Health care initiatives and the modern presdiency

Bryan Hilliard

ABSTRACT

We catalogue significant activities and specific Executive Orders relating to health care and healthcare policy from Franklin D. Roosevelt through the first three years of George W. Bush's term in office. As the federal government's role in health care has expanded, presidents have had, and continue to have, significant impact on policies and regulations that in turn affect individual and public health care in the United States. No doubt, other factors such as the influence of powerful special interest groups, legislative intent, and judicial oversight may alter presidential initiatives. Yet presidents, especially those of the modern era, have immense prestige and power to influence policies related to American health. Any assessment--ethical, political, and social--of a particular chief executive's effectiveness in influencing health policy begins with knowledge of specific policies and initiatives (those that have succeeded as well as those that have failed) undertaken by the White House. This list is by no means exhaustive, and some may quarrel with particular items, but it should provide a foundation for understanding presidential priorities regarding individual public health measures. Also, it is hoped that this catalogue provides an historical perspective for continued discussions on the ethical obligations presidents have in shaping health care policy.

INTRODUCTION

In 1798 President John Adams signed the Act for Sick and Disabled Seamen. This legislation passed by the 5th Congress provided for the care of seamen in existing facilities, and the building of hospitals where there were none, with financing to come from deductions from seamen's wages. Debate over the bill was intense. Supporters noted that the states would have to assume the burden of care if the federal government did not act. Opponents argued that seamen were no different from other sick and disabled individuals who could not take care of themselves, and thus should rely on charity care, not the government. President Adams' signature on the legislation represented the first action in what would become a long history of federal involvement in, and presidential initiatives concerning, the nation's health. (1)

The next 206 years saw a dramatic increase in federal involvement in policies directed at the personal and public health needs of the nation. This federal role involved many players, including Congress, the judiciary, various administrative and regulatory agencies, several offices and councils inside the White House, and the presidency itself. The years following the presidency of John Adams also witnessed a great deal of debate centered on the degree to which the federal government should participate in matters related to the nation's health. While no one today seriously maintains that government has no role, considerable disagreement exists over the proper scope of such involvement. Lack of consensus regarding regulatory, financial, and legal control in matters related to health has resulted in many of the efforts of the federal government becoming incremental.

Since the beginning of the modern presidency, debate over federal control of programs and policies designed to protect and promote the health of Americans has intensified. Problems related to financing, access, distributive justice, and what constitutes proper government intervention have occupied, to one degree or another, all presidents from FDR to George W. Bush. Regardless of whether a particular piece of legislation or initiative can be characterized as incremental or comprehensive, modern presidents have had a direct impact on health care policy. In some cases, presidential involvement was voluntary, influenced by a set of ideals, and motivated by a sense of justice. In other cases, presidents found themselves forced to act, either from political expediency, or as a result of overwhelming events. As the current crisis in America's system of healthcare financing and delivery deepens, the next occupant of the White House will continue to face many of the same challenges encountered by previous occupants as well as new challenges stemming from advances in technology and threats of bioterrorism.

FRANKLIN D. ROOSEVELT (1933-1945)

Selected Significant Activities

In 1935 the Social Security Act was passed, thus creating the modern Social Security system. The Act included a federal/state unemployment compensation system, grants to develop public health programs, and benefits to the elderly and to poor families with dependent children. In 1935 the Works Project Administration designated funds to build hospitals and improve existing ones. In 1943 the Emergency Maternity and Infant Care Program authorized the provision of health care to wives and children of men in the military, The program was terminated in 1949.

Selected Executive Orders

EO 7709-A Abolishing the National Emergency Council

* Signed: September 16, 1937

* Amended by: EO 7776, December 27, 1937; EO 7906, June 6, 1938

EO 7710 Authorizing the Appointment of Dr. Winfred Overholse as Superintendent of St. Elizabeth's Hospital without Regard to Civil Service Rules

* Signed: September 17, 1937

EO 7846 Prescribing Regulations Relating to Sick Leave of Government Employees

* Signed: March 21, 1938

* Revoked by: EO 8385, March 29, 1940

EO 8807 Establishing the Office of Scientific Research and Development in the Executive Office of the President and Defining Its Functions and Duties

* Signed: June 28, 1941

* Amended by: EO 9389, October 18, 1943

* Superseded by: EO 9913, December 26, 1947

EO 8890 Establishing the Office of Defense Health and Welfare Services in the Executive Office of the President and Defining Its Functions and Duties

* Signed: September 3, 1941

* See: EO 9310, March 6, 1943

EO 9039 Authorizing Sick and Rest Leave for Alien Employees of the Panama Canal and the Panama Railroad Company

* Signed: January 24, 1942

* Revoked by: EO 9740, June 20, 1946

EO 9079 Making Certain Public Health Service Hospitals Available for the Care and Treatment of Insane Persons

* Signed: February 26, 1942

EO 9219 Extension of Provisions of EO 9001 of December 27, 1942, to the Office of Scientific Research and Development in the Office for Emergency Management

* Signed: August 11, 1942

* Amended by: EO 9296, January 20, 1943

* Note: The authority of this Executive Order was repealed by Pub. L. 89-554 (80 Stat. 651).

