Joan Hoff wrote, sought to use a “peace dividend” that he had gained from the withdrawal of American troops from Vietnam for domestic purposes. Under this moderate Republican president, social welfare spending more than doubled, from $55 billion in 1970 to $132 billion by 1975. It was Nixon, not Lyndon Johnson, Hoff wrote, who more properly deserves the label of “last of the big spenders” on domestic programs. Indeed, from 1970 to 1975, for the first time since World War II, spending on social welfare and other human resources exceeded defense spending.51 It’s never happened again.
Health Care
For years, health care has been a flashpoint of partisan conflict in the United States, and the Obama administration’s Affordable Care Act, passed in 2010, has recently elevated the issue to a defining one in American politics. Here again, however, the combatants on both sides are battling over terrain that Nixon had previously trod. And as many commentators pointed out in 2010, the ACA bears more than a passing resemblance to the various health care proposals that Nixon made during his presidency.
These proposals were not incremental reforms but rather transformative new formulations designed to address the growing cost crisis in health care as well as the problem of the uninsured. Nixon’s first attempt came in 1971, in his State of the Union address, when he set out an ambitious reform agenda for health care that still sounds remarkably contemporary, over forty years later:
I will offer a far-reaching set of proposals for improving America’s health care and making it available more fairly to more people. I will propose:
—A program to insure that no American family will be prevented from obtaining basic medical care by inability to pay.
—I will propose a major increase in and redirection of aid to medical schools, to greatly increase the number of doctors and other health personnel.
—Incentives to improve the delivery of health services, to get more medical care resources into those areas that have not been adequately served, to make greater use of medical assistants, and to slow the alarming rise in the costs of medical care.
—New programs to encourage better preventive medicine, by attacking the causes of disease and injury, and by providing incentives to doctors to keep people well rather than just to treat them when they are sick.52
Nixon called his plan the National Health Insurance Partnership, and included in it the now-familiar set of competing interests: private insurers who write plans for employers, government-provided plans for low-income people, and the then-new concept of health maintenance organizations (HMOs), which Nixon believed held great potential for improving services. In 1973, Nixon signed a bill sponsored by Ted Kennedy pledging federal dollars for the creation of HMOs (unfortunately, forty years later, HMOs haven’t quite fulfilled their promise, to put it gently). Nixon’s plan was comprehensive and ambitious, the first genuine attempt to provide national insurance since Harry Truman. However, Nixon’s 1971 plans never got anywhere in Congress.
Yet again, as with welfare reform, Nixon did not give up. In his 1974 State of the Union address—the last he would give as president, delivered under a swelling cloud of the Watergate scandal—he put health care reform back on the agenda: “I shall propose a sweeping new program that will assure comprehensive health insurance protection to millions of Americans who cannot now obtain it or afford it, with vastly improved protection against catastrophic illnesses. This will be a plan that maintains the high standards of quality in America’s health care. And it will not require additional taxes.”53
Nixon also made clear during the address that he opposed what would come to be known as a “single payer” system—making the government the sole health care insurer in the United States in a vast federal system of nationalized health care:
Now, I recognize that other plans have been put forward that would cost $80 billion or even $100 billion and that would put our whole health care system under the heavy hand of the Federal Government. This is the wrong approach. This has been tried abroad, and it has failed. It is not the way we do things here in America. This kind of plan would threaten the quality of care provided by our whole health care system. The right way is one that builds on the strengths of the present system and one that does not destroy those strengths, one based on partnership, not paternalism. . . . Government has a great role to play, but we must always make sure that our doctors will be working for their patients and not for the Federal Government.54
One week later, on February 6, 1974, Nixon introduced the Comprehensive Health Insurance Plan (CHIP). Nixon’s plan, like subsequent plans that would be proposed by Bill Clinton, Barack Obama, and, in Massachusetts, Governor Mitt Romney, was built around private, employer-provided insurance. CHIP would penalize all but the smallest employers for failing to sponsor insurance for their employees—just as Obama’s plan does today—though it would also provide subsidies to small employers and the self-employed to help them cover these costs. Like the ACA, Nixon’s plan guaranteed coverage with no exclusions for preexisting preconditions. Nixon’s plan had generous coverage as well for mental illness, drug addiction, and alcoholism. But unlike Obama’s ACA, the Nixon plan contained no mandate—Americans would enter CHIP voluntarily. When they agreed to participate, they would get a health card that could be used like a credit card to pay for their services. (Bill Clinton copied this detail in 1993, when he pushed for national health insurance reform, and it did not go over well. Twenty years later, millions of Americans had developed more skeptical attitudes toward big government, and they saw the health card as a symbol of an overweening government.)
CHIP had three main parts: an expanded system of employer-provided health insurance, in which employers would pay 75 percent of premiums and employees would pay 25 percent; an improved Medicare program; and, for lower-income Americans or those with special occupations or health status, a new system, Assisted Health Insurance, which, for most services, would replace state-run Medicaid. Nixon felt strongly that the lower-income health insurance coverage benefits needed to be standardized nationally; Medicaid, by contrast, had benefits that varied state by state. To get CHIP started, Nixon envisioned a price tag of about $7 billion. If “promptly enacted by Congress,” Nixon said, CHIP would be fully operational by 1976.
The roots of these bold ideas could be found, once again, in Nixon’s upbringing. Not only had the struggles of his parents made him sympathetic to those who struggled to make ends meet but he had also seen how medical crises could wipe out a family’s savings and leave them in desperate circumstances—to say nothing of the human toll of the tragedy. Nixon lost two of his brothers to tuberculosis, an experience that stayed with him all his life. As an adult, he was heartened by the medical profession’s achievement in finding a cure for TB, and he pointed to it and other advances as examples of how government and private industry could work together on health care issues. His interest in the issue dated back to the beginning of his political career: in 1947, as a first-term congressman, he had proposed a system of national health care. “It was something personal for him,” said speechwriter Ray Price.55
Now, a quarter century later, Nixon stood before the Congress with a better-thought-out, more-comprehensive health care proposal than the one he had floated in 1971. Unfortunately, while his plan was better in 1974, his timing was worse. Watergate already hovered over everything.
“The wagons were not only circling, but they were heavily arming and out for blood,” Price remembered. “It was very difficult to get anything through at that point.”56
But it wasn’t just Watergate that brought CHIP down. As had happened with the FAP, Nixon faced opposition from both the Left and the Right on his health care plan—but given the Democrats’ edge in numbers in both houses of Congress, it was liberal opposition that really sank the program. In chapter 4, I’ll describe in detail why liberals blocked Nixon’s health care reform
