Sort of. Welcome everyone.
I think most of you know me, I'm Hal Jones, I'm the director of the rather new American Institute,
and it's a real pleasure to welcome you this week to what is our weekly American Politics seminar,
but also a special seminar on our calendar for this term.
And we're very pleased to welcome John Price for a presentation on Nixon's initiatives in the area of health care.
But a historical topic, but one that I think as John will show us,
has a lot of significance to subsequent policy debates in this area, sort of down to the present day in the United States.
John was a firsthand protagonist, a participant in some of the events that [INAUDIBLE] be telling us about.
He was special assistant to President Nixon for urban affairs in the in the Nixon administration.
But he's also, importantly, a longtime friend of the University of Oxford and of the rather more American Institute.
US with regularity over the years has spoken here previously, drawing on some of his insights and perspectives from public service.
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
the US political party conventions as a resource of their homes worth library,
thanks to to John's generosity. So he's a good friend.
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
delighted that that you've come through Oxford right now to to speak on this important part of the Nixon administration.
We were talking just yesterday about how we are just at the 50th anniversary of Richard Nixon's inauguration.
For his his first term. So it's, you know, with a half centuries perspective,
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.
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
important the pivotal in the sense of being a real turning point in the contemporary political history of the United States.
So we're delighted John's here and able to share some of his insight into that
era and to speak with us about health policy in particular at that time.
Thank you and thank you. Also, not just for the very nice introduction, but for your stewardship here at the.
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.
And I might also say the certainty in debt to Nigel Bowles, who was your not your immediate predecessor,
but was an important sort of fairly formal director of the RGA.
So I'm delighted to be in the presence of both of you with my gratitude to you both.
I might just before I start to read this lengthy opus of mine for you to just
touch on the point that Hal mentioned about the 50th anniversary of the inaugural,
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,
a Pulitzer prise winning journalist who used to cover Washington for the worst of
the Wall Street Journal and the Boston Globe and the Post-Gazette in Pittsburgh.
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.
Not personally, but by reading so much about it was a fraught, traumatic year.
And so Nixon had gone through the campaign very much as a law and order candidate.
But then, as he said himself, I watched Chicago, I watched the Democratic convention, he said.
I couldn't believe my eyes. You know, it was. It was everywhere. It was racial.
It was economic. It was just pandemonium.
And so when we came in with a very narrow victory, not a majority,
but rather almost a spread of only a point between Nixon and Humphrey, with George Wallace having taken 10 percent of the vote.
George Wallace, a basic white nationalist Dixiecrat candidate.
So it was it was a tense time, and Nixon came in really seeking to heal the American spirit in a way.
And it's curious because people sometimes forget he had this Quaker background to him and it was always there.
Unlike Herbert Hoover, we were talking earlier about the Hoover. Library in in West Branch, Iowa.
And I talked to the archivist there, and I said, to your knowledge,
did did Richard Nixon and Herbert Hoover ever talk about the fact they were the only two Quaker presidents in American history?
Said no, he said. You know, Hoover didn't take it seriously at all, he said.
I think Nixon did. There was something more deeply embedded in Nixon about it.
So there was a sense of wanting to heal the country. And 68, the tone was interesting.
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.
And he and I've compared notes and he makes the point that it was in its own way like a mini Camelot.
Everybody thinks of the Kennedy start up as Camelot. But he was saying, You know, John there was placed around the government,
not just in the White House, but in various departments, particularly health,
education and welfare,
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.
There was a sense of wanting to do something right.
There was a sense of having come from a more liberal Republican trajectory. And so it was a very, very uplifting time.
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.
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.
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.
Bob Dole had had his right arm mangled in combat in World War Two and was never able to use it again.
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.
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.
But Dole paid a silent tribute to Bush, 41, a quarter-century earlier.
Dole was present for the memorial service and interment at the childhood California home.
There was no state funeral for this man of Richard Nixon.
And on that occasion, Dole gave voice to his tribute, and then it literally tears streaked farewell.