EO 9280 Delegating Authority with Respect to the Nation's Food Program

* Signed: December 5, 1942

* Amends: EO 8734, April 11, 1941; EO 8942, November 19, 1941; EO 9023, January 14, 1942; EO 9040, January 24, 1942; EO 9125, April 7, 1942; EO 9138, April 17, 1942

* Amended by: EO 9334, April 19, 1943; EO 9392, October 28, 1943; EO 9915, December 30, 1947

* Note: The Administrations established in this Executive Order were terminated by EO 9577, June 29, 1945.

EO 9310 Transferring the Nutrition Functions of the Office of Defense Health and Welfare Services to the Department of Agriculture

* Signed: March 6, 1943

EO 9322 Centralizing and Delegating Authority with Respect to the Production and Distribution of Food

* Signed: March 26, 1943

EO 9411 Prescribing Rates for Hospitalization and Medical Care of Dependents of Naval Personnel and Others

* Signed: December 23, 1943

* Revoked by: EO 11116, August 5, 1963

EO 9414 Regulations Relating to Annual and Sick Leave of Government Employees

* Signed: January 13, 1944

* Note: The authority of this Executive Order was repealed by the Annual and Sick Leave Act of 1951.

EO 9454 Temporary Appointments as Officers in the Army of the United States of Members of the Army Nurse Corps and Female Dietetic and Physical-Therapy Personnel of the Medical Department of the Army

* Signed: July 10, 1944

EO 9498 Amending Executive Order 9079 of February 26, 1942, Making Certain Public Health Service Hospitals Available for the Care and Treatment of Insane Persons

* Signed: November 11, 1944

HARRY S. TRUMAN (1945-1953)

Selected Significant Activities

In 1946 Congress passed the Hospital Survey and Construction Act (Hill-Burton Act). The legislation was designed to assist states in building hospitals. In 1954 the Act was amended to provide funding for the construction of long-term care facilities, rehabilitation centers, and outpatient departments. (2) On January 6, 1947, in his State of the Union address, Truman called for a national health insurance program that would include support for mental health, childcare, and hospital construction. (3)

Selected Executive Orders

EO 9568 Providing for the Release of Scientific Information

* Signed: June 8, 1945

* Amended by: EO 9604, August 25, 1945; EO 9809, December 12, 1946

EO 9575 Declaring the Commissioned Corps of the Public Health Service to Be a Military Service and Prescribing Regulations Therefore

* Signed: June 21, 1945

* Superseded by: EO 13049, April 26, 1952

EO 9655 Regulations Relating to Commissioned Officers and Employees of the Public Health Service

* Signed: November 14, 1945

* Amended by: EO 9897, October 10, 1947

* Revoked by: EO 9993, August 31, 1948

EO 9680 Abolishing the United States of America Typhus Commission

* Signed: January 17, 1946

EO 9703 Regulations Relating to the Medical Care of Certain Personnel of the Coast Guard, Coast and Geodetic Survey, Public Health Service, and Former Lighthouse Service

* Signed: March 12, 1946

* Amended by: EO10122, April 15, 1950; EO 10400, September 27, 1952; EO 11160, July 6, 1964

EO 9708 Specifying Communicable Diseases for the Purpose of Regulations Providing for the Apprehension, Detention, or Conditional Release of Individuals to Prevent the Introduction, Transmission, or Spread of Communicable Diseases

* Signed: March 26, 1946

* Amended by: EO10532, May 28, 1954; EO 11070, December 12, 1962

* Revoked by: EO 12452, December 22, 1983

EO 9791 Providing for a Study of Scientific Research and Development Activities and Establishing the President's Scientific Research Board

* Signed: October 17, 1946

* Amended by: EO 9809, December 12, 1946

* Note: EO 9841 terminated the office, April 23, 1947.

EO 9993 Regulations Relating to Commissioned Officers and Employees of the Public Health Service

* Signed: August 31, 1948

* Revokes: EO 9655, November 14, 1945; EO 9879, October 10, 1947; EO 9955, May 6, 1948

* Amended by: EO 10031, January 26, 1949; EO 10280, August 16, 1951; EO 10354, May 26, 1952; EO 10497, October 27, 1953; EO 10506, December 10, 1953

* Revoked by: EO 11140, January 30, 1964

EO 10014 Directing Federal Agencies to Cooperate with State and Local Authorities in Preventing Pollution of Surface and Underground Waters

* Signed: November 3, 1948

* Superseded by: EO 11258, November 7, 1965

EO 10122 Regulations Governing Payment of Disability Retirement Pay, Hospitalization, and Re-Examination of Members and Former Members of the Uniformed Services

* Signed: April 14, 1950

* Amended by: EO 10400, September 27, 1952; EO 11733, July 30, 1973

EO 10166 Establishing the National Advisory Committee on the Selection of Doctors, Dentists, and Allied Specialists

* Signed: October 4, 1950

* Amended by: EO 10185, December 1, 1950

* Revoked by: EO 11415, June 24, 1968

EO 10194 Establishing the Federal Safety Council

* Signed: December 19, 1950

* Revokes: EO 8071, March 21, 1939

* Superseded by: EO 10990, February 2, 1962

EO 10262 Suspension of Professional Examinations for Promotion of Medical, Dental, and Veterinary Officers in the Regular Army and Air Force

* Signed: June 28, 1951

* Note: See Pub. L. 94-412 (90 Stat. 1255), which terminated, effective September 4, 1978, all powers and authorities, except those expressly cited, possessed by the President and/or other Federal officials as a result of any declaration of a national emergency in effect on September 14, 1976.

