As we watch a beleaguered president try to deliver a major health care proposal—likely to be considered on the Senate floor within days—history offers some perspective. Presidential scandal and health initiatives have crossed paths before, and health care was the loser.
In the spring of 1974, the stars aligned to produce a rare moment of opportunity for health care reform. Then-President Richard Nixon, a Republican, had a soft spot for health care problems, a proclivity rooted in his own family’s struggles with health troubles—two brothers died in childhood of tuberculosis. Early in his second term, he championed the development of new legislation, the Comprehensive Health Insurance Plan, that would have provided generous health insurance for all Americans. At the same time, the powerful chairman of the House Ways and Means Committee, Democrat Wilbur Mills, had teamed up with the Senate’s liberal health care leader, Democrat Edward Kennedy, to draft a different version of comprehensive national health insurance.
As it turned out, key staffers for Nixon, Kennedy, and Mills knew and trusted one another, and saw a chance to team up. After secret meetings in the basement of a Washington, D.C., church, they hatched a Nixon-Kennedy-Mills proposal for comprehensive national health insurance, which their principals endorsed. In a maneuver that current House leaders have used repeatedly, Mills decided that hearings were unnecessary and took the new plan directly to his committee for consideration.
The morning of the vote, one of Mills’s staff later recalled, he met the committee chairman in the men’s room, where Mills unhappily confided that they didn’t have the votes.
In fact they did. The proposal passed Ways and Means by one vote, 16–15, the first time a comprehensive national health insurance plan had ever passed this formidable committee. But the famously cautious Mills only took bills to the floor when he had a decisive majority. The chairman had brought along committee Democrats, but he couldn’t get Republican members to back their own president’s plan.
Which brings us to presidential scandal. At this point in his presidency, the Watergate scandal had rendered Nixon a dead politician walking. He had no legitimacy with the public, and no influence with Congress. Mills couldn’t rely on him even to convert reluctant Republicans whether in committee or—looking forward—on the floor of the House.
As we are seeing once again, health care is not only complicated but politically treacherous. Passing major legislation—whether to add coverage or cut it—is the governing equivalent of the D-day landings. It requires all hands on deck, plus a good deal of luck. A president missing in action drastically reduces the odds of success.
The circumstances confronting proponents of repealing and replacing the Affordable Care Act (ACA) are very different from those facing President Nixon and the Congress in 1974. For one thing, the current Republican House and Senate majorities and their leaders are strongly committed in principle to repeal and replace. Democratic majorities in 1974 were far less mobilized about national health insurance. Majority leader Mitch McConnell is also a skilled and tested legislative warrior with significant influence over his caucus. And President Trump is as yet nowhere near as damaged as Nixon was during Watergate.
But the major point remains. Imagine how relieved McConnell might be to have the Republican equivalent of President Lyndon Johnson in the White House. Johnson, perhaps the most skilled practitioner of legislative arts ever to reside at 1600 Pennsylvania Avenue, was famous for the “Johnson treatment,” in which the relentless, six foot four President would corner a recalcitrant legislator and, towering over him, “make his case.” That case might involve a policy argument—or a naval base, a judgeship, or presidential support for unrelated legislation important to the victim of the moment.
The Johnson treatment, in all its color and physicality, may not be the ideal way to exert presidential influence, and in any case having a skilled, powerful, supportive president would not guarantee Republicans the legislative triumph they seek. But it might change the odds.