The Problem: The United States has tried and failed to enact comprehensive health coverage for its citizens for close to a century. What role have American presidents played in these policy battles and what was behind the limited success some of them had in broadening health care?
Grantee Background: James Morone, PhD, counts himself a lucky man on most counts, with the possible exception of having been born in Staten Island, N.Y., in 1951 instead of in Rio de Janeiro, as his younger brothers were. Morone was deprived of an "exotic birthplace" on somewhat of a technicality. His father, an American World War II veteran and Columbia University graduate, met and married Morone's mother, a post-war refugee from Poland, while working in Brazil—and insisted that his firstborn be born in the United States. Shortly after Morone's birth, the family returned to Brazil, where they would remain for nine years, providing Morone with both an early lesson in the influence of culture and habits of observation that would prove useful as a political scientist.
"I think the Brazil experience was absolutely formative," he says of his childhood experiences, "and forced me to see the world of American politics through fresh eyes when we moved [back to the United States]. "His early adventures also seem to have given him a taste for intellectual excursions beyond the lecture hall. He has made the case for health care reform in a variety of public forums, including multiple appearances on "CBS Sunday Morning"; "Newshour with Jim Lehrer"; National Public Radio's "All Things Considered," "Science Friday" and "Morning Edition"; and Los Angeles's Zócalo Public Square. In addition, he hosted a local political affairs television program in Rhode Island and was a commentator for a Canadian radio station, for which he did a seven-minute weekly segment.
"The Canadians were trying to figure out how our health care system was working," Morone explains, "which led to other political issues. They had me on a couple of weeks, and then asked me to do a regular weekly commentary on American politics—because you could never understand our health care debate without understanding our politics."
Morone's dual career: That awareness of the interplay between health care policy and the broader political landscape has shaped Morone's dual career. "Since I came out of grad school I've worn two hats," he says. The first is straightforward health care politics and policy, in which he earned a doctorate at the University of Chicago in 1982 (he received his BA in political science from Middlebury, in Vermont) and about which he teaches at Brown University, where he is a professor of political science and urban studies.
Morone's second "hat"—as a historian of the broad philosophical and moral underpinnings of American politics—covers territory that is at once broader and more nuanced than his first subject, but also complementary. "In the '90s, when moral politics was so intense and so furious," he says, "there really seemed to be something missing from the discussion about health policy. People were up in arms about these deep moral questions, but that reality never made it into policy discussions."
As a graduate student at the University of Chicago, Morone had studied under Theodore Marmor, author of The Politics of Medicare, among multiple other works (Marmor is currently professor emeritus of public policy and management and professor emeritus of political science at Yale). Teaching at Chicago's Center for Health Administration Studies at the time, Marmor was the recipient of two RWJF research grants to study and write about health care financing; Morone was his research assistant, so those grants not only "helped put me through grad school," says Morone, but also introduced him to the Foundation's range of interests.
Grantee project: In 1995, Morone applied for and won his first RWJF Investigator Award in Health Policy Research to study "Moralism, Politics, and the Construction of Health Policy." The award ran from 1995 to 1998, but as he plunged into four centuries of American political history, he soon discovered "it couldn't be dealt with quickly. You need to see the long historical train, to appreciate how big the swings are and how deeply they imprint themselves on us. The whole magilla."
His in-depth research yielded Hellfire Nation: The Politics of Sin in American History (Yale University Press, 2003), a 500-plus page exploration of the power of moral fervor in American politics. The book's history tour ranges from the Puritans who posited a "them and us" universe of the deserving and the undeserving; to extended national debates over slavery, the rights of women, temperance and the New Deal; to the Cold War, the political and cultural battles of the Sixties and the rise of the religious right in the late 20th century. "If I had known how huge it was," he says of the landscape he chose to explore, "I'm not sure I would have tried."