EO 10302 Interdepartmental Committee on Narcotics

* Signed: November 2, 1951

* Revoked by: EO 11529, April 24, 1970

EO 10317 Establishing the President's Commission on the Health Needs of the Nation

* Signed: December 29, 1951

EO 10356 Continuing the Commissioned Corps of the Public Health Service as a Military Service

* Signed: May 29, 1952

EO 10399 Designating the Surgeon General of the Public Health Service to Perform Certain Duties under the International Sanitary Regulations

* Signed: September 27, 1952

EO 10400 Amending EO 10122 of April 14, 1950, entitled "Regulations Governing Payment of Disability Retirement Pay, Hospitalization, and Re-Examination of Members and Former Members of the Uniformed Services"

* Signed: September 27, 1952

DWIGHT D. EISENHOWER (1953-1961)

Selected Significant Activities

In 1954 Eisenhower proposed a comprehensive health and welfare plan that included a proposal to re-insure private health insurance companies against losses. Congress rejected the plan. (4) Also, in 1954, the Internal Revenue Code was amended to exempt employer purchased health benefits from taxable income. In 1956 Eisenhower oversaw the expansion of Social Security benefits to include the disabled. (5) And, in 1956 the federal government established the Civilian Health & Medical Program of the Uniformed Services (CHAMPUS). This program extended benefits to military dependents in civilian medical facilities.

Selective Executive Orders

EO 10506 Delegating Certain Functions of the President under the Public Health Service Act

* Signed: December 10, 1953

* Superseded by: EO 11140, January 30, 1964

EO 10510 Establishing a Seal for the Department of Health, Education, and Welfare

* Signed: December 17, 1953

EO 10532 Amendment of the List of Communicable Diseases Contained in EO 9708 of March 26, 1946

* Signed: May 28, 1954

* Revoked by: EO 12452, December 22, 1983

* See: EO 11070, December 12, 1962

EO 10555 Establishing a Seal for the President's Committee on Employment of the Physically Handicapped

* Signed: August 23, 1954

EO 10640 The President's Committee on Employment of the Physically Handicapped

* Signed: October 10, 1955

* Superseded by: EO 10994, February 14, 1962

EO 10673 Fitness of American Youth

* Signed: July 16, 1956

* Amended by: EO 10704, March 25, 1957; EO 10740, November 21, 1957; EO 10772, June 30, 1958; EO 10785, October 17, 1958; EO 10931, March 29, 1961

* Revoked by: EO 11074, January 8, 1963

EO 10779 Directing Federal Agencies to Cooperate with State and Local Authorities in Preventing Pollution of the Atmosphere

* Signed: August 20, 1958

* Superseded by: EO 11282, May 26, 1966

EO 10807 Federal Council for Science and Technology

* Signed: March 13, 1959

* Revokes: EO 9912, December 24, 1947

* Amended by: EO 11381, November 8, 1967

* See: Pub. L. 94-282 (90 Stat. 472) (Council abolished)

* Note: The Council was physically located at the National Science Foundation. NSF assumed the functions of the old Office of Science and Technology under Reorganization Plan 1 of 1973.

EO 10858 The President's Committee for Traffic Safety

* Signed: January 13, 1960

* Revoked by: EO 11382, November 28, 1967

JOHN F. KENNEDY (1961-1963)

Selective Significant Activities

In 1962 the Migrant Health Act was enacted, providing federal funding to migrants for health services. On January 11, 1963. in his State of the Union address, Kennedy called for the creation of the National Institutes of Health. Also, in early 1963, he spoke out forcefully for health reform legislation and health insurance for seniors. (6) In 1963 the Mental Retardation Facilities and Community Mental Health Centers Construction Act was enacted. See Pub. L. 88-164.

Selected Executive Orders

EO 10914 Providing for an Expanded Program of Food Distribution to Needy Families

* Signed: January 21, 1961

EO 10994 The President's Committee on Employment of the Handicapped

* Signed: February 14, 1962

* Supersedes: EO 10640, October 10, 1955

* Superseded by: EO 11480, September 9, 1969

EO 11001 Assigning Emergency Preparedness Functions to the Secretary of Health, Education, and Welfare

* Signed: February 16, 1962

* Revoked by: EO 11490, October 28, 1969

EO 11022 Establishing the President's Council on Aging

* Signed: May 14, 1962

* Amended by: EO 11376, October 17, 1967; EO 12106, December 28, 1978

* Revoked by: EO 12379, August 17, 1982

EO 11060 Prescribing Certain Regulations and Delegating to the Attorney General Certain Authority of the President to Prescribe Other Regulations Relating to the Recovery from Tortuously Liable Third Persons of the Cost of Hospital and Medical Care and Treatment Furnished by the United States

* Signed: November 7, 1962

* Amended by: EO 12608, September 9, 1987

EO 11070 Amendment of the List of Communicable Diseases Contained in EO 9708 of March 26, 1946, as Amended by EO 10532 of May 28, 1954

