The Heart of Power: Health and Politics in the Oval Office
David Blumenthal and James A. Morone
University of California Press, Berkeley, 2009, 484 pp., $26.95, ISBN: 978-0520260306
Reviewed by Philip Caper, M.D.
(This review was originally published in The Journal of Public Health Policy, Volume 31, Number 1, April 2010, pp.88-95)
The opening paragraph of The Heart of Power by David Blumenthal and James Morone describes a conversation that Blumenthal, then an undergraduate at Harvard College, had with Richard Neustadt, the noted presidential historian and one time member of John F. Kennedy's White House staff. Blumenthal credits Neustadt, his course on the American presidency, and their subsequent long friendship with the inspiration for his and Morone's new book.
I'm certain that professor Neustadt would be proud of the product he inspired. In this readable, well-documented, and comprehensive study, the authors lucidly explore how presidential personalities, priorities, political philosophy, and personal health experience have influenced their approaches to health policy. They analyze legislative and policy successes and failures in 11 US presidential administrations, ranging from Franklin D. Roosevelt to George W. Bush. (They omit only the brief presidency of Gerald Ford.)
From FDR's New Deal to George W. Bush's Ownership Society, Blumenthal and Morone explain how each president, cognizant of the unique history, political opportunities, and risks they faced, learned (or didn't) from their predecessors and built on what had gone before. Their source material includes presidential library archives plus interviews with former presidential staff, and staff of the libraries.
Despite my lifelong involvement in and study of American health- care policy, I learned a great deal from this book. I was not fully appreciative, for example, of the depth and passion of Truman's commitment to a social insurance model of national health insurance, nor was I aware of the level of detailed involvement by Lyndon Johnson in the birth of Medicare, the federal insurance program for the elderly. It was part of a conscious strategy on Lyndon Baines Johnson's (LBJ) part to give Representative Wilbur Mills most of the credit for passing that landmark legislation in 1965. Flattery, it turns out, is an important policy tool. There are many other examples. The final chapter called "Eight Rules For The Heart of Power' is thoughtful and thought-provoking. I won't spoil the ending by listing them here.
Most important, the authors drew on their own experiences as political scientist and physician, as scholars, researchers, and participants in our chaotic and bewildering policy process. Together, they have created a fascinating story of health policy development over a period of more than 75 years. This book is well worth reading by anyone interested in the role of US presidents and the presidency in the development of American health policy.
Still, after reading the book, I was left with the feeling that an important set of issues legitimately beyond the scope of The Heart of Power were left unaddressed. As this book makes clear, in the health field strong presidential leadership is critical to enacting major legislation. Yet, even the most skillful, determined, and powerful president is limited by the political environment of the day. Contrary to the rhetoric, politicians are usually followers, not leaders of popular sentiment. There is only so much any leader can do before he runs up against the barriers to change inherent in the political environment of the day.
What are the barriers to reform of the American health-care system? Why has it been so difficult for American politicians to create a statutory right to health care for Americans a right that every other affluent democracy created years ago?
First and most basic, the concept of health care as a right remains a polarizing concept in the United States. As Lewis Carroll once said, "If you don't know where you're going, any road will get you there'. The wisdom of that observation is clear to anybody watching Congress struggle with the issues raised by the most recent health- care reform effort.
Second, Americans are inherently suspicious of central authority secular or religious. Thomas Paine's concept of government as "a necessary evil' is alive and well. Establishing a right to health care requires a stiff dose of that necessary evil. Our political institutions are designed to decentralize power.