats can increase their margin among white, college and Hispanics,  Asian/other race voters and make some inroads into Trump’s white, non-college voters.
Advantage:  Democrats by a small margin
2020:   Trump 186   Democrat 259
Colorado:  9 electoral votes
Clinton won Colorado by 5 points.  Demographic changes favor Democrats particularly because of an expected decline in white, noncollege voters.  Teixeira and Halpin say Democrats should be able to hold Colorado and possibly by increasing their lead with white, college and Hispanic, Asian/other race voters.
Advantage:   Democrats
2020:   Trump  186   Democrat  268
Nevada:  6 electoral votes
Clinton won Nevada by 2.5 points.  Demographic changes favor Democrats but not enough to deliver a win.  Clinton won but by a smaller margin than Obama in 2008 and 2012.  Democrats need to focus on white, college voters and Hispanics, Asians and other races to try to get back to 2012 or 2008 levels of support.
Advantage:  Democrats
2020:  Trump  186   Democrats 274   Democrat Wins
New Mexico:  5 electoral votes
Clinton won New Mexico by 8 points which was less than the Obama wins in 2008 and 2012.  Demographic changes favor the Democrats.  Democrats probably will win New Mexico in 2020 and could do better than Clinton by focusing on increasing turnout among Hispanics, Asians, and other races. 
Advantage:  Democrats
2020:  Trump  186    Democrat  279
Georgia:  16 electoral votes
Trump won Georgia by 5 points.  Demographics favor Democrats but are not enough for a win.  Democrats need a huge Black turnout to win, something close to 2012 levels.  Democrats need to increase their support from white, college voters by focusing on white, college-educated women.  Democrats cannot afford to allow Trump to make gains among white, college voters.
Small Advantage:   Trump
2020 Possible:  Trump 202  Democrat  279
North Carolina:  15 electoral votes
Trump won North Carolina by less than 4 points.  Demographic changes favor Democrats and should narrow his lead.  As in Georgia, the Black vote is critical for Democrats who need a Black turnout similar to 2012.  Democrats must also increase their share of white, college voters.
Small Advantage:  Trump
2020 Possible:  Trump 218  Democrat  279
Virginia:  13 electoral votes
Clinton won Virginia by 5 points.  Demographic changes in Virginia should be enough to give Democrats another win primarily because of a decline in white, noncollege voters which are Trump’s base.  Democrats can increase their margin by getting Black turnout back to 2012 levels.
Advantage:  Democrats
2020 Possible:  Trump 218  Democrat  284
Florida:  29 electoral votes
Trump won Florida by 1 point.  Demographic changes favor Democrats and will probably make the 2020 race very close.   To win, Democrats need to get Black turnout back to 2012 levels and either increase their margin with Hispanic, Asian and other race voters and/or with white, college voters.
Advantage:  Tie
If Trump Wins Florida:  Trump 247  Democrat  284
If Democrat Wins Florida:  Trump 218  Democrat  313
DEMOCRATS HAVE A CHANCE TO WIN
Regardless of what happens in Florida, Teixeira and Halpin’s analysis suggests that Democrats have a good chance of winning in 2020 by a margin of 37 to as much as 95 electoral votes gaining a total of somewhere between 284 to 313 electoral votes.
That outcome assumes of course, that Teixeira and Halpin’s estimates of the demographic changes in each state are correct AND that the voting patterns of the key voting groups (white, noncollege; white, college; Black; Hispanic; and, Asian/other race) remain the same.
Conclusions-What Must Democrats Do To Win?
Teixeira and Halpin have done a tremendous job of analyzing the available data and you should read their entire report here: https://www.americanprogress.org/issues/politics-and-elections/reports/2019/10/24/476315/path-270-2020/
In the conclusion of their report, Teixeira and Halpin note that Donald Trump won in 2016 because of strong support from white, noncollege voters who made up more than half of the total voters in states that put him over the top such as Pennsylvania, Ohio, Michigan, Wisconsin, and Iowa. Five of the 15 key states he carried in 2016.  In 2020, demographic changes are likely to shift the voting population more toward the Democratic Party core white, college-educated voters, Blacks, Hispanics and Asians, and other races.  Trump’s approval rating among these voters is weak and in some cases hostile.  Additionally, Trump's popularity among white, noncollege women seems to be declining.  The demographic changes and Trump’s lack of popularity among groups that will be playing a larger role in Presidential elections makes it difficult for him to win in 2020 following the same strategy as he did in 2016.  How much can he enlarge his already huge lead among white, noncollege voters, particularly when white, noncollege voters are actually declining as a percentage of the voting population?
Demographic changes are working in Democrats’ favor.  However, these changes have not yet reached the point in most states where they can tip a presidential race to the Democrats.  How can Democrats win?  If you review the analysis I just provided, you will notice that returning Black turnout to the 2012 Obama levels is key to victory for the Democrats in 6 of the 15 battleground states in 2020.  The second key, which is critical for Democrat’s in 7 of the 15 battleground states is peeling away at least some of Trump’s support among white, noncollege voters, particularly among white, noncollege women.  Finally, in four of the battleground states, Democrats need to add to their margins among white, college-educated voters while increasing turnout and their margins among Hispanics.
PICKING A DEMOCRATIC PARTY CANDIDATE
Now, comes the hard part.  If Teixeira and Halpin are right, and their analysis is the best I have seen, Democrats need to find a candidate who can:
  • Excite Black voters to turn out at levels similar to 2008 and 2012 when Obama ran,
  • Appeal to white, noncollege women who voted for Trump in 2016 but are having second thoughts and may be prepared to abandon Trump for a Democrat,
  • Increase Hispanic turnout and support, and
  • Simultaneously, maintain and/or expand Democratic support among white, college-educated voters. 

If Democrats want to have the best chance of beating Trump in 2020, they must find a candidate that can do all four of these things.  That's a tall order but necessary.  The question is;  Can any of the current Democratic candidates accomplish these four things?  

Monday, February 24, 2020

The Coronavirus Could Mean the End of Trump

Trump is one of the most unpopular presidents to have ever run for re-election with average ratings throughout his first term stuck mostly in the low 40s.  He has never achieved an average of 50% approval or higher.  History tells us that such low approval ratings are a disaster for incumbent presidents seeking a second term.  Since Eisenhower, no sitting president with an average approval rating like Trump’s has won a second term.  Yet, Trump seems to have a shot of doing just that. Why?  Largely because the economy is in pretty good shape.  
Trump has earned an average approval of 50% or better on the economy throughout his first term.  It does not matter that Trump really hasn’t improved the economy during his term.  He inherited a good economy from Obama and the positive trends have continued largely despite and not because of Trump’s policies.  There is little doubt that Trump’s average approval rating overall would probably be close to the lowest, if not the lowest, of any president running for a second term if it were not for his positive ratings on the economy.   See the following on Trump’s approval ratings:
So, what would happen to Trump’s chances if the good economy suddenly collapsed between now and election day?  For example, what would happen if we had a repeat of 2008?  Trump would probably be in big trouble.  Many people who now give him credit for the good economy could change their minds.  See the timeline for the 2008 crisis here: https://en.wikipedia.org/wiki/Financial_crisis_of_2007–08
Until now, there has been little sign that the U.S. economy was likely to change that much over the remainder of 2020.  Everyone expected a recession eventually but it did not look like that will happen this year.  At least, it did not look like that could happen until now.
Why are some people becoming less confident about the economy in 2020?  One word:  
Coronavirus
The U.S. Stock Market just took a big hit on fears of the impact of the Coronavirus on the world economy because the coronavirus, which started as an epidemic now may be turning into a Pandemic like the Spanish Influenza of l918, the Asian Influenza in 1957 and the Hong Kong Influenza of 1968.  See: https://finance.yahoo.com/news/stock-market-news-live-updates-february-24-2020-123446614.html
Pandemics, in addition to being health disasters that can lead to the death of millions, can have a significant impact on the world economy.  For example, the World Bank estimated that the Hong Kong Influenza of 1968 that killed 71 million people, caused a recession that cost over $3 trillion and resulted in a global reduction in the gross domestic product of between 3.1 and 4.8 percent.  
Why do Pandemics harm the economy?  Douglas Holtz-Eakin at American Action Forum explains the impact this way:
“On the supply side of the economy, the pandemic harms the supply of labor, both temporarily – some workers get ill but recover – and permanently – sadly, there will be fatalities. With fewer workers and hours, the economy shrinks. The second area is reduced spending, that is, a drop in demand. The prevalence of the disease leads people to “self-quarantine” – they stop going to movies, restaurants, malls, and other public places. There are severe reductions in the entertainment business and smaller impacts elsewhere in the retail economy.”  Source: https://www.americanactionforum.org/daily-dish/the-economics-of-pandemics/
We are already seeing this reduction in supply and demand caused by the Coronavirus which could lead to a collapse of the Trump economy.  If that happens, Trump’s approval, already bad, will worsen.  His approval may collapse altogether once Americans realize that his policies have made fighting the spread of diseases like the Coronavirus more difficult. 
The Coronavirus pandemic will not be nearly as bad as previous pandemics.  Maybe a treatment or vaccine will be found in time.  Maybe (hopefully) the death toll will be far below other pandemics due to better medical care and governments taking action to prevent or, at least slow, the spread of the virus.  If that happens it will be no thanks to Trump.  
Most Americans don’t know, but Trump has made the fight to stop the spread of Coronavirus-type diseases harder.  Since he took office, Trump has sought to cut funding for research on the spread of infectious diseases.  For example, in 2018 he tried to cut funding for the spread of infectious diseases like the Coronavirus by 10%.  He sought a 19% reduction in 2019 and a 20% reduction in the 2020 budget.  Each time Congress reinstated the funding, but funding for such CDC programs is currently 10% below 2016 levels when adjusted for inflation.  See: http://theconversation.com/the-trump-administration-has-made-the-us-less-ready-for-infectious-disease-outbreaks-like-coronavirus-130983
The United States and the world are less prepared and less capable of fighting the spread of the Coronavirus due to Trump’s healthcare policies.  
If the Coronavirus becomes a full-blown pandemic, many people will suffer or die from the disease and almost everyone will feel its economic impact whether they contract the disease or not.  Trump will pay a price.  
The Coronavirus may cost Trump re-election regardless of who becomes the Democratic Party candidate.

Wednesday, February 19, 2020

Trump Could Win Re-Election Without Gaining a Majority of Either the Popular OR Electoral Votes: Here’s How.

Trump won the 2016 election while losing the popular vote.  Something worse could happen in 2020.  Trump could win re-election WITHOUT winning a majority of either the popular OR Electoral College votes.  Here is how that could happen.
Assume that like in 2016, Trump loses the popular vote but neither Trump nor the Democratic candidate wins a 270 electoral vote majority.  Such an outcome is not likely but could happen with just a few changes in the election outcome from 2016.  Miles Coleman at the University of Virginia Center for Politics provides one possible scenario.  He writes, imagine that “Democrats win back Wisconsin and Michigan and finally turn Arizona blue. In this scenario, Pennsylvania stubbornly stays with Trump, and he’s able to replicate his 2016 showing in ME-2 (Maine House District 2). If Democrats can return NE-2 (Nebraska House District 2) back to their fold, it would provide their 270th electoral vote… If NE-2 stays Republican, the result would be a 269-269 tie, in which, ironically enough, ME-2’s single electoral vote would prevent the Democrat from winning an Electoral College majority.”  See: http://centerforpolitics.org/crystalball/articles/the-electoral-college-maine-and-nebraskas-crucial-battleground-votes/
If no candidate wins a majority (270) electoral votes, the Constitution says the newly elected House of Representatives chooses the President.  Let’s say the Democrats retain their majority in the House, which is likely.  That means the Democratic candidate would become President if the vote is along party lines, right?  Wrong.  
Under the 12th amendment, in the case of a tier in the Electoral College vote, the House elects the new President but each state delegation has only one vote.  Currently, Republicans control 26 of the State delegations (more Republican House members than Democratic House members).  Going into 2020, it looks like 19 State delegations are Safe Republican, 6 are Likely Republican and 1 Leans Republican.  At least 26 State delegations are Safe, Likely or Leaning Republican.  Contrast that to what Democrats can expect.  Going into 2020, 14 State delegations are Safe Democrat, 3 are Likely Democrat and 2 are Leaning Democrat.  5 States are Toss-ups. In Short, the odds are very much in the favor of Republicans when it comes to who will have the necessary 26 State delegations to elect the next President.  Trump wins. See: http://centerforpolitics.org/crystalball/articles/republican-edge-in-electoral-college-tie-endures/ on these projections.
If House Republican delegations picked Trump, and they almost certainly would, Trump would be the first President to be re-elected after being impeached, the first President to gain office twice without ever winning the popular vote and the 2ndPresident to win office after the adoption of the 12th Amendment in 1804 without gaining a majority in the popular vote OR electoral college vote.   He would also be the most unpopular President ever re-elected office.
What a nightmare! 

Monday, February 17, 2020

Defeating Trump. What It Will Take.

Trump has a clear advantage in running for President as an incumbent, particularly being an incumbent at a time when the U.S. economy is strong.  There have been only nine Presidents who ran for a second term and lost.  Some people include two others-Grover Cleveland and Lyndon Johnson.  Actually, Johnson decided not to seek a second term, so technically he probably should not be included.  Cleveland actually served two terms, but they weren’t consecutive.  He served from 1885 to 1889.  Lost to Benjamin Harrison in 1888 but won in 1893.
In all nine cases where a sitting president lost a bid for a second term, the economy was a factor.  There were usually other factors, for example, Carter was burdened with the Iran hostage crisis.  Never-the-less, presidents who seek a second term usually win re-election provided the economy is in reasonably good shape.
Read more about presidents who lost their bid for a second term here: https://www.thoughtco.com/one-term-us-presidents-3322257   
And here: 
While Donald Trump can not take credit for the state of the U.S. economy in 2020 since he inherited an economy in good shape from Obama, he will get credit for at least not causing a reversal in positive trends that existed when he took office.  In short, as far as the economy goes Trump is in good shape to be elected.  His biggest problems that make him vulnerable, except for his healthcare and tax/debt policies, have to do with his personality, especially as expressed through his tweets.  One can make a good argument that the biggest thing Trump could have done to secure re-election was to stop tweeting and to keep his mouth shut except when reading carefully scripted addresses.  In short, Trump's mouth has been his own worst enemy.  
To beat Trump in 2020, Democrats have to do five things:
1. Remind Americans how much they personally dislike Trump as a human being and why. Unlike every other President going back to Harry Truman (1945-1953), Trump’s average approval rating has NEVER been above 50%, in fact, he got an average approval above 45% only once and that was during his first month in office.  Since 1952, no sitting President has been elected for a second term if his approval rating was less than 50%. American’s really don’t like this man, even those who agree with many, if not most of his policies.  We must remind them of what they dislike about Trump.  See: https://projects.fivethirtyeight.com/trump-approval-ratings/
2. Offer Americans a candidate who is just the opposite of Trump, i.e., smart, likable and someone they can be proud to have as their leader and spokesperson for the country.  Our candidate must have a record of accomplishment that contrasts sharply with Trump’s record of failure.  
3. Reassure Americans that the policies Democrats offer will continue the trends that started in the Obama years—low unemployment, rising incomes, strong stock market—and address issues that Americans face that Trump and Republicans have failed to address or even made worse such as expanding access to affordable healthcare and education, income inequality, the national debt, and the environment.  Democrats must offer Americans a positive and non-threatening future.   And, the word “Socialist” is a big problem for Democrats.  In January, Gallup conducted a poll in which it asked Americans whether they would vote for a candidate for President based upon candidate characteristics, one of which was a candidate who was a Socialist.  Only 45% of Americans said they would vote for a Socialist compared to over 90% who would vote for a Black, Catholic, Hispanic, Jewish person, or Woman.  Fewer Americans would vote for a Socialist than a Muslim or Atheist.  Socialist was the ONLY label that turned off more than half of Americans when it came to selecting a President.  Democrats may be able to overcome this reluctance to vote for a Socialist by distinguishing between Socialism and Democratic Socialism but that will require a lot of educating of Americans while Republicans hammer away with the simple messages—Socialism=BAD, Socialism=DANGEROUS, Socialism=UNAMERICAN.  That said, it is true that Bernie Sanders, who has embraced the label Democratic Socialist, currently leads Trump in the RealClear Politics polling average, although by a smaller margin (4.3 points) than Bloomberg (6 points) and Biden (5.6 points).  And, as Pete Buttigieg pointed out Republicans are going to try to label all Democrats as Crazy Socialists regardless of the label the Democrats apply to themselves or the policies they put forward even if those policies are conservative.  
4. Stay united in their determination to beat Trump.  This is perhaps the most important thing Democrats must do.  Trump will have a united party.  Most Republicans, even those who don’t like Trump, will still vote for him and work to get him re-elected.  If Centrists and Progressives can’t unite around the person who wins the Democratic nomination, Trump is almost guaranteed to win.  We can’t go into the fall election still fighting among ourselves.  We can’t win if Democrats don’t turn out in record numbers. In particular, we need a large turnout among the type of voters that made a substantial difference in the outcome of the 2018 mid-term election.

