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LBJ Could Be Obama's Guiding Light for Health Care Overhaul, Experts Say

By Emily Ethridge, CQ Staff

December 2, 2008 -- To ensure a successful overhaul of America's health care system, President-elect Barack Obama should take a page from the playbook of President Lyndon B. Johnson, who used a combination of political savvy and sheer will to help enact Medicare and Medicaid programs in 1965, say two policy experts in the latest issue of the New England Journal of Medicine.

"Policymakers focus a lot on other health reform missteps but little attention is paid to the successful lessons of Lyndon Johnson and Medicare," said David Blumenthal, who served as an adviser on the Obama campaign. Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital, co-wrote the article along with James Morone, chairman of political science at Brown University.

Johnson was deeply committed to passing Medicare, and moved quickly on the legislation, the authors said. He chose to make the bill his first priority—it was designated HR 1 in the House and S 1 in the Senate—and said he would pass it whatever the cost.

"Johnson made passing Medicare a priority and he worked tirelessly to get it done," Morone said.

Cost may be one of Obama's biggest challenges in passing significant health care overhaul. According to a November 2008 estimate from the PricewaterhouseCoopers accounting and consulting firm, Obama's proposed plan would cover 30 million Americans without health benefits at a cost of $75 billion if enacted in 2009.

To help pass Medicare, Johnson went so far as to underestimate its true cost and avoided projecting the legislation's economic impact so the bill could more quickly. "An accurate economic forecast might have sunk Medicare," Blumenthal and Morone wrote. Johnson decided "to expand coverage now and worry about how to afford it later."

However, Obama faces a much bleaker economic situation than Johnson did. The Congressional Budget Office, which did not exist in 1965, will be reviewing the economic impact of any legislation Obama introduces, as will the White House's Office of Management and Budget.

For a health care overhaul bill to succeed, Obama will need to use much of his political capital, the authors noted. Johnson was victorious because he was personally committed to passing Medicare, and willing to spend money and energy as well as use his clout. "Only a president with a deep emotional commitment to improving our health care system would start down such a risky and dangerous path," they said.

In addition, Obama must move quickly. Any delay gives the opposition time to form attacks that will defeat the bill, Blumenthal and Morone advised. One of the problems with President Bill Clinton's health care overhaul plan, they said, is that he waited nine months to introduce it, allowing opponents to assemble and defeat it. In contrast, Johnson got to work right away on the Medicare bill, because he saw his mandate as "fragile and fleeting," they said.

After Johnson was elected, along with large liberal Democratic majorities in the House and Senate, the powerful House Ways and Means Committee Chairman Wilbur Mills, D-Ark., switched his position on health care and promoted the Medicare system. Johnson worked closely with Mills, allowing him and other members of Congress to figure out the specifics of the plan, while Johnson stayed true to basic principles, the article noted. For example, when Mills suggested a bill with a Social Security cash benefit, a hospital benefit and an expansion of health care for the poor, Johnson agreed to all those things but also pushed for a bigger, more complete Medicare bill.

Johnson gave Mills and other members of Congress credit for the bill. A former senator, he understood how Congress worked, and assembled a skilled legislative team to navigate through the lawmakers. While he created political momentum, he allowed Congress to work out the details to give the bill a better shot, the article said. He also tracked the bill's progress nearly daily.

Johnson's keys to success—moving quickly, using political capital and ignoring costs—could put Obama on the right path, Blumenthal and Morone said, but added that even with employing such actions, the president-elect faces a tough path on health care.

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