Dole said of Nixon, I'm sorry, I always have these problems. Is Nigel now?
Will remember?
He leapfrogged the conventional wisdom to propose revolutionary solutions to health care and welfare reform, anticipating by a full generation.
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,
spoke then as the Clinton health care proposals were being aired before a sceptical Congress.
Those elements, which succeeded over their lineage to Richard Nixon's strategy on health care and the failure of the others,
was followed many years later by the Affordable Care Act under President Barack Obama without a single Republican vote.
And since that moment, we've been subjected to nearly a decade of denigration by Republicans over Obamacare.
That health care legislation itself contained many elements which had been advanced by Richard Nixon.
Nearly a half century before, Dole was deeply emotional, according to those there.
But in a more academic and detached manner, two authors David Blumenthal, William James Morone,
say simply of Nixon that quote he left a richer health policy legacy than almost any other president.
Within his first year as President, Nixon introduced his dramatic family assistance plan.
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.
But Nixon was a relative latecomer to issues of public welfare and things of that character, however, in the area of the health field.
It wasn't the case in this. He had a much longer and far deeper understanding.
Nixon's was a visceral feeling of empathy for those families,
overwhelmed by serious health problems and the emotional and financial carnage which was wrought by that.
It also was informed by his involvement in the far reaching changes to health care that had been either accomplished or attempted under Eisenhower,
whose Vice President Nixon was for eight years.
And on Eisenhower's watch, one of the two most significant post-war developments in health policy occurred.
He saw the expansion of the most, most dramatic health care and private insurance coverage of the latter 20th century.
It was called ECI or employer sponsored health insurance.
And when the war ended, a major boom had ensued.
Employment grew dramatically throughout the American economy. The classic American middle class was born at that moment in time.
The medium for Eisenhower's massive expansion of health coverage was the revenue code, the internal tax code,
nineteen fifty four revisions of the tax code and I was for two and a half years a tax lawyer.
I plead guilty. But this was this was a major, comprehensive change.
And what he did in 54 was he clarified and expanded the availability of tax deductions or the freedom from tax liability,
either for employees, employers to offer or employees to be beneficiaries of employer sponsored private health insurance.
And his characteristic budgetary constraint was concealed.
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.
Everybody was happy. Still left out, though, were the elderly, the unemployed and the indigent.
Nixon had first stepped earlier into the health care debate in 1949, when Harry Truman,
after his very unexpected re-election victory in 1948, was again trying to promote his vision of health care.
Congressman Richard Nixon, in only his second term, joined the most liberal member of his party in the house.
New York's Jacob Javits and two liberal Republican senators to introduce a private insurance system,
which would cover all without regard to whether they could afford the premiums.
This was a move highly suggestive of future action on Nixon's part in the health care arena.
Nixon did not align himself here with the crusty conservative lie and Robert A. Taft of Ohio in Taft tepid
and constrained response to a democratic move toward fully federally funded and overseen medical care.
He Nixon did not go the route of allowing the states to point the way at their own pace
and with their often meagre percentage of participants in health insurance programmes.
He was not passive. Rather, he was a marquee name on activist legislation with Republican liberals.
Senator Ralph Flanders of Vermont and Republican Irving Ives of New York and Jack Javits.
There was an aggressive alternative using the private sector to a government he does or proposal of that has some resonance today.
From this, the authors I mentioned before, Blumenthal and Moran, conclude that quote,
this was the first intimation that the ambiguous Nixon would eventually stand alongside Harry Truman.
Two presidents who cared about health care failed to win their own signature programme and
yet decisively shaped the policy debates long after their troubled days in the White House.
Eisenhower sought to find a path to protection for the elderly in a 1954 reinsurance plan.
I won't bother to tell you the details, but it would backstop private insurers coverage of the elderly.
Don't forget, we're we're not yet covered.
Medicare not yet been passed, so they were out lying out there, exposed because they were no longer employed.
Therefore, not being the beneficiaries of these these tax tax incentives, the employer provided health programmes.
