Origins of the Affordable Care Act

Today on the show, we have a story about healthcare from our friends over at GBH News. Mitt and Ted, hosted by Ian Coss, tells the story of how Mitt Romney and Ted Kennedy began their political careers on very different sides of the healthcare debate, but for a short while, worked together to pass a law that provided healthcare to everyone in Massachusetts. Their work eventually paved the way for what became the Affordable Care Act. We bring you Part One of their series, which takes us all the way back to the Nixon era. You can listen to the whole series over at: https://www.wgbh.org/podcasts/mitt-ted-a-healthcare-story Support public media with NPR+ and enjoy perks for over 25 podcasts like this one. This show’s perks include sponsor-free listening. Learn more at plus.npr.org http://plus.npr.org/. See pcm.adswizz.com https://pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences. NPR Privacy Policy https://www.npr.org/about-npr/179878450/privacy-policy

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  This message comes from NPR sponsor Viori with the Halo Essential Wide-Like Pant. Receive 20% off your first purchase at viori.com/NPR on any US orders over $75 and free returns. Exclusions apply. Visit the website for full terms and conditions.

• 0:18Rund Abdelfatah?

  I'm Randaab Del Fatah, and you're listening to Throughline from NPR.

• 0:25Rund Abdelfatah?

  Progressive Democrats like Troy Jackson and Abdul Al Sayed have been campaigning on Medicare for All, a type of system that would cover healthcare for everyone, regardless of age or income. Now, Democrats have won full control over Congress in a jaw-dropping wave of victories, which means they may just have the mandate to make good on their promises. Last week, we re-upped our story about how we ended up with a healthcare system where the majority of Americans depend on their jobs for health insurance.

• 0:57Rund Abdelfatah?

  If you haven't listened to it yet, definitely go back and check it out, because today, we have a story about where that leaves off. It takes us to the Nixon era, when a plan that looks a lot like what would eventually become Obamacare was first proposed.

• 1:14Rund Abdelfatah?

  It's the first episode of a new podcast series called Mitt and Ted from the team at GBH News in Boston. The podcast is about how two politicians, Mitt Romney and Ted Kennedy, began their political careers on totally different sides of this issue. But for a brief period, they worked together to pass a law that provided healthcare to everyone in Massachusetts. It eventually laid the groundwork for what became the ACA, the Affordable Care Act, Obamacare. We'll have that first episode after a short break.

• 1:50Speaker 02

  This message comes from Superhuman. Have you heard of Superhuman Go? Their Go AI chat helps you draft emails and messages and can also summarize long threads and documents. It can search across your apps, all without leaving the page you're on. It collaborates with you where you are, whether it's in a doc you're reading or the email you are writing. Try Superhuman Go, from the makers of Grammarly. Find out more at superhuman.com.

• 2:16Speaker 00

  This message comes from The Hartford. One of the most powerful things you can do for someone is to believe in them, strengthening that belief they already have in themselves. The Hartford does that every day for over 200 years now, providing insurance for businesses from small and middle to large and global, and for employees and employers navigating life's ups and downs. The Hartford delivers insights that reduce risk and keep customers ahead of what's next. Visit thehartford.com today and see what's possible when belief is put into action.

• 2:46Speaker 02

  This message comes from Open Door. With cash now, more later. Get cash upfront for your home, plus all the profit later. That's no chaos now, no cash left behind later. Skip the showings now and move on your own timeline. Cash now, more later. Now available nationwide. Start your offer at opendoor.com/NPR. Profits calculated after fees and costs. Eligibility and offer price may vary.

• 3:12Speaker 00

  This episode's sponsor is HubSpot, which offers the following message. What if, instead of updating your CRM, your CRM updated you? HubSpot's self-updating CRM keeps your customer context current, so you can win more deals. Learn more at hubspot.com.

• 3:30Rund Abdelfatah?

  Here's producer and host Ian Kos with the first episode of the series Mitt and Ted from GBH News in Boston.

• 3:41Speaker 03

  Part one, my greatest regret.

• 4:12Speaker 04

  I think it started when his son got cancer. And that was, that was really a turning point, I think.

• 4:28Speaker 03

  In late 1973, Senator Ted Kennedy was faced with what he later called, "The hardest thing I ever had to do," telling his son he had bone cancer, that it was serious, that they would have to amputate his leg.

