From the guest editor: the presidency and U.S. health care: political, ethical, and policy considerations

As this special issue of White House Studies goes to press, the 2004 election for President of the United States is heating up. In this election cycle, as with so many in recent history, a great deal of discussion and debate--and, partisan rhetoric according to some--focuses on the American health care system, with its myriad problems and dilemmas concerning financing, delivery, equality, access, and quality.

The proposals, counter-proposals, promises, and obfuscation presented by the various candidates, as well as by the current occupant of the White House, demonstrate at least tacit acknowledgement that the American health care system, in whole or in part, is in crisis. But, more than simple acknowledgement of a crisis is present in the campaign rhetoric, policy speeches, bill signing ceremonies, and State of the Union addresses leading up to the election. Present also, often implicit, but at times explicit, is the message that the President of the United States can and should, and will address the myriad health care needs of the nation. That is, the public is led to believe, perhaps led to hope, that the next president will take responsibility for articulating, developing, and implementing health policies that will at least ameliorate, if not solve, the current crisis in American health care.

As the American electorate chooses its next president it makes sense then not only to examine the role of the chief executive in identifying and communicating an understanding of the individual, and public health needs of the nation, but also to evaluate the ethical and political responsibilities of the president in articulating, and developing a framework for addressing those health needs. Such an examination and evaluation of the president's role is no doubt extremely difficult: federal involvement in health policy is notoriously complex and convoluted, involving not only local and state governments, but the various branches of the federal government as well. Disagreement over the extent to which the federal government should be involved in health care, not to mention the various competing solutions for "fixing" the American health care system, contributes to this complexity.

Consequently, to single out for examination and evaluation the role of the Office of the President in addressing national health issues may seem misguided. Yet, no one can deny that the White House plays a central role in health policy development, and that the importance, or lack of importance, of health issues on a particular president's agenda has dramatic implications for legislative and regulatory action or inaction on health related matters.

Once the potential is acknowledged regarding the White House's ability to impact, positively or negatively, health policy, then presidents would be obligated to resolve the ethical, political, and policy complexities surrounding the development of an effective, comprehensive health care system.

Many definitional issues and disagreements complicate the discussion, as well as a consensus on presidential involvement in health care policy development is lacking. How should such terms as "health care," "health policy," and even "health" itself be defined? If there is wide disagreement over the meaning of such important terms, then little hope exists for agreement over the degree to which the White House should be involved in health issues. The following definitions are not only convenient and reasonable; they are for the most part in accord with how contributors to this issue use these terms. (1)

Health care consists of the organized methods used by a society to promote the health of its members, ordinarily encompassing the fields of public health and medicine. A society's health policy will be the organization of those methods into some overall financial and distributional structure designed to pursue the general goals of health care and, ultimately, of health. Health might best and most simply be defined as an individual's experience of well-being and integrity of mind and body. It is characterized by an acceptable absence of malady and consequently by a person's ability to pursue his or her vital goals and to function in ordinary social and work contexts.

This description provides a context in which to think about and evaluate presidential actions and initiatives regarding health policy. But, even if universal agreement over the meaning and scope of relevant terms existed, many problems would remain.

Indeed, connecting presidential leadership to the development of health care policies that are politically feasible, morally defensible, and practicable is difficult. Not only are there disagreements over the political wisdom of particular actions, the moral justification of those actions, and whether certain policies are indeed feasible; there is also the realization that addressing problems in health care is not the sole province of the Office of the President. Congress, federal and state courts, state legislatures, advocacy groups, professional organizations, private institutions, and the public all bear responsibility for addressing and attempting to resolve the current crisis in health care. Certainly, much has been written on the duties and obligations of various actors in the policy making process; yet, little commentary seems directed toward the meaning and scope of any particular set of duties and responsibilities on the part of presidents.