Eisenhower encountered a wall of opposition from the American Medical Association, the AMA and from the insurance industry itself,
which was regulated by state regulators and feared this would be a first step toward regulation of their industry by the federal government.
In their view, a less pliant or supportive overseer, I explain, lost by a single vote in the US Senate.
He tried another tack. The new Eisenhower plan carried the name Medicare programme for the agent.
The name survived. The substance didn't. I guess Bill would give federal grants to the states and through them, give money to elderly,
low income Americans to pay for buying private health care insurance coverage.
Liberal Republican Senator Jacob Javits of New York,
once again finding himself teaming up with now vice President Richard Nixon, introduced the administration bill.
A diverse group dammed the proposal.
The AFL-CIO organised Labour, the AMA Organised Medicine, the emerging conservative icon Barry Goldwater of Arizona,
who was gathering visibility as the next Robert Taft but even more of a heartthrob for conservatives.
Kennedy, once elected, attempted a Medicare bill, a government managed programme, but adopting Ike's name for it, believe it or not,
and failed Lyndon Johnson, as he did with Kennedy's hapless results on the civil rights bills,
took Medicare and Medicaid and saw them through to success.
Once the demand for services, which was induced by Medicaid and Medicare had spurred it, costs of care were skyrocketing.
As Medicaid's passage had spirited and the grounded in a retrospective payment system,
Medicare invited an almost inevitable inflation of medical costs.
Nixon was the first president to be in office when the full effect of these important great society
initiatives came into play and the urgency of containing the costs of these entitlements was felt.
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.
In fact, it was the element of his 1971 proposals which did first become law and was built upon and later administrations,
especially Clintons and Obama's.
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.
The Family Assistance Plan, or FAP, if they paid where there was a need to integrate it with housing assistance, food stamps,
Medicaid, in other words, all those programmes which were out there providing help to low income individuals or families.
So they had to figure out a way in which whatever health insurance programme you developed would fit into those.
As FAP was working its way through the Congress in 1970, Nixon's domestic council created a committee on health care.
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.
It was a big signature issue. Basically Medicare for all, but also just because it was it was out there and increasingly so.
And so the concept this is from my diary was quote, not a White House Working Group concept.
Elliot Richardson, the head of the Department of Health, Education and Welfare,
intends to make this a model for policy development within the department.
This for you students of political science would be the lead agency concept versus a White House staff initiative or battling for the approach.
This approach failed. Seven options were flirted with by AGW, ranging in price from $1 billion to $30 billion,
and health options have been winnowed from hundreds down to 60, some unrelated specifics.
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,
agreed with me that I would begin picking up health can call Erlichman Principal Deputy Quote,
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.
Call focussed on the insurance features while I took charge of the more novel part of the Nixon initiative.
This was the idea of supporting prepaid group practises in California,
and a few other places there had emerged in non-profit form organisations whose structure and incentives encouraged cost containment.
Nixon had met with a man named Edgar Kaiser earlier in 1970. The principal in the so-called Kaiser Permanente prepaid group practise entity.
His argument appealed to Nixon build an incentive structure that emphasises keeping a patient well, not hospital bound preventive attention and care.
The patient is healthy and the costs of care are lessened, and I worked hard with the staff at health,
education and welfare to refine the idea, and at last it was to roll out and incent a nationwide programme of prepaid group practises.
We would call these health maintenance organisations or HMO.
It must have had a patina of socialism about it in certain eyes,
or at least too much novelty, or at least the antipathy of the American Medical Association.
Spiro Theodore Agnew, the vice president,
took a dislike to it and a dislike to me as its agent of encouragement with the president
some days before the president's message was to go to Capitol Hill in mid-February of 1971.
I got a phone call from Ken Kohl. He said that the president had just received a phone call from Vice President Agnew.
Agnew was on Air Force Two, winging his way westward to play golf with Frank Sinatra at Palm Springs, California.
His aeroplane reading was my decision paper on this part of the president's health strategy.
Agnew weighed in with Nixon about how I had either not consulted properly with him or even if I had.
