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 have had in broadening health care coverage? David Blumenthal, MD, MPP, wanted to explore this question.
An eclectic career. Blumenthal left his home in New York City for Cambridge, Mass., at the age of 18 and never looked back. He completed an academic tripleheader—a Harvard BA, MD, and Masters in Public Policy—and aside from a three year stint working for the late Senator Edward Kennedy in the 1970s and two years in the Obama administration as National Coordinator for Health Information Technology, his base has remained in Cambridge and Boston. Blumenthal's interests and his accomplishments—primary care practice, teaching, research, health policy formulation and commentary—range over a large tract of the world of medicine.
In an era of specialization, Blumenthal might be described as a pragmatic generalist, balancing multiple interests that nourish rather than compete with one another. He completed his internship in medicine and primary care at Massachusetts General Hospital, and then started his appointment at the medical school, teaching and doing research. "For the first 10 or 15 years of my academic career," he says, he maintained a part-time practice with the idea "that if my grants ran out I would have a way to earn a living."
"Then I got in the habit of practicing medicine and I found it a great contrast and a refreshing departure from my other work. I found my practice a great source of ideas for my research. It gave me a lot of insight into what was important and what wasn't among the many research ideas that could be pursued."
Thinking about health policy. Blumenthal's private practice also influenced his thinking about health policy. "It gave me a lot of perspective on the policies that were being advocated, promoted and promulgated, because I was sitting with a group of 14 very, very skilled, intelligent, prominent physicians at Mass General. All of these people were doing tons of interesting things. But, they weren't necessarily thinking about the same issues that people at the policy level were talking about. This experience gave me the chance to observe what policies were diffusing to practitioners and what were not."
Blumenthal's choice of research topics reflected his interest in a wide range of issues. "I wrote a book called Improving Clinical Practice: Total Quality Management and the Physician. I did work on: safety of care; partnerships between academics and industry; academic health centers and their missions; and the effects of managed care on academic health centers. I also did work on continuing medical education. My publications are all over the map."
In the late 1970s Blumenthal stepped more firmly into the policy arena when he served as an adviser to Senator Edward Kennedy on health care reform.
Asked whether he thought his taste for variety reflected the multiple questions primary care throws at practitioners, he laughed. "I think it reflects the fact that I'm instinctively a dilettante."
"There are some themes I've pursued over time, but I have a lot of interests. I've always been interested primarily in big questions—cost control, quality improvement, coverage. But in an academic career it's hard to support yourself studying big things. So you need to find specific issues you can look at and focus on questions you can answer empirically." To this end, Blumenthal also wrote several articles about the adoption and use of technology in the health field. He found ways to balance the multiple strands of his career with "a lot of very specific kinds of research" while continuing to turn out "opinion pieces and sounding boards and essays that I would publish in the New England Journal of Medicine (as a national correspondent) or JAMA or Health Affairs on broader topics. That's why my CV is as diverse as it is."
An RWJF award and a book about presidents. It was in yet another role, that of political historian, that Blumenthal became a Robert Wood Johnson Foundation (RWJF) Investigator.
As a Harvard undergraduate, Blumenthal had been a student and great admirer of Richard Neustadt, PhD, the celebrated presidential historian, adviser and founder of Harvard's John F. Kennedy School of Government (now called the Harvard Kennedy School). Teacher and student became university colleagues and later close friends. Not long after Neustadt's death in 2003, Blumenthal was "hit by a bolt from the blue. Why not a book about how presidents deal with health care issues?"
Blumenthal wrote a proposal for such a book and applied to RWJF's Investigator Awards in Health Policy Research national program for funds. RWJF established the Investigator Awards program in 1992 to enhance society's understanding of significant problems and policy issues and to provide information that can help improve the formulation of sound policies.
After his first proposal was rejected, he decided he needed to connect with a political scientist and "someone recommended Jim [James Morone, PhD, a prominent political scientist and professor at Brown University; see his Grantee Profile] and Jim, bless his soul, was just too nice to say no. I suspect he was a little ambivalent when we actually got funded in 2003. As Jim will readily say, the presidency was not a fashionable topic in political science. He wasn't an expert on the presidency. At the time, I didn't know how great a writer Jim is, how brilliant a synthesizer he is.
"Jim was finishing another book when the Investigator grant came through, so I kind of kept the project going while he finished other work. It turned out to be a great partnership." Blumenthal and Morone worked in close collaboration, Blumenthal drafting chapters at Harvard in Cambridge, Morone reworking them at Brown in Providence, R.I. "I did more groundwork at libraries and information gathering," remembers Blumenthal, "Jim did more editing and conceptualizing of the historic themes."
The project turned out to be much more work than either man foresaw. But, the ride was thrilling—and perfect for a self-proclaimed dilettante.
"I loved the gold, the sort of treasure hunt in the archives," Blumenthal says, something he hadn't expected. Spending four or five days at a time in one or another president's archives—the book spans presidents from FDR to George W. Bush—he felt under "constant pressure, trying to rush, given that the archives didn't open until 9:00 a.m. and they closed at 5:00 p.m. Basically from 4 o'clock, you couldn't check out new materials, so I always felt frustrated. I was never ready for the week to end.
"What I also didn't anticipate was that I would get to know each of these presidents so well—hearing their own words, looking at their calendars. For each of them, I of course read multiple biographies and I began to get to see them as people. Then, the process of trying to recreate them as real people with health concerns of their own was enormous fun. I think it was a combination of history and health care and the original material."
Researching Heart of Power says Morone, "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."
The Heart of Power: Health and Politics in the Oval Office, published in September 2009 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."
A stint in Washington: By the time Blumenthal and Morone's book was released, Barack Obama was in the White House, putting together his health reform plan. Blumenthal had served as a senior health adviser to the Obama campaign, and then took a job he'd never anticipated—coordinating Obama's high profile push to broaden adoption of information technology in medical practice. To his surprise, his eclectic background had prepared him well for a bureaucrat's job. "All these things seemed to come together. Being a manager was an incredibly valuable thing for setting up a new office, hiring senior people and motivating them. My earlier stint as a senior VP at the Brigham and Women's Hospital was a terrific asset.
"Having written the book, I knew the White House, how it's organized and what the roles of different departments are—how the Domestic Policy Council works and how the Office of Management and Budget works, what kinds of things a president deals with, what's a presidential issue and what's not a presidential issue. That experience was incredibly valuable."
Blumenthal spent two years in Washington before returning to Harvard. Back at Harvard Medical School and Massachusetts General Hospital in May 2011, Blumenthal will no doubt be weaving his newest experience into the fabric of a rich academic life.
RWJF Perspective: "One of the important criteria for selecting investigators is the likelihood that their work will inform health policy," says Lori Melichar, PhD, MA, 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!"