* Signed: December 12, 1962

* Revoked by: EO 12452, December 22, 1983

EO 11074 Establishing the President's Council on Physical Fitness

* Signed: January 8, 1963

* Amends: EO 10830, July 24, 1959

* Revoked by: EO 11398, March 4, 1968

EO 11076 Establishing the President's Advisory Commission on Narcotic and Drug Abuse

* Signed: January 15, 1963

EO 11116 Prescribing Rates of Charges for Certain Hospitalization and Dispensary Services and Delegating Authority to Prescribe Such Rates

* Signed: August 5, 1963

* Revokes: EO 9411, December 23, 1943

* Amends: EO 10530, May 10, 1954

* Superseded in part by: EO 11230, June 28, 1965

* Revoked by: EO 12553, February 25, 1986

LYNDON B. JOHNSON (1963-1969)

Selected Significant Activities

In 1964 the Surgeon General released the first report on smoking and health. On July 30, 1965, President Johnson signed the Medicare Act into law.

Selected Executive Orders

EO 11140 Delegating Certain Functions of the President Relating to the Public Health Service

* Signed: January 30, 1964

* Supersedes: EO 10506, December 10, 1953

* Amended by: EO 12608, September 9, 1987

EO 11258 Prevention, Control, and Abatement of Water Pollution by Federal Activities

* Signed: November 17, 1965

* Supersedes: EO 10014, November 3, 1948

* Superseded by: EO 11288, July 2, 1966

EO 11279 Establishing the President's Committee on Health Manpower and the National Advisory Commission on Health Manpower

* Signed: May 7, 1966

EO 11280 Establishing the President's Committee on Mental Retardation

* Signed: May 11, 1966

* Superseded by: EO 11776, March 28, 1974

EO 11282 Prevention, control, and abatement of air pollution by Federal Activities

* Signed: May 26, 1966

* Supersedes: EO 10779, August 20, 1958

* Superseded by: EO 11507, February 4, 1970

EO 11357 Administration of the National Traffic and Motor Vehicle Safety Act through the National Highway Safety Bureau and its Director

* Signed: June 6, 1967

* See Pub. L. 91-605 (84 Stat. 1739), functions vested in National Highway Traffic Safety Administration

EO 11415 Reconstituting the National Advisory Committee on the Selection of Physicians, Dentists, and Allied Specialists and the Health Resources Advisory Committee

* Signed: June 24, 1968

* Revokes: EO 10166, October 4, 1950; EO 10185, December 1, 1950

* Committee continued by EO 11827, January 4, 1975; EO 11948, December 20, 1976

* Revoked by EO 12148, July 20, 1979

RICHARD M. NIXON (1969-1974)

Selected Significant Activities

In 1971 the National Cancer Act was signed into law. In 1972 Medicare eligibility was expanded to include people under 65 who were receiving disability benefits and people with end-stage renal disease. In 1973 the Health Maintenance Organization Act was signed into law. The Nixon administration viewed the establishment of HMOs as a major health care initiative; the Act authorized federal financial support for HMOs and promoted their adoption by Employer-sponsored health plans. See Pub. L. 93-222, (87 Stat. 914). (7) In 1974 the Employee Retirement Income Security Act (ERISA) was signed into law. See Pub. L. 93-406, (88 Stat. 832). ERISA is the legislation that has made the proliferation and success of managed care organizations possible. In 1974 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was established and was active until 1978.

Selected Executive Orders

EO 11472 Establishing the Environmental Quality Council and the Citizens' Advisory Committee on Environmental Quality

* Signed: May 29, 1969

* Revokes: EO 11278, May 4, 1966; EO 11359A, June 29, 1967: EO 11402, March 29, 1968

* Committee continued by: EO 11827, January 4, 1975 ; EO 11948, December 20, 1976

* Committee terminated by: EO 12007, August 22, 1977

* See Pub. L. 91-190 (83 Star 852) and Pub. L. 91-224 (84 Stat. 114)

EO 11480 The President's Committee on Employment of the Handicapped

* Signed: September 9, 1969

* Supersedes: EO 10994, February 14, 1962: EO 11018, April 27, 1962

* Amended by: EO 12106, December 28, 1978; EO 12608, September 9, 1987

* Superseded by: EO 12640, May 10, 1988

EO 11523 Establishing the National Industrial Pollution Control Council

* Signed: April 9, 1970

* Council terminated, January 5, 1975, by Pub. L. 92-463 (86 Stat. 770)

EO 11562 Developing and Coordinating a National Program for Physical Fitness and Sports

* Signed: September 25, 1970

* Amended by: EO 11945, October 25, 1976; EO 12098, November 14, 1978

* Revokes: EO 11398, March 4, 1968; EO 11492, October 30, 1969

* Revoked by: EO 12345, February 2, 1982

EO 11599 Establishing a Special Action Office for Drug Abuse Prevention

* Signed: June 17, 1971

* Nullified by: Pub. L. 92-255 (86 Star. 65), which establishes the Special Action Office for Drug Abuse Prevention superseding this Executive order

EO 11612 Occupational Safety and Health Programs for Federal Employees

* Signed: July 26, 1971

* Superseded by: EO 11807, September 28, 1974

EO 11628 Establishing a Seal for the Environmental Protection Agency

* Signed: October 18, 1971

EO 11735 Assignment of Functions under Section 311 of the Federal Water Pollution Control Act, as Amended

