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How Will History View the Health Reform Debate?

What is the historical significance of Sunday’s health care reform vote and what does it mean for the Obama presidency?

Answers were given via phone and e-mail, and have been edited for space and clarity.

Robert Dallek

Presidential Historian, Stanford University

Any historian who discusses this with you will tell you that we’ll have to see how it plays itself out. You just never know how these things evolve. But on the face of it, my guess is that this is a very big step forward, a very big moment in American social history. The parties have been fighting about this for 100 years. Teddy Roosevelt, FDR, Truman, Kennedy, LBJ, Nixon, Clinton — they all wrestled with this issue of having universal health insurance in the United States, emulating what you see in other advanced industrial countries. In that sense, it’s a landmark moment.

What makes it problematic is what the costs might be. You know there are these 10-year projections. I’m always skeptical of these; you never know how it’s going to work out. When you look at what Medicare cost back in 1965 when LBJ got it through, the cost was about $3 billion. And now of course it costs hundreds of billions. Covering Medicare recipients with physician office visits was $500 million in 1965. So we’re talking about a huge increase. Now will this happen again? And if so, will there an inclination to raise taxes? Those are the uncertainties.

This is a very big social reform, which involves one-sixth of the economy and something that has been argued and debated for 100 years. When Republicans said, “Let’s start over,” I was puzzled because we had been arguing about it for 100 years.

For President Obama, I think it became essential for him to get this passed. If this had failed, it would have been a terribly devastating blow to his administration, because he had invested so much of his political capital and credibility on this. And for this to fall short — especially having Democratic majorities in both houses — it would have been seen a devastating failure for him to not get it through. So I think it was essential for him to pass it.

I think he will be able to savor it. And I do think the Democrats will be able to trumpet it, in the sense that the country has been so divided, there’s been so much political acrimony, the Democrats will be able to say they’ve been able to unify, they’ve been able to get enough of a consensus within their party to do something really big. They came to Congress with a majority in 2008; they can say this is what we were sent here to do — pass big advances, big reforms.

In terms of the future, I would say the argument will not disappear. I don’t think we’ve seen the last of this debate about national health insurance. If it works well, the Democrats will have a very significant talking point for the future. If it falls short, if it’s somehow seen as a failure, the Republicans are going to have a powerful talking point against the Democrats.

In some ways, I would compare this to how national security has played out — because Democrats fell short in the Korean War, were voted out and Eisenhower was given the presidency in significant part to secure the Korean War. That was echoed with Vietnam War and Lyndon Johnson. Again the Democrats fell short. It gave the Republicans an argument against the Democrats that we have heard for 50 years now on national security. And I think it’s similar with this legislation. If this is successful, the Democrats will be able to beat up successfully on Republicans.

Ellen Fitzpatrick

Professor of History, University of New Hampshire

The health care reform bill passed yesterday is highly significant historically. For the first time since the passage of Medicare in 1965, the United States moves sharply toward, rather than away, from the principle that broad public access to affordable health care is the responsibility of the national government. That case was made by Theodore Roosevelt nearly a century ago. And it has been pursued, with varying degrees of success, ever since with familiar language, shifting strategies and equally stringent opposition very much in evidence.

Over60 years ago, The New York Times headlined the “bitter debate” over Harry Truman’s attempt to steer to passage a bill that “defines an obligation of government which has never before been assumed in this country. It transforms medical care from the category of a comparative luxury to that of a national resource, available to all the people on a basis of equality.”

Critics denounced the legislation as socialism. Congress twisted in the wind, caught between the determination of the Truman administration and a powerful lobbying campaign waged by insurance companies, the American Medical Association, conservative Democrats and Republicans. As the Times put it in February 1949, “the pressure on Congress from both sides is mounting daily toward a climax, which many members sorely dread. Most are ‘in the middle’ and say frankly that they do not know which way they will jump when the time of decision finally arrives.'”

Yesterday Democrats in Congress jumped.

The current legislation is a long way from the vision of national health insurance many progressive activists hoped to see enacted. It is far less sweeping than the Medicare program Lyndon Johnson steered to passage or Franklin Roosevelt’s Social Security in its provisions and its implications. But it does represent a step of momentous — indeed, historical — proportions toward federal responsibility for adequate health care provision.

It moves toward realizing a principle President Kennedy articulated in 1962 as he attempted to mobilize support for Medicare against seemingly intractable opposition. “I read that this bill will sap the individual self reliance of Americans,” Kennedy observed of his proposed Medicare legislation. “I can’t imagine anything worse, or anything better, to sap someone’s self reliance, than to be sick, alone, broke — or to have saved for a lifetime and put it out in a week, two weeks, a month, two months.” Noting that some say “Why doesn’t the government mind its own business?” Kennedy responded: “‘What is the government’s business?’ is the question. Harry Truman said that 14 million Americans had enough resources so that they could hire people in Washington to protect their interests and the rest of them depended upon the President of the United States and others. This bill serves the public interest.”

