It is both the tragedy and irony of contemporary American politics that former President Barack Obama is impugned as a radical leftist for reprising, in more moderate tones, the legislative health care legacy of a fiscal conservative, President Richard Nixon.
With leading 2020 candidates like former Vice President Joe Biden now providing the outlines of what they think are more achievable paths to healthcare reform, and particularly as attention is again focused on the Trump administration’s on-again, off-again efforts to derail the entire Affordable Care Act, it’s important to consider how unprecedented such actions are within a partisan historical lens. Dating back to President Franklin Roosevelt, sequential Democratic and Republican administrations have, despite ideological misgivings, moved toward broadening healthcare access. Such progress, however uneven, is generally premised on the basic understanding that doing otherwise would be politically suicidal.
There’s perhaps no better example of this than the way Nixon worked to improve the 1965 Medicare Act ushered in by Democratic President Lyndon Johnson. Realizing that government-sponsored health insurance was now a political reality that needed to be navigated carefully, Nixon chose to embrace the cause of universal health reform in the early 1970s. He advocated for the Comprehensive Health Insurance Plan (CHIP), which had three pillars: generous employer-sponsored insurance, assisted health insurance (akin to federalizing Medicaid, which was previously a state-run program) and an improved Medicare plan.
The goal was to ensure that all Americans would have access to one of these programs and participation would be voluntary. Pre-existing conditions would not be disqualifying, mental illness and drug addiction would be addressed, and long-term care needs would also be covered.
The similarities between Nixoncare and Obamacare are clear, but Nixon’s conception of the employer mandate was actually more generous in some ways: no exemption for small employers of less than 50 employees, lower caps on proportion of costs to be covered by the employee and increased federal subsidies to ease the burden on employers. Further, he wanted to expand Medicaid via unlimited federal support indefinitely, ensuring a standard set of services were provided nationwide with no state choice. Conversely, a similar, though far less generous measure advocated by Obama was deemed an unconstitutional infringement of the Tenth Amendment and states’ right to choose.
The legacy of Nixon’s efforts on health reform rarely receives much attention given the degree to which his presidency was tainted by Watergate’s aftermath. Yet, he still presided over a period of Medicare expansion, increasing its funding mechanism and extending coverage to individuals under 65 who had been severely disabled for at least two years.
Ultimately, though, much of what Nixon envisioned in his 1971 and 1974 health plans fell in committee to a resurgent Democratic caucus that viewed Nixoncare as not liberal enough. These efforts were headed by the now deceased Sen. Ted Kennedy, whose maximalist positions on single-payer health reform proved decisive (and evocative of today’s absolutist climate). Ironic, considering that Kennedy helped push early efforts bolstering a much less generous package of government-backed health services in Obamacare 40 years later.
Though the Reagan and Bush years lacked significant progress in healthcare reform, none of these administrations pursued legislative efforts to significantly walk back the progress of their predecessors. Reagan’s healthcare legacy centers on passage of catastrophic health coverage for all Medicare recipients in 1988, though it was ultimately repealed soon after he left office. As part of that same set of reforms, he introduced outpatient prescription drug coverage benefits, which President George H.W. Bush ultimately enacted — and President George W. Bush later improved upon.
Access to affordable health coverage is popular, as are protections for those with pre-existing conditions. There’s been no shortage of commentaries and polls leading up to and since the midterms which clearly reflect that. Which is why it’s difficult to reconcile how current efforts to eliminate the ACA constitute smart politics or the beginnings of a longer-term strategy to broaden healthcare access for Americans.
However imperfect, Obamacare is a conservative compromise to the provision of greater healthcare coverage for Americans and a restrained incarnation of the more liberal attempts at reform put forth by prior GOP leaders. If history is any guide, incrementalism as advocated by leaders like Joe Biden is often the safest bet at the ballot box, an approach adopted by both prior Republican and Democratic administrations alike for the past 80 years. President Donald Trump is gambling against history, which is rarely a wise bet.