By MICHAEL L. MILLENSON
Former President George H.W. Bush may have been every inch the caring individual portrayed in the eulogies of those who knew him, but when it came to health care reform, two words characterized his attitude: Don’t care.
However, compared to Congressional Republicans, Bush was a profile in conservative courage – a lesson with unfortunate parallels to now.
I covered health policy as a reporter for the Chicago Tribune during the Bush years. One strong memory, confirmed by checking original sources, was the presidential debate on Sept. 25, 1988 between Bush and his Democratic challenger, Massachusetts Gov. Michael Dukakis. When Bush was asked what he’d do for the 37 million people without health insurance – about one in seven Americans – he answered that he would “permit people to buy into Medicaid.”
I remember turning from the TV to my wife and saying, “I have no idea what he’s talking about.” Neither, apparently, did anyone else. A Washington Post story that followed, headlined, “Bush’s Mysterious Medicaid Plan” noted that seeking details from the Bush campaign yielded “answers [that] are contradictory.” The story added that “Bush had never publicly mentioned the idea” until the debate.
However, the proposal did serve a political purpose by showing that Bush had an alternative to Dukakis’ plan to require most employers to provide health insurance to their employees.
Speaking of politics, fast forward to Bush’s State of the Union Address in 1992. Just a couple of months before, a Democratic political maverick named Harris Wofford had stunned political observers with his victory in a special U.S. Senate election in Pennsylvania over Republican Dick Thornburgh, who’d served both as the state’s governor and the Bush administration attorney general. The central theme of Wofford’s campaign was the compelling need for national health insurance.
Until that point, as I wrote in July, 1991, the Bush administration had “conspicuously refrained from proposing any specific reforms, concentrating instead on promoting good personal health practices such as eating right and exercising.”
Panicked Republicans prepared a response to the administration’s plummeting approval ratings. A public television program in Chicago invited me to be on a panel commenting on Bush’s expected national health reform proposal. But instead of a detailed plan, there was just a vague mention of tax credits to “make basic health insurance affordable.”
Not long ago, I happened to come across a tape of that show as part of my year-end, “clean out stuff” campaign. That tape reflected a second strong memory of the Bush administration, which is that my reporting showed the president paid little attention to some very savvy health care advisors. Or, at least, invested little political capital in following their advice.
In the case of the State of the Union speech, powerful Congressional Republicans had forced the administration to retreat at the last moment. They’d “objected to a provision in which health insurance assistance for the poor would have been subsidized by taxing health benefits for the highly paid,” according to a Reuters story. One critic, then-Rep. Bill Gradison (R-Ohio), reportedly made an “irate” phone call to Bush. It was, perhaps, the most consequential phone call of Gradison’s career.
Because, you see, not only did Bush pull the offending provision from his speech, but when Bill Clinton was elected president later that year, Gradison was recruited to head up the main lobbying group of the health insurance industry. And when Clinton fulfilled his campaign promise to propose comprehensive health care reform, the “Harry and Louise” commercials run by the health insurance group, which paid its chief executive far more than a mere Congressional salary, were widely credited with helping turn the tide against the Clinton proposal.
But here’s the kicker. The plan that Bush eventually proposed included a mixture of vouchers and tax credits. However, as commentator Michael Kinsley noted, while the Bush plan was putatively based on a proposal from the conservative Heritage Foundation, his plan left out the politically difficult part. Heritage helped pay for vouchers by ending the economically distorting tax subsidy for employer-provided health care. The Bush plan, said Kinsley, relied instead on dishonest math.
Does that Heritage initiative ring a bell? It should, since the Affordable Care Act, the “Obamacare” derided by so many Republicans, was based on that same Heritage plan. Fiscally dishonest politicians of both parties continue to seek repeal of Obamacare’s so-called “Cadillac tax” on employer plans with rich benefits, while hard-right conservatives continue the tradition of fuzzing over the difference between “some health insurance coverage for some” and “useful coverage for all.”
In 1992, Kinsley wrote: “The Heritage proposal should have great appeal to principled liberals as well as principled conservatives.” George Herbert Walker Bush may, indeed, have been a principled conservative. He showed that in foreign policy, his great strength. But when it came to health care, Bush just didn’t care enough to effectively lead.
Michael Millenson is a consultant specializing in quality of care, patient empowerment and web-based health. He is President of Health Quality Advisors, an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine, and an associate editor of THCB.
The cost and quality debacle continues to assume that healthcare research and CMS funding proposals will eventually “win-out.” Probably not, and meanwhile we continue to ignore the true “elephant in the closet.” No matter how we solve the healthcare delivery problems, we still have yet to express a nationally acknowledged deterioration of our nation’s social capital, community by community.
As it has for 30 years, our nation’s annual maternal mortality incidence has increased from 7.2 deaths per 100,00 live births in 1987 to 26.4 deaths per 100,000 live births in 2016. Nearly simultaneously, the number of mass shootings was ” 88 ” from 1985 through 1999 and ” 206 ” from 2000 through 2015. Obesity, chemical addiction, homelessness, adolescent suicide, mid-life depression and decreasing longevity (now 4 years in a row) continue to worsen with epidemic dimensions.
We must begin with a locally driven, community by community funded and nationally structured investment in the Social Capital deficits affecting the next-door-Neighbor Network of each citizen’s FAMILY. This is not a bricks and mortar investment. We now have robust evidence that Trust improves community health and improved community health in turn improves the level of Trust within the community’s municipal life.
See Giordano and Lindstrom “Trust and Health: Testing the reverse causality hypothesis” 2015 at http://dx.doi.org/10.1136/jech-2015-205822
Nothing ever changes.