5.  Learn the lessons of 2018.  Democrats need to pay close attention to the 2018 mid-term elections.  According to an excellent analysis by Catalist Analytics ,  “young voters and voters of color, particularly Latinx voters, were a substantially larger share of the electorate” in 2018 and that benefited Democrats.   Catalist says the youth turnout double between the 2014 and 2018 mid-terms.  Democrats saw the biggest gains among young white voters (25-39 age group shifted Democratic by 17 to 18 points), white college voters (10-point gain), and people …historically modeled as neither Democratic nor Republican,” but in the middle ideologically.  Finally, a large portion of Democratic “gains came from people who voted in (2016 and 2018), switching from supporting Trump in 2016 to supporting Democrats in 2018.” Democrats must keep those types of voters in the Democratic column in 2020.  They could and very likely will provide the margin of victory for whichever party wins.  In short, Democrats must get a large turnout from their base while keeping 2016 Trump voters who switched and voted for Democrats in the 2018 mid-terms.  That’s going to be tricky since the former are more liberal/progressive and the latter more centrist.  Additionally, Trump and the Democrats will be going after some of the same key voters who may provide the margin of victory in the election.  One of Trump’s goals is to go after black voters and to win back the upper-income white voters that the Republicans lost in 2018.
Winning in 2020 will not be easy.  
Trump has the advantage of a strong economy, the incumbency, dedicated core supporters, and a united party. Additionally, Trump and Republicans generally have no qualms about cheating, suppressing the vote, spreading disinformation, encouraging other nations to interfere in the election on behalf of Trump, and deploying a wide range of dirty tricks.  Trump and Republicans will do anything do secure Trump’s re-election and control of Congress without concern for whether their actions are legal or ethical.
2020 will be one of the most challenging elections Democrats have ever faced.  Winning is possible with the right strategy, one that builds upon the lessons of 2018, but the Democratic core voters must be united and focused on one thing above all—Defeating Trump.  Above all, Republicans must not be allowed to retain control of the White House and Senate and regain control of the House.  That would be a nightmare for the country.  The outcome of the 2020 election will shape the country for decades to come.
Folks, this is going to be a watershed year and a tough, tough battle for people who care about America.  We can win but it will not be easy.  That’s why we need the most electable candidate we can find AND why we must stay united in one goal on which all Democrats can agree:  
Beat Donald Trump.

Thursday, February 13, 2020

Getting Legislation Passed: Medicare--Lessons for Progressives.



I've never posted this before.  It is from my book Getting Things Done in Washington.  I think it contains important lessons for all those who want so much to elect someone who can enact universal healthcare.   

3
The Struggle for
Health Insurance

On July 30, 1965, 47 guests, including the Vice President, members of Congress and other dignitaries, accompanied President Lyndon Johnson to join 200 others including former President Harry S. Truman in the auditorium of the Truman Library in Independence, Missouri to witness a historic signing ceremony.  The occasion was the signing into law of Medicare.  Johnson said, “I’m so proud that this has come to pass in the Johnson Administration…And through this new law…every citizen will be able in his productive years, when he’s earning, to insure himself against the ravages of illness in his old age…No longer will old Americans be denied the healing miracle of modern medicine.  No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years.”[1]  With the enactment of Medicare, the United States joined the rest of the industrialized world in providing a guarantee of health insurance to at least some of its citizens.  The U.S. was more than 70 years late and chose an approach that no other nation would have considered.  

THE LONG ROAD TO MEDICARE

Most Americans do not know that the drive for national health insurance that was so much in the news in 2009 actually began in the early 1900s.  Germany had been the first to enact national compulsory health insurance for its workers in 1883.  By 1911, England and several other European nations had followed Germany’s lead and adopted their own programs.  
The push for national health insurance in industrialized nations in the early 20th century was reflective of a significant change in the practice of medicine.  In 1912 a Harvard professor, Lawrence Henderson, had this to say about advances in medical treatment at that time:  “For the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter.”[2]  Medicine stopped being art and became a science.  However, in the early 1900s, medicine was a science unaffordable to most working men and women in America.
If you worked in America in the late 1800s and early 1900s, you suffered not only from near-starvation wages but also from a range of medical ailments, many serious.  If you worked for long as a miner, stonecutter, textile worker, furrier, cap maker, baker or hairdresser, you almost certainly would develop bronchitis, asthma and very likely tuberculosis.  Regardless of occupation, you worked long hours, with little time to rest or even seek fresh air.  You and your family lived in overcrowded and unsanitary tenement housing.  You were constantly under stress and exhausted. You likely sought refuge in alcohol that soon ravaged your body.  If you were a woman and became pregnant, you worked as long as you could before giving birth and then, assuming you survived the delivery, returned to work as soon as possible since your family depended upon your wages.  Your child would very likely never live to reach the age of five. Any bout of sickness for you or a family member had disastrous consequences even if the ill person recovered.  Your life would quickly spiral out of control as it did for Emil Bollhausen, a German immigrant and cabinetmaker, one of several hundred cases reported in a study of New York City working for families in a 1917 study by the Russell Sage Foundation.
Bollhausen had arrived in the United States in 1882.  He quickly found work in New York City’s furniture industry employing cabinet making skills his father had taught him in Berlin.  He married and had a son.  His wife worked as a janitress and the family, while not prosperous, could pay the bills.  They survived.  By 1915, at the age of fifty-four, Bollhausen had found better and higher-paying employment working for an antique dealer doing fine finishing and repairs.  Then, Bollhausen had heart trouble.  He developed pleurisy and pneumonia and was hospitalized.  His income naturally stopped since there was no such thing at the time as paid sick leave.  Bollhausen and his family entered a downward spiral as described in a report at the time:
“[H]  ospital treatment, then a few day’s works, illness again, no money to pay the doctor, the use of patent medicines suggested by neighbors, the hospital again with some improvement followed by four weeks in the country…work again too hard for him, another illness, dispensary treatment…eight months of  sickness and treatment and still unable to undertake regular work.”[3]

Bollhausen’s experience was typical of most workers who were unfortunate enough to become ill.  What little assistance workers could obtain for dealing with medical expenses came from fraternal organizations such as the Freemasons or Odd Fellows often in the way of a fraternal or “lodge” doctor who the association paid to treat members.  Most good doctors refused to take such patients because the payments were small.  Members might also receive a small cash benefit if they could not work because of illness for a length of time, usually a week or more. Such benefits lasted only for a limited time and diminished over time.  For example, one association in New York paid $4.00 a week for the first six weeks then $2.00 a week for the next six weeks with nothing thereafter.[4]
In 1916, about one-quarter of unionized workers belonged to unions that provided some kind of sickness benefits to their members.  This was at a time when only a little over 5 percent of American workers were in labor unions so the coverage was available only to a small segment of the workforce. 
Some employers offered health benefits but usually only as a union-avoidance tactic.  Employer plans were typically available only to employees over a certain wage level who had been with the company for a certain period and who were under a certain age.  All benefits ended when a person left the company regardless of years of service.  Most companies would enroll women but most companies in the south restricted health benefits to whites only.  Benefits were usually limited to small cash payments to employees who were sick.  The payments were usually not sufficient to pay the cost of medical treatment.  Other than a few large companies such as Western Union and American Telephone and Telegraph, most companies required employee contributions.  Some required employees to cover 100% of the cost through their contributions.
Such “industrial medicine” was better than nothing but not always welcomed by workers.  The company nurse that made a free visit to offer you medical care was often required to report your condition to your employer.  A physical examination ordered at one company might lead to treatment but at another company, it might lead to immediate dismissal.  One could never be sure.  Many workers distrusted the company doctors suspecting that they were really just company spies out to eliminate workers found to be poor health risks.  Additionally, many companies, particularly Southern timber companies, automatically deducted the cost of paying for company doctors from worker paychecks even if the workers who never saw a doctor.  Unions consistently denounced “industrial medicine” as coercive and undemocratic.
Most people got the little medical care they received through charities that operated free medical dispensaries (health clinics).  These were particularly popular in urban areas with large immigrant populations.  Dispensaries served not only the poor and unemployed but the working poor.  Many who might have had some limited access to assistance through an association or employer chose to go to a dispensary out of the belief (unfounded) that free care was superior to that they could obtain in doctor’s offices.  In reality, “dispensaries were not all well equipped, however.  In many cases, overcrowding, absentee doctors, haphazard care, and decaying facilities made dispensary treatment ad harrowing experience.”[5]  Additionally, dispensaries were typically open for only a few hours a day or week and usually only during working hours so it was difficult for most working people to visit them without losing perhaps an entire day’s pay.  Those who did visit found the wait to see a doctor a long one and their visit with the doctor fleeting as he rushed on to another patient.  For example, two doctors in one New York dispensary one morning in 1914 reportedly saw 162 patients in just four hours, a rate of more than 40 patients per hour. 
Some private physicians were willing to wave their fees for low-income patients.  Nurses and midwives, usually female, charged less.  Most of these options were available only to whites and only in urban areas.  If you were black or lived in a rural area, you had little medical care available either public or private.
Urban or rural the typical experience of the American worker of the time who became seriously ill was similar to that of a cook in New York in 1915.  He had held a number of good positions but lost work when he developed a cough because no one wanted to employ a cook with a serious cough.  He entered a hospital for treatment but was discharged homeless in a few days.  He eventually was able to obtain medication through a dispensary and found lodging at a home for destitute tuberculosis patients run by the Salvation Army.  Like most working poor who became seriously ill, the cook soon died.  The city buried him in a pauper’s grave in potter’s field.[6]   A person born in 1900 had a life expectancy of just 47 years.  

EFFORTS OF THE AMERICAN ASSOCIATION

FOR LABOR LEGISLATION

It was not that progressives had not tried to make the benefits of modern medicine available to all Americans.  They had.  Progressives began pushing for some kind of national compulsory health insurance in the United States at about the same time as in other nations.  Theodore Roosevelt made such insurance a major feature of his platform when he ran as the nominee of the Progressive Bull Moose Party against Woodrow Wilson in 1912.  When Roosevelt lost, the American Association for Labor Legislation (AALL), a group of progressive social scientists, labor activists, and lawyers, picked up the campaign for national health insurance.  The AALL had been successful in getting states to adopt workmen’s compensation laws.  After Roosevelt’s defeat, the AALL turned its attention to national health insurance and introduced a model bill for state-based compulsory health insurance in 1915.  
AALL directed its efforts toward the working poor.  It excluded higher-income workers and the unemployed.  The AALL assumed that higher-income workers could better afford to pay for their own care and charity should cover the non-working poor.  The AALL’s model legislation excluded casual, seasonal and temporary workers (mostly non-whites) also.
Leaders of the AALL expected to have the same success with their model health insurance proposal that they had with their push for workmen’s compensation and launched a sophisticated “public education” campaign.  Initially, leaders of the American Medical Association (AMA) supported the AALL initiative, reasoning the United States would follow Europe and adopt some kind of compulsory health insurance.  Although the AALL was able to get its model bill introduced in the legislatures of 15 states and to get 10 other states to appoint commissions to study the matter, it was unable to secure passage.  

LESSON: Gains in one area do not automatically translate into gains in another, even a closely related policy area.  The AALL assumed that its success in pushing states to adopt workman’s compensation laws could be transferred relatively easily to success in getting states to pass comprehensive health insurance.  It was wrong.  The reality is that each new drive for change is a war that you must fight on its own.  You can use lessons from previous efforts and you do benefit if you have a track record of success but you still have to fight the current battles just as you fought the battles in the previous war.

THE AMA SWITCHES SIDES

In 1920, the AALL lost AMA support when a group of conservative doctors, fearing that a program of national health insurance would threaten the growing income and prestige of medical professionals, revolted against the AMA leadership in opposition to national health insurance.  The AMA announced that it was now opposed to “the institution of any plan embodying the system of compulsory contribution insurance against illness, or any other plan of compulsory insurance which provides for medical service to be rendered contributors or their dependents, provided, controlled or regulated by any state or Federal government.”[7]  Leaders of the insurance and pharmaceutical industries, large employers and the leadership of the American Federation of Labor joined the conservative AMA doctors in opposing compulsory health insurance.  
Doctors were horrified.  If medical services were free to the insured, the demand would skyrocket.  People would expect doctors to treat every little ailment.  If access to health care became a right, doctors could no longer deny treatment.  Doctors would be at the beck and call of patients with no say-so over who they treated or when.  Patients, not doctors, would be in control of the relationship.  Relief from caring for charity patients would be no relief at all.  One doctor wrote; “confiscation by the State of the ancient heritage of the medical professions, the care of the sick poor, is without right, reason, or justification”[8]  Another argued that poor people were taken care of and should be taken care of by choice, not compulsion.  A law compelling a physician to treat a patient whether poor or rich was “obnoxious to the freedom and democratic spirit of the people of the …nation.”  Another wrote, “When a man gives away his services he retains his self –respect; when a man sells them at a ruinous reduction he feels that he has become a bargain counter remnant of his former self.”  Health insurance would “revolutionize the practice of medicine so that the physician will professionally cease to be an individualist and will be but a cog in a great medical machine.”  Health insurance would destroy quality.  A lowered income would ‘limit [a doctor’s] training, equipment, and efficiency, and in the end [would] react on the people.” Health insurance would “imperil the advancement of medical research…all the great discoveries in medicine have resulted from individual effort.  There is no initiative in bureaucratic medicine…Bring your health insurance and what incentive will a young man have to spend his time in research work?  You will strike a blow at the very foundation of medicine.” 
Employers were threatened.  A brush manufacturer wrote that he was appalled by the “idea of caring for everybody in this world, whether they have been thrifty or not…No distinction is made in the bill between workmen.  The dissolute, lazy and incompetent workman is grouped with the industrious, careful and temperate workman.  The latter pays for the vices of the former.”  A mill owner wrote “This law would [encourage] indifference, lack of initiative and lack of responsibility and loyalty to the employer.  It would also tend to dishonesty on the part of an employee to obtain coveted benefits…The inevitable tendency of many workers under compulsory health insurance is to feign illness.There is no effective check provided in the measure against malingering.”  Another wrote that if health insurance were passed, “the public won’t buy, the employer won’t manufacture, and the man won’t have a job.”
Private insurers were threatened.  “If we have one duty to perform greater than another,” wrote one insurance company executive, “it is to turn the tide of public opinion against all kinds of federal and state insurance schemes.”  Compulsory health insurance would, he said, “bring about the result that all forms of insurance—life, casualty, fire and every other form—shall be carried solely by the government…This is only the entering wedge; if once a foothold is obtained it will mean attempts to have such State Insurance of all kinds..” 
As Beatrix Hoffman, author of The Wages of Sickness: The Politics of Health Insurance in Progressive America, points out opponents of compulsory health insurance had a common fear that the passage of any such legislation would not only negatively impact their financial interest but would undermine their autonomy and independence.  
All of these groups opposed health insurance on economic grounds. Doctors feared that their incomes would drop if the AALL’S bill became law. Employers denounced the burden of compulsory premium payments. Insurance companies raffled against the threat to their dominance of the life insurance market. The leaders of the American Federation of Labor (AFL) thought social insurance would undermine trade union benefits and forestall labor’s demands for higher wages. But equally important to opponents was the perception that compulsory health insurance would erode their group’s autonomy. For doctors to be free to set their own fees, for employers to limit their responsibility for the health of workers, for insurance companies to sell more policies, and for labor leaders to win the loyalty of workers, each group demanded the ability to operate independently, free from government (and reformer) interference. For these groups, protecting their economic interests was inseparable from defending their autonomy.[9]

In the case of compulsory health insurance, the negative consequences fell especially hard on doctors who would lose autonomy.  “Autonomy—the freedom of physicians to choose their own patients, work hours, fields of specialization, courses of treatment, and fee schedules—had long been an essential principle of American medical practice.”[10]  There could be no reform without some loss of control by physicians on their ability to act independently. 