This lack of attention is due in part to the fact that the American public itself cannot agree on morally justifiable goals for national health care policy. Can a case be made that the President of the United States is in a unique position to articulate a moral vision for promoting the nation's well being and to lead on issues related to health care? Might a case be made that the actor most likely to forge consensus among various competing constituencies is the president? Is it possible, both morally and politically, to demand that the person elected to the White House not only take health issues seriously but also contribute to the development of far reaching and perceptive policies; policies that make a real difference in the health services and medical care all Americans receive?

The collection of articles assembled for this issue should engender lively discussion regarding the role of the White House in addressing and resolving the countless issues that surround health care, and the policies developed to address those issues. The authors consider the role of the chief executive, and various pressures and influences--ethical, political, and practical--that exist for any president who wishes to take health care seriously., American presidents have contributed to the current state of health care delivery and service in America; whether positively or negatively, intentionally or by accident. To be sure, the initiatives of some presidents have been incremental while other presidents have envisioned and attempted more far reaching reforms. In various ways all the articles in this issue consider the contributions presidents have made, and the obstacles presidents have faced in addressing and resolving the complex problems associated with crafting and implementing national health care policies.

The first article in our issue catalogues major initiatives, legislation, and activities impacting both individual and public health that are directly or indirectly associated with modern presidents. Beginning with Franklin D. Roosevelt, and continuing through the first three years of George W. Bush's term; Richard Yon and I present some of what we consider to be the most important initiatives and activities of these presidents.

As federal involvement in the delivery and financing of health care by the three branches of government has increased; specific action, or lack thereof, on the part of the White House has become obvious, and deserving of serious study. In considering the political, ethical, and practical issues surrounding health care policy, and White House involvement in that policy, creating a picture of presidential involvement is instructive. Such a picture is enlightening and creates the foundation for further research. This outline provides a roadmap of sorts of where the Office of the President has made or has failed to make contributions to the development and implementation of health care policies.

One of the most influential and ambitious plans to overhaul the health care system in America is Medicare. No other legislation has directly impacted the health and welfare of individuals and populations as much as the Medicare program, and the various modifications to the program over the years. In his thought provoking and insightful article, Max Skidmore details the development of Medicare, and the extent to which various presidents have embraced and then modified this massive government program. In tracing the development of Medicare--both the events that led to LBJ signing the Act into law, and the changes that followed--Skidmore invokes the phrase "political courage," while noting that on occasion, presidents lack the political will or moral conviction to propose grand responses to health care problems.

Problems associated with the delivery and financing of health care services, and the policies developed to address those problems, are certainly complex. This complexity demands involvement at the federal level, and, as a result, presidents must be strong, resourceful leaders, for they are the source of progressive reform. Skidmore's approach makes a strong argument in support of presidential leadership in addressing and resolving the multiple problems associated with government involvement in the health needs of the nation. Skidmore's analysis takes on even stronger relevance, given the recent debate and subsequent passage of the $400 billion Medicare reform package.

Health care policy; its development, implementation, and degree of success involves many factors. Among these are ethical justification, scientific merit, availability of appropriate medical technology, and political pragmatism. Kant Patel and Mark Rushefsky highlight these various aspects of one health care policy in particular; President George W. Bush's position on federal funding of embryonic stem cell research. Public fascination with the promise, and the possibility of new treatments and cures emerging from such research collided with popular, deeply held beliefs regarding the sanctity of human life. Only six months after taking office, President Bush found himself at the center of this collision in values, and in priorities. The degree to which he devoted thoughtful and careful consideration to the policy is fascinating.

Patel and Rushefsky offer a detailed analysis of the process by which Bush considered the merits of federal involvement in stem cell research. In examining the ethical, political, and scientific arguments for and against stem cell research, in and of itself; the authors conclude that Bush's embryonic stem cell policy is flawed on several levels. It is apparent that one of the first challenges President Bush faced involved the development of a medical technology with far ranging beneficial consequences for many sick and injured individuals is instructive for anyone interested in examining the degree of presidential involvement in health care issues. Whether or not one agrees with the policy put forth by the president, one cannot escape the perception that President Bush squandered an opportunity to lead on this issue.

