Copyright by David Howard Johnson 2009 The Dissertation Committee for David Howard Johnson Certifies that this is the approved version of the following dissertation: A Structure by No Means Complete: A Comparison of the Path and Processes Surrounding Successful Passage of Medicare and Medicaid under Lyndon Baines Johnson and the Failure to Pass National Health Care Reform under William Jefferson Clinton Committee: Diana M. DiNitto, Supervisor Barbara W. White King E. Davis Kirk von Sternberg Michael D. Forster A Structure by No Means Complete: A Comparison of the Path and Processes Surrounding Successful Passage of Medicare and Medicaid under Lyndon Baines Johnson and the Failure to Pass National Health Care Reform under William Jefferson Clinton by David Howard Johnson, M.S.W., B.Mus. Dissertation Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas at Austin August, 2009 Dedication Dedicated to the memory of the unknown 54,000 Americans who died for lack of health insurance in the two years it took me to write this dissertation and to the hope of a better tomorrow for the 47 million Americans who will lay down to sleep tonight in the greatest country on Earth without the blanket of health insurance protection. Acknowledgements To stand on the shoulders of academic giants was my dream when I came to the University of Texas. I have lived that dream. I am beyond grateful to my committee, and especially my supervisor, Diana DiNitto, who has survived the process alongside me. I am particularly glad to have learned under the leadership of Dean Barbara White, who also served on my committee. King Davis has provided extraordinary wisdom and stimulating discussion. Kirk von Sternberg, under whom I also worked at the Health Behavior Research and Training Institute, has been a true mentor and a supportive friend. The faculty at the University of Texas at Austin School of Social Work are unparalleled, and I consider myself fortunate to have been tutored by so many of them. I also thank Dr. James Galbraith of the Lyndon Baines Johnson School of Public Affairs who taught me several exciting new ways to think about public policy. I also stand on the shoulders of the faculty of the University of Southern Mississippi Department of Social Work. The Dean of the College of Health, Mike Forster, was Director of the School of Social Work when I was a student there. He has been a faithful member of my dissertation committee, and a constant friend since 2005. Joyous Bethel and Ray Scurfield of that faculty have been avid supporters through this trying process. I would not have survived without their love, care, and attention. v I have stood on the shoulders of family as well – family of birth and family of choice. My parents, Howard and Willa Dean Hood Johnson, have been daily companions on this journey if only by telephone. Their sacrifice paid for my first degree and set the stage for this one as well. My brothers and their families have maintained an active interest in my academic shenanigans. They have helped keep me sane. Family of choice members include Charles L. “Chip” Maxey III of Houston, Texas, my closest friend for many years. Chip has supported this effort in every conceivable way, and its completion is a tribute to his patience and care. Robert and Cheryl Sims of Coral Springs, Florida are the friends I have known the longest. Robert taught me most of what I know about the health insurance business. They have frequently posted my grades on their refrigerator as if I am one of their own. I know that I am. Rose March of Belmont, Massachusetts, believed in me when I could hardly drag myself out of bed six years ago. She still believes in me, and tells me constantly. Her love has been a sustaining influence for so long that I know I could not breathe without it. Finally, none of this work could have been accomplished had it not been for the archivists who have prepared and maintained the files over the years at the Lyndon Baines Johnson Presidential Library and Museum, The William Jefferson Clinton Presidential Library and Museum, and The Wilbur Mills Archives at Hendrix College in Conway, Arkansas. Many of them assisted me by dragging out boxes, making copies, helping me take pictures of the documents, and just generally being helpful. They informed me of their rules and enforced them gently. They rose to every request with grace and professionalism. I thank them for their every kindness. vi A Structure by No Means Complete: A Comparison of the Path and Processes Surrounding Successful Passage of Medicare and Medicaid under Lyndon Baines Johnson and the Failure to Pass National Health Care Reform under William Jefferson Clinton Publication No._____________ David Howard Johnson, Ph.D. The University of Texas at Austin, 2009 Supervisor: Diana M. DiNitto In this comparative policy development analysis, I utilize path-dependence theory and presidential records to analyze President Lyndon Johnson’s success in passing Medicare and Medicaid and President Bill Clinton’s failure to pass national health care reform. Findings support four major themes from the Johnson administration: 1) President Johnson had a keen understanding of the importance of language in framing debate; 2) He placed control of the legislative process in the hands of a small, select group of seasoned political operatives and career policymaking professionals; 3) He paid considerable attention to the details of negotiations and the policy consequences; and 4) He had a highly developed sense of the political and legislative processes involved in passing major legislation. The case study of the Clinton administration reveals five major vii themes: 1) There is a lack of evidence that President Clinton remained actively engaged throughout the policy development and legislative processes, instead choosing to delegate the process to the First Lady; 2) There was a naiveté on the part of the Clintons and many administration staff members with regard to the legal and political ramifications of their decisions; 3) The Clintons tried to make the plan fully their own, sharing little credit for its development with Congress; 4) Their attempts to incorporate existing corporate health care delivery structures with their vision for universal coverage proved unworkable; and 5) The extended time from task force launch to bill delivery gave opponents ample time to marshal their opposition forces. I conclude that in developing health care legislation, Johnson had the advantages of: 1) a small group of key policymakers; 2) multiple, simultaneous legislative initiatives which diffused the attention of a more limited media; and, 3) national crises which promoted an environment conducive to sweeping policy change. I suggest that major, national health care reform will not occur until: 1) an economic or geopolitical crisis sets the stage for change; 2) business interests and progressive interests find common ground; and, 3) Americans achieve a new cultural understanding of universal health care as both economically just and economically necessary. viii Table of Contents List of Tables ........................................................................................................ xii List of Figures ...................................................................................................... xiii Chapter 1: Sick of Being Uninsured ........................................................................1 A Word About the Remaining Chapters .........................................................7 Conclusion ......................................................................................................9 Chapter 2: American Health Care at the Breaking Point ......................................11 Cultural and Structural Dimensions Leading to the Status Quo ...................11 Health Care Today ........................................................................................11 Poverty and Plenty ........................................................................................15 Pricing of Hospital Care................................................................................17 Trends in Employment-Based Insurance ......................................................22 How National Health Expenditures Relate to the American Economy ........27 Review of the Literature ...............................................................................30 Presidents Johnson and Clinton and First Lady Hillary Rodham Clinton .....................................................................................................31 Literature on Medicare .........................................................................34 Clinton Reform Effort and The Future of Health Care Reform...........35 How this Work Differs..................................................................................39 Summary .......................................................................................................40 Chapter 3: Theoretical Foundations and Methodology The Path-Dependent Nature of Federal Health Policy ....................................................................................42 Path-Dependence Theory ..............................................................................42 Methods.........................................................................................................48 Applying the