Lesson: It is the nature of change that one or more groups, often well-financed and influential groups, will be threatened by the change your propose just doctors in the AMA were.  Reforms inevitably have negative consequences for some groups since there are always groups of people who reap benefits from the status quo.  These people will see the change you propose as a threat to their power, position, prestige, and even financial well-being.  Your challenge is to identify such individuals and groups early on, understand how your proposed changes affect them, anticipate the form their opposition might take, and prepare to defend your effort.  You should try to structure the change you propose to minimize the threat or make it less apparent.  Ideally, you should try to co-opt the opposition.

HEALTH INSURANCE IS UNAMERICAN

Critics charged that health insurance was un-American.  Compulsory health insurance, opponents argued “is autocratic and not democratic.  It strikes at the root and foundation of the fundamental law of our land: life, liberty and the pursuit of happiness.”[11]  Another wrote, “this legislation is an immediate institution of State socialism and an abrogation of the rights of the individual to the control of his own life and property.”  Compulsory health insurance was “Un-American, Un-economic, Unfair, Un-Scientific, and Un-scrupulous.”
Opponents of AALL’s health insurance proposal and those of other progressives in the early 1900s frequently cited the shortcomings and “horrors” of the European models that progressives relied upon in designing their plans.  When statistics on German sickness rates went up slightly after implementation of compulsory health insurance, American opponents of health insurance cited the increase in sick Germans as evidence of a failed system.  In fact, German sickness rates went up simply because more Germans were seeing doctors.  Similarly, opponents reported that British National Insurance was a “menace to the health of people’ because the system of capitation, whereby doctors received payment based upon the number of patients treated, led to hasty and slipshod service.”[12]  In fact, capitation had almost doubled the average income of British physicians participating in the system, thereby attracting many more doctors to join the system.  Additionally, improved access to care had actually raised, rather than lowered, the health of the average working man.  When proponents of the British system pointed out that since the passage of the health act demands on charities had dramatically decreased, opponents argued that the same statistics simply proved that the British Insurance Act was “drying up the sources of private and voluntary relief.”[13]

LESSON: Expect opponents to charge that the change you propose is un-American.  You should never make the case for your policy change by citing what other countries have done, particularly European countries, even if these countries have been highly successful and you are basing your proposal on lessons learned from their efforts.  Opponents of reform champion the uniqueness of America and the American people that make any system developed and implemented in a foreign country, particularly Europe, entirely unworkable in the United States.  The un-American argument is a standard conservative opposition tactic and one you should be prepared to counter.  In particular, they will claim that what you are proposing is European and point to any weakness; failing or flaw in the “European” approach, no matter how minor, as evidence that such a reform is not anything Americans would want for their country.  Failure immediately to counter such attacks from the opposition can lead to certain disasters for the reform effort particularly if the opposition is engaging in fear tactics that it usually will be.  Show how the change you propose, rather than being un-American, is indeed what America is all about.  Turn the un-American argument on its head.  Argue that the opponents are the ones who are being un-American since they are setting out to destroy the country by ignoring a wrong and not fixing it, wishing a cancer away rather than treating it aggressively with the healing power of change.  Argue that the truly un-American thing to do would be to do nothing.  Americans are not “do nothings,” they are doers and that is what you are proposing.

THE AALL SERIOUSLY UNDERESTIMATED THE OPPOSITION.  

Leaders of the AALL assumed that the need for national health insurance and its benefits were so obvious that their proposal would succeed on its own merits.  Consequently, they failed to counter the demagoguery and fiery rhetoric the opposition adopted effectively.  By the time the AALL recognized how effective the opposition had been in demonizing national health insurance it was too late.  

LESSON: You are less likely to persuade Americans with rational thought than passionate presentation.  Expect opponents of change to make loud arguments and lace them with conspiracy theories and predictions of dire consequences should whatever you are advocating be done.  Never assume that Americans will recognize the benefits of change, even benefits that you think are obvious unless you point out those benefits to them specifically and repeatedly.  Never be seduced by the logic and rightness of your cause.  Never assume that what is obvious to you will be obvious to the average American.  Never assume that the average American will accept facts more readily, or even as readily, as he will accept arguments based on speculation, superstition or even outright fabrication of data.  Do not expect Americans to recognize the difference between the truth and lies unless you specifically point out the difference.  As Rashi Fein, author of Medical Care, Medical Costs: The Search for a Health Insurance Policy, points out, “It is easy for those who favor particular legislation to be persuaded by the logic of their position, to assume that others will also be persuaded, and..to believe that logic or a just cause that cannot be denied will translate into votes…[It] is easy to forget that the political arena has its own logic and that legislators have their own ways of analyzing public and private costs and benefits.  The desire to be reelected does not influence [proponents of reform].  It does influence legislators.”[14]

Another mistake that the AALL made was failing to provide sufficient detail about how their model plan would operate.  For example, designers of the AALL model plan left out specifics on how health insurance would pay doctors.  They assumed that administrators could work out the details later.  The absence of details made the plan ripe for attack.  As soon as a campaign began for health insurance in New York, rumors began to circulate with abandon.  Opponents warned medical professionals that doctors would receive as little as twenty-five cents for an office visit and just a dollar for a home visit, exceedingly low sums.  The editor of one medical journal declared at a physician's conference that “a report he had in his hand…proved a chilling fact.[that]..medical men of Pennsylvania reaping $5,400 a year [would receive] from health insurance..[would receive] more like $400.” [15]  Another doctor wrote to his state legislator, “In talking with reputable physicians…I am convinced that the best [physicians] would be driven out of business   for they would not submit to the paltry salaries that would be paid physicians [under compulsory health insurance].[16]

LESSON:  Keep it simple but do not leave out too many details.  It is critically important to keep your proposed reforms as simple as possible.  Americans are uncomfortable with complexity and never understand nuance.  At the same time, you must flesh out the details of what the change would mean and you will accomplish the change.  Any absence of detail or confusion about what is being proposed leaves you open to the wildest charges and speculation.  The Devil is in the details and when you offer few details or none at all; your opponents will invent lots and lots of Devils.  Rumors fill the void and they are usually dire warnings of impending disaster.  Once these rumors start circulating it becomes exceedingly difficult to counter them.  Proponent’s explanations do little good.  Voters remember the rumors.  So, keep it simple but be ready to supply the details when the opposition challenges you.  Most importantly, move to squash rumors right away.

 

The AALL’s battle for health insurance essentially ended with the outbreak of World War I.  There were many reasons for the failure of the AALL effort as Harry Millis, a former president of the American Economic Association pointed out in 1938 article:
The success of the opposition to the proposed legislation was due more to self-interest on the part of many organizations, to fear, to misunderstanding, to willful misrepresentation, to the charge that it was German  [a severe indictment in the period around the First World War], and to  the fact that the country had not been prepared by investigation and  discussion for a system of health insurance than to any of the weaknesses  in what was proposed. Instead of such a system being seen as effecting  little more than an assembling of existing costs, it was generally regarded  as something that would add an enormous and unsupportable burden.  It was denounced as unnecessary, socialistic, un-American, a wrong  method of attack—sickness prevention was what was needed.  [Opponents argued that] it would beget simulation and malingering; it would involve contract medicine,  reduce the income of the doctors, destroy the close personal relationship between doctor and patient, and discourage and undermine medical research. It was not working well in Europe. Such were the more important sources of opposition and the most frequently voiced objection in the absence of a strong, coherent, actively interested group, to an early end the first period in an American health-insurance movement.[17]

NATIONAL HEALTH INSURANCE AND SOCIAL SECURITY

A second opportunity for national health insurance came in 1932 with the election of Franklin Roosevelt, who supported health insurance as part of social insurance legislation.  The initial draft of Social Security Legislation, however, failed to call for a national health insurance program although it did contain a single line calling for a “study of health insurance.”  That one line received so much opposition from a well-orchestrated campaign launched by the AMA that the administration eventually struck it, fearing that the mere mention of health insurance could doom Social Security.
Although the administration dropped national health insurance from the Social Security bill, its mere mention created alarm in the medical community that some government-sponsored health insurance program might eventually pass as a way, in their opinion, “to get a foot-in-the-door for socialized medicine.”[18]  This fear led to a shift in the position of the AMA toward health insurance in general.  Until then, the AMA had opposed all forms of health insurance, public or private.  After 1935, the organization and medical community, in general, ceased opposing private health insurance.  In an effort to ward off government involvement, the medical community began supporting private hospital insurance and began supporting private health insurance plans for surgical and medical expenses like those offered by the non-profit Blue Cross and Blue Shield plans.

EXPANDED ACCESS TO PRIVATE INSURANCE AFTER WWII

Health insurance had been available in at least some parts of the country since the 1930s but it only became widely available after World War II.  During the war, the War Stabilization Board restricted wages and prices so companies and unions turned to providing other non-cash benefits as a way to attract and retain workers.  One of these benefits was medical insurance.  Once the AMA dropped its opposition to health insurance, American’s access to private health insurance began to expand rapidly.  In 1940, only about 10 million Americans had hospitalization insurance.  By 1964, nearly 150 million did.  In 1940, insurance covering major medical expenses such as doctor fees was non-existent.  By 1964, over 45 million Americans had such insurance.[19]
In 1939, Senator Robert Wagner of New York introduced a bill for national health insurance but failed to make any progress in even getting it through committee.  Four years later two Democratic members of Congress, Senator James Murray of Montana and Representative John Dingell of Michigan joined Wagner and began introducing health insurance legislation for all Americans, not just industrial workers, annually.  None of the Wagner-Murray-Dingell proposals made much progress, however.

THE TRUMAN ADMINISTRATION

After President Roosevelt died, President Truman endorsed the Wagner-Murray-Dingell bill and became the first sitting American president to offer support formally for national health insurance.  Under Truman’s proposal:
 insurance benefits would cover all medical, dental, hospital and nursing-home care expenses, sixty days of hospital care per year plus drugs and auxiliary services;
beneficiaries would include all contributors to the plan and their dependents, and for the medical needs of a destitute minority which would not be reached by the contributory plan, provisions were made for Federal grants to the states;
the financing mechanism would be a compulsory 3 percent payroll tax divided equally between employee and employer;
administration would be in the hands of a national health insurance board within the Federal Security Agency which included the Social Security Board, the U.S. Public Health Service, the Food and Drug Administration, the Civilian Conservation Corps, the Office of Education (later the United States Department of Education), the National Youth Administration and a number of other agencies; 
to minimize the degree of federal control over doctors and patients,
doctors and hospitals would be free to choose whether or not to join the plan, 
patients would be free to choose their own doctors, and
doctors would reserve the right to reject patients whom they did not want to treat; and
doctors who agreed to treat patients under the plan would be paid a stated fee, per capita amount or salary for their services by a national health board with the choice of method of payment (fee, per capita, or salary) left to the majority decision of the participating practitioners in each health service area.[20]
After his surprise victory in 1948, Truman pressed Congress to pass his health insurance bill.  He met with strong and determined opposition, particularly from the American Medical Association.  
The AMA launched a $5 million national propaganda campaign professionally designed and directed by a public relations firm, Whitaker and Baxter (W&B.)  The campaign played on American’s post-war fears of Communism. Americans were told that Truman’s proposal was an attempt on the part of the government “to assume control not only of the medical profession but of hospitals—both public and private—the drug and appliance industries, dentistry, pharmacy, nursing, and allied professions.”[21]  Behind this conspiracy were the Federal Security Administration, the President, Socialists, and the Communist party.  The AMA warned Americans that government health insurance “would inevitably erode the quality of medical care by giving the government control over medical services, overcrowding hospitals, and reducing the incentives of physicians to provide quality care.” [22]  
Whitaker and Baxter solicited local physicians to address meetings of state and county medical societies opposing the Truman plan planted anti-legislation articles in local papers and prepared and distributed newspaper editorials and op-ed pieces.  Doctors, dentists, druggists, insurance agents, and others distributed some 40 to 50 million pieces of literature attacking the Truman plan.  In October of 1950, W&B placed a paid 70-column-inch advertisement in 11,000 newspapers across the country, ran spot ads on over 1,000 radio stations, and mailed letters to 25,000 companies asking for help in opposing the Truman plan.
A key feature of the campaign was a poster showing a doctor sitting at the bedside of a sick child that doctors were encouraged to post in their waiting rooms.  The caption read,
KEEP POLITICS OUT OF THIS PICTURE

When the life—or health of a loved one is at stake, hope lies in the devoted service of your Doctor.  Would you change this picture?  Compulsory health insurance is a political machine.  It would bring a third party—a politician—between you and your Doctor.  It would bind up your family’s health in red tape.  It would result in heavy payroll taxes—and inferior medical care for you and your family.  Do not let that happen! [23]

It was a clever scare tactic.  Allow Truman’s proposal to pass and the government will get between you and your doctor.  That false charge would be repeated time and time again by opponents to health reform, most recently by those opposed to reforms sought by the Obama administration
The AMA was supported by Conservative business groups such as the Chamber of Commerce and insurance industry companies such as Blue Cross, which argued that voluntary, private insurance was the only “American way” to provide health insurance to the country.  A conservative coalition in Congress consisting of Republicans and southern Democrats that held a de factor majority weakened Truman’s efforts further.  This conservative coalition was opposed to Truman’s entire Fair Deal political agenda not just national health care.
The campaign worked.  In 1950, the strongest supporters of national health care in the Senate were defeated.  Truman was to continue to seek compulsory health insurance but the AMA campaign and losses in the 1950 election doomed these later efforts.