• 4:44Speaker 03

  Ted Jr. was 12 years old, and for a time, the child was quiet. He put a towel over his face so no one could see him, while his father, who was usually so full of life, so full of energy, simply held the kid in his arms and said over and over again that everything would be okay.

• 5:05Speaker 03

  Eventually, the phone in the hospital room rang. It was the President of the United States, Richard Nixon. The senator picked up, then handed the phone to his son so the president could wish him well before the operation.

• 5:22Speaker 03

  At 8:30 the following morning, the doctor removed Ted Jr.'s leg. It also happened to be the day that Bobby Kennedy's oldest daughter was getting married, and Ted, as the last of the Kennedy brothers still alive, had to be there to walk his niece down the aisle. Just think about that, leaving your son's hospital bed to go walk your murdered brother's daughter down the aisle at her wedding. Ted went straight from the hospital to the church and back to the hospital. He never changed his suit.

• 6:05Speaker 03

  A few months later, in early 1974, Ted Jr. began his chemotherapy treatment at Boston Children's Hospital. He was not out of the woods yet.

• 6:15Speaker 04

  And he had to have experimental treatment every three weeks for three days. And the Senate flew up for every one of those treatments, stayed in the hospital with him.

• 6:27Speaker 03

  Barbara Suleotis ran Kennedy's Boston office, so she would see the senator on these trips as he anxiously watched his son, Teddy Jr., suffer through nausea, fever, terrible pain, waiting to see if the treatment would work.

• 6:41Speaker 05

  This was on an experimental research basis. Experimental research basis.

• 6:46Speaker 03

  Ted Kennedy himself described this period in an oral history interview a few years before he died. And he remembered how, at first, this experimental treatment was completely free.

• 6:56Speaker 06

  While it's an experiment, it's paid for by the company.

• 7:00Speaker 03

  But then, a few months in, the clinical experiment ended. The good news was that the results were extremely promising, a 90% survival rate for a condition that used to have more like a 20% survival rate, truly the difference between life and death.

• 7:16Speaker 06

  So that was enormously encouraging.

• 7:18Speaker 03

  The bad news was that families would now have to pay for it.

• 7:21Speaker 06

  And it's $2,700 a treatment. That's what it could cost. And none of the insurance would cover it, except mine.

• 7:32Speaker 03

  In this hospital, Teddy Jr. was one of the lucky ones. His father had US government health insurance, the kind all congresspeople get. So Teddy Jr. could keep coming back every three weeks, receiving the shots, waiting for this new wonder drug to do its work. Ted Senior would wait there, too.

• 7:51Speaker 04

  And when Teddy was sleeping, he would walk the cards and talk to parents who couldn't pay for the treatments.

• 8:03Speaker 04

  Some had to mortgage their houses, basically go bankrupt because they had no health insurance.

• 8:09Speaker 03

  These families Kennedy met would tally up all their savings, all their assets, to see if they could cover even just a few more months of treatment, hoping that would be enough to save their child's life.

• 8:23Speaker 04

  And they would ask him,

• 8:27Speaker 04

  "What if we can only do one treatment, you know, with that help, their kid?" Because they couldn't afford it. And he said, "This shouldn't not be happening in this country."

• 8:42Speaker 03

  Walking the corridors of that cancer ward, Ted Kennedy fully embraced what became the cause of his life: universal health insurance. He knew it was a complicated and divisive issue. He wasn't naive. But he couldn't possibly know just how hard it would be, how long he would have to fight.

• 9:01Speaker 07

  The issue before the American people isn't, "Can we afford national health insurance?" Is, "Can we afford not to have it?"

• 9:08Speaker 03

  Through the '70s, the '80s, the '90s, the 2000s.

• 9:11Speaker 07

  Comprehensive, universal, for every child in America and every adult, too.

• 9:15Speaker 03

  On the Senate floor, on convention stages, in forums and town halls around the country, Kennedy voiced the outrage he felt in that hospital ward.

• 9:25Speaker 07

  It is a national disgrace.

• 9:27Speaker 03

  This was the issue Kennedy just kept coming back to again and again over his nearly 50-year career in the US Senate. Because even for one of the greatest dealmakers that chamber has ever known, this was the issue that just kept on eluding him.