I had not then listened. Regardless, he disagreed with the recommendation to Nixon.
Nixon asked Cole to call me and tell me of the phone call, and for me not to worry.
Naturally, I was concerned that the vice president had bent the ear of the president complaining of you.
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.
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.
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.
When I needed it. Erlichman notes Agnew then shared a series of interdepartmental meetings on health issues,
but he seemed incapable of organising the work and guiding the staff to a result.
I watched the vice president closely during this health project, trying to discover the cause of his mental constipation.
I concluded that the man was exceedingly narrow. New thoughts were unwelcome to him.
As a result, his health project did not gather for the present all the practical alternatives for a final choice.
Instead, it became a narrow reflection of Spiro Agnew preferences.
The plan went forward in a briefing held for the congressional leadership before its unveiling.
And it was here for it. The president was expansive in his description of the pending message.
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,
expand to the balance exactly what his 1971 proposal did.
He went on to say it would provide diversity, competition and experimentation.
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.
We have to have something which is acceptable, at least minimally to the profession.
Then we goes again. To quote, this will save the best of the private initiative medical care system, which was an underlying fundamental principle.
He wanted to preserve the best in American medical practise.
The core parts of the plan included a National Health Insurance Standards Act, a family health insurance plan, 50.
Remember FAP and health maintenance organisations. As you told us in the meeting,
Nixon would extend private insurance coverage to the balance by having all employers of one
or more employees provide a minimum standard coverage for employees and their dependents,
including inpatient hospital care, extended care facilities, home health services.
Outpatient care. Catastrophic cost coverage.
All with employers paying 65 percent of the premiums to start and then raising to 75 percent in future years.
Private insurance pools were to be established for risk sharing amongst small employers,
the self-employed and people outside of the labour force in order to permit purchase by these health consumers at group rates.
Then the family health insurance plan would provide insurance to all low income families,
with children not covered by employer plans and with uniform national definitions of eligibility.
Like FAP, the whip removed inequities between male and female headed families, the working poor and dependent poor.
And like his food stamp programme rationalisation,
CIP eliminated the eligibility inequities between states based on income and made uniform the existing wide variation in benefits.
And this next point is important just in standing back and thinking of what might have been at work more in Nixon's psyche,
as seemed true of all of Nixon's main messages, addresses or extemporaneous comments on his consequential social policy initiatives.
There wasn't their language, not alone, their substance and insight into the more liberal and humane side of this complex man.
True of the February 1971 message on health. True, the message on hunger and the expansion of the food stamp programme.
True of the August 1969 announcement of the Family Assistance Plan.
Welfare reform for all his calculation, realism, cynicism,
even spleen or bile is coherent and strategic approach to poverty and need was striking and passionately felt.
Nixon's Quaker background intrudes from time to time in these welfare and health policies.
A remarkable example was his personal, dramatic conception of doing something with the former Fort Detrick,
Maryland, facility for manufacturing chemical warfare agents into the home of the National Cancer Institute.
Nixon in 1969 had announced, announced and abandoned the US use retention or future development of chemical and biological warfare weapons.
Now, the chemical weapons production site was to be the headquarters for cancer fighting research and funding swords into ploughshares.
Reception was very positive.
Small business, however, was concerned about the cost impact on them of providing insurance to one or a couple or three employees.
Nixon Gerald Ford, then Republican leader in the House.
Secretary Richardson, Ken Cole and I met with Congressman John Burns of Wisconsin, the ranking Republican,
on the Ways and Means Committee, the relevant committee for Health Issues in the Congress.
This was after the message going up and after I and the head of the Small Business Administration,
had met with the small business lobby about their concerns,
and it was agreed that Burns would offer an amendment that the one or more employees would be used to 10 or more employees.
But Nixon started out with You got one employee, you provide health insurance for them.
Neither it nor any part of the 1971 Nixon plan achieve passage that year.
I left government at the end of 1971 empty handed on health.
Besides AMA opposition, the Democrats, as they had with Nixon's radical welfare reform proposals,
just could not bring themselves to support his idea, given their patrimony.