LESSON:  Do not ignore the built-in distrust Americans have of power, in particular the power of government.  The failure of Truman’s efforts to win government-run universal health insurance, as I said, can be attributed to the AMA’s long, intensive and expensive propaganda campaign that played upon American’s fears of Communism in the post-war period.  However, something else was at work that goes deeper to the core of American belief.  Europeans recognize that strong government action is often necessary and frequently desirable to address public issues and serve the common good.  Americans hold the opposite belief.  Political scientist Samuel Huntington speaks of an American creed whose distinctive feature is a deep-seated distrust of power, particularly government power. “Opposition of power, and suspicion of government as the most dangerous embodiment of power,” he writes, “are themes of American political thought.”   That fact creates an additional, and often insurmountable, hurdle for progressives in the United States.  In order to pass comprehensive legislation to address a public need, you must not only convince the public that action is needed and that your proposal is the best approach but you must also overcome the strong and widely held American belief that any expansion of government even for a good cause is inherently dangerous.  Those who wish the government to do nothing have a much easier argument to make.  Consequently, you should minimize the appearance of the expansion of government as much as possible.  Create few or no new boards, agencies, or organizations.  You want to present your change as a logical and limited expansion of government, not something new but rather just an improvement on existing government activity and preferably one that is popular.  Proponents of Medicare sold it not as something new but rather as just an extension of Social Security that was highly popular at the time

By 1952, Truman’s drive for universal health insurance or even limited coverage like Ewing proposed was over.  He was in his last year in office and the Democratic nominee for president, Adlai Stevenson, was focusing on other issues recognizing that the efforts of the AMA, Republicans, and others to label the Democratic health insurance proposals socialism had largely worked.  Anyway, American’s were losing interest.  Many already had health insurance through their employer and more enrolling each year—5 million in 1949, 11 million in 1950, and 9 million in 1951.  Middle-class workers, in particular, were benefiting from the post-war economy and job growth, most of which came with employer-sponsored health insurance.  

LESSON: Keep it simple.  Early I noted that Americans fear complexity.  That is why it is extremely important to keep your proposal simple or at least give it the appearance of being simple.  The more comprehensive the plan the more difficult it is to get anything passed simply because as you add features, you add to the number of groups and individuals who will feel they have something to lose if your policy change is implemented.  Consequently, the more comprehensive your reform, the more enemies you create.  Every president who sought comprehensive health reform until the Obama administration failed.  Truman failed.  Clinton failed.  Obama almost failed and Republicans at this writing are threatening to undo most if not all that he accomplished..   Your challenge is to construct legislation that is complex enough to address the problem while keeping it simple enough not to frighten your fellow citizens.  

 

THE EISENHOWER ADMINISTRATION

With the election of Dwight David Eisenhower in 1952, the prospects of universal coverage or any expansion of the government’s role in health insurance turned dark.  Eisenhower had no interest.  Indeed Eisenhower campaigned against “socialized medicine.”  In 1958, he made clear his long time opposition to government health insurance and social security-related programs in general when he said, “If all that Americans want is security, they can go to prison.  They’ll have enough to eat, a bed, and a roof over their heads.”  Ironically, as an Army officer for most of his life, Eisenhower had been provided free medical care by physicians and dentists working for the government on salary—i.e., socialized medicine.  He never liked it when people reminded him of that fact.[24]
It was not only the President.  There was little interest in Congress.  Members of the Ways and Means Committee in the House and Finance Committee in the Senate were either actively opposed to universal health insurance or showed no interest.    There was no real activity toward health care reform until 1958 even though Democrats gained control of Congress in 1954.  

THE NEW STRATEGY TO PASS HEALTH INSURANCE LEGISLATION

Various congressmen introduced legislation annually.  Proponents of compulsory health insurance switched tactics.  Their new strategy had three primary components:
Focus on just covering the elderly, not the entire population.  High-risk people always have a problem getting health insurance.  It is not just that health insurers consider them to be a bad risk, their fellow citizens actually abandon those at high-risk by refusing to insure with insurers who enroll high-risk people and thus have to charge higher premiums.  The problem in the 1950s, as Rashi Fein points out in his book Medical Cae, Medical Costs, just continued to worsen as more people enrolled in insurance programs.  Those Americans who were a high risk found it even more difficult to find an insurer who would take them.  Proponents of mandatory universal health insurance shifted their focus from universal coverage to how to deal with segments of the population—the poor, the unemployed, the retired, those working at low-wage jobs, and those considered high risk—that could not obtain health insurance on their own.  
The aged became a primary focus for logical reasons.  Since World War II, labor unions had made significant gains for their members in the provision of access to health care insurance.  However, the elder and retired were left out.  If you worked from an employer who offered health insurance, you usually lost that insurance when you retired.  Only 22 percent of union contracts provided health insurance for retirees and then only for those who had been with the company for 20 years or more.  Additionally, most contracts excluded the worker’s spouse from coverage.  If by chance you were able to keep your insurance, it was usually not affordable.  The average retiree, if he could get coverage, had to spend 15 percent or more of his income on health insurance.  Blue Cross and Blue Shield had grown dramatically in the 1940s and 1950s but it was becoming increasingly difficult for workers who had chosen Blue Cross and Blue Shield to keep their coverage after they retired.  Premiums for retirees had increased to a point that people living on pensions or Social Security could no longer afford them.  Additionally, if you had coverage but missed even a single payment you insurance companies could drop you and you would have little chance of being able to get coverage elsewhere.  Consequently, almost no one over the age of 73 in the late 1950s had access to health insurance.[25]
In addition, there were still other reasons to focus on the elderly.
They faced high premiums if they could get insurance at all.
They did not have an employer to contribute to financing their coverage.
They had limited resources
Their medical needs were great.
They were heavy users of medical care.
Unlike other groups, they could be identified with ease—anyone over 65.
Unlike a qualification for benefits such as income that might change from year to year, the aged did not suddenly get younger and thus disqualified from coverage.
A massive social insurance program—Social Security—was already in place to serve the elderly.
The private insurance market had had its opportunity to cover the elderly and had failed.  The only remaining option was a single-payer system of public health insurance guided by the federal government.
Proponents could sell the health insurance program as just an extension of something that already existed rather than something entirely new.
There would be no income test so the legislation would not compromise the principle of universal coverage. Indeed the inclusion of everyone regardless of income would set a precedent for universal coverage.
By agreeing to cover just the aged (who were just 9% of the population), proponents of universal health insurance could portray themselves as reasonable people who were willing to compromise and portray their opponents inflexible and negative.
In the heterogeneous nation with competing groups—black/white, rich/poor, urban/rural—most people supported the aged if for no other reason than that everyone would someday be in that group.  Whites would not become suddenly black.  The rich could hardly imagine suddenly becoming poor.  People were moving from rural to urban areas not from urban to rural.  However, everyone who lived long enough would eventually become old.
Covering the aged undercut a central argument of opponents to universal health insurance such as the AMA that had argued for nearly a decade that private insurance was continuing to expand and thus a government program was unnecessary.  By the late 1950s, it was clear that private insurance would never adequately cover the aged.[26]  
Medicare would be just the beginning.  The ultimate goal was universal health coverage for the entire population.  The expected next step was Kiddicare—federal insurance for America’s children.
Build on Social Security.  People paid into social security during their working years and then received benefits when they retired.  This provided the illusion that Social Security was an insurance program to which people were entitled because of their years of contribution, not a social welfare program.  Medicare would be limited to those over 65 and dependents who had contributed to Social Security during working lives.  Recipients would have rights to payments because they had contributed to the fund like paying insurance premiums.  Medicare would not be a welfare program.
Restrict the scope of benefits.  Truman had proposed covering hospital, medical, dental and nursing home costs.  Medicare would cover the only hospitalization and then only for 60 days per year.  In other words, Medicare would be catastrophic insurance.  By not covering normal medical expenses, the designers hoped to minimize opposition from Conservatives who were concerned with cost.  Doctors and others in the medical profession were concerned about losing income.  By focusing on hospitalization advocates sought to change the statement of the problem from one of the unequal distribution of medical care services (thus one about the distribution or redistribution of a limited resource) to one of addressing the financial consequences to the aged of using hospital services.  Hospital costs were increasing dramatically and the aged were much more likely to be hospitalized and when they were their hospital, the stay was twice as long as that for younger patients.

Theodore Marmor, author of The Politics of Medicare writes:
The concentration on the burdens of the aged was a ploy for sympathy. The disavowal of aims to change fundamentally the American medical system was a sop to AMA fears, and the exclusion of physician services benefits was a response to past AMA hysteria. The focus on the financial burdens of receiving hospital care took as given the existing structure of the private medical care world and stressed the issue of spreading the costs of using available services within that world. The organization of health care, with its inefficiencies and resistance to cost-reduction, was a fundamental but politically sensitive problem that consensus-minded reformers wanted to avoid when they opted for 60 days of hospitalization insurance for the aged…as a promising “small” beginning.[27]

LESSON: Appeal to Americans’ self-interest.  You must convince the majority of Americans, and preferably a supermajority, that the problem or issue your proposed policy change addresses affects them personally.  Do not expect Americans to support substantive policy change for altruistic reasons.  Americans are selfish when it comes to what their government does.  They may contribute to private charities and support government intervention when they see vivid, emotional images of suffering, but their support for such efforts quickly fades.  You must construct an emotional argument that the problem affects most Americans lives or potentially could.  You must convince the majority of Americans that the problems threaten them and their family’ and that they will personally benefit from the policy change you propose even if that is only partially true.  Americans only support public policy that will benefit them directly and concretely or at least will not cost them anything.  You must make that case for your proposal even if it is largely a false one.  That is what proponents of Medicare did.  The majority of Americans were not elderly but most had relatives who were and everyone if they lived long enough would become elderly.  It was not hard to convince Americans, even young Americans, that they could personally benefit from the government caring for their aging parents or grandparents do they would not have to do so.  In addition, it was confronting to know that when one became old, one would have the power of government protecting one from the financial harm that an extended serious illness might cause.

LESSON: Be careful about redistribution issues.  Americans accumulate.  It is part of the American character to seek out, assemble and hoard possessions either real or imagined.  Likewise, Americans live in constant fear of loss of their possessions.  Americans are ever watchful that something or someone might come along and take things, physical or emotional, real or imagined, from them.  Americans are particularly concerned that the taker might be the government.  Conservatives will prey upon American’s redistribution fears.  They will argue that what you are proposing is an evil endeavor to take from the deserving and give to strangers who are largely undeserving because otherwise, they would not be in need of government assistance.  You must provide reassurance that no American will lose because of the change you propose.  You must project all boats to rise.  You must guarantee that all futures will be positive.  The final tally must place all above average.  There must only be gains.  Loses are not allowed.  

The search was on for a bill that would pass rather than the “best” bill.  Medicare proponents were willing to exclude coverage of outpatient care (doctors’ bills) even if that meant that hospital-only Medicare coverage would mean that doctors would be encouraged to recommend more and longer hospital treatments which were considerably more expensive than outpatient care as a way of both increasing their fees and reducing the patient’s cost.  This was typical “vote-buying,” going for the possible rather than the ideal even when the possible will clearly cost the taxpayers considerably more in the long run.[28]
Jonathan Oberlander, the author of The Political Life of Medicare, adds “in sum, the narrowing of the Truman national health insurance proposal into Medicare reflected an incremental strategy of ‘consensus mongering.’  The aim was to identify less controversial problems and more politically feasible solutions than had previous health insurance proposals.  However, despite their carefully crafted strategy, there would be no easy consensus on Medicare.”[29]

LESSON: Remember politics is the art of the possible.  You have to take what you can get. Progressives do not want to make things just a little bit better.  They want to right wrongs.  Unfortunately, it is hard to get a lot done in one piece of legislation.  The framers did not construct our government that way. 

THE FORAND BILL

In August 1957, Congressman Aime Forand of Rhode Island introduced the first legislation to provide health insurance coverage for the aged.  Forand was an unlikely candidate to sponsor what was to lead to the greatest piece of social legislation since the passage of Social Security.  He was “a slightly bald, round, cigar-smoking man of medium size and somewhat lackluster manner,”[30] who was nearing retirement, not that committed to health insurance legislation, and thought that there was little chance of passing such legislation for at least ten years.  However, Forand had long been interested in helping the “old folks,” as he called them and he was on the right committee—Ways and Means.  He agreed to sponsor the bill.  “He did not spend too much time thinking about the bill.  A few days before the close of the 85th session, he quietly dropped the bill into the hopper.  It was a shock to all supporters.  “They didn’t think I was going to do it,” Forand later said.[31]
There was little support on the Ways and Means Committee for the Forand Bill.  Of the 15 Democrats and 10 Republicans on the committee, only four members, all Democrats, supported the bill.  One of the Democrats most opposed to the bill was the chairman, Wilbur Mills who refused to allow the Forand bill to be scheduled even for hearings.  Mills had two criteria for what he would allow out of the Ways and Means Committee.  First, he was a jealous guardian of Social Security, opposed to anything that might affect its financial soundness or result in the need to increase taxes to keep it viable.  Second, Mills refused to allow anything to come to the floor from his committee until he was certain it had majority support in Congress and the nation.  The Forand Bill met neither of these criteria.  Until it did, Mills would not support it and without Mills’ support, it would never get out of committee.  

WILBUR D. MILLS—THE ARCHITECT OF MEDICARE AND MEDICAID

Wibur Daigh Mills was born in Kensett, White County Arkansas on May 24, 1909.  He graduated as valedictorian of his high school, salutatorian of Hendrix College and studied constitutional law under later Supreme Court Justice Felix Frankfurter at Harvard law school from which he graduated.  He was admitted to the bar in 1933 and served as a county and probate judge in Arkansas from 1934 until 1939 when he was elected to Congress.  In 1957, Mills became chairman of the powerful House Ways and Means Committee. 
People liked Mills.  He could speak in the voice of a knowledgeable, Harvard-trained lawyer or in the Southern cracker cadence of an Arkansas man of the people, switching back and forth with ease as the occasion demanded.  He believed that “life was based on mutual respect and understanding…[and that]…people took care of their own problems and families, including their elderly members.”[32]  Mills held to traditional values or was at least appeared to do so until U.S. Park police stopped him one early morning in the Fall of 1974 driving drunk and accompanied by an Argentine stripper by the name of Fannie Fox.  Later that year, reporters sighted Mills performing a drunken dance on stage with Ms. Fox at a burlesque theatre where she was performing.  The ensuing scandals led to Mills making the prudent decision not to seek reelection in 1976.  However, that was 1976.  In 1960, Mills was one of the most powerful people in Congress.
In 1957, members of Congress respected Mills for his thoroughness and lawyerly attention to detail.  As Chairman of the House Ways and Means Committee, he had special responsibility for oversight of Social Security and he had immersed himself in that responsibility.  Those who knew him said he had a “complete understanding of the system,” and “was the only one out of 535 Congressmen who was able to master the actuarial basis of Social Security as well as its financial underpinnings.  He was ‘completely conversant’ with all the factors involved in making actuarial estimates of Social Security payments.” [33]
Mills’ power stemmed not just from his personal qualities but also from his position.  He was the Chairman of the House Ways and Means Committee.  All tax, tariff, Social Security, and welfare legislation had to pass this committee on its way to becoming law.  This committee made individual committee assignments in the House and the committee Chairman had a big say so in those decisions.  House rules and traditions allowed this committee to meet in closed executive sessions to discuss tax and Social Security changes and then bring such legislation to the floor of the House under a “closed rule,” meaning that House members could not offer amendments but rather had to vote up or down on the measure as presented by the committee.  As Rashi Fein writes:
Mills’s power stemmed from his expertise in tax matters, his control of the professional staff, his political acumen in welding coalitions and doing favors, and his seniority status under the rules of the House than in force. He could call meetings or postpone them, determine the agenda, and orchestrate the debate. In addition, he served as a bridge between the two wings of the Democratic party; the more numerous and liberal Northerners and the more senior, powerful, and conservative Southerners. Finally, there was the fact that a bill that was popular among constituents back home but unpopular among individual Congressmen could be killed in executive session in committee rather than on the floor of the House, where everyone would have to stand up and be counted. Members appreciated Mills’s willingness to spare them from the need to cast a public vote.[34]

LESSON:  Inevitably, the support of a few powerful figures in Congress is critical to success.  You must cater to their needs whatever they are.  Each of these figures have their own personal criteria for what they will and will not support and until the proponents of change can craft their legislation to at least appear to meet the requirements of these powerful men and women, no change is possible.  No legislation can be passed.

