1 00:00:01,100 --> 00:00:23,150 Sort of. Welcome everyone. 2 00:00:23,150 --> 00:00:27,320 I think most of you know me, I'm Hal Jones, I'm the director of the rather new American Institute, 3 00:00:27,320 --> 00:00:33,740 and it's a real pleasure to welcome you this week to what is our weekly American Politics seminar, 4 00:00:33,740 --> 00:00:38,180 but also a special seminar on our calendar for this term. 5 00:00:38,180 --> 00:00:47,030 And we're very pleased to welcome John Price for a presentation on Nixon's initiatives in the area of health care. 6 00:00:47,030 --> 00:00:50,960 But a historical topic, but one that I think as John will show us, 7 00:00:50,960 --> 00:01:01,670 has a lot of significance to subsequent policy debates in this area, sort of down to the present day in the United States. 8 00:01:01,670 --> 00:01:10,430 John was a firsthand protagonist, a participant in some of the events that [INAUDIBLE] be telling us about. 9 00:01:10,430 --> 00:01:18,560 He was special assistant to President Nixon for urban affairs in the in the Nixon administration. 10 00:01:18,560 --> 00:01:26,360 But he's also, importantly, a longtime friend of the University of Oxford and of the rather more American Institute. 11 00:01:26,360 --> 00:01:37,460 US with regularity over the years has spoken here previously, drawing on some of his insights and perspectives from public service. 12 00:01:37,460 --> 00:01:47,510 He's he hasn't asked me to mention this, but I should say we're able to enjoy the electronic collection of the records of 13 00:01:47,510 --> 00:01:52,760 the US political party conventions as a resource of their homes worth library, 14 00:01:52,760 --> 00:01:56,840 thanks to to John's generosity. So he's a good friend. 15 00:01:56,840 --> 00:02:02,570 We always enjoy seeing him when he's here and then catching up with him when when some of us get over to the United States 16 00:02:02,570 --> 00:02:11,900 delighted that that you've come through Oxford right now to to speak on this important part of the Nixon administration. 17 00:02:11,900 --> 00:02:18,200 We were talking just yesterday about how we are just at the 50th anniversary of Richard Nixon's inauguration. 18 00:02:18,200 --> 00:02:22,340 For his his first term. So it's, you know, with a half centuries perspective, 19 00:02:22,340 --> 00:02:36,110 we can is obviously a figure and it is an administration that draws a lot of comment is one that ended in in in controversy and and and scandal. 20 00:02:36,110 --> 00:02:45,140 But I think it's important to take an objective historical look at the the policy debates of that moment at what was really an 21 00:02:45,140 --> 00:02:52,560 important the pivotal in the sense of being a real turning point in the contemporary political history of the United States. 22 00:02:52,560 --> 00:02:55,880 So we're delighted John's here and able to share some of his insight into that 23 00:02:55,880 --> 00:02:59,990 era and to speak with us about health policy in particular at that time. 24 00:02:59,990 --> 00:03:07,580 Thank you and thank you. Also, not just for the very nice introduction, but for your stewardship here at the. 25 00:03:07,580 --> 00:03:16,010 And it's been a good run and looking forward to even greater things, but we all are in your debt for what you've done. 26 00:03:16,010 --> 00:03:22,010 And I might also say the certainty in debt to Nigel Bowles, who was your not your immediate predecessor, 27 00:03:22,010 --> 00:03:26,900 but was an important sort of fairly formal director of the RGA. 28 00:03:26,900 --> 00:03:32,900 So I'm delighted to be in the presence of both of you with my gratitude to you both. 29 00:03:32,900 --> 00:03:38,870 I might just before I start to read this lengthy opus of mine for you to just 30 00:03:38,870 --> 00:03:44,300 touch on the point that Hal mentioned about the 50th anniversary of the inaugural, 31 00:03:44,300 --> 00:03:51,890 there was a very interesting piece on that day the 20th of January, just a week ago Sunday in the Los Angeles Times by David Sherman, 32 00:03:51,890 --> 00:03:56,720 a Pulitzer prise winning journalist who used to cover Washington for the worst of 33 00:03:56,720 --> 00:04:02,870 the Wall Street Journal and the Boston Globe and the Post-Gazette in Pittsburgh. 34 00:04:02,870 --> 00:04:16,700 But he made a point about how it was a very in a positive way, a very emotional time, and that 1968 is any one of you in the room will remember. 35 00:04:16,700 --> 00:04:22,640 Not personally, but by reading so much about it was a fraught, traumatic year. 36 00:04:22,640 --> 00:04:28,040 And so Nixon had gone through the campaign very much as a law and order candidate. 37 00:04:28,040 --> 00:04:33,170 But then, as he said himself, I watched Chicago, I watched the Democratic convention, he said. 38 00:04:33,170 --> 00:04:37,580 I couldn't believe my eyes. You know, it was. It was everywhere. It was racial. 39 00:04:37,580 --> 00:04:43,250 It was economic. It was just pandemonium. 40 00:04:43,250 --> 00:04:48,110 And so when we came in with a very narrow victory, not a majority, 41 00:04:48,110 --> 00:04:58,070 but rather almost a spread of only a point between Nixon and Humphrey, with George Wallace having taken 10 percent of the vote. 42 00:04:58,070 --> 00:05:03,530 George Wallace, a basic white nationalist Dixiecrat candidate. 43 00:05:03,530 --> 00:05:11,060 So it was it was a tense time, and Nixon came in really seeking to heal the American spirit in a way. 44 00:05:11,060 --> 00:05:18,110 And it's curious because people sometimes forget he had this Quaker background to him and it was always there. 45 00:05:18,110 --> 00:05:24,950 Unlike Herbert Hoover, we were talking earlier about the Hoover. Library in in West Branch, Iowa. 46 00:05:24,950 --> 00:05:27,950 And I talked to the archivist there, and I said, to your knowledge, 47 00:05:27,950 --> 00:05:36,650 did did Richard Nixon and Herbert Hoover ever talk about the fact they were the only two Quaker presidents in American history? 48 00:05:36,650 --> 00:05:40,190 Said no, he said. You know, Hoover didn't take it seriously at all, he said. 49 00:05:40,190 --> 00:05:44,030 I think Nixon did. There was something more deeply embedded in Nixon about it. 50 00:05:44,030 --> 00:05:50,530 So there was a sense of wanting to heal the country. And 68, the tone was interesting. 51 00:05:50,530 --> 00:05:59,750 A friend of mine who is still alive and well and working in the public policy arena, was in the Bureau of the Budget when we took office. 