* Signed: August 3, 1973

* Amended by: EO 12418, May 5, 1983

* Revoked by: EO 12777, October 18, 1991

EO 11738 Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with Respect to Federal Contracts, Grants or Loans

* Signed: September 10, 1973

* Supersedes: EO 11602, June 29, 1971

EO 11752 Prevention, Control, and Abatement of Environmental Pollution at Federal Facilities

* Signed: December 17, 1973

* Amended by: EO 12038, February 3, 1978

* Revoked by: EO 12088, October 13, 1978

EO 11776 Continuing the President's Committee on Mental Retardation and Broadening Its Membership and Responsibilities

* Signed: March 28, 1974

* Amended by: EO 12608, September 9, 1987

* Supersedes: EO 11280, May 11, 1966

* Committee continued by: EO 11827, January 4, 1975; EO 11948, December 20, 1976; EO 12110, December 28, 1978; EO 12258, December 31, 1980; EO 12399, December 31, 1982; EO 12489, September 28, 1984; EO 12534, September 30, 1985; EO 12610, September 30, 1987; EO 12692, September 29, 1989; EO 12774, September 27, 1991; gO 12869, September 30, 1993: EO 12974, September 29, 1995

* Superseded by: EO 12994, March 21, 1996

GERALD R. FORD (1974-1977)

Selected Significant Activities

As Vice-President, Gerald Ford directed the Nixon administration's efforts regarding right to privacy legislation. As President, Ford signed into law the Privacy Act, which granted rights to individuals to control their personal information and gave citizens the right to view information the government had gathered about them. In his State of the Union address on January 19, 1976; President Ford stated, "We cannot realistically afford federally dictated national health insurance providing full coverage for all 215 million Americans. The experience of other countries raises questions about the quality as well as the cost of such plans." In the same address, Ford called for budgetary consolidation of 16 health programs, including lead paint poisoning prevention, maternal and child health, and family planning, that did not require states to match the federal funds provided. (8)

Selected Executive Orders

EO 11807 Occupational Safety and Health Programs for Federal Employees

* Signed: September 28, 1974

* Supersedes: EO 11612, July 26, 1971

* Federal Advisory Council on Occupational Safety and Health continued by: EO 11827, January 4, 1975; EO 11948, December 20, 1976; EO 12110, December 28, 1978

* Revoked by: EO 12196, February 26, 1980

EO 11914 Nondiscrimination with Respect to the Handicapped in Federally Assisted Programs

* Signed: April 28, 1976

* Revoked by: EO 12250, November 2, 1980

JIMMY E. CARTER (1977-1981)

Selected Significant Acitivites

In 1977 the administration introduced a proposal to contain health care costs in hospitals. No legislation was adopted, but some hospitals tried for a year to contain costs. In 1978 President Carter issued 10 Principles for a "National Health Plan" designed to insure comprehensive health coverage for all Americans. No legislative action was ever taken. In 1978 the Ethics Advisory Board was established, and continued until 1980. On October 17, 1979, Carter signed the Department of Education Organization Act, which established the Department of Health and Human Services. Pub. L. 96-88. HHS was activated on May 4, 1980. In 1980 the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research was established,and it continued until 1983.

Selected Executive Orders

EO 11973 President's Commission on Mental Health

* Signed: February 17, 1977

* Revoked by: EO 12110, December 28, 1978

EO 11991 Relating to Protection and Enhancement of Environmental Quality

* Signed: May 24, 1977

* Amends: EO 11514, March 5, 1970

EO 12109 Federal Physicians Comparability Allowance

* Signed: December 28, 1978

EO 12133 Drug Policy Functions

* Signed: May 9, 1979

* Revoked by: EO 12368, June 24, 1982

EO 12184 Relating to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research

* Signed: December 17, 1979

* Revoked by: EO 12553, February 25, 1986

EO 12196 Occupational Safety and Health Programs for Federal Employees

* Signed: February 26, 1980

* Revokes: EO 11807, September 28, 1974

* Amended by: EO 12223, June 30, 1980; EO 12258, December 31, 1980; EO 12399, December 12, 1982; EO 12489, September 28, 1984; EO 12534, September 30, 1985; EO 12610, September 30, 1987; EO 12692, September 29, 1989; EO 12774, September 27, 1991; EO 12869, September 30, 1993; EO 12974, September 29, 1995; EO 13062, September 29, 1997; EO 12608, September 9, 1987; EO 13138, September 30, 1999; EO 13225, September 28, 2001

EO 12270 President's Council on Spinal Cord Injury

* Signed: January 15, 1981

* Revoked by: EO 12553, February 25, 1986

EO 12286 Responses to Environmental Damage

* Signed: January 19, 1981

* Revoked by: EO 12316, August 14, 1981

RONALD W. REAGAN (1981-1989)

Selected Significant Activities

In 1983 major revisions in the financing of Social Security were recommended, and adopted. These revisions included the Medicare prospective payment scheme on a diagnostic-related group basis. In 1986 dramatic changes in Medicare and Medicaid occurred through the Consolidated Omnibus Budget Reconciliation Act. In addition to expanding Medicaid coverage for children and pregnant women, the Act prescribed federal penalties for hospitals that denied care to poor people in emergencies. The Emergency Medical Treatment and Active Labor Act was also part of COBRA. In 1987 President Reagan signed into law the McKinney Act, which provided, among other things, health care to homeless persons. See Pub. L. 100-77. In 1988 the Biomedical Ethics Advisory. Committee was established, and it continued until 1989.