BUILDING A RECORD

Forand was able to get his bill discussed briefly during hearings on extending Social Security benefits in June of 1958.  Later that year, six members of the House during a debate on a social security amendment took the opportunity to endorse the Forand bill even though it was not then under consideration.  Senator Wayne Morse of Oregon further publicized the Forand bill by offering it as an amendment to a social security bill under consideration in the Senate. Morse’s amendment was defeated on a voice vote but its introduction prompted Senator John Kennedy to include an endorsement of the bill in a speech he gave before the senate the same year outlining what he called a ten-point “bill of rights for our elder citizens.”  In December of that year, the Democratic Advisory Council, a group of party leaders outside Congress, added its endorsement to the Forand proposal.

LESSON:  You must build a record.  The discussions on the Forand bill like the discussions surrounding the earlier Wagner-Murray-Dingell proposals were important not because they resulted in any movement on the bill but because they began the process of “building the record,” which is a critical step in getting anything done in Washington.  You must take testimony from experts and the people.  You must accumulate data.  You must assemble statistics documenting the nature and extent of the problem.  People must get comfortable with the topic and with the people and organizations representing each side of the issue.  You must document, define, and plant in the minds of those who can affect change that an issue exists and a remedy is required even if they are unclear about the nature of that remedy.  Building a record is a ritual all major legislation must pass through.  That is the reason you want to get legislation introduced as early as possible even if you know you have little chance of success.  If nothing else, each failure to get legislation through a committee or brought to the floor helps to build the record.

 

THE AMA CAMPAIGN TO KILL MEDICARE

At that point, the AMA made a tactical error.  Instead of ignoring a bill that initially had little chance of passing, they countered with a major campaign attacking it.  The Forand proposal, said the AMA president, was “at least nine points evil and one part sincerity.”[35] If passed, said the AMA, the legislation would undermine voluntary efforts by private organizations including efforts of the medical profession, private voluntary insurance, and public assistance (relief or welfare) to help the aged.  If Medicare passed, it would endanger such efforts since a government program would “curb community incentive to support hospitals, nursing homes, health campaigns, and health centers.  It would discourage communities from experimenting with new techniques, such as home care programs, homemaker services, progressive patient care, and new concepts for treatment through outpatient departments and doctors’ offices and the like.  It would usurp—albeit inadequately—the magnificent role played by our fraternal, civic, religious, and philanthropic groups in the care of the aged.”[36]
Medicare was “socialized medicine and, above all, a dangerous first step toward national health insurance.”[37]  Dr. Frank Krusen, an AMA spokesperson, denounced everything about the bill in testimony before Congress.  
The government would control the disbursement of funds; the government would determine the benefits to be provided; the government would set the rates of compensation of hospitals, nursing homes, and physicians; the government would audit and control the records of hospitals, nursing homes, and patients; and the government would promulgate and enforce the standards of hospital and medical care.  The professional relationship between the doctor and his patient would be hampered. Government regulations would be imposed on patients and physicians alike.  The bill would lead to the ‘dangerous overcrowding’ of hospitals with ‘personal and family financial responsibility eliminated.[38]

Anyway, argued the AMA, government insurance for the elderly was unnecessary since private insurance would cover 90% of the elderly by 1970.  [This figure was, of course, from a biased industry-sponsored study.]  Regardless of coverage, argued the AMA, the problem was not as severe as advocates of Medicare claimed.  The elderly were not going without care.  “Medical care is readily available to every citizen of this country, regardless of his age, and regardless of whether he is able to pay for it.”[39]  If the aged were not using these services it was just because they didn’t know they existed. 
The AMA hired the master of the bogus argument, Ronald Reagan, to spread its message of fear outlining the “horrors” of the proposed Medicare and its threat to the freedoms that Americans treasured.
Write those letters now; call your friends and tell them to write them. If you don’t, this program, I promise you, will pass just as surely as the sun will come up tomorrow. And behind it will come other federal programs that will invade every area of freedom as we have known it in this country. Until one day. we will awake to find that we have socialism. And If you don’t do this, one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.[40]

Oh, Medicare was an insidious and dastardly plot, a genuine anti-American conspiracy.  James Stuart, an associate of Blue Cross, declared that the Forand Bill was a “frightening nightmare” that would result in families across the country rushing their “aged relatives into nursing homes at the government’s expense.”[41]

THE AMA ATTACK BACKFIRES

In 1959, the Senate Labor Committee created a Sub-committee on Aging with the encouragement of William Reidy, a staff member of the Labor Committee.  Reidy had been on the staff of Dr. Michael Davis, a New York physician, sociologist and expert in medical economics, who had worked on several of the Wagner-Murray-Dingell bills and long supported national health insurance.  Reidy thought the Eisenhower administration had made a mistake by ignoring the problems of the aged and Democratic candidates in the upcoming election “needed issues to go against Eisenhower’s popularity.”[42]  He knew that the young Senator John Kennedy had presidential aspirations.  Serving as head of a sub-committee on aging would give Kennedy badly needed exposure.  Other staff members on the Labor Committee supported Reidy’s idea as did Chairman Lister Hill, a moderate Democrat from Alabama who was interested in healthcare.
Kennedy was aware of the Forand Bill and had even requested a copy of the bill to review.  However, he was tied up with managing a labor reform bill and with work on the McClellan Committee investigating labor racketeering.  Reidy approached Kennedy’s assistant Theodore Sorensens about the Aging Sub-Committee idea.  Sorensen showed no interest.  Not giving up, Reidy approached another member of Kennedy’s staff, Myer Feldman, who was much more positive and agreed to discuss the idea with Kennedy.
While Reidy was waiting to hear from Kennedy, another member of the Labor Committee, Senator Pat McNamara from Michigan heard about the sub-committee and expressed interest.  McNamara was a liberal Democrat who had supported a variety of labor and civil rights issues such as the minimum wage and voting rights for blacks.  He was in a tight race for re-election and saw the chairmanship of a sub-committee on aging as a way of giving him a good political issue to run on in the 1960 election campaign.
With McNamara expressing interest and Kennedy at least considering the matter, Hill decided to move ahead.  Typically, someone wanting to create a new sub-committee would present the idea to the parent committee during a regular session.  However, there were no sessions scheduled for the committee in the near future, so Hill decided to move on his own.  He requested both the McNamara and Kennedy staff to draft a resolution creating a Sub-committee on Aging.  The McNamara resolution reached Hill’s office first.  Hill established the sub-committee and appointed McNamara chairman.  Joining McNamara were Democrats Kennedy, Joseph Clark of Pennsylvania and Jennings Randolph of West Virginia.  The Republican members were Everett Dirksen of Illinois and Barry Goldwater of Arizona.
The movement to pass health insurance legislation had taken one additional step forward.  As is typical, progress came when proponents were able to link their legislation to the political ambitions of politicians.  Kennedy and McNamara would both benefit politically from the publicity surrounding hearings on health insurance for the aged that the Subcommittee on Aging would hold.

LESSON:  Link your legislative proposal to the political ambition of key politicians.  Senators and Congressmen may proclaim that they work for their constituents and “the good of the country,” but they actually work for themselves.  Show them how they can get personal political mileage out of supporting your proposal and you will get their support.  Do not expect them to get behind your cause just because your cause is right and does a lot of good for the country.  They could care less.  They want to know, “what’s in it for me?”  You need a good answer to that question.  In the case of Kennedy and McNamara, they knew that getting to go around the country holding a lot of hearings on the plight of old people would be good for their political careers.  They had a lot to gain and little to lose.

 

HEARINGS BY THE SUBCOMMITTEE ON AGING IN 1959

During 1959, the Subcommittee on Aging held hearings in Washington, D.C., Boston, Pittsburgh, San Francisco, Charleston, Grand Rapids, Miami and Detroit.   The hearings were informal.  The Subcommittee invited representatives of the elderly and the elderly themselves to express their opinions and tell their personal stories.  Local Congressmen joined in the discussions.  The Sub-Committee began incorporating discussion of the Forand bill in these meetings as it took testimony from the elderly and expert witnesses on the problems of older Americans.  Wherever the subcommittee held hearings, its staff sought to stimulate interest among local journalists in covering the hearings and reporting on the debate about the Forand bill.  
The hearings garnered a great deal of publicity and rejuvenated grass roots interest in the health problems of the aged.  Additionally, the hearings boosted morale among proponents of health legislation who came away with heart-rending stories the elderly told about their inability to afford the cost of health care.  McNamara said on delivering his final report to the Labor Committee that he came away from the hearing convinced that “there is simply no human justification…for any American to have to suffer unnecessarily a prolonged illness or put off a medical check-up because of his fear of hospital bills and the exorbitant prices of medicines.”[43]
As might be expected, the Republicans on the Committee were not impressed with what they heard.  The aged, said Dirksen and Goldwater in their minority report, did not have problems much different from other Americans.  There was nothing unique about Americans suffering physically and financially from lack of health insurance.  
It was a weird and heartless argument.  Since suffering was widespread and the proposal was to provide relief to just a segment of the population, the proposal should be abandoned as should the segment of the population whose suffering might be alleviated by action.  Of course the reason proponents of the legislation had narrowed its coverage in the first place was repeated Republican opposition to universal coverage.
Throughout 1959 and 1960, supporters of the Forand bill continued to assemble the data, statistics and facts needed to provide a justification for action.  However, they recognized that facts alone would not be enough.  They had to convince the American people that the elderly were suffering and that legislation was required to alleviate their suffering. They needed an emotional appeal.  To that end, the labor movement began organizing rallies and demonstrations in support of the Forand bill.  For example, the United Auto Workers (UAW) organized a rally in Detroit where 13,000 attendees heard speeches from the three Democratic candidates for the presidency, John Kennedy, Hubert Humphrey, and Stuart Symington on the problems of the aged including access to health insurance.

THE GRASSROOTS MOVEMENT

The Forand bill had an inauspicious beginning and yet in just three years it became a major issue in a national presidential election. As James Sundquist notes, all this happened without benefit of any of the circumstances that usually thrust a legislative measure into the national spotlight.  
No presidential message or television appeal supported it; no crisis compelled attention to it; it had no status as a party measure in Congress; its sponsor was a little-known congressman who could not bring national attention to it and, indeed, did not try; its existence was not reported on the front pages of the newspapers until after it had become a major national political issue.  Yet many thousands of people managed to learn of the bill’s existence and join[ed] the ‘crusade’ for its enactment.  Support for the Forand bill began as a genuine grass roots movement—surely the most phenomenal such movement of the period.”[44]

Ironically, one of the major groups contributing to the growth of the grassroots movement to support the Forand bill and Medicare was the bill’s chief opponent, the AMA.  There aggressive, even vicious attack on the Forand bill and its supporters backfired.  Indeed, Forand thanked the members of the AMA for their efforts.  In a 1960 speech, he said “I want to pay tribute to the AMA for the great assistance they have given me in publicizing this bill of mine…They have done more than I ever could have done [to generate widespread interest in the bill.].[45]

Lesson:  Turn opposition to your advantage whenever you can.  The AMA made a tactical mistake in launching such a loud and expensive campaign opposing the Forand bill.  Proponents of health reform took advantage of the vicious attacks to rally their supports and gain new recruits to the cause.  The saying “there is no such thing as bad publicity” fully applies when it comes to getting things done in Washington.  Do not be discouraged when opponents attack your proposal.  Find a way to turn those attacks to your advantage by using them to stimulate grassroots interest and support.

 

MOVING THE FORAND BILL THROUGH THE SENATE

Supporters of the Forand Bill had built a record and generated grassroots interest.  Now they had to decide upon the best path to follow in bringing the Forand Bill to the floors of the House and Senate for a vote.  There was a difference of opinion about how to proceed in the Senate.  The two most logical committees to handle a health insurance bill would be the Senate Labor Committee or the Finance Committee. Bill Reidy and others on the Labor Committee staff argued that the Labor Committee had dealt with previous Medicare bills such as the Wagner-Murray-Dingel bills so it had more experience with health insurance legislation.  Additional a majority of the members of the Labor Committee already supported Medicare.  On the other hand, Cohen, Cruikshank, Biemiller and other Medicare advocates argued that the Finance Committee had much more power and influence in the Senate whose members were mostly conservative.  Additionally, since the bill involved Social Security funding, the Finance Committee had to be review and approve it at some point.  Of course, there was the option of having both committees consider separate bills.  However, having two bills under consideration in two different committees would have significantly slowed the process which was exactly what happened in 2008 when two separate Senate committees worked on separate bills for the Obama administrated health reforms.  In 1960, supporters of taking the bill through the Finance Committee alone won the argument. 
The question then became who would sponsor the Medicare bill in the Finance Committee.  There were five possible ranking committee members considered as sponsors on the committee: Chairman Harry Byrd of Virginia, Russell Long of Louisiana, George Smathers of Florida, Robert Kerr of Oklahoma, Paul Douglas of Illinois and Clinton Anderson of New Mexico.  Supporters of the bill immediately rejected Byrd, Long, Smathers and Kerr.  Byrd and Kerr opposed all forms of national health insurance.  Long had made it clear that he disliked the Forand Bill.  Smathers was indebted to doctors in his state for supporting him in his win over former Senator Claude Peppers so was not likely to agree to sponsor legislation the vehemently opposed.  Douglas would have sponsored the bill but he was a liberal intellectual and well-known supporter of labor causes.  His sponsorship, indeed even his active involvement in the Medicare cause, would do more harm than good when it came to winning over a majority of the committee.  Consequently, Clinton Anderson got the job by default.[46]  It was not a bad choice. Anderson was a close friend of Lyndon Johnson and Robert Kerr; he was popular in the Senate and, perhaps most importantly, no one had accused him of having socialist sympathies and connections although they later would. 
Anderson had a daunting task.  As hearing began in 1960, he could count only four or five possible favorable votes from the seventeen-committee members.  Additionally, a number of bills dealing with health insurance for the aged were now before the committee.  Senators Morse, Kennedy and Hart proposed bills that incorporated a payroll tax deduction as the means of financing health insurance for the aged.  Senator McNamara, joined by 23 other Democrats, proposed to expand Medicare coverage beyond recipients of Social Security to cover all those over 65 and to expand coverage.[47]  The New Republic declared these competing bills to be “a disorderly collection of jerry –built substitutes and compromises.”[48] The Forand bill like all the others seeking a comprehensive approach died in committee.
Never the less, it was clear that, responding to growing public interest in health insurance for aged, Congress had decided that some form of health insurance must at least be considered, if not passed.  As The Nation put it, “Not in years had Congress be subjected to so much pressure…for and against health insurance for the aged.”[49]  The New York Timesadded that the “question of medical insurance for persons 65 years of age [had] become one of the hottest political issues in the nation.”[50]  The Republicans, in particular, were beginning to feel the political heat.  