52 00:05:59,750 --> 00:06:05,960 And he and I've compared notes and he makes the point that it was in its own way like a mini Camelot. 53 00:06:05,960 --> 00:06:13,340 Everybody thinks of the Kennedy start up as Camelot. But he was saying, You know, John there was placed around the government, 54 00:06:13,340 --> 00:06:17,780 not just in the White House, but in various departments, particularly health, 55 00:06:17,780 --> 00:06:18,890 education and welfare, 56 00:06:18,890 --> 00:06:28,220 but also at housing and urban development and even the poverty programme where a lot of moderate Republicans and there was a sense of efficacy. 57 00:06:28,220 --> 00:06:31,670 There was a sense of wanting to do something right. 58 00:06:31,670 --> 00:06:41,570 There was a sense of having come from a more liberal Republican trajectory. And so it was a very, very uplifting time. 59 00:06:41,570 --> 00:06:52,880 So with that background, let me hop into my comments on Nixon's health strategy and its role down through the decades since that time. 60 00:06:52,880 --> 00:07:04,010 Again, some of you may have watched the funeral of Bush 41 George Herbert Walker Bush and just weeks ago in the rotunda of the US Capitol. 61 00:07:04,010 --> 00:07:16,250 Senator Robert Dole rose with help from his wheelchair, and he gave a salute the silent salute to the casket of Bush, 41, but with his left hand. 62 00:07:16,250 --> 00:07:22,760 Bob Dole had had his right arm mangled in combat in World War Two and was never able to use it again. 63 00:07:22,760 --> 00:07:30,590 And he even would carry a pencil just gripped in his hand. So when people would proffer a handshake to him with a right hand, it couldn't be done. 64 00:07:30,590 --> 00:07:38,570 And he made a point. Richard Nixon was one of the only people he knew in public life who would make a left hand handshake to him. 65 00:07:38,570 --> 00:07:44,900 But Dole paid a silent tribute to Bush, 41, a quarter-century earlier. 66 00:07:44,900 --> 00:07:51,650 Dole was present for the memorial service and interment at the childhood California home. 67 00:07:51,650 --> 00:07:56,360 There was no state funeral for this man of Richard Nixon. 68 00:07:56,360 --> 00:08:06,380 And on that occasion, Dole gave voice to his tribute, and then it literally tears streaked farewell. 69 00:08:06,380 --> 00:08:09,950 Dole said of Nixon, I'm sorry, I always have these problems. Is Nigel now? 70 00:08:09,950 --> 00:08:10,940 Will remember? 71 00:08:10,940 --> 00:08:19,700 He leapfrogged the conventional wisdom to propose revolutionary solutions to health care and welfare reform, anticipating by a full generation. 72 00:08:19,700 --> 00:08:29,900 The debates now raging on Capitol Hill. Those speaking at Nixon's grave in 1994, a quarter century before we hear today at the rather mere dole, 73 00:08:29,900 --> 00:08:36,350 spoke then as the Clinton health care proposals were being aired before a sceptical Congress. 74 00:08:36,350 --> 00:08:43,250 Those elements, which succeeded over their lineage to Richard Nixon's strategy on health care and the failure of the others, 75 00:08:43,250 --> 00:08:51,670 was followed many years later by the Affordable Care Act under President Barack Obama without a single Republican vote. 76 00:08:51,670 --> 00:08:58,520 And since that moment, we've been subjected to nearly a decade of denigration by Republicans over Obamacare. 77 00:08:58,520 --> 00:09:05,390 That health care legislation itself contained many elements which had been advanced by Richard Nixon. 78 00:09:05,390 --> 00:09:11,750 Nearly a half century before, Dole was deeply emotional, according to those there. 79 00:09:11,750 --> 00:09:17,780 But in a more academic and detached manner, two authors David Blumenthal, William James Morone, 80 00:09:17,780 --> 00:09:27,260 say simply of Nixon that quote he left a richer health policy legacy than almost any other president. 81 00:09:27,260 --> 00:09:32,600 Within his first year as President, Nixon introduced his dramatic family assistance plan. 82 00:09:32,600 --> 00:09:42,530 In essence, a guaranteed income for American families whose income was at or below the poverty line and that became Nixon's early domestic priority. 83 00:09:42,530 --> 00:09:50,600 But Nixon was a relative latecomer to issues of public welfare and things of that character, however, in the area of the health field. 84 00:09:50,600 --> 00:09:56,240 It wasn't the case in this. He had a much longer and far deeper understanding. 85 00:09:56,240 --> 00:10:00,230 Nixon's was a visceral feeling of empathy for those families, 86 00:10:00,230 --> 00:10:07,580 overwhelmed by serious health problems and the emotional and financial carnage which was wrought by that. 87 00:10:07,580 --> 00:10:17,180 It also was informed by his involvement in the far reaching changes to health care that had been either accomplished or attempted under Eisenhower, 88 00:10:17,180 --> 00:10:21,440 whose Vice President Nixon was for eight years. 89 00:10:21,440 --> 00:10:28,610 And on Eisenhower's watch, one of the two most significant post-war developments in health policy occurred. 90 00:10:28,610 --> 00:10:37,100 He saw the expansion of the most, most dramatic health care and private insurance coverage of the latter 20th century. 91 00:10:37,100 --> 00:10:42,130 It was called ECI or employer sponsored health insurance. 92 00:10:42,130 --> 00:10:46,150 And when the war ended, a major boom had ensued. 93 00:10:46,150 --> 00:10:55,780 Employment grew dramatically throughout the American economy. The classic American middle class was born at that moment in time. 94 00:10:55,780 --> 00:11:03,910 The medium for Eisenhower's massive expansion of health coverage was the revenue code, the internal tax code, 95 00:11:03,910 --> 00:11:08,620 nineteen fifty four revisions of the tax code and I was for two and a half years a tax lawyer. 96 00:11:08,620 --> 00:11:14,020 I plead guilty. But this was this was a major, comprehensive change. 97 00:11:14,020 --> 00:11:23,260 And what he did in 54 was he clarified and expanded the availability of tax deductions or the freedom from tax liability, 98 00:11:23,260 --> 00:11:34,570 either for employees, employers to offer or employees to be beneficiaries of employer sponsored private health insurance. 99 00:11:34,570 --> 00:11:38,650 And his characteristic budgetary constraint was concealed. 100 00:11:38,650 --> 00:11:48,190 At this point, it was it was not an outlay in the budget. It was a tax expenditure, a tax benefit to the employer and employee. 