On the journey, Morone encountered some surprises. While exploring America's Puritan legacy, he discovered another formidable moral perspective, one that dominated American public policy for several generations: the social gospel movement. "This was the self-conscious rhetorical and philosophical framework advanced by leaders like President Franklin D. Roosevelt and Martin Luther King," Morone wrote in a report to RWJF. "The social gospel shifts the focus. It turns public policy away from punishing (or controlling) irresponsible individuals and toward shared social duties. The focus flips from individual to community, from personal responsibility to communal obligations. This moral tradition challenges Americans to help the weakest and poorest members of the community.
These two competing moral traditions—the Puritan and the social gospel—"set the implicit framework for our policy debates," Morone says.
Two years after Hellfire Nation's publication (he also contributed to and co-edited Healthy Wealthy & Fair: Health Care and the Good Society, a collection of essays by 15 Investigator Awards' winners, Oxford Press, 2005), Morone received his second Investigator Award, in concert with co-investigator David Blumenthal, MD, MPP, a professor of medicine and health care policy at Harvard Medical School and director of the Institute for Health Policy and a physician at the Massachusetts General Hospital/Partners HealthCare System. The fruit of their collaboration, Heart of Power: Health and Politics in the Oval Office (University of California Press, 2009), took a similarly sweeping view of a perfectly timed subject: how 11 American presidents, from Franklin Roosevelt to George W. Bush, addressed the challenge of broadening health care coverage.
"With both these books, I feel like I took a fantastic journey, and learned things I didn't know," Morone says. Researching Heart of Power "was like putting together a terrific movie, sitting in the archives, learning one thing after another. Our idea was to understand how the presidents made health policy. Listening to the tapes that had just been released on Medicare and hearing Lyndon Johnson talking was an extraordinary experience," says Morone. Heart of Power describes how the particular political and economic forces that weighed on each of the 11 presidents helped define the incremental advances and retrenchments in a health policy that, as Robert Reich put it in a front-page review in the New York Times Book Review, have "bedeviled, eluded or defeated every president for the last 75 years."
"George W. Bush really cared about health care," says Morone, "in part, some think, because his father was so maladroit on the subject. Bush One was bored to tears by health policy; his staff couldn't get him to focus on it. But his son learned from the mistake his one-term father made, and he saw a chance to turn health care into a market-based system, with prescription drug coverage as the hook."
Morone's two areas of interest converged with particular clarity in the health care debates of 2009. "We're at a very rare moment when our politics is poised to go either way," Morone observed in the wake of a long summer of fierce town hall debates on the issue. "Barack Obama ran for president explicitly because he believed in the social gospel tradition. His exchange with 'Joe the Plumber' during the campaign was a perfect example. He laid out the social gospel view—FDR couldn't have said it better—and the response, 'this sounds like socialism,' was the perfect expression of the opposite view. It was a genuine moment when the two sides articulated the different perspectives that run through American history.
"It's fascinating that this standoff is coming to a head around health care. Democrats are espousing this explicit social gospel view, Republicans have responded, and though they haven't put it into explicit moral terms, the town hall meetings on the issue certainly have that fervent flavor.
"I went to one of the town hall meetings in New Hampshire. They are really feeling something powerful. I think what they are feeling is the possibility of deep change in American politics, and it could go in multiple ways.
"What happens in the next four years will help determine where we go for a long time to come. Imagine the Democrats and Obama succeeding, using health care as the breakthrough issue? If he's successful you can imagine that being the beginning of a swing towards 'we stand for a communal vision.'
"On the other hand, if it's defeated, if we can't stand together, we end up with health care reforms that are trivial and small."
In the Clinton-era battle over health care, says Morone, there was something of that same tension, "but Republicans actually won that one, and it tightened the grip of the Puritan vision.
"We're at another one of those pivot points."
RWJF Perspective: "One of the important criteria for selecting investigators is the likelihood that their work will inform health policy," says Lori Melichar, PhD, RWJF director. "Some investigator awards are more successful than others at meeting this goal. The Blumenthal–Morone team produced a rigorous, relevant examination of history in time to inform the president's journey through health reform. It doesn't get more policy relevant than that!"