It was Richard Nixon, after all.
And Caspar Weinberger succeeded Richardson at AGW and succeeded where Richardson had not in securing one part of Nixon's health legacy.
In December of 73, Nixon signed into law the Health Maintenance Organisation Act of 1973.
It pre-empted state laws, which banned or restricted the HMO type prepaid group practise.
It beefed up and mandated the health services, which had to be offered by these entities.
As Weinberger came into the act,
the beginning of the Watergate drama gave him more sway over policy than his predecessor had on Pearl Harbour Day, December 7th of 1973.
The new UAW secretary described to the president the options he hoped that Nixon would embrace.
Nixon announced them in his State of the Union address only weeks later in January of 74.
Instead of whip, there was Chip, the Comprehensive Health Insurance Plan.
It pushed beyond the 1971 plan and mandated all employers provide comprehensive coverage
for their employees with reduced employee cost sharing and with very generous benefits.
To augment the reach of Chip, there was the assisted health insurance programme.
This provided health insurance for any who did not get it through their employer or Medicare.
The states were involved as with Nixon's food stamp reform, which did become law and his welfare reform,
only part of which made it the eligibility and the benefits standards, would be set by federal law and apply uniformly across the country.
A benefit which Nixon proposed, which has particular resonance today, this is almost 50 years ago,
was that no individual could be denied insurance because of pre-existing conditions.
Richard Nixon 50 years ago. OK.
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.
Just like Richard Nixon abolished income tax on those before the low, the defined poverty level of income.
So to Harry said, you will not pay any premiums for your health insurance.
And then he went on. The coverage was to include prescription drugs.
All right. That didn't materialise till 30 years later with George W. Bush for Medicare.
But Nixon proposed prescription drugs for everybody, not just Medicare recipients.
And Nixon proposed that they the Medicare benefits, be enhanced to match those he was proposing under his other programmes.
There was serious discussion of what finally was, and this is very important politically, what was finally decided to be a bridge too far.
This was the bridge that Barack Obama was later to cross.
Nixon and Weinberger wrestled with the question of whether to adopt a mandate on individuals to purchase health insurance policies.
The purpose and the need what it was then,
is it is now to assure that there would be within the pools of insured the full range of age, health experience and risk.
This would mean that the insurers actuarially could assess the risk of coverage and consequently price it rationally.
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.
In the end, Nixon felt that the politics would be difficult. I think it was right.
Furthermore, if he felt it might mean too much intrusion into people's personal choices,
that was more of a philosophical than a purely political attitude.
So even though it would be a natural part of a rational,
self-contained system of providing privately financed insurance, he foresaw moving forward with it.
There followed the unhappy concurrence of Nixon's collapse of power and his efforts
to make common cause with Senator Democratic Senator Ted Kennedy and Democratic
Ways and Means Chair Wilbur Mills in finding a way to national health insurance
between Watergate and the Republican resistance in the Ways and Means Committee.
It became the impossible dream. Kennedy had moved to agreeing to deductibles and co-payments for patients to try to impose some costs consciousness.
This cost him the support of organised labour. It was just, you know, their bridge too far.
But he moved there and this gave him common cause. Kennedy common cause with Chairman Mills of Arkansas.
Then Weinberger and Kennedy started to spark together.
They conceived a combined comprehensive health insurance programme, Nixon's Chip and Kennedy Mills.
Weinberger talked Nixon into speaking publicly about a possible deal, which the president did.
Mills managed to get a combined Nixon built Mills bill out of his committee,
but the Republican opposition on the committee and at large Republican opposition was so strong that
Mills chose not to take it to the floor for a house rule and it came out of his committee by one vote.
Almost all Republicans voted against Nixon's proposal.
That was the high tide moment for Nixon's dream of a national health care bill bearing his imprint.
It came as the rip tide of Watergate carried Nixon out to California in exile by the sea.
President Ford had a lot on his plate and never got around to health legislation.
President Carter did finally propose change. It might have been Richard Nixon writing.