101 00:11:48,190 --> 00:11:54,910 Everybody was happy. Still left out, though, were the elderly, the unemployed and the indigent. 102 00:11:54,910 --> 00:12:02,020 Nixon had first stepped earlier into the health care debate in 1949, when Harry Truman, 103 00:12:02,020 --> 00:12:10,360 after his very unexpected re-election victory in 1948, was again trying to promote his vision of health care. 104 00:12:10,360 --> 00:12:17,770 Congressman Richard Nixon, in only his second term, joined the most liberal member of his party in the house. 105 00:12:17,770 --> 00:12:24,880 New York's Jacob Javits and two liberal Republican senators to introduce a private insurance system, 106 00:12:24,880 --> 00:12:30,160 which would cover all without regard to whether they could afford the premiums. 107 00:12:30,160 --> 00:12:37,570 This was a move highly suggestive of future action on Nixon's part in the health care arena. 108 00:12:37,570 --> 00:12:45,820 Nixon did not align himself here with the crusty conservative lie and Robert A. Taft of Ohio in Taft tepid 109 00:12:45,820 --> 00:12:52,390 and constrained response to a democratic move toward fully federally funded and overseen medical care. 110 00:12:52,390 --> 00:12:58,360 He Nixon did not go the route of allowing the states to point the way at their own pace 111 00:12:58,360 --> 00:13:04,060 and with their often meagre percentage of participants in health insurance programmes. 112 00:13:04,060 --> 00:13:11,110 He was not passive. Rather, he was a marquee name on activist legislation with Republican liberals. 113 00:13:11,110 --> 00:13:17,860 Senator Ralph Flanders of Vermont and Republican Irving Ives of New York and Jack Javits. 114 00:13:17,860 --> 00:13:26,830 There was an aggressive alternative using the private sector to a government he does or proposal of that has some resonance today. 115 00:13:26,830 --> 00:13:31,330 From this, the authors I mentioned before, Blumenthal and Moran, conclude that quote, 116 00:13:31,330 --> 00:13:38,560 this was the first intimation that the ambiguous Nixon would eventually stand alongside Harry Truman. 117 00:13:38,560 --> 00:13:44,590 Two presidents who cared about health care failed to win their own signature programme and 118 00:13:44,590 --> 00:13:51,790 yet decisively shaped the policy debates long after their troubled days in the White House. 119 00:13:51,790 --> 00:13:58,090 Eisenhower sought to find a path to protection for the elderly in a 1954 reinsurance plan. 120 00:13:58,090 --> 00:14:04,450 I won't bother to tell you the details, but it would backstop private insurers coverage of the elderly. 121 00:14:04,450 --> 00:14:07,430 Don't forget, we're we're not yet covered. 122 00:14:07,430 --> 00:14:13,670 Medicare not yet been passed, so they were out lying out there, exposed because they were no longer employed. 123 00:14:13,670 --> 00:14:21,040 Therefore, not being the beneficiaries of these these tax tax incentives, the employer provided health programmes. 124 00:14:21,040 --> 00:14:29,230 Eisenhower encountered a wall of opposition from the American Medical Association, the AMA and from the insurance industry itself, 125 00:14:29,230 --> 00:14:38,500 which was regulated by state regulators and feared this would be a first step toward regulation of their industry by the federal government. 126 00:14:38,500 --> 00:14:46,680 In their view, a less pliant or supportive overseer, I explain, lost by a single vote in the US Senate. 127 00:14:46,680 --> 00:14:54,150 He tried another tack. The new Eisenhower plan carried the name Medicare programme for the agent. 128 00:14:54,150 --> 00:15:04,410 The name survived. The substance didn't. I guess Bill would give federal grants to the states and through them, give money to elderly, 129 00:15:04,410 --> 00:15:10,410 low income Americans to pay for buying private health care insurance coverage. 130 00:15:10,410 --> 00:15:13,770 Liberal Republican Senator Jacob Javits of New York, 131 00:15:13,770 --> 00:15:21,150 once again finding himself teaming up with now vice President Richard Nixon, introduced the administration bill. 132 00:15:21,150 --> 00:15:24,240 A diverse group dammed the proposal. 133 00:15:24,240 --> 00:15:34,410 The AFL-CIO organised Labour, the AMA Organised Medicine, the emerging conservative icon Barry Goldwater of Arizona, 134 00:15:34,410 --> 00:15:40,650 who was gathering visibility as the next Robert Taft but even more of a heartthrob for conservatives. 135 00:15:40,650 --> 00:15:50,520 Kennedy, once elected, attempted a Medicare bill, a government managed programme, but adopting Ike's name for it, believe it or not, 136 00:15:50,520 --> 00:15:58,740 and failed Lyndon Johnson, as he did with Kennedy's hapless results on the civil rights bills, 137 00:15:58,740 --> 00:16:03,700 took Medicare and Medicaid and saw them through to success. 138 00:16:03,700 --> 00:16:12,090 Once the demand for services, which was induced by Medicaid and Medicare had spurred it, costs of care were skyrocketing. 139 00:16:12,090 --> 00:16:19,470 As Medicaid's passage had spirited and the grounded in a retrospective payment system, 140 00:16:19,470 --> 00:16:25,760 Medicare invited an almost inevitable inflation of medical costs. 141 00:16:25,760 --> 00:16:31,160 Nixon was the first president to be in office when the full effect of these important great society 142 00:16:31,160 --> 00:16:39,110 initiatives came into play and the urgency of containing the costs of these entitlements was felt. 143 00:16:39,110 --> 00:16:48,020 Cost control was therefore very much on Nixon's mind and a prompt for one of the most significant initiatives he took in the health arena. 144 00:16:48,020 --> 00:16:55,850 In fact, it was the element of his 1971 proposals which did first become law and was built upon and later administrations, 145 00:16:55,850 --> 00:16:59,190 especially Clintons and Obama's. 146 00:16:59,190 --> 00:17:08,250 A further prop from the Nixon administration to look more closely at financing of health care came from the crafting of his welfare reform proposal. 147 00:17:08,250 --> 00:17:16,860 The Family Assistance Plan, or FAP, if they paid where there was a need to integrate it with housing assistance, food stamps, 148 00:17:16,860 --> 00:17:24,180 Medicaid, in other words, all those programmes which were out there providing help to low income individuals or families. 149 00:17:24,180 --> 00:17:32,190 So they had to figure out a way in which whatever health insurance programme you developed would fit into those. 