Selected Executive Orders

EO 12316 Responses to Environmental Damage

* Signed: August 14, 1981

* Revokes: EO 12286, January 19, 1981

* Amended by: EO 12418, May 5, 1983

* Revoked by: EO 12580, January 23, 1987

EO 12345 Physical Fitness and Sports

* Signed: February 2, 1982

* Amends: EO 12258, December 31, 1980

* Revokes: EO 11562, September 25, 1970; EO 11945, October 25, 1976; EO 12098, November 14, 1978

* Amended by: EO 12399, December 31, 1982: EO 12489, September 28, 1984; EO 12534, September 30, 1985; EO 12539, December 3, 1985; EO 12610, September 30, 1987; EO 12692, September 29, 1989; EO 12634, October 11, 1989; EO 12709, April 4, 1990; EO 12774, September 27, 1991; EO 12869, September 30, 1993; EO 12974, September 29, 1995; EO 13062, September 29, 1997; EO 13138, September 30, 1999; EO 13225, September 28, 2001

* Revoked by: EO 13265, June 6, 2002

EO 12358 Presidential Commission on Drunk Driving

* Signed: April 14, 1982

* Amended by: EO 12376, August 5, 1982; EO 12415, April 5, 1983

* Revoked by: EO 12553, February 25, 1986

EO 12368 Drug Abuse Policy Functions

* Signed: June 24, 1982

* Revokes: EO 12133, May 9, 1979

* Amended by: EO 12590, March 26, 1987

EO 12450 Interagency Committee on Handicapped Employees

* Signed: December 9, 1983

* Amends: EO 11830, January 9, 1975

EO 12452 Revised List of Quarantinable Communicable Diseases

* Signed: December 22, 1983

* Revoked by: EO 13295, April 4, 2003

EO 12511 President's Child Safety Partnership

* Signed: April 29, 1985

EO 12564 Drug-Free Federal Workplace

* Signed: September 15, 1986

EO 12566 Safety Belt Use Requirements for Federal Employees

* Signed: September 26, 1986

* Revoked by: EO 13043, April 16, 1997

EO 12590 National Drug Policy Board

* Signed: March 26, 1987

* Amended by: EO 13284, January 23, 2003

EO 12591 Facilitating Access to Science and Technology

* Signed: April 10, 1987

* Amended by: EO 12618, December 22, 1987

EO 12595 White House Conference for a Drug Free America

* Signed: May 5, 1987

EO 12601 Presidential Commission on the Human Immunodeficiency Virus Epidemic

* Signed: June 24, 1987

* Amended by: EO 12603, July 16, 1987

* Revoked by: EO 12692, September 29, 1989

GEORGE H.W. BUSH (1989-1993)

Selected Significant Activities

In 1990 Congress passed the Americans with Disabilities Act, perhaps the most extensive civil rights legislation since 1964. In the spring of 1992 President Bush proposed a "Comprehensive Health Reform Program" that included tax incentives and vouchers to meet the problem of the rising number of Americans without health coverage.

Selected Executive Orders

EO 12696 President's Drug Advisory Council

* Signed: November 13, 1989

* Amended by: EO 12756, March 18, 1991

EO 12700 President's Council of Advisors on Science and Technology

* Signed: January 19, 1990

* Amended by: EO 12768, June 28, 1991; EO 12869, September 30, 1993

* Revoked by: EO 12882, November 23, 1993

EO 12737 President's Commission on Environmental Quality

* Signed: December 12, 1990

* Revoked by: EO 12852, June 29, 1993

* EO 12777 Implementation of Section 311 of the Federal Water Pollution Control Act of October 18, 1972, as Amended, and the Oil Pollution Act of 1990

* Signed: October 18, 1991

* Amends: EO 12580, January 23, 1987

* Amended by: EO 13286, February 28, 2003

* Revokes: EO 11735, August 3, 1973; EO 12123, February 26, 1979; EO 12418, May 5, 1983

EO 12806 Establishment of a Fetal Tissue Bank

* Signed: May 19, 1992

* Revoked by: Pub.L. 103-43 (107 Stat. 133)

WILLIAM JEFFERSON CLINTON (1993-2001)

Selected Significant Activities

On September 22, 1993, Clinton gave a speech before a joint session of Congress in which he outlined his plan for national health care reform. (9) The Clintons tried, but failed, to develop and implement sweeping policy changes in the American health care system. In November of 1993 Clinton signed the Brady Handgun Violence Prevention Act. See Pub. L. 103-159, 107 Stat. 536. The Act provided, in part, that background checks be conducted on persons buying handguns. In 1997 the U.S. Supreme Court found certain provisions of the Act unconstitutional. In 1993 the Family Medical Leave Act was passed, requiring employers to provide 12 weeks of unpaid leave to employees for birth or to take care of a sick child or spouse.

And, in September 1994, Senate Majority Leader George Mitchell declared the Clinton healthcare reform proposals (Health Security Act) dead. (10) In 1996 concern over what was commonly referred to as "drive-through" deliveries led to passage of the Newborns' and Mothers' Protection Act. The legislation prohibited managed care plans from restricting inpatient hospital benefits to less than 48 hours. In 1996 Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Among the Act's provisions is the requirement for private insurers to stop using pre-existing conditions as a reason to deny coverage.