Next, the Lord gave us and the Lord took it the way Ronald Reagan did achieve a significant addition to Medicare.
Catastrophic coverage.
But his vice president, George Herbert Walker Bush, 41, in his first year as president, saw that very expansion reversed mostly by Republican votes.
Within five days of his inauguration, President Clinton announced that a close friend,
IRA Magaziner and Clinton's wife, Hillary, would be in charge of his effort to craft health care proposals.
What followed was a sprawling, Hydra headed committee creation with hundreds of experts involved.
The sprawling late night and weekend sessions.
Teething on the issues of health care and health care, financing came to be called Oxford on the Potomac.
Not really meant as a compliment in this case, only a few weeks following the 1993 inaugural.
The First Lady came to my bank headquarters in New York in Manhattan,
honouring a commitment to speak that she had given the month before the election.
Mrs. Clinton was given by us an office in our building prior to the reception for the non-profit that she was to address.
Before the event, she agreed to meet with about 25 of US senior officers of the bank.
And I was amongst the first to arrive. I greeted her by mentioning a Dear Grinnell College, which I graduated.
Grinnell College friend of mine Donald Stewart and his wife, Isabel, known well to her and her husband.
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.
Thank you, Nigel. She nodded, and I continued saying that I wish her every success, knowing it would be arduous and fraught.
Graciously, she smiled. I said I was aware of the difficulties and hope there would be a positive outcome because
I had been one of those who put together Richard Nixon's 1971 health care proposals,
too little of which had, alas, become law. Her smile became a cold mask.
She turned on her heel and walked away. Richard Nixon.
Clinton gave a September 1993 peace speech, which provided for universal coverage through an employer mandate and managed care.
Both Nixon ideas but also federal regulation of premiums in the State of the Union just shortly thereafter on 19 January '94.
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,
which did not quote guarantee every American private health insurance that can never be taken away.
His efforts collapsed. Democrats were themselves divided.
Republicans soon were in lockstep in determination to oppose him.
But nothing like the lockstep opposition by Republicans to the Patient Protection and Affordable Care Act,
better known for its sponsor, Barack Obama, as Obamacare.
President Obama avoided embracing a government run and general revenue where Social Security financed health insurance programme.
He turned to principles Nixon had laid down. He chose to use the private health insurance industry as the main vehicle.
Despite the lingering antipathy to the industry which had crushed Clinton's care proposals with its brilliant advertising campaign
of Harry and Louise sitting around the kitchen table ruminating over the problems the Clinton plans would would promote.
He was concerned he Obama was concerned about cost, so he proposed accountable care organisations with much the same concept and
remit as Nixon's HMOs to incent prevention and reduce more costly forms of care.
Some other Obama efforts were using data about quality of care to justify reductions
in Medicare reimbursements to institutions whose performance was measurably poor.
Hospitals, which had a higher percentage of readmissions of patients than their peers, for example.
The facts were simple. Obama chose the private sector route over the Kennedy Labour Medicare for All approach.
Having made that crucial choice, his Obama's approach did not radically differ from what Nixon had saw almost 40 years earlier.
He understood what Nixon had, that you needed to mandate the private sector to cover its employees.
He understood, as Nixon had that to get premiums down to affordable levels.
You needed to create pools of risk, which were broad enough to allow that.
They both called for risk sharing through pools. In Nixon's case for small employers and unemployed or unemployable to buy into,
with premiums subsidised in Nixon's case for those unable to afford them.
In Obama's case,
the state sponsored exchanges and some subsidies to insurance companies to bring premiums within reach of those who could not afford them.
Obama faced up to the conundrum about adverse selection.
Nixon had always been for as universal a programme as possible, but he could not cross that bridge to compel elimination of slippage,
slippage where the young or the healthy or the insouciance simply would not sign up.
Those who left were older, left left behind were older,
sicker or more worried about their health and with reason to be so all the way back to the 1940s.
Nixon had been more on the forward looking frontier of using the private sector to provide health care than his Republican colleagues.