No discussion of presidential involvement and leadership in health care would be complete without an analysis and evaluation of President Clinton's comprehensive plan to overhaul health care in the early part of his first administration. By the early 1990's many Americans realized what most professionals in health care already knew: the system for delivery and financing of medical care in the United States was in crisis. Not only were federal and state governments, employers, private insurers, and individuals paying more for medical services, but also, access to needed services seemed more difficult to obtain, and the quality of care people were receiving seemed to be decreasing.

Gary Wekkin presents a behind-the-scenes description and evaluation of the efforts of the Clinton administration (most notably Hillary Clinton and Ira Magaziner) to put forth and pass a comprehensive health care package. Many explanations--from the Clintons themselves, from participants of the White House Health Care Interdepartmental Working Group, from Washington insiders, and from the media--of why health care reform failed have been offered. Wekkin examines some of these competing explanations for the failure of the Clinton proposal. He notes a distinction between structural causes and tactical or ad hoc reasons for its demise. Both Hillary and Bill Clinton tend to appeal to the latter; blaming Bob Dole, and the Republicans, as well as the crowded agenda of the White House, for the failure.

In detailing some of the behaviors, motivations, and activities of First Lady Hillary Clinton, Wekkin concludes that the First Lady herself may have acted hastily, even irresponsibly, in developing and promoting the health care plan. Wekkin's article serves to remind us that many competing forces are in play in any attempts by presidents to design and implement a health care policy that is broad in scope.

Hillary Clinton's involvement in, perhaps dominance over, the development of a major, comprehensive health care proposal for legislation early in her husband's first term naturally leads to speculation regarding the role of first ladies in the development of health care policy. Over the past decade a great deal of scholarly interest and commentary has emerged regarding the role of presidential wives in shaping their spouses' policies and initiatives in a wide array of areas. Health care policy and reform is one area where first ladies have definitely had an impact.

In examining the role of first ladies, scholars not only gain insight into their commitments, but also are provided with a vantage point from which to view presidential policies on health care. Jerome Short, Colleen Shogan, and Nicole Owings focus on the role of first ladies in the development of mental health policy. Beginning with Eleanor Roosevelt, and ending with Laura Bush, the authors examine the influence of presidential spouses in persuading their husbands, and the public to take seriously the mental health needs of the nation. The authors point out that mental health is a nebulous term, and that various administrations have construed mental health needs differently.

The public's perception that mental and emotional well being are somehow secondary in importance to the physical health of individuals and populations has no doubt contributed to the lack of immediacy many presidents have brought to mental health issues. As a result, various forms of legislation have been proposed, and various programs developed to meet needs identified as most important to a particular administration. The authors conclude that the influence of first ladies on presidents, especially in the realm of mental health policy, is worth further study. Such study may well provide insight not only into the power of first ladies but also into the decision making process of the president.

Future occupants of the White House will no doubt struggle over what constitutes the wisest, most ethically defensible, most politically advantageous, and most effective health care policies and initiatives. All the contributions to this volume recognize and appreciate this fact, and they provide hints at how the struggle over developing and implementing workable health care policies might be more effectively undertaken by future presidents.

The American public faces a number of challenges in the health policy arena. As many as 44 million Americans have no health insurance, and another 40 million lack adequate insurance. In addition, new threats to the nation's health are arising from threats of bioterrorism which have kept health care on the agenda of politicians, policy makers, and the general public. Presidents are in a unique position to demonstrate leadership and moral vision regarding health care. One could easily argue that they have a moral obligation to step forward even if their policies are not popular. Presidents have both ability and skill to ask Americans to make sacrifices. Will the occupant of the White House after the 2004 election have the political and moral courage to step forward and lead?

(1) Daniel Callahan, "Ends and Means: The Goals of Health Care," in Ethical Dimensions of Health Policy, edited by Marion Danis, Carolyn Clancy, and Larry Churchill (New York: Oxford University Press, 2002), p. 4.

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