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Past as Prologue—Presidential Politics and Health Policy

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Past Fights Shape Today’s Health Policies

In a “Perspective” column for the New England Journal of Medicine, The Commonwealth Fund’s David Blumenthal, M.D., and Brown University’s James Morone discuss the impact of decades of policy proposals and related political maneuverings on the health care platforms of Hillary Clinton and Donald Trump. Clinton supports the Affordable Care Act and proposes expanding it, while Trump promises to repeal it and replace it with limited, market-based mechanisms. But how did they get arrive at their positions?

Politics Drives the Evolution of Health Policy

The current platform from the Democrats has its ideological origins in Harry Truman’s call in 1948 for a single-payer system. But it has evolved to adopt numerous Republican ideas, albeit broadly in pursuit of expanding health care coverage. The Republican platform, while less well defined, has also shifted to the right, reflecting trends in the party’s base.

Democratic proposals for a single-payer system have largely vanished. Instead, Democrats have pursued more focused efforts to expand coverage, most notably by passing Medicare in 1965. Later, in 1992, President Bill Clinton again took up the mantle of covering all Americans, attempting to overhaul the nation’s health care system while preserving its market-based core. The effort met stiff Republican opposition, failed, and helped return the House to Republican hands.

More recently, President Obama succeeded in passing the Affordable Care Act in 2010. The ACA adopted many ideas from the Republican playbook—managed competition, coverage mandates, and subsidies—in an attempt to make the legislation more politically palatable. Even so, it was passed without a single Republican vote.


Opposition to Democratic proposals still appears to galvanize the Republican base. But this may not always be so: Republican voters today include many downwardly mobile Americans who could lose insurance and benefit from the ACA in the future. Once elected the next president will need to move past partisan rancor if he or she is to accomplish their respective health care objectives, the authors say.

Publication Details



Mary Mahon, Former Vice President, Public Information, The Commonwealth Fund

[email protected]


D. Blumenthal and J. Morone, "Past as Prologue—Presidential Politics and Health Policy," New England Journal of Medicine, Oct. 6, 2016 375(14):1314–16.