REPUBLICANS DEVELOP THEIR OWN ALTERNATIVE

The sub-committee hearings, union rallies and the AMA’s misguided attacks on the Forand bill throughout 1959 and 1960 had gained media attention and the press began asking the Eisenhower Administration and Republicans why they had not developed any alternative legislation.  The Administration simply responded that it needed more time to study the problem.  Delay is a standard tactic of those who oppose change.  If they can stall and delay, request time for studies, and generally argue for slowing the process down, they can increase the chance that those proposing change will become frustrated and exhausted and give up the struggle or that they will gradually lose support as their cause seem increasingly hopeless to their supporters. 
That was not happening.  Public interest in health care for the elderly was building, not diminishing and advocates of change were anything but frustrated.  Republicans became increasingly grumpy about this demand for health insurance for the aged.  Dirksen, in particular, became belligerent during new hearings shouting at witnesses and calling the proposals of Forand supporters “insane” and “stinking.”[51]

LESSON: Whenever to opposition proposes to study the problem, respond by pushing harder to get something done right away.  An offer to study the problem is a standard delaying tactic opponents will resort to when they discover that public pressure is building to get something done.  It is a sign that your efforts to educate the public and garner support from politicians are paying off.  It is a signal that you should redouble your efforts to move legislation forward.  Do not back off or agree to slow down.  Push harder.

The AMA attacks and Aging sub-committee meetings raised public awareness to the point that Vice President Richard Nixon became concerned that opposition from the Eisenhower administration might doom his chances in the 1960 presidential campaign.  Attacking socialized medicine was one thing but opposing legislation designed to help the elderly, a growing voter block was another thing.  
Many Republicans, particularly Vice President Richard Nixon who was running for the presidency, wanted some kind of Republican plan to put up against the Democratic proposals.  However, Eisenhower showed little interest.  Eisenhower maintained that action was unnecessary.  The problem of health insurance for the aged could perfectly well handled by individuals themselves or voluntary groups.  Passing something like the Forand Bill would, testified Arthur Flemming, Secretary of HEW, just mean that insurance “would become frozen in a vast and unfair government system, foreclosing future opportunity for private groups, non-profit and commercial, to demonstrate their capacity to deal with the problem.” [52]  Senate Russell Long of Louisiana prophesied that if a national health bill like Forand passed and Congress gave the elderly hospitalization at government expense “many of them would spend their summer vacations in the hospitals” and “the medical resources of the country would become social clubs for elderly.[53]  

THE REPUBLICANS PRESENT A PLAN

Secretary of HEW Arthur Flemming came up with five possible Republican plans but Eisenhower still refused to endorse any option supposedly because he equated any use of tax-derived funds to support health insurance for the aged as socialized medicine.  Publicly Nixon announced that he was “searching for an acceptable solution to the [Medicare] problem” and was leading toward one of Flemming’s options that involved having Federal and state governments subsidize the purchase of health insurance by those of the elderly who wished to do so.[54]
Finally, in June of 1960, after much urging by Nixon and other members of his party, President Eisenhower agreed to have one of Flemming’s options introduced in the Senate by Senator Levertt Saltonstall (R, MASS).  Essentially the plan offered only a modest expansion of existing public assistance programs.  Columnist Edward Chase wrote: “It is hard to escape the conclusion that the [Republican] plan is strictly a political gesture, reluctantly taken to ease the politically untenable situation into which sheer negativism had placed the party.”[55]

TWO SHARPLY CONTRASTING APPROACHES

By 1960, Congress was considering two sharply contrasting approaches to dealing with the problem of insuring the elderly.  First, there was the Social Security-based approach found in the Forand bill and other variations.  These bills sought to provide at least some coverage of hospitalization, nursing home care, and cost of surgery financed by an increase in Social Security taxes.  The second approach championed by the Eisenhower administration relied upon federal financial assistance to encourage the states to create or expand health insurance coverage for the aged poor.  This approach went beyond the Social Security approaches since it covered not only hospitalization, surgery, and nursing home care but also physicians’ services.  However, the assistance would be limited “to the small minority of old and poor who were very sick for an extended period, lived in states that joined the program, and could meet the burdensome, if not prohibitive, out-of-pocket payments.”[56]  There was very little possibility of reaching accommodation between supporters of the two approaches.  People on both sides were pretty much locked into their positions.  Consequently, each side sought to gain support for its approach by courting Senators and Representatives who were still undecided and the largest block of undecided was among Southern Democrats. 

THE SOUTHERN DEMOCRATS

Southern Democrats felt the growing public pressure to do something about insuring the elderly but they did not like either approach that offered.  They were uniformly opposed to any type of federal health insurance but they also knew that their states could not afford the state matching required under the approach championed by the administration.  Even if the states could find the funding, few elderly poor in the Southern states would be able to pay the premiums and out-of-pocket costs.  They respected Eisenhower and agreed with most of his conservative principals but this was an election year.  Supported by House Speaker Sam Rayburn, Senate Majority Leader, Lyndon Johnson of Texas was seeking the presidential nomination and most Southern Democrats wanted to support Johnson and distance themselves from the Republicans.  Southern Democrats were in a bind.  They did not like the Social Security approach but they could not support the Eisenhower approach either.  They wanted a way out.  All eyes were on one man who might find a solution—Democratic Representative Wilbur Mills from Arkansas.  Southern Democrats were looking to Mills to solution to their problem. He delivered.

THE KERR/MILLS BILL—THE THIRD APPROACH

Mills decided to offer an alternative approach.  Together with Senator Robert Kerr of Oklahoma, he introduced a bill to address the problem of health insurance for the aged by providing matching grants to states to expand aid to states providing health care assistance to the elderly poor.  The bill would cover 50% to 80% of the cost to provide benefits that actually went beyond those in the Forand bill and other Medicare proposals.  Essentially, the Kerr-Mills bill just expanded upon a program that Congress enacted in 1950 to provide federal funds for states to pay for medical care for the aged poor who were welfare recipients by removing the requirement that a person be on welfare to qualify.  Participation by states was voluntary and neither Democrats nor Republicans argued that the bill would solve the problem of health insurance for the aged.  However, the Kerr-Mills bill was attractive to many Conservatives in the House and Senate because while the bill actually did little or nothing to address the issue it gave Conservatives political cover.  
LESSON:  Conservatives will always argue that the states can do it best.  When pressured by an aroused public to do something about an issue, Conservatives, who are philosophically opposed to ever doing anything, take political cover by arguing that if something must done about a problem the best approach is for the federal government to simply provide funding and let the states actually administer the program.  The problem with this approach is that states often fail to enact programs even when substantial funding is provided because the will not or cannot provide the matching funding.  However, this approach provides the appearance of actually doing something without doing anything much at all.  The best way to counter this argument is to have already tried a state-based approach that you can point to as a example of why state-based remedies won’t work.

Mills rapidly pushed the Kerr-Mills bill through the House Ways and Means Committee without debate or even discussion.  On June 3, 1960, the Committee passed the bill under closed rule.  The New York Times described Mills’ handling of the bill a “hand washing performance.”  “Mills had indeed washed his hands, dried them, and walked away from the sink.  To his satisfaction he discharged his obligations to the Democratic Party.”[57]  That was that.  The bill went to the Senate.
Robert Kerr of Oklahoma took over the job of pushing the bill through the Senate.  Kerr had personal reasons for wanting to get a bill passed as quickly as possible.  It had nothing to do with Social Security or Medicare.  Kerr was up for reelection.  He was certain John Kennedy, the Democratic nominee for president, was going to lose Oklahoma if for no other reason than that, Kennedy was a Catholic and mostly Baptist Oklahomans were never going to vote for a Catholic for president or much of anything else.  Kennedy favored the Social Security approach to health insurance for the elderly and planned to make it a issue in his campaign.  Kerr needed to separate himself from Kennedy.  The Kerr-Mills bill was just the ticket.  It was an approach to the elderly insurance problem that would appeal to Oklahomans, especially the powerful Oklahoma medical association.
Progressives were no match for Kerr when the Kerr-Mills bill came to the floor of the Senate.  They had pointed and well thought out questions about the implications of the bill but Kerr was ready for them.  As one observer said, “there was no match for Kerr, he was the master of ‘resounding rebuttal’.”[58]  House Speaker Sam Rayburn said, “Bob Kerr is the kind of man who would charge hell with a bucket of water and believe he could put it out.”[59]  Senate Albert Gore of Tennessee said, “The distinguished Senator from Oklahoma can take the least amount of information and look and act more authoritative than any man in the world.  Carl Albert, also of Oklahoma who would later become Speaker of the House said Kerr “was like a great engine powered by super fuel.”[60]  If Progressives had meant to launch a challenge to the Kerr-Mills bill, they had seriously underestimated their opponent when it came to Kerr.  
The Senate passed the Kerr-Mills bill.  The Conference Committee quickly reached agreement.  President Eisenhower signed it into law on September 13th.
At the time Aime Forand said that while the Kerr-Mills bill would “not do any harm, it would not do any good.  Personally,” he said, “I think it is a shame, I think it’s a mirage that we are holding up to the folks to look at and think they are going to get something.”[61]  Forand was right.  “By the time Eisenhower left office, only five states had passed legislation providing for at least some of the benefits under Kerr-Mills: Michigan, Oklahoma, Massachusetts, West Virginia, and Kentucky.”[62]  In many states, the program covered few new groups of people over 65 since frequently states just transferred people already covered under older programs to Kerr-Mills in order to get the matching funds.  

SALAMI SLICING

It was true that progressives were no match for Mills in the House or Kerr in the Senate.  It was also true that they had offered only limited opposition.    Wilbur Cohen convinced most of them that Eisenhower was never going to sign a Forand-type Social Security-based bill.  Kerr-Mills, he argued, while woefully inadequate, was desirable as a step in the right direction.  Cohen recognized that before Medicare legislation could be enacted, the public and Congress had to get used to the idea of public funding of medical care.  Once passed Kerr-Mills would establish the precedent of financing medical care for the elderly with public dollars then it would be possible for advocates of Medicare to say “let’s get a better way of carrying out the principles [already established by Kerr-Mills.]  Some called Cohen’s incremental approach to passing legislation “salami slicing”[63]  Cohen would get one slice of the political salami then another and another. Eventually he would have enough for an entire policy sandwich.  Cohen’s true accomplishment was not just his expertise in getting individual slices of political salami but his ability to keep the final sandwich clearly in mind.  He never lost sight of his final policy goal. 

LESSON: You must engage in “salami slicing.”  Salami slicing is an important tool for all who want to achieve policy revolutions.  Policy revolutions are rarely built all at once but rather slowly, bit-by-bit and step-by-step.  The real trick is not to lose sight of the ultimate goal.  Each piece of political salami has to add to the ultimate policy sandwich.  Cohen knew how to make that happen.  Of course, the danger of salami slicing is that opponents of change will use it against those who want meaningful reform.  They will argue that the current slice of salami is enough or that at a minimum more time they need more time to see if it is enough.  They will suggest that you can add small portions over time if you determine policy sandwich needs more salami.  Of course, what they are really saying is that there is no need to slice the entire salami or even build the sandwich.

THE KENNEDY ADMINISTRATION

In the 1960 campaign, Kennedy endorsed Medicare after seeing polls that suggested health care was a wedge issue he could use to gain an advantage over his opponent Richard Nixon.  Upon election, President Kennedy launched a campaign to obtain passage of a new Medicare bill sponsored by Senator Clinton Anderson of New Mexico and Representative Cecil King of California similar to the Forand bill that would provide 90 days of hospitalization, 240 days of home health services and 180 days of nursing home care to the elderly.  In spite of holding rallies and making a national televised appeal for support, Kennedy was unsuccessful proving that even a popular president cannot push major legislation through Congress on his own.
Major opposition came from the Southern Democrat/Republican Conservative coalition.  Wilbur Mills remained opposed.  He was afraid that the addition of Medicare would threaten the solvency of the Social Security program.  Additionally, and perhaps more importantly, due to redistricting, Mills was facing a highly conservative member of the House, Dale Alford, in what was going to a struggle for Mills to maintain his seat in the House.  He was in no mood to support legislation that his Little Rock constituents would view as too liberal.  Without the support of Mills and his committee, no Medicare legislation could make it to the House floor for a vote.  
Kennedy was not prepared to risk all of his political capital on Medicare.  He was seeking passage of several other bills on such things as foreign aid, taxes, housing and trade that had a good chance of passing provided the administration didn’t push to hard on the health insurance bill and alienate Mills as well as others.  Regardless, it wasn’t clear that Kennedy had the necessary 60 votes to end an almost certain Republican and Southern Democrat filibuster in the Senate even if he could force a House vote in favor.  The Anderson/King bill was going nowhere.  Medicare wasn’t going to pass in 1961.  The timing wasn’t right for Medicare in 1961.  However, it was getting right.

LESSON: Just because a presidential candidate or a sitting president, even a popular one, expresses support for a change effort don’t assume that achieving that change will be easy.  It might be easier to have the president behind your cause but that does not make the passing legislation easy or guaranteed.  Progressives often get over confident when they are finally able to elect a popular president who shares their agenda.  They expect him to expend his considerable political capital on their behalf.  They forget that presidents are not all powerful even if they are extremely popular and they are never pursuing a single agenda item.  There are no single-issue presidents.  Progressive legislation has to compete with all the other legislation, conservative, moderate, liberal, domestic and foreign that presidents have to juggle.  At least four presidents or presidential candidates, including Kennedy who was very popular, supported some form of health insurance reform but only one was successful in passing legislation and then, as we will see, it was less than proponents of change had originally sought.

 

THE PR STRUGGLE

By the end of 1961, proponents and opponents were gearing up for a serious PR fight over Medicare.  Proponents created the National Council of Senior Citizens with Aime Forand, who had just retired from Congress, as its chairman.  By the end of 1961, the Council was claiming 525,000 members with additional support from 900,000 non-seniors.  The council launched a series of massive rallies in major cities, began distributing materials (seven million pieces eventually) and developed alliances with senior citizen clubs and organizations with a collective membership of over two million.
The AMA countered by distributing posters for its members to display in their offices warning of “socialized medicine,” and launched an aggressive letter writing campaign targeting congressmen, particularly those on the House Ways and Means Committee.  The AMA also launched a campaign to persuade health professionals who had expressed support for senior health insurance through social security such as the American Nurses Association and American Hospital Association to reverse their decisions and join the AMA in a “united front” of opposition.  The nurses association complained of “unethical pressure” but held its ground. 
By the summer of 1962, advocates for change seemed to be winning the propaganda war.  Gallup reported that 67% of Americans now favored Medicare.[64]  That was in spite of the fact that organized medicine had pumped as much as $7 million in just 18 months into the campaigning to defeat Medicare.  
The AMA did however have one victory.  In May of 1962, President Kennedy gave a major speech in New York City to a massive gather of seniors at Madison Square Garden that was shown to other rallies of seniors across the country via closed-circuit TV and carried on all major TV networks.  The AMA demanded equal time from the networks but the networks refused.  The organization responded by purchasing time the next night for an address by Dr. Edward Annis of the AMA delivered from the Garden with a symbolic empty arena as a backdrop.  Dr. Annis urged viewers to “trust their doctors’ judgment on the ‘sacred’ human relationships involved in the practice of medicine” and ignore the “hippodrome tactics” and “circuses” being orchestrated by the President and Medicare advocates.  By most accounts, the proponents “long-planned publicity coup” backfired.  Kennedy’s address received a loud and enthusiastic reception in Madison Square Garden and around the country at the senior citizen rallies but played less well to the home TV audience.  As Fein notes: “the president had forgotten the lesson of his campaign, that arousing a partisan crowd in a vast arena and convincing the skeptical TV viewer at home required wholly different kinds of presentation.  He already had support from the senior citizens; he needed more support from the home viewers, and that speech did not induce it.”[65]  The AMA won the debate that time.

