Joseph Califano remembers the moment well.
The nation’s doctors were threatening to boycott the new Medicare program, and President Lyndon Johnson had to get them on board or the 1965 extension of health care to elderly Americans would collapse. So the president set a trap.
Before a discussion of Medicare could begin in a White House meeting with American Medical Association leaders, Johnson pitched the idea of doctors doing rotations in Vietnam to ease a physician shortage during the war.
The doctors accepted the patriotic appeal, and Johnson promptly called reporters into the room to announce it, putting James Appel, the AMA president, on the spot.
“The first question was, ‘Will the AMA support doctors in Medicare?’, and Johnson turns to this poor guy sitting next to him and said, ‘These men are willing to put their lives on the line in Vietnam; Medicare is the law of the land. Of course, they will’,” Califano, 82, said in an interview. “Then he turns to the doctor and says ‘tell them’,” and Appel did.
It was a power play that President Barack Obama can’t replicate in a far more partisan political climate in Washington, Califano said. Johnson’s opponents -- mainly doctors and hospitals -- were driven by financial motives, while Obama’s are galvanized by “ideological” ones, he said.
Historically, Congress has been willing to do both technical fixes and major amendments to Social Security and Medicare, particularly once they were being implemented. Glitches and oversights are inevitable when passing laws that require the construction of new bureaucracies to carry out massive programs.
In 2006, President George W. Bush’s rollout of a prescription drug subsidy for seniors drew complaints about its complexity and rising costs, and adjustments were made to make the program more accessible and to close loopholes.
Yet it’s a pattern that’s unlikely to be repeated with the Affordable Care Act, Obama’s signature legislative achievement aimed at expanding health coverage to about 30 million uninsured Americans. Republicans, mainly in the U.S. House, are continuing a push to defund or repeal the law, which received no Republican votes when it was passed, to starve it into submission.
That means the Obama administration must implement the law, albeit with flaws, and count on enough Americans embracing it to both provide more coverage and reduce costs.
“They’re making it impossible to do what a president would normally do, which is go get some of these changes made in the law,” said Califano, a Johnson adviser who went on to serve as secretary of the Department of Health, Education and Welfare in the administration of President Jimmy Carter. “It’s kamikaze politics. I don’t understand it.”
Obama acknowledged that changes to the law are unlikely in the short term. “That would be the normal thing that I would prefer to do, but we’re not in a normal atmosphere around here when it comes to quote-unquote ‘Obamacare’,” the president said in an Aug. 9 news conference. “It’s just become an ideological fixation.”
This month, the House Republican Conference gave its members a planning kit entitled, “Fighting Washington for all Americans,” offering tips on hosting an “Emergency Health Care Town Hall” on the “negative effects of Obamacare and the House Republican plan to dismantle it.”
“The member should use personal stories from the town hall during local media interviews to highlight the negative effects of Obamacare on the community,” the kit advises. It also counsels members to write op-ed pieces for local newspapers that say, “I’m working to dismantle Obamacare.”
House Republicans have voted 40 times to repeal, defund or delay the law and have pledged to oppose even technical fixes. Heritage Action for America began a nine-city tour on Aug. 19 in Fayetteville, Arkansas, to try to create a movement that would pressure Congress to deny funding for the law.
Eighty House Republicans have signed a letter urging their leadership to support efforts to withhold money to implement the health-care law from must-pass legislation to keep the government running after Oct. 1.
“We urge you to affirmatively defund the implementation and enforcement of Obamacare in any relevant appropriations bills brought to the House floor” in the current Congress, “including any continuing appropriations bill,” said the letter to House Speaker John Boehner of Ohio and Majority Leader Eric Cantor of Virginia.
Obama’s plight has echoes of the early 1900s when some of the nation’s wealthiest men worked with compliant lawmakers to try to defund an agency that Congress had just passed a law to create -- the U.S. Forest Service -- under President Theodore Roosevelt.
It would take a disastrous fire in 1910 that consumed millions of acres of forests and entire towns, a story recounted in the 2009 book “The Big Burn” by Timothy Egan, for the public to embrace the need for conservation of federal lands.
Obamacare is the culmination of an effort that began with Roosevelt’s administration a century ago to provide a form of government health insurance for the poor. And in each phase, presidents -- Republican and Democratic, alike -- had to overcome spirited opposition.
President Franklin Roosevelt won passage in 1935 of Social Security, which provides government stipends to elderly residents for living expenses; he specifically deferred a health-care component because he didn’t believe it would pass.
Roosevelt faced opposition largely from the business community. Silas Hardy Strawn, a former head of the U.S. Chamber of Commerce, called it an effort to “Sovietize America.”
Thirty years later, Johnson delivered Medicare and Medicaid, making deals with the doctors and hospitals to provide health care for seniors and the poor. Bill Clinton lost his 1993 battle for universal insurance even as he won a 1997 fight to expand children’s health care.
When Bush got his Medicare prescription drug benefit for the elderly, it was no easy triumph. The House speaker, Republican Dennis Hastert of Illinois, had to take the extraordinary step of keeping the roll call vote on the bill open for more than three hours while the leadership twisted arms to get a majority vote, 220-215, at about 5 a.m.
Each time, Congress has had to go back and make amendments to the laws, some minor, others sweeping.
In 1939, when Social Security was revised to include survivor benefits, “it was done with a minimum of controversy,” Wilbur Cohen, an adviser to presidents from Franklin Roosevelt to Johnson, said in an oral history at the LBJ Presidential Library in Austin, Texas.
With Medicare, Califano said, there was no accurate estimate of the costs, and if there had been, the program probably wouldn’t have passed even with two-to-one Democratic majorities in the House and Senate. The funding mechanism has been changed repeatedly over the years.
In the Carter era, Califano said he was able to win approval for numerous fixes for Medicare. “I didn’t have guys saying, ‘You are the devil, Califano’,” he said.
Lawrence Kocot, a senior adviser to the administrator of the Centers for Medicare & Medicaid Services from 2004-2007, said a divided Congress passed technical and more substantive changes to the prescription drug program for seniors.
“The partisan atmosphere in the ACA right now does not lend itself to any technical correction bill,” said Kocot, now a visiting fellow at the Brookings Institution, a policy research group in Washington. “There is too much polarization.”
Johnson made a point of engaging Republicans on the issue, something Obama has failed to do. Califano said Johnson made it a priority to get at least half the Republicans in Congress to vote for the Medicare plan.
“He said the law is not self-executing,” Califano said. “If we don’t do this, they will kill us in appropriations,” a presidential warning that foreshadowed the strategy some Republicans want to adopt today.
At the same time, Johnson didn’t always win. In 1968, the embattled president delivered a message to Congress asking it to fix three “major deficiencies” in Medicare, and none passed.
“We couldn’t get anything done,” Califano said. “We were out of steam.”
There were also contrasts in presidential temperament. “The climate is dramatically different between two different presidents,” Califano said. “One who knew where every story was buried on the Hill and loved to do all the tough things that you’ve got to do, night after night meeting with people.”
He said Johnson instructed his aides to treat Senator Everett Dirksen of Illinois, the Republican leader, the same as Democratic Senate Majority Leader Mike Mansfield of Montana, and House Minority Leader Gerald Ford, a Michigan Republican, just like House Speaker John McCormack, a Massachusetts Democrat.
“That’s inconceivable today,” Califano said.