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50 years before Obamacare, JFK's own health care debacle

This post originally appeared on Slate.

In the spring of 1962, President John F. Kennedy launched a bold effort to provide health care for the aged--later to be known as Medicare. It culminated in a nationally televised presidential address from Madison Square Garden, carried on the three television networks. It was a flop. The legislation foundered amid charges that it was an attempt to socialize medicine and a threat to individual liberty--the same charges President Obama encountered over the Affordable Care Act five decades later.

While Obama crosses his fingers and waits for to flicker to life, he can at least comfort himself knowing that he has already done more to reform the health care system than JFK, a president with a vigorous reputation and vibrant legacy. The Gallup poll reports that 74 percent of the country believe John F. Kennedy will go down in history as an outstanding or above-average president, a more positive review than any other post-World War II president receives.

But the story of Kennedy's health care failure is not just about the enduring difficulty of addressing such a thorny issue. It is about how even an energetic and determined chief executive can be constrained by the limitations of the office. Kennedy's story of botched congressional relations, the limits of public persuasion, and the rise of a grassroots opposition that can match the power of the bully pulpit foreshadows many of the same problems President Obama faces today.

Kennedy took office with a grand new vision for the presidency. In September 1960, before his narrow victory over Richard Nixon, the then-senator read the first of several memos he had requested from political scientist Richard Neustadt. The Columbia professor had just published his seminal work "Presidential Power," which offered a new theory on how a president, limited by the Constitution, can still succeed through personal persuasion, backroom maneuvering, and public prestige. Kennedy was in a hurry to put its thinking into action. By using the right formula, he could achieve the greatness he craved. Days before taking the oath, he outlined his approach to the National Press Club. Eisenhower had a "detached, limited concept of the presidency," he said. The 1960s required a president to "place himself in the very thick of the fight ... prepared to exercise the fullest powers of his office ... to ensure enactment of that legislation--even when conflict is the result."

Kennedy embraced conflict on Medicare. Soon after taking office, he asked Congress to move on the issue, but like Obamacare it languished while its members pawed over it. By the spring of 1962, the president had political and personal reasons to push the fight again. Kennedy's pollster Lou Harris counseled that he would need domestic accomplishments for his re-election and that Medicare would be an important one. The issue was also essential for the AFL-CIO, a key Democratic Party ally, and so could be incredibly helpful for Democrats facing election that year.

Kennedy had his eye on his legacy, too. That's usually a topic for a president's second term, but Kennedy was always in a hurry. JFK, who repeatedly referred to the gravity of foreign policy issues, also thought the measure of a great president was how much of his agenda had been pushed through Congress. He quibbled with presidential rankings that had put Teddy Roosevelt and Woodrow Wilson ahead of Harry Truman and James Polk, who had actually achieved more. "[P]eople who educated the nation without necessarily accomplishing their particular purposes rated, in his judgment, below those who accomplished their purposes without necessarily bringing the nation along with them," wrote Arthur Schlesinger Jr. in "A Thousand Days," his chronicle of his time in the Kennedy administration.

Inside the administration they debated how to proceed. Should the president's aides play the inside legislative game or should the president build public pressure that would force members of Congress to act? Wilbur Mills, the powerful chairman of the House Ways and Means Committee, had blocked the legislation, and Kennedy had to treat Mills carefully. He was the gatekeeper for all of Kennedy's policy priorities, from taxes to trade to foreign aid. But Mills had sent signals that he might allow Medicare to sneak in under the cloak of a welfare bill, which Mills wanted to pass. Medicare would be added to the bill in the Senate, and then Mills could water it down in the conference committee where the House and Senate versions of the welfare bill were reconciled.

It was a plausible strategy, but some on Kennedy's staff and the AFL-CIO wanted a public fight to get a stronger bill. Since the dawn of the television age, every president has faced this inside-outside tension, with presidents and their staff putting more and more stock in their ability to rally the country. It was also President Obama's main legislative strategy.

Kennedy, who faced this presidential conundrum in its infancy, decided to follow both routes, working to persuade on the inside but also "going public"--over the heads of Congress and directly to the voters--to create pressure in Washington. He was determined to take control of his office and he had cause to press his advantage. The New York Times reported on the eve of the fight that members of Congress "on the whole appear to be far friendlier toward him and his program than at any other time since the session began in 1961. This results chiefly from the growing election-year sensitivity to Mr. Kennedy's popular influence in the country. Even Republicans are sensitive to this influence."