150 00:17:32,190 --> 00:17:39,390 As FAP was working its way through the Congress in 1970, Nixon's domestic council created a committee on health care. 151 00:17:39,390 --> 00:17:47,910 Nixon was convinced that in 72, it would be a big issue, partly because of Ted Kennedy and Nixon expecting Kennedy to run for Kennedy. 152 00:17:47,910 --> 00:17:56,520 It was a big signature issue. Basically Medicare for all, but also just because it was it was out there and increasingly so. 153 00:17:56,520 --> 00:18:02,490 And so the concept this is from my diary was quote, not a White House Working Group concept. 154 00:18:02,490 --> 00:18:07,650 Elliot Richardson, the head of the Department of Health, Education and Welfare, 155 00:18:07,650 --> 00:18:12,990 intends to make this a model for policy development within the department. 156 00:18:12,990 --> 00:18:24,420 This for you students of political science would be the lead agency concept versus a White House staff initiative or battling for the approach. 157 00:18:24,420 --> 00:18:33,300 This approach failed. Seven options were flirted with by AGW, ranging in price from $1 billion to $30 billion, 158 00:18:33,300 --> 00:18:40,050 and health options have been winnowed from hundreds down to 60, some unrelated specifics. 159 00:18:40,050 --> 00:18:49,080 In any case, in December 1970, John Erlichman, who by now was the domestic tsar in the Nixon White House and in charge of domestic policy, 160 00:18:49,080 --> 00:18:55,500 agreed with me that I would begin picking up health can call Erlichman Principal Deputy Quote, 161 00:18:55,500 --> 00:19:03,480 and this is my diary and I in the winter on a crash basis, put together another White House working group to pick up the pieces. 162 00:19:03,480 --> 00:19:09,870 Call focussed on the insurance features while I took charge of the more novel part of the Nixon initiative. 163 00:19:09,870 --> 00:19:15,870 This was the idea of supporting prepaid group practises in California, 164 00:19:15,870 --> 00:19:26,220 and a few other places there had emerged in non-profit form organisations whose structure and incentives encouraged cost containment. 165 00:19:26,220 --> 00:19:36,390 Nixon had met with a man named Edgar Kaiser earlier in 1970. The principal in the so-called Kaiser Permanente prepaid group practise entity. 166 00:19:36,390 --> 00:19:48,780 His argument appealed to Nixon build an incentive structure that emphasises keeping a patient well, not hospital bound preventive attention and care. 167 00:19:48,780 --> 00:19:54,330 The patient is healthy and the costs of care are lessened, and I worked hard with the staff at health, 168 00:19:54,330 --> 00:20:03,150 education and welfare to refine the idea, and at last it was to roll out and incent a nationwide programme of prepaid group practises. 169 00:20:03,150 --> 00:20:08,430 We would call these health maintenance organisations or HMO. 170 00:20:08,430 --> 00:20:13,500 It must have had a patina of socialism about it in certain eyes, 171 00:20:13,500 --> 00:20:19,920 or at least too much novelty, or at least the antipathy of the American Medical Association. 172 00:20:19,920 --> 00:20:23,940 Spiro Theodore Agnew, the vice president, 173 00:20:23,940 --> 00:20:31,560 took a dislike to it and a dislike to me as its agent of encouragement with the president 174 00:20:31,560 --> 00:20:38,280 some days before the president's message was to go to Capitol Hill in mid-February of 1971. 175 00:20:38,280 --> 00:20:46,230 I got a phone call from Ken Kohl. He said that the president had just received a phone call from Vice President Agnew. 176 00:20:46,230 --> 00:20:54,270 Agnew was on Air Force Two, winging his way westward to play golf with Frank Sinatra at Palm Springs, California. 177 00:20:54,270 --> 00:21:00,060 His aeroplane reading was my decision paper on this part of the president's health strategy. 178 00:21:00,060 --> 00:21:06,840 Agnew weighed in with Nixon about how I had either not consulted properly with him or even if I had. 179 00:21:06,840 --> 00:21:12,300 I had not then listened. Regardless, he disagreed with the recommendation to Nixon. 180 00:21:12,300 --> 00:21:18,120 Nixon asked Cole to call me and tell me of the phone call, and for me not to worry. 181 00:21:18,120 --> 00:21:24,210 Naturally, I was concerned that the vice president had bent the ear of the president complaining of you. 182 00:21:24,210 --> 00:21:32,250 I was reassured, though, at the time by John Erlichman, and then even more later, reading his memoir not to worry about Agnew's enmity. 183 00:21:32,250 --> 00:21:42,090 In his memoir Witness to Power, Erlichman mentions that the early idea from Nixon was for Agnew to be in charge of developing a new health programme. 184 00:21:42,090 --> 00:21:53,990 Health experts were to be added to Agnew staff. A communications director at Erlichman is caustic, hence his confident reassurance to me at the time. 185 00:21:53,990 --> 00:22:02,670 When I needed it. Erlichman notes Agnew then shared a series of interdepartmental meetings on health issues, 186 00:22:02,670 --> 00:22:08,610 but he seemed incapable of organising the work and guiding the staff to a result. 187 00:22:08,610 --> 00:22:17,880 I watched the vice president closely during this health project, trying to discover the cause of his mental constipation. 188 00:22:17,880 --> 00:22:23,280 I concluded that the man was exceedingly narrow. New thoughts were unwelcome to him. 189 00:22:23,280 --> 00:22:30,720 As a result, his health project did not gather for the present all the practical alternatives for a final choice. 190 00:22:30,720 --> 00:22:36,580 Instead, it became a narrow reflection of Spiro Agnew preferences. 191 00:22:36,580 --> 00:22:42,250 The plan went forward in a briefing held for the congressional leadership before its unveiling. 192 00:22:42,250 --> 00:22:47,590 And it was here for it. The president was expansive in his description of the pending message. 193 00:22:47,590 --> 00:22:58,450 This is the president in my notes. Some 65 percent of employers have insurance now, which is up to the minimum standard will expand to the balance, 194 00:22:58,450 --> 00:23:04,450 expand to the balance exactly what his 1971 proposal did. 195 00:23:04,450 --> 00:23:08,860 He went on to say it would provide diversity, competition and experimentation. 196 00:23:08,860 --> 00:23:15,010 This is a quote from Nixon. We have to think of the horse and buggy. If the horse doesn't like it, it will call it. 197 00:23:15,010 --> 00:23:19,810 We have to have something which is acceptable, at least minimally to the profession. 