• 9:43Speaker 07

  The cause endures, the hope still lives, and the dream shall never die.

• 9:59Speaker 03

  Something I've come to appreciate about politics in America is that there are windows of opportunity in which major change can happen. I'm talking about change on the scale of a Social Security Act or Civil Rights Act, laws that redefine what it means to be a citizen of the nation. These windows of opportunity are like celestial events, far beyond the control of any one individual, even an individual as powerful as Ted Kennedy. They're the rare moments when public sentiment, political power, pent-up frustration, that perfect mix of personalities and incentives, all these things click into alignment to open up a door.

• 10:42Speaker 03

  And when the door opens, everyone has to be ready to rush through it. But the tragic irony of Kennedy's nearly 40-year health care crusade is that his first and best opportunity to make it happen came too soon, before he was ready. This opening came without warning, even as his son was lying in that cancer ward in 1974. And it came from Nixon himself.

• 11:14Speaker 07

  Mr. Speaker, the President of the United States.

• 11:22Speaker 03

  When Richard Nixon rose to give his State of the Union address in January of 1974, he was speaking as a man desperate to change the subject, anything but Watergate. And the subject he chose was health care.

• 11:38Speaker 07

  Turning now to the rest of the agenda for 1974, the time is at hand this year to bring comprehensive, high-quality health care within the reach of every American.

• 11:48Speaker 04

  He didn't want to call it national health insurance. We had to call it universal health care.

• 11:53Speaker 03

  Stuart Altman was a staffer in the Nixon administration, and he basically wrote the president's plan specifically for this speech.

• 12:01Speaker 04

  I never had so much power. And it was around Christmas time, because I remember saying to others, including my wife, "Don't count on me for Christmas."

• 12:13Speaker 03

  The final plan included measures that today would seem wildly progressive, especially for a Republican president, like a mandate on all employers to either provide health insurance to their workers or pay a penalty. Again, that's a government mandate on businesses to provide health insurance. That is what Nixon himself proposed in 1974.

• 12:35Speaker 04

  A real, serious national health reform plan.

• 12:39Speaker 07

  That will assure comprehensive health insurance protection to millions of Americans who cannot now obtain it or afford it.

• 12:45Speaker 03

  See, you might think Ted Kennedy would be over the moon. I mean, a Republican president talking about universal health care. But for Kennedy at that time, Nixon's plan did not go far enough. And when you watch the footage of the 1974 State of the Union, there's a moment where you can see this tension play out.

• 13:03Speaker 07

  And doing it as well as I possibly can.

• 13:06Speaker 03

  Right as Nixon makes his case for universal health care, the camera cuts to Ted Kennedy out in the chamber. He's leaning back comfortably with a wide checkered tie and that strong Kennedy chin jutting straight out. His eyes are locked on Nixon. But when the congresspeople around him burst out in applause, he just sits there. Because laced into Nixon's grand vision was a not-so-subtle critique.

• 13:32Speaker 07

  Now, I recognize that other plans have been put forward.

• 13:36Speaker 03

  You should know that even before his son's cancer, Kennedy was already a leading voice on health issues. And just the year before, he had put forward his own sweeping health reform bill. It would have created a true national health insurance system, European-style, run by the government, what gets called "single payer" or Medicare for All.

• 13:57Speaker 07

  And that would put our whole health care system under the heavy hand of the federal government.

• 14:02Speaker 03

  Nixon was clearly not ready to go that far. But in 1974, desperate for anything that could change the course of his doomed presidency, he was willing to go pretty far, farther than many of his own advisers wanted him to go, and farther than any other Republican president in recent memory.

• 14:20Speaker 07

  But my colleagues, this I believe.

• 14:23Speaker 03

  In the closing lines of his speech, Nixon explicitly asked the Congress to work with him, to put the chaos of Watergate aside and do something together that they could never do on their own. In that moment, the celestial alignment I talked about started to come into view, that narrow path forward. The question was, would Kennedy join Nixon on that path?

• 14:48Speaker 07

  And in the support of the American people, we can and we will make the year 1974 a year of unprecedented progress and a new prosperity without war in the United States of America.

• 15:07Speaker 03

  After the break, health care reform goes underground.