Selected Executive Orders

EO 12856 Federal Compliance with Right-to-Know Laws and Pollution Prevention Requirements

* Signed: August 3, 1993

* Revoked by: EO 13148, April 21, 2000

EO 12859 Domestic Policy Council

* Signed: August 16, 1993

* Note: The Domestic Policy Council and the National Economic Council compose the Office of Policy Development. These offices aid in the formulation, coordination, and implementation of domestic social and economic policies, including public health policies. The president may assign one or more members of the Domestic Policy Council to observe and act upon certain health issues. (11)

EO 12880 National Drug Control Program

* Signed: November 16, 1993

* Amended by: EO 13008, June 3, 1996

EO 12881 Establishment of the National Science and Technology Council

* Signed: November 23, 1993

* Amended by: EO 13284, January 23, 2003

EO 12882 President's Committee of Advisors on Science and Technology

* Signed: November 23, 1993

* Revokes: EO 12700, January 19, 1990; EO 12768, June 28, 1991

* Amended by: EO 12907, April 14, 1994; EO 12974, September 29, 1995; EO 13062, September 29, 1997; EO 13138, September 30, 1999

* Revoked by: EO 13226, September 30, 2001

EO 12891 Advisory Committee on Human Radiation Experiments

* Signed: January 15, 1994

* Revoked by: EO 13062, September 29, 1997

EO 12911 Seal for the Office of National Drug Control Policy

* Signed: April 25, 1994

EO 12961 Presidential Advisory Committee on Gulf War Veterans' Illnesses

* Signed: May 26, 1995

* Continued by: EO 13034, January 30, 1997

EO 12963 Presidential Advisory Council on HIV/AIDS

* Signed: June 14, 1995

* Amended by: EO 13009, June 14, 1996

EO 12975 Protection of Human Research Subjects and Creation of National Bioethics Advisory Commission.

* Signed: October 3, 1995

* Amended by: EO 13018, September 16, 1996; EO 13046, May 16, 1997; EO 13137, September 15, 1999

* On October 3, 2001, the NBAC ceased to exist.

EO 12994 Continuing the President's Committee on Mental Retardation and Broadening Its Membership and Responsibilities

* Signed: March 21, 1996

* Supersedes: EO 11776, March 28, 1974

* Amended by: EO 13062, September 29, 1997; EO 13138, September 30, 1999; EO 13225, September 28, 2001

EO 13017 Advisory Commission on Consumer Protection and Quality in the Health Care Industry.

* Signed: September 5, 1996

* Amended by: EO 13040, March 25, 1997; EO 13056, July 21, 1997

* Note: The Commission produced two reports, Consumer Bill of Rights and Responsibilities: Report to the President of the United States and Quality First. Better Health Care for All Americans. The procedural recommendations of the Commission served as the foundation for most of the patient protection legislation introduced by the Democrats in the 105th and 106th Congresses. (12)

EO 13023 Amendments to EO 12992, Expanding and Changing the Name of the President's Council on Counter-Narcotics

* Signed: November 6, 1996

EO 13040 Advisory Commission on Consumer Protection and Quality in the Health Care Industry

* Signed: March 25, 1997

* Amends: EO 13017, September 5, 1996

* Note: EO 13040 is nullified by virtue of the Commission being abolished by EO 13138, September 30, 1999.

EO 13045 Protection of Children from Environmental Health Risks and SafEty Risks

* Signed: April 21, 1997

* Revokes: EO 12606, September 2, 1987

* Amended by: EO 13229, October 9, 2001; EO 13296, April 18, 2003

EO 13046 Extension of the National Bioethics Advisory Commission

* Signed: May 16, 1997

* Amends: EO 12975, October 3, 1995

EO 13058 Protecting Federal Employees and the Public from Exposure to Tobacco Smoke in the Federal Workplace

* Signed: August 9, 1997

EO 13100 President's Council on Food Safety

* Signed: August 25, 1998

* Amended by: EO 13286, February 28, 2003

EO 13124 Amending the Civil Service Rules Relating to Federal Employees with Psychiatric Disabilities

* Signed: June 4, 1999

EO 13137 Amendment to EO 12975, as Amended, National Bioethics Advisory Commission

* Signed: September 15, 1999

EO 13139 Improving Health Protection of Military Personnel Participating in Particular Military Operations

* Signed: September 30, 1999

* See: Food and Drug Administration rule of May 25, 1999 (64 FR 54180)

EO 13145 To Prohibit Discrimination in Federal Employment Based on Genetic Information

* Signed: February 8, 2000

EO 13147 White House Commission on Complementary and Alternative Medicine Policy

* Signed: March 7, 2000

* Amended by: EO 13167, September 15, 2000

EO 13155 Access to HIV/AIDS Pharmaceuticals and Medical Technologies

* Signed: May 10, 2000

EO 13164 Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation

* Signed: July 26, 2000

EO 13165 Creation of the White House Task Force on Drug Use in Sports and Authorization for the Director of the Office of National Drug Control Policy to Serve as the United States Government's Representative on the Board of the World Anti-Doping Agency

* Signed: August 9, 2000

* Amended by: EO 13286, February 28, 2003

EO 13168 President's Commission on Improving Economic Opportunity in Communities Dependent on Tobacco Production while Protecting Public Health