198 00:23:19,810 --> 00:23:28,420 Then we goes again. To quote, this will save the best of the private initiative medical care system, which was an underlying fundamental principle. 199 00:23:28,420 --> 00:23:32,410 He wanted to preserve the best in American medical practise. 200 00:23:32,410 --> 00:23:39,320 The core parts of the plan included a National Health Insurance Standards Act, a family health insurance plan, 50. 201 00:23:39,320 --> 00:23:45,870 Remember FAP and health maintenance organisations. As you told us in the meeting, 202 00:23:45,870 --> 00:23:51,720 Nixon would extend private insurance coverage to the balance by having all employers of one 203 00:23:51,720 --> 00:23:58,320 or more employees provide a minimum standard coverage for employees and their dependents, 204 00:23:58,320 --> 00:24:04,110 including inpatient hospital care, extended care facilities, home health services. 205 00:24:04,110 --> 00:24:08,460 Outpatient care. Catastrophic cost coverage. 206 00:24:08,460 --> 00:24:15,960 All with employers paying 65 percent of the premiums to start and then raising to 75 percent in future years. 207 00:24:15,960 --> 00:24:21,630 Private insurance pools were to be established for risk sharing amongst small employers, 208 00:24:21,630 --> 00:24:31,460 the self-employed and people outside of the labour force in order to permit purchase by these health consumers at group rates. 209 00:24:31,460 --> 00:24:36,950 Then the family health insurance plan would provide insurance to all low income families, 210 00:24:36,950 --> 00:24:44,390 with children not covered by employer plans and with uniform national definitions of eligibility. 211 00:24:44,390 --> 00:24:54,200 Like FAP, the whip removed inequities between male and female headed families, the working poor and dependent poor. 212 00:24:54,200 --> 00:24:57,680 And like his food stamp programme rationalisation, 213 00:24:57,680 --> 00:25:09,320 CIP eliminated the eligibility inequities between states based on income and made uniform the existing wide variation in benefits. 214 00:25:09,320 --> 00:25:18,620 And this next point is important just in standing back and thinking of what might have been at work more in Nixon's psyche, 215 00:25:18,620 --> 00:25:28,670 as seemed true of all of Nixon's main messages, addresses or extemporaneous comments on his consequential social policy initiatives. 216 00:25:28,670 --> 00:25:37,580 There wasn't their language, not alone, their substance and insight into the more liberal and humane side of this complex man. 217 00:25:37,580 --> 00:25:45,350 True of the February 1971 message on health. True, the message on hunger and the expansion of the food stamp programme. 218 00:25:45,350 --> 00:25:50,090 True of the August 1969 announcement of the Family Assistance Plan. 219 00:25:50,090 --> 00:25:55,790 Welfare reform for all his calculation, realism, cynicism, 220 00:25:55,790 --> 00:26:06,050 even spleen or bile is coherent and strategic approach to poverty and need was striking and passionately felt. 221 00:26:06,050 --> 00:26:11,780 Nixon's Quaker background intrudes from time to time in these welfare and health policies. 222 00:26:11,780 --> 00:26:19,880 A remarkable example was his personal, dramatic conception of doing something with the former Fort Detrick, 223 00:26:19,880 --> 00:26:29,540 Maryland, facility for manufacturing chemical warfare agents into the home of the National Cancer Institute. 224 00:26:29,540 --> 00:26:40,220 Nixon in 1969 had announced, announced and abandoned the US use retention or future development of chemical and biological warfare weapons. 225 00:26:40,220 --> 00:26:50,330 Now, the chemical weapons production site was to be the headquarters for cancer fighting research and funding swords into ploughshares. 226 00:26:50,330 --> 00:26:52,100 Reception was very positive. 227 00:26:52,100 --> 00:27:00,350 Small business, however, was concerned about the cost impact on them of providing insurance to one or a couple or three employees. 228 00:27:00,350 --> 00:27:04,460 Nixon Gerald Ford, then Republican leader in the House. 229 00:27:04,460 --> 00:27:11,000 Secretary Richardson, Ken Cole and I met with Congressman John Burns of Wisconsin, the ranking Republican, 230 00:27:11,000 --> 00:27:16,850 on the Ways and Means Committee, the relevant committee for Health Issues in the Congress. 231 00:27:16,850 --> 00:27:21,830 This was after the message going up and after I and the head of the Small Business Administration, 232 00:27:21,830 --> 00:27:25,310 had met with the small business lobby about their concerns, 233 00:27:25,310 --> 00:27:32,690 and it was agreed that Burns would offer an amendment that the one or more employees would be used to 10 or more employees. 234 00:27:32,690 --> 00:27:38,510 But Nixon started out with You got one employee, you provide health insurance for them. 235 00:27:38,510 --> 00:27:44,270 Neither it nor any part of the 1971 Nixon plan achieve passage that year. 236 00:27:44,270 --> 00:27:49,070 I left government at the end of 1971 empty handed on health. 237 00:27:49,070 --> 00:27:55,220 Besides AMA opposition, the Democrats, as they had with Nixon's radical welfare reform proposals, 238 00:27:55,220 --> 00:27:59,290 just could not bring themselves to support his idea, given their patrimony. 239 00:27:59,290 --> 00:28:02,230 It was Richard Nixon, after all. 240 00:28:02,230 --> 00:28:14,220 And Caspar Weinberger succeeded Richardson at AGW and succeeded where Richardson had not in securing one part of Nixon's health legacy. 241 00:28:14,220 --> 00:28:22,140 In December of 73, Nixon signed into law the Health Maintenance Organisation Act of 1973. 242 00:28:22,140 --> 00:28:28,710 It pre-empted state laws, which banned or restricted the HMO type prepaid group practise. 243 00:28:28,710 --> 00:28:34,880 It beefed up and mandated the health services, which had to be offered by these entities. 244 00:28:34,880 --> 00:28:36,980 As Weinberger came into the act, 245 00:28:36,980 --> 00:28:47,240 the beginning of the Watergate drama gave him more sway over policy than his predecessor had on Pearl Harbour Day, December 7th of 1973. 246 00:28:47,240 --> 00:28:54,200 The new UAW secretary described to the president the options he hoped that Nixon would embrace. 247 00:28:54,200 --> 00:28:59,810 Nixon announced them in his State of the Union address only weeks later in January of 74. 248 00:28:59,810 --> 00:29:05,430 Instead of whip, there was Chip, the Comprehensive Health Insurance Plan. 249 00:29:05,430 --> 00:29:12,210 It pushed beyond the 1971 plan and mandated all employers provide comprehensive coverage 250 00:29:12,210 --> 00:29:18,800 for their employees with reduced employee cost sharing and with very generous benefits. 