At a time of strident anti-government rhetoric, and extreme polarization among various factions in the health care debate, the steps taken by Congress yesterday vindicate the idea the health care provision is the government’s business and will remain so for some time to come.

Barack Obama will thus stand in a line of other presidents who stood that ground and triumphed in this unlikely season of renewal and reform. Imperfect, sure to be altered, revised, and amended over the ensuing years, the health care bill of today won’t be recognizable to future generations.

“All the great revolutionary movements of the Franklin Roosevelt administration in the thirties we now take for granted,” President Kennedy observed nearly a half century ago. “What we are now talking about, in our children’s day will seem to be the ordinary business of government.” And so it may become.

The battle over this legislation — waged with skills and determination by House Speaker Nancy Pelosi, reinforced by pressure from the grassroots who looked with dismay upon the prospect of another defeat at the hands of political inertia and incompetence — marks a milestone in the young Obama presidency. Having staked so much on a promise of change, Obama redeems that pledge in ways that — whatever the struggles ahead — casts in stark relief the recalcitrance of his opponents.

Richard Norton Smith

Scholar in Residence, George Mason University

To state the obvious, it is an enormous personal victory for Barack Obama — not only the magnitude and scope of what is being achieved but how it’s been done, how it has been brought back from the grave. That is the stuff of instant legend as well as lasting history.

In some ways, it’s almost easier to predict what historians a generation from now will say than what voters will say six or seven months from now. What we can’t know, what no poll can measure, is what aura will accrue to this president and his party as a result of pulling this rabbit out of a hat.

For example, logic suggests that one of the real problems the Democrats have been facing is the discrepancy in voter intensity. Every poll suggests that Republicans are intensely motivated to express anger at the polls in November. And conversely as long as this process has dragged on interminably, seemingly at the expense of any tangible accomplishment in this field, Democrats have been correspondingly depressed. It will be fascinating to see a week from now, two weeks from now, what the underpinning is — not the raw polling data but the back story if you will — in terms of people’s attitudes toward his presidency, his ability to get things done, his leadership qualities and how that manifests itself within the Democratic coalition. Logic suggests it will produce a significant boost.

The other thing is history tells us is there’s no correlation between historical presidential achievement in off-year elections and being rewarded at the polls. In 1962, arguably the greatest accomplishment of the Kennedy presidency, perhaps of the entire Cold War, was the prevention of nuclear Armageddon in Cuba. Two weeks later in the midterm elections of ’62, Democrats lost four seats in the House and picked up four seats in the Senate. As midterm elections go, that was viewed relatively speaking as a victory. But it was not viewed as the kind of roaring endorsement that in retrospect one would have expected considering the magnitude of Kennedy’s triumph, even as it was perceived at the time of the Cuban missile crisis.

In 1978, you had Jimmy Carter in September brokering the Camp David accords which ultimately led to the peace treaty between Israel and Egypt. And yet two months later, the Democrats scored modest losses in midterm elections. And you can say Bill Clinton in 1993, along a straight party line vote — a very difficult vote on the budget package which along with George H.W. Bush’s tax and budget program from 1990 basically put the economy on line for surpluses later in the decade which clearly had long term benefits — yet a year later the electorate turned both houses over to the Republican Party.

I’m not saying history will repeat itself, all I’m saying is that as significant as this is, history does not suggest that it will automatically produce victories in the fall.

[In terms of the political process] this is enormous. It’s enormous in a number of ways, because not only is it a huge achievement for President Obama, but it really is in the face of overwhelming cynicism a huge achievement for the political process.

We tend to understandably focus on the animosity between the parties. We tend not to pay much attention to the institutionalized animus that exists between the House and the Senate. Ironically, the way this is happening, complicated as it may be — including reconciliation, including the majority of the House having to take on faith the willingness of the Senate to make changes to its own version of the plan — that raises a huge question: Having achieved that level of trust, what can be built on that? Is this unique? Will it disappear in a week? Or has the political process, convoluted as it may have been getting us to this point, can it open the door to perhaps getting us more? Can we look seriously at immigration reform?

Is it possible, for example, that Lindsey Graham will find other Republicans to join him in some serious effort to address global warming, although it may not be cap and trade? In other words, can the political process, having performed constructively on issue of this historical magnitude, be equally instructive in addressing other large issues?