John F. Kennedy made health care a major issue in his 1960 campaign. He concentrated on what then was called medical care for the aged, a title that wouldn't play well with the current Medicare set, people now described as senior citizens. He couldn't get it through Congress.
Lyndon B. Johnson did, but even with his legendary legislative skills and the overwhelming Democratic majorities in Congress after the 1964 elections, it took more than a year of hard, sometimes arm-bending persuasion to get Medicare enacted. It was a hard sell with conservative Democrats, not unlike the problem Obama faces now.
That one major victory for government health insurance was an exception to the pattern of starting each attempt from scratch instead of evolving it from what had gone before. When Johnson signed the Medicare bill in 1965 and gave Truman card No. 1, he traveled to Independence, Mo., to share "this moment of triumph" with the president who had first proposed it 20 years before.
It provided government health insurance at age 65, tied to Social Security. Broader coverage, which FDR, Truman and Johnson all would have liked to gain, was beyond political reach.
Not only for LBJ, but also for Republican Richard M. Nixon, who proposed universal health insurance in 1974, seeking to use employer-based coverage along with federal subsidies so that all Americans would be insured. It was to be done by private insurers, not the government. There was bipartisan support until Watergate intervened.
The political perils of change were dramatized in 1988 after Congress enacted a Medicare overhaul that included prescription drug benefits financed with higher fees on upper-income recipients, who rebelled. They protested, demonstrated and even chased the sponsor, then-Rep. Dan Rostenkowski, D-Ill., to his car. Those changes were repealed the next year.
Prescription drug coverage was added to Medicare in 2003, pushed by President George W. Bush, who claimed it as one of his major achievements in winning re-election. It did not come easily. The administration understated cost estimates by half, and Republican leaders muscled it through the House by one vote. To hold down the cost, they wrote a gap into the coverage.
That may be changed in an Obama health plan. It points to a chronic challenge in health overhaul efforts: the price of change. Covering nearly 50 million uninsured Americans would cost an estimated $1 trillion-plus over the next decade. Obama promised to do it without adding to the deficit. Now he and Congress have to figure out how.