251 00:29:18,800 --> 00:29:23,660 To augment the reach of Chip, there was the assisted health insurance programme. 252 00:29:23,660 --> 00:29:29,840 This provided health insurance for any who did not get it through their employer or Medicare. 253 00:29:29,840 --> 00:29:36,980 The states were involved as with Nixon's food stamp reform, which did become law and his welfare reform, 254 00:29:36,980 --> 00:29:47,330 only part of which made it the eligibility and the benefits standards, would be set by federal law and apply uniformly across the country. 255 00:29:47,330 --> 00:29:53,750 A benefit which Nixon proposed, which has particular resonance today, this is almost 50 years ago, 256 00:29:53,750 --> 00:29:59,990 was that no individual could be denied insurance because of pre-existing conditions. 257 00:29:59,990 --> 00:30:03,560 Richard Nixon 50 years ago. OK. 258 00:30:03,560 --> 00:30:13,040 Further, premium levels and any co-pays or deductibles would be related to income and the poor would not have to pay any premiums at all. 259 00:30:13,040 --> 00:30:20,570 Just like Richard Nixon abolished income tax on those before the low, the defined poverty level of income. 260 00:30:20,570 --> 00:30:27,130 So to Harry said, you will not pay any premiums for your health insurance. 261 00:30:27,130 --> 00:30:34,180 And then he went on. The coverage was to include prescription drugs. 262 00:30:34,180 --> 00:30:39,820 All right. That didn't materialise till 30 years later with George W. Bush for Medicare. 263 00:30:39,820 --> 00:30:47,080 But Nixon proposed prescription drugs for everybody, not just Medicare recipients. 264 00:30:47,080 --> 00:30:56,560 And Nixon proposed that they the Medicare benefits, be enhanced to match those he was proposing under his other programmes. 265 00:30:56,560 --> 00:31:06,370 There was serious discussion of what finally was, and this is very important politically, what was finally decided to be a bridge too far. 266 00:31:06,370 --> 00:31:10,300 This was the bridge that Barack Obama was later to cross. 267 00:31:10,300 --> 00:31:19,780 Nixon and Weinberger wrestled with the question of whether to adopt a mandate on individuals to purchase health insurance policies. 268 00:31:19,780 --> 00:31:22,630 The purpose and the need what it was then, 269 00:31:22,630 --> 00:31:32,200 is it is now to assure that there would be within the pools of insured the full range of age, health experience and risk. 270 00:31:32,200 --> 00:31:40,540 This would mean that the insurers actuarially could assess the risk of coverage and consequently price it rationally. 271 00:31:40,540 --> 00:31:49,750 The impact would also be to keep premiums down if the healthy were not opting out of coverage, leaving only the more costly cases in the pool. 272 00:31:49,750 --> 00:31:56,030 In the end, Nixon felt that the politics would be difficult. I think it was right. 273 00:31:56,030 --> 00:32:01,430 Furthermore, if he felt it might mean too much intrusion into people's personal choices, 274 00:32:01,430 --> 00:32:05,690 that was more of a philosophical than a purely political attitude. 275 00:32:05,690 --> 00:32:09,470 So even though it would be a natural part of a rational, 276 00:32:09,470 --> 00:32:18,170 self-contained system of providing privately financed insurance, he foresaw moving forward with it. 277 00:32:18,170 --> 00:32:23,480 There followed the unhappy concurrence of Nixon's collapse of power and his efforts 278 00:32:23,480 --> 00:32:28,940 to make common cause with Senator Democratic Senator Ted Kennedy and Democratic 279 00:32:28,940 --> 00:32:34,520 Ways and Means Chair Wilbur Mills in finding a way to national health insurance 280 00:32:34,520 --> 00:32:39,560 between Watergate and the Republican resistance in the Ways and Means Committee. 281 00:32:39,560 --> 00:32:50,890 It became the impossible dream. Kennedy had moved to agreeing to deductibles and co-payments for patients to try to impose some costs consciousness. 282 00:32:50,890 --> 00:32:55,660 This cost him the support of organised labour. It was just, you know, their bridge too far. 283 00:32:55,660 --> 00:33:02,680 But he moved there and this gave him common cause. Kennedy common cause with Chairman Mills of Arkansas. 284 00:33:02,680 --> 00:33:06,340 Then Weinberger and Kennedy started to spark together. 285 00:33:06,340 --> 00:33:14,470 They conceived a combined comprehensive health insurance programme, Nixon's Chip and Kennedy Mills. 286 00:33:14,470 --> 00:33:21,020 Weinberger talked Nixon into speaking publicly about a possible deal, which the president did. 287 00:33:21,020 --> 00:33:26,300 Mills managed to get a combined Nixon built Mills bill out of his committee, 288 00:33:26,300 --> 00:33:32,090 but the Republican opposition on the committee and at large Republican opposition was so strong that 289 00:33:32,090 --> 00:33:38,720 Mills chose not to take it to the floor for a house rule and it came out of his committee by one vote. 290 00:33:38,720 --> 00:33:43,340 Almost all Republicans voted against Nixon's proposal. 291 00:33:43,340 --> 00:33:50,090 That was the high tide moment for Nixon's dream of a national health care bill bearing his imprint. 292 00:33:50,090 --> 00:33:59,080 It came as the rip tide of Watergate carried Nixon out to California in exile by the sea. 293 00:33:59,080 --> 00:34:03,250 President Ford had a lot on his plate and never got around to health legislation. 294 00:34:03,250 --> 00:34:08,930 President Carter did finally propose change. It might have been Richard Nixon writing. 295 00:34:08,930 --> 00:34:17,010 Next, the Lord gave us and the Lord took it the way Ronald Reagan did achieve a significant addition to Medicare. 296 00:34:17,010 --> 00:34:19,120 Catastrophic coverage. 297 00:34:19,120 --> 00:34:29,830 But his vice president, George Herbert Walker Bush, 41, in his first year as president, saw that very expansion reversed mostly by Republican votes. 298 00:34:29,830 --> 00:34:36,310 Within five days of his inauguration, President Clinton announced that a close friend, 299 00:34:36,310 --> 00:34:44,200 IRA Magaziner and Clinton's wife, Hillary, would be in charge of his effort to craft health care proposals. 300 00:34:44,200 --> 00:34:51,550 What followed was a sprawling, Hydra headed committee creation with hundreds of experts involved. 301 00:34:51,550 --> 00:34:56,930 The sprawling late night and weekend sessions. 