* Signed: September 22, 2000

* Revoked by: EO 13225, September 28, 2001

EO 13172 Amendment of EO 13078 (March 13, 1998), to Expand the Role of the National Task Force on Adults with Disabilities to Include a Focus on Youth

* Signed: October 25, 2000

EO 13181 To Protect the Privacy of Protected Health Information in Oversight Investigations

* Signed: December 20, 2000

EO 13193 Federal Leadership on Global Tobacco Control and Prevention

* Signed: January 18, 2001

GEORGE W. BUSH (2001-PRESENT)

Selected Significant Activities

As early as 2000, Bush claimed that he opposed any type of national health care plan, saying he did not want the federal government making decisions for consumers or providers. On August 9, 2001, Bush gave a nationally televised speech in which he outlined the administration's policy on federal funding of embryonic stem cell research. While on November 6, 2001, Attorney General John Ashcroft issued a memo to Asa Hutchinson, Chief Administrator of the Drug Enforcement Administration, asserting that physician assistance in a suicide is not a legitimate medical purpose under the Controlled Substances Act. Ashcroft's directive was aimed at Oregon physicians who prescribe medication to assist their terminally ill patients in committing suicide. The DEA was instructed to review prescribing records of physicians, and to take administrative action against those physicians deemed to have violated the Controlled Substances Act. In 2002 a federal district court granted summary judgment for the state of Oregon, and issued a permanent injunction prohibiting Ashcroft, and the Bush Justice Department from implementing the directive. (13) On September 27, 2002, the Bush administration announced that it would begin considering developing fetuses as "unborn children" for purposes of meeting requirements of the government funded health initiative known as the Children's Health Insurance Program (CHIP). On December 13, 2002, President Bush put forth a plan making it mandatory for all military personnel in risky areas to have the smallpox vaccination and recommending that all health care workers take the vaccine. One week later the President was vaccinated against smallpox. On November 5, 2003, Bush signed legislation banning a certain type of abortion commonly referred to as "partial-birth" abortion. The legislation shares so much in common with a Nebraska law that the U.S. Supreme Court found unconstitutional in 2000. And, on November 22, 2003, the House, by a vote of 220-215, approved a $400 billion restructuring of Medicare. Three days later the controversial measure passed in the Senate by a 54-44 margin. The changes include more federal money for rural doctors and hospitals, allowing the creation of tax-sheltered saving accounts for medical expenses, and federal payment for outpatient prescription drugs. The proposed legislation represents the largest single change to Medicare since its inception in 1965.

Selected Executive Orders

EO 13198 Agency Responsibilities with Respect to Faith-Based and Community Initiatives

* Signed: January 29, 2001

EO 13199 Establishment of White House Office of Faith-Based and Community Initiatives

* Signed: January 29, 2001

EO 13214 President's Task Force to Improve Health Care Delivery for Our Nation's Veterans

* Signed: May 28, 2001

EO 13217 Community-Based Alternatives for Individuals with Disabilities

* Signed: June 18, 2001

EO 13226 President's Council of Advisors on Science and Technology

* Signed: September 30, 2001

* Amended by: EO 13305, May 28, 2003

EO 13229 Amendment to EO 13045, Extending the Task Force on Environmental Health Risks and Safety Risks to Children

* Signed: October 9, 2001

EO 13237 Creation of the President's Council on Bioethics

* Signed: November 28, 2001

EO 13263 President's New Freedom Commission on Mental Health

* Signed: April 29, 2002

EO 13265 President's Council on Physical Fitness and Sports

* Signed: June 6, 2002

* Revokes: EO 12345, February 2, 1982

EO 13295 Revised List of Quarantinable Communicable Diseases

* Signed: April 4, 2003

EO 13296 Amendments to EO 13045, Protection of Children from Environmental Health Risks and Safety Risks

* Signed: April 18, 2003

(1) Jo Ivey Boufford and Philip R. Lee, "Health Policy Making: The Role of the Federal Government," in Ethical Dimensions of Health Policy, edited by Marion Danis, Carolyn Clancy, and Larry Churchill (New York: Oxford University Press, 2002), pp. 161-162.

(2) See http://indylaw.edu/healthlw

(3) David McCullough, Truman (New York: Simon & Schuster, 1992), pp. 473-474.

(4) See http://indylaw.edu./healthlw

(5) Ibid.

(6) Robert Dallek, An Unfinished Life: John F. Kennedy 1917-1963 (Boston: Little, Brown and Company, 2003), pp. 490-496.

(7) Eleanor Kinney, Protecting American Health Care Consumers (Durham, NC: Duke University Press, 2002), p. 132.

(8) Stephen J. Williams and Paul R. Torrens, Introduction to Health Services, 4th edition (Albany, NY: Delmar, 1993), p. 100.

(9) Marc Landy and Sidney M. Milkis, American Government. Balancing Democracy and Rights (New York: McGraw-Hill, 2004), p. 285.

(10) Ibid.

(11) Boufford, and Lee, p. 171.

(12) Eleanor Kinney, p, 194.

(13) Ben A Rich, "Oregon v. Ashcroft: The Battle Over the Soul of Medicine," Cambridge Quarterly of Health Care Ethics, 12, 3, (2003), 310-321.

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