• 15:24Speaker 02

  Stay tuned for the following announcements and messages from our sponsors. This message comes from BetterHelp. Your brain has limited storage, so why is it still holding on to that embarrassing moment from years ago? BetterHelp is an online therapy platform that gives you space to talk about what's taking up too much of yours. BetterHelp is now in-network with more than 125 health plans, with many copays as low as $15 for eligible members. And if you don't have eligible insurance, you can still get 20% off your first month. Visit betterhelp.com/NPR. Cost and coverage may vary. Discount cannot be combined with insurance.

• 16:03Speaker 00

  This episode's sponsor is HubSpot, which offers the following message: What if instead of updating your CRM, your CRM updated you? No catching up on manual edits, no more guesswork. HubSpot's self-updating CRM keeps your customer context current and helps you understand what to do next. So, marketing builds more demand, sales wins more deals, and customers keep coming back. Learn more at hubspot.com. This message comes from Xero. That's Xero with an X, a simple but powerful platform built for small business owners that makes managing business finances easier from day one.

• 16:38Speaker 00

  Learn more at X E R O dot com.

• 16:49Speaker 03

  Kennedy saw Nixon's bill as a half-measure, at best, a tweak to the system that rewarded the private insurance companies. At worst, Nixon's bill was a threat, something that could suck energy away from true, meaningful reform. Senator, what does this mean for your bill?

• 17:05Speaker 05

  Well, first of all, we have to understand that--

• 17:07Speaker 03

  So politically speaking, Kennedy had plenty of reasons to deny Nixon's invitation and stick with his own bill.

• 17:14Speaker 05

  I believe that the statements that the president--

• 17:17Speaker 03

  But then, in April, so a couple months after the State of the Union, Ted Kennedy surprised everyone. He linked up with the most powerful congressman in the House, the chair of the Ways and Means Committee, and together they said, "We're willing to work with Nixon's plan."

• 17:32Speaker 04

  And they announced, "We would like to work with the administration and the president to pass this legislation right away."

• 17:42Speaker 05

  We're going to build upon the existing strengths of our system.

• 17:45Speaker 04

  Which just sent signals all over the place. Front pages of The New York Times and The Washington Post, "We're going to have national health insurance."

• 17:56Speaker 03

  It seemed like a done deal at that point.

• 17:57Speaker 04

  Absolutely.

• 17:58Speaker 05

  The issue of national health has been before this country for many years, almost since the turn of the century.

• 18:04Speaker 03

  That spring, Kennedy himself told reporters, "A new spirit of compromise is in the air."

• 18:11Speaker 06

  Wow.

• 18:12Speaker 04

  You know, President, the most powerful senator, all agree.

• 18:15Speaker 05

  And now all we have to do is find the cure.

• 18:18Speaker 03

  But the challenge wasn't just Kennedy and Nixon themselves. It was also their more hardline allies, who didn't want them talking in the first place. On the right, the pressure came from Nixon's own cabinet, who, again, were not on board with the plan he had just proposed to Congress. And they were all screaming at him, "We just read this thing. This is socialism. What have you done?" Meanwhile, on the left, the pressure came primarily from organized labor. From the unions and from liberal groups, saying, "What are you doing?" Remember, Nixon was wounded at this point. Impediment hearings were about to begin. He was fighting for his political survival. And you want to throw this guy a line?

• 19:00Speaker 03

  You want to work with his plan? With all this pressure building, Kennedy decided to call a meeting with leaders from the United Auto Workers and AFL-CIO to try and bring them along. The tricky part of this is that for many working people, getting health insurance was a big part of the reason to join a union and support your union. So for the big labor groups, any kind of health reform was bound to be a sensitive issue. Now, those labor leaders were in Kennedy's office, a whole group of them, and they were furious. The way they saw it, Democrats would probably win a landslide in that year's midterms.

• 19:43Speaker 03

  They could soon have big majorities in both houses. Nixon could be gone entirely, and that would be the time to pursue true reform, not this hodgepodge compromise Nixon was offering. Kennedy began fuming, and he grabbed a copy of the Congressional Directory and just started reading out the names of all the senators who would never support anything like a single-payer plan, asking again and again, "What are you going to do about him? And him? And him?" Finally, one of the top lobbyists in the room hurled back an almost unthinkable insult, which was also a threat. He said to Ted Kennedy, "You are, quote, 'a traitor to labor' for even entertaining

• 20:28Speaker 03

  a deal with Nixon." At that, Kennedy stood and opened the door for his guest to leave, saying, "Well, you're just going to have to call me a traitor."