302 00:34:56,930 --> 00:35:06,010 Teething on the issues of health care and health care, financing came to be called Oxford on the Potomac. 303 00:35:06,010 --> 00:35:13,960 Not really meant as a compliment in this case, only a few weeks following the 1993 inaugural. 304 00:35:13,960 --> 00:35:20,110 The First Lady came to my bank headquarters in New York in Manhattan, 305 00:35:20,110 --> 00:35:25,750 honouring a commitment to speak that she had given the month before the election. 306 00:35:25,750 --> 00:35:34,210 Mrs. Clinton was given by us an office in our building prior to the reception for the non-profit that she was to address. 307 00:35:34,210 --> 00:35:39,610 Before the event, she agreed to meet with about 25 of US senior officers of the bank. 308 00:35:39,610 --> 00:35:46,300 And I was amongst the first to arrive. I greeted her by mentioning a Dear Grinnell College, which I graduated. 309 00:35:46,300 --> 00:35:52,480 Grinnell College friend of mine Donald Stewart and his wife, Isabel, known well to her and her husband. 310 00:35:52,480 --> 00:36:01,330 She warmed up immediately. I went on to say that she was embarking on a very difficult task in trying to forge a health care strategy. 311 00:36:01,330 --> 00:36:09,760 Thank you, Nigel. She nodded, and I continued saying that I wish her every success, knowing it would be arduous and fraught. 312 00:36:09,760 --> 00:36:16,930 Graciously, she smiled. I said I was aware of the difficulties and hope there would be a positive outcome because 313 00:36:16,930 --> 00:36:23,080 I had been one of those who put together Richard Nixon's 1971 health care proposals, 314 00:36:23,080 --> 00:36:28,990 too little of which had, alas, become law. Her smile became a cold mask. 315 00:36:28,990 --> 00:36:35,950 She turned on her heel and walked away. Richard Nixon. 316 00:36:35,950 --> 00:36:45,700 Clinton gave a September 1993 peace speech, which provided for universal coverage through an employer mandate and managed care. 317 00:36:45,700 --> 00:36:55,390 Both Nixon ideas but also federal regulation of premiums in the State of the Union just shortly thereafter on 19 January '94. 318 00:36:55,390 --> 00:37:03,700 He again made health the centrepiece. The So to the State of the Union contained a threat by him to veto any piece of health legislation sent to him, 319 00:37:03,700 --> 00:37:09,880 which did not quote guarantee every American private health insurance that can never be taken away. 320 00:37:09,880 --> 00:37:13,610 His efforts collapsed. Democrats were themselves divided. 321 00:37:13,610 --> 00:37:18,910 Republicans soon were in lockstep in determination to oppose him. 322 00:37:18,910 --> 00:37:25,870 But nothing like the lockstep opposition by Republicans to the Patient Protection and Affordable Care Act, 323 00:37:25,870 --> 00:37:30,400 better known for its sponsor, Barack Obama, as Obamacare. 324 00:37:30,400 --> 00:37:38,170 President Obama avoided embracing a government run and general revenue where Social Security financed health insurance programme. 325 00:37:38,170 --> 00:37:45,460 He turned to principles Nixon had laid down. He chose to use the private health insurance industry as the main vehicle. 326 00:37:45,460 --> 00:37:54,070 Despite the lingering antipathy to the industry which had crushed Clinton's care proposals with its brilliant advertising campaign 327 00:37:54,070 --> 00:38:02,690 of Harry and Louise sitting around the kitchen table ruminating over the problems the Clinton plans would would promote. 328 00:38:02,690 --> 00:38:10,640 He was concerned he Obama was concerned about cost, so he proposed accountable care organisations with much the same concept and 329 00:38:10,640 --> 00:38:18,290 remit as Nixon's HMOs to incent prevention and reduce more costly forms of care. 330 00:38:18,290 --> 00:38:24,110 Some other Obama efforts were using data about quality of care to justify reductions 331 00:38:24,110 --> 00:38:30,430 in Medicare reimbursements to institutions whose performance was measurably poor. 332 00:38:30,430 --> 00:38:36,970 Hospitals, which had a higher percentage of readmissions of patients than their peers, for example. 333 00:38:36,970 --> 00:38:43,900 The facts were simple. Obama chose the private sector route over the Kennedy Labour Medicare for All approach. 334 00:38:43,900 --> 00:38:51,910 Having made that crucial choice, his Obama's approach did not radically differ from what Nixon had saw almost 40 years earlier. 335 00:38:51,910 --> 00:38:57,760 He understood what Nixon had, that you needed to mandate the private sector to cover its employees. 336 00:38:57,760 --> 00:39:02,860 He understood, as Nixon had that to get premiums down to affordable levels. 337 00:39:02,860 --> 00:39:07,630 You needed to create pools of risk, which were broad enough to allow that. 338 00:39:07,630 --> 00:39:16,060 They both called for risk sharing through pools. In Nixon's case for small employers and unemployed or unemployable to buy into, 339 00:39:16,060 --> 00:39:21,250 with premiums subsidised in Nixon's case for those unable to afford them. 340 00:39:21,250 --> 00:39:22,300 In Obama's case, 341 00:39:22,300 --> 00:39:33,520 the state sponsored exchanges and some subsidies to insurance companies to bring premiums within reach of those who could not afford them. 342 00:39:33,520 --> 00:39:38,200 Obama faced up to the conundrum about adverse selection. 343 00:39:38,200 --> 00:39:47,290 Nixon had always been for as universal a programme as possible, but he could not cross that bridge to compel elimination of slippage, 344 00:39:47,290 --> 00:39:53,860 slippage where the young or the healthy or the insouciance simply would not sign up. 345 00:39:53,860 --> 00:39:57,820 Those who left were older, left left behind were older, 346 00:39:57,820 --> 00:40:04,330 sicker or more worried about their health and with reason to be so all the way back to the 1940s. 347 00:40:04,330 --> 00:40:12,700 Nixon had been more on the forward looking frontier of using the private sector to provide health care than his Republican colleagues. 348 00:40:12,700 --> 00:40:19,510 He and Jack Javits were on the Flanders IVs bill, which Taft and the conservative wing Republicans were not. 349 00:40:19,510 --> 00:40:25,120 Nixon supported the various Eisenhower ideas, such as reinsurance and private health insurance, 350 00:40:25,120 --> 00:40:30,220 to enable coverage for the elderly and then the revival of a form of Flanders IVs. 351 00:40:30,220 --> 00:40:36,900 In 1960. In his own 1971, but even more in his 73 and 74 efforts, 352 00:40:36,900 --> 00:40:46,560 Nixon was a strong advocate for virtually universal coverage and with support for those who did not have enough to pay premiums. 