The AFL-CIO held 33 rallies across the country, culminating with Kennedy's address on May 20 in Madison Square Garden; the union packed the arena with almost 20,000 older voters.

The president started his remarks by addressing criticisms that he was unduly trying to whip up the public, instead of leaving the business of government to those who govern. He argued any large piece of legislation required public consent and called on his audience to make Medicare a public crusade. He referred to his father, whom he had just visited in the hospital--much as President Obama spoke about his mother when making the case for his reforms. But where Obama had talked about his mother wrestling with medical bills, Kennedy referred to his father's good experience with the health care system and suggested the same should be available for any elderly person. Kennedy concluded by saying, "I refuse to see this country, and all of us, shrink from these struggles which are our responsibility in our time. Because what we are now talking about, in our children's day will seem to be the ordinary business of government."

The ladies in flowered hats and men in thick black glasses cheered enthusiastically, but they weren't the audience the president needed. "[T]he president had forgotten the lesson of his campaign that arousing a partisan crowd in a vast arena and convincing the skeptical TV viewer at home require wholly different kinds of presentation," wrote his closest aide, Ted Sorensen. "He already had support from the senior citizens; he needed more support from the home viewers, and that speech did not induce it."

That wasn't Kennedy's only problem. He had competition for the public mood. After the 1960 election, the American Medical Association girded for the Medicare battle, raising its dues from $35 to $70 and blanketing its members with warnings about Kennedy's plan to socialize medicine. The organization brought in doctors from England to describe the dire straits of Great Britain's insurance system. In advance of the Madison Square Garden push, the AMA said the Treasury was being "looted" to subsidize the biggest lobbying campaign the nation had ever seen.

To rebut Kennedy directly, the lobby purchased half an hour of television time and Dr. Edward Annis, a Miami surgeon, went to Madison Square Garden to deliver his own address. Annis spoke to an empty hall, where the banners from two nights before still hung, portraying himself as an underdog. "Nobody--certainly not your doctors--can compete in this unfamiliar art of public persuasion," he said, lamenting that the president appeared on all three networks but the AMA (your doctor) had to purchase time and therefore could appear on only one. "We doctors fear that the American public is in danger of being blitzed, brainwashed, and bandwagoned," he said, arguing the laws on the books allowed people to be covered through private programs. Annis then held up the legislation and attacked the president's claims one by one. Kennedy and his aides knew immediately that they had lost the battle with the good family doctor.

But the damage didn't end there. By going to the public, Kennedy antagonized the very members of Congress he needed to get the legislation moving. "To get a vote on Medicare in the House, we had to persuade Mills, and you don't persuade Mills with a rally in Madison Square Garden," said Larry O'Brien, Kennedy's close aide, who was working the bill in Congress. "Kennedy understandably wanted to take his case to the people, but in this particular instance that approach didn't work."

The last chapter of Kennedy's failure on Medicare came as a result of either being hoodwinked by members of Congress or in misreading them, which, given the nature of backroom deals in the 1960s, may have been the same thing. In a last-ditch effort, the president and Medicare proponents returned to the original strategy of trying to attach the health care program to the welfare bill in the Senate. The measure was debated for three weeks, after which Democratic leader Mike Mansfield thought he had the 50 votes needed for passage. (Vice President Lyndon Johnson would break the tie.)

The opposition, made up of Republicans and Southern Democrats, did not filibuster the bill the way they would today, but that's because they had better weaponry. Oklahoma Sen. Robert Kerr, a Democrat and one of the most powerful men in the Senate, was the leader of the opposition. He was highly skilled at manipulating his colleagues through almost any means necessary. ("Mr. Kennedy asked; Mr. Kerr decided," wrote the Wall Street Journal at the time.) Kennedy and Kerr had both been trying to win over West Virginia Sen. Jennings Randolph to their side, but according to historian Irving Bernstein, Kerr wrote a provision into the welfare bill that extended a $21 million overexpenditure to West Virginia--essentially a kickback--and Randolph voted against Kennedy.

In the end, Kennedy's attempt to play both the outside game and the inside game failed. Such defeats led to the kind of appraisals that President Obama now faces as his approval ratings and personal ratings hit new lows. "There is a vague feeling of doubt and disappointment about President Kennedy," wrote James Reston in the New York Times. "He has touched the intellect of the country, but not its heart. He has informed but not inspired the nation. ... [H]is problem is probably not how to get elected, but how to govern." Fifty years later, it's a fitting description of another president in the midst of his own health care fight.

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