• 20:44Speaker 03

  What Kennedy understood was that desperation, Nixon's desperation, could be the key ingredient for deal making. It forced him to do something rather than nothing. But the negotiations would have to go underground.

• 20:58Speaker 04

  So we formed a secret work group.

• 21:05Speaker 03

  One day in June of 1974, Stuart Altman took a short cab ride to the corner of Third Street and A Street, St. Mark's Episcopal Church. He paused for a moment to glance around and make sure no one was on the street who might recognize him. Then he stepped through a side door of the church and down a steep flight of stairs to a room known as the pub.

• 21:28Speaker 04

  They actually, at night, serve beer.

• 21:31Speaker 03

  Remember, Altman was one of Nixon's health aides. And there waiting for him in the empty pub was a top health aide for Ted Kennedy. Given the level of tension between these two men and the forces pulling them apart, this was like sending a secret envoy to the Soviet Union. Top secret.

• 21:49Speaker 04

  We met in the basement to not have all these people down our throats.

• 21:55Speaker 03

  So the two aides got to work, trying to hone in on that acceptable balance of government control and free competition.

• 22:02Speaker 04

  To see if we could find common ground.

• 22:05Speaker 03

  But outside that church basement, the time for a deal was running out.

• 22:10Speaker 07

  Mr. Butterfield, are you aware of the installation of any listening devices in the Oval Office of the President?

• 22:15Speaker 03

  Watergate was now a national obsession. Formal impeachment hearings were underway in the House and broadcast straight into American living rooms.

• 22:23Speaker 07

  Those who wanted seats had waited through the night on

• 22:26Speaker 03

  The story was everywhere, all consuming.

• 22:29Speaker 07

  And so there is tonight a real persistent and substantial question of whether the President can in fact carry out his responsibilities.

• 22:44Speaker 03

  Somehow, the secret church meetings continued through June and into July, with the two sides inching ever closer together on a health care bill.

• 22:55Speaker 03

  Even as Ted Jr. received his cancer treatment and began to recover, even as Nixon's Oval Office tapes were handed over to prosecutors, down at St. Mark's, they were talking about payroll taxes and insurance rules. Because Altman and others could still see the historic opportunity, the narrow opening before them.

• 23:16Speaker 04

  You're never going to see anything more liberal than this. This is the best health insurance plan you're ever going to get. I said, we got to get this done.

• 23:34Speaker 03

  As late as July 8, 1974, one month before Nixon's resignation, Kennedy was still on the phone with Nixon's Health Secretary, who was still telling him, a deal is possible. If you get it to his desk, Nixon will sign it. But soon after that call, Kennedy sat down with his top aide, the one in those basement negotiations, and they truly took stock. It was a tough situation. Kennedy was looking at how much ground he had given up already, how far there was still to go, and how fiercely his own allies were trying to pull him back. He said to his aide, they're ready to crucify me out there.

• 24:18Speaker 03

  For Kennedy, it ended quietly. There simply was no next meeting, no next phone call. He just let it go.

• 24:30Speaker 07

  Good evening. This is the 37th time I have spoken to you from this office.

• 24:37Speaker 03

  On August 8, Nixon addressed the nation directly. This was more than two years after a group of burglars was arrested at the Watergate Hotel. And finally, the never-ending drama was over. Nixon was resigning.

• 24:51Speaker 07

  As I recall the high hopes for America with which we began this second term, I feel a great sadness that I will not be here in this office, working on your behalf, to achieve those hopes in the next two and a half years. May God's grace be with you in all the days ahead.

• 25:21Speaker 03

  That day in August of 74, a doorway closed, and it stayed closed for a long time.

• 25:27Speaker 04

  Health insurance went kaput. It just disappeared.

• 25:39Speaker 03

  How did Ted Kennedy reflect back on the summer of 1974?

• 25:44Speaker 04

  I got to meet him, and he said several times, I thought we were going to do it, Stuart. I thought we were going to make it. I'm, I, we should have done it. We should have got it done.