353 00:40:46,560 --> 00:40:55,040 He was the first to propose prescription drug coverage for all and capping out-of-pocket costs, including those from catastrophic illnesses. 354 00:40:55,040 --> 00:41:04,250 Nixon understood the tug of war between cost and coverage. His memos were meant to be major artillery in that battle. 355 00:41:04,250 --> 00:41:08,660 He got it about pool risk really being pool risk. 356 00:41:08,660 --> 00:41:14,690 He felt that the lower premiums available through his plans would appeal to consumers and motivate them 357 00:41:14,690 --> 00:41:20,750 to take advantage of the coverage offered by their employer or through group pooling opportunities. 358 00:41:20,750 --> 00:41:25,310 But he could not bring himself to mandate them to buy insurance. 359 00:41:25,310 --> 00:41:33,470 He was having enough trouble mobilising his own Republican House and Senate members to support his then quite radical ideas. 360 00:41:33,470 --> 00:41:37,460 He would, as a partisan politician, have understood the opening. 361 00:41:37,460 --> 00:41:42,800 The Obama individual mandate gave to his Republican opponents. 362 00:41:42,800 --> 00:41:50,480 But Nixon wanted universal health coverage and the supply of doctors facilities, research, good public health campaigns and so on. 363 00:41:50,480 --> 00:41:58,400 He truly believed in finding and moving the levers in the private sector to bring about a public good. 364 00:41:58,400 --> 00:42:06,020 Where are we today? The sappers in the Republican Party had been undermining for a decade the Affordable Care Act. 365 00:42:06,020 --> 00:42:13,610 Their proposed replacement does not exist even after the luxury of that decade for development of an alternative. 366 00:42:13,610 --> 00:42:19,970 The miserably messy rollout of Obamacare gave them explosive ammunition against it. 367 00:42:19,970 --> 00:42:25,820 It has its faults. It has its court challenges. But time has run out. 368 00:42:25,820 --> 00:42:33,700 Last week, the death of Harris Wofford, a one term United States senator from Pennsylvania, was noted. 369 00:42:33,700 --> 00:42:40,450 In nineteen ninety one against a formidable former Republican governor, Richard Thornburgh, 370 00:42:40,450 --> 00:42:46,420 who enjoyed a forty four point lead in opinion polls as the campaign began. 371 00:42:46,420 --> 00:42:52,570 Wofford campaigned for a single payer health insurance programme, 1991, in a special election. 372 00:42:52,570 --> 00:42:57,610 A lot of national attention focussed on you won after. 373 00:42:57,610 --> 00:43:02,930 Dick Thornburgh was a good friend of mine, blew forty four point lead. 374 00:43:02,930 --> 00:43:10,340 It put that issue on the front pages. The George H.W. Bush White House was in disarray and had not seriously thought 375 00:43:10,340 --> 00:43:15,200 through its own health policy to say nothing of a coherent domestic policy. 376 00:43:15,200 --> 00:43:19,730 Bush was stunned by his defeat by Bill Clinton. 377 00:43:19,730 --> 00:43:25,790 Just months ago, the campaigns of many successful candidates for the Congress centred on health care, 378 00:43:25,790 --> 00:43:33,870 as Wofford had in 1991, most called for a single payer health insurance plan, Medicare for All, as it is now termed. 379 00:43:33,870 --> 00:43:39,810 The political landscape for intractable opposition is bleak just this past week, 380 00:43:39,810 --> 00:43:44,610 a widely respected Gallup poll showed that the percentage of adults without 381 00:43:44,610 --> 00:43:49,560 insurance climbed to thirteen point seven percent in the last quarter of last year, 382 00:43:49,560 --> 00:43:57,090 2018. This compared to twelve point four percent in 2017 and only ten point nine percent in 2016. 383 00:43:57,090 --> 00:44:06,210 This two year trend is in stark contrast to the increase in actual enrolment from passage of the Obamacare ACA. 384 00:44:06,210 --> 00:44:15,420 Today, we see a landscape not too dissimilar to what Nixon saw in the early 1970s on momentum back toward a patchwork of coverage, 385 00:44:15,420 --> 00:44:21,780 a mishmash of states having differing eligibility requirements for such programmes as there 386 00:44:21,780 --> 00:44:28,920 were many plans not really protecting against catastrophe or against pre-existing conditions. 387 00:44:28,920 --> 00:44:37,090 Legitimate concerns about costs. Where can we go because of an understandable fear of entitlement costs? 388 00:44:37,090 --> 00:44:41,830 One party or another may once again become a steward of the public purse. 389 00:44:41,830 --> 00:44:49,720 Yet in some quarters, a push toward more comprehensive and committed coverage in health care seems to be relentless. 390 00:44:49,720 --> 00:44:58,870 Just last month, the mayor of New York City proposed a municipal programme of universal health coverage health insurance. 391 00:44:58,870 --> 00:45:03,580 He said it would cost New York City one million dollars a year to provide. 392 00:45:03,580 --> 00:45:10,270 But Mr. de Blasio has said New York City will have its own universal coverage health programme. 393 00:45:10,270 --> 00:45:19,270 We can expect more of these one off proposals, but at their root is the disproportionate cost of American health care and the affordability of care, 394 00:45:19,270 --> 00:45:27,990 regardless of whether it is a federal programme, a municipal programme or one provided through the mediation of the health insurance industry. 395 00:45:27,990 --> 00:45:37,680 Coverage versus cost, Nixon would likely despair at the continued disparities in coverage toward which we appear to be moving again. 396 00:45:37,680 --> 00:45:48,960 He would likewise be disappointed that the managed care concept he promoted did not did not do more in cost containment by inserting prevention. 397 00:45:48,960 --> 00:45:56,790 But most likely, he would wish that in 1974, the planets could have aligned so that he, 398 00:45:56,790 --> 00:46:05,250 Ted Kennedy and Wilbur Mills could successfully have advanced their ideas for a comprehensive national health care programme. 399 00:46:05,250 --> 00:46:13,290 Maybe, just maybe, it could have meant that the American people would have felt more invested in the institutions 400 00:46:13,290 --> 00:46:22,900 of their country and done so because those institutions were truly serving and protecting them. 401 00:46:22,900 --> 00:46:30,017 OK. OK.