LESSON: It’s not enough to convince those who are already on your side.  You have to make those who are not yet convinced comfortable with your ideas.  It is great to have a charismatic leader who you can put forward to sell your cause.  In addition, it feels great to see him enthusiastically received by partisan crowds roaring their support.  However, don’t lose sight of the fact that those adoring fans of your proposed legislation aren’t the ones you have to convince.  The people you need to reach are the show-me skeptics that frown and a twitch as you lay out your ideas.  Your task isn’t to rally the already convinced but to turn the frowns and nervous ticks of the skeptics into relaxed smiles.  You have to make those folks comfortable with your ideas.

PROSPECT OF PASSING SOME FORM OF MEDICARE IMPROVE

Prospects for the passage of Medicare improved between 1961 and 1964.  The administration focused on increasing the size of the pro-Medicare members of the House Ways and Means Committee by working with House Democratic leadership to extract pledges of support at least for moving a Medicare bill out of the committee from members wishing a Ways and Means committee assignment.  By the summer of 1964, pro-Medicare members on the committee were just one vote short of a majority.  
Anti-Medicare forces on the committee fought back with a clever legislative trick.  Republican John Byrnes of Wisconsin proposed that the five percent increase in Social Security benefits called for in the Anderson bill be increased to six percent.  Marmor notes that “this would have raised social security taxes to 10 percent,[66] widely accepted within Congress at that time as the upper social security tax limit, and thus leave no fiscal room for Medicare.”[67]  Byrnes proposal fell one vote short of approval when ultra-conservative Bruce Alger of Texas, voted no.  Alger explained that “’since he opposed the entire Social Security system, consistency would not permit him to expand it,’ even to undermine the chances of Medicare.[68]

THE JOHNSON ADMISTRATION

Senate Democrats attempted to get a Medicare bill passed in the fall of 1964 by attaching it to the Social Security bill for cash increases in benefits that had already passed the House.  Mills undermined the effort by promising pro-Medicare Democrats that he would make Medicare the first order of business in the Ways and Means Committee in 1965 if they would reject the rider.  Enough agreed with Mills that the rider was defeated and the Senate/House conference committee finally admitted that it was deadlocked.  The Social Security measures would have to wait until the next session.  
In the 1964 election, Johnson asked Americans “pass judgment” on Medicare.  He asked for a mandate and got it.  Johnson got 61% of the popular vote and 90% of the electoral vote crushing his Republican challenger Barry Goldwater.  Democrats retained majorities in House and Senate gaining 32 seats in the House and 2 in the Senate.  The Democratic landslide brought a surge of new Democratic congressman to the House, all pro-Medicare.  The National Council of Senior Citizens claimed a net gain of 44 votes for Medicare in the House.  
The political climate changed dramatically.  Democrats now controlled the White House and both houses of Congress by considerable majorities, enough to overcome the Southern Democrat/Republican Coalition.  With their large majorities in both houses, Democrats could have expanded Medicare coverage.  Instead, they stayed with the existing Medicare proposals that provided limited benefits to a limited segment of the population. 

LESSON:  Don’t overreach  Once you gain public support for your reform, particularly if it is accompanied by control of both houses of Congress and the presidency, it is tempting to try to set your sights higher, to try to expand your legislative proposal to accomplish more.  Do not do it.  If you overreach, you give ammunition to your opponents. They will use it to scare the public.  Public support for any legislative effort is a fragile thing.  Do not abuse it.  Take what you can get.  You can come back for more a later day.

Johnson immediately made Medicare his top legislative priority. Perhaps more importantly than the net gain of seats in the House as a hold, the lopsided Democratic majority insured the Democrats of getting two more, badly needed, pro-Medicare seats on the House Ways and Means Committee.  
When opinion polls showed overwhelming public support for Medicare, Wilbur Mills, who had blocked previous efforts, switched sides.  Republican John Byrnes on the Ways and Means Committee said of Mills late involvement in cobbling together a bill “I assume Wilbur saw the election returns and he could see he was being left behind.  The troops were rushing right past him.  He figured he’d better give his horse some oats and get up there in front where a leader belonged.”[69]
In January of 1965, Anderson and King re-introduced their standard Medicare package covering limited hospital care Social Security beneficiaries and financed through Social Security.  The bills were numbered H.R. 1 and S.1 to signify their significance as the highest priority for Johnson’s Great Society programs.  

ELDERCARE

Recognizing that some form of Medicare was now inevitable and fearing that they could be labeled as obstructionists, Republicans and the AMA changed tactics.  They came out with their own “more positive” proposal arguing that the Anderson/King bills would provide inadequate benefits, were too costly, and provided coverage not just to the deserving poor but to the rich who could afford to purchase private insurance.  Introduced by Representative Thomas Curtis, Republican of Missouri and Senator Sydney Herlong, Democrat of Florida, the Republican/AMA bill was called “Eldercare.”
States would implement Eldercare with federal matching dollars.  It would provide a wide spectrum of benefits, including physicians’ care, surgical and drug costs, nursing home charges, diagnostic services, x-ray and laboratory fees, and other services.  Medicare’s benefits would be far more limited, covering about one-quarter (25 percent) of the total yearly healthcare costs of the average person.  Medicare would not cover physicians’ services or surgical charges. Neither would it cover drugs outside the hospital or nursing home, nor x-ray or other laboratory services not connected with hospitalization.  Instead of funding the program from Social Security type taxes, the Republicans proposed to pay for the program out of a combination of general revenues (2/3rds) and insurance premiums.[70]   
The AMA argued that Eldercare was better than Medicare because it “covered 100 percent of all health expenses including surgery and drugs” which Medicare did not.  In fact, Eldercare came nowhere close to covering 100 percent of expenses and was nothing more than an extension of the Kerr-Mills program that was not working.  “The AMA was using the literal language of the 1960 Kerr-Mills [bill] to advertise the potential benefits of Eldercare [with full knowledge that only three or four states had come even close to living up to the promises of coverage contained in the Kerr-Mills bill].[71]  The language may have been there but the delivery was not.  Other Republicans offered similar bills that falsely promised more benefits than Medicare when in reality they offered, if anything, fewer benefits.  Representative John Byrnes (R-Wisconsin) offered “Bettercare.”  As Sheri David points out, “the psychological climate of Congress [in 1964] was shifting from why so much? to why so little?”

LESSON:  Once they realize they are about to lose, opponents will offer a watered-down alternative and/or seek to hijack the change effort.  When the political climate begins to move in the direction of those who have long advocated major change, opponents of change shift tactics and pretend that they have had a change of heart.  In fact, nothing has changed but the opposition’s strategy.  Once they recognize that they cannot stop change, they seek to manipulate it.  The manipulation may involve efforts to hijack the change movement and mold it into something more acceptable by watering down elements.  Alternatively, the manipulation may involve an effort to outdo the proponents of change with false promises of benefits that far exceed what is practical in order to make the proposals of long-term advocates of change seem insufficient.  

 

THE THREE-LAYER CAKE

From January to March, Mills led his committee in deliberations over HR 1—The House Medicare bill.  Most members assumed that the bill would be reported out of committee favorably and would pass.   When AMA representatives appeared before the committee and argued that H.R. 1 was socialism, the committee dismissed them and Mills from then on refused to consult the AMA.  
On March 2, in an effort to reach a compromise with Republicans, Mills invited the ranking Republican on the committee, Representative John Byrnes to present an alternative bill he had been working on since January.  The Republicans had decided that their strong identification with the AMA opposition to Medicare may have contributed to their defeat in November and they wanted an alternative Medicare proposal that would not be as closely identified with the AMA as Eldercare was.  
Byrnes based his plan on the Aetna Life Insurance Company plan that covered federal government employees. The Byrnes bill would cover hospitalization plus doctor fees and prescription drugs.  Individuals over 65 could join but participation was voluntary.  Premiums would be “scaled to the amounts of the participants’ social security cash benefits,” so those receiving higher benefits would pay higher fees.  The government would pay for its share out of general revenues.
That same day, Mills met with Wilbur Cohen with a suggestion.  Why not combine Medicare, Eldercare and the Byrnes bill?  Cohen at first thought Mills was attempting to kill the President’s bill but on reflection realized that Mills was suggesting something Cohen himself had proposed.  This “three-layer” approach would include 
1.         Hospitalization Insurance for the aged (Medicare Part A) like the administration proposal [Forand/Anderson bills].
2.         A voluntary program of physician coverage (Medicare Part B) like the Republican proposals, and
3.         An expanded Kerr-Mills program of assistance to the poor similar to the AMA proposal (Medicaid)
That night Cohen wrote a memo to the President describing Mills proposal and recommending that the administration consider it. [72]  Cohen concluded his memo with the observation that “at least nobody will vote against it.”[73]  He later called Mills solution the “most brilliant move” he had seen in 30 years of legislative experience.  He marveled at Mills ability to construct legislation that undercut all of the major opposition.  “The doctors couldn’t complain because they had been carping about Medicare’s shortcomings and about it’s being compulsory.  In addition, the Republicans couldn’t complain, because it was their own idea.  In effect, Mills had taken the AMA’s ammunition, put it in the Republican’s gun, and blown both of them off the map.”[74]  Newsweek  said Mills’ three-layer approach was “aimed to please all of the people some of the time.“[75]
Over the next twenty days, the Ways and Means Committee under Mills’ leadership focused on merging the three bills. The committee made a number of changes in the Byrnes bills:
1.         Benefits were reduced, 
2.         Payment for drugs outside of a hospital was dropped, and
3.         The program was to be funded in part from premium payments of $3 per month per participant rather than being tied to social security benefits.
The Medicare bill was left largely intact although the length of hospital stays was reduced and the deductibles and co-insurance were increased.  The administration had wanted to cover radiology and anesthesiology but Mills insisted that “no physician service, except those of interns and residents under approved teaching programs would be paid.”.[76]
Mills served as the chief-negotiator, manager, and facilitator.  On March 29, the committee reported out its proposed bill (now known as the Mills Bill) as amendments to the Social Security Act: Titles 18 and 19.  Title 18, Part A was Medicare offering hospital insurance, Title 18, Part B was the modified Byrnes proposal for voluntary insurance to cover doctor fees.  Title 19 was an expanded Kerr-Mills program.  The bill was voted out of committee on a straight party-line vote with all but two Republicans opposing.  It passed the House on April 8, 313 to 115.

THE BILL GOES TO THE SENATE

Having passed the house the three-part Medicare bill went to the Senate for consideration first in the Senate Finance Committee.  Immediately proponents recognized that they were in trouble.  The Chairman of the Finance Committee, Harry Byrd of Virginia, was opposed to the bill and in no hurry to get on with Senate hearings.  Additionally, Senator Russell Long was concerned, among other things, that the House bill only covered 60 days of hospitalization.  He was determined to introduce amendments to change the bill to remove the 60-day limit and provide unlimited catastrophic and long-term care that he thought would make the costs of Medicare skyrocket.  Proponents had to neutralize both Byrd and Long if Medicare was to pass the Senate.  Byrd came first with the President playing a key role.
Johnson invited Byrd to the White House for a meeting which Byrd thought was to be about Vietnam.  Initially, Byrd declined saying he had pressing business in Virginia but ultimately agreed when Johnson promised to provide him with transportation back and forth from Virginia so that he could keep his commitments.  When Byrd arrived at the oval office, he discovered to his surprise that nine other Democrats including Mills, House Speaker McCormick, and Majority Leaders Carl Albert from the House and Mike Mansfield from the Senate had also been invited to what Byrd thought was to be an informal and private meeting just between him and the president.  Byrd was further surprised when Johnson marched his guests into the Cabinet room where TV cameras awaited.  Johnson stepped to the podium and delivered a formal statement supporting Medicare.  He then called upon his guests to step before the cameras with their comments.  As Byrd came forward, Johnson said loudly, “I know that you will take an interest in the orderly scheduling of this matter and give it a thorough hearing.”[77]  He then asked if Byrd could schedule the hearings promptly.  “A red-faced and ‘barely audible’ Byrd said yes.  Johnson banged his fist on the table in front of the Congressman and said ‘Good.’”[78]  The Byrd issue was resolved.  That left what to do about Long.
Mills had constructed a bill with a firm eye on costs, thus the limitation to 60 days hospitalization.  Long was more concerned about coverage, particularly for the elderly with serious illnesses requiring long-term care.  Additionally, proponents of Medicare had long fought to avoid any means-testing.  Medicare, like Social Security, would be an entitlement that people earned with their contributions and it would treat everyone equally.  It would not be a welfare program.  Long was proposing that the deductibles and out-of-pocket costs of Medicare recipients would vary by income.  That was unacceptable to Medicare advocates since it introduced a welfare-like component. 
People questioned Long’s motives.  The New York Times speculated that Long was either making a graceful retreat from his previous opposition to Medicare, or attempting to sabotage the whole program.  The New Republic commented that Long couldn’t expect to win his amendments, ‘but it does his Louisiana heart good to see his friends squirm.”[79]  
Long was not only willing to cause his friends on the Committee to squirm but was willing to engage in a bit of sleight of hand to get his amendments adopted.  On June 17th he went before the Committee with a quick explanation of his amendments, apologizing that he had not been able to bring copies to hand out.  However, he assured the Committee that the Johnson administration had approved of the amendments and asked for a quick vote.  The vote was called and Long won.  The Committee approved his amendments by a vote of 7-6..  At that point, Senator Anderson jumped to his feet to announce that he had the proxy vote of Senator Fulbright who was not in attendance and he was casting the proxy vote against Long’s amendments.  Long objected arguing that he had a more recent proxy from Fulbright.  The senators submitted the two proxies to the clerk for review.  The clerk ruled that Long’s proxy was indeed more recent.  Long cast his proxy in favor of his amendments.  The vote was now 8 to 6 in favor.  Anderson then asked to see Long’s proxy.  It turned out to deal with different legislation.  Long had tricked the Committee.  When Fulbright returned, he and Anderson along with Mike Mansfield went to Long to protest the proxy incident.  Long said that there must have been some misunderstanding.  He agreed to another vote.
There were other “misunderstandings” about the vote on Long’s amendments.  Senator Douglas said that the vote on Long’s amendments had happened so fast that he had voted in error.  After considering the implications of the amendments, he now wished to change his vote from “yea” to “nea.”  Albert Gore, who like Fulbright had missed the meeting, had given his proxy to Senator Ribicoff.  Ribicoff had cast Gore’s vote in favor of the amendments.  Wrong, said Gore, he was opposed to the amendments and had intended Ribicoff to vote in the negative.
Johnson exploded.  He called each Democrat on the Committee individually to express his anger.  Long’s actions were an affront and personal.  Long had voted for the Civil Rights Voting Act.  Now he was trying to put distance between himself and the President’s Great Society agenda just to gain political points in Louisiana.  Worse, the vote in favor of Long’s amendments, if it held, would kill any chance Johnson had to pass Medicare that year.  
The administration went into overdrive.  Long’s amendments had to be defeated on the next vote or Medicare was dead.  Cohen held an emergency strategy session with the White House team.  Maybe they could placate Long by extending hospital coverage for an additional 60 days.  Anderson objected.  On June 23, the Committee took a second vote.  Anderson won.  The Medicare bill without Long’s amendments was voted out of Committee by a margin of 12 to 5.  On July 9, the Senate passed its version of Medicare 68 to 21.  
The bill went to conference.  After a series of amendments, dealing primarily with cost-cutting the Conference Committee submitted its report on July 21.  The House passed the final bill six days later, followed by the Senate on July 28.  On July 30, Johnson signed Medicare into law in front of Truman and the 200 invited guests.  The United States joined the rest of the industrialized world in offering a government guarantee of medical insurance to at least a portion of its population.  We were just 70 years late.
Policy change is not something for ideologues.  You must court the powerful even if you find the task distasteful. Most frequently, proposed legislation in the House and Senate moves ahead, is stalled, or disappears because of what a few powerful individuals do or fail to do.  You must know who these individuals are.  You must know their personal criteria for supporting or opposing legislation that usually has nothing whatsoever to do with what is best for the country, their party, or even necessarily their constituents.  It frequently has much more to do with personal power, privilege, position and sometimes just the desire for attention.  Wilbur Mills shifting role in Medicare had more to do with status and power than it had to do with policy.  Similarly, Russell Long’s efforts to amend, and perhaps destroy, Medicare during the final debate over its provisions had as much to do with attention-seeking and just play cussedness, as it had to do with concern for the long term care of the elderly.  Regardless of why or how you feel about why powerful individuals support policy proposals, you must obtain their support.  That means catering to their eccentricity, even those you find unwarranted and/or even distasteful.