He and Jack Javits were on the Flanders IVs bill, which Taft and the conservative wing Republicans were not.
Nixon supported the various Eisenhower ideas, such as reinsurance and private health insurance,
to enable coverage for the elderly and then the revival of a form of Flanders IVs.
In 1960. In his own 1971, but even more in his 73 and 74 efforts,
Nixon was a strong advocate for virtually universal coverage and with support for those who did not have enough to pay premiums.
He was the first to propose prescription drug coverage for all and capping out-of-pocket costs, including those from catastrophic illnesses.
Nixon understood the tug of war between cost and coverage. His memos were meant to be major artillery in that battle.
He got it about pool risk really being pool risk.
He felt that the lower premiums available through his plans would appeal to consumers and motivate them
to take advantage of the coverage offered by their employer or through group pooling opportunities.
But he could not bring himself to mandate them to buy insurance.
He was having enough trouble mobilising his own Republican House and Senate members to support his then quite radical ideas.
He would, as a partisan politician, have understood the opening.
The Obama individual mandate gave to his Republican opponents.
But Nixon wanted universal health coverage and the supply of doctors facilities, research, good public health campaigns and so on.
He truly believed in finding and moving the levers in the private sector to bring about a public good.
Where are we today? The sappers in the Republican Party had been undermining for a decade the Affordable Care Act.
Their proposed replacement does not exist even after the luxury of that decade for development of an alternative.
The miserably messy rollout of Obamacare gave them explosive ammunition against it.
It has its faults. It has its court challenges. But time has run out.
Last week, the death of Harris Wofford, a one term United States senator from Pennsylvania, was noted.
In nineteen ninety one against a formidable former Republican governor, Richard Thornburgh,
who enjoyed a forty four point lead in opinion polls as the campaign began.
Wofford campaigned for a single payer health insurance programme, 1991, in a special election.
A lot of national attention focussed on you won after.
Dick Thornburgh was a good friend of mine, blew forty four point lead.
It put that issue on the front pages. The George H.W. Bush White House was in disarray and had not seriously thought
through its own health policy to say nothing of a coherent domestic policy.
Bush was stunned by his defeat by Bill Clinton.
Just months ago, the campaigns of many successful candidates for the Congress centred on health care,
as Wofford had in 1991, most called for a single payer health insurance plan, Medicare for All, as it is now termed.
The political landscape for intractable opposition is bleak just this past week,
a widely respected Gallup poll showed that the percentage of adults without
insurance climbed to thirteen point seven percent in the last quarter of last year,
2018. This compared to twelve point four percent in 2017 and only ten point nine percent in 2016.
This two year trend is in stark contrast to the increase in actual enrolment from passage of the Obamacare ACA.
Today, we see a landscape not too dissimilar to what Nixon saw in the early 1970s on momentum back toward a patchwork of coverage,
a mishmash of states having differing eligibility requirements for such programmes as there
were many plans not really protecting against catastrophe or against pre-existing conditions.
Legitimate concerns about costs. Where can we go because of an understandable fear of entitlement costs?
One party or another may once again become a steward of the public purse.
Yet in some quarters, a push toward more comprehensive and committed coverage in health care seems to be relentless.
Just last month, the mayor of New York City proposed a municipal programme of universal health coverage health insurance.
He said it would cost New York City one million dollars a year to provide.
But Mr. de Blasio has said New York City will have its own universal coverage health programme.
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,
regardless of whether it is a federal programme, a municipal programme or one provided through the mediation of the health insurance industry.
Coverage versus cost, Nixon would likely despair at the continued disparities in coverage toward which we appear to be moving again.
He would likewise be disappointed that the managed care concept he promoted did not did not do more in cost containment by inserting prevention.
But most likely, he would wish that in 1974, the planets could have aligned so that he,
Ted Kennedy and Wilbur Mills could successfully have advanced their ideas for a comprehensive national health care programme.
Maybe, just maybe, it could have meant that the American people would have felt more invested in the institutions
of their country and done so because those institutions were truly serving and protecting them.
OK. OK.