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Presidential Leadership in US Health Reform

President’s Day is an opportune moment to reflect on the great moral potential of the presidency. Lincoln’s fine example, told by a historian, looms large. The role of presidents in health care reform, summarized by ChatGPT, is impressive but piecemeal, shy of the ultimate moral and practical victory of universal comprehensive insurance.

February 19, 2024

Letters from An American
February 18, 2024
By Heather Cox Richardson

That the American people in the twenty-first century celebrate Abraham Lincoln as a great president would likely have surprised Lincoln in summer 1864, when every sign suggested he would not be reelected and would go down in history as the man who had permitted a rebellion to dismember the United States.

The news from the battlefields in 1864 was grim. …  As the casualties mounted, so did criticism of Lincoln. …

[Lincoln wrote:] “… it seems exceedingly probable that this Administration will not be re-elected. …”

But then his fortunes turned.

 …the Democrats chose as a presidential candidate General George McClellan … [and] rejected the new, popular measures the national government had undertaken since 1861—the establishment of state colleges, the transcontinental railroad, the new national money, and the Homestead Act—insisting on “State rights.” 

Americans who had poured their lives and fortunes into the war and liked the new government were not willing to abandon both to return to the conditions of three years before. 

Lincoln won about 55% of the popular vote compared to McClellan’s 45%, and 212 electoral votes to McClellan’s 12.

February 19, 2024
Query by JGK: What is the role of presidents in health reform?

The role of presidents in health insurance reform in the United States has been significant, as they often serve as the primary advocates for major policy changes and help set legislative agendas. Here’s an overview of how U.S. presidents have influenced health insurance reform:

Vision and Agenda Setting
Presidents often use their platform to highlight the need for health insurance reform, setting the vision and goals for what they hope to achieve. This can include expanding coverage, reducing costs, improving the quality of care, or a combination of these objectives.

Legislative Leadership
Presidents work closely with Congress to draft and promote health insurance reform legislation. They may propose specific bills or outline key principles that they want the legislation to address. Through negotiations and collaborations with lawmakers, presidents can guide the legislative process.

Public Advocacy
Presidents engage in public advocacy to garner support for health insurance reform. This can involve speeches, press conferences, and public appearances. Effective communication can help rally public support, which in turn can influence legislators.

Political Capital
Presidents often expend significant political capital to push through health insurance reforms. This can be risky, as unsuccessful reform efforts or unpopular policies can impact a president’s approval ratings and influence over other policy areas.

Executive Actions
When legislative efforts stall, presidents may use executive actions to implement certain health insurance reforms. While these actions are generally more limited in scope compared to comprehensive legislation, they can still have a significant impact on the health insurance landscape.

Collaboration with Stakeholders
Presidents and their administrations engage with various stakeholders, including insurance companies, healthcare providers, patient advocacy groups, and the business community, to build consensus and address concerns related to proposed reforms.

Historical Examples

  • Harry S. Truman: Failed in attempt to enact national health insurance.
  • Lyndon B. Johnson: Enacted Social Security Amendments of 1965, creating Medicare and Medicaid, for elderly, long-term disabled, and low-income individuals.
  • Bill Clinton: After failed comprehensive reform, implemented the State Children’s Health Insurance Program.
  • George W. Bush: Expanded Medicare to include prescription drugs.
  • Barack Obama: Enacted the Affordable Care Act (ACA).
  • Donald Trump: Failed to repeal the ACA; implemented rules to undermine parts of it.
  • Joe Biden: Temporarily increased ACA premium supports and extended Medicaid enrollment, as part of COVID response. Enacted Medicare drug beneficiary spending caps and some price negotiations.


Comment by: Jim Kahn

Lincoln’s moral vision and practical political skills saved the union and freed the slaves. Toward the end of his first term, the war was going poorly, and he faced dismal re-election prospects. Then, his opponent’s rejection of fundamental reforms intended to strengthen the nation and give a hand up to the less fortunate – along with key military victories – turned the tide to resounding victory at the polls. He was soon assassinated, undermining his legacy, and the nation suffered decades of disruption as the South resisted equality for the freed slaves. Yet his shining moral example and accomplishments reverberate more than 150 years later.

Each major health reform is properly associated with the president under whom it occurred — reflecting their vision of the needed and possible. Of course, presidential affiliation with a particular reform doesn’t tell the full story – of the perceived needs for change, a sense of the possible, advocacy by interest groups, and Congressional deal-making.

All the presidents have fallen short of the ultimate solution – universal comprehensive benefits through a greatly simplified financing system. Some tried (e.g., Truman and in a different form, Nixon); some aimed low (e.g., GW Bush); and some combined ambitiousness with perpetuation of the current flawed structure (e.g., Clinton and Obama).

In my view, there is only one reasonable way forward: the globally tried and true uniform insurance for all. In the US, that’s single payer. If we want to start with a few states to test and refine, that’s ok.

Many will say, it’s not politically possible. To which I respond that in Lincoln’s time many didn’t think it was possible to preserve the union and free the slaves, and in Washington’s time most assumed he would retain power indefinitely – but he stepped down.

The most morally visionary presidents take the US in great directions. A president who brings us universal comprehensive health insurance will become as hallowed as the two leaders we most celebrate today.

About the Commentator, Jim Kahn

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Jim (James G.) Kahn, MD, MPH (editor) is an Emeritus Professor of Health Policy, Epidemiology, and Global Health at the University of California, San Francisco. His work focuses on the cost and effectiveness of prevention and treatment interventions in low and middle income countries, and on single payer economics in the U.S. He has studied, advocated, and educated on single payer since the 1994 campaign for Prop 186 in California, including two years as chair of Physicians for a National Health Program California.

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