• 26:03Speaker 03

  Many years later, in a speech, Kennedy said, to every cause, there is a moment. But how can you know it's the moment when you're in it? How could Kennedy have known that he would never again get an opportunity this good? A chance to pass something so ambitious? How could he have known that after Watergate, trust in government would only fall? That the appetite for new government programs would only shrink? And that with time, bipartisanship itself would only get weaker? How could Kennedy have known he would spend the next 30 years fighting tooth and nail to get even close to what Nixon was offering? Of course, he couldn't.

• 26:50Speaker 03

  Kennedy would say many times that failing to seize that opportunity with Nixon was the greatest regret of his political life.

• 26:59Speaker 04

  Several years later, he said, we should have jumped on that.

• 27:03Speaker 03

  He told Barbara Suliotis the same thing. It haunted him.

• 27:07Speaker 04

  He just regretted that he couldn't get it done.

• 27:15Speaker 03

  But Ted Kennedy, over his long career in politics, would get another shot at his dream. A moment when the planets once again aligned, when an unlikely partner once again reached out, and when Kennedy would once again have to choose whether to make a deal.

• 27:41Speaker 03

  My name is Ian Cosse, and in the new season of The Big Dig podcast, we tell the story of that second shot, the one Kennedy would not miss, the one that would transform American health care forever. And no, I'm not talking about Obamacare, at least not quite yet. I'm talking about a little statewide health care bill here in Massachusetts that was the template and inspiration for Obamacare. To me, this is one of the great undertold stories in our health care debate today. I mean, where did the actual ideas in the Affordable Care Act come from? Why was that the moment they exploded onto the national stage? And why did they become so deeply, deeply divisive?

• 28:25Speaker 03

  Follow those questions far enough, and you will find yourself, like me, in Massachusetts.

• 28:40Speaker 03

  In part two, Ted Kennedy meets his new negotiating partner, and not on the best of terms.

• 28:46Speaker 06

  Senator Kennedy, my impression has been that you have followed a campaign of trying to divert the voters' attention from the issues at hand and instead making personal attacks on me.

• 28:55Speaker 03

  His name is Mitt Romney.

• 28:57Speaker 06

  When will this end?

• 29:02Speaker 03

  To hear that story, search for The Big Dig wherever you listen. The new season is called Mitt and Ted.

• 29:53Speaker 03

  The Big Dig is produced by Isabel Hibbard and myself, Ian Cosse. It's edited by Lacey Roberts. The editorial supervisor is Azita Guaramani, with support from Ryan Alderman. The executive producer is Devon Maverick Roberts. If you want to hear the other seasons of this podcast, produced by the same team, just search for The Big Dig wherever you listen, and you should see, at the very least, seasons one, two, and three, as well as four. Archival sound for this episode came from the Richard Nixon Presidential Library and Museum, as well as the Miller Center at the University of Virginia. The artwork is by Bill Miller. Our closing song is "Things Will Be Different" by The Shads.

• 30:36Speaker 03

  The Big Dig is a production of GBH News and distributed by PRX.

• 31:03Rund Abdelfatah?

  And that's it for today's show. Throughline production for this episode was done by me, Amy Padula, and Lou Alkowski. Next week on Throughline.

• 31:12Speaker 06

  Two black guys in white uniforms get out with afros and beards, and they bring into your house an oxygen tank, a heart monitor. So the residents are saying, what are you doing?

• 31:25Rund Abdelfatah?

  The story of how an all-black team of medics from Pittsburgh wrote the blueprint for emergency medicine in the US.

• 31:32Speaker 06

  So we had to teach the community that we were bringing the emergency room to them.

• 31:39Rund Abdelfatah?

  That's next week on Throughline.

• 31:51Speaker 00

  Stay tuned for the following announcements and messages from our sponsors. This message comes from Midi Health. Most women never get real answers about their hormonal health. Midi is changing that with virtual care covered by most major insurances. Understand your hormones. Visit joinmidi.com to book your first visit today.

• 32:11Speaker 02

  This message comes from Instacart. Game day is here, and with Instacart, missing a play for a snack run is a thing of the past. Get veggies, chips, dips, and drinks delivered right to the door, along with groceries for the week. One order, everything needed from favorite local stores. Download the Instacart app and get delivery in as fast as 30 minutes.