A PARTIAL VICTORY BUT A VICTORY NEVER-THE-LESS

Proponents of Medicare won more than they ever expected.  As Oberlander notes “The contest over Medicare…ended with a broader government role in health insurance than anyone had anticipated. Not only would the federal government provide hospitalization coverage to the elderly, but it would also operate a program of physicians’ insurance and subsidize state medical assistance to the poor. Moreover, the final bill extended Medicare coverage initially to the nearly three million seniors who were not eligible for Social Security.”[80]  Medicare delivered less than Truman had proposed but much more than proponents of the legislation had considered possible.
Many progressives thought Medicare and Medicaid would be just the beginning.  They had carved off a big piece of Cohen’s salami with the passage of health insurance coverage for the elderly and poor.  They expected to be able to take another slice very soon, this time by extending health insurance to children under a program they were already calling “Kiddiecare.”  However, more than 30 years would elapse before a program for uninsured children would pass (the State Children’s Health Insurance Program or S-CHIP) and then it would cover only children of the working poor and would be a state-based rather than federal program.   Several presidents and presidential candidates would propose expanding health insurance coverage—Richard Nixon and Ted Kennedy in 1971, Carter in 1976, and Clinton in 1993.  Each would fail largely because they did not know or heed the lessons we have examined so far about what it takes to get things done in Washington.  Obama finally succeeded by applying a number of the lessons from this chapter but his reform remains under attack as I write this with Republicans vowing to repeal it as soon as they can.  
While progressives were unable to keep slicing the health insurance salami as they hoped, they were able to retain the slices that already had.  Progressives have successfully defended Medicare and Medicaid from attacks from the Right for over 40 years.  That is not always the case.
In the next chapter, I will examine a time when progressives won a great victory and then lost much of what they had won a little more than a decade later.  After a struggle that was even more lengthy and difficult as the struggle for pure food and drugs and health insurance, the American labor movement won the passage of historic legislation guaranteeing workers the right to organize and negotiate with management for better pay and working conditions.  In just 12 years, Conservatives were able to push legislation through Congress undoing much of the hard-won protections.  That Conservative victory started the U.S. labor movement on a slow process of decline that continues to this day.  It is a cautionary lesson about the need for progressives to be vigilant and to work as hard to maintain and preserve gains as they did to win them.

A SUMMARY OF LESSONS FROM

THE STRUGGLE FOR HEALTH INSURANCE

Just because a presidential candidate or a sitting president, even a popular one, expresses support for a change effort don’t assume that achieving that change will be easy.  It might be easier to have the president behind your cause but that doesn’t make the accomplish easy or guaranteed.  At least four presidents or presidential candidates including Kennedy who was very popular supported some form of health insurance reform but only one was successful in passing legislation and then it was less than proponents of change had originally sought.  Gains in one area do not automatically translate into gains in another, even a closely related policy area.  The AALL assumed that its success in pushing states to adopt workman’s compensation laws could be transferred relatively easily to success in getting states to pass comprehensive health insurance.  It was wrong.  The reality is that each new drive for change is a war that you must fight on its own.  You can use lessons from previous efforts and you do benefit if you have a track record of success but you still have to fight the current battles just as you fought the battles in the previous war.

Anticipate well-funded opposition and be prepared to counter it.  It is the nature of change that one or more groups, often well-financed and influential groups, will be threatened by the change you propose just doctors in the AMA were.  Some people and groups will see the change you propose as a threat to their power, position, prestige, and even financial well-being.  Your challenge is to identify such individuals and groups early on, understand how your proposed changes affect them, anticipate the form their opposition might take, and prepare to defend your effort.  You should try to structure the change you propose to minimize the threat or make it less apparent.  Ideally, you should try to co-opt the opposition.

Expect opponents to charge that the change you propose is un-American.  You should never make the case for your policy change by citing what other countries have done, particularly European countries, even if these countries have been highly successful and you are basing your proposal on lessons learned from their efforts.  The un-American argument is a standard conservative opposition tactic and one you should be prepared to counter.  Show how the change you propose, rather than being un-American, is indeed what America is all about.  Turn the un-American argument on its head.  Argue that the opponents are the ones who are being un-American since they are setting out to destroy the country by ignoring a wrong and not fixing it, wishing a cancer away rather than treating it aggressively with the healing power of change.  Argue that the truly un-American thing to do would be to do nothing.  Americans are not “do nothings,” they are doers and that is what you are proposing.  Argue that your approach does not copy any other countries.  Your approach is a one-of-a-kind, uniquely American way of solving the problem.

Never be seduced by the logic and rightness of your cause.  Never assume that what is obvious to you will be obvious to the average American.  Never assume that the average American will accept facts more readily, or even as readily, as he will accept arguments based on speculation, superstition or even outright fabrication of data.  Do not expect Americans to recognize the difference between the truth and lies unless you specifically point out the difference.  It is okay to use facts and logic but keep in mind that Americans think with their hearts and not their heads.

You must present the change you propose in the simplest of possible terms but don’t leave out too many details.  Americans are uncomfortable with complexity and never understand nuance.  At the same time, do not forget to work out the details or at least most of them before you come forward with your proposal.  If you offer few or limited details, your opponents will fill the void with rumors, some involving wild charges and dire warnings of impending disaster should your policy become law.  Once such rumors start they are very difficult to counter so you must be prepared to counter them aggressively early on.  Do not bore Americans with the details but be prepared to discuss them thoroughly when the occasion demands.  Talking to Americans about public policy is like talking to kids about sex.  Answer their questions honestly and give them as much detail as they seem to want and are prepared to digest but not more.

Be prepared to counter the argument that states can solve their problem on their own. Initially, conservatives will try to convince Americans that no problem exists or that it is a minor problem that will solve itself if only it is left alone.  Failing that, your opponents will argue that if something must be done to remedy the problem it is best done by the private sector.  Conservatives worship the private sector and the profit motive.  Counter the private-sector- can-do-it-best argument by demonstrating that the private sector has had ample opportunity to remedy the problem but has failed to do so.  Use the profit motive to your advantage.  Demonstrate that because of the nature of the problem and the cost of even the cheapest practical remedy there is simply no profit for private companies in remedying the problem and thus no profit motive to do so.  Proponents of Medicare were able to show that private insurance was never going to solve the problem of the elderly’s access to health insurance since there was little or no profit for private insurers in doing so.  It was easy to demonstrate that by 1960 private insurance providers were covering an increasing number of working Americans but that few strides were being made in expanding that coverage among the aged for the simple reason that the cost of covering them did not yield sufficient profit.  Only a non-profit entity such as the federal government could address the issue.

Do not ignore the built-in distrust Americans have of power, in particular the power of government.  Minimize the expansion of government as much as possible.  Create few or no new boards, agencies, gurus, czars, or government departments.  You want to present your change as a logical and limited expansion of government, not something new but rather just an improvement on existing government activity and preferably one that is popular.  Proponents of Medicare sold it not as something new but rather as just an extension of Social Security that was highly popular at the time.

You must convince the majority of Americans, and preferably a supermajority, that the problem or issue your proposed policy change addresses affects them personally if you want to win their support.  Do not expect Americans to support substantive policy change for altruistic reasons.  Americans are selfish when it comes to what their government does.  They may contribute to private charities and support limited government intervention in times of disaster or when they are confronted with vivid, emotion arousing images of suffering, but their support for such efforts quickly fades.  You must construct a rational or better yet highly emotional argument that the problem impacts or potentially could impact nearly all Americans in some way.  You must convince the majority of Americans that the problem threatens them or their family and that they will personally benefit from the policy change you propose even if that is only partially the truth.  Americans only support public policy from which they believe they will benefit directly and concretely or which will cost them little or nothing.  You must make that case for your proposal even if it is largely a false one.  That is what proponents of Medicare did.  The majority of Americans were not elderly but most had relatives who were and everyone if they lived long enough would become elderly.  It was not hard to convince Americans, even young Americans, that they could personally benefit from the government caring for their aging parents or grandparents so they would not have to do so.  In addition, it was confronting to know that when one became old, one would have the power of government protecting one from the financial harm that an extended serious illness might cause.

Be careful about redistribution issues.  Americans accumulate.  It is part of the American character to seek out, assemble and hoard possessions either real or imagined.  Likewise, Americans live in constant fear of loss of their possessions.  Americans are ever watchful that something or someone might come along and take things, physical or emotional, real or imagined, from them.  Americans are particularly concerned that the taker might be the government.  Conservatives will prey upon American’s redistribution fears.  They will argue that what you are proposing is an evil endeavor to take from the deserving and give to strangers who are largely undeserving because otherwise, they would not be in need of government assistance.  You must provide reassurance that no American will lose because of the change you propose.  You must project all boats to rise.  You must guarantee that all futures will be positive.  The final tally must place all above average.  There must only be gains.  Loses are not allowed. 

You must build a record.  The discussions on the Forand bill like the discussions surrounding the earlier Wagner-Murray-Dingell proposals were important not because they resulted in any movement on the bill but because they began the process of “building the record,” which is a critical step in getting anything done in Washington.  You must take testimony from experts and the people.  You must accumulate data.  You must assemble statistics documenting the nature and extent of the problem.  People must get comfortable with the topic and with the people and organizations representing each side of the issue.  You must document, define, and plant in the minds of those who can affect change that an issue exists and a remedy is required even if they are unclear about the nature of that remedy.  Building a record is a ritual all major legislation must pass through.  That is the reason you want to get legislation introduced as early as possible even if you know you have little chance of success.  If nothing else, each failure to get legislation through a committee or brought to the floor helps to build the record.

You must engage in “salami-slicing” and be willing to “buy votes.”  You must seek that which will pass even if what passes will be less, and perhaps much less, than ideal. Proponents of Medicare were willing to exclude coverage of outpatient expenses if that was what it took to placate doctors and other opponents.  You must be pragmatic.

Policy change is not something for ideologues.  You must court the powerful even if you find the task distasteful. Most frequently, proposed legislation in the House and Senate moves ahead, is stalled, or disappears because of what a few powerful individuals do or fail to do.  You must know who these individuals are.  You must know their personal criteria for supporting or opposing legislation that usually has nothing whatsoever to do with what is best for the country, their party, or even necessarily their constituents.  It frequently has much more to do with personal power, privilege, position and sometimes just the desire for attention.  Wilbur Mills shifting role in Medicare had more to do with status and power than it had to do with policy.  Similarly, Russell Long’s efforts to amend, and perhaps destroy, Medicare during the final debate over its provisions had as much to do with attention-seeking and just play cussedness, as it had to do with concern for the long term care of the elderly.  Regardless of why or how you feel about why powerful individuals support policy proposals, you must obtain their support.  That means catering to their eccentricity, even those you find unwarranted and/or even distasteful.



[1] Quoted in Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), P. 142
[2] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 5.
[3] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.6
[4] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.10.
[5] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.20.
[6] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.22.
[7] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 7.
[8]  The quotes that follow are from Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America(Chapel Hill: University of North Carolina Press, 2001), p.85-106..
[9] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p. 3.
[10] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.84.
[11]  Quotes from Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p. 86..
[12] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.53,
[13] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.53.
[14] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p.36-37.
[15] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.83.
[16] Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America (Chapel Hill: University of North Carolina Press, 2001), p.83.
[17] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. 35-36.
[18] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. p. 8-9.
[19] Feingold, Eugene, Medicare: Policy and Politics, A Case Study and Policy Analysis, (San Francisco: Chandler Publishing Co., 1966), p. 6-12.
[20] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), pp. 11-12.
[21] Feingold, Eugene, Medicare: Policy and Politics, A Case Study and Policy Analysis, (San Francisco: Chandler Publishing Co., 1966), p. 97-100.
[22] Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), p. 22
[23] Feingold, Eugene, Medicare: Policy and Politics, A Case Study and Policy Analysis, (San Francisco: Chandler Publishing Co., 1966), p. 100.
[24] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 13.
[25] This discussion draws largely from Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), P. 4-5.
[26] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. p. 54-55.
[27] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 20
[28] Rashi Fein makes this point in Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. 64.
[29] Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), p. 25.
[30] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 5.
[31] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 5.
[32] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. 34.
[33] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. 34.
[34] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. 58-59.
[35] Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), p. 26.  
[36] Feingold, Eugene, Medicare: Policy and Politics, A Case Study and Policy Analysis, (San Francisco: Chandler Publishing Co., 1966), p. 159.
[37] Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), p. 27.  
[38] Sundquist, James L. Politics and Policy: The Eisenhower, Kennedy and Johnson Years, (Washington, D.C.: The Brookings Institution, 1968), p. 300.
[39] Feingold, Eugene, Medicare: Policy and Politics, A Case Study and Policy Analysis, (San Francisco: Chandler Publishing Co., 1966), p. 159-160.
[40]  Quoted in Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), p. 27. 
[41] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 14.
[42] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 19.
[43] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 21-22.
[44] Sundquist, James L. Politics and Policy: The Eisenhower, Kennedy and Johnson Years, (Washington, D.C.: The Brookings Institution, 1968), pp. 298-299.
[45] Sundquist, James L. Politics and Policy: The Eisenhower, Kennedy and Johnson Years, (Washington, D.C.: The Brookings Institution, 1968), p298-299.
[46] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 27 makes this argument.
[47] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), pp. 28-29.
[48] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 28.
[49] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 28.
[50] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 28.
[51] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 24.
[52] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 13
[53] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 81.
[54] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 29.
[55] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 30.
[56] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), pp. 57-58.
[57] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 37.
[58] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 39.
[59] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 39.
[60] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 39.
[61] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 42.
[62] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 42-44
[63] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 38-39.
[64] Sandquist, James L. Politics and Policy: The Eisenhower, Kennedy and Johnson Years. (Washington, D.C.: The Brookings Institution, 1968), p. 310.
[65] Rashi Fein, Medical Care, Medical Costs: The Search for a Health Insurance Policy, (Cambridge, MASS: Harvard University Press, 1986), p. 61.
[66] The 10 percent limit on Social Security taxes wasn’t a legal limit it was just something that had been surggested by Abraham Ribicoff in 1960 as a psychological limit.  The 10 percent figure stuck and became known as the “Rubicon” that could not be crossed.
[67] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 55.
[68] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 55.
[69] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), P. 131
[70] From AMA publication cited in Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 61.  
[71] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 126.
[72] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 64.
[73] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 129.
[74] Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), pp, 30-31
[75] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 131.
[76] Marmor, Theodore R., The Politics of Medicare, (Chicago: Aldine Publishing Company, 1973), p. 66.
[77] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 132 tells this story of the Johnson meeting.
[78] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 132.
[79] Sheri I. David, With Dignity: The Search for Medicare and Medicaid, (Westport, CT: Greenwood Press, 1985), p. 136.
[80] Oberlander, Jonathan.  The Political Live of Medicare, (Chicago